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Dear Dr. Saltzman--

Just wanted to say how much I appreciated your reply to the last question posted on your "Ask Dr. Robert" page: How Can I Forgive Sexual Abuse?. Also the way you addressed the woman torn about her child and her child molester boyfriend was a bitter pill of truth you somehow managed to still lovingly prescribe. God I hope you "got to her" in that she did the right thing for him, for her self, and for her child.

In fact there is very little about your insights, in general, that haven't totally inspired me. I would like to know though, why is most therapy such a failure, and why aren't there more insightful therapists around like yourself? What's the fundamental problem here with the therapeutic community at large? Is it the individuals themselves or is it their training? How does one find therapists like yourself?


Dear Monica--

Thanks for your kind words. I do put heart and soul into this work, and I am always glad to hear that someone has been helped.

Therapy is no different from any other profession in that there is a spectrum of competence ranging from those who are just marvelous at the job, to those on the other end of the spectrum whose lack of skill and/or lack of ethics is positively criminal, and the spectrum naturally includes everything in between.

But therapy is a bit different from many other service professions because there are no objective standards by which the competence of a therapist can be estimated. For example, if I take my car to an auto mechanic for repairs, and the car is running fine when he or she returns it to me, and if I am not overcharged for the work, then I feel confident in using his or her services again, and probably would recommend that mechanic to a friend. In a similar way, a surgeon will have a record, reviewed by his or her peers, of the outcomes of surgeries performed. But if I am depressed, for example, and spend thirty or forty hours speaking with a therapist, and then, if after all that expenditure of time and money, I am still feeling depressed, how can I know if the fault is with the therapist's approach and competence, or if my depression is just a difficult case which might need more time to heal?

Really it is even more complicated than that since a certain therapist might be helpful for one person, but not for the next, while a therapist who would not have been any good for the first person, might do just fine with the second. And again, this is not easy to determine in advance.

To answer your specific question: a good therapist is both born and made by training. The best therapists begin their training already being what I like to call "naturally therapeutic." The naturally therapeutic kind of person is recognized, perhaps even from childhood, as a good person with whom to speak about problems. He or she is known as a good listener, and seems naturally able to soothe and encourage someone with a troubled mind. But even with this natural gift, a long period of reading, training, and supervised practice will be required so that the naturally therapeutic person can learn the many things that good therapists need to know: everything from the details of various mental disorders and their treatment to how to conduct a therapeutic interview.

Can someone who is not naturally therapeutic become a good therapist? With sufficient motivation and good training, probably yes, but perhaps not the very best kind of therapist, since the most delicate therapeutic work is done with the heart, not with the intellect, and the special gifts of compassion and non-judgmental consideration towards others are not easily taught or readily learned.

Unfortunately, many are attracted to our profession who are not naturally therapeutic, and some are attracted also for the wrong reasons (such as wanting to solve their own emotional difficulties, wanting to make a lot of money, or wanting to have power over others). Further, psychotherapy training ranges from excellent--my teachers, for example, were special people, deeply dedicated to helping others through therapy, and also to training people like me to be good therapists--to just appallingly bad.

In the hands of good teachers like the ones I had, the person who is not suited to practicing good therapy will be discouraged from continuing, even if that means having to give that person failing grades or even denying him or her a degree. Indeed, from my initial class of around forty therapy students, fewer than half graduated, and only some of these actually went on to practice. But some psychotherapy training academies are for-profit situations which are little more than diploma mills, turning out one incompetent, badly trained therapist after another. And licensing examinations are ill-fitted to deciding if someone is qualified to do effective work. In some places, there are no exams, or, if there are, they may be little more than a formality. In fact, in some places a person can claim to be a "therapist" without any training at all.

I won't lie to you: in my opinion, there are far too many inadequate practitioners of psychotherapy, and these incompetents often injure the people who consult them. I know this because, sadly, a significant part of my work involves trying to repair the damage done by unskilled or even criminal "therapists." And there is no easy way of removing these unqualified people from the consulting room: Since what goes on in therapy goes on in private, any complaint will almost always end up being a kind of "he said, she said" argument which the patient seldom can win.

Nevertheless, there are many good therapists out there, and some really great ones too, so if you need therapy, please don't be discouraged. Just look for a good one, and keep trying until you find someone you feel you can trust to help you.

Since there also are some bad therapists, the rule in choosing a therapist must be caveat emptor (let the buyer beware). In other words, be careful. Be as careful as if you were choosing a brain surgeon, or someone with whom to spend a long time on a desert island. If you begin therapy and it feels wrong, don't wait. Just leave and look for someone else. If you keep looking, you will find the help you need.

Here is some advice about choosing a therapist:

1. The therapist is there to serve your needs, not vice versa. Therapy should always be about the patient, never about the therapist.

2. You should feel free to say anything at all to your therapist. If your therapist has "boundaries" about what you can talk about or say, find a new one.

3. You should feel that your therapist is doing everything possible to hear you and understand you. If you do not feel this way, try discussing it with the therapist. For example, you might say, "You know, doctor, often I feel as if you are not really hearing me, or, if you are, you don't seem to understand what I mean." If you do not get a good answer to this kind of question, get a new therapist right away.

4. Feel free to ask your therapist about his or her training and approach to the work. If you don't get good answers, find a new therapist.

5. If your therapist makes any demands whatsoever besides that you pay the fee, find a new one.

6. Try to find a therapist who does not have a political, religious, or "spiritual" agenda of his or her own. In my experience, the best foundation for effective therapy is for the therapist to follow the patient's interests and ideas, not to try to convert the patient to those of the therapist.

7. If you feel sexual "vibes" coming from the therapist, or if you feel unsafe for any other reason, feel free to ask him or her what is going on. If you do not get a good answer, find a new therapist.

I could go on with this list, but you get the idea. When you buy therapy services, you have the right to be a tough customer, and an educated consumer. If you need a referral to a therapist, ask friends you trust, and/or ask the department of psychiatry at your local hospital.

Be well.

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