THERAPY
Help Wanted: a Good Therapist
Amid Increasing Choices, How to Know What Treatments Work, When to Move On
By Melinda Beck : WSJ : October 15, 2011
Therese Borchard likens herself to Goldilocks of the mental-health world: She tried six psychiatrists before she found one that was "just right." One learned she was a writer and asked for help with a book proposal. Another put her on sleeping pills, ignoring her history of substance abuse. One even wanted to try hypnotic regression by candlelight to address unresolved childhood issues.
Finally, No. 7 diagnosed bipolar disorder, found medication that was effective, helped her to be less hard on herself and "salvaged the last crumb of my self-esteem," says Ms. Borchard, who writes the popular "Beyond Blue" blog on Beliefnet.com.
The search for the right therapist can be baffling—and it comes at a time when would-be patients are feeling most vulnerable.
Patients who aren't sure what's wrong with them can be stumped about the type of therapist to call and ill-equipped to evaluate what they're told during treatment. How well a therapist's personal style matches a patient's individual needs can be critical. But experts also say that patients shouldn't be shy about pressing their therapist for a diagnosis and setting measurable goals.
David Palmiter, a public-education coordinator for the American Psychological Association (APA), likens good therapy to going to a good restaurant: "You should be able to peer into the kitchen and see what they're doing."
About 3% of Americans had outpatient psychotherapy in 2007—roughly the same as in 1998—although the percentage taking antidepressants and other psychotropic drugs rose sharply, according to an analysis in the American Journal of Psychiatry last year. The same study found that the average number of visits dropped from nearly 10 in 1998 to eight in 2007.
By some estimates, one-quarter of the U.S. population has some kind of diagnosable mental illness. But many don't believe they need help, don't know how to get it, think they can't afford it or that it won't be effective. There's also the lingering stigma attached to seeing a "shrink."
Approaches
There are many types of therapy, including:
Numerous clinical trials have shown that various forms of psychotherapy, with or without medication, can help ease depression, anxiety and other disorders. One oft-quoted analysis of 2,400 patients found that 50% improved measurably after eight sessions, and 75% improved after six months in therapy. Still, that doesn't mean that any given therapist will be effective for any particular patient.
One issue for prospective patients is that therapists generally specialize in one treatment approach and tend to see patients' problems through that lens. A cognitive-behavioral therapist will focus on changing patients' negative thinking patterns, while a psychoanalyst will want to probe more deeply into how the past is affecting current issues.
Some clinics and university mental-health centers offer consultations to help evaluate which treatment might be best. "Patients shouldn't have to decide this by themselves," says Drew Ramsey, an assistant clinical professor of psychiatry at New York's Columbia University, who says he loves to play "shrink matchmaker."
Patients can also ask friends, family members and physicians for referrals, then call several recommended therapists themselves and ask about their experience and techniques. "You may not know what kind of approach is right, but you can say, 'Here's what's going on in my life. How would you propose treating that? And how long do you think it would take?' " says Lynn Bufka, assistant executive director for practice research and policy at the APA. Increasingly, therapists are measuring outcomes, such as asking patients for evaluations, she adds. "So it's very reasonable to ask, 'How do you know what you do works?' "
Once in treatment, both the therapist and the patient should be familiar enough with each other by the third session to know if it's a good fit, experts say.
"Some people need a therapist who gives them instructions and assignments, and some people hate that. Some people need a therapist who is basically silent and lets them talk," says Betsy Stone, a psychologist in Stamford, Conn.
Dr. Stone says she can often tell even in the first session if the fit isn't right. "I like to push patients pretty hard, because I want them to get their money's worth, and some people are just too fragile," she says. "Then I say, 'I'm not the right therapist for you, but I'll help you find someone else.' "
Increasingly, therapists are collaborating with patients on a treatment plan rather than remaining aloof and omniscient. "I encourage patients to look up the science for themselves. How can they do that if they don't know what terms to search for?" says Dr. Palmiter.
Effective therapy can be difficult at times—particularly when the patient is exploring painful thoughts or fears. "A good therapist should give you comfort and discomfort at the same time. They should make you feel understood but challenged," says Dr. Stone.
Distinguishing that from having an uncomfortable relationship with the therapist can be tricky. "If you leave therapy every week feeling worse than when you went in," says Dr. Bufka, "it's probably not the right place for you."
Studies show that patients often hesitate to break it off because they don't want to hurt the therapist's feelings or seem ungrateful. "But believe me, we're used to it—and it's a very valuable thing to hear," says Dr. Palmiter.
Even close relationships sometimes fail to get at the right issues. Victoria Maxwell, 44, an actress and blogger from Half Moon Bay, British Columbia, says she worked with a therapist for 2½-years as a teenager and liked her enormously. But she never made much progress, because the therapist didn't recognize Ms. Maxwell's underlying bipolar disorder. "I became a really insightful depressed person. But it wasn't helping my depression," she says.
Years later, after several hospitalizations, a nurse referred Ms. Maxwell to an older psychiatrist. She initially thought they'd be a bad fit—but found he was the only one who believed she could have both a profound spiritual experience and bipolar disorder. "I trusted him, so I was willing to try what he suggested, which included medication," she says. "I wouldn't be where I am today without his help and understanding."
Setting measurable goals is crucial for knowing whether a therapy is working. In Ms. Maxwell's case, her psychiatrist said, "I think you're capable of moving out of your parents' home, living with roommates and driving a car—and I was," she says.
Amid Increasing Choices, How to Know What Treatments Work, When to Move On
By Melinda Beck : WSJ : October 15, 2011
Therese Borchard likens herself to Goldilocks of the mental-health world: She tried six psychiatrists before she found one that was "just right." One learned she was a writer and asked for help with a book proposal. Another put her on sleeping pills, ignoring her history of substance abuse. One even wanted to try hypnotic regression by candlelight to address unresolved childhood issues.
Finally, No. 7 diagnosed bipolar disorder, found medication that was effective, helped her to be less hard on herself and "salvaged the last crumb of my self-esteem," says Ms. Borchard, who writes the popular "Beyond Blue" blog on Beliefnet.com.
