I am evaluating if I should change therapists. The information gatherer in me wants some concrete advice to make the decision. Part of me wants to stay, and another part wants just as strongly to go.
Changing therapists is a difficult decision for anyone. But it becomes even more challenging if you are a multiple.
This article is about my research in order to make this decision. That maybe will help you with the decision as well.
Because this post got long, here is a short table of contents:
- Things to consider
- What you are losing vs. what you are gaining
- First, a bit on what psychotherapy REALLY is
- Predictors of success in therapy
- Choosing a therapist
- What patients want
- Your responsibilities in therapy
- How do you know if therapy is working
- The end of therapy
- Premature termination of therapy
- Switching therapists – how to decide
- Items to consider when thinking about changing therapists
Things to consider
Changing therapists is a big deal. I chanced upon my therapist via recommendation and interviewed no one else. I wasn’t really in the state to.
Afterwards, I noticed internet articles that provided questions to ask your therapist. After reading, I realized I was lucky that this woman was behaving ethically and with genuine concern. But a few of the recommended questions I never sought answers to. And part of me has always been a tad uncomfortable with the relationship.
Now that the rift between us is much larger, I am back to the research to learn more about how the therapeutic relationship should be, what are the expectations from both sides, how do you evaluate if the relationship is working, what aspects of a relationship are the best determinants of treatment success, and questions to consider when you decide to leave.
What you are losing vs. what you are gaining
My best friend has repeatedly said, “You have to start over with a new therapist. It will take several sessions to get back up to speed. And with your particular situation, it will probably take longer. And there goes your summer.” He is right – this is something that must be considered.
Another consideration – during the initial phase with the new therapist, you are probably not getting any additional therapeutic help because you are too busy getting the new therapist up to speed. And if a current crisis is the reason you are considering switching therapists, it could be a particularly bad time.
On the other hand, if the current relationship is not good and you don’t feel comfortable with your therapist, it may be time to leave.
Changing therapists is not taboo as it was 20 years ago. This idea was new in 1985, when research was first showing that changing therapists, even months into therapy, could be beneficial if the patient is not satisfied with the relationship and that dissatisfaction persisted. [Goleman]
So here are some concrete items to consider in your (my) decision.
First, a bit on what psychotherapy REALLY is
To understand what helps make therapy and a therapeutic relationship a success, it is first important to understand what therapy IS. Ainsworth presents a wonderful article entitled, How to choose a competent counselor that covers this and many other relevant topics.
The most important aspect is the foundation of trust and a sense of safety between the client and therapist. I have read in many places that this relationship is more important than the technique that the therapist uses. It is vital in order to allow yourself to be vulnerable to another human being, but “it is this very process of self revealing and trust building that can be the means of your healing. At the end of this frightening and difficult path lies the inner wholeness you long for.” [Ainsworth]
While I don’t think she is specifically referring to multiples, the idea of “inner wholeness” is a broader way of defining integration. It does not imply that all alters are fully integrated, but allows for the possibility that full cooperation among selves can also constitute inner wholeness. Yeah.
I like Aimsworth’s description that the therapist should provide of a “secure frame” or a safe place to allow yourself to be vulnerable. This frame is both the physical environment of therapy, as well as the structure of therapy and relationship with your therapist. She asserts that many researchers feel this frame is vital to therapy, and deviations are unconsciously felt by the patient which can adversely affects therapy.
Deviations that can affect safety in therapy may be less obvious things like not having a regular meeting schedule. “Flexible schedules” can actually leave the client feeling unsafe, that there is not structure of support. Financial issues can also impede on progress. These unconscious things that plant the seed of discomfort are something to consider when starting therapy, and again when deciding to switch therapists. [Aimsworth]
Read the entire article – it includes many topics about selecting a therapist, what to expect, what you deserve, more links, etc.
