What is a good therapist?
A good psychotherapist is one who shows clients how to be successful in therapy.
That opening sentence was carefully phrased. It points to the fact that, in psychotherapy, it is the client who (mostly) completes the work of recovery. Research shows that around 40% of successful outcomes in therapy are due to the personal resources clients bring to therapy. These include commitment to change, adaptability, problem-solving, solution-finding, social support, and external changes in circumstances that improve the client’s position.
The other 60% is made up 30% from the therapeutic relationship between therapist and client, 15% from the placebo effect, with only 15% due to the therapist’s technical skills and knowledge.
A good psychotherapist is primarily a person skilled in building relationships that earn trust, explore the sources of distress, explain the problem, motivate clients to change, set achievable targets, utilise the client’s strengths and available solutions, and accompany them on their journey back to mental health.
The strange thing is that research also shows that the approach used by the therapist, whether it is cognitive-behaviour therapy, psychoanalysis, counselling, or solution-focused therapy, is the least important factor in client improvement. It is the therapist’s communication skills that are crucial, not the technical skills they acquired in training that make the largest difference.
This article explains each of these factors in depth. Thereby providing readers with clues on what to look for in seeking an effective psychotherapist.
Good therapists build relationships
Earning your trust
Psychological studies show that it takes most people one-tenth of second to form an initial impression when they meet someone for the first time. And around seven seconds for them to make key decisions about this new relationship. Some of those decisions may be accurate, some not so much. But once made those decisions are hard to shift.
Research also shows that one is the most common number of sessions. Indicating that some clients do not return for a second session because they do not trust they are in the right hands. However, other clients get all they want to know from a single session with some therapists.
The first impression a therapist should make on you is that they seem genuine, competent and trustworthy. Some therapists put their certificates on the walls to foster this belief (I don’t). Others take care to ensure that their office is a welcoming, professional setting. Experienced therapists will not appear over-dressed, but somewhere between formal and informal. They will combine a business-like approach to the work in hand with empathetic attention to you as a person.
All therapists are required to carry out an assessment at the start of the session. Good psychotherapists will do this while showing they are still interested in you as a person. Others will treat you as an exercise in form-filling.
I use the word ‘charm’ with reservations, as charm can be manipulative. What I have in mind are qualities like warmth, humour, kindness and consideration – all characteristics of persuasive communicators. But added to sincerity; hence coming across as genuine rather than fake.
Like everyone else, psychotherapists have to have personal boundaries. Professional ethics dictate that in any case. However, they will keep them sufficiently open so that you feel included and valued.
Empathetic questioning skills
Empathy is an over-used word which is sometimes confused with being ‘nice’. Good psychotherapists employ empathy for a professional purpose: understanding you as a person. In the short time they have available they will try to get a feel for your communicational style, the source of your distress, and your hopes, fears and desires.
To do this they ask open-ended questions and listen carefully to the answers. For example:
What brings you here today?
What changes would you like to see?
How can I best help you to achieve that?
Using empathetic questions – and knowing which ones to ask – are the hardest thing a psychotherapist has to learn. It can take anything between three thousand and ten thousand hours client hours to become really skilled at it. Good psychotherapists develop a nose for where best to go with each client, knowing that every person in front of them is a unique human being. And tailoring each question to the answer received in response to the previous question until you understand the problem thoroughly. You can’t learn how to do that on a training course. To some degree it comes with the innate gifts some therapists are born with.
Good psychotherapists can adapt to your social and cultural background, usually because they have met clients from all walks of life. It helps, also, if they had a lot of life experience before they took up the profession.
The approach they might use with a nervous college student is different from they one they might employ with a loud, assertive middle-aged business-owner. The same goes for people from minority groups; disadvantaged communities; professional people; ex-prisoners; people on income support; wealthy people; old, young and middle-aged.
In short, good psychotherapists try to meet you on your own ground, not theirs. Thus making it more likely they can earn your trust.
Good therapists use the ‘placebo effect’
The chart above refers to the placebo-effect, stating that this accounts for around 15% of successful outcomes in therapy. Let us look at this effect in more detail.
