How to Find a Therapist
The path to developing greater mental well being entails, in my view, the development of a healthy relationship between the mature and immature parts of our personality. I locate these aspects of our personalities in the left and right hemispheres. I believe we each have left and right minds, the relationships between which will vary with different people. As we have mentioned a number of times in Of Two Minds, it is often helpful to have a psychotherapist assist us in our journey. I believe, the task of the therapist is simply (or not so simply) to help us in our attempts to improve our two minds and the relationship between them. What is required is that we find a therapist whom we can respect and trust --not only with our more mature minds, but also with our more troubled sides. For this reason it is very important to consult one's intuition when selecting a therapist. Choosing a therapist is a bit like choosing a friend or spouse, there has to be a good chemistry between the two people. I would ask if you have a feeling of safety and confidence about the person? I would avoid therapist who seem condescending or who seem rigid. And if you don't feel right about him or her, trust your instinct, even if the therapist calls you a resistant mental weakling. If you are resistant, find someone you like and then the two of you can explore that possibility.
Finding this likable, trustworthy psychotherapist can be difficult. Good sources are friends or doctors you regard. You can often describe the type of therapist you feel you might be able to relate to and they may be able to suggest someone. Sometimes an even better option is to call your local Psychoanalytical Association. I am not recommending psychoanalysis for most people because of its time and expense, but as a group psychoanalysts are extremely well trained, and most do weekly psychotherapy as an important part of their practice. That doesn't mean you can't find a dull or rigid analyst, but if you can't get a reliable recommendation from someone you know and don't know where to turn, then you have to try professional groups in which you are more likely to find someone you'll be pleased with. Personally, I think the best analysts are within the sub-group called "self-psychologists." These are the analysts who are apt to be the most empathic and least remote and least pathologizing. That is they tend to look at you with more understanding and regard.
Most psychoanalysts are psychiatrists, that is they have medical degrees. Most psychiatrists on the other hand are not psychoanalysts. I am a psychiatrist but not a psychoanalyst.
Psychiatrists tend to come in 2 overlapping flavors. There are the talking types, like the psychoanalysts and myself. We are called dynamic psychiatrists, essentially because we believe that there is a dynamic meaning to our emotional upsets and problems, a meaning which with skill can be understood and worked out. On the other side are the ardent psychopharmacologists. Many of these psychiatrists believe that talk therapy is about as useful as a warm bath. They believe that psychological problems are in general the primary result of yet to be discovered biochemical changes in the brain, and see psychotherapy as no more reasonable than trying to talk a stoke victim into becoming able to walk again.
Most psychiatrist try to hedge their bets and use both medications and psychotherapy. Personally, I use medications as an adjunct to therapy when the patient's symptoms and distress are interfering with his functioning or when the pain seems unreasonable. I have often been disappointed with results of medications, and feel that we have been taught to expect too much from them. As soon as I hear that a person has some anxiety or sadness, I don't reach for the Prozac or Klonapin, but for some patients such medications can be quite helpful, for a few they can be remarkably helpful.
Clinical psychologists have a Ph.D. and have gone through rigorous training. As a group I think they are very skilled, and I think they tend to be slightly less formal in their demeanor than psychiatrists. But, again, within the group there are different branches. Some are dynamic therapists like myself. Others are more into behavioral therapy, which has more to do with relaxation techniques or learning procedures. Psychologists cannot prescribe, but most non-psychiatrists work closely with a psychopharmacologist who can prescribe for those patients for whom they feel medications would be helpful.
Most states have psychological associations which can make referrals. Often the secretaries know the therapists and can try to make a match, but be careful though because sometimes the secretaries know the psychologists who are most politically active within the organization and political activity my not correlate with therapeutic skill.
A psychologist can also have an Ed.D., a doctorate in educational psychology, or a Ph.D. in social work. Then there are the therapists who have a masters degree in psychology or in educational psychology, and then there are the social workers who have a masters degree in clinical social work. Other therapists have no degrees. They are called lay therapists by professionals, but they call themselves psychotherapists.
Does it make a difference what degree a therapist has? I don't think anyone knows for sure. My own impression is that intellectually there is a pecking order with the analysts on top and the lay therapists on bottom, but the most brilliant mind might not be the best therapist for a given person. And even within a groups there can be a wide range of temperaments and abilities. My wife is a clinical social worker, and she is one of the most talented therapists I know of.
Well, what can one do with such a confusing array of choices? I think the good part is that, in general, the quality of therapists is fairly high across licensed, professional groups, at least in the Boston area, and I presume the same holds true for most other metropolitan areas. I would probably avoid lay therapists. All things being equal, I would start with analysts or with Ph.D. psychologists. I would ask if they have an interest in "Self-Psychology," and use their answer as a kind of pass word. If they don't know what you're talking about, I'd call the next name on the list.
