The following is from an article entitled "How to choose a competent counsellor"
Counselling versus Psychotherapy
Counseling is generally used to denote a relatively brief treatment that is focused most upon behaviour. It often targets a particular symptom or problematic situation and offers suggestions and advice for dealing with it.
Psychotherapy is generally a longer term treatment which focuses more on gaining insight into chronic physical and emotional problems. It's focus is on the patient's thought processes and way of being in the world rather than specific problems.
Psychotherapy requires more skill than simple counseling. It is conducted by professionals trained to practice psychotherapy such as a psychiatrist, a trained counselor, social worker or psychologist. While a psychotherapist is qualified to provide counseling, a counselor may or may not possess the necessary training and skills to provide psychotherapy.
What is Psychotherapy?
The foundation of psychotherapy is the relationship you establish with the therapist. Research has shown that the technique the therapist uses is not as important as the relationship you build together. As therapy progresses and trust is established, you will actually use the relationship between you and your therapist as a workspace, to resolve problems in your life. Because the relationship with the therapist is so essential to the process, it is important to find a therapist to whom you feel connected, with whom you feel safe. In psychotherapy, you intentionally make yourself deeply vulnerable to another human being. That is a very frightening assignment indeed. It is this very process of self revealing and trust building that can be the means of your healing.
The answers are already within you
There is a part of your mind, beyond your conscious awareness, that knows if your therapist is helping you. Your unconscious controls your deep emotional satisfaction, or dissatisfaction. If your therapist does something unhelpful, your unconscious knows it, and will tell you. Messages from your unconscious mind are messages from you to yourself, and you can use them to evaluate the true success of your therapy.
Of course, learning to evaluate messages from your unconscious mind can be difficult at first, since your unconscious mind communicates with the outside world only indirectly. After all, it is unconscious. The unconscious mind speaks only through dreams, and through broad themes that play themselves out through other aspects of your life. Furthermore, your unconscious and your conscious mind often disagree.Consciously, you might think one thing; but deep inside your unconscious, your true feeling is otherwise. Nevertheless, since your unconscious mind controls your deep-seated emotional satisfaction or dissatisfaction, the unconscious mind is often the theater of psychotherapy.
When the unconscious part of the mind communicates, it uses a conscious piece of information as a disguise for its meaning. Although we are saying one thing consciously, another meaning is being expressed unconsciously by way of the same images. In other words, when a patient in therapy tells a story or a dream, there are two levels of meaning in the images being expressed. One level is the conscious level. A story refers directly to the people and events being talked about. But a story may also contain unconscious information -- that is, the details and images may pertain indirectly and unconsciously to what has taken place in the treatment experiences itself. --Robert Lang, MD
Feeling safe with your therapist
In psychotherapy, you make yourself deeply vulnerable to another human being, and allow many disturbing feelings and thoughts to be expressed. This is absolutely necessary to your healing. But to allow yourself to do it, you will need to have a strong feeling of trust in your therapist; you will need to feel safe. The process of creating a safe space in which therapy can take place is referred to as building a secure frame, and it is a very important aspect of therapy.
The "frame" is the environment of your therapy. It includes the physical surroundings, the emotional environment, the psychotherapeutic structure, and the relationship between you and your therapist. A secure frame is a private psychic space in which you feel safe, "held" and supported. A secure frame is an environment in which every detail reflects structure, containment, safety, and support.
Psychodynamic therapists believe that the secure frame is a vital element of the therapy. Others disagree about its place in the scheme, but certainly if the frame is not secure, you will find it difficult to accomplish much that is meaningful, whatever type of therapy you pursue. From what I have seen, I believe that the secure frame is the element of therapy that is most frequently abused by poor therapists, and frame deviations are too often tolerated by unknowing clients. Consciously, you may dismiss most frame deviations as unimportant. However, your unconscious mind pretty much requires a secure frame, if your therapy is to have any lasting effect.
Confidentiality is paramount
The most important ingredient in the secure frame is privacy. You have a right to expect absolute privacy and confidentiality in therapy. You need to know that no outsider is listening in (either in fact or in unconscious perception), and that anything you say is safely contained in the therapeutic space, with no leaks. This assures you that it is safe to speak, because nothing you say can ever get outside the room. But your privacy can be contaminated in subtle ways.
Your unconscious mind will sense intrusion if you have to discuss an appointment with a secretary, if you can hear someone speaking outside the therapy room, or if your therapist talks to a friend or family member for any reason. In all of these cases, your unconscious mind will sense that outsiders have invaded your therapeutic space, and that it is not safe to talk because there is not sufficient privacy.