Continuing on that theme, a researcher named Gudrun Frerichsin exapnds on the idea of a “therapeutic relationship in her article The importance relationships have in the treatment of Dissociative Identity Disorder Rather than the sometimes unequal level of power between the therapist and client, she relays that the therapeutic relationship can also be referred to as “mutual recognition.”
My newest research study showed that they had the important function of facilitating the development of resilience and distress tolerance which, paradoxically, assisted the recovery process.
Predictors of success in therapy
How do you know therapy will be successful? These predictors are often referred to in the literature as “determinants of successful therapeutic outcome.” This really just refers to the aspects of the relationship between you and your therapist that tend to be the best predictors of how well you ultimately do in therapy. Seems that the answer is universal – the relationship between client and therapist.
As part of his dissertation, Reynolds found that good advice and understanding, taken together, were strongly associated with continuing or completing treatment in his study.
[T]he patient’s own feelings about the quality of that match, experts now suggest, may be a key indicator of how successful the therapy will be. [Goleman]
Research performed by Lester Luborsky and reported by Goleman indicate that there are three main aspects to a positive personal alliance between therapist and patient:
- The patient’s belief that his therapist and the treatment are helping him, so that he feels some new understanding of his problem and is hopeful about feeling better and working out his problems.
- The patient trusts the therapist and his ability to understand and help him.
- The patient and therapist have common expectations. The patient feels he and the therapist share common ideas about his problems and about therapy, and is not trying to impose his own views.
The therapist’s ability to form an alliance is possibly the most crucial determinant of his effectiveness. [Luborsky]
Okay, this is great. But what happens of that trust is not fully established, or breaks down. Can the relationship be salvaged?
One indicator of good fit between patient and therapist, and of how well therapy is progressing, is the ease with which the patient can bring up any negative feelings to the therapist.'[Goreman]
So it’s all about safety and trust. The relationship. Is that so surprising?
Choosing a therapist
First, let’s talk about some of the recommendations for choosing a good therapist, and see how they relate to positive therapeutic outcomes and to leaving a therapist. I will list here the items that I find recommended by many references, and the ones that resonate the most with me.
- Trust your instincts. If you don’t feel respected or listened to, seek out someone else.
- If the person’s pet theories don’t fit what makes sense in your case, seek out someone else. If the person doesn’t want to deal with your diagnosis and hasn’t kept up with the research, go somewhere else. [Kreger]
Sidran Institute has volumes of excellent information on dissociation and trauma. One article presents much information on choosing a therapist. Without repeating the whole article, they present the four most important things a therapist can offer:
In general, the most helpful therapists are:
- willing to share information about themselves as helpful and appropriate
- have respect and a high positive regard for their clients
- are warm and empathic
- are responsive and hopeful
- have firm boundaries but are not domineering.
Here is a reference for the alphabet soup of credentials for therapists: Credentials.
What patients want
I read some forums (which I rarely do) about what patients want from their therapists. From the PSTD forum, Post-Traumatic-Stress-Disorder forum, and Crazy Meds forum. Items tagged * indicate items mentioned by several people.
- Pays attention *
- Maintains eye contact
- Listens but also helps me along and shares with me; instead of me talking and them just staring at me. I prefer a flowing conversation. It helps me feel comfortable and build trust. *
- Be good listener, ask good questions *
- Would like to know if therapist has ever experienced what patient is going through – would like therapist to share a little personal information to build trust
- Don’t just prescribe meds if therapist has a prescription pad
- Is this person doing his/her own inner work, receiving regular supervision/mentoring? *
- Therapist has training/certification/part of a professional body/professional experience regarding your concern(s)/symptoms/diagnosis *
- How do you feel in the office – “appropriate” level of neatness/clutter for your own comfort? #
- Open to innovation and not be stuck in old practices.
