Sunday, January 23, 2011

How to Choose a Competent Therapist

1 - Why I wrote this article
This article was the result of real-life consumer experiences (good, bad and ugly) with psychotherapy. I have been leading support groups online for about fifteen years. Members of my groups have written to me relating their experiences, and have asked questions such as those I pose here. I wrote this article to address their questions.

My own experience is part of the process. After several therapeutic encounters ranging from the destructive to the merely ineffective, I finally found a highly competent therapist. The difference is so astounding that I felt compelled to share what I learned.

You deserve a competent counselor, someone who can really help you, and not hurt you, or waste your time. You probably agree. But do you know how to find one? Do you know how to tell a good therapist from a bad therapist? I found that people put up with unsound and even dangerous and abusive behavior from their therapists and counselors, simply because they don't know that they don't have to.

In the course of my cyberspace travels, I have met many readers who gave up on psychotherapy, because of a bad experience. If they had known just a little about how psychotherapy works, and what they should have expected, they might have been able to avoid a bad therapist and find the help they deserved.

So in this article, I will try to equip you, as a consumer, with one method you can use to judge whether you are getting the help you need.

When you do find the right therapist, you will be truly amazed at the dramatic difference good counseling can make in your life -- you can at last begin your journey toward the inner wholeness you long for.

It will be apparent that the focus of this article draws mainly on psychodynamic ideas about therapy, but its principles apply to any therapeutic method that is offered to you.

The chapters that follow are based on interviews and conversations with numerous readers, therapists, friends and acquaintances about their experiences with psychotherapy, gathered over a period of about seven years. I am, admittedly, not a mental health professional, just a fellow seeker, but what I do know I am happy to share with you. I wish you the best in your explorations. 

2 - How To Tell If A Therapist Is Competent, Or Not
For you to be able to answer this question for yourself, first you need to know just a little about two things:

1.  You need to know what psychotherapy is and what it isn't
2.  You need to know how to find the answer in your own mind

The material on the next two pages explains (very briefly) the theory behind the practical suggestions to come. It explains why they are important.

3 - What is Psychotherapy?
Psychotherapists are not just people who give you advice. Psychotherapy is not simple problem-solving. Therapy produces change in your life, but not primarily because of advice you get from the therapist.

In reality, therapy is a much, much richer experience. Psychotherapy is a specialized technique which is effective in helping you cope with a wide range of difficulties. It can produce lasting change in your life.

Specialized techniques of caring have been developed which have the potential to produce change in human life, even when there are deep and persistent problems.

Psychotherapy helps individuals explore and resolve more enduring and deeply felt sources of conflict and dissatisfaction in their lives, so that they will gain confidence and inner wholeness.

Building an alliance of trust with the therapist leads to a reshaping of significant emotional experiences, and builds confidence and wholeness in new and enduring relationships. It provides the presence of personhood, not just technique. --Gary Hellman

The foundation of psychotherapy is the relationship you establish with the therapist. research has shown that the technique the therapist uses is not as important as the relationship you build together. As therapy progresses and trust is established, you will actually use the relationship between you and your therapist as a workspace, to resolve problems in your life.

Because the relationship with the therapist is so essential to the process, it is important to find a therapist to whom you feel connected, with whom you feel safe. In psychotherapy, you intentionally make yourself deeply vulnerable to another human being. That is a very frightening assignment indeed. But you must realize it is this very process of self-revealing and trust building that can be the means of your healing. At the end of this frightening and difficult path lies the inner wholeness you long for.

Obviously, if you are to make yourself so vulnerable, you must feel safe. I will show you how a good therapist builds that sense of trust and safety with you.

4 - Finding the Answer You Already Know
(You just don't know that you know!)

There is a part of your mind, beyond your conscious awareness, that knows if your therapist is helping you. Your unconscious controls your deep emotional satisfaction, or dissatisfaction. If your therapist does something unhelpful, your unconscious knows it, and will tell you. Messages from your unconscious mind are messages from you to yourself, and you can use them to evaluate the true success of your therapy.

Of course, learning to evaluate messages from your unconscious mind can be difficult at first, since your unconscious mind communicates with the outside world only indirectly. After all, it is unconscious. The unconscious mind speaks only through dreams, and through broad themes that play themselves out through other aspects of your life.

