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Portland Marriage and Couples Counseling

 
Bernard McDowell, LCSW
Psychotherapist & Licensed Clinical Social Worker
  811 NW 20th Avenue, Suite 104, Portland, Oregon 97209
503-234-9904
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Choosing A Therapist

     Unlike giving a neighbor an unsolicited recommendation for a plumber, people tend to keep their couples counseling experiences private. They are also more likely to be emotionally biased and less knowledgeable when evaluating a therapist.  Conversely, many people are reluctant to ask friends or family for recommendations.  Further, how informed would their recommendations be?

     Insurance companies recommend therapists based on the licensure status of the therapists under contract with them, geographic location, cost, and on the questionnaires those therapists filled out about their “specialties”. Corporations or government agencies often have Employee Assistance Companies which, by contract, refer only to therapists on particular insurers’ panels. Of course, that doesn’t say much about whether that therapist will be a good fit for a particular client.
Most importand factor to consider
Gender or Sexual Orientation?
School of therapy or specialization?
Ask questions!
What to expect in first phone call with me.

     Clients, not knowing much about where to begin searching, often pick someone of the same gender while others frequently seek out a counselor of the same religion or with the same status-- married with kids or divorced, etc. People with a little more sophistication may look for a therapist advocating a particular type of therapeutic theory. Below, we take a quick look at some of the research on key factors and offer a few practical suggestions for your consideration.  (Please feel free to jump ahead to what to expect in an inital phone call to me.)

What is the single most important factor to consider?

     The great preponderance of research on outcomes of counseling underscores that the most highly correlated factor to positive outcome is the rapport between clients and therapists—one study found the highest correlation with rapport as rated at the end of the second session. So, as the rest of this article emphasizes it makes sense to evaluate your initial contacts with potential therapists in terms of whether you felt she or he was, at least, trying to tune into your concerns. However, that research implies that you may have to pay for a few sessions before settling on a therapist.

Is gender or sexual orientation important?

     Some research concludes that the outcome of therapy is the same whether the therapist is a woman or a man--irrespective of the client’s initial gender preferences. That’s one statistical result which may not apply to you and it doesn’t mean not to seek out a counselor of a particular gender.

     A very common scenario at the beginning of couples counseling starts with a woman calling male therapists on the premise that her “macho”, therapy resistant husband needs a “strong male” to get him to listen. Conversely, a woman may feel outnumbered by a male therapist and her male partner. For a moment let’s consider the first case, if he is more inclined to see a male therapist and she is willing also, that’s a good enough start. However, a successful course of counseling with a female therapist may help the couples’ relationship and establish a reference experience for both spouses--that he can have a respectful relationship with a powerful woman; on the other hand, not all male therapists hold their own with an intimidating or reluctantly participating male. In this scenario, better information than the counselor’s gender is the therapist’s comfort level with men who have a bias against therapy (or tend to express anger, etc).

Rather than start with a gender preference, you may put direct questions to potential therapists about their experience and comfort level they have with a husband fitting that description or with women clients; or with gay people.  Unfortunately, research on gay and lesbian couples isn't nearly as extensive as on heterosexual couples.  The leading scientific researcher, John Gottman, attributes that to the extra degree of getting funding for that research.  Given that, my advice is to go with your intuition about who you are more comfortable beginning with.

What is most important: Theoretical school of therapy or Specialization?

     First, let's consider an important distinction about the term, "specialization". Unlike certain branches of medicine like orthopedic that reinforce highly standardized treatment protocols, specialization in types of "mental health" problems (e.g., anorexia, depression or anxiety) tells us very little about the how that person works with their clients. And that's not necessarily bad. Once again, research indicates that the rapport is more important than almost any factor including the therapist's specialty. I’ll go further one step further: more critical than their "specialization" is a therapist's theoretical approach and/or counseling style. First, note that the term “specialty” has little legal standardization in therapy. At best, the mere fact that a therapist advertises a “specialty” tells us that they've had a certain amount of general education towards their status as a therapist, further continuing education credits in that specialty, and unspecified amount of experience with that type of problem.

