How select a therapist

I'm okay. Are you okay? No? Then let's find a shrink and get your crazy ass some help.

That approach to finding the right therapist is, . . . well, . . . okay. But there are better ways to do it. The first thing to understand is that most of the time, seeing a therapist has nothing to do with being crazy. We've all got problems. Therapy just involves talking privately to someone who has gone to school for many years to learn how to deal with them. (Don't worry about electrodes . . . they're optional).

If your situation is really bad, and you are seriously thinking of hurting yourself or ending your life, you need to stop reading this and go to an emergency room or dial the police. They can get you to somebody right away.

If your predicament is less urgent, but you think that talking to someone for a few weeks might sort out what's bothering you, there are some fairly simple steps to take. Therapy is a collaborative process, and it only works if you are comfortable telling your therapist everything he/she needs to know to help you.

Unfortunately, the process isn't free, and your therapist will charge either you or your friendly insurance company for his/her services. So, it's worth shopping around a while to find the right person.

Get some referrals

Most interstate highways are not cluttered with billboards advertising licensed therapists, so finding a good, qualified professional may take a little bit of digging. If you're not at all sure where to begin, there are a number of standard places to go to get referrals. A referral is when somebody points you in the direction of a specific therapist. This is important because 1) it helps you find a good therapist, and 2) different therapists are better suited for different issues, and you want to find one that matches you. Once you make the call, that therapist can refer you to another one, and so on and so on. If you're hesitant about openly asking people where to get help, we found it easy just to pretend to be doing research for www.soyouwannaknow.com

Some of the most common places to get referrals include:

  • Your primary care doctor
  • State psychological organizations
  • Clinics at colleges or universities
  • Hospitals
  • Community mental health centers
  • Local clergy
  • Friends
  • Family members
  • The Yellow Pages

Each method has its advantages and disadvantages, and there are debates about which ones you should avoid. Friends may know you the best, but may not be able to line you up with someone who can really deal with your specific situation. Psychological organizations may have oodles of names, but no way to recommend the good ones. Reading the Yellow Pages may get you started, but could also distract you into shopping for an above ground swimming pool.

Regardless, a combination of these approaches should yield two or three people to at least call. If you are asking friends which therapist they would recommend, keep in mind that you don't have to wind up seeing that person. You can simply ask that therapist whom else he/she would suggest for your situation. It is probably not a good idea, though, to see a therapist whom you know socially. Chances are he/she would refer you to someone else anyway.

If you obtain a referral from a primary care doctor as part of a managed care plan, he/she may select someone on staff with their organization or a member of a network approved by your insurer.

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Know the different types of therapists

Anybody who wants to can call himself a "therapist" or "counselor" (camp counselors are 15 years old!). "Psychiatrist" and "psychologist," on the other hand, are terms protected by state law pretty much everywhere in the United States. If you want to legally call yourself one of those, you need a license and several years of graduate education.

Licensed Clinical Social Workers are another type of mental health professional, often denoted by the acronym, L.C.S.W. (Keep in mind that sorting through the therapy world's forest of academic suffixes will only waste your time, so don't spend any energy trying to tell the Ph.Ds from the Psy.Ds from the Ed.Ds.)

There are, however, several basic types of mental health professionals that you should know about:

PSYCHIATRISTS

Are medical doctors (e.g., Frasier and Lilith on Cheers, Dr. Melfi on The Sopranos). They have completed medical school and a residency in psychiatry. The main thing to remember here is that these are the folks who can write prescriptions and give you meds. So if you want Prozac, Lithium, or any other non-over-the-counter drugs, you have to go here. These guys have M.D. after their names, and are especially expert at M.D. problems. For more info, check out the American Psychiatric Association.

PSYCHOLOGISTS

have a doctorate in psychology, and are licensed to practice in their state. (Bob Newhart on "Newhart"). They can't write prescriptions or give you Prozac, but they can talk to you for a long time about why they think you need it. Psychologists have usually slogged through eons of postgraduate study at some point in their lives. The American Psychological Association notes that psychologists have an average of 7.2 years of education and training in addition to their undergraduate education. These guys have Ph.D. or Psy.D. or Ed.D. after their names. They also get the Doctor title. But the big difference between psychiatrists and psychologists is that psychiatrists went to medical school, while psychologists went to graduate school and got a degree in psychology.

LICENSED CLINICAL SOCIAL WORKERS

Have generally completed a two-year Master's degree in social work. (They don't make too many TV characters out of these people.) These counselors have some amount of supervised clinical training and are licensed in their state. Social workers tend to work with family problems such as domestic abuse or kids in foster care. They are given sexy titles like L.C.S.W. or A.C.S.W. or C.S.W. For more info, check out the National Association of Social Workers web page.

In addition, family therapists and psychiatric nurses are other types of mental health professionals who may be specifically licensed to practice therapy.

No one of these is better than the rest – and since therapy is such an individual and subjective experience, much of it depends on the individual counselor and client. Generally, if you think that your problem is in part related to something biological, you should go to a psychiatrist. If you just have weighty issues on the mind, a psychologist may do. One thing that will play into your choice, however, will be how much you want to spend. Psychiatrists are the most expensive and social workers are generally the cheapest. Psychologists usually fall somewhere in between. Figuring out how you will finance your therapy is an important step in finding the right person to talk to.

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Decide how you will pay

Psychiatrists often charge an hourly rate of around $200. Psychologists get roughly between $80 and $135, and clinical social workers may bring in $75 - $125 an hour. This varies widely depending upon your geographic location, and obviously somebody in Paducah, Kentucky is going to be a tad cheaper than some turtle-necked hipster on the Upper West Side of Manhattan.

