Tuesday, April 05, 2011

What Makes A Good Therapist?

This is for Dr. D.

We were having lunch when Dr. D mentioned she wanted to write a book aimed at teaching residents how to do psychotherapy. It would start with a section on What Makes a Good Therapist? What does she thinks makes a good therapist? Real life experiences which impart an ability to empathize. Do we grow from our own difficulties? More specifically, do we grow in to better therapists? I asked another shrink this, and he said that people like to believe there is some meaning to their suffering, and perhaps it's nice to believe that if you've been stuck suffering, then it makes you a better therapist, but he wasn't so convinced it was true. Me? I don't know, maybe. Or maybe not. Personally, I'm fine with the idea of not suffering, at all, ever again, so long as I live.

In residency, I was taught that warmth and empathy are important to being a good therapist. Empathy would speak to Dr. D's theory. These are hard things to teach--- I don't know how you make someone feel what they don't feel and empathy is there or it isn't. I do think people can learn responses that get perceived as empathic, and that this is important. When a patient talks about sadness around an issue and the shrink does not feel empathy, it's still important to have a modulated response that acknowledges the patient's feelings-- this sounds terribly difficult....tell me more about how you are feeling...or kind, gentle, silence, but not, "Yeah, yeah, well I'm glad your old hag of a cousin died, she was never nice to you anyway."

So what do I think makes a good therapist? The ability to listen and hear what the patient is saying, even if the shrink doesn't agree. A non-judgmental stance, and this can be harder than it appears. It seems obvious, but it can be hard when a patient talks about hard-to-hear things, such as a pro-racism viewpoint, or disliking people of the doctor's religion or political party, or feeling happy that another person is person is suffering.

Non-dismissive is even better. No one wants to hear that their feelings are stupid or unjustified.

Kind. That's important.
Probing in a way that brings up new information and insights.

Mostly, I think therapy is about pointing out to people their patterns of behaving and responding in a way that is not so painful that the patient becomes defensive, and lets the patient choose to make changes in these patterns. Some patterns are harder to break than others, and the really entrenched one are often components of one's personality.

I'm not doing so well here. I Googled What Makes A Good Therapist, so you can check out these links:

From here, I'll leave it to you. What makes a good therapist?


Lost in Wonderland said...

A great book on this topic:

The Making of a Therapist: A Practical Guide for the Inner Journey by Louis Cozolino

moviedoc said...

Dinah, your efforts to describe the "good therapist" sound more like the description of a good friend. Before you talk about what makes a good "therapist" you must talk about goals and measurements, ie, at the end, how do you determine whether the psychotherapist was "good." Psychiatry is about treating mental illness. If you're really good at empathy and keeping patients in treatment, it's great for the professional, but an ill patient deserves remission or cure of the illness. Can a psychotherapist be "good" without being effective? The operation was a success but the patient died?

Erin said...

IMHO, the ability to find common ground for making a connection with the patient. My doc and I were relatively close in age which made connecting easier, but I finally felt like I wasn't talking to a complete stranger when we found out that we shared a favorite book. It's a simple, little thing like that which can help put a patient at ease, especially if they're wary of being in therapy in the first place.

Anonymous said...

"I don't know how you make someone feel what they don't feel and empathy is there or it isn't. I do think people can learn responses that get perceived as empathic, and that this is important."
Moviedoc's comment aside since is in line with his usual........there is a bit of a problem with what you wrote. Makes me think of the sociopath who can learn the responses that are perceived as empathetic and yet feel no empathy.No one has shown beyond a shadow of a doubt that you can teach empathy but if you are not an empathetic person, do not go into psychotherapy. patients can pick those things up and they will not be happy with the pat canned responses. More and more, medical schools stress the soft skills so yes patients deserve competent docs but empathy goes a long way no matter what field you are in unless you prefer dealing with robots. I don not mind that an ATM machine does not have people skills but even my bank teller notices when I am sick and asks me how things are going and I do the same.
You do not have to suffer to develop empathy. If everyone who suffered in life developed empathy, how to explain all the bitter people in the world?

moviedoc said...

