A good therapist is hard to find. I’m new to the field, relatively speaking, and I’ve already encountered a number of horrible therapists as well as many outstanding ones.
Finding a good therapist is trickier than finding a good dentist or gynecologist. Most people choose their healthcare providers based on a three simple factors: proximity to their home or work, whether the provider takes their insurance, and personal recommendations. For most healthcare issues, this works out well. After all, a biannual dental cleaning is a biannual dental cleaning; a pap smear is a pap smear – there’s not a whole lot of variation in how these procedures are done. You can be pretty confident that you’re getting decent care regardless of which doctor you choose. If you don’t like your doctor, no big deal – you only see her once or twice a year, and besides, she takes your insurance and she’s two blocks away from your office! You may opt to switch doctors due to a negative experience with one or a change in insurance coverage, but this is not a big deal either. You just go back to square one and choose someone based on those initial three criteria.
Choosing a therapist is not so simple. Therapists are not interchangeable like dermatologists or orthodontists. The treatment you get with one therapist differs tremendously – in terms of the nature of treatment, the type of treatment, and the quality of treatment – from the treatment you would get with other therapists. The problem is that most people outside the field are not aware of this, and it is difficult to find out what you are getting before you get it. The licensing process does very little to weed out incompetent psychologists. The two written exams we must pass – one based on a general knowledge of psychology and one based on state laws and rules for psychologists – have no predictive validity in determining whether someone is a good therapist. Basically, therapists can do whatever they want in their sessions, so long as it doesn’t violate ethical codes. Therapists are not prohibited from practicing outdated, ineffective treatments. Although research has shown certain psychological treatments to be vastly superior to others for certain disorders, the majority of therapists do not use these empirically-supported treatments.
Choosing a therapist based on proximity alone is not a good idea. The therapist closest to you may not be a good fit for you. Choosing a therapist based on insurance alone is also not a good idea because many therapists don’t take insurance. Further, if you do use your insurance to pay for treatment, the insurance company will likely request a great deal of personal information about your mental health conditions, may discriminate against you based on diagnosis (or lack thereof), and will probably limit the number of sessions you can receive. Getting personal recommendations for therapists is tricky because it involves disclosing at least some personal information to a friend or colleague, and many people are not comfortable doing that. It is not always wise to choose a therapist based on how much experience she has in the field, because many therapists who have been practicing for decades remain entrenched in antiquated theories of mental disorders and practice less effective treatments Also, if you are a young person, it may feel more comfortable to talk to someone closer to your age who can relate to you more easily and who has a better understanding of your generational issues.
So how do you choose a therapist? Well, that depends on why you’re seeking therapy. If you need some support in dealing with normal developmental or social stressors (e.g., death of a friend or family member, relationship issues, stress management, divorce or breakup, difficult transitions), it is helpful to use the following selection criteria:
• A personal recommendation from a trusted friend may be helpful in this case.
• Find someone who has experience dealing with the types of issues you are facing. For example, if your sibling just died, find a therapist who is experienced in working with grief.
• Consider whether you have a preference in terms of your therapist’s gender, ethnicity, age, or sexuality. Many people prefer to work with a therapist of their same gender and/or someone who is close to their age. Many LGBT clients prefer therapists who are openly gay or lesbian, or who have considerable experience working with these populations. Some ethnic minority individuals prefer working with someone who shares their ethnic background. On the other hand, some clients don’t have demographic preferences, and that’s OK too.
• Find a therapist with whom you feel comfortable. You may need to have a session or two with the therapist before really being able to tell whether it is a “good fit.” Developing a strong, trusting therapeutic alliance will facilitate the healing process.
• Find a therapist who is a clinical psychologist (Ph.D. or Psy.D.), Licensed Mental Health Counselor (LMHC), Licensed Clinical Social Worker (LCSW), or Marriage and Family Therapist (MFT).
