Any seasoned therapist knows a fair number of other counselors, some casually, some quite well. We refer patients to a few of these people and steer clear of making referrals to others. The reason for the latter is pretty simple: doubts about their skills. That raises a second question: should their patients have the same uncertainties?
Going to the doctor in the days before there were lots of different types of medical professionals was a no-brainer. The doc was the expert. The medical model required the patient to submit to the physician’s ministrations. You were passive, he was active, and everything was supposed to work without much thought on your part.
To begin, there are many different types of counselors: clinical psychologists, psychiatrists (some of whom only prescribe medication), psychiatric social workers, marital and family therapists, licensed clinical professional counselors, and other titles. The first two are doctoral level practitioners, the rest most often hold masters degrees. The type and extent of training varies.
Then there are an enormous number of therapeutic approaches. Here, for example, you will find descriptions of 30 different kinds and this list does not include all the specialities within each type: http://www.counselling-directory.org.uk/counselling.html
The plethora of therapy modes creates a dilemma for the patient. At bottom, the issue is trust:
- Is the doc expert at the precise model of treatment best suited to my condition?
- Is the type of therapy he might recommend for me empirically validated? Empirical validation refers to a large body of well-controlled research demonstrating that therapy approach X for diagnosis Y produces better results than either no treatment or a placebo.
If you multiply the number of diagnoses by the number of approaches to treatment, you come up with a number so large as to confuse many patients. Indeed, we can say with certainty that there is no therapist who is expert in each approach for every type of diagnosis. Mental health professionals must therefore narrow their focus to a limited number of diagnoses and a small selection of approaches to those diagnoses.
Most practitioners possess training and experience in one or more forms of healing Depressive and Anxiety Disorders. They may not be prepared, however, to take on all subtypes under these headings. Thus, for example, a person who accepts patients with Anxiety Disorders might not be prepared to work with all 10 of the coded diagnoses listed below the broad descriptor “Anxiety Disorders:”
- 309.21 Separation Anxiety Disorder
- 312.23 Selective Mutism
- 300.29 Specific Phobia
- 300.23 Social Anxiety Disorder
- 300.01 Panic Disorder
- 300.22 Agoraphobia
- 300.02 Generalized Anxiety Disorder
- 293.84 Anxiety Disorder Due to Another Medical Condition
- 300.09 Other Specified Anxiety Disorder
- 300.00 Unspecified Anxiety Disorder
Why an Empirically Validated Treatment is Important? An Example:
Given all the issues mentioned, consulting a therapist who can diagnose and recommend the treatment most likely to help is crucial.
Here is an example of how this might best work in practice. The recommended and empirically validated treatments for Obsessive Compulsive Disorder (OCD) include Exposure and Response Prevention (ERP) or medication, with a 70% effectiveness rate overall. Our hypothetical patient is hamstrung whenever leaving his home, his office, his car, etc. He checks over and over whether he has locked everything for fear of an irrational catastrophe. This causes him to waste an hour or more a day. Our friend is late for appointments, work, and social events, angering many people and placing his job and family relationships in jeopardy.
If one were to treat this gentleman with ERP, the therapist and patient would together rank those situations that are the least anxiety provoking to the ones most upsetting. The client would then be exposed to a fear-inducing event at the low end of the list, having agreed not to engage in his usual compulsive checking despite his turmoil. The patient’s fight against the urge to check is the portion of treatment called response prevention. The expected outcome is a diminution in his fear and checking as he repeats these exposures without confirming the security of the lock. The patient gradually faces the more unsettling items on the hierarchy until the troubling behavior is eliminated.
Traditional talk therapy, designed to uncover the underlying “reasons” for such compulsivity, is ineffective in treating OCD. At this point in the history of this condition, if a therapist chooses to provide a treatment not meeting the standard for “best practices,” he risks not only his patient’s well-being, a waste of his money, and a squandering of his time, but a malpractice suit.
What Increases the Risk of a Therapist Not Choosing an Empirically Validated Treatment (Assuming It Exists)?
At least three possible reasons:
- He is unaware of the research pointing to the recommended approach.
- He doesn’t “believe” in the validated mode of therapy.
- He doesn’t possess the training to deliver it properly.
As noted above, therapists are not schooled in every method of doing their job. They perform in a competitive field, especially in large urban areas, and are under downward pressure from insurance companies regarding their fees. There is the possibility of unconscious self-persuasion of the knowledge and skill to treat a wider range of conditions than close scrutiny would justify, thus enlarging the potential pool of patients who might consult them. All health practitioners are required to spend more time documenting their work than previous generations of peers. Therapy clients also often desire evening or weekend appointments, creating an incentive for the doc to be available for sessions during “leisure” hours. Any of these factors can unintentionally limit the time needed to keep up with the latest research and receive the necessary training.
Depending on the practitioner’s location and discipline, there are requirements for continuing education. Licensed psychologists in Illinois must take at least 24 hours of continuing education every two years to maintain their practice. At least three hours cover professional ethics. No other directives point him toward a particular area of knowledge. In other words, these requirements are not guaranteed to remedy any shortfall in competence to treat OCD or any other particular disorder.
