A Buyer's Guide To Psychotherapy
How does a consumer, shopping for answers to life's dilemmas, know whose wisdom to buy? Hire a therapist who leads a life that seems desirable to you, insists psychiatrist Frank Pittman III, M.D.
By January 1, 1994 - last reviewed on February 13, 2018published
For 33 years as a psychotherapist, I've sold myself by the hour. People pay to talk to me about themselves. They come singly, in pairs, and in small groups. Some of them ask me to help them figure out what they could do differently to make their life and relationships work better. Others just bitch and moan and demand pity.
I sell them my time and whatever wisdom I have developed. If they expect their insurance to pay for it, I may apply a psychiatric diagnosis to them as well. If their brain chemistry is too messed up for them to think through their situation and to do whatever needs to be done, I sometimes prescribe medicine to fix the problem in their brain so they can then go on to fix the problems in their life. I also give them my humor; I try to make an hour with me entertaining as well as enlightening. I feel honored that they have brought their pain to me. The least I can do is make the removal of their pain as painless as possible.
I used to be proud of what I did. That has changed. Perhaps it was the unsettling experience of trying to explain to friends from abroad—for whom American psychotherapy is a foreign culture—how perennial psychotherapy customer Woody Allen could have undergone therapy for most of his life and still not have seen anything incestuous in his sexual relationship with his de facto stepdaughter, the sister of his children. When asked about his analyst's reaction, Allen is rumored to have said, "It didn't come up. It wasn't a relevant issue for my therapy."
Most humiliating for a respectable psychotherapist is the recently popular application of the format and jargon of psychotherapy to people's search for a victim identity. The victim identity is like a doctor's excuse from a gym class or history exam, only it is an excuse from life itself. People who want to be victims may nurture their inner child, may style themselves as adult children of imperfect parenting, or may announce that they are survivors of real or imagined unpleasant experiences. Either way, they resign from the adult world, eschew responsibility for their conduct in relationships, and whimper that the world owes them a life.
Values And Psychotherapy
There is such a thing as mental illness. It is real and it is horrible, whether it occurs as schizophrenia or mania or depression. Treating real mental illness may be the major professional expertise of mental health professionals, but it is a minor activity of psychotherapists. Most psychotherapy is about values—about the value dilemmas of sane and ordinary people trying to lead a life amidst great personal, familial, and cultural confusion. The therapists who do psychotherapy effectively do so because they understand value conflicts and they convey, without having to preach about it, values that work.
Psychotherapy is a process in which people in pain and/or turmoil purchase the time and expertise of a therapist who helps them: 1) define the problem; 2) figure out what normal people might do under these circumstances; 3) expose the misinformation, the misplaced loyalty, or the uncomfortable emotion that keeps the customer from doing the sensible thing; and 4) provide the customer with the courage (or fear of the therapist's disapproval) to change—that is, to do what needs to be done.
Psychotherapists vary widely in the rapidity with which they provide their customers with answers to the questions being raised, and the degree to which they take credit for providing the answers. Some will simply tell people what to do; others will make the customer guess for a few years before subtly signaling they've finally gotten it right.
Most therapists work hard at trying to get people to do what we think is right and to take credit for it themselves. The trick is to keep pushing and hinting without seeming so bossy, controlling, or disapproving that we run them out of therapy before they have changed their behavior or solved their problems. It's not an easy job and, while it doesn't require brilliance or magic or even a loving nature, it takes both talent and skill—the talent to keep the customer in therapy long enough for it to work and the skill to define the problems and solutions to the dilemmas of human existence.
Psychotherapy ordinarily offers a safe and accepting format for helping people come to grips with their emotions and then go ahead and do sensible things with their lives, whether they feel like it or not. It's a process by which people identify and talk about what they feel, rather than act on their emotions and do what they feel like doing. In the process, there may be a transfer of sanity and reality testing from therapist to patient. The therapist's calm may soothe the frantic patient. Sometimes the therapist is the one who must get frantic in order to alarm an inappropriately calm patient who fails to see the dangers in his or her actions.
