In the United Kingdom, the Improving Access to Psychological Therapies (IAPT) programme has transformed mental health care over the past decade, offering structured, short-term therapies—primarily cognitive behavioural therapy (CBT)—to millions of people with depression and anxiety disorders. Yet a growing number of patients are asking for something different: longer-term psychodynamic therapy, which explores unconscious patterns and past relationships. This mismatch between what is funded and what is wanted has created a quiet tension within the system, one that pits guideline-driven efficiency against patient preference.

The Waiting List Paradox: CBT Offered Faster, Psychodynamic Therapy Requested More

IAPT services typically offer CBT within a few weeks for mild-to-moderate depression and anxiety. National Institute for Health and Care Excellence (NICE) guidelines endorse CBT as a first-line treatment based on a robust evidence base from randomised controlled trials. Trusts argue that CBT is cost-effective: roughly 6 to 20 sessions per patient, compared with 40 or more for psychodynamic therapy. As a result, waiting times for psychodynamic therapy in the NHS can exceed 12 months, and some trusts do not offer it at all.

Yet surveys suggest that between 40% and 60% of therapy seekers would prefer a psychodynamic approach if it were available. Patient forums and advocacy groups report that many feel CBT is too symptom-focused and does not address the underlying causes of their distress. This creates a paradox: the therapy most readily available is not necessarily the one most wanted.

Trusts face a difficult balancing act. With fixed budgets, they must treat as many patients as possible. A 2023 report from the King's Fund noted that mental health spending in England has increased in real terms, but demand has risen faster. Prioritising shorter therapies allows trusts to reduce waiting lists and meet national targets, even if some patients remain unsatisfied.

The situation is further complicated by regional variation. Some trusts in London and the South East offer dedicated psychodynamic services, while others in the North and Midlands have none. A patient in Cumbria may face a choice between CBT or nothing, whereas someone in central London might access both modalities. For example, the Tavistock and Portman NHS Foundation Trust in London provides a range of psychodynamic therapies, while a trust in a rural area may only offer CBT through IAPT. This postcode lottery means that where you live can determine what therapy you receive, regardless of your personal needs or preferences.

Why Patients Want More Than Symptom Reduction: Deeper Work Demanded

Many patients who have tried CBT report that it feels superficial. CBT focuses on identifying and changing unhelpful thought patterns and behaviours—a practical, skills-based approach. For some, this is exactly what they need. But for others, especially those with histories of trauma, complex grief, or long-standing relational difficulties, symptom reduction alone does not feel like recovery.

Psychodynamic therapy, by contrast, aims to uncover unconscious conflicts and patterns rooted in early relationships. It is typically longer-term, sometimes lasting a year or more. Proponents argue that this depth leads to more enduring change. A 2023 meta-analysis in the Journal of Consulting and Clinical Psychology found that psychodynamic therapy had comparable long-term effects to CBT for depression and anxiety, with some evidence of continued improvement after treatment ended.

Patients with borderline personality disorder (BPD) or complex trauma often find CBT insufficient. Mentalization-based therapy, a psychodynamic variant, is NICE-recommended for BPD and is delivered in some specialist services. However, access is limited. A 2022 survey by the charity Mind found that nearly half of respondents with BPD had been unable to access any psychological therapy at all.

The preference for psychodynamic therapy is not merely anecdotal. A 2021 study in BMJ Open asked 1,500 people with depression what therapy they would choose if all types were equally available. Roughly 48% chose psychodynamic therapy, 32% chose CBT, and the rest preferred counselling or other approaches. The researchers noted that patient preference is rarely incorporated into treatment allocation.

The Evidence Gap: NICE Guidelines vs. Real-World Preferences

NICE guidelines are based on systematic reviews that prioritise randomised controlled trials (RCTs). For depression and anxiety, the evidence for CBT is strong: dozens of RCTs show it reduces symptoms more than waiting-list controls. Psychodynamic therapy has fewer RCTs, partly because it is harder to manualise and standardise. Critics argue that the evidence base for psychodynamic therapy is weaker, making it harder to justify funding.

