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How to Pick A Good Therapist

Posted Aug 27 2009 11:38pm
More people than ever are seeking professional counseling services in one form or another. Thankfully, the stigma of seeing a mental health professional is waning and people are becoming better educated regarding the various options available to them. Needless to say, psychotherapy can be extremely helpful, and it is almost always a good idea if a person is at all interested in it, assuming there are no major contraindications (see Part II) and the client-therapist relationship is a good fit. Unfortunately, as many people have experienced, a trial of psychotherapy can also result in disappointment and/or greater confusion. As is the case with medical malpractice between doctors and patients, it is a fact of life that some therapeutic alliances between professional counselors and their clients go terribly awry. In some cases this is because of the relative inexperience of an otherwise well-intentioned therapist; in other instances it may be due to a therapist's gross negligence, or his or her own psychological morbidity; in still other cases, it’s simply due to a poor match: some client-therapist alliances just aren't meant to be.

Because the start of a successful psychotherapeutic endeavor begins with the therapeutic relationship itself, selecting the right therapist is of paramount importance. It is also one of the most uncertain tasks, especially when practical considerations such as geographical location, availability and insurance requirements come into play. The topic of selecting the right therapist could fill a book. This article will briefly touch upon a few things to consider when making that selection. Part II, to be published separately, will discuss how to embark upon meaningful, successful psychotherapy by setting goals, avoiding pitfalls and engaging your therapist.

Because there is no practical way of comprehensively screening a potential therapist before therapy actually begins (it is often not until therapy is well under way that both the client and the counselor begin to develop a true sense for the other person), you will probably have to settle for an empiric, trial-and-error process, but the following guidelines should improve your chances of success without encouraging you to "therapist-shop." We'll see that, while it is reasonable to "interview" a potential new therapist on the first visit before committing to weekly sessions, you will want to resist the urge to shop around for someone who is only going to tell you what you want to hear, enable your maladaptive behaviors, or just validate you without asking you to really examine yourself and take a critical look at your choices in order to effect real change. It's not always a comfortable, pleasant experience, but if you invest in it fully, the rewards can be great.

In searching for a good psychotherapist, you will certainly want someone with acceptable credentials, which involves four things: schooling, training/experience, certification, and more experience. None is more important than experience.

There are various types of degreed professionals who engage in psychotherapy, primarily social workers, clinical psychologists, and some psychiatrists. Although psychiatrists are medical doctors whose formal education and training is the most extensive of the group, M.D.s and D.O.s are not necessarily any better at providing professional counseling than social workers or psychologists. In fact, doctors may be significantly less prepared in that respect. This is because physicians of any specialty are licensed to conduct therapy, despite the fact that they are not required to take any psychology or sociology courses as part of their pre-med curriculum and likewise, they are not schooled in psychotherapeutic principles as medical students (graduate students may take a brief, basic course in behavioral health before their psychiatric rotations in their third or fourth year). As for psychiatric training, the trainee may or may not spend a significant amount of time practicing counseling under supervision, depending upon the specific residency training program, but in any case this is not the primary focus of residency training. Psychiatrists are medical doctors first and foremost, so they concentrate on diagnosing mental illness, ruling out treatable physical causes and managing symptoms with medications. Some residents in psychiatry receive surprisingly little in the way of formal instruction regarding psychotherapy. Do not assume that, because doctors have endured a rigorous and lengthy program of education, it makes them better therapists.

The only distinct advantage to having an M.D. or a D.O. as a therapist, beyond the fact that a doctor is able to bring the full breadth and depth of her medical knowledge to bear in diagnosing any physical conditions that may be present (as well as ruling them out) is that your therapist then also has prescriptive authority, in the event that you need or would benefit from a trial of psychotropic medication. A therapist comes to know you very well with the typical, once-weekly hour-long sessions, so if and when it becomes necessary to prescribe or adjust a medication, such an arrangement places the prescribing physician at an enormous advantage in terms of being able to consider, in-depth, the psychosocial factors relevant to your situation before deciding what to recommend regarding the medication. Even if you are meeting only every other week, you are still spending far more time, far more often with your psychiatrist than you would otherwise. Imagine the advantage of having up to a full hour to discuss medication issues and your various treatment options, as opposed to the standard 15-minute "medication check" every few weeks or months that is currently the industry standard.