You have a right to expect acceptance. As you begin to feel safe with and held by your therapist, you may begin to talk about some pretty painful things. You should be able to know that your therapist will not pass judgement on you, or be repulsed by anything you say, no matter how awful. You should feel that your therapist will not react negatively, even if you become enraged at him/her. He/she should respond to you therapeutically, allowing all your feelings, good and bad, to be released in a therapeutic frame which is strong enough and secure enough to hold them.
How to find a therapist
The way you find out about your therapist might end up becoming an issue in your therapy. Perhaps most important: Your therapist cannot have a close connection with any relative or friend of yours. It will be extremely difficult, if not impossible, to build a secure frame under those circumstances.
It is unlikely that any competent therapist will accept you as a client if you are the friend or relative of a current or former client. Therapy is already too difficult (and too expensive) to intentionally handicap yourself in this way.
A secure-frame therapy requires anonymity, confidentiality, privacy, and therapist neutrality. For best results, IF SOMEONE YOU KNOW IS SEEING OR HAS SEEN THIS THERAPIST, FIND ANOTHER THERAPIST.
The best referrals are professional referrals, from a professional who knows the therapist professionally, and who is not involved with you or the therapist socially. Your therapist may be suggested by: your family doctor, a professional organization, a counselor whom you have consulted for the purpose of obtaining a referral, your minister or rabbi, or some similar person who is in a professional position to have general feedback that this therapist's clients have worked successfully (and who is NOT themselves a client).
It should be unlikely that you will ever see your therapist outside therapy. Therapy works best when your relationship is confined to the therapeutic frame. Less good are referrals in which you have no choice: therapists to whom you are assigned by an employer, court, HMO or clinic. These assignments may turn out to be good; but if they are not, you need the freedom to select another therapist. Also less good are therapists about whom you know something personal, or who you are likely to see outside of the therapy frame. These situations can be made to work, but they are much more difficult to deal with in your unconscious and so make therapy longer and harder.
Avoid selecting a therapist arbitrarily, say from the yellow pages. This gives you less guarantee of the persons competence. If you have no other choice, pay very close attention to the themes expressed in your dreams and narratives when you start seeing a therapist selected in this way, and discuss them with the therapist. If you use a therapist referral service or directory, especially those online, keep in mind that most of them are commercial services. They may not have screened the therapists; any therapist who pays for a listing could be included, which guarantees you nothing. In other cases, the service could be restricted to only one variety of therapist, giving you less of a choice. When you get the referral, you may find out about the therapists education, training and experience, and, if you know you have a particular need, the therapists specialty, if any (i.e. alcohol/addiction, depression, family or couples therapy, etc.) Keep reading to find out what you should look for.
Credentials of therapists
A lot of bandwidth has been spent attempting to compare, defend, or even just explain the professional credentials of psychotherapists. It is incredibly confusing. There are literally hundreds of designations, and you can quickly drown in a sea of letters: Ph.D., M.D., L.P.C., Psy.D., M.F.C.C., L.C.S.W., etc. Some are licensed, some are certified, others are registered. They may have a particular orientation like psychoanalytic, psychodynamic, cognitive/behavioral, gestalt, solution-focused, etc.
It can be traumatic just trying to understand it all, let alone decide what kind of therapist to see. Of course people worry about making a wrong choice. When youre in emotional pain, you want help and you want it now. Just as you dont want an incompetent doctor, no one wants to waste their money on an incompetent therapist.
Surely, somewhere in that alphabet soup is the key to good therapy... right? Well, no. I can tell you that the energy that goes into these explanations will not necessarily help you find a good therapist. Some of that information is important. But the letters after a therapists name cannot reliably be used as a rating system to distinguish between good therapists and incompetent ones.
Unfortunately, the professions themselves dont help you figure it out. Naturally, each psychotherapist believes that his/her credentials (whatever they are) are the best, and maybe even the only valid psychotherapy credentials. If a therapist is licensed by the government, he/she will probably tell you that licensing is crucial, and may even imply that anyone without a government license is shockingly incompetent. (It isnt so!)
If you ask a professional association, of course they will lead you to believe that their members are the most worthy therapists. Anyone who had to spend six years in graduate school will tell you that all counselors should have spent six years in graduate school. No matter which profession you ask, they want you to believe they are the best.