Furthermore, your unconscious and your conscious mind often disagree. Consciously, you might think one thing; but deep inside your unconscious, your true feeling is otherwise. Nevertheless, since your unconscious mind controls your deep-seated emotional satisfaction or dissatisfaction, the unconscious mind is often the theater of psychotherapy.

When the unconscious part of the mind communicates, it uses a conscious piece of information as a disguise for its meaning. Although we are saying one thing consciously, another meaning is being expressed unconsciously by way of the same images. In other words, when a patient in therapy tells a story or a dream, there are two levels of meaning in the images being expressed. One level is the conscious level. A story refers directly to the people and events being talked about. But a story may also contain unconscious information -- that is, the details and images may pertain indirectly and unconsciously to what has taken place in the treatment experiences itself. --Robert Langs, MD

You can use these encoded messages from your own unconscious to evaluate the success of your psychotherapy. If you examine and decode the images in your dreams and the broad themes of your stories, you can find out what your unconscious mind really thinks about your therapy -- whatever therapeutic methods your therapist uses.

For instance, after a particularly satisfying therapy experience, you may dream about being held and comforted. Conversely, if someone should interrupt your therapy session, you might dream that someone is breaking into your home. Throughout the therapeutic experience, from referral to termination, you can examine your dreams and conversations for these encoded messages from your unconscious, and use them not only to know yourself in a deeper and more real way, but also to judge the effectiveness of your therapy. Read on to find out more about what I mean. 

5 - How a Good Therapist Makes You Feel Safe
As I stated before, in psychotherapy, you make yourself deeply vulnerable to another human being, and allow many disturbing feelings and thoughts to be expressed. This is absolutely necessary to your healing. But to allow yourself to do it, you will need to have a strong feeling of trust in your therapist; you will need to feel safe.

The process of creating a safe space in which therapy can take place is referred to as building a secure frame, and it is a very important aspect of therapy. The "frame" is the environment of your therapy. It includes the physical surroundings, the emotional environment, the psychotherapeutic structure, and the relationship between you and your therapist.

A secure frame is a private psychic space in which you feel safe, "held" and supported. A secure frame is an environment in which every detail reflects structure, containment, safety, and support. Psychodynamic therapists believe that the secure frame is a vital element of the therapy. Others disagree about its place in the scheme, but certainly if the frame is not secure, you will find it difficult to accomplish much that is meaningful, whatever type of therapy you pursue.

From what I have seen, I believe that the secure frame is the element of therapy that is most frequently abused by poor therapists, and frame deviations are too often tolerated by unknowing clients. Consciously, you may dismiss most frame deviations as unimportant. However, your unconscious mind pretty much requiresa secure frame, if your therapy is to have any lasting effect.

6 - The Perfect Therapist 
In subsequent pages, I will describe an ideal therapy experience. However, a therapeutic frame is rarely perfect. There will be intrusions, and failures, and there is no such thing as a perfect therapist (they too are human after all). The realities of managed care unfortunately make a perfect therapy experience even more elusive.

Luckily, therapy can be helpful and healing even if it is not totally perfect. You may not find the perfect therapist, but if you understand the importance of a secure frame, you can certainly evaluate the relative competence of your therapist, and quickly weed out incompetent and abusive therapists.

Managed care increasingly intrudes on the effectiveness of psychotherapy. If you are in a managed care system, you will likely discover that there will be compromises. However, I think it's important that you know what you should be able to expect. Hopefully, current efforts to reform managed mental health care will eventually be successful. In the meantime, if the service offered by your managed care system is just too awful, consider paying your own way, perhaps by going to a nonprofit counseling center with a sliding scale fee. Don't let the hurdle of managed care bureaucracy keep you from getting the help you deserve.

7 - Privacy: The Essential Ingredient
The most important ingredient in the secure frame is privacy. You have a right to expect absolute privacy and confidentiality in therapy. You need to know that no outsider is listening in (either in fact or in unconscious perception), and that anything you say is safely contained in the therapeutic space, with no leaks. This assures you that it is safe to speak, because nothing you say can ever get outside the room.

But your privacy can be contaminated in subtle ways. Your unconscious mind will sense intrusion if you have to discuss an appointment with a secretary, if you can hear someone speaking outside the therapy room, or if your therapist talks to a friend or family member for any reason. In all of these cases, your unconscious mind will sense that outsiders have invaded your therapeutic space, and that it is not safe to talk because there is not sufficient privacy.