Because psychiatrists and independent therapists are not always easily able to coordinate the care of the many patients they see and whom they may treat in common, having a therapist who is also your psychiatrist (and vice-versa) can definitely be an advantage, assuming that your psychiatrist is adept at therapy. To reiterate: the combination of seeing your psychiatrist for therapy practically guarantees that you will receive better psychiatric treatment (diagnosis and medication management), but it does not necessarily mean you are getting the best psychotherapy.

LPCs. As for social workers and psychologists, all licensed professional counselors (LPCs) in Texas must have a master's or doctoral degree in counseling or a counseling-related field from an accredited college or university. Here again, a Ph.D. will not necessarily make a better therapist for a given client than someone with a master's degree, because the ability of a particular therapist to help you depends on a number of factors, least of which is whether or not that therapist completed a dissertation as a graduate student.

When it comes to credentials, check for the minimum requirements (although if the therapist is licensed, the State in which the person is practicing has already done that for you), but beyond that, don't base too much of your first impression on how advanced the degree is, or which institution of higher learning granted it. There is absolutely nothing to indicate that a Harvard or Stanford graduate is going to do a better job working with you than the therapist who spent the first few years earning his degree at a local community college. Therapy is an art, not a science; many aspects of it cannot be learned except through direct experience, and some people are just naturally more gifted with regard to practicing it. Also, therapy is a collaboration, and the right fit often has little if anything to do with how accomplished the therapist's academic career was before sitting down to meet with a client for the first time.

Certification. That said, there are subspecialties in which LPCs can become certified, and inasmuch as these certifications indicate additional experience in a given area, they are certainly a source of added confidence. If you are seeking treatment for drug dependency, for example, you probably want to see an LPC who is also an LCDC: a licensed chemical dependency counselor. (And although not a requirement by any means, still…if substance abuse is the focus of treatment, you might even consider a therapist who is also a recovering addict herself; there is no greater teacher than direct personal experience, and these individuals are especially equipped to guide you through the process of your own recovery in a way that others who have never personally dealt with addiction simply are not.)

Other counseling subspecialists include cognitive and behavioral therapists, child and adolescent therapists, couple, family, and group therapists, and psychoanalysts, to name a few.

Definitely beware the "life coach" with absolutely no official credentials whatsoever. There are State laws governing the way in which these unlicensed individuals are allowed to advertise their services, but claims can be misleading. (Some practitioners may refer to themselves "life coaches" and be schooled, trained and properly certified; I'm only referring to individuals with no formal training whatsoever).

Experience. Do pay attention to how many years a therapist has been in practice. It bears repeating that the best credentials are not diplomas and certifications, but actual experience (the formal training that qualifies for State licensure always includes a significant amount of supervised experience). This is not to discriminate against those therapists who are just starting out, but as with medical doctors, the more time a practitioner has spent in practice and the more clients she has treated, the more opportunity she has had to master her own strengths and weaknesses and to learn from her mistakes.

Seek the best fit. A fully credentialed, Board-certified brain surgeon is going to do the best job she is capable of doing, regardless of what type of person the brain belongs to, but when it comes to engaging the mind, even the most seasoned clinician with one of the most well-honed techniques may not be the best suited to you, if that technique does not meet your particular needs. Someone who may be a wonderful therapist for one type of client may turn out to be a disappointing choice for someone else. Again, therapy is an art, not a science, which is why M.D.s and Ph.D.s--even those extensively trained in psychotherapy--are not necessarily better equipped to counsel you through your particular problems than someone with less formal training but who is perhaps culturally and ideologically a better fit (or simply someone with more innate talent).