But an academic degree, and even a government license, are not infallible guarantees that a particular therapist will be successful helping you. Since therapy is as much an art as a science, there is a degree of plain old talent required, which is difficult to define with credentials; not to mention human qualities of compassion, empathy and character. Some very talented counselors have no official credentials at all.
It is important that your therapist have some kind of professional credentials. To be a competent psychotherapist, one needs ALL THREE of the following:
- Intensive academic study in a mental health field A good therapist starts with a masters or a doctorate in a mental health field (MA, MS, MDiv, MSW, PhD, PsyD, EdD, DMin, MD). Wisdom, compassion and character are necessary, but they arent enough; knowledge is essential.
- Supervised clinical experience A good therapist has completed an extensive psychotherapy training program (clinical residency). It may have been part of his/her academic degree, or it may have been a separate postgraduate program. This is important to know about, because some PhDs and MDs have academic knowledge about psychological research or medication, but have never had actual training or practice in psychotherapy. You cant simply learn psychotherapy out of a book or in a classroom. You need the books and the classrooms, but they arent enough. A supervised residency is where they learn their trade. Within this, i would argue a competent therapist should also have undertaken a minimum 150 hours or more of personal one to one therapy. In this way they can work through their own projections.
- Certification or registration or licensure. After residency, and supervised experience, the therapist has been pronounced worthy by an authority to which they will be accountable. It could be a government licensing board, or some other credentialing organization. Some of the more common designations you might see include: LCSW, CSW, MFT, LMFT, MFCC, AAPC, LPC, NCC, NCPsyA. If the therapist doesnt have all three, find someone who does. The type of credential is not as important as therapists want you to believe. A licensed psychologist is not necessarily a better therapist than a certified pastoral psychotherapist. An M.D. psychiatrist is not necessarily a better psychotherapist than a licensed professional counselor, etc.
Likewise, research has shown that the orientation of the therapist, and the technique that he/she uses, is not the biggest factor in the success of your therapy. As with credentials, therapists like to say that their techniques are the best. But research suggests that it has much more to do with their relationship with you. Even if they've run the gauntlet and managed to get the professional credentials, all therapists are not equally good, and just any therapist might not be right for you personally. The very best way to evaluate a therapist is within you. If you follow the advice in this article learn just a little about the process of therapy, know what you should be able to expect, and how to listen to your own unconscious you will be able to tell if a psychotherapist is any good, or not.
The first session
The day is here and you have arrived for your first session with the psychotherapist. While you are waiting, take stock of the surroundings. Ideally here is what you should find:
- The therapist has a private office with a comfortable waiting room.
- If the office is in a home or other less-than-private location, it has a private entrance and is completely shielded from any contact with people or sounds in the home.
- There is no secretary or receptionist in the waiting room.
- You encounter no other people either while waiting for your session, or when you leave your session.
- The waiting room and office are soundproof, and any windows have shades or blinds so that no one can see in.
By now, you no doubt can see that all these elements are ensuring your privacy and helping you to build a secure frame. If, shortly after your first session, you have dreams or find yourself telling stories about intruders, spies or the like, take a look at the therapy setting.
In the "ideal" therapy office, the therapist comes out to the waiting room, introduces him/herself, and shows you into his/her office. If it isn't immediately obvious where to sit, you can ask; the therapist's chair is usually evident, since he/she spends the majority of his/her time in it. Otherwise, sit wherever is comfortable for you. When you are settled, it's usually up to you to start; otherwise the therapist may prompt you with a general question such as "What brings you here?" You can describe the problem you are having, or anything else that comes to mind. Don't worry about whether you can say everything with absolute precision. The therapist should be able to help you get it all out.
In this first session, you can expect to do nearly all the talking. You can expect your therapist to listen actively. He/she may not say anything at all until halfway through the hour, or may make one or two interpretive comments or ask for clarification. While you are talking, the therapist will be listening carefully, evaluating your situation and deciding on possible treatment. In order for the therapist to do this, he/she must listen to you, and not influence what you say, or the way you say it. Beware of a therapist who talks more than you do in the first session, especially about him/herself.
Toward the second half of the time, the therapist should indicate whether or not he/she can be of help to you. He/she should then propose a therapeutic structure: a schedule of appointments, a fee, and any other related details. You have the opportunity to react to this structure, and decide whether to continue. Remember that this therapeutic structure -- the schedule, fees and other details -- is not incidental, it is a very important element of therapy. This "holding" environment is an important step in establishing the secure frame.
