When Coaching Isn't Enough, and Therapy Feels Like Too Much

Most of the founders and senior leaders I work with are not falling apart.

The board meetings happen and the numbers land. Their teams would describe them as calm and capable, maybe a little stretched. In private it looks different. They wake at 4 a.m. running scenarios. Decisions that used to take an hour now take a weekend. They're shorter with the people closest to them, and rest keeps getting pushed back until after the next funding round or the next quarter.

Many of them have already tried coaching. It helped them set goals, communicate better and think more strategically. But the same patterns keep coming back, because they were never only about strategy. Therapy, on the other hand, can feel like the wrong fit: open-ended, slow to get going, and with no clear endpoint for someone whose diary is already full.

I'm a psychotherapist and also a founder. I've worked clinically for more than 15 years, in the UK, US, Singapore, Qatar and India, and for the last few years I've also been building a healthtech company. Having been on both sides, I think the most useful work for leaders happens somewhere between coaching and therapy. Below I explain what that looks like, and why a short, structured programme suits it.

The hidden cost of high function

The research suggests this is common among people at the top.

In a study of 242 founders led by Michael Freeman at UCSF, nearly half reported one or more mental health conditions. Once family history was included, 72% were affected directly or indirectly [1]. When Deloitte surveyed 1,050 C-suite leaders across the US, UK, Canada and Australia, nearly 70% said they were seriously considering leaving for a role that better supported their wellbeing. 73% said they could not take time off and disconnect [2].

The UK figures show how widespread this is. Deloitte estimates that poor mental health costs UK employers £51 billion a year. The largest share, around £24 billion, comes from presenteeism: people at work, but not working well [3]. In the same research, 63% of workers showed at least one sign of burnout, up from 51% in the previous survey [3]. The Health and Safety Executive records 22.1 million working days lost to work-related stress, depression or anxiety in 2024/25. That is more than half of all working days lost to work-related ill health and injury [4].

For leaders, presenteeism is the figure to pay attention to. Founders rarely take sick days. Instead, the cost shows up in their decisions, which become slower, more defensive and more rigid. Research on sleep loss finds that flexible, creative thinking is affected first. People who are short of sleep tend to stick with strategies that worked before, and are slower to change plans when the situation changes [5]. That's a real problem for someone whose job is to read a changing market and adjust.

Where coaching stops and therapy starts

Coaching works. A meta-analysis of coaching in organisations by Theeboom, Beersma and van Vianen found significant positive effects on every outcome measured: performance, wellbeing, coping, work attitudes and goal-directed self-regulation. Effect sizes ranged from moderate for coping (g = 0.43) to large for goal-directed self-regulation (g = 0.74) [6]. Good coaching gives people structure, accountability and a forward focus, and leaders respond to all three.

But coaching is built to work with the conscious, rational parts of how we operate: goals, plans and behaviours. It is less equipped for the parts that run underneath. Examples include the vigilance learned in a chaotic childhood that now shows up as micromanagement, the conflict avoidance that once kept the peace and now lets a co-founder relationship quietly decay, and the sense of worth that rises and falls with the company's valuation.

Those patterns are what psychotherapy is designed to work with. They also turn up in coaching sessions far more often than most coaches are trained for. In a survey of 148 coaches, only 20% had formal training in psychology or another helping profession. The researcher recommended that all coaches be trained to recognise mental health issues and refer appropriately [7].

Many of the best coaches I know are the ones who notice when a client's "time management problem" is really sleep loss, grief or anxiety, and refer them on. But too often the leader is left choosing between a coach who can't go deep enough and a therapist whose format doesn't fit their life.

What a synthesis looks like

I'm not suggesting coaches should become therapists, or that therapy should become coaching. What I'm suggesting is taking the most useful parts of each and combining them in one programme. It should be led by someone with clinical training, who can work at depth and can also tell when a client needs more than a short programme.

