by Robert Duff
I definitely fall into the integrated camp. My personal approach to therapy probably lies somewhere between CBT and psychodynamic treatment. I feel that it is important to first stop the “emotional bleeding” in therapy and address what is going on right in the moment. If there is a crisis happening, you can worry about self-exploration later. After the person is stabilized, I use many strategies from CBT and solution-focused therapy to start to help the person develop skills and different ways of thinking that can help them to better interact with their world. Eventually, I believe that it is important to work toward insight and depth of understanding about the origins of problems. To me, I think of this final process as a shield. Sure, you can learn better ways of treating your symptoms and coping, but learning about where they came from in the first place can help you avoid falling into a relapse later on. Theoretical orientation in therapy is basically just the unique way in which your shrink makes sense of your mess. Even if they are going by the book and using whichever techniques are most supported by research for your particular issue, they are probably translating it in their head to make sense with their theoretical orientation.
There are also clinicians that have particular specialties when it comes to the issues that they like to treat. Some therapists prefer to be a jack of all trades type, while others choose to specialize in a particular niche. This is independent of their theoretical approach. For instance, you might have a psychodynamic therapist that specializes in working with survivors of trauma, or you might have a cognitive behavioral therapist that focuses on sexual dysfunction. When you are looking for a therapist, take note about whether they have a specific focus or area of specialty. These concepts of theoretical orientation and area of specialty will be MUCH more important to consider than what school they graduated from when you are searching for a therapist.
Let’s shift gears here and talk about how you go about searching for a therapist. (Again, I need to give the caveat that I’m giving advice that is specific to the United States. The process is hopefully similar in other countries, but I’ve never practiced there, so I can’t be sure. Actually, if you don’t mind, give me some feedback about that. Tweet me (@duffthepsych) from other countries and help me understand how it is similar or different where you live.)
The way that you search for a therapist will depend on how you plan on paying for it. The main factor to consider is whether you will be using insurance. If you are a university or college student, you probably have access to free or extremely low-cost therapy through your school’s insurance plan. In fact, many schools have a clinic right on campus that you can go to. If you want to see whether your school offers mental health services, check out their website. Usually, the student health section of the site is a good place to start looking. Don’t be afraid to call or email your school if you need help finding those services. They can sometimes be a little tricky to track down.
If you have private insurance provided by your employer or something like that, you will usually have to search for a therapist that is within your “network.” Obviously there are many different types of insurance out there, so this is an inelegant explanation. When in doubt, contact your insurance company directly and ask about it. These days you can usually log into your insurance provider’s website and use their own search engine to find mental health providers around you. These tools are great because you can usually filter by different criteria. For instance, you can tell the search engine to find you a female therapist within 10 miles of your zip code that does couples therapy. If you want to kick it old school, you can usually also call and ask for the company to send you a list of all providers near you. These search engines are great for locating therapists, but they often don’t do a great job of giving you all of the information that you want. For that reason, I encourage you to visit your potential therapist’s website if they have one. This helps to give you a general feel for the person that you might be diving into a therapeutic relationship with. Maybe this is a generational thing, but I have a really hard time deciding to see a shrink if they don’t have a website or if their website looks like total shit. Ideally, their site should tell you about them, what sort of treatment they provide, and how to get in contact them to learn more.
If you are using a larger healthcare network for insurance, you may have less of a choice in deciding which therapist you see. Don’t be freaked out by this. Usually you will be paired with whoever is available to start with. They want to get you in at a time that works for your schedule to get your into the system and started with your intake appointment. After you have your initial contact and first appointment, they will typically send you to a therapist that can meet your needs. When I say you have less of a choice in the matter, I mean that you won’t be able to look at a giant list of people and make your choice out of anyone that seems to be a good fit for you. That does not mean that you don’t have choice or influence in who you end up seeing for treatment. You always have a say in the matter. They may suggest a particular therapist for you to start with and you can always switch therapists if need be. You are also allowed to state your preferences. For instance, many survivors of sexual trauma prefer to have a therapist who is not the same gender as their abuser and there is nothing wrong with that. Other people may have preferences in regards to age or interpersonal style. While larger healthcare networks have somewhat less flexibility, you can still work within the bounds of the system to find something that works well for you.
If you don’t have insurance or don’t want to be constrained by it, you will be looking at paying out of pocket for treatment. The rate for out of pocket therapy sessions can vary quite a bit. For the most part, it is not cheap. It is hard to give a generalized price, but a doctoral level therapist charging their full rate will be in the triple digits per hour. Depending on education level, experience, and specialty, there will obviously be a range in the price here. For some people, price is not a primary consideration and they are willing to pay just about anything within reason for their mental health.
