Medications A-Z: The Prozac Family (SSRIs)

The most commonly prescribed class of antidepressants today are the selective serotonin reuptake inhibitors (SSRIs), the so-called "Prozac family" of medications, of which Prozac was the prototype, but which also includes Zoloft, Paxil, Luvox, Celexa, and Lexapro. They are widely prescribed because they are very safe and generally well-tolerated, and they are highly effective at improving a person's mood and reducing symptoms of tearfulness, hopelessness, irritability and also anxiety, including panic attacks, obsessions, and compulsions.

Because they all share the same mechanism of action--increasing the bioavailability of the neurotransmitter serotonin--they are all remarkably similar with respect to how they help, as well as in regard to their side effect profiles. This is because, by and large, it is the increase in serotonin itself that is responsible for both the beneficial effects on the brain as well as the bothersome physical effects that occur elsewhere in the body, such as the GI tract. Various types of serotonin receptors are widespread throughout the body and wherever serotonin acts upon one of these receptors, you get an effect, sometimes a desired effect, but also more often than not, a side effect. In this respect the SSRIs are remarkably similar; differences are usually a matter of degree. Where these medications tend to differ more so is in relation to their effect at other, non-serotonergic, receptor sites, such as acetylcholine or histamine receptors, which is what accounts for the differences in their side effect profiles and hence, their tolerability for a given patient.

Practitioners are fond of saying that the choice of SSRI is an empiric one: starting an SSRI for the first time, making dosage adjustments, resuming therapy and/or switching to a new and different medication in this class is essentially a trial-and-error process, they explain, but that doesn't mean that it is completely arbitrary or haphazard (although some prescribers tend to want to approach it that way). Educated guesses can be made before a medication trial is undertaken, if not regarding how useful a medication's effect on an individual's mood will be, then at least with regard to how well or how poorly it will be tolerated. This mindfulness on the part of the prescriber, as well as the person agreeing to subject himself to a trial of this type of medication, can avoid wasted time and an unpleasant experience.

So, how best to choose among this family of medications? Well of course your doctor will be the one making the final recommendation, but with regard to treatment with an SSRI there is never only one option for a patient (unless she's tried them all). This article explains what considerations should go into that decision-making process; there is no reason why, armed with a little information, you cannot be an active participant in that process. It is you who will be taking the medication, after all. Why not help your doctor save you some trouble and/or wasted effort, if you can?

Assuming this is the best class of medication from which to choose, there are two main considerations: 1) selecting a medication that is likely to work and 2) selecting the medication that will best be tolerated by the patient. Because the SSRIs are more-or-less equally likely to work, the ultimate decision is more often based on the second consideration.

Selecting an SSRI that is likely to work. Assuming that the diagnosis is correct and that medication management is indicated in the first place and that the target symptoms in question indicate that an SSRI would be the best initial option (agitated, irritable depressions and/or anxiety states), I have already stated that there is little to predict beforehand whether one or another SSRI will ultimately have the desired effect; unless there is prior history to indicate one way or another, they all start out with the same likelihood of helping. Although in general we can expect that certain symptoms will be significantly reduced on these medications as a person's threshold for tearfulness or irritability or feeling overwhelmed is raised with increasing serotonin levels, in terms of overall efficacy--in terms of remission--it is never possible to predict with 100% accuracy whether a given compound will "work" on a person's depression. Likewise, while panic attacks can always be stopped with these medications if taken properly, residual, sometimes unacceptably high levels of generalized anxiety may fail to completely resolve despite treatment with one or another SSRI, necessitating a switch of medication.

The lesson here is that, while some people respond better to one SSRI over another, to a large extent this is unpredictable. Differences in efficacy are idiosyncratic; that is to say, they depend largely upon the individual who is taking them, and they do so for unknown biological reasons. And so we try one medication to see if it works, and we ensure that a good therapeutic trial is completed before trying something else, if necessary. However, what I have found in my practice is that switching from one SSRI to another is not usually because of a lack of effectiveness, but instead due to tolerability issues. By anticipating these tolerability issues (which is more methodical than anticipating efficacy), time and frustration can be saved.

Selecting the SSRI that will best be tolerated by the patient. While the reasons for differences among individuals in terms of the efficacy derived from medications in this class is a mystery, differences in tolerability can often be explained, and even predicted, by the relative affinity of one SSRI versus another for certain receptor types. If you reviewed the complete prescribing information for any of the following medications, you would be left with the impression that all of them can cause all of the same potential side effects, which is true, but the clinical reality is that some of them are much, much more likely to cause certain side effects than the others. All you need to know as a patient is that one SSRI tends to cause more diarrhea or constipation or dry mouth than another, or that a given SSRI tends to cause more weight gain or more sexual dysfunction than the others, etc.

Likewise, if you read the pages and pages devoted to each medication in the Physician's Desk Reference (PDR), you would come to realize that nearly every side effect known to man has been reported at one time or another or associated in some way or another with every known medication, rendering an encyclopedic book like the PDR practically useless to the individual who just wants to know which side effects are likely, not which ones are possible. Of the 1001 potential side effects listed for any given medication, there are only a handful of truly common problems.

When I first started routinely prescribing these medications in the mid-nineties there were only four available SSRIs in the United States, but even then I had no idea how Prozac would be different for a patient than Zoloft, or Paxil versus Luvox. Now, after having prescribed these medications for more than a decade, although they all share the same general side effect profile, it has become clear to me which SSRIs are more likely to induce which unacceptable side effects, and to what degree. (Remember that, often, it is simply a matter of degree to which the medications differ.) For example, while they all induce sexual dysfunction, some are simply worse offenders in this regard. Similarly, while they all can cause weight gain, some unequivocally have a greater propensity to do so. What follow are some general profiles, what you might expect from treatment with one SSRI versus another.

All of the SSRIs tend to cause diarrhea, headaches, queasiness, restless legs/body, sexual dysfunction (delayed orgasm, decreased libido), sweating/hot flashes, lethargy, yawning (not related to feeling tired), waking up in the middle of the night, jaw clenching, and weight gain. Sounds terrible, but any list of potential side effects does. The fact is that many of these side effects, if they present themselves at all, are mild and resolve over time. Given that the above-listed are all common SSRI side effects, the side effects mentioned below are not being highlighted because they are in any way exclusive to the medication in question. Rather, the medication in question is simply especially prone to inducing those particular side effects. Given that they are all equally likely to help, carefully consider which unwanted effects you would most like to avoid.

The following blurbs are not at all meant to be comprehensive. They are not even highlights; they are highlights of the differences of each medication with respect to its sister medications. The last thing I'll say here is that there are always exceptions, of course, and you may be that one rare person who actually gets more diarrhea on Paxil than on Zoloft, but otherwise these guidelines will prove true, time and again.

Prozac (fluoxetine). Still the most famous, in part because it was the first, Prozac truly revolutionized the pharmacologic treatment of depressive and anxious mood disorders when it was released in 1987. It was far safer than the first-generation antidepressants available up to then, particularly in overdose, and induced far fewer side effects.