- Challenge me (also challenge me gently) if I what I am saying is BS, or denying, hiding, or shutting down. Not sensing that I was lying, believed me when I said I was fine. * #
- Nonjudgmental, not yell at me * #
There is some expected overlap between this list and the list that Sidran presents. (Sidran Institute has a wealth of information for trauma and is an excellent resource.) I was interested in the similarities and differences between the researchers/practitioners and the patients themselves. I placed a # next to items in the patient’s list above that are echoed in Sidran’s list.
But what is more interesting are the non-overlapping items. What Sidran lists and patient’s don’t, and what patients want that Sidran doesn’t suggest.
In addition to the above #’s; Sidran also stresses that good therapists should have the following as well:
- Will not get upset if you disagree with what he or she has said, but instead encourages you to express yourself when you do not agree.
- Will not try to force you to talk about things that you might not be ready for.
- Wants neither a friendship nor a sexual relationship with you outside of your counseling sessions.
- Is more than willing to discuss problems that might arise between the two of you within the therapist/client relationship.
- Will help teach you new and healthier ways to cope.
Patients mention the following, not echoed by Sidran in this list (although a few appear elsewhere)
- Pays attention
- Maintains eye contact
- Sharing a bit of personal experience to show understanding and empathy
- Desire that therapists keep up with current research and are involved in professional societies/training.
I find it interesting that Sidran’s list includes items that seem targeted to overreaching goals or guidelines of therapy, while the patient’s list includes more specific requests that would help meet these goals. Strategic versus tactical. Forest for the trees.
Other tactical items I have seen elsewhere include
- Defining specific milestones for progress in therapy, and have progress review sessions to review the list and track progress. This gives the patient a tool to measure progress, and can proactively address the stress of knowing if therapy “is working.” [Grold]
- Understand what goals signal the end of therapy.
Also, check out the post Bad Therapy Warning Signs by Keepers Corner that lists some really specific DID concerns. While it is a serious topic, one reader who commented added what may or may not be humor: “Beware of therapists who tell you not only do they have DID but they have alters with the same names as yours.”
Sound like the “roadmap” I have been searching for? 🙂
Your responsibilities in therapy
Below are some realizations that patients have had about their relationships and responsibilities in therapy. These come from the same forums listed above.
Be honest with your therapist. The patient who admitted lying to her therapist was advised to be honest She then admitted that the advice was good, otherwise “how can she help me. She can’t read my mind!” But another patient countered, indicating that a good therapist should be able to see through that.
Give the relationship a little time to solidify. “[M]aybe I should give it some time and give my Therapist a little more time. I have only had two sessions with her.”
Realize therapists will not get offended if you leave. If they are good, they understand. I see several patients on forums feeling pressured (by themselves) to stay with a therapist because they didn’t want the therapist to be upset with them.
How do you know if therapy is working?
How do you know if therapy is helping? As Grold states, establish milestones to evaluate progress, and define what constitutes the endpoint of therapy.
Ainsworth asserts that the answer is in all of us – in our subconscious, and that we need to be aware of the signs our inner selves are sending. Dreams are a common pathway to the unconscious, and she suggests that dreams that include being held and comforted are more suggestive that therapy is working than dreams of someone breaking into your home. [Aimsworth]
On a personal note, I have come to learn a lot about myself through dreams – my dreams are quite vivid and often pretty easy to interpret now that I have tools to do so. Last night, I dreamt of a knife on a table, and woke in my dream to realize this was the dream about my continuing therapy. It tells me that my feelings are still mixed – I was attacked by knife point, so I still sense danger (and I know trust is a current problem in my therapeutic relationship) but the knife is on a table, and not in someone’s hand. That tells me that the relationship is in negotiation – on the table between us. I still have the decision to make, and that is why I am writing this article.
The end of therapy
The job of therapy is to make the therapist expendable. (Joseph Napoli, MD, associate chief of psychiatry at Englewood Hospital and Medical Center in Englewood , New Jersey)
It is never a good idea to stop therapy abruptly without discussing it first with your therapist. The decision should be a mutual one. [Grold]
Therapy apparently has a normal endpoint. Tom Cloid is a mental health counselor who has two sites dealing with mental health issues I poked through: Sleight of Mind (I just love that play on words!) and his professional site.
