I was in private practice before commissioning into the U.S. Public Health Service. My practice specialized in providing services to adults and adolescents who were experiencing signs and symptoms of stress, anxiety, depression, relationship issues, and/or other concerns with general wellness or well-being. Since becoming a PHS officer, I have maintained a small caseload of clients to whom I provide services pro bono. I am not currently accepting new clients. If you are interested in finding a therapist and receiving services, I offer the below information to assist you in being an informed consumer.
The purpose of therapy is to help clients realize change and experience improved quality of life. Just as healthy diets are not only for those suffering from obesity, but can also benefit those of a healthy weight. Just as physical exercise is not only for those who lead sedentary lives, but can also benefit those who are active and even athletic. Just as education is not only for the unlearned, but can also benefit the scholarly. So too is therapy not only for those with a diagnosable mental illness, but can benefit anyone seeking to realize change and experience an improved quality of life.
Making changes to improve quality of life is critical to overall wellness. As you will note from my Wellness Model, the well-being you experience in multiple domains of your life are interconnected. If you are experiencing financial problems, for instance, this can have a negative effect on your relationships, your housing situation, your ability to access healthcare, your physical health, and so on. If you are experiencing relationship problems, this can have a negative effect on your mental well-being, your job performance, your faith, your diet, your physical health, etc. The good news is: the opposite of this is also true. When you experience improved mental well-being, for instance, you also tend to perform better at work, participate better in your relationships, be more physically active, have improved physical health, and so on. No part of your life exists in a vacuum. It is important to leverage your successes as resources to build upon and create more successes. It is also important to accept the things you cannot change and let go of the resentment, anger, frustration, or animosity you may harbor so they do not further compromise your well-being.
Bringing about and maintaining these changes is a difficult process. This is why New Year's resolutions have a success rate lower than 10%. When I was in private practice, my clients enjoyed the inverse of those odds: a success rate greater than 90%. Therapy can be useful for those who are looking to improve the quality of their lives and prefer a 90% success rate to a 10% success rate.
What Many Therapists Are Not Likely to Tell You
(but you deserve to know)
Most therapists will explain the limitations of therapist-client confidentiality. This will include a discussion of their status as a mandated reporter, which requires they carry out a Duty to Report and a Duty to Warn if the occasion arises. A therapist will breach confidentiality to report to legal authorities if you present a threat to harm yourself or someone else, or if you provide information suggesting a minor or vulnerable adult (i.e., elderly person or dependent adult) is being abused or neglected. A therapist will also breach confidentiality to warn a third party directly if you present a clear plan to physically harm that party. These are usually the only two duties the therapist will explain in detail. Then the therapist will have you sign an Informed Consent form before providing you services. But do they tell you what you really need to know in order for you to provide consent that is actually informed? They should! This is called Duty to Inform.
A therapist's Duty to Inform requires that you be told what you need to know as a potential client about how therapy works; what methods, techniques, and approaches the therapist uses; what success rate the therapist has with clients; how the therapist measures success; and so on. If you were having a surgical procedure done in a hospital, you would want to know the answers to these questions, wouldn't you? A client needs this information in order to make adequately informed decisions and provide actual informed consent. So I am going to answer some of these questions for you now.
What Therapy Is and How Therapy Works
In a very general sense, therapy (i.e., psychotherapy, talk therapy, counseling) is a process of expressing your concerns to a therapist, who listens and provides useful feedback. This process ideally yields greater insight into the client's circumstance(s), solutions to the client's concerns, and continual progress toward and ultimately realization of those solutions. So what are the common factors that account for the client experiencing positive change, and how do these factors measure against each other?
40% - Client and Extra-therapeutic Factors
Client factors are those things that make up who the client is biologically, physically, physiologically, experentially, etc. These would be things like the client's height, age, race/ethnicity, and sex/gender; whether or not the client has terminal cancer, graduated from college, was born into a loving family, or is an introvert.
Extra-therapeutic factors are those things that exist outside of the client and outside of the therapy session. If a client has therapy 1 hour a week, extra-therapeutic factors are those things that happen in the client's life the remaining 167 hours of that week. These would be things like whether or not the client was the victim of a crime, won the lottery, was in a car accident, fell in love, had difficulty sleeping because his/her neighbors played loud music all night, or had a Whole Foods open just around the block from where the client lives.
In my practice, I approach all issues from what is called a strengths perspective. Many times, a client does not realize all the strengths he/she has. It is easy to overlook what you have going for you when you are distracted by what is troubling you. I help the client identify the good things that make up his/her client factors and extra-therapeutic factors, and then we strategize how best to use those things as resources for addressing the problems, issues, and concerns that the client wants to work on.
30% - Therapeutic Relationship
The therapeutic relationship refers to the quality of the rapport the client has with the therapist. This is more than just whether or not the client and therapist "click." The therapist can do a great deal to make sure the client feels heard, understood, safe, valued, respected, and so on. To this end, I practice a person-centered approach. In a general sense, this means I see you as a whole person, more unique and complex than the single thing that brought you to therapy. Specifically, this means I practice congruence, empathy, and unconditional positive regard. Congruence is the act of being genuine and authentic. You are trusting me with your vulnerabilities; I owe it to you to be honest and transparent. Empathy is a sincere desire to understand and appreciate the client's perspective. Unconditional positive regard is accepting the client without judgment—neither approval nor disapproval. It is not my job to judge you, and I have no interest in doing so. My job is to accept you as you are, and to provide my services in a professional and ethical manner.
15% - Therapeutic Model/Technique
Therapeutic model(s) and/or technique(s) are those conceptual skillsets the therapist employs to actually address the client's concerns. In my practice, I predominantly use cognitive behavioral therapy.
Cognitive behavioral therapy (CBT) is an evidence-based treatment that focuses on the client's presenting problem (sometimes also called a chief complaint), and is oriented toward taking actions that resolve the presenting problem. CBT is comprised of two types of therapy: cognitive therapy and behavioral therapy. Cognitive therapy primarily endeavors to educate the client on the nature of his/her diagnosis and the treatment moving forward, and to assist the client in developing healthier and more positive thought patterns. Behavioral therapy aspires to help the client develop healthier and more positive behavioral habits and physical reactions to stressors and other stimuli.
15% - Hope and Expectancy
Hope and expectancy is also known as the placebo effect: the tendency of a treatment to exhibit results simply because the recipient believes that it will work. The placebo effect is a legitimate phenomenon that can yield actual improvements in the client's condition. This is why randomized controlled trials are considered the gold standard in clinical experimentation, because they eliminate (or control for) the placebo effect that can confound results.
The critical component that drives the placebo effect is the client's belief that the treatment will work. I garner this belief from my clients through a simple concept: competence earns confidence. I find that if I do my job and do it well, and measure my results to prove that I do my job well, then my clients develop confidence in my abilities. This confidence yields a belief that our work together will produce desired results. And this belief in turn actually helps create the desired results. It becomes part of the treatment via a positive feedback loop; a self-fulfilling prophecy.
So how do I measure results? I employ treatment measures that assess three domains: the client's experience with our sessions, the client's experiences between our sessions, and the client's progress towards his/her desired treatment goals.
The below figure illustrates another way to conceptualize the aforementioned common factors and how I address each of them:
I hope the above information helps to give you a better understanding of what therapy is and how therapy works, and makes you a better informed consumer if you are interested in finding a therapist and receiving services. If you have questions or feedback, please feel welcomed to post to my blog or send me an email at the below address and I will be glad to respond.