Illustration by Sébastien Thibault
It’s time for change but who should you see? The choice can be baffling but asking the right questions will make it clearer
by Kate Smith
Illustration by Sébastien Thibault
is head of division for health sciences at Abertay University in Dundee, Scotland. She also chairs the Pluralistic Practice steering committee, leads the team running the annual International Conference on Pluralistic Counselling and Psychotherapy, and has published and presented on a range of topics pertaining to the pluralistic framework. She is a trustee and governor of the British Association of Counselling and Psychotherapy.
Edited by Christian Jarrett
Therapy is a place where you can open your life to a stranger whose role is to help you come to terms with, evaluate and change how you understand yourself and how you live. Therapy can begin a profound process of change fundamentally linked to your identity, or it can simply be a way to assist your adjustment and adaptation to life’s challenges.
The aim of this Guide is to provide you with some preparatory information to help select and optimally engage in counselling or psychotherapy. I won’t be providing a set of therapist selection criteria based on your particular mental health diagnosis (if you have one) or problems in living. Rather, I will draw on contemporary evidence to guide you toward choosing a therapist with the style and approach that’s most likely to lead to the outcomes you want.
I am a practitioner and educator in pluralistic therapy, a relatively new integrative framework developed in the United Kingdom as a response to the need for practitioners to adapt their methods appropriately to clients’ varied preferences and experiences.
This Guide is designed to be relevant not just to those who have the financial freedom to choose a particular therapist, but also to those whose choice of therapist is limited, either because of financial or cultural circumstances, or because you’ve been compelled to enter into psychotherapy by your healthcare or legal system. Even when you can’t choose your therapist, your approach to therapy is under your command because you choose who to be when you enter the room.
Undertaking therapy as a way to change is not to be taken lightly or with the hope of an easy or quick fix. Also, while distressing events might be the motivation for seeking therapy, the experience doesn’t have to be framed in the context of something having gone wrong. By embarking on a therapeutic route, you’re making choices about who you want to be and how you want to live. It might be better to see therapy not as providing a fix for life, but as a way to thrive, blossom, breathe or roar, and express yourself in a way that has both meaning and purpose.
Your therapist is the person who will be helping you on this journey and so, where possible, should be chosen with a commensurate level of care. Before I get to specifics, it’s worth bearing in mind the purpose of your therapy, what you hope to gain from it, and how these factors might be affected by the therapist and type of psychotherapy you undertake. To think these things through, it helps to know a little about the different kinds of therapist and therapy on offer.
The specific term psychotherapist tends to indicate someone who trained in a particular model of therapy, usually of the Freudian and psychodynamic schools where there is an emphasis on uncovering the role of unconscious thoughts and emotions, and past experiences, in a person’s problems. Many psychotherapists with other orientations prefer the term counsellor, particularly those from more humanistic practice backgrounds where the emphasis is on listening and helping clients to flourish. The term counsellor is also common among practitioners where psychotherapy forms only a part of their job, such as social workers and mental health nurses.
A clinical psychologist is usually a doctoral-level therapist who, following a psychology degree, has undergone training in a wide range of evidence-based therapy interventions and might be able to offer high-intensity interventions for clients presenting with more serious distress and behavioural problems, as compared with a typical counsellor or psychotherapist.
Similarly, a counselling psychologist is trained in high-level and evidence-based interventions, but usually in more ‘relational approaches’ (that is, with a particular emphasis on the importance of the relationship between therapist and client). These qualitative differences between clinical and counselling psychologists are fairly subtle and might be further diluted or emphasised by the personality of the practitioners themselves.
Therapists grounded in a particular approach often define themselves according to their training. For example, a cognitive behavioural therapist is someone who provides one particular type of intervention grounded in cognitive behavioural therapy (CBT); a Rogerian therapist is someone who trained in the humanistic, person-centred approach established by Carl Rogers. These therapists tend to have a slightly more ‘one size fits all’ or monistic approach.
In many mental health contexts, therapeutic interventions are delivered by a mixture of mental health nurses, psychological practitioners and sometimes occupational therapists or social workers. Whichever type of professional you see, it’s notable that CBT has become increasingly prevalent over the past 30-40 years, so it’s highly likely that you might encounter this approach.
CBT is based on the idea that we can develop unhelpful biases in the ways we think about the world, ourselves and our relationships, and it works to help the client address these. There is strong research evidence that CBT, and its associated practices, are effective for addressing a range of psychological problems. However, the ubiquity of CBT today is not entirely due to its strong evidence base, but also to the fact that it’s structured in such a way that it fits well with the healthcare system’s concepts of diagnosis and intervention, followed as soon as possible by resolution and cessation of symptoms. In contrast, psychodynamic psychotherapy, Rogerian person-centred therapies and many similar approaches are unable to provide the linear surety of intervention-treatment-outcome, and are currently less favoured by mainstream care providers.
