Therapy · lilharper.dev

"Every single person is the expert on their own lived experience and their own mental illness. A practitioner brings training and an outside view, which are genuinely valuable, but they are working from a summary. You're the one living in the full text. Finding someone who treats that as a starting point rather than an inconvenience matters more than almost anything else about them."

Why therapy is worth it, without the sermon

The most common reason people give for not going is that things aren't bad enough yet. Bad enough for what, though? That framing quietly assumes therapy is an emergency service, and it mostly isn't. A lot of what happens in a therapy room is skill building: noticing what you're feeling before it has already made a decision for you, saying a difficult thing without either exploding or disappearing, learning what your own patterns look like from the outside. Those are teachable, and waiting for a crisis to learn them is like waiting for a fire to buy a smoke alarm.

It's also maintenance. Plenty of people see someone regularly while their life is fine, in the same unremarkable way they get their teeth checked. That version of therapy is boring. That's exactly the point. The sessions where nothing dramatic happens are often the ones doing the most work, because they're where you build the thing you'll need later.

And the stigma is almost entirely inherited. Most people who feel weird about therapy absorbed that feeling from a parent or a culture that treated needing help as a character defect, not from anything they worked out themselves. It's worth checking whether the voice telling you not to bother is actually yours. Mine wasn't.

I've written elsewhere about the parts of my own head I'm still working through with professionals: the in-progress version is here. This page deliberately isn't about me. It's about the system, because the system is the part I can be useful about.

Who is who, in plain language

This is the section I'd have found most useful, so it's the longest one. People swap these titles around in casual conversation like they're synonyms. They aren't synonyms. Training, legal powers, and accountability differ significantly between them.

Psychiatrist

A medical doctor who specialized in psychiatry. Can diagnose and, crucially, can prescribe medication. Appointments are often short and focused on medication management: how you're responding, side effects, dosage. Most psychiatrists don't deliver ongoing talk therapy, so it's common to see a psychiatrist for medication and someone else for the talking.

Psychologist

Doctoral-level training in psychology. Can carry out formal assessment and diagnosis, including the long structured testing used for things like ADHD, autism and learning disabilities, and delivers therapy. In most jurisdictions a psychologist can't prescribe medication. If you need a formal assessment on paper, this is usually who does it.

Psychotherapist / registered therapist

Delivers talk therapy. This is where titles vary most by jurisdiction, so read carefully. In Ontario, "Registered Psychotherapist" is a protected title under the CRPO, which means using it without registration is an offence. In much of the United States the equivalents are licensed under different letters: LPC, LCSW, LMFT. Elsewhere the word "psychotherapist" may not be protected at all.

Counsellor

Usually shorter-term and more focused: grief, a specific relationship problem, a work situation, addiction. Often excellent value for a defined issue. Regulation varies enormously, so "counsellor" tells you what someone does, not what training stands behind it. Ask.

Social worker

Regulated in most places, and frequently the person who can actually get things moving. Many clinical social workers deliver therapy to a high standard. They also know the system: benefits, housing, disability paperwork, which local services exist and which have a six month waitlist. Deeply underrated.

Peer support worker

Someone with lived experience of mental illness, often formally trained in peer support, who works alongside you instead of treating you. Not a substitute for clinical care and not trying to be. What they offer is the specific relief of talking to a person who has been in the same room you're in now, which no amount of training substitutes for.

Wellness practitioners, coaches, unregulated roles

Life coaches, wellness coaches, breathwork and mindfulness practitioners, ADHD coaches, yoga therapists. Some are measurably helpful, and I'm not interested in sneering at something that works for someone. But "coach" and "therapist" aren't the same word. The difference is regulation and accountability, not vibes.

That last card deserves a bit more, because I'd sooner be fair here than dismissive. A good coach can be excellent at the things coaching is for: structure, accountability, goal setting, getting unstuck on something practical. Plenty of people have got more out of an ADHD coach than out of a therapist who didn't understand ADHD. That's a real result and it counts.

The distinction is about what happens when things go wrong. An unregulated practitioner has no college, no register, no mandated training standard, no complaints process with teeth, and no obligation to recognize when something is beyond their scope and refer you on. If a registered practitioner harms you, there's a body you can go to. If an unregulated one does, largely there isn't. That's not a judgment about any individual; it's a description of the safety net, and it's worth knowing which side of it you're standing on. The honest position is: use what helps you, and know what it is.

