Talking therapies (including counselling, psychotherapy and CBT)
Talking therapies (or psychological therapies) give people the chance to speak in confidence to a trained professional about problems or issues that are causing them concern. Some people use talking therapies to help them cope with specific difficulties, such as serious illness, bereavement, stress, anxiety or depression, whereas other people may use them for personal growth and development. There are a number of different talking therapies. This factsheet outlines some of these therapies and explains how people with dementia and their carers might find them helpful.
Talking therapies are not the only type of non-drug treatment available for a person with dementia or their carer, however. If a person has depression or anxiety but the symptoms are mild, they may be offered self-help, referred to a support group or encouraged to exercise and engage in social activities.
If the person's symptoms are severe, drug treatment (eg an antidepressant) is usually offered, sometimes before or in combination with a talking therapy. Some people with dementia who have depression or low mood will also benefit from activities such as life story work or reminiscence. For more about these approaches, which are not talking therapies, see factsheet 444, Depression and anxiety.
Types of talking therapies
Talking therapies encourage people to talk about their thoughts and feelings, and how these affect their mood and behaviours. They are delivered by a professional, such as a counsellor, clinical or counselling psychologist, psychotherapist, psychiatrist or nurse. Each will have been trained in the respective approach and have a recognised qualification that is monitored by their professional body or the Health and Care Professions Council (HCPC - see 'Other useful organisations').
Talking therapies are all based on a certain understanding of how the mind works. The approach to therapy is tailored to each individual, and is based on the person and the therapist working out what might be causing their particular difficulties.
Counselling is a general term for a range of talking therapies. A counsellor listens to a person's concerns in a non-judgemental and supportive manner. The aim of counselling is to help the person seeking support (often called the 'client') to be clearer about their problems. In this way, people are able to come up with their own answers to their problems, rather than being offered answers by someone else.
Counselling is often used to help someone cope with recent events that they have found difficult. For someone with dementia, being diagnosed with such a life-changing and life-limiting condition is clearly a major event.
There are different types of counselling available, including individual, group or self-help group sessions. Family counselling involves focusing on the whole family who have been affected by an issue rather than an individual.
Psychotherapy is a term for another range of talking therapies. There are many different types of psychotherapeutic approach. These include:
- Cognitive behavioural therapy (CBT) - see below.
- Psychodynamic therapy - focuses on how a person's current behaviour and relationships are affected by their unconscious thoughts and past experiences (particularly childhood experiences).
- Interpersonal therapy (IPT) - used when difficulties in the person's relationships with others are causing their distress. Interpersonal therapy attempts to improve someone's mood by improving these relationships.
- Family therapy or systemic therapy - involves a family working with one or more therapists to help resolve their problems. Family therapy is particularly focused on the relationships between family members.
- Humanistic therapies - encourage people to think about their feelings and take responsibility for their thoughts and actions by reflecting on their life's meaning and values. The emphasis of humanistic therapies is on personal growth.
A psychotherapist will help a person to understand how their personality, beliefs and life experiences influence their current thoughts, feelings, relationships and behaviour. This may lead to changes in the way people think and behave that will in turn help them to deal with their problems and difficult situations more successfully.
Cognitive behavioural therapy (CBT)
Cognitive behavioural therapy is a specific form of psychotherapy. It relies on the fact that the way we think about something ('cognition') affects how we feel about and behave towards it. A person having CBT will be supported to explore the links between thoughts, feelings and behaviour. With their therapist, the person will try to develop more positive ways to think, feel and act.
Unlike some of the other talking therapies, CBT focuses mainly on the 'here and now'. Instead of focusing on the causes of distress in the past, it looks for ways to improve the person's current situation. This begins with the therapist and client together working out what is triggering the person's distress. Armed with this shared understanding, the client can focus on specific goals by developing more effective ways of thinking, or of coping with difficult problems. An example of a goal for a person with dementia might be 'Feel able to go back to the singing group that I used to enjoy'. CBT may also involve learning relaxation techniques or breathing exercises or trying out different activities.
What do talking therapies involve?
Talking therapies can involve a number of regular face-to-face sessions. Each usually lasts for an hour, but can be shorter. There is an initial assessment during which the therapist will obtain an idea of the problem and some background information about the person. The therapist will then agree a therapy plan with the person. It is also possible to receive certain talking therapies, such as counselling and CBT, over the telephone or online. If someone is having CBT, they will agree to do 'homework' between sessions to help reinforce what is learnt in the session and to try out new ideas. This may include keeping a diary or filling out 'thought records'. It may also include practising breathing exercises and relaxation techniques.