When you are seeking treatment for a mental illness, such as major depressive disorder, OCD, anorexia nervosa, PTSD, or borderline personality disorder, I would recommend using a different (and more stringent) set of selection criteria because the stakes are higher. Having a good therapist is a powerful predictor of your chances for recovery, so it is important to take the therapist selection process seriously. Most therapists offer free phone consultations in which you can briefly describe your issues and ask about her qualifications and approach to treatment. I recommend using the following selection criteria in choosing a therapist to treat a mental illness:
• Do as much research as you can on your diagnosis and effective method(s) of treating your particular condition.
• Look for a therapist who specializes in providing evidence-based treatment for your disorder. For example, if you suffer from OCD, you will want to find a therapist who specializes in OCD and practices behavior therapy. You can find out this information by looking on the therapist’s website (if she has one) or simply by calling to ask her about her specialties and her treatment approach.
• Ask the therapist about her views on your particular disorder and the treatment thereof. If her explanation of your illness is unscientific (e.g., “Anxiety disorders are the result of unresolved inner conflicts”) or if her treatment approach sounds flaky or non-directive (e.g., “I provide clients with a safe place in which they can explore their issues”), move on to someone else. It’s great to explore your issues in a safe place, and this may be exactly what you need when struggling with the normal developmental or social stressors described above. If you have a mental illness, however, you’re going to need a whole lot more than that in order to recover.
• Look for a therapist with a doctoral degree in psychology (Ph.D. or Psy.D.). Doctoral level psychologists have 5-7 years of graduate training and supervised clinical practice, plus a post-doctoral residency. Most Ph.D. programs in clinical psychology are extremely selective and have very low acceptance rates (for example, 250 applications for 6 slots). In addition, Ph.D. psychologists have extensive training and experience in scientific research. While a Ph.D. in clinical psychology does not guarantee therapeutic effectiveness, it does reflect a high level of ambition and academic accomplishment, a scientific background, and at least five years of intensive, high-quality training. In contrast, a master’s level therapist such as a social worker (LCSW), licensed mental health counselor (LMHC) or marriage and family therapist (MFT) has significantly less clinical training (usually 2 years of graduate school) and very little, if any, training in scientific research. Psychiatrists are medical doctors (MD’s) who focus primarily on prescribing psychotropic medication. Some of them provide psychotherapy in addition to medication, but most do not. Their training is primarily in the practice of medicine, not scientific research or psychotherapy. Most psychiatrists these days have little training in psychotherapy. Of course, there are exceptions to this rule. If you decide to see a psychiatrist for therapy, make sure she is one of the exceptions.
• University-based mental health clinics and academic medical centers are excellent places to seek psychological treatment. Many of them offer low-cost services or provide treatment for free as part of research studies. The therapists are typically doctoral-level graduate students, pre-doctoral psychology interns, and/or post-doctoral residents, all of whom are closely supervised by licensed clinical psychologists. Advanced graduate students, interns, and post-docs tend to make excellent therapists because they are young, idealistic, energetic, fully informed about recent advances in the research and practice of therapy, well-trained, and constantly evaluated on their performance.
• Find a therapist whose patients actually recover. The proof is in the pudding. Ask the therapist how many patients with your diagnosis she has treated in the past three years, and how many of those patients have fully recovered. If she hems and haws, or describes therapy as a lifelong journey, or claims that one never recovers from your particular disorder, move on to someone else.
• If the therapist is empathic, great. If she’s really nice and makes you feel at ease, wonderful. If you feel very connected to her, fantastic. These qualities are important, but if you are struggling with a mental illness, what matters most is whether she can help you recover. Mental illnesses are treatable and manageable; some are even curable. So don’t mess around with your mental health care. If you had cancer, your priority would not be finding an oncologist who was warm and kind and empathic and emotionally connected to you. These qualities are icing on the cake, but what you need most of all is the cake. And the cake is effective treatment that will cure your cancer. Don’t need to settle for anything less in your mental health care.
