How to Choose a Psychotherapist: A Guide to Recognizing Competence
What to look for and what to look out for.
Upcoming workshop: I’ll be leading a full-day clinical case discussion workshop on April 25: Treating Challenging Patients: From Case Formulation to Shared Treatment Focus. Open to clinicians and trainees worldwide via Zoom.
Student rates available. Early Bird registration now open.
Having taught psychotherapy to many cohorts of psychologists and psychiatrists, I am well-versed in the major therapy models—and therefore do not impose them on my patients.
Red Flags
Beware of therapists who are over-identified with a therapy “brand.” They’ve already decided how to treat you before they even meet you. Also beware of therapists who claim expertise in many approaches. No one is expert at everything. You may end up with a dilettante, or someone more concerned with filling hours than serious work.
Beware of those who promote themselves as experts in a specific diagnosis. A diagnosis tells us little about how to help. The causes of suffering are generally woven into the fabric of our lives—how we live, how we see ourselves and others, how we connect or fail to connect, what we desire and dread, what we know about ourselves and do not wish to know.
A psychotherapist’s expertise lies in understanding how this fabric is woven and can potentially be rewoven, not in applying diagnostic categories.
The causes of suffering are woven into the fabric of our lives.
Finding a Focus
The initial sessions should establish a shared understanding of what is really the matter—an understanding that makes sense to both of you. “What is really the matter” is not your depression, anxiety, or eating disorder; it’s what’s going on psychologically that causes or perpetuates it. This becomes the focus of psychotherapy.
This shared understanding may emerge in the first session or over several. It will evolve as therapy progresses. But there should be a focus from the beginning: both participants must know what they are there to do.
The Therapeutic Alliance
Many therapists speak of the “therapeutic alliance.” Few understand what it means. It’s not just feeling connected. A therapeutic alliance is based on a shared purpose—a shared understanding of the work to be done. Three elements are required:
Connection.
Mutual agreement about the purpose of therapy.
Mutual agreement about the methods to achieve that purpose.
All three elements are necessary. I often see the first without the other two. This makes for warmth and support, but not psychological change.
The shared understanding must be truly shared. It cannot be just the therapist’s understanding, or just the patient’s. It is something patient and therapist develop together, transcending what either can know alone. If you could already say what is the matter and why, you wouldn’t need therapy.
If you could already say what is the matter and why, you wouldn’t need therapy.
When the Patient Doesn’t Know What’s Wrong
My students often ask what to do when patients have no idea what is the matter. They know something is wrong but can’t say what. They may feel empty, lost, or stuck. This is where the therapist’s expertise and perspective are essential.
One possibility is that the patient may be a stranger to herself. I might say, “Something feels very wrong, but you don’t have words for it.” If she agrees, I may suggest: “It could help to find words. If we can find words, we’ll see more clearly. Then we may see how things could be better.”
Then I ask—and this is crucial, because the understanding must be truly shared—“Do you think it would help to find words for what is wrong?” If she agrees, we have an initial treatment focus: our shared task is to find words. Neither of us can find the right words alone, but we can together. The treatment focus will evolve, but we have a starting point. Next time we meet, we both know what we are there to do.
I make a recommendation to proceed with treatment only when we are on the same page about its purpose.
If she does not think finding words will help, we keep exploring until we find a focus we both believe in. I make a recommendation to the patient to proceed with treatment only when we are on the same page about its purpose.
I don’t always take “yes” for an answer. If a patient agrees with a treatment focus in a way that feels like acquiescence, we don’t have a shared understanding. If she agrees because she thinks I know best—because I’m the “expert”—we don’t have a shared understanding. But I have a new hypothesis about what may be wrong: if she is accustomed to deferring to authority figures about what she should think or feel, it may explain why something feels wrong that she cannot put into words. I will bring this up for joint consideration.
How to Choose
So how do you choose a therapist? Steer clear of ideologues and “experts at everything.” Don’t look for someone who claims to specialize in people with exactly your problem, because no one else has exactly your problem.
When you meet, notice whether the therapist seems more interested in you or in your diagnosis. Notice whether the therapist invites you to think together about what is the matter. Notice whether you are able to develop a shared understanding of what is causing difficulties, one that rings true but wasn’t already obvious. The last part may take a few meetings, but the work should be moving in that direction from the start.
If all these ingredients are there, you’ve likely found a good one.
Related Essays
Getting Started in Psychotherapy: A Guide for Patients (and Their Therapists) (September 3rd, 2025)
What Every Therapist Needs to Find Out in the First Session (October 7th, 2025)
50 Therapy Red Flags (November 24th, 2025)
15 Therapist Green Flags (December 15th, 2025)
A Psychiatric Diagnosis Is Not a Disease (January 5th, 2026)
More writing, interviews, and related work on my Linktree.
I agree with all of this. I’d also add that the theoretical orientation or background of therapist matters far less than the non-specific factors, such as whether the therapist seems someone you can work with, who cares for your welfare, who will keep confidence, etc. The theory is more for the therapist to maintain a sense of order in the chaos, just as a biologically oriented psychiatrist might think in neurochemical terms to maintain order. Again, it’s the non-specific factors that largely determine the therapeutic outcome. I’d also say, give the therapist a chance - don’t give up after the first session; but don’t play a sunk cost game either. If after a few sessions (rarely, after the first one), if the non-specific vibe just isn’t there, move on. But don’t go therapist shopping.
I have to say that I have been extremely impressed with the "reality based" therapist that I got by some miracle from BetterHelp. She was the first one I'd ever encountered whose goal it was to help me graduate from therapy -- to not need it any more! It was a very difficult eight months where I had to do a lot of exhausting emotional work, as well as prove to myself that some assumptions I had made about myself and things that were fixed and unchangeable were just wrong. I don't think this is a "brand" but more like a results-based approach.