A good therapist is hard to find. I’m new to the field, relatively speaking, and I’ve already encountered a number of horrible therapists as well as many outstanding ones.
Finding a good therapist is trickier than finding a good dentist or gynecologist. Most people choose their healthcare providers based on a three simple factors: proximity to their home or work, whether the provider takes their insurance, and personal recommendations. For most healthcare issues, this works out well. After all, a biannual dental cleaning is a biannual dental cleaning; a pap smear is a pap smear – there’s not a whole lot of variation in how these procedures are done. You can be pretty confident that you’re getting decent care regardless of which doctor you choose. If you don’t like your doctor, no big deal – you only see her once or twice a year, and besides, she takes your insurance and she’s two blocks away from your office! You may opt to switch doctors due to a negative experience with one or a change in insurance coverage, but this is not a big deal either. You just go back to square one and choose someone based on those initial three criteria.
Choosing a therapist is not so simple. Therapists are not interchangeable like dermatologists or orthodontists. The treatment you get with one therapist differs tremendously – in terms of the nature of treatment, the type of treatment, and the quality of treatment – from the treatment you would get with other therapists. The problem is that most people outside the field are not aware of this, and it is difficult to find out what you are getting before you get it. The licensing process does very little to weed out incompetent psychologists. The two written exams we must pass – one based on a general knowledge of psychology and one based on state laws and rules for psychologists – have no predictive validity in determining whether someone is a good therapist. Basically, therapists can do whatever they want in their sessions, so long as it doesn’t violate ethical codes. Therapists are not prohibited from practicing outdated, ineffective treatments. Although research has shown certain psychological treatments to be vastly superior to others for certain disorders, the majority of therapists do not use these empirically-supported treatments.
Choosing a therapist based on proximity alone is not a good idea. The therapist closest to you may not be a good fit for you. Choosing a therapist based on insurance alone is also not a good idea because many therapists don’t take insurance. Further, if you do use your insurance to pay for treatment, the insurance company will likely request a great deal of personal information about your mental health conditions, may discriminate against you based on diagnosis (or lack thereof), and will probably limit the number of sessions you can receive. Getting personal recommendations for therapists is tricky because it involves disclosing at least some personal information to a friend or colleague, and many people are not comfortable doing that. It is not always wise to choose a therapist based on how much experience she has in the field, because many therapists who have been practicing for decades remain entrenched in antiquated theories of mental disorders and practice less effective treatments Also, if you are a young person, it may feel more comfortable to talk to someone closer to your age who can relate to you more easily and who has a better understanding of your generational issues.
So how do you choose a therapist? Well, that depends on why you’re seeking therapy. If you need some support in dealing with normal developmental or social stressors (e.g., death of a friend or family member, relationship issues, stress management, divorce or breakup, difficult transitions), it is helpful to use the following selection criteria:
• A personal recommendation from a trusted friend may be helpful in this case.
• Find someone who has experience dealing with the types of issues you are facing. For example, if your sibling just died, find a therapist who is experienced in working with grief.
• Consider whether you have a preference in terms of your therapist’s gender, ethnicity, age, or sexuality. Many people prefer to work with a therapist of their same gender and/or someone who is close to their age. Many LGBT clients prefer therapists who are openly gay or lesbian, or who have considerable experience working with these populations. Some ethnic minority individuals prefer working with someone who shares their ethnic background. On the other hand, some clients don’t have demographic preferences, and that’s OK too.
• Find a therapist with whom you feel comfortable. You may need to have a session or two with the therapist before really being able to tell whether it is a “good fit.” Developing a strong, trusting therapeutic alliance will facilitate the healing process.
• Find a therapist who is a clinical psychologist (Ph.D. or Psy.D.), Licensed Mental Health Counselor (LMHC), Licensed Clinical Social Worker (LCSW), or Marriage and Family Therapist (MFT).
