Choosing the Right Therapist
Overview
This document provides a comprehensive guide on selecting the right therapist, detailing the types of mental health professionals, key factors to consider, various therapeutic orientations, and the importance of building a therapeutic relationship.
Recently, I was at a family gathering and an acquaintance sat down next to me and we started talking about how she had started therapy. It was a big step for her but the look on her face was not positive. She looked discouraged. She asked me, point blank, “are you supposed to really feel like you got something out of therapy?” To which I replied, “absolutely!” Although I could not give her my card as that would be a conflict of interest, I was happy to give her some advice. That conversation was the spark to produce this episode.
Once you've decided on pursuing therapy, I honestly want to congratulate you because your numbers are far and few between compared to the masses. Surprisingly, many people just ignore obvious signs of problems within their relationships or within themselves. Can you imagine driving and you suddenly heard your car making unusual sounds. You continue driving and the car started shaking a bit. Would you keep driving on and say to yourself, “oh it's no big deal…it will work itself out in time.”
People often make excuses for not going to therapy such as it’s too expensive. I sometimes say with a hint of sarcasm in response to that, “divorce is more expensive.” People spend money on what they really want and far too often people just want to be distracted and entertained. Can you imagine going about your business and suddenly your heart started beating in an irregular pattern followed by mild chest pain. Would it be wise to tell yourself, “I’ll ignore it…maybe I will treat myself to a hair appointment.” Why would your need to take appropriate action in these situations be dissimilar from making wise choices regarding your mental, emotional or relational health? It is common sense to ask for help when we need it. We don't usually learn mental, emotional or relational health in school, nor do we typically have the most stellar models from our own family system. It shows intelligence to hire a therapist. I want to help you find the right one.
Choosing the right therapist is critical to finding success in the counseling process. There are three key factors to finding the right therapist. The first is to consider your level of acuity and need. The second is to consider the therapist’s expertise and theoretical orientation. Lastly, and definitely not the least important is the therapist’s personality. Let's face it, you have to like the person enough to continue the process. Let’s look at these three factors one by one.
Mental health acuity is a way to measure how severe and urgent a person's mental health conditions are. It's a spectrum that ranges from low acuity to high acuity. In other words, how intense are your symptoms? How badly do you need help? Low acuity issues are conditions that are not always diagnosable, like anxiety or stress. They require less intensive care or services and often require less therapy or intervention. Examples of low acuity case clients include feeling down, depressed or anxious, feeling low motivation or lack of clarity or purpose in your life or your relationships. High acuity on the other hand are more severe and potentially dangerous conditions that require comprehensive and critical care. Examples of this include a client having suicidal thoughts or potentially dangerous behaviors alone or within relationships.
May involve closer monitoring, more frequent interventions, and specialized treatment.
If your symptoms are such that you are suicidal, you must call for help. Call your local hospital, police, or at least a family member or friend to let them know you need help.
If you are not suicidal but unsure of your current state of mind, a licensed therapist is trained to assess your level of acuity and can direct you accordingly.
If your problems revolve around relationships and more common mental health challenges such as anxiety, depression, addictions, trauma, anger, mood swings, this is where licensed therapists are on the front lines.
Some of you may be considering, consulting with a Life Coach. There are many excellent Life Coaches out there with real talent, knowledge, and wisdom. However, if you consider looking at it from a practical perspective, licensed clinicians such as Licensed Marriage and Family Therapists had to go to graduate school and then were required to fulfill thousands of hours working as an intern supervised by a seasoned professional. After the intern hour requirements are fulfilled, an intern therapist is then eligible to take a rigorous state licensing exam. As a result, Licensed Therapists are equipped to treat higher acuity mental health cases. There are of course no guarantees of competency yet, a licensed clinician is usually much more capable of handling a wider variety of mental illness and higher acuity cases. Licensed therapists are also accountable to the laws and ethics as defined by the licensing board within the state. In contrast, Life coaches are often self-appointed and some are certified within a matter of weeks or months. Again, I am not trying to be demeaning, one of my most favorite and influential professional mentors is a Life Coach; Tony Robbins. I just want you to be well aware of the background behind various mental health professionals so you can make an informed decision.
When assessing the competency of a therapist, a good place to start is by learning how long they have been working in mental health and how long they have been licensed. You can do this by asking them directly or looking up their license number, which is usually accompanied with their published advertisements. Age is not always synonymous with wisdom. There are many seasoned licensed professionals that lack competency. You have to be decerning. Yet, it’s safe to say that newly licensed therapists have a greater learning curve. Trust a therapist who position’s themself with confidence as opposed to arrogance. There is a difference. Use your best instincts and make an informed decision.