As an example, one therapist I saw occasionally discussed my case with my employer, who provided the therapy. Consciously, this seemed acceptable to me, since I felt my employer cared about me. But I never understood why it was so hard for me to reveal important feelings to that therapist (or to myself), or why I had so many dreams about betrayal and entrapment. After I learned what a secure frame was, I understood why -- and understood that I did not have one there. Another therapist I know of violated the frame in another important way. My group member, his client, did not have a regularly scheduled appointment time with him. Each week she would call him and arrange an appointment. Consciously, they both said this was preferable since their schedules were so flexible. However, the fact that she had no assured place with him -- a reality perceived by her unconscious, of which the appointment behavior was a symptom -- prevented her from expressing any negative feelings in his presence. Unconsciously, she felt the frame was not strong enough to contain her anger. 

 8 - Non-judgmental acceptance: you deserve it
You have a right to expect acceptance. As you begin to feel safe with and held by your therapist, you may begin to talk about some pretty painful things. You should be able to know that your therapist will not pass judgement on you, or be repulsed by anything you say, no matter how awful. You should feel that your therapist will not react negatively, even if you become enraged at him/her. He/she should respond to you therapeutically, allowing all your feelings, good and bad, to be released in a therapeutic frame which is strong enough and secure enough to hold them. 

An important addendum: if you are a survivor of abuse, there is a strong possibility that your unconscious mind will deliberately lead you to choose an abusive therapist, one who does not respect the therapeutic frame. Hopefully, this article will, at the very least, lead you to have some awareness of it, if that is happening to you. 

9 - Choosing a Therapist To Call
You start to build a secure frame long before you start therapy. The process begins the first time you consider calling a therapist for an appointment. The way in which you find out about the therapist, the time while you are deciding whether to call, when you leave the first message on the answering machine, the first phone conversation when you arrange an appointment -- these are events that have an important effect on your therapy before it even starts. For that reason, its important to talk about how you find and contact your therapist.

How do you choose a therapist to call? This is the biggest question most of us have -- AND its the hardest to get answered in a meaningful, reliable way. Publications written by mental health professionals are mainly marketing tools. A pamphlet from a professional association will, naturally, tell you its members are the most reliable. An article by a therapist will espouse the credentials he/she happens to have.

I want to give you some better information. Well, at least I want to point you toward some better information. It is far beyond the scope of this article (and probably beyond your attention span) to offer a comprehensive description of the over 300 varieties of counselors and psychotherapists in the U.S. today. But I think I can summarize it quickly, so youll be better equipped to make a responsible choice.

1.      Start by getting a professional referral.
2.     Take into consideration the therapist's qualifications.
3.     Evaluate that therapist yourself, using encoded messages from your unconscious.

10 - A Professional Referral

The way you find out about your therapist might end up becoming an issue in your therapy. Perhaps most important: Your therapist cannot have a close connection with any relative or friend of yours. It will be extremely difficult, if not impossible, to build a secure frame under those circumstances. It is unlikely that any competent therapist will accept you as a client if you are the friend or relative of a current or former client. Therapy is already too difficult (and too expensive) to intentionally handicap yourself in this way. A secure-frame therapy requires anonymity, confidentiality, privacy, and therapist neutrality. For best results, IF SOMEONE YOU KNOW IS SEEING OR HAS SEEN THIS THERAPIST, FIND ANOTHER THERAPIST.

The best referrals are professional referrals, from a professional who knows the therapist professionally, and who is not involved with you or the therapist socially. Your therapist may be suggested by:

  • your family doctor,
  • a professional organization (see below),
  • a counselor whom you have consulted for the purpose of obtaining a referral,
  • your minister or rabbi, or
  • some similar person who is in a professional position to have general feedback that this therapist's clients have worked successfully (and who is NOT themselves a client).
It should be unlikely that you will ever see your therapist outside therapy. Therapy works best when your relationship is confined to the therapeutic frame. Less good are referrals in which you have no choice: therapists to whom you are assigned by an employer, court, HMO or clinic. These assignments may turn out to be good; but if they are not, you need the freedom to select another therapist. Also less good are therapists about whom you know something personal, or who you are likely to see outside of the therapy frame. These situations can be made to work, but they are much more difficult to deal with in your unconscious and so make therapy longer and harder.