The search for the right therapist can be baffling—and it comes at a time when would-be patients are feeling most vulnerable.
Patients who aren't sure what's wrong with them can be stumped about the type of therapist to call and ill-equipped to evaluate what they're told during treatment. How well a therapist's personal style matches a patient's individual needs can be critical. But experts also say that patients shouldn't be shy about pressing their therapist for a diagnosis and setting measurable goals.
David Palmiter, a public-education coordinator for the American Psychological Association (APA), likens good therapy to going to a good restaurant: "You should be able to peer into the kitchen and see what they're doing."
About 3% of Americans had outpatient psychotherapy in 2007—roughly the same as in 1998—although the percentage taking antidepressants and other psychotropic drugs rose sharply, according to an analysis in the American Journal of Psychiatry last year. The same study found that the average number of visits dropped from nearly 10 in 1998 to eight in 2007.
By some estimates, one-quarter of the U.S. population has some kind of diagnosable mental illness. But many don't believe they need help, don't know how to get it, think they can't afford it or that it won't be effective. There's also the lingering stigma attached to seeing a "shrink."
Approaches
There are many types of therapy, including:
- Cognitive-behavioral therapy. Identifies and changes harmful thinking patterns; may involve gradual exposure to whatever is causing fears.
- Interpersonal therapy. Explores how relationships involving grief, isolation, conflict or changing family roles contribute to psychological problems.
- Psychoanalysis. Emphasizes how the unconscious mind influences behavior and how the past affects the present.
Numerous clinical trials have shown that various forms of psychotherapy, with or without medication, can help ease depression, anxiety and other disorders. One oft-quoted analysis of 2,400 patients found that 50% improved measurably after eight sessions, and 75% improved after six months in therapy. Still, that doesn't mean that any given therapist will be effective for any particular patient.
One issue for prospective patients is that therapists generally specialize in one treatment approach and tend to see patients' problems through that lens. A cognitive-behavioral therapist will focus on changing patients' negative thinking patterns, while a psychoanalyst will want to probe more deeply into how the past is affecting current issues.
Some clinics and university mental-health centers offer consultations to help evaluate which treatment might be best. "Patients shouldn't have to decide this by themselves," says Drew Ramsey, an assistant clinical professor of psychiatry at New York's Columbia University, who says he loves to play "shrink matchmaker."
Patients can also ask friends, family members and physicians for referrals, then call several recommended therapists themselves and ask about their experience and techniques. "You may not know what kind of approach is right, but you can say, 'Here's what's going on in my life. How would you propose treating that? And how long do you think it would take?' " says Lynn Bufka, assistant executive director for practice research and policy at the APA. Increasingly, therapists are measuring outcomes, such as asking patients for evaluations, she adds. "So it's very reasonable to ask, 'How do you know what you do works?' "
Once in treatment, both the therapist and the patient should be familiar enough with each other by the third session to know if it's a good fit, experts say.
"Some people need a therapist who gives them instructions and assignments, and some people hate that. Some people need a therapist who is basically silent and lets them talk," says Betsy Stone, a psychologist in Stamford, Conn.
Dr. Stone says she can often tell even in the first session if the fit isn't right. "I like to push patients pretty hard, because I want them to get their money's worth, and some people are just too fragile," she says. "Then I say, 'I'm not the right therapist for you, but I'll help you find someone else.' "
Increasingly, therapists are collaborating with patients on a treatment plan rather than remaining aloof and omniscient. "I encourage patients to look up the science for themselves. How can they do that if they don't know what terms to search for?" says Dr. Palmiter.
Effective therapy can be difficult at times—particularly when the patient is exploring painful thoughts or fears. "A good therapist should give you comfort and discomfort at the same time. They should make you feel understood but challenged," says Dr. Stone.
Distinguishing that from having an uncomfortable relationship with the therapist can be tricky. "If you leave therapy every week feeling worse than when you went in," says Dr. Bufka, "it's probably not the right place for you."
Studies show that patients often hesitate to break it off because they don't want to hurt the therapist's feelings or seem ungrateful. "But believe me, we're used to it—and it's a very valuable thing to hear," says Dr. Palmiter.
Even close relationships sometimes fail to get at the right issues. Victoria Maxwell, 44, an actress and blogger from Half Moon Bay, British Columbia, says she worked with a therapist for 2½-years as a teenager and liked her enormously. But she never made much progress, because the therapist didn't recognize Ms. Maxwell's underlying bipolar disorder. "I became a really insightful depressed person. But it wasn't helping my depression," she says.
Years later, after several hospitalizations, a nurse referred Ms. Maxwell to an older psychiatrist. She initially thought they'd be a bad fit—but found he was the only one who believed she could have both a profound spiritual experience and bipolar disorder. "I trusted him, so I was willing to try what he suggested, which included medication," she says. "I wouldn't be where I am today without his help and understanding."
Setting measurable goals is crucial for knowing whether a therapy is working. In Ms. Maxwell's case, her psychiatrist said, "I think you're capable of moving out of your parents' home, living with roommates and driving a car—and I was," she says.
Will You Be My Therapist? Expert Advice on Finding the Right One
Elizabeth Bernstein : WSJ : September 23, 2014
People write me from time to time to ask, "How do I find a good therapist?"
I went to Prudence Gourguechon, a Chicago psychiatrist and psychoanalyst and past-president of the American Psychoanalytic Association, to find out what people entering therapy should look for in a therapist, how to establish the relationship and what the best ways are to work together to maximize treatment.
To find a therapist to try out, Dr. Gourguechon recommends asking friends if they know of someone they can recommend. If a friend has his or her own therapist, ask the friend to ask the therapist for a referral. Refrain from seeing the same therapist that a close friend or family member sees.
If you can't find a word-of-mouth recommendation, she suggests using a website such as Psychology Today; professionals post information about themselves on its "Find a Therapist" feature. When you see a promising listing, check out the therapist's website. Does he or she write well and view things similarly to how you do?
At the first meeting, Dr. Gourguechon says, pay attention to the fit. Are you comfortable with the office environment and the person's style of relating? Do you get the sense the therapist has a good preliminary understanding of what you are going through? "You should feel that they are tuned in and on your wave length, and that you can expect the relationship and understanding to deepen," Dr. Gourguechon says.
