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Choosing A Psychotherapist: Determining Which Professional is Right for You

Natalie Staats Reiss, Ph.D. & Mark Dombeck, Ph.D.

Many people wonder about the differences between the varied types of mental health clinicians. Although it might sound straightforward, explaining this information is a bit tricky, because there are a range of professions that can provide therapy. In addition, there are some differences across states with regard to licensing. Use the information presented here as a general rule of thumb, and then check with your particular state's licensing board for more specific information.

A mental health practitioner is often referred to as a "therapist," "counselor," or "clinician." These terms are not specific, nor do they mean anything about a person's background, training, or license to provide mental health care. So, a "therapist" could be a psychologist, psychiatrist, social worker, minister, nurse, or someone with a high school degree. In other words, technically speaking, anyone can "hang a shingle" and call themselves a psychotherapist.

If you are looking for a therapist, it is acceptable (and necessary) to ask a lot of questions before starting your relationship. Find out about a therapist's training and experience, clarify their exact title (psychologist, psychiatrist, social worker, etc.) and licensure status. Clinicians who are unwilling or unable to provide this information should be avoided!

The Practitioners

Even though psychiatrists and psychologists are both correctly referred to as "Doctor" there are some differences between the two roles. Also, be aware that the title "Doctor" can refer to anyone who has an advanced degree. A "Doctor" could have a Ph.D. in English or Engineering, and obviously would not be qualified to provide psychotherapy.

Psychiatrists are medical doctors (with an M.D.) who are able to prescribe medication. Although psychiatrists are trained in psychotherapy, some specifically focus on prescribing and monitoring medications. The M.D. degree is usually obtained in four years (after completing four years of undergraduate education). Psychiatrists then complete at least one year of internship training and additional specialized training in the form of a psychiatric residency (usually three to four years of clinical training). Some physicians elect to complete a fellowship, which can add additional one or two years to their training.

Psychologists (with a Ph.D., Psy.D., or Ed.D.) are licensed doctoral level professionals who are experts in the practice of psychotherapy. They are also fully trained and qualified to use psychological assessments or tests (e.g., to clarify the type or severity of a particular psychiatric diagnosis; measure someone's I.Q., personality, academic achievement; determine strengths and weaknesses after a brain insult or injury; or clarify issues related to legal cases, custody decisions, guardianship and competency decisions. In some states, psychologists who receive additional training can also prescribe medications. The Ph.D. or Psy.D. is usually obtained in four or five years (after completing four years of undergraduate education). Psychologists then complete one year of internship. Most states require 1 to 2 years of postdoctoral training (beyond the internship) before someone qualifies for licensure. Psychologists may have degrees in Clinical Psychology (focused upon research and practice), Counseling Psychology (focused upon counseling people with day-to-day problems), School Psychology or just Psychology. Traditionally, a person with a Ph.D. degree received both research and clinical training. A Psy.D. Degree focused more upon the practice of psychology than research. The title "psychologist" can only be used by someone who has gone through the training described above and has then passed a national licensing test as well as a state test. Some states allow clinicians with a master's degree (M.A.) in psychology to provide psychotherapy. Due to Medicare restrictions, however, master's level psychologists can only work with clients who have other forms of insurance or can pay privately.

Social workers who practice psychotherapy are called clinical social workers or psychiatric social workers. Licensed clinical social workers (L.C.S.W., L.I.S.W., L.I.C.S.W.) can provide psychotherapy, but they cannot conduct psychological testing or prescribe medication. Licensed clinical social workers have completed a two-year Master's degree (M.A. or M.S.) beyond undergraduate coursework. Most LCSW's are required to obtain 2-3 years of counseling experience prior to practicing independently, depending upon licensure requirements for their state.

Marriage, Family and Child Family Counselors (M.F.C.C.) and Marriage and Family Therapists (M.F.T.) are clinicians who have earned a Master's Degree beyond undergraduate coursework (although some M.F.T's have earned Doctoral Degrees). These clinicians are usually required to obtain at least 2 years of counseling experience prior to licensure, depending upon state requirements.

A Licensed Professional Counselor (L.P.C.), has a Master's degree in counseling or a related educational field, and at least a year and a half of supervised post-graduate clinical experience.  In addition, this type of clinician has passed a state licensing exam. Typically, these therapists are also qualified to administer and interpret educational and vocational assessment tests.