Let's talk about, theoretical orientations. Theoretical orientation is just a fancy way of describing a therapist’s style and the tools they use to help a client. Most therapists have many “tools in the toolbox” combining theoretical orientations. I use many different styles and techniques to suite the variety of personality types, age demographics and cultural characteristic of people. I’m going to describe a few so that you can get a better idea of what to look for when deciding upon your therapist.
In grad. school, we learned a certain format and categorization to theories and styles but I’m going to break this down into my own style in order for this to be more digestible for the common listener. Here are the five simplified categories I have created to compare and contrast the various types of counseling available: Psychodynamic, Cognitive, Emotive, Behavioral and Experiential.
Let’s start with psychodynamic. This is a great starting place because really what we’re talking about are the origins of psychology which has great depth. Are you ready to take a deep-dive? Follow me.
Let’s break down the word psychology as it relates to psychodynamic. The etymology of the word psychology has its origins from ancient Greece. Not to be confused with the word “psycho” the derogatory slur describing someone who is antisocial. The word psycho comes from the Greek word psȳchḗ, which means breath, spirit, soul, or mind. The suffix "-ology" simply means "the study of.” Put it together and the true meaning of the word psychology refers to the study of spirit, soul, or mind. I really prefer this more rich and deep meaning to the contemporary meaning of psychology which tends to focus just on mind alone. We are as humans quite dynamic…not just walking talking cognitions. The older psychological trains of thought seemed to touch upon deeper aspects of the human experience. That brings us back to the word psychodynamic.
The word dynamics has its origins in the Greek word “dynamis,” which translates to "force, or power." Put that all together and you have a word that means the power that influences the breath, spirit, soul or mind. What could possibly be that powerful?
The belief behind the psychodynamic orientation is that human behaviors are motivated by unconscious parts of ourselves. Insight into unconscious processes is the pathway to understanding, and personal growth. As we become more self-aware, we discover that conditioning from your family and your environment has contributed to creating a template or blueprint from which your live your life. If a person strives to change their life, they must rewrite the blueprint. This is the psychodynamic orientation in a nutshell.
When you think of psycho-dynamic theoretical orientation, relate it to such legends in the field of psychology as Sigmund Freud or Carl Jung. It is a very deep and contemplative approach to therapy that tends to be long-term.
Some of you may have heard of Attachment Theory. The origins of Attachment Theory are psychodynamic. The fundamental premise is that the child's earliest attachments with caregivers created a blueprint for all future relationships. I can talk more in debt about that and become side tracked in another episode. I just want to mention it to illustrate that these older theories have been the foundational building blocks for other theories to build upon. In fact, most of these theories simply evolve when inspired leaders build upon them.
Next, let's talk about the category I call, Cognitive. CBT, or Cognitive Behavioral Therapy is a theoretical orientation with the most empirical data behind it because the processes are very quantifiable and measurable. For this reason, CBT is very common in hospitals, programs, addiction recovery centers and other such facilities that provide mental health services.
Cognition is just a fancy word for “though.” In essence, CBT can be reduced to the practice and process of being mindful of our though patterns. Cognitive therapies are active, structured, and time-limited. Identification and correction of clients' disoriented negative cognitions are the central focus of the therapeutic process. The practitioner teaches the client to do the best they can to identify negative cognitions and essentially reprogram thought patterns. Process leads to more adaptive problem-solving and more adaptive behavior.
Interestingly enough the roots of CBT are inspired from Zen Buddhism. Being self-aware, involves understanding your thought patterns and how these thought patterns, if you're attached to them, can either influence suffering or enlightenment. CBT is an essential “tool in the toolbox” to promote mental/emotional transformation. It should be noted that (DBT) or Dialectical Behavioral Therapy is considered to have originated from Cognitive Behavioral Therapy (CBT). Again, these theories build off each other. DBT is essentially a specialized form of CBT that builds upon its core principles, particularly focusing on managing intense emotions and interpersonal issues. DBT has a history of measured success treating clients with extreme emotional dysregulation, like those with Borderline Personality Disorder.
Neuro Linguistic Programming has similarities as CBT as the focus in on the relationship of thought patterns and language. Tony Robbins uses NLP at one of his many tools to influence strategic behavior change. He defines (NLP) Neuro Linguistic Programming as “the science of programming your brain to achieve the objectives you want in life.” NLP incorporates ideas from professionals in cybernetic and computer programming with additional influence from experts in humanistic rapport building such as: Virginia Satir and Milton Ericson. NLP also sources some of its inspiration from hypnosis.
