Let’s bring out into the open something that might be a bit uncomfortable and awkward, but that we all know is going on: beginning the instant that you contact a therapist, that person is assessing you. It’s this fact, that I think often stops people from going to therapy to begin with. There are fine lines between assessment, assumption, and judgement and you don’t know this person yet! It’s normal to feel a bit vulnerable and the idea of being assessed carries a negative connotation that can be uncomfortable. But remember, we are all to some degree assessing one another all the time. As humans, this keeps us safe and able to relate to one another. A therapist’s assessment actually might be safest of all: from a therapeutic perspective, assessment should be objective, non-judgmental and function to lead the therapist to determine which interventions will be most likely to help.

Sometimes people welcome a therapist’s assessment and want to know right away, am I going to be ok, can you help me? But from your perspective, at any time you may be thinking, what does this therapist really think of me? Like any relationship, therapy does require taking a leap of faith. You may feel safer however, knowing that most therapists come from a strengths-based approach. This means that they are most interested in assessing your strengths, to help you build on these strengths and employ them towards solving any problems or working through any issues that are bringing you to therapy.

Trusting this process helps, but at the same time it is essential to reflect on your experience and make your own assessment of how it works- or doesn’t work- for you. Sharing your own honest assessment of this with your therapist, especially when it’s difficult to do so! actually presents a huge opportunity for growth – what you are there for.

Not who you are, but where you are at

Is growth what you are there for? What are your goals? It’s ok if you don’t know yet. A skilled therapist will be less interested in who you are and more interested in where you are at, from one moment to the next. To a large extent, where you are at will determine the make-up of the client-therapist relationship. It’s the therapist’s assessment of this ever-changing relationship that should weigh heavily in determining which interventions they employ. Largely the client-therapist relationship determines how quickly and effectively one works towards meaningful change.

How can we create a highly productive and helpful client-therapist relationship? What type of relationship do you have with your therapist or what type of relationship would you like to build with a therapist? A competent therapist can usually facilitate this, but learning about and reflecting on client-therapist relationships can provide you with insight that may help you set and progress towards your goals more quickly. I’ll give you the inside scoop.

More than guess work 

Solution-focused brief therapy (SFBT) is an evidence-based therapeutic intervention that is widely considered to be an essential component of a therapist’s toolbox of basic skills. It was developed by Insoo Kim Berg, possibly the most influential psychotherapist of our time and her husband Steve De Shazer. The therapist’s intent in SFBT is to help a client to identify and work towards their own goals, that when reached will improve their life. The therapist hopes to assist the client to uncover, enhance, and employ their already present strengths to reach these goals. The quality of the client-therapist relationship is a key component in establishing and determining progress in these regards and one that both client and therapist can actively influence.

In order to build an understanding that can help one influence this relationship in a helpful way, let’s examine these relationships further. The client-therapist relationship, like any relationship, is dynamic, unique, and constantly changing. While categorizing relationships can be tricky, sometimes not possible, and should be done with great care, it can be useful to understand 3 common categories of client-therapist relationships posited by SFBT: visitor, complainant, or consumer.

1. Visitor: In this type of client-therapist relationship, the client is able to identify a problem or problems, but they do not yet see a possibility of change. Here, no progress is made toward setting goals. Commonly, but not always one may be coming to therapy only because someone else wants them to. They may have been given an ultimatum or they may be trying to please someone else. Perhaps they are coming of their own volition, but are feeling hopeless and/or helpless. There may be any number of factors contributing to this type of relationship, but what we know for sure is that this person is struggling and usually suffering. Without the right intervention(s), they run the risk of using therapy to perfect some neurosis instead of getting help. Essential point: they are stuck.

2. Complainant: In this type of relationship, the client is coming from a perspective where they see something(s) as painful or troubling and can describe it (or them) very well. They are in the beginning stages of seeing that they themselves need to take concrete steps towards change, but they are not yet committed to doing so. This person is in a place where they need encouragement to keep thinking it through to find their way to their next step.

3. Consumer: In this type of client-therapist relationship, the client is ready and able to set goals. They see that a solution to their problem(s), regardless of the source(s), requires them to take action and they are ready to do so. This type of client-therapist relationship facilitates change. Building and maintaining a consumer relationship is thus central to therapy working well. After all, nothing changes if nothing changes!