M.F.C.C., M.F.T., and L.P.C. therapists are not qualified to prescribe medication.

In the United States, there are several different types of Psychiatric or Mental Health Nurses. An advanced practice psychiatric registered nurse (RN) has a master's or a doctoral degree, and can perform behavioral assessments and psychotherapy. A psychiatric nurse practitioner can provide psychotherapy, and prescribe medication under the direct supervision of a licensed physician.

A Pastoral Counselor (who has a D.Min. Degree, which stands for Doctor of Ministry; or a M.Div. Degree, which stands for Masters of Divinity) is trained in both psychology and theology (religious studies). Typically, pastoral counselors have completed a three-year master's program, plus an additional degree or the equivalent of four years of graduate academic work. Many pastoral counselors are licensed by the state in which they live; however, most states do not require it due to their clergy exemption clause. This type of clinician cannot prescribe medication.

Approaches

A person's degree and license does not necessarily tell you about their approach and style of therapy. As discussed in our article in psychotherapy, there are several different theories that can guide a therapist. Psychodynamic psychotherapy (which was originally called "psychoanalysis") focuses on understanding a person's problems in the context of their social and emotional histories. More specifically, psychodynamic therapy focuses on the impact of life events, desires, internal or external conflicts (e.g., denying or repressing painful emotions or conflicts), and past and current relationships (e.g., problematic connections with attachment figures such as parents). For example, someone may be unsuccessfully and repeatedly attempting to master or overcome dysfunctional relationship patterns experienced in childhood or earlier life.

Cognitive-behavioral psychotherapy combines two types of techniques based on cognitive and behavioral theories. Cognitive Behavioral therapists suggest that a person's problems result from a combination of unhelpful thoughts (cognitions) and maladaptive behavior. Because these thoughts and behaviors are learned, people can learn new, more adaptive skills that will decrease their symptoms and increase their ability to cope with daily hassles and life stressors.

Family systems therapists see a person's problems as a symptom of larger "systems" problems within a family or couple. Systems that involve inappropriate boundaries (either "enmeshed" where people are not separated enough from each other, or "detached" where people are too separated) are problematic. These therapists treat the entire system (e.g., both partners in a couple, or the whole family) rather than an individual. Therapists try to help reconfigure the family or couple system so that boundary problems are resolved and restored to a more ideal shape.

Humanistic/client-centered/gestalt therapists are focused on the quality of the relationship between therapist and client. These therapies are focused more on helping patients to achieve better general mental health and wellness states and less on removing specific mental illnesses. According to these therapists, human dysfunctions are caused by a faulty or interrupted developmental process (i.e., immaturity) usually relating to social/emotional skills. The goal of humanistic therapies is thus to promote social/emotional maturity and growth. By helping people to guide their derailed developmental processes in healthy directions, patients are helped to grow up and out of the immature mental and emotional states that cause them to be in pain and to inflict pain upon others.

There has been a recent push toward using empirically valid treatments in psychotherapy. Empirically valid psychotherapies are standardized forms of therapy that are supported by data from scientific studies showing that they help people recover from specific conditions like depression, or anxiety disorders. Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT) have the most documented success in treating Major Depression, for example. However, these modes of therapy may not be optimal for your specific situation.

When you are trying to find a therapist to work with, it is appropriate (and recommended) to ask about their style of psychotherapy or their "theoretical orientation." A person's educational degree and professional title can often give you a clue about the sort of therapy they practice, as specific professions tend to align themselves with specific theories and schools of thought.

The training of Psychiatrists and psychiatric mental health nurses is focused on biological and medical explanations and treatments for mental illnesses. Obviously, people who are most interested in exploring medication treatment for their particular issue should start with these clinicians. However, people usually have the most success with a combination of psychotherapy and medication, so finding a psychotherapist (either a psychiatrist or nurse) who also provides "talk" therapy, or a separate professional who only provides talk therapy may be useful.