Within the first few meetings, the therapist should take a thorough history, give you a diagnosis and articulate how he or she can help. "They need to come up with something of a formulation that says: 'This is what I think your problem is, this is how I think it developed and this is what I can offer you," Dr. Gourguechon says. There should be a treatment plan—specifying how often you will meet, for how long and what type of therapy you will have, such as cognitive behavioral therapy or psychoanalysis.
The therapist also should be able to acknowledge his or her limitations. For example, if you have a major mental illness and you go see someone who does cognitive behavioral therapy, he should explain that while this therapy is helpful with many issues, you may need more help.
Like good physicians, effective therapists are good listeners. "You want an open-minded person who doesn't put you in their box, but gets to know you in all your complexity," Dr. Gourguechon says. "You want to hear: 'Let's keep talking.' You want to hear uncertainty—'It could be this or it could be that.' You want to hear an exploratory, curious stance."
"It's like when you go to a financial planner," she adds. "You can tell if they are really thinking about your needs and who you are as a person, or if they are just trying to sell you a product with the littlest effort."
As a patient, it is your job to participate in the process, Dr. Gourguechon says: "You are not there to receive wisdom or a bolt from the sky. You want expertise. But in many ways you share in the expertise."
Dr. Gourguechon's tips for maximizing the therapeutic relationship:
Don't edit yourself in therapy. Let thoughts float to the surface. This will help your therapist understand what is really bothering you the most, on an unconscious level.
Find out what your therapist wants you to do, and try to do it. If you have difficulties with any of it, talk about them. Don't pretend you are going to try a suggestion if you aren't actually going to try it. Don't pretend something is working.
Ask questions. If you don't understand something your therapist says, ask him or her to clarify. If something isn't helping, or you don't feel better, ask why not. Your therapist should be able to give you an explanation.
Give your therapist feedback. He or she will make a lot of suggestions and interpretations. Some will be good and some won't, Dr. Gourguechon says. Share your reactions, both positive and negative.
"Some people think just coming to therapy is going to change things for them, but it doesn't work that way," Dr. Gourguechon says. "You have to venture out trying to change, and then come back with reports on what is working and what isn't working. It's an active process, where there are constant adjustments on both the patient's and the therapist's part."
And how can you tell if you've gone as far as you can with your therapist—that it's time to break up? If you feel that your therapy has stalled, the first thing to do is talk to your therapist about it, Dr. Gourguechon says. Ask why he or she thinks it isn't working and request an updated treatment plan. Your therapist should take you seriously and not become defensive. You might not like the answer ("Sometimes it takes a long time to change"), but you should get a clear one.
"If they say, 'Just keep coming and we will keep doing the same thing—and they have no rationale for why you will feel different in a year when you haven't yet—that's not too promising," Dr. Gourguechon says.
Of course, sometimes it can be part of therapy to get angry. You'll need to talk that through with your therapist and examine together whether you are recreating a pattern.
Another option, if you feel stalled, is to tell your therapist you want a second opinion and see what kind of response you get. "They should say, 'That's great, let's see what someone else thinks,' " Dr. Gourguechon says.
One big indication it may be time to leave: A relationship that feels empty, one-sided or like an ordinary friendship. "The therapeutic relationship should be a challenge. You should be learning new things about yourself," Dr. Gourguechon says. "Maybe not every day or every week, but pretty consistently. There should be progression."
Elizabeth Bernstein : WSJ : September 23, 2014
People write me from time to time to ask, "How do I find a good therapist?"
I went to Prudence Gourguechon, a Chicago psychiatrist and psychoanalyst and past-president of the American Psychoanalytic Association, to find out what people entering therapy should look for in a therapist, how to establish the relationship and what the best ways are to work together to maximize treatment.
To find a therapist to try out, Dr. Gourguechon recommends asking friends if they know of someone they can recommend. If a friend has his or her own therapist, ask the friend to ask the therapist for a referral. Refrain from seeing the same therapist that a close friend or family member sees.
If you can't find a word-of-mouth recommendation, she suggests using a website such as Psychology Today; professionals post information about themselves on its "Find a Therapist" feature. When you see a promising listing, check out the therapist's website. Does he or she write well and view things similarly to how you do?
At the first meeting, Dr. Gourguechon says, pay attention to the fit. Are you comfortable with the office environment and the person's style of relating? Do you get the sense the therapist has a good preliminary understanding of what you are going through? "You should feel that they are tuned in and on your wave length, and that you can expect the relationship and understanding to deepen," Dr. Gourguechon says.
Within the first few meetings, the therapist should take a thorough history, give you a diagnosis and articulate how he or she can help. "They need to come up with something of a formulation that says: 'This is what I think your problem is, this is how I think it developed and this is what I can offer you," Dr. Gourguechon says. There should be a treatment plan—specifying how often you will meet, for how long and what type of therapy you will have, such as cognitive behavioral therapy or psychoanalysis.
The therapist also should be able to acknowledge his or her limitations. For example, if you have a major mental illness and you go see someone who does cognitive behavioral therapy, he should explain that while this therapy is helpful with many issues, you may need more help.
Like good physicians, effective therapists are good listeners. "You want an open-minded person who doesn't put you in their box, but gets to know you in all your complexity," Dr. Gourguechon says. "You want to hear: 'Let's keep talking.' You want to hear uncertainty—'It could be this or it could be that.' You want to hear an exploratory, curious stance."
"It's like when you go to a financial planner," she adds. "You can tell if they are really thinking about your needs and who you are as a person, or if they are just trying to sell you a product with the littlest effort."
As a patient, it is your job to participate in the process, Dr. Gourguechon says: "You are not there to receive wisdom or a bolt from the sky. You want expertise. But in many ways you share in the expertise."
Dr. Gourguechon's tips for maximizing the therapeutic relationship:
Don't edit yourself in therapy. Let thoughts float to the surface. This will help your therapist understand what is really bothering you the most, on an unconscious level.
Find out what your therapist wants you to do, and try to do it. If you have difficulties with any of it, talk about them. Don't pretend you are going to try a suggestion if you aren't actually going to try it. Don't pretend something is working.
