Choosing A Therapist


Introduction
Caveat Emptor

What Kind Of  Therapy?  

Specialization In Psychotherapy
What Kind Of Professional?  
They're Not All Psychoanalysts
Not All Docs Are Psychotherapists
Length Of Treatment    
Finding Dr. Right  
Choosing A Psychotherapist
Ethnic Background & Race    
Gender  
Therapists Who Have "Been There"
Trust Your Gut-Level Reaction  
Affording Help  
26 Questions To Ask
 
Evaluating Your Therapist  
Definitely Time To Leave
 


 
Introduction

The services of psychologists, psychiatrists and other medical doctors, and counselors can be expensive and time-consuming---and all at the very period when you may be feeling low and most vulnerable. But just because you need help doesn't mean that you can't exercise good judgment in choosing someone to help you! You wouldn't buy a car or any other major item without knowing what kinds there are, how they work and what their past performance record has been, would you? Of course not! So before you enter psychotherapy, do a little investigating.

"Caveat Emptor!" (Let The Buyer Beware!)

The "helping" field is unfortunately full of many people who are not really qualified to help, despite having a professional degree. Frankly, a lot of psychotherapy is bunk. And today, under managed care, psychotherapists with less and less training are pressured to take on cases of greater and greater difficulty. Don't assume that all mental health helpers are equal. There are competent professionals around, but you'll have to shop around to find one. Your money and your well-being are at stake!

What Kind Of Therapy?

It's difficult to choose among so many different approaches to therapy. Over 300 "schools" of psychotherapy each claim great success with their clients and each claim to have "the answer." You will have a very, very different experience in one kind of therapy compared to another.

Educate yourself!  Visit the psychology section of one of the larger book stores or your public library and read up on the various schools of psychotherapy so you can at least look for a therapist who uses the approach you think will work for you.

If you are a computer buff, search the Internet. Here are some key words: behavior therapy, cognitive therapy, cognitive-behavioral therapy, behavior modification, psychoanalysis, dynamic therapy, existential analysis, Adlerian therapy, rational-emotive therapy, transactional analysis, client-centered therapy, Rogerian therapy, brief therapy, reality therapy, Gestalt therapy, family therapy.  There are more, but this should be enough to overwhelm anyone! 

Specialization In Psychotherapy

Many psychotherapists are "general practitioners" in that they treat all sorts of problems. They tend to specialize in a particular orientation to treatment rather than a particular problem to be treated. On the positive side, these therapists become very expert at one treatment approach. On the negative side, no matter what problem you come in with, you get the same treatment approach. Some such therapists think that the problem you come in with is really just a "symptom" and is not important, as the important thing is the "underlying problem." Therefore, they feel no need to become knowledgeable in any particular problem.

Other psychotherapists do focus on one particular problem area. For example, one psychotherapist may treat only eating disorders. Another therapist may specialize in child and spouse abuse. Another may  treat only depression. Psychotherapists who focus on one problem area tend to be affiliated with specialty clinics or hospital programs.  These therapists tend to be very knowledgeable about a particular problem, though they too may have their biases or favorite treatment "orientation."  

Still other psychotherapists focus on a limited number of problems areas---more than one type of problem but not every type of problem. They tend to be in solo private practice.

If you don't really know what's bothering you, you might consider going to a generalist. But if you're pretty clear on what your specific problem is, you might want to seek out someone who specializes in treating that problem. There are so many problems in the world today, that it is difficult for any one psychotherapist to be fully informed on everything.

Also, realize that anyone can claim to be a "specialist." It's not enough to ask only, "Do you specialize in helping people with my problem?" or "Have you ever treated someone with my problem before?"   Instead, ask "How many people with my problem have you treated before?" and, "How many got over it?" and, "What specialized training have you received in treating my problem?" A true specialist will be glad to answer these questions directly. Someone who is not a specialist may try to duck the issue, or make you feel wrong for asking.

What Kind Of Professional?

