- What good does talking do?
- What is the difference between “counseling,” “psychotherapy,” and “coaching”?
- What are the similarities and differences between the mental health disciplines and how do I know what I need?
- Why is it so difficult for many people to find a good therapist who takes their health plan?
- What is meant by the term “mental illness”? Does seeing a therapist mean I have a “mental illness”?
- How confidential is the information that I give a therapist?
- What does it mean when a therapist says they have a “psychodynamic” orientation?
- What is meant by “different forms of depression”?
- Does psychotherapy make you dependent on it?
- Can you be required to go into treatment?
- Is there anything I should do to prepare for my initial meeting with a therapist
- How do I know when I am ready to end my treatment?
What good does talking do?
When it comes to seeking help for personal problems, talking isn’t really “just talking”. In psychotherapy, it is a unique means by which we share (re-process) many thoughts and feelings. These in turn may be associated unconsciously with a much larger reservoir of emotions and memories that are playing a role in the current situation. These may include long-standing low self-esteem, contradictory thoughts and intentions, patterns of undermining oneself and of making poor decisions. The therapist provides a particular kind of listening, reflecting, and responding that help clients become “unstuck” and more able to handle their lives effectively in the future. While past events cannot be changed, their impact and influence on us can be altered.
What is the difference between “counseling,” “psychotherapy,” and “coaching”
These terms do not have technical definitions because they are used loosely in conversation and can mean different things by different people in different contexts. In some settings, they are used or implied interchangeably. New York State licenses social workers (LMSWs), Mental Health Counselors (LMHCs), and Masters in Marriage and Family Therapy (LMFTs). This training provides an introduction to counseling, psychoeducation, and psychotherapy. However, a good deal of additional post-masters clinical training is necessary for their career development as psychotherapists and, eventually, clinicians.
For the resolution of specific kinds of problems for which a focused psychoeducational approach may be most useful, some practitioners have developed a “life-coaching” format for some situations. This venue does not involve a diagnosis and, therefore, is not accepted for insurance benefits. The NYS Professional Licensing Board has also licensed a number of other fields to provide therapy, such as pastoral counselors. Each of the above has its own “skill sets” with boundaries that are both permitted and limited by law. Training programs at the masters level vary widely in length, breadth and depth and in their requirements for coursework, supervision, and direct treatment of clients/patients. In order to be an “informed consumer”, one may want to have a familiarity with these boundaries before making a decision in choosing a therapist.
What are the similarities and differences between the mental health disciplines and how do I know what I need?
“Psychotherapist” is a non-technical term referring to someone who uses primarily “talking treatment” to explore and understand emotional (‘what one feels’) and cognitive (‘what one knows’) concerns. Those who have received the most extensive training and intensive clinical supervision in personality development, defenses, and diagnosis, particularly in working with subconscious and unconscious material as it relates to current difficulties, are the “clinicians.” There are four primary clinical disciplines: clinical psychology, clinical social work, psychiatric nursing, and psychiatry. The latter two can prescribe psychiatric medications. Experienced clinicians generally practice a combination of skills and approaches as may be useful for each client.
Clinical psychologists (PhD or PsyD) are especially knowledgeable about various areas of research and about cognitive/learning problems. Their training also covers neurological and other medically-related issues. They are distinguished by their training in psychological testing which works as a kind of “x-ray” into the functioning of the mind and the personality. There are two main categories of testing, learning/cognitive (achievement tests as used in school settings) and “projective” testing which relates to underlying meanings and associations in the functioning of the personality. The PhD of some therapists may not be in a clinical field, and clients may wish to clarify this.
The clinical social worker (LCSW) comes from a long tradition, dating to the 1940s, of focused short-term treatment with specified goals and ready utilization, as needed, of a broad range of ancillary services. The clinical social worker (to be distinguished from other social workers) also has training and experience in addressing a broad range of emotional problems, psychopathology, and formal diagnosis. In addition to treating individuals and couples, clinical social work has a foundation in its traditional specializations over the decades of work with families, cultural/ethnic diversity, trauma, domestic violence, child abuse, and substance abuse. Many clinical social workers have had advanced training in psychotherapy, psychoanalysis, DBT, cognitive-behavioral approaches, EMDR, EFT, among others. For purposes of state licensing, the most experienced clinical social workers also have the R designation. Of all the mental health disciplines, LCSW “skill sets” cover the widest spectrum.
