
The Science of How to Evaluate Therapists - thelettere
http://thomastberry.com/the-ideal-therapist-and-the-troublesome-client-dr-melfi-and-tony-soprano/
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thelettere
I'm curious what others thoughts are on the choices one is confronted with
when mental illness or significant distress surfaces. Psychotherapy,
medication or informal help? If psychotherapy, which therapist? What algorithm
for making this decision do you use?

In my own experiences the rough sketch of ideal characteristics mentioned
match up with whom I have found helpful. Practically, I've found the issue a
nuanced one; I've had times where I was focused so much on finding a great
therapist that I overlooked ones who were "good enough", and others where I
settled for someone who was not helpful at all. The balance is elusive, and
that no objective criteria is helpful in evaluating a therapist made a
difficult choice more difficult still.

What I've learned is that word of mouth recommendations may be most helpful,
as the pattern of effective therapists is surprisingly consistent across
clients (although by no means perfect). Of course this method may be hampered
by the general public silence on the subject and the stigma that still exists
in some quarters - which is very much alive and kicking in my circles.

~~~
throwaway342946
Note that there is a divide between clinical psychologists, who also do
private practice, and psychotherapists. CP are more expensive, but also worth
evaluating.

Now for more anecdotal part: neither type has that much time to think about
your problem and most likely spend time between sessions thinking about their
newest patients. So I would advise against seeing the same one for more than 6
months unless you see consistent progress.

~~~
thelettere
Technically there are clinical social workers, clinical psychologists,
counseling psychologists, counselors, and psychiatrists - all of whom
typically perform some form of psychotherapy, at least here in the US. Whom
will be more expensive typically depends more on years of experience and
demand than which division they fall under.

And I don't follow your second point.

~~~
throwaway342946
In the UK there is a separate profession (and qualifications) of
psychotherapists. They don't necessarily have a qualification in psychology or
psychiatry, or work as a social worker. I thought this was true also in the
US?. (Anyone can call themselves a counselor in the UK. Not sure what
qualification clinical social workers have).

My second point was simply that pragmatically, an hour or less per week, which
is how much time you see any of these practitioners, is not all that much
time, and during an actual session they have to deliver the therapy. Most
decent practitioners will spend some of their time outside actual sessions
thinking about their patients, and human nature is that they will probably
think most about the newer ones. Unless your therapy needs no serious 'course
corrections' after the first few months, it is probably easier to find a new
therapist than to get an existing one to rethink. As I said, this is based on
my anecdotal (but unfortunately very long) experience; take it how you will.

~~~
thelettere
In the US the regulations differ, and depend on the discipline (i.e. it is not
unusual for a therapist to meet qualifications for one state, but move to
another and no longer be able to practice without further education or
testing). There is no actual "psychotherapy" discipline so named - just the
collection of ones I mention above.

However, in the vast majority of states the terms counselor or psychotherapist
or psychologist or any number of related terms are protected by law for those
who are licensed by a psychotherapeutic discipline alone. The only popular
categorization of those who perform psychotherapy-like services here that
anyone can use is "coaching" \- but that's sort of therapy for well people
looking to reach for the stars - they are barred from treating people with
serious disturbances.

On your second point, I find that an interesting idea. I do wonder though what
the correlation is between the amount of time a therapist spends thinking
about a particular client and their case and that case outcome. The research
I've seen indicates that generally a good therapist (one whose clients achieve
consistently better than average outcomes) does so regardless of the number of
clients he has, or how disturbed his clients are.

Out of curiosity, have you gravitated towards a particular type of therapy
(CBT, psychodynamic, existential, ect)? Not because the treatment type matters
a great deal, but its been shown that certain personality types tend to
congregate in different theoretical orientations.

Random thought that just popped in my head - I wonder whether one of the
reasons why CBT is getting less effective is because it has attracted many
therapists who feel pressured to do it because of its public relations
successes rather than any deep affinity with its principles.

~~~
DanBC
> I wonder whether one of the reasons why CBT is getting less effective

No it's probably about better placebo controls.

Pain meds in US:
[https://news.ycombinator.com/item?id=10351230](https://news.ycombinator.com/item?id=10351230)

Anti depressant meds:
[http://onlinelibrary.wiley.com/doi/10.1002/wps.20241/abstrac...](http://onlinelibrary.wiley.com/doi/10.1002/wps.20241/abstract)

Better response to placebo is not a new thing, and is not limited to
psychological therapies. (These are all the same source, but lots of
discussion.)

[https://news.ycombinator.com/item?id=783912](https://news.ycombinator.com/item?id=783912)

[https://news.ycombinator.com/item?id=1032149](https://news.ycombinator.com/item?id=1032149)

[https://news.ycombinator.com/item?id=3015479](https://news.ycombinator.com/item?id=3015479)

~~~
thelettere
To be a bit more explicit - the finding of that study was not that efficacy
had gone down relative to placebos, but rather that the absolute efficacy of
CBT is going down. The authors of the study actually suggest that the reason
its becoming less effective is because of the opposite of your suggestion -
it's going down because the placebo response is likely getting weaker in CBT
(1). Which goes back to my original point about the factors that influence of
efficacy of placebos - and of course, to the parent article. I think this
would have been a much more productive conversation if you had just read it
first before replying.

(1)
[https://uit.no/Content/418448/The%20effect%20of%20CBT%20is%2...](https://uit.no/Content/418448/The%20effect%20of%20CBT%20is%20falling.pdf)

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i336_
@Mods: the flag was because this needs to be marked NSFW due to the picture at
the top of the page.

[This comment can be altered or deleted]

~~~
thelettere
A picture of an artistic nude statue is NSFW?

~~~
sam_goody
Yes, and in very poor taste IMHO.

If the boss comes by with that image taking up half the screen, he's not going
to assume you are researching what makes for good therapy, hence the acronym
"NSFW".

~~~
thelettere
I don't know anyone who gets their erotic jollies from looking at statues -
but maybe I'm weird. It's the shot that frames the opening scene of Tony's
first and last meeting with Melfi, which seemed fitting. If someone is so
sensitive to representations of nudity, then they are unlikely to have seen
the Sopranos and therefore unlikely to get much from this article beyond a
perfunctory summary of the research - which can be had easily elsewhere.

~~~
i336_
I should probably have qualified my original comment.

I can recognize the artistic merit and value of such imagery where
appropriate, and while I didn't know where the image was from (TIL!), I knew
it had been included for a very good reason.

I was just snap-reacting to the "woop, that wouldn't have been great to open
on lunch break" thing, for its' own sake. Basically what sam_goody said.