As if this isn't complicated enough, you also need to decide what particular profession you want to consult. There are at least eight different professions that offer "psychotherapy" or help with emotional and behavioral problems: psychologists, psychiatrists, psychiatric or clinical social workers, marriage-family-child counselors, psychiatric nurses, pastoral counselors, vocational counselors and certified alcohol/drug counselors.  They are all "psychotherapists." Each receives a different kind and amount of training, ranging from only one year to six or seven years.  Some require no college degree; some require a doctoral degree.  In fact, by law, anyone can call himself a "psychotherapist"---with no training at all!  Ask whether the person already has a degree, license or certificate or whether he or she is a student intern or "in training."  A legitimate professional will be glad to tell you.

Usually (but not always), the more training, the better the help. Almost always, the more training, the higher the fee.

A clinical psychologist is a doctor (Ph.D. or Psy.D.) who has spent at least four years in graduate school and at least one year in an internship. A clinical psychologist must pass a state examination and be licensed to practice psychology. Clinical psychologists specialize in understanding and helping people who are experiencing problems with troublesome emotions or behaviors. A counseling psychologist or vocational psychologist (Ed.M. or Ed.D.) has spent two to four years in graduate school and usually deals with less severe problems or with helping people choose a career. (Other kinds of psychologists may focus on college teaching, research, animal or human learning, child development, group behavior or organizational management. They do not see individuals for the purpose of changing troublesome behaviors and emotions.)

A psychiatrist is a medical doctor (M.D.), who first spends four years in medical school, mostly studying the physical body, diseases and the treatment of physical illness. Then, the next one to three years are spent in an on-the-job training site or "residency," in which s/he chooses a specialty.  All medical doctors who pass a state examination in medicine are allowed to practice psychiatry, whether or not they specialized in psychiatry when in training.  Medical doctors who did train in psychiatry and passed an examination given by the American Board of Psychiatry & Neurology are called "board-certified psychiatrists." Psychiatrists and other medical doctors can prescribe medication to treat emotional and behavioral problems.  Some of them do nothing but that.  Nowadays, even the ones who used to engage in more psychotherapy are being pressured by managed care to prescribe medication instead.

A clinical or psychiatric social worker is a psychotherapist who has attended one to three years of graduate school, and has received a master's degree in social work (M.S.W.). Licensed clinical social workers (L.C.S.W.) have passed a licensing exam, required in some, but not all states.

A marriage, family, or child counselor is a psychotherapist who has gone through one or two years of graduate school and has received a master's degree of some sort (M.Ed., M.F.C.C., M.A. or M.S.). Training focuses on the interpersonal problems that arise between couples and family members. In some states, master's level counselors must be licensed to practice; in other states, no license is required.

A psychiatric nurse is a psychotherapist who is either a clinical nurse specialist or a psychiatric nurse practitioner.  Both are registered nurses who have attended four years of nursing school, followed by two years of graduate school, where they receive an M.S.  Both may have prescription-writing privileges. Clinical nurse specialists are certified by the American Nurses Certification Center, while psychiatric nurse practitioners are usually required to be licensed by the state. Some psychiatric nurses may have only an undergraduate college nursing degree specifically in psychiatric nursing A psychiatric nurse aide may or may not have a college degree at all.   

A pastoral counselor is a minister, priest or rabbi who has received extra training in mental health, such as a master's or doctoral degree in theology and psychotherapy. They undergo a good deal of clinical training under supervision.  Some are not licensed as pastoral counselors, because they wish to maintain separation of church and state. Others are licensed as mental health professionals (who also just happen to be members of the clergy).  A pastoral counselor may be certified by the American Association of Pastoral Counselors or be associated with the Samaritan Institute.  

A certified drug & alcohol counselor is a psychotherapist who has two or three years of training, undergone several thousand hours of supervised work and has received a CDAC diploma. A CDAC may or may not have a college degree and is often (though not necessarily) a person "in recovery."  CDAC's must pass a state certification test.

They're Not All "Psychoanalysts"!

"Psychoanalysts" are psychotherapists who subscribe mostly to Freud's approach to psychotherapy. Some psychologists, psychiatrists, social workers, psychiatric nurses and pastoral counselors use this method. Many different approaches to therapy have been developed since Freud's time. Psychotherapists who practice other types of therapy are not "psychoanalysts".