One of the things that distinguishes Prozac from the other SSRIs that followed is that it has an exceptionally long half-life. A drug's half-life is a measure of how long it takes the body to metabolize it away. The longer the half-life, the longer the drug remains in circulation in its original form. Once drug levels have reached steady-state, it takes five half-lives to clear 97% of the drug. The half-life of most SSRIs is approximately one day, so stopping them means they will be cleared by the body in about one week. Fluoxetine, on the other hand, has a half-life of 4-6 days with chronic dosing, and its active metabolite norfluoxetine has a half-life of 1-2 weeks. Compared with most other drugs, this is extraordinarily long. The practical implications are that, because a drug's half-life also affects how quickly it builds up to steady-state levels in the body with regular dosing, 1) it takes longer for Prozac to reach therapeutic levels, possibly delaying the onset of action even more so than what is typical for these types of medications (typically around two weeks) and even more significantly, 2) when you stop taking Prozac, it can take 5 or more weeks to fully exit your system, although the clinical effects of the medicine will begin to wane long before that. One advantage to this is that Prozac withdrawal is not seen; you can abruptly stop taking the medication and it tapers itself out of your system (abruptly stopping any psychotropic medication is generally frowned upon, however). One disadvantage would be a delay in switching to a different medication or starting a new medication that cannot be co-administered with Prozac, such as the MAOIs (monoamine oxidase inhibitors).

Prozac is also known to be among the more "activating" of SSRIs. It tends to cause jitteriness and motor restlessness (akathesia) more so than some of the others. Prozac may not be the best choice if you are already troubled with restless legs syndrome or the general inability to sit still for very long periods of time due to motor restlessness.

Prozac is also famous for what is affectionately called the Prozac "poop-out." It is not at all uncommon for any SSRI, after a time, to not work as vigorously as it did initially, or even to stop working altogether. Usually a simple dose adjustment is all that is needed to jump start the treatment, but sometimes a medication switch becomes necessary. I have certainly seen many cases of "Prozac poop-out," although it is difficult to say based on anecdotal evidence alone whether Prozac is truly more prone to this disappointment than the other SSRIs. Why a medication stops working or stops working as well over time is a complicated issue that may have a lot to do with extra-pharmaceutical factors as well.

Fluoxetine (the generic preparation) is also marketed in the U.S. under the brand name Sarafem. Sarafem was approved by the FDA for the treatment of symptoms associated with premenstrual dysphoric disorder (PMDD) in adult women, but it's just fluoxetine; a generic preparation would work as well. In fact, any of the SSRIs are useful in lessening the emotional lability some women experience due to hormonal shifts that occur mid-cycle. SSRIs are well-indicated for both PMDD as well as milder premenstrual syndromes.

Prozac Weekly. When pharmaceutical companies lose their patent on brand-name medications and other companies are allowed to sell generic preparations of the drug, the original company will often rebrand the medication in order to hold on to some of the market share for their product. This was the case with Sarafem. A more aggressive strategy involves obtaining a new patent for a medication by either slightly tweaking the molecule (so that legally it is now a "new" compound) or else revamping the delivery system by pairing it with a different vehicle or placing it in a new type of capsule. Although the pharmaceutical companies spend many hundreds of millions of dollars developing and marketing these novel preparations, many times it amounts to nothing more than a marketing ploy. The most common scheme is to take a drug and place it in an extended-release capsule.

Prozac Weekly is just that: 90mg of good old fluoxetine in a fancy, enteric-coated capsule that dissolves more slowly and thus releases the medication more slowly, but that's not what allows for once-weekly dosing. It is fluoxetine's exceptionally long half-life that facilitates once-weekly dosing, and there's nothing new about the half-life. As a psychiatrist, I never recommend once-weekly dosing of any anti-depressant; the only reason to dose once a week instead of every day is apparently a matter of convenience, although this is arguable, since it may actually be more challenging to remember to take your medication if you only take it once a week, as opposed to every day. When Prozac Weekly was first released, the manufacturer touted the fact that once-weekly dosing would allow individuals to feel "less daily dependence on the need for medication" that many patients find stigmatizing, but this does not change the fact that individuals who are clinically depressed do, in fact, require daily levels of the medication that the long half-life allows, even when it is not being taken every day. Marketing ploys aside, my own preference is to be completely upfront with my patients and to educate them regarding the exact nature of their need for treatment, whatever that may be, and to encourage destigmatization in other, healthier and more honest ways. The last thing I would ever want to do as a psychiatrist is to downplay the physical nature of a patient's major mood disorder and lull that person into a false sense of security by promoting the idea that his illness is not so serious because he "only needs to take medication once a week." Too many patients who truly need medication to function and remain safe already underestimate their need for treatment and eventually disregard their regimens, often with disastrous results. But, if I ever were to recommend once-weekly dosing, a patient could just as easily take generic fluoxetine once a week and save a lot of money.

Zoloft (sertraline). Zoloft was the next SSRI to be developed, and it was just as effective across the board and just as well tolerated as its predecessor, with subtle differences that varied from individual to individual. In my experience, Zoloft is not as overtly activating as Prozac, although akathesia is common enough. Zoloft is also one of the SSRIs that is especially prone to produce diarrhea. And again, while the other SSRIs also frequently cause loose stools--at least initially--the diarrhea that Zoloft brings on is often more pronounced, and often endures for a longer period of time, than the others.

Unlike Prozac, which is often started at the target dose of 20mg, Zoloft is started at 25mg, a subtherapeutic dose for the vast majority of people, thus it requires more of a titration to reach the recommended dose, which could eventually be as high as 200mg for some. With each adjustment, side effects like diarrhea can reappear even after they had previously resolved (although this effect becomes attenuated over time as well; in general, the more dosage is tolerated, the less increasing that dosage further will renew old side effects).

Plenty of patients have noticed weight gain on Zoloft, but in my experience it is not the worst in this regard (see Lexapro, and especially Paxil).

Paxil (paroxetine). Paxil is the most potent inhibitor of serotonin reuptake in vitro. Clinically, I have found it to be the most aggravating in terms of sexual dysfunction. Many patients report complete anorgasmia on even starting doses (10mg or less). This makes low-dose Paxil an excellent treatment for premature ejaculation, but something of a problem in treating depression and anxiety, particularly at the higher doses recommended for those conditions.

Paxil is unusual among the SSRIs in that it is highly anticholinergic; that is, it blocks one subtype of receptor that is normally bound by the neurotransmitter acetylcholine. The result is side effects such as dry mouth, constipation, and blurred vision for close-up objects (e.g., text on a page). Anticholinergic effects can also include a subtle impairment in short-term memory. For this reason, Paxil is usually a poor choice for an elderly person, who may already be experiencing significant problems with constipation, presbyopia and noticeable short-term memory loss.

And while all of the SSRIs can potentially lead to weight gain, Paxil is one that I consider notorious for doing so. I avoid it in patients for whom this is a particular concern.

Unlike Prozac, Paxil is also one of the SSRIs that is associated with a peculiar discontinuation syndrome. I call it a "discontinuation" syndrome, as opposed to "withdrawal" purposely, to avoid the notion that Paxil is in some way addicting. In the classic sense it is not. However, because of its particular neurochemistry, abruptly stopping this medication or abruptly lowering the dosage--or even for some people taking it a few hours later than scheduled--can lead to dizziness, flu-like symptoms and paresthesias that feel like tiny, lightening-fast "electric shocks" in the brain. These paresthetic jolts do not represent seizure activity and they are more uncomfortable than painful; they are not harmful and they eventually subside, but they are very unpleasant.

SSRI withdrawal paresthesias (also commonly experienced upon the abrupt discontinuation of Luvox and Effexor, which has an SSRI component) are exacerbated by rapidly turning or moving the head, which can bring one on, and by stimulants. Conversely, they are reduced in intensity or blocked entirely by mild tranquilizers and do not wake people up from sleep. The way to avoid them is to avoid abruptly stopping the medication, which is always ill-advised. The recommendation is always to lower the dose gradually over several days under a doctor's supervision before stopping the medication entirely. If you are going out of town you want to take extra precautions not to leave your Paxil behind, and you want to avoid getting caught between refills for the same reason.

