Help me be a good therapist!
November 21, 2013 7:18 AM   Subscribe

Therapist in training. Finally got my first clients. This is my calling and I want to be damn good at it. Naturally, I turn to AskMe.

I'm finishing year 3 of a very good 5-year training in counseling and psychotherapy. I've learned a lot in my training program, and read many many books on my own time, about what clinicians think makes for good therapy, but less about what clients think. I recently discovered that despite many therapists' pride in their grasp of complex theory and ability to make sophisticated interpretations, what clients often find most valuable about the experience is the small things -- expressions of support, or of the willingness to go above and beyond for the client. So obviously there's something of a communication gap between therapists as a body and clients as a body.

I know what I like and need in my own therapist, but I'm aware my preferences may be peculiar to me. Mefites who have had positive experiences of therapy, please help inform my practice: what specific qualities, behaviors or interventions do you feel made your therapist a good one?
posted by stuck on an island to Human Relations (13 answers total) 18 users marked this as a favorite
 
The best therapists I have had were professional yet friendly (i.e. did not talk down to me). Stated how they work (I will give you tools to work with but it's up to you to use them or not). Sense of humor and empathy.

Validating -- which is especially important if you are in relationships with people in the outside world who may be the opposite of validating.

Empowering: one lady I saw told me to go walking (for anxiety and depression related to a bad divorce) and I said, "but it's cold," and she said, "bundle up! You gotta do it!" She was just kind of straightforward and cheerful and by the time I had my shrink appt 3-4 weeks later, he said, "whelp, you seem fine, no meds for you!" But I also appreciated that she had me in to see a pdoc as I have known others who were adamant that talk therapy was it.

I also had one once for marriage counseling that gave out little exercises to do at home, nothing too difficult but like, draw a square and put a door at each corner and label it how you exit the relationship mentally (watching too much TV, on the internet too much, going out with other people, stuff like that). Also gave handouts like the personal bill of rights. She gave us a sliding scale if we would see her at her home office.

I did have one therapy relationship that sort of foundered because it seemed aimless like there was no direction, just endless sessions. She was nice but I left feeling okay, now what? I still felt the same and didn't feel like there was any progress or learning or insights going on. So I guess I like the straightforward approach the best. Good luck!!!
posted by Marie Mon Dieu at 8:28 AM on November 21, 2013


It's nice to be liked by your clients, but that goal can interfere with what the client actually needs. I (a therapist) often find clients whose previous therapist was supportive and a good listener but, now, 10 years later, they're still where they were when they started, because they were never confronted or pushed to take any risks or make changes.
posted by Obscure Reference at 8:30 AM on November 21, 2013 [8 favorites]


I think what made my long term psychologist good for me was multifaceted. When I was having particularly bad weeks, he would make time to meet with me daily. He fought with the insurance company tooth and nail to get me the sessions I needed. He saw me in the hospital even though he wasn't required to do so. Having someone familiar to talk to about the things that a) got me there and b) were freaking me out being there were so helpful. He had a pager and insisted I page him if I was having problems. He was able to be a bit creative with me. He encouraged me to write things down, in essay or poetry form usually, when I couldn't just talk about it. He let me be intellectual when I needed to be. Meaning he let me take a break. I was also a grad student in dev psych and he always treated me as if I had a brain in my head. He was interested in what I was doing in my classes and research. Basically he treated me like a human being instead of the damaged goods I perceived myself to be.

I know this is a bit scattered, but I haven't had a therapeutic relationship as good as this one ever and he's a large part of the reason I'm alive today.
posted by kathrynm at 8:30 AM on November 21, 2013 [3 favorites]


My therapist (of about 3 years) says nice things about me, all the time and appears (much to my ongoing amazement) to genuinely like me and not feel like I'm the lamest loser on the planet.

She also reframes things a lot for me -- at first when she did this I was like "I must be stupid because I didn't think of it that way," and so we talked about that too. She remembers what I say, for the most part, from session to session. She tells me things about her own life, and when she's trying to help me understand an idea or a different perspective, she'll give me examples from her own life and sometimes they aren't the most flattering stories. I find this enormously comforting, because I think she's one of the smartest, most accomplished person I know. It's helpful to see that vulnerability.

She is educational -- I'm interested in the process of therapy, so we talk about different ideas and techniques in the field, and she's happy to explain different approaches and how she feels about them and explain concepts that she does use. She lifts the veil.

