Psychology Today Blogs - In Therapy

The Many Hats of the Psychotherapist

Ryan Howes, Ph.D. — Wed, 14 May 2008 14:31:00 -0700

We return to my fictional client Jane, who is discussing the significant relationships in her life.

"Well, there's my parents, but they don't really listen, they just tell me what to do. There's my brother and sister, but they're caught up in their own lives. I've got three or four close friends, but we seem to be drifting farther apart. And then there's you, but this doesn't count."

I believe that understanding our relationship takes top priority, as it is the foundation for all our work. I ask for her to clarify.

"This is your job. I pay you, and we only meet 50 minutes per week. You seem to care and everything, but it's not a real relationship."

I can't count how many times I've heard a client say that. I know what she means, though. We don't chat on the phone, see one another at block parties or exchange birthday cards. Our relationship has a particular structure and boundaries that set it apart from other relationships Jane might call "real." But I believe it is still very much a relationship; an intense, dynamic, powerful one at that. The question is not whether or not the relationship is real, but what kind of relationship it is.

The media doesn't help matters much. Depending on the movie or TV show, viewers may come to understand therapists as cold dictators, magical psychics, brainwashing manipulators, inept goofballs or secret lovers. The topic for a future blog, to be sure. But it's not all Hollywood's fault: I don't think our profession does a very good job of clearly defining the therapist's role either.

Therapy shares qualities with many other professions and relationships, yet none are a complete match. I'll do a little compare and contrast:

Physician: We go to physicians seeking the diagnosis and treatment of physical illness or injury. The physician is the authority, asking the questions and applying the treatments we passively receive. Clients do come to therapy for diagnosis and treatment, but the process requires much more collaboration. It's you and me working together on your problem, not me working on you.

Friend: Friends share experiences with one another and talk about anything from the deep and meaningful to the mundane. They feel mutual respect, provide support for one another and give advice. While communication, respect and support are at the heart of therapy, therapy includes one-way disclosure (discussed here), infrequent advice (discussed here) and does not typically involve shared experiences. You're not going to have your therapist over for this weekend's barbecue.

Teacher: Some people imagine therapy works like an individual tutoring session: "Today the topic is codependency, take good notes." There are times when therapists may teach certain theories or techniques (we call this "psychoeducation"), and some theoretical orientations do include giving homework like reading a book or writing a letter. Just like the comparison with the physician, however, therapy is much more collaborative than the classroom.

Psychic: The allure of the psychic stems from their ability to read minds and predict the future. Therapists study human behavior and may have a deep understanding of their client's lives, but they can't read minds.

Priest/Pastor/Rabbi/Shaman: You may choose to discuss spiritual issues in therapy or confess transgressions. You may even have epiphanies that feel like divine intervention. But therapists do not absolve sin and don't typically dispense moral advice.

Parents: Like a friend, a parent may listen and/or give advice. In some situations, the parents may even take steps to resolve their child's problem for them. Sometimes therapy does help fill in gaps or re-tool messages we heard in childhood, picking up where parenting left off. The aim of therapy is helping empower clients to face life's challenges on their own, not fostering the dependency of an early parent/child relationship.

Personal Trainer: This may be the closest match. People go to personal trainers with a goal - lose weight, get toned, drop a dress size, etc. The trainers work with you to develop a plan of action, stand next to you as you do the work, give encouragement, and revise the plan if obstacles arise. It's collaboration with distinct roles: both trainers and therapists use their knowledge and experience to guide the process, but you do the work and reap the benefits.

So where does that leave us? At times, the therapist's role can look similar to any of the above relationships. It can seem a little confusing. But like every other relationship in your life, each therapy relationship is unique. I encourage you to discuss your relationship with your therapist whenever you have questions about it. Together you can decide what kind of relationship works best to meet your needs.

Give a Man a Fish...

