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Having taught psychotherapy to many cohorts of psychologists and psychiatrists, I am well-versed in a range of therapy models—and therefore do not impose them on my patients.

Beware of therapists who are too identified with a particular therapy “brand.” They have already decided how to treat you before they have met you, let alone understand you. Also beware of therapists who claim expertise in many forms of therapy. No one is expert in everything. You may end up with a dilettante, or someone more concerned with filling his schedule than his integrity.

Beware of therapists who overemphasize that they specialize in certain diagnoses or disorders. A psychiatric diagnosis tells us little about how to help (see my blog on this). The causes of emotional suffering are generally woven into the fabric of our lives—how we live, how we view ourselves and others, how we connect with people or fail to connect, what we desire and dread, what we know about ourselves and do not wish to know. A therapist’s expertise is about understanding how that fabric is woven and can potentially be rewoven, not about diagnosis.

The early sessions should focus on developing a shared understanding of what is really the matter—an understanding that makes sense to both of you. “What is really the matter” is not your depression or anxiety or eating disorder. It is what is going on psychologically that is causing these difficulties. A shared understanding of what is the matter provides a focus for therapy. Effective therapy has a focus.

This shared understanding may develop in the first session or require a number of sessions. It will evolve and change as therapy progresses—it is dynamic, not static. But there should be a focus from the outset, as a foundation on which to build. There is no point “doing” therapy unless both participants know what they are there to do.

Many therapists speak of the “therapeutic alliance” but fewer seem to understand what a therapeutic alliance entails. It does not just mean that you feel a positive connection. It is not an alliance based on anything. A therapeutic alliance is an alliance based on a shared, mutually agreed upon purpose—an alliance around the work you are there to do. A therapeutic alliance has three elements: 1) There is connection; 2) there is mutual agreement about the purpose of therapy; 3) there is mutual agreement about the methods you will use in pursuit of this purpose. All three elements are necessary. I often see the first without the other two. That makes for a warm and supportive relationship—but not meaningful psychological change.

The shared understanding of what is the matter must be truly shared. It cannot be just the therapist’s understanding or just the patient’s. It is something you and you therapist develop together that transcends what either of you can know alone. If you could reach this understanding yourself—if you could come in and say what is really the matter and what to do about it—you probably would not need therapy. The therapist’s job is to help you sort out what is the matter in a way you cannot do by yourself. When you reach a shared understanding, you know you have identified something vital. It is not something you take on faith.

My students always ask what to do when patients have no idea what is the matter. The person knows something is wrong but cannot say what. She may feel empty, or lost, or stuck, but doesn't know why. This is where the therapist’s expertise comes in, because the therapist brings a perspective the patient cannot have. One thing that may be the matter is that the patient is a relative stranger to herself. I may comment, “Something feels very wrong, but you don’t have words for it.” If she feels this is accurate, I may suggest, “Perhaps it would help to find words for what is wrong. If we can find words, we will see things more clearly. When we see more clearly, we may be able to see a way out.”

Then I ask—this is crucial, because the understanding must be truly shared—“Do you think it would help to find words for what is wrong?” If the patient resonates with this—if she also feels that finding words will help—we have an initial focus for our work. Our shared task is to find words. The patient cannot find the right words without my help and I cannot find them without hers, but we can likely find them together. The treatment focus will evolve over time, but we have a starting point. Next time we meet, we both know what we are there to do.

If the patient does not resonate with the suggestion that finding words will help, we continue exploring until we find a focus we both agree will be helpful. I do not make a recommendation to proceed with therapy until we are on the same page about its purpose. I do not “do therapy” for the sake of doing therapy. I do therapy when patient and I both understand what we are there to do and why.

I don’t always take “yes” for an answer. If the patient agrees with a treatment focus but agrees in a way that suggests she is merely acquiescing, we do not have a shared understanding. It is only my understanding, not our understanding. If she agrees because she believes I know best—because I am the “expert”—we do not have a shared understanding. We need to continue exploring. (But I have a new hypothesis about what may be the matter. If she is accustomed to deferring to other people about what is right for her instead of attending to her own reactions, that could explain why something feels wrong and why she has no words for it. And I will raise that for mutual consideration).

When I write about therapy, I get self-conscious about terminology. Many therapists, besides psychiatrists, are taught to say client rather than patient. I have misgivings about both words. People who come to me for treatment need help, often urgently. Some are literally entrusting me with their lives. The work we do has profound, often permanent consequences (if not, then we are not doing real psychotherapy). To me, the medical metaphor (patient) seems more congruous with what is at stake than the mercantile metaphor (client).

So how do you choose a therapist? You steer clear of ideologues and experts-at-everything. You don’t search far and wide for a therapist who specializes in people with exactly your problem because there are no other people with exactly your problem. When you meet, notice whether the therapist seems more interested in you or your diagnosis. Notice whether the therapist invites you to think together about what is really the matter. Notice whether the two of you are able to develop a shared understanding of what is the matter that rings true to you, that was not already evident to you. The last part may take a few meetings but the trajectory should be moving in that direction from the beginning. If all of these ingredients are there, you’ve probably found a good one.

Jonathan Shedler, PhD practices psychology in Denver, Colorado. He is a Clinical Associate Professor at the University of Colorado School of Medicine and formerly Director of Psychology at the University of Colorado Hospital Outpatient Psychiatry Department. Dr. Shedler lectures to professional audiences nationally and internationally and provides online clinical consultation and supervision to mental health professionals around the globe.

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© 2013 by Jonathan Shedler

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