With all of its extra tolerability issues, Paxil is often clinically superior to the other SSRIs in certain conditions that require a truly potent serotonergic medication. I have seen it outperform the other SSRIs, even at maximal doses, in generalized anxiety disorder and obsessive-compulsive disorder in particular. Paxil definitely has its place.

Luvox (fluvoxamine). Luvox is not as well-recognized among laypersons, due in large part to the fact that it was originally approved and marketed for the treatment of obsessive-compulsive disorder, which is not as common as other anxiety disorders and major depression. But as repeatedly stated above, all of these medications are useful for all of the same types of depressive and anxious mood disorders.

Like Paxil, Luvox is associated with a pronounced "withdrawal" syndrome if not gradually tapered before discontinuation. Like Zoloft, Luvox typically has to be titrated from a starting dose to a significantly larger final dose and is more likely to cause GI disturbances than the others, either loose stools or alternately, constipation. Weight gain is another not uncommon issue with Luvox.

Celexa/Lexapro (citalopram/escitalopram). Whereas Paxil is the most potent selective serotonin reuptake inhibitor, Celexa and Lexapro are the most selective, referring to their relative effect on serotonin receptors versus other receptor types; i.e., among SSRIs, their action is the most specific to serotonin receptors. Lexapro (escitalopram) is the left-handed stereoisomer of Celexa (citalopram). Escitalopram is the biologically active molecule; the right-handed enantiomer is not only inert with regard to blocking the reuptake of serotonin, but actually competes with the left-handed enantiomer, so that by removing it from the mix, both potency and efficacy are increased. Lexapro can therefore be thought of as a "purified" form of Celexa that works better on a milligram-per-milligram basis because the active component is not competing with the inactive component for receptor sites.

If Paxil has the worst sexual dysfunction, Lexapro typically has the least. However, like Paxil, Lexapro is notorious in my book for causing significant weight gain. I have also noticed (and this of course is purely anecdotal) more "rebound" symptoms between doses in anxious patients taking Lexapro. I have had several cases in which panic attacks and symptoms of social anxiety seemed to do worse at various times of the day despite consistent dosing and even with divided dosing.

Effexor (venlafaxine). Effexor is actually a dual-acting agent: it was the first commercially available (non-tricyclic) serotonin-norepinephrine reuptake inhibitor, or SNRI. SNRIs can be advantageous over SSRIs based on their dual mechanism of action and indeed have been shown to be somewhat more efficacious with respect to depression. They may also have a more rapid onset of action, which I have certainly seen with Effexor in some cases.

I include Effexor in this discussion because at low starting doses, Effexor is essentially an SSRI. The affinity of venlafaxine for serotonin reuptake is many orders of magnitude greater than that for norepinephrine and noradrenergic reuptake does not occur until higher doses are reached. Effexor's side effect profile is very similar to the other SSRIs, with significant sexual dysfunction and a marked discontinuation syndrome. In my experience, I have seen a lot more temperature dysregulation (sweating and hot flashes) in patients taking Effexor, but no weight gain, which is rare with Effexor.

Other considerations that come into play in choosing one SSRI over another may be practical: cost, for example, or whether or not the medication is supplied in liquid form, for those patients (children, usually) who are unable to swallow a capsule. Most of the SSRIs are also available in extended release (XR) or controlled-release (CR) preparations, which, although their development may have been prompted by corporate financial interests, can nonetheless be very useful at reducing immediate side effects by prolonging absorption and simplifying a regimen to once-a-day that you might otherwise be taking in divided doses throughout the day.

Family History. One other point bears mentioning in any discussion regarding psychotropic medication selection. Importantly, if you have a blood relative--particularly a first-degree relative, such as a parent, sibling or child--who responded favorably to a particular medication, you have a statistically higher probability of responding favorably to that medication yourself, so inasmuch as selecting a psychotropic medication can be a trial-and-error process, be sure to mention that to your prescribing doctor if you know about it.

Tip: Ask for samples. If you are trying a medication for the first time, your doctor will often be able to provide you with free samples or a coupon for a free month's supply.

How to Engage in Meaningful, Successful Psychotherapy

More people than ever before are seeking professional counseling services. Thankfully, the stigma of seeing a mental health professional is waning and people are becoming better educated regarding the various options available to them. Needless to say, psychotherapy can be extremely helpful and--assuming there are no major contraindications (see below) and the client-therapist relationship is a good fit--it is almost always a good idea if a person is at all interested in it. Unfortunately, a trial of psychotherapy can also result in disappointment and/or even greater confusion. This article discusses how to embark upon meaningful, successful psychotherapy by setting goals, avoiding pitfalls and engaging your therapist.

Pick the right therapist. Because the start of a successful psychotherapeutic endeavor begins with the therapeutic relationship itself, selecting the right therapist is of paramount importance. This not only gets you off to a good start, but will prove absolutely vital to your ultimate success. It is a complicated issue, and there are no guarantees, but it is the sine qua non of engaging in successful therapy. It is also one of the most uncertain tasks, especially when practical considerations such as geographical location, availability and cost come into play.

A therapist is not a friend. Therapists and clients do not, and should not, socialize outside of scheduled appointments. While many clients want to become friends with their therapists and even understandably consider themselves to be on friendly terms, it is never appropriate for a degreed professional to seek personal validation and social enjoyment by dropping his professional role and adopting the client as a friend. This is not only counterproductive, it is unethical. Similarly, a therapist is not a parent, a therapist is not a policeman, and a therapist is not a personal savior.

A good therapist is well-trained, experienced, non-judgmental, empathetic, unbiased, open to feedback, transparent (honest, upfront and sincere), and directive when you need it or ask for it. She is there to facilitate your growth and to help you help yourself and solve your own problems; she is not there to take charge or solve them herself. See my previous article, "How to Pick a Good Therapist", for some general guidelines in making this selection.

More specifically, the type of therapist you choose to see may depend upon your particular concerns. There are therapists who specialize in a host of specific conditions, such as chemical dependency counselors and other addictionologists, relationship counselors, therapists who specialize in eating disorders, forensic psychologists, and others. Within these groups there may be further differences, as various therapists subscribe to various forms of therapy, based on one school of thought or another. For example, there are cognitive-behavioral therapists, interpersonal therapists, psychoanalysts and other psychodynamic therapists, group therapists, hypnotherapists, faith-based counselors, etc. A discussion of all of the available forms of talk therapy is well beyond the scope of this article, but see below for some links to organizations that can provide additional information.

Manage your expectations. The degree of satisfaction we come to derive from any given venture depends in large measure upon our expectations going in. When expectations are excessively high, this can be a setup for disappointment. Conversely, when expectations are unreasonably low, this can sabotage the process by preventing us from adequately investing of our time and energy. Decide what you are looking for and identify any reservations you might have, and discuss this openly at your first visit. Managing expectations involves being in touch with why you are seeking counseling in the first place. Perhaps you were referred by someone else, but in that case you should especially do some soul-searching and ask yourself why (or even whether) you agree that professional assistance is the best next step.

Once you have reconciled yourself to the notion of conferring with a professional counselor, ask yourself: are you needing someone who is going to employ a highly directive approach, an active therapist who will ask a lot of close-ended questions, challenge your previously held assumptions, supply expert advice and give you "homework assignments?" Or are you more interested in someone who will mainly listen, someone to whom you can reveal and with whom you can discuss things you might not yet be able to share with family and friends, a person who can remain objective and who can provide you with a safe forum in which to explore how you truly feel about your situation, as well as give you time to weigh your options in a non-threatening environment? Both approaches are valid and alternately warranted, depending upon the given circumstances. A good therapist is flexible and can provide both.