Ryan Howes, Ph.D. — Wed, 07 May 2008 12:58:52 -0700

Allow me to introduce Jane Doe, an imaginary client offering her services to illustrate some of the finer points of therapy. Jane is a 30 year-old, single, educated and successful woman entering therapy for the first time. She and I have met for a couple sessions. Today she appears particularly upset. Here's how she opens the session:

"I don't know what to do. John and I were out to dinner last night and his cell phone rang. He ignored the call, but I had this sense it was his ex-girlfriend calling. He got up to use the restroom a few minutes later and left his phone, so I grabbed it and checked to see who called. It wasn't her. Now I feel bad for not trusting him. We've only been dating a month, so I'm not sure what he'd say if I told him. Should I keep it to myself, or tell him?"

What is about to transpire can be a very frustrating aspect of therapy for many clients. It's what distinguishes this relationship from friends, family, Dear Abby and Dr. Phil. But it may also be incredibly helpful for Jane in the long run.

I'm not going to tell her what to do.

You've probably heard this proverb (generally attributed to Lao Tzu): "Give a man a fish, and feed him for a day. Teach him to fish, and feed him for life." The goal of therapy is helping people understand and ultimately solve problems on their own, not solving their problems for them. Many people want their therapist to give answers and advice, and I don't blame them. Jane has a dilemma here, she wants it resolved, and she's paying me to help her. But in therapy we need to look at the bigger picture.

If I tell Jane what to do, she is no closer to understanding herself than when she walked through the door. She is no more enlightened, empowered or independent. She could leave with an answer for her quandary, but would feel no satisfaction for resolving it herself. If and when a similar issue arises in the future, Jane will not have tools to resolve it and would probably look to me again to give her another answer. Furthermore, I would be assuming the responsibility for her decision, as well as taking the credit or blame. That's empowering me, not Jane.

Instead of giving Jane advice about John, I'm curious about a few other things. I wonder if trying to understand the thoughts and feelings behind Jane's snooping could be helpful. Perhaps her suspicion has deeper roots and impacts other areas of her life. But first, maybe we should understand what gets in the way of Jane making her own decisions. Hers is an innocent enough question, but I've known clients who have great difficulty making decisions. They'll poll everyone they know and go with the greatest number of votes. I call this "living life by committee," and it's a painfully disempowering way to live. I'd want to explore this for a while to see how and why she may be giving her power away.

Of course, there are many exceptions to the "no advice" rule. The severity of the situation, the length of the therapy or the theoretical orientation of the therapist may deem advice necessary. But in general, therapists aren't part of the committee. If Jane can address these deeper issues in therapy, she may come to understand her thoughts and motivations better and develop confidence in her decision making skills. This will feed her for a lifetime.

Shrinks Are People Too: When Life Happens to a Therapist

Ryan Howes, Ph.D. — Mon, 28 Apr 2008 17:38:50 -0700

As I write this, 500+ acres in the mountains surrounding my home are aflame. 1000 people have been evacuated, myself included. What a perfect opportunity to discuss the topic of therapeutic objectivity.

One area of psychotherapy that confuses and even upsets clients is its one-sided nature. Clients share their problems, therapists do not. Some clients wonder how therapy can be a real relationship if the information doesn't flow both ways. They may wonder if their therapist has experienced their same problem, or wonder what therapists do to cope with their own life issues. Or, perhaps the one-sided nature of therapy promotes a fantasy that therapists have no problems - that they are immune to the tragedies, misfortunes or bad moods suffered by the rest of the populace. Not true.

Therapists lose loved ones, have bad days and get evacuated from their homes just like everyone else. They cry, get angry, say stupid things and get grumpy. But they don't often bring this into the therapy session for a few reasons:

1. It's your time: Therapy is a place where clients should feel like their issues are the purpose and focus of the hour. Relationships with friends and family are more reciprocal - you help me with my problem and I'll help you with yours. In therapy, the only person you need to take care of is yourself. For many, this is the best part of therapy.