What You Can Do:
Where does this leave you, the present or future patient?
Counselors almost all mean well, but we all should recognize “the road to hell is paved with good intentions.” It is in your power to do the following:
- As early as possible, understand what the initials after your therapist’s name mean, e.g. M.D., Ph.D., L.C.S.W., etc. This is not meant to disparage any particular group, all of whom include excellent practitioners. Rather, knowing this gives you the most basic information about the counselor’s background.
- Learn about the kind of training he received subsequent to his degree and what he specializes in, both in terms of diagnosis and approach to treatment.
- Ask him why he is suggesting a particular approach and find out what other approaches exist, and, especially whether they have been empirically validated. It should be noted empirically validated therapies do not exist for every diagnosis.
- Be sure to confirm, as much as possible, whatever you are told by doing your own research.
Once again, I’m not assuming any wrong doing by your counselor. However, remember, you are dealing with another human being, no matter how kind or intelligent.
As an old Russian proverb tell us, “trust but verify.”
You are welcome, Sheila.
Dr Stein….I would like to add something to what you need to know about a potential therapist. — Is he or she fundamentally a good person, who is concerned about your well being, regardless of training, experience etc?. There are, unfortunately, many therapists, who are fundamentally not “good people”. When I worked at a private psychiatric hospital years ago it was totally clear that some, although a minority, of the Psychologists and Psychiatrists were there more than anything else, for the money. This did not necessarily mean that all of their patients were not helped, but many probably were not. I knew of many professionals who would see their patients in groups, and then bill the insurance company for individual sessions.
If these patients left improved, it was perhaps more because of a very supportive in patient milieu which was staffed by very motivated young graduate students who were earning very little money, but were full of enthusiasm for the work they were doing. This was what made change possible.
In another hospital everything was determined by insurance (as it is now) . Insurance sometimes expired before the patient was ready to leave. I know that myself and one other Psychologist were constantly pressuring the Hospital Administrator to allow a few more days or weeks of treatment, I was not doing it to make more money, but to avoid throwing a patient out into the street, where he or she was still in crisis. I was not the most popular attending Psychologist with the Administration, but I think at some point they came to respect. As an out-patient therapist, when I patient could no longer pay, I reduced the fees or advocated with the insurance company myself, to try to extend treatment if I genuinely believed it was necessary. I am not saying that I was so great, I just did what any compassionate human being working in the “helping professions” should try to do.
You can do research as to whether or not a therapist has been properly trained, but it is much harder to research the issue of whether or not they are fundamentally compassionate and caring human being. And this can also be subjective. Transference, being as it is, almost all patients want to see their therapist as caring, competent, etc. Some of them may indeed be helped because they truly need to believe in their therapist. For others this is not the case.
And it can be on a spectrum. At one point when in long term therapy myself I believed that my therapist was almost God and I do know that he helped me in many ways. But later, after lessons learned too late, I came to realize that because of his Rogerian (almost obsessively “client centered” approach, , very little advice, etc, etc) that some things happened to me that might have been prevented by a therapist who was more pro-active in giving advice based on common sense, or on allowing himself to borrow wisdom from other schools of therapy.
I realized later that I could have practically walked into his office and said I was planning to rob a bank, and he would have said “so you feel like you need to rob a bank” (and nothing more) It my case, a little more specifically when I was falling into a deep depression and sleeping up to 18 hours a day, he never once suggested that I should make a serious effort to get out of bed and be more active. Instead he would reflect back to me about the “meaning” of my sleeping or some such useless thing, even though this hypersomnia had gone on for months and months, while I became more and more depressed, and slowly lost my ability to funcion.
So he was good for me for a while, but I really wish I would have “quit while I was ahead” and looked for someone else. This may or may not be a unique situation.
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Your detailed account of your experience, Rick, reveals the dark side of (to me) a mostly humane field. The inpatient mischief has, I think, has been significantly reduced now that long psychiatric hospital stays in the USA have become rare. With respect to transference, you are again right that the pedestal therapists are placed on is a high one and and contributes to patients finding the counselor almost flawless, therefore sometimes not asking the questions that need to be asked. The remedies with respect to therapist competence that I wrote about here often can be accomplished at the beginning of therapy, before a strong transference has developed. On a different note, I think you’d be a great blogger if you ever choose to try it. Thanks for your comments.
Trust, unfortunately, is a double edged sword that is the centerpiece of therapy and the very foundation of the work that needs to be done there. But, even following all your wise advice above and even if you find the most top echelon of therapists, a professional, conscientious, knowledgeable, caring individual with all the best intentions, when you trust someone and allow them in your head and in your heart, you leave yourself wide open not only to him but also to fate and circumstance. In the end, you can be more deeply hurt due to this trust then you ever thought possible.
I don’t disagree, Brewdun, but I’d widen the scope of the danger. Much of life involves risk, from going to school and taking tests, to going on dates, to having a child, to making friends and falling in love. We might wish it were otherwise, but, I think, we would then be talking about something quite different from human life as we know it. Thanks for commenting.
I’m not in a position to comment on this week’s post but I thought of you this morning when reading the weekly post from BrainPickings. if you don’t know this site, I would suggest you check it out as I think you might find lots of posts valuable.
