Episode 12: Is Your Therapist Any Good? How Do You Know?

What is the frame in psychotherapy and why do we need to keep it from breaking? This week I discuss the importance of boundaries and guidelines set forth by Robert Langs, MD regarding how to know when your relationship with your therapist is healthy – and when it is not. I also talk about the concepts of transference and countertransference in psychotherapy.


Notes From This Episode

Download a Word doc on Lang’s guidelines for psychotherapy.

Go to the webpage for the European Society for Communicative Psychotherapy where you can learn more about Robert Langs’ work.

Here’s a good site, called Good Therapy for locating a psychotherapist

Guidelines for Psychotherapy

From the book: Rating your Psychotherapist
Author: Robert Langs, M.D.

1) Ideal conditions which constitute the "frame"

  • A single, set fee
  • A single, set location
  • A set time and length of the session
  • A soundproof office (or noise machine)
  • Relative anonymity of the therapist (no self-revelations or opinions, focus should be on the patient)
  • Total privacy
  • Total confidentiality

2) Referrals

Good:

  • Local Medical Society, Mental Health Association, or other professional organization
  • Recommendation from a friend who is a psychiatrist, psychologist or social worker or other mental health worker
  • Employer, principal or lawyer recommendation


Bad:

  • A co-worker, social acquaintance, or relative sees or used to see him/her and says he/she is good
  • Therapist is the wife/husband of one of your friends
  • Therapist is a friend or used to be a friend of the family

3) Your first interaction with the therapist

Good:

  • He/she was concerned and listening
  • Said nothing of a personal nature
  • No physical contact except for an initial or concluding handshake
  • At the end of the meeting the therapist set the ground rules for treatment

Bad:

  • He was very physically demonstrative, that is, hugging or holding your hand
  • He/she came on to you sexually
  • Was unprofessional and self revealing
  • Talked more than you did

4) The fee and Schedule:

Good:

  • Set a single, reasonable, fixed fee
  • Won't let you build up debt
  • Won't accept gifts or other forms of compensation beyond the fee
  • Arranged a definite schedule for therapy (day, time, length and frequency) and these have not changed throughout the course of therapy (except when necessitated by work or life circumstances)

Bad:

  • He/she is willing to falsify a fee to an insurance company
  • He/she negotiated a barter arrangement
  • There are repeated changes in time/location/day, length of sessions
  • Sessions start late because other patients stayed late
  • He/she lets you stay longer than the scheduled time

5) Treatment:

Good:

  • Treatment types vary a great deal (cognitive, behavioral, humanistic, etc.): but in all cases: Does it make sense to you?
  • Does it feel okay?
  • It should always remain a professional relationship
  • In general, the therapist should let you do most of the talking

Bad:

  • Therapist keeps directing you to talk about particular issues (your marriage, your sex life, etc.
  • He/she frequently tells you what they think you should be doing with your life ("If I were you I would…)
  • The therapist is hostile, makes you feel guilty, or is seductive

6) Termination:

Good:

  • You felt like a sense of new insight and understanding had been reached and your symptoms had largely (though probably not completely) been resolved
  • It seemed like the right time to end therapy
  • A specific date was set and adhered to (didn't happen in an unplanned way)
  • All the ground rules mentioned previously had been maintained up until the end
  • Once therapy was over you had no further contact with the therapist

Bad:

  • You decide impulsively to stop therapy and your therapist accepts this without encouraging you to consider your decision
  • Therapist badgers you to continue despite your feeling that it is time to stop. He/she insists that you still need help

Resources for this episode

Read Robert Lang’s book on psychotherapy on Amazon.


Comments

  1. Brent B says

    After listening to this webcast I wondered if sex therapy is still practiced? Is this a thing of the ’70s and ’80s? Or are there accredited therapists around who actually do teach and model good sexual interaction with their clients? What does this do to the frame?
    I enjoy you webcasts. First saw them on iTunes. I like that you are easy to listen to and yet have a strong scholarly back ground ending with a PhD. A PhD is no golden wreath around the head. But for me it appeals a great deal combining a good base of information, scientific study, skepticism and lastly the human element which can set so much on its ear.

  2. says

    Interesting thought. I assume that sex therapy is still available, although I’ve never seen a therapist advertise this service. Whether or not this kind of therapy “breaks the frame” would depend on exactly what the therapist does in this kind of therapy. If all the therapist and client do is talk about one’s attitudes toward sex, then I don’t think there would be any frame breaking.

    Thanks for your final comments. I try to present the latest information and a healthy respect for critical thinking in the podcasts without, hopefully, being preachy or “lecture-y”. There’s no reason for that. Glad it’s coming across that way. Thanks again for your comment too.