2. It's not the therapist's time: Therapists are compensated through fees and the satisfaction of a job well done, not through a two-way sharing of problems. I believe therapists should have their own therapy, supervision and/or consultation group to make sure they are not imposing their needs or issues onto their clients. These resources help therapists know what their issues are; the ones that could cause them to react out of a selfish need rather than in their client's best interest. And therapists should have their own support through friends or family so they don't find themselves looking to their clients.

3. Transference: Freud proposed (and many contemporary therapists maintain) the idea of a blank screen: the fewer personal details of the therapist known by the client, the more the client will project their needs and motives onto her. For example, a client is ambivalent about his girlfriend and the therapist hasn't shared her opinion. The client says "you want me to break up with her, don't you?" Why the client would assume this is rich material to explore.

Therapy is a real relationship, one that is based on care for the client. If our own life circumstances make it too difficult to maintain focus with our clients, we shouldn't come to work. If a client's particular issues push our own buttons in a way that could cause us to lose our objectivity, we should refer them to another therapist who will better serve them.

In my own case, I'm safe and optimistic that the brave firefighters will have this blaze under control soon. If this hardship or any other makes it difficult to do my job, I'll postpone sessions out of respect for my clients and my own needs. Some of my clients know I live in the fire zone, and if asked I'll let them know I appreciate their concern and that I'm safe and sound. And then it's back to our common purpose - helping them gain understanding and control in their life.

Fundamentals of Therapy #2: Finding a Therapist

Ryan Howes, Ph.D. — Wed, 23 Apr 2008 12:08:54 -0700

Choosing a therapist is no easy task: there are about a million in the U.S. alone. From all those willing prospects, you'll select a professional with the training, experience, personality and style to provide the help you need. But you're also forming a relationship with this person, whether it's for two sessions or 200. It's important you feel comfortable and safe as you disclose your private matters to another human being.

I'll hit some of the major points here, but for further reading you may wish to check PT's How to Choose a Therapist or Carl Sherman's excellent book How to Go to Therapy.

The research on therapist selection has some interesting results. The 2004 survey I referred to last week reported:

The most common factors cited in the choice of a mental health professional include: recommendation from a doctor (28%), whether the therapist is part of the individual's health-plan network (26%), proximity to home or work (22%), and cost (17%). In contrast, the factors ranked as most important in making therapy successful include: the therapist's listening skills (63%), the therapist's personality (52%), the personal connection with the therapist (45%), the therapist's being active in the session (38%), and the cost (38%).

It's something they tell therapists early in our training: it's all about the relationship. A clinician with a wall full of credentials and 30 years experience may seem to have the edge on paper, but if the 24 year-old trainee has a better connection with the client, it may provide a better outcome. Referrals, degrees and demographics matter, but the quality of the relationship appears to matter more.

I suggest clients make a list of potential therapists based on the factors below, then get a feel for them during an initial consultation or brief interview. "Test driving" potential therapists will provide a sense of the therapist that may not be conveyed through their curriculum vitae. Here are a few initial factors to consider when making your list:

Referral: When people first contemplate therapy, they usually talk it over with someone they trust: a friend or family member, their physician, a religious leader or a teacher. Helpful as this may be, it doesn't always result in the best match. The referral sources may know the therapist socially or professionally, but don't know how the therapist works in session. Even if they do, there is no guarantee their style will work best for you. Certainly gather these referrals from trusted sources, but don't make your final decision based on referral alone.

Age/Ethnicity/Gender/Sexual Orientation/Religion: Generally speaking, people tend to choose therapists similar to themselves in these areas, with the belief that someone with shared demographics will better understand them. Are these similarities necessary or important for you? Also, are the issues you want to address related to any of these traits? For example, if you are seeking help for a fear of flying, how important is the age of the therapist? Probably not very important. Or if you're a woman who wants help relating to men, would you feel more comfortable discussing this with a woman, or might working with a man be beneficial? That's worth thinking about.