Not All Doctors Are Psychotherapists

If you have a behavioral or emotional problem, the first person you might think of consulting may be your medical doctor. This is especially true if you're struggling with something that obviously affects your body (an eating disorder, drugs, alcohol, stroke, amputation, other physical diseases). Unfortunately, most medical doctors are not trained to treat behavioral or emotional problems.

A few medical doctors may treat you anyway by trying to do "psychotherapy" with no background in it at all. (Usually they don't have time for this.)  More and more medical doctors may treat you with medication, due to managed care pressures. But taking a pill, by itself, rarely solves everything.

Unless a medical doctor is a specialist in treating psychological problems (i.e., a psychiatrist) or is a specialist in treating your particular problem, the best thing he or she can do for you is to refer you to someone else. Unfortunately, doctors nowadays are sometimes penalized by their managed care company for making referrals to a specialist. Still, many medical doctors  do refer patients with emotional or behavioral problems to a psychologist. A good number of my patients come to me through a referral from their own primary care provider.

Length Of Treatment

How long do you think it will take for you to get over whatever is bothering you? That depends on both you and the school of therapy you have chosen. Generally, psychoanalysts expect treatment to take many years, while behavior therapists expect it to last less than one year, maybe as little as a few months. Other types of psychotherapy fall somewhere in between these two extremes. You may even run into someone who will claim to "cure" you in only one or two sessions.  (Be wary of this!) Before you start treatment with any psychotherapist, ask how long it will take. A competent and confident psychotherapist, should be able to give you at least a ball-part figure.

Of course, the amount of time it will take will also depend on how consistent you are in keeping appointments and in following your therapist's instructions. If you come faithfully to every appointment and you are willing to take risks and you make helping yourself the top priority in your life, you are more likely to get through it faster. Also, realize that if your problem started a long time ago, occurs frequently or is very intense, it will probably take longer for you to get over it than if it started only a short time ago, occurs  infrequently or is mild. The involvement of family and friends is likely to speed up your progress if they are supportive and non-judgmental. They can also slow down your progress if they are non-supportive or critical.

Finding Dr. Right

After you've decided what "school" of psychotherapy you want to try and what kind of professional you want to consult, you are ready to look for the best individual who can help you. There are several other ways you can get names or "referrals" for psychotherapists. First, you might ask your friends or family members. They may know a psychotherapist or be seeing one themselves. Ask your own medical doctor. School counselors, school nurses, college counseling centers and university psychology departments are also sources for referrals.

The telephone book can be a great source of names  if you know how to use it properly. Do not pick someone at random from the yellow pages! Instead, look for the phone number for the local professional associations for psychologists, psychiatrists, social workers, etc. in your area. The professional associations usually keep lists of psychotherapists who specialize in different problem areas and different approaches to treatment. You should be able to get at least three names from each professional association.

The yellow pages of the phone book also may contain advertisements for psychotherapists who specialize in particular problems. Look under the listings for "Psychologists," "Psychiatrists," "Social Workers," and "Marriage, Family & Child Counselors." Also, look under "Hospitals" and "Mental Health" for out-patient programs.

In some of the larger metropolitan areas, there will be listings for "therapy referral networks." Psychotherapists often pay a fee to join such a network. They are then required to provide evidence of their training and specializations, and information about their fees, approach to therapy, foreign language capabilities, etc. If you call one of these networks, you can get the names of several psychotherapists who meet your specifications. Be careful though.  Some of these "referral networks" are really group practices who will simply assign you to someone who is a member of their group practice.

Look under the government listings for free or low-cost mental health services under "Department of Health," or "Department of Mental Health." In Hawaii, the State operates a number of regional community mental health centers. In other states, these may be run by the city or county.

Seek out organizations that deal with the particular problem you're struggling with. Often they have lists of therapists who specialize in that problem. 

Use all these resources to compose your own list of prospective therapists.

Choosing A Psychotherapist

Don't sign up with the first name you discover!  You are likely to be disappointed, no matter how highly recommended the individual was. Interview prospective therapists---initially over the phone. Tell them, "I would like to ask you some questions, so that I can decide whether to make an appointment." Interview the psychotherapist just like you'd be interviewing someone for a job.

I've written something called 26 Questions When Shopping For A Psychotherapist which appears below.  Don't just read it over. Print it out! Use it when making that initial phone call and after your initial appointment.

