By MICHAEL SHAPIRO, PhD
So…you’ve been diagnosed with a mental, behavioral, or emotional issue that requires treatment. Or not. Maybe you’ve just hit some “bump in the road,” and you’d like a little guidance to help you navigate a work issue, career issue, or relationship issue. Or, maybe you’ve begun to suspect that something that happened to you in the past, like some trauma or stressful family event, has been interfering with your progress along the path of life (or tunnel of existence, or whatever colorful metaphor you’d like to use). Who should you go see? To whom will you bare your soul in the interest of getting “better”? Who will help you get all those skeletons out of your closet? Who will shrink your head? (Okay…enough is enough).
These days, in the context of ever-increasing awareness of mental health disorders and the need to treat them, it seems that there has been a proliferation of different kinds of mental health professionals with a multitude of degrees and qualifications. Therapists, counselors, life coaches, psychologists, psychiatrists…so many different providers, with an alphabet soup of bewildering letters after their names. Who are these people, and how can you choose the right one to help with your particular issue?
First, I think that a brief history mental health treatment is in order. As you are probably aware, there was a time when only the most severe of mental problems came to the attention of a professional, and then, treatment was mostly undertaken in a hospital. In the early 1500s, Swiss physician Paracelsus was among the first to advocate for a psychotherapeutic approach for treating the insane; as opposed to some of the more “advanced” medical approaches, such as bloodletting (which, apparently, wasn’t covered by Blue Cross/Blue Shield at the time). The term “psycho-therapeia” (talking psychological therapy) was first introduced in 1853. Then, of course, came the father of my profession (and, according to some, my personal doppelganger), Sigmund Freud, who revolutionized the world by developing a technique called psychoanalysis. He used his “talking cure” to explore the minds of his patients (many of whom were middle class Viennese women) and eventually concluded that most neuroses are the result of repressed memories and impulses. Oh, and he had a really nice couch.
The next 50 years or so saw the birth of a number of psychotherapeutic techniques, particularly here in America. By the 1960’s, there were over 60 different forms of psychotherapy, most of which were more efficient (and, therefore, cheaper) than traditional Freudian psychoanalysis.
And with each new form of therapy, there had to be an expert. And with each expert, there had to be students. And with each class of students, there had to be a certificate of training. And with each new certificate, there had to be a degree (and a bunch of initials) to testify that the practitioner had the brains to “carry the banner” responsibly. Hence, we now have a multitude of mental health providers with different degrees, different licenses, and different levels of training and experience. Interestingly, they all take cash, check, or credit card.
So, just as there’s always a “right tool for the right job,” how does one find the right clinician for the right problem? Before trying to answer that question, let me first offer an observation, one that has been distilled from my 36 years of experience as a psychologist: if you and your mental health provider don’t “click;” if you don’t feel like that provider is listening to you and cares about you and takes your concerns seriously; then it doesn’t matter how experienced or well-trained he or she is: you’re not going to get the results you want. More on that in a minute.
So let’s talk about levels of training, beginning with the doctors. Psychiatrists and psychologists both have terminal degrees and are typically referred to as “doctor.” What’s the difference between the two? About $30 an hour! (Yeah, I never get tired of that joke).
But seriously, psychiatrists are physicians (MDs or DOs) who have gone to medical school and are, therefore, allowed to prescribe medications. They are experts in psychoactive medications; and they are well-versed in understanding how medications interact with each other, and how certain physical illnesses (like thyroid disease) may cause psychiatric symptoms. These days, most psychiatrists use medication as their main form of treatment. Despite Freud’s best efforts, few psychiatrists do psychotherapy (fun fact: Freud was actually a neurologist, not a psychiatrist!). Therefore, they may work in tandem with psychologists.
Psychologists are doctoral-level clinicians (PhD, PsyD, EdD) who are involved in research, teaching, clinical practice, or a combination of all three. In addition to doing psychotherapy of one sort or another, most of them are also trained to perform psychological evaluations, which involves the use of psychological tests to measure things like intelligence, personality, and emotional functioning. Although they cannot prescribe medications, many (including Yours Truly) specialize in understanding the biological and neurological components of mental health problems.
Lastly, there are clinicians with Master’s degrees who provide counseling and psychotherapy in a number of contexts. These include LCSWs (Licensed Clinical Social Workers), LMFTs (Licensed Marriage and Family Therapists), Certified Addiction Counselors (CACs), and Licensed Professional Counselors (LPCs). Most of these clinicians pursued their specific degrees because they were interested in doing a specific kind of treatment (for example, marriage therapy, family therapy, stress management, or substance abuse treatment) or working with a specific population (like families, children, or military veterans). They are highly trained in one or more specific kinds of treatment, to which they dedicate their careers.
In a perfect world (such as the one we have here at SR-AHEC), a patient with a mental health issue would be able to get help through an “integrated” model, wherein he or she might have access to all of these clinicians. A psychiatrist might manage a patient’s medication, for example, while a counselor or psychologist provides ongoing therapy. Unfortunately, this is rarely the case. More often, a patient is referred to one of these mental health professionals by a primary care provider, such as a Family Physician. Therefore, if you are struggling with a mental health issue and don’t know where to turn, the best place to start is your good old family doc. Since most insurance companies require them to make referrals to specialists, most family docs know who know who is good, reputable, competent, and qualified. Also, your family doc is most likely to know if medication will be involved (in which case, you may be referred to a psychiatrist), or if this is more of a “phase of life” problem (in which case, you may be sent to a counselor or therapist).
But here’s the thing: once a referral has been made, it is up to you—the consumer—to thoroughly vet the professional to whom you have been referred. I advise people not to be intimidated by all those degrees and diplomas! Call the psychiatrist, psychologist, or counselor. Ask if they have the training to deal with your particular problem. Ask about their education and licensure. Ask other important questions, like, “How often will I be seen?”, “How long will I be in therapy?”, “What kind of therapy do you use?”, and (most importantly) “Exactly how much will I have to pay?” In fact, ask whatever you need to ask to feel comfortable about the person treating you! As I mentioned earlier, your relationship with a mental health professional is a little like a marriage…if there isn’t some “chemistry” in the relationship, it may not work out! If the clinician is resistant to being “interrogated” or questioned about his or her training, then (to my mind) this is a sign of arrogance, and you should go elsewhere! As a clinician myself, I have always welcomed the opportunity to answer any question from a prospective patient.
Oh…and one more important thing. Everyone who seeks psychiatric or psychological treatment should be assured that nothing…NOTHING that they say during therapy will be divulged to anyone else. Confidentiality is one of the highest-held principles of mental health care, and in most mental health professions, the penalty for violating a patient’s confidentiality is usually akin to being made to walk the gangplank on a pirate ship. Being assured of confidentiality will help you feel more relaxed about exposing those skeletons in the closet. However, please keep in mind that there are circumstances in which confidentiality can be legally broken, as when the patient threatens harm to self or someone else. In such cases, the clinician may have a duty to warn an intended victim, although these “duty to warn” statutes vary slightly from state to state.
Once again, it’s a good thing that our current culture has promoted increasing awareness of mental health issues, and it’s a wonderful thing that there are so many dedicated clinicians who have been thoroughly trained to help people who are facing mental or emotional challenges. I hope that the information in this month’s blog will help you be an informed consumer. Meanwhile, I’m going to put on my tweed jacket, light a cigar, trim my beard, and head back to that big couch in my office.