5 Myths About Therapy

Beliefs about therapy shape who books an appointment and who waits. Kaplan and Sadock's textbook argues that the primary barriers to mental health care are psychological, and chiefly stigma.² A systematic review of 144 studies reported a small median association between stigma and help-seeking, with internalised stigma and treatment stigma most often associated with reduced help-seeking.¹

Five of these beliefs come up repeatedly in consulting rooms. Each one below is set against what the evidence supports, including the places where that evidence is thin. Titles, training and law differ by country, so every figure here carries the population it was measured in.

Myth 1: Therapy is only for people who are seriously ill

The World Health Organization estimates that more than 25 percent of people worldwide develop a mental disorder at some point in their lifetime.³ Rates are far from uniform. In the same series of surveys, lifetime prevalence of any disorder ran from 12.0 percent in Nigeria to 47.4 percent in the United States.³ The Global Burden of Disease study measured the prevalence of mental disorders across 204 countries and territories.⁴

People consult therapists after a bereavement, during a marriage under strain, after a job loss, or when fear has started to limit what they do. None of that needs a diagnosis to justify it. Therapy is also used at the severe end: clinical accounts in psychosis describe symptoms that can be understood to have meaning, and psychotherapy that eases them.⁶

The belief is common enough that health agencies correct it in public. The United States agency SAMHSA publishes a myths and facts page to help destigmatize common beliefs about mental health.⁵ The US Surgeon General's 1999 report identified the central place that stigma plays in unequal treatment.⁷ Stigma sits inside services too. Corrigan noted that many psychiatrists and other mental health clinicians work outside the public service system that carries the USA's most serious psychiatric cases.⁸

Campaigns have tried to shift it. In the United Kingdom the Defeat Depression Campaign ran from 1992 to 1996 and aimed to encourage earlier treatment-seeking and to reduce the stigma of depression.⁹ National surveys during the campaign showed small but significant changes in the share of the public willing to seek professional help.⁹ England's NICE depression guideline tells clinicians to take steps that reduce stigma, discrimination and barriers for individuals seeking help for depression.¹⁰

Myth 2: Therapy is the same as talking to a friend

A friend listening matters, and health bodies advise both. The World Health Organization advises someone living with depression to talk to a health worker, such as a doctor or counsellor, and to keep talking to people they trust.¹³ The two do different jobs.

The American Psychological Association describes psychotherapy as a collaborative treatment in which psychologists apply scientifically validated procedures.¹¹ It adds that psychotherapy helps people talk openly with someone who is objective, neutral and nonjudgemental.¹¹ A friend is on your side by definition. That loyalty is the value of a friendship and also its limit.

The relationship itself does work. Researchers treat the therapeutic alliance as a common factor and a predictor of outcome across therapies.¹² Therapists are trained to notice when that alliance breaks and to repair it, which is not something a friendship is set up to do.

If you are the friend

If someone close to you is struggling, the useful moves are ordinary ones.

• Listen without moving straight to solutions.
• Ask again in a week, and the week after.
• Help with the practical part: finding a number, making the call, sitting in the car outside.
• Say plainly that talking to a doctor or counsellor is an option.¹³

If you are in immediate danger of harming yourself, or you believe someone else is, contact local emergency services now and see our list of helplines and suicide hotlines worldwide.

Myth 3: A therapist will tell you what to do

Instruction is not the main instrument. The American Psychological Association describes work in which psychologists and the person together identify and change thought and behaviour patterns.¹¹ Your therapist will usually ask questions, follow what you step around, and sometimes say something you would rather not hear. In shorter structured work you may also get practical guidance and tasks between sessions.

Change of this kind has been measured outside the consulting room. Rogers reported a study in which the group which had undergone therapy developed a higher frustration threshold, tracked through autonomic measures rather than self-report.¹⁵ He argued that the hypotheses behind the approach are testable, capable of proof or disproof.¹⁴

Myth 4: All therapy is the same

Approach

Reviews of depression trials have shown that humanistic psychotherapies are efficacious treatments, roughly equivalent to cognitive behavioural therapy.¹⁶ The same reviews found humanistic treatments less effective for generalised anxiety disorder, agoraphobia and panic.¹⁶ In one controlled trial, prolonged exposure and a present-focused interpersonal therapy were equally effective for PTSD symptoms.¹⁷ Meta-analyses confirm the efficacy of CBT in reducing anxiety in autistic youth, with effect sizes that differ by who rates the symptoms.¹⁸