If a medical doctor informs a patient they have a drug available that can relieve pain, and hands over a bottle of pills that contain starch around 30% of those patients will experience some reduction in pain. Why? Because they believe the pills will work. That belief will trigger brain mechanisms that reduce inflammation.
In the same way, if clients believe a therapist can help them they are more likely to receive benefit from having therapy.
For clients to believe this the therapist has to earn their trust. Partly, they do this through empathy, partly from cultural adaptability. But there are other factors too.
Understanding the client’s position. Nothing inspires trust more than feeling another person truly understands you. Your background, your strengths and weaknesses, your troubles, and your unique personality. Good psychotherapists are equipped with listening skills that elicit this information from you, while also helping you to understand yourself.
Explaining and normalising problems. This is helped along by the therapist’s technical knowledge (the ’15 per cent’ area shown in orange at the top of the chart). Based on what they know about the most common mental health disorders: anxiety, depression, OCD, addictions and trauma they can help you to understand how these disorders come about – and how they can be resolved. Good psychotherapists will also normalise these problems – helping you to understand they are not unusual, and that you are not alone in having them.
Setting out a clear pathway to recovery. Having explained that you have a treatable problem, the next thing good psychotherapists do is to outline a recovery plan: the step-by-step process through which you can get well with a mentor beside you. For example, anxiety is well known to be triggered by anxious thoughts and memories arising from the mind. A good psychotherapist will explain to you how you, too can learn to defuse from anxious thoughts.
Goal-setting. The final element in the assessment process is to set targets for change. That is important for both the therapist and the client. Effective psychotherapy is evidence-based: using symptom-reduction, behavioural and cognitive change, and client satisfaction as evidence that psychotherapy works in individual cases. The client’s trust in the therapist is strengthened by knowing that the goals of therapy are clear-cut and achievable.
Good therapists draw attention to clients’ strengths
Experienced psychotherapists are aware that clients contribute at least 40% towards success in psychotherapy, and for that reason they exercise a proper humility. Be wary of practitioners who claim to have a superhuman power to change others, for such people will not be interested in forming a deeper relationship with you, but only in using you to exercise their “powers”.
Based on a collaborative relationship, good therapists will utilise as many of the clients existing skills, strengths and opportunities they can find. For example:
- Your values (i.e. the things that inspire and motivate you to change)
- Interpersonal skills (your ability to communicate with others and resolve conflict)
- Thinking skills (especially problem-solving)
- Your powers of resilience
- Existing solutions (moments when you succeeded in overcoming difficulties)
- Life-expanding activities (exercise, creative pursuits, community projects, etc).
- The relationships you have with friends, family members and colleagues who can support you in your difficulties.
Good therapists are aware that, in a large number of cases, mental health problems will clear up by themselves. For example, it has been estimated that in over 50% of cases clinical depression will clear up within 12 months. The reason for that is that many mental health disorders are linked to life problems. Poor working environments, relationship breakdown, family conflict, money troubles, and illness and death can all form the background for anxiety and depression. While trauma is invariably linked to specific disasters such as abuse, rape, assault, major accidents and terrorist activity. Resolving these life difficulties (or helping people come to terms with them) will contribute to a reduction in mental health problems.
Good therapists will join with the client in addressing the life problems that form the background to their distress. And will be on the alert for opportunities to make changes in those areas. That could be a job change, relationship counselling, conflict management, debt reduction and spontaneous changes (such as a home move) that make it more likely that the client can recover.
Summary of traits
The personal qualities you should look for on meeting a psychotherapist for the first time include:
- Warmth, humour and compassion
- Close, professional attention to you as a person
- Adapts to you, rather than making you adapt to them
- Expert listening and questioning skills
- Answers your questions simply and clearly
- Helps you to understand both the problem, and its potential solutions
- Sets out a clear plan for recovery, with some simple first steps
- Inspires hope and trust
- Is honest about what can, and what can’t be, achieved in psychotherapy.