There is no standard length of time for a course of therapy. The number of sessions required will depend on the type of problem, the type of therapy, how it is delivered (eg face-to-face or by phone) and who is providing the therapy (eg NHS therapist, private therapist or charity). Some people get everything they need from one session or from just a few. Others may require counselling or psychotherapy over a much longer period of time, for months or, more rarely, years. CBT usually involves a programme of 5-20 sessions.
Successful therapy depends very much on the development of a trusting relationship between the therapist and the client. It is therefore important that people work with a therapist whose approach and manner they are comfortable with. The relationship between a client and a therapist is confidential. This means that what is discussed during therapy will not generally be disclosed to anyone else. However, there are some exceptions to this which should be discussed during the first meeting. For example, someone with dementia may - with their consent - be supported by a family member in the sessions.
How can talking therapies help someone with dementia?
People living with dementia may also experience anxiety and depression. This may have developed before the dementia or may be caused by adjusting to the diagnosis and its effect on their lives. Talking therapies offer someone living with dementia the opportunity to speak openly about their feelings, and can help them to adjust to and live with their condition more successfully. There is evidence that talking therapies can directly reduce symptoms of anxiety and depression in people with dementia.
Psychological approaches are particularly appropriate for people with dementia because they focus on the individual and their viewpoint. Talking therapies are by nature structured, collaborative and focused on achieving goals and solving problems. Many people also prefer treatments that are not based on medication. This is important because the evidence suggests that antidepressant drugs do not work very well for people with dementia.
Counselling has been shown to be a way for people living with dementia to gain support and make sense of living with the condition. Many people living with dementia struggle to make sense of their diagnosis and how their life is changing. They may feel lost, confused, vulnerable or anxious. Anxiety over what the future might hold is particularly common.
Research suggests that counselling can play a particularly important role in helping people with an early diagnosis of dementia - for example, by reducing feelings of depression. Even before diagnosis, just going through assessment for suspected dementia can be confusing and stressful, and may cause feelings of anxiety. It is best practice for someone to be offered pre-diagnostic counselling to support them through this difficult and uncertain time.
There is growing evidence that psychotherapy can also help someone living with dementia. Recent trials, for example, show that CBT and interpersonal therapy can reduce symptoms of depression and anxiety in people with dementia. This is important because in the past it was unclear whether talking therapies worked in older people or those with dementia.
Anxiety and depression are distressing in their own right but they can also affect a person's memory and thinking. Maintaining mental wellbeing can therefore ensure these abilities are not made worse for a person living with dementia.
Talking therapies such as CBT for depression or anxiety are best suited to someone who is in the mild (early) or moderate (middle) stage of dementia. At this stage people have fewer difficulties holding things in their memory, communicating and reasoning. They are also usually more aware of their condition and of their own thoughts and emotions. This means they can still engage with the therapy.
The therapy may need to be adapted to help a person with dementia to benefit. This may mean shorter sessions, use of memory aids (eg cue cards) and more reinforcement and summarising. If the person living with dementia agrees, a family member or close friend may attend sessions. This supporter can also help the person outside of sessions to put agreed CBT strategies into place.
How can talking therapies help carers?
Caring for a family member or close friend with dementia is often stressful. While some carers report positive feelings of fulfilment from helping the person, many experience feelings of loss, sadness, grief, guilt or anger. Carers of people with dementia also experience high levels of anxiety and depression. Talking therapies for carers can help in all of these areas.
Talking therapies may help family and carers to explore their feelings in confidence, as well as providing extra support outside their network of friends and family. This can be especially important at times when decisions are being made about how to look after a person with dementia.
Counselling can help carers to be more aware of how their own behaviours towards the person with dementia will affect how that person feels and acts, both positively and negatively. If the carer is stressed and becomes short-tempered with the person, they are more likely to develop feelings of anxiety, depression or problematic behaviours as a result.
For carers who are depressed, telephone counselling has been shown to be an effective option. Counselling over the phone may fit in with a person's caring responsibilities more conveniently than face-to-face sessions.
Dementia affects relationships between partners greatly and some people benefit from relationship counselling or couple therapy for depression. This can be with either partner separately or both together, but the focus is on improving difficulties within the relationship. (The organisation Relate offers relationship counselling - see 'Other useful organisations' below for details.)
