published 10/10/06, updated 7/06/09

Choose the Therapist, Not the Therapy

When you’re in pain, you want to know “what works,” but what you should look for is an honest therapist of any kind

by Paul Ingraham, Vancouver, Canada MORE
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Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

Clients ask me all the time, “What works?” Does chiropractic work? Does ultrasound work? Does craniosacral therapy work? And, of course, they especially want to know if massage therapy works — even as we’re doing it! Good for them.

But it’s not the best question. It’s too broad. No matter what you might say in favour of a kind of therapy, or against it, the more important consideration will always be the quality of the individual practitioner: his or her intellectual honesty, social skills, emotional maturity, academic diligence, and so on. These personality traits are by far the most important variables that determine quality of care. Find a professional with those qualities, and it doesn’t really matter which letters they have behind their name, or what kind of therapy they are selling.1 Get stuck with a dishonest or socially incompetent professional, no matter what kind of professional they are, and all bets are off — you don’t want to pay them to do anything to you.

The most important consideration is the quality of the individual practitioner.

It’s a truism that not everyone can graduate top of his or her class. Although the nature of the therapy offered is not unimportant — some things aren’t going to work, no matter what — the skill and good sense of the therapist is much more important. A few ethical, intelligent practitioners of any helping profession will always deliver better care than the less responsible members of any profession.

The effectiveness or ineffectiveness of therapists bears little relationship to either the type or duration of their training.

Watkins, “The efficacy of treatment: therapy or therapist?” in Clinical Medicine2

Doctors — friends or foes?

I tend to admire doctors, and I know some wonderful ones. My last two general practitioners have been awe-inspiringly competent and decent people. As the publisher of this website, I have been privileged to a few of the world’s best doctors. However, in no profession is the range of quality of practitioners more evident. The best are truly great, and that’s to be expected when you combine the best of medical science and technology with a good heart and brain. But the worst are as bad as the worst anywhere else.

A friend of mine recently experienced a sudden onset of severe anemia (low iron) — something that is almost always a not-so-early warning sign of Very Bad News. Her general practitioner — a doctor she had been unhappy with for some time — showed an appalling lack of interest. She was rudely dismissive and apathetic. What accounts for such poor care from someone so well-trained?

Personality.

It really comes down to strength of character. Credentials ultimately mean nothing. “With doctors like these,” one patient quipped to me, “who needs enemies?”

Buyer beware

Of course, the quality of the therapist is not the only consideration, just the most important. Unfortunately, many therapies truly are a waste of your time and money, and the absolute best that you can hope for is a placebo effect, no matter who is offering them. And while I’m the last person to turn up my nose a good placebo, I’d much rather have mine on the side than served to me as the main course.

You should look for a good therapist rather than a good therapy because a good therapist will tend to recommend therapies based on the best evidence available, therapies that have been shown in peer-reviewed scientific research to have more benefit than a placebo. A good therapist will do this because that’s what being a good therapist is all about. If you have a good therapist, you don’t really have to worry about doing your own homework so much. It’s never a bad idea, of course, but it’s nice knowing that you have an honest guide.

I’d much rather have my placebo on the side than served to me as the main course.

An extreme example: antidepressants

Here is a fairly extreme example of a situation where even a bad therapy can be used applied effectively with a good therapist

“Do antidepressants work?” In a word, no, they do not. I can’t think of a better example of a therapy that doesn’t work. The scientific rationale is tissue-paper thin, they have proven dangerous side effects, a proven lack of therapeutic effect on depression, and the companies that make them have the largest snake oil profit motive in history, and have been caught red-handed buying off American juries to block prosecution for their crimes. No, antidepressants do not work. They are not medicine.3 And yet …

Although anti-depressants aren’t “medicine” and basically just scramble people’s brains a bit, patients often report benefits. These benefits can be attributed to a combination of placebo, dumb luck avoiding the worst side effects, and the merciful relief of simply being “stoned” with medical approval and supervision. And that’s not such a bad thing. It might even be worth the risk … with the right psychiatrist.

What if your psychiatrist were not only impressively credentialled — I’m going to go out on a limb here a bit — but also wise and compassionate?

What if your psychiatrist were not only impressively credentialled — I’m going to go out on a limb here a bit — but also wise and compassionate? What if she actually warned you about the dangers? What if she helped you go into it with your eyes wide open, deliberately leveraging the admittedly potent effects of the drug in your favour, and with expert guidance in evaluating the side effects and switching to other kinds if necessary? And what if she was there to help you process the consequences of being “stoned”?

In this context, antidepressants could definitely “work.” So what’s more important: the therapy, or the therapist?

Be a secret shopper

Most people feel uncomfortable telling a health care professional, “I’m just checking you out. If you don’t seem to practice evidence-based care, I won’t be back.” So do it in secret. Go shopping for therapists before you are in trouble, present some minor problem for their consideration, and take the opportunity test them discreetly.

Do they ever refer to research or evidence?
Do they explain their treatment choices?
Do they promise too much?
Do they seem curious about you?
Do they admit to any shortcomings?

If not, run away.

I strongly recommend trying one therapist after another — of any kind, of many kinds — until you find one who seems knowledgeable, compassionate, and intellectually honest. That person will be a valuable resource for life.

Notes

By my definition, intellectually honest professionals will never try to sell you any serious nonsense. Really dubious cures are eliminated from concern, because professionals of a certain quality just never get into offering bogus cures in the first place — or they get into it like wandering down a dark alley and then smarten up, Dr. Edzard Ernst being the classic example. Someone offering you a remedy on the margins of credibility is either (a) not actually intellectually honest, or (b) will present it to you in an honest way, fully informing you about its disadvantages and uncertainties as well as its possible benefits. Return to text.
Watkins. Clinical Medicine, Journal of the Royal College of Physicians. 2005. Return to text.
See SSRI Antidepressants Are Not Medicine. Return to text.