The principles of good therapy

Once you've found a good-enough therapist, how do you know if you're getting good therapy? One of the best and simplest ways to think about what comprises good therapy is to consider the principles of change that are shared across all the main forms of therapy (Pachankis & Goldfried, 2007).

We list below what many people consider to be the five principles that lead to change in psychotherapy:

Good therapy depends on you and your therapist believing that it will help

One of the key elements of successful therapy is that you believe it will change something about your life for the better. Research finds this to be true time and time again (Bartholomew et al., 2021), most obviously in medicine, where the placebo effect shows how powerful your thoughts and expectations are. Having confidence that something will help you usually means that it does.  As we've discussed above, in therapy you gain that confidence by working with a therapist who inspires your trust and gives you a realistic sense that they can help you because they have helped others in a similar situation. Your therapist's job is to convey that optimism to you. Good therapy feels hopeful.

Good therapy requires a good working relationship with your therapist

If you don't trust or respect your therapist, then it's unlikely you'll get much out of therapy. Similarly, if you feel they don't 'get you', or if they speak down to you or confuse you, that will not lead to an effective working partnership. The good news is you can usually tell this very early on. If you detect problems in the first few sessions, don't ignore them or hope for the best. Whatever the issue is, raise it with your therapist, give them a chance to respond, but if they don't, it's time to look elsewhere. It's not going to be possible to be honest about the most difficult aspects of your life with someone you don't trust or respect or feel comfortable with. 

Good therapy improves your awareness of what's going on in your life

That includes the way your mind tends to work and how you tend to be in your relationships, whether with bosses, partners, friends, children or parents. Your therapist's job is to help you see when you overreact or when you are inflexible or impulsive or you assume you know exactly what others are thinking. Your therapist can help you stand back and spot things you can't see for yourself.  It can be uncomfortable to have your views challenged or your 'flaws' pointed out. At times, your therapist might make observations or ask questions that feel challenging. Therapy is not always fun. It's meant to help you change something about your life. And the first step to that is noticing when you do things on autopilot that are not in your best interests. Once that's in place, you can often make rapid changes (Gingerich & Peterson, 2013).

Therapy is an opportunity to do things differently

Improved awareness of how you think and act is step one, but it's not enough. In time, it will also mean doing things differently. That might be speaking up at work or asking the guy at the gym to go for coffee. Either way, it's making a deliberate choice to act differently, in the hope of a better outcome. If you want change, you will have to take a risk and behave differently. Good therapy makes sure those changes are at a speed and intensity you can tolerate. Like a good fitness programme, therapy should feel challenging but not overwhelming. Working with a good therapist is a lot like working with a personal trainer. In both cases, they assess what you are ready for and won't suggest more than they think you can handle. But they are also in your corner, encouraging you to work hard and sometimes do uncomfortable things. In the end, whether you do them or not is up to you. And, as with physical exercise, outcomes in therapy are largely determined by the effort you put in. 

Tie it all together into a virtuous circle

Therapy helps you link increased awareness of the things you want to change with a new experience of doing them differently. This means recognising something that you are avoiding or noticing a pattern that you have been repeating on autopilot, and then doing something differently to break that cycle. Often this produces a different and better outcome, which results in you thinking that it was a risk worth taking. Even when the risks don't pay off – your boss rejects your proposal or the guy you ask out for a coffee says no – you realise it's not the end of the world. You might well still feel proud you took the risk, and you might be more inclined to do so again. Good therapy helps you realise that you really do miss 100% of the shots you don't take. While the stereotype of therapy is that it focuses on your childhood and the pain of your past, good therapy is every bit as much focused on the future and getting on with living. What do you want to do more of and build on? How did you get through previous tough times? Can you identify the smallest change that you can quickly put into practice to improve your life? When you've done so, can you recognise those improvements, give yourself credit, and build on them? Over and over?

Summing it up

Good therapy can't be separated from the therapist who delivers it. Different therapists get very different results. Not only are some better than others, but the worst therapists can make you feel worse. And this has nothing to do with age, experience or training; it's about their interpersonal qualities. 

Research suggests you should be looking for a therapist who is empathic, non-judgemental, validating, genuine, focused on your goals and willing to challenge you to reach them; one who believes in your resilience, builds on your strengths and is committed to guiding you towards solutions that work for you. A good therapist blends and balances those characteristics. Your preferences matter too. If you know that some qualities are more important to you than others, take that seriously when choosing your therapist. Clearly, you also need someone properly trained and registered with a recognised professional body or statutory register. Online directories are the most convenient way of finding them and are a useful first port of call. But don't let the search for the perfect therapist be the enemy of finding one who is good enough.

The only way to really tell if a therapist is right for you is to go ahead with the first session. Did you feel understood? Did they seem genuine? Have you started to build a rapport? Were there any red flags? If so, don't be afraid to cut your losses and move on. The aim is not to find the perfect therapist. The aim is to find someone who can help you make changes that enable you to live a better life. 

At its best, therapy can change your life. So, it's important that you get the best therapy you can. In the end, however, its effectiveness depends on the amount of effort you put in. Your therapist can't and won't fix you on their own – we'll look at your own readiness and motivation in more detail in Chapter 9. At the other end of the spectrum, the worst therapists can cause you harm. They can reduce your trust in other people; they can make you leave therapy despite not getting the benefits; they can make you feel you are to blame for your own problems. And there are therapists who are simply just not that good at their job. You'll end therapy with them feeling no better, having wasted your time and money. So in the next chapter, we discover what bad therapy looks like, why there is so much of it and how you can avoid it.

A Straight Talking Introduction to Therapy: what it is, why it works, how to get it (rrp £12.99) by Matt Wotton and Graham Johnston is published by PCCS Books.