He writes about the end of therapy – what it means, how to decide, and how to do it. Great article. Leaving may be difficult and distressful for the patient because therapy is often an intimate relationship, a revealing of life details. Not sexual, but sharing some of the same emotional intimacy as in a relationship or good friendship. “Intimate knowledge creates vulnerability. Where intimate knowledge is asymmetrical, vulnerability is also.” This asymmetry refers to the therapist in a more powerful position – which can be easily exploited to ruin the relationship. Therapist and client should be partners in the healing as much as possible.
Leaving therapy is hard, even if the time is right. Cliod lists several reasons: you may never have left therapy before. Your therapist may not have prepared you for it. You have unfinished business. Other people want you to stay. Then, he goes into some detail addressing each of these issues, and admits that managing the end of therapy is not something well discussed in his field.
Rather than present each item, I’d rather summarize some of the major points, and direct you back to his good work. Think about how these points relate to your situation.
The strongest theme through his article is that the client needs to talk to the therapist about all concerns, especially concerns about leaving. It may be the first therapeutic relationship for a client, and he/she simply does not know how to decide, and then how to actually initiate termination. Therapists are taught that the client makes the decisions – the client decides with therapy is over. But how do we (the clients) know how to evaluate this? Tough point, and he recommends that therapists directly address the issue before it becomes an issue.
Patients may have an internal conflict about staying/going, and this is normal. (And for multiples, damn near universal! Some parts want to stay, others want to go.)
Another issue deals with feelings and expectations. After a point, you may find that the therapist has become more interested in your issues than you are. He admits that some problems are fascinating and therapists may get caught up in working with it – after all, it’s their chosen profession. Also, some clients (like those I quoted above) relay that they don’t want to hurt the therapist’s feelings. Cloid reports that this is common with young women who are in touch with their maternal side. While this may be true, and while therapists are people too and often enjoy working with their clients and often develop a strong sense of compassion, the “therapist has experience with this problem, and can take care of themselves.”
Your therapy is about you, and it is your decision to leave. Other people in your life may have reservations about your leaving therapy, talk to them and get their concerns. Cloid relays that they may provide useful information you are not seeing, and they may have their own fears unrelated to you. But you have to ask for specific details.
But leaving is a loss, and managing a loss can be difficult. Another thought is that you have the option to leave therapy and then return. A trial separation, to see if you are truly ready to leave. Talk to your therapist about this option – it can provide a sense of relief that there is a way to see if your decision to leave is a good one.
Cloid also provides some sample statements to take to your therapist if/when you are ready to end therapy. Good stuff. See if any resonate with you. But he stresses that the theme of his advice is to take your issues to your therapist and deal with them calmly as issues.
One of the issues to address in leaving is the ending date. It should be several sessions in the future rather than immediately. This period is also to address the feelings of loss, and for “further exploration and emotional growth.” [Plotkin] Therapists should encourage clients who decide to leave immediately to spend a few sessions wrapping up and addressing the end.
Premature termination of therapy
From my research, understanding the endpoint of therapy is difficult for patients, and not often well addressed by therapist.
In his PhD dissertation, Reynolds explored factors involved when patients leave therapy before the therapist feels that treatment is complete. Patients were asked to rate several aspects of their therapy and these were compared to the patient demographics – information about themselves. Reynolds found that
[individuals who terminated therapy early] rated as significantly lower their overall benefit from treatment, and the extent to which their therapists were likable, understanding, and gave good advice.
“[G]etting good advice” and “being understood” were the best predictors of early termination. Meaning, those who did not feel they were getting good advice or felt the were not understood were the most likely to stop therapy early.
Although Reynolds considered several demographic factors, he found that “race (African-American), education (lower), and income (lower) have consistently been associated with premature termination.” His conclusions for this are interesting and probably apply to many people in therapy to some extent – the concept of “fast-food mentality.”
