Can You Always Trust Your Therapist?

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Any seasoned therapist knows a fair number of other counselors, some casually, some quite well. We refer patients to a few of these people and steer clear of making referrals to others. The reason for the latter is pretty simple: doubts about their skills. That raises a second question: should their patients have the same uncertainties?

Going to the doctor in the days before there were lots of different types of medical professionals was a no-brainer. The doc was the expert. The medical model required the patient to submit to the physician’s ministrations. You were passive, he was active, and everything was supposed to work without much thought on your part.

No more.

To begin, there are many different types of counselors: clinical psychologists, psychiatrists (some of whom only prescribe medication), psychiatric social workers, marital and family therapists, licensed clinical professional counselors, and other titles. The first two are doctoral level practitioners, the rest most often hold masters degrees. The type and extent of training varies.

Then there are an enormous number of therapeutic approaches. Here, for example, you will find descriptions of 30 different kinds and this list does not include all the specialities within each type: http://www.counselling-directory.org.uk/counselling.html

The plethora of therapy modes creates a dilemma for the patient. At bottom, the issue is trust:

  • Is the doc expert at the precise model of treatment best suited to my condition?
  • Is the type of therapy he might recommend for me empirically validated? Empirical validation refers to a large body of well-controlled research demonstrating that therapy approach X for diagnosis Y produces better results than either no treatment or a placebo.

If you multiply the number of diagnoses by the number of approaches to treatment, you come up with a number so large as to confuse many patients. Indeed, we can say with certainty that there is no therapist who is expert in each approach for every type of diagnosis. Mental health professionals must therefore narrow their focus to a limited number of diagnoses and a small selection of approaches to those diagnoses.

Most practitioners possess training and experience in one or more forms of healing Depressive and Anxiety Disorders. They may not be prepared, however, to take on all subtypes under these headings. Thus, for example, a person who accepts patients with Anxiety Disorders might not be prepared to work with all 10 of the coded diagnoses listed below the broad descriptor “Anxiety Disorders:”

ANXIETY DISORDERS:

  • 309.21 Separation Anxiety Disorder
  • 312.23 Selective Mutism
  • 300.29 Specific Phobia
  • 300.23 Social Anxiety Disorder
  • 300.01 Panic Disorder
  • 300.22 Agoraphobia
  • 300.02 Generalized Anxiety Disorder
  • 293.84 Anxiety Disorder Due to Another Medical Condition
  • 300.09 Other Specified Anxiety Disorder
  • 300.00 Unspecified Anxiety Disorder

Why an Empirically Validated Treatment is Important? An Example:

Given all the issues mentioned, consulting a therapist who can diagnose and recommend the treatment most likely to help is crucial.

Here is an example of how this might best work in practice. The recommended and empirically validated treatments for Obsessive Compulsive Disorder (OCD) include Exposure and Response Prevention (ERP) or medication, with a 70% effectiveness rate overall. Our hypothetical patient is hamstrung whenever leaving his home, his office, his car, etc. He checks over and over whether he has locked everything for fear of an irrational catastrophe. This causes him to waste an hour or more a day. Our friend is late for appointments, work, and social events, angering many people and placing his job and family relationships in jeopardy.

If one were to treat this gentleman with ERP, the therapist and patient would together rank those situations that are the least anxiety provoking to the ones most upsetting. The client would then be exposed to a fear-inducing event at the low end of the list, having agreed not to engage in his usual compulsive checking despite his turmoil. The patient’s fight against the urge to check is the portion of treatment called response prevention. The expected outcome is a diminution in his fear and checking as he repeats these exposures without confirming the security of the lock. The patient gradually faces the more unsettling items on the hierarchy until the troubling behavior is eliminated.

Traditional talk therapy, designed to uncover the underlying “reasons” for such compulsivity, is ineffective in treating OCD. At this point in the history of this condition, if a therapist chooses to provide a treatment not meeting the standard for “best practices,” he risks not only his patient’s well-being, a waste of his money, and a squandering of his time, but a malpractice suit.

What Increases the Risk of a Therapist Not Choosing an Empirically Validated Treatment (Assuming It Exists)?

At least three possible reasons:

  • He is unaware of the research pointing to the recommended approach.
  • He doesn’t “believe” in the validated mode of therapy.
  • He doesn’t possess the training to deliver it properly.

As noted above, therapists are not schooled in every method of doing their job. They perform in a competitive field, especially in large urban areas, and are under downward pressure from insurance companies regarding their fees. There is the possibility of unconscious self-persuasion of the knowledge and skill to treat a wider range of conditions than close scrutiny would justify, thus enlarging the potential pool of patients who might consult them. All health practitioners are required to spend more time documenting their work than previous generations of peers. Therapy clients also often desire evening or weekend appointments, creating an incentive for the doc to be available for sessions during “leisure” hours. Any of these factors can unintentionally limit the time needed to keep up with the latest research and receive the necessary training.

Depending on the practitioner’s location and discipline, there are requirements for continuing education. Licensed psychologists in Illinois must take at least 24 hours of continuing education every two years to maintain their practice. At least three hours cover professional ethics. No other directives point him toward a particular area of knowledge. In other words, these requirements are not guaranteed to remedy any shortfall in competence to treat OCD or any other particular disorder.

What You Can Do:

Where does this leave you, the present or future patient?

Counselors almost all mean well, but we all should recognize “the road to hell is paved with good intentions.” It is in your power to do the following:

  • As early as possible, understand what the initials after your therapist’s name mean, e.g. M.D., Ph.D., L.C.S.W., etc. This is not meant to disparage any particular group, all of whom include excellent practitioners. Rather, knowing this gives you the most basic information about the counselor’s background.
  • Learn about the kind of training he received subsequent to his degree and what he specializes in, both in terms of diagnosis and approach to treatment.
  • Ask him why he is suggesting a particular approach and find out what other approaches exist, and, especially whether they have been empirically validated. It should be noted empirically validated therapies do not exist for every diagnosis.
  • Be sure to confirm, as much as possible, whatever you are told by doing your own research.