My "usual" may be to get out of line, but Anon raises interesting question about empathy that is relevant: We talk about it like black and white. You can or you can't. But how can you tell? Is pretend empathy a mark of sociopathy? Can one learn to empathize? As Anon implies should not all docs be able to empathize? Should we administer an empathy test before admission to med school? Other professions, too?

Anonymous said...

Empathy csn be learned, just as listening can be learned. The two are quite similar, because both require focus on another person rather than one's self.

Empathy can also be faked, even by those who are not sociopaths. I'd suggest it does not matter so long as the other person doesn't know it's fake. Empathy is not about the person expressing it, it's about the person receiving it.

MovieDoc is right that a good therapist needs to be effective, though what is effective may vary from patient to patient.

And I would say that a good therapist also needs to be mindful of the patient's autonomy. Inpatient, outpatient, or whatever, the mentally ill are still people. Many doctors have a tendency to be paternalistic, and that can be offensive to patients.

moviedoc said...

Respect. If you don't respect the patient at least treat them with respect. If there's respect, Anon, there's no room for paternalism.

Katie said...

Respect, absolutely. Compassion, but not in a demeaning way. Intelligence. Comprehensive knowledge about medication, if psychiatrist. Ability to individualize treatment. Efficacy. Knowledge of when to reach out for a second opinion, or a referral out.

clairesmum said...

the ability to be present to whatever the client brings and stay present with it in the session - to manage own's own issues well enough to keep that stuff OUT of the client's presence. this skill obviously has to grow over time, one of the reasons i've done better with therapists with some experience. the therapy room and process is a container to dump out all the life stuff and psychic stuff and pick through it to make sense of it and decide what to keep and discard - so the 'good therapist' is always developing skills.

Anonymous said...

Of course emapthy can be faked by people who are not sociopaths. The sociopath fakes it to ensare his/her victims. So is it fake empathy or a tool in the kit of a dangerous person? Empathy means being able to look at something from another's perspective. It doesn't mean you must agree with that person, but it does mean you have to have some sense of what they are going through.There are all times we fake or exaggerate the extent we give a hoot about the lives of other people. I can understand a doctor having a bad day, but on the whole if they are always having to fake emapathy then they do not understand what the patient is going through even if they have no bad intentions towards them. Again, I prefer to deal with people who want to be able to understand and who try hard to do so and who often manage it.
Teaching empathy can be tough. There are a lot of people who have great difficulty getting beyond themselves, ever.

Dinah said...

LostInWonderland: thanks for the reference

Moviedoc: There was a time I'd have agreed with you that it's about outcomes (and I still basically do), but Shrink Rap readers and my patients who have often had prior shrinks seem to say that the interpersonal aspect is very important. There are people who are looking for cures, and there are people looking for connection, and obviously most are looking for both. Oddly enough, I think there are many patients out there who aren't expecting to be 'cured.'

Anon1: I struggled a bit (and probably not quite enough) with how to word this so it didn't sound cold or manipulative. It would be nice if every therapist could be empathic with the issues of every patient, but it just doesn't happen that way. Even the most empathic of people don't empathize with every patient issue. Would you blame a psychiatrist who couldn't fully empathize with Jared Loughner? Or a psychiatrist who's spouse had advanced cancer who faked it a little to behave kindly towards a patient who was upset about a breakup with a boyfriend?