The problem, as already mentioned, is that it is difficult, if not impossible, to know from the outset who is going to have the best approach for you and with whom you are going to relate the best over time. You won't know if you are going to clique with your new therapist until it starts to happen. Sometimes you get a good feeling on the first visit, but the therapeutic alliance is a relationship--a special kind of relationship, but a relationship nonetheless--and as in real life, meaningful and rewarding relationships build over time, with the establishment of trust and the building of familiarity. The more your therapist comes to know and understand you, the better able he will be to help you help yourself, and the better your initial choice in therapist will prove to be. Alternately, as you continue working together, differences in philosophy and approach may lead you to realize over time that you are not making as much progress as you would like.

Despite this limitation, it is reasonable to screen a potential therapist at your first appointment. Although the clinician will be performing a formal interview and will have many questions for you, one of them should be what you expect to gain from therapy, and in the context of discussing that, a good therapist will welcome inquiries from you regarding her therapeutic philosophy, experience and style. It's a start.

Give it time. Ultimately this is the only way that you are going to be able to make an informed decision. It may take several visits to get comfortable with a new therapist and to fully determine whether or not therapy is going to work between you. Unless you are immediately put off, you won't really appreciate whether or not you will be able to build a good working relationship until you both have had time to build one, so be patient, but ask questions and reserve some time early on to find out as much as you can about the person with whom you will be sharing and confiding your most important personal information.

The following are some specific qualities to look for in a therapist. Some of these you can ask about, but most you will have to discover for yourself, and the way to begin is to be aware of them.

Empathy. Does the therapist seem to care? Is he engaged with you, does he ask a lot of probing questions that invite you to stop and consider and reveal yourself a little in the answers? And when you go to answer, is he listening, or is he just waiting to ask the next question? Body language and eye contact are things a competent therapist is going to be evaluating in you, but you will also take your cues--consciously or unconsciously--from the therapist's demeanor, so take note if your new therapist seems distracted or disengaged. I've heard plenty of sad stories from patients about therapists actually yawning and looking bored in the middle of a session and yes, even falling asleep! One patient described to me how put off she was by the therapist's slurping his coffee when he met her for the first time. (It wasn't just the fact that he was drinking coffee, of course; it was the disaffected tone in his voice and the way he peered at her dubiously over the rim of his cup.)

It may be tempting for the sake of convenience to simply dismiss a really bad first impression, but this is a professional you have come to see: if your counselor seems indifferent or spends a lot of time quickly asking rote questions that she obviously asks everybody, with no real interest in your answers and no follow-up questions that are tailored to your responses, and she doesn't bother to look up much from her notepad during that first interview (a good therapist takes notes on the first visit, by the way), take these as precautionary signs.

Client-Centered Therapy. There is an entire school of thought built around the notion of empathy for one’s client. Carl Rogers' Client-Centered Therapy (CCT), developed in the 1940s and 1950s and later rebranded as Person-Centered Therapy, was the founding movement in the humanistic school of psychotherapies. It relies heavily upon the notion of "unconditional positive regard" that a therapist should demonstrate for his client. Rogers' belief was that people naturally tend to move toward personal growth and healing if merely allowed the opportunity, and therefore the principal aim of therapy should be to allow that spontaneous process by fostering a comfortable, non-judgmental environment and demonstrating "the utmost respect and regard" for the client. Chief among the therapist's tasks is to listen and try to understand how things are from the client's point of view.

CCT is a non-directive approach in which the beneficial effect of therapy is believed to ensue from a client's ability to feel accepted and valued, which occurs in the context of a properly fostered therapeutic relationship. It is the relationship itself, as a model for what other relationships in the person's life can be like, that is considered instrumental in alleviating a person's symptoms. It is a simple but powerful philosophy, and although most modern therapists (myself included) adopt a more eclectic approach to psychotherapy, drawing what works best from various disciplines and judiciously applying the various principles and tactics to individual cases based on the patient’s ability to benefit from a given technique, I do believe that the Rogerian principles of unconditional positive regard, empathy and openness should underlie every psychotherapeutic relationship. It is a solid, and I think necessary, foundation from which to proceed and build.