Here are some links to more advice on choosing a therapist:

Dr. John Grohol's How To Choose A Therapist

Dr. Ofer Zur's What to Look For In A Therapist 

Once you've interviewed several psychotherapists on the phone, you'll be in a better position to make a tentative choice.  Think of your initial appointment it as another interview.  You have as much to find out about that therapist as he or she has to find out about you!  If you are satisfied with the initial interview, make yourself a promise to give it at least three more sessions before deciding to commit yourself to employing that therapist on a continuing basis.  If you're not satisfied with the initial interview, or three more sessions have convinced you that this was not the right choice, don't be afraid to look for another therapist.

Ethnic Background & Race

It might help if you and your therapist share the same ethnicity and race...but not necessarily. You might feel more rapport with someone who is similar to you than with someone who is very different. And certain emotional problems may be directly related to one's race and ethnic background. So you might start by seeking out a psychotherapist who is similar to you in these respects.

But being similar is not enough to insure that you will get the best treatment and make the most progress. Often a psychotherapist who is of a different ethnic background or race from you may be better able to help you, provided that you feel a good rapport with that person.

Gender

For most problems, it makes little difference whether your psychotherapist is of the same sex as you or of the opposite sex. It's really a matter of your preference. When it comes to eating disorders and weight loss, it might be better for women to see female therapists--- though not necessarily. Weight and physical beauty are such uniquely female concerns in our society, that a female therapist may be more like ly to understand ---really understand---how another women feels. Also the emotional reasons that lead to overeating (lack of assertiveness, lack of power, feelings of hopelessness and depression) are very closely tied to the way women are brought up in our society.

This is not to say that a woman should rule out a therapist, just because he's a male. But if you're a woman, you do need to be more selective in choosing a male therapist.

Also, if you are a woman seeing a male therapist, make sure he is not a "father figure" to you---you know, the silver-haired-father-knows-best-doctor-knows-all type who leaves you feeling like a foolish little girl. Make sure you feel he treats you as an equal, and as a competent adult, capable of making her own decisions. His job is not to "take care" of you, but to teach you how to take care of yourself.

Therapists Who Have "Been There" Themselves

Be alert and notice whether your psychotherapist may be suffering from the same problem as you. Don't laugh! Psychotherapists are people too! Some of them attempt to treat people for problems with which they themselves are still struggling. A psychotherapist should either have resolved his or her own problem, or have never suffered from it in the first place. It may be difficult or even impossible for you to know that much about a psychotherapist's personal struggles, especially since certain types of psychotherapy require that the therapist remain somewhat anonymous. But sometimes you can tell. Also, feel perfectly free to ask the therapist directly, "Have you ever had this problem yourself?"

Though you may find yourself feeling a very strong rapport with a therapist who once suffered from the same problem as you, this does not necessarily mean he or she is better able to help you get over your problem. Often, people who have "been there" themselves feel that their experience alone qualifies them to help others. They tend to forget that what worked for them might not work for someone else. This attitude is prevalent among therapists with minimal professional training.

Trust Your Gut-Level Reaction

No matter how many degrees, qualifications or specialties a psychotherapist has, if you don't feel comfortable with that person, you are not likely to get much out of it! Trust your own feelings! Do you feel you can easily talk to this person? Do you feel he or she understands you? Do you feel he or she respects you and looks upon you as an equal human being? Or do you feel he or she is looking down on you, patronizing you and making you feel like a little child?

The rapport you have with your psychotherapist is very important! Of course, good rapport is not enough. Your therapist should still be educationally qualified.


Affording Help

Your choice of psychotherapist may be limited by one big practical constraint: what you can afford.

More and more psychotherapists are offering sliding scale fees in order to make services affordable so you can pay out of pocket.

If you are fortunate to still have an old style indemnity insurance policy (more common here in Hawaii than on the mainland), it will probably cover from 50% to 80% of the cost for seeing a licensed psychologist or psychiatrist. There is usually a yearly limit on how much they will pay. There also may be other specific limitations. Read your policy, or call your insurance company if you are not sure what your policy covers.

if your insurance is through an HMO (health maintenance organization), that is, under managed care, you may have to choose a therapist from their "panel" or pay a higher fee to see someone who is "outside the network." You may also have to get "pre-approval" to see a therapist, or to continue beyond a few initial sessions.