If you can’t use insurance and cost is prohibitive (been there…), you will probably want to look for therapists that have a “sliding scale.” A sliding scale basically just means that their fee for treatment is adjustable and is dependent on your income (or lack thereof). If you are really hurting in the money department, you can often find treatment for very cheap. This does not mean that you will be getting budget quality therapy. We are just in the business of helping and don’t want you to be without treatment if you really need it. You can find sliding scale therapists individually or as part of regional organizations. To find a therapist in your area that might be able to meet your needs, you can definitely use the all-powerful Google, but that isn’t always the most reliable method since a lot of therapists don’t focus much on search engine optimization. There is also a really great tool available online through the website of the popular publication Psychology Today. As of right now, the tool is available at therapists.psychologytoday.com, but you know the internet… that url could change in the future. Psychology Today’s search engine is a great one because its sole purpose is to help you find a shrink near you. That means it has filters that allow you to search by the issue you are struggling with, type of insurance you have, treatment orientation, religion or faith, and more. It’s super nifty. I encourage you to spend a little time just exploring some of the people around you, even if you aren’t yet ready to take the plunge and try to schedule something. The last tool that I will mention is that there are often local “psychological associations” that have lists of therapists and other resources in your community. To find these, you can usually just Google the name of your city and psychological association (ex: New York Psychological Association).
It is important to mention your consumer rights as someone who will potentially be getting therapy. One of the main goals of therapy during the early stages is to develop a rapport, or a working relationship, with your therapist. It’s just like any other rel
ationship; sometimes you can just tell when you and the other person aren’t clicking. Think of it like baristas at the coffee shop. Some of them are great and some of them are shitty. There are also some baristas that make your coffee exactly the way you want it, but can’t pull a shot of espresso to save their life. In the same way, there are some shrinks out there are that just legitimately bad at their job and there are others who might be great for some people, but just do not quite float your boat. The bottom line is that therapists are people and we don’t always get along super well with every person that we meet. If you are feeling pretty sure that it is not working out with a therapist, you are allowed to move on. Please don’t let one negative experience spoil your perception of therapy on the whole. There is a good fit for you out there and by having a “miss”, you are actually getting better at recognizing your preferences for a therapist, which you can keep in mind as you continue your search. Therapists should not take it personally. It is part of the job and we understand. They probably felt somewhat of a disconnect as well. Ideally, you would give a therapeutic relationship a little while to develop and see if you can overcome some of these obstacles, but sometimes you really do just know when it’s not gonna happen.
Now before I talk about drugs, I want to talk about some of the different names and titles that you might hear in reference to people who provide psychological help. Maybe I should have talked about this before I started throwing the terms around throughout this whole book… oh well.
So, the first thing that we need to make completely clear is the difference between psychologists and psychiatrists. I have no idea why we decided to make these terms so goddamn similar. It’s understandably super confusing for anyone that isn’t in the mental health field to know the difference. Psychologists are people with a doctoral degree (Ph.D. or Psy.D.) in some form of psychology. They can teach, write, research, practice therapy, or do psychological testing. The one thing that they cannot do is prescribe medication. That is where psychiatrists come in. Psychiatrists are medical doctors (M.D.) that specialize in treating mental disorders through the use of medication. Psychiatrists can do therapy, but they typically do not in this day and age. They will certainly talk to you and be therapeutic in their approach, but the main focus of their job is to gather information, make a diagnosis, and suggest strategies for treatment. So that’s the difference between psychologists and psychiatrists. Now that you have that distinction in mind, let me confuse you a little more. You might hear the terms “psychological” or “psychiatric” thrown around as well. When they are not referring to the professions that I just talked about, these terms mean the same freakin’ thing. For instance psychiatric illness means the same as psychological dysfunction, which means the same as mental health issues. Just remember that psychiatrists are M.D.s, psychologists are Ph.D.s and that all of the rest basically means the same thing.
In order to practice therapy, one does not have to be a psychologist. At least in the United States, psychologist is a title reserved for those of us with a doctoral degree, but a huge portion of people who provide therapy (which is the same thing as psychotherapy or counseling) do not have doctorates. In other words, not all therapists or mental health clinicians are psychologists. There are definitely regional differences depending on what country you live in, but here we have titles such as Marriage and Family Therapist (MFT), Master’s in Social Work (MSW), and Licensed Clinical Social Worker (LCSW), which are master’s level graduate degrees that allow someone to practice psychotherapy after going through the state licensure process. You really don’t need to worry too much about all of this crap. I just wanted to make sure you had the information in case you come across some of these strange acronyms and wonder what they mean.
When it comes to therapy itself, you are pretty much looking at the same picture regardless of the type of clinician that you see. Someone with a doctoral degree obviously has a few more years of education under their belt and may also specialize in things that master’s level therapists cannot do such as teaching at the university level or psychological assessment. That doesn’t necessarily mean that they are going to be “better” at therapy than someone with a master’s degree. In fact, master’s level therapists can be super skilled because they start jumping into clinical practice a lot earlier than doctoral level psychologists and their attention is not as split. By that I mean that in a doctoral program, you are often expected to focus on clinical practice, academic research, pedagogy (teaching), and assessment. On the other hand, someone in an MSW program will be focusing much more exclusively on providing therapy. Really, it comes down to personal preference. There are superstar therapists within any given category.