Ask questions. If you don't understand something your therapist says, ask him or her to clarify. If something isn't helping, or you don't feel better, ask why not. Your therapist should be able to give you an explanation.
Give your therapist feedback. He or she will make a lot of suggestions and interpretations. Some will be good and some won't, Dr. Gourguechon says. Share your reactions, both positive and negative.
"Some people think just coming to therapy is going to change things for them, but it doesn't work that way," Dr. Gourguechon says. "You have to venture out trying to change, and then come back with reports on what is working and what isn't working. It's an active process, where there are constant adjustments on both the patient's and the therapist's part."
And how can you tell if you've gone as far as you can with your therapist—that it's time to break up? If you feel that your therapy has stalled, the first thing to do is talk to your therapist about it, Dr. Gourguechon says. Ask why he or she thinks it isn't working and request an updated treatment plan. Your therapist should take you seriously and not become defensive. You might not like the answer ("Sometimes it takes a long time to change"), but you should get a clear one.
"If they say, 'Just keep coming and we will keep doing the same thing—and they have no rationale for why you will feel different in a year when you haven't yet—that's not too promising," Dr. Gourguechon says.
Of course, sometimes it can be part of therapy to get angry. You'll need to talk that through with your therapist and examine together whether you are recreating a pattern.
Another option, if you feel stalled, is to tell your therapist you want a second opinion and see what kind of response you get. "They should say, 'That's great, let's see what someone else thinks,' " Dr. Gourguechon says.
One big indication it may be time to leave: A relationship that feels empty, one-sided or like an ordinary friendship. "The therapeutic relationship should be a challenge. You should be learning new things about yourself," Dr. Gourguechon says. "Maybe not every day or every week, but pretty consistently. There should be progression."
Finding the best therapist can be confusing
Patricia Wen : Boston Globe : February 4, 2013
A Dedham mother remembers when her teenage daughter became overwhelmed with anxiety and was using illicit drugs. When her daughter’s doctor suggested she see “a therapist,” the mother began investigating, and soon found a dizzying array of options — psychiatrists, psychologists, psychiatric nurse practitioners, and social workers, among others.
Some specialized in prescribing mood-altering medications, while others focused on psychotherapy that delves into the child’s past. Some focused on changing destructive behaviors, while others probed family and school stresses. Beyond that, there were also pastoral counselors, yoga therapists, and life coaches.
“I used to think all therapists were the same,” said the mother, who asked to remain anonymous to protect her child’s identity.
“See a therapist” has become standard advice to many going through periods of anguish. Whether they’re victims or bystanders coping with traumatic events such as school shootings and natural disasters, or individuals going through a divorce or losing a job, some 13 percent of Americans use mental health services each year. These clinicians are in short supply nationwide, though Greater Boston — and the Northeast in general — has more than in most parts of the country. Among the available providers comes a confusing blizzard of options — and terminology.
“Terms like therapist, counselor, or psychotherapist are not regulated,” said Elana Eisman, executive director of the Massachusetts Psychological Association, which represents some 1,700 psychologists in the state. “Anyone can use those terms.”
In Massachusetts, however, not just anyone can promote themselves as a psychiatrist, psychologist, mental health counselor, or marriage and family therapist — professions that are licensed and regulated by the state with established educational and training standards. And though most health insurers will cover treatment provided by most state-licensed mental health professionals, some are excluded, such as certain types of licensed social workers with less training and education.
Finding the best therapist is not an easy task. Many mental health advocates say that patients should look for only state-licensed practitioners. The oversight of the state board, they say, ensures the clinician meets eligibility standards, and exposes them to investigation and possible disciplinary action if they are targets of complaints.
Alternative mental health treatments generally fall outside licensing and insurance systems, for better or worse. John Kepner, executive director of the International Association of Yoga Therapists, describes his area as an “emerging field” that promotes physical and emotional well-being, and says many suffering from stress-related ailments have been aided by yoga therapists. He said his group is working on establishing professional standards.
Though state licensing may have its benefits, he said, he’s ambivalent about the spiritual principles of yoga getting entangled in the bureaucracy of government regulations.
“Yoga and licensing are uneasy bedfellows,” he said.
Another issue to consider is the privacy of confidential information shared during therapy sessions. While state-licensed mental health practitioners covered under insurance are required to comply with federal laws limiting the disclosure of private information to others, alternative practitioners may be excluded or fall in the “gray space” of these laws, said Mark Schreiber, a Boston attorney who specializes in, among other things, medical privacy laws.
Mental health advocates say people need to consider many questions when looking for a therapist — and whether it’s a psychologist with a doctoral degree or a mental health counselor with a master’s may not be the most pressing issue.
Given tight budgets for most people, Larry DeAngelo, a staffer for the National Alliance on Mental Illness in Massachusetts, advises that most people first see what their insurance will cover, what clinicians fall under the insurer’s plan, and if specific clinicians have room for new patients. Availability remains tight, he said, and the debate over what type of therapist someone wants to see can almost be a luxury.
“It’s like when people are desperately starving, and you ask — do you want a chocolate bar or ice cream?” DeAngelo said.
Though insurers have come under fire for low reimbursement rates for behavioral health clinicians — as compared with those providing medical services for physical problems — many insist they are committed to giving members broad coverage from a wide variety of professionals.
For instance, Michael Sherman, chief medical officer for Harvard Pilgrim Health Care, said his company, as a general rule, pays for treatment administered by state-licensed mental health clinicians with advanced degrees who can practice without supervision. By that standard, over the past decade, Harvard Pilgrim began reimbursing licensed independent social workers, mental health counselors, and marriage and family therapists.
According to many mental health specialists, anyone seeking therapy services should first see a primary care doctor (or a pediatrician in the case of a child) to rule out any physical ailment to explain the emotional distress. For instance, some hormonal or neurological problems can explain depression or mood issues. Once a physical problem is ruled out, then a doctor can often help advise the patient about what type of therapist is best suited for their specific issue — such as a psychiatrist who can prescribe medications if bipolar illness is a possibility, a social worker if school troubles loom large, or a marriage and family therapist if divorce is on the horizon.
