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YOU can say what you like about the TikTok generation, but you can’t fault their dedication to mental health. In recent years, with a little help from a global pandemic, they have brought therapy firmly into the mainstream. From therapists on TikTok offering 60-second videos on everything from trauma to perfectionism, to AI-based chatbot apps, it has never been easier to get advice on improving your mental health.

More formal therapy is easier to come by too, with many therapists operating online and the rise of platforms such as BetterHelp, which matches people with those therapists. In fact, with all this new availability, you might wonder whether we should all be giving therapy a try.

But where to start? With a bewildering variety of options, from talk therapies to body-based approaches – and even those involving fantasy games like Dungeons & Dragons – it is hard to know how to choose, never mind how likely it is that any of them will work for you.

Until recently, science could offer little assistance. People and their problems are, by definition, individual, so it has proven difficult to compare like with like. And with estimates suggesting there are more than , most yet to be tested in rigorous trials, linking outcomes to particular treatments is difficult.

But things have begun to change. In the past few years, scientists have made a concerted effort to better understand not only what therapy does to the brain, but also who it helps and why. In the process, they have even found that it can sometimes do more harm than good.

Psychotherapy is a catch-all term that describes the application of ideas from the field of psychology to treat mental or emotional problems. Psychology has moved on from the early days, when Sigmund Freud asked people to recline on his couch, and the number of therapeutic options has grown too. Modern therapy draws on various schools of thought. Some focus on the mind and brain, or on our relationships with others, or the connection between body and mind.

Demand for the services of therapists is rising. The US, which you might say is the spiritual home of talking therapies, has seen a , from around 27 million in 2001 to 42 million in 2020. The impact of covid-19, particularly the lockdowns imposed to control it, has since stimulated demand further. Last year, the World Health Organization said the pandemic had triggered a . Ninety per cent of countries have included mental health support in their response package to covid-19.

Does therapy really work?

All of which sounds like great news, provided therapy works. So does it? If you ask therapists working with people with mental health conditions, the answer is a resounding yes. The UK Council for Psychotherapy (UKCP), a professional body representing UK-based therapists, points to . These meta-analyses show that psychotherapy is effective in both the short and long term for most mental health conditions, including depression and anxiety, and is at least as effective as medication.

But the evidence base is far from unequivocal. A 2017 umbrella review of meta-analyses of randomised controlled trials, widely considered the gold standard when it comes to gathering reliable evidence, found that 80 per cent of them came down in favour of psychotherapy working to some degree. The problem is that only 7 per cent of the studies in question . That proportion covered 16 studies, six of which involved cognitive behavioural therapy (CBT). Many of the rest involved a mixture of different types of psychotherapies.

According to , a clinical epidemiologist at the University of Ioannina in Greece, who was an author on the umbrella review, lumping together many small studies in this way is part of the problem when it comes to trying to objectively assess what works. “These factors introduce a significant number of biases in psychotherapy research,” he says.

CBT, which involves a therapist helping a person make connections between thoughts, emotions and behaviour, is the best-studied type of therapy. This is partly because it is relatively simple to evaluate a user’s progress via standardised questionnaires. That kind of evaluation “has demonstrated that, very, very crudely, roughly half of people treated will gain benefit”, says , a psychotherapist based in the West Midlands, UK.

What this also means, of course, is that roughly half of those who try it don’t benefit. The puzzle is why it works for some people and not others – and whether a different kind of therapy might work better. With so little research comparing different modes of therapy, it is difficult to know. In March 2016, the European College of Neuropsychopharmacology held a meeting in Nice, France, to begin to address the problem and work towards a better understanding of whether and . Doing so should help us move towards more evidence-based treatments.

Research of this sort is beginning to bring results. Studies of anxiety disorders, including panic disorder, have shown that symptoms are associated with hyperactivity in the brain circuits involved in monitoring threats and processing fearful memories. Now, studies are looking at whether specific types of therapy make meaningful changes to those circuits.

A randomised controlled trial published in 2018 used functional magnetic resonance imaging (fMRI) to study changes in brain activity in key regions involved in threat monitoring in 28 people diagnosed with panic disorder. Half of the group underwent four sessions of CBT focused on strategies for regulating emotions in fearful situations. The other half were assigned to a waiting list. After four weeks, when shown fear-provoking images while their brains were scanned. In particular, activity in the amygdala, a region involved in threat detection, reduced to levels seen in people without panic disorder after CBT. Seventy-one per cent of the CBT group could be considered to be in recovery based on symptoms compared with just 7 per cent of controls.

What CBT does to your brain

This would suggest that CBT can change the brain in meaningful ways. Yet other studies suggest it isn’t as simple as assuming that one therapy leads to one type of brain change.

