What is therapy — and what actually happens in a session
One first session minute by minute. Who does what: psychiatrist, psychologist, counsellor. What it costs and where to find it in Pakistan, honestly. What the science shows, and ten things that make therapy work instead of being quit at session three.
If you have thought about getting help and stopped because you do not know what would happen in the room, this page is for you. It walks through one first session minute by minute, explains who does what (psychiatrist, psychologist, counsellor, and the titles anyone can use), tells you honestly what it costs and where to find it in Pakistan, says what the science really shows, and gives you ten things that make the difference between therapy that helps and therapy quit at session three.
BasicNo jargon yet. One first session, from the gate to the walk home.
Start hereOne first session, minute by minute↑ contents
Most people who want help never go, and the biggest reason is not cost or stigma. It is not knowing what will happen in the room. So here is what happened to Sara, 27, Lahore, on a Thursday in March.
She arrives twenty minutes early at a clinic on the second floor of a building that also has a dentist and a travel agent. Nobody in the street knows what the second floor is. The waiting room has four chairs, a water dispenser, and a receptionist who asks for her name and hands her a two-page form: name, age, contact, who referred her, and one line: "what brings you here today?" She writes "not sleeping, low, cannot concentrate" and feels stupid.
The psychologist, a woman in her late thirties in an ordinary shalwar kameez, comes to the door and says her name. No white coat. The room has two chairs at an angle, a small table, a box of tissues, a clock the therapist can see and Sara cannot. The door closes. Sara's heart is going.
"Before we start, a few things. Everything you say here stays here, with two exceptions: if I believed you were in danger of seriously harming yourself or someone else, I would need to involve someone to keep you safe, and I would tell you first. Nothing goes to your family. Sessions are fifty minutes. Today is mostly me listening and asking, so I can understand. Is that okay?" Sara nods. She had not known about the fifty minutes.
"So. What brings you here?" Sara says the three words from the form. The therapist waits. Sara says a bit more. The therapist says, "When did you first notice the sleep going?" and Sara, to her own surprise, starts at the beginning, which was her engagement being broken off in November, and talks for twelve minutes, and cries at minute eight, and the therapist does nothing about the crying except push the tissues an inch closer and wait.
Questions, gentle and specific. How is the sleep exactly: falling asleep, or waking early? Appetite? Energy? Has she stopped doing things she used to enjoy? Any thoughts of not wanting to be here? (Sara says no, and the therapist nods and moves on, and Sara is relieved it was asked like a normal question.) Has this happened before? Anyone in the family? What does she do when the mood is at its worst? Who knows she is here? What does she hope will be different in three months?
The therapist says, roughly: "From what you have told me, this sounds like depression, which is common after a loss like this and which responds well to the kind of work I do. It is not weakness and it is not your fault. I would suggest we meet weekly for around eight to twelve sessions. Each session we will look at what happened in the week, work on one thing, and I will give you something small to try between sessions. If at any point you feel it is not working, tell me, and we will change it. What do you think?"
Homework, small: keep a note each evening of what she did and one thing that was not terrible. Next Thursday, same time. The fee is paid at reception. It was more than a doctor's visit and less than she feared.
On the stairs she realises she has said things she has never said to anyone, that nothing bad happened, and that she is exhausted and slightly lighter. She goes home. Nobody asks where she was. She says she went to a friend's.
What did not happen. Nobody lay on a couch. Nobody analysed her childhood. Nobody told her what to do. Nobody wrote a prescription (a psychologist cannot). Nobody called her family. Nobody said she was mad. Nobody said "log kya kahenge". The therapist did not fix anything, and Sara left feeling that for the first time in four months someone had understood the shape of it. That is what a first session is: the shape of it, said out loud, to someone whose job is to hear it.
Two more, briefly. Ahmed, 41, went to the psychiatry OPD of a government teaching hospital in Peshawar. He waited two hours on a bench, was seen for fifteen minutes by a doctor with a queue outside, was asked most of the same questions faster, and left with a diagnosis, a prescription for a generic antidepressant costing a few hundred rupees a month, and a follow-up in three weeks. It was not a conversation like Sara's. It was medicine, and it worked. Zainab, 33, in a town with no psychologist, sees one in Karachi by video every Tuesday from the roof, where the signal is best and nobody can hear. The first session was awkward for ten minutes and then it was a session.
Therapy is a conversation with structure, with a trained person whose only job in the room is your recovery, held in confidence, over a fixed number of sessions, with things to try between them. That is the whole definition. Everything else is detail.
Three words in that sentence do the work. Structure: it is not a chat; there is a purpose to each session and a direction across them. Trained: the person has learned methods that have been tested on thousands of people with what you have. Only job: unlike a friend, a parent or an imam, they need nothing back, have no stake in your choices, and will not be hurt by what you say.
What it is not
Not lying on a couch talking about your mother. That image is a hundred years old. Most therapy now is two chairs, a notebook, and this week.
Not advice. A therapist will rarely tell you what to do. If you want to be told, an elder is cheaper. What a therapist does is help you see the patterns you are inside and give you tools for them.
Not just talking. Talking is the medium. The work is noticing, testing, practising, and doing things differently between sessions. A therapy where you only talk and nothing changes in the week is a therapy that is not working yet.
Not for mad people. The people in the waiting room are students before exams, mothers after births, men after redundancies, people after deaths. It is for anyone stuck in something that talking to friends has not moved.
Not forever. Most therapy for depression and anxiety is eight to sixteen sessions. Some people go back for a few sessions in a hard year. Endless therapy is unusual and usually a sign something is wrong.
Not a replacement for medicine when medicine is needed, and not replaced by it. The two do different things and are often used together.
Therapy compared with the help you already have
A good friend
An elder or imam
Our team on WhatsApp
A therapist
What they give
Love, company, their own experience.
Wisdom, faith, the long view, standing in the community.
A private place to say it first, any hour, in your language; help finding the next step.
Trained methods, structure, and a relationship whose only purpose is your recovery.
What they need from you
Something back. Friendship is mutual.
Respect; sometimes agreement.
Nothing.
Nothing except honesty and the work between sessions.
Confidentiality
Depends on the friend.
Depends on the person.
Yes.
Yes, with a stated exception for danger to life.
Will they tell you what to do
Usually, and it is usually what they would do.
Often.
No; we listen and point to help.
