What's the Best Kind of Therapy for You?

In a recent two-part interview, "Finding a Therapist" and "What's the Best Kind of Therapy for You?", Marcia Perlstein offered her views on what to look for in a therapist and how to assess the type of therapy one is getting. Like Marcia, I, too, am a licensed Marriage and Family Therapist, having been in the field since 1973. I currently work at the Center for Creative Growth in Berkeley, whose staff specializes in recovery issues. I also am involved in my own recovery program, which I believe is essential for any therapist who hopes to effectively assist others in their own growth and recovery.

I think Marcia makes some useful points in the two articles, but I want to take issue with some of the pronouncements she makes, especially regarding her beliefs about the best kind of therapy for people. Ultimately, I believe that people can and need to rely on their own inner voice, their own inner prompting, as to which therapist and what type of therapy format will suit them best. The overall concern I have with Marcia's presentation is that she presents "rules to follow," rather than encouraging a person to rely primarily on her or his sense of the "right fit." Instead, she glibly offers unequivocal statements about what is the "right choice" vs. what would prove "bad." Even the "rules" that she offers as guidelines are often off the mark.

For example, she states that "there can be a problem if you do group therapy and 12-step work simultaneously, because you get the group effect from 12-step meetings." I'm not sure what she means by "group effect" but, from my perspective, there are significant differences between a group therapy session and a 12-step meeting. These differences allow both growth experiences to work well simultaneously.

It's clear, for example, that no cross-talk is allowed at a 12-step meeting whereas an effective group therapy session will have cross-talk in abundance . That's one of the main attributes of group therapy: the opportunity to give and receive feedback from peers in a safe, supportive setting. A group therapy format enables people to work on communication and relationship patterns directly -- providing an environment where we learn and practice skills that enhance our relationships with others in our lives, both in and outside of group.

Also, a participant has the opportunity to form long-term, authentic relationships with members of his or her therapy group -- because the same members can be counted on to return week after week. I know that people can and do form important and meaningful relationships with others in their 12-step meetings as well. But there is a special quality and bond that comes from participating in a long-term therapy group. Perhaps the most major asset of a group therapy setting is that there is one person there who is playing a special role: the role of therapist. The therapist is there, ideally, to stay attuned to the "process" of the group, and not get ensnared in the "content" of the struggles that might go on. She or he can offer a unique perspective combining the functions of guide, elicitor, counselor, coach, and teacher.

In another part of her presentation, Marcia describes some of the dangers of bad therapy. Marcia makes the point that one danger is "recreating the dysfunctional family - you can get into a relationship that's comparable to the relationship you had with one of your parents...where you find yourself acting out a lot, in rebellion against the therapist." Rather than a "danger," I see this as a wonderful opportunity in therapy -- if it is used properly. In fact, I'd say that if the therapy is really "good therapy," -- meaning that it takes one down to deep levels of experience -- it's quite common for the client to experience such a re-creation of the feelings of her/his dysfunctional family .

Ideally, the same patterns of protection, of defense, of survival, that each of us learned as children, will emerge in effective therapy. That's how it becomes conscious! As John Bradshaw suggests, if you can't name it, you can't tame it. With the assistance of a therapist who is willing to stay engaged with you during this process, a person can identify the dysfunctional pattern, see what deeper feelings it's designed to avoid or cope with, accept those feelings, and then be more focused on present time. The phenomenon of recreating previous dysfunctional relationships is technically called "transference" in psychological jargon -- and it simply means doing it the same way again, a pattern most people in recovery would be familiar with. It's not "bad" per se. The advantage of being in group or individual therapy is that you have some help in identifying it when it happens and getting to the root of it.

For example, I was working with a man in his 20s who came into therapy very distrustful and reserved. After a few months of discussing his history and current life, he began to tell me that he was becoming increasingly uncomfortable with me -- he found me distant and unapproachable, cold and reserved. Rather than seeing this as a problem or as evidence that he should perhaps seek another therapist, I saw his sharing as a great step in his therapy. The win for him was that he was feeling safe enough to give me feedback rather than hold onto it. It gave me a chance to ask him, "Who am I reminding you of?" and that led him into exploring -- at a feeling level, not just at his head level --his long held-in and denied emotional pain about his dad, who was distrustful, distant, cold, and reserved.