So I just looked up the word "empathy" and perhaps this is part of my problem. Here's what I found:

Definition of EMPATHY
: the imaginative projection of a subjective state into an object so that the object appears to be infused with it
: the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner; also : the capacity for this

I'm not sure it's something that is teachable, though certainly one can be taught how to better convey all these things---

Anonymous said...

good, good stuff. I've had really great therapists, psychologists etc. and some really bad ones. The bad therapists always made me feel like I just needed to "tough it out" and to quit being so whiny... That just made me feel worse about myself. The best psychiatrist I had LISTENED with out being dismissive.... that line that you said about not being dismissive, is KEY!! I felt validated and heard, it was so refreshing and gave me some comfort. Just having those encouragements is what has helped me stick with my treatment plan and work towards managing my life and issues.

Anonymous said...

No the doctor with the sick spouse can get a break but a surgeon with a sick spouse who leaves the scalpel in my belly is going to get sued. Theapists, being human, have their own crap in life. If they are being paid to tune in to other people in order to help them, they need to know when to take time off. It is funny but I bet a therapist who has just broken up with a boyfriend would have a tough time feeling for the patient with the sick spouse. You make it sound like patients bring trivialities but therapists only get ruffled over the big stuff.

moviedoc said...

"there are many patients out there who aren't expecting to be 'cured.' "

I'm well aware of that. Many patients want a comfy place where they can get unconditional acceptance or whatever and pretend that they're working to change. That's why we need to decide whether a good or effective psychotherapist is skilled at keeping the patient in treatment forever, or starts encouraging the patient to fire them from the getgo. (Guess what my vote is.)

Anonymous said...

A good therapist = honest (which may not always be pleasant), sense of humor, integrity, emotionally stable, treats the people she sees as adults, not hung up on labels but sees the patient as an individual who can be well.


Sunny CA said...

I want a psychiatrist (therapist) I can respect who respects me in return. In that respect for the therapist I include intelligence and good reasoning, plus a life lived without any obvious-to-me inability to manage his/her own life. (For example, I left a therapist who was on her 6th marriage who I was seeing regarding marital issues in my first and only marriage whose regular response was...(of course)..just leave.)

In keeping with the above, I think that shared values and belief system is essential for me. I am an atheist and would not wish to go to someone heavily invested in God and Fate. I met a therapist once who was a believer in astrology, palm reading, aura reading etc, and I would not go to someone like that either. I also want my therapist to be and believe in honesty and treating others with respect.

Also I think that being polite, punctual and kind are all attributes I wish in my therapist.

Having a therapist who just "clicks with you" may not be essential, but certainly is terrific.

I think empathy can be part of the "cure". I would not want a therapist without empathy and contrary to some who have written I feel that my psychiatrist's ability to express his feelings about my life to me have been part of the process of curing. My psychiatrist really does feel and is not faking it, I am certain. Considering I have a history of "not" feeling, it has been shocking at times to tell him things and see much more feeling expressed by him than is "in" me. It feels like running into a wall. This has been amazingly transformative and has given me the push to try to find my own feelings.

I also feel that being non-judgmental is essential. My psychiatrist made me feel that what I found painful to disclose (of a sexual nature) was really nothing much of anything and perfectly normal. That acceptance made it easier to accept myself and things I have done.

Why has no one mentioned a sense of humor? My psychiatrist has a terrific sense of humor. For you shrinks out there who keep your sense of humor out of the office, I think it is better to be able to joke at times. I have surmised, also, that my psychiatrist will crack a few jokes and watch my reaction to assess how bad I really feel when I have told him I feel really bad. He has told me I am extremely difficult to "read", and now that he has pointed it out to me, I can feel how disconnected my face is from my feelings, particularly when I feel my worst. I can feel face-feeling disconnected, but have not been able to "reconnect" the face, though I am able to report how I feel, so the humor helps him do his job. I can't laugh some times. I can "think" it sounds funny in my brain, but can't process it through my emotions as funny (when extremely low), so his humor is another tool he has, not discounting his genuine sense of humor.

My psychiatrist also has a terrific memory. There are times he will bring something up from a long-past session to compare to what I am saying. He also pays attention, remains completely focused.