At first I was taken aback, but I think he is right.
“[P]remature termination from psychotherapy may reflect the larger social phenomenon of dropping out (from school, from work, from community involvement), which is a result of the fast-food mentality popular media leads many to believe in: that you can have it your way, when you want it, as you like it.
“And if you do not like it you can just walk away. In short, people may transpose their typical expectations for services (from teachers, employers, and fast-food vendors) to psychotherapy, resulting in a tendency for patients to go elsewhere if they do not get what they want.”
That is a strong message, but based on our present reality. Hoffman echos that patients become frustrated with therapy early on, expecting quick-fix results like seen on Dr. Phil.
So I ask myself, is this why you want to run from your current therapist? Make a list of concrete reasons. Take that list to your therapist.
Switching therapists – how to decide
“If you don’t feel respected, valued, or understood, or if your experience is being minimized or distorted, it may be a sign that your therapy is not working. If you feel there is something wrong in your therapy, or if you get upset or angry with your therapist, discuss it in your session. If your therapist discounts your feelings or responds in a defensive manner, you can choose to switch to a different, more respectful therapist.” [Sidran]
Reynolds recommends that the therapist be aware of these factors during treatment (good advice and understanding – considered together ), and address them directly if it appears early termination is a possibility. The therapist needs to anticipate.
One option is to get a second option from a “consultant therapist.” A consultation will help you decide if some aspect of your current therapy is not optimal. These include issues from both sides – perhaps your therapist’s treatment approach may not be a good match for you, or there are changes in your personal situation. If you are so enmeshed in the issues of your therapy, it may be difficult for you to get a high level picture of what the therapy is doing for you – seeing the forest for the trees, as they say. A consultant therapist can help you see that, and help you make a more informed decision. [Carver] [Goreman]
As Goleman reported, switching therapists can be beneficial if the therapeutic relationship is not solid. Some therapists argue that periods of dissatisfaction are normal, and should not be a reason to leave. Problems in therapy are not always the patient’s fault – it doesn’t mean the patient is untreatable and it doesn’t mean the therapist is incompetent. [Goleman] There is just a mismatch where the two do not “click.”
The alliance can be damaged if the patient has ongoing doubts about the therapist’s competence or the therapist’s ability to understand the patient. It may be as little as the “patient’s expectations about what should happen … are not being met.” [Goreman]
Expressing anger at a therapist is part of a normal healthy relationship, as therapists are people too and can make mistakes. [I never] It may be due to misunderstandings, but Louis Hoffman recommends talking it out with the therapist, even though some topics may be uncomfortable. [Hoffman]
Items to consider when thinking about changing therapists
In addition to the above, here are some more things to consider.
My best friend and my husband both independently posed another question for me to ponder.
Are you leaving this therapist because she told you something that you didn’t want to hear, or because there is really something wrong with the relationship?
That shows they have good insight into what makes me tick. I am stubborn and sometimes unwilling to admit I am wrong. Sometimes I pursue the path I want to be true and resist being diverted from it. While this can be a good trait to get a job done or reach new levels in a hobby, education or career goal, it can also be a detriment to personal development.
Resistance can be due to several things – fear of what will come up in therapy, difficulty trusting, a basic character trait (whether honed from trauma or not)
Transference. Transference is a “biological time machine.” “A nerve is struck when someone says or does something that reminds you of your past.” Your therapist reminds you of someone else and that adversely affects your relationship with the therapist. “Termination of treatment pre-maturely is a sign of transference – unless the therapist is just doing a bad job.” [Conner]
Patients from forums also pose the following questions when considering a change of therapists:
- Whether you are making progress or not
- Whether or not you find yourself making the choices you want to be making
- Is there a belief that, if you changed therapists, you would be doing something differently that you’re not doing now? Really? What is that something? How do you see the change in therapist affecting that?
- Why the switch now?
- What about the relationship disturbs you?