Moving down my list of five, let's talk about the category I call, Emotive, which is the polar opposite of cognitive. In short, we can think of these modalities as less mind-centered and more feeling centered. The way I group the emotive theoretical orientations would include humanistic theories, narrative therapies, and somatic therapies. The similarities of these theoretical orientations reside in holding space for the subjective experience and the client’s feelings in a nonjudgemental environment. Humanistic psychology grew in opposition to behaviorism and psychoanalysis. You can view it as a sort of counter balance to the focus of cognition and deeper analytical approaches to psychology. Humanistic psychology focuses on the whole person, their potential, and their free will.
A fundamental premise with such emotive theories is that authentic and honest expression of feelings leads to maturation and healthier self-esteem. Understanding and increasing emotional intelligence is also a common goal within these therapies. A simplified definition of emotional intelligence that I share with clients is as follows: the ability and process of first understanding the emotion within you, defining the emotion, understanding the need or perceived need behind the emotion and then being able to express it in a way that is adaptive to the intended recipient. In emotionally focused therapies, the therapists are coaches and teachers, often down to earth as opposed to authoritative. Expression of emotions can be conversational, interactive or even experiential including movement such as Yoga or dance to help with the processing of emotional energy. Therapy can be short-term or long term.
The next category is Behavioral. Within this category I've grouped action oriented theoretical orientations together such as: solution focused, strategic and life coaching. What these approached have in common is less focus on emotion or psychodynamic processes and more focus on creating behavior change. Again, I want to remind you that I am creating my own somewhat non-conventional categorization of Theoretical Orientations to simplify it for the listener. Behavioralist Theory is a whole field of study on its own. Think Pavlov’s Dog’s and ringing bells to demonstrate classical conditioning of behavior. Look it up and go down a fascinating road. To stay on point, the common focus of this category of Behavioral change type therapy’s is on the “here and now.” Setting goals, achieving goals, and creating behavioral change is accomplished by taking action, changing power dynamics within relationships, and understanding and altering patterns of human behavior. A fundamental belief within these therapies is that the client possesses within them the inherent ability to solve their own problems. Common strategies within these therapeutic approaches are to build wellness through lifestyle change. Paying attention to nutrition, exercise, sleep, stress management, and other such holistic lifestyle choices not only improves physical health but also overall mental, emotional and relational health. The therapist often plays an active role, they take charge, and it's power-based like a coach. Therapy is usually short-term.
The last category I define as Experimental. This is where we can go down the “rabbit hole” a bit. This category includes many therapeutic techniques and technology that has varying degrees of science behind it. Such examples are: EMDR, Brain Spotting or therapy’s that include the clinical use of controlled substances such as ketamine or psilocybin therapy. Let’s high-light a few.
Eye Movement Desensitization and Reprocessing (EMDR) is a psychotherapy technique used to treat trauma and other distressing experiences. It involves focusing on traumatic memories while simultaneously engaging in rhythmic eye movements, auditory stimulation, or other forms of bilateral stimulation. The main purpose is to break down some of the client’s defenses or resistance in order to process trauma. EMDR is based on the premise that certain eye positions can activate the brain's limbic system, which is involved in emotional regulation.
Brainspotting is a relatively new therapy, that has been built off the foundational work of EMDR. Both are based on the idea that the brain can heal itself from trauma through a process of desensitization and reprocessing. During Brainspotting, a therapist uses a pointer to guide the client's eye gaze to specific spots in their visual field. The therapist then asks the client to focus on their thoughts, feelings, and body sensations while maintaining eye contact with the pointer. This process is believed to help the client access and process unprocessed trauma or other emotional material. I have had experience with both modalities and can see the value in there use with treatment resistant clients. That brings us to our next topic.
Let’s talk about Psychedelic Therapies. My strongest instinct guides me to look within first before searching for answers externally through the aid of any substance or pill. However, medications absolutely have their rightful place within psychiatric treatment. On the more experimental side of psychiatric interventions is the growing use of controlled substances such as psilocybin, and ketamine administered in a clinical environment. There is a growing body of evidence that psychedelic therapies treat a wide range of mental and emotional issues with great success. These drugs induce altered states of consciousness and perception, which may facilitate insights and emotional healing.
According to a publication from Harvard Medical School: Harvard Health Publishing, February 2024, a prescription version of ketamine called esketamine (Spravato), has proven to be very successful in treating chronic depression. This has been especially true treating PTSD and combat trauma within veterans of war populations.
Research on psychedelic therapies is ongoing, but preliminary studies have shown promising results. The Johns Hopkins Center for Psychedelic and Consciousness Research is leading the way in exploring innovative treatments using psilocybin. At the center, researchers focus on how psychedelics affect behavior, mood, cognition, brain functioning and biological markers of health. Upcoming studies will determine the effectiveness of psilocybin as a new treatment for opioid addiction, Alzheimer’s disease, post-traumatic stress disorder (PTSD), post treatment lime disease syndrome, anorexia versa, and alcohol use in people with major depression.
