'I'd been cutting myself since the age of 15," says Angela Harper, 21. "My friends told the school and the teacher made me an appointment with my GP." Harper's GP referred her for counselling, but there was a six-month waiting list. During those months, Harper was left to fend for herself. "I was only 17. I didn't want tell my parents. There were no check-ups or follow-ups from the GP. It was down to me to keep calling the counselling service to check on the waiting list. My self-harming got worse and worse - I was cutting myself every day."
At any one time, about one in six adults in the UK has a mental health problem such as depression or anxiety. Many talking therapies, such as cognitive behavioural therapy (CBT), are known to get excellent results, particularly for those with mild to moderate depression and anxiety. But finding a therapist on the NHS can be a massive challenge.
In theory, your GP should be able to refer you. In reality, waiting lists can be vast, therapists few and far between, and specialist help almost impossible to find. In some parts of the country it is not unusual to wait two years.
The National Institute for Health and Clinical Excellence, which sets guidelines for doctors, recommends that a range of psychological therapies be made available on the NHS. While the government is trying to make this easier, "Progress is slow, to say the least," says Moira Fraser, head of policy for the Mental Health Foundation. According to the mental health charity Mind, 93% of GPs admitted in a survey last year that they were prescribing antidepressants purely because they lacked viable talking alternatives.
More than 31m prescriptions for antidepressants were written last year - an all-time high. Economically, none of this makes sense. The NHS spends £338m a year on antidepressant medication alone and GPs have been accused of dashing off Prozac scripts willy-nilly to save time and money. "We reject the suggestion that GPs prescribe antidepressants too readily," says Professor Mayur Lakhani, chair of the Royal College of General Practitioners. "We are determined to reduce the prescribing of antidepressants, [but] some hard choices have to be made."
Many people go private but, at up to £50 a session, it is not an option for all. And finding a good independent therapist can be hit-and-miss. "It is sensible to go via an organisation such as the British Association for Counselling and Psychotherapy or the UK Council for Psychotherapy," says Phillip Hodson, fellow of the British Association of Counsellors and Psychotherapists. "They have a register of qualified, accredited counsellors or psychotherapists." This gives safeguards, but it is not foolproof.
If a therapist asks you to pay for several sessions in advance, or suggests a long, open-ended relationship, beware. "It is unusual to be asked to pay up front," says Hodson, "and there should never be an obligation to continue at any point." Vagueness over terms should also set alarm bells ringing. Your initial meeting should cover their qualifications, therapeutic approach, fees, when and where you will meet, and their review procedure - these should not change. Furthermore, says Hodson, anything that makes you feel "as if you have a new friend" is a cause for concern. Touch is inappropriate, as is letting a session continue after the time is up. Basically, if anything your therapist does makes you uncomfortable, check them out (you can call the BACP information line and talk it over).
Studies show that the public want less pharmacology and more talk. A huge public consultation conducted by the Department of Health in 2005 showed that the second most popular thing people wanted from the NHS (after free care for the elderly) was access to more counselling. Certainly, there is evidence that talking therapies such as CBT can work wonders, but some say it is being overhyped. "CBT is the current big trend," says Hodson, "but this is partly because it is easier to evaluate than other forms of therapy. This does not mean that CBT is necessarily 'better'."
"CBT helps a lot of people," says Fraser, "but it is not the only solution. We need a range of evidence-based therapies so that people can get the kind of therapy they really need." People with eating disorders, for instance, or those who self-harm, need to see specialist therapists trained to tackle these issues.
Part of the problem, says Hodson, is that the majority of GPs have no understanding of the different types of therapy available. Even those who understand the subtleties of psychodynamic therapy are not going to be in a position to choose between Kleinian, Jungian and Rogerian practitioners. Only about 60% of GPs' surgeries even have their own counsellor attached - the rest use pooled counselling resources or subcontract local counsellors.
This lack of choice can be problematic. By the time Harper's appointment with a counsellor came up, her self-harming had become acute. "The counsellor was a general counsellor," Harper says. "She didn't know anything about self-harming. I felt I was teaching her about it from what I'd learned off the internet, rather than the other way round." Eventually, Harper "just stopped", by herself. Others in her situation may not be so fortunate
· BACP information line: 0870 443 5252. www.bacp.co.uk
Breaking it down: the main types of therapy
1. Person-centred counselling (sometimes called "Rogerian")
A qualified counsellor helps you identify problems in your life and work out ways to resolve them, without "directing" you. The aim is "self-actualisation" - achieving what you want in your life.
Duration: usually 10 weekly sessions.
NHS availability: usually via GP referral, but there are often long waiting lists.
Private cost: £30-£50 a session.
2. Cognitive behavioural therapy (CBT)
CBT does not delve into the past, but aims to deal with "here and now" issues by helping you challenge negative thought patterns. According to the Royal College of Psychiatrists, this is the most effective psychological treatment for moderate and severe depression and works as well as antidepressants.
Duration: Richard Layard's 2006 report claimed that, after fewer than 16 meetings (costing the state just £750), at least half of people with depression or clinical anxiety can be cured.
NHS availability: GP referral, but waiting times can be at least 18 months in some areas.
Private cost: around £30-£50 a session.
3. Psychodynamic counselling and psychotherapy
Umbrella term for a huge range of disciplines, including Jungian, Freudian, Kleinian and Adlerian, which aim to unpick psychological issues from childhood.
Duration: weekly sessions for a year or much longer.
NHS availability: Extremely hard to access (usually via community mental health services, in which case, little choice of discipline).
Private cost: £40-£60 a session.
4. Specialist therapies
Evidence-based specialist therapies - such as those to tackle eating disorders (often a mixture of person-centred and CBT), or art therapy (helpful for people recovering from strokes, people with dementia, or for children), or dialectical behavioural therapy, which uses techniques similar to CBT to help people who self-harm or have borderline personality disorder - can be effective.
NHS availability: often hard to access. Some therapies may be unavailable in some parts of the country.
Duration and cost vary widely.