Format

Teletherapy is the term for therapy conducted over the telephone, the internet, or by video.¹⁹ The American Psychological Association states that teletherapy delivered by telephone or videoconferencing has similar outcomes to in-person therapy.²⁰ A review of randomised trials found that for anxiety and related conditions, interventions delivered by telehealth appear to be as effective as face-to-face care.²¹ Among the remote options, videoconferencing is the closest to real world interaction, because it carries both verbal and visual cues.²² Online therapy services that pair people with clinicians, often through live video, have grown quickly.²³

Length

Acute distress improves in about three-quarters of cases within 25 sessions, on average.²⁴ For chronic difficulties the improvement rate is less than 60 percent after 25 sessions.²⁴ Where someone has three or more diagnoses, or a personality disorder diagnosis, improvement rates are under 40 percent after 25 sessions.²⁴ Short work suits a single defined problem. Long-standing difficulty usually takes longer, and a therapist who promises otherwise is selling something.

What the evidence supports, and where it is thin

Across probably over 1,000 studies, the average effect size of psychotherapy has been found to be 0.8.²⁵ For psychotherapy the number needed to treat is 3, which means three people treated for one case of clear benefit that would not have happened anyway.²⁵

Individual results vary a great deal around that average. An umbrella review found almost 80% of meta-analyses reported a statistically significant finding favouring psychotherapy, while only 16 provided convincing evidence without bias.²⁶

Therapy can also go badly. A qualitative meta-analysis found that a considerable number of clients report adverse or unwanted effects of psychological treatments.²⁷ Clients described therapist misbehaviour, hindering aspects of the relationship, poor treatment fit, and negative impacts of treatment.²⁷ Saying that something is not working is part of the work, and a therapist who cannot hear it is the wrong therapist.

Myth 5: A therapist means the same thing everywhere

Who may call themselves a counsellor or a psychologist is set by national law, and that law differs. Kenya's Counsellors and Psychologists Act, 2014 gives a statutory Board the function to supervise the professional conduct and practice of counsellors and psychologists, and to take disciplinary measures.²⁸ The same Kenyan Act empowers that Board to determine the fees to be charged by professional counsellors and psychologists.²⁸

Other countries arrange it differently. In the United States, the American Psychological Association's guide states that psychologists, psychiatrists and social workers can all offer psychotherapy, and that psychiatrists can prescribe medication.²⁹ That guide advises interviewing a prospective therapist about credentials, experience and approach to psychotherapy.²⁹

Neither arrangement is the world's arrangement, and a title that carries a register in one country may carry none in another. Before you book, find out what applies where you live.

• Which body registers you, and what is your registration number?
• What does your title require in this country?
• Can I check your registration on a public register?
• If you practise from another country, are you registered to see people in mine?

When therapy is not the first step

If you are in immediate danger of harming yourself, emergency services and crisis lines come before an appointment. Some symptoms need a medical assessment first, because physical illness, medication effects and sleep problems can produce symptoms that look psychiatric. The World Health Organization's advice for depression includes talking to a health worker, such as a doctor or counsellor.¹³

Lower intensity support sometimes comes first. In United States Department of Veterans Affairs guidance on acute stress, there is preliminary evidence that a stepped care model can be helpful, with intensity raised only as needed.³⁰ England's NICE guideline splits new episodes into less severe and more severe depression, using thresholds on validated scales.¹⁰ What counts as severe enough to need what is decided differently in different systems. The United States National Institute of Mental Health publishes a fact sheet on assessing your mental health and determining if you need help.³¹

Finding someone

TherapyRoute lists practitioners by country, so a search starts where you actually live. Our guide on how to find the right therapist covers what to ask on a first call. TherapyRoute also carries a page on mental health myths and facts. A first session is mostly assessment: what brings you now, what has been tried before, and what you want to be different.

