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gaudiorOver the past year or so, a number of people have asked me for recommendations for psychotherapists. In helping them find one, I've realized that most people don't know much about how to choose a shrink, besides a sense of the personality with which they'd feel most comfortable. Now, it's true that personality maters, but there are also other factors to keep in mind. Namely: there are about half-a-dozen different theoretical orientations and types of degrees which therapists have, and these make them differently equipped to help you with different problems.
So, the following is a list of exactly what the different types of therapist are and what they're good for. I hope this is useful-- and please pass it on to anyone else who might need it! Thanks!
Psychiatrists A psychiatrist is, specifically, a person with an MD degree who specializes in mental health. They will be legally permitted to prescribe medication, and they are the only people who can do this except for your primary care doctor (not a great idea-- some primary care docs are very good, but some of them don't know very much about the specific effects, side effects and interactions of different psychiatric meds. Also, such a doctor is more likely to prescribe just medication to make you feel better, when it really is best for most people to combine medication with therapy to be most effective). I think that Massachusetts, at least, is working on legislation to allow specially-trained therapists to also prescribe medication, but I don't know whether it's happened yet. A psychiatrist is great in that s/he can look at things from the point of view of the medical model, and be very aware of exactly how medications work and what they do. However, many psychiatrists will not do in-depth psychotherapy-- they're often too busy to give you a full fifty-minute hour every week. Many people have both a psychiatrist and a therapist, and if you/your health insurance can afford it, that's great. Otherwise, it's sometimes a good idea to see a psychiatrist long enough to find a medication regime which really works for you-- but once you have, to get your primary care doctor to write your prescription instead, unless you start having problems with the medication.
Psychologists A psychologist is a person with a doctoral degree in psychology, who has also passed the licensing exam and other requirements in your state. These can be either a PhD, who will have gotten his/her degree through a university, and may have gotten it either in clinical psychology (most likely to then be a therapist), experimental psychology, or I suppose in some more academic field (history of psych, etc), or a PsyD (Doctorate of Psychology), who will have gotten his/her degree through a school specifically for psychology. I chose to get a PsyD because it means that I have four years of both internship and academic training-- I end up with much more real-world experience than I would have in a PhD program (though there is some argument that the PsyD academics are less rigorous. I feel like they're rigorous enough for me).
Social Workers A clinical social worker is a person with a social work degree (LICSW, ACSW, a few with PhDs in Social Work). They're generally trained to have a more social-justice or pragmatic approach to things than a psychologist, who might be trained more in a theoretical or research-based way, but how the person uses the training very much depends on the individual.
Counselors These are usually people with a very specific area of expertise, whether it's substance abuse, what sort of job to find, college admissions, etc, etc, etc. They'll have very practical knowledge for you, and very practical ways of using it. Not the people to go to for a vague sense of ennui.
Note: any of the above can call themselves "psychotherapists", as can someone with an Ed.D, an LMHC (licensed mental health counselor), or, in some states, your Uncle Bob with a GED and a desire to Help People. A degree is not always necessary to start a business. And, in some cases, the degree doesn't actually make that much difference in whether or not the person can help you-- you might find an awesome shrink who's not got a particularly reputable background, but happens to be very, very good at helping people heal. (Or you might find a very experienced psychiatrist with a degree from Harvard who turns out to be a clueless asshole.) However, the advantage of someone with a license is that s/he is subject to supervision-- if s/he does anything unethical, s/he can be reported to the local board, and lose his/her license. And some shrinks do do things which are blatantly unethical-- but it's less likely when they're accountable to someone.
Now: some theoretical orientations. Most therapists have at least one of these, some have a combination.
Psychodynamic
Premise: Problems and mental illness are caused by experiences (particularly in childhood and adolescence) leading to different unconscious forces, beliefs, worldviews and ways of behaving. The best way to deal with them is to try to explore one's own thoughts and beliefs in order to better understand oneself. Therapy usually consists of once-a-week sessions, sometimes twice a week, talking to the therapist.