When I was going through a particularly tough time, she asked me to email her everyday. I was at first guilty at taking her time that way, but she assured me it was okay and that she enjoyed reading what I wrote. She never wrote back anything very long, but she always responded.

She occasionally lends me books from her own collection that she thinks are helpful. I've given her book recommendations too, and sometimes she'll read the things I recommend and talk to me about them. Occasionally I email her a link, or she emails me something she thinks I might find interesting.

These sorts of things -- and the idea that she sometimes thinks about me outside of our office meetings -- is also very validating.

She is not always "nice" -- and by that I mean she pushes me to extend my cognitive distortions to their natural conclusions -- and that makes me uncomfortable. She's willing to make me uncomfortable, but tells me why she's doing it.

She has been flexible about payment and insurance issues. She has a calming office. She makes jokes. She tells me when she is moved by something I've said. She has a very expressive face so I can tell when she's empathizing with me. She is in the Carl Rogers humanism camp, if that helps.

I once had a therapist who wasn't a good fit for me and I often got the vibe that she was impatient with me and dismissive of my issues. I felt lectured by her, more than listened to. It was a more combative relationship. She gave me homework assignments -- make a vision board, try mediation -- that I often felt like I failed at. Even though with my current therapist we've had conflict and tension sometimes, I always feel like she is listening and not passing judgement. Sometimes she gives me homework assignments, but she doesn't chide me if I don't do them. She just wants to understand why. It's all about process with her, rather than reaching certain predetermined endpoints.

Sometimes I wonder what the point of all this talking is, since my progress toward change has been glacially slow. I wonder if something very concrete and short-term like pure CBT would be better. Maybe so. Regardless, I don't think any of these slow changes would have been possible without someone believing in me the way she has.
posted by megancita at 8:31 AM on November 21, 2013 [5 favorites]


Things I have liked about therapists:

- Impeccable boundaries, always started and finished sessions exactly on time, revealed almost no information about herself, got more sessions out of my insurance company when I needed some but only within reasonable limits. Her therapeutic approach was very concerned with integrity and it showed.

- Generally quite serious and cerebral, but dropped a reference to a Clash lyric in a session once in a way that made me think, "Oh she's human! I'm totally keeping her."

- When we terminated because I was moving out of state, told me she'd miss me and (consensually!) gave me a hug. Not every therapist could pull this off, I'm sure. In this case it seemed both genuine and something she did for legitimate therapeutic reasons.

Things I have not liked:

- Super awkward home office setup in a tiny space with suboptimal climate control.

- Shitty web presence.

- Couldn't remember names and events between sessions though they took notes the whole time.

- Person managing my meds once was way too quick to draw conclusions: "Wow you look WAY better!" right when I walked into a follow-up appointment. She was right, but that gut reaction did not inspire confidence. Listen first.
posted by clavicle at 9:40 AM on November 21, 2013 [1 favorite]


For a while I saw a post-doc who was still learning how to be a good therapist, and there were things she did that I think she thought were useful that drove me up the wall. Since you asked what is helpful, I guess my opinion is that it's helpful to avoid these behaviors:

- Interrupting the client to share your brilliant insights. Please don't interrupt except in extreme circumstances.
- Stating your opinion as though it's fact ("Well I think what it is, is [blah]"). Instead try exploring with curiosity whether the client might agree with the judgment you're making in your head ("I wonder if it might be [blah]? What do you think?").

I also think to be a good therapist, you have to be comfortable with silence. Some clients will need several seconds to collect their thoughts, or to mull over a realization they've just had. Listen for the difference between ellipses and periods at the end of spoken sentences. Body language can also give you a clue about whether the person is ready to hear your feedback or just trying to figure out how to phrase their next sentence. Filling that space by talking, even if you're using a therapeutic communication technique when you speak, can make it hard for a client to process the potentially good things that are happening in the session. It can prevent them from sharing difficult-to-discuss topics with you, which might be the most important ones.

