A User’s Guide to the 7 Criteria for ‘Good Therapy’
Recently I was listening to one of my favorite podcasts called “Very Bad Therapy.” The show generally features people who have had horrendous experiences in therapy and gives them a platform to share their stories and help others. Full disclosure: I began listening to this podcast after ending a very bad therapeutic relationship. I have written numerous articles on the Mighty about how this therapist gaslit me, retraumatized me, and used my vulnerability against me. I also appeared on this podcast about four months ago to share my story.
Periodically, the podcast does episodes that they call “VBT in Focus” where they bring on an expert in some aspect of therapy to interview. In episode 90, they sidetracked a bit and did a very long and somewhat esoteric discussion about the ideas surrounding “what makes therapy good?” They discuss the fact that regardless of treatment modality, the experience of the therapist, and education of the therapist… the single greatest predictor of positive outcomes in therapy is in fact the therapeutic alliance. This ineffable quality is something that you cannot really teach in a classroom and is completely subjective. So, how can it be integrated into the field of therapy?
The host of the podcast, Caroline Wiita, suggests a fascinating idea that immediately got my wheels turning… turning to a service marketing strategy to help reorient the way therapists approach therapy. Having been in the service industry and in particular the hospitality industry for the vast majority of my life, this intrigued me. She outlined a system of measurement for value and quality of service provided called SERVQUAL, which assesses a customer’s satisfaction on the basis of five criteria: Reliability, Assurance, Tangibles, Empathy, and Responsiveness. The idea that a therapist could modify their approach to their work from this perspective immediately brought into focus for me a list of criteria for “good therapy” that situates the client’s needs and desires front and center.
This list encompasses my own experience with a tremendous therapist as well as my history as an innkeeper for the last 16 years. Fun fact: Innkeepers are often called “Rent-a-Friends” and there’s a kind of insider notion that an innkeeper is somewhat of an expert in the human condition, as we spend most of our time reading our guests’ body language, words, and other nonverbal cues to ensure that we are giving them exactly what they want and need — not unlike a therapist. The list also keeps in mind standard ethical considerations and proper boundaries which are a core part of the curriculum that any therapist has to master.
Without further ado, here is my comprehensive list of factors that make for “good therapy.”
In the spirit of the therapeutic alliance being the most important factor in positive outcomes in therapy, it’s not surprising that having good compatibility with a therapist is crucial. Not to make it sound creepy, but in a lot of ways, it’s like dating. It may take a few tries before you find someone who feels right. Not only do they make you feel understood and safe, but they are easy to talk to, have a pleasing voice and presence, and there is a natural flow to the sessions.
Kind of an extension of compatibility is the uniqueness of the therapist. Not just in terms of their skillset, education, and background, but also things like how they dress, what the decor of their office looks like, and where they are located. You are going to be spending a lot of intimate time with this person and who they are will inevitably come through, beginning with how they present themselves and extending to what kind of art is on their walls, what photos are on their desk, and what books are on their shelves. All of this gives you information about who the therapist is and what they value.
This may be one of the most important factors for those who have trauma histories, particularly developmental trauma. Growing up with uncertainty and fear creates a hypervigilant mentality that craves security. Having a therapist who doesn’t cancel frequently, is on time, is present, attentive, and speaks in a predictable way helps to strengthen the therapeutic alliance and reduce anxiety. This consistency also goes for the environment of the office. I can assure you that in both my good and bad therapy experiences, one of the things that I was acutely aware of was changes in clothing, hair color, and office decor. I tend to scan a room when I arrive for security; it’s probably a product of my trauma. I make a note of and document things like artwork, photos, books, etc and if something is out of place or different, I get anxious. It’s not that a therapist isn’t entitled to change things, but… when changes do occur, it’s important that they discuss them and help reassure the client that the therapy and therapist haven’t inherently changed, even if the environment may have.
A therapist who has a big toolbox and isn’t afraid to use it is crucial. My first therapist swore by her psychodynamic approach to a fault. She asserted her superiority and refused to adapt her approach to my treatment even though we had been at a standstill for months. It became a source of angst for me in that I was certain I was the problem, I was doing therapy “wrong” and I couldn’t be healed. The truth is that what I needed was a different approach. My current therapist shifts based upon what is and is not working and continuously asks me questions to assess whether something is resonating or not. Therapy isn’t a one-size-fits-all proposition and it requires a therapist who can and will adjust to the client for it to be successful.
An adjunct to adaptability is a therapist’s creativity. While psychotherapy is in fact a science, certain aspects of it involve some creativity. For example, a patient may benefit from eye movement desensitization and reprogramming (EMDR), however, they may not be comfortable with the protocol as it was originally designed. Being able to think on the fly and come up with a novel way of doing the protocol that better suits the client is key. This applies to almost any modality. I would also argue that tapping into creativity can help a client connect with their own playfulness and play has been shown to be one of the most healing behaviors for adults and children alike.
Again, continuing in the vein of the importance of the therapeutic alliance to a positive outcome, while the therapist-client relationship is unlike any other in that it is essentially one-sided, it is still an intimate experience and ultimately a dialogue between two human beings. I do not believe that the classic notion of “tabula rasa” or “blank slate” is necessary or effective in treatment. Contrary to what therapists think, clients can and do sense when something is going on in the therapist’s personal life no matter how well the therapist thinks they are masking it. I’m not saying the therapist needs to divulge personal information indiscriminately, but telling a client that they may not be 100% today, and it’s not a reflection on anything the client did, is crucial in ensuring the consistency of the relationship. I also believe that it is up to a therapist to determine when and how much personal information they choose to disclose, where it may in fact benefit the client’s progress or strengthen the relationship. To strip a therapist of their humanity completely is in my opinion dangerous and does a disservice to both the client and therapist… a therapist’s ability to empathize and show a client true care is immensely healing.
Being human means being fallible and having the humility to acknowledge mistakes or missteps is not only important in helping a client build confidence, but it also offers an invaluable opportunity to learn how to do what’s called “rupture and repair.” Conflict is a natural part of any relationship and is to be expected in the therapist-client dyad. If a therapist fails to appropriately address the rupture and help the client repair that rupture effectively, the client cannot learn that they do not have to shrink themselves to avoid conflict with others. This is especially important for clients who have experienced childhood emotional abuse or neglect.
All of this makes finding a good therapist seem as elusive as finding a rainbow-horned unicorn. But, I assure you that good therapists do in fact exist. And maybe the hosts of this podcast are onto something important in terms of how we can reinvent the ways in which therapists approach their work to encourage better, safer, and more effective therapy on a broader scale. If nothing else, it empowers clients by giving them a concrete set of criteria from which to determine whether a therapist is in fact “good” or “bad.”
Photo by Mathilde Langevin on Unsplash