How to check someone is actually registered

This takes about two minutes and almost nobody does it. Every regulated profession has a public register, and it exists precisely so that members of the public can look people up. Find the regulator for that profession in your jurisdiction, search the register for the practitioner's name, and check that their registration is current and that there are no restrictions listed.

CRPO status check (Ontario)

The College of Registered Psychotherapists of Ontario. If someone in Ontario uses the title "Registered Psychotherapist" or the letters RP, they're in this register or they shouldn't be using it.

College of Psychologists (Ontario)

Now the College of Psychologists and Behaviour Analysts of Ontario. The public register covers psychologists and psychological associates. Other provinces have their own equivalent college.

US state licensing boards

In the United States licensure is state by state, not national. This directory points you at the right board for your state, and each board runs a searchable license lookup.

BACP register (UK)

The British Association for Counselling and Psychotherapy holds an accredited register you can search directly. The UKCP holds another.

You can also just ask them. A registered practitioner will never be annoyed by "what's your registration number and which college are you registered with?" They get asked, they expect it, and several will tell you unprompted in a first call. Reluctance to answer that question is itself the answer, and you're allowed to treat it that way and walk.

Modalities, briefly and without the hype

The acronyms are one of the most alienating parts of looking for therapy, so here they're in plain terms. Some have a much stronger evidence base than others, and I've said so where it's true. What follows all of them is the same caveat: fit matters more than fashion, and the best-evidenced approach delivered by someone you can't talk to will do less for you than a decent approach delivered by someone you can.

CBT (cognitive behavioral therapy)

Structured, present-focused work on the loop between thoughts, feelings and behaviour, usually with homework between sessions. The most heavily researched talk therapy there is, especially for anxiety and depression. Suits people who like structure and a plan. Can feel superficial to people whose difficulties are older and more tangled than a thought pattern.

DBT (dialectical behaviour therapy)

A skills-heavy relative of CBT built around distress tolerance, emotion regulation, interpersonal effectiveness and mindfulness. Developed for people who feel emotions at very high intensity, and strongly evidenced there. Often runs as a group skills class plus individual sessions. Demanding, and worth it if intensity is the core problem.

EMDR

A structured trauma therapy using bilateral stimulation, usually guided eye movements, while working with a specific memory. Well evidenced for PTSD and recommended by several national guidelines. The mechanism is still argued about; the outcomes for single-incident trauma aren't. Needs a properly trained practitioner, and pacing matters a great deal.

IFS and parts work

Treats the mind as made up of parts that each developed doing a job, and works on the relationships between them instead of trying to delete any of them. Intuitive for people who already experience themselves as more than one voice. The evidence base is younger and thinner than CBT's, worth knowing before you commit, though clinical uptake has been rapid.

ACT (acceptance and commitment therapy)

Less about arguing your thoughts into a better shape, more about loosening their grip and acting according to your values anyway. Good fit for chronic conditions, long-term pain, and anyone who has already tried to think their way out and found the thinking was the trap. Reasonable evidence base.

Somatic approaches

Work through the body: what you notice physically, what your nervous system is doing, regulation more than analysis. Often helpful for people who can explain their problem perfectly and still feel nothing shift. The research is mixed and the field contains both careful clinicians and complete nonsense, so registration checks matter more here than anywhere else.

Psychodynamic therapy

The long, open-ended kind: patterns, early relationships, what keeps repeating and why, including inside the therapy relationship itself. Slower and less structured than CBT, with a smaller but real evidence base. Suits people who want to understand themselves more than they want to fix one defined symptom, and who can afford the time.

Finding someone you click with

This is the part I'd underline twice if the stylesheet let me. The therapeutic alliance, meaning the quality of the working relationship between you and your practitioner, is one of the strongest and most consistent predictors of whether therapy helps at all. It shows up across modalities and across decades of research. It's not a soft extra on top of the technique. In a lot of studies it outperforms the technique.

Which means: if it isn't working, changing therapist isn't giving up. It's the correct move, and it's an intervention in itself. People stay for years with someone they dread seeing because leaving feels rude. That's a terrible trade of your money, your time and your one hour a week. A good practitioner won't be wounded. Many will help you find someone better suited, because a poor fit is a professional matter to them and a personal one only to you. If someone reacts to you leaving by making you feel guilty, they've just given you the clearest possible evidence that leaving was right.

