Well Action Psychotherapy

This is often the first question I’m asked by somebody seeking mental health support for the first time.

Actually, it’s really complicated. The plethora of mental-health-professional titles is confusing even to those working in the profession. For those coming in from the outside it seems … well … completely mad.

So here is a serious run-down (with some humourous commentary to lighten the mood), to the best of my knowledge, from my various experiences of psychology theory and practice from across the years.
Note, these definitions are very UK-centric. Other countries, especially on other continents, including the USA, Canada, South/Central American countries, even other European countries, may see things differently.
My apologies for the length of this essay. It is really complicated:

“Psychiatrist”: A “Head Doctor” who has had a full medical training. Sees mental health from the medical perspective: symptom, diagnosis, treatment, prognosis, recovery (or not).
Heavily reliant on the use of prescription psychoactive drugs (many of which, it must be remembered, are highly poisonous even in small doses).
Psychiatrists treat a wide range of patients, but usually end up treating those who are most seriously unwell and who don't respond to most treatments. Some treatments prescribed by psychiatrists are highly controversial, such as ECT and brain surgeries such as cingulotomy.
Psychiatrists have 2 competing bibles, the DSM (Diagnostic and Statistical Manual) maintained by the American Psychiatrists Association, and the ICD, essentially the same thing but maintained by the World Health Organisation.

The greatest weakness of psychiatry is that there is no definition of mental good-health.

In my experience, unless they have also trained in psychotherapy, psychiatrists are deeply suspicious of any other approach to treating mental ill-health and some can be contemptuous towards other mental health professionals.
Psychiatrists are awarded MD (Medical Doctor) status on qualifying, but may also gain a PhD (Doctor of Philosophy) if they do significant research or further taught qualifications such as clinical psychology.

Psychiatrists are not required to undergo any psychiatric assessment or treatment, or any psychotherapy treatment. Unless they also train as a psychotherapist (see below), which is not uncommon.

Why would I see a psychiatrist?
Most people end up in a psychiatrist's clinic soon after they arrive in mental hospital, or if they believe they're "going mad" or a relative, partner or close friend believes they're "going mad". Many people end up seeing a psychiatrist when they would probably be better off seeing a psychotherapist.

“Trick-Cyclist”: Derogatory term for a psychiatrist.

“Psychologist”: In the UK refers to a Psychology graduate, who is thus eligible for membership of the British Psychological Society. Generally awarded a BSc.

Why would I see a psychologist?
You wouldn't.

“Clinical Psychologist”: A psychology graduate who has gone on to do a specialist training in working with mental health patients. The training, which can take between 3 and 6 years after graduation, involves lectures and significant work experience, and successful students are awarded a PhD.

Clinical psychologists administer "third wave" evidence based therapy (see "evidence based psychotherapist" below) like CBT, DBT and CFT, mostly drawn from behavioural psychology. Some older treatments are highly controversial, including "Flooding" and Applied Behavioural Analysis.

They are also trained in administering psychometric tests (e.g. testing for ADHD) and creating “Case Formulations” which involves making sense of a series of test results in combination with reported symptoms, and putting forward ideas for what the root problem might be (e.g. High Psychopathy score, low IQ score, low ASD score, difficulty with friendships, might indicate trouble empathising and thinking about emotions, recommendation for Mentalisation Based Therapy.) A case formulation is a report that can be many pages in length.

Most clinical psychologists are not required to undergo any experience of receiving mental health treatment

Why would I see a clinical psychologist?
Clinical psychologists will give you a diagnosis for a specific condition or disability, such as ADHD, so that you can demand "reasonable adjustments" at work, or access specific support and NHS services. They can also make an assessment for what evidence based psychotherapy might help you, and then deliver that therapy, or arrange for you to receive it from another professional.

“Counselling Psychologist”: A clinical psychologist who has specialised in psychotherapy-like treatment. Often not highly regarded either by clinical psychologists as their breadth of knowledge is narrower, nor by psychotherapists since psychotherapists have to receive psychotherapy treatment before qualifying whereas counselling psychologists don’t.