Either way, psychotherapy involves applying the value system of the therapist to the dilemmas of the clients. The most important work of psychotherapy takes place inside the therapist's head as he or she thinks through the patient's snag points in dealing with this latest bump along the road of life.
When you go to a psychiatrist for medication or shock treatment, or to a psychologist for psychological testing, it may not matter very much what sort of person the professional is. But if you're choosing to bring a psychotherapist in to your life as a consultant, his or her value system is more important to you than training, credentials, or even a professional degree.
The Myth Of Therapeutic Neutrality
Whatever psychotherapy is, it is not about therapeutic neutrality. Therapeutic neutrality is a stance inherited from classical psychoanalysis, in which the silent, passive analyst refuses to react or comment on what the patient is saying or doing, thus encouraging the patient to regress into a "transference neurosis" on the analyst. Needless to say, such unresponsiveness brings forth all manner of crazy emotional responses. Except in classical psychoanalysis, neutrality is not only rude and inappropriate, it also makes you crazy.
Even if a therapist could be neutral about the issues at hand—impossible!—that neutrality would at best bring the therapy to a limping halt and at worst seem to be an endorsement of the client's persistence to barrel the wrong way down a one-way street. (For a therapist to feign neutrality about someone racing for disaster is not neutral; it is sadistic.)
Yet therapists try to make themselves less threatening by pretending to be neutral about anything that borders on a moral issue. We therapists are trained to pretend to have no sense of direction about the client's life, except for such benign virtues as unlimited patience, accurate empathy, steady optimism, nonpossessive warmth, and unconditional positive regard for whoever has rented the couch for that hour. Some therapists are opinionated people, with clearly established values, but they try to maintain their cramped neutral stances by detaching from patients and their dilemmas.
The Blaming Blight
One of the horrors of psychotherapy is the affirmation clients may feel from their seemingly neutral therapists that they are "okay" even when they are doing terrible things to themselves and their loved ones. Some therapists listen without comment to tales of violence, substance abuse, infidelity, even incest. Their silence is tacit approval. Some therapists do worse than silently accept whatever the customer says or does; some actively affirm that the customer is always right. Therapists, as they ingratiate themselves to their customers, may actually provide "interpretations" to relieve clients of the guilt they need in order to keep them from hurting others and bringing disaster upon themselves.
Therapists may actually encourage customers to feel better about themselves by blaming their lives on other people, on the nature of human existence, or on the peculiar mores of the society around them. Repeatedly, men who are being unfaithful or violent are told by therapists that they are working out their anger at their mothers, while women who are being dishonest or mean are told they are battling patriarchy. Everyone gets distracted from the impact of the betrayal or the power play upon the marriage.
It used to be stylish for therapists to help people blame their lives on their mothers or on their wives—whoever loved them too possessively. Lately, the style has been to blame everything on fathers, husbands, or men in general—whoever failed to love them enough. There are therapists who are expert at finding errors made by parents and grant the now-grown children the right to consider themselves adult children of imperfect parenting. People who center their lives around blaming their parents aren't free to be adults and parents themselves. This blaming of others may relieve pain briefly, but it is not therapeutic; it does not lead to empowerment or control over one's life and behavior.
If people can't remember being victimized, some therapists specialize in uncovering forgotten abuse of various sorts. Forgotten incest is especially popular. I don't know whether it does more harm to forget abuse or to remember it, but I'm sure that much of the incest gradually remembered in therapy or under hypnosis is a dutiful fabrication of dependent people trying to please a victimizing therapist.
Therapy Is An Adversarial Process
Therapists should of course help people step out of their crippling state of victimhood. Good therapy is not a chaste love affair between buyer and seller of psychotherapeutic services. The therapist and the customer don't even have to like one another. The therapy may be working best when you don't like your therapist, when you get the firm impression that your therapist doesn't like you very much either, and when you are being told that you have to do something you don't want to do if you are ever to feel good about yourself.
