Last edit of this page 29/05/08
"Therapy works. Over the last 40 years, study after study finds that the average treated client is better off than 80% of the untreated sample in those studies. Now for the bad news. In spite of years of careful research, the same data has not found any one model, method or approach that results in reliably better outcomes for specific diagnoses." From talkingcure.com and their article on 'what works' in word format
Carl Roger’s theories developed in the 1950’s are often over-looked and rarely cited in mental health literature these days. He predicted,
- much of the training which psychotherapists received in university professional programs would be irrelevant
- that a great deal in therapy depended upon the therapist having his ‘heart in the right place’ rather than on technical expertise
- the enormous amount of professional time and resources expended on assessment and diagnosis may be a waste of time
- there may be no essential difference between what constitutes a good psychotherapeutic relationship and what constitutes a good helping relationship in many other settings such as education, social work, child rearing or even management consultancy.
1.0 What a therapist brings to the task affects the outcome
Studies of therapists show their relationship skills and personal style have a greater impact on the outcome of therapy than the modality of treatment they provide.
Orlinsky and Ronnestad have a large scale international study of what therapists bring to treatment, reported in the May/June 2005 Psychotherapy Networker.
Early results indicate that therapists experience the process of doing therapy in two distinct states of mind named healing involvement (alive, engaged and productive) and stressful involvement (bored and anxious). About 50% of therapists in their sample at any one time, are alive and engaged in their work. The other 50% of therapists were described as: challenged (25%); distressed (10%) or disengaged (15%).
A fair conclusion is that there is a 50% chance of working with a therapist who is committed, affirming, with a high level of empathy and relationship skills, enjoying a sense of flow during the sessions, who is effective with any model they have chosen.
It is okay to ask a therapist how they are traveling in their work. It directly impacts on their effectiveness. A useful way to illicit that is to ask something like, what are the growing areas and the challenges in your professional life? How do you take care of yourself? How do you keep yourself interested and alive in your work? How do you know which clients you work best with?
Some therapists don't feel comfortable disclosing more than terms of service in an initial telephone call. How they handle the discomfort and deal with a direct question about self-care from a stranger and about their client selection process, can give you a feel for how they might behave when challenged.
Some therapists have a lousy answering machine message or email process. This might indicate a lack of awareness of their client's desire for a soothing phone message when they are distressed. Many ongoing clients just want to hear a familiar voice or see a kindly face or read their point of view on the web in the early hours of the morning and don't want the therapist to pick up the phone nor send an email reply.
The links between perception and reality.
1.10 Individual therapy
On the Australian Psychological Society website you can search for Medicare registered psychologists. With a GP's Mental Health Care plan you can get $110 of their fees refunded for up to 12 session per year. Two informative Australian resources are good therapy and psychoz where you can also search for a local practitioner and read a choose therapist article.
Here is a useful article about choosing a therapist in USA. How to choose a therapist at grohol.com
Word of mouth referral from a friend or from another health professional and a chat over the phone for about ten minutes, before making an appointment are good initial indicators of the potential for a working relationship.
That chat or lack of it, will give you some information about the therapist - especially if you are clear on what you want and don't want and are unafraid to ask.
A seasoned therapist will know how they select a client from an initial paid session. You don't want to waste time or money if you are clearly not in their bag. Both of you want a good fit and want to work that out early in the relationship. It takes time to get to real talk and often the most effective therapist responses are simple asides. (These are rarely recorded in the research proving the effectiveness of treatment programs such as CBT.)
I have had clients quote back to me, when returning to do some more work year later, something I said a decade ago that was for me just a throw away line, which had served them well as a principle for making many life choices. That has taught me not to be too pre-meditated in how I respond.
1.11 Telephone and recorded sessions
If you are in rural or remote Canada or Australia you may not have much choice of therapist. Given the travel time, some sessions by email, telephone or teleconferencing will be important and necessary. A therapist with clear, companionable telephone manner and a warm, unambiguous, jargon free writing style will help clarify and resolve issues using those media. Depending on your circumstances the same may apply in an urban setting.
Here is a discussion about therapy on line.
A therapist's willingness to audio record a talking session and/or have you video the session, particularly for process work, music, movement, dance therapy or interplay is a good sign of therapist accountability. The recording can help you bring it back home to you partner; review what was said or done; track the change points; assess your authenticity, the therapist's listening skills and their clarity in hearing/reading you and responding to you correctly.
Theoretical models are not as useful as the ability to engage you in changing your behaviour. After an initial appointment assess the experience with this how to choose a therapist questionnaire. Try to get get a reading of which 50% they are currently traveling in their career - particularly if they appear disengaged or distressed. Here is a list of focused questions to assess how your body feels after a session and in what proportions did you or the therapist influence the direction of the session.
If you have a low Emotional Quotient then ask a friend who is both a good judge of character and has high EQ to check them out first. What's your EQ - quiz here.