Rarely. They help you find what you will do.
Can they treat depression or anxiety
They can help you carry it. They cannot treat it.
They can give it meaning and comfort. They cannot treat it.
No. We connect you to those who can.
Yes, for most mild to moderate cases; alongside a psychiatrist for severe ones.
Cost
Free, and it accumulates.
Free.
Free.
From nearly free (hospital, NGO) to expensive (private). See below.
Swipe the table sideways on a phone.
The basicsWho does what: CBT, counselling, psychotherapy, psychiatry↑ contents
The most common reason people end up in the wrong room is that they do not know the difference between the doors. Here is the map. In Pakistan the titles are used loosely, so the second table matters as much as the first.
Psychiatrist
Clinical psychologist
Counsellor
"Psychotherapist"
What they are
A medical doctor (MBBS) who then specialised in mental illness (FCPS or equivalent in psychiatry).
A psychology graduate with a clinical training degree (MS, MPhil or PhD in clinical psychology) including supervised practice.
Someone trained in counselling, from a short diploma to a master’s degree. Training varies a great deal.
Not a protected title in Pakistan. Anyone can use it. Ask what their actual qualification is.
What they do
Diagnose; prescribe and adjust medication; manage severe illness; admit to hospital when needed. Some also do therapy, most do not have time.
Supportive talking, listening, guidance, some structured methods. Best for milder problems and life difficulties.
Depends entirely on who they are.
Session
Often 15 to 30 minutes, medication-focused; longer at first visit. Follow-ups every few weeks.
Usually 45 to 60 minutes, weekly, for a fixed course.
Usually 45 to 60 minutes, weekly or as needed.
Varies.
Registration
Must be registered with PMDC (the Pakistan Medical and Dental Council; you can check the number). Specialist qualification from CPSP.
No single national regulator yet. Look for an HEC-recognised clinical degree and ask about supervision and membership of a professional body.
No regulator. Ask about training and supervision.
Ask.
Best for
Moderate to severe depression or anxiety; anything with psychosis, mania, or serious risk; when therapy alone has not worked; medication decisions.
Mild to moderate depression and anxiety; panic; OCD; trauma; anything where learning skills is the treatment; alongside a psychiatrist for severe cases.
Grief, stress, relationship and life problems, milder low mood; support alongside other treatment.
Find out before deciding.
Where in Pakistan
Teaching-hospital OPDs in every province; private clinics in cities. Fewer than one per hundred thousand people nationally.
Hospital psychology departments, university clinics, private practice in cities, online.
On registration, plainly. A psychiatrist must be a registered doctor and you can check the PMDC number. For psychologists and counsellors there is, as of this writing, no single national register; the field is regulated by degree recognition and professional bodies rather than a licence. That is not a reason to distrust psychologists; it is a reason to ask three questions before you book: what is your qualification, where did you train, and do you have supervision. A good one will answer without offence. Someone who calls themselves a "psychotherapist", "life coach" or "healer" and cannot answer is someone to walk away from.
The approaches
Within talking therapy there are several methods. You do not need to choose one; a good therapist will suggest what fits. But knowing the names helps you understand what is happening in the room and why. The most common, CBT, is built on one picture, which is worth seeing once because it explains what most sessions are doing.
The CBT picture. Thoughts, feelings, body and actions all feed each other. You cannot change a feeling by deciding to, and you cannot order your heart to slow down. You can test a thought and you can change what you do, and when those two shift, the other two follow. Most of what happens in a CBT session is work on one of the two green corners.
Approach
What it works on
What a session feels like
Best evidence for
CBT (cognitive behavioural therapy)
The links between thoughts, feelings, body and actions, here and now. Testing beliefs; changing what you do.
Structured. An agenda, a review of homework, one problem worked on with pen and paper, new homework. Practical, sometimes brisk.
Depression, anxiety, panic, OCD, insomnia, health anxiety. The largest evidence base.
Behavioural activation
Doing more of what gives something back, in small steps, before motivation returns.
Even simpler than CBT: activity records, ladders, planning the week.
Depression; as effective as full CBT and easier to deliver.
Counselling (person-centred, supportive)
Being heard; making sense of a situation; your own resources.
Less structured. You lead; the counsellor listens, reflects, asks. Warm.
Grief, adjustment, mild low mood, life crises.
Interpersonal therapy (IPT)
The relationships around the depression: loss, conflict, role changes, isolation.
Structured, time-limited, focused on one or two relationship problems.
Depression, especially around loss or role change; postnatal depression.
ACT (acceptance and commitment)
Your relationship to painful thoughts; what you value; doing what matters even with the pain present.
Exercises, metaphors, some mindfulness. Less arguing with thoughts, more stepping back from them.
Anxiety, chronic pain, depression; people who found CBT too argumentative.
Memories that intrude; the meaning of what happened.
Careful, paced; revisiting the memory in a safe structure.
PTSD after violence, accidents, abuse.
Psychodynamic / psychoanalytic
Patterns from early relationships repeating now; what is outside awareness.
Open; you talk, the therapist notices patterns; longer-term.
Long-standing relationship and personality patterns; some depression. Slower; less evidence for acute anxiety.
Family / couples therapy
The system, not one person.
Several people in the room; the therapist manages the conversation.
When the problem lives between people; adolescents; couples.
Swipe the table sideways on a phone.
The basicsWhat actually happens in the room↑ contents
The first session
The first session is an assessment. You will not be treated; you will be understood. It takes most of the hour and it is mostly questions. Here is what they are and why.
They will ask
Why
It helps to have thought about
What brings you here, and when it started
To understand the shape and the trigger.
Five lines: what, since when, what it is stopping you doing.
Sleep, appetite, energy, concentration, interest
The signs of depression and anxiety, checked one by one.
Honest answers. "Sleeping twelve hours" and "sleeping four" are both useful.
Thoughts of death or self-harm
Routine and necessary; asked of everyone. It does not mean they think you are dangerous.
The truth. If yes, say yes. This is the room for it.
Whether it has happened before, and what helped
Past episodes shape the plan.
Rough dates; what you tried; any medicines.
Family history, physical health, medicines, alcohol or drugs
Some conditions run in families; some medicines and substances affect mood.
Honesty about the last two. They have heard it all and they cannot help with what they do not know.
Your situation: work, study, family, marriage, money
The problem lives in a life.