There are of-course safety considerations. These treatments best be administered under the supervision of a health care provider in a certified doctor's office or clinic. That means medical professionals need to watch you use it, and then support you after you've taken your dose, checking your vital signs and how you are doing clinically. It's important to note that psychedelic therapies are not a substitute for conventional mental health treatment. It is recommended that they be used in conjunction with traditional therapeutic approaches.
Ketamine is legal to use in California with a valid prescription. Psilocybin however, is currently illegal in California under state law, classified as a Schedule I controlled substance. Psilocybin decriminalization has occurred in some California cities, but there is currently a bill pending in the state legislature that would legalize psilocybin for certain uses. Psilocybin therapies are currently legal in the state of Colorado and Oregon.
Experimental Therapies are an area of convergence where technology meets, psychology. Many therapists go on to become certified to specialize in any one or multiple techniques that I have mentioned. I want to encourage you to do your research and make an informed decision regarding which type of therapy is best for you. Also keep in mind that most therapist use a variety of techniques that overlap many Theoretical Orientations. I for example use many different ways to reach clients yet I predominantly have a humanistic and solution focused therapeutic style. In other words, I operate from a straight-forward and “down-to-earth” perceptive. I aim to be relatable and goal oriented regardless of the demographic.
The last suggestion I have for finding the optimal therapist is finding a therapist that has a personality you resonate with. A therapist can have all the knowledge in the world and the greatest and most effective treatment strategies but if they position themselves in a condescending manner or seem arrogant or aloof they simply will not reach the client. That’s human nature. Human rapport building creates safety and respect which are the bedrock foundations of healthily human relations. As a Therapist, I work toward influencing people to look at the parts of themselves they are scared of, not proud of and generally do not want to show in public. I am wise to proceed with the utmost care and respect when guiding a client through these places.
Interesting fact, that the concept of fundamental rapport building even applies to working with a-social people, that is people with antisocial personality traits. This topic is potentially a whole other episode but I’ll share with you briefly to illustrate the point. As explained by Chris Voss, ex FBI Hostage Negotiator, the same skills used by therapists to develop professional trust and rapport were similar to those used for negotiating with criminals and terrorists. As Chris explains in his fascinating book: Never Split the Difference, fundamental rapport building was essential for producing successful outcomes. The fundamental rapport building skills that Chris talked about were not like, “Hi my name is Sam, let’s not kill anyone today and we will all go home happy.” Yet, when psychology and fundamental human relation skills were put to the ultimate test as it turns out, we are all human and have the same fundamental needs for safety and security. Tapping into that knowledge is the key. In essence, if a therapist presents too forceful or in a way that is perceived as not caring about the other, the human defense mechanism will close the door and game over. The primitive brain will prevail; fight, flight or freeze will win. Point being…you need to trust your therapist.
Wrapping up these ideas, I want to summarize and close with a few final points.
When you meet your therapist for the first time, ask detailed questions about their training, approach to therapy, and how they handle specific situations during the initial consultation, while also paying close attention to your gut feeling about their communication style and overall demeanor.
If you find that your therapist, does not, resonate with you, don't waste your time or money. It is precious. A competent therapist can reach you regardless of your gender, your culture, your sexual orientation, your religion, your age, your upbringing or your attitude. Use your best instincts. Don't give the therapist too much power. They are just as human as you are.
Once you have found a therapist you believe has earned your trust, the journey begins. This is not for the faint of heart. Now the work of looking at yourself is right before you like looking into a mirror. Far too often a client wants to place blame, shame and guilt in the direction anywhere but themselves. Yet, we must begin with what we can control and that is our own mind and our ability to choose our thoughts, our words and our habits of behavior. Change starts with us. A competent therapist knows this.
In order to have the most optimal therapeutic relationship, you want a therapist that can not only support you, but also respectfully challenge you. There's a quote, I honestly don't remember where I picked it up, but just as it applies to leadership, it applies to therapists: “comfort the afflicted and afflict the comfortable.” I have used this as a general guiding principle for my therapy, as people often need to be comforted yet, people can also become very comfortable in their maladaptive behaviors. As a therapist, at times I have to gently shake them out of the malaise of poor habits.
One thing is for certain, change and transformation is not always comfortable but a competent therapist will treat you with dignity and respect as they guide you through the process. Mental, emotional and relational growth is not unlike any other area of growth in life; it requires the application of skills, strategy, consistency, and determination fueled by a compelling desire to change. Sometimes we need help, so if you do, don’t be an island, be part of humanity and reach out for guidance. It’s the smartest thing you can do.
