What if I can’t afford a psychologist?
If you cannot afford a psychologist, clinical social workers are the next best thing. They have less initial training and experience than psychologists, but after a dozen years in the field or so, this becomes a less noticeable and important difference. They are much more prevalent in giving psychotherapy as the managed care field has grown in recent years in America.
A couple of things should be noted here, lest you think I’m just self-promotional (as I was trained as a psychologist). One, you can peruse over the other literature I have here about the distinct differences between the degrees. Two, research so far has not shown any real or significant differences between how well patients feel after therapy given by these various practitioners. So, in the long run, as far as we know now, the differences I outlined may not be all that important.
So how does one even choose a therapist to begin with, regardless of their degree?
The answer to this question depends on that tricky insurance question again. Some HMOs and other insurance companies are setup so that you must first consult with their GP and get a referral from that person, before you can see a therapist (either within their system or outside of it). Consult your health benefits handbook for the procedure for this, or contact your HMO directly and ask.
Otherwise, the procedure is bit more difficult, since there is no easy way to choose any professional in any field (e.g.- dentist, ophthalmologist, etc.). In many larger suburban or metropolitan areas in the United States, there are referral agencies set up to handle this problem. In smaller communities, this might be handled by a local professional association or the mental health advocacy association. The answer to this question is likely to be found in the Yellow Pages of your local telephone book under one of the following headings, “Mental health,” “Therapists,” “Psychologists,” or “Psychotherapists.”
What are the minimum qualifications I should look for?
Look for a therapist who is licensed (or registered) in the state or territory in which he or she practices in. Psychologists, for instance, likely will have to have a valid license before being listed under the ‘psychologists’ heading in the Yellow Pages (or before they can call themselves “psychologists”). For clinical social workers, they will generally have an “L” in front of their degree (e.g.- L.C.S.W.). Some states may not license clinical social workers, or do not require they display licensure in this format. Ask the therapist if you are unsure. No professional or ethical therapist should mind being asked about their educational or professional backgrounds. If a therapist has a degree, it will almost always follow their names in the advertisement (and may be required by law). You should likely stay away from individuals who don’t have at least a Master’s degree (e.g.- M.S., M.S.W., C.S.W., M.A.). Avoid “counselors” who have little or no formal training, or titles that are not easily recognizable. For instance, in New York state, you need nothing more than a high school diploma to become a “Certified Addictions Counselor.” While this sounds pretty impressive, it is misleading since the training required to receive this title is minimal.
And as a large-scale survey of Consumer Reports readers showed in 1995, people in therapy generally rated psychologists, clinical social workers, and psychiatrists about as equally effective. Marriage counselors were rated significantly worse, according to patient improvement skills. (I get a lot of flak in e-mail for saying this, but I won’t contest the data. I’ll leave that to others in a larger debate on this topic. Please don’t e-mail me complaining about this… It’s only my opinion backed by my reading of the data.) You’ll likely be better off if you follow the above criteria.
Okay, so I’ve made the plunge and set up my first appointment with a therapist. What should I expect now?
You will likely be told a little about financial information you should bring with you on your first appointment over the phone. Bring it and expect to fill out a few forms (especially if you’ll be going to a community mental health center or other government-involved agency for therapy). The first session, sometimes called an Intake Evaluation, usually is very unlike what you can expect of all of your following sessions. During it, you will be asked to explain what brings you into therapy (e.g.- What’s wrong at this point in your life?), what kind of symptoms you might be experiencing (e.g.- can’t sleep, always thinking about some things, feel hopeless, etc.), and your family and general history. The depth of this history-taking will vary according to the therapist and the therapist’s theoretical orientation. It will likely include questions on your childhood, education, social relationships and friends, romantic relationships, current living situation and housing, and vocation or career.
When this history is completed, and the clinician has a beginning understanding of you and what goes to make up the important things in your life, as well as your current difficulties, he or she should ask you if you have any questions for them. If you do, please feel free to ask them (and ask them even if the clinician forgets to offer this). This would be a good time to ask a few questions about the clinician’s theoretical orientation, training, and background, especially in treating your specific type of problem. As mentioned previously, professional and ethical therapists should have no problems in answering such questions. If your clinician does, that might be your first warning about that person’s ability to help you with your problems.
You’ve mentioned “theoretical orientation” in the above paragraph. What is that and what concerns should I have about it?
