Evaluating Therapists and Therapy
Jeannie Riseman, MSW
Speech given at the May 8, 2004 Survivorship East Coast Conference>
I'm Jeannie, and I am a survivor of ritual abuse and early mind control experimentation. I'm also a retired clinical social worker, and I saw some ritual abuse clients back in the late 80's and early 90's. So I have worked with many therapists, both as a client of theirs and as a colleague. I've also been in group supervision and seen what has and hasn't been helpful for both my clients and my co-workers' clients. With this experience under my belt, I can get a little opinionated discussing what goes into making decent therapy.
I'll start by giving you a pep talk about being entitled to choose and entitled to quality. Then I will go over some of the things I look for in a therapist, things I feel are important. Next I'll talk about some of the things that would send me running for the door. I'll end by talking about evaluating therapy when you are in the middle of it.
The first thing I want to say is that you are the consumer. Although the therapist hopefully has some knowledge that you don't, you are in charge. It is your money, your time, and your life. You don't deserve a lemon when you go to buy a car why should you settle for a lemon of a therapist? There's no earthly reason why you should.
Sometimes survivors feel that they don't have much choice in therapists. They believe that they deserve second best, if that, and that they should be grateful that anybody is willing to see them. This kind of "old tape" thinking -- thinking that the cult and probably your parents drummed into you is a real liability in adult life. If allowed to continue unchecked, it's going to restrict your choices and set you up for failure over and over again.
Sometimes people really don't have much choice. Clinics and HMO's usually assign therapists, or else there are only a limited number of therapists on staff. Insurance plans often specify which therapists can be seen, and for how long. And in rural areas, there may not be a therapist within a hundred miles.
If you are stuck in a situation like this, it's helpful to remember that therapy was only invented a hundred years ago and only really became widely available about thirty years ago. People have been healing without therapists for thousands and thousands of years.
I feel strongly that no therapy is better than bad therapy. A good therapist doesn't "do" anything to you or for you. He or she is a guide, a support, a cheering section, a coach. You can find support and encouragement among friends. You can buy books to give you the knowledge you lack and to suggest new ways of handling your issues. Without a therapist, you do for yourself as best you can. With a therapist, you do for yourself, with the therapist's support, as best you can. It's still up to you to change and grow.
So, if you want and can find a therapist, what do you look for? How do you choose? <
I would start by making a list of characteristics you absolutely must have and characteristics that would be nice but not necessary. Another list might be of things that you cannot tolerate in a million years and things that you could put up with if you had to.
Please a try and remember that therapists are just people, just really ordinary people like everybody else. They have strengths and weaknesses, areas of insight, and blind spots, endearing and annoying habits. You are looking for a good match, not the therapist of your dreams.
Here's what my own personal list would look like. No need to copy it, for we all are individuals, and what's best for me isn't necessarily best for you.
Willingness to learn
Sees self as equal to me, not above me
Shares control of the work: sees us as partners
Nice to have:
Knowledge of RA, multiplicity, and mind control, in that order
Is in supervision
Within two hours drive
Social Worker or Marriage and Family Therapist
Doesn't believe in RA, doesn't believe abuse is common
Sees self as an expert, a guru, as possessing special knowledge others don't have
Tries to make decisions for me, pushes own agenda
Tries to sell self
Can't follow what I say
Talks about self a lot, contradicts me, interrupts a lot
Weird or dishonest money arrangements
On the obsessive side of life
Little sense of humor
Not much experience with trauma, incest
A lot younger than me
Any questions about my lists? About why I have certain things on them? Remember! Your lists will be different.
Do you-all want to go over the difference between psychiatrists, psychologists, Social Workers and Marriage and Family Therapists? Okay.
Psychiatrists went to medical school and then specialized in psychiatry. Only psychiatrists can prescribe medication. They have been trained in the medical model that is, emotional problems are seen as diseases or conditions with certain clearly defined symptoms.
Psychologists have a Ph.D. in psychology. (They used to only need a masters.) Most have been trained in research. They tend to see problems as residing inside the client and they often use the medical model.
Social Workers and Marriage and Family Therapists usually have a masters, but a few have Ph.D's. They have been trained to view the client in context that is, as a part of their family and society. Most take into account poverty, oppression, trauma and other obstacles and try to build on the client's strengths rather than "fixing" their weaknesses. Those that take insurance will use medical model categories in their paper work, but the "client in context" is more important in their work.
Okay, back to choosing a therapist. I hope everybody decides that above all, they want a decent human being. Now, with your list in hand, start the search.