Many therapists today actually take an integrative approach – they might understand a problem in one theoretical frame, but will choose to use activities from other theoretical schools. They might even use a pluralistic frame, which espouses an openness to theoretical fluidity, prioritising the experience of the client and adopting whatever approaches are helpful given a shared understanding between client and therapist – a key part of the therapeutic alliance.
The rise in integrative therapy has been accelerated by research showing that, broadly speaking, the outcomes of all therapeutic approaches, in terms of client progress, are similar (a phenomenon dubbed the ‘Dodo bird verdict’, from the Alice in Wonderland character who declared that everyone had won a race). Although some experts contest these findings, they suggest that the particular theoretical and methodological approach of the therapist is not all that important compared with other so-called common factors, such as the therapists’ flexibility and adaptability, their consideration of their clients’ goals, the relational ‘fit’ they have with clients, and their sense of optimism for therapy being helpful.
In other words, the relationship between you and your therapist is key, and this underpins my guidance on how to choose a therapist who is right for you. A beneficial therapeutic relationship is based on the ability of both therapist and client to understand, trust and communicate with one another. With this kind of relationship, you’ll have the ability to open up, feel confident that you’ll be understood, knowing that your therapist is aligned to your needs while striving to help. Take this into careful consideration when you meet a therapist, to evaluate their potential value to you.
Check your therapist’s qualifications and professional affiliations, but also their attitude
An important factor in the effectiveness of therapy is a client’s belief that the process of therapy will actually help. Therefore, it’s important to consider if there are things that need to be in place for you to feel confident in your therapist, or other factors that might create a real or anticipated barrier to working with someone.
These factors might include gender, race and whether a therapist comes with a personal recommendation. Even if your choice of therapist is limited by your financial or social circumstances, it’s often possible to exert some influence over the gender and/or ethnic background of your therapist.
Another essential consideration, especially if you’re searching for a therapist in private practice, is whether they’re suitably qualified. Unfortunately, this is a complicated area. There are huge variations around the world in how qualifications are obtained and verified. For example, in the United States, psychotherapy and counselling are aligned to state-based licensure, with separate qualifications in a range of different therapeutic activities, such as marriage therapy and family therapy. In other countries, there are professional and regulatory standards held by the central government, or a larger regional authority, usually at a minimal postgraduate level, but there are often anomalies resulting from the undefined nature of the role of the therapist.
In the UK where I’m based, unless a practitioner uses a professional title protected by a regulatory body such as the Health and Care Professions Council (which requires people to meet certain professional and qualification standards to use specific titles such as ‘clinical psychologist’ or ‘counselling psychologist’), then they will be subject only to a voluntary professional standards structure. Unregulated titles such as ‘counsellor’, ‘psychotherapist’ or ‘psychologist’ can effectively be adopted by anyone wishing to claim them.
This situation might sound discouraging, but it’s worth bearing in mind that the ultimate mark of quality is that a therapist is interested in developing their self-awareness and relational skills – even if the qualification and accreditation system were made more transparent, it would still be hard to assess and monitor these factors that are more about professional attitude.
It’s telling that a study in 2015 found no evidence for an effect of a therapist’s years of experience or qualification level on client outcomes. Rather, the important factors were therapists’ efforts to maintain and improve their therapeutic skills, and the time they spent reviewing their client work. So what you should look for is someone who is qualified, belongs to a relevant professional body or holds the required licence, but will in addition be working hard at improving themselves, rather than someone who comes across as overconfident or overbearing. Many therapists in private practice will have a website where they lay out their approach to therapy and professional standards, so you might be able to pick up some clues here as to whether they meet your expectations.
Think about your reasons for wanting or needing therapy, and consider your goals and priorities
It makes sense to try to find someone who has specific expertise in the particular issues for which you’re seeking help (be they relationship problems, depression, addiction or something else) and/or someone who will understand your lived experience. If, for example, you identify as gender-fluid, you might wish to talk to someone who also identifies in that way; if you’re African American, you might feel that there are aspects of this experience that a therapist with a similar background will share and therefore understand on a deeper level than someone who does not.
A further consideration is your hopes and priorities and how these align with your would-be therapist. Research supports the idea that a match between a client’s preferences and their therapist and type of therapy is beneficial for therapeutic outcomes. For example, would you rather explore how you feel, or start making more immediate practical changes? If it’s the former, you might wish to speak to a psychodynamic therapist; if the latter, then it’s possible that CBT will be more to your preference.
