Choosing a Good Psychotherapist

Uploaded 5/4/2011, approx. 6 minute read

My name is Sam Vaknin. I am the author of Malignant Self-Love, Narcissism Revisited.

The dogmatic scores of psychotherapy, such as psychoanalysis, psychodynamic therapies and behaviorism, more or less failed to ameliorate, let alone cure or heal, personality disorders. Disillusioned, mass therapies today adhere to one or more of three modern methods, brief therapy, a common factors approach and eclectic techniques.

Conventionally, brief therapies, as their name implies, are short-term but effective treatments. They involve a few rigidly structured sessions directed by the therapist. The patient is expected to be active and responsive. Both parties sign a therapeutic contract or alliance in which they define the goals of a therapy and consequently, its themes.

As opposed to earlier treatment modalities, brief therapies actually encourage anxiety because they believe that it has a catalytic and cathartic effect on the patient.

Supporters of the common factors approach point out that all psychotherapies are more or less equally efficient or rather similarly inefficient in treating personality disorders.

As Garfield noted in 1957, the first step per force involves a voluntary action. The subject, the patient, seeks help because he or she experiences intolerable discomfort, egodystonic, dysphoria, dysfunction. The act, this act of approaching the therapist is the first and indispensable factor associated with all therapeutic encounters regardless of their origins or methodology.

Another common factor is the fact that all talk therapies revolve around disclosure and confidences. The patient confesses his or her problems, burdens, worries, anxieties, fears, wishes, intrusive thoughts, compulsions, difficulties, failures, delusions, and generally the patient invites the therapist into the recesses of his or her innermost mental landscape.

The therapist leverages this torrent of data and elaborates on it through a series of attentive comments and probing, thought-provoking queries and insights.

This pattern of give and take should in time yield the relationship between customer, client, or patient and healer based on mutual trust and respect.

To many patients, this may well be the first healthy relationship they experience and a model to build on in the future.

Good therapy empowers the client and enhances her ability to properly gorge reality, enhances her reality test. It amounts to a comprehensive rethink of one's self and one's life.

With perspective comes a stable sense of self-worth, well-being, and competence, known collectively as self-confidence or self-esteem.

In 1961, a scholar by the name of Frank made a list of important elements in all psychotherapists, regardless of their intellectual provenance and technique.

The first is that the therapist should be trustworthy, competent, and caring. Therapists should facilitate behavioral modification in the patient by fostering hope and stimulating emotional arousal, as Theodore Millon puts it.

In other words, the patient should be re-introduced to his repressed or stunted emotions and thereby undergo a corrective emotional experience.

The therapist should help the patient develop insight about herself, a new way of looking at herself and her world and of understanding who she is.

All therapies must weather the inevitable crisis and demoralization that accompany the process of confronting oneself and one's shortcomings.

The loss of self-esteem and devastating feelings of inadequacy, helplessness, hopelessness, alienation, and even despair, they are all an integral, productive, and important part of the sessions, if handled properly and competently.

Compare this to eclectic psychotherapy.

The early days of the emerging discipline of psychology were inevitably rigidly dogmatic. Clinicians belonged to well-demarcated schools and practiced in strict accordance with canons of writings by masters such as Freud or Jung or Adler or Skinner.

Psychology was lesser science than an ideology or even an art form.

Freud's work, for instance, though incredibly insightful, is closer to literature and cultural studies than to proper evidence-based medicine.

Not so nowadays.

Mental health practitioners today freely borrow tools and techniques from a myriad therapeutic systems. They refuse to be labeled and boxed in.

The only principle that guides modern therapies is what works, the effectiveness of treatment modalities, not their intellectual roots.

The therapy insists these eclectics should be tailored to the patient, not the other way around.

This sounds self-evident, but as Lazarus pointed out in a series of articles in the 1970s, it is nothing less than revolutionary.

The therapist today is free to match techniques from any number of schools to presenting problems without committing himself to the theoretical apparatus or baggage that is associated with them.

The therapist can use psychoanalysis or behavioral methods while rejecting Freud's ideas on Skinner's theory, for instance.

Lazarus proposed that the appraisal of the efficacy and applicability of a treatment modality should be based on six data. He called them basic IB, behavior, effect, sensation, imagery, cognition, interpersonal relationships, and biology.

What are the patient's dysfunctional behavior patterns? How is her sensorium sense data? In what ways does her imagery connect with her problems, presenting symptoms and signs? Does he or she suffer from cognitive deficits and distortions? What is the extent and quality of the patient's interpersonal relationships? Does the subject suffer from any medical, genetic, or neurological problems that may affect his or her conduct and functioning?

Once the answers to these questions are correlated, the therapist should judge which treatment options are likely to yield the fastest and most durable outcomes.

And this is based on empirical data.

As Butler and Halkin noted in a groundbreaking article in 1990, therapists no longer harbor delusions of omnipotence.

Whether a course of therapy succeeds or not depends on numerous factors such as the therapist and the patient's personalities and past histories and the interactions between the various techniques used.

So what's the use of theorizing in psychology? Why not simply revert to trial and error and see what works?

Butler, a staunch supporter and promoter of eclecticism, provides the answer.

He says that psychological theories of personality allow us to be more selective. They provide guidelines as to which treatment modalities we should consider in any given situation and for any given patient.

Without these intellectual edifices, we would be lost in a sea of everything goes.

In other words, psychological theories are organizing principles, kind of filters. They provide the practitioner with selection rules and criteria that he or she would do well to apply if they don't want to drown in a sea of ill- delineated treatment notions.

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