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​​How to Pick a Therapist

(This piece, written for The Washington Post some years ago, has been reprinted in a great many places. Though the article refers only to psychotherapy--because that's what The Washington Post asked--the advice applies to whatever help you seek.)

By Robert T. Fancher
Copyright The Washington Post Company

Anyone with an ounce of sense has some fear of psychotherapy -- and not just because he doesn't want to "face his problems." People fear the influence of therapy. What if therapy influences you to change in "bad" or "wrong" ways?

If mental health professionals knew objective truths on what makes people healthy or ill, the fear of psychotherapy would be misguided. But one need not be a scientist to know that they don't. Over 60 different kinds of therapy are well established in the United States, and within each of these there are many alternate views. Most clinicians sample a variety of different systems and cobble together idiosyncratic therapeutic repertoires; there are (at least) as many opinions as therapists. The mental health community is an incoherent melange of overlapping and competing professions and ideologies, not a community of experts in truths about human nature.

Still, psychotherapy works. Hundreds of studies have been done over the past 20 years or so, and cumulative analysis shows that about 70 to 80 percent of therapy patients do better than people with similar problems who forgo therapy. Consumer Reports -- which has no vested interest in proving that psychotherapy works -- surveyed several thousand therapy consumers two years ago, reaching the same conclusion.

We face a conundrum: People are prey to severe distress that defies all ordinary efforts at relief, which psychotherapy can ameliorate; yet we have a nearly infinite variety of therapeutic ideologies and techniques, many of which offend people's values and commitments, and none of which can reasonably claim to be "the truth." What is a reasonable, conscientious consumer to do?

The simple answer: Change what you expect from therapy, choose your therapist wisely, and make judicious use of his observations.

Do not expect a therapist to be an authority on "health." 

Do not expect therapy to show you "the way" to be healthy, but instead view it as a way of changing your life, given your commitments and preferences.

Above all, recognize that following your therapist's ideas or not is your choice. Never submit to ideas with which you cannot in good conscience agree. Instead, expect therapy to be a resource. Look to the therapist as a "third eye," a source of independent observations and ideas for your consideration. Expect the therapist to support his ideas with reasons -- and to take your reservations seriously, not simply as signs of your problem.

You need not be afraid to choose a therapist, for the simple reason that a good outcome does not depend on the therapist's having "the right" ideas or academic degree. Of the sorts of psychotherapy that have been well researched, all have roughly equal positive outcomes. These robust findings give consumers freedom to look for therapists whose ideologies and commitments are congruent with their own.

How, then, do you choose? Get clear with yourself on what you are willing to put in question or not. Ask questions in the early sessions. 

Research shows that successful treatment shifts the patients' values toward the therapists'. While you do not have a right to know about a therapist's private life, you have a right to know what sort of influence he is likely to exert. 

If, for instance, you want to talk about problems in your marriage, you should know how binding the therapist considers marriage vows. 

If you are religious, you have a right to know whether the therapist considers religious devotion immature. If the therapist will not reveal his values on matters of central concern to you, go elsewhere.

Beyond congruence on basic values, you need to consider the therapist's clinical skills. 

Therapists, unlike schools of therapy, differ significantly in effectiveness. If therapists (under controlled experimental conditions) use a variety of therapeutic systems with different patients, therapists who get good results with one system get good results with all. Therapists who cannot make one work cannot get good results from any.

As best we can tell at present, the therapist's ability to forge a certain kind of relationship with the patient determines his effectiveness. 

Effective therapists are good at establishing rapport, including the ability to understand and communicate with the patient in a natural, easy way. They take a supportive but disinterested stance -- they want the best for the patient but have no investment in whether the patient agrees with them or not. They give feedback from a more dispassionate perspective than the patient (who is immersed in his difficulties) can take on his own. They offer for consideration perspectives patients have not considered before.

Any patient can evaluate such matters. You can tell whether the therapist listens carefully, offers understandable feedback addressing your concerns, and cares about you while recognizing that neither your problems nor your choices have much to do with his personal welfare.

Likewise, any patient can tell when a therapist fails to provide the aid that's needed. 

The therapist may identify too strongly with you, agreeing uncritically with the views you already possess. He may let your anxiety infect him. He may act more like a saving hero than a source of perspective. He may try to promulgate his own values as if they were the sole definition of "health." 

Discerning whether a therapist listens wisely and well is not rocket science.

Fear of therapy makes sense, if we look at therapists as authorities we ought to accept. Yet the very diversity that makes therapy frightening from that perspective becomes reassuring when we shift viewpoints. Diversity makes for choice. 

If you remember that the therapist is a helper whom you hire, not a guru you follow, you need not be afraid. Make your choices thoughtfully, but make them yourself. Hire -- and fire -- whom you wish, without apology.