If I client seems to get lost in their thoughts, encourage them to say more rather than trying to sum up what's already been said. Try "Can you say more about that?" or "What was that like for you?" If they seem really lost in their thoughts, and you've given them plenty of time to start talking again, try "It seems like you're having trouble talking about this. What's going on as you're thinking?" You don't know if the topic you've been discussing is really emotional, or if they're distracted by worry about their grandpa who's in the hospital, or what. Avoid assuming; ask.
posted by vytae at 9:59 AM on November 21, 2013 [3 favorites]


I know you asked what therapists have done that have made them good, but for me, the bad usually stuck out. I've had therapists who, after finding out I was in school for writing, spent the rest of our session talking about the novel-in-progress in their desk drawer. Likewise, I've had therapists who've spent the majority of the sessions talking only about themselves. My most recent therapist was decent, but when I felt he was asking me the same questions over and over, I felt like he wasn't paying attention to me, or couldn't be bothered to remember (or just take notes or something) on what I said last week, so I gave him the boot.

So from that, I'd say, give your clients the floor, let them talk. Of course, offer advice, help, your perspective, but don't bogart (this seems so obvious to me that I feel I shouldn't have to say it, yet I've come across more than a few therapists who make me feel like I need to say this, just in case). And remember what your clients have said in the past. Not everything, but take general notes, perhaps reread them before a session to refresh.

Thinking back, I had two therapists I liked, and they both treated me like I wasn't stupid, respected my intelligence and catered to my creative side. From that, I guess I would say learn each individual person and try to find a way to help them (and have them help themselves) that is unique to them. A method that helps a more creative person may not help a more by-the-book person and so forth.

Best of luck!
posted by dearwassily at 10:05 AM on November 21, 2013


Boundaries and objectivity. Also, read histories thoroughly.
posted by Lesser Shrew at 10:42 AM on November 21, 2013


I am an expert on therapists. At last count I think I've seen at least 11 therapists in my life as an individual client, for family therapy and for couples therapy. I've tried somatic, CBT, and "regular" talk therapy. I've seen students, interns, and therapists with decades of experience.

I really, really think a lot of this is just individual chemistry: what makes someone a good therapist for me probably makes them a crappy therapist for someone else, but having said that, I think I can come up with a few pointers:

1) Confidence. You're new to the field, so draw as much as you can on your other life experience. This is hard, because over-confidence or false-confidence shows. But be confident and assertive. Don't let the client boss the session in the sense that I like a feeling that even if I am producing the content of the discussion, the therapist has a big-picture of where the conversation is going and why, and will step in to steer or call bullshit on me when necessary.

2) Be interactive. I know this is something that some people like more than others, but I find the whole, "Uh huh, tell me more about that." to be basically useless except for just a fleeting feeling of moderate goodness that someone is listening to me. Even for that purpose it doesn't feel that good because it's kind of invalidating. Like, OK, you are listening to me, but you really have zero opinion or reaction? This is a big deal to me and you're just like, "Uh huh, uh huh, uh huh..."

3) I like when my therapist treats me like an adult. For example, I totally get and agree with a policy that you pay for a session if you don't give 24 hours notice for cancellation. However, I've had therapists who had that policy, but occasionally made exceptions when they had established I was responsible about paying and had a true emergency. I'm not saying that specific thing has to be your policy, but what it communicated to me was that the therapist respected me, believed I was trustworthy, and was treating me like a regular human instead of being like some kind of strict 6th grade teacher. So that.

4) Use humor.

5) Don't stare straight at me when there is a conversation lull. This makes me uber uncomfortable. My favorite therapists are the ones who have figured out a magical way to make eye contact regularly without boring holes in my skull with their staring eyeballs!

6) Don't try to make people stay longer or come more often than they want. This almost always comes off to me like a desire to have my money and not like my best interests are at heart. If someone wants to quit and you think it's not therapeutic to do so, maybe suggesting something like trying 3 more sessions instead of just saying that's a bad idea overall?

Good luck, I'm sure you'll be awesome!
posted by latkes at 10:48 AM on November 21, 2013 [1 favorite]


I have done some therapy in my time, and I also have a friend who's a therapist. She said something really interesting about a session* once, that her client said, "You get me." Meaning, I think, that the client felt completely understood.

I had one therapist who I felt "got me" and another who didn't. I think the reason I felt that way with the first one was that she didn't challenge me on stupid stuff. An example: At the first session, describing my history, I said something like "and of course high school was a nightmare..." First therapist nodded and encouraged me to continue. The second therapist challenged me: "Why would you say that?!" Like she had never heard any client say that high school sucked.

Other things about therapist #1-- she did occasionally share a detail about her personal life, but not often. (#2 shared inappropriate things, like about her underwear. I am not kidding.) #1 usually started and ended our sessions on time. She mainly used CBT with me, which worked well for my issues. I still use it today.