On a side note, the opposing ideology of the time was Behaviorism, an experimental approach which rejected notions of introspection and approached psychology on a strictly empirical basis. All behavior can be explained and predicted as a result of mindless conditioning, it argued. Behaviorism gave way to modern cognitive theory, which to be sure includes some of the most useful and effective techniques utilized in modern-day treatment, but even when we, as therapists, opt to focus on extinguishing or reinforcing behavioral responses as opposed to delving more deeply into our shared humanity, there is no reason those techniques cannot be taught and applied with due compassion for their subjects.

Compassion and wisdom. These may sound like fairly lofty qualities--and they are--but they are also necessary virtues for anyone who is serious about practicing the art of psychotherapy and truly helping people. Meaningful, well-administered therapy is a growth process for both the clinician and the client, which is why experience over time is the best guru for a dedicated counselor who truly loves the work. Teachers learn from their students, and therapists learn about the human condition, and about themselves, from their therapy subjects. So if it seems to you that the person who is supposed to be serving as your advocate and guide is narrow-minded, rigid, intolerant or embittered--and this does happen--move on.

Good boundaries. A proper therapist respects appropriate professional boundaries. This ranges from availability issues (see below) to issues such as whether your therapist calls you by your first name and encourages you to do the same, to actual touching. With regard to whether you and your therapist should be on a first-name basis, this is largely a matter of personal preference. With the exception of doctors and their patients, most clients and their therapists seem to be on a first-name basis, as it fosters a more comfortable and intimate therapeutic relationship, but if you have a particular preference regarding what your therapist should call you--and this is entirely your decision--make it known.

With regard to touching, it is accepted that a light hand on the shoulder or in some cases even a comforting or congratulatory hug are within the limits of propriety, but with hugs in particular it is also generally accepted that the client should be the one initiating or asking for that type of gesture, not the therapist. It is generally frowned upon for a therapist to routinely hug his patients, or to ask for hugs, although some therapists would disagree with that, and if a patient asks me for a simple hug, I have found that it is usually okay to grant the request. But if you find yourself wanting to hug or touch your therapist at every visit, that's something you may want to discuss in therapy (cf. transference). Whatever else, a therapist should never make you feel uncomfortable by touching you. If he does, this is something you will need to address.

I learned a valuable lesson once when I extended my arm in an offer to shake hands at the end of my first visit with a patient who was a young, unmarried female Muslim. Despite the fact that she had been reared and educated in the United States, her culture did not permit her to feel at all comfortable making that kind of physical contact with her male treating physician. Although this intelligent young woman was an adult who had lived and worked independently as an engineer before becoming seriously ill, she came to my office in traditional dress, always chaperoned by her mother, and I learned that at the end of subsequent visits, a warm smile and a simple nod conveyed all the politeness and graciousness that any offer of a handshake could have. More, in fact. By being mindful and respectful of her personal boundaries and modifying my overtures accordingly, I earned her trust and respect.

Cultural sensitivity. Entitled, self-righteous, ethnocentric individuals (bigots) are poorly suited for this line of work. Thankfully, few apply! But, particularly if you are a non-native resident who was reared in a different culture, you want your therapist to be interested in and sensitive to the differences that exist between you. Many clients who belong to a minority class perfectly reasonably prefer to see a member of their own ethnic group, to obviate the possibility of cross-cultural misunderstandings. Moreover, if English is not one’s first language, one may do better conducting insight-oriented psychotherapy in one’s native tongue.

Along the same lines, many lesbian, gay, bisexual and transgendered individuals prefer therapy offices that are likewise owned and operated, or at least recommended, by members of the LGBT community, and the same can be said for any minority group that is subject to discrimination. A decent therapist, regardless of his own personal demographics, affords all human beings the respect and dignity they deserve.

One alarming exception to this seen today that bears mentioning because it is so pernicious is the example of "gay conversion" therapy, which is destructive and unnatural in my professional opinion, and unethical and immoral in my personal opinion. Thankfully it is not a mainstream movement in modern-day mental health treatment.