If you receive welfare, you can apply for Medicaid coverage for psychiatric or psychological services. This covers 100% of the cost, with certain limitations. In Hawaii, this is called, "Quest," and the three main carriers are: HMSA-Quest, AlohaCare Quest, and Kaiser Quest.  

Senior citizens may be covered by Medicare or may receive some kind of cost reduction.

If you're a military dependent, you may use TriCare for mental health services. Active duty military personnel can receive free or low-cost mental health services at a clinic on base. In Hawaii, many active duty military receive mental health services from Tripler Army Medical Hospital.

College students can usually receive free or low-cost services at the college counseling center. Also, the Psychology Department of many big universities have a free or low-cost clinic or a research program that offers therapy conducted by student therapists or interns, who are supervised by their professors.

Some free and low-cost mental health clinics are supported by charities or run by the state or county. 

26 QUESTIONS TO ASK
WHEN SHOPPING FOR A PSYCHOTHERAPIST

1.  Is this psychotherapist a:

____ psychologist (Ph.D. or Psy.D.)
____ psychiatrist (M.D.)
____ psychiatric nurse (R.N. or M.S.)
____ vocational/educational counselor (Ed.M or Ed.D.)
____ clinical social worker (M.S.W. or A.C.S.W. or L.C.S.W.)
____ marriage-family-child counselor (M.F.C.C.)
____ pastoral counselor
____ certified alcoholism/drug counselor (C.D.A.C.)
____ intern or student practicing under supervision
____ ...don't know (Ask!)
____ ...none of the above (Beware!)

2. If this psychotherapist is a psychologist, psychiatrist or clinical or psychiatric social worker, for how many years has s/he been licensed and in good standing with your State Professional Licensing Board?

____ years ____ Don't know (Ask!)
____ Not licensed or in good standing (Find another psychotherapist!)
(Not applicable for other kinds of psychotherapists)

3. If this psychotherapist is a psychiatrist, is s/he "board certified" in psychiatry?

____ Yes ____ No ____ Don't know (Find out!)

4.  What "school" of psychology or "orientation" does this psychotherapist follow?

___ Traditional Freudian/psychoanalytical/psychodynamic
___ Jungian
___ Adlerian
___ Existential
___ Behavioral
___ Cognitive
___ Cognitive-behavioral
___ Rational-Emotive (R.E.T.)
___ Family-oriented
___ Gestalt
___ Client-centered/Rogerian/humanistic
___ Transactional analysis (T.A.)
___ Mixed or eclectic
___ Other:____________

5. Does this psychotherapist specialize in treating the problem I have?

____ Yes ____ No ____ Don't know (Ask!)

6. What percentage of this psychotherapist's caseload has the same problem I have?

____ % ____ Don't know (Ask!)

7. What is this psychotherapist's success rate?

___ 100% (Be wary of such a claim!)
___ 75%
___ 50%
___ 25%
___ less than 25%
___ other: _____%

8. How does this psychotherapist define "success?"

________________________

9. What specialized training did this psychotherapist have in treating the problem I have?

_______________________

10. Did this psychotherapist explain to me exactly how s/he would go about treating my problem.

____ yes ____ no (Ask!)

11. Does this psychotherapist recommend or prescribe medication for my problem?

___ Yes
___ No

12.  Does this psychotherapist willingly and thoroughly describe to me the possible side effects of medication?

___ Yes                 ___ No

13. This psychotherapist's approach to treating my problem

____ makes sense to me
____ doesn't make sense to me

14. What does this psychotherapist charge?

$____ per hour, individual therapy
$____ per group
$____ for other services such as: _________________________
$____ sliding scale
____ Don't know (Ask)

15. Is this psychotherapist a "preferred provider" or on the "panel" of providers covered by my  insurance?

____ Yes ____ No ____ Don't know (Ask!)

16. Does this psychotherapist accept

____ Medicaid/Quest (or whatever it's called in your area)
____ Medicare
____ TriCare
____ payment from my insurance plan

17.  Can I afford to pay this psychotherapist the co-payment (that is, the portion of the fee that my insurance does NOT cover)?
____ yes
____ no

18. Can I afford to pay this psychotherapist out of my own pocket (once my insurance is used up, or if I have no insurance, or if my insurance company denies me)?