In fact, the therapist is hired to scrutinize you sharply and find something about you that is unlikable and unworkable, and then to help you isolate and discard the offending behavior. If the therapist sees everything the way you do, the therapist would be in the same fix you're in. And if the therapist thinks you're wonderful the way you are and just wants you to realize it, the love affair that results is different from therapy. Therapy is an inherently adversarial process, not an alliance to buffer innocent victims against a world that isn't gentle enough.
The World Turns
We are all given faulty instruction books by our parents. For the past 200 years, the old patriarchal system of gender role assignments has been eroding, too slowly of course, but still with disorienting speed. Each generation faces a new world in which girls have more options and more challenges in life and boys have less deference and less expectation that they will automatically sacrifice their lives for the masculine mystique.
While this is liberating for both men and women, it is also disorienting. Each generation of boys and girls must redefine for themselves and for one another what it expects of men and women. Boys and girls, to become men and women in a new world, must challenge, reject, and selectively rebel against their parents' values, which is frightening and can feel painfully disloyal.
Boys and girls don't have to fix their parents and don't have to cut off from them. They make the best use of their parents' values when they study their parents closely and question them about how they came to hold the values they hold, as well as how they find them to be working.
There are other aspects of us besides gender that are affected by the rapid changes in society. Social, cultural, and economic expectations change. We are now in a period of economic reversal. In many families the younger generation won't have it as cushy as their parents did, and may remain dependent on them.
Most younger people have moved part or all the way from their patriarchal roots and are enjoying greater range in their gender expression. Yet even the most progressive and open-minded of men and women may still carry within them, unchallenged, some of the models of marriage from their parents' or great-great-grandparents' generation, with the responsibilities, expectations, and privileges of a "head of the household" and his little "helpmate." Gender equality in marriage, championed by most (but not all) marriage therapists, may feel foreign operationally to many men and women. Those who recoil from equality may seek out a patriarchal therapist, perhaps a fundamentalist Christian counselor, who will try to protect them from having to challenge the model they learned growing up. Intellectually, they may want an equal relationship, but they feel deprived if they don't also have the loving domesticity of an idealized old-fashioned mother or the imperturbable strength of an idealized old-fashioned father. They just want the world to slow down until they can catch up.
Thus Come The Therapists
The world is changing so rapidly that people don't have to be mentally ill to be out of their minds some of the time, behaving inappropriately much of the time and a little bit disoriented all of the time. Therapists claim to have expertise in dealing with mental illness but also in dealing with the problems of living, in finding happiness and security in a rapidly changing world. Therapists, in effect, claim to have wisdom about human existence.
Actually, some probably do and some definitely don't. Therapists don't come into the business with any more wisdom than anyone else, though an inordinate number of them come from messed-up families that have made them wiser and more alert than those who slide into adulthood without enough trauma to trigger development of an armamentarium of coping skills.
But after meddling intimately in a few lives, the therapist changes. If the therapist is paying close attention to what is going on inside the client and inside the therapist, and having success in understanding people and in helping them change, the experience of doing therapy should make the therapist increasingly aware of various layers of emotional, interpersonal, and social reality. The therapist must either get callous, get depressed, or get wise. The most experienced therapist is not necessarily the best, but the happiest experienced therapists are undoubtedly the wisest, since the therapy they do works and the wisdom they get from doing therapy helps them shape values that work in their own lives.
Thinking Like A Therapist
I know as a therapist I don't have to have all the right answers to life's questions. But I do have to have some. I'm likely to have better answers than the people who are stuck. If I don't, at least I have different ones, which may be just as good in moving someone out of the fix they're stuck in. It takes only a little wisdom to provide hope that there are other ways to do things.