The one or two things that press hardest.
What you want to be different
Therapy has goals; this sets them.
Something concrete. "Sleep through the night." "Go to the wedding." "Stop crying at work."
Who knows you are here; what you need kept private
To keep you safe and to respect your situation.
What you want them to know about your family.
Swipe the table sideways on a phone.
At the end, a good therapist will tell you what they think is going on in plain words, what they suggest, how many sessions, and what they want you to do this week. They will ask whether that sounds right to you. You are allowed to say no, to ask questions, and to decide after the session. Many people cry in the first session; nobody minds, and it is often the first time in months.
A middle session
The shape of a session. Structured therapy has a rhythm, and knowing it takes away the fear of the unknown. Most of the fifty minutes goes on one problem from this week, worked on concretely. The homework is not extra; it is where the change happens. Counselling is looser than this; a psychiatry follow-up is shorter and mostly about how the medicine is going.
By session three or four the shape is familiar. You come in, rate your week, agree what to work on, look at what happened with last week's task, and spend most of the time on one specific thing: a thought that keeps coming, a situation you avoided, a night you could not sleep, a conversation with your mother. There is often pen and paper. You leave with something to try. The next week you report back. Progress is rarely dramatic in any one session and usually visible across four or five.
How many, and how it ends
For depression and anxiety, eight to sixteen weekly sessions is typical, and many people feel real movement by six. Sessions may space out towards the end, to fortnightly, then monthly. The last sessions are about what you have learned, what to watch for, and what to do if it comes back; a good therapist works towards you not needing them. Some people return for a few sessions in a hard year. That is a top-up, not a failure.
A psychiatry appointment
Different room, different job. A first psychiatry visit is thirty to sixty minutes of similar questions, ending in a diagnosis and, if the doctor thinks it will help, a prescription, with clear instructions about how long it takes to work and what side effects to expect. Follow-ups are short (often fifteen minutes, in a hospital OPD sometimes less), and mostly about whether the medicine is working and how you are tolerating it. Bring a list; card seven is about getting the most from fifteen minutes. In a busy government OPD the doctor may not have time to talk; that is not indifference, it is a queue of eighty people, and it is why therapy and psychiatry are often done by different people.
Going deeperOne level down. What is actually doing the work, and what gets in the way.
Going deeperWhy it works, and why people quit at session three↑ contents
What is doing the work
Decades of research on what makes therapy help point to a handful of things, and the surprise is how ordinary most of them are.
The relationship. Feeling understood, respected and safe with the therapist predicts outcome more reliably than which technique they use. Researchers call it the alliance. It is why "do you feel they get you?" after session two is a better question than "are they doing CBT properly?"
Being heard, in full, without consequences. Most people have never once told the whole story to someone who needed nothing back and would not be hurt by it. Session one is often the first time, and the relief is real, and it is also not the treatment.
A shared explanation. "This is depression; it works like this; here is why the mornings are worst; here is what we will do." A problem with a name and a mechanism is smaller than a fog.
New experiences, not just new ideas. The anxious person who stays in the crowded room until the fear falls learns something no conversation could teach. The depressed person who walks to the shop on a day they "could not" gets evidence. Therapy that produces new experiences between sessions works; therapy that stays in the room works less.
Practice. The homework. Every trial that measured it finds that people who do the between-session work improve more. The session is the lesson; the week is the practice.
Hope, honestly given. Not "you will be fine", but "people with this, doing this, mostly get better". Expectation is part of the medicine, and it has to be earned.
The dip. Session one often brings relief simply from being heard. Then the real work starts, the novelty goes, and around sessions three to five many people feel worse or stuck and conclude therapy does not work. The drop-out rate peaks here. The people who stay past session six are the ones the outcome studies are about. Shape illustrative.
Why people quit at session three
Roughly one in five people who start therapy stop early, and the peak is around the third session. The reasons are predictable. The first session brought relief; the second was more questions; the third asked something of them, and it felt like homework at school, and the mood was no better, and money was involved, and it was easier not to go. Some quit because the therapist was wrong for them, and should. Most quit in the dip, which is the point just before the work starts to pay. The three-session rule below is about telling the two apart.
When the therapist is the problem
Some are. Here is how to tell a bad fit or a bad therapist from an ordinary dip.
Red flag
Why it matters
Green flag instead
Will not say what their qualification is, or is vague about it
Anyone can call themselves a therapist here.
Tells you the degree, the institution, and who supervises them, without offence.
Tells you what to do in the first session; lectures; moralises
That is advice, not therapy, and you can get it free.
Asks, listens, reflects; offers a plan and asks what you think.
Talks about themselves a lot; tells you their problems
The hour is yours.
Says little about themselves unless it serves you.
Promises a cure, a number of sessions guaranteed, a "technique that works on everyone"
Honest therapy makes no guarantees.
Says "for most people with this, this approach helps; we will review as we go".
Breaks confidentiality (mentions other clients by name; tells your family things)
Confidentiality is the foundation.
States the limits of confidentiality in session one and keeps them.
Any romantic or sexual comment, touch, or request to meet outside sessions
Never acceptable. Leave, and tell someone.
Professional warmth, and nothing else.
Discourages you from seeing a psychiatrist when you are clearly severe, or from stopping medication without a doctor
Outside their competence and dangerous.
Works alongside a psychiatrist and says so.
Pushes religious or political views, or shames you for yours
Your beliefs are yours.
Works within your values, whatever they are.
Sessions are always late, cut short, or interrupted by their phone
Disrespect for the frame is disrespect for you.
Starts and ends on time; phone away.
You feel worse after every session for weeks, and they are not curious about it
A therapist should want to know.
Asks for feedback and changes the plan when it is not working.
Swipe the table sideways on a phone.
The basicsCost and availability in Pakistan, honestly↑ contents
Two honest facts first. There are far too few professionals: fewer than one psychiatrist per hundred thousand people nationally, concentrated in the big cities, and clinical psychologists similarly scarce and similarly urban. And there is no single system: no GP referral, no insurance for most, no register you can search for psychologists. The good news inside that is that there is also no gatekeeper; you can walk into any of the doors below, and most people who get well use more than one.
The real pathways. There is no single front door in Pakistan and no GP gatekeeper; you can walk into any of these. Most people who get well use more than one: medicine from a hospital OPD, therapy privately or online, and something free in between. Our directory lists the first three by city; the seeking help page walks through each in detail.