Eisman, of the Massachusetts Psychological Association, said there is also the intangible of chemistry between a patient and clinician — no matter if they have a MD, PhD, or LICSW after their name. She said any good clinician has had his or her share of therapeutic relationships that just didn’t work, and often can facilitate a better referral if necessary.
“Therapy works best when you can talk honestly,” she said.
Patricia Wen : Boston Globe : February 4, 2013
A Dedham mother remembers when her teenage daughter became overwhelmed with anxiety and was using illicit drugs. When her daughter’s doctor suggested she see “a therapist,” the mother began investigating, and soon found a dizzying array of options — psychiatrists, psychologists, psychiatric nurse practitioners, and social workers, among others.
Some specialized in prescribing mood-altering medications, while others focused on psychotherapy that delves into the child’s past. Some focused on changing destructive behaviors, while others probed family and school stresses. Beyond that, there were also pastoral counselors, yoga therapists, and life coaches.
“I used to think all therapists were the same,” said the mother, who asked to remain anonymous to protect her child’s identity.
“See a therapist” has become standard advice to many going through periods of anguish. Whether they’re victims or bystanders coping with traumatic events such as school shootings and natural disasters, or individuals going through a divorce or losing a job, some 13 percent of Americans use mental health services each year. These clinicians are in short supply nationwide, though Greater Boston — and the Northeast in general — has more than in most parts of the country. Among the available providers comes a confusing blizzard of options — and terminology.
“Terms like therapist, counselor, or psychotherapist are not regulated,” said Elana Eisman, executive director of the Massachusetts Psychological Association, which represents some 1,700 psychologists in the state. “Anyone can use those terms.”
In Massachusetts, however, not just anyone can promote themselves as a psychiatrist, psychologist, mental health counselor, or marriage and family therapist — professions that are licensed and regulated by the state with established educational and training standards. And though most health insurers will cover treatment provided by most state-licensed mental health professionals, some are excluded, such as certain types of licensed social workers with less training and education.
Finding the best therapist is not an easy task. Many mental health advocates say that patients should look for only state-licensed practitioners. The oversight of the state board, they say, ensures the clinician meets eligibility standards, and exposes them to investigation and possible disciplinary action if they are targets of complaints.
Alternative mental health treatments generally fall outside licensing and insurance systems, for better or worse. John Kepner, executive director of the International Association of Yoga Therapists, describes his area as an “emerging field” that promotes physical and emotional well-being, and says many suffering from stress-related ailments have been aided by yoga therapists. He said his group is working on establishing professional standards.
Though state licensing may have its benefits, he said, he’s ambivalent about the spiritual principles of yoga getting entangled in the bureaucracy of government regulations.
“Yoga and licensing are uneasy bedfellows,” he said.
Another issue to consider is the privacy of confidential information shared during therapy sessions. While state-licensed mental health practitioners covered under insurance are required to comply with federal laws limiting the disclosure of private information to others, alternative practitioners may be excluded or fall in the “gray space” of these laws, said Mark Schreiber, a Boston attorney who specializes in, among other things, medical privacy laws.
Mental health advocates say people need to consider many questions when looking for a therapist — and whether it’s a psychologist with a doctoral degree or a mental health counselor with a master’s may not be the most pressing issue.
Given tight budgets for most people, Larry DeAngelo, a staffer for the National Alliance on Mental Illness in Massachusetts, advises that most people first see what their insurance will cover, what clinicians fall under the insurer’s plan, and if specific clinicians have room for new patients. Availability remains tight, he said, and the debate over what type of therapist someone wants to see can almost be a luxury.
“It’s like when people are desperately starving, and you ask — do you want a chocolate bar or ice cream?” DeAngelo said.
Though insurers have come under fire for low reimbursement rates for behavioral health clinicians — as compared with those providing medical services for physical problems — many insist they are committed to giving members broad coverage from a wide variety of professionals.
For instance, Michael Sherman, chief medical officer for Harvard Pilgrim Health Care, said his company, as a general rule, pays for treatment administered by state-licensed mental health clinicians with advanced degrees who can practice without supervision. By that standard, over the past decade, Harvard Pilgrim began reimbursing licensed independent social workers, mental health counselors, and marriage and family therapists.
According to many mental health specialists, anyone seeking therapy services should first see a primary care doctor (or a pediatrician in the case of a child) to rule out any physical ailment to explain the emotional distress. For instance, some hormonal or neurological problems can explain depression or mood issues. Once a physical problem is ruled out, then a doctor can often help advise the patient about what type of therapist is best suited for their specific issue — such as a psychiatrist who can prescribe medications if bipolar illness is a possibility, a social worker if school troubles loom large, or a marriage and family therapist if divorce is on the horizon.
Eisman, of the Massachusetts Psychological Association, said there is also the intangible of chemistry between a patient and clinician — no matter if they have a MD, PhD, or LICSW after their name. She said any good clinician has had his or her share of therapeutic relationships that just didn’t work, and often can facilitate a better referral if necessary.
“Therapy works best when you can talk honestly,” she said.
In Therapy Forever? Enough Already
By Jonathan Alpert : NY Times : April 21, 2012
My therapist called me the wrong name. I poured out my heart; my doctor looked at his watch. My psychiatrist told me I had to keep seeing him or I would be lost.
New patients tell me things like this all the time. And they tell me how former therapists sat, listened, nodded and offered little or no advice, for weeks, months, sometimes years. A patient recently told me that, after seeing her therapist for several years, she asked if he had any advice for her. The therapist said, “See you next week.”
When I started practicing as a therapist 15 years ago, I thought complaints like this were anomalous. But I have come to a sobering conclusion over the years: ineffective therapy is disturbingly common.
Talk to friends, keep your ears open at a cafe, or read discussion boards online about length of time in therapy. I bet you’ll find many people who have remained in therapy long beyond the time they thought it would take to solve their problems. According to a 2010 study published in the American Journal of Psychiatry, 42 percent of people in psychotherapy use 3 to 10 visits for treatment, while 1 in 9 have more than 20 sessions.
