A neighbor of mine recently consulted a psychotherapist for help with depression. Her internist had put her on an anti-depressant and referred her to a psychotherapist. She had just come from her first session. She asked me questions that many people have when beginning therapy (or even when they've been there for a while): What's supposed to happen, she asked? We talked and she asked me a lot of questions, including some about my childhood. The therapist told me the name of her approach, what she called her "orientation," and had diplomas on her wall, but does any of that really matter?
It's not always clear to patients what to ask a potential psychotherapist and how to know if he or she is any good. It's also hard to know if it's working. Most people find it easier to assess the skill of a medical practitioner. Although by no means always reliable, the medical school and residency where your medical doctor or surgeon trained is sometimes significant. Sometimes he or she might be mentioned as one of the "100 Best Doctors" in a magazine (although such lists are rather suspect). The intelligence, interest, and care that your doctor communicates are all usually apparent right away and, most of all, his or her treatment recommendations either help you feel better or they don't. Their interventions relieve you of your symptoms, cure your illness, or the practitioner offers a good explanation as to why not. There are exceptions to all of these considerations, but, in general, there are some obvious guideposts in assessing traditional medical care.
But are the same things relevant to assessing your therapist? For example, psychiatrists (practitioners with M.D.s), clinical psychologists (Ph.D.s), clinical social workers (LCSWs), marriage and family therapists (MFTs) all offer some form of psychological therapy. In addition, there are counselors of various kinds and "life coaches" that, for all intents and purposes, talk to and help clients in ways that are often similar to traditional "psychotherapy."
Obviously, this proliferation of degrees and training doesn't mean that there aren't important professional differences and boundaries. For example, only clinical psychologists are trained to administer and interpret many psychological tests. And almost all therapy of the sort I'm describing involves talking and not touching (although there are powerful approaches to healing that do involve work with the body, but that's outside the scope of this blog).
With the exceptions already mentioned involving medications and testing, the fact of the matter is that degrees matter very little in "vetting" the ability of a therapist. I've known MFTs who are much better therapists than those with Ph.D.s. I've known coaches who have helped heal someone's suffering every bit as thoroughly as a licensed clinical social worker. In the therapy world, each degree-based "professional" likes to sell him or herself as unique, but my experience has taught me that the letters after someone's name and the plaques on his or her wall are rarely the most important consideration in choosing a professional to help you with your psychological suffering. Finally, there seems to be a wider range of individual differences in the effectiveness of practitioners within each of these so-called specialties than there is between professions and certainly more variation that one usually sees within medical specialties.
Our field, then, is a veritable Tower of Babel of degrees, approaches, and specialties. Add to this the aforementioned chasm of individual skill and experience levels within each category, and the consumer is often left confused. To make matters worse, when that consumer doesn't feel any better either in the short or long run, there is a natural but insidious tendency for him or her to feel responsible. Such a person's original self-doubts and pessimism are reinforced. Self-blame is often the terrible price paid for failed treatments. Demoralization can result.
So, what can one do? Bearing in mind that there are exceptions to every rule and that, when it comes to the human mind and heart, few generalizations are 100 percent reliable, here are some guidelines for someone seeking psychotherapeutic help:
1) Trust your gut. After a few sessions, you may not feel "better" or "cured," but you should be feeling more optimistic, relatively understood, and have an intuitive sense that you and your therapist are on the right track. If you do, stay the course. If these feelings are clearly lacking, don't continue and, instead, get a referral to someone else. If you're not sure, then go back and raise your doubts and uncertainties about the process directly with your therapist. A good therapist will often respond to such doubts in a smart and empathic manner, enough to immediately reassure you that he or she "gets it" and is worth some further investment. On the other hand, some therapists will respond in ways that are defensive or subtly blame you for whatever doubts you are voicing. You'll feel worse. That's a clue that the relationship is probably not going to work.
2) Nothing that I've just said should imply that therapy isn't sometimes hard, even very hard. Digging into what ails you isn't much fun. Giving up old assumptions, addictions or familiar defenses can unleash painful feelings. Feeling pain isn't necessarily a bad thing, especially if you can see where it comes from and how experiencing it might help you eventually get better. For example, you might leave a therapy session feeling lousy, not because your therapist didn't understand you but because she or he did. The therapist's empathy helped you experience something important. My view is that a patient can usually differentiate between feeling something painful more deeply as a result of insight and empathy and feeling bad because a therapist just didn't "get it."
3) Good psychotherapy usually involves acquiring a deeper understanding of how your mind and heart work and something about the reasons that you're suffering. But therapy isn't an intellectual exercise. You have to feel understood and you have to feel that there's a connection between what you're learning about yourself and the suffering that brought you into therapy to begin with. In other words, insight is usually a core part of any good therapy, but not for its own sake. In a good therapy, you will have a gut feeling about how self-exploration will help you with what ails you.
4) Good therapists don't have to be right and shouldn't act like they do. We understandably endow therapist with authority in the same way we do anyone upon whose expertise we depend, but an expert who always has to have the answer, can't admit mistakes or change his or her mind in response to what a patient is saying, is not someone you'd want to entrust with your care.
5) Good therapists can explain not only how their approach can potentially help you feel better but can periodically and non-defensively review with you the progress -- or lack thereof -- of your treatment. It's your treatment. Your therapist isn't using a secret decoder ring to plan and plot it all out. Good therapists are comfortable with honest and transparent conversations about your progress and, if its stuck or lacking, are open to trying different approaches or taking different tacks. Problematic therapists are covertly defensive, always throwing the question of progress back in your lap and, therefore, appearing to avoid their responsibility for at least half of what's going on.
Unfortunately, there are many people practicing the psychological healing arts who are poorly trained or unable to empathically tailor their approach to the particular personalities and difficulties of their clients. Given the degree to which people who are suffering from emotional problems are often self-blaming, suspicious of their own judgment, and struggling with a secret belief that they are doomed, it's easy to see the potential for damage in any therapeutic dyad. Patients have to be encouraged and taught how to judge the abilities of their therapists and the value of the therapeutic outcomes that result.