The summary of the book Crazy Therapies begins, there are very few sure things in life, but the following guide to recognizing an incompetent, immoral or quack therapist is about 99.9% guaranteed.
1.2 Couple's counseling and therapy
A dirty little secret is that couples therapy may be the hardest form of therapy, and most therapists are not very good at it. Yet, most discussions of marital problems occur in individual psychotherapy, where a lot of the damage to marriage goes on.
Individualistic therapy approaches to couple problems can be hazardous to an enduring relationship. Caveat emptor!
How to mend a broken relationship on this site. How to choose a marriage therapist, off site.
Here's a list of things a couple's therapist asks their clients to do to improve their relationship and here's how to benefit from sessions with a couple's therapist. Here's a coaching and mentoring view and a marriage therapy view of the process.
Relationship therapy is likely to be less expensive than divorce or interruption to a career. However, it is not always successful. In Gottman's studies, 50% of those in relationship therapy (coming on average after 6 years of compromising and negotiating around key issues) continue on to divorce. Of the 50% who continue in their relationship, 35% report distress two years later. Prevention is superior to cure hence I recommend pre-commitment counseling every time.
A therapist offering their services to couples attempting to solve long standing problems, would be wise to have done at least 5000 hours of straightforward couples and family counseling, coaching or therapy.
And,
- is a State Board registered clinical professional such as clinical psychologist or clinical social worker
- has firm and clear boundaries; vigilant of their own duplicity; honest with themselves and up front after they err
- is skillful at catching and discriminating double think and complex ambiguities i.e. has a good crap detector
- authoritative yet kind, respectful and responsive to their client's wants and needs
- not minimize the enormity of the presenting problem whilst over time gently invite the relationship to explore its own culture and history
- okay with fierce conversations and raw anguished emotions
- calm in the face of shattered beliefs and catastrophic threats
- a seasoned trauma therapist able to differentiate complicated traumatic grief from depression; addiction from recovery
- astute in differentiating contrition from both toxic shame and addictive remorse
- able to confront dissembling, plausible promises and false acceptance, without losing the respect of either party
- a wise and timely sense of humour
- not take sides, collude, take a moral position nor become triangulated
- rather always take the side of survival and growth of the primary relationship.
Good counsel is expensive, poor counsel is more expensive, especially when navigating the complexities of intimate betrayal.
Eventually all information and help has a use by date, when both people have enough of it to get on with the work of repairing and growing again or not.
1.3 A candidate for couple's therapy rather than the individual therapy they initially chose
Q: 'My partner of 4 years has been seeing a psychotherapist for the last 8 months and there is no change in his behaviours or attitude. Apart from the financial issues involved I resent that he pays money to communicate with someone else when he doesn’t communicate with me. He thinks that I am jealous - it’s more like a feeling of betrayal that he refuses to talk to me about anything. This is causing problems in our relationship and whenever we try to discuss these issues it always ends in a major argument. I feel betrayed by his reluctance to share anything with me and he feels that he is being restricted by my reluctance to support his therapy. I feel like the therapy is more important to him than working on saving our relationship and we always end up in a stalemate and neither of us can move past these issues. Is it normal for partners to feel this way? How do we get through this? I want him to give up for a while (not for good), he insists on going even at the expense of our relationship.' quoted from good therapy forum
A: It's impossible to build a mental map of a relationship when your partner doesn't let you in. Mind reading won't take you far. We require an accurate map in order to navigate the tides of intimacy and to know where we stand with our loved ones. When a stranger is getting a big look in at your expense, the ground can feel very slippery; the map obscured and you'd be unusual if you didn't feel a bit ripped off. From your point of view you are in a triangle
Some intimate conversation has been outsourced to a therapist, barring your access to all that is going on inside your loved one.
You fight to get back in, he fights back to protect his choice. The therapy has become in effect a third party and a new exit from intimacy that both of you have agreed to argue about and at the same time, feel yucky being wound up about a peripheral issue. It's unlikely to be the real issue, but at this stage it feels real; is perceived as a threat and has purchased yet another stale mate. Anyone could discount the impact of his therapy on your relationship by denying your experience and blaming you for feeling threatened, but neither discount will secure a relationship built on respect, friendship and love.
The current issue is probably the latest escalation of a pattern that has dogged you both from the outset. Each new version of the pattern erodes trust and safety and pushes owning and addressing the core issues further away. Many give up on a relationship at these points - too much like hard work - only to go on to create a new version of the old pattern in the next one.
My guess is that both of you have co-operated over the last 4 years in producing a now predictable disengagement, where one ends up the pursuer (mostly you, 'tell me what's going on with you, come closer') and the other the withdrawer (mostly him, 'I'll work it out on my own, give me some space'). It's a pattern also described as fuser and isolator. Weird to think that our exits from intimacy are co-operative behaviours like dance routines, defined by and refined in our peer groups and families of origin.