Avoid selecting a therapist arbitrarily, say from the yellow pages. This gives you less guarantee of the persons competence. If you have no other choice, pay very close attention to the themes expressed in your dreams and narratives when you start seeing a therapist selected in this way, and discuss them with the therapist.

If you use a therapist referral service or directory, especially those online, keep in mind that most of them are commercial services. They may not have screened the therapists; any therapist who pays for a listing could be included, which guarantees you nothing. In other cases, the service could be restricted to only one variety of therapist, giving you less of a choice.

When you get the referral, you may find out about the therapists education, training and experience, and, if you know you have a particular need, the therapists specialty, if any (i.e. alcohol/addiction, depression, family or couples therapy, etc.) Keep reading to find out what you should look for. 

11 - Therapist credentials: the truth revealed
A lot of bandwidth has been spent attempting to compare, defend, or even just explain the professional credentials of psychotherapists. It is incredibly confusing. There are literally hundreds of designations, and you can quickly drown in a sea of letters: Ph.D., M.D., L.P.C., Psy.D., M.F.C.C., L.C.S.W., etc. Some are licensed, some are certified, others are registered. They may have a particular orientation like psychoanalytic, psychodynamic, cognitive/behavioral, gestalt, solution-focused, etc. It can be traumatic just trying to understand it all, let alone decide what kind of therapist to see.

Of course people worry about making a wrong choice. When youre in emotional pain, you want help and you want it now. Just as you dont want an incompetent doctor, no one wants to waste their money on an incompetent therapist. Surely, somewhere in that alphabet soup is the key to good therapy... right?

Well, no. After 20 years as a mental health consumer advocate, I can tell you that the energy that goes into these explanations will not necessarily help you find a good therapist. Some of that information is important. But the letters after a therapist’s name cannot reliably be used as a rating system to distinguish between good therapists and incompetent ones.

Unfortunately, the professions themselves don’t help you figure it out. Naturally, each psychotherapist believes that his/her credentials (whatever they are) are the best, and maybe even the only valid psychotherapy credentials. If a therapist is licensed by the government, he/she will probably tell you that licensing is crucial, and may even imply that anyone without a government license is shockingly incompetent. (It isnt so!) If you ask a professional association, of course they will lead you to believe that their members are the most worthy therapists. Anyone who had to spend six years in graduate school will tell you that all counselors should have spent six years in graduate school. No matter which profession you ask, they want you to believe they are the best.

But an academic degree, and even a government license, are not infallible guarantees that a particular therapist will be successful helping you. Since therapy is as much an art as a science, there is a degree of plain old talent required, which is difficult to define with credentials; not to mention human qualities of compassion, empathy and character. Some very talented counselors have no official credentials at all.

After many years of experience as a mental health consumer advocate, I can tell you three things with certainty:

1.      It is important that your therapist have some kind of professional credentials. To be a competent psychotherapist, one needs ALL THREE of the following:

1.      intensive academic study in a mental health field
A good therapist starts with a masters or a doctorate in a mental health field (MA, MS, MDiv, MSW, PhD, PsyD, EdD, DMin, MD). Wisdom, compassion and character are necessary, but they arent enough; knowledge is essential.

2.     supervised clinical experience
A good therapist has completed an extensive psychotherapy training program (clinical residency). It may have been part of his/her academic degree, or it may have been a separate postgraduate program. This is important to know about, because some PhDs and MDs have academic knowledge about psychological research or medication, but have never had actual training or practice in psychotherapy. You cant simply learn psychotherapy out of a book or in a classroom. You need the books and the classrooms, but they arent enough. A supervised residency is where they learn their trade.

3.     certification or registration or licensure.
After residency, and supervised experience, the therapist has been pronounced worthy by an authority to which they will be accountable. It could be a government licensing board, or some other credentialing organization. Some of the more common designations you might see include: LCSW, CSW, MFT, LMFT, MFCC, AAPC, LPC, NCC, NCPsyA.

If the therapist doesnt have all three, find someone who does.

2.   The type of credential is not as important as therapists want you to believe. I speak from experience. A licensed psychologist is not necessarily a better therapist than a certified pastoral psychotherapist. An M.D. psychiatrist is not necessarily a better psychotherapist than a licensed professional counselor, etc. Likewise, research has shown that the orientation of the therapist, and the technique that he/she uses, is not the biggest factor in the success of your therapy. As with credentials, therapists like to say that their techniques are the best. But research suggests that it has much more to do with their relationship with you which is why what I'm telling you in this article is so important.

