Some things to look for when selecting a therapist
The first time you meet a therapist can be overwhelming. How can you tell if they know what they're doing?
[Edit: scroll to the bottom for some additional advice from my friend Lillian McKinley!]
One downside of our society’s general “uncomfortable silence” approach to mental illness is that when you do decide to seek help, it can be difficult to know what to expect and what to look for.
I really wish somebody had told me it was okay to try out a couple of therapists before settling on one, because my first therapist was awful and I didn’t realize because I had nothing to compare him to! And I wish somebody had told me it was okay to want somebody better, because the things I was upset about were actually quite reasonable!
But I also wish somebody had given me some idea of what to look for in a therapist, because my entire understanding of therapy at the time was like “well, you show up, and talk about your feelings, I guess?” What makes a therapist like that good or bad?
So here’s my best attempt to lay out what I’ve learned about therapist searching, arranged by topic. If you have things to add I’m happy to add them in with attribution (as long as I agree with them!)
What this is not
This is not a guide to how to pay for therapy if you don’t have health insurance, or how to find a therapist who takes your health insurance, even though these are super important questions. I just don’t have any personal experience to offer on them, since I’ve found all my therapists through referrals from my school’s wellness center.
Scientific Understanding
Just like you shouldn’t be seeing a doctor who thinks vaccines might cause autism, you shouldn’t be seeing a therapist who doesn’t understand the basics of scientific mental health treatment. There are a couple things I’ve learned to look out for here.
First, your therapist should be able to clearly tell you what styles of therapy they like to use. These should have names like “cognitive behavioral therapy” or “dialectical behavioral therapy”, and when you google them a trusted source like Wikipedia should list them as genuine evidence-based forms of therapy. This is important because not all therapy styles are created equal — when you test them head-to-head, “actual” therapy really is better than just talking to somebody about your feelings.
The phrase “biblical counseling” sometimes is used to refer to any counseling in a Christian setting, including proper therapy. But if your therapist can’t be more specific than that about what kinds of techniques they’ll be using, this is a real cause for concern. Phrases like “nouthetic counseling” or “conversion therapy” are huge red flags, and I would be concerned about a therapist who practices either of these actively harming me, even if they do other kinds of therapy too.
Second, almost every mental illness is best treated with a combination of medication and therapy. Unless your therapist is a doctor themselves, they should be encouraging you to speak to a psychiatrist to determine if psychiatric medication is right for you.
Sometimes you’ll hear people in counseling settings say things like “Well, I’m not opposed to medication, but…” and try to portray themselves as “nuanced.” This is a red flag. The evidence is indisputably clear that a combination of medication and therapy works better to treat most mental illnesses than either factor on its own. The only person who should be telling you medication is not the right choice for you is a professional psychiatrist.
Confidentiality
You have the right to a therapist who won’t violate your trust. In licensed professional settings there are strict rules, and if you’re seeing an unlicensed therapist (e.g. a biblical counselor) you should ask for a clear and explicit list of situations in which they would break your confidentiality.
Therapists are required to break confidentiality in a handful of well-defined situations: e.g. if you’re an immediate danger to yourself or others, if you mention abuse of certain protected classes (including children and the elderly, I think there are a few others), or if they’re required to hand over their notes by a court of law.
This can be fairly subjective, and it’s completely okay to ask your therapist to clarify parts of this, especially if you’re meeting them for the first time. I typically ask for clarification on what would count as being “an immediate danger to myself” — partly because I want to make sure it’s safe1 to talk about my suicidal ideation, and partly to judge whether the therapist has enough experience with suicidal ideation to have a thought-out answer to that question!
Your therapist might also ask you to sign statements allowing them to speak to other people about your treatment. I’ve signed statements like this to let my therapist and my psychiatrist communicate, and to let my therapists speak to other people who work at their clinic (e.g. for advice on how deal with something I’m struggling with.)
This is good practice as long as the people they ask to talk to are professionally relevant — I’m glad my therapist and psychiatrist are able to coordinate my care effectively and I don’t have to spend any time relaying messages back and forth between them. But if your therapist wants to break confidentiality for reasons that aren’t legally required and aren’t to coordinate mental health care, this is a huge huge HUGE red flag. Your therapist has no business talking to your boss or your school or your pastor under any circumstances. I have heard horror stories about therapists getting pastors involved to “invoke church discipline” and this is 100% unacceptable behavior on the part of both the therapist and the church — I would instantly leave a therapist or church who did this, even if it wasn’t to me.
Respect
When you are at a low point in your life it can be difficult to respect yourself, let alone to demand respect from an authority figure. This makes it particularly frustrating that there seems to be an entire class of therapists who believe in talking to mentally ill people as if they were children.
Sometimes this is a matter of tone of voice and is just kind of annoying — I can tell you from experience that “well, we don’t want that, do we bud?” is an absolutely infuriating thing to hear as an adult man trying to talk about intrusive suicidal thoughts.
But I would also be wary about it because in my experience this sort of condescension correlates strongly with therapists who won’t take you seriously later on when it really matters. I once tried to explain to such a therapist that her anti-anxiety technique wasn’t working for me and I wanted some new ones to try, and she insisted that I was wrong and that it did work and that I was no longer feeling anxious (???). While I aspire to that level of self-confidence, it is not particularly helpful in a therapist.
You deserve a therapist who talks to you like an adult. Your therapist should listen to you and take you seriously, and when they disagree with you (it will happen!) they should be able to tell you directly, respectfully, and lovingly.
“Fit” With You
There is an easy notion of “fit” and a harder one. Your therapist should be somebody you’re comfortable talking honestly to, and you will have an easier time if your therapist understands your values.