Consultation calls and what to ask

Most therapists offer a free short consultation, usually fifteen or twenty minutes. Use it, and use it for more than one person. You're interviewing them. Things worth asking:

What are you registered as, with which college, and what's your registration number?
What do you actually work with most? Everyone's website says everything; the honest answer to this is narrower.
How do you work? What does a typical session look like with you?
Have you worked with people like me before? Be specific about what "like me" means to you.
What are your fees, do you sliding-scale, and do you do direct billing to insurance?
What happens if I tell you something isn't working?

Then pay attention to the part that isn't the answers: whether you felt talked over, whether you felt assessed or met, whether you'd dread the next call. That reaction is data. Give it a few sessions before you decide, because the first one is awkward for everybody, but don't spend a year overriding an instinct you had in week two.

Queer, trans, and neurodivergence competent care

Ask directly whether they have experience working with trans clients, or queer clients, or autistic and ADHD clients, whichever applies to you. Not whether they're "open minded" or "an ally", because everyone says yes to that. Ask about experience. There's a real difference between someone who supports your existence and someone who has actually worked with people like you and doesn't need the basics explained.

The reason this is practical and not political: a practitioner who needs educating on your existence is spending your session on their learning, and you're paying for that hour. I've watched people burn months explaining what a pronoun is, or being told their autistic traits were avoidance, or having something that was plainly an executive function problem treated as a motivation problem. That isn't therapy, it's unpaid teaching with a bill attached. Community recommendations are worth a great deal here, and so are the directories that let you filter properly.

Being the expert on yourself

The thing I believe most firmly about all of this: you live in your own head full time, and they see you for an hour a week. Nobody has more data about your experience than you do. Good practitioners know this and behave accordingly. They treat you as a collaborator, they explain their reasoning, and they're comfortable being asked why. You're allowed to disagree. You're allowed to ask where a framing came from. You're allowed to say "that doesn't fit" and expect it to be taken as information, not as resistance.

But I want to be honest about the other half of this, because a page that only said the above would be flattering and incomplete. Being the expert on your experience isn't the same as being right about everything. The whole value of an outside perspective is that it's outside: it can see the pattern you're standing inside of, and it isn't invested in the story you've been telling yourself about why you do a thing. Some of the most useful sentences anyone has said to me were ones I disliked immediately and understood about three weeks later.

So both are true at once, and living in that tension is the actual skill. Your experience is authoritative. Your interpretation of your experience isn't automatically correct, and neither is theirs. The difference between a practitioner who's challenging you usefully and one who's simply overruling you is mostly in whether they can explain their reasoning and stay curious when you push back. Someone who says "let's sit with why that landed badly" is doing their job. Someone who says "that's just your illness talking" and stops there is not.

A rough test I'd offer: does it feel like you're both looking at the same problem together, or like you're the problem being looked at? The first one is worth staying with even when it's uncomfortable. The second one is worth leaving even when it's polite.

Cost and access, honestly

Therapy is expensive, and in most places private sessions cost more per hour than a lot of people earn. That's a structural problem, not a personal failing, and I'd like to say plainly that not being able to afford it says nothing whatsoever about you. It's also the single most common reason people don't go, so what can you actually do about it? More than you'd think:

Sliding scale. Many therapists reserve a few reduced-fee slots and don't advertise it. Ask. The worst outcome is a no.
Training clinics. Universities and training institutes run clinics where supervised students see clients cheaply or free. The trainee is closely supervised by an experienced clinician, and they tend to be extremely motivated. Underused.
Employee assistance programs. If you're employed, check whether you have one. Usually a limited number of free short-term sessions. Worth reading the confidentiality terms first, but for many people it's the fastest available door.
Community health centres. Often free or low cost, and often have counselors, social workers and groups running that nobody knows about because they don't market.
Group therapy. Substantially cheaper than individual work, well evidenced for a lot of conditions, and the thing people are most reluctant to try. Hearing someone else say your exact thought out loud does something individual therapy can't.
Coverage. Public and insurance coverage vary wildly by country, province, state and plan. In Canada, psychiatry is typically covered by the provincial plan while psychotherapy usually isn't. In the UK there are NHS routes including self-referral in England. In the US it depends entirely on your plan. Check what you already have before paying out of pocket.