     However, in the field of psychotherapy there are literally hundreds of different educational programs and theoretical approaches to resolving psychological issues. The following examples illustrate how understanding the theoretical style of a therapist may give more valuable information than whether they "specialize" in a particular problem. Imagine a client seeking help for depression and considering three different therapists all specializing in depression. Using a rigorous traditional "psychoanalytic" approach, the first therapist seeks to stimulate the client to gain insight by asking questions and listening quietly. The theory is, that eventually, as the relationship matures, clients reenact the same dynamics with the therapist as they had with their parents; but now, with the therapist, there's a chance to end old, unconscious patterns causing the problem. Psychoanalytic therapy addressng depression will likely have much more in common with psychoanalysis for anxiety or trauma than with a gestalt or cognitive therapy treating depression

     "Cognitive-behavioral" therapy [CBT] proceeds on the premise that depression stems from faulty cognitive (thought) patterns.  Here's a simple example.  If something goes wrong for a depressed person, they may say "I always suck".  "Always" is a type of word called a universal quantifier.  It portrays our experience as fixed and in this case, negatively. The cognitive therapist may challenge the use of "always" by asking the client if "always" is really accurate or if there have been exceptions.  The client is then urged to stop using universal quantifiers because, at least in some small way, that reinforces their depression. Of course, there are dozens of other thought patterns to be addressed.  Again, if you were a fly on the wall watching CBT therapy for depression, it would look an awful more like CBT for other conditions than it would look like psychoanalysis for depression.

     Various family therapies, group therapies, psychodrama, and Ericksonian therapy among a number of other methods aim to create more directly what some call a "corrective emotional" experience. For example, if a woman links her depression to difficulty asserting herself or saying no to others, a Gestalt group therapist might ask everyone in the group to ask the client for something.  She is given the task of telling them no.  If she agrees to try this experiment, she's practicing saying no but if she refuses to play along, she's also getting the direct experience of saying no (to the therapist's suggestion).  Either way she may have, at least, a mini corrective emotional experience.  That seems ridiculously artificial in this brief explanation, but such experiences emerge quite naturally in therapy and can be very effective.  Once again, the point here is simply to notice that in these brief examples the "specialization in depression" tells us much less about what the actual therapy experience is like than understanding a little about the style of therapy.

Though their differences are highlighted here, in practice most schools of therapy aren't at all mutually exclusive. Despite their claims to be unique and exclusive, a careful examination of therapy reveals that at times each method actually relies on similar techniques at any given moment in therapy.

     In an exhaustive review of decades of research, Dr. Bruce Wampold concluded that the qualities of specific therapists were much more important than the type of therapy they advocated. Further, many schools of therapy have claimed to be THE best or only “empirically supported” type; but those claims consistently fail under the scrutiny of research.

     Keeping that research in mind, I’ll add my personal bias for couples counselors taking an active, catalytic role. In individual therapy, especially longer term work, therapists may do well to take what looks like a more passive role—asking question occasionally to keep the focus on the client (rather than the therapist’s assessment).  But with couples, if the therapist is passive, the couple quickly reverts to their well practiced patterns of conflict which they came to therapy to resolve.

Ask Questions

     Even with a suggestion from a friend or a referral from another professional, the success of therapy depends on a number of intangibles.  Many people find that identifying a therapist who will work them effectively isn't a simple straightforward process.  Here are some of my own practical suggestions.

     Call and talk on the phone first with several potential therapist; try to have 10 minutes or so aside in case the therapist is free to talk. If you’re like many people inquiring about couples counseling, you may be upset at the time of the call.  So take a few extra breaths and gather your wits to get information about the business arrangements clear.  It may be wise to ask prospective therapists questions about their style, how they might work with your type of concerns, and about their fees and availability.  More important than the information you’ll get from this approach is the opportunity to get a sense for the rapport you might have with each therapist.  To the point made above you may ask about their assessment of whether their style is more active than passive. Freely ask about their fees and policies; take note of whether they take the time to be clear in detail about their cancellation policy and what kinds of payment they accept.  I’d pass if they deflect those questions by saying they’ll discuss when you come in.  After that it is matter of picking someone and going to a first appointment.

     Remembering the study correlating success of therapy with rapport at the end of the second session, freely bring up any concerns you have about whether the therapist is on track with what’s important to you.  Rather than expect the therapist to tune into you perfectly or remember every detail, put more stock in how he or she responds when you bring up a problem or correct them about their misperception.  If she or he takes your feedback and adjusts accordingly, you’ve got a working relationship.

What to Expect In Your Initial Phone Call With Me
     In initial phone call  I will invite you to ask questions you may have.  I also have a few of my own.  The goal of my questions is to make an assessment of whether your concerns, as you formulate them, are in my domain of experience and competence.  It's true that given 20 years of experience working with couples, I don't encounter many curve balls anymore but occasionally I may decide someone else would be a better fit for you.  I that case, I'll happily refer you to that specialist.  My main questions go to learning a little about what you hope to address, a connect the dots version of what see as the problem?  If it seems we are a likely match, I'll review fees, formats, and we can look at our schedules and set an appointment time.

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