He also remembers correctly what I have said, and does not distort things I have said to fit a 5 minute diagnosis. On the topic of diagnosis, he prefers not to "give" a diagnosis, and I like that. He feels that people are on a continuum and ought not be pigeon-holed.

I also like that he is unconventional and does not follow a strict doctrine, but rather has developed his own methods based on reason, experience, observation, and common sense.

I have to insert a few additional "bad" therapist characteristics (not true of my psychiatrist, but true of others) and say a good therapist does NOT fall asleep in a session, does NOT look down at the floor when "greeting" me and does not look down at his notes while we talk. Also a good therapist does not "put down" the patients, nor does he/she try to prove to the patient that he/she is superior to the patient. All the above have stories.

Anonymous said...

"there are many patients out there who aren't expecting to be 'cured. "

When the doctors tell you that you have an illness that can be treated, not cured and that you must take drugs the rest of your life. In some cases, people don't expect to be cured because they will not be cured, they will be managed. Is the doctor upset with the diabetic who does not expect to be cured?

Anonymous said...

I fully believe that everyone who wants to act as a therapist must have gone through therapy themselves.

moviedoc said...

Anon 1: Cure may be a poor choice of words. A good psychotherapist will work to get the patient done with treatment, but recognize that for patients with illnesses like schizophrenia psychotherapy has a supportive rather than curative role.

Anon 2: How can the psychotherapy trainee "go through therapy" unless they suffer from a mental disorder that is amenable to that form of treatment.

Anonymous said...

Sunny CA - I found your comment about a shared belief system interesting. I too am an athiest and thought I would not want a shrink who was clearly religious. And yet I ended up with a shrink who is quite religious. And it isn't a problem at all - it's about what others have mentioned - respect. I respect that he is religious, he respects that I'm not, and that's that.

Randall Sexton said...

Best therapist I ever had shook me and called me an asshole...imagine that, lol!

I reading "On Becoming a Better Therapist" by Barry L. Duncan. Just started it but he's making a big point about obtaining client feedback about progress in therapy and quality of the alliance.

Anonymous said...

Worst therapist I ever had came from similar background and religion and assumed they knew me when that was not the case. Best experience was with someone from another world, so to speak, who knew the value of respect and basic human decency.

Moviedoc: there are patients in the world who are not schizophrenic ,and yet not malingering dependant types, who still benefit from supportive therapy.You don't have to treat them and probably best that you don't.

Anonymous said...

For me, shared values/belief system is important in a therapist and/or psychiatrist, particularly because of what I experienced with a psychiatrist. I live in the bible belt and I had a psychiatrist once who said that he believed most people who attend charismatic churches and speak in tongues are psychotic. Now, that religion is not my belief system but I find it a little scary that because someone has different religious practices that he decides they're psychotic.

I guess he felt comfortable to say that because he knew that wasn't my religious belief, but it made me concerned about patients who may end up in his office who attend a charismatic church. I guess he loads them all up on antipsychotics.

Alison Cummins said...


Out of curiosity, which mental illnesses are "cured" by psychotherapy and which mental illnesses require supportive therapy?

How do you establish goals for therapy?

I loved my psychiatrist. After the first few appointments we had a twelve-year history of 20-minute med checks at two- to six- month intervals. I'm still taking the meds, so obviously she didn't "cure" me. I guess she wasn't as helpful as I thought. (She retired, so my GP is doing my med checks for now.)

I found a psychotherapist I really like. When I'm not doing so well I see her and she models being nice to me. It helps remind me how to be nice to me, gives me something to compare how I feel in other relationships to, and gives me the boost in self-assurance I need to take action in my own self-interest. I've been seeing her a couple of times per year for maybe eight years. So I guess she's a terrible psychotherapist too, because she hasn't cured me either.

Interestingly, the tough-love psychiatrists who told me that I wasn't depressed, just immature and malingering and to stop imagining that I needed meds - they didn't help. The one who was nice and acted as if she cared and prescribed me an antidepressant and later a mood stabilizer - she got me back to work. That helped.