What next?

What can you do to help build a relationship with your therapist that is that of a consumer? Perhaps start by asking them! If you are not already building this type of relationship, no need to worry. In fact, in my experience as a therapist most client-therapist relationships do not start out as that of consumer. Furthermore, we all enter relationships of complainant and visitor now and then.

A skilled therapist understands that there are reasons that client-therapist relationships develop as they do. A professor of mine in graduate school said something that enlightened me and helped me move past judgment: there are always reasons for reasons. If you are struggling with self-judgement, it should be helpful to discuss this with your therapist. A good therapist will help you address your reasons and to understand any patterns of thinking and feeling that are getting in your way.

An illustration:

For example, if you feel the urge to spend your session venting about your spouse, but this feels like spinning your wheels- talk about it! Your therapist can help you understand your thoughts and feelings and work through them in order to become empowered towards the change that is right for you. Visitor or complainant client-therapist relationships may be an essential step in your process. You can’t fast forward to setting and taking steps towards your goals. You may not yet know what goals are right for you!

Ultimately, your therapist may end up helping you to learn and implement good communication skills to broach a difficult topic with your spouse. It may mean that they help you to develop skills to cope with a reality about the relationship that is currently too painful for you to face. Perhaps it will look like helping you to develop a deeper understanding of your own reactions or triggers in response to your spouse, and to work on resolving something painful and difficult that you bring to the table in the relationship. It may look like all of the above, all of which stem from consumer relationships, or like something else altogether! There is no right or wrong, there is only knowing and trusting yourself or not being there yet. The best therapeutic relationships help you to learn to know and trust yourself.

Describing the problem in detail (complainant relationship) can help you and your therapist gain clarity about the situation and then lead you to figure out what next steps are right for you (consumer relationship).

Try to let go of any idea that we should already know ourselves and that growth in this area means we are not good enough, not smart enough, not emotionally intelligent enough. Who we are and what we are capable of is not fixed and finite, but infinite and unknowable! What we do know is that the opposite of growth is stagnancy.

If it’s hard to let go of self-judgement or shame or if you feel stagnant or stuck (visitor relationship) talk with your therapist about this. Talking about being in a visitor or complainant client-therapist relationship is in itself building a consumer relationship.

But every therapist may not have considered naming their firstborn child Insoo!

While widely considered basic therapeutic skills and interventions, your therapist may not be trained in SFBT, and/or they may not be thinking of therapeutic relationships in these terms. Every therapist has their own unique style and practice. It is hard to say whether any one way is right or wrong, but what is important is your own reflection on what’s right for you.

While it’s normal and natural to wonder what your therapist thinks of you, trained in SFBT or not they are probably more concerned with assessing the type of therapeutic relationship that is forming, than with an assessment of you. After all, the type of relationship that you are building with your therapist forms the safe base from which your own process of growth stems. Your insight and reflection on what this base looks like, can help you figure out what to do next.

No right or wrong answers

Do some people come to therapy with a bunch of things going on around them that should change? Most definitely! Can a therapist do anything about those things? In most cases, no. Even in the most complex, problem-saturated situations, the person- regardless of where they are when they start the process of therapy, has an infinite and unknowable potential to impact meaningful change in their life. Insoo Kim Berg believed that people can create their own miracles– and she proved it! through research.

A skilled therapist thinks that you are courageous. They believe, even when you don’t, that you have the strengths within you to set and reach goals that will improve your life, regardless of circumstances! and lead to your fulfillment. They believe you are inherently valuable and genuinely want to know you in order to help you to know and trust yourself. If the relationship doesn’t feel right, and this isn’t resolved through an honest discussion with your therapist, it may make sense to look for someone new.

It’s easy to say that things would be so much better if our therapist had a magic wand. But would they really? The therapeutic relationship works best when the outcome is that you develop your own magic wand – wouldn’t you rather have that instead?

Bottom Line:

It’s normal to wonder what your therapist thinks of you. Many people are leery and/or want to know right away, am I going to be ok? but what’s more important is the type of relationship that you form with your therapist. It’s the quality of this relationship that will determine the outcome of your work together. A good therapist will meet you where you are at and work with you to facilitate the formation of a productive relationship.