Frequency. At your first visit you will also need to determine the frequency of visits. Once-a-week, hour-long sessions are standard, but in some cases your therapist may initially recommend twice-weekly sessions, until the crisis has passed and your situation has stabilized somewhat. Rarely, if ever, are more frequent visits called for (traditional psychoanalysis is an exception, but the goal of analysis per se is not really what this article is about). If a person needs to see a mental health professional more than twice a week to function and to stay safe, a brief course of hospitalization is often indicated.

Duration. Therapy can be brief, short-term or long-term. Certainly some individuals have done well to remain in therapy for years with one or more providers, but most practitioners agree that a principal goal of psychotherapy is to foster autonomy and to sufficiently improve a client's situation and symptoms such that she no longer requires frequent, ongoing sessions. To the extent that this is so, from the beginning there is at least the implication of an eventual endpoint, although the exact duration of treatment is not typically discussed or determined at the outset (with the exception of some forms of highly structured brief therapy).

In some cases in which a client has developed a good working relationship with a certain therapist, he may resume weekly or biweekly sessions only during difficult or particularly symptomatic periods and otherwise suspend regular sessions in the interim. Other clients may graduate to monthly visits and remain on that "maintenance" schedule over the long term, to stay on track; this is particularly appropriate for individuals who are in the later phases of recovery from substance abuse or some other form of addiction as a means of relapse prevention, to compliment involvement in a community-based twelve-step program.

Once you have voiced your preferences and agreed upon a general plan for treatment, the next order of business is to focus on what needs to be "fixed." Enrolling in professional psychotherapy is not a casual decision for most people, and so the reason for investing what could be a significant amount of time, money and energy needs to be made explicit. If you are not exactly sure, then this is an excellent opportunity to have that discussion with your new therapist and it will also give you something to report back to the person who initially referred you.

Identify target symptoms. Sometimes the goal of therapy involves understanding and controlling specific target symptoms, such as panic attacks, crying spells, or feelings of hopelessness, helplessness and/or worthlessness. Identifying target symptoms early on is especially important when therapy is a means by which to determine whether or not you should consider a trial of psychotropic medication. One of the things an experienced therapist can tell you is whether or not she feels you might be suffering from a physical condition the cause of which is biological and that you would benefit from a consultation with a doctor who can prescribe medication.

Or, when therapy is part of a multidisciplinary approach in which you are already taking a psychotropic medication, focusing on the reduction or the elimination of your target symptoms in therapy is an effective way of making sure your treatment is well-rounded. Sometimes medications reduce symptoms to the extent that you are then able to accomplish the work you need to do in psychotherapy. Conversely, psychotherapy can always go beyond what the medications are designed to do by assisting you in taking personal inventory and effecting change that ensures your long-term well-being in a way that has more to do with your environment, your relationships, your attitude and outlook on life, and your lifestyle choices. There is a lot of research that indicates that patients do better with a combination of medication and psychotherapy than with medication alone.

Set goals. Beyond defining your immediate needs, the best way to evaluate the outcome of therapy in the long-run is to establish concrete, realistic goals that you hope to achieve and setting a timeframe for reaching (or at least reexamining) those goals. Timeframes, of course, should be flexible and subject to adjustment, as becomes necessary; although certainly in real life, decisions may have to be made and certain problems dealt with in a timely manner, there are never any "deadlines" in therapy beyond which personal growth cannot occur. And while you will want to have thought this through a bit before your first consultation with a new therapist, determining all of your goals is not something you have to have accomplished prior to that first visit. Proper goals evolve over time and your therapist should actively engage you in determining what they are and modifying them as you go along, as appropriate. Whatever else, don't be shy about discussing the treatment plan. How will progress be measured?

Seek to understand. Concrete goals are a good idea, but remember also that the lasting benefits of therapy involve more than having simply put out fires and surmounted specific obstacles. Life is full of trials and there will always be something else to negotiate. What enduring lessons has therapy taught you? For example, one goal might be: "Deciding by the end of the fiscal year whether or not to offer my resignation at work," but this decision could also be paired with gaining a broader, further-reaching insight, such as, "Understanding why I become so frustrated at work and why I resent my supervisor," and ultimately, "Am I satisfied with my chosen profession and will I feel fulfilled doing this for the rest of my career?" Or, alternately, a person might be confronted with the decision, "Do I want to try to salvage my marriage?" and at the same time come to consider questions like, "Have I approached my current and previous relationships in a healthy and compassionate manner? If not, why not?" and, "What do I really need in a long-term companion?"

A perfectly valid, if somewhat more ambiguous, goal for therapy is to answer questions such as these and to come to know oneself better in the process. Of course, with questions like these, it may be that at the outset of therapy you won't even know which ones need answering. Often one of the long-term benefits of psychotherapy is discovering the important questions in your life, and working to resolve them is one of the rewards, even when some of them do not necessarily have definitive, absolute answers, because life circumstances do change, and we evolve as individuals.

Be honest with your therapist. There are many ways to sabotage your efforts in therapy, both purposely and inadvertently. Perhaps the most common is not being completely honest with your therapist. There are two ways to be dishonest in treatment, and thereby to cheat yourself of the full benefit of therapy. One way is to lie or distort the truth. This we do on purpose, and there are many reasons for it, all of which seem like a good idea at the time, but of course lying only detracts from the usefulness of therapy. But examined logically, lying to your therapist is pretty pointless. Remember that your therapist is like your lawyer; she is your advocate, and is not there to judge. She is also bound by the ethical guidelines of her profession, which includes strict confidentiality. There are only a few instances in which confidentiality can be violated (see clients' rights, below), so unless you know for a fact that "anything you say can and will be used against you in a court of law," the urge to deceive your therapist is at best irrational, at worst self-defeating.

The other way to be dishonest is through blatant omission: holding back the truth or the whole truth, often due to feelings of guilt or embarrassment. Sometimes what we don't reveal is more misleading than the little white lies we are apt to tell. Though it may be difficult, do yourself a favor and try your best to tell the whole truth and nothing but the truth. I promise you will get so much more out of therapy! Not having to worry about censoring yourself with your therapist is one of the great benefits of the professional therapeutic relationship; it is one of the things that makes it so unique and that gives it the power to be so helpful to you.

Being completely honest and relaxed can be incredibly liberating and highly therapeutic in itself, but understandably this may be something you will only slowly gain comfort with over time, as you come to better know and trust your therapist. That's perfectly natural. Just don't be afraid to admit to your therapist when the time comes that you may have failed to mention something important early on, or even that you gave an untruthful answer before, because you were unsure. Many times a client will come to feel comfortable fully confiding in his therapist, but then worries about courting the therapist's disapproval because he was not honest the entire time. Believe me when I say that a compassionate, competent therapist will not take it personally and would much rather prefer knowing what she needs to know to best counsel you as soon as you are comfortable enough to reveal it. Better late than never. Unfortunately, when it is part of a client's avoidant personality, sometimes a client feels so guilty about having lied that he can't bring himself to set the record straight, and therapy is then corrupted by an unnecessary tension and the added stress of having to avoid what may be at the heart of the matter.