In my experience, counselling psychologists are somewhat suspicious of both clinical psychologists and psychotherapists.

Why would I see a counselling psychologist?
Counselling psychologists mainly operate in specialist services within the NHS. You might hire one privately instead of seeing a psychotherapist if you have a particular desire to see somebody with "PhD" after their name. Also, because "Counselling Psychologist" is a protected title you're very unlikely to be duped into paying for a "fake" one.

“Forensic Psychologist”: There is some argument about whether forensic psychologists can be considered clinical psychologists, but their roles are very similar. Forensic psychologists specialise in the psychological theories, assessments and case formulations of criminals, usually within the prison system. The training, and PhD outcome for forensic psychologists is very similar to that of clinical psychologists.

Clinical psychologists regard forensic psychologists as over-specialised and not broadly trained enough to administer many common psychological tests and therapies whereas forensic psychologists disagree and complain about not being interviewed when applying for clinical psychology posts. Likewise, clinical psychologists complain about not being interviewed for applications to forensic psychology posts.

Why would I see a forensic psychologist?
You'll be ordered to see one when you arrive in prison.

“Experimental Psychologist”: A psychology graduate who explores human nature through experiment, and reports their findings in peer-reviewed journals. Experimental results can be as trivial as “The most exciting part of angling is catching a fish” or as intriguing as “100% of children with dyslexia fell off the balancing beam when asked to count backwards from 10, but none of the non-dyslexic children fell off.”

Experimental psychologists usually aspire to gain a PhD through research, at which point they usually become university lecturers alongside working in a research laboratory. There is a clear career path through running your own team up to becoming Professor.

The psychological assessment tools used by clinical psychologists are devised by specialist experimental psychologists.

Why would I see an experimental psychologist?
If you sign up to take part in a psychology experiment you will be attended to by an experimental psychologist.

“Psychoanalyst”: Somebody who offers “Talking Therapy” mental health treatment based on the theories of early psychology theorists such as Sigmund Freud, Carl Jung, Alfred Adler, Melanie Klein, etc.

Although these theories have been significantly revised in the 150 years or so since their invention, they suffer from some severe limitations, including:

• • Poor differentiation between unmeasurable internal experience and measurable observation. Internal experience can only be described by metaphor and simile (e.g. “it’s like when you’re hungry …”) while observation can be described by measurement (e.g. when asked “Is it like when you’re hungry?” 90% of my patients responded “Yes”).
• • Reliance on hypothesised “internal structures” that have no external reality, such as “Unconscious mind”, “Ego”, “Id”, “SuperEgo”, etc. While these make excellent metaphors for our experience, they are not scientific concepts, but are treated by psychoanalysts as if they are.
• • Contempt for experimental results: when results from experimental psychology contradict psychoanalytical theory, the experimental results are often ignored.
• • Most of us enjoy beautiful metaphors (e.g. When she smiles the sun comes out from behind the clouds) whereas psychoanalysts tend to choose the ugliest metaphors: “Castration” to describe “Disempowerment”; “Anal Fixation” to describe “Tidy-mindedness”; “Oedipal Complex (he just wants to f*** his Mother)” to describe the enchanting physical affection between children and their parents.

Most psychoanalysts offer a (very expensive) service called a “Full Analysis”, which is a detailed description of a patient or client in terms of the ugliest metaphors that psychoanalysts can invent.

For some reason, psychotherapists – most of whom have at best a tolerant attitude towards psychoanalysts – often voice the aspiration to pay for a “Full Analysis”, and express admiration for those who have survived this tortuous, and in my opinion pointless, process. People who have undergone a full analysis have a particularly peculiar view of the world, themselves, and others.

Why would I see a psychoanalyst?
People visit a psychoanalyst when they're unhappy or troubled and want a "traditional" approach to self-understanding. Some psychoanalysts have quite an authoritarian approach to therapy; I have heard the experience described as "being beaten into submission with a rubber banana".