Here is how the pieces fit together:

• A defined goal and an endpoint (coaching) plus understanding why a pattern exists (psychotherapy) gives you two specific shifts, traced back to their roots.
• Accountability between sessions (coaching) plus working with emotion and the body, not only thought (psychotherapy) gives you practical techniques used in real high-stakes moments.
• Forward focus (coaching) plus attention to relationships and history (psychotherapy) gives you one key relationship changed, with a script to do it.
• Practical tools (coaching) plus clinical assessment and safeguarding (psychotherapy) gives you measured outcomes, and an honest referral if more is needed.

In practice, that means a few things a typical coaching engagement doesn't offer:

• An assessment at the start, using validated measures of stress, burnout, sleep and wellbeing, repeated at the end.
• Work on the emotional and physiological side of pressure, not only the strategic side.
• The willingness to say, at the outset, "this isn't the right format for what you're carrying", and to suggest what is.

It also means a few things open-ended therapy usually doesn't offer: a clear endpoint, a weekly agenda tied to the client's real calendar, and something written to keep.

Why short, structured and intensive can work

A fair question is whether four to eight sessions can make a real difference. The research suggests they can for many people, though not for everyone.

The best-known study of how much therapy people need comes from Howard and colleagues in 1986. Pooling 15 datasets, they found that around 53% of patients had measurably improved by the eighth session, rising to 74% by the twenty-sixth [8]. Later analyses were more conservative. A review by Hansen, Lambert and Forman estimated that 13 to 18 sessions are needed for half of patients to recover. The same review found that in routine practice the median number of sessions attended was only about three [8].

That last figure stood out to me. Many people stop therapy before it has had time to work. Often the problem is the format rather than the method. There's no agreed endpoint and no clear agenda, and for a busy leader it's always easy to justify cancelling the next session.

There is also growing evidence that even very brief, focused work helps. A 2025 umbrella review in the Annual Review of Clinical Psychology covered 24 systematic reviews, 415 trials and more than 40,000 participants. It found that single-session interventions produced small but real benefits for anxiety, depression and substance use. Multi-session therapies showed a similar, slightly larger effect. The authors conclude that brief interventions should be used alongside longer-term support rather than instead of it [9].

Based on this evidence, I think a short programme works best when:

• it is aimed at a focused problem, such as how someone carries pressure, rather than a long-standing clinical condition;
• it has a clear structure and endpoint, so the time isn't lost to drift;
• it measures where the person started and finished; and
• it is honest, from the first conversation, about when longer-term therapy is the better choice.

Four to eight sessions won't undo patterns that have built up over a lifetime. They can interrupt the ones causing you the most trouble now, and give you the tools to keep doing that yourself.

What actually changes in a reset

The phrase "thought process reset" can sound vague, so here is what it means in practice.

1. You see the load clearly. Most leaders can describe their pressures, but few have mapped them. Where does pressure enter the week? Which relationships amplify it? Which decisions keep getting deferred? Putting that on paper, alongside scored measures of stress, burnout and sleep, turns a general sense of strain into something specific enough to work on.

2. You notice anxious predictions before they shape the meeting. Under sustained pressure, the mind tends to predict the worst. It assumes the board has already decided against you, or that one bad result means everything is failing. Much of the work is slowing those predictions down before a real high-stakes moment. That means naming the pattern, separating the worst case from the most likely case, and going in with one clear point you want to make.

3. You use your body to calm your mind. Understanding a problem rarely slows a racing heart before a difficult call. Simple breathing techniques can help. In a randomised controlled study published in Cell Reports Medicine, five minutes a day of cyclic sighing (breathing with a long, slow exhale) improved mood more than mindfulness meditation over one month. It also lowered breathing rate more [10]. Leaders tend to like it because it's quick, you can track it, and you can use it in the two minutes before a meeting.

4. You protect sleep and recovery. Sleep, recovery and attention directly affect the quality of your judgement. Given what sleep loss does to flexible thinking [5], setting limits on meetings, messages and evening work is part of doing the job well.

