Choosing A Therapist

Mary Gail Frawley-O'Dea, Ph.D.

Executive Director, Trauma Treatment Center - Manhattan Institute for Psychoanalysis

Co-Author, Treating the Adult Survivor of Childhood Sexual Abuse: A Psychoanalytic Perspective

It can be a daunting task to begin looking for a therapist to assist in the journey of recovery from sexual abuse. It may be difficult to know what to ask, what not to ask, what are generally appropriate treatment parameters, etc. Since it is important to work with someone you trust, as well as someone you "click" with, these guidelines may be helpful in selecting the right person for you.

Consultations: You are looking for another human being whom you can trust to guide you through the sometimes treacherous shoals of recovery from sexual abuse. You have both the right and the responsibility to gather data to help you make a good decision. It is not unusual for someone to have one consultation session with at least three therapists before choosing someone with whom to work. Most therapists will charge for a consultation, and it is money well spent to be sure you make a choice that is healthy for you.

What to Ask at a Consultation: In addition to being a person in need, you are a consumer. Again, you have the right and the responsibility to ask a potential therapist enough questions to get a sense of the way s/he works and how comfortable you are talking with him/her. Some things to ask:

Years of Experience: How many years has this person practiced as a psychiatrist, psychologist, or clinical social worker?

Trauma Training: What specific training and/or supervision has the therapist had in working clinically with abuse survivors? Until the 1980's, there was little formal training available in trauma. Since then, many academic programs and postgraduate institutes have added trauma courses. Other therapists have sought out seminars, conferences, and supervision with clinicians more experienced with sexual abuse survivors.

Look at the Bookshelf: If the therapist displays a collection of books, look for titles on sexual abuse and psychological trauma. It gives you a sense of the person's interest in this field. Some people keep their books at home, though, so don't leap to conclusions.

Personal Therapy: Most clinicians feel it is imperative to have gone through their own therapy before or during their professional careers. Some postgraduate programs require that the therapist be in treatment during training. Some people disagree with me, but I think it is a fair question to ask a potential therapist if they themselves ever have been in treatment. It is NOT fair to expect the therapist to talk about how long s/he was in therapy or for what reasons. Most therapists also will not say if they themselves were abused, at least until well into treatment, if at all, and this is appropriate boundary setting.

Approach to Therapy: This can be a little tough to answer, but I think you can ask a therapist how they generally work. What do they think is important in therapy: changing behaviors, changing beliefs, identifying how past relationships continue to be played out unconsciously in the present? Are they active therapists who engage in a "conversation" or are they more quiet, speaking mostly to make interpretations? There are no right or wrong answers here, but the responses help you get a feel for what it might be like to work with this person.

Therapeutic Frame: What is the therapist's cancellation policy? It is not unusual for a therapist to charge for missed sessions depending on the circumstances and insurance cannot be billed for those sessions. What is the person's policy regarding between session contact - e.g. phone calls - if you are having a difficult time? What is the fee, and how does the therapist expect to be paid? For instance, some therapists collect only the co-pay from insured patients and wait for insurance to pay them the rest. Others want to be paid in full and let you collect the insured portion of the fee. Again, there is no right or wrong, but it's good to know ahead of time. Is the therapist available for more than one session per week if you need it?

Psychiatric Referrals: Does the therapist work with a psychiatrist who is also knowledgeable about trauma and to whom s/he can refer you if medication is needed? Don't be surprised if it is needed. Many survivors of sexual abuse greatly profit from antidepressants, anti-anxiety agents, or mood stabilizers for various periods of time. One has to suffer to recover but not beyond what is necessary to do the work of therapy. Medication often allows someone to make better use of treatment and recover more quickly. We know now that trauma effects the brain, not just the psyche. The new medications help a lot.

Limits of Confidentiality: Review the limits of confidentiality with your potential therapist. All therapists will break confidentiality if you are a lethal threat to yourself or someone else. In those cases, the therapist can and must do everything possible to protect you life and/or the life of another person. If you tell the therapist that a child is being abused, by you or by anyone else, s/he must report it. If you are in litigation, you should know that your therapist's records and/or sworn testimony legally can be supoenaed. The therapist can argue client privilege, but if ordered by a judge to comply with the supoena, s/he can be held in contempt of court for not going along. Beyond those limitations, the contents of your sessions and any other information about you should be held in confidentiality by therapist. In no cases, beyond these mentioned, should a therapist share information about you or your treatment without your written and very specific permission.

Therapist's Expectations: What does the therapist expect of you? What is his/her view of the therapeutic alliance and each party's role in it?

Contract: It is often helpful for you and the therapist you choose to contract for six sessions in order to come to a final decision about working together. At the end of six sessions, you both can review how you think it is going and whether or not it is a good match for you. This kind of beginning allows both of you a fixed time to decide to go further or to part company.

Once You Start: When you have begun to work steadily with a therapist, you may develop doubts about how things are going. Since therapy for a sexual abuse survivor often is rocky, it is important not to bolt without carefully considering with the therapist the reasons for leaving. If you don't hate your therapist at some point, the work probably is not getting done.

On the other hand, it is also important to feel that you can terminate a treatment if it really is not working for you. Since recovery from sexual abuse often involves a volatile therapy, it is a good practice to set the same kind of six-week contract before leaving that you did when you began. Once you feel that you want to leave, talk to the therapist about your experiences of the treatment and see if you can contract for a six-week mutual discussion of the issues before a final decision is reached. Many therapeutic partnerships that seem to be foundering have find it tremendously helpful to consult another therapist skilled in the area. Whether the therapy is then rescued or ends, both the therapist and the patient may feel validated and affirmed by having a consultation with a third party.