I'd also ask if the therapist underwent their own psychoanalysis. All psychoanalysts go through a training analysis, and many other therapists like myself go through a private psychoanalysis during their training. I think this experience is an invaluable part of becoming a therapist. First, it helps the therapist in training work out his or her own issues so they don't so easily get put abusively on the patient. This is not an inconsequential consideration. Secondly, the experience of undergoing treatment is very instructive in how to give treatment. Unfortunately, today's graduates from training programs are less likely than in the past to undertake the pain, time, and money required, and I think this trend will bode poorly for the future if it is not reversed.
Once you have an appointment, see how you feel with the person. Do he or she seem intellectually competent, that is do they seem to know what their doing? Don't accept someone who just nods his head and smiles. The person should clearly convey that they have some understanding of you and of psychology, and this should happen in one or two sessions. If he or she can't speak intelligently about what your problem has to do with and how he or she might try to help you work on it, then I would be leery. I personally would avoid people who try to emphasize diagnoses because diagnoses usually cover up a lack of understanding of you and of your psychology, essential ingredients to any successful therapy.
I think, of course, that you should strongly regard your gut feelings about the person. If you feel the therapist may not be able to bear your pain or may not be able to believe in you, I'd consider this a strong negative factor. You should have a very positive feeling about the therapist as a person. He or she, of course, must be someone you have a positive regard and respect for. Listen to your gut very hard on this one. If you don't feel right, you should try somewhere else.
Of course, when you're in distress you don't want to go around and interview the entire psychiatric association, but on the other hand this is a large undertaking and it can be a very different experience depending on with whom you do it. The best studies show that the best predictor of psychotherapy outcome is the alliance between the therapist and patient. When there is a good alliance, the outcome very much tends to improve.
The fact that the trend in health care today is toward managed mental health programs is unfortunate. These companies do several things which severely interfere with one's ability to form a good therapeutic relationship. First, they have limited panels of providers, and the providers are as far as I can tell not chosen because of their clinical successes, but rather for their compliance with the companies demand to discharge patients quickly. One company I know would not allow patients to choose their own therapist, but would assign patients to therapists. The assignment was based mostly on the patient's address. The company kept their list of providers secret so that neither primary care doctors nor patients could choose from the company's limited provider list. If the patient didn't like the therapist, he or she could request another (while using up the benefit). I know one woman whom I found very bright and reasonable who went through this process many times before she found someone who either had time for her or whom she found compatible enough to work with.
These companies sometimes also interfere with the treatment alliance by doling out sessions so that the patient and therapist never know what time frame they have to work within and are always working under the threat of a sudden termination. Further, the companies require that detailed clinical information be reported back to them, not something to foster trust and advance the therapy. Interestingly, if an alliance is interfered with and the patient does not engage in treatment, then the insurance company reaps a profit because they then don't have to pay the advertised benefit.
The unfortunate fact is that if you belong to a managed care insurance plan and really want good therapy, you may have to be willing to go outside the plan and pay out of pocket. I would try to find a suitable therapist within the plan, but if you can't, then I think you have to be careful not to deprive yourself of help because you paid an insurance premium. If you absolutely can't afford treatment, then perhaps you need to work with the plan. But, many people who can afford treatment, won't pay for it because they feel they have already paid their premiums, and if they pay out of pocket then they feel they're being cheated and would rather go without professional help.
My advice is that if you use these guidelines and
find a therapist with a deep mind and a loving heart with whom you can
feel connected, then go for it. If its good therapy, its probably
the best investment you'll ever make.
1 Krupnick JL, Sotsky SM, Simmens S, Moyer J, Elkin I, Watkins J, Pilkonis PA: The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting & Clinical Psychology. 1996;64:532-9
2 Horvath AO, Luborsky L: The role of the therapeutic alliance in psychotherapy. Journal of Consulting & Clinical Psychology. 1993;61:561-73
3 McLellan AT, Woody GE, Luborsky L, Goehl L: Is the counselor an "active ingredient" in substance abuse rehabilitation? An examination of treatment success among four counselors.Journal of Nervous & Mental Disease. 1988;176:423-430
4 Luborsky L, Crits-Christoph P, McLellan
AT, Woody G, Piper W, Liberman B, Imber S, Pilkonis
P: Do therapists vary much in their success? Findings from four outcome
studies. American Journal of Orthopsychiatry. 1986; 56:501-512
® Copyright by Fredric Schiffer, M.D., 1999
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