“Psychotherapist”: Somebody who offers “Talking Therapy” based on one of a number of theories of psychology that have emerged subsequent to, or in parallel with, psychoanalytical theory. Broadly these can be classified as “Evidence-based” and “non-Evidence-based”.
Nearly all psychotherapy trainings require a first degree and significant experience working in a responsible position with others. Qualifications include Postgraduate Diploma (PgDip), Advanced Postgraduate Diploma (AdvPgDip) and Masters (MA), though many trainings exceed these standards.
Nearly all psychotherapy trainings require the trainee to receive psychotherapy treatment themselves, basically to ensure that they’re not completely mad when they start treating others.
Psychotherapy is the only mental health discipline that has this requirement.

Why would I see a psychotherapist?
People visit a psychotherapist when they're miserable or very troubled, which could mean many things: low mood, anxiety, trauma flashbacks, insomnia, nightmares, recurring dreams, difficulty making or keeping friends, marriage or relationship problems, panic attacks, self-harm, eating disorders, suicidality, difficulty holding down a job, repeated failure, meaninglessness, rupture with family, overwhelming feelings of guilt, inability to grieve, difficulty controlling anger and rage, trouble coming to terms with childhood abuse, difficulty leaving an abusive relationship, phobias, you're questioning your sexuality or gender, and many other things.

“Evidence-based Psychotherapist”: Somebody who offers a short-term talking therapy based on an “Evidence-based theory”.
This is a theory that has some basis in the results of experimental psychology. Treatment is time-limited, e.g. “12 sessions over 3 months”.
It's important to understand that just because a psychotherapy (particularly a "long-term" or "depth" psychotherapy) isn't advertised or described as "Evidence-Based" it doesn't mean there is no evidence of its beneficial effects. Because of this contradiction evidence-based therapies are sometimes referred to as "Manualised" therapies because there is greater emphasis on what's written in the manual than on the patient.
During development of the therapy (which usually takes years) patients will have been given psychological assessments before and after treatment and the differences analysed statistically.
A treatment is only regarded as evidence-based if a large number of patients have presented to the experimenter with the same symptom (e.g. “Depression” or “Anxiety”), half (roughly) have been treated and the rest haven’t, and there is a statistically significant difference between the outcome of the treated patients and the outcome of the untreated patients.
“Statistical Significance” means there’s only a 1% chance (or less) that this difference in outcome can be accounted for by the random chance that the treated patients might all have recovered anyway.

The NHS Talking Therapies for anxiety and depression service basically delivers evidence-based psychotherapy. Other forms of psychotherapy may be available through a variety of NHS complex needs services.

The main criticism of evidence-based psychotherapy is that the evidence doesn’t include assessments of a patient’s long-term mental health. There are increasing concerns that the impacts of some evidence-based therapies are only short term and that the therapies don’t address the fundamental problem.
Another criticism is that evidence-based psychotherapies are not good with complex patients who may have several interacting mental health challenges, such as eating disorders combined with depression and hallucinations.

Examples of evidence-based treatments include CBT (Cognitive Behavioural Therapy), DBT (Dialectical Behaviour Therapy), CFT (Compassion Focused Therapy) and MBT (Mentalisation Based Therapy).

Why would I see an evidenced-based psychotherapist?
If you visit your NHS GP for any of the reasons given above under "Psychotherapy" you are most likely to end up seeing an evidence-based psychotherapist. It's the "cheap option" that most people find helpful to some extent, at least for a while.