    Michael

  3. Anonymous says

    This ipod maded alot of sense thank you . looking forward to following you. Laurie H

  4. Steve says

    I am new to Pych Files and I find this episode interesting after watching HBO In Treatment. My question is about transference in the work place. Are there studies about the the effects of transference between employee and boss? I have seen many seminars about conflict resolution and I wondered if there is work being done where managers learn to recognize transference?
    I enjoy your podcasts very much and look forward to listening to all of them.
    Steve

  5. says

    I’ve heard about that program In Treatment. Haven’t had a chance to watch it yet. Good point about transference between employee and boss. I haven’t seen any research on it, but I would guess there’s got to have been research on this. Since your boss is an authority figure, it seems natural that employees would transfer feelings from their fathers to their bosses. Also haven’t seen any research on training bosses to recognize transference but I really like the idea. Good stuff. The problem I think is that the concept of transference has its roots in Freudian theory and you don’t see Freud mentioned that often in the workplace. Still, I agree with you wholeheartedly about transference occuring between boss and employee. -Michael

  6. Matthew says

    As a therapist, I’m afraid I have to take issue with some of the absolutististic tone that was taken with this podcast for some of the therapy warning signs.

    Self revelation can be indicated in the therapeutic process. If a therapist has been through a similar situation to the client, it can help the client to feel better understood to reveal this. There are limits, of course, to how much personal information is revealed, but it should not automatically be seen as an indicator of bad therapy should it occur. However, I do believe that the concern that such a revelation may be the result of countertransference is a valid one. It is important to ask oneself what purpose is being served by such a revelation before putting it out there.

    The use of touch is another tricky one. To say that handshakes are the only touch that should ever occur in a therapeutic setting seems extreme. Touch can be extremely powerful. Excessive touching is certainly a warning sign, but a hand on the shoulder at the end of the session can be powerful and beneficial.

    As for previous sessions running over, this cannot always be prevented. There may be extenuating circumstances (suicidal threats at the end of the session, etc.). This should only really be a concern should it occur frequently.

    In addition, when practicing in rural areas, bartering is sometimes the only option for many clients. It is not ideal, but it is accepted by the APA. However, it should only occur with items that have a known value (services should not be accepted). Many therapists are split on this issue, but it tends to be that those practicing in urban areas are the ones to voice concerns. Funny, that.

    As for a therapist creating a feelings of guilt in a client, it is important to note that no one can “make” anyone feel anything. A feeling is a response based on the perception of something. If a client feels guilty, it is not because the therapist made them feel this way. Sometimes past mistakes will come up in the therapeutic process. The goal is to look at these dispassionately and learn from them. A therapist should do his or her best to show unconditional positive regard, but the client may not have the same regard for his or herself. Guilt can and will happen.

    Overall, I agree with many of your points. However, I fear a client may ditch their therapist prematurely on the basis of some of your more unyielding statements.

  7. Michael says

    Matt,

    I’m glad to see your comment on this episode. This is one of my earliest episodes before there were a lot of listeners to the podcast, and as a result the episode I think gets lost among all the others. Langs’ ideas regarding the “frame” are a bit stringent and perhaps old fashioned, so it’s good to see someone take issue with a few of them.

    Regarding self-disclosure: this is one I feel pretty strong about in terms of agreeing with Langs. However, you say that “It is important to ask oneself what purpose is being served by such a revelation before putting it out there.” I’ll agree with that.

    As for a “hand on the shoulder” – okay. I’m with you on that. I can see that this could have a powerfully positive effect when honest and at the right time.

    Also agreed that sessions that start late could be very well justified if the therapist has an emergency that must be taken care of. Again, the critical factor here is why these “breaks in the frame” occur. When they occur because of counter-transference issues – then you have a problem.

    As for bartering – very good point there. I don’t have any experience with this so I’ll defer to you on that one. As for the point about guilt: I don’t think I disagree with you. I was thinking of a situation where the therapist might be trying to make a client feel badly if he/she ends therapy early, or when a therapist is reacting (again) out of his/her own unacknowledged and unresolved issues by getting mad at a client. This is a bigger issue than can be easily discussed here in a comment.

    I appreciate your thoughts and as you see I agree with many of them. Many people want to know whether or not their therapist is “good”. This is a very, very hard question to answer, but I hope that Robert Langs’ ideas provide some broad guidelines.

    Michael

  8. Kelly says

    When I was seeing a therapist she was accusing me of having thoughts that I know I didn’t really have. Essentially, she didn’t believe in what I was saying.
    Is this a sign of bad therapy? Or was she trying to help me in a way I saw as extremley hurtful?
    (I ended the sessions on an impulse, by the way)
    Another question: Are therapists trained extensivley on not letting their own opinions interfere in their “advice”? Or wouldn’t one even do that without even realizing it?

    Thanks.

  9. Michael says

    As far as whether or not your experience was bad therapy: it would be really hard for me to tell based upon only this information. It depends upon how she was trying to get at these thoughts (“accusing” certainly doesn’t sound like a good way to go about it). Wish I could say more, but I don’t want to make any judgments based upon only this information.

