Finding a good psychotherapist – the pitfalls

You want to find a good psychotherapist? Of course, you want the best in the business. You are looking for a leading expert in the field of healing the emotional and personality damage caused by early emotional abuse. This is a very specialised field, and I believe there are very few therapists who are really equipped to do it. Having said that, there is a huge range of different methods, theories, schools of thought and approaches to therapy, and within each approach there are more skilled and less skilled practitioners.

There are many people hanging out their shingle, with various backgrounds, qualifications and accreditations. They all find themselves with patients or clients who turn out to have a background of trauma which has affected their emotions and personality.

So how do you choose the best person for the job? It is a complicated question.

One of Australia’s most respected psychiatrists, Prof. Graham Parker, recently retired and has just published his autobiography. He set up the Black Dog Institute, and worked there for ten years, creating a better understanding of major depression and bipolar disorder. I heard him being interviewed by Margaret Throsby on ABC-FM. He said that depressive illnesses were still poorly diagnosed and poorly treated in Australia. He said that the problem was that practitioners generally offer patients whatever they have been trained to do. If you have been trained as a counsellor, you offer counselling; if you have been trained to write prescriptions, you offer prescriptions; if you have been trained as a Kleinian analyst, you offer Kleinian analysis; if you have been trained in cognitive-behavioural therapy, you offer cognitive-behavioural therapy, and so on, across the spectrum.

The problem with this is that each person has individual needs, and needs therapy tailored to these needs. Not only that, each person will need different types of therapy at different times in the course of their treatment. One day you might walk in and just need a prescription. Another day, you might need help to develop better cognitive-behavioural skills. Another day you might need emotional support. Another day it will be the right time to explore the emotional traumas that underlie your condition. To respond to your needs, the therapist needs to have a wide range of skills in his or her toolkit. Not only that, the therapist has to know when each technique is needed. Unfortunately, few people working in the system have such a breadth and depth of skills.

But there is a further difficulty, which Prof. Parker did not raise. That is that when a person first consults a professional, no-one really knows what they need. The first port of call could be anyone – a GP, a counsellor, a social worker, an allied health professional, a clinical psychologist, some other kind of psychotherapist and so on. For example, if a patient goes to their GP with a sleeping problem, what can the GP do? Prescribe sleeping pills, refer the patient to a sleep disorders clinic, a stress management course, or decide that the sleep problem is a symptom of depression and refer the patient to someone who treats depression, such as a psychiatrist. If the patient comes along with emotional issues, referral to any of the therapists I have mentioned earlier is an option.

So let’s assume the patient goes to some kind of therapist. At this stage it is highly unlikely that either of them will have much idea of what the issues are. The patient is taking the first step of could turn out to be a very long journey, and doesn’t yet know where it will lead. The therapist doesn’t yet know the patient very well, and furthermore it’s impossible to predict what will happen next. What could happen is something like this: the patient starts talking about his or her emotional problems; the therapist puts a finger on some underlying issue. This opens up a proverbial Pandora’s box, stirs up a hornets’ nest and opens a can of worms, all rolled into one. The question then is: how does the therapist deal with what has been unleashed? What kind of support can the therapist offer the patient to help him or her cope with the pain of uncovering injury and trauma? Sometimes the consequences of stirring up old traumas is that the patient goes mad, goes to pieces, falls apart, loses their “ego” system or “decompensates”. A dangerous method indeed.

One of the debates between different schools of thought is about the issue of “support”. Some professionals think it is all about providing support. Others, for example those taking a classical psychoanalytic approach, totally repudiate the idea of support. I was once referred to a practitioner like this. I said I was looking for someone supportive. He said “I don’t do support”. Then he relented a little and said there was some support in terms of the reliability of the therapist and the regularity of sessions. However, it was pretty austere, the patient had to do all the work, and interaction was minimal. This may seem unkind. For the patient it may even re-enact an original trauma of emotionally withholding parents. However, I do understand where this therapist was coming from.

There can be no change without upheaval. This is true of individual psychodynamic change, but you will also recognise the same issue happening in the debates about large-scale social change. Do we opt for revolution, which is supposed to bring about fundamental change but will take a heavy toll? Or do we try to bring about reform – changes that improve social conditions, while at the same time trying to protect people from the harm that comes with more sweeping change? If a psychotherapist provides support, does this make it less likely that the patient will undergo fundamental change? Alternatively, if the therapist triggers fundamental change, what protection should he or she offer the patient who will have to endure all the fallout?

I believe that the better approach is for the therapist to provide a specific kind of support. Not a band-aid that makes it more tolerable to live with the effects of trauma, without bringing about change, but an expression of empathy and appropriate interaction, which gives the patient an experience comparable to “good parenting” rather than the abusive treatment they have experienced in the past. This is a very difficult balance to strike. Psychotherapists have been dealing with traumatised patients for over a century now. We know that complex emotional damage can take years to repair. Quick fixes, which the Government would like to promote and fund (for example six sessions cognitive-behavioural therapy) can give a person coping skills, but they do not bring about fundamental change. Freud used to worry that these “difficult patients” seemed to need interminable treatment. A recent report in the news said that survivors of torture never recovered – they always suffered from the effects of their trauma. I have not seen the evidence for this claim. However, the good news is this: the most recent work done on treating patients affected by the most extreme forms of severe childhood abuse indicates that even under these circumstances, healing is possible. If the therapist provides a specific type of good experience, it is literally possible to re-program the brain to react to this positive experience, and replace the patterns of reaction set up by previous traumatic experiences. See my post on The Boy Who Was Raised As A Dog.

This is very good news, and provides a strong argument against the traditional notion that a psychotherapist should be “neutral” and should not “gratify” the patient.