I have found that a good place to start is rape crisis centers and women's centers. They tend to be more tuned into trauma and sexual abuse than the general mental health system and they may even have resources for ritual abuse. Take down all the names they give you. Ask them what other organizations you should call and ask for names in case nobody on their list can work with you.
If you have survivor friends in therapy, ask them if you may call their therapist for referrals. It's generally not a good idea to work with a close friend's therapist. You can get into all sorts of sticky situations around confidentiality, mixed loyalty, and jealousy. That's why you are asking for referrals, not an appointment. With acquaintances, there's less apt to be problems.
The next step in this process is to write down some questions that you will use for phone screening and that you will take to the first appointment. Maybe they will get answered in the course of things as the two of you talk, maybe you will ask them outright.
Next, call and make an initial interview appointment. Be up front and say you plan to meet several therapists and see who feels best to you. You'll be asking a few questions on the phone, like "Are you taking new clients?" (If not, ask for the names of other therapists you can call.) Take notes on your first impressions. If you have more than two people you are contacting, you are bound to get confused if you don't write things down.
Now many people are shy about asking a therapist direct questions. They expect the therapist to ask them questions about themselves and their problems, but they figure it isn't their place to question the therapist.
It is, though. You are going to be entrusting very intimate parts of yourself with this person, and you have a right to know something about them beforehand.. It's okay to ask a therapist anything you want. They can always say, "I don't want to answer that." After all, they are grown-ups, right? And they know how to say no, right? If they aren't grown-ups or don't know how to say no, there's a problem there.
Some therapists are savvy enough to tell you that you may ask them questions, or to ask if you have any. Others are open to questions but don't routinely say so. Others are terribly up-tight about questions. Hmmm... Wonder why? That tells you something about the person in itself. Many will answer questions in the first or second interview that they won't in the middle of therapy.
Be careful of somebody who dodges questions. It's fine if they ask, "Is that really important to you?" or briefly explore what the answer might mean to you. But they better answer it or tell you why they would rather not and not just fudge around.
There were some questions I wouldn't answer as a therapist, but I did explain why. I never revealed my politics or my religion, because I had to work in a small community with all kinds of people and I wanted to be judged for myself and my skills. I would ask a prospective client if they thought they couldn't work with me if we didn't belong to the same party or religion. It worked out fine. I respected their right to ask, they respected my reasons for not answering. That's what you are looking for -- honesty and respect, not necessarily a particular answer.
The vast majority of questions people asked were totally appropriate and I was happy to answer them.
You might want to start with the easy questions. "Where did you go to school?" "How long have you been a therapist?" "What do you charge?" and then work up to the harder ones. "Have you heard about ritual abuse?" "Do you believe it exists?" "Have you ever worked with an RA survivor?" "If not, are you willing to read up on the subject?" "Have you ever worked with multiples?"
By the end of the first hour, you should have a pretty good idea of the person and which criteria on your list are filled and which are not. Ask what his or her process is and describe what your process will be. For example: "I'd like to think this over for two weeks. Then I will call you." When you get home, take notes on how you felt about the therapist.
At some point, after you have interviewed a few or a lot of therapists, you will be ready to choose. Theoretically, it should be easy, between the notes you have made after phone calls and interviews and your own feelings or instincts. In practice, it isn't always cut and dried.
One of my friends had been through four, I believe, destructive therapists until she found somebody truly competent. When she heard I was talking on this subject, she wrote to me: "How to get beyond flashback/trauma thinking while looking?? Or while stuck in a bad therapy relationship? Looking back, knowing what I know now, could I have seen where there were checkpoints and choices to be made? Maybe it's just unavoidable to make big mistakes, given the territory?
What she meant was that she selected the first four therapists while she was still thinking the way the cult taught her to think about herself. She wasn't thinking as a rational adult, with autonomy and power. She was thinking as a wounded little kid grateful to be thrown a few crumbs and she expected to have to apologize for being needy and greedy. She felt powerless, like she was as a kid, and the therapist felt all-powerful to her, like the adults back in her childhood. And you don't question all-powerful and all-knowing people. She was stuck in a feeling flashback, feeling the emotions of long ago.
You could say, "Well, of course, we are all stuck in old patterns. That's why we are looking for therapy." That would mean it was only a matter of luck whether we ended up with a competent therapist or a crook. We might as well just look in the Yellow Pages.