"Long term psychotherapist" or "Depth psychotherapist" or “Non-Evidence-based Psychotherapist”, often just called "Psychotherapist": Somebody who offers a long-term talking therapy based on some plausible but unproven psychological theory such as Gestalt Psychotherapy, Psychosynthesis psychotherapy, Integrative psychotherapy, Neuro-linguistic programming, and more.
Some of these theories claim a scientific status – that they are based (at least partly) on observation, measurement, experimentation and validation – but they fall short of the experimental validation of evidence-based therapies.
Other theories, which often label themselves as “Humanistic” or “Existential” are entirely metaphorical in nature, concerning themselves only with the internal experience of the patient. “If the patient thinks they are living on the moon, then they are living on the moon, and we have to visit them there.” [CG Jung]
Most humanistic and existential therapists keep up to date with relevant experimental results and make an effort to avoid practices which have been shown experimentally to be harmful.
Despite not being classified as "Evidence-based" there is a large amount of good quality scientific research that indicates these therapies can be highly effective, but research is patchy. For instance, an enormous amount of research has been done on the effectiveness of psychotherapy treatment for sex offenders and other serious offenders, but there has been very little research done on the effectiveness for long-term unemployment.
Non-Evidence-based psychotherapy typically explores how past experiences affect current emotions and behaviour, and supports the client/patient in some process of reparation.
This may be framed as “self-integration”, “self-actualisation”, “self-repair”, “reprogramming”, etc. These are all metaphors for the same underlying process of ‘becoming well’ that clients often report.

Critics of non-evidence based psychotherapy point to the fact that it’s often a slow and expensive process, that we don’t really understand it, and that there’s no evidence that it actually does anything.
However, the testimony of many people who have been through the process is that psychotherapy has turned their lives around where other approaches have failed, and there is actually much evidence for this. The profession continues to thrive mainly on the recommendations of satisfied customers.

Why would I see a non-evidence-based/depth/long-term psychotherapist?
For any of the reasons given above under "Psychotherapy". Perhaps a trusted friend or colleague recommended a particular psychotherapist, or psychotherapy in general; perhaps you've seen an evidence-based psychotherapist and it didn't help, or only helped for a while; perhaps you've been referred to an NHS complex needs service and have ended up seeing a psychotherapist.

“Creative Psychotherapist”: Somebody who treats clients and patients using a variety of creative methods: Art therapy, drama therapy, music therapy, dance therapy, dance and movement therapy, etc.
Creative therapies are Practice led: They were introduced into the mental health system out of despair: “We can’t just leave these untreatable patients with nothing to do all day and no treatments, let’s at least try something”.
However, they have turned out to have exceptional efficacy, especially with some of the hardest-to-treat patients such as schizophrenics, high-dependency autistic children and adults, serious offenders and those suffering personality difficulties.
Since we have no real understanding of the phenomena of creative actions, or the impact of creative activities on the brain, there is very little underpinning theory to creative therapies.
Creative therapy training is long, arduous and thorough, but is basically a training in “What we know works”, “What we know doesn’t work” and “What we know works for some people but not others and we don’t know why.”
Creative therapy training includes a comprehensive training in other psychological theories, and in experimental results, as these can help to direct the course of therapy.

Creative therapies are often criticised by other psychotherapists as having no theoretical basis.
Creative therapists are critical of other psychotherapists because non-creative psychotherapists are comparatively ineffective despite the huge amount of psychotherapeutic theory.

Why would I see a creative psychotherapist?
For any of the reasons given above under "Psychotherapy", particularly if you enjoy the arts and creativity. You will also see a creative psychotherapist if you're receiving treatment in a therapeutic community, a secure mental hospital or a therapeutic prison.

“Psychodrama Psychotherapist”: A psychotherapist using the methods of psychodrama, which are almost but not quite completely different from the methods of “Drama Therapy”. Yes, that’s confusing. No, the confusing nomenclature is not going away any time soon.
In common with creative therapies psychodrama is highly effective, especially for difficult-to-treat clients; however, there is a significant body of plausible theory that supports psychodrama practice, and there are clear parallels between psychodrama treatment and other forms of psychotherapy.
Psychodrama methods are so effective that almost all non-creative psychotherapists use at least one psychodrama method, often not even realising where the methods come from.

Critics of psychodrama object to the claims of exceptional efficacy made by psychodrama therapists, and also claims that the methods can be used effectively for almost all mental health problems.
Psychodrama therapists point out that if the methods couldn’t be used with exceptional efficacy for almost all mental health problems, then so many other psychotherapists wouldn’t be using psychodrama methods in their clinical work without theoretical justification.