    As far as whether therapists are trained to not their opinions interfere with their advice: yes, I’d say that most therapeutic training programs do emphasize this. However it is one thing to try to train people to do it, and another (hard) thing for therapists to be constantly aware of what they are doing and to be able to separate themselves and their needs from their patients. The hope is that most all of them can do this.

  10. EastCoaster says

    On fees and the frame more generally: My psychiatrist and I, who started treating me when he was a resident, set a very low fee, because I was out of work when he started his part-time private practice. He thought that he would be taking insurance, but then chose not to. It’s always been understood that I would pay him more as I did better financially. And some aspects of the frame are being worked out over time. He suggested that we cancel an appointment when there was a very bad snow storm. If I had suggested the same, he wouldn’t have charged me, even though there was less than 24 hours notice. We are still working out what might constitute an emergency forwhich I shouldn’t be charged.

    Psychotherapeutic Orientation: I think you ought to explicitly acknowledge that these are basically psychodynamic rules. DBT would give different answers about what constitutes appropriate boundaries.

    On touch: I was in a therapy group led by two residents. It was primarily behavioral, being focused on midfulness and *some* of the principles of DBT. (It ended abruptly, because the residency program decided to drop all group therapy at its 2 private sites. Since both of our leaders were leaving the clinic that year, we only had a week’s notice. A rising resident had already been chosen, but she wasn’t going to start by terminating over 2 months, but that’s another story.) As the female resident got ready to go, our all female, all straight group gave her a hug goodbye. In context, I don’t think that was inappropriate. When one of the other leaders left to go to a child fellowship, one of the group members bought her some flowers. Again, not inappropriate in my book. Of course, this was in a clinic setting, so some of the baseline rules had been established from above.

  11. says

    PS I actually think reading his work he is bordering on paranoid, or at the very least is somewhat reductionist in his view of what influences the patient somewhat discounting the inevitable influence and experience by the patient of the real therapist behind the frame… :0)
    Joanna

  12. Michael says

    I think that both “EastCoaster” and the Sydney psychologist make good points. It’s true that Langs’ is heavily psychoanalytical and I have to agree that his stance on these boundaries is quite strict. EastCoaster: the arrangement your psychiatrist and you made regarding payment sounds quite reasonable and I agree with you that the hug goodbye you describe sounds actually quite therapeutic.

    It’s hard to provide a list of “rights and wrongs” that will fit every situation, and Langs’ ideas may be a bit extreme, but they certainly make people think about boundaries and their importance in the therapeutic relationship and that’s a good thing.

  13. says

    As an avid follower of your podcasts, I must say that this (Episode 12) has made the most lasting impression on me. I’ve even forwarded it to my supervisor for discussion as it’s a vry practical reference for discussion around many general therapeutic issues.

    I also want to address the issue of self-disclosure and reinforce Mathew’s point-of-view as this has been an ongoing issue for me a ‘sexual health’ counsellor who has worked within the GLBT community for 5+ years. I should also include here that I am openly gay and have been HIV+ for close to 25 years. Having lived with HIV for what constitutes my entire adult life, my ‘lived experience’ often provides me with insights and perspectives inaccessible to non-HIV+ therapists, however, does not always have appropriate therapeutic value, even to HIV+ clients. That said, there are particular clients, circumstances and interventions (acute crisis (suicidal intention/plan) triggered by HIV+ diangosis) which may benefit from such intimate self-disclosure. Although I have no empiral evidence, I can say with confidence that sharing this with clients in such cases is often the most effective means of demonstrating empathetic support who might otherwise lack any connection or experience to such a stigmatized condition/experience.

    Initially, I purposely avoided bringing this into sessions with clients and struggled with the inherent conflicts of being a gay, HIV+ counsellor (working at the AIDS Council of NSW aka: ACON), however with the support of my very experienced and skilled supervisor, developed confidence in my therapeutic skills to guide this aspect of my practice.

    There are/will always be extenuating circumstances to any ‘frame’ and as such it becomes increasingly important to remain mindful of (to quote yet another of your previous podcasts) “throw the baby out with the bathwater”.

    Thank you for your time and tireless efforts in providing such a useful resource through your podcasts.

    Kind regards,
    Ron

  14. says

    On a side note…my apologies for the many typos in my previous post…perhaps I could take take a few minutes to review before posting next time.
    R

  15. Dan hennessey says

    I think it would be fairly obvious that a therapist ‘coming on to you sexually, would constitute a bad session. I feel that most people would feel rather patronised by this. You should also not expect total confidentiality , as suggested here. Any competent therapist has a duty to break confidentiality in some events- for example where a patient’s disclosure is of a serious crime or abuse or constitues a threat to the public or another party. A competent therapist clarifies this at the start, and the promise of complete confidentiality is thereFore not ‘good’.

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