Cost: Fees for therapy vary widely, from free (or nearly free) at some community clinics to $250+ in elite private practices. It is an investment of not only money, but time and emotional energy, so it's important for you to honestly assess your resources. Therapy can be expensive, but consider how much money we spend on other things (new clothes, fine dining, entertainment) to help us feel better, but don't produce a lasting change. Fees tend to rise with levels of therapist experience and training, but not always. Also, therapy is one of the few modern professions that will sometimes employ a sliding scale - where the fee is based on your income level.

Insurance: Many licensed therapists are registered with major health networks which cover most, if not all therapy fees. If you'd like to see someone out-of-network, insurance may reimburse a portion of your fees when you submit an itemized receipt from the therapist. Some clients choose not to use insurance because the therapist may need to share treatment details with the insurance company. You can check with your insurance to determine how payment works and get a list of clinicians.

Location/Availability: How flexible are you here? Some therapists offer evening and weekend appointments, but these tend to fill up quickly.

Degree: Many paths lead to the field of psychotherapy. Psychiatrists have an M.D., tend to focus on the biological elements of behavior and may or may not conduct psychotherapy. Psychologists have a Ph.D., Psy.D. or Ed.D., typically conduct psychotherapy and may have training in psychological assessment. Clinicians with a Masters in Social Work provide therapy with an emphasis on the client's social system. Marriage and Family Therapists or Marriage, Family and Child Counselors hold a master's degree and specialize in relationship issues. Licensed Professional Counselors have master's degrees and conduct general psychotherapy as well. Again, cost and areas of focus vary widely among these professionals.

Experience: Clinicians with years of experience have seen and treated many people with a variety of issues; they know what has helped and what hasn't. Newer clinicians are closer to their training and potentially equipped with the latest techniques and theories. More experience usually means higher fee.

Therapeutic Orientation: These approaches to therapy (also called treatment modalities or theoretical orientations) influence how therapists understand and treat your problem - even how they relate to you. There are hundreds of therapeutic orientations, but they tend to fall in a few major groups that help explain our thoughts, feelings and behaviors. The categories are based on the environment and experiences that formed us (psychodynamic), our patterns of thought and belief (cognitive), achieving our human potential (humanistic), or the influence of family dynamics (family systems). Some therapists use several theories, which we call being "eclectic."

Expertise: Through their training and/or experience, most therapists focus on a few areas of clinical interest. Some therapists have written books on the topic, published articles, spoken at conferences or received special training.

That's a lot of information to sort through. The good news is, all this information is easily obtained through Psychology Today's Therapy Directory. By entering your zip code, you can find all this data, read personal statements from the therapists and even see a photo. Hopefully, by using your referral sources, your insurance provider and/or The Therapy Directory, you'll be able to gather a good list of potential candidates.

I suggest a test-drive of the two or three top choices from your list. Call them up and arrange for an initial consultation - some therapists will even offer this for free. Or if you'd like to get started quickly, ask for 10 minutes of their time over the phone to ask some questions. It's fine to let them know you're interviewing several therapists.

When you speak with the candidates, ask them to elaborate on any of the points above you're not clear about. The therapist should be able to communicate their experience, style and approach in a way that makes sense to you. Tell them about your problem and ask how they would proceed with treatment. Feel free to ask whatever you'd like to know - they are applying to work for you, after all.

Trust your gut. The research is pretty clear: the therapist's ability to listen, their personality and the connection you feel are vital components of successful psychotherapy. Your subjective experience of the therapist is just as important as their credentials. Were there any red flags during your interviews? With whom did you feel the strongest connection? If you don't find a match in your top three, keep moving down your list - a decision as important as this has to feel right.

Fundamentals of Therapy #1: Who Goes to Therapy?