Also, consider how you like to approach problems. If you prefer to understand an issue first, then contemplate and refine your understanding prior to making any practical changes, you might need a therapist who will give you the space and time to do this – if so, a psychodynamic therapist might be more suited to this approach. Conversely, if you prefer to dive straight into action and practical exercises, you might benefit more from working with a therapist, such as a CBT-therapist, who will help guide your behaviour or interactions early in the process.
Think about how you want to be helped and what kind of relationships suit you
More effective therapists tend to be what the clinical psychologist Arnold Lazarus called ‘authentic chameleons’ who are adept at accommodating to their client’s style of interacting, to allow a relational tapestry to emerge as the therapy progresses. They are also far more likely to give and ask for feedback about how the therapy is going, and what (if anything) might be done differently and more helpfully. The key message here is that you should expect therapy to form around you and suit your needs. If it doesn’t feel that way, you should say something. Bear in mind that, even if your therapist is insightful, they will rarely be reading your mind and should welcome you speaking up about how things are going.
A relevant consideration is that different therapeutic schools vary in their perspectives on the exact role of the therapist, and this can influence the manner and presentation of the therapist in the room, including the way you’ll work together. This is easier to understand if you consider a monistic therapist, who will work from within a single theoretical frame.
Generally speaking, psychodynamic therapists are highly attuned to their clients’ emotional responses toward them, and their own to the client (processes known as transference and countertransference, respectively). Psychodynamic therapy provides insight and interpretation, and is more likely to suit someone who likes to explore their deeper feelings and hidden depths, who is open to challenge and able to accept that lots of things about them cannot be easily seen.
Humanistic therapists strive to locate and deploy Rogerian ‘core conditions’ that involve a central valuing of the client no matter what is brought to the therapy, and an empathic engagement in the client’s ‘life-world’. This approach will suit someone who wishes to reflect and develop a better understanding of themselves and their life-world without too much distraction, interpretation and structure. Humanistic therapists also prioritise making a person feel safe and accepted.
Other therapy training, usually within the CBT school, might comprise a process of ‘how to and when’ interventions, which means using a client’s diagnosis and presentation to decide what therapeutic activities or exercises to undertake, which allows the therapist to form a strong working alliance with which to support the client in undergoing change. If you’re more interested in being given a frame of understanding for your problems and being supported in finding a way of changing what you do, then CBT would probably be a good choice
Pre-session and expectations
Once you have found a therapist and arranged a first meeting, it’s important to take some time to think through your expectations, concerns and hopes for therapy. You might find yourself feeling a little preoccupied with what it’s going to be like, and how you’re going to manage your side of the conversation.
Initial meetings in therapy can be emotionally raw – it might be the first time you’ve articulated the concerns that are troubling you, and it could also be that this is your first contact with someone who’s actually trying to understand what’s going on for you entirely from your own perspective. Conversely, first sessions can sometimes feel a little formal while you get to know your therapist, especially if you’re feeling guarded at the start.
Don’t set your expectations too firmly, go with an open mind, but do make sure you’re timing your session so that, if it’s emotional, you have space and time to adjust before getting on with the rest of your day. Remember too that your therapist isn’t going to have a solution for you, but rather will be helping you find a route through your challenges in a way that’s right for you. The more they understand you and what you want out of therapy, the better. Writing a few ideas on what you want to talk about, or where you’d like to end up after therapy, is a good place to start.
What to think about during the session
I recommend that you aim to treat your first meeting with a therapist as a combination of a job interview (with the mindset that you’re looking to employ this person) and a chance to start to unpick the problem or problems you’re experiencing. Be prepared to find the meeting daunting or to feel vulnerable during the session.
Your optimism around therapy can make a big difference to the outcomes. In turn this can be influenced a lot by the early impressions you form of your therapist. Their behaviour, the décor, their clothing, even choice of perfume, can all have an impact on your belief that they will be able to help, and so be aware and allow yourself to be influenced by these – you don’t want to spend the first weeks of therapy struggling to suppress thoughts such as ‘Why is her room so untidy?’ or ‘I’m not sure his smile is sincere.’ Different approaches will suit different clients. If your therapist sits with a glass of water in the comfortable chair, and doesn’t supply you with a drink, would you think them rude, inconsiderate or that they are empowering you to take responsibility for your own comfort and hydration?