Psychologists tend to adopt a biopsychosocial point of view. This means that they are taught to consider biological (genes, disease), psychological (thoughts, behaviors, emotions), and social (family, interpersonal relationships, and environment) factors when figuring out what might be going wrong with someone. Psychologists are the professionals who are working hardest to put psychotherapy on an empirical (scientific) basis. They are behind the creation of the major empirically validated forms of psychotherapy today, and the sort of professionals who are most likely to have been trained in these approaches. Traditionally, clinical psychologists were trained to treat individuals with more severe mental illnesses, and counseling psychologists dealt with less severe "life" issues that impact people's daily lives. However, that distinction is not necessarily true today.

Social workers are skilled in treating emotional, psychological and relationship issues, and addictions usually from a social and family systems perspective. Social workers are also excellent at connecting a person to community resources and supports, which is often a fundamental component and prerequisite of people getting better and staying better. Someone who is homeless, for example, doesn't need therapy so much as they need a safe place to live.

Master's level counselors/therapists are often trained in the family systems perspective. They look at people's family structure and relationships (past and present), cultural background, and other social and identity considerations. They can also help with personal development, life/job coaching, communication skills and relationship issues.

Pastoral counselors are uniquely poised to address the interplay between psychological and spiritual issues. People who are too ashamed to discuss their problems and issues with a conventional therapist may find it easier to confide in a pastoral counselor. This is particularly true when patients self-identify as religious and want a counselor or therapist who is of their same religious background.

If therapists report that they offer an "eclectic approach" that simply means that they pull different techniques and strategies from various different psychological theories and schools.

Again, these divisions are somewhat arbitrary. You can find a psychiatrist who practices cognitive behavioral psychotherapy. Or, you may find a clinical psychologist from a family systems theoretical orientation who provides couples and family therapy. Clinicians from each discipline may also vary in terms of whether they provide individual, marital, couple, family and/or group counseling.

Other Considerations

As you look for a therapist, there are some factors besides degrees, licensure, and theoretical orientation that you should also consider. For example, the gender of the therapist matters a great deal to some people. You should also ask whether a therapist has expertise in treating your particular issues. Seeing a therapist who specializes in grief and bereavement issues when you suspect that you have an eating disorder is probably not going to get you very far. Also make certain to ask about the typical time necessary to treat someone with your issue or problem. Keep in mind that the clinician you consult with may not be able to answer this question without first performing a thorough assessment to determine your specific diagnosis. Usually, people are more interested in short-term problem-focused styles of therapy (10-20 therapy sessions, generally offered once a week), as this time frame is less expensive and time consuming than old-style long-term psychotherapy.

Cost may be a concern when considering psychotherapy. Do not be shy in asking about fees, and do so at the earliest opportunity so that you are not surprised later on. Be upfront if you do not have health insurance (or if you don't have mental health benefits). Some practitioners offer sliding scale (reduced) fees for people who are paying out of pocket. In addition, clinical social workers, master's level therapists, nurses and pastoral counselors are usually less expensive than psychiatrists or psychologists. However, certain types of therapists may not be on your approved provider list if you have health insurance, so make sure to check your particular plan.

Privacy may also be a concern. If you use your health insurance to offset the cost of therapy, you will also be agreeing to let your therapist send information about your issues to your health insurance company. In some cases, this information ends up being recorded in what is known as the Medical Information Bureau, or MIB, which is a kind of clearinghouse for health information on millions of Americans. If you ever lose your health insurance (because you are separated from your employment) and you try to purchase health insurance on a individual basis, you may be denied coverage on the basis of past diagnoses recorded in your MIB record. If privacy is a concern for you, you are best off paying for your therapy in cash.

Finding a Recommendation for a Therapist

Once you've thought about the types of therapists available and have an idea of the sort of therapist you want to work with, you will next need to figure out which therapist to call. Often there will be more than one professional with the background you desire in your area, so you will have to choose between individuals.

When possible, go with a professional who comes with a good recommendation from people you trust to make a referral, and correspondingly, avoid those professionals who have poor reputations. Obtain recommendations from trusted family members, friends, or colleagues if you can. You can also ask your family doctor or psychiatrist for referrals. If you don't know anyone who will admit to having worked with a therapist in your area, you can often get a referral from the state agency that licenses the sort of professional you are interested in working with. You may also contact the counseling center, or psychology/counseling department of a local university or college for names of local therapists. Area community mental health centers and hospitals may also maintain lists of local providers. There are also several Internet databases, which provide therapist listings. You could even randomly select a name from a provider directory (check with your health insurance company) or the yellow pages of the phone book.