3.     Even if theyve run the gauntlet and managed to get the professional credentials, all therapists are not equally good, and just any therapist might not be right for you personally. The very best way to evaluate a therapist is within you. If you follow the advice in this article learn just a little about the process of therapy, know what you should be able to expect, and how to listen to your own unconscious you will be able to tell if a psychotherapist is any good, or not.

If all meets with your approval so far, you're ready for the first phone call. 

12 - What Happens In The First Contact?
You've selected a therapist to call for an appointment. For most people, the hardest part is now: that first phone call. I thought it would be helpful to let you know what ought to happen when you call. This might decrease your anxiety about the unknown. It also gives you additional means to evaluate the therapist's professional competence.

Keep in mind what I said before: I am describing here a "perfect" encounter, and your experience can be helpful if it is a little less than perfect. Use the following scenario as a guideline to judge the relative competence of your prospective therapist.

In your very first phone call, you will probably encounter either an answering machine or (less likely) a receptionist. With either, you only need to leave the following information:

1.      that you want to talk to the therapist
2.     your name and telephone number
3.     briefly, when you can be reached

That's it. At this time, it is not necessary to explain the reason for your call. You should never have to discuss the reason that you want to talk to the therapist with anyone except the therapist. A receptionist is NOT entitled to know and should not ask. If he/she does, a red flag should go up for you because the secure frame is already being broken.

You also shouldn't have to convince the therapist to see you. I think it would be extremely unusual that any therapist in private practice would not agree to see you at least once, as long as they have time available. Don't feel that you have to "qualify" for the appointment by offering a suitable reason. If you are dealing with an HMO or a community mental health clinic, this may, unfortunately, be compromised.

Okay: you've left the message, and now you are waiting anxiously for the therapist to call you back. He/she should call within a few hours, certainly the same day (unless you have called in the evening, in which case he/she may return the call the following morning). When he/she calls you back, ideally, the following should happen:
  • The therapist identifies him/herself.
  • You say that you want to make an appointment.
  • You mention where you heard about the therapist.
  • The therapist proposes a day and time no more than a week away.
  • You agree on a day and time. (Note: you have to be flexible here; be aware that good therapists' schedules are usually full, especially evening hours. However, if this is an emergency, say so.)
  • The therapist gives you clear directions to his/her office.
  • You confirm the appointment, say goodbye and hang up.
That's it. The first contact is for the sole purpose of arranging an appointment as soon as reasonably possible. Everything else is superfluous at this point and should be left until the first session (the exception being that you should make clear any emergencies, such as suicidal feelings or acute personal crises). There may be some need for working out difficulties related to the appointment, but it is best not to barrage the therapist with extensive details at this time. These are better worked on in the first session. Likewise, the therapist should not ask you lots of questions or get into an extended conversation. Though you may perceive this as caring, it isn't; it says far more about the therapist's own needs than about his/her true caring.

It may be necessary for you to ask what the therapist charges, though this is better left to the first session unless you are extremely limited. If the therapist has no hours available for an appointment, he/she should give you one or more alternate phone numbers for other therapists.

The therapist's manner should be professional and to the point. Unacceptable practices to watch out for:
  • the therapist answers the phone while in session with another client, and worse, proceeds to discuss an appointment with you;
  • the appointment is made for you by a friend or relative or other person, and worse, the other person goes to the first session with you;
  • the therapist asks you to make the appointment with his/her secretary;
  • the therapist offers to send you something in the mail.
All of these situations contaminate the frame by admitting other persons to it and compromising your privacy. 

Now that you have made the appointment, KEEP IT. Nothing short of a major unexpected emergency should make you call to cancel or reschedule. Anything else might be a reflection of your anxiety and resistance to getting help. 

13 - What Happens In The First Session?
The day is here and you have arrived for your first session with the psychotherapist. While you are waiting, take stock of the surroundings. Ideally (remember what I said about "ideally"), here is what you should find:
  • The therapist has a private office with a comfortable waiting room.
  • If the office is in a home or other less-than-private location, it has a private entrance and is completely shielded from any contact with people or sounds in the home.
  • There is no secretary or receptionist in the waiting room. You encounter no other people either while waiting for your session, or when you leave your session.
  • The waiting room and office are soundproof, and any windows have shades or blinds so that no one can see in.
By now, you no doubt can see that all these elements are ensuring your privacy and helping you to build a secure frame. If, shortly after your first session, you have dreams or find yourself telling stories about intruders, spies or the like, take a look at the therapy setting.