Once again, I’m not assuming any wrong doing by your counselor. However, remember, you are dealing with another human being, no matter how kind or intelligent.

As an old Russian proverb tell us, “trust but verify.”

 

How to Choose a Therapist

Most of us are not at our best under pressure. Similarly, when depressed, anxious, or otherwise stressed and in crisis, the patience and clarity of thinking needed choose a therapist might well be in short supply. So here are a few pointers, things to consider, when you decide to consult someone for psychological assistance:

1. Ask a friend if he or she is able to recommend a therapist with enthusiasm. Also be sure to request that your acquaintance explains “how” the therapist was helpful. Not all counselors are equally adept at treating every problem, so your friend’s recommendation should be carefully considered in light of whether your issues are different from your friend’s. You might also ask your physician for a recommendation. A good way to phrase the question is, “If you needed to get a therapist for someone you loved, who would you choose?”

2. Internet searches of various kinds can help find a good person. Various organizations list therapists who perform a certain type of therapy or work with certain types of problems. An example would be the Association For Behavioral and Cognitive Therapies: www. abct.org/ The National Register of Health Care Providers in Psychology is another such group: http://www.nationalregister.org

3. Some information about the therapist is usually available on web sites such as those mentioned above. If the therapist has a web site of his own, you will usually find out a good deal more.

4. What kind of therapist are you looking for? There are many choices. Clinical Psychologists are doctoral-level professionals (Ph.D. or Psy.D) who typically have completed four years of training beyond their college Bachelors degree and had additional instruction and supervision in the form of a year-long internship, often within hospitals or clinics. In most states psychologists cannot prescribe medication, but have received more graduate training in psychological evaluation (testing) and therapy than is typical of any of the other disciplines who perform therapy.  Psychiatrists are physicians trained in medicine, who also receive specialized training during a psychiatric residency. They can and do prescribe medication and a number of them also do therapy. Clinical Social Workers generally have a Masters Degree obtained in the course of two years of post-college study, in addition to practical experience and a history of supervision. Marriage and Family Therapists usually also have a Masters Degree and may have a similar amount of training as do the social workers, although their education is not identical to that group. All of these disciplines encourage and sometimes require therapists to continue their study via post graduate course work, supervision, and reading.

4. What kind of therapy do you want? In part, that might depend on what kind of problem or problems you have. Psychodynamic psychotherapists will tend to pay much attention to early life issues including unresolved feelings toward one’s parents, and the potential impact of additional events that occur during the growing-up years in an attempt to free you from repetitive patterns of behavior that might have started at that time. Cognitive behavioral therapists use CBT to focus more on present day concerns, attempting to help you take steps to alter the automatic and self-defeating thoughts that influence your mood and fuel your depression and anxiety, as well as assisting you in changing your behavior. They spend much less time on early life events as a rule, and do not usually consider “insight” into the causes of your troubles to be crucial to assuaging your emotional pain. Marriage and family therapy aims to treat couples and family systems, usually meeting with the marital pair or family group rather than with one person at a time.

5. Try to determine how much experience your potential therapist has with a given kind of problem. Some therapists specialize, for example, in treating alcohol and drug abuse and are certified in this field (CADC or certified alcohol and drug counselor). If you have anxiety issues, on the other hand, ask your therapist how many people he has treated with this condition. Similar questions might be asked of someone who you wish to consult for the treatment of depression or schizophrenia. Don’t be afraid to ask. Any reasonable professional in the health care field will welcome your making an informed decision.

6. Other factors might be considered. How active do you want the therapist to be? Some tend to direct the therapy, while others are more comfortable listening to you and responding to just those issues that you believe are important. Some people choose therapists based on gender, believing that they will feel more comfortable with one or the other sex. Age of the therapist is important, since it tends to be correlated both with professional experience and life experience. If you believe that not everything in life is learned in a classroom, you will probably want to see someone who has a few gray hairs and who has been married with children.

7. Financial considerations often enter into the choice of a therapist. MDs are usually the most expensive people to see and Masters level professionals are the most economical. Ask your therapist about what he charges for his services and what portion, if any, of his fee is covered by insurance. Some communities have public mental health agencies that offer therapy at a heavily discounted price, although they often have long waiting-lists. A portion of therapists will discount their fees if you can make a good case for such a discount.

If you go through your insurance company, it is likely that they will steer you toward a practitioner who has a contract with them and has agreed to discount his fee to you. Understand, however, that the discount also typically benefits the insurance company, since they will have to pay less money in benefits if you choose a provider who is in their network. Therefore, their recommendation comes with a degree of self-interest.

Be aware that (as the old saying goes), sometimes “you get what you pay for.”

8. Some people choose not to use their medical insurance to pay for counseling. They make this decision because they have concerns about the impact of a mental health diagnosis on their future ability to get life or disability insurance, and the possibility that having a “pre-existing (mental health) condition” will complicate their medical coverage should they ever change jobs or go for a period without insurance and then attempt to obtain it again.

9. Remember that the most important element in obtaining a therapist is getting a person who is accomplished, talented, experienced, and a good fit for your therapeutic needs. You should also have a sense that he really cares and wants to help. While some of the other considerations mentioned previously might be important, if the therapist can’t help you, nothing else really matters. When you meet the therapist (see my blog post “What to Expect in Your First Therapy Session“) he should be able to convey expertise, compassion, and competence, as well as giving you a sense of hope. Don’t settle for less.