What it's good for: Self-acceptance, deep personality change, long-term solutions to recurring problems.
What it's not good for: Quick results, problems whose root is primarily outside the person.
Psychoanalytic A subset of psychodynamic; this is the old-school, Freudian, three-days-a-week-on-the-couch, free associating, the analyst as a blank-slate way of thinking.
What it's good for: Very deep self-understanding. Recurring patterns of interacting with people which are extremely problematic (the sort of thing that gets diagnosed as borderline, sociopathic, narcissistic or other personality disorders).
What it's not good for: Solving your problems (no, really).
Cognitive, Behavioral, or Cognitive-Behavioral
Premise: Problems and mental illnesses are caused by learned habits, conditioned responses and illogical beliefs. There are two major solutions to this; one is (going by Pavlov's and Skinner's ideas of conditioning), trying to de-condition one's problematic learned responses, sometimes by learning techniques of conscious relaxation and other ways of influencing one's own body. Another is to question and re-consider one's irrational beliefs to find a less-problematic way of thinking. Therapy often consists of sessions, homework assignments, and sometimes going on-location to deal with phobias in their natural environment.
What it's good for: Set length of treatment (eight weeks, thirty weeks, etc), phobias, and the practical details of managing major mental illnesses, particularly depression and anxiety.
What it's not good for: Working on deep emotional issues, understanding one's past
Humanistic
Premise: People hold within them the innate ability to heal themselves, if they are able to look at themselves deeply. Thus, the therapist's job is to try hard to understand and empathize with what the client is saying, and so create a space wherein the client can be accepted and valued, to make it safe for him/her to figure out what s/he needs to do to heal. This approach is very egalitarian; the client is considered the expert on him/herself, and s/he can direct the therapy to what s/he needs; the therapist tries his/her hardest to be authentic and "real" with the client, and much of the vaue is in the relationship between the two.
What it's good for: ...'kay, so this is tricky. Because almost all therapists, at this point, agree that the relationship between therapist and client is very important, that the therapist should respect the client, that the therapist should try to understand how the client is feeling, etc. So, in theory, this is useful for everyone.
What it's not good for: On the other hand, a purely humanistic therapist will be so focused on empathizing with the client and letting the client lead that s/he may not make use of any particular skills or plan to direct the training. At which point, you may as well be talking to a particularly patient and understanding friend, pastor, or Golden Retriever. I suppose I would say that any "humanistic" therapist should be judged on his/her own merits, but a blend is a good sign-- "humanistic and psychodynamic" or "humanistic and feminist," for example.
Existentialist
Premise: A subset of humanistic. All people deal with the questions of mortality, finding purpose in life, suffering, and our essential aloneness. In this sense, the therapist and client are fellow-travellers, both trying to deal with the essential questions of life.
What it's good for: wrestling with deeper issues-- purpose, meaning.
What it's not good for: Real, concrete problems-- with the caveat that few therapists are purely existentialist. Most will work with clients on a variety of issues, in many useful ways-- it's just that they'll be keeping an ear out for existential issues, and addressing them if and when they come up.
FeministPremise: Exactly what it sounds like-- this is therapy which pays particular attention to issues of gender and power.
What it's good for: Anyone for whom gender is a major issue-- particularly GLBT clients. Also often useful for survivors of rape or abuse, for whom issues of power and control can be really important.
What it's not good for: Again, this is often good to have as a blend with something else-- there's not a verycomplex feminist model of psychopathology or treatment.
Biomedical
Premise: Most mental illness has a physical component; it's either caused by an actual dysfunction in brain or nervous system, and/or it can be alleviated by making adjustments to them.
What it's good for: Major mental illnesses-- particularly schizophrenia, bipolar disorder, depression, ADHD, and some of the anxiety disorders, for which there are fairly effective medications. Particularly useful when people have gotten to the state where they really can't function-- ravingly psychotic, can't-get-out-of-bed-depressed, etc.
What it's not good for: More complex issues of personality, getting to the psychic/emotional root of the problem to keep it from reocurring.