Adaptability. Inasmuch as the typical therapist will see a wide array of individuals in the course of a work week, she cannot demonstrate the same persona with all of them if she has truly mastered the art of psychotherapy. A truly capable therapist, no matter his theoretical persuasion, adapts himself to accommodate the intellect, culture, communication style and symptomatic limitations of the person seeking services. We do not relate to our spouse or partner the same way we relate to our parents or the way we relate to authority figures; we adapt our style to suit the situation and the expectations of the other person. Why would a therapist relate to every patient in the same manner?

If your new therapist uses language you cannot understand and fails to express herself more clearly when you indicate your confusion, or else makes you uncomfortable in the manner and style with which she addresses and interacts with you, despite voicing the hesitation and concern you may be feeling, that may be an indication that the therapist is not a good fit for you, especially if she seems out of touch with the fact that you are not entirely at ease. A therapist must be able and willing to adjust her personality to accommodate the client’s social vulnerabilities, whether they are inherent or whether they are the result of a temporary episode of illness. This is not to say that a therapist’s job is to make sure the client is always comfortable; that may not be possible, or even desirable. It is merely to say that a skilled therapist notices and adjusts the rate, tone and volume of his speech and gestures accordingly.

Openness. A good therapist is not only sensitive to your comfort level at all times, but is likewise continually open to feedback, including criticism; she will not take things personally or become defensive when you point out your dissatisfaction or discomfort with some aspect of your therapy. A truly experienced therapist will carefully consider what you have to say, and either accept it at face value if it is a valid criticism, or else explore it further with you if there are questions or concerns about a possible misunderstanding. Often a client's disillusionment or frustration with the therapeutic process is an opportunity for further introspection and interpretation that neither of you would want to miss. A therapist who remains transparent, honest and genuine in his emotional responsiveness to a client (a quality Rogers called "congruence") encourages the client to do the same, greatly facilitating the therapeutic process and leading to greater satisfaction for both client and practitioner.

Spiritual alignment. Some clients specifically seek faith-based counseling services, which includes pastoral counseling, and in these cases obviously a person would seek a minister, rabbi, priest or guru as appropriate to his religion. If you are atheist or agnostic, it may or may not be important to you to find a like-minded therapist, but an evangelical counselor who specializes in faith-based therapy with a heavy emphasis on prayer would obviously be a poor fit, so keep that in mind.

Also realize that, while some licensed counselors incorporate their own faith in their work and specialize in faith-based psychotherapy, pastoral counselors (clergy) are not licensed therapists. In Texas, theology is not considered a "counseling-related field" by the Department of State Health Services, and so students of theology are not eligible for licensure based on seminary work alone. Absent formal training in providing professional counseling services, pastoral counselors rely more on wisdom and simple compassion than do their professional counterparts, whose philosophies are not dependent upon church doctrine and who are trained in specific therapeutic techniques and interventions that have been tested by research.

Little can go wrong when compassion is the guiding principle, surely, but when compassion fails to refute dogma, suffice to say that not all religious doctrines are necessarily conducive to the mental health of a given individual. If you are a person of strong faith and it is important to incorporate God in your treatment, perhaps it is better to seek a licensed professional counselor of the same religious affiliation as yourself who advertises faith-based services than to simply discuss your problems informally with your clergyperson, although discussing any problem with as many caring individuals who might help is always a good idea, even if you are bound to receive contrasting points of view.

My own personal opinion is that I consider a strong spirituality an invaluable asset for a therapist to bring to bear in the therapeutic context, when it comprises humility and altruism, whereas adamant religiosity, on the other hand--especially of the arrogant and self-righteous variety--only exacerbates real-life struggles in a way that fails to preserve the autonomy and dignity of the individual who suffers…but that’s just my personal opinion.