Reflecting on your initial impressions should allow you to make a judgment about whether you wish to spend your time (and possibly money) on working with them. An explorative approach would be to talk to the therapist about your misgivings, this could be a rich ground for learning about yourself, but if this doesn’t feel constructive then you can always trust your instincts and let them know you won’t be back.
How you experience your therapist is also likely to be influenced by your preconceptions and needs. Consider the following example of a client’s response to a therapist who allowed her the space to feel her own distress and simply recognised how difficult this was for her:
I spent the first session offloading, trying in my muddled way to tell her everything I was feeling and what life was like. At the end of the session, I felt as confused as when I started, but then she just said that probably I felt quite overwhelmed, that there was so much I was carrying … Because she didn’t simplify it, she just really recognised what it was like, I felt better almost straight away – she didn’t try and fix it, she just tried to see how hard it was for me.
– June, 34, a mature student seen in a UK research clinic because she was dealing with extreme anxiety and insomnia. The interview took place three months after a 10-week series of pluralistic therapy sessions
It’s possible that a different client might have perceived a therapist responding in this way as being insufficiently able to help solve their problems. Indeed, it’s clear from speaking to clients following their experiences in therapy that there is rarely one ‘right way’ of responding. Again, this shows the importance of finding a therapist who engages in a way that you personally find fruitful, while also bearing in mind that it can take time to settle into a relationship.
So my advice is to spend time reflecting after your first session and deciding a way forward. It might be helpful to think about the following questions:
The answers to these questions can help you decide whether to continue working with this therapist or – if the option is available to you – to change to a different therapist. Before rushing into a decision, a caveat here is to consider how your response to a therapist might have as much to do with you as with them. Consider this quote, from a client at a research clinic in the UK:
The first couple of sessions were hard for me, I felt a mix of anger and frustration towards my therapist, I was telling him about the issues, and when he spoke about how I was behaving, just as I had told him, I felt myself thinking that he was trying to blame me for what was going on … It was only down the line that I realised that this was one of the ways I react to being understood, that I felt responsible, and feel that people will blame me for things that I am not in control of.
– Mark, 49, an unemployed writer who was dealing with depression and the break-up of his marriage. The interview took place three months after a 24-week series of pluralistic therapy sessions
In this case, Mark initially responded in a negative way to his therapist, but later on during the therapeutic process he reinterpreted this as part of the way he tended to respond to events with feelings of blame or responsibility. This is a reminder of how important it is to find a therapist whom you trust and feel comfortable with, while also being patient if you can, and reflecting on your part in the relationship.
You should feel able to discuss any of the issues I’ve raised in this Guide with your therapist. Above all, remember that, if you’re unhappy, it’s perfectly within your rights to request working with someone else.
The video ‘Psychotherapy’ (2015) from the School of Life covers the things you need to know when deciding to start therapy. For example, it might lead you to feel that psychodynamic psychotherapy rather than CBT is your preferred choice.
The TEDx talk ‘Why You Should Try Therapy Yesterday’ (2019) by Emily Anhalt, a clinical psychologist and co-founder and chief clinical officer of Coa, the mental fitness community in the US, is another good starting point.
The episode ‘How to Choose a Therapist: Finding the Right Fit’ (2019) – the second of two parts on finding a therapist from the Deerfield counselling podcast based in the US – discusses the seven factors that are important to consider.
The factsheet ‘What Works in Counselling and Psychotherapy Relationships’ (2020) from the British Association for Counselling and Psychotherapy is based on research from the US and the UK.
The article ‘How to Find a Therapist’ (2017) by the journalist Kristin Wong for New York magazine describes the process of getting therapy for people in the US and flags some of the considerations.
The online guide to the questionnaire called the C-NIP (for the Cooper-Norcross Inventory of Preferences) offers an accessible and informative explanation of some of the variables that can influence how helpful you find your therapist, from Mick Cooper and John Norcross, the pluralistic therapists who devised the inventory in 2015.
The movie Prince of Tides (1991) is a romantic drama that highlights the insight and change that can happen when people examine their past. The affair between a therapist (Barbra Streisand) and her client’s brother (Nick Nolte) can be viewed as strongly metaphorical: many people feel a sense of profound love for their therapist, which in turn allows them to develop self-love. Do note, however, that in real life personal relationships between therapists and their clients are strictly prohibited.
The American psychotherapist Irvin Yalom shares his stories of therapy in a number of books. My favourite is his first, Love’s Executioner (1989).
The book Counselling for Toads: A Psychological Adventure (1998) by the late Robert de Board takes familiar characters from Kenneth Grahame’s children’s book The Wind in the Willows (1908) on a therapeutic journey. It’s a great read for anyone wanting to understand the process of counselling and psychotherapy.