What Makes Therapy Work?

Research clearly shows that the most important element of therapy—aside from the client’s willingness and ability to engage fully in the process—is the relationship between the client and therapist. A key aspect of this relationship or working alliance is that you feel that the therapist “gets” you. Therapy should feel like a safe, caring and non-judgmental space.

Research suggests that you should know whether there is a “good fit” between you and your therapist by the second or third session. However, this is only an average; depending on your personality, interpersonal style and past experiences, it may take longer to determine if you are with the right therapist. Don’t make any decisions in haste but don’t feel that you should stay with someone “just because.”

Finding the “Right Fit”

Not all therapists are created equal. Even the most “technically sound” therapist (i.e., they know how to employ certain techniques) might lack in many other important traits such as “people skills.” Or, they have their own problems they haven’t really resolved and they seep into therapy. Or maybe the two of you just don’t “click.”

In speaking with a (potential) therapist, ask about their orientation. Do they get defensive when you ask such questions? Can they explain things to you in clear, “plain English” without falling back on jargon? If they say they are “eclectic,” what exactly do they mean; what are the specific orientations/techniques they incorporate into therapy and how do they do that?

If you have any doubts about anything regarding the therapist or therapy, ask. Don’t assume things will be laid out clearly for you. The therapist should never respond poorly or make you feel bad about asking something, e.g., how long they think therapy might last or whether they think you’ve been making adequate progress—as long as you ask respectfully.

Different Types of Therapists

Before you begin with a therapist, check out their credentials. If the therapist does not belong to a College, you may have no recourse if they do anything wrong. Many people do not know the difference between a psychiatrist, psychologist, psychological associate, psychotherapist, “life coach,” counselor, etc. In Ontario, literally anyone can call him/herself a “psychotherapist” (but this should change soon). Do your due diligence and see if you can determine beforehand if they are the right person for you.

Psychologists have a Ph.D. and must be registered with the College of Psychologists of Ontario. We have extensive training in dealing with psychological and social matters. We cannot prescribe medication and cannot bill OHIP but private insurance often covers therapy with a psychologist to some extent. Many psychologists charge the fees recommended by the Ontario Psychological Association: $225/session (usually about 45-50 minutes, with the remainder of the hour dedicated to administrative work).

Psychological associates have completed a Masters degree in psychology and, depending on their training, are often very similar to psychologists in the work they do. This page tells you everything you need to know about the similarities and differences between psychologists and psychological associates.

Psychiatrists have an M.D. and must be registered with the College of Physicians and Surgeons of Ontario. Although some psychiatrists conduct actual psychotherapy, most take a “medical” approach to mental health and may thus only prescribe medication; with such psychiatrists, treatment often consists of 5- to 15-minute appointments every month or less frequently, during which the psychiatrist briefly checks on how the client is doing on the current dose/type of medication(s) and determines whether any adjustments need to be made. Psychiatrists can bill OHIP (some charge above the rate of OHIP) and, because of this, their wait lists are often very long or non-existent.

Psychotherapists, (life) coaches, counselors and others are unregulated unless they belong to a College that oversees their profession. For instance, social workers must register with the Ontario College of Social Workers and Social Service Workers, and nurses must register with the College of Nurses of Ontario. Many of these professionals choose to see clients privately as psychotherapists and may charge as much as psychologists. Although other types of counselors or psychotherapists might not be registered with a College, some of them have undergone extensive training or have years of experience helping people. As a consumer, you should do your due diligence in making sure the person with whom you work is the right fit for you.

Cost of Therapy

Although psychotherapy is not usually covered by OHIP (unless the therapist is a psychiatrist or other MD such as a family doctor/GP), many insurance companies do provide at least some coverage for registered psychologists. Please check with your employer, university, private insurer or other institution to see how much coverage you may be eligible to receive.

I follow the fee structure recommended by the Ontario Psychological Association (OPA). Sessions are about 50 minutes for therapy and 10 minutes for administrative work; if I have time, I try to stretch the therapy closer to an hour. For longer-term clients, I do offer a sliding scale based on the individual’s financial need. I also offer a free 25-minute initial consultation for those who would like to meet first to determine whether we would be a good fit before making the commitment to commence therapy.

When considering the cost of therapy, it should be noted that many psychotherapists with no real credentials charge between $100 and $150 per session. Although it would obviously be preferable to have your therapy covered by OHIP, it is very hard to find a psychiatrist or GP psychotherapist who is currently accepting clients or who even has a wait list. If you do find a psychiatrist taking on new clients, please check whether they offer psychotherapy or whether they only provide medication consults.

Duration of Therapy

Since cost is an important factor for most people, duration of therapy is important to consider. For some issues such as certain phobias, treatment can be effective in relatively short periods of time (e.g., 4-12 sessions). For many other issues, you may be able to make certain changes in your behaviour and perhaps modify your manner of thinking somewhat in 8-20 sessions. But real, “deeper,” more “meaningful” and long-lasting change can take far longer because you’re dealing with issues that you may have been harbouring for a lifetime.

The therapist can probably not give an exact answer to how long therapy will last and the answer may change as the sessions progress. But it’s important to get a sense of these things. Clients often come in wanting to work on one or two particular things and then begin to realize that there were other issues they had previously been unwilling or unable to acknowledge.

In a good client-therapist relationship, you will both “have your hands on the wheel” while working together to deal with issues that are most important to you, either in your current life or something in the past. Most therapists “have their foot on the gas” with you as well, with the understanding that you are always able to “hit the brakes” when necessary. If the therapeutic alliance is secure and you are prepared to take the journey, you will likely find yourself easing your foot back onto the gas pedal at some point after slowing down or braking each time. But the decision to drive forward and the speed at which you do so must ultimately be determined by you.