However, observational studies and naturalistic trials suggest that psychodynamic therapy produces meaningful improvements that persist after treatment ends. A 2020 Cochrane review found that psychodynamic therapy was superior to no treatment for depression, but the quality of evidence was moderate. The authors called for more head-to-head trials.

Health economists question whether longer therapy is worth the cost. A typical course of CBT costs roughly £400–1,600 per patient, while psychodynamic therapy can cost £2,400–8,000 or more. Trusts argue that with limited funds, CBT offers the best return on investment, measured by symptom reduction per pound spent.

Yet patient advocacy groups counter that short-term savings may ignore long-term relapse costs. Depression and anxiety are often chronic conditions. If a patient relapses after CBT and requires further treatment, the total cost may exceed a single course of psychodynamic therapy. A 2019 study in Lancet Psychiatry modelled this and found that for patients with recurrent depression, longer-term therapy might be cost-effective over a 10-year horizon.

Another counter-argument is that the evidence hierarchy itself may be biased. RCTs require manualised treatments and homogeneous samples, which favour CBT. Psychodynamic therapy, which is more individualised and flexible, does not fit neatly into the RCT framework. Some researchers argue that other forms of evidence, such as practice-based evidence from large naturalistic datasets, should carry more weight. For instance, the UK's National Audit of Psychological Therapies collects data from thousands of patients in routine care and has shown that psychodynamic therapy produces clinically significant improvements in real-world settings.

The Cost Calculus: How Trusts Allocate Limited Mental Health Budgets

Mental health trusts in England spent roughly £14 billion in 2023–24, according to NHS England. Psychological therapies account for a small fraction of that, but the pressure to treat more patients is intense. CBT sessions cost roughly £50–80 each; psychodynamic sessions cost £60–100. Over 40 sessions, the difference adds up.

Training and supervision also differ. CBT therapists can be trained in a few months, while psychodynamic therapists typically require years of supervised practice. Trusts therefore face a workforce shortage: there are simply not enough qualified psychodynamic therapists to meet demand, even if funding were available.

Some trusts have responded by offering stepped care: patients start with low-intensity CBT, and those who do not respond are stepped up to longer therapy. In theory, this balances efficiency with individual need. In practice, stepping up can involve long waits and bureaucratic hurdles. A 2022 audit by the Royal College of Psychiatrists found that only about 20% of patients who did not respond to low-intensity CBT were offered a higher-intensity therapy within 12 weeks.

Patient-led campaigns, such as the "Right to Choose" movement, have pushed for shared decision-making. Under NHS England's Choice Framework, patients have a legal right to choose their provider and, in some areas, their therapy type. But this right is often poorly communicated, and many patients do not know they can ask for an alternative to CBT.

There is also the question of whether the cost-effectiveness argument holds when considering indirect costs, such as lost productivity or disability benefits. A patient who remains depressed for years due to inadequate treatment may cost the economy far more than a longer therapy upfront. Some health economists advocate for a societal perspective that includes these broader costs, which could tip the balance in favour of psychodynamic therapy for certain patients.

Beyond Depression and Anxiety: Severe Mental Illness and Substance Use

For severe mental illnesses such as schizophrenia and bipolar disorder, psychological therapies are less central, but they do play a role. CBT for psychosis has some evidence and is recommended by NICE. Psychodynamic approaches for psychosis are rare and controversial, with limited evidence. Most trusts do not fund them.

For substance use disorders, motivational interviewing (a CBT-adjacent approach) dominates. Psychodynamic therapy is sometimes used for underlying trauma or personality issues, but it is not standard. A 2021 review in Addiction found that psychodynamic therapy for substance use had mixed results, with some studies showing benefit and others not.

Patients with co-morbid PTSD often seek trauma-focused therapies such as EMDR or prolonged exposure, which are CBT-based. However, some prefer psychodynamic therapy that addresses relational trauma. Trusts typically offer trauma-focused CBT first, and psychodynamic therapy is rarely available for PTSD outside specialist clinics.