In fact, a 2019 study found that . In it, researchers compared the effects of CBT and Eye Movement Desensitisation and Reprocessing (EMDR) therapy on the brain connectivity patterns of people with post-traumatic stress disorder (PTSD) after a deadly earthquake in Italy in 2002. EMDR, which involves an individual making side-to-side eye movements while they think about the traumatic experience, is approved by the US Food and Drug Administration and supported for use in England and Wales by the National Institute for Health and Care Excellence and the World Health Organization. However, it has been controversial because there has been and, if so, how.

In the study, 31 volunteers had fMRI scans before and after four sessions of CBT or EMDR. The results showed that the treatments were equally effective at reducing clinical symptoms of PTSD and that both resulted in increased connectivity between the bilateral superior medial frontal gyrus, which is involved in cognitive control, and the right temporal pole, which is involved in memory and emotional processing.

Both interventions also led to decreased connectivity between areas that process visual information and those involved in memory. The researchers speculated that, taken together, these brain changes may explain why the volunteers reported fewer visual flashbacks after treatment, although a limitation of the study was that there was no control group of people with PTSD who received no therapy.

It is too early to draw definitive conclusions from these few, small studies, but, if confirmed, it may turn out that the magic of therapy isn’t in the type you choose, but that you choose it at all. What also seems to be important is the extent to which you connect with your therapist. “There is a large and growing bunch of evidence to suggest that the biggest determinant of outcomes is not the model of therapy, but the relationship between the therapist and the individual,” says Adam Jones at the UKCP.

It has long been known that some therapists get better outcomes than others. In 1974, psychologist David Ricks at Harvard University . One therapist was nicknamed “supershrink” by the children he saw, of whom only 27 per cent went on to develop adult schizophrenia, compared with 85 per cent of those seeing another therapist. This has become known as the “therapist effect”. Yet despite many years of research, it still isn’t clear exactly what is in the special sauce that makes .

In 2019, an American Psychological Association task force attempted to narrow it down, listing that meta-analyses had found to contribute to better outcomes. These included the quality and strength of the relationship, collaboration, consensus about goals and an empathetic therapist.

Of course, none of these factors is exclusive to the therapist-patient relationship, so some of the benefits of therapy may be achievable through the wise counsel of friends or family. In fact, earlier this year, Harvard psychiatrists and expressed concern that the , rather than loved ones, could be fuelling loneliness.

Some, however, argue that therapists can help people work on specific issues in ways that an untrained confidant couldn’t, no matter how well-meaning and supportive. Psychodynamic psychotherapy, for example, focuses not on thinking behaviours, but on relationships and feelings that tend to be “very patterned” from childhood, says Heyland. Therapy can help root out these patterns and challenge them. If a person has trouble with authority, for instance, that may show up in the interaction with the therapist, allowing them to help the client become aware of what is going on and learn to relate differently.

With so much potential to enhance our future relationships and reconfigure our brains, perhaps therapy would benefit everyone? Jones, perhaps unsurprisingly, is a proponent of this view. “Mental health has traditionally been looked at through the lens of a medical model: something wrong that needs to be fixed. For many people, that is the case, but the broad approach is that it’s not what’s wrong with people, but what’s happened to people,” says Jones. Having therapy as a child or young adult could help people “break patterns before they become entrenched”, he says.

, an experimental psychologist at the University of Oxford, is more wary. She says there is an assumption that the worst that can happen is that therapy doesn’t work for you. “But there’s very little discussion that it could actually be harmful,” she says. “Nobody expects all medicines to work and we know they have side effects, but the same logic is not extended to psychotherapy.”

When therapy does more harm than good

There is some research indicating that therapy can occasionally do more harm than good. A major review of the evidence in 2007 estimated that somewhere between , and flagged specific interventions that can cause harm. The worst offenders include critical incident stress debriefing, in which people who have gone through a major trauma are encouraged to discuss it within 72 hours, and therapies that claim to help people recover repressed memories.

Foulkes is concerned about . Even the rise of awareness of mental health issues –particularly on social media, where many teenagers spend much of their time – may be harmful, she says.

For adults, too, greater awareness of mental health issues may be a double-edged sword. at the University of Melbourne and his colleagues have identified terms – including abuse, trauma, bullying and mental disorder – that have undergone “” in their everyday usage, with their definitions broadening to a potentially harmful extent.

Some therapists are seeing the effects of this in their practices. “There is much speculation about whether the rise of ‘TikTok therapy’ is encouraging the pathologising of normal emotions, especially in younger people,” says Sally Brown, a UK-based therapist in private practice. She says that, while the appetite for education on psychological matters among young people isn’t necessarily a bad thing, what is concerning is that the biggest influencers often aren’t trained professionals.

To avoid getting ill-informed advice, Jones advises anybody considering therapy to make sure that the therapist they choose is fully qualified and accredited by a professional body like the UKCP. “You might disclose things that you have never told anybody,” he says. “It is very important that you have trust in your therapist.”

And anyone seeking therapy has to be prepared to work at it. Therapy isn’t a quick fix of the sort often offered by the self-help industry on social media. “Therapy is a process,” says Jones. “It takes work.”

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