I try to explain to therapists who are overwhelmed by what they see in their offices that there are no techniques and no solutions that will solve these problems. But there are ways in which the therapist can think about the issues, ways in which the therapist can reframe the problem, that permits it to be either accepted or solved, not perhaps in the way that anyone would want to solve it, but at least in a way that permits life to go on. I try to teach therapists how to think about human dilemmas in a way that is therapeutic.
The Dangers Of Emotion Worship
Some therapists can't think therapeutically because they let feelings take priority, as if all actions must be emotionally coherent. These therapists assume that when people follow their feelings purely and clearly, they will get to the desired destination. In his book, Another Roadside Attraction, Tom Robbins says "Living from your feelings is like nailing a chiffon pie to the wall."
When therapists give their primary attention in therapy to how people feel, they convey the notion that feelings are the most important determinant of action. They distract customers from their exercises in reality testing, their efforts to explore and observe, and to understand the workings of the world around them. Instead, they turn their patients' attention inward, as if they were doping them up on hallucinogens. Such therapists seem to believe that the secrets of the universe, the true and accurate instruction book of life, are inside the increasingly muddled heads of their customers.
This might have made some sense back in Freud's day, when people were not accustomed to thinking, much less talking, about how they felt. But no one has an inner emotional life any more, since any feeling, before it is fully formed, is spilled out to the world on Sally, Oprah, or Phil. Introspectiveness does not lead to workable relationships because romantics spend their time thinking about how they want the people around them to be in order to make their dreams come true, rather than attempting to understand what their loved ones are like and why they are like that. Unceasing introspectiveness leads to narcissism and ultimately to loneliness and very few invitations to dinner with others.
If your therapist seems to give a great deal more weight to your feelings than to the feelings of the people who share your life, you may have to keep your attention focused on how you might be affecting them rather than just on how they are affecting you. You may even need to remind your therapist that acting on your impulses may not necessarily be good for your loved ones.
The most dangerous extreme of emotion worship is romanticism. Romantics are eager to sacrifice their lives, or the lives of their loved ones, in pursuit of emotional coherence. For romantics, life is inherently tragic. Romantic therapists may encourage the notion that following your emotions will give you the power to overcome reality, time, or gravity. Married people in affairs may think that, if they love each other enough, they can leave their mates and children and, after stepping over their bodies in their walk down the aisle, live happily ever after.
Beware Of Conspiratorial Therapists
A few years ago, I wrote a book about the disruptive effect of infidelity and secrets, and found myself attacked by prominent marriage therapists. They explained that infidelity was normal behavior but too emotionally provocative to bring up in therapy, especially since it was no doubt the fault of the marriage partner who was being betrayed, and who could thus not be told about it. My male colleagues explained that women who had been betrayed would just get "stirred up" and ruin the therapy with a lot of anger. My female colleagues explained that men shouldn't be told bad news since they would just get violent. Both explained that it was necessary to lie to people of other genders. Those therapists who were still speaking to me after the book came out offered to teach me their techniques for keeping the cuckold so disoriented about what was going on in the marriage and in therapy that the infidelity wouldn't have to be dealt with at all, and could continue untouched by the therapy.
To me it is arrogant of therapists to conspire with one member of a family or a couple to keep others in the family disoriented about matters that are crucial to their orientation and understanding of their life. Infidelity scares therapists. Couples therapists who conspire to keep sexual secrets are showing tremendous disrespect for the cuckold who is being betrayed, first by a spouse and then by the therapist.
Men have come in, referred by their divorce attorneys, asking for a course of ersatz marriage counseling that will look good in the divorce case and distract their wives from realizing that there is a secret affair going on. They hope that I can sufficiently confuse and disorient the wife, and make her think she is in some way responsible for the failure of the marriage. Then they can get by with a less expensive divorce settlement. Most therapists would refuse such a mission, but some enjoy the chance to champion a client against enemies.
