This blog is intended to simplify the process of finding a therapist. This is not a unique idea. Many other guides offer suggestions on how to find a therapist, from finding a specialist to treat obsessive-compulsive disorder to general resources on how to identify your preferred therapist style. Because I had the good luck to have you happen upon this page, I wrote this to make sure you can get routed to some tools no matter where you look.
What makes therapy work well
Back in the day, there was much debate over the effectiveness of therapy. While skepticism of treatment still runs amok in some spaces, we’ve got ample evidence that psychotherapy works dating back to the late 70s. What there is less agreement on now, including among treatment providers, unfortunately, is what makes therapy work. This is difficult to answer in part because there is no one size fits all despite the often quoted adage of many therapists that the “relationship is the best predictor of therapeutic outcome.” In non-academic terms, this basically means, if you get along well with your therapist and feel comfortable with them, you’re more likely to get better. But the reality is much more complicated.
In fact, the answer is so complex that is not easily summed up in a blog. In fact there’s a whole book on the matter that is a little over a decade out of date as of the time I’m writing this. This blog is an attempt to distill a very complicated body of research down to practically useful terms and arm you with a little bit of historical context, so that you can set realistic expectations, coexist with uncertainty about the outcome of your choices, and be empowered to search for a “good enough” therapist.
The relationship is indeed important. If you cannot tolerate being in the same room as the person, you’re unlikely to stay long enough to receive the treatment. Psychotherapy is a very unique sort of treatment in that the provider themself is the method of treatment delivery. At minimum, you deserve a provider who listens when you talk, expresses curiosity about what it’s like to be you, uses respectful language that mirrors how you describe your own culture and identities, and maintains appropriate boundaries. Therapists should be taking up far less space—some approaches expect the therapist to take up no space at all—with their own personal needs and hold space for your therapy. If there’s any disclosure about themselves, it should only be in the service of furthering your treatment. To put this general rule more crassly, if it can be accomplished by a priest, a bartender, or a sex worker, it’s probably not psychotherapy. In the words of one of my clients far wiser than me, “it’s not a professional friend.”
Emphasizing the relationship at the exclusion of all other factors does a great disservice to people who are discouraged by stagnating in psychotherapy for years with a very well-meaning, kind and supportive provider with healthy boundaries. Put differently, I’d love it if the person performing my open heart surgery has good bedside manner and can clearly explain the risks of the procedure and what my recovery might look like in a way I can understand. But I’d still strongly prefer that they know how to use a scalpel.
Unfortunately, humans, much less people looking for therapists, don’t move around the world with built-in alert systems that start beeping louder when they come into proximity with therapists can meet their needs. While asking preliminary questions is not a stand-in for the lived experience of participating in the therapy itself, it can still be useful to get some information before going through the rigamarole of filling out a bunch of paperwork and then attending (and paying for) an intake.
Getting Started
The first step in officially engaging in psychotherapy is sometimes called an intake appointment. Sometimes it’s called a psychodiagnostic assessment. Other times a clinical interview. Whatever name it’s given, think of this as the first official appointment. Here you can get a sense for the therapist’s style, while the therapist gathers background information about you, your family, and life up until the moment of therapy. Intakes are billed at the same or sometimes a slightly higher rate than ongoing therapy appointments because the therapist is doing a formal assessment, analyzing treatment needs, creating a treatment plan that they can propose to you, and self-reflecting on whether they have the chops to meet your needs or if a different provider might be a better fit. Because the intake appointment can be quite the investment both emotionally and financially, many therapists offer a free, brief consultation prior to a formal intake to try to route you to the “good enough” therapist more quickly.
A free consultation prior to the formal intake can be a great opportunity to streamline the process. Free consultations are usually 10-20 minutes. This service in and of itself can be a green flag; it often means they want to be respectful of your time, vulnerability, and money, giving you a chance to ask your deal-breaker questions before engaging more fully. Consultations themselves are by their nature very brief, so it may not be possible to firmly conclude whether it’s full steam ahead for both you and the therapist until after an actual intake appointment. They are, however, an opportunity to get a general idea of the therapist and ask the questions that are nonnegotiable for you.