Thus far I've discussed important qualities and characteristics inherent to the personhood of the therapist, qualities that cannot be taught, but that can be cultivated with a sincere effort and interest in the art of psychotherapy. One question you might ask your new potential therapist is why she chose counseling as a profession in the first place. The answer might give you a good idea about how interested in and dedicated to the practice she is. The following considerations are likewise a testament to the type of professional you will be relying upon, but have more to do with the practical aspects of your treatment.

Availability. Being on-call and available to clients for after-hours emergencies and consultations is an unavoidable part of any health profession. The question is: how badly does your therapist try to avoid it? Therapists who flat-out tell their prospective new clients up front that they don't normally make themselves available after hours are sending a very clear message, one you should hear for what it is. I personally find the practice of broadcasting such a thing in such a manner a bit distasteful. I want my patients to understand that they can rely upon me in an emergency, not that I don't want to be bothered. Posted signs and other communications from your therapist's office that warn that you may be charged extra for after-hours services are one indication of where the therapist's priorities lie.

On occasions when you do have to contact your therapist outside of your usually scheduled appointment time for more routine matters, how easy is it to leave a message and how long does it take to get a callback? If you call during normal business hours, it is customary to get a call back by the end of the day, unless you call late in the afternoon.

Confidentiality. This almost goes without saying, but your therapist is required by law to maintain the privacy of your protected health information, and should provide you with a copy of her office's privacy practices. Just as you would never want your therapist to casually discuss your case with others, your therapist should never discuss the treatment of her other clients with you, except in the most general of terms, for illustrative purposes that pertain to your situation and that have to do with her experience in dealing with the issue at hand. It is very bad form to overhear a therapist discussing his cases with other professionals, and if your therapist is fond of gossiping in session with you directly, think seriously about the implications that has on your own treatment. I have witnessed these types of behaviors myself, and so while I hesitate, I have to mention it here.

Other therapist variables depend on you: do you have a gender preference? It's okay if you feel more comfortable with someone of the same gender, for example, especially if your issues are gender-specific or involve sexuality. Age can be another preference; many adults prefer a therapist who is at least their age, if not older. Whether or not your therapist has ever been married might also be a consideration if you are seeking couples' counseling, although don't discount divorced therapists, who may have even more valuable insights into marriage--as well as the process of extricating yourself from one that isn't healthy--because of having lived through it.

Finally, it's okay to "fire" your therapist if things aren't working out, but before you terminate the client-therapist relationship be sure to discuss your concerns openly and honestly. A good therapist welcomes constructive feedback, which might salvage the therapy if offered sincerely and early on, or if not, at least provides the therapist the opportunity to improve for the next client.

Also, sometimes a person will become disenchanted with her therapist or with therapy in general because the therapeutic process has become difficult or anxiety-provoking. This may actually indicate that progress is being made, albeit uncomfortably, and that therapy should definitely not be interrupted. Having one final debriefing session to discuss your reasons for wanting to quit or switch to a different therapist prevents sabotaging perfectly good therapy when it gets stressful and helps to avoid "therapist shopping."

Less commonly, a therapist might suggest or even insist upon the need to terminate the therapeutic relationship and that you find another provider. There are only a few situations in which this is professionally appropriate. In every instance, adequate referrals should be offered to you, as well as instructions as to how to have your medical records forwarded to your next provider.

Of course, people "graduate" from therapy all the time, and since that is generally the goal, even with longer-term therapies, it is an occasion to celebrate, indeed.

It's good to have many advisors in your life, some of whom may be licensed professional counselors, but most of whom will be the people in your life: family, friends, colleagues, a member of the clergy, a teacher, a mentor, or any of a number of other role models. Perhaps you consult regularly with a fitness instructor or a dietician, or a home health nurse. Maybe you look up to a supervisor at work. Perhaps you are particularly impressed by the works of your favorite author, or inspired by the imagination of a great artist. Anywhere you encounter wisdom and compassion and a desire to be helpful, assistance can be found. And if you go through life with a healthy outlook and the right attitude, at the right time and with the right persons you may be that altruistic guiding influence.
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