I have written a book about anxiety, investigating why so many people across the world live with disorders that, although often invisible to others, mean living with all kinds of distressing thought patterns, behaviours, and physical symptoms.
Anxiety disorders are thought to be the most common kind of mental health problem and, overall, one of the biggest burdens of illness in the world. Anxiety is something every single human being experiences because our flight-or-flight response serves a tremendous evolutionary function to keep us safe. In the path of perceived danger, our brain quickly syncs up with the rest of our body in order to get us ready for battle, or to leg it. Only, for some people, through a confluence of factors both genetic and environmental, the fight-or-flight system can start to over-serve. We begin to fear our thoughts and memories as if they were real dangers in a way that can impair our ability to function. Anxiety becomes disordered.
Since the age of 17, when I had my first panic attack – a mysterious and terrifying experience of which death seemed the only logical outcome at the time – I have lived with a tendency to panic big and ruminate small. On a couple of occasions, my anxiety has become so acute I’ve had to seek urgent professional help. The last episode happened three years ago. Over the years I had developed a mistrust in therapy, believing that, because it hadn’t “worked” for me in the past – the very notion of which is subjective, but for me can largely be boiled down to being frustrated that I didn’t just stop having panic attacks – but at the crest of this new, sour terror, one that made me question my entire existence, I knew I needed to find someone to help me unpick the thought patterns and avoidance behaviours I’d lived with almost entirely in secret for so long. I was packing a lot of shame about the way I was, which, I’ve come to believe, was at the root of me not seeking help before reaching crisis point.
I was ashamed that I needed help.
Three years on, after reaching an open and trusting dialogue with my therapist, I am doing better than I ever have. I have always been high functioning, the storm of fearful thinking and physical discomfort I carried around hidden by professional success and natural gregariousness, but things feel more…real. Real in the sense that I am mostly (I still have bad episodes and shitty days, all the time) able to do and experience things with anxiety, rather than in constant battle with it, only feeling half present. I am learning to accept anxiety as something for which there is no cure or neat panacea to rid it from my being, and something I have to accept as part of who I am.
Through having cognitive behavioural therapy (CBT) and isolating my thought patterns, I have learned – am still learning, may always be learning – to develop strategies for seeing them as just that: thoughts. I may not be able to stop them coming in, because 15 years of deep conditioning is a huge obstacle, but I have, with my therapist’s kind yet challenging approach, learned to develop strategies for dealing with them. In doing so, I can “catch” my anxiety levels before they go into overdrive and make me feel profound physical discomfort – a state it can be difficult to get out of once you’re in it.
There are different types of talking therapies. The mental health charity Mind and NHS Choices provide clear information. Psychological therapies generally fall into the following categories: behavioural therapies, which focus on cognitions and behaviours; psychoanalytical and psychodynamic therapies, which focus on the unconscious relationship patterns that evolved from childhood; humanistic therapies, which focus on self-development in the present; arts therapies, which use creative arts within the therapeutic process; and couples counselling. However, some counsellors or psychotherapists practise a form of "integrative" therapy, drawing on and blending different techniques according to the person.
Different talking therapies suit different people. For otherwise healthy people who need help coping with a current crisis like relationship problems, bereavement, redundancy, anger, or the onset of a serious illness, counselling may be appropriate. You can spend an hour with someone who will help you think about your problems and how to tackle them. In CBT, which has been shown to work for a variety of mental health problems like depression, anxiety disorders (panic attacks, obsessive compulsive disorder, PTSD, phobias), and eating disorders, the goal is to help analyse and free yourself from unhelpful patterns of thinking and behaviour. It deals much more with your current situation than events in your past or childhood. If you seek help for any of these problems from your NHS GP, it is likely that CBT will be what’s offered to you. There are no strict guidelines – there cannot be, every person’s brain and manifestation of anxiety is different – but you may set goals with your therapist and carry out tasks between sessions, of which there are typically between five and twenty. Many CBT therapists now apply mindfulness-based techniques into their approach to help you focus on your thoughts and feelings without becoming overwhelmed by them.
Unlike CBT and counselling, psychodynamic (psychoanalytic) therapy will involve talking more about how your past has influenced what is happening in your present and the choices you make. A psychoanalytic therapist will encourage you to vocalise whatever if going through your mind, helping you become aware of patterns or hidden meanings in what you do or say that may be contributing to your issues. If you enter psychoanalytic therapy, it is likely to go on for a lot longer than a course of CBT and is, by its very nature, more open-ended. This type of therapy is available on the NHS, but if you present to your GP with a mental health issue, you are more likely to be referred for CBT. Not because it is inherently “better”, but because it has been the type of therapy studied the most and therefore with the most evidence of success.
