How long do we REALLY need to be in therapy? Thoughts from both sides of the couch.

An article in the April 22, 2012 New York Times entitled: “In Therapy Forever? Enough Already” did its job and caused me to reflect on my career, my personal journey, and the complexity of the therapeutic process.  I ended up evoking an audible “hmmmmm.”

Some of my therapist colleagues and I meditated on the clinical and ethical reasons for working with clients and wondered how we know when our clients can ‘graduate’ from therapy.  The article, written by New York psychotherapist Jonathan Alpert, is not anti-therapy.  It’s mostly a conversation-starter about why clients seek therapy and the reasons that they stay in it.  I strongly encourage you to read the article and come up with your own thoughts and opinions about it — as it is a very personal subject.

Therapy, in general, is very personal.  This is why I don’t think there is a black-and-white answer to the question of “when is enough, enough?”.  When are we ever finished evolving and changing as human beings?

I was motivated to reflect on my own personal philosophy about therapy as I read the article, both as a client of therapy myself and as a clinician.  As I work often with eating disorders (bulimia nervosa, anorexia nervosa, binge eating), I contemplated an additional factor of readiness for change in the therapeutic process.  I am blessed with encountering clients who are at every stage of the change process….for some, this means coming once or twice and then taking their own journey, perhaps, to decide how and when they are ready to commit to recovery.

Recovery in and of itself is fluid and ambiguous.  Some clients come for a while, take some time off, and then return when they feel they need some accountability, some support, some insight.  When I was struggling with my own eating disorder, I was in and out of therapy many times — “tasting” it a bit, smelling it, figuring out if it was what felt right at the time.  I had to do a lot of soul searching before I committed to therapy, and I credit my experience in therapy as my saving grace and the avenue I chose to get to my own recovery.  Since that time, I have gone back to therapy several times, as a way of checking in and tuning up any loose ends.  I believe that therapy will be an essential tool for my mental health for decades to come.  I also believe it helps me grow as a mental health professional, as I am able to know and understand the benefits of working with a therapist whom I wish to emulate myself.

What struck me about the article was the way the author looked at different therapeutic orientations and how (he felt) some are more effective than others.  For example, Mr. Alpert states: “there’s a difference between feeling good and changing your life; feeling accepted and validated by your therapist doesn’t push you to reach your goals.  It might even encourage you to stay mired in dysfunction.”  Herein lies the debate between supporting and enabling a client: how do we know when to encourage a client to try to spread their wings and fly, and how do we know if it would be harmful (ethically, therapeutically) to do so?  This caused me to consider three of the foundations of therapy: unconditional positive regard, empathy, and non-judgment.

Are these enough and sufficient to help clients create the change they wish to see in their lives?  Or do clients need something more?

I believe that the answers depend on each unique client and the therapist with whom they commit to working with.  Not every client and therapist are going to be a perfect fit at the perfect time.  This is why it is important for clients to get to know a therapist, see if they connect, decide if the therapeutic relationship will be strong enough to create a framework for healing and change.  I feel that when the relationship is based on trust, safety and honesty, change can happen.  What is said or not said can be secondary.

I am still reflecting on the complexity of therapy and the players that it involves.  Client needs and goals are the focus of the process, but these can be met in so many different ways.  Just as every human is different, there is no one “perfect” or “right” way to engage in therapy…and that’s the beauty of it!

Ten things to consider when choosing a psychotherapist

Taking that step and beginning the process of selecting a therapist that is a good fit can be a daunting challenge.  When considering the decision to open up to someone about the inner-most feelings, emotions, thoughts, and secrets that you might not even know are there, you want to be talking with someone you trust.  It can seem unnatural to open up and process feelings with someone you don’t know – someone whose inner secrets you will never know yourself.  But, in a way, that is the point of therapy – talking to someone about those things that you may not want to or cannot unravel with your best friends and family members.  So how do you decide which therapist is going to be the truest fit for your needs, offering you trust, empathy, and safely?

We all are different and have different qualities that we look for in friends, mates, and even therapists.  There cannot be a “top ten list” that fits everyone, based on these unique characteristics and backgrounds.  But perhaps you can consider these items and fit them to your specific situation, and perhaps they can help you in some way to narrow down the necessities you desire in that confidential communicator you meet with every week.