This is fabulous, exactly what I needed to read as I am embarking on a new therapist search.
As a clinical Ph.D. applicant…the rates of acceptance have gone down in the past few years…it is now about .3% to .5%. Which is ridiculous for those of us applying, but even better for our future clients.
You spoke some about questions to ask a potential therapist, I was wondering if you might be willing to list what you consider the five most important questions to ask a potential therapist in the case of a serious, long-standing eating disorder.
Grace,
Wow, it’s hard to believe that programs are even more competitive now than they were when I applied back in 2001. And keep in mind that not all of the 0.3 – 0.5% who are accepted into programs will become licensed psychologists. Each year, 25% of candidates seeking pre-doctoral internships don’t match. And a similar percentage of people don’t pass the licensure exam. Not to intimadate you….but it’s unbelieveable what they put us through in order to become psychologists.
In regards to your question, here are the five important questions (in my opinion) that one should ask a potential therapist when seeking treatment for a serious, long-standing eating disorder:
1.) In your opinion, what causes eating disorders?
(Make sure they have a science-based explanation that involves neurobiology, genetics, personality traits, and the role of malnutrition. It’s OK if she mentions societal pressures for thinness as triggers, so long as that’s not the ONLY thing she mentions.)
2.) Describe your philosophy of treatment for eating disorders.
(Make sure she emphasizes full nutrtion and weight restoration to ideal body weight (for AN) and nutritional stability / cessation of binge-purge behaviors (for BN) as the first step in treatment. Make sure she also emphasizes the acquisition of coping skills, learning to eat healthfully and independently, self-care, treatment of co-morbid conditions, and relapse prevention)
3.) Describe your training and experience in empirically-supported treatments.
(Make sure she has some training and/or experience with CBT, DBT, ACT or other third-wave behavior therapies, and/or Maudsley FBT).
4.) How many patients with eating disorders have you treated in the past three years? How many of these patients have fully recovered?
(Make sure she’s seen at least a few other people with EDs, and make sure that the majority of them are fully recovered (or at least well on their way to recovery).
5.) What is your opinion on the involvement of family members and significant others in the treatment of eating disorders?
(If she advocates parentectomies or exclusion of family members, or implies that families cause EDs, this is bad news. If she views family members as potential emotional or nutritional support for the patient, this is good news).
Dr. Ravin,
I’m glad that it’s an incredible feat to become a psychologist. There are enough bad therapists out there who manage to get through all of the requirements, I can’t imagine how many there would be if the requirements were less rigorous.
Thank you so much for the list.
Thank you, Dr. Ravin, for another very helpful article. In order to treat anorexia nervosa, does a therapist need to pass a licensing exam specific to eating disorders? If so, what kinds of questions are asked in the exam, and what are considered to be the correct answers?
CB –
A therapist does not need to pass an ED-specific licensing exam, meet any specific criteria, or have any specific credentials in order to treat anorexia nervosa. And therein lies the problem. Any psychologist can, technically, treat any disorder. Granted, it does state in the APA ethical guidelines that clinicians practice within their areas of expertise, but this is not really enforced, and “expertise” is not explicitly defined. And there is nothing preventing psychologists from practicing treatments which are not evidence-based.
As Ph.D. psychologists, we devote so many years of our lives (some people not-so-jokingly refer to it as “writing off your 20’s”) to our schooling and training, and we jump through so many hoops, but most of these hoops have very little predictive validity in terms of determining one’s effectiveness as a therapist.
For example, passing the licensure exam requires that one has basic knowledge of psychology, which includes everything from infant development to industrial-organizational psychology to the anatomy of a neuron. Clinical psychology questions comprise only a fraction of the exam (maybe 20% or less….I’m not quite sure), and most of the questions have little to do with what one would actually need to know as a practicing psychologist.