If this happens to you, trying writing your therapist a brief note explaining why you felt you couldn't be entirely honest before and ask for her assistance in moving through this unexpected roadblock. Remember that in therapy everything is fair game and, inasmuch as it provides added insight into the nature of the way in which you tend to relate to other people and what it says about your emotional sensibilities, many times the therapeutic process and relationship itself needs to be the focus of the discussion for a while to achieve the personal growth that is one of the goals in therapy.

Be honest with yourself. Sometimes you can't be honest with your therapist because you're not being entirely honest with yourself. Denial, rationalization, and intellectualization are some of the defense mechanisms we use to protect ourselves from the sometimes unpleasant truth. Being honest with oneself is perhaps more easily said than done, but like seeking to understand, it is a valid work-in-progress and something an astute therapist will encourage and remind you to do from time to time. As clients, we rely upon the professional's objectivity and impartiality to help us see ourselves more accurately.

Engage your therapist. Therapy is not a monologue (again, with the exception of classical psychoanalysis; Freudian analysis is a form of therapy with many extremes). Instead, psychotherapy should be a dialogue between client and therapist, so don't be shy about asking questions, providing critical feedback, and even challenging your therapist's assumptions if they don't make sense to you or you fundamentally disagree. Your therapist may have training and experience and some measure of objectivity on his side, but he is not infallible. Not only that, but it is in the exchange of ideas with a therapist that some of the most important discoveries take place. Remember that neither you nor your therapist know everything that is going on with you at the start of therapy, or for that matter, at any point along the way. An active, vibrant discussion keeps the lines of communication open, prevents misunderstandings, spontaneously gives rise to new hypotheses worth exploring and at the very least, assures you that you are being heard.

Don't sabotage treatment. I've already talked about how anything less than complete honesty can detract from and even derail treatment, and I mentioned how low expectations and skepticism can sabotage you before you even get started, but nothing wrecks the entire process more completely and permanently than abruptly walking away from therapy because of a momentary flash of emotion. Sometimes it's anxiety, usually it's anger or hurt feelings, but it's always a bad idea if you do it without first signaling your intention and scheduling at least one final session to discuss your reasons for doing so. It could be that you are justified in your decision, and that terminating therapy is actually the right thing to do, whether you take a break from it completely or find a new therapist with whom to work, but if you act impulsively and you don't process it with your therapist before you abandon treatment, you might miss the opportunity to either clarify a simple misunderstanding, or else, at the very least, speak your mind and leave the therapist with something to think about for his next client. Especially if you are motivated by anger to "fire" your therapist, give yourself some time to calm down and give your therapist the opportunity to refer you to someone else so you can continue to work on your issues. Remember that therapy is for your benefit, not your therapist's, and you should never make decisions about your treatment based on hard feelings aroused in you by something your therapist said, or something he did or didn't do.

The other possibility is that you are feeling vulnerable or threatened precisely because you are getting somewhere in treatment. Therapy is not always comfortable, and it can actually be a bit stressful or even daunting at times, depending on the strength and nature of your defense mechanisms. Particularly if you want to quit altogether, ask yourself if you are not avoiding moving through and dealing with something difficult or painful.

Know your rights. Because getting the most from psychotherapy requires a certain piece of mind (for example, regarding the legal limits on confidentiality), familiarizing yourself with your rights as a therapy client can be an important part of committing to the process, especially if you are new to it.

Confidentiality. The law in all 50 States protects the privacy of communications between a client and a psychotherapist, but there are limited situations in which a therapist is permitted or required to disclose information without your consent. These are situations involving certain court proceedings when a judge issues a subpoena, if you file a complaint or lawsuit against your therapist and the therapist has to defend herself, specific diagnostic and treatment information as requested by your insurance company in order to authorize payment for services rendered, situations involving the potential abuse of a child, or an elderly or disabled person, or if you make a serious threat of homicide against a specific person, and you have every intention of actually carrying out that threat, the therapist may be required to notify the potential victim directly and contact law enforcement. Depending on the law, minors who are not emancipated may also have their treatment record subject to review by their parents; it is best for teenagers to come to a clear understanding with their therapists regarding what information, if any, will be shared with their parents without their explicit prior consent. Parental involvement in therapy is extremely important, but a therapist should also be sensitive to the fact that a lack of confidence can seriously undermine the therapeutic process as well.

Protected Health Information. You have the right to examine and/or receive a copy of your clinical record, if you request it in writing and pay for it, but your therapist has the prerogative to refuse the request on clinical grounds, or to release to you a redacted copy of her notes, whose decision you then have the right to appeal. This is based on the fact that professional records can be misinterpreted and/or upsetting to untrained readers and can actually do psychological harm to the client.

Although you have a legal right to request a copy of your therapy record, I generally advise against it on therapeutic grounds. I myself frequently make observations and other notations in a patient's chart that would not necessarily be therapeutic for him to read verbatim himself, and that in a few cases might actually be detrimental to progress in therapy, or even downright psychologically harmful. Any helpful observations, insights and interpretations that should be communicated will be brought up by a deft therapist in session when the time is right, and in such a manner that is measured and most appropriate, with the client's well-being and best interests in mind.

If you need records sent to your doctor or another provider, it is best to sign a release of information form and have your therapist mail or fax the records directly to that professional. In some instances where it was necessary for me to release records directly to a patient and I had concerns about what the patient or the patient's family might read there, I sat down with the patient to review specific portions of the record with him. A debriefing session of this kind can easily be incorporated into your final visit if you are moving or terminating treatment for some other reason and you need direct access to your record.

Contraindications. Finally, there are a few circumstances in which engaging in psychotherapy is not a good idea at the time. These all involve periods during which the potential client is too sick to engage in healthy, conducive talk therapy, including periods of detoxification from drugs or medicines, episodes of acute psychosis (when a person’s reality testing is impaired), and during a severe major mood episode. Acutely manic individuals do poorly in therapy and therapy should be deferred or suspended until symptoms come under control on medications. Similarly, if an episode of depression is especially severe, talk therapy is relatively contraindicated until medical treatment has a chance to work. A seriously disturbed mood will contaminate the therapeutic process; patients who are deeply depressed are often incapable of formulating positive interpretations and of envisioning a better future. All therapy may accomplish for these individuals at these times is to induce a great deal of painful, mood-congruent and ultimately harmful ideations and helpless conclusions. It is better to wait until the client is physically capable of fostering hope and of feeling empowered before proceeding to introspect and problem-solve.


International Society for Interpersonal Psychotherapy

National Association of Cognitive-Behavioral Therapists

American Psychoanalytic Association

American Psychological Association

Read this: Current Psychotherapies

How to Pick A Good Therapist

More people than ever are seeking professional counseling services in one form or another. Thankfully, the stigma of seeing a mental health professional is waning and people are becoming better educated regarding the various options available to them. Needless to say, psychotherapy can be extremely helpful, and it is almost always a good idea if a person is at all interested in it, assuming there are no major contraindications (see Part II) and the client-therapist relationship is a good fit. Unfortunately, as many people have experienced, a trial of psychotherapy can also result in disappointment and/or greater confusion. As is the case with medical malpractice between doctors and patients, it is a fact of life that some therapeutic alliances between professional counselors and their clients go terribly awry. In some cases this is because of the relative inexperience of an otherwise well-intentioned therapist; in other instances it may be due to a therapist's gross negligence, or his or her own psychological morbidity; in still other cases, it’s simply due to a poor match: some client-therapist alliances just aren't meant to be.