The psychotherapists who wanted to "cure" my deep-seated unhappiness or personality disorder - they didn't help either and one of them did a lot of harm. The one who agreed to be nice to me when I need someone to be nice to me - she's been a rock in some tough times. She helps, as measured by my ability to manage a marriage to someone more mentally ill than I am with my self-esteem intact.

Alison Cummins said...


The experience of a psych patient is often to receive inappropriate therapy and then to be blamed for not responding well to it. Very crazy-making.

I think it would be great for psychotherapy trainees to be randomized to a cycle of appropriate therapy, inappropriate therapy and no therapy so they could experience how terrible it is to get inappropriate therapy. (For best results, make their grades conditional on responding appropriately as defined by the therapist to the inappropriate therapy.) If someone is in perfect mental health and could not learn from anything at all, never makes cognitive errors etc, then they can get two assignments of inappropriate therapy because they probably need it.

Everyone recognizes that prescribing inappropriate medications is a problem. The same awareness RE inappropriate psychotherapy seems to be missing, because people, including psychotherapists, often seem to believe that psychotherapy can only have upsides. Rubbing their noses in it might be necessary.

moviedoc said...

Alison: I could write pages on the issues you raise but will try to stay on topic.

A good psychotherapist is honest and can give you a kick in the butt when you need it respectfully. (That can be scary for the psychotherapist. Someone who does that well is REALLY good.)

I don't know about "nice," but compassionate, whatever the opposite of mean is, and they must care.

A good psychotherapist can work with both (marital) partners in the same session, focusing on the problems between them as well as or instead of the problems that are "in" them.

AA may be a great Tx for personality disorder. Maybe one could like about being an alcoholic in order to get in.

Anonymous said...

There is great variability between practioners which can have a significant impact on the effectiveness of therapy. Some, although they may be well intentioned, actually help keep patients stuck. I experienced that first hand. Under one I was a chronic patient who needed meds for life and was continually reminded of how ill I was - which only reinforced depression and helplessness. Another therapist believed I could be well and encouraged me toward that end - guess where I had the better outcome?


moviedoc said...

Also inspired by Alison:

A good psychotherapist takes responsibility for failure and blames the patient for success.

Anonymous said...

I liked this link you gave:

what makes a good therapist?

and the same doctor has a question and answer forum which is really good too.

Fat Bastardo said...

What makes a good therapist is one that gets good results and that would be one trained in RET.

If you don't know about Albert Ellis and if you see what you do as a profession as opposed to an industry you will learn his techniques.

Gluttony is good.

Unknown said...

The basis always has to be a relationship. I liked your post because it focuses on that need to for a trusting, genuine, loving relationship. "Unconditional positive regard" is still, I believe, the best cornerstone I use in my sessions. I come from a solution-focused/ Motivational Interviewing modality, and I use structural and narrative as needed. The theories applied are secondary to the relationship; a psychoanalyst can be just as meaningful as a CBT-er or any branch you like if the basis is a loving, respectful regard for the client.

Anonymous said...

What makes a good therapist. I think a good therapist is just someone you can feel comfortable opening up with. When I started going to the therapist I asked for an older male individual so I can feel comfortable throughout their sessions. However, now that I do not mind other people, because I kind of do not care anymore. I just decided that male figures are better than female figures because of personal preference and went with that. You want someone who can get down to business without the fluff.

Anonymous said...

I would say that a good therapist is a person who knows how to make a conversation seem real when there is hardly a conversation in the room. A good therapist is one with good resources and references that can help the patient be active as well as the therapist (somehow without breaking the rules and guidelines of the therapist) for receiving that cure. Some patients are looking for cures but the therapist should be active as well as the patient for treating that "cure". I am talking outside of the the therapists room and other than the sessions. A good therapist is also an open-minded therapist with resources to hand out when one is need of support groups let say.