The proposed structure should be clear and unambiguous, and should reflect safety, consistency, and containment. Though you may think, consciously, that flexibility on the part of the therapist is desirable, the opposite is true. At this point, you need the therapist to be firm and consistent (like a good parent). If you are able to manipulate the therapist, you may find yourself dreaming and telling stories about seduction, infidelity, or theft. Having agreed on the fee and on a regular day and time for your appointments, you are, hopefully, on your way to emotional healing. You say goodbye and leave. Many therapists allow extra time for a first session; this is probably an exception.
Safety is in the details
Fees and times may seem incidental to the actual therapy; but consistency in the temporal aspect of the frame contributes greatly to your sense of security, of being held. If your schedule is constantly changing, you will find that it is difficult to get any work done in therapy, and you will likely find yourself with subtle feelings of danger, chaos and abandonment. If, however, these details remain solid and secure, your unconscious mind will see your therapist as healthy, consistent, safe, strong, and devoted to your care.
SCHEDULE and TIME -- The usual schedule is once a week, though you and your therapist may decide to meet more frequently; twice a week is not uncommon. In cases of financial hardship, a therapist may agree to see you every other week. At your first session, you and the therapist should agree on a regular day and time and place for your appointment. After that, your appointment should, ideally, stay the same as long as the therapy lasts; that is best for the success of your treatment. You may think that flexibility in the schedule is helpful to you; but it has been shown over and over again that to your unconscious mind, it is not. If you are depending on a structure for support, any change to that structure will leave you feeling unsafe. Therapy sessions are typically 45 or 50 minutes. To maintain the secure frame, your therapist will hold you to that time absolutely. If you arrive late, you still must stop at the agreed time. At some point, it will probably happen that you will be in the middle of something deep and anguishing when the time comes to stop. This may be extremely frustrating to your conscious mind, but a good therapist will not allow you to run over the time, and that should satisfy your unconscious. If, on the other hand, the therapist is late, he/she should give you the full time. Your absences and lateness, as well as persistent silence, wanting to leave therapy, forgetting to pay or delaying payment, and bouncing checks, are often symptoms of "resistance", or fighting therapy. These may (or may not) reflect outside issues, and should be discussed with your therapist. In most cases, you will be responsible for paying for any regularly scheduled sessions that you miss or cancel; you are not responsible for paying for sessions cancelled by the therapist.
FEES -- At your first session, the therapist should propose a fee. What is normal? It varies enormously with the area, the therapist's qualifications, and the setting. Non-profit counseling centers and clinics with sliding scales may reduce the fee significantly. Your health insurance may pay a portion of the fee. For your own mental health, keep your bill paid up to date.
PHYSICAL CONTACT -- Many therapists have a standard policy that they usually do not engage in physical contact with clients (hugs etc.). Such contact has many ramifications for your unconscious mind. Certainly, no therapist should ever suggest sexual contact with you. As therapy progresses and you build a deep connection with your therapist, you will find that because of the intensity of your relationship, you can feel "held" emotionally without actually being held physically.
PRIVACY AND CONFIDENTIALITY -- It should go without saying that you can expect absolute privacy and confidentiality.
ABSOLUTE. Under no circumstances may your therapist ever reveal, without your permission, even the fact that you are a client, let alone any information at all about you or your case, to anyone, even to a family member. As an example, a friend of mine called his wife's therapist hoping to discuss "his side" of the issues. The therapist politely but firmly refused to talk to the man. She simply offered to refer him to another therapist if he wanted to work on his own issues. You can ask your therapist not to take notes or record your session in any way. (One therapist I went to wanted to videotape all my sessions. Not!) Again, some differ on this issue; however, most clients find that it compromises their sense of privacy. There may be instances when you choose to allow information to be released; in that case, your therapist should obtain a signed consent form from you. If your therapy is provided as an employment benefit, there should be no requirement for the therapist to report back to an employer about your progress. Managed health care programs increasingly intrude on this.
TERMINATION -- In most cases, you will be the one to decide when it is time to stop therapy. This decision should be discussed in great depth with your therapist, to make sure you are not terminating prematurely as an unconscious reflection of some important issue in your life. If, however, you both agree that problems have been resolved and termination is appropriate, set a specific date for termination and stick to it. The frame should remain absolutely intact right to the end. After terminating, you have no further contact with your therapist, unless you experience some new emotional disturbance, in which case you can arrange another course of therapy.