In a world in which pharmaceutical companies bombard consumers with ads for drugs that treat everything from anxiety to ADHD, it's easy to regard a pill as the be-all and end-all to life's difficulties. Research on the effectiveness of the most commonly prescribed medications show that these drugs can alleviate the symptoms in people with severe depression. This fact didn't stop Dr. Peter Kramer from claiming recently in a highly controversial New York Times article that antidepressants are good for almost all of what ails us mentally, even if we're psychologically normal or perhaps a bit neurotic. We're not told, though, that results of drug company sponsored studies that don't show a positive effect of medications are not published, a problem called the "file drawer" phenomenon.
What you might not know is that these drugs are not effective for moderate or mild depression symptoms. What's worse, their side effects and interactions with other medications can make someone's psychological symptoms worse and cause serious health problems. As if this weren't bad enough, the majority of drugs intended to treat psychological disorders are not prescribed by mental health experts, but by physicians who in 15 minutes or less dispense therapy in a bottle without trying to address the patient's thoughts or feelings.
The public is not being served by these pharmacological solutions to life's problems. Moreover, the cost of these medications is adding to our whopping health care costs which themselves are tied in with the deficit, the debt ceiling problems, and escalating insurance premiums. For example, in 2010, according to an IMS report, antidepressants were the second highest class of medications prescribed by physicians in the U.S. (253.6 million prescriptions). The annual total price tag was11.6 billion U.S. dollars, which was 4% of all spending on prescription medications.
Psychotherapy is cheaper and more effective than medications for many of the problems that lead people to seek treatment. Estimates of psychotherapy's effectiveness, based on hundreds of empirical studies, are that it works approximately 75-80% of the time. That's a pretty impressive figure. And believe it or not, psychotherapy is cheaper than prescription medications particularly when you consider the impact on your ability to achieve your long-term life goals.
To be effective, psychotherapy needs to be provided in a way that meets a set of well-defined criteria. Condensing many hundreds of studies, psychologist Bruce Wampold, in a recent American Psychological Association symposium, boiled these ingredients down to this baker's dozen. I've listed them in brief and translated them into practical terms that you can use in evaluating mental health professionals serving you or those close to you.
1. Possession of a sophisticated set of interpersonal skills. Effective psychotherapists are able to express themselves well. They are astute at sensing what other people are thinking and feeling. In relating to their clients, they show warmth and acceptance, empathy, and a focus on others, not themselves.
What this means for you: When you talk about what you're experiencing, does your therapist seem to be interested in learning about how you feel? Can your therapist communicate to you in language that you understand? Does your therapist talk about you, rather than him or herself?
2. Ability to help you feel you can trust the therapist. According to Wampold, people determine whether or not they can trust someone within 50 milliseconds of meeting them. Clients of effective therapists believe that their therapists will be helpful because the therapist communicates both verbally and non-verbally that he or she is someone the client can trust.
What this means for you: What do your inner vibes tell you when you first meet this person? Is this someone who allows you to feel that you can have a good working relationship and that your faith in this person won't be betrayed? It's true that the ethical code of psychologists includes the proviso that revelation of illegal or dangerous intention must be reported to authorities such as the police or social service agencies. However, even this requirement can help you feel that you can trust the therapist, because you know that you and the others you care about will be protected.
3. Willingness to establish an alliance with you. One of the solidest predictors of good therapeutic outcome is the feeling that clients are in a partnership with their therapists. This is known as the therapeutic alliance. Effective therapists are able to form these alliances with many types of patients.
What this means for you: Do have the sense that your therapist is interested in getting you on board by establishing goals that both of you agree on? Though the therapist is obviously the expert, do you feel that the therapist cares about your goals in therapy and is willing to work with you to set goals that both of you agree on?
4. Ability to provides an explanation of your symptoms and can adapt this explanation as circumstances change. Clients want to know why they're experiencing their symptoms even if this isn't the first time they've sought therapy. Effective therapists provide explanations that clients can understand but they are also willing to shift according to the way in which treatment unfolds.
What this means for you: Do you understand what the therapist says about the possible contributors to your symptoms? The explanation needn't be (and probably shouldn't be) "scientific;" it should be an explanation that is grounded in your own sense of who you are and why you're feeling the way you do. You should also feel that the therapist is willing to be flexible if circumstances change or new information about your symptoms becomes apparent over the course of treatment.
5. Commitment to developing a consistent and acceptable treatment plan. Effective therapists conduct an assessment very early in treatment. Following that assessment, they should develop a treatment plan and share that treatment plan with you.
What this means for you: Is your therapist sharing with you his or her plans for what type of therapy you'll be receiving? You should not feel unsure about what's happening or why. Unless you know what the treatment plan is, you run the risk of not complying with the therapist's recommendations because you won't know why they are important.
6. Communication of confidence about the course of therapy. An effective therapist keeps clients in therapy by communicating to clients the feeling that therapy will be worthwhile. These therapists allow their clients to feel secure in the knowledge that the therapists know what they're doing and why.