What it costs, as honestly as we can say
Prices vary by city, by seniority, and by year, and we would rather be vague than wrong. What follows is the pattern people report to us; check before you book, and ask about reduced rates, which many therapists offer and few advertise.
Setting
Who you see
Cost, as people report it to us
Wait
Privacy
Honest notes
Government teaching-hospital psychiatry OPD
Psychiatry trainees and consultants; sometimes a clinical psychologist attached.
A small registration fee, often under a few hundred rupees; generic medicines usually cheap.
Hours on the day; no appointment system in many.
Crowded, but nobody knows why anyone is there.
The backbone of care in Pakistan. Short visits, real doctors, real medicine. Therapy rarely available in the OPD itself.
Private psychiatrist, city
A consultant psychiatrist.
A consultation fee that varies widely; commonly in the low thousands of rupees per visit in big cities, more for senior names. Ask when booking.
Days to a couple of weeks.
High.
Longer first visits than the OPD; follow-ups still short. Many also run OPDs, so the same doctor may be cheaper at the hospital.
Private clinical psychologist, city
A clinical psychologist doing therapy.
Per session, varying widely by city and experience; commonly somewhere between a good meal and a small household bill per session. Some offer sliding scales. Ask.
Days to weeks.
High.
This is where structured therapy actually happens. Eight to sixteen sessions is a real cost; budget for it, and ask about a reduced rate.
University psychology clinics
Supervised trainee psychologists.
Free or a nominal fee.
Varies; often term-time.
Good.
Under-used and often good. Supervised trainees are careful. Check the university’s psychology or applied psychology department.
NGO and charitable services
Counsellors, psychologists, sometimes psychiatrists.
Free or subsidised.
Varies.
Good.
Some are excellent and some are stretched; quality varies. Our directory marks the ones we know.
Online therapy (Pakistani platforms and independent therapists)
Psychologists and counsellors by video or voice.
Per session, often cheaper than in-person; check the therapist’s qualification, not the app’s branding.
Days.
Depends on your corner of the house.
Real therapy for people in towns with no therapist. Evidence says it works about as well as in-person for depression and anxiety.
Helplines and our team
Trained volunteers; our team.
Free.
Minutes.
Yes.
Not treatment. A first conversation, a pointer, company at 2am.
Swipe the table sideways on a phone.
Making it affordable
Medicine from the OPD, therapy from wherever you can. The two most expensive things (a senior private psychiatrist for medicine, and long private therapy) can often be replaced by the OPD for medicine and a university clinic, NGO, or online therapist for the talking.
Ask for a reduced rate. "I can manage this much per session; is that possible?" Many say yes to students, the unemployed, and people who ask.
Fewer sessions, done properly. Eight sessions with homework done beats sixteen with none. Ask for the shortest course that fits.
Self-help first, for milder problems. This site's master pages are built on the same programmes therapists use. For mild depression or anxiety, doing the exercises for a month before paying for therapy is reasonable; for moderate or severe, do not wait.
Group therapy, where it exists, is much cheaper and for some problems as effective.
The scienceThe science, kept honest. Skip if you do not want it.
The scienceThe science, stated carefully↑ contents
Therapy works, moderately, for the common conditionsHundreds of trials of psychotherapy for depression and anxiety, pooled, show a moderate benefit over no treatment and over placebo-type conditions, comparable in the short term to medication and with gains that tend to last better after treatment ends. The benefit is real and it is not miraculous; a good share of people improve substantially, some do not, and the trials are of people who completed the course.
Cuijpers, P. et al. (2020, 2023), meta-analyses in World Psychiatry; Carpenter, J.K. et al. (2018), Depression and Anxiety.
The relationship predicts outcome across every kind of therapyThe alliance (agreement on goals and tasks, and a bond) is one of the most consistent predictors of whether therapy helps, across CBT, psychodynamic, counselling and the rest. It is measurable by session three, and a poor alliance at session three predicts drop-out and poor outcome.
Horvath, A.O. et al. (2011), Psychotherapy, 48(1), 9–16; Flückiger, C. et al. (2018), Psychotherapy, 55(4), 316–340.
Different approaches, similar results for many problemsFor depression, several structured approaches (CBT, behavioural activation, interpersonal therapy, problem-solving) come out roughly equal in head-to-head trials. For specific conditions there are clearer winners: exposure-based CBT for panic and phobias, trauma-focused therapies for PTSD, CBT-I for insomnia. The honest summary: for common depression and anxiety, a competent therapist you trust doing any well-evidenced method beats the "right" method with a therapist you do not.
Cuijpers, P. et al. (2008), Journal of Consulting and Clinical Psychology; Wampold, B.E., Imel, Z.E. (2015), The Great Psychotherapy Debate.
Dose: most of the benefit comes in the first eight to sixteen sessionsClassic dose-response research found that about half of people had improved meaningfully by eight sessions and three-quarters by around twenty-six; later work suggests many improve faster. Very long therapy adds little for most common conditions.
Howard, K.I. et al. (1986), American Psychologist, 41(2), 159–164; Robinson, L. et al. (2020), Journal of Affective Disorders.
Homework predicts outcomeAcross CBT trials, people who do the between-session tasks improve more, and the effect is moderate. This is the evidence for treating the week as the treatment.
Kazantzis, N. et al. (2016), Behavior Therapy, 47(5), 755–772.
Drop-out is common, and earlyAbout one in five people stop therapy early, more in routine clinics than in trials, with the highest risk in the first few sessions. Drop-out is lower when expectations are set in session one, when the therapist asks for feedback, and when cost and travel are manageable.
Swift, J.K., Greenberg, R.P. (2012), Journal of Consulting and Clinical Psychology, 80(4), 547–559.
Online and telephone therapy workGuided online CBT and video-delivered therapy produce outcomes comparable to face-to-face for depression and anxiety in most comparisons, provided there is a real therapist involved. Unguided apps do less. For a country with one psychiatrist per several hundred thousand people outside the cities, this matters.
Andersson, G. et al. (2019), World Psychiatry, 18(1), 20–28; Carlbring, P. et al. (2018), Cognitive Behaviour Therapy.