The other practical thing: waitlists are long, sometimes absurdly so. Get on more than one. There's nothing rude about being on four lists and taking whichever comes up first, and it's the difference between waiting three months and waiting a year.

How long this has actually taken

I've been in some form of therapy since I was five years old. I'm thirty six.

I mention that because of how therapy gets talked about, which is usually as an intervention with a start and an end, a thing you do for a while until it works. For some people it is. For me it has been closer to a permanent piece of infrastructure, running at different intensities depending on the year, occasionally paused, never really finished.

Two things follow from that, and both took me a long time to accept. The first is that a long history isn't evidence that it failed. I'd be in a considerably worse position without those years, including the stretches that felt like nothing was happening. The second is that being in it for decades doesn't make you an expert at receiving it. I have started over with new people this year and been just as bad at the first few sessions as anybody, because the skill is specific to the person you're sitting with.

I have also checked myself in when I needed to. That wasn't a collapse and it wasn't brave, it was the correct call at the time, and it's worth saying out loud because the version of that in most people's heads is far more dramatic than the real thing.

What that looked like, for me

Everything above is advice, and advice is cheap. So: the version with real numbers on it, from this year. When I was reading pages like this one, what I wanted was for somebody to just tell me what it costs and whether asking works.

Asking for a reduced rate works. The trauma specialist I needed was expensive. Not slightly, either. Properly out of reach, the sort of number that makes you close the tab. So I told them that, plainly, without dressing it up or apologising for it, and asked whether anything could be done. They came back with a rate I could manage for the first block of sessions.

That's the single highest return on any awkward conversation I have ever had, and I nearly didn't have it, because I assumed the price on the page was simply the price. It very often isn't. The people doing this work generally know exactly what it costs and would rather see you than not.

Missing a deadline isn't always the end. There was a twelve-week group program I wanted, running through a local women's organisation, aimed at complex trauma. Signups had closed. I wrote and explained my situation anyway, and they reopened a place. I wouldn't have bothered a year ago.

The actual load, at the busiest point. Twenty seven appointments in about seven weeks: eight group sessions, eight trauma sessions, four psychiatric, seven with my regular psychotherapist, plus eight massage therapy appointments for the physical side of trauma processing, which is a real thing and not a luxury. That's most of a part time job, on top of the reason you needed the appointments in the first place.

I'm saying that plainly because the reason people don't do this is usually money and admin, not willpower, and anyone telling you otherwise hasn't recently tried to book it. The scheduling alone defeats people who want the help badly.

You're allowed to turn one down. I was referred to a psychiatrist I didn't want to see, for reasons that were about who he is, not about his credentials. I waited for a different referral instead. That felt like being difficult at the time. It wasn't. A clinician you can't be honest in front of isn't going to be able to help you, and the waiting was the cheaper cost.

Specific fit takes longer and is worth it. It took me two years to find a massage therapist who was queer, non-binary, and offered gender-affirming work. Two years is a long time to keep an eye out for something. It was still the right call, because the alternative was spending every appointment braced.

Places to start

Real organizations, split by country, because this site gets readers from all over. I've deliberately left phone numbers off where I'm not confident they're current; the organizations themselves publish the live ones. Same disclaimer as everywhere else on this page: I'm not a clinician, and none of this is medical advice.

If you're in crisis or thinking about suicide, please skip the rest of this page and contact a crisis line now. In Canada and the United States, 988 is the national suicide and crisis line, by call or text. In the UK and Ireland, Samaritans is on 116 123, free and around the clock. If you're elsewhere, your local emergency number is a legitimate option.

Last thing

None of this makes finding care easy. The waitlists are still long, the fees are still high, and the odds of the first person you see being the right one aren't great. What I'd want you to take from this page is narrower than that: that you're allowed to be picky, that asking a practitioner to justify themselves is normal, and that the expertise you already have about your own head is real expertise even when nobody has handed you a document confirming it.

I'm still somewhere in the middle of my own version of this, and I don't have a neat ending for it. That's fine. Most of it doesn't have one.

The in-progress version → ADHD & the tools I built →

You're the expert on your own head