Family & Couples
Premise: The most important factors in someone's life often have to do with other people, not just the individual. In fact, families will sometimes unconsciously create an "identified patient"-- one person who has obvious problems, and into whom everyone else's stress can be channeled. Thus, it's most effective to do therapy both with the individual and with all the other people in his/her life, in various combinations.
What it's good for: Kids and teenagers, for whom their family has so much more influence than the therapist that it's not even funny. People who are having major problems in their relationships.
What it's not good for: ...well, it's useful for many things, as just about any problem can be helped by having the people in your life involved and knowledgeable. But it's also true that, unless the problem is very specifically about the relationship, it's generally useful for people in couples/family therapy to also have an individual therapist.
Group
Premise: People's lives involve many people, with more complex dynamics than can exist between just a client and a therapist. And it is often easier for people to hear advice from a peer than from an authority figure.
What it's good for: Social-skills training, support, and specific education about topics like self-care, substance use, etc.
What it's not good for: Individual attention, social anxiety.
Community/Systems
Premise: People are part of a much bigger system than the individual-- their neighborhoods, cultures, governments, health insurance, etc have huge effects on their lives, and must be considered.
What it's good for: Helping to empower people to deal with their lives, make their own choices, address oppression and discrimination, join with the people around them to make changes, etc.
What it's not good for: Specific mental illnesses.
Other things Oh dear... there are quite a lot. And they range from quite reputable things about which I know very little (DBT, Narrative Therapy, etc) to the quite out-there. If you find a therapist who advertises something not listed here, I would recommend Googling it, or you're welcome to ask me or some other psych person.
But with all of this, the best way to judge a therapist is simply to meet with him or her and see how you feel. A good therapist should seem to be genuinely interested in you and be upfront about his/her practices and what s/he can and can't do. You shouldn't expect to be immediately blown away by his/her insight, or to immediately feel safe in trusting him/her with all of your deepest darkest secrets-- but you should feel like you might get something out of talking to the him/her. It's often a good idea to see said person about three times before making a decision-- and don't be afraid to shop around. Think of it as like dating-- you're going to be in a serious relationship with this person, so give it some thought.
Hope this was helpful, and good luck!
--R
So, the following is a list of exactly what the different types of therapist are and what they're good for. I hope this is useful-- and please pass it on to anyone else who might need it! Thanks!
Psychiatrists A psychiatrist is, specifically, a person with an MD degree who specializes in mental health. They will be legally permitted to prescribe medication, and they are the only people who can do this except for your primary care doctor (not a great idea-- some primary care docs are very good, but some of them don't know very much about the specific effects, side effects and interactions of different psychiatric meds. Also, such a doctor is more likely to prescribe just medication to make you feel better, when it really is best for most people to combine medication with therapy to be most effective). I think that Massachusetts, at least, is working on legislation to allow specially-trained therapists to also prescribe medication, but I don't know whether it's happened yet. A psychiatrist is great in that s/he can look at things from the point of view of the medical model, and be very aware of exactly how medications work and what they do. However, many psychiatrists will not do in-depth psychotherapy-- they're often too busy to give you a full fifty-minute hour every week. Many people have both a psychiatrist and a therapist, and if you/your health insurance can afford it, that's great. Otherwise, it's sometimes a good idea to see a psychiatrist long enough to find a medication regime which really works for you-- but once you have, to get your primary care doctor to write your prescription instead, unless you start having problems with the medication.
Psychologists A psychologist is a person with a doctoral degree in psychology, who has also passed the licensing exam and other requirements in your state. These can be either a PhD, who will have gotten his/her degree through a university, and may have gotten it either in clinical psychology (most likely to then be a therapist), experimental psychology, or I suppose in some more academic field (history of psych, etc), or a PsyD (Doctorate of Psychology), who will have gotten his/her degree through a school specifically for psychology. I chose to get a PsyD because it means that I have four years of both internship and academic training-- I end up with much more real-world experience than I would have in a PhD program (though there is some argument that the PsyD academics are less rigorous. I feel like they're rigorous enough for me).