I do think, though, that even when you are stuck in the old patterns of thought you can momentarily step out of that way of thinking to get something done. Knowing that you are stuck, and knowing what your actions would look like if you weren't stuck, helps a great deal.
One trick I often used with myself actually I still use it it to ask myself "What would a 'normal" person do, think, feel?" A kinder variation is "What advice would I give somebody else?" This allows me to step outside myself for a moment, to gain some distance. It's very, very useful.
The whole process of making lists and writing things down also helps gain distance. I'm not a list person, myself, but I use the technique when I am confused or afraid of forgetting something. I sometimes pretend I am writing about somebody else. I describe the problem and suggest possible solutions, sleep on it, then read through what I have written and apply it to myself.
Probably the best way of all to gain some distance is to talk things over with somebody who isn't all wound up in you, somebody who doesn't have much of a stake in your decision. That way, the person will be responding to the pros and cons of what you are telling them, and won't be pushing for you to choose somebody who will turn you into what they want you to be. You will know from experience whether a partner or close friend can be objective enough to respond to your needs and not push their own agenda.
All right. I've gone over the process of empowering yourself enough to evaluate therapists and to choose between them and outlined some simple ways to organize your evaluation. It's not rocket science, but then not much is.
Let's move on to things that a therapist should never ever do, either in the first session or later on. I'll start with some of the absolutes, then discuss the concepts of transference and counter-transference, resistance, and reality (in 200 words or less, oh yeah), and go on to some of the more minor things a therapist shouldn't do.
A therapist should never make a pass at you, ask you out on a date, try to have sex with you, tell dirty jokes, or touch you in sexual way. This is sexually abusive. It is just as abusive as a priest or a parent trying to have sex with you. It should never, never happen.
What should you do if this does happen? Get up and leave, quickly. Do what you need to take care of yourself right away. As soon as you can, write everything down. Do not go back. Consider consulting an attorney or making a report to the police, to the therapist's licensing bureau, or to their professional organization.
If this happens, try not to blame yourself. It's normal to feel like you are to blame, but you are not. The therapist is. Period.
The therapist is supposed to act in your best interest, and only in your best interest. It is not in your best interest to try to rape you or seduce you. Even if a client makes a pass at a therapist, it is the therapist's responsibility to say no, to be firm but kind, and to help the person figure out what is behind his or her feelings. The therapist cannot use the fact that the client initiated things as an excuse for abuse.
A therapist should not be sexual with a former client, no matter how much time has passed. Similarly, the client's relatives and friends are off-limits. If a therapist has dated you or a relative or close friend of yours, he or she should decline to see you and give you some other names of therapists for you to call.
Some therapists, fewer than in the past, use "safe touch" judiciously. This means holding your hand when you cry, giving a hug, putting an arm around your shoulder. You should be asked first whether this is acceptable to you. If you think it might be, and it then feels uncomfortable, say so. The therapist will stop. This should not be sexual in any way it should be like a friend comforting you.
A therapist should never use physical force on you or threaten to use physical force. The "no force" rule isn't quite as hard and fast as the "no sex" rule. What if you lose it and start throwing punches? What if you start destroying the office? Self-defense is okay, even for a therapist. But if you didn't become violent first, physical force has no place in therapy.
Some therapists use non-destructive techniques to help clients express anger. You should be asked first if you want to try it, and you should feel free to stop if you are uncomfortable. These techniques include hitting pillows with tennis rackets or toy baseball bats and punching pillows or special punching bags.
A therapist should never shame you, humiliate you, calls you name, put you down. Now you don't have to take this from anybody, and especially not a therapist who is supposed to be on your side.
Humiliation has been used as a therapeutic technique. This horrible technique comes from encounter groups (specifically Tavistock, in England, which was funded to do research for the cold war). It's been used in drug treatment (think Synanon) and money-machines like EST. It is a brainwashing technique designed to break you down and then make you accept the "authority's" point of view. It has no place, in my opinion, in legitimate therapy.
I'm totally irrevocably opinioned on these three points: no sex, no violence, no put-downs.
Now let me detour for a while and talk about transference, counter-transference, and resistance. I want to discuss these concepts because they are often used to make a client feel like he or she is responsible for what is not working and is a "bad" client.
I was taught that there is no such thing as a "bad" client. There are just clients that you, as a therapist, haven't yet learned to work with effectively. It's the therapist's responsibility to face up to the fact that they don't have the necessary skills and either to acquire them or to refer the client to somebody else. And there is no shame in this: no one person can be expected to be competent with every single human being that walks in their door. That's just plain unrealistic.