The psychiatrist is a medical doctor with advanced training in a broad range of psychiatric and neurological disorders, in medical symptoms or illnesses that may have a psychological component, and in prescribing medication for psychiatric symptoms associated with depression and anxiety. A lot of future psychiatric research into the mind and personality will have a significant impact on treatment protocols, and will likely be in the relatively uncharted areas of biochemistry and genetics.
The psychiatric nurse practitioner (NPP) has completed advanced course work of one or two years of an amalgam of psychiatry and advanced nursing, and psychotherapy training is primarily within medical/psychiatric settings, such as in-patient and out-patient psychiatric settings. Many go on to obtain additional clinical training in psychotherapy and in various clinical specialties.
Why is it so difficult for many people to find a good therapist who takes their health plan?
As a generalization, in mental health the managed care industry functions as a business concerned with profit and loss, not with ensuring that the “insured” obtains suitable and adequate treatment. Their practices and policies are based on expedience, which has a profound effect on patient care. For example, having to find a therapist according to zip code is one of the least reliable ways to find a therapist who is an appropriate “fit” for a client’s needs. Essentially it is “the luck of the draw” as to whether the “right therapist” is located. Benefits are usually very limited regardless of the amount of treatment that someone may need. The industry maintains that the administrators of many companies/schools are not willing to negotiate premiums necessary for more than rudimentary coverage. “Only the squeaky wheel gets the oil,” so it is unlikely that there will be any improvements unless and until employees/students make their dissatisfactions known. Also, as part of managed care’s policies of “cost-containment,” micro-management of therapy practice, low “allowable fees”, and delays in the processing of claims, has made it necessary for many therapists to resign from insurance panels. Managed care companies, particularly now in Affordable Care Act plans, limit payment of benefits by imposing huge annual deductibles (such as $3000-4000).
What is meant by the term “mental illness”? Does seeing a therapist mean I have a “mental illness”?
No, seeing a psychotherapist does not imply having a “mental illness.” This term generally refers to (1) disabling and enduring emotional disturbances, such as severe, protracted, and/or intermittent major depressions and bipolar illnesses; (2) the severest and most debilitating disorders or illnesses of the mind characterized by a significant inability to distinguish reality from unreality, i.e. thoughts and behavior that are irrational, often bizaare, and that interfere significantly with the person’s ability to function in society. Included would be delusions or hallucinations and severe mood disorders that leave the person “out of control” and/or chronically at risk. (3) Severe personality disorders, particularly in combination with other disorders. Except for personality disorders, psychiatric medications are usually extremely successful, especially in combination with a period of psychotherapy. There is much confusion in the media and in society generally as to the meaning of “mental illness”. Many emotional disturbances are misunderstood as mental illnesses when they are temporary and often in response to painful and highly stressful life circumstances. According to known statistics, only a small proportion of the population is considered mentally ill.
How confidential is the information that I give a therapist?
I observe strict standards of confidentiality which means that nothing whatever, including the simple fact that the person has consulted the therapist or is in treatment, can be disclosed to anyone or any party without the person’s signed consent. The only exception is in the rare instance that a client’s life, or someone else’s, is in imminent danger of life-threatening proportions. Claims procedures cannot be depended upon to be entirely confidential, HIPPA reassurances notwithstanding, and clients can clarify any concerns with me.
I, and mental health professionals generally, take the position that clinical records are only for the use of clinicians. Unless the client/patient signs a release, I cannot confirm or deny that the individual was in treatment with me. Even with the patient’s signed consent, I will not send records or information from patient records to anyone who is not a licensed mental health professional. This policy protects the patient’s right to full and uncompromised confidentiality (in perpetuity). Without this, patients will not be able to engage in a full and honest discussion of difficult matters, otherwise the treatment will be undermined.