Therapy adapted for Pakistan, delivered by non-specialists, worksThe Thinking Healthy Programme, a CBT-based intervention for mothers with depression delivered by lady health workers in rural Punjab, roughly halved depression rates compared with usual care in a large trial, and has since been adopted by the WHO. Culturally adapted CBT has been tested in Pakistani settings with good results. Therapy is not a Western import that does not fit; adapted and delivered locally, it fits well.
Rahman, A. et al. (2008), The Lancet, 372(9642), 902–909; Naeem, F. et al. (2015), Behavioural and Cognitive Psychotherapy.
Medication and therapy togetherFor moderate to severe depression and anxiety, combining medication with therapy does better than either alone in most comparisons; for milder cases, therapy alone is usually first. Stopping medication when therapy starts is a decision for the prescriber, not the therapist and not the page.
Cuijpers, P. et al. (2020), World Psychiatry, 19(1), 92–107; NICE NG222.
What predicts whether it helps. The order is well supported; the exact sizes are argued over, so no numbers. The relationship and the work you do between sessions carry more than the brand of therapy, and a therapist’s years of experience predict surprisingly little. The practical lesson: choose someone you feel understood by, and do the homework.
One-paragraph version. Therapy helps most people with depression and anxiety, moderately, in eight to sixteen sessions, and the gains last. What predicts success is feeling understood by the therapist and doing the work between sessions, more than the brand of therapy or the therapist’s seniority. One in five quit early, mostly in the dip around session three. Online works. Adapted for Pakistan and delivered by trained non-specialists, it works here too. For severe cases, medicine and therapy together.
Exercises & solutionsThe practical part. Ten cards, same shape each time.
Exercises & solutionsTen things that make therapy work↑ contents
These are not therapy exercises; every other master page on this site has those. These are the things that make the difference between therapy that helps and therapy that is quit at session three: choosing well, preparing, doing the week, speaking up, and keeping it afterwards. The first three are before you start; four to six are during; seven is for the psychiatrist; eight and nine are logistics; ten is the end.
1
The goal sheet (what do you actually want?)
15 min
What it does
Turns "I am not okay" into two or three concrete things therapy can aim at, which makes the first session sharper and lets you tell later whether it is working.
Why it works
Therapy with agreed goals has better outcomes, and the agreement is half of the alliance. Vague goals ("feel better") cannot be measured; concrete ones ("sleep through the night", "go to the wedding", "stop shouting at the children") can.
Step by step
Write what the problem is stopping you doing. Not the feeling; the thing. "I have stopped going to Friday prayers." "I cannot open my emails." "I cry at work."
Turn each into what "better" would look like, in behaviour. "Go to Friday prayers three weeks in four." "Open the emails by 10am." "Get through a shift without crying."
Rate each 0 to 10 for how bad it is now. Keep the sheet.
Bring it to session one. Say: "These are the three things I want to change." The therapist will be grateful.
Re-rate every four sessions. If the numbers are not moving by session six, say so in the room.
Use it when
Before the first session, and every four sessions after.
Common mistake
Writing the goal the family wants ("get married", "be normal"). Your goals. If you do not know, "I want to find out what I want" is a legitimate first goal.
2
Finding the right person (and the questions to ask)
30 min
What it does
Gets you to a qualified person who fits, in a country with no register and a lot of people using titles they have not earned.
Why it works
The fit and the qualification both matter, and neither is visible from a Facebook page. Five questions, asked before booking, sort most of it out, and a good professional answers them gladly.
Step by step
Start with our directory, a hospital psychology department, a university clinic, or a name from someone who has actually been. Not an ad.
Ask, by message or on the phone: (1) What is your qualification and where did you train? (2) What approach do you use for [depression / anxiety / panic]? (3) How many sessions do you usually suggest? (4) What is the fee, and is a reduced rate possible? (5) Do you have supervision, or work with a psychiatrist if medicine is needed?
For a psychiatrist, check the PMDC registration number. For a psychologist, expect an MS, MPhil or PhD in clinical psychology from a recognised university; for a counsellor, ask about the training and who supervises.
Gender, language and age matter for comfort; it is fine to ask for a woman, or for someone who speaks Pashto, or who is older.
Book one session as a trial, and say so. "I would like to see if we are a good fit."
Use it when
Before booking anyone.
Common mistake
Choosing on the strength of a video, a title, or a relative’s recommendation of someone who "fixed" them in one session. Nobody is fixed in one session.
3
Preparing for the first session
20 min the night before
What it does
Takes most of the fear out of the first hour and makes it count.
Why it works
The first session is an assessment; the better the information, the better the plan. And people who know what will happen are far less likely to cancel that morning, which is when most cancellations happen.
Write the story in five lines: what, since when, what it stops you doing, what you have tried, what you want.
List: any medicines, any past episodes, anything about the family history, and honestly, anything you use to cope (chai count, cigarettes, anything stronger).
Decide what you want kept private and from whom, and say it at the start.
Plan the logistics: how you will get there, what you will say you were doing, who knows. Give yourself an hour after; you will be tired.
If you cry, you cry. Everyone does. If you cannot say something, say "there is something I cannot say yet." That counts.
Use it when
The night before session one.
Common mistake
Rehearsing so much that you deliver a speech and cannot hear the questions. Five lines, then let them lead.
4
The between-session notebook
5 min a day
What it does
Makes the week the treatment, which is where therapy actually works.
Why it works
Homework predicts outcome. The session is fifty minutes; the week is ten thousand. A small notebook (or notes app, never in bed) captures what happened, what you tried, and what to bring back, so the next session starts from data rather than "I think it was okay".
Step by step
After each session, write in three lines: what we worked on, what I am to try, what I did not understand.
Each day, one line: what I tried, what happened, mood 0 to 10.
Note the moments the problem showed up ("Tuesday, the meeting, chest tight, left early") in the words you would use in the room.
The night before the next session, read it back and pick the one thing to bring.
Bring the notebook. Therapists love a notebook.
Use it when
Every week of therapy, and for a month after it ends.
Common mistake
Treating the homework as optional because the week was busy. It is not extra; it is the treatment. Tell the therapist honestly if you did not do it; that is useful information too.
5
Telling the therapist when it is not working
2 min, in the room
What it does
Fixes most therapy that is going wrong, without quitting, and is the thing almost nobody does.
Why it works
Therapists cannot read minds, and the research finds that therapists who ask for feedback and adjust get better outcomes. Most people who quit never said anything. One sentence in the room changes the course more often than not.
