A Matter of Personality

From borderline to narcissism

Finding a Good Psychotherapist

What to look for in a potential therapist

Despite protestations to the contrary from some psychologists, helping someone to change problematic behavior and feel better about themselves is still an art form rather than a pure science. Not that there is no science to it—there is. But the science is limited by one indisputable fact: A therapist can provide the exact same intervention to two patients who have similar symptoms, the same diagnosis, are of similar age, gender, and socio-economic status, and may even have a somewhat similar life story. With one patient, the intervention works like a charm. With the other, it not only does not work, but makes things even worse than they were before!

When looking for a therapist, individuals must of course find one with whom they are comfortable. That is a prerequiste. But it is not enough. One must also find one who is competent. Some are not.

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Asking a potential therapist about his or her training and theoretical orientation is a good first step in making a choice, but often not particularly telling. Therapists within any theoretical school can be either good therapists or bad therapists. Also, most therapists today have one “home” school with which they are most familiar, but liberally borrow ideas and treatment techniques from two or three other schools. In other words, most therapists are eclectic.That is a good thing, unless they use techniques indiscriminately and incoherently in ways that create confusion rather than enlightenment. 

Psychiatrists, psychologists, clinical social workers, and marriage and family therapists may all be effective therapists, just as many of them can be ineffective. They all may subscribe to any of the different psychotherapy schools. Psychiatrists who do therapy have been decreasing in number. The ones that continue to do therapy can also handle your medication needs at the same time, as well as understand and help with you any problematic interactions between your psychological issues and any medical conditions that you may have. So-called "split treatment" (where a psychiatrist manages the medications and another professional provides the psychotherapy) is workable—but in many instances it is less cost effective.

Good therapists will generally be empathic, non-judgmental and personable without being too familiar. They will not be afraid to ask you difficult questions that might upset you or make you cry, nor will they be completely insensitive to how difficult opening up may be for you. They will not be threatened if you question their credentials or if you express interest in getting a second opinion about your problem. 

If you experience a negative reaction to something they do or say, they should be open and non-defensive about discussing your thoughts and feelings about it. Of course, they will never under any circumstances try to have a relationship with you of any kind outside of the consulting room, nor a relationship other than that between a client and a therapist while inside the office.

Good therapists will, after they evaluate you, offer you some sort of verbal treatment contract that specifies, with your agreement, what behaviors or bad feeling states you are there to work on and change. Treatment goals in the contract should be specific, so that you will know if and when the therapy has been successful and should therefore discontinue sessions. These goals may be changed later in therapy if new information comes to light, although only with your agreement. 

Although therapists may not be able to be specific about how exactly they will approach your problem until they get to know you much better, the treatment contract should also inform you in general about what you are expected to do during the early therapy sessions, and something about what the therapist will do in response. The therapist should address any concerns you have about treatment, and also inquire about any potential behavior that you might engage in that would interfere either with the process of therapy or with a successful outcome.

A therapist is not supposed to be just a paid friend who asks you about how your week went, allows you to ventilate feelings, and provides you with a shoulder to cry on. If that is all that the therapist is doing for a significant period of time, then you should probably look for another one. Most of the time, psychotherapy treatment should address and try to resolve specific problems. It is designed to do two things: find out what is creating, exacerbating, and/or triggering your problems, and then figure out how you can fix them.

In any good therapy, you should learn something. You should gain insight into yourself and your significant others, and/or learn new behavioral strategies and coping skills that can be used to improve both your situation and the way you feel. I never cease to be amazed at the number of times I have asked patients what they had learned from a previous therapist, and in response they stare back at me blankly as if to say, “You mean I was supposed to learn something?” Often they cannot seem to remember what it is they were working on in therapy or if it had anything to do with the complaint they came to me with.

One aspect of a therapist’s behavior that you should be wary of is the use of what has been called “accusatory interpretations.” In some types of "psychodynamic" therapy, patients are believed to behave the way they do because they have suffered from a case of arrested development and are therefore functioning at the level of a two year old. No matter how the therapist dresses it up, that kind of statement is an insult. In my opinion, it just is not true.

For certain psychiatric problems, one or two types of psychotherapy treatment interventions have been shown to be more effective that the others. But for many problems, no clear evidence exists that clearly shows that one school is significantly superior to another. 

In most cases of a simple, single, isolated psychological symptom, going to a psychodynamically or relationship-oriented therapist would be a waste of time. In that case, you should seek an old-school cognitive behavioral therapist. For example, if you have  a public speaking phobia that was never an issue in the past because you never had to speak publically, but due to a promotion you suddenly need to give oral presentations in order to do your job, short term treatment with a CBT therapist would in most instances help you to get over your fears. 

Patients who are not very disturbed can usually benefit from just about any standard type of psychotherapy in which the therapist is empathic and helps them to think about their problems consistently in a new way that makes sense to them. Obviously, just like with any medical condition, the more severe a psychiatric problem is, the worse the prognosis, no matter what sort of treatment is given. Unlike problematic and highly distressing reactions to one-of-a-kind environmental situations, such as an unexpected loss of a loved one, chronic ongoing problems usually require longer-term therapy. 

An old joke among therapists is that the best candidate for all types of psychotherapy is a "YAVIS."  That acronym stands for young, attractive, verbal, intelligent, and successful. One might ask why such a person would ever even need therapy, although they too can suffer from significant emotional distress and need help. Surely, the YAVIS is the best candidate for brief rather than long term therapy. (The opposite of a YAVIS has been, in some circles, derisively referred to as a "FUBAR"—F***’d up beyond all recognition). 

When it comes to treatment for chronic dysthymia or anxiety symptoms with unclear triggers, chronic repetitive self defeating or self destructive behavior patterns, severe family discord, multiple complex psychiatric complaints, or severe personality disorders, longer-term treatment is probably going to be more beneficial than short term treatment. The interventions used by many schools of treatment start to look a lot alike when it comes to these cases. 

For these types of problems, I advocate for the psychotherapy schools that pay particular attention to ongoing interpersonal and family relationship patterns and that help you to change the patterns. And I mean change the patterns with the real live people with whom you are involved, not just with an empty chair. Unfortunately, many of the treatment strategies that specifically address family problems in this manner are not widely practiced, and finding a good therapist who does this sort of work may take time and effort. I believe that the potential rewards are well worth the effort.

In addition to my own treatment paradigm called Unified Therapy, I would recommend therapists who are familiar with techniques from Bowen Family Systems Therapy, Lorna Benjamin’s Interpersonal Reconstructive Therapy, Paul Wachtel’s Relational Therapy, Jeffrey Magnavita’s Personality-guided Relational Psychotherapy, Anthony Ryle’s Cognitive Analytic Therapy, or Jeffrey Young’s Schema Therapy.

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Paul Wachtel
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Jeff Young
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David M. Allen, M.D., is a Professor of Psychiatry at the University of Tennessee and author of the book How Dysfunctional Families Spur Mental Disorders.

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