A buyer of psychotherapy should not use a therapist as an instrument for inflicting harm on loved ones, for dispensing misinformation or concealing information that will drive his or her partner too crazy to understand what's going on. A therapist is not supposed to be your champion, but your critic. A therapist is not like a lawyer. The lawyer is out to prove you innocent of any wrongdoing; thereby the lawyer saves your skin. The therapist is out to show you how you screwed up and brought disaster upon yourself; thereby the therapist saves your life. Your therapist, in pleading your case to the people in your life, will emphasize your guilt, not your innocence. Your lawyer wants to confuse the judge and the jury so you will never have to deal with those people again. The therapist wants to reveal the truth and enlighten the people in your life, so you can honestly and intimately deal with those people forever after.
As a therapy consumer, you may be tempted to see the therapist as a judge rather than as a defense attorney, and ask the therapist to take your side and declare you to be right. That would be a misunderstanding of the function of the therapist, which is to understand the ways in which you are wrong.
Foolish therapy customers have been known to hit their relatives with actual extracted or invented quotes from the therapist that are critical of the relatives and defensive of the patient. This can effectively sabotage couples or family therapy, where the therapist knows the relatives being criticized. When the relatives are criticized in absentia by a therapist, they understandably go on the defensive and will actively undercut the therapy. What a waste of a therapist!
What's Your Therapist's View Of Marriage?
Some therapists believe in marriage so strongly they see singlehood as a state of emotional deprivation that is the cause of all the pain in the life of single people. Such therapists may rush people into ill-advised marriages; some of which will work and some of which won't.
Other therapists distrust marriage so totally they see it as a dangerously oppressive state of exploitation and impending doom. They assume that any pain a married person suffers is brought on by the marriage. These therapists likely experienced disappointment in their marriages or their parents' marriages.
In between are therapists who idealize marriage, and give full support to perfect marriages and short shrift to those with problems. Some therapists, especially those who didn't come in from the Sixties in time, still believe that mental health comes from running away from home, and if people are too old to run away from their parents, they can run away from their marriage.
They don't understand that the struggle of marriage is second only to the raising of children as the central maturing experience of life. As with the combat of war, you win the important victory the one over yourself and your fears, simply by not running away.
Married people would do well to stick with therapists who believe in marriage. But such therapists must believe in divorce too, not as a path to happiness and a more perfect partner next time (second marriages have an even higher divorce rate than first ones, and third marriages are probably uninsurable), but as an escape from the unendurable, like recurrent violence, chronic alcoholism, or philandering. Therapists should make customers contemplating divorce aware of the devastating impact on the children and the shock waves that will continue for generations.
A therapist who endorses divorce too glibly or dismisses marriage too offhandedly is dangerous. But so is a therapist who does not empower you to leave a truly abusive marital situation. Knowing you can leave, and convincing your abusive partner that you can leave, perhaps by actually leaving for a time, may be more helpful than divorce. The point of therapy should not be to protect you from unpleasantness and disappointment, but to empower you to take charge of your life and your marriage. You must realize your marriage is not the property of your partner, but is yours. And you have a say in how it goes and whether it goes. You must not be bullied into it. Or out of it.
Choosing A Therapist To Hire
Before you turn your life over to a therapist, you need to know what manner of person that therapist is. Find out. If you can, hire a therapist who has worked effectively with people you know. Find out what sort of person the therapist is and hire a therapist who leads a life that seems desirable to you. Read anything he or she has written. Ask questions, even personal ones about whatever you consider relevant. The therapist being interviewed may not want to answer personal questions and may treat your asking them as if it were pathological, but don't be daunted by that. You have a right to know.
Even if the therapy you're considering is classical psychoanalysis (where the analyst just sits there silently treating everything you do as neurotic), you should insist on a couple of sessions at the beginning in which you ask all the questions you can think of about the therapy being proposed: how long it takes; how much it costs; and what happens if you want to drop out.