There is good evidence that psychotherapies reduce distress in carers of people with dementia. This evidence is strongest for face-to-face or telephone CBT targeted at carers with depression and tailored to the individual and their circumstances. Carers who learn more about dementia, depression, anxiety and changes in behaviours - for example, through a structured group programme - also generally experience less distress and are better equipped to cope with their situation.
Former carers or care workers may benefit from talking therapies as well. They may feel lost or sad when the person they have cared for moves away from them or dies. After the caring relationship ends, it may be difficult to move on, to recover from the loss and to accept a new and different role. Talking therapies may help a former carer to accept the past and look ahead to the future. Some talking therapies, such as bereavement counselling or bereavement CBT, are specifically aimed at helping people come to terms with the loss of someone close to them.
What should I look for in a therapist?
It is important that you feel comfortable with your therapist. This will depend on your own personality and that of the therapist. You might want to use a therapist who has experience or an understanding of the effects of dementia. You may need to speak to several different therapists before you find the right person. It is also important to check that the therapist:
- is accredited by the relevant professional body (see 'Other useful organisations')
- abides by a professional code of ethics
- has regular ongoing professional supervision to ensure safe and ethical practice
- discusses their approach, confidentiality, fees (if applicable), length of sessions and responsibilities (yours and theirs) with you before committing to sessions.
What is the best way to find a therapist?
Your GP is a good place to start if you are looking for a therapist. Talking therapies accessed through the NHS are usually free of charge.
Many of the talking therapies for depression and anxiety mentioned in this factsheet are now available through an NHS programme called Improving Access to Psychological Therapies (IAPT - see 'Other useful organisations'). Your doctor can refer you to a local IAPT service where you will be assessed and offered support. This could include signposting to relevant activities, self-help materials or psychological therapies. Some IAPT services also now offer people the option to refer themselves without having to go through their GP.
GPs can often provide details of other local therapists and some GP surgeries have talking therapy services based in their practices. While talking therapies are becoming increasingly available, you may still find that there is a wait before you are seen.
Your GP or local social services department may also have information about local charities offering services - the number of your local social services department will be in the phone book.
Another option is to find a private therapist. There are many ways to find a private therapist but a recommendation from someone you trust - or possibly also your GP - can be very helpful. Most private services operate a sliding scale for fees. The British Association for Counselling and Psychotherapy (BACP) can provide more information about local counselling and psychotherapy services. For an accredited CBT therapist, contact the British Association for Behavioural and Cognitive Psychotherapies (BABCP). For a clinical psychologist or counselling psychologist, contact the British Psychological Society (BPS). See 'Other useful organisations'.
Other useful organisations
British Association for Counselling and Psychotherapy (BACP)
15 St John's Business Park
Leicestershire LE17 4HB
National body representing counsellors and psychotherapists. Can provide a list of counsellors and psychotherapists in your area.
British Association for Behavioural and Cognitive Psychotherapies (BABCP)
Lancashire BL9 5BN
Can provide a list of CBT therapists in your area.
British Psychological Society (BPS)
St Andrews House
48 Princess Road East
Leicester LE1 7DR
Provides access to a list of clinical and counselling psychologists that offer private therapy services.
Health and Care Professions Council
184 Kennington Park Road
London SE11 4BU
T 0845 300 6184
A regulator that keeps a register of health and care professionals who meet set standards for their training, professional skills, behaviour and health. You can search the register to check whether a named psychologist is included as well as make complaints about registered professionals.
Improving Access to Psychological Therapies
IAPT is an NHS programme of services in England for therapies that are approved by the National Institute of Health and Care Excellence for depression and anxiety. You can search for IAPT services in your area at NHS Choices (visit www.nhs.uk/service-search and search on IAPT).
Doncaster DN4 5RA
Offers relationship counselling for individuals, couples and families in England and Wales. Provides advice and support face-to-face, by phone and through its website. (For Relate in Northern Ireland visit www.relateni.org or call 028 9032 3454.)
UK Council for Psychotherapy
2nd Floor, Edward House
2 Wakley Street
London EC1V 7LT
A UK professional body for the education, training and accreditation of psychotherapists and counsellors. Includes a searchable register of psychotherapists and psychotherapeutic counsellors.
Last reviewed: April 2015
Next review due: April 2018
Reviewed by: Marie Claire Shankland, Chartered Clinical Psychologist, NHS Education Scotland, Glasgow and Cath Burley, Clinical Psychologist and former Chair, Faculty of the Psychology of Older People, British Psychological Society