People sometimes spend more energy researching a car they are going to buy than researching the psychotherapist they are going to trust with their psychological and emotional well being. It is important to become an informed consumer of your mental health treatment. Choosing a psychotherapist can be very complicated for someone unfamiliar with the process, and therefore the following information can be used to help you feel more confident that you are choosing a qualified psychotherapist who best fits your needs and interests.
Once in therapy, allow yourself 2-3 sessions to determine whether the therapist you chose and the therapy techniques she uses are compatible with what you are looking for. Do not be afraid to ask the therapist questions that will help you feel more comfortable. Questions can include, "What do you see as my problems," "What do you think is going on," and "How is therapy going to help," "What are the goals for treatment and how might we get there?" This is your therapy, and you are in charge of getting the most out of it!
TYPES OF PSYCHOTHERAPISTS
In my experience, many people who are not working in the mental health field are unfamiliar with the differences between the various mental health practitioners who provide psychotherapy, or counseling. To help you make an informed decision, I will describe to you the different practitioners in the mental health field based on their degree and training. Keep in mind though that regardless of the degree, it will certainly be important for you to find a “licensed” practitioner meaning they have met both national and state requirements for their field of study. Essentially anyone can call him or herself a “psychotherapist,” as this term refers to anyone who uses psychological techniques to assist in the changing of thoughts, feelings, and behaviors, and not all psychotherapists may have adequate education, training, and licensure.
Psychiatrist: Psychiatrists are physicians with medical degrees (M.D.s) who specialize in the diagnosis, treatment, and prevention of psychological disorders. Any medical doctor can practice as a psychiatrist, and therefore, it would be important to find a psychiatrist who has had post-graduate residency training in psychiatry (usually 3-4 years) and has passed a national examination to become board certified by the American Board of Psychiatry and Neurology. In the states of California, only psychiatrists and other licensed physicians are approved to prescribe medications, electroconvulsive therapy, or other medical procedures. Regarding psychotherapy, not all psychiatrists have had extensive training in psychotherapy, and therefore, it would be important to inquire about training and experience in psychotherapy if you are considering engaging in psychotherapy with a psychiatrist.
Clinical/Counseling Psychologist: A clinical psychologist has an academic doctorate (Ph.D. or Psy.D.) and, to officially use the term “psychologist,” must have a license to practice in the state. Clinical and counseling psychologists have expertise in psychological testing and in the assessment, diagnosis, treatment, and prevention of psychological disorders. Academic training is usually 5-7 years and includes clinical experiences ending with a full year at a pre-doctoral internship. In California, about one year pre-doctoral and one year post-doctoral experience and a passing score on a national examination are required for licensure. Licensure as a psychologist is denoted by the letters PSY followed by a series of numbers.
Counseling vs. Clinical: There does not seem to be much of a difference between clinical and counseling psychology programs, though clinical programs have traditionally included more training in the areas of more severe psychological disorders. Both clinical and counseling psychologists can be seen in academia, community clinics, private practice, and college counseling centers. In medical settings, it is more common to see clinical psychologists rather than counseling psychologists.
Ph.D. vs. Psy.D.: Many Ph.D. programs are based on a scientist-practitioner model that emphasizes the balance between clinical and research training whereas Psy.D. programs focus more on clinical training. The Ph.D. scientist-practitioner model emphasizes the importance of developing practitioners who can also evaluate or produce research on the causes and treatments of psychological disorders. Though clinical Ph.D. programs tend to have smaller class sizes and more rigorous admissions requirements, the quality of the practitioner seems to be more related to the individual practitioner’s own background education and experience.
Social Worker: A licensed clinical social worker (LCSW) holds a master’s degree in social work (2-3 years of academic training), has completed about 2 years of supervised post-degree clinical experience, and has passed a written examination. LCSWs have training in mental health and social welfare systems and are qualified to provide psychotherapy. For more information on California's requirements for social workers, click here.
Psychiatric/Mental Health Nurse: To be listed in the state of California as a psychiatric/mental health nurse, a California Registered Nurse must hold a master’s degree in psychiatric/mental health nursing and either two years of supervised clinical experience or credentialing by the American Nurses Association as a Clinical Specialist in Psychiatric/Mental Health Nursing. A psychiatric/mental health nurse often focuses on the treatment of psychiatric disorders and is qualified to provide psychotherapy and those with special training in psychopharmacology hold an advanced practice license that allows them to prescribe medication.
Marriage and Family Therapist (MFT): Psychiatrists, psychologists, social workers, and psychiatric nurses are the four nationally recognized mental health providers, but some states also provide licenses to practice psychotherapy to master’s level counselors. In the state of California, a Marriage and Family Therapist holds a master’s degree in a relevant field, has about 2 years of supervised post-degree clinical experience, and has passed the California licensing exam. While their training is in marriage and family therapy, they may also be qualified to treat individuals. Click here for more information regarding MFTs and LCSWs in California.