For this 11 percent, therapy can become a dead-end relationship. Research shows that, in many cases, the longer therapy lasts the less likely it is to be effective. Still, therapists are often reluctant to admit defeat.
A 2001 study published in the Journal of Counseling Psychology found that patients improved most dramatically between their seventh and tenth sessions. Another study, published in 2006 in the Journal of Consulting and Clinical Psychology, looked at nearly 2,000 people who underwent counseling for 1 to 12 sessions and found that while 88 percent improved after one session, the rate fell to 62 percent after 12. Yet, according to research conducted at the University of Pennsylvania, therapists who practice more traditional psychotherapy treat patients for an average of 22 sessions before concluding that progress isn’t being made. Just 12 percent of those therapists choose to refer their stagnant patients to another practitioner. The bottom line: Even though extended therapy is not always beneficial, many therapists persist in leading patients on an open-ended, potentially endless, therapeutic course.
Proponents of long-term therapy have argued that severe psychological disorders require years to manage. That may be true, but it’s also true that many therapy patients don’t suffer severe disorders. Anxiety and depression are the top predicaments for which patients seek mental health treatment; schizophrenia is at the bottom of the list.
In my experience, most people seek therapeutic help for discrete, treatable issues: they are stuck in unfulfilling jobs or relationships, they can’t reach their goals, are fearful of change and depressed as a result. It doesn’t take years of therapy to get to the bottom of those kinds of problems. For some of my patients, it doesn’t even take a whole session.
Therapy can — and should — focus on goals and outcomes, and people should be able to graduate from it. In my practice, the people who spent years in therapy before coming to me were able to face their fears, calm their anxieties and reach life goals quickly — often within weeks.
Why? I believe it’s a matter of approach. Many patients need an aggressive therapist who prods them to face what they find uncomfortable: change. They need a therapist’s opinion, advice and structured action plans. They don’t need to talk endlessly about how they feel or about childhood memories. A recent study by the National Institute for Health and Welfare in Finland found that “active, engaging and extroverted therapists” helped patients more quickly in the short term than “cautious, nonintrusive therapists.”
This approach may not be right for every patient, but the results described in the Finnish study are consistent with my experience.
If a patient comes to me and tells me she’s been unhappy with her boyfriend for the past year, I don’t ask, as some might, “How do you feel about that?” I already know how she feels about that. She just told me. She’s unhappy. When she asks me what I think she should do, I don’t respond with a return interrogatory, “What do you think you should do?” If she knew, she wouldn’t ask me for my thoughts.
Instead I ask what might be missing from her relationship and sketch out possible ways to fill in relationship gaps or, perhaps, to end it in a healthy way. Rather than dwell on the past and hash out stories from childhood, I encourage patients to find the courage to confront an adversary, take risks and embrace change. My aim is to give patients the skills needed to confront their fear of change, rather than to nod my head and ask how they feel.
In graduate school, my classmates and I were taught to serve as guides, whose job it is to help patients reach their own conclusions. This may work, but it can take a long time. I don’t think patients want to take years to feel better. They want to do it in weeks or months.
Popular misconceptions reinforce the belief that therapy is about resting on a couch and talking about one’s problems. So that’s what patients often do. And just as often this leads to codependence. The therapist, of course, depends on the patient for money, and the patient depends on the therapist for emotional support. And, for many therapy patients, it is satisfying just to have someone listen, and they leave sessions feeling better.
But there’s a difference between feeling good and changing your life. Feeling accepted and validated by your therapist doesn’t push you to reach your goals. To the contrary, it might even encourage you to stay mired in dysfunction. Therapy sessions can work like spa appointments: they can be relaxing but don’t necessarily help solve problems. More than an oasis of kindness or a cozy hour of validation and acceptance, most patients need smart strategies to help them achieve realistic goals.
I’m not against therapy. After all, I practice it. But ask yourself: if your hairstylist keeps giving you bad haircuts, do you keep going back? If a restaurant serves you a lousy meal, do you make another reservation? No, I’m sure you wouldn’t, and you shouldn’t stay in therapy that isn’t helping you, either.
Jonathan Alpert is a New York psychotherapist and the author of “Be Fearless: Change Your Life in 28 Days.”
How to Figure Out When Therapy Is Over
Richard A. Friedman, MD NY Times : October 30, 2007
If you think it’s hard to end a relationship with a lover or spouse, try breaking up with your psychotherapist.
A writer friend of mine recently tried and found it surprisingly difficult. Several months after landing a book contract, she realized she was in trouble.
“I was completely paralyzed and couldn’t write,” she said, as I recall. “I had to do something right away, so I decided to get myself into psychotherapy.”
What began with a simple case of writer’s block turned into seven years of intensive therapy.
Over all, she found the therapy very helpful. She finished a second novel and felt that her relationship with her husband was stronger. When she broached the topic of ending treatment, her therapist strongly resisted, which upset the patient. “Why do I need therapy,” she wanted to know, “if I’m feeling good?”
Millions of Americans are in psychotherapy, and my friend’s experience brings up two related, perplexing questions. How do you know when you are healthy enough to say goodbye to your therapist? And how should a therapist handle it?
With rare exceptions, the ultimate aim of all good psychotherapists is, well, to make themselves obsolete. After all, whatever drove you to therapy in the first place — depression, anxiety, relationship problems, you name it — the common goal of treatment is to feel and function better independent of your therapist.
To put it bluntly, good therapy is supposed to come to an end.
But when? And how is the patient to know? Is the criterion for termination “cure” or is it just feeling well enough to be able to call it a day and live with the inevitable limitations and problems we all have?
The term “cure,” I think, is illusory — even undesirable — because there will always be problems to repair. Having no problems is an unrealistic goal. It’s more important for patients to be able to deal with their problems and to handle adversity when it inevitably arises.
Still, even when patients feel that they have accomplished something important in therapy and feel “good enough,” it is not always easy to say goodbye to a therapist.
Not long ago, I evaluated a successful lawyer who had been in psychotherapy for nine years. He had entered therapy, he told me, because he lacked a sense of direction and had no intimate relationships. But for six or seven years, he had felt that he and his therapist were just wasting their time. Therapy had become a routine, like going to the gym.