If you think these details don't bear mentioning, think again; a therapy office in a town where I once worked had a glass storefront on a main street, where all clients were clearly visible to passers-by. The words "drug counseling" were prominently painted on the window. It happens.

However, in our "ideal" therapy office, the therapist comes out to the waiting room, introduces him/herself, and shows you into his/her office. If it isn't immediately obvious where to sit, you can ask; the therapist's chair is usually evident, since he/she spends the majority of his/her time in it. Otherwise, sit wherever is comfortable for you.

When you are settled, it's usually up to you to start; otherwise the therapist may prompt you with a general question such as "What brings you here?" You can describe the problem you are having, or anything else that comes to mind. Don't worry about whether you can say everything with absolute precision. The therapist should be able to help you get it all out.

In this first session, you can expect to do nearly all the talking. You can expect your therapist to listen actively. He/she may not say anything at all until halfway through the hour, or may make one or two interpretive comments or ask for clarification. While you are talking, the therapist will be listening carefully, evaluating your situation and deciding on possible treatment. In order for the therapist to do this, he/she must listen to you, and not influence what you say, or the way you say it. Beware of a therapist who talks more than you do in the first session, especially about him/herself.

Toward the second half of the time, the therapist should indicate whether or not he/she can be of help to you. He/she should then propose a therapeutic structure: a schedule of appointments, a fee, and any other related details. You have the opportunity to react to this structure, and decide whether to continue. Remember that this therapeutic structure -- the schedule, fees and other details -- is not incidental, it is a very important element of therapy. This "holding" environment is an important step in establishing the secure frame. The proposed structure should be clear and unambiguous, and should reflect safety, consistency, and containment. Though you may think, consciously, that flexibility on the part of the therapist is desirable, the opposite is true. At this point, you need the therapist to be firm and consistent (like a good parent). If you are able to manipulate the therapist, you may find yourself dreaming and telling stories about seduction, infidelity, or theft.

Having agreed on the fee and on a regular day and time for your appointments, you are, hopefully, on your way to emotional healing. You say goodbye and leave. Many therapists allow extra time for a first session; this is probably an exception. 

14 - Safety Is In The Details
Fees and times may seem incidental to the actual therapy; but consistency in the temporal aspect of the frame contributes greatly to your sense of security, of being held. If your schedule is constantly changing, you will find that it is difficult to get any work done in therapy, and you will likely find yourself with subtle feelings of danger, chaos and abandonment. If, however, these details remain solid and secure, your unconscious mind will see your therapist as healthy, consistent, safe, strong, and devoted to your care.

SCHEDULE and TIME -- The usual schedule is once a week, though you and your therapist may decide to meet more frequently; twice a week is not uncommon. In cases of financial hardship, a therapist may agree to see you every other week.

At your first session, you and the therapist should agree on a regular day and time and place for your appointment. After that, your appointment should, ideally, stay the same as long as the therapy lasts; that is best for the success of your treatment. You may think that flexibility in the schedule is helpful to you; but it has been shown over and over again that to your unconscious mind, it is not. If you are depending on a structure for support, any change to that structure will leave you feeling unsafe.

Therapy sessions are typically 45 or 50 minutes. To maintain the secure frame, your therapist will hold you to that time absolutely. If you arrive late, you still must stop at the agreed time. At some point, it will probably happen that you will be in the middle of something deep and anguishing when the time comes to stop. This may be extremely frustrating to your conscious mind, but a good therapist will not allow you to run over the time, and that should satisfy your unconscious. If, on the other hand, the therapist is late, he/she should give you the full time.

Your absences and lateness, as well as persistent silence, wanting to leave therapy, forgetting to pay or delaying payment, and bouncing checks, are often symptoms of "resistance", or fighting therapy. These may (or may not) reflect outside issues, and should be discussed with your therapist.

In most cases, you will be responsible for paying for any regularly scheduled sessions that you miss or cancel; you are not responsible for paying for sessions cancelled by the therapist.

