How to choose a therapist.

Prospective therapy clients in the San Francisco Bay Area are among the best-informed people anywhere in the world. Counseling and therapy have been embedded in the cultural landscape for decades. But too much information can be bewildering. Especially since there are many different kinds or theories of counseling and therapy and people seem to feel quite strongly about them.


The dominant paradigm for helping people with problems used to be psychoanalysis. After WWII things began to change. There were many more people looking for psychological services and most of them did not fit the profile of the ideal candidate for analysis: for one thing analysis is expensive in time and money; for another there were too few analysts. At this time people began experimenting with new ways of doing talk therapy. The great theoretical pioneers of the second part of the 20th century were mostly trained in psychoanalysis and operated in a context in which psychoanalytical constructs were part of the background. Fast-forward forty or so years. The dominant paradigm for helping people with problems is now cognitive-behavioral therapy or CBT. A dominant paradigm always provokes reactions, and thinkers and researchers are now reacting to CBT in the same way as, four or five decades ago, they reacted to psychoanalysis. New ways of doing therapy are springing up.


So what do you do if you are looking for a therapist? Some clients decide on the kind of treatment they want: "I'm looking for Gottman couples therapy." Some decide on the kind of clinician they want to work with: "I want a woman, older, but not too old, and really smart." Some prospective clients come with experiences they feel they want to see reflected in their therapist: "I'm gay/straight and I want a gay/straight therapist." "I'm a divorcing heterosexual woman of color and I want to see a nonwhite female therapist with experience working with divorce and eating disorders." All these ideas are sensible. The person looking for therapy is anxious, and these ideas give some reassurance, feelings of certainty and of being in control.


But such feelings do not predict how therapy will in fact turn out. Therapy outcome researchers such as Bruce Wampold believe that "if there are differences among treatments, the differences are quite small." Wampold further writes: "Therapists vary in their effectiveness: some therapists consistently achieve better outcomes with their clients than do other therapists." The conclusion to be drawn is that good clinical judgment and expertise are primary determinants of good outcome and that the clinician's professed theoretical orientation matters far less. This means that if, for example, your last good therapist was a good CBT clinician, and your choice now is between a psychodynamic clinician you know to be good and a CBT clinician about whom you are unsure…you should choose the clinician you know to be good, irrespective of theoretical orientation.


This choice makes sense because no model of counseling and therapy is "pure." Your CBT therapist will inevitably deviate from the CBT model at some point and work psychodynamically with you. Your psychodynamic therapist will use CBT techniques. Your Gottman couples therapist will also use other methods. All clinicians make clinical choices to switch between goals-based ways of working (such as CBT strategies and sequences) and process-based ways of working (such as uncovering and working through feelings). Good therapy is good therapy irrespective of its label: the good therapist is more versatile in switching between goals and process in order to give each unique client what you need at each stage in the therapy.


How to choose a good therapist? Use your gut instincts to guide your choice. Shop around. Interview two or three clinicians. Check in with yourself: how did your interaction with this therapist make you feel? If your response to this therapist is to feel more hopeful, understandable and safe, then book a session.


Good luck in your search for a clinician and please email me with any comments on this blog post—

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