Step by step
Say it at the start of a session, not the end: "Can I say something about how this is going for me?"
Be specific: "I feel like we talk but nothing changes in the week." "I do not understand the homework." "I felt judged last week when I said X." "I wanted to talk about my marriage and we keep doing thought records."
Watch what they do with it. A good therapist is curious, not defensive, and changes something.
If they dismiss it, or it happens twice with no change, that is your answer; card six.
Use it when
Any session where you leave thinking "that was not useful", and especially around session three.
Common mistake
Being polite to protect their feelings. Their feelings are their job. Your recovery is the only thing in the room.
6
The three-session rule (and when to switch)
a decision
What it does
Stops you quitting in the dip, and tells you when the problem is the therapist rather than the dip.
Why it works
Drop-out peaks around session three, when the relief of session one has faded and the work has begun. Most who leave then are leaving just before it pays. But some therapists are wrong for you, and staying with a bad one wastes months and money. Three sessions and one honest question separate the two.
Step by step
Commit to three sessions before judging, whatever session two felt like.
After session three, ask one question: do I feel understood by this person? Not "am I better" (too early), not "do I like them" (irrelevant). Understood.
If yes: stay to session six before judging progress. Do the homework. Use the feedback card if something is off.
If no, or if any red flag has appeared: switch. Say so plainly: "I do not think this is the right fit; thank you." You owe no explanation. Find the next person (card two).
By session six with someone you feel understood by: if the goal-sheet numbers have not moved at all, say so in the room and ask what changes.
Use it when
At session three, and again at six.
Common mistake
Confusing "this is hard" with "this is wrong". The right therapy is often uncomfortable. The wrong therapist is the one who does not get you.
7
Getting the most from fifteen minutes with a psychiatrist
10 min to prepare
What it does
Turns a short, crowded psychiatry appointment into a useful one.
Why it works
A hospital OPD visit may be ten minutes with a queue outside. The doctor is not indifferent; they have eighty people. A prepared patient gets a better decision in that time than an unprepared one gets in an hour.
Step by step
One page, in your hand: the five-line story; current medicines with doses (bring the boxes); what has changed since last visit; side effects, honestly; sleep, appetite, mood 0 to 10; any thoughts of self-harm (say it, even if it is hard; it changes the plan).
Your questions, written: What is this medicine for? How long until it works? What side effects should I expect and which should make me call you? How long will I take it? What if I miss a dose? Can I stop it suddenly? (Almost always no.)
Ask about cost: "Is there a generic?" Usually yes and usually much cheaper.
Ask whether they recommend therapy alongside, and whether the hospital has a psychologist.
Write the answers down before you leave the room. Book the follow-up before you leave the building.
Do not change or stop the medicine between visits without calling. If you cannot tolerate it, call or go back; do not just stop.
Use it when
Every psychiatry appointment.
Common mistake
Saying "theek hai" to "how are you" because the doctor looks busy. That answer wastes the visit. Say the number.
8
Setting up online therapy in a shared house
30 min once
What it does
Makes video or voice therapy actually private and actually work, for the many people whose town has no therapist and whose house has no empty room.
Why it works
Online therapy works about as well as in-person when there is a real therapist; what breaks it is a session interrupted by a brother, a signal that drops, and a person whispering so nobody hears. A little setup solves most of it.
Step by step
Find the corner: the roof, the car, a room with a lock at a fixed time, the courtyard when everyone is out. Zainab uses the roof. Test the signal there.
Earphones, always. Then only your side is audible.
A fixed weekly time when the house is predictably quiet, and one person in the house who knows not to knock (if there is such a person).
Tell the therapist your constraints in session one: "I am on the roof, if I go quiet someone has come up." They have heard it before.
Voice-only is fine if video is impossible. Text-only is weaker; use it only if nothing else exists.
Keep the notebook somewhere private, or use a locked note on the phone.
Use it when
Before the first online session.
Common mistake
Whispering from a shared room and cancelling half the sessions. Therapy needs a door, even if the door is the sky.
9
Telling the family (or not)
10 min to decide
What it does
Settles the question that stops many people booking: who has to know.
Why it works
Nobody has to know. Adults can see a doctor or a psychologist privately; confidentiality is the rule. But some people need someone in the house on side (for money, for transport, for the children), and how you tell them shapes whether they help or interfere.
Step by step
Decide first whether anyone needs to know. Often the honest answer is no, and "I went to a friend’s" is a complete sentence.
If one person should know, choose the one most likely to help, not the most senior. A sibling, a spouse, a cousin who has been.
Frame it as health: "Main kaafi time se theek nahi thi. Main ek doctor se mil rahi hoon, jaise kisi aur bimari ke liye milti. Mujhe bas ye chahiye ke aap kisi ko na batayein aur Thursday ko mujhe jaane dein." "I have not been well for a while. I am seeing a doctor about it, like I would for anything else. I need you to keep it private and to let me go on Thursdays."
If they say nazar, marriage, or "bas dua karo": "It may be all of those. I am also doing this. Both."
If the family is the problem, the therapist will help you decide what to tell and when. That is a legitimate topic for session two.
Before the first session, if the logistics need someone; otherwise, never, if you prefer.
Common mistake
Announcing it to the household as a group. One person, chosen, in private.
10
Keeping it after it ends (the relapse plan)
the last two sessions, then 10 min a month
What it does
Makes the gains last, which is the point of therapy over medicine, and tells you what to do when the old signs come back.
Why it works
Therapy’s advantage over medication is that the effect persists after it stops, but only if the skills are kept and the early warning signs are known. Relapse prevention work in the last sessions reduces the chance of a full return, and a written plan is what people actually use at 3am a year later.
Step by step
In the last two sessions, write with the therapist: my early warning signs (the specific first three: "sleeping past ten", "cancelling Friday", "checking my pulse"); what helped most (the two or three tools, named); what I will do in the first week the signs return; who I will tell; when I will come back.
Keep it somewhere you will find it: the notebook, a photo on the phone.
Once a month, five minutes: re-rate the goal sheet, and read the plan.
When the signs return (they may; that is life, not failure): run the plan for two weeks before deciding whether to book a top-up.
A top-up of two or three sessions in a hard year is normal and cheap compared with a full relapse.
Use it when
The last two sessions, and monthly after.