Top ten things to consider when selecting a therapist:

1.) Specializations.  Do you have a specific issue that you need/want to work on more than others?  Is there a need to focus on one or two things so that you can lessen your anxiety or depression? Do you want to see a therapist with your partner?  If this is the case, search for a therapist based in his or her specialization.  Some examples might be: substance abuse, trauma, grief and loss, eating disorders, couples therapy, bipolar disorder, divorce issues.

2.) How is the therapist spoken of by others? If you know someone who sees this therapist, or if you were referred to him/her by a colleague or friend, or if you found him or her on the internet, what reputation does the therapist have?  Are they known to be comfortable to talk to, have they given speeches or seminars in the area and had feedback given, do they try innovative practices or are they comfortable with traditional techniques (also may be a quality that you are looking for in a good fit), what sort of credentials do they have?  Their impression on others can tell you a lot about how they do their work and impact those they interact with.

3.) Location.  Is the therapist close by?  It can seem inconvenient to drive an hour every week to meet with a therapist, and you could arrive worn out and stressed.  Or, you may prefer the traveling and you may seek out therapists in another area.

4.) What is their office like? This is something that you can only truly know once you have met with the therapist.  Is the office warm, accepting, inviting? Or is it stark, dark, and drab?  You might consider what type of environment you would feel most comfortable in as you process your thoughts with your therapist.  Location can also factor into this.

5.) Is she or he professional?  Meaning, do they approach you with professionalism and do you feel respected? Another reason we go to therapy is so that we can have a nonjudging third party to bounce our thoughts off of.  We don’t want our therapist to act like our friend — we have friends for that, who don’t charge so much!  We want a friendly, organized therapist who will be honest and direct with us when we are working on our goals.  A recent blog talks about 21 tips for clients in psychotherapy…and it mentions the same thing in reverse: clients should also be professional and responsible. It reduces awkwardness and increases trust.

6.) Is your therapist listening to you?  Again, this is something you will know after the first session, but it’s important.  As you are searching for a therapist, take note of the therapists that truly listen to your story in a non-judgmental, open, curious way.  You are going to therapy to work through things that you are having difficulty with, and the last thing you want to do is have to repeat yourself or for your therapist to get a blank glaze over their eyes as they stare off into space. You are the client: you are in charge, this is your therapy, and your therapist is there to listen to, support, challenge, understand, empathize with, and encourage you.

7.) Do your needs fit?  Some therapists do not see certain types of clients, like children, or men, or couples, or those who are perpetrators in abusive or violent situations.  Some therapists offer 24 hour care; some have strict limits on the amounts and types of services they offer.  Be sure to check with the therapist to see if he or she is qualified to work with you, if he or she meets your needs, and if you are a client that fits with his or her treatment approach.

8.) Does your therapist accept insurance, or does he or she have a sliding scale that fits your ability to pay?  Some of us are able to pay the full amount that a therapist might ask for, and some of us are unable.  This is an important thing to talk to your therapist about, so that you can develop a strong relationship with him or her by being able to attend weekly sessions.  Financial restrictions are very real, but it is unfortunate if these are the reasons that you cannot find the treatment you need and want.

9.) Does your therapist make you do the work?  Yes, that is what therapy is about: you processing your struggles with the help of a trained professional.  Therapists do not give you advice, do not tell you what to do, do not tell you what not to do.  They are a reflecting board, a mirror, a discussion.  They will help you answer your questions and work on your goals, but they will not do it for you.  If you have a therapist that does the work for you, he or she is not listening to you and is instead doing you a disservice.  Make sure your therapist is supportive, sometimes directive, but not directing you in what you “should” think, feel, or do. The “shoulds” are never healthy.

10.) Do you LIKE your therapist?  Is he or she someone you can laugh with, cry with, be honest with, be upset with, be trusting of?  The therapeutic relationship is the most important part of the healing process in therapy, and work cannot be achieved without the basis of a solid and human therapeutic relationship.  This may take a few sessions, so don’t rush it, but if after several weeks you do not feel connected in the way you want to be, bring it up with your therapist.