Social Workers A clinical social worker is a person with a social work degree (LICSW, ACSW, a few with PhDs in Social Work). They're generally trained to have a more social-justice or pragmatic approach to things than a psychologist, who might be trained more in a theoretical or research-based way, but how the person uses the training very much depends on the individual.
Counselors These are usually people with a very specific area of expertise, whether it's substance abuse, what sort of job to find, college admissions, etc, etc, etc. They'll have very practical knowledge for you, and very practical ways of using it. Not the people to go to for a vague sense of ennui.
Note: any of the above can call themselves "psychotherapists", as can someone with an Ed.D, an LMHC (licensed mental health counselor), or, in some states, your Uncle Bob with a GED and a desire to Help People. A degree is not always necessary to start a business. And, in some cases, the degree doesn't actually make that much difference in whether or not the person can help you-- you might find an awesome shrink who's not got a particularly reputable background, but happens to be very, very good at helping people heal. (Or you might find a very experienced psychiatrist with a degree from Harvard who turns out to be a clueless asshole.) However, the advantage of someone with a license is that s/he is subject to supervision-- if s/he does anything unethical, s/he can be reported to the local board, and lose his/her license. And some shrinks do do things which are blatantly unethical-- but it's less likely when they're accountable to someone.
Now: some theoretical orientations. Most therapists have at least one of these, some have a combination.
Psychodynamic
Premise: Problems and mental illness are caused by experiences (particularly in childhood and adolescence) leading to different unconscious forces, beliefs, worldviews and ways of behaving. The best way to deal with them is to try to explore one's own thoughts and beliefs in order to better understand oneself. Therapy usually consists of once-a-week sessions, sometimes twice a week, talking to the therapist.
What it's good for: Self-acceptance, deep personality change, long-term solutions to recurring problems.
What it's not good for: Quick results, problems whose root is primarily outside the person.
Psychoanalytic A subset of psychodynamic; this is the old-school, Freudian, three-days-a-week-on-the-couch, free associating, the analyst as a blank-slate way of thinking.
What it's good for: Very deep self-understanding. Recurring patterns of interacting with people which are extremely problematic (the sort of thing that gets diagnosed as borderline, sociopathic, narcissistic or other personality disorders).
What it's not good for: Solving your problems (no, really).
Cognitive, Behavioral, or Cognitive-Behavioral
Premise: Problems and mental illnesses are caused by learned habits, conditioned responses and illogical beliefs. There are two major solutions to this; one is (going by Pavlov's and Skinner's ideas of conditioning), trying to de-condition one's problematic learned responses, sometimes by learning techniques of conscious relaxation and other ways of influencing one's own body. Another is to question and re-consider one's irrational beliefs to find a less-problematic way of thinking. Therapy often consists of sessions, homework assignments, and sometimes going on-location to deal with phobias in their natural environment.
What it's good for: Set length of treatment (eight weeks, thirty weeks, etc), phobias, and the practical details of managing major mental illnesses, particularly depression and anxiety.
What it's not good for: Working on deep emotional issues, understanding one's past
Humanistic
Premise: People hold within them the innate ability to heal themselves, if they are able to look at themselves deeply. Thus, the therapist's job is to try hard to understand and empathize with what the client is saying, and so create a space wherein the client can be accepted and valued, to make it safe for him/her to figure out what s/he needs to do to heal. This approach is very egalitarian; the client is considered the expert on him/herself, and s/he can direct the therapy to what s/he needs; the therapist tries his/her hardest to be authentic and "real" with the client, and much of the vaue is in the relationship between the two.
What it's good for: ...'kay, so this is tricky. Because almost all therapists, at this point, agree that the relationship between therapist and client is very important, that the therapist should respect the client, that the therapist should try to understand how the client is feeling, etc. So, in theory, this is useful for everyone.