Okay, so let’s talk about drugs now. Yay drugs! This is an area that I am always hesitant to talk about because, as we discussed before, I am not a psychiatrist and medication is not my area of specialty. However, I so often get questions about medication for psychiatric issues that I feel obligated to at least give you my perspective on them as a psychologist. Spoilers: I think that they are incredibly valuable. In my work providing psychotherapy for people, I have had the opportunity to work hand in hand with psychiatrists to develop comprehensive plans that treat both the immediate and the big-picture aspects of psychiatric illness. In my opinion, which is based on both clinical research and my own experience, the best course when considering psychopharmacological (drug) treatment for depression is to combine it with therapy. Both therapy and medication are effective, but for that sticky, gross, oppressive kind of depression that some of you are experiencing, the most effective thing is combining medication and solid psychotherapy. The reason for this is that they treat the problem from different sides.
Remember how I mentioned earlier that sometimes fighting against your depression is so hard because you are literally fighting against your biology? Well, psychiatric medications can help with that by temporarily modifying your biology so that it is less of a roadblock on your quest to improve. If your symptoms are so oppressive that it is hard for you to make any changes to your thinking or progress in therapy, that is when you may want to consider medication. Most people are a bit wary of medication, which is a good thing. You don’t want to rely on it as a first line defense for depression. Let’s return to that backpack metaphor we talked about at the beginning of the book. If having depression is like walking through your life with a backpack full of bricks weighing you down, medication serves the purpose of taking out a few of those bricks for you. It doesn’t solve any direct problems for you, but it frees you up to be less of a slave to your symptoms so that you can make positive changes to your thinking patterns, your behaviors, your environment, and all of that good stuff. Of course, there are individual differences in this, but it is typically nobody’s goal to keep you on antidepressant medication for your entire life. If I can throw another metaphor here, you can think of medication as providing you with an initial boost or elevation. Ideally, you take advantage of that boost to build the skills that you need, either through self-help or through therapy, to create scaffolding underneath you. That way, when the support of the medications is eventually phased out, you still have this structure that you have built through all of your hard work that will keep you elevated and you won’t tumble back down into the nasty black pit of depression.
The way that antidepressant medication works is related to those neurotransmitters that we talked about during the motivation chapter. There are many different types of medication that are effective for treating depression. Each type has a different mechanism of action by which they alter your biology and help to take that immense weight off of your chest. You really don’t need to know about all of them. Leave that to your psychiatrist. Currently, you are probably most likely to run into a class of medications called SSRIs, or selective serotonin reuptake inhibitors (catchy right?). Let me break that down to make a little more sense. So, you have those neurons right? They are the cells in your brain that communicate with one another by sending n
eurotransmitters back and forth. When neuron #1 sends a neurotransmitter across the synapse (space between neurons) to neuron #2, neuron #2 needs to have a receptor open to receive that neurotransmitter. If it does not, the neurotransmitter continues to bounce around in the synapse looking for a home. We don’t want a bunch of homeless neurotransmitters bouncing around in there though, so the brain has a nifty function called reuptake. If the neurotransmitter does not find a home in neuron #2, after it bounces around for a while, neuron 1 will reuptake the neurotransmitter because it doesn’t appear to be necessary. So when you want to have MORE of a certain neurotransmitter available, the obvious solution would be to increase the amount of that neurotransmitter that neuron #1 pumps out. A more elegant solution, which is what SSRIs do, is to prevent the reuptake of the neurotransmitter. If there is a lot of the neurotransmitter floating around in the synapse, there is a higher chance that any open slot on neuron #2 will be filled quickly. So, that’s about the simplest way that I can break down the way SSRIs work. Instead of letting neuron #1 suck back up the unused serotonin in the synapse, SSRIs tell it to just let them be homeless for a while in the hopes that eventually there will be some space for them in neuron #2. You can also think about it in terms of that pub metaphor that we used earlier. Let’s say the neuron #1 is sending patrons to the pub at neuron #2. If some people can’t get into the pub because it’s full, they will likely wander around and look for another pub. Typically neuron #1 will say, “Hey guys, sorry for the bad suggestion. Come back over here, so you don’t have to wait out in the cold.” Inhibiting reuptake would mean that the patrons have no other option except to wait in line for the pub at neuron #2 because neuron #1 isn’t opening its doors to let them back in. As any good bar or club manager knows, a long line is a good thing. That means steady service. In the same way, a bunch of neurotransmitter floating around in the synapse means a more steady effect. Got it? Good.