“It’s not that anything bad has happened,” he said. “It’s that nothing is happening.”
This was no longer psychotherapy, but an expensive form of chatting. So why did he stay with it? In part, I think, because therapy is essentially an unequal relationship. Patients tend to be dependent on their therapists. Even if the therapy is problematic or unsatisfying, that might be preferable to giving it up altogether or starting all over again with an unknown therapist.
Beyond that, patients often become stuck in therapy for the very reason that they started it. For example, a dependent patient cannot leave his therapist; a masochistic patient suffers silently in treatment with a withholding therapist; a narcissistic patient eager to be liked fears challenging his therapist, and so on.
Of course, you may ask why therapists in such cases do not call a timeout and question whether the treatment is stalled or isn’t working. I can think of several reasons.
To start with, therapists are generally an enthusiastic bunch who can always identify new issues for you to work on. Then, of course, there is an unspoken motive: therapists have an inherent financial interest in keeping their patients in treatment.
And therapists have unmet emotional needs just like everyone else, which certain patients satisfy. Therapists may find some patients so interesting, exciting or fun that they have a hard time letting go of them.
So the best way to answer the question, “Am I done with therapy?” is to confront it head on. Periodically take stock of your progress and ask your therapist for direct feedback.
How close are you to reaching your goals? How much better do you feel? Are your relationships and work more satisfying? You can even ask close friends or your partner whether they see any change.
If you think you are better and are contemplating ending treatment but the therapist disagrees, it is time for an independent consultation. Indeed, after a consultation, my writer friend terminated her therapy and has no regrets about it.
The lawyer finally mustered the courage to tell his therapist that although he enjoyed talking with her, he really felt that the time had come to stop. To his surprise, she agreed.
If, unlike those two, you still cannot decide to stay or leave, consider an experiment. Take a break from therapy for a few months and see what life is like without it.
That way, you’ll have a chance to gauge the effects of therapy without actually being in it (and paying for it). Remember, you can always go back.
Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College.
Richard A. Friedman, MD NY Times : October 30, 2007
If you think it’s hard to end a relationship with a lover or spouse, try breaking up with your psychotherapist.
A writer friend of mine recently tried and found it surprisingly difficult. Several months after landing a book contract, she realized she was in trouble.
“I was completely paralyzed and couldn’t write,” she said, as I recall. “I had to do something right away, so I decided to get myself into psychotherapy.”
What began with a simple case of writer’s block turned into seven years of intensive therapy.
Over all, she found the therapy very helpful. She finished a second novel and felt that her relationship with her husband was stronger. When she broached the topic of ending treatment, her therapist strongly resisted, which upset the patient. “Why do I need therapy,” she wanted to know, “if I’m feeling good?”
Millions of Americans are in psychotherapy, and my friend’s experience brings up two related, perplexing questions. How do you know when you are healthy enough to say goodbye to your therapist? And how should a therapist handle it?
With rare exceptions, the ultimate aim of all good psychotherapists is, well, to make themselves obsolete. After all, whatever drove you to therapy in the first place — depression, anxiety, relationship problems, you name it — the common goal of treatment is to feel and function better independent of your therapist.
To put it bluntly, good therapy is supposed to come to an end.
But when? And how is the patient to know? Is the criterion for termination “cure” or is it just feeling well enough to be able to call it a day and live with the inevitable limitations and problems we all have?
The term “cure,” I think, is illusory — even undesirable — because there will always be problems to repair. Having no problems is an unrealistic goal. It’s more important for patients to be able to deal with their problems and to handle adversity when it inevitably arises.
Still, even when patients feel that they have accomplished something important in therapy and feel “good enough,” it is not always easy to say goodbye to a therapist.
Not long ago, I evaluated a successful lawyer who had been in psychotherapy for nine years. He had entered therapy, he told me, because he lacked a sense of direction and had no intimate relationships. But for six or seven years, he had felt that he and his therapist were just wasting their time. Therapy had become a routine, like going to the gym.
“It’s not that anything bad has happened,” he said. “It’s that nothing is happening.”
This was no longer psychotherapy, but an expensive form of chatting. So why did he stay with it? In part, I think, because therapy is essentially an unequal relationship. Patients tend to be dependent on their therapists. Even if the therapy is problematic or unsatisfying, that might be preferable to giving it up altogether or starting all over again with an unknown therapist.
Beyond that, patients often become stuck in therapy for the very reason that they started it. For example, a dependent patient cannot leave his therapist; a masochistic patient suffers silently in treatment with a withholding therapist; a narcissistic patient eager to be liked fears challenging his therapist, and so on.
Of course, you may ask why therapists in such cases do not call a timeout and question whether the treatment is stalled or isn’t working. I can think of several reasons.
To start with, therapists are generally an enthusiastic bunch who can always identify new issues for you to work on. Then, of course, there is an unspoken motive: therapists have an inherent financial interest in keeping their patients in treatment.
And therapists have unmet emotional needs just like everyone else, which certain patients satisfy. Therapists may find some patients so interesting, exciting or fun that they have a hard time letting go of them.
So the best way to answer the question, “Am I done with therapy?” is to confront it head on. Periodically take stock of your progress and ask your therapist for direct feedback.
How close are you to reaching your goals? How much better do you feel? Are your relationships and work more satisfying? You can even ask close friends or your partner whether they see any change.
If you think you are better and are contemplating ending treatment but the therapist disagrees, it is time for an independent consultation. Indeed, after a consultation, my writer friend terminated her therapy and has no regrets about it.
The lawyer finally mustered the courage to tell his therapist that although he enjoyed talking with her, he really felt that the time had come to stop. To his surprise, she agreed.
If, unlike those two, you still cannot decide to stay or leave, consider an experiment. Take a break from therapy for a few months and see what life is like without it.
That way, you’ll have a chance to gauge the effects of therapy without actually being in it (and paying for it). Remember, you can always go back.
Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College.
Looking for Evidence That Therapy Works
By Harriet Brown : NY Times : March 25, 2013
Mental-health care has come a long way since the remedy of choice was trepanation — drilling holes into the skull to release “evil spirits.” Over the last 30 years, treatments like cognitive-behavioral therapy, dialectical behavior therapy and family-based treatment have been shown effective for ailments ranging from anxiety and depression to post-traumatic stress disorder and eating disorders.