Important Factors to Consider: Having a license to practice psychology does not necessarily mean that the psychologist’s doctoral training was in clinical psychology. Ph.D.s i n cognitive, social, organizational, and developmental psychology can feasibly sit for the exam and become licensed as long as they have met the other requirements for licensure. In addition, some practitioners have a Ph.D. after their name but have a license to practice under an MFT license. This can be misleading as the PhD may or may not be in the field of psychology and the individual may not have fulfilled the requirements described above. Therefore, it is in your best interest to look beyond the license and look also at the practitioner’s education and background to fully understand his or her competencies.
Most mental health practitioners would agree that more important than specific educational background would be amount of experience, range of experience, and quality of experience in determining the therapist’s competence. In addition, a strong therapeutic relationship and a culturally competent therapist may also be important components of effective therapy.
Quality of experience: To become a professional dancer, one can read a book on dancing or practice dancing at home in front of a mirror, but to become the most proficient dancer often requires training with a competent instructor. In the same way, it is certainly possible to become a good therapist by reading about therapeutic techniques, being supervised by anyone who is licensed, or by getting a lot of experience (see below), but I have found it invaluable to have learned from experts in the field who have been practicing, learning, teaching, and developing for many years. I do feel that for the cognitive behavioral treatment of anxiety disorders, it is important to find a therapist who has had quality training and supervision.
Amount of experience: Reading from a text, learning in a classroom, or seeing one client with one particular problem can all be great learning experiences but most professionals really begin to develop their skills with repeated, hands-on clinical experience. With each new client a therapist sees, she reevaluates what she has read and learned and reevaluates her treatment approach allowing her to continuously develop and hone her skills. Though it may seem biased for me to say, psychologists have a tremendous amount of supervised clinical experience.
In most established PhD programs, students begin to see clients by their second year, then spend the next two years working 20 hours at approved local institutions (and often also work extra hours at other community organizations for more variety of experience), and then spend their last year working full-time at competitive APA-accredited* institutions. Most psychologists, therefore, graduate with an enormous amount of experience, and in addition to graduation requirements, psychologists in California must also have 3,000 hours of clinical experience to obtain state licensure, which all translates to approximately 300 clients seen just by the time they obtain licensure.
* Definition of APA-accredited: The American Psychological Association (APA) accredits professional training programs in psychology based on whether the programs meet the standards and guidelines set forth by the APA. Accreditation requires the training program to undergo regular reviews to ensure the quality and integrity of a training program.
Range of experience: If you are seeking assistance with social anxiety, is it necessary to see someone with training in schizophrenia, bipolar disorder, medical illnesses,
or substance abuse? Most problems do not occur in a vacuum but are rather part of a complex network of emotions, life experiences, and relationships. Having seen a wide range of clients in a wide
range of settings may allow the therapist to see problems with sufficient depth and clarity to put them into perspective. In addition, many people’s lives are touched by issues that they may not
struggle with themselves. For example, clients may be overwhelmed by having to care for a family member with a serious mental or physical illness or they may come from a family where substance abuse
was common. A therapist with some experiences in these areas may be better able to provide direction for the struggling client.
Is it necessary to see a therapist who has research experience and assessment experience? Every year, there are new medications and treatments that flood that market. In addition, existing therapies are also being constantly reevaluated and improved upon. Therefore, it can be important to have a therapist who has been trained to evaluate research on the effectiveness of psychotherapy techniques and will only utilize those therapies that have been “clinically proven” through scientifically valid research trials. An interest in research shows a therapist’s commitment to providing the most up to date and effective treatments available.
As for assessment experience, quality therapy begins with quality assessment. Though comprehensive psychological assessments are not a standard part of psychotherapy, experience in assessment can give the therapist a trained eye to quickly identify issues of concern and can also assist in the development of the most effective treatment plans. If further assessments are necessary, clinicians who themselves have had training in assessment, may be better able to make the appropriate referrals for more comprehensive assessment.
General therapist qualities: In a survey by Consumer Reports, readers indicated that a caring attitude, ability to listen empathically, genuine commitment to client’s welfare, sincerity, warmth, and responsiveness were all important therapist characteristics. These factors are thought to be important for promoting a positive therapeutic relationship which is characterized by feelings of mutual respect, trust, and hope. The most successful outcome in psychotherapy occurs when there is a good match between the therapist, the client, and the treatment method. For example, research evidence has consistently shown that cognitive-behavioral therapy is the most effective treatment method for obsessive-compulsive disorder, but you do not feel comfortable with the therapist or do not have trust in her abilities, the treatment method will have limited effectiveness.