I think that a licensure exam with more predictive validity would consist of the following elements:
1.) Questions about diagnosis and assessment
2.) Questions about evidence-based treatments for various mental disorders
3.) Case reports of fictional clients’ presenting problems, requiring you to diagnose the client, devise a treatment plan, and suggest possible therapeutic interventions
“I think that a licensure exam with more predictive validity would consist of the following elements:
1.) Questions about diagnosis and assessment
2.) Questions about evidence-based treatments for various mental disorders
3.) Case reports of fictional clients’ presenting problems, requiring you to diagnose the client, devise a treatment plan, and suggest possible therapeutic interventions”
The grad students (clinical) at my university have to pass two exams like this in order to graduate. I don’t know if that applies elsewhere…
Grace –
My graduate program also required clinical students to pass an exam such as this in order to graduate. However, this isn’t standardized across various programs. As I understand it, each program develops their own comprehensive exams.
My T went on maternity leave and she sent me to this other woman who was just AWFUL. She was so analytical and felt the need to analyze EVERY little thing that came out of my mouth. I got so annoyed with her and was so mad and frustrated by the time I left her office, I wanted to scream. My T thought she would be good for me because she thought she wouldn’t take any of my “small talk,” but the plan backfired a bit. She, well, sucked.
I am so glad mine is back, that’s for sure!!
I felt bad not liking her, but we just did NOT click at all. She probably hated me, but that’s okay. She was a nice person, I just thought she sucked as a T.
I’m wondering if PTC may be willing to say more about the experience of having a pregnant therapist? It’s a fascinating event, and I’m interested in learning more about it.
Dr. Ravin, thank you very much for this post, it is very helpful. I just got back home from residential treatment for my eating disorder (as well as a brief stay in the psych ward) and am having to find a new therapist. I’ve done a lot of “therapist-hopping” in the past, and I want to make sure the person I find this time is really the right fit. I really appreciate all the information here!
Dr Ravin,
Has the word humble ever crossed your mind? You are extremely proud of yourself and have no problem tooting your own horn at the expense of others. There are thousands of great therapist who have “only” a masters degree. Get over yourself and give them the credit they deserve!
Sure Ginia!
Well, I totally called her out on her pregnancy, which is pretty crazy when I think about it now. What an uncomfortable spot I put her in. I just picked up on a lot of things. She was NOT showing at all. One day it just got to me and I said, “Someone in this room is a little bit pregnant while the other is a little bit eating disodered. (She always says to me, “You can’t be a little bit pregnant or a little bit eating disordered,” which is why I said what I said). She didn’t deny or confirm anything until the following week, after I had written her a long email sort of freaking out.
Anyway, I watched her grow and we talked a little bit about her pregnancy. She went on maternity leave a week or 2 before Thanksgiving. I was seeing her three times a week, so going from that to nothing was really hard. I was extremely stressed out during that time too because I had to go home for Thanksgiving (eating and worrying about people saying things to me), was leaving for a 10 day trip to Italy and worried about food and not exercising, and had a few other things going on. She sent me to this fill in therapist who completely sucked. She overanalyzed EVERYTHING and I hated her. That stressed me out, well, moreso annoyed me to death because she was so irritating. My therapist returned after New Years, which was so nice. I started off seeing her only once a week, which was weird because I was used to going 3x, but now we’re back to twice a week. Her maternity leave went by pretty quickly because of the holidays and me being away. I planned my trip according to her maternity leave. I was able to stay home for Christmas longer, which was nice. So, it wasn’t too bad. I missed her and definitely felt like I needed her sometimes, but it was okay.
Do you have any specific questions, Ginia?? I don’t think my little schpiel was any good.
Thanks so much for your post, and your blog. Millions of Americans suffer from a diagnosed, misdiagnosed or undiagnosed mental illness. Silver Hill Hospital has clinicians trained in evaluation, diagnosis and adult and adolescent psychiatric treatment and provides hope for people who may not have been getting the right care.
Valuable info. Lucky me I found your site by accident, I bookmarked it.