Team TherapyRoute

References

• [1] Clement and colleagues. The impact of mental health-related stigma on help-seeking: a systematic review. Psychological Medicine. doi.org/10.1017/S0033291714000129.
• [2] Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed (2017, vols 1+2). 33.15: Evaluation of Psychotherapy (pp 7306-7313).
• [3] Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed (2017, vols 1+2). 62. World Aspects of Psychiatry (pp 11488-11495).
• [4] Global Burden of Disease Study collaborators (2022). Global, regional and national prevalence and burden of 12 mental disorders, 1990 to 2019. pmc.ncbi.nlm.nih.gov/articles/PMC8776563.
• [5] Substance Abuse and Mental Health Services Administration. Mental health myths and facts. samhsa.gov/mental-health/what-is-mental-health/facts.
• [6] Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed (2017, vols 1+2). 33.16: Individual Psychodynamic Psychotherapy and Cognitive Behavioral Therapy for Psychosis (pp 7323-7330).
• [7] Arboleda-Florez & Sartorius - Understanding the Stigma of Mental Illness (2008). 11 Stigma measurement approaches: conceptual origins and current applications. (pp 190-197).
• [8] Arboleda-Florez & Sartorius - Understanding the Stigma of Mental Illness (2008). 9 Other people stigmatize . . . but, what about us? Attitudes of mental health professionals towards patients with schizophrenia. (pp 170-175).
• [9] The British Journal of Psychiatry. Mental health literacy. cambridge.org/core/journals/the-british-journal-of-psychiatry.
• [10] National Institute for Health and Care Excellence (2022). Depression in adults: recommendations, NG222. nice.org.uk/guidance/ng222.
• [11] American Psychological Association. Understanding psychotherapy and how it works. apa.org/topics/psychotherapy/understanding.
• [12] Eubanks, Burckell & Goldfried (2018). Clinical consensus strategies to repair ruptures in the therapeutic alliance. Journal of Psychotherapy Integration. pmc.ncbi.nlm.nih.gov/articles/PMC5966286.
• [13] World Health Organization. Depression fact sheet. who.int/news-room/fact-sheets/detail/depression.
• [14] Rogers - Client-Centered Therapy (1951). pages 21-30. (pp 21-28).
• [15] Rogers - Client-Centered Therapy (1951). pages 191-200. (pp 199-200).
• [16] Cain, Keenan & Rubin - Humanistic Psychotherapies: Handbook of Research and Practice (2nd ed, 2016, APA). Chapter 2 Effective Humanistic Psychotherapy Processes and Their Outcomes. (pp 75-82).
• [17] Herman - Trauma and Recovery (2015). Epilogue to the 2015 Edition. (pp 305-312).
• [18] National Library of Medicine, PubMed Central. Meta-analyses of cognitive behavioural therapy for anxiety in autistic children and young people. pmc.ncbi.nlm.nih.gov/articles/PMC8487131.
• [19] Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed (2017, vols 1+2). 33. Psychotherapies (pp 6825-6832).
• [20] American Psychological Association (2024). Telehealth and telepsychology. apa.org/practice/telehealth-telepsychology.
• [21] Journal of Telemedicine and Telecare. Telehealth compared with face-to-face care for anxiety conditions: systematic review and meta-analysis. pubmed.ncbi.nlm.nih.gov/34860613.
• [22] Frontiers in Psychology (2021). Videoconferencing in tele-psychotherapy. frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2021.773030.
• [23] American Psychological Association (2023). Monitor on Psychology: online therapy services. apa.org/monitor/2023/03/online-therapy-services.
• [24] Lemma, Target & Fonagy - Brief Dynamic Interpersonal Therapy: A Clinician's Guide (2011). The demise of the randomized controlled trial. (pp 23-30).
• [25] Lemma, Target & Fonagy - Brief Dynamic Interpersonal Therapy: A Clinician's Guide (2011). 1 Dynamic Interpersonal Therapy: New Wine in an Old Bottle?. (pp 20-22).
• [26] Acta Psychiatrica Scandinavica (2017). Umbrella review of meta-analyses on the efficacy of psychotherapy. pubmed.ncbi.nlm.nih.gov/28240781.
• [27] Vybiral, Ogles, Rihacek, Urbancova & Gociekova (2024). Negative experiences in psychotherapy from clients' perspective: a qualitative meta-analysis. Psychotherapy Research. pubmed.ncbi.nlm.nih.gov/37410872.
• [28] Republic of Kenya (2014). Counsellors and Psychologists Act, 2014. new.kenyalaw.org/akn/ke/act/2014/14.
• [29] American Psychological Association. What is the difference between psychologists, psychiatrists and social workers? apa.org/ptsd-guideline/patients-and-families/psychotherapy-professionals.
• [30] US Department of Veterans Affairs, National Center for PTSD. Acute stress disorder: treatment essentials. ptsd.va.gov/professional/treat/essentials/acute_stress_disorder.asp.
• [31] National Institute of Mental Health. Psychotherapies. nimh.nih.gov/health/topics/psychotherapies.