Cultural sensitivity: More recently, cultural sensitivity has also been identified as an important factor that promotes the effectiveness of psychotherapy. The American Psychological Association has focused on developing culturally component therapists over the last decade, and training in cultural sensitivity has become an important component of all established training programs. A culturally competent therapist:
TYPES OF PSYCHOTHERAPIES:
Research evidence has not found any consistent evidence showing superiority of one type of psychotherapy over another except for certain specific psychological issues. There has been overwhelming evidence supported by both the National Institute of Mental Health and the American Psychological Association that indicates that cognitive-behavioral therapy is more effective than other therapies for specific problems and symptoms such as seen in anxiety disorders, depression, weight management, body image disturbance/eating disorders, and habit and stress-related disorders. Therefore, though some may argue that all therapists are essentially the same, this may be true for more general issues. For those seeking specific treatment for specific issues, then it may be more important to find a mental health professional with specialized training for these particular issues.
INDIVIDUAL PSYCHOTHERAPY: Below is a brief description of the types of individual psychotherapies that have proven efficacy and research support. Though there are many other types of therapies marketed, not all have undergone rigorous examination and testing.
Psychoanalysis: Psychoanalysis refers to a type of therapy developed by Sigmund Freud. The major goals in psychoanalysis are to uncover and explore repressed or unconscious conflicts, impulses, or anxieties. A technique often used is called free association, where the client spontaneously reports all thoughts, feelings, and mental images that come to mind. The therapist often attempts to remain netural so that the client can project unconscious thgouhts and feelings on to the psychoanalyst. Traditionally psychoanalysis occurred four to five times a week for a course of four years or longer, but currently short-term psychodynamic therapies have become the norm. Short-term psychodynamic therapies are based on psychoanalysis, but are often time-limited, have a specific goal, and involves a more active therapist. Psychoanalytic and psychodynamic therapies are often referred to as "insight-oriented" because the major focus is on gaining insight, or understanding, of why you are the way you are.
Humanistic Therapy: Humanistic therapy is also called "client-centered therapy" as the client directs the focus of each session, and the goals of therapy are to increase self-awareness, promote psychological growth, and create a healthier self-concept. Carl Rogers developed this humanistic therapy, and he emphasized the importance of the therapist providing the client with unconditional positive regard (accepting, valuing, and caring for the client whatever their problems or behaviors). He also believed that the therapist needed to share her thoughts and feelings with the client as a way of being genuine and also that the therapist needed to communicate an empathic understanding of the client's experiences. Through this healthy relationship, the client is able to make more self-fulfilling decisions without fear of negative evaluation.
Behavioral Therapy: Behavior therapy assumes that emotional distress is caused and/or maintained by maladaptive behaviors. These behaviors are thought to have developed through a learning process, and therefore, techniques in behavioral therapy focus on unlearning maladaptive behaviors or replacing them with more positive behaviors. For example, if a fear is learned because a client had an aversive experience with, say, an elevator, then the learned behavior is avoidance. The treatment is to replace avoidance-behaviors with approach-behaviors, so a therapist may guide a client in developing techniques such as relaxation or distress tolerance to help the client begin to approach the feared situation. Other techniques might involve creating a system of rewards and punishments to help develop a new behavior. For example, to help a client who is feeling depressed, a therapist may help the client develop a weekly schedule that includes some kind of reward or reinforcement each day. This may be as simple as creating and completing a checklist of thinkgs-to-do, buying oneself flowers, taking a walk, or meeting friends for dinner.
Cognitive Therapy: The basis of cognitive therapy is that the way we think affects the way we feel. Treatment focuses on identifying unhealhty thinking patterns and replacing them with healthier patterns of thinking. Albert Ellis focused on challenging irrational beliefs that leave us vulnerable to psychological distress. Aaron Beck focused on teaching clients to identify distortions and biases in thinking and developing more realistic thoughts. Click here for a more comprehensive review of cognitive therapy and its history.
Cognitive-Behavioral Therapy (CBT): Most therapists combine cognitive and behavioral techniques. See my section on Problems and Disorders and the Process of Psychotherapy to learn more about the cognitive behavioral treatment of anxiety disorders.
Mindfulness-Based Cognitive Therapy (MBCT): MBCT combines cogntive behavioral ideas with meditative practices. Mindfulness meditation involves purposefully attending without judgment to the present moment and retrains the brain to acknowledge, accept, and eventually let go of thoughts rather than fighting to suppress negative thoughts and emotions. MBCT has been found to be helpful in the treatment of anxiety and depression. Click here for more information about MBCT. Click here for Dr. Segal's TEDTalk on MBCT.
GROUP THERAPY: Group therapy involves seeing several people simultaneously and has several advantages. Clients often benefit from the support of other people having similar struggles. Group members can motivate each other to change. Group members can provide each other with practical advice. Groups allow clients to learn how to give and receive social suport and clients can also practice new social behaviors, such as through role-playing, in a safe environment.
FAMILY/COUPLE THERAPY: Family therapy assumes that psychological distress, even of an individual, is part of a complex interacting system. To just treat an individual may not be sufficient. Through family therapy, each part of the interdependent system can be addressed. Family therapy can be for families that are having difficulties as a unit, or even when one family member seems to be experiencing much of the distress. Couple therapy or marital therapy often focuses on improving communication, reestablishing intimacy, and increasing problem-solving skills.
MEDICATIONS: Click here for a more thorough explanation of medications.