Okay, transference. Transference means feelings that you transfer onto the therapist. In trauma terms, it's a feeling flashback. The therapist sneezes the way your mother did (trigger) and all of a sudden you are feeling all the emotions you used to feel around your mother. Since your mother isn't there, you assume it was the therapist that brought those feelings about. Does this make sense? Shall I give another example?
Let's look at an every-day example. If, in the past, you have had pleasant experience with puppies, the next time you see a puppy you are going to think "Aw how cute" and want to play with it. But if puppies have been used to hurt you, you are going to shrink away and try and protect yourself. If you have seen puppies tortured, you are probably going to feel they are fragile and delicate and you're going to be afraid of hurting them if you touch them. And you may be puzzled why you suddenly feel sad or afraid or angry. But the "Aw how cute" response is every bit as much of a feeling flashback as the other responses.
I'd like to add that everybody, not only trauma survivors, has feeling flashbacks and experiences transference. It's part of the human psychological make-up. It's just that trauma survivors have more flashbacks of terror and anger and fewer of warm fuzzy feelings. And their flashbacks are usually more intense.
Counter-transference is when the same thing happens to the therapist. In other words, the therapist has a feeling flashback. Suddenly the therapist is not reacting to you as you really are, but to you as seen through a film of feelings about somebody else. Doesn't matter if the therapist had a lovely or a horrible childhood - he or she will experience counter-transference at some point. It's human nature.
Many books and graduate schools teach students to concentrate on the client's transference feelings. The assumption is that the client is "sick" and the therapist is "well." Counter-transference, instead of being a part of life, is considered shameful. This distortion can lead to all sorts of problems in therapy.
Consider the therapist with a younger client and a teen-aged daughter. The daughter is in that lovely stage where Mom is an idiot, totally out of it. Chances are the therapist is going to be hyper-alert to put-downs from the client. So if the client says, "It's cold in here" the therapist, rather than saying, "Yes it is. Would you like to get your jacket?" might get defensive and go on about how it isn't her fault, the landlord controls the heat, etcetera etcetera. She's expecting the client to act pissy, like her daughter. But since she's been taught to look for the source of the distortion in the client, not in herself, she will probably look for "mother issues" or "authority issues" in the client. Confusing, isn't it?
Here's an example from my own long history in therapy. My therapist said he hadn't received my check, and was I angry at him? We'd been working on my feelings about my father, which included a lot of anger. So he assumed I was experiencing transference. I said, well, I'd mailed it, and no, I wasn't angry at him. He kept probing for three sessions for the source of my anger at him, by which time he had created it. I was also feeling royally mind-fucked, which was exactly the way my father made me feel. Hooray! Transference had been created.
Next session he sheepishly told me that he had made a mistake. He had received the check but had forgotten that he had. His issue was that he wanted to raise my fee and was annoyed that the check was so small. This was responsible on his part. He owned up to his mistake, and also to putting it on me, when it really belonged to him. Things got straightened out, and we proceeded. But if he hadn't figured out his part and if he hadn't been honest enough to 'fess up, things would have gotten messier and messier between us.
To complicated things further, you may have feelings about the present situation and the same kind of feelings from the past transferred onto the present situation. It doesn't always have to be either/or. Sometimes it is both. Here's an example. The therapist is late. The client feels hurt, unimportant. The client's mother was habitually late, and the client felt hurt and unimportant. The therapist gets a double dose of those feelings, one from the present, one from the past.
Now if the therapist assumes it's "all" transference, and there's no reason for the client to be hurt by the therapist's lateness, then the client is going to feel mind-fucked. But if the therapist can divide it up between the past and the present, some good work can be done.
"Resistance" is another psychological concept that sometimes gets used to put responsibility on the client for things that go wrong. If the client doesn't get better in the way the therapist wants in the time frame the therapist wants, it's labeled resistance. Well, what if what the therapist wants is bad for the client? What if the client isn't ready? What if the therapist's goals are unrealistic? What if the client doesn't have the vaguest idea what the therapist is talking about? The therapist should assume that the client had a real good reason for not making the change and help the client to figure it out. There is no place for guilt-tripping in therapy.
I've spent so much time on transference, counter-transference and resistance because misuse of these concepts is fairly common and can lead to long periods of being stuck in therapy. Something just isn't right, and neither person can put their finger on it. It's not as easy to understand as "no sex," but it's really important.
Now I'm going to mention some of the things that can be symptomatic of poor therapy, but which sometimes can be worked through. This isn't a complete list -- I am sure you can add lots of things.