If you can afford it, paying out of your own pocket to see a therapist in private practice may be the most straightforward approach. You won't have to mess with fine-print restrictions and your therapist won't have to mess with your insurance company.

For many of us, however, insurance will play some role in the process, whether the therapist is in private practice or part of a Health Maintenance Organization. Insurance coverage for mental health is generally more restrictive than that for medical health, and you will have to do your homework to find out exactly what type of therapy your plan covers. Ask specifically about limits to coverage and annual or lifetime maximums. The American Psychological Association recommends seven questions to ask your benefits manager before trying to get your therapy covered by your health plan. Check out the web page to get full explanations of each, but in a nutshell, you should ask about:

  • Benefits
  • Professional Expertise
  • Contractual Limitations
  • Appeals and Grievances
  • Confidentiality
  • Choice
  • Treatment decisions

Aside from privately practicing therapists and HMOs, community mental health centers are a third option. They are often run by your county or municipality, but can also be private, non-profit centers funded by organizations such as the United Way or religious groups. Many community mental health centers offer 'sliding-scale' fees - or prices based on your income or ability to pay. Other advantages of these places may include broader on-site resources. They often have different types of in-house therapists and programs for other members of your family.

Finally, outpatient clinics at hospitals are another widely used mental health resource. You can walk in to these facilities and pay out-of-pocket or with your insurance.

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Pick up the phone and call around

You've already gotten the list of doctors to talk to, so now it's time to talk to them. The goal here is to call two or three therapists and find out a little about each one. Chances are, you will be speaking to an answering machine at first, or in some cases, a secretary who will go ahead and book you an appointment. Therapists will generally call you back during thin slices of free time between appointments. So, whatever you initial conversation, don't expect it to be too extensive.

Sometimes it will be nothing more than giving your name, how you were referred to that person, and then setting up a time for a first visit. In other cases, you will have the opportunity to ask a few basic questions. If you don't feel comfortable setting up the first visit, then ask the therapist to call you back when he/she has more time so that you may get all of your questions answered. The important thing is to not interpret the fact that a therapist is too busy to talk as a sign that he/she is a bad therapist.

If they do have a few minutes, some standard questions may include:

  • Are you licensed?
  • How long have you been practicing?
  • Do you specialize in a particular type of therapy?
  • How does your practice work for new people?
  • How can I pay? Will you accept my insurance?

Again, sometime these questions will be left to the first meeting. All that matters, though, is that you ask these questions and are satisfied with the answers. If the first therapist that you talk to has a full schedule or thinks he/she may not be best suited for your situation, he/she will probably refer you to someone else.

Once you have talked with two or three people, and you get a sense from at least one of them that he/she may be able to help you, go ahead and set up an official session.

The choice is yours whether you want to attend initial meetings with more than one therapist. If you feel you have received enough information over the phone, just make one and go for it.

Know what to expect in your first meeting

Your first consultation will set the administrative ground rules for your treatment, and it is there that you will finalize things like fees, schedules, and the length of your sessions.

Some therapists will need payment up-front, and some will bill your insurance, accepting only a co-payment. (A co-payment is a fee you pay yourself in addition to that which is covered by your insurance).

You can generally expect to see your therapist once a week and sessions are usually in the neighborhood of 45-55 minutes long. The important thing is not to be late, though, since most therapists will keep you to your original end time. If the therapist is late, they may give you extra time for that session or tack it on to a later date.

Individual therapists may also have different policies on cancellations, requiring different levels of advance notice. Your insurance provider may also care about missed appointments, so you will want to ask them too.

Mandy Aftel and Robin Tolmach Lakoff, authors of When Talk Is Not Cheap (this great book is unfortunately out of print - try your local library), recommend a set list of questions to ask your therapist on the first visit. Aside from basic scheduling and payment details, they suggest asking your therapist how long he or she thinks your treatment will last, what their theoretical orientation is (cognitive, behavioral, etc.), if they themselves have ever been in therapy, and if they have been in therapy, what they got out of it. Sometimes, a therapist will actually write out this information.

Regardless, the authors say you should avoid any therapist who refuses to discuss the rules, clarify them, or listen to your input when setting them up.

Beyond scheduling, though, there are some basic expectations you must have:

CONFIDENTIALITY

Is crucial. You need to be completely comfortable while working out your treatment. This could be greatly compromised if you sense that your comments are leaving the office. It goes without saying that your therapist should not discuss your case, or even your status as a client, with anyone else. That's also why you shouldn't choose a therapist who is somebody that you know socially. (The APA notes that state laws on this do vary. In some instances, confidentiality can be legally broken by a court order, if the therapist finds evidence of the client's intent to harm himself or others, or if the client sues the therapist)

PRIVACY

Is also important. Make sure the physical setting of your therapist's office is such that you feel your confidentiality is not being violated. Going to a therapist who shares a waiting room with the local newspaper might not be a good idea.

N0 SEXUAL ADVANCES

Should be made by your therapist. Not hard to figure this one out. If this happens in any way at all, you need to stop seeing this person and report him or her to your state licensing board.

The way your first session unfolds no doubt depends on you and the individual therapist. It could just be you talking the most of the time, explaining the basics of your problem. Or, your therapist could fill the session with a series of questions.

A large study by Consumer Reports published in 1995 suggested that most people are satisfied with their treatment and that it does help people make changes in their lives. But if your therapist is not making a difference in your life, always keep in mind that you can change the situation. If after three sessions you feel you are not being helped enough to continue, switch therapists. Your life is too important and therapy is too expensive to waste that kind of time.

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