Theoretical orientation describes what theories the clinician subscribes to in thinking about a person’s problems and how best to treat them. Most clinicians nowadays subscribe to what is called an “eclectic” orientation. This means that, in general, they try to tailor their treatment approach to your own way of relating and the problems you present with. Other popular approaches to treatment are “cognitive-behavioral,” “behavioral,” and “psychodynamic.” I plan on writing another article soon, which I will put up here on the Page, about the major theories and theoretical orientation and the treatment approaches used by each school of thought. You should also be aware that some therapists think (or theorize) in one school, while they treat in another school. The most common example of this type of merging of two different theoretical orientations is conceptualizing or thinking about your case in a psychodynamic manner, while treating in an eclectic or cognitive-behavioral approach.
What about confidentiality and my rights as a client or patient?
See an example of a typical “Patient Rights” handout given to patients at the onset of their therapy here.
Okay, so now I’ve begun therapy and feel comfortable with the therapist I’ve chosen. How long should this take and what should I expect the course of therapy to be like?
While this might seem like an easy question, it is the most difficult to answer since individuals vary widely with their own backgrounds, severity of the problem, and other factors. For mild problems, treatment should be relatively brief or short-term and will likely end within 12-18 sessions. For more severe problems (especially chronic or long-term difficulties), it’s going to take longer. Some therapy can even last up to a year or more. The choice is always yours, however, when you want to end therapy. If you feel you’ve benefited as much as you’d like, you can tell the therapist and end therapy accordingly. A good therapist will respect your decision (questioning it a little to look at the reasoning behind it and make sure it is sound) and will seek to end the process with another session or two, to wrap things up and summarize progress made on treatment goals. An unethical or unprofessional therapist will attack your decision and seek to keep you in therapy. Be firm with this kind of therapist and leave whether the therapist wants you to or not. After all, unfortunately, not all therapists act appropriately in all respects in this field.
You’ve mentioned “treatment goals” in the above paragraph. What is that and what if my therapist doesn’t use them?
I feel strongly that all therapists should use treatment goals, but there is no one standard in the field. Naturally, if you come into therapy with particular problems or difficulties in your life, you would like to have them solved (or at least begin working on them). Treatment goals, especially ones that are formalized and written down, ensure that both you and your therapist are on the same “track” and working on the same problems. Also, by occasionally reviewing said goals, you can chart your progress (or lack thereof) in therapy and work with your therapist to change therapy if need be. But, as mentioned, this is an individual therapist decision; if you’d like to have some goals set up, you can always ask your therapist to help you do so. I would certainly recommend it.
Sometimes, however, treatment goals don’t need to be formalized and written down. For instance, in couples therapy, the goal is generally understood at the onset — to help improve communication and improve the relationship. In such cases, it is usually not necessary to write specific goals down to work on every week. But if you feel more comfortable being concrete about your goals in therapy, let your therapist know. Most therapists (but not all) will comply with such a request. (Some therapists are simply “anti-treatment goals” and don’t believe in them. This doesn’t automatically make them a bad therapist, but it is something to be aware of.)
What if I suspect that my therapist has acted or conducted him or herself in an unprofessional or unethical manner?
It is best, but not always easiest, to report such violations to your state’s licensing board (likely found in the “Blue Pages” in your telephone book, under state government agencies) as well as that therapist’s professional association (American Psychological Association for psychologists; American Medical Association for psychiatrists; don’t know for others). It is not always easy to follow through on these charges, however, because these professions are generally “self-policed.” This means that it is up to the profession (e.g.- the licensing board or professional association) to investigate the charges and follow up on them. This is a slow process.
If your therapist has done something harmfully wrong to you during therapy (e.g.- made sexual advances on you, which is never appropriate in any profession), it really should be reported, or else the therapist may continue to harm others after you. Inappropriate behavior which violates your trust, including engaging in a sexual relationship with you or violating your confidentiality without your expressed written consent, should also always be reported.
Remember, always keep in mind the most important key to having a good therapy experience . . . Find a therapist you feel comfortable with talking to and feel he or she is helping you work through your problems. Therapy isn’t meant to be easy, so if it is, that might be a sign that your therapist or you are not working hard enough. Don’t be afraid to stand up for yourself on this important issue and change therapists as often as need be until you find the right fit.