WHAT SHOULD I LOOK FOR IN A THERAPIST?

Most psychologists believe themselves to be "good" therapists. No clinician wants to think of themselves as simply average in knowledge and therapeutic ability, or even worse, incompetent. However, it seems to me that many of us will necessarily overestimate our level of competence, and our clients will seldom know the difference until after they have invested a significant amount of time, money, and emotional energy in the process of therapy. Potential clients can sometimes secure a good referral through word of mouth - either by a friend or family physician. I think another way to ensure you get the most from your investment is to do a little bit of research. I am admittedly biased about what qualities I think make a good clinician, and not all approaches or personality styles will work for every client, but I believe some of the ideas below will help you think about what you might want to look for.

A Sensible Therapeutic Approach

A common misconception is that psychologists are more-or-less homogenous in their therapeutic approach. Many clients expect, for example, that if they are struggling with "anxiety," then no matter what psychologist they book with, the approach should be essentially the same. However, this is not at all true. All psychologists will tend to make sense of their clients, their presenting symptoms, and other therapeutically-relevant material in the context of the specific theoretical paradigm(s) they adhere to. These paradigms serve as a roadmap or blueprint to assess presenting issues and plan a therapeutic intervention. The many paradigms in clinical psychology may include: Cognitive-Behavioural, Psychodynamic, Interpersonal, Existential, Humanistic, Client-Centered, and so on. It is important to note that these individual theoretical camps or conceptual communities tend to be quite restricted or narrow in their thinking - each one will tend to read the same kinds of books, attend the same conferences, and share the same preferred language or jargon particular to their specific paradigm. For these reasons, the field of psychology has been historically divided by warring theoretical camps that all believe they have the most effective or empirically validated approach to therapy.

This raises an important question: if psychologists cannot seem to agree on the most appropriate form of treatment, then how is a client supposed to know which treatment will work best for them? Well, one thing to keep in mind is that psychotherapy research has consistently shown that a psychologist's therapeutic approach often accounts for less than 10% of the therapeutic outcome (2007, Parker & Fletcher). Does this mean that therapeutic approach does not matter? No, not necessarily. Despite their limitations, the research literature seems to suggest that an approach must be somewhat sensible and "likely efficacious" to have a positive influence beyond "placebo" or "expectancy" effects. So, while therapeutic approach may not be as important as you might think, it should nonetheless be clearly explainable and should make some reasonable sense to both the therapist and client. My own experience tells me that therapy approach is indeed important, though it ought to be individually tailored to the personality style of each client and the nature of their presenting issues - the large sample empirical studies are generally too broad to do this kind of detailed analysis or evaluation, though qualitative case-studies would seem to support my position.

I think it boils down to this: 1) your clinician should be able to tell you, at any given moment, why they are taking a particular stance or approach in therapy - after all, your clinician MUST be accountable for what they are doing in those sessions, and 2) the therapeutic approach should make sense to you, or you ought to have enough trust in your clinician that you are willing to let them guide you along for a short period of time until it does. If either of these two points are ongoing therapeutic issues, I recommend you discuss them with your clinician - if they cannot be answered or resolved, it might not be a good therapist-client fit.

You can read more about my own therapeutic approach on the about me page. In short, I consider myself a "theoretical integrationist," which means that I draw from various paradigms to create a unified theoretical framework which allows me to broadly conceptualize the issues my clients want to address in therapy. In other words, the conceptual framework that I use is theoretically diversified. This stance is also supported by my other professional and academic interests within the field of psychology. For example, I teach a fourth-year theoretical course on human personality, which allows me to appreciate the overlap and points of integration among seemingly opposing theories. My academic interests and professional writing also involves topics within "the philosophy of psychology" - a subfield that critically examines the methodological and scientific assumptions within the larger field of psychology. This perspective allows me to better question some of the assumptions of my discipline, to think critically about my own theoretical approach, and to reason carefully about the client and therapist role in the therapy process.

A Flexible & Tailored Therapeutic Approach

Many psychologists, in accordance with the recent "evidence based therapy" movement, believe that when clients meet criteria for specific "mental disorders" (e.g. depression or anxiety), they should be prescribed therapies that have been "empirically validated" for treating that specific disorder. This increasingly popular approach is based on research that supposedly demonstrates the effectiveness of a specific kind of therapy with specific kinds of disorders. The less critical psychologists usually take the research at face value, and will often practice exclusively from one or perhaps two theoretical paradigms claiming to be empirically validated. I am sure this approach is also attractive to potential clients, as they likely feel some reassurance when a psychologist advertises that they engage in "evidence based therapy" or practice in a way that is allegedly "supported by science."

I do not doubt that one?s approach should be guided by sound reasoning, careful judgment, and when available, empirical evidence. However, it seems to me that our field has a tendency overestimate the claims of "empirical research" while failing to use sound reasoning in how they go about interpreting the so-called "evidence." This should not come as surprising, for in all of the training a psychologist may have in data collection and statistical analysis, most will never take a university course in basic logic, critical thinking, or theory analysis. There are plenty of problematic assumptions and methodological issues related to the interpretation of the "evidence based" literature, but I will just briefly mention a few that have likewise been acknowledged by countless other psychologists.