The trouble is, surprisingly few patients actually get these kinds of evidence-based treatments once they land on the couch — especially not cognitive behavioral therapy. In 2009, a meta-analysis conducted by leading mental-health researchers found that psychiatric patients in the United States and Britain rarely receive C.B.T., despite numerous trials demonstrating its effectiveness in treating common disorders. One survey of nearly 2,300 psychologists in the United States found that 69 percent used C.B.T. only part time or in combination with other therapies to treat depression and anxiety.
C.B.T. refers to a number of structured, directive types of psychotherapy that focus on the thoughts behind a patient’s feelings and that often include exposure therapy and other activities.
Instead, many patients are subjected to a kind of dim-sum approach — a little of this, a little of that, much of it derived more from the therapist’s biases and training than from the latest research findings. And even professionals who claim to use evidence-based treatments rarely do. The problem is called “therapist drift.”
“A large number of people with mental health problems that could be straightforwardly addressed are getting therapies that have very little chance of being effective,” said Glenn Waller, chairman of the psychology department at the University of Sheffield and one of the authors of the meta-analysis.
A survey of 200 psychologists published in 2005 found that only 17 percent of them used exposure therapy (a form of C.B.T.) with patients with post-traumatic stress disorder, despite evidence of its effectiveness. In a 2009 Columbia University study, research findings had little influence on whether mental-health providers learned and used new treatments. Far more important was whether a new treatment could be integrated with the therapy the providers were already offering.
The problem is not confined to the United States. Two years ago, Dr. Waller studied C.B.T. therapists in Britain treating adults with eating disorders to see what specific techniques they used. Dr. Waller found that fewer than half did anything remotely like evidence-based C.B.T.
“About 30 percent did something like motivational work, and 25 percent did something like mindfulness,” said Dr. Waller. “You wouldn’t buy a car under those conditions.”
Why the gap? According to Dianne Chambless, a professor of psychology at the University of Pennsylvania, some therapists see their work as an art, a delicate and individualized process that works (or doesn’t) based on a therapist’s personality and relationship with a patient. Others see therapy as a more structured process rooted in science and proven effective in both research and clinical trials.
“The idea of therapy as an art is a very powerful one,” she said. “Many psychologists believe they have skills that allow them to tailor a treatment to a client that’s better than any scientist can come up with with all their data.”
The research suggests otherwise. A study by Kristin von Ranson, a clinical psychologist at the University of Calgary, and colleagues published last year concluded that when eating-disorder clinicians did not use an evidence-based treatment or blended it with other techniques for a more eclectic approach, patients fared worse, compared with those who received a more standardized treatment.
Therapists who skew toward the “artistic” side say that so-called manualized treatment devalues crucial aspects of therapy like empathy, warmth and communication — the “therapeutic alliance.”
“If you want a patient to be using a treatment that works, what’s most likely to get them there is the relationship you build with them,” said Bonnie Spring, a professor of psychiatry at Northwestern’s Feinberg School of Medicine.
But some experts believe this is a false choice. “No one believes it’s a good idea to have a bad relationship with your client,” said Dr. Chambless. “The argument is really more, ‘Is a good relationship all we need to help a patient?’ ”
Besides, evidence-based treatments like C.B.T. still require expertise, clinical judgment and skill from practitioners, noted Terry Wilson, a professor of psychology at Rutgers University. “A stereotype of manualized treatment is: you go buy a book and it’s a rigid, lock step thing,” he said. “But when done competently, it’s anything but.”
Differences in background and education play a role in a therapist’s perspective on evidence-based treatment. “You can become a therapist with very little training in how to think scientifically,” said Carolyn Becker, a professor of psychology at Trinity University in San Antonio. Psychiatrists, clinical psychologists, social workers and other mental-health professionals complete years of rigorous schooling and apprenticeships, but it is possible to practice therapy without such a foundation.
“A lot of students come in and say, ‘I hate science, but I’m good with people. I like to listen and help them,’ ” said Dr. Becker. There is little incentive for therapists to change what they are doing if they believe it works. But “every clinician overestimates how well they’re doing,” said Dr. Spring. Often patients simply feel they can’t tell a therapist when things aren’t going well.
“A lot of times, therapists just don’t know,” Dr. Chambless said. “People will say, ‘Thank you, I’m fine now, goodbye,’ and go into a different therapy.”
Despite the gap between research and practice, some experts are cautiously optimistic. Dr. Wilson believes mental health practitioners, especially younger clinicians, are slowly moving toward more evidence-based treatments. He pointed to a parallel shift among physicians that took place, he said, when medicine committed itself to science rather than to producing medical artists or gurus.
“As a field, clinical psychology needs to do the same thing,” he said. “We need to commit ourselves to science.”
Need to find a therapist well-grounded in the latest research? Experts recommend interviewing prospective providers before starting therapy, especially if you are looking for a specific type of treatment. Useful questions include:
¶What kind of trainings have you done, and with whom?
¶What professional associations do you belong to? (If you’re looking for a C.B.T. therapist, for instance, ask whether the therapist belongs to the Association for Behavioral and Cognitive Therapies, where most top C.B.T. researchers are members.)
¶What do you do to keep up on the research for treating my condition?
¶How do you know that what you do in treatment works?
¶Do you consider yourself and your approach eclectic? (Therapists who subscribe to an eclectic approach are less likely to adhere to evidence-based treatments.)
¶What manuals do you use?
¶What data can you show me about your own outcomes?
“A clinician who can’t tell you how many patients get well isn’t going to care that much if you get well,” said Dr. Waller.
Annie Hall: Oh, you see an analyst?
Alvy Singer: Yeah, just for fifteen years.
Annie Hall: Fifteen years?
Alvy Singer: Yeah, I'm gonna give him one more year, and then I'm goin' to Lourdes
Alvy Singer: Yeah, just for fifteen years.
Annie Hall: Fifteen years?
Alvy Singer: Yeah, I'm gonna give him one more year, and then I'm goin' to Lourdes