Step back from the dance and consider your contribution to its steps.
What's his take on this? Is he a bit scared showing tenderness and vulnerability with you? Of willingly exposing his heart to the risk of hurt or of being controlled by you as he struggles to maintain a sense of self, up close? There's an edge in getting close with love, when one can experience confusion about where I end and you begin. I wonder if the kindest explanation of your partner's insistence on his therapy at the risk of his relationship, is that at some level he knows he has to grow; develop more self-differentiation and learn how to care for himself up close with you. He may sense that postponing his growth will keep the relationship going around and around in circles, and fears that he can't make that leap in growth with you. It's difficult to articulate that knowledge when you are just in the process of learning about it.
How about the therapist? The kindest interpretation of the therapist's role is that of an unwitting participant in a triangle. Many therapists directly invite and re-invite the partners of their clients to come in over the course of individual therapy. Still, some of those partners refuse to attend until after it is too late and the horse has bolted. Were you invited in at the outset? Numbers of partners have and do feel the way you do and that normality doesn't make the normal omission of couple support okay. Your distress is foreseeable and it is not okay.
If those joint sessions have not occurred you can choose to call his therapist, raising your concerns and asking for a joint session to safeguard the relationship from further injury. BUT! Warning! Without your partner's blessing of that contact he could perceive it as an invasion by you and if it takes place, as betrayal by his therapist if h/she hasn't cleared that contact with him before talking to you. It could just be another escalation of the fuser isolator routine.
More on site about pre-commitment and marriage education.
1.4 Is counseling neutral, objective and value free
Therapists carry into their sessions, sometimes unexamined, culturally prescribed 'normal' prescriptions about what is good and poor health, good or dangerous therapy, male and female traits etc. Clients do the same.
A therapist urging or not urging a partner to 'seriously consider leaving a particular relationship' depends a lot on the client's ability to fairly represent what goes on in three sides of their relationship: his story, her story and the whole story; on what they have been told and what is omitted in the telling of their client; on how savvy the therapist is about the triangle of influence they inevitably join when they pick up or ignore an issue, and particularly on their views of what is healthy and unhealthy.
To one therapist the relationship problem may be an opportunity for growth but for another the same problems may be described as a bitter power struggle.
Whatever psychotherapy is, it is not about therapeutic neutrality. Therapeutic neutrality is a stance inherited from classical psychoanalysis, in which the silent, passive analyst refuses to react or comment on what the patient is saying or doing, thus encouraging the patient to regress into a "transference neurosis" on the analyst. Needless to say, such unresponsiveness brings forth all manner of crazy emotional responses. Except in classical psychoanalysis, neutrality is not only rude and inappropriate, it also makes you crazy.
Even if a therapist could be neutral about the issues at hand - impossible! - that neutrality would at best bring the therapy to a limping halt and at worst seem to be an endorsement of the client's persistence to barrel the wrong way down a one-way street. One of the horrors of psychotherapy is the affirmation clients may feel from their seemingly neutral therapists that they are "okay" even when they are doing terrible things to themselves and their loved ones. Therapists may actually encourage clients to feel better about themselves by blaming their lives on other people, on the nature of human existence, or on the peculiar mores of the society around them. Therapists should of course help people step out of their crippling state of victim hood.
Good therapy is not a chaste love affair between buyer and seller of psychotherapeutic services. The therapist and the customer don't even have to like one another. The therapy may be working best when you don't like your therapist, when you get the firm impression that your therapist doesn't like you very much either, and when you are being told that you have to do something you don't want to do if you are ever to feel good about yourself. In fact, the therapist is hired to scrutinize you sharply and find something about you that is unlikable and unworkable, and then to help you isolate and discard the offending behaviour. If the therapist sees everything the way you do, the therapist would be in the same fix you're in. And if the therapist thinks you're wonderful the way you are and just wants you to realize it, the love affair that results is different from therapy. Therapy is an inherently adversarial process, not an alliance to buffer innocent victims against a world that isn't gentle enough.
Some therapists believe in marriage so strongly they see single hood as a state of emotional deprivation that is the cause of all the pain in the life of single people. Such therapists may rush people into ill-advised marriages, some of which will work and some of which won't. Other therapists distrust marriage so totally they see it as a dangerously oppressive state of exploitation and impending doom. They assume that any pain a married person suffers is brought on by the marriage. These therapists likely experienced disappointment in their marriages or their parents' marriages. In between are therapists who idealize marriage, and give full support to perfect marriages and short shrift to those with problems. Some therapists, especially those who didn't come in from the Sixties in time, still believe that mental health comes from running away from home, and if people are too old to run away from their parents, they can run away from their marriage. Quoted from 'a buyers guide to psychotherapy' by Frank Pittman
© Ziji Fox 2006 All Rights Reserved peterfox.com.au
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