It is certainly appropriate to ask about a therapist's training and experience. In addition, go ahead and ask a therapist about his or her marital status and children, experiences with therapy, and personal experience with the issues (including grieving, divorce, infidelity, substance abuse, sexual orientation, depression, etc.) being addressed in the therapy. The therapist doesn't have to answer, of course, but should not object to being asked. I worry a bit about therapists who play it too close to the chest and fear revealing very much of themselves. It would be grossly inappropriate for a therapist to share a personal secret with a patient, but it seems almost paranoid to withhold the parts of a therapist's life that are common knowledge.
From time to time, prospective customers will call and ask if I am a 'Christian psychiatrist.' Some of them want reassurance that I do not seduce customers or conduct satanic rituals in my office. Some of them want to know that I will try to hold or bring families together rather than seeing mental health as an escape from responsibilities and relationships. Some of them want to know that I am committed to preserving patriarchy and protecting women from the burdens of gender equality and men from feminism. As I answer their questions, I realize that very few are concerned with whether I might be Baptist, Jewish, Hindu, or atheist. Religious affiliation is not a reliable gauge of people's values, or lack thereof.
You can't interview the therapist about only his or her life. You have to tell the therapist about you and your life, and then assess the response; a therapist's values are in his or her responses to you and your dilemmas.
As the therapy proceeds, you should expect responses from the therapist. Unless you have agreed to go into classical psychoanalysis, you should expect the therapist to talk to you and to demonstrate understanding and good sense. Don't go back to a therapist who passively listens to your story and has nothing enlightening or intelligent to say. You can't demand magical solutions, but don't assume the therapist is thinking sensible thoughts if they are not voiced.
A therapist should treat you with respect. Don't go back to a therapist who makes a sexual pass at you or hits on you. It might be nice if the therapist hugs you, or laughs at you, or tells you you've screwed up. But if you don't like being hugged, or laughed at, or told you've screwed up, say so—but expect your reticence to be explored rather than simply respected. The therapist must be able to move in close and to help you laugh at life and at yourself.
If you convince your therapist you are dangerously fragile, you may be able to control the therapy so totally that you will be treated just as you want to be treated—and no therapy will take place. Do not expect the therapy sessions to make you feel good. Worry instead if the therapy sessions fail to provoke any thoughts at all, and you don't think about them between sessions.
Be a demanding consumer, although you probably will be labeled difficult. Challenge the therapist when his or her values seem to conflict with your own or when he or she has a different take on reality than you have. The therapist may be offering you the wisdom that will save your life, but not until you thoroughly examine and understand it. You don't need a therapist to agree with you; you need a therapist to disagree with you and the way you have handled things, and then to explain at least one alternative way of looking at your dilemma and handling it.
Don't be in too big a hurry. Brief therapy can bring about magical fixes in some situations, such as phobias or family conflicts. But the social and psychological learning that makes psychotherapy transformative takes time, as all aspects of the customer's value system are challenged by the value system of the therapist—and vice versa.
There are a lot of therapists you can hire to listen to you if you are feeling lost and lonely, but there are not many therapists worth hiring for you to listen to. There are plenty of therapists out there eager to save you or protect you, which may be bad for you. There are some out there ready and able to fix you, which may be good for you. But try to find one who wants to help you understand how to take responsibility for your life, and how to live it.
Therapy is a highly personal process and the match between a therapist and a customer is highly personal. Good therapy may be rare, but it is well worth seeking, purchasing, savoring.
Most important, if a therapist is gentle and soothing and makes you feel that your life is not your fault, run for your life. Choose the therapist who pisses you off by insisting that you take more than your share of the responsibility for your life and your relationships. Hire the one who cuts through your defenses, your projections, and your rationalizations; one who makes you feel like a fool for continuing to screw up your life in the same old way, and offers optimism that he or she finds life worth living, so you can come to feel that way too.
The Mental Health Professionals
How does a consumer, shopping for answers to life's dilemmas, know whose wisdom to buy? There are several recognized professions of mental health experts. I can make a few generalizations about them, but like all generalizations, they are often false and frequently inapplicable.