Firstly, the study designs of the "empirically based therapy" research generally assume that disorders are homogenous and specified. In reality, people will often meet criteria for multiple diagnoses at any one time. These studies also categorize individuals based on diagnosis, which may fail to account for individual differences - in my experience, a person may meet criteria for "anxiety" for very different underlying reasons, and in my opinion they ought not to be treated the same. These "empirical" studies also rely on the process of standardization - researchers must try to use a very specific therapeutic approach that will be essentially the same for everyone. However, some therapeutic approaches allow for greater flexibility, which may make it more difficult to standardize, and more difficult to research - but this should not imply that they are comparatively ineffective. It is also worth mentioning that while research studies must focus on strict standardization, real world therapists rarely practice so inflexibly, so again, the results of these studies may only apply to those who strictly adhere to a "theoretically pure" model of therapy, which in practice, is almost impossible. Though well-intended I am sure, in my estimation the uncritical interpretation of the "evidence based" literature has the unfortunate effect of treating clients according to their diagnostic labels, while failing to have greater appreciation for the very real human qualities of our clients, their unique histories, and specific life circumstances.

This is a long way of me explaining, and hopefully justifying, the importance of finding a psychologist who can think critically, and who can be flexible enough in their therapeutic approach to know what is best for your specific situation or most appropriate to your therapeutic goals - regardless of whether you meet criteria for one diagnostic label or another. There is an old adage that seems to apply here: "if the only tool you have in your toolbox is a hammer, everything starts to look like a nail." Psychologists that are too rigid in their therapeutic approach will, in my opinion, tend to assess and treat clients in a way that may not appreciate the different needs of their clients. Good psychologists, in my opinion, will not only have multiple tools, but they will be experts in knowing exactly when to use them and why. Again, at any given moment, a psychologist should be able to justify their approach and relate it to your individual circumstances and goals.

A Working Therapeutic Relationship

In contrast to the 10% difference in outcome attributed to specific approach, at least 30% of the difference is estimated to result from having a strong therapeutic relationship (2007, Parker & Fletcher). Among the many variables that have been researched over the years, the therapeutic relationship had consistently shown itself to be by far the most important. This should not be surprising. Therapy works best when clients are able to trust their psychologist and know that they have their best interests in mind. It allows clients to feel more comfortable in the therapy room, which facilitates the therapy process by allowing them to be more open and honest in disclosing and discussing thoughts, feelings, and behaviors related to the issue(s) they want to address. Having a solid rapport also means that the client will at times allow the therapist to lead them into a conversation or emotional exploration that might be slightly anxiety provoking or emotionally uncomfortable. This is only possible if clients trust their clinician's good intention, judgment, and capability. They both know and intuitively feel that their clinician would not do anything to jeopardize their psychological well-being and are ultimately working toward what is in their best interest.

The therapeutic relationship is so important that it is hard to imagine therapy being effective without it. In my experience the beginnings of a working rapport are usually developed in that first session. In this first meeting, a client will typically express the concerns or issues they would like to address. The clinician is actively present as they listen to those concerns, communicating genuine empathy where appropriate, and demonstrating that they have heard what their client has been sharing. The clinician may reflect back what they have heard and make some tentative suggestions as to what might be a helpful direction to take in the therapy process. If the client feels like their clinician "gets it," and if they sense that their clinician may have some useful insights or sensible ways of navigating through the process of change, then both therapy and the working therapeutic relationship are off to a good start. However, if a client feels like the therapist does not quite understand their concerns, if they suggest an approach that does not fit with their needs, or if they come across as uncaring or insensitive, then rapport and the therapeutic relationship will suffer.

A client who trusts their clinician and values the relationship will also be more willing to work through potential impasses, misunderstandings, or situations where client and therapist are not feeling attuned to one another. Clients who do not have this kind of relationship will often become silently frustrated or will simply drop out of therapy. Due to the importance of rapport, and in the interest of catching potential impasses in therapy, I will usually check-in on the therapeutic relationship. Regular clients are likely accustomed to my asking questions such as: "how has this session been for you?" or "how are you and I doing in here today"? Openness and honesty, of course, is always encouraged - as it should be when you have a good working relationship in therapy.

Someone who will Challenge you

Sometimes people just need a place to talk about their experiences, a place where they can have their feelings validated, and where an impartial professional will help them better articulate their thoughts and feelings while helping them understand them within the larger context of their developmental history and current life circumstances. However, much of the time people are feeling genuinely stuck in their lives - they need more than an empathic listener.

I should also mention that if therapy was simply about getting advice or a set of well-reasoned professional opinions, I would be out of a job by now. Most of my clients, for example, are fully capable of researching their issues online or of reading a self-help book. Furthermore, it seems to me that many clients will even "know" what they should be doing about their problem, but are still unable to overcome their issues or make those lasting changes. This all makes sense to me, since I think most people are not rationally stuck, but are more "emotionally stuck." The "solution" then, is to provide a certain kind of therapy - not just one which appeals to the client's rational mind, but to their emotional self. It means seeking to provide people with experiences, not advice.

