Psychotherapy Part 5: choosing a psychotherapist
This article is one of over 280 articles and audio recordings that can be found in the Resources section of this website. Access to Resources is available to patients who complete Assessment and start attending sessions weekly.
When choosing the right psychotherapist it’s important to remember some basic facts about psychotherapy if you want it to work for you:
Psychotherapy is founded upon a trustworthy, secure relationship
The best evidence from the longest-term study supporting psychotherapy’s effectiveness in helping people make changes in their lives says that the quality of the therapeutic relationship is the most important factor. Trust, acceptance, warmth, feeling understood and emotionally attuned are amongst the key elements of therapeutic value in the relationship, regardless of what theory or model the therapist uses. Seeking out psychotherapists who have trained in the importance of establishing these qualities in relationship would then be a sensible approach to finding a psychotherapist. You should be able to get a sense of the therapist’s skill in doing this quite early on and should be able to ask questions about the therapist’s ways of encouraging these qualities of relationship before you start working with them. (Equally, as you will form the other half of the relationship, it is also very important that you bring the required qualities to the work e.g. good motivation to engage, commitment, respect, courtesy, honesty and a willingness to be open. Together, both patient and therapist create the trust and security in the relationship, not just the therapist).
The therapist’s personal authenticity
This is something that, again, is linked closely to the above qualities and is more of a gut feeling area of exploration in your determining its importance for you. My own personal experience of going to see a psychotherapist tells me that personal authenticity has a direct bearing on the degree of trust I have in relation to anyone, but particularly relationships, especially therapeutic ones, where trust really is at the core of the relationship’s effectiveness. The more willing the psychotherapist is to be with me as a real human being with the openness, candour, honesty and caring that entails, the more I feel confident that he or she will treat me as a human being.
Being treated as a human being
This might sound self-evident. But here I’m thinking of Martin Buber’s ‘I-Thou’ thesis, where he talks about two distinct ways that we can relate to the world. The first is the I-It mode of relating, whereby we – as ‘I’ – relate to the world in ‘It’ terms. Namely, as objects or things. Believe it or not, many of us go about the world in I-It mode much of the time, relating to people as if they were objects that are either useful to us or of no use to us. We can relate to the natural world, plants and animals in the same way. Buber sees this as a problem because it denies the true nature and existential value of people and life-forms in and of themselves. Buber’s solution is the I-Thou mode of being, which is a simple shift in attitude and awareness so that instead of relating to the world and other people in terms of judging, defining, labelling, diagnosing and assessing their usefulness to us, we relate to them as ‘mystery’, suspending our selfish impulses towards them and being open to them as beings – in the case of people, human beings. In therapy, it’s important to know that you’re being related to as a human being, not an object.
Advocacy
Whilst your psychotherapist isn’t a best friend, it is reasonable to expect him or her to be your best advocate in helping you to identify and find ways to meet your needs in safe, responsible, healthy ways. This doesn’t mean doing everything to please or accommodate you, approving of your ideas about yourself or self-defeating behaviours. Having a good advocate can sometimes entail your being frustrated where, for example, your psychotherapist refuses to meet needs that you should be meeting in yourself, or where he or she refuses to agree with disrespectful or self-defeating behaviour. Having a psychotherapist who you are confident is ‘on your side’ in this way means having someone who clarifies to you in detail their personal and professional boundaries and limits. Clear boundaries help protect you and your therapist, clarify your responsibilities, and help model good self-management. Advocacy is not about comfort, it is about genuine caring, professionalism and support in the service of your personal growth, independence and maturity.
Seeing you in context
This is something that I know – having worked in a variety of private and public health settings – most psychologists and psychotherapists ignore to a large degree. Some technique-based therapies are purely symptom-focussed or diagnosis-focussed with no concern for the therapeutic relationship of reasons behind a person’s suffering. But in my view it is important to view any problems you bring to therapy in their wider context, not only of your own personal situation, but the social, economic and political influences of the culture that we live and survive in. Often this societal context is ignored completely because it is taken forgranted that ‘all is well’ and that society is ‘normal’. However many of us know all too well that the so-called ‘normal’ influences, demands and pressures upon us in contemporary society are far from optimal for mental wellbeing.
The right kind of discomfort
Remember that personal growth and change tend to be uncomfortable – not always, but very often. Comfort tends to be a product of our adherence to familiarity and in a therapy situation our familiar ways of being tend to be the ones in which we create or encounter the problems that prompt us to see a psychotherapist in the first place. Conversely, the unfamiliar and the unknown can bring up anxiety, fear, resistances and discomfort. In order to accommodate new learning, new experiences, new ways of thinking, feeling and doing things, you can expect to be exposed to the unfamiliar. This means that it’s important to prepare yourself to experience varying degrees of discomfort in the name of personal development. However, this doesn’t mean that any kind of discomfort you feel is ok. The discomfort that might come from feeling manipulated, judged or pathologised unfairly, or betrayed, for example, wouldn’t be the kind of discomfort that you would reasonably have to tolerate in a therapeutic relationship, or any other for that matter. If you feel these kinds of discomfort then discuss them openly in the relationship until you’re satisfied with their resolution. Know the difference between therapeutic discomfort and discomfort that comes from disrespect.
