For years, I’ve asked therapist colleagues the following question:
Imagine a loved one calls you from her home in a major American city to tell you that she keeps getting in her own way in life and has gone to see a therapist. What percentage of therapists do you think are minimally competent, such that you would feel that she’s in good hands?
The answers hover around 5 percent (although trainees tend to be more generous). My friend Jonathan Shedler has also been asking therapists this question and getting similar results. We were going to write a book called, Five Percent: How to Do Good Therapy and How to Get It. It turns out, though, that we are better at writing book titles than book proposals.
How are we to make sense of this finding? Most obviously, therapists probably include themselves in the 5 percent, like the vast majority of people who claim to be above-average drivers, twisting some flexible metric so that it includes themselves. My metric follows, but I preface it by saying that many people get help from incompetent therapists because even incompetent therapists give you a place to mull things over, try out personas, and feel accepted. But I think a therapist should be able to do more for you than a bartender, a kind uncle, or even a friend. Analogously, a competent architect will design and build a house that works for you on your property, giving you more than you could get from copying something in a magazine.
Here are my four expected fundamentals in a therapist who’s doing in-office talk therapy with an individual client:
1. The therapist understands that a therapeutic relationship is very different from a social relationship.
Good therapy requires the patient to take off the social mask, but the therapist keeps the mask on. Regardless, though, competent therapists promote a mode of relating that is very different from social relating, and from other forms of (non-therapy) professional relating. In particular, the therapist must accept responsibility for his or her setbacks, potholes, and failures.
2. The therapist establishes a joint sense of purpose and a mutual understanding with the patient about what they are there to do together.
This is captured in a clinical case formulation that is unique to the individual patient (versus a generic, off-the-rack formulation that could apply to nearly anyone). By “unique,” I mean unique.
3. The therapist interprets the patient’s speech as metaphorical or literary, not as merely literal.
The therapist can never know what happened in someone's childhood, and can’t even be sure about what happened to a patient yesterday. The therapist understands that this is not a limitation on effectiveness, because the meaning that experiences hold for an individual is all-important.
4. The therapist interprets the patient’s speech.
This means not only as a window into his or her narrative, constructed self, and the world, but also as a metaphorical response to the environment in which it occurs—as a commentary on the therapy itself. This is the therapist’s primary source of feedback about what works and what doesn’t.
That’s only four things I’m looking for when evaluating in-office individual talk therapy, just to get to minimal competence—and setting aside such niceties as pursuing wisdom and having a big heart. In my experience, the vast majority of therapists practice none of these.
Here’s something interesting I’ve noticed over the years: While I am a snob when it comes to evaluating psychotherapy, only incompetent therapists get angry at me for it. When a master clinician finds out that I think ending sessions on time is essential to minimal competence (because it promotes the first factor I described above), she may agree or disagree, ignore or wrestle with the proposition, but she doesn’t get angry.
This observation supports my view that the Number One thing holding harmless therapists back from becoming excellent therapists is the desire to be told that everything they do is beneficial. This blinds them to the effects of their techniques. It’s like trying to learn how to bowl without looking at how many pins you knocked down and insisting the scorekeeper record every roll as a strike.
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