____ yes, indefinitely
____ yes, for _____ sessions (How many?)
____ no

19. This psychotherapist expects treatment to take

____ sessions
____ weeks
____ months
____ years
____ couldn't say

20. This psychotherapist has

____ experienced the same problem I have and is over it
____ experienced the same problem I have and is still struggling with it
____ not experienced the same problem I have
____ ...don't know (Ask!)
____ ...wouldn't say

21. This psychotherapist and I are of the same/opposite sex.
                                                                      (Circle one)

22. This psychotherapist and I are of the same/different races.                                                                          
                                                                       (Circle one)

23. It is important to me that my psychotherapist and I

(Circle all that apply):

____ be of the same gender
____ be of the same race
____ have experienced the same problem
____ none of the above

24. I    feel/do not feel    romantically or sexually attracted to
              (Circle one)
this psychotherapist. (If you DO feel romantically or sexually attracted, find another psychotherapist!)

25. I sense that this psychotherapist is/is not romantically or
                                                           (Circle one)
sexually attracted to me. (If you DO feel s/he is romantically or sexually attracted to you, find another psychotherapist!)

26. In talking to this psychotherapist, I get the impression s/he

                                  (Circle one of each pair.)

respects me as a human being...looks down on me/patronizes me
is truly interested in me..............isn't really interested in me
is warm and comforting...............is cold and detached
is on my side................................is against me
accepts me as a person...............doesn't accept me as a person
is genuine, emotionally honest....is phony and artificial
understands what I think..  .........doesn't understand what I think
understands what I feel...............doesn't understand what I feel

26\7. When I asked some of these questions, this psychotherapist

____ answered willingly
____ sounded annoyed (Maybe find another psychotherapist)
____ refused to answer (Definitely find another psychotherapist!)

Evaluating Your Therapist

Maybe you've been going to therapy for a while and you're still wondering whether you've chosen the right therapist, whether your treatment is going on too long, and whether it's really helping. These are legitimate concerns. After all, it's your money, your time and your peace of mind.

There are so many different ways to measure progress! Often, the therapist's idea of progress may be very different from yours. You may think you haven't gotten anywhere, while your therapist may think that you've shown tremendous progress. Or maybe you think you've gotten a lot out of therapy, but your therapist doesn't agree.

After two or three months of therapy, and every so often after that, evaluate in your own mind how far you've come. If you see you've made some progress (according to your definition of "progress"), consider continuing with that therapist until you reach your goal. If you feel you've made no progress at all, again, discuss this with your therapist. Maybe he or she can find some other way to help you progress. If not, and if you are unwilling to continue for the amount of time which the therapist predicts is necessary, you might start looking for another therapist.

Beware of the therapist who frightens you into staying in treatment with him or her, even though it has gone on for a long time without any progress. Be very suspicious of any therapist who insists that only he or she can help you, or that dire things will happen if you leave.

Be careful though! If you do not really want to be in therapy (it's someone else's idea), or if you are ambivalent about wanting to get over your problem, or if you don't follow the therapist's directions, or if you keep cancelling appointments,  then you can hardly blame the therapist for your lack of progress or for dragging therapy on and on!

Definitely Time To Leave

It doesn't happen very often, but when it does, it can be devastating.  If a psychotherapist ever suggests or makes any attempt to approach you sexually or romantically, get out of there fast. Report this behavior to the ethics board or licensing board of that therapist's profession. It is never, never, never okay for psychotherapists to date or have sex with patients they are treating. It is not a form of "therapy." It is a form of exploitation. Every profession's code of ethics forbids it.  

Even if a therapist doesn't make a move toward you, if you feel that he is "coming on" to you in any way, change therapists immediately.  (I say "he" because most violators of this rule are male psychotherapists pursuing female patients.)   Trust your gut level feelings on this!

There is some disagreement in the professions about the acceptability of a romantic or sexual relationship between psychotherapist and patient long after the end of therapy. How long? A year later? Five years later? Ten years later? That's unclear. 

Nada Mangialetti, Ph.D.

drnada@kapoleicounseling.com

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