Because the start of a successful psychotherapeutic endeavor begins with the therapeutic relationship itself, selecting the right therapist is of paramount importance. It is also one of the most uncertain tasks, especially when practical considerations such as geographical location, availability and insurance requirements come into play. The topic of selecting the right therapist could fill a book. This article will briefly touch upon a few things to consider when making that selection. Part II, to be published separately, will discuss how to embark upon meaningful, successful psychotherapy by setting goals, avoiding pitfalls and engaging your therapist.

Because there is no practical way of comprehensively screening a potential therapist before therapy actually begins (it is often not until therapy is well under way that both the client and the counselor begin to develop a true sense for the other person), you will probably have to settle for an empiric, trial-and-error process, but the following guidelines should improve your chances of success without encouraging you to "therapist-shop." We'll see that, while it is reasonable to "interview" a potential new therapist on the first visit before committing to weekly sessions, you will want to resist the urge to shop around for someone who is only going to tell you what you want to hear, enable your maladaptive behaviors, or just validate you without asking you to really examine yourself and take a critical look at your choices in order to effect real change. It's not always a comfortable, pleasant experience, but if you invest in it fully, the rewards can be great.


Credentials. In searching for a good psychotherapist, you will certainly want someone with acceptable credentials, which involves four things: schooling, training/experience, certification, and more experience. None is more important than experience.

There are various types of degreed professionals who engage in psychotherapy, primarily social workers, clinical psychologists, and some psychiatrists. Although psychiatrists are medical doctors whose formal education and training is the most extensive of the group, M.D.s and D.O.s are not necessarily any better at providing professional counseling than social workers or psychologists. In fact, doctors may be significantly less prepared in that respect. This is because physicians of any specialty are licensed to conduct therapy, despite the fact that they are not required to take any psychology or sociology courses as part of their pre-med curriculum and likewise, they are not schooled in psychotherapeutic principles as medical students (graduate students may take a brief, basic course in behavioral health before their psychiatric rotations in their third or fourth year). As for psychiatric training, the trainee may or may not spend a significant amount of time practicing counseling under supervision, depending upon the specific residency training program, but in any case this is not the primary focus of residency training. Psychiatrists are medical doctors first and foremost, so they concentrate on diagnosing mental illness, ruling out treatable physical causes and managing symptoms with medications. Some residents in psychiatry receive surprisingly little in the way of formal instruction regarding psychotherapy. Do not assume that, because doctors have endured a rigorous and lengthy program of education, it makes them better therapists.


Psychiatrists. The only distinct advantage to having an M.D. or a D.O. as a therapist, beyond the fact that a doctor is able to bring the full breadth and depth of her medical knowledge to bear in diagnosing any physical conditions that may be present (as well as ruling them out) is that your therapist then also has prescriptive authority, in the event that you need or would benefit from a trial of psychotropic medication. A therapist comes to know you very well with the typical, once-weekly hour-long sessions, so if and when it becomes necessary to prescribe or adjust a medication, such an arrangement places the prescribing physician at an enormous advantage in terms of being able to consider, in-depth, the psychosocial factors relevant to your situation before deciding what to recommend regarding the medication. Even if you are meeting only every other week, you are still spending far more time, far more often with your psychiatrist than you would otherwise. Imagine the advantage of having up to a full hour to discuss medication issues and your various treatment options, as opposed to the standard 15-minute "medication check" every few weeks or months that is currently the industry standard.

Because psychiatrists and independent therapists are not always easily able to coordinate the care of the many patients they see and whom they may treat in common, having a therapist who is also your psychiatrist (and vice-versa) can definitely be an advantage, assuming that your psychiatrist is adept at therapy. To reiterate: the combination of seeing your psychiatrist for therapy practically guarantees that you will receive better psychiatric treatment (diagnosis and medication management), but it does not necessarily mean you are getting the best psychotherapy.

LPCs. As for social workers and psychologists, all licensed professional counselors (LPCs) in Texas must have a master's or doctoral degree in counseling or a counseling-related field from an accredited college or university. Here again, a Ph.D. will not necessarily make a better therapist for a given client than someone with a master's degree, because the ability of a particular therapist to help you depends on a number of factors, least of which is whether or not that therapist completed a dissertation as a graduate student.

When it comes to credentials, check for the minimum requirements (although if the therapist is licensed, the State in which the person is practicing has already done that for you), but beyond that, don't base too much of your first impression on how advanced the degree is, or which institution of higher learning granted it. There is absolutely nothing to indicate that a Harvard or Stanford graduate is going to do a better job working with you than the therapist who spent the first few years earning his degree at a local community college. Therapy is an art, not a science; many aspects of it cannot be learned except through direct experience, and some people are just naturally more gifted with regard to practicing it. Also, therapy is a collaboration, and the right fit often has little if anything to do with how accomplished the therapist's academic career was before sitting down to meet with a client for the first time.

Certification. That said, there are subspecialties in which LPCs can become certified, and inasmuch as these certifications indicate additional experience in a given area, they are certainly a source of added confidence. If you are seeking treatment for drug dependency, for example, you probably want to see an LPC who is also an LCDC: a licensed chemical dependency counselor. (And although not a requirement by any means, still…if substance abuse is the focus of treatment, you might even consider a therapist who is also a recovering addict herself; there is no greater teacher than direct personal experience, and these individuals are especially equipped to guide you through the process of your own recovery in a way that others who have never personally dealt with addiction simply are not.)

Other counseling subspecialists include cognitive and behavioral therapists, child and adolescent therapists, couple, family, and group therapists, and psychoanalysts, to name a few.

Definitely beware the "life coach" with absolutely no official credentials whatsoever. There are State laws governing the way in which these unlicensed individuals are allowed to advertise their services, but claims can be misleading. (Some practitioners may refer to themselves "life coaches" and be schooled, trained and properly certified; I'm only referring to individuals with no formal training whatsoever).

Experience. Do pay attention to how many years a therapist has been in practice. It bears repeating that the best credentials are not diplomas and certifications, but actual experience (the formal training that qualifies for State licensure always includes a significant amount of supervised experience). This is not to discriminate against those therapists who are just starting out, but as with medical doctors, the more time a practitioner has spent in practice and the more clients she has treated, the more opportunity she has had to master her own strengths and weaknesses and to learn from her mistakes.

Seek the best fit. A fully credentialed, Board-certified brain surgeon is going to do the best job she is capable of doing, regardless of what type of person the brain belongs to, but when it comes to engaging the mind, even the most seasoned clinician with one of the most well-honed techniques may not be the best suited to you, if that technique does not meet your particular needs. Someone who may be a wonderful therapist for one type of client may turn out to be a disappointing choice for someone else. Again, therapy is an art, not a science, which is why M.D.s and Ph.D.s--even those extensively trained in psychotherapy--are not necessarily better equipped to counsel you through your particular problems than someone with less formal training but who is perhaps culturally and ideologically a better fit (or simply someone with more innate talent).

The problem, as already mentioned, is that it is difficult, if not impossible, to know from the outset who is going to have the best approach for you and with whom you are going to relate the best over time. You won't know if you are going to clique with your new therapist until it starts to happen. Sometimes you get a good feeling on the first visit, but the therapeutic alliance is a relationship--a special kind of relationship, but a relationship nonetheless--and as in real life, meaningful and rewarding relationships build over time, with the establishment of trust and the building of familiarity. The more your therapist comes to know and understand you, the better able he will be to help you help yourself, and the better your initial choice in therapist will prove to be. Alternately, as you continue working together, differences in philosophy and approach may lead you to realize over time that you are not making as much progress as you would like.