When you are seeking treatment for a mental illness, such as major depressive disorder, OCD, anorexia nervosa, PTSD, or borderline personality disorder, I would recommend using a different (and more stringent) set of selection criteria because the stakes are higher. Having a good therapist is a powerful predictor of your chances for recovery, so it is important to take the therapist selection process seriously. Most therapists offer free phone consultations in which you can briefly describe your issues and ask about her qualifications and approach to treatment. I recommend using the following selection criteria in choosing a therapist to treat a mental illness:
• Do as much research as you can on your diagnosis and effective method(s) of treating your particular condition.
• Look for a therapist who specializes in providing evidence-based treatment for your disorder. For example, if you suffer from OCD, you will want to find a therapist who specializes in OCD and practices behavior therapy. You can find out this information by looking on the therapist’s website (if she has one) or simply by calling to ask her about her specialties and her treatment approach.
• Ask the therapist about her views on your particular disorder and the treatment thereof. If her explanation of your illness is unscientific (e.g., “Anxiety disorders are the result of unresolved inner conflicts”) or if her treatment approach sounds flaky or non-directive (e.g., “I provide clients with a safe place in which they can explore their issues”), move on to someone else. It’s great to explore your issues in a safe place, and this may be exactly what you need when struggling with the normal developmental or social stressors described above. If you have a mental illness, however, you’re going to need a whole lot more than that in order to recover.
• Look for a therapist with a doctoral degree in psychology (Ph.D. or Psy.D.). Doctoral level psychologists have 5-7 years of graduate training and supervised clinical practice, plus a post-doctoral residency. Most Ph.D. programs in clinical psychology are extremely selective and have very low acceptance rates (for example, 250 applications for 6 slots). In addition, Ph.D. psychologists have extensive training and experience in scientific research. While a Ph.D. in clinical psychology does not guarantee therapeutic effectiveness, it does reflect a high level of ambition and academic accomplishment, a scientific background, and at least five years of intensive, high-quality training. In contrast, a master’s level therapist such as a social worker (LCSW), licensed mental health counselor (LMHC) or marriage and family therapist (MFT) has significantly less clinical training (usually 2 years of graduate school) and very little, if any, training in scientific research. Psychiatrists are medical doctors (MD’s) who focus primarily on prescribing psychotropic medication. Some of them provide psychotherapy in addition to medication, but most do not. Their training is primarily in the practice of medicine, not scientific research or psychotherapy. Most psychiatrists these days have little training in psychotherapy. Of course, there are exceptions to this rule. If you decide to see a psychiatrist for therapy, make sure she is one of the exceptions.
• University-based mental health clinics and academic medical centers are excellent places to seek psychological treatment. Many of them offer low-cost services or provide treatment for free as part of research studies. The therapists are typically doctoral-level graduate students, pre-doctoral psychology interns, and/or post-doctoral residents, all of whom are closely supervised by licensed clinical psychologists. Advanced graduate students, interns, and post-docs tend to make excellent therapists because they are young, idealistic, energetic, fully informed about recent advances in the research and practice of therapy, well-trained, and constantly evaluated on their performance.
• Find a therapist whose patients actually recover. The proof is in the pudding. Ask the therapist how many patients with your diagnosis she has treated in the past three years, and how many of those patients have fully recovered. If she hems and haws, or describes therapy as a lifelong journey, or claims that one never recovers from your particular disorder, move on to someone else.
• If the therapist is empathic, great. If she’s really nice and makes you feel at ease, wonderful. If you feel very connected to her, fantastic. These qualities are important, but if you are struggling with a mental illness, what matters most is whether she can help you recover. Mental illnesses are treatable and manageable; some are even curable. So don’t mess around with your mental health care. If you had cancer, your priority would not be finding an oncologist who was warm and kind and empathic and emotionally connected to you. These qualities are icing on the cake, but what you need most of all is the cake. And the cake is effective treatment that will cure your cancer. Don’t need to settle for anything less in your mental health care.