Potential Barriers and Facilitators to the Uptake of Psychotherapy

In summary

• Despite the wide range of psychotherapy options available for patients with mental health conditions, potential barriers may limit their uptake
• Making that first step into the therapy room can be hindered by access, stigma, reliance on existing coping mechanisms, and previous negative experiences of therapy
• The positive impact of moral support from a friend or family member cannot be overestimated when it comes to making the decision to start therapy, while a trusting patient–therapist relationship is what keeps people coming back
• There are several steps that therapists can take to build and maintain the therapeutic alliance and improve psychotherapy outcomes

 

Psychotherapy is a mainstay of treatment in psychiatry, with psychological interventions recommended as the primary treatment approach for a variety of mental health conditions such as borderline personality disorder.¹ With the wide range of therapy types and settings available, psychological interventions can be selected or combined to suit individual patient needs and preferences.^1,2 Why, then, are there still barriers to initiating therapy?

The elusive first step: What are the potential barriers for patients initiating therapy?

With only one in five people with mental health problems seeking professional support, it is important to understand why so many people feel either unable or unwilling to enter the therapy room.³ People commonly experience internal and external barriers to seeking therapy:^4–7

“I thought, I cannot afford this right now.” (45-year-old woman)⁴
Therapy is costly, particularly in countries where treatment is not subsidized. So, it is not surprising that patients put off seeking help due to concerns regarding affordability and financial burden.^4–7

“[Psychotherapy] is a somewhat notorious story. It’s more of a secret.” (26-year-old woman)⁴
The shame and stigma associated with mental health problems prevents many people from seeking therapy.^4–7

“I did not go for treatment for half a year because, at that time, I was feeling terrible and went to men’s counselling for a while instead.” (28-year-old man)⁴
Often, people desire to handle their mental health problems themselves and find alternative ways to cope that keep them functioning in the short term.^4–6

“I saw this therapist who just nodded the whole time, like mhm, mhm, mhm.” (20-year-old woman)⁴
One of the most frequently reported barriers to accessing therapy is a previous negative experience with psychotherapy. Patients report feeling misunderstood or not being answered well enough by their previous therapist.^4–6

Going the distance: Facilitating therapy initiation

Getting patients into therapy may seem like a tall order, but many factors promote positive attitudes and willingness to participate in psychotherapy:^4,6

“I have a good friend who regularly sees a therapist and we talked about it a bit. That was when I said, OK, now I need to tackle it and look for help.” (36-year-old woman)⁴
The most common facilitator by far is receiving moral support from others who recommend seeking psychotherapy and share knowledge on finding a psychotherapist.^4,6

Most patients state that they experienced a crisis point in their suffering, which led to a desire for change and to seeking treatment.^4,6

“It impressed me that she said: You do not have to stay here [in psychotherapy]. You may say: this does not fit me. Alternatively, you can always say it does not work for me anymore. So, I felt I could tell her that at any time, and that inspired much trust in me when I first saw her.” (26-year-old woman)⁴
The patient–therapist relationship can make or break the therapy experience. Having a positive impression from early sessions and immediately feeling trustful of a therapist are the factors that help patients to go the distance in therapy.⁴

Therapeutic alliance is a strong predictor of long-term psychotherapy outcomes.⁸ While engagement from the patient is critical for building this alliance, therapists’ behaviors also significantly contribute to the success of psychotherapy.⁸ The American Psychological Association Task Force on Evidence-Based Psychotherapy Relationships and Responsiveness recommends the following clinical practices to maintain therapeutic alliance:⁸

• Create a warm emotional bond or collaborative attachment with the patient
• Agree on therapy goals and tasks early on; be flexible to negotiate on goals
• Be responsive to the patient’s capabilities, individual problems, and preferences
• Address challenges directly and immediately

Further reading

• Schaffler Y, et al. Perceived Barriers and Facilitators to Psychotherapy Utilisation and How They Relate to Patient’s Psychotherapeutic Goals. Healthcare (Basel) 2022;10:2228.
  Barriers and facilitators to psychotherapy utilization, as reported by patients.
• King’s College London. Barriers to accessing talking therapies for service users from racial and ethnic minority groups. Available at: https://www.kcl.ac.uk/barriers-to-accessing-talking-therapies-for-service-users-from-racial-and-ethnic-minority-groups.
  Access to therapy: the inequality experienced by people from racial and ethnic minority backgrounds.

Cite this article as Psychotherapy. Connecting Psychiatry. Published May 2023. Accessed [month day, year]. [URL]

SC-US-75164

SC-CRP-13469

April 2023