It may be helpful though, for you to reflect on the 3 most common types of therapeutic relationships: visitor, complainant, or consumer; in order that you actively influence the building of the most productive client-therapist relationship- that of consumer.

Helpful mantras:

-I will be open with my therapist.

-My goal is to be comfortable being uncomfortable in order to grow.

-Nothing changes if nothing changes.

 

Alisa Reed, LCSW-R

First and foremost: congratulations! In therapist-speak, you have moved from the pre-contemplative stage of change to the contemplative stage of change and are making progress towards your goals already! Seriously though… good for you. It takes courage to look for and ask for help and this is an excellent first step. Secondly, take heart: the process of finding a therapist can be arduous and tricky at best, not to mention any lingering reservations you may have about the whole thing.

I hope to provide you with some information that can make it easier and help you get to the next step- whatever that may be for you! It can be as easy as picking up the phone, but sometimes the long can be the short. Putting in a little time to research and prepare could save you time, money, and opportunity. It’s complicated and there is misinformation out there. I’ll give you the inside scoop!

Where to start and a word about word of mouth:

Surprise! The yellow pages are not the place to look anymore! With the exception of word of mouth, the internet is your best friend here. Word of mouth can be extremely valuable, but needs to be taken with a grain of salt.

It can be tricky to try to assess how helpful and in line with what you are looking for, a word of mouth recommendation is. Consider a person lingering in therapy for many years who loves their therapist, but for who those close to the person continue to worry about their loved one’s high level of depressive symptoms. That would probably be a word of mouth recommendation that you don’t want to take!

Recommendations from primary care doctors and other therapists can be safer, however I myself actually once inadvertently recommended a terrible therapist to my best friend! You need to feel things out. And reach out, online and/or directly.

When you do find a good therapist, they may have a long wait list. Contact them anyway and ask who they recommend.

The internet however, can be overwhelming. Rather than wade through random websites, the easiest way to narrow your search is to use a website called psychologytoday.com. While not every therapist uses psychologytoday.com, it is widely used because of the low cost and ease of connecting with potential clients.

Front and center, in the middle of the homepage is a search field to enter your zip code. Entering your zip generates a list of nearby therapists. You can use the qualifiers on the left to further narrow your search, but use this feature with care. For example, if it is a priority to use your insurance, definitely select your company, however if you start selecting from the list of “issues” presented, you may weed out some therapists that would be a good fit.

For example, a therapist may not have selected “depression” as one of the top 3 issues that they work with, because they assume that all therapists are well versed in treating depressive symptoms and they have chosen to highlight other areas that they may have advanced training in and that are more specialized. They are likely more than qualified and open to referrals for people with depressive symptoms and should not be counted out.

Experiment with it, though and start reading some pages. The best part of this website is that you can read a bit about each therapist before emailing or calling them, including what they want you to know about their practice up front.

What about insurance?

Should you want to use insurance to pay for your therapy, calling your insurance company to ask for a list of providers that participate with your insurance is also a possible starting point.

Regardless, you will need to call your insurance company to verify that the provider you find participates with them and to determine your benefit information. Click here for a printable list of questions to ask your insurance company before your first appointment.

You can also google any relevant phrases like “treatment for depression” and your area code. Many therapists register on google with a list of relevant search terms that link to their contact information and website if they have one.

Keep in mind, though: having a fancy website can give you information, but does not necessarily correlate with the therapists’ level of skill. I for one have never had a website for my practice because I’ve never seen a need for one.

Understanding your options:

There is a myriad of different types of professionals who provide talk-therapy, also referred to as psychotherapy. Licensing differs from state to state, which means that some professionals are more common in some places than others and in some places, some professions have little to no representation.

I’ll put it out there up front: I’m going to give a very anecdotal, biased, non-scientific, but very finger on the pulse level of information regarding who is doing therapy and how to understand your options. I will also preface my thoughts by stating that while research has shown no correlation between outcomes in therapy and profession of therapist, it’s good to be informed of your choices.