The gap is widest for patients with complex needs who fall between diagnostic categories. A person with depression, a history of childhood abuse, and mild substance use may not fit neatly into any single treatment pathway. These patients often report feeling bounced between services, with no one offering a coherent therapeutic relationship. For example, a patient with complex PTSD and substance use may be referred to separate services for each condition, with no coordination. Psychodynamic therapy, which can address multiple layers of difficulty within a single therapeutic relationship, might be more suitable but is rarely offered.

What Patients Can Do: Navigating the Referral Maze

For patients in England, the first step is usually a visit to the GP, who can refer to IAPT. Under the Choice Framework, patients can request a specific therapy type, though availability varies. Asking about local psychodynamic services is worth doing, but be prepared for long waits.

Private therapy is an alternative. Psychodynamic therapists charge roughly £40–80 per session, and some offer sliding-scale fees. Charities such as the Anna Freud Centre and the Tavistock Clinic offer lower-cost psychodynamic therapy, though waiting lists can be long. Online directories from the British Association for Counselling and Psychotherapy (BACP) and the UK Council for Psychotherapy (UKCP) list registered therapists by modality.

Some trusts offer a stepped-care model where patients can move from low-intensity CBT to longer therapy if needed. It is worth discussing this with your IAPT practitioner and asking about the criteria for stepping up. Patient advocacy groups, such as the National Survivor User Network (NSUN), provide peer support and information on navigating the system.

Campaigns like "Therapy First" and "Choose Therapy" have lobbied for greater patient choice in mental health. They argue that shared decision-making improves outcomes and satisfaction. While policy change is slow, individual patients can still exercise their rights.

The Future of Therapy Provision: Blended Models and Stepped Care

The tension between CBT and psychodynamic therapy may eventually resolve not through one winning, but through integration. A number of pilot programmes in London and Manchester are testing blended models: for example, starting with 8 sessions of CBT and, if needed, offering 20 sessions of psychodynamic therapy. Early results suggest improved outcomes for patients who do not respond to CBT alone.

Digital CBT apps, such as SilverCloud and Beating the Blues, are increasingly commissioned by trusts. These are cheap and scalable, but they are even further from the relational depth that psychodynamic therapy offers. Some patients find them helpful; others feel they are a poor substitute for human contact.

Therapy integration models, such as cognitive analytic therapy (CAT) and schema therapy, combine CBT techniques with psychodynamic understanding. These are gaining traction but are not yet widely available. NICE is currently reviewing its guidelines for depression, and patient preference may receive more weight in the updated version.

Ultimately, the debate is about values as much as evidence. Do we prioritise treating the most people quickly, or do we respect individual preferences and invest in longer, deeper work? The answer is not clear-cut, and reasonable people disagree. What is clear is that the current system leaves many patients feeling unheard. As the NHS grapples with rising demand and tight budgets, the choice between efficiency and depth will only become more urgent.

Another emerging model is the use of group-based psychodynamic therapy, which can reduce costs while maintaining a relational focus. Some trusts are experimenting with short-term psychodynamic groups of 12 to 20 sessions for depression and anxiety. Early evaluations suggest that group psychodynamic therapy can be as effective as individual CBT for some patients, at a lower cost per patient. If these findings hold, group psychodynamic therapy could become a middle ground that addresses both budget constraints and patient demand for depth.

Finally, there is growing interest in personalised medicine approaches to therapy matching. Researchers are developing algorithms that predict which patients are most likely to benefit from CBT versus psychodynamic therapy, based on baseline characteristics such as attachment style, personality traits, and treatment history. If such tools become clinically usable, trusts could allocate resources more efficiently while respecting individual differences. However, these tools are still in early stages and require validation in real-world settings.

This article is for informational purposes only and does not constitute personalised medical advice. If you are experiencing mental health difficulties, please consult a qualified professional.