The right kind of theoretical approach
You may have some distinct, straightforward problems to solve that a simple problem solving, symptom-focussed approach can take care of. Or you may have something that is a bit more involved, complex or subtle. Problem-solving, technique-based helping approaches can be useful for the former and often also come in the form of self-help books for this reason. Relationship and process-based approaches may be better for the latter and they never come in the form of self-help books because they are part of relationship with the psychotherapist who uses them. It’s worth educating yourself on what therapies might fall into what catergories in order to determine what broad types of therapy might best suit you. As with patients, some therapy approaches use psychiatric labels and diagnoses as the basis of their way of viewing and ‘treating’ the person. And as with other patients, other psychotherapists have a resistance to using psychiatric diagnoses in this way, preferring to view emotional, relational and psychological disturbances and difficulties as part of the spectrum of human nature, rather than as defects, deficits or disease. This latter approach is based on the premise that our emotional and mental worlds don’t necessarily function according to the medical, psychiatric or disease models of understanding and therefore should be treated quite differently.
The right kind of practical approach
By this I mean the importance of any psychotherapist providing thoroughness and clarity about the therapy process they offer. You may be happy submitting yourself to a process that hasn’t been clearly explained to you, or you may not. Personally, I believe it’s important for us to know exactly what we’re in for when we entertain getting involved in a relationship that may entail revealing close, personal, intimate details about our lives to someone we don’t know. I’ve been in therapy with psychotherapists who haven’t explained anything to me upfront, or even undertaken any form of assessment, and the problem with this approach is that it can take the patient quite a long time to know what they’re involved in and whether the approach that is being taken with them is the right one. For this reason I personally have a system of meetings and assessments that are completely upfront and open, inviting patients to ask any and all questions before considering therapeutic work. Fees, personal history, lifestyle factors, problem formulation (what I as the therapist think is behind your problems), my methods, support planning, and what a patient might expect from psychotherapy: all of these are made crystal clear prior to any therapeutic work. That way patients know what they can expect before they make a commitment. If this could be valuable to you then it’s important that you seek out a psychotherapist who offers this approach to the work.
Regulation
In the UK psychotherapy and counselling are not regulated or licensed by the government as they may be in other countries. Instead, private trade organisations set themselves up, charging membership fees in return for each practitioner’s compliance with the organisation’s rules and regulations. This is entirely voluntary, not a legal or professional requirement. Whilst such organisations and those who support them suggest that membership is ‘safer’ or ‘more ethical’, in reality, like any bureaucratic form of control, practitioner competence is never guaranteed by such voluntary registration and action is taken after any damage is done. Many practitioners object to even more control and over-sight being exerted upon them from a ‘Nanny State’ that already continues to erode the citizen’s civil liberties and freedoms. And so membership of private trade organisations, in my opinion, are no real guarantee that you will be working with a truly ethical, authentic practitioner who is right for you. However, if you prefer to see a practitioner who belongs to a trade organisation then you should contact each organisation and they will provide you with a list of their members who may be local to you.
Male or female psychotherapist?
You may have a preference for a male or female psychotherapist. But personally speaking, having worked with many psychotherapists, psychologists and counsellors, I would be more focussed on who they are as individual people rather than their gender. It’s not always very helpful to assume personality or character traits or values based on a psychotherapist’s gender or their assumed sexual orientation, for example. I’ve met aggressive female therapists and emotionally sensitive male therapists, and vice versa – there really isn’t a rule that determines personal qualities, emotional intelligence, skill or understanding in therapists according to gender or any other external factors. And if your problems or history are marked by painful or difficult experiences regarding a specific man or woman, sometimes it can be of therapeutic value to go against any fears or discomforts you might have regarding the prospect of seeing a man or a woman. The therapist may well turn out to be an excellent counter-example to a bad experience you had in the past and they may also elicit feelings in you that could usefully be looked at as part of the work. Only you can decide what might be helpful here, but it could be worth an initial discussion with any prospective psychotherapist.
Cost and quality
In our capitalist culture we have, unfortunately, learned to equate the price of something with its intrinsic value. This, in my opinion, is one of the fallacies of life in consumerist culture because it is very frequently not true at all. It may have been true to some extent when manufacturers made high quality products that worked well and lasted a lifetime. But the trend now is to produce much poorer quality products quickly, using cheaper materials, low paid workers with poor working conditions, and poor workmanship, and then to place a high price tag on products that are nicely packaged, presented and marketed. A cheap-to-produce product that is packaged well and marketed in the right way can help separate us from our hard-earned money and we still end up taking something home that is poor quality under the illusion that it is good quality. Some therapies are like this!
In our consumer culture psychotherapy is no different and it is important that you don’t confuse how high or low a psychotherapist’s fee is with high or low quality therapy and relationship. I’ve come across psychotherapists in the UK who have charged shocking amounts of money for 50 minute sessions, otherwise known as ‘the therapeutic hour’ (I offer full 60 minute sessions). Even simple, problem-solving approaches that offer training courses that only last a few months e.g. CBT. Some problem-solving therapies don’t even require the therapist to have ever had even an hour’s worth of therapy themselves, and don’t require any development of relationship skills in the application of their therapy. And yet I’ve had direct personal experience of such therapists charging as much as £200 per session. There are others who have trained in more depth but who still charge £280 per session or more. I saw a very well known psychotherapist in London for a number of years who only charged me a fraction of what other therapists were charging and it is the therapy that had the biggest positive impact on me because of the kind of genuine, decent person he was.
My advice here is, as with anything you purchase in our consumer market, please do not for a second assume that higher cost means higher quality, or lower cost means better value. Fee level really is not a gauge of therapist quality at all. Indeed, fee levels may be of most use to us in revealing the therapist’s priorities more than anything else. In reality, you should use your good judgement to discern quality based on your common sense and direct personal experience.
I hope that these points help make the process of finding, choosing and working with the right psychotherapist a good, enjoyable and rewarding one.