Common mistake
Ending therapy on a good week and forgetting all of it by the first bad one. The plan is the therapy you take home.
Exercises & solutionsWhich kind of help, when↑ contents
Help comes in steps, and the right step depends on how bad it is and what has already been tried. The picture first, then a flowchart for the first decision, then the situations people write to us about.
Stepped care. Every good health system uses the same idea: the least intensive help that is likely to work, stepped up if it does not. Mild, recent problems often move with self-help and a first conversation. Moderate ones usually need structured therapy. Severe ones need a psychiatrist, often alongside therapy. Danger goes straight to the top. You can enter at any step; nobody will send you back down.
Right now, is there any thought of ending your life, or have you stopped being able to eat, wash, or get up most days?
↓
Yes
Psychiatry firstA psychiatrist, this week, not a counsellor: hospital OPD or private (directory). If in danger tonight, 1122 or the helplines. Therapy comes alongside, once you are safe and steadier.
Self-help, supportedThis site’s master pages and their exercises for a month, our team when you need to talk, a counsellor or university clinic if you want company in it. Retake the test in four weeks; if it climbs, go up a step.
Moderate (10 to 19)
Therapy, with a psychiatrist in reserveA clinical psychologist for structured therapy (CBT or similar), in person or online, eight to sixteen sessions. If it has not moved by session six, or you cannot function, add a psychiatrist. Use the exercises here alongside.
Severe (20 or more)
Both, togetherA psychiatrist for assessment and probably medicine, and a psychologist for therapy alongside; the hospital OPD often has both. Do not try to do this with a page alone.
Common situations
Panic attacks, phobia, cannot take the bus→A psychologist who does exposure-based CBT. Ask that exact question. Our panic page meanwhile.
Grief, months on, stuck→A counsellor or psychologist who works with grief; if it is constant at a year, one who knows prolonged grief. See the grief page.
Intrusive thoughts, washing, checking, repeating wudu→A psychologist who does ERP for OCD, specifically. Not general counselling. A psychiatrist alongside is common.
Memories of violence or abuse that intrude, nightmares, jumpiness→Trauma-focused therapy (trauma-focused CBT or EMDR) from someone trained in it. Ask.
Cannot sleep, and it is the main thing→CBT for insomnia, from a psychologist or from the sleep page, which is built on it. A psychiatrist if mood is also low.
The problem is the marriage, the in-laws, the household→A counsellor or family therapist; sometimes both partners, sometimes you alone first. Individual therapy can help you decide what to do inside a system you cannot change.
A town with no therapist at all→Online therapy from the roof; the nearest teaching hospital for a psychiatrist; our team in between.
Money is the problem→Hospital OPD for medicine, university clinic or NGO for therapy, online for cheaper sessions, a reduced rate asked for plainly. The cost section.
Already on medicine and want therapy too→Good; the combination does best for moderate to severe. Tell each professional about the other. Do not stop the medicine because therapy has started; that is the prescriber’s call.
Not sure any of this is for you→Message our team. "I do not know if I need therapy" is a sentence we hear every day, and we will help you work it out.
The first month of therapy is mostly about getting to session four. Most people who reach session four with someone they feel understood by go on to finish, and most who finish get better. Here is the month.
No. Confidentiality is the foundation of the work, and a therapist who broke it would not be one for long. The one exception, which they should state in the first session, is if they believed your life or someone else’s was in immediate danger, in which case they would involve someone to keep you safe and would tell you first. Short of that, what you say stays in the room. If you are under eighteen, ask what the rules are for you; they vary.
Does going to therapy mean I am mad? Log kya kahenge?
The people in a psychologist’s waiting room are students before exams, mothers after births, men after redundancies, people after deaths, and people whose sleep has gone. Madness is not the entry requirement; being stuck is. As for log: almost nobody will know, because appointments are private and nobody on the second floor of a building with a dentist is looking at who else is there. What people do notice, months later, is that you seem more like yourself.
Is it just talking? How can talking fix depression?
Talking is the medium, not the mechanism. What changes things is what the talking produces: a clear picture of the pattern you are inside, tools for it, and new experiences between sessions (the walk you took, the crowd you stayed in, the thought you tested) that teach the brain something argument cannot. Therapy where you only talk and nothing changes in the week is therapy that is not working yet, and you should say so.
How long will it take?
For depression and anxiety, eight to sixteen weekly sessions is typical, with many people feeling real movement by six. Panic and phobias can be faster; long-standing patterns and trauma take longer. Very long therapy is unusual for the common conditions and worth questioning. A good therapist tells you the expected length in session one and reviews it as you go.
What if I cry? What if I cannot say it?
You will probably cry, and the therapist will push the tissues an inch closer and wait, because it is the most ordinary thing in that room. If there is something you cannot say, say "there is something I cannot say yet." That sentence is itself progress, and the therapist will not force it. Many people say the thing in session four that they could not in session one.
Can I do it online? My town has nobody.
Yes. Video and voice therapy with a real therapist produce outcomes comparable to in-person for depression and anxiety in most studies, and for a town with no psychologist it is the difference between treatment and none. The practical problem is privacy in a shared house; the online card is about the roof, the earphones, and the fixed hour. Check the therapist’s qualification, not the app’s branding.
Medicine or therapy? Can I stop the medicine now that I have started therapy?
For mild to moderate depression and anxiety, therapy alone is usually the first choice; for moderate to severe, the two together do best; for severe, medicine is usually needed to get you to a place where therapy is possible. Stopping medicine is a decision for the person who prescribed it, never for the therapist and never for a page; most antidepressants need to be reduced slowly and stopping suddenly can make you ill. Tell each professional about the other, and let them coordinate.
Is therapy against Islam? Will they tell me to stop praying or question my faith?
We are not scholars, and we can only tell you what we see: a great many practising Muslims in therapy, therapists who are themselves practising, and no conflict between the two in the rooms we know of. A good therapist works within your values, whatever they are, and never pushes their own. If faith is central to you, say so in session one and ask for it to be part of the work; many therapists will use it as a resource. If a therapist mocks or dismisses your beliefs, that is a red flag, and you should leave. The tradition’s own scholars have written on the care of the self and the treatment of illness for a thousand years; therapy is a modern part of that, not an enemy of it.
What will it cost, really?