Why would I see a psychodrama psychotherapist?
You would see a psychodrama psychotherapist for any of the reasons given above under "Psychotherapy".
There are very few psychodrama psychotherapists in the UK so you would be very lucky to get to see one. You would specifically seek out psychodrama psychotherapy if: you tried psychoanalysis and realise it's the very opposite of what you wanted; you want the best and most effective; you enjoy drama (or at least you're not unbearably shy); you want the opportunity to rehearse future scenarios or different approaches to solving a problem.

“Counsellor”: A person who listens to somebody’s problems and helps them to find their own solutions.
Counsellors are often taught some psychotherapeutic or psychoanalytical theory.
Counsellors often have a very limited level of educational attainment. Many don’t have a first degree, have little experience working with people, and might only attain a (pre-graduate) diploma (Dip).

Critics of counsellors dismiss them as “paid friends”, whereas counsellors clearly provide a valuable service for people whose lives are disrupted by some shameful, criminal or financially sensitive episode that can’t be shared with friends or family.
Counsellors often aspire to be psychotherapists but are frustrated in their ambitions either by lack of educational attainment or lack of resources for training. Some counsellors offer psychotherapy services despite not being trained or qualified, claiming that psychotherapy training is not required in order to be an effective psychotherapist.
Psychotherapists, who can charge a lot more than counsellors, obviously don’t agree.

Why would I see a counsellor?
You would see a counsellor for many of the reasons given under "Psychotherapy" above, but you don't want to open up the past too deeply, or spend too much money, or challenge yourself too much.

“Hypnotherapist”: Somebody who uses hypnosis to temporarily change the experience of life. Can be thought of as “Super-persuasive meets mind-over-matter.” Hypnotherapy training is very specialised but requires no prior educational achievement or experience, and is awarded as pre-graduate diploma.

Why would I see a hypnotherapist?
Hypnotherapy methods are particularly helpful in overcoming temporary life-crises, coaching top-performing sports competitors, breaking addictions and other habits, controlling anxiety until the cause of the anxiety has gone away, and managing pain.

”Coach” or "Life Coach": Somebody to bounce ideas off for achieving your aspirations. Coaches are typically beautiful and charismatic but require no qualifications or experience and are usually paid more than any of the above professions.

If I sound envious or cynical, this has no basis in reality.

Why would I see a coach?
People see coaches when they're feeling ambitious but aren't making the career progress they expect. They usually hope to repay the coaching fees out of the extra money they make after career promotion.

The thorny issue of “Protected Titles”: Who can call themselves what?
In the UK, anybody can call themselves a Psychotherapist, Counsellor, Coach, Hypnotherapist, Psychodrama Psychotherapist, Dance Therapist, Dance Psychotherapist, Dance and Movement Psychotherapist, Dance and Movement Therapist, Psychologist, Experimental Psychologist or Psychoanalyst.
In the UK it is a criminal offence to call yourself one of the following without the appropriate qualification and a current registration with the appropriate professional body:
Art Therapist, Art Psychotherapist, Music Therapist, Music Psychotherapist, Drama Therapist, Drama Psychotherapist, Psychiatrist, Clinical Psychologist, Counselling Psychologist, Forensic Psychologist.

Professional Registration Bodies for Psychotherapists: Because "Psychotherapist" is not a protected title, professionals who have paid tens of thousands of pounds for their training, and have completed hundreds of hours of training and work experience, want to draw a clear distinction between themselves and people with little or no training.

A number of professional registration bodies exist which psychotherapists can use to help accredit their abilities. Membership criteria vary widely, from bodies which will register anybody who wants to create an appearance of competence, to bodies which will only register the most experienced and qualified psychotherapists.

The two most respected registration bodies are the British Association of Counsellors and Psychotherapists (BACP) and the United Kingdom Council for Psychotherapy (UKCP). The membership and accreditation requirements for the UKCP are the most exacting, much more stringent than the BACP's. UKCP accredited psychotherapists are generally considered competent and qualified to work within the NHS and HM Prisons Service, whereas BACP accredited psychotherapists are not.