I think a lot of it does boil down to "chemistry" and it's hard to quantify. I bet you'll develop your own style and you'll do great.

*Of course not revealing any possible identifying details-- she is very professional!
posted by tuesdayschild at 5:53 PM on November 21, 2013


I've only seen two counsellors, and one was for hypnotherapy predominantly, so I am not an expert. The thing that worked for me with one was something that the other didn't do and it really pissed me off, so this might still be useful:

1. Asked me what I wanted to get out of the sessions, and what I was looking for in terms of "treatment".

2. Attempted to deliver that, and didn't get too sidetracked with digressions.

The hypnotherpatist listened to what I had to say - i.e. the reasons for coming to see him, explained what he would (and could) do, and how he would do it, and then did it - gathering my feedback as we went. It was iterative, there was a real dialogue between us, and I felt like he was really listening to what I wanted to say, and responding his treatment accordingly. He also didn't delve unecessarily into things that weren't relevant.

The other guy lacked focus, let me go on about stuff. Seemed almost pathological about refusing to say anything insightful, or making a guess. I called out that I was seeing him for strategies in order to deal with some short term but unavoidable and intense stress in my life. He gave me nothing, and just, like, kept wanting me to talk about the issue (which was actually quite straightforward). I felt like he wasn't actually listening to me, because he never said anything beyond what someone following the most superficial thread of the conversation would say. I felt like I was talking to myself basically, and got a weird passive-aggressive vibe from him, like I wasn't being honest with myself, or he was challenging me to man-up and deal with the problem, basically - which defied the whole point of asking for help. He wouldn't commit to anything, even when I said, do you think I should schedule another session, he was like "What do you think?" It was like, fuck dude, just give me a straight fucking answer to a question for once, you are the professional here, not me.

Needless to say, my internal answer to that rhetorical question was "not with you".
posted by smoke at 7:00 PM on November 21, 2013


Have a decent web presence. Speaking as a client, it can be nice to have an idea of who you're going to meet before the initial appointment, especially if you are anxious, and email is a nice alternative for people who are uncomfortable with the phone, for whatever reason. (And by "nice alternative," I mean "absolutely critical." I wouldn't be in therapy today if I hadn't been able to set up appointments via email.)

Try to address any issues or prejudices you have yourself before dealing with clients. I briefly saw a therapist whose entire attitude changed when she found out that I had gone to a highly-ranked university--suddenly she was much more attentive and less condescending. She also clearly had food issues of her own, as evidenced by her body language when I attempted to bring up my eating disorder.

If you can possibly help it, stick to holding your sessions in one office. I had an amazing therapist for two years that I saw through a clinic, and once she moved to part-time status she had to run her sessions in whatever space was available. It was surprisingly disconcerting to be in a different room every week.
posted by corey flood at 9:06 PM on November 21, 2013


The beginning of the relationship is trickiest, and in that beginning, I've really appreciated interpersonal warmth and generally putting me at ease, and responding well when I shared whatever drove me to seek therapy. On that second one, starting therapy was a time of feeling "crazy," bad, and beyond hope. I feared the psychological equivalent of a doctor looking at an ingrown toenail and saying "oh my god, that is infected and SO disgusting! I don't even know if we can cure this!" And a few first sessions did manage to make me feel worse rather than better by going too far into what was wrong without enough "you're normal and will get through this" mixed in.

What helped were the therapists who:
- sympathized and validated feelings (nodding sadly, "that sounds very tough"),
- approached it with familiarity ("when dealing with grief, people often go through a phase of intense anger"),
- normalized pieces ("no wonder you wanted to scream!"),
- defended me to myself ("sometimes our bodies just shut down when things are too much. It sounds like the depression is really paralyzing you, and we can work on addressing that, but I just want to say that it may be coming from a part of you that is actually trying to help you heal or cope"), and
- demonstrated confidence and professional expertise (didn't seem too eager to please, but were self-assured that the two of us could find a solution together).

Over the longer term, it's hard to say what most helped, but what stood out the most are mostly things that have been mentioned: remembering details, lending books, and having done their own work. The therapists I've picked were the ones that had a little extra spark that (I imagined) came from knowing who they are and being happy in their own life. I'd add: rarely giving advice but giving it clearly at moments when I was about to make an uncharacteristically-bad mistake ("I rarely give advice, but I'd strongly encourage you not to invest your life savings in his business at this time").
posted by salvia at 1:35 PM on November 22, 2013


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