Ryan Howes, Ph.D. — Wed, 16 Apr 2008 18:51:52 -0700

Before addressing how clients can get the most from their therapy, we should cover some basics: who goes to therapy, how to find a therapist and the roles/rules/boundaries of therapy. We'll start with who goes to therapy, and why.

According to Psychology Today's own 2004 survey, more than 27% of all adults (an estimated 59 million people) received mental health treatment in the two years prior. Of this group, "47% report a history of medication, but no therapy; more than a third (34%) report a history of both medication and therapy; and 19% report a history of therapy, but no medication." If my math is correct, that means somewhere around 30 million adults were in psychotherapy during that two year period. So who goes to therapy? A lot of us. An APA study found that 50% of Americans believe the stigma associated with therapy has decreased, which may be one reason for a rise in numbers. But why do people go?

People come to therapy to get help. The impetus for therapy is as unique and diverse as the individuals who seek it, but typically people come to find assistance they haven't found in other areas of their life. Depending on the issue and type of therapy, this help may come in the form of support, information, guidance, self-knowledge and/or the space to learn and practice new tools. Here is just a sample of the issues that may cause someone to seek therapy:

Mental Disorders: People struggling with depression, anxiety, phobias, addiction, PTSD, ADHD, etc. may seek therapy to treat the problem and/or learn healthy ways to cope. In many cases, disorders are treated medically in conjunction with therapy.

Distress: One way therapists determine the severity of an issue is to look at how much distress it causes the individual. For example, one young woman may be distressed about leaving home for college, while another is delighted. If the level of distress is prohibiting her ability to sleep, eat, study, socialize or enjoy life, therapy may be a healthy option.

Support/Coping: Loss is a common reason for people to seek therapy. Therapy can provide a safe, supportive place for people to talk about grief, adjustment to physical illness, the end of a relationship or job, abuse issues, or any change in life circumstances that cause distress. Therapists help clients learn coping skills to get them through these times.

Communication: Many people come to therapy looking for help with their relationships. Individual, couples or family therapy can address a common source of distress: poor communication and difficulty resolving conflicts. Some therapists are highly skilled at helping people communicate their needs and feelings constructively.

Self-Exploration: Some people come to therapy to gain a deeper understanding of self. They want to know why they do what they do, why they feel what they feel and determine how much control they have over those areas. Sometimes this exploration is used to determine career, relationship and personal goals.

Again, this is just a sample of the many reasons people seek therapy. The good news is, it seems to work. According to the Psychology Today study: "A large majority (80%) of those with a history of either therapy or medication use report that their treatment was effective."

Next blog: Finding a therapist.

Power to the People

Ryan Howes, Ph.D. — Thu, 10 Apr 2008 18:14:24 -0700

It's time to level the playing field. Therapists have had the upper hand in this psychotherapy gig long enough - this blog will help clients make the most of their time, effort and dollar.

Think about it: therapists spend years in school, read stacks of books and have countless hours of experience perfecting our craft. Clients seeking our help don't always have those tools. They'll come in, sit down and ask in earnest "so how does this work, anyway?" Valuable session time can stretch into weeks or even months educating clients about the rules, roles, techniques and theories that make therapy work. And all too often we therapists misinterpret this lack of information as "resistance".

I envision this blog as a place to empower the client and demystify the process. Where people can learn how to prepare for sessions and talk about difficult issues. A place to learn why professional boundaries are so important, to understand the significance of the therapeutic relationship, and to learn what to do when feeling stuck. I plan to cover these topics and many others - there's plenty of rich soil to till when it comes to the mysteries of therapy.

These ideas for client empowerment have bounced around in my head for many years, but are in no way complete. I gladly seek your input for topics and will do my best to address them. While this blog will be written primarily to clients, I expect a healthy amount of kibitzing from my fellow therapists and I welcome your input as well. I have no corner on the market when it comes to therapeutic wisdom, I'm growing and learning like everyone else.

Thanks for clicking through, and check back soon.