- Does it feel unsafe?
- If it’s an issue of frustration with failure to progress, has it been discussed with the therapist?
- Is the type of therapy method used uncomfortable to you? (“The therapy is psychoanalysis, modern Freud. I hate the couch.” “It’s endless psychodynamic therapy. No benchmarks, milestones, whatever. On the one hand, I like that nothing is rushed. On the other, I hate that a snail moves faster.”)
Either before and/or during therapy, continue to evaluate if your therapist is right for you. Your therapist should provide the “secure frame” to allow you to feel comfortable and safe. If doubts arise, make a rational list and raise the issues. Plan a session specifically to do so, because your therapist (if they are good), know how to deal with it and what to establish your trust. Changing therapists can be positive but also has negative aspects – time invested, re-interviewing therapists, etc. Make the decision carefully.
Questions to take to your therapist
Let me state up front that this list is targeted to me, although many of the items here may be relevant to many other people. So, may issues you may need to bring up may be different, or missing here. Please do your own research, perhaps using this article as a starting point, and develop your own list. This is the email that I sent. (Ed. note: Please be aware, this email caused quite an explosion as I report in a later post.)
(To my therapist)
I would like to continue to work with you. I want to be able to. I would like to talk about the following in no particular order.
I will say up front, I know we have covered some of this before. I don’t remember what we discussed. Which is also an issue. With me. So I ask that you be patient with me and answer some of these again. I am maybe bringing my husband to Monday’s session so he can hear this to to help me remember/interpret, etc. And also for his information.
- What is the end goal of this therapy and how do we know we have reached it? Are there intermediate milestones I can use to gauge my progress? At one of my last sessions when you said I had made so much progress and I said I can’t remember enough to feel that, you said that eventually I would. Since I am more aware of my obvious memory problems and my issue with remembering positive things, is there anything we can do to help me recognize this progress?
- Tell me about your training. Where, how much, what did you learn about treating people like me (severe dissociation, DID, PTSD).
- Tell me your thoughts on this diagnosis. I can’t help this lingering doubt you believe. I wonder if you keep up to date on research in this area. I am worried that you don’t. Tell me about patients you have treated, some of the methods you used (yes, everyone’s recovery is different) and their relative success. Help me really believe inside that you have the tools and experience to treat me and that I will get better following this path..
- I have an inability to trust others and that is a problem. This is clearly related to my trauma history, but it is impeding complete trust in this relationship. It also prevents me from being able to reach out for help to you and others when I most need it. I know this is a problem with me. How will you help me address this?
- Please give me feedback on what you think are the biggest impediments to my success here. What are the major problems with my perception of reality? What do you think the cause is – is/are they related to my trauma history? And, how do we address them? I understand this may trigger me and I will try to be prepared to hear this analytically and not emotionally. You told me one thing last week which I understand, and it makes me suspect there are more I need to hear.
- The rage is here in deadly pockets. You have given me one skill to address uncontrollable rage (overwhelm as many senses at once…I submerged myself in a cold river to the point of mild hypothermia, while seeing the beautiful colors of spring and seeing/hearing the creatures around me.) I am paralyzed in your office – how do I work through the rage if I don’t feel I can there? Or, when I obviously am very angry and unable to communicate, how to we try to open that channel?
- Sometimes I feel like you are treating me like the kids you treat. I can’t define it – maybe it seems like you talk down to me. Or the way you try to sooth me I can’t identify with and it feels wrong. My perception may be wrong, I can’t define it any better than that, and I don’t know how to deal with that, but I know it affects my ability to open up completely.
Part of me wants this relationship to work. Another part of me has lost the trust. I do want to find it again, but I need to discuss these issues in order for me to feel in my gut if we can continue.
Am I a hard sale or what? <smile>
Which brings me to #8
8. Dark humor is good. I like humor. Do not be afraid to use it more with me. It is an easier way to convey heavy shit. This all doesn’t have to be so serious.
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