- Psychiatrists are medical doctors who go all the way through medical school with the surgeons, pediatricians, and dermatologists, learning to take responsibility for people's lives. They then spend four or more years in a psychiatric residency, learning a fair amount about how the brain works, a lot more about how medicine works, and even more about how to make diagnoses according to an ever changing manual put out by the American Psychiatric Association. Psychiatrists used to learn how to do psychotherapy according to the model designed by Freud. Classical Freudian psychoanalysis seems too inefficient and expensive to be applied generally these days, so current psychiatric residents are more likely to learn various modifications that make it more practical and more applicable to more kinds of patients.
Psychiatrists used to learn how to do family therapy and group therapy, too. Some still do. The psychoanalytic preoccupation in the training of psychiatrists has given way to a psychopharmacological preoccupation in recent years, so older psychiatrists are more likely to be well-trained psychotherapists than are younger psychiatrists.
Many psychiatrists have become little more than pill pushers for nonmedical psychotherapists. Some psychiatrists seem not to know how to treat people who are upset without first locking them up in an expensive and unwieldy psychiatric hospital, which is rarely necessary.
- Psychologists, who may have a degree of Doctor of Philosophy (Ph.D.) or Doctor of Psychology (Psy.D.), don't go to medical school, are not licensed to prescribe medicine, and generally don't hospitalize patients (there are exceptions in some places). They have traditionally gotten more academic training with far more emphasis on behavioral and psychological research, on the process of learning and education, and on objective psychological testing and diagnosis. Psychologists are likely to spend more actual years (if not more hours) learning to do psychotherapy, and are likely to devote most of their training to people with less severe problems, i.e., with neurotic rather than psychotic people.
Family therapy and concern with systems came late to psychology, and many older psychologists are stuck with an individual perspective with which they try to protect individuals from their relationships. A therapist oriented toward only individuals can permit clients to retain a single-minded preoccupation with themselves, with their own wants and needs, slights and dissatisfactions, and may inadvertently encourage customers to become increasingly dependent on the therapist and detached from the real people in their lives.
- Social workers have a master's degree, and while they have fewer years of training than doctors of either psychology or psychiatry, their training is quite practical. They may get more continuing supervision of their therapy than either psychiatrists or psychologists. Social workers get less training in the brain chemistry of severe mental illness, less training in the more intricate details of people's mental functioning, and more training in the things that are happening in the society to affect people's relationships and security. Social workers are likely to be well-grounded in family theory and family therapy.
M.S.W.s have been especially active in developing feminist therapies, and while this brings an awareness of societal and historic context to people's lives, it may also infect social workers with political correctness, which blames just about everything on social forces. (There are psychologists and psychiatrists infected with political correctness as well, of course.) Political correctness is incompatible with therapeutic correctness, which empowers people to get control of their lives in an unfair, imperfect, and rapidly changing world. A therapist can't easily turn a patient into an innocent victim of social inequities and then help the patient take responsibility for his or her own life.
- Marriage and family therapists (MFTs) are also master's-level professionals. Like M.S.Ws, their training has centered more on practical supervision than on academic theorizing. Theirs is a new profession, and they are especially well trained to deal with systemic issues, intergenerational conflicts, and marriage problems. Many marriage and family therapists got their training before the new profession was designated, and they may have masters degrees in psychology (M.A.) or in educational counseling (M.Ed.) with many years of supervision and experience. Like M.S.W.s, MFTs are likely to be cheaper than psychiatrists and psychologists, but insurance may not cover masters-level therapists. MFTs also may not have much training in brain chemistry or individual psychology.
There are lots of other people who call themselves counselors and who have various kinds of training of various quality. Some are officially educational counselors, others are pastoral counselors, and still others are trained to counsel people with specific problems like grief and mourning, drug and alcohol abuse, or posttraumatic stress. States vary in their licensing requirements, some counselors have only a bachelor's degree, most have a master's, and some have a doctorate. Some of the therapists I respect most have an M.Ed. or Ed.D., a master's, or doctorate in educational counseling. The designation "counselor" does not tell me much about a person's training, but I do know that the profession and the training of a psychotherapist are far less important than what type of person the therapist is.