From nearly free (a teaching-hospital OPD, a university clinic, an NGO) to a real monthly expense (private therapy in a big city, eight to sixteen sessions). We would rather be vague than wrong: prices vary by city and by year, and the cost section gives the pattern and the ways to bring it down, including asking for a reduced rate, which many therapists offer and few advertise. Our directory marks the low-cost options.
What if the therapist is younger than me, or a woman, or a man, or from a different background?
Ask for what you need; it is normal to request a woman, or someone older, or someone who speaks your language, and a good service will accommodate it. Beyond that, the research is clear that years of experience predict outcome less than you would think, and that feeling understood predicts it more than matching. Give it three sessions and ask the one question: do I feel understood? If yes, age and background rarely matter. If no, switch, without guilt.
What if I do not like them?
Liking is not the test; being understood is. But if by session three you do not feel understood, or any of the red flags has appeared, switch. Say "I do not think this is the right fit; thank you," and find the next person. You owe no explanation and no loyalty. Switching therapists is common, and the second one is often the one that works, because you now know what you need.
Is Zara, your WhatsApp companion, a therapist?
No. Our team on WhatsApp is free, private, and there at any hour to talk in English, Urdu or Roman Urdu. It is not therapy, not a diagnosis, and not a crisis line. It is a good place to say "I think I need therapy and I am scared" for the first time, to work out which door, and to be company between sessions. For treatment, use the directory.
Getting helpWhen therapy is not enough, or not yet possible↑ contents
When therapy alone is not enough
Thoughts of ending your life, at any point. A psychiatrist this week, and if in danger tonight, 1122 or the helplines.
You cannot eat, wash, get up, or function most days. Medicine usually has to lift the floor before therapy can work.
Hearing or seeing things, or periods of needing no sleep and feeling wonderful. These need a psychiatrist, not a counsellor.
Six good sessions with someone you feel understood by, homework done, and no movement. Time to add a psychiatrist, or change the approach.
You are using alcohol or drugs most days. Both need treating, and the order matters; a psychiatrist can advise.
When therapy is not yet possible
No money, no therapist within a hundred kilometres, no private corner, a family that would not allow it. These are real. In the meantime: the master pages on this site are built on the same programmes therapists use, and a month of the exercises is not nothing; our team is free and private at any hour; a teaching-hospital OPD is usually reachable and cheap; and online therapy from a roof is real therapy. Read how to seek help in Pakistan for the pathways, and message our team to work out which one is yours.
If you are in danger tonight. Do not wait for an appointment. In Pakistan, emergency services are 1122. Our crisis helplines page lists free, confidential lines you can call now. Tell one person in the house. Therapy is for tomorrow; tonight is about staying here for it.
Check where you are (2 minutes)The free PHQ-9 and GAD-7 self-check. Private; nothing is stored. It tells you which door, and it is what the therapist will ask you anyway.
Find someoneOur directory covers psychiatrists, psychologists and counsellors across Pakistani cities, including low-cost hospital OPDs and online options. How to seek help in Pakistan walks through the pathways, the costs, and what registration means.
Talk to our teamFree, private, any hour, in English, Urdu or Roman Urdu. Not therapy, not a crisis line, but a real place to say "I do not know if I need this" and be helped to find out. Use the button at the bottom of this page.
Peer supportThe HEALING community below is people walking the same road, many of them in therapy or thinking about it. Not a treatment, not for emergencies; for the question "what was your first session like?"
Everything factual on this page traces to one of these. Where we were not sure of a number, especially on cost, we did not give one.
Cuijpers, P. et al. (2023). Psychological treatment of depression: a systematic overview of a ‘Meta-Analytic Research Domain’. Journal of Affective Disorders, 335, 141–151. Cuijpers, P. et al. (2020). A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in adult depression. World Psychiatry, 19(1), 92–107.
Carpenter, J.K. et al. (2018). Cognitive behavioral therapy for anxiety and related disorders: a meta-analysis. Depression and Anxiety, 35(6), 502–514.
Flückiger, C., Del Re, A.C., Wampold, B.E., Horvath, A.O. (2018). The alliance in adult psychotherapy: a meta-analytic synthesis. Psychotherapy, 55(4), 316–340.
Wampold, B.E., Imel, Z.E. (2015). The Great Psychotherapy Debate (2nd ed.). Routledge. Common factors and the relative weight of technique.
Howard, K.I., Kopta, S.M., Krause, M.S., Orlinsky, D.E. (1986). The dose-effect relationship in psychotherapy. American Psychologist, 41(2), 159–164.
Kazantzis, N. et al. (2016). Quantity and quality of homework compliance: a meta-analysis of relations with outcome in cognitive behavior therapy. Behavior Therapy, 47(5), 755–772.
Swift, J.K., Greenberg, R.P. (2012). Premature discontinuation in adult psychotherapy: a meta-analysis. Journal of Consulting and Clinical Psychology, 80(4), 547–559.
Andersson, G., Titov, N., Dear, B.F., Rozental, A., Carlbring, P. (2019). Internet-delivered psychological treatments: from innovation to implementation. World Psychiatry, 18(1), 20–28.
Rahman, A., Malik, A., Sikander, S., Roberts, C., Creed, F. (2008). Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. The Lancet, 372(9642), 902–909.
Naeem, F. et al. (2015). Brief culturally adapted CBT for psychosis (CaCBTp) and for depression in Pakistan: feasibility and randomised trials. Behavioural and Cognitive Psychotherapy and Schizophrenia Research.
World Health Organization (2021). Mental Health Atlas 2020. Country profile: Pakistan. Workforce figures.
NICE (2022). Depression in adults: treatment and management (NG222). Stepped care; therapy first for less severe; combination for more severe.
Pakistan Medical and Dental Council: registration verification for doctors. College of Physicians and Surgeons Pakistan: FCPS in psychiatry. Higher Education Commission: recognised degrees in clinical psychology.
Written by the Depression.pk team. Reviewed for safety before publication. Not medical advice: a place to start, and a description of what to expect. We are not clinicians; we connect people to independent professionals, and we do not endorse any individual practitioner. Costs are described as patterns people report to us, not as quotations; check before you book. Last updated September 2026.
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House rules: privacy first · no judgement · no private messages to members · no medical advice · no selling · no politics or religious debate. Read the rules. If you're in danger right now, please use the helplines below — the group is for support between people, not emergencies. Note: group members can see each other's phone numbers, so share only what you're comfortable with.
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