Many people will therefore need a psychologist who is willing to challenge them in therapy. Why? Because there are almost always 2-parts to a person entering therapy. The first part obviously wants something to be different - they desperately need something in their life to change and have the determination to make it happen. If this was not the case, the person would not be in therapy. However the second part of a person is naturally resistant to that change. No matter how badly we want something to be different, and no matter how painful, unhealthy, or uncomfortable our current situation, in some ways change can be just as uncomfortable, since it means letting go of old thoughts, feelings, and behaviors, that have until now served as a stable psychological foundation; up until this point, it is all that we know. A therapist thus seeks to align themselves with the part of the individual seeking change, while gently challenging the part that is resistant to it. I think a good therapist should be capable of pushing their client, when necessary, to readily tolerate feelings that may have been unknowingly avoided or to entertain ways of thinking that are uncomfortable or foreign to them. If one does not, it risks the therapy becoming "stale," "unmoving," or worst of all, unhelpful.

Someone who knows the Difference Between Symptom Management & Resolution

Clinical psychology has seen dramatic changes in the last couple of decades, in large part due to the advent of Managed Care in the United States, and by the influence of insurance companies everywhere. These "third-party payers" are beneficial in that they give many people access to services that they could not otherwise afford. However, in the interest of reducing costs, such organizations severely limited the number of therapy sessions they would reimburse, and added psychologists to "approved provider lists" based on their accepting reduced rates and on their implicitly agreeing to work with clients for shorter periods of time. The "Evidence Based Therapy" movement has also played a role in the changing practice of clinical psychology. This movement sought to target the most effective kinds of therapeutic interventions based on empirical evidence - unquestionably a worthy goal. However, the research designs within the so-called "efficacy studies" typically define therapeutic progress in terms of criteria on diagnostic checklists or degree of negative symptom relief. These studies do not necessarily separate partial symptom relief from full resolution of clinically relevant issues as they relate to each individual person. Furthermore, these studies focus entirely on alleviation of negative or pathology-based symptoms, and often fail to assess positive growth-based variables, including broadening one's capacity to think, feel, or act, to live with purpose and vitality, or to relate more meaningfully to others.

In short, the above-mentioned pressures and influences caused psychologists to focus on treatment approaches that could quickly provide their clients some symptom relief, while allowing them to get back to acceptable levels of day-to-day functioning. At first glance, this sounds like a reasonable goal, since most clients would be happy to find any symptom relief at all. However, I think it is important to differentiate between treating the symptom versus the underlying cause. For example, someone who is morbidly obese can be given diet pills or even liposuction, but unless the underlying cause of their overeating is addressed, they will only re-gain their weight. I think we can make similar comparisons within clinical psychology. The first mistake, in my opinion, is when psychologists make a diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (DSM), and then claim to "treat" the alleged disorder. However, it is important to note that a diagnosis of "Major Depressive Disorder" is not a causal explanation. It is a label that merely describes a set of symptoms without saying anything about the underlying cause. Psychologists who have bought into the "medical model" of mental illness either do not seem to understand this, or quickly forget it. They instead believe that their primary goal is to treat the disorder - to treat the symptoms. The problem, in my view, is that in many cases these approaches offer only short-term relief, and can sometimes even worsen the situation by effectively giving our clients a crutch - by teaching them how to cope, instead of helping them resolve their issue, which would otherwise permit them to thrive.

In my opinion, many of our modern graduate programs encourage DSM diagnostic labelling, while implicitly advocating for psychologists to be "expert technicians" who will assist their clients in managing their symptoms. For example, after diagnosing a client with "Generalized Anxiety Disorder," a psychologist may engage in a course of therapy that involves superficial deep-breathing techniques, or a process of rationally challenging irrational or excessive worries, in an attempt to pacify the anxiety response. But in many cases the symptoms of anxiety can arise from underlying (and often unresolved) feelings that typically operate just outside of the client's awareness. The anxiety in this hypothetical example is a symptom - not a cause. A competent and knowledgeable clinician should know the difference, and know what to be looking for in therapy so that they can rule out underlying issues that could be addressed in therapy once and for all. A psychologist must be capable of understanding the different ways that people can become "stuck" in life - beyond reductionist labels, and their approach must be flexible enough that they can attempt to resolve their client's issues - not manage them.

In sum, I believe in providing psychological services that attempt to treat underlying issues - not short-term "Band-Aid" solutions that simply manage symptoms or surface problems. As clinicians, I believe we need to challenge ourselves to do more than just help our clients "cope" with life - we should aim to provide a therapeutic approach that has depth, substance and power, and strive to remove psychological roadblocks so that our clients are able to truly thrive. I think this will result in fewer "failed" or "repeat" courses of therapy that can lead to frustration and often requires additional time, money, and resources. The approach that I advocate does not necessarily mean a longer course of therapy - only a more holistic view of what it should entail.