This is the article related to music that I made me think of you:
This gives you the entire post for this week:
April is my favorite month of the year (early spring is just so alive) but May in NorCal is nice too.
I don’t know the site, JT, but will investigate it. Most importantly, I appreciate your thoughtfulness. In Chicago we are still waiting for some warmth, but the weatherman says the end of the week looks good. Take care and thanks.
Thanks for your response. I find that the older I get the less I trust anyone, including myself.
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An informative article, Dr. Stein. Trust is important in all of our dealings with health and other professionals with the potential to improve or ruin our lives.
In the world’s richest and most powerful nation, without bombs raining down overhead, it’s sad to note the vast range of anxiety disorders among Americans.
Thank you, Rosaliene. The list I displayed only indicates categories, not frequency. Unfortunately, those categories are filled with people all over the world.
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I was devastated by my former therapist’s actions. So much so that the National Association of Social Workers asked me to file a complaint (I’m not, not now anyway).
But with regard to trust, I want to say that I had a wonderful pain management therapist before this therapist who destroyed my therapy with her needs. And so I have put my trust in a new therapist. Her boundaries are quite obviously strict, and she, like me doesn’t believe in self disclosure.
So I am willing to trust again, because I know there are good therapists out there. But if red flags ever go off again, I will not second guess myself, and I will act. It’s not worth the pain of staying with a therapist who on the one hand makes you believe she loves and accepts you unconditionally, but is clearly (admittedly) not holding the boundaries of a therapeutic relationship.
And if you’re working through a strong transference, PLEASE make sure your therapist is on the same page. Even though she at first normalized the transference, after six months of me discussing and sharing embarrassing things to her, she said, “I don’t even THINK about transference or counter transference.” That was shocking, to say the least. I shared everything with her, which is what a former therapist AND even Psychology Today recommended was the best way to deal with transference.
There ARE good therapists out there.
My point: if you have a bad experience, don’t give up. Trust your gut when trying to find someone new.
I think Dr. Stein is an excellent example of a therapist who obviously cares, but has healthy boundaries, even in his blog.
Thank you for that, Dr Stein.
Your are welcome, Sheila, and thanks for your kind words.
The therapy relationship can certainly be an intense one. To me, relationships are one of the most complex things on this earth (and then there is family and that takes it out of this world, but that’s a different subject) but to add a healing aspect to it and only keep it one way is a big ask of anyone. But then that is what the professional boundaries are for, and peer review and supervision, to guide the therapist through when emotions get intense. I just wish that patients could get the same training and support to deal with the therapist,that they get to deal with us ( the patient). It’s one of the reasons I am drawn to blogs like yours Gerald, it’s hard to talk about the therapy relationship with others to because they don’t get the intensity of it.
I would like to agree with what Sheila said about you in the previous post and add that your honesty in writing about the hard stuff and not sugar coating the challenges faced in therapy and bringing the reality in (which sometimes gets us out of fantasy land). It sometimes hurts but is necessary for our growth and independence and in the end, our wellbeing which is ultimately what we are striving for.
The idea of training for patients, at least in anticipation of what therapy is — what it should and shouldn’t be — sounds like a wonderful idea, Claire. I recently had knee replacement surgery and the hospital offered a two hour, free seminar on what to expect, what not to eat, etc. Thanks, too, for your praise. Your steadfast attention to my writing is appreciated.
Ah, Dr. Stein & Claire…what a wonderful idea: training for patients.
I asked my former therapist (the one who left me devastated by referring me out and stating we could be friends [I said no to the friendship, which left me high and dry in the middle of a crisis]) why therapists don’t discuss the possibility of transference at the onset of therapy, and she said, “Most clients aren’t as smart as you.” (?)
Looking back now, I TRULY feel sorry for any of her clients that experience transference and DON’T have the knowledge or inclination to look into what transference is, and how to make sure you’re not being manipulated.
Just as a follow up, my new therapist said that my former therapist should most definitely lose her license for her behavior. It was devastating, but I’m slowly picking up the pieces.
My new therapist, as stated, has wonderful boundaries and ethics. Thank goodness!
I, too, appreciate the candidness of your blog, Dr Stein. I always learn so much. Thanks again!
Many thanks, Sheila. I’m glad you seem to have found a good therapist and are bouncing back. Brava!
I’m not sure in retrospect, that I would have wanted or appreciated an introduction to therapy & what to expect. Although I found it incredibly frustrating to start with as I thought my counsellor was ‘playing a game of chess’, but I thought we were ‘playing tidily winks’ I think I’d have headed for the hills! If I’d been told that I’d feel some of the pain I’ve experienced over the last four years of such vulnerability, embarrassment, shame, self loathing & disgust, I’d have never started. I got drip fed information & whenever I felt something I’d research it & bring it up in my next session. I wouldn’t have had the confidence to start & would have given up the notion. I’d have lost out on so much. So for me, I think not knowing what to expect, was better for me.
You are not alone. Disclosure, in medicine or therapy, probably in many other situations, would discourage us. For many of us, “too much information,” would not be helpful. Thanks, Joanna.