FEES -- At your first session, the therapist should propose a fee. What is normal? It varies enormously with the area, the therapist's qualifications, and the setting. I have heard of psychotherapists in private practice charging anywhere from $25 per session in Nebraska, to $150 or more in Manhattan. Non-profit counseling centers and clinics with sliding scales may reduce the fee significantly. Your health insurance may pay a portion of the fee. For your own mental health, keep your bill paid up to date.

PHYSICAL CONTACT -- Many therapists have a standard policy that they usually do not engage in physical contact with clients (hugs etc.). Such contact has many ramifications for your unconscious mind. Certainly, no therapist should ever suggest sexual contact with you. As therapy progresses and you build a deep connection with your therapist, you will find that because of the intensity of your relationship, you can feel "held" emotionally without actually being held physically.

PRIVACY AND CONFIDENTIALITY -- It should go without saying that you can expect absolute privacy and confidentiality. ABSOLUTE. Under no circumstances may your therapist ever reveal, without your permission, even the fact that you are a client, let alone any information at all about you or your case, to anyone, even to a family member. As an example, a friend of mine called his wife's therapist hoping to discuss "his side" of the issues. The therapist politely but firmly refused to talk to the man. She simply offered to refer him to another therapist if he wanted to work on his own issues.

You can ask your therapist not to take notes or record your session in any way. (One therapist I went to wanted to videotape all my sessions. Not!) Again, some differ on this issue; however, most clients find that it compromises their sense of privacy.

There may be instances when you choose to allow information to be released; in that case, your therapist should obtain a signed consent form from you. If your therapy is provided as an employment benefit, there should be no requirement for the therapist to report back to an employer about your progress. Managed health care programs increasingly intrude on this.

TERMINATION -- In most cases, you will be the one to decide when it is time to stop therapy. This decision should be discussed in great depth with your therapist, to make sure you are not terminating prematurely as an unconscious reflection of some important issue in your life. If, however, you both agree that problems have been resolved and termination is appropriate, set a specific date for termination and stick to it. The frame should remain absolutely intact right to the end. After terminating, you have no further contact with your therapist, unless you experience some new emotional disturbance, in which case you can arrange another course of therapy. 

15 - Now What? Where To From Here?

In summary: You deserve the best possible psychotherapy experience. You deserve a competent counselor, someone who can really help you, and not hurt you or waste your time. Don't settle for less. Learn to trust yourself, and listen to the messages from deep within yourself, by learning to listen to your dreams and other messages from your unconscious mind. Give yourself every advantage you can. 

To all who are entering the theater of psychotherapy: you are about to embark on the most exciting, terrifying and ultimately rewarding experience of your life. I wish you the best of luck, and, most of all, the courage to go the distance in the pursuit of the inner wholeness which lies at the end of your journey.

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This article was prepared with the generous assistance of Gary Hellman, Director of the Psychotherapy & Spirituality Institute of New York City. PSI is highly recommended as an outstanding and trustworthy source for caring, high quality psychotherapy and counseling. They have seven locations in the New York metropolitan area, and offer services at modest fees based on a sliding scale. Visit their website for more information.

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If you’d like additional points of view, here are some similar articles you might wish to read. Caution: some of them tell you what questions to ask - but they dont tell you what answers to expect! Oh well.

How To Choose A Therapist - by John Grohol, PsyD
How To Choose a Psychologist - From the American Psychological Association, so predictably it directs you toward psychologists specifically, but a good article nonetheless
About Psychotherapy - Also psychologist-centric, and you might get overloaded by the abundant information, but useful overall
How To Diagnose A Therapist - Specifically tuned to anxiety disorders
How To Choose A Therapist - from HealthGate, a commercial site

For general mental health interests, be sure to visit these excellent websites:

Psych Central - The leading mental health network with mental health and psychological resources and information
Depression Central - Ivan Goldberg, MD, great resource on depression and related mood disorders. Includes a list of his very reliable recommendations for The Best Psychiatrists in the U.S. for Mood Disorders.
ABCs of Internet Therapy - what you need to know about consulting a psychotherapist over the Internet; includes a directory of online therapists
The Samaritans - non-judgmental crisis support, by e-mail (every day) or phone (24 hours, 7 days)
Suicide: Read This First - To help suicidal people cope, plus links to other online help

©1991, 1996, 1999 Martha Ainsworth

Reprinted with permission