Despite this limitation, it is reasonable to screen a potential therapist at your first appointment. Although the clinician will be performing a formal interview and will have many questions for you, one of them should be what you expect to gain from therapy, and in the context of discussing that, a good therapist will welcome inquiries from you regarding her therapeutic philosophy, experience and style. It's a start.

Give it time. Ultimately this is the only way that you are going to be able to make an informed decision. It may take several visits to get comfortable with a new therapist and to fully determine whether or not therapy is going to work between you. Unless you are immediately put off, you won't really appreciate whether or not you will be able to build a good working relationship until you both have had time to build one, so be patient, but ask questions and reserve some time early on to find out as much as you can about the person with whom you will be sharing and confiding your most important personal information.

The following are some specific qualities to look for in a therapist. Some of these you can ask about, but most you will have to discover for yourself, and the way to begin is to be aware of them.

Empathy. Does the therapist seem to care? Is he engaged with you, does he ask a lot of probing questions that invite you to stop and consider and reveal yourself a little in the answers? And when you go to answer, is he listening, or is he just waiting to ask the next question? Body language and eye contact are things a competent therapist is going to be evaluating in you, but you will also take your cues--consciously or unconsciously--from the therapist's demeanor, so take note if your new therapist seems distracted or disengaged. I've heard plenty of sad stories from patients about therapists actually yawning and looking bored in the middle of a session and yes, even falling asleep! One patient described to me how put off she was by the therapist's slurping his coffee when he met her for the first time. (It wasn't just the fact that he was drinking coffee, of course; it was the disaffected tone in his voice and the way he peered at her dubiously over the rim of his cup.)

It may be tempting for the sake of convenience to simply dismiss a really bad first impression, but this is a professional you have come to see: if your counselor seems indifferent or spends a lot of time quickly asking rote questions that she obviously asks everybody, with no real interest in your answers and no follow-up questions that are tailored to your responses, and she doesn't bother to look up much from her notepad during that first interview (a good therapist takes notes on the first visit, by the way), take these as precautionary signs.

Client-Centered Therapy. There is an entire school of thought built around the notion of empathy for one’s client. Carl Rogers' Client-Centered Therapy (CCT), developed in the 1940s and 1950s and later rebranded as Person-Centered Therapy, was the founding movement in the humanistic school of psychotherapies. It relies heavily upon the notion of "unconditional positive regard" that a therapist should demonstrate for his client. Rogers' belief was that people naturally tend to move toward personal growth and healing if merely allowed the opportunity, and therefore the principal aim of therapy should be to allow that spontaneous process by fostering a comfortable, non-judgmental environment and demonstrating "the utmost respect and regard" for the client. Chief among the therapist's tasks is to listen and try to understand how things are from the client's point of view.

CCT is a non-directive approach in which the beneficial effect of therapy is believed to ensue from a client's ability to feel accepted and valued, which occurs in the context of a properly fostered therapeutic relationship. It is the relationship itself, as a model for what other relationships in the person's life can be like, that is considered instrumental in alleviating a person's symptoms. It is a simple but powerful philosophy, and although most modern therapists (myself included) adopt a more eclectic approach to psychotherapy, drawing what works best from various disciplines and judiciously applying the various principles and tactics to individual cases based on the patient’s ability to benefit from a given technique, I do believe that the Rogerian principles of unconditional positive regard, empathy and openness should underlie every psychotherapeutic relationship. It is a solid, and I think necessary, foundation from which to proceed and build.

On a side note, the opposing ideology of the time was Behaviorism, an experimental approach which rejected notions of introspection and approached psychology on a strictly empirical basis. All behavior can be explained and predicted as a result of mindless conditioning, it argued. Behaviorism gave way to modern cognitive theory, which to be sure includes some of the most useful and effective techniques utilized in modern-day treatment, but even when we, as therapists, opt to focus on extinguishing or reinforcing behavioral responses as opposed to delving more deeply into our shared humanity, there is no reason those techniques cannot be taught and applied with due compassion for their subjects.

Compassion and wisdom. These may sound like fairly lofty qualities--and they are--but they are also necessary virtues for anyone who is serious about practicing the art of psychotherapy and truly helping people. Meaningful, well-administered therapy is a growth process for both the clinician and the client, which is why experience over time is the best guru for a dedicated counselor who truly loves the work. Teachers learn from their students, and therapists learn about the human condition, and about themselves, from their therapy subjects. So if it seems to you that the person who is supposed to be serving as your advocate and guide is narrow-minded, rigid, intolerant or embittered--and this does happen--move on.

Good boundaries. A proper therapist respects appropriate professional boundaries. This ranges from availability issues (see below) to issues such as whether your therapist calls you by your first name and encourages you to do the same, to actual touching. With regard to whether you and your therapist should be on a first-name basis, this is largely a matter of personal preference. With the exception of doctors and their patients, most clients and their therapists seem to be on a first-name basis, as it fosters a more comfortable and intimate therapeutic relationship, but if you have a particular preference regarding what your therapist should call you--and this is entirely your decision--make it known.

With regard to touching, it is accepted that a light hand on the shoulder or in some cases even a comforting or congratulatory hug are within the limits of propriety, but with hugs in particular it is also generally accepted that the client should be the one initiating or asking for that type of gesture, not the therapist. It is generally frowned upon for a therapist to routinely hug his patients, or to ask for hugs, although some therapists would disagree with that, and if a patient asks me for a simple hug, I have found that it is usually okay to grant the request. But if you find yourself wanting to hug or touch your therapist at every visit, that's something you may want to discuss in therapy (cf. transference). Whatever else, a therapist should never make you feel uncomfortable by touching you. If he does, this is something you will need to address.

I learned a valuable lesson once when I extended my arm in an offer to shake hands at the end of my first visit with a patient who was a young, unmarried female Muslim. Despite the fact that she had been reared and educated in the United States, her culture did not permit her to feel at all comfortable making that kind of physical contact with her male treating physician. Although this intelligent young woman was an adult who had lived and worked independently as an engineer before becoming seriously ill, she came to my office in traditional dress, always chaperoned by her mother, and I learned that at the end of subsequent visits, a warm smile and a simple nod conveyed all the politeness and graciousness that any offer of a handshake could have. More, in fact. By being mindful and respectful of her personal boundaries and modifying my overtures accordingly, I earned her trust and respect.

Cultural sensitivity. Entitled, self-righteous, ethnocentric individuals (bigots) are poorly suited for this line of work. Thankfully, few apply! But, particularly if you are a non-native resident who was reared in a different culture, you want your therapist to be interested in and sensitive to the differences that exist between you. Many clients who belong to a minority class perfectly reasonably prefer to see a member of their own ethnic group, to obviate the possibility of cross-cultural misunderstandings. Moreover, if English is not one’s first language, one may do better conducting insight-oriented psychotherapy in one’s native tongue.

Along the same lines, many lesbian, gay, bisexual and transgendered individuals prefer therapy offices that are likewise owned and operated, or at least recommended, by members of the LGBT community, and the same can be said for any minority group that is subject to discrimination. A decent therapist, regardless of his own personal demographics, affords all human beings the respect and dignity they deserve.

One alarming exception to this seen today that bears mentioning because it is so pernicious is the example of "gay conversion" therapy, which is destructive and unnatural in my professional opinion, and unethical and immoral in my personal opinion. Thankfully it is not a mainstream movement in modern-day mental health treatment.