The bad news first; one type of therapist to be careful about:

More education and authority is not always better. A Psychiatrist is a medical doctor who has specialized in psychiatry. They are qualified to provide therapy and to prescribe medication, which sets them apart from other professions.

In watching any amount of television one could surmise that medication easily and best treats any mental health concern. At the same time, in most areas there is a shortage of Psychiatrists, especially Child and Adolescent Psychiatrists, and not surprisingly a high need for prescribers. **Warning bells going off!**

However, a competent and ethical Psychiatrist will tell you that therapy is the first line of treatment for almost all issues that bring people to seek help. Ask about CBT. THEY should explain that Cognitive Behavioral Therapy is the gold standard for the vast majority of people seeking treatment. 

I am not just someone with an axe to grind with some wacky Psychiatrist(s), although there may be some of those in the back of my closet somewhere… axes, not Psychiatrists!!!! But I digress. The Adolescent Psychiatrist who gave the most recent psychopharmacology training that I attended (2016) stated that with the exception of ADHD (which I take issue with, but that’s beyond the scope of this post), he will not prescribe to people who have not first tried talk-therapy for a minimum of 3 months.

He was extremely cautionary about people even referring clients to Psychiatrists at all, and remember this is coming from an actual Psychiatrist! He recommended Psychiatric Nurse Practitioners when medication is needed (a widely held position of those working in this field).

Shhh, what’s that noise? Did I just hear a Psychiatrist sharpening an axe somewhere? Don’t’ get me wrong, there are some great Psychiatrists out there. Unfortunately however, the field of psychiatry has shifted almost 100% away from providing therapy and towards prescribing medication. Of course, there are circumstances when medication is necessary and important. Research consistently shows though, that the right type of talk therapy produces better outcomes for the vast majority of people.

Furthermore, in my own experience, over the years there have been very few people that I have needed to refer for a psychiatric evaluation at all. I could count on one hand the number that I have needed to refer immediately.

Moving on…

Since 2004 I have worked for 3 large, non-profit, mental health/behavioral health organizations in 2 states: Maine and New York. I have also spent the last 8 years building a private practice in New York. In private practice, I’ve come across all types of therapists, but primarily Clinical Social Workers, Psychologists, and Marriage and Family Therapists.

In Maine, though I worked in the field there for over 5 years, I never heard of any Marriage and Family Therapists! Doesn’t mean they don’t exist there, but I never came across one.

What I did hear of in Maine, albeit rarely, were LCPC’s (Licensed Clinical Professional Counselors). I have never come across this term in New York, but I believe Marriage and Family Therapists and Mental Health Counselors may be types of LCPC’s? Not sure.

No wonder there is so much misinformation out there, online and in general regarding who provides what type of therapy and to whom. Even WebMD gets it wrong in their description of therapists who are social workers.

In my experience working with people from all different backgrounds, in all different levels of care, social workers are more widely providing therapy than any other type of clinician. Why is this? It’s impossible to nail that down, but what we do know:

The differences between the types of professionals providing therapy are vast and complicated, but the main difference between social workers and the others is that the field of social work is based on a set of values. These values are service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence. While of course not every social worker lives up to these values, it is notable that they are at the core of our profession. They are also the values that one should look for in a therapist, regardless of the credentials after their name or their level of education or experience. These are values that lend themselves to good outcomes. It’s no surprise- insurance companies want to pay us (though, not nearly enough!) and clients want to see us.

 

Bottom line:

When looking for a therapist, ask yourself if the person seems non-judgmental, caring, sensitive, and if they will meet you where you are at. If they are a social worker, bonus! 😊 Ask if they are experienced and trained to do CBT and if it is an integral part of most of their work (it should be!).

Use the internet and those around you, feel things out armed with information, and call your insurance company (if using). Click here for an easily printable list of questions to ask your insurance company before scheduling at appointment.

Hint: If your nerves or procrastination are getting the better of you, a helpful mantra might be “just do it”. You’ll be glad you did.

 

Alisa Reed, LCSW-R

 

 

-The opinions presented in this post are just that: solely opinions of this writer, and not professional recommendations. Statements are to be taken at your own discretion and resulting choices, at your own risk. Please seek the assistance of a licensed therapist of any kind if you would like help understanding any of the ideas presented here.