I have been a therapist in private practice for 25 years, but I was in therapy for about 15 years before that. I started as a client when I was 11 years old; and over the years, I had great therapists and terrible therapists. Here is what I learned from being a mental patient and from working with (and witnessing) a wide variety of colleagues for decades.
1. There’s no need to be defensive or awkward about needing help and support.
I called myself a “mental patient” above, on purpose. Look, I seriously needed therapy. I had to see a shrink. A check up from the neck up. Some serious psycho-archaeology. Where is all this shame about needing therapy coming from? I grew up in the D.C. area where a ton of people (kids and adults) were in therapy in the 70s and 80s. It seemed totally normal and lots of people could get it (insurance paid for it much more freely than it does now). It’s sad how awkward people are about it, and it’s now 50 years later.
2. Everyone is different, and no therapist or therapy is the “best”:
There are approximately 1.7 trillion different “approaches” to therapy, and each of these forms of therapy has 14 million therapists practicing it (or at least they say they do, because they took a workshop, read a book, and listened to a really good podcast). Just because you read a compelling article saying you need ABC Therapy or XYZ Therapy doesn’t make it true. The evidence is that just about every bona fide type of therapy is about as effective as every other type. They are all “pretty good” overall. The difference is between the individual therapists—there is much more variation in quality between the therapists than the brands of therapy. The evidence is pretty solid about this one. It’s just easier to sell certification programs about a new “brand” of therapy, and easier to market. You want a therapist who somehow seems to really get you, and who has a really solid understanding or “theory” about how to help you, and who has enough humility to check from time to time whether this approach to therapy actually is helping.
3. Date your therapist before marrying them.
The best way to judge the quality (or fit) of a therapist for you is to “go on a date.” If I were looking for my own therapist after all these years, I would know there are people with a certain approach (or credentials) that look great on paper but they are a disaster as a clinician, and other people who might sound as if they have a much more modest academic background or as if they come from a very different treatment philosophy that sounds iffy, but might be stunningly, movingly helpful. Having one (or more than one) discussion with the therapist before plunging in can give you more of a sense of how they are in the room, but the first session will tell you almost 100% of what you need to know about going forward. And before spending months (or possibly many years) working with a therapist, it makes sense to try out a few. The money spent on these first dates will more than pay for itself in the long run. You will likely get something out of each session. And you will have a greater chance of finding someone very good, not just someone who is “okay.” You can’t tell by looking at credentials.
4. If your therapist is just “pretty good,” keep looking.
Therapy is expensive on many levels: not just financially but in terms of time spent, hope lost, and having an accurate sense of possibility for growth and change. You don’t have to fire your therapist quite yet, and trying out a few options or a second opinion will give you a better sense of your real options. Let the therapists know you are doing this. It’s a good psychological test of your therapist: how threatened or jealous do they sound? Your therapist should want you to try different options so you can have a clearer sense of the best direction for you. Be open about this (with all therapists you may talk with).
5. You may benefit from working with the same therapist over many years -
or you may benefit from a fresh direction from time to time. As with the “dating” advice and “everyone is different” items above, there is no one single way to do this. And there is no wrong way to do it, although each therapist will have their own philosophy or values (or personal limits) about how best to do it. And most therapists are open to you experimenting to some degree with the right approach, and this might change as your life changes.
6. There is nothing wrong with asking for a sliding scale -
if you cannot manage the cost of your therapy with a certain therapist. Many therapists do not have a sliding scale at all, others have a limited number of openings, and still others commonly discount their rate. Just ask, so you know what you are dealing with.
7. If you get upset or angry at your therapist.
this might be (a) a critically important moment in your therapy where a successful “working through” will be of utmost importance to your clinical outcome, or (b) a sign that you should terminate this therapy with this therapist right away because something bad (and not therapeutic) is happening. Usually, the best way to discern whether it is (a) or (b) is to bring up the issue with your therapist. This can be scary, but for many types of therapy, conflict is expected and even desired from time to time. It’s the open discussion about it that will help you understand what is happening from each of your perspectives, and more importantly will tell you if your therapist has the capacity to care about how upsetting or hurtful or frustrating their comments or actions were to you. You also can get a second opinion from another therapist to give you another perspective.
8. Don’t switch from individual therapy to couples therapy with the same therapist.
Under some circumstances, a couples therapist might meet individually with each member, or might allow one member of the couple to continue after the couple has stopped therapy; but once a therapist develops a long-term relationship (an imbalanced relationship by starting with one individual), it’s not going to be a balanced approach. Similarly, if it feels as if the couples therapy is relentlessly imbalanced, this should be addressed until it is either resolved or you find a new couples therapist.
9. I should not have to write this one, but therapists have crossed boundaries and have been abusive or exploited their clients’ vulnerabilities.
The State of Colorado used to publish the names of these therapists, and sent them to other therapists to see. Those were the days. Therapists have suggested that clients sit in their laps, they have exchanged heartfelt cards, playacting as if they were parent and child, and done other things that “act out” an inappropriate relationship. Often, there are strong feelings that arise in the therapy relationship. It is the therapist’s job to keep the relationship boundaries clear and restricted so it is safe to explore the feelings that may come up, without the danger of these feelings being acted out in the relationship and causing real chaos.
10. If your therapist seems very “flat” or detached or overly clinical-
This might not be a sign of professionalism, but rather someone who is not bringing their humanity into the work to meet your humanity. This kind of overly professional “presentation” by a therapist often has the effect of making the client feel awkward, stupid, self-conscious, or weird. This can then be ‘explored’ by the therapist as if this reaction to the therapist is the problem. There are very limited cases where this is truly useful, but it should be talked about beforehand and agreed to by the client, not just “done” to the client. Otherwise, it’s awful. This kind of gaslighting is a way for a therapist to feel psychologically protected and superior around their shifty, uncomfortable clients. There’s a term for this: “iatrogenic harm.” That means that the treatment itself causes the harm (and then the treatment attempts to treat the harm that it caused). Do you really want to be paying for that? It’s like going to an autobody shop for some scratches and the workers beat on the car with a hammer and then bill you for all the dent repair that the car needs. Sometimes, a bit more temporary denting is helpful, but there better be a real conversation about this, and it better make sense to the client.
11. Checking in from time to time with your therapist about where you are headed together-
(what are the goals, here?), or why you are working this way together (why these particular therapeutic exercises, discussions, or ‘tasks’?) is a great idea to make sure you are in agreement about what you are there to do, or what you want from this process. How do you want your life to be different? These brief discussions can make the process between you much more productive.