5. You change one relationship pattern. Very often, the pressure that matters most runs through one relationship, with a co-founder, a chair or a partner at home. Once you understand the cycle, including where your own history feeds into it, you can have a different conversation instead of repeating the same one.

6. You leave with something written. Coaching and therapy usually leave nothing on paper. A reset should end with a short, confidential document in the client's own words. It sets out their patterns, the techniques that work for them, and the early signs that pressure is building again. Having it written down helps the changes last after the sessions end.

Who this is for, and who it isn't

A structured reset is a good fit if:

• you lead a company, team or practice, and the pressure has been sustained for months rather than a single bad week;
• you are functioning well on the outside and paying for it privately, in your sleep, your patience or your health;
• you have tried coaching or self-help and keep returning to the same patterns; or
• you want structure, a clear endpoint and something to keep.

It is not the right fit if you are in crisis, if you are experiencing a mental health condition that needs ongoing treatment, or if what you are carrying needs open-ended space to explore. In those cases, longer-term therapy is the better choice, and a good clinician will tell you so in the first conversation. If you are struggling right now, please contact your GP, call NHS 111, or call Samaritans on 116 123.

A closing thought

The leaders I work with don't usually need to be told to work harder or think more positively. They need a clear picture of where their pressure comes from, practical ways to handle it differently, and time to look at the patterns underneath, in a format that fits around their lives.

That is why I built the Executive Reset, a structured programme for founders and senior leaders. It is delivered in person in London and online, with measured results and a confidential written Blueprint at the end. I'm currently offering founding places to my first five clients. You can find the details below.

If you're a coach and this sounds familiar from your own work, I'd like to hear from you. Clients get the best results when coaches and therapists know when to refer to each other.

Sana Fatima is a BACP-registered integrative psychotherapist (MBACP), holds an MSc in Psychology, and is the founder of MySafeTherapy.

References

[1] Freeman, M. & Johnson, S. (2015). Study of 242 founders' mental health, UCSF. Reported in KQED, "In the entrepreneurial world, mental health problems can have positive effect, says researcher", 23 April 2015.

[2] Silverglate, P. H. & Fisher, J. (2022). The C-suite's role in well-being. Deloitte Insights. Survey of 2,100 respondents (1,050 C-suite) in the US, UK, Canada and Australia.

[3] Deloitte UK (2024). Poor mental health costs UK employers £51 billion a year for employees. Press release, 17 May 2024. Survey of 3,156 UK working adults by YouGov.

[4] Health and Safety Executive (2025). Working days lost in Great Britain, 2024/25.

[5] Harrison, Y. & Horne, J. A. (2000). The impact of sleep deprivation on decision making: A review. Journal of Experimental Psychology: Applied, 6(3), 236–249.

[6] Theeboom, T., Beersma, B. & van Vianen, A. E. M. (2014). Does coaching work? A meta-analysis on the effects of coaching on individual level outcomes in an organizational context. The Journal of Positive Psychology, 9(1), 1–18.

[7] Spence, G. B. (2006). New directions in the psychology of coaching: The integration of mindfulness training into evidence-based coaching practice. Doctoral thesis, University of Sydney.

[8] Hansen, N. B., Lambert, M. J. & Forman, E. M. (2002). The psychotherapy dose-response effect and its implications for treatment delivery services. Clinical Psychology: Science and Practice, 9(3), 329–343. Includes a summary of 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.

[9] Schleider, J. L., Zapata, J. P., et al. (2025). Single-session interventions for mental health problems and service engagement: Umbrella review of systematic reviews and meta-analyses. Annual Review of Clinical Psychology, 21. Summary: The Mental Elf; Northwestern University.

[10] Balban, M. Y., Neri, E., Kogon, M. M., et al. (2023). Brief structured respiration practices enhance mood and reduce physiological arousal. Cell Reports Medicine, January 2023.