I am not at all convinced that the training of psychotherapists determines how they will practice after they have gotten some experience under their belt. They tend to get away from their training and to do the things that they find workable in their practices. Almost all psychotherapists, however dutifully purist they may be at the beginning of their careers, become eclectic or "integrative" before long. The training serves the crucial function of grounding fresh therapists, of providing a road map through the morass of all that pain and all that dependency and all those emotions. The seasoned therapist can improvise creatively and personally after he or she is safely and comfortably on familiar territory. After a few years, some therapists are a great deal better than they were trained to be.
Sad to say, some therapists get a great deal worse—having forgotten or rejected what they were trained to do, or having so few successes in their own lives or the lives of their clients, that they haven't learned anything new to take its place. Some therapists are nuts, and get nuttier the longer they try to absorb the pain of their clients that they can't relieve. I remember Timothy Leary-like therapists who got increasingly drug-soaked in the Sixties and took a lot of people with them on their trip out of reality. A life without crisis or pain is not helpful for a therapist; a clear head is.
It may be that the therapists who spent the most years in training and in personal therapy are better grounded and more secure. They should certainly have had the most opportunity to deal with themselves as therapists, to discover their own sensitivities, prejudices, and blind spots. It is clearly better to deal with one's personal weaknesses while still in training and supervision than to stumble across them later. Still, some of the worst therapists I've encountered were among the best trained and had undergone the most personal psychotherapy. All the training and supervision and psychotherapy in the world is not going to make a good therapist out of someone who is not naturally therapeutic.
What Makes A Good Therapist?
- A good therapist has got to like doing therapy. A wise old therapist friend acknowledged that those of us who become psychotherapists are people who need more hours of therapy each day than we can afford to buy for ourselves. I don't mean that therapists have more mental illness than other people, but that they get more out of therapy. Good therapists are good patients, people who enjoy swimming in emotions without drowning in them. They feel refreshed after an emotional workout.
- Good therapists have got to be optimistic, believing that life is a comedy, not a tragedy, even if you can't get out of it alive. They can't be afraid of failures and embarrassment and pain, or even of tragedies. Good therapists aren't protective of their clients. Therapists can't do good therapy when they are afraid of losing their customers, of having customers commit suicide or sue them.
- Good therapists have got to be eager detectives and explorers, people who like to solve mysteries and figure out how life works. They have a homing device that leads them quickly and directly to the aspects of the situation that don't make sense. Sherlock Holmes and Sigmund Freud had more in common than cocaine. Good therapists don't take things at face value, they don't assume they understand everything from the beginning, and they certainly don't assume that everyone is alike and that one solution fits all. They have to be eager to understand the intricacies of a new situation. Good therapists are excited by each new client, and learn something new from each.
- Good therapists certainly have to be warm—they may not be especially loving or nurturing, but they delight in intimacy. They must be able to understand and share experiences: their own, those of their customers, and those of the people whose lives are touched by their customers. Good therapists are not quite like good parents, who are massively invested in those they would raise—that position is inevitably too possessive. They are more like aunts and uncles, offering an alternate view of reality while invested in the outcome, but not so possessive that their own identity is at stake.
- Good therapists have got to have a sense of humor. Without it, they may try to protect their customers from the cruelties of life—those unpleasant but necessary experiences that give people chances to expand consciousness and build character. Of course, good patients have to have a good sense of humor too. Good therapy is fun, and spoils both therapist and patient for the sort of cautious, polite interaction that takes place at social occasions.
- Above all, good therapists have got to be fairly sane—not rigidly, anxiously, cautiously sane, but able to see fairly clearly how the world works. It also helps if therapists are happy people, not stuck in happiness like manics or TV weather forecasters, but able to experience a full range of human emotions.