I had an old therapist who did not understand my religious beliefs, and this meant our conversations would frequently get derailed because she’d give advice I wasn’t willing to follow and it would turn into a whole conversation about that instead of the problem her advice was meant to address. I’ve also had non-Christian therapists who were absolutely wonderful and were willing to work within my values. My current therapist is a Christian and I like that we have a common shorthand to draw from.
Depending who you are, it might be hard to find a therapist in your area who shares your cultural background, and that’s something you have the right to be upset about (therapy is getting more diverse, but it’s still pretty white.) But at the very least you deserve someone willing to show your values respect.
There’s a deeper level of “fit” that’s a lot trickier because it’s nuanced: you want your therapist to agree with you on lots of stuff, but not too much.
It’s easy to see how things can go wrong if your therapist’s beliefs are too different from yours. When I started seeing my current therapist, she wanted to talk a lot about my childhood and probe around for trauma, which I found very frustrating because I had quite a happy childhood and I wanted to talk about my problems.
If she were unwilling to talk about anything at all except childhood trauma, this would clearly have been an unhealthy therapy relationship. (I know people who have had therapists like this, so this isn’t purely hypothetical!)
But what I didn’t know at the time was that the fact that her starting point was so different from what I’d expect would actually prove to be really helpful for us making progress together. Something about my family I’ve never really noticed until (separate) conversations with my therapist and my sister-in-law is that we don’t talk very much about our feelings.
This has led to all sorts of therapy insights about how I’m bad at describing my feelings in person but love writing about them and different ways I’ve tried to deal with them over time. Her “something from my childhood scarred me” idea wasn’t correct, but talking about my childhood eventually led to some really helpful discussions on the ways I process emotions and whether or not they’re healthy. None of that would have happened if she’d listened to my initial insistence that “I don’t think it’s worth talking about my childhood at all.”
The therapy dynamic is at its healthiest when there’s some give-and-take between you and your therapist. You need enough differences to challenge each other so you can grow and your therapist can better understand you, but enough similarities that you aren’t just speaking past each other.
I realize this is difficult to glean from an initial session, but at the very least you should be able to tell if your therapist is a) completely on a different page from you, or b) just kind of being a yes man, both of which are red flags.
The Leland Townsends of the World
Dr. Leland Townsend is a character in Evil, which is either one of the best or one of the worst TV shows I’ve ever seen. (I still haven’t figured it out after two seasons). Leland is a villain who preys on the emotionally vulnerable, posing as a therapist and manipulating them into scapegoating other people for their pain.
Leland is an extreme (and fictional) example, but there are therapists and counselors who (intentionally or not) use their position of power to talk their clients into doing bad things. In an early session with my first therapist I confided that I was feeling really sad because a friend had rejected me, and he immediately told me that my problem was “giving up”, and that I should “just keep asking every time [I] see her because eventually she’ll see she’s wrong and give in.”
In case it somehow isn’t clear from the subset of his lecture I quoted, this is literally sexual harassment and of course I didn’t do that. But the mistake I made, and the reason I’m writing about this, was to think I could separate his terrible advice from his therapy. I was self-aware enough to identify ways he was asking me to hurt others, and to ignore that advice.
But I wasn’t self-aware enough to identify the ways our therapy sessions were hurting me, and that made my depression worse in ways I’m still sorting out a few years later. (I’m not willing to write about this in more detail, sorry.) I think the upshot is that when you’re in a severe mental health episode you tend to feel like crap, and that means that when other people treat you like crap you don’t always realize the problem is with them and not with you.
But even if your “standing up for yourself” sense is totally broken, you might still notice that your therapist (or really anyone else in your life) is mistreating other people — either directly or by asking you to do so — and this should be a huge red flag that they might be mistreating you too.
Epilogue: Feeling Comfortable
This is an epilogue because I don’t have more than a few sentences to say about it, but therapy should be somewhere you feel comfortable being completely honest. If you’re the sort of person it takes a while to completely open up that’s okay! But if you’ve been seeing a therapist for a few months and you still haven’t told them you stay up at night thinking of ways to kill yourself, it’s probably time to find a new therapist.
I had a whole lot of anxiety the first time I quit a therapist because I (incorrectly) felt an obligation to stay with him because of “what he’d done for me”. (In hindsight, a lot of damage!) You are literally paying your therapist, and you should only stay with them as long as they’re helping you.
Unlike breakups, there’s no obligation to see your therapist in person or think through how they’ll take it or anything like that, especially if you’ve started to feel uncomfortable with them. You can just send a text or an email saying you won’t be coming to therapy anymore. They’re used to this and it’s completely okay.
Best of luck finding a therapist who works for you!!
Update: Some additional thoughts from my friend Lillian McKinley
Quoted with her permission:
- “There are licensed therapists and unlicensed people who usually can't call themselves therapists. A licensed therapist will not have a problem giving you information about their qualifications and licensure.
- Conversion therapy isn't just a red flag; in many states, it's also illegal. If you're somewhere it's illegal (which includes the whole state of Illinois) and a licensed therapist says they practice it, you should definitely report them. Unfortunately, there's not much that can be done about unlicensed therapists who offer it, but you can also report unlicensed people who are pretending to be real therapists.
- Psychology Today has a lot of filters to find demographic fits, including queer identity, race, religion, and language. There are also directories for some specific groups, like the Poly-Friendly Directory or Kink-Aware Professionals. I know that directories exist for Black therapists and AAPI therapists, but not what they're called offhand.
- Most directories or websites will mention insurance info. Psychology Today has a filter for it. Insurance companies have their own directories. Absolutely none of those are fully reliable and the best thing to do is check a therapist's own website or ask them.”
I have friends who have had really bad experiences with this. Shame on those therapists. Shame shame shame shame shame.
This article is important and should be published in a mainstream journal, Colin. Thank you for putting pen to paper about it.
This is so important! Thank you Colin!!!