What this means for you: If you sense that your therapist is in control- not of you but of the course of therapy- you will be more likely to be able to make progress. Uncertainty about whether therapists know what they're doing can undermine the course of treatment. Obviously, if you're unhappy with something about the way that therapy is proceeding, you should be able to bring this up. However, a good therapist makes you feel that, like the insurance commercial states, you're in "good hands."
7. Attention to the progress of therapy and communication of this interest to the client. Good therapists are interested in finding out how their clients are responding to treatment. They show that they want their clients to improve.
What this means for you: Given the reality of treatment in managed care settings, it's increasingly difficult for therapy to proceed for long periods of time. Even if you're not receiving treatment under this condition, you know your therapist is effective when he or she checks in with you to see how you feel about the treatment you're getting. This doesn't mean that you need to show progress at every session, but it does mean that your therapist shows concern for you by checking in with you to see how you feel things are working, or not, as the case may be.
8. Flexibility in adapting treatment to the particular client's characteristics. A good therapist doesn't follow a rigid schedule of treatment- a "one size fits all" approach (as stated by Scranton University psychotherapy researcher John Norcross). Research into psychotherapy showed convincingly in large numbers of studies that some treatments are better than others for particular psychological disorders. However, a therapist needs to be willing to make accommodations for the client's particular characteristics.
What this means for you: If you feel that your therapist is following a set of rules and isn't responding to your specific concerns, it's important for you to express these feelings. Be specific about what is and is not working for you. In some cases, your discomfort may be related to the phase of treatment that you're in. Nevertheless, it's important to let your voice be heard.
9. Inspiration of hope and optimism about your chances of improvement. Hope is a terrific motivator. Feeling that something is going to work is often a large part of the equation in successful treatment. However, a good therapist isn't unrealistically hopeful. Effective therapists know how to strike a balance between realism and hope.
What this means for you: A good therapist will inspire you to think that you can get better. However, you may know from your own past experiences, perhaps those you've had with previous therapists, that your symptoms may come back again. Still, it's better to approach therapy with optimism than with pessimism and if your therapist inspires you to feel hopeful, you'll benefit more from treatment.
10. Sensitivity toward your cultural background. The principles of Evidence Based Practice approved by the American Psychological Association recommend that therapists adapt treatment to their client's cultural values. This includes showing respect for your background and being aware of attitudes within your culture or community toward, for example, family relationships, religious practices, and appropriate behavior.
What this means for you: It should go without saying that an effective therapist does not make offensive comments about your gender, race, ethnicity, sexual orientation, religion, or cultural background. However, therapists might not be aware of specific prohibitions or traditions that are an important part of your life. If this happens, explain why you find this to be the case. It's possible that your therapist simply is unaware of this situation, and will appreciate gaining this knowledge.
11. Possession of self-insight. An effective therapist is self-aware and is able to separate his or her own issues from those of clients. Freud coined the term "counter-transference" to refer to cases in which the issues expressed by a client lead to emotional reactions on the part of the therapist. It's important for therapists to be able to identify and manage their responses to the issues their clients present to them.
What this means for you: If you find that your therapist brings up his or her own problems when you talk about yours, and you feel this is overstepping the line on self-disclosure, bring this up as a concern. The unconscious can play interesting tricks on all of us, including therapists, but the best ones are able to control their reactions even if those come close to experiences that hav affected them.
12. Reliance on the best research evidence. Therapists acting in accordance with APA's Evidence Based Practice Guidelines stay abreast of the latest developments in clinical psychology, particularly in their areas of expertise. Ideally, therapists alter their treatment approaches to be consistent with the latest knowledge.
What this means for you: There are many sources of information available now to clients to evaluate the treatment they are receiving. Although it's usually not advisable for clients to insist that their therapists try out new and untested methods that they read about online, it is still a good idea to check out reputable websites to ensure that you're getting the latest, empirically tested, treatments and ask your therapist about them.
13. Involvement in continued training and education. Licensed mental health professionals must participate in continuing education to maintain their credentials. They are required by law to seek and complete this training.
What this means for you: As long as your therapist has a current license, you can be assured that he or she is acquiring relevant educational and training experiences. You can use your state association website to ensure that your therapist's license is being maintained and also check to see if there are any irregularities in his or her record.
Summing it up:
The outcome of therapy depends on many factors, but psychotherapy researchers have evidence to show that these 13 qualities in a therapist play a key role in increasing the odds of a successful outcome. Therapy can occur in many types of situations, ranging from marital counseling to employee assistance. Each therapist may not meet each of these 13 criteria, but as long as you are aware of them all, you can decide whether you or a loved one are getting the best possible treatment.
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Copyright Susan Krauss Whitbourne, Ph.D. 2011
In addition to the links I've provided above, this book is an excellent summary of the state of the art:
Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work (2nd ed.). New York: Oxford University Press.