Double relationships. What is meant by this is having a therapeutic relationship, and also another, separate kind of relationship with the same client. Licensing boards and professional organizations are moving more and more toward banning all double relationships. Canada is looser about this, maybe because so much of Canada is rural.
Banning double relationships is probably a good idea because it is hard to keep your client's well being in mind when you have to relate in another way. Certainly therapists should not have a financial relationship with their clients. This means no hiring the client to paint your house or do your books, no trading lobsters for appointments, no accepting gifts. If a client wants to give a gift, it should be something with no monetary value -- a hand-made card, a poem, something like that.
In small isolated communities, it's almost impossible to avoid double relationships. People are spread out, and there is only one therapist, one carpenter, one doctor, and so on, for miles. But since I don't think we need to worry too much about that in New England, I'd suggest being wary of somebody who suggests a double relationship.
There's another circumstance that I don't know very much about, and that's ministers, priests, or rabbis who are also counselors. I don't know how the different denominations ensure that the two roles stay separate. If you are considering working with a religious counselor, it might be a good idea to ask about this.
Flakiness. The therapist is consistently late, forgets appointments, often calls at the last minute to cancel or reschedule, or forgets to keep phone appointments in a crisis. Or messes up the bookkeeping. Or forgets important facts about you. Forgets to tell you about vacations. Once or twice is forgivable, but a lot? You need consistency, not chaos.
Over-stepping their knowledge. The therapist says he or she has expertise which he or she doesn't. I'm not only talking about padding a resume: I'm talking about giving medical or legal advice, diagnosing somebody (like your parents) who they have never met. Let's have a little humility here! Or a little more self-confidence! A therapist should be honest enough and confident enough to admit to not knowing something or not being qualified on a particular subject.
I'm going to finish up by talking about when you feel stuck in therapy. This happens. It seems to happen to everybody who is in therapy more than a few weeks. Sometimes it's just part of the process, sometimes it indicates that you and your therapist have something that needs to be looked at. What to do? How to sort it out?
The first thing would be to check and see if your therapist agrees with you or not. If you don't agree, just discussing it might make the explanation clear.
Myself, if I have an appointment two or three days before a satanic holiday (or worse yet, on the very day), I feel totally stuck. Therapy is useless, a waste of time, money, and energy, always has been, always will be. So my therapist reaches for the calendar, and the mystery is solved. I often then choose to work on something non-cult related.
Many people often feel stuck just before a big issue or a set of new memories comes up. This is very, very common. Sometimes they have been in this place often enough that they can recognize the signs of an emerging memory or issue. Some signs might be changes in eating or sleeping, isolating, stirring up trouble for yourself, taking on extra work or projects. All these things can serve to distract you from yourself and keep the memory down. If your therapist has worked with you for a while, he or she may be able to recognize these or other signs and ask you if you think this is what is going on.
On the other hand, you might not feel stuck before a break-through. Your pattern might be to reach a plateau, stay there a while to catch your breath and build your strength, and then plunge forward.
Sometimes the stuck feeling has something to do with the relationship between the therapist and the client. There might be a misunderstanding, a disagreement that hasn't been fully worked out, or, not unusually, something that isn't being talked about. Might be those old boogiemen, transference and counter-transference. At any rate, the two people need to talk about the stuckness until they figure out what the block is.
If you find you are stuck early and often, it might be a good idea to look for deliberate programming designed to sabotage therapy. These programs are quite common. They may prevent you from seeking therapy in the first place, make you chose poor therapists, or make you leave as soon as you start to get anywhere. Anti-therapy programs may kick in after, say, six sessions or only when you find a competent therapist. They may lead you to view the therapist as a perpetrator and mis-hear his or her words.
Finally, there is the kind of stuckness that signals that therapy is coming to an end, at least with this person. There doesn't seem much to do. It's pleasant to chat with somebody who you know and trust so well, but you have the feeling that there isn't much more productive work ahead. Maybe it's time for graduation. How bittersweet endings are!
I've gone over what I consider are the main points in evaluating a therapist and therapy. I hope that some of this material has helped focus your thoughts. We have half an hour for questions. I'd like to invite you-all to respond to the questions, as well as ask them, because everybody in this room is an expert.
Copyright © 2004 by Jeannie Risesman and Survivorship.
All rights reserved. You may print out one copy for use
in your own healing. For additional reprints, write
Survivorship, PMB 139, 3181 Mission St, San Francisco CA 94110.