I want to talk about the costs of seeing a therapist privately, because there is much variation. If you were thinking of going down to Harley Street, you may be looking at paying hundreds of pounds for an hour’s therapy and not a whole lot less for the privilege of follow-up phone calls or Skype sessions. I have lots of thoughts about the private sector and the unfortunate us-and-them feeling it generates around many aspects of health, namely the idea that having money will get you better care. But private healthcare also isn’t going anywhere fast and it’s pointless having a blanket disdain for anyone who has money and can genuinely afford to pay Harley Street prices. However, the credentials of the psychiatrists and therapists practising there are unlikely to be "better" than someone you’d pay considerably less to see. In fact, most private psychiatrists and therapists also do NHS work, which says a lot.
Beyond the affluent echelons of London, private psychotherapists usually charge between £40 and £100 for each hour-long session. If you are considering having CBT privately, for example, you can ask your GP to suggest a local therapist. You can also visit the British Association for Behavioural & Cognitive Psychotherapies, which keeps a register of all accredited therapists in the UK. Also, the British Psychological Society has a directory of chartered psychologists, some of whom specialise in CBT.
Not everyone knows this – I didn’t – but many private therapists will offer fees on a sliding scale, depending on income. One afternoon, I picked 25 random private therapists of varying disciplines across most major UK cities and towns. Over the course of a few days I called them all and asked if they’d offer a concessionary rate if someone’s circumstances were difficult. All but one said yes. Twenty-four people is small fry when we’re talking about an entire country’s needs, I know, but it’s some insight.
CBT vs psychoanalysis
Taxpayer-funded CBT has a clear beginning and end point, will be highly structured over its course – a minimum of five sessions, but anywhere up to 20 – and inevitably includes lots of "homework" for the patient to do. It’s not just plopping down in a chair and unloading – it takes work. It is work. And many people feel a lot better afterwards. However, recent studies have shown that CBT may become less effective at treating long-term depression over time.
The results of the first big NHS study of long-term psychoanalysis were published by London’s Tavistock Centre in October 2015 and showed that 18 months of psychoanalysis had more of a long-lasting effect than the treatment you usually get on the NHS: largely CBT. After two years of analysis, 44% of patients didn’t fit the profile of major depression. For the others, the figure was one-tenth.
There is certainly weight to the opinion that psychoanalysis may alter our personalities in a more lasting way, but can we really say that CBT is just a plaster, superficially holding together much deeper cracks in our psychic archeology? Particularly given that any CBT therapist isn't going to hold up a director’s clapperboard and shout "CUT" every time someone mentions their past – it’s very much taken into account.
These so-called therapy wars aren’t just about what’s best for people. Much of the debate is coloured by people trying to protect their vested interests. Psychoanalysis, or psychodynamic therapies, and CBT are fundamentally different approaches.
If I could summarise everything I’ve written about therapy so far here, it would be to tell people that they have options and to go to their GP as the first point of call. Asking a professional for help is an incredibly important part of the picture, but you’re not obliged to wait for a GP referral. With the Improving Access to Psychological Therapies (IAPT) programme, you may be able to refer yourself.
Many clinical commissioning groups (CCG) offer the option of self-referral. GPs may rather you didn’t cut them out altogether, but you can. You should also be aware that if you’re ever unsatisfied with the way you’ve been treated, with what has been made available to you or how long you’ve had to wait for a therapy referral on the NHS, you can complain. Local patient advice and liaison services (PALS) can be very helpful and are easily located online.
If you’re thinking about paying for private therapy and are worried about cost, then call or email the therapist you like the look of and ask about it. They are only people and have put themselves through years of tough training to be able to offer compassion and help to people just like you. Some will be nicer and more economically conscious than others, but your happiness is worth that inquiry. Above all, if there are things you’re struggling with, or feel dissatisfied with, during the course of your therapy, say something. Always say something. You got there by being honest, after all.
Being "better" looks different for different people. Personally, I want to carry on developing my skills for working on relief in the present, and I’m lucky to have found a therapist who I feel helps me do that. I am more open than I’ve ever been to accepting that there are sedimented layers of thoughts and beliefs that haven’t been washed away in the tide of the present and which affect who and how I am today, but I’m not going to seek out a psychoanalyst’s couch any time soon. Why? Because – and I’m going to be bold here – I think gaining relief, clarity, and coping mechanisms from talking therapy probably depends on the therapist more than the type of therapy they’re giving. It depends on the human relationship, on a rapport, compassion, patience, and kindness. All these things significantly affect a person’s commitment to change. As Oliver Burkeman says in his Guardian piece on CBT and psychoanalysis, “If one therapy is better than all others for all or even most problems, it has yet to be discovered."
Anxiety for Beginners is published by Bluebird Books and is available now.
Always consult with your doctor about your personal health and wellness, including any recommendations you find online. BuzzFeed posts are for general informational purposes only, and cannot replace professional and individualised medical diagnosis, treatment, or advice.
Clinical Commissioning Groups offer the option of self-referral. A previous version of this article used the term Primary Care Trusts.