Adaptability. Inasmuch as the typical therapist will see a wide array of individuals in the course of a work week, she cannot demonstrate the same persona with all of them if she has truly mastered the art of psychotherapy. A truly capable therapist, no matter his theoretical persuasion, adapts himself to accommodate the intellect, culture, communication style and symptomatic limitations of the person seeking services. We do not relate to our spouse or partner the same way we relate to our parents or the way we relate to authority figures; we adapt our style to suit the situation and the expectations of the other person. Why would a therapist relate to every patient in the same manner?

If your new therapist uses language you cannot understand and fails to express herself more clearly when you indicate your confusion, or else makes you uncomfortable in the manner and style with which she addresses and interacts with you, despite voicing the hesitation and concern you may be feeling, that may be an indication that the therapist is not a good fit for you, especially if she seems out of touch with the fact that you are not entirely at ease. A therapist must be able and willing to adjust her personality to accommodate the client’s social vulnerabilities, whether they are inherent or whether they are the result of a temporary episode of illness. This is not to say that a therapist’s job is to make sure the client is always comfortable; that may not be possible, or even desirable. It is merely to say that a skilled therapist notices and adjusts the rate, tone and volume of his speech and gestures accordingly.

Openness. A good therapist is not only sensitive to your comfort level at all times, but is likewise continually open to feedback, including criticism; she will not take things personally or become defensive when you point out your dissatisfaction or discomfort with some aspect of your therapy. A truly experienced therapist will carefully consider what you have to say, and either accept it at face value if it is a valid criticism, or else explore it further with you if there are questions or concerns about a possible misunderstanding. Often a client's disillusionment or frustration with the therapeutic process is an opportunity for further introspection and interpretation that neither of you would want to miss. A therapist who remains transparent, honest and genuine in his emotional responsiveness to a client (a quality Rogers called "congruence") encourages the client to do the same, greatly facilitating the therapeutic process and leading to greater satisfaction for both client and practitioner.

Spiritual alignment. Some clients specifically seek faith-based counseling services, which includes pastoral counseling, and in these cases obviously a person would seek a minister, rabbi, priest or guru as appropriate to his religion. If you are atheist or agnostic, it may or may not be important to you to find a like-minded therapist, but an evangelical counselor who specializes in faith-based therapy with a heavy emphasis on prayer would obviously be a poor fit, so keep that in mind.

Also realize that, while some licensed counselors incorporate their own faith in their work and specialize in faith-based psychotherapy, pastoral counselors (clergy) are not licensed therapists. In Texas, theology is not considered a "counseling-related field" by the Department of State Health Services, and so students of theology are not eligible for licensure based on seminary work alone. Absent formal training in providing professional counseling services, pastoral counselors rely more on wisdom and simple compassion than do their professional counterparts, whose philosophies are not dependent upon church doctrine and who are trained in specific therapeutic techniques and interventions that have been tested by research.

Little can go wrong when compassion is the guiding principle, surely, but when compassion fails to refute dogma, suffice to say that not all religious doctrines are necessarily conducive to the mental health of a given individual. If you are a person of strong faith and it is important to incorporate God in your treatment, perhaps it is better to seek a licensed professional counselor of the same religious affiliation as yourself who advertises faith-based services than to simply discuss your problems informally with your clergyperson, although discussing any problem with as many caring individuals who might help is always a good idea, even if you are bound to receive contrasting points of view.

My own personal opinion is that I consider a strong spirituality an invaluable asset for a therapist to bring to bear in the therapeutic context, when it comprises humility and altruism, whereas adamant religiosity, on the other hand--especially of the arrogant and self-righteous variety--only exacerbates real-life struggles in a way that fails to preserve the autonomy and dignity of the individual who suffers…but that’s just my personal opinion.

Thus far I've discussed important qualities and characteristics inherent to the personhood of the therapist, qualities that cannot be taught, but that can be cultivated with a sincere effort and interest in the art of psychotherapy. One question you might ask your new potential therapist is why she chose counseling as a profession in the first place. The answer might give you a good idea about how interested in and dedicated to the practice she is. The following considerations are likewise a testament to the type of professional you will be relying upon, but have more to do with the practical aspects of your treatment.

Availability. Being on-call and available to clients for after-hours emergencies and consultations is an unavoidable part of any health profession. The question is: how badly does your therapist try to avoid it? Therapists who flat-out tell their prospective new clients up front that they don't normally make themselves available after hours are sending a very clear message, one you should hear for what it is. I personally find the practice of broadcasting such a thing in such a manner a bit distasteful. I want my patients to understand that they can rely upon me in an emergency, not that I don't want to be bothered. Posted signs and other communications from your therapist's office that warn that you may be charged extra for after-hours services are one indication of where the therapist's priorities lie.

On occasions when you do have to contact your therapist outside of your usually scheduled appointment time for more routine matters, how easy is it to leave a message and how long does it take to get a callback? If you call during normal business hours, it is customary to get a call back by the end of the day, unless you call late in the afternoon.

Confidentiality. This almost goes without saying, but your therapist is required by law to maintain the privacy of your protected health information, and should provide you with a copy of her office's privacy practices. Just as you would never want your therapist to casually discuss your case with others, your therapist should never discuss the treatment of her other clients with you, except in the most general of terms, for illustrative purposes that pertain to your situation and that have to do with her experience in dealing with the issue at hand. It is very bad form to overhear a therapist discussing his cases with other professionals, and if your therapist is fond of gossiping in session with you directly, think seriously about the implications that has on your own treatment. I have witnessed these types of behaviors myself, and so while I hesitate, I have to mention it here.

Other therapist variables depend on you: do you have a gender preference? It's okay if you feel more comfortable with someone of the same gender, for example, especially if your issues are gender-specific or involve sexuality. Age can be another preference; many adults prefer a therapist who is at least their age, if not older. Whether or not your therapist has ever been married might also be a consideration if you are seeking couples' counseling, although don't discount divorced therapists, who may have even more valuable insights into marriage--as well as the process of extricating yourself from one that isn't healthy--because of having lived through it.

Finally, it's okay to "fire" your therapist if things aren't working out, but before you terminate the client-therapist relationship be sure to discuss your concerns openly and honestly. A good therapist welcomes constructive feedback, which might salvage the therapy if offered sincerely and early on, or if not, at least provides the therapist the opportunity to improve for the next client.

Also, sometimes a person will become disenchanted with her therapist or with therapy in general because the therapeutic process has become difficult or anxiety-provoking. This may actually indicate that progress is being made, albeit uncomfortably, and that therapy should definitely not be interrupted. Having one final debriefing session to discuss your reasons for wanting to quit or switch to a different therapist prevents sabotaging perfectly good therapy when it gets stressful and helps to avoid "therapist shopping."

Less commonly, a therapist might suggest or even insist upon the need to terminate the therapeutic relationship and that you find another provider. There are only a few situations in which this is professionally appropriate. In every instance, adequate referrals should be offered to you, as well as instructions as to how to have your medical records forwarded to your next provider.

Of course, people "graduate" from therapy all the time, and since that is generally the goal, even with longer-term therapies, it is an occasion to celebrate, indeed.

It's good to have many advisors in your life, some of whom may be licensed professional counselors, but most of whom will be the people in your life: family, friends, colleagues, a member of the clergy, a teacher, a mentor, or any of a number of other role models. Perhaps you consult regularly with a fitness instructor or a dietician, or a home health nurse. Maybe you look up to a supervisor at work. Perhaps you are particularly impressed by the works of your favorite author, or inspired by the imagination of a great artist. Anywhere you encounter wisdom and compassion and a desire to be helpful, assistance can be found. And if you go through life with a healthy outlook and the right attitude, at the right time and with the right persons you may be that altruistic guiding influence.