I believe that we recreate what we are used to, what we know, not because we are bad or deficient, but because each of us really wants to heal and become more whole. We so much want to heal not only ourselves but our parents, to set things "right," to bring things into balance. On the one hand that sometimes leads us into "codependence," acting in ways that cut into our true selves. But the impetus, the motivating impulse, is a very natural one, I believe. It's like tugging at a knot until it gets loose enough to be deliberately and consciously unraveled. We each revive that piece of our history or experience that isn't complete, isn't whole, so as to try again, with new tools this time, to transform the pain into a gain.

Good therapy, whether in individual or group settings, establishes a safe, challenging, and inviting environment in which this process of reenactment occurs.

In another part of her interview, Marcia also comments that she thinks it works better to see a therapist of your own gender. I would take issue with that. In my own practice, I have found it very helpful to work with the feelings that come up when one's gender elicits a reaction in a person. The point of therapy is to explore reactions and feelings so that a person can get unstuck, rather than act in a way that reinforces anxieties and fears. It can be very healing, for example, for an incest survivor, who is a woman, to have the opportunity to establish and maintain a trusting, caring, and safe relationship with a therapist, who is a man.

Marcia cites an example in her own practice where, after a year of therapy, a male client found that he was not able to talk about his sexuality with her. She sent him to a male therapist, saying (in her article) that "we went as far as we could go." She describes how this male client was shy about sharing the intense aggression fantasies he was having because he was afraid he'd "freak me out." She says, "The fact that he was afraid...meant that he couldn't get from me all he needed at that point in his therapy."

I felt saddened reading that because it seems like such a lost opportunity. What a win it could have been for this man to learn, in his therapy, that he could express his fantasies to a woman and still be accepted. That even those fantasies that were, to him, unacceptable would not cause him to lose a valued relationship. What a sense of freedom and self-acceptance could be gained from learning that his worst fear fantasies are ok, that a woman could accept, take in, and not be destroyed by his rage.

To pronounce that a therapist of the "same sex is better" just limits the possibilities. I had been working with a 35 year old woman for a year individually and, during the course of therapy, she had begun to remember long-repressed memories of incest. As is often the case with such repressed experience, the remembrances came as inklings and senses, more than full-blown memories. At a certain point in the therapy, she told me that she wanted to work with a woman therapist because issues of sexuality were coming up for her that she just didn't think I'd understand. Rather than just assume, "well of course one should work with the same gender therapist on certain issues," we explored what was coming up for her, what her fears were about. Was there anything else underlying her new sense that she wanted a woman therapist? Was she afraid to show me how enraged at men she felt? Was she trying to protect me and our relationship? Was she afraid that if she really let her rage out, that she'd lose her sense of boundaries, and that I would take advantage of her like other men had? This exploration was helpful. She got more in touch with the fact that she was feeling a lot of rage towards men and that that was scary for her. We would have lost the opportunity to identify this deeper level and to work with it had either of us subscribed to the belief that one should automatically work with a therapist of the same gender.

I think it's more of a success to leave therapy when it feels like a completion or if you determine the therapist is not really there for you in important ways. To learn to persevere in the face of obstacles is a big lesson for those of us in recovery. But to leave one's therapist as a defense doesn't work. It robs us of the experience and joy of fulfillment that good therapy helps create. If we leave our therapy as a defense, the therapist then just joins the list of people we have left because we've reached the same stuck point that keeps us from having what we want or need.

Ultimately, what a person can depend on in making her or his choice of beginning therapy and staying in therapy is relying on one's Higher Power, that knowing voice of wisdom that manifests as intuition , insight, feeling, groundedness. To me, perhaps the greatest contribution of 12-step recovery programs (and there are many contributions) is helping people focus on recovering their personal relationship with God. HP doesn't always give us what we want but certainly always gives us what we need. Getting in touch with God's perspective and will is perhaps the ultimate good therapy.