Helpful Tips for the Consult
When cooking up a list of questions for the consult, I usually encourage folx to think first of the information they’re seeking and then work backward to determine how to ask the question. For example, when I’m looking for my own treatment provider, I often ask something like, “tell me about a time that you made a mistake when working with a nonbinary person and how did you fix it.” The type of questions each person needs to ask vary on the person’s processing style, their identities, what they want help with, and their schedule. The following set of principles can help you construct those questions.
1. Therapy is a time commitment. Each person is different in terms of whether they need the structure and predictability of regularly recurring appointments versus the flexibility to change their appointment time week to week to factor in changing work or educational commitments. Consider first what you have capacity for in your schedule, including a range from your ideal therapy schedule to what would be workable for you, and then ask the therapist whether that would be compatible with what they have to offer and whether that frequency is an effective “dose” of treatment.
2. Cultural competence. You may recall in grade school when writing assignments were accompanied by a “show, don’t tell” instruction. The same is true when we are trying to determine whether a therapist can attend to all aspects of our personhood without requiring us to do emotional labor of educating them about an entire community, rather than just our own experience. For example, you might ask therapists whether they have experience with your religious background if you’re struggling with obsessive-compulsive disorder (OCD) focused on scrupulosity. Therapist A says, “I have tons of experience. I myself have OCD and have XYZ religious affiliation.” Therapist B says, “While I’ve worked with other people who have your religious background, each person is different. I like to work closely with trusted faith leaders when possible, so that we can take a team approach and work within your belief system and values. I also attend the Faith & OCD conference when I can to make sure I’m getting updated perspectives from people with lived experience, as well as faith leaders.”
3. Type of treatment. I think one of the hardest things about shopping for any kind of expert is that we don’t know what we don’t know. That’s the reason we’re seeking help! A green flag is when a therapist can clearly describe to you what treatments they utilize, what they are used for, and the risks, benefits and alternatives to that treatment approach in terms you can understand. This is particularly important for some conditions—like OCD—where certain treatments risk exacerbating self-doubt and reinforcing excessive self-scrutiny. It’s a green flag when the therapist not only understands how the treatment they deliver works to create change but can also explain it in terms that make sense to you.
4. Authenticity about clinical competence. No one can be an expert in everything, and that includes therapists. Think of a primary care provider (PCP) or pediatrician. While they do need to be adept at knowing when to send out for a specialist and what type, not every PCP could do open heart surgery. If you don’t know what kind of specialist you need, that’s okay. That’s part of what you are figuring out together during the intake (and sometimes first few appointments). If you do already know what the problem is that you’re having, don’t hesitate to ask the therapist during the consult for information about their familiarity with treating your particular concern, what treatment approach they are considering, and what the alternatives are. We do need someone who knows their stuff and is confident enough to deliver, but we don’t want someone who oversells competence and undersells growth areas.
5. Give yourself permission to take a beat. If you had your questions answered to your satisfaction and are ready to move forward, by all means schedule the intake. You also reserve the right to take some time to sit with the information that you learned before committing to the next step. If the therapist rushes you or puts pressure on you to schedule, consider this another data point. When a therapist’s style on the consult is essentially the opposite of a high pressure salesperson, that might be another green flag.
The freedom to choose
Once you get started, it does not mean you are contractually obligated to the same therapist forever. I believe I’m borrowing this quote from some therapist who influenced me over the years who was talking about romantic relationships, though I think it applies neatly here too: Sometimes a successful relationship is an ended one. If you (or the therapist) determine that the treatment is failing you in some way, not only is it totally above board for you to broach the topic, but it’s actually the therapist’s ethical responsibility to invite this conversation.
Like with most things, it’s not fair to yourself to judge the success of a decision with the benefit of hindsight. Any choice about a therapist is the right choice for you at any given time based on the information you had available at that time. Anxiety about finding a provider is common, so with most things anxiety related, we can incorporate the wisdom of exposure therapy: proceed slowly in the face of uncertainty. Pay attention to your direct experience as you move forward. And above all else, bring the anxiety with you while you do what matters.