What it's not good for: On the other hand, a purely humanistic therapist will be so focused on empathizing with the client and letting the client lead that s/he may not make use of any particular skills or plan to direct the training. At which point, you may as well be talking to a particularly patient and understanding friend, pastor, or Golden Retriever. I suppose I would say that any "humanistic" therapist should be judged on his/her own merits, but a blend is a good sign-- "humanistic and psychodynamic" or "humanistic and feminist," for example.
Existentialist
Premise: A subset of humanistic. All people deal with the questions of mortality, finding purpose in life, suffering, and our essential aloneness. In this sense, the therapist and client are fellow-travellers, both trying to deal with the essential questions of life.
What it's good for: wrestling with deeper issues-- purpose, meaning.
What it's not good for: Real, concrete problems-- with the caveat that few therapists are purely existentialist. Most will work with clients on a variety of issues, in many useful ways-- it's just that they'll be keeping an ear out for existential issues, and addressing them if and when they come up.
FeministPremise: Exactly what it sounds like-- this is therapy which pays particular attention to issues of gender and power.
What it's good for: Anyone for whom gender is a major issue-- particularly GLBT clients. Also often useful for survivors of rape or abuse, for whom issues of power and control can be really important.
What it's not good for: Again, this is often good to have as a blend with something else-- there's not a verycomplex feminist model of psychopathology or treatment.
Biomedical
Premise: Most mental illness has a physical component; it's either caused by an actual dysfunction in brain or nervous system, and/or it can be alleviated by making adjustments to them.
What it's good for: Major mental illnesses-- particularly schizophrenia, bipolar disorder, depression, ADHD, and some of the anxiety disorders, for which there are fairly effective medications. Particularly useful when people have gotten to the state where they really can't function-- ravingly psychotic, can't-get-out-of-bed-depressed, etc.
What it's not good for: More complex issues of personality, getting to the psychic/emotional root of the problem to keep it from reocurring.
Family & Couples
Premise: The most important factors in someone's life often have to do with other people, not just the individual. In fact, families will sometimes unconsciously create an "identified patient"-- one person who has obvious problems, and into whom everyone else's stress can be channeled. Thus, it's most effective to do therapy both with the individual and with all the other people in his/her life, in various combinations.
What it's good for: Kids and teenagers, for whom their family has so much more influence than the therapist that it's not even funny. People who are having major problems in their relationships.
What it's not good for: ...well, it's useful for many things, as just about any problem can be helped by having the people in your life involved and knowledgeable. But it's also true that, unless the problem is very specifically about the relationship, it's generally useful for people in couples/family therapy to also have an individual therapist.
Group
Premise: People's lives involve many people, with more complex dynamics than can exist between just a client and a therapist. And it is often easier for people to hear advice from a peer than from an authority figure.
What it's good for: Social-skills training, support, and specific education about topics like self-care, substance use, etc.
What it's not good for: Individual attention, social anxiety.
Community/Systems
Premise: People are part of a much bigger system than the individual-- their neighborhoods, cultures, governments, health insurance, etc have huge effects on their lives, and must be considered.
What it's good for: Helping to empower people to deal with their lives, make their own choices, address oppression and discrimination, join with the people around them to make changes, etc.
What it's not good for: Specific mental illnesses.
Other things Oh dear... there are quite a lot. And they range from quite reputable things about which I know very little (DBT, Narrative Therapy, etc) to the quite out-there. If you find a therapist who advertises something not listed here, I would recommend Googling it, or you're welcome to ask me or some other psych person.
But with all of this, the best way to judge a therapist is simply to meet with him or her and see how you feel. A good therapist should seem to be genuinely interested in you and be upfront about his/her practices and what s/he can and can't do. You shouldn't expect to be immediately blown away by his/her insight, or to immediately feel safe in trusting him/her with all of your deepest darkest secrets-- but you should feel like you might get something out of talking to the him/her. It's often a good idea to see said person about three times before making a decision-- and don't be afraid to shop around. Think of it as like dating-- you're going to be in a serious relationship with this person, so give it some thought.
Hope this was helpful, and good luck!
--R