Regarding legal matters: If I am contacted by an attorney or law firm requesting a client’s record, even with the client’s release I will not send the record to any attorney/law firm. Rather, my procedure is to send the client/patient a letter alerting them to the likely repercussions and complications if their record is sent to anyone in the legal community, and inviting them to come in to discuss the situation with me. Ultimately it is up to the client, not an attorney, whether the record is released. Attorneys can understand, however, that they do have the option of asking the client in litigation to arrange a forensic evaluation with a qualified forensic evaluator, submitting specific questions to be addressed. The forensic evaluator can contact me who, with the patient’s signed release, may be able to respond to specific questions from the clinical record.
What does it mean when a therapist says they have a “psychodynamic” orientation?
The personality has “interacting parts” just as the body does. This includes cognitive functioning (intellectual comprehension and information processing) and emotional capacities such as impulse control, regulation of moods, empathy with others, and characteristic ways of dealing with conflict and stress. For the purpose of psychotherapy, the key word is “conflict”– between the many parts of the personality. This includes conscious, subconscious, and unconscious elements in a person’s mental and emotional life. By definition, “psychodynamic” work requires the ability and willingness on the part of the client/patient to engage in self-reflection regarding her/his behavior, emotional/feeling states, and internal associations (connections) that link current discomforts with earlier life experience. Therapists that are “clinicians” bring their many years of training and clinical experience to the difficult process of helping patients use this level of work in psychotherapy to resolve current symptoms and difficulties. The therapist’s psychodynamic understanding of the patient’s difficulties can actually “speed up” the therapeutic process. I.e., The sooner the therapist understands the different “layers” of a patient’s problems, the sooner the therapist can focus the treatment and choose the most suitable techniques and approaches for resolving them.
However, some clients are more interested in learning “steps to take” toward emotional and behavioral change, such as Cognitive Behavioral Treatment. CBT and DBT (dialectical behavior therapy) therapists are particularly knowledgeable about specific training protocols (training of the client) such as in treatment of phobias (CBT) and of borderline conditions (DBT).
What is meant by “different forms of depression”?
Depression is manifest in many different ways. These differences are determined by variations in the person’s personality, culture, earlier history, and current place in the life cycle, as well as by biological or genetic factors. A depression may be the main problem to be addressed, or it may be part of another medical or psychiatric illness. Examples of these are bipolar disorder, post-traumatic stress disorder, and chronic fatigue syndrome. If a person has had an earlier experience with depression, it is important to clarify the nature of that depression as well as the current one. The diagnoses may or may not be the same.
It often comes as a surprise when people learn that there are several different kinds of depression, with different characteristics and possibly requiring different treatment approaches. In fact it is important that a “depressed” person learn from the psychotherapist her/his own form of depression and the treatment recommended for it. Sometimes there can be more than one kind of depression at the same time, or different forms at different times in their life. This is why the evaluation and treatment of depression may be complicated. And unlike medications that are helpful for some kinds of anxiety, and that may be prescribed by primary care physicians, medication(s) for depression is considerably more complex and may take more time before the most helpful regimen is established. Sometimes only one type of anti-depressant medication is adequate, while other depressions require a combination of two or three different antidepressants at the same time because they have to treat different brain chemistries. For example, it is now known that some depressed people who have had severe and protracted trauma earlier in their lives, have had permanent changes in their brain chemistries which require long-term and/or intermittent regimens of anti-depressant medications in order to stabilize moods over time. These disorders are treated (and covered by insurance without limits) as in the case of any other long-term medical illness (such as diabetes).
Depending on the severity and nature of the symptoms, psychotherapy can be the treatment of choice, especially at the outset. However sometimes antidepressant medication needs to be considered either in the very beginning or at a later time in treatment. Overall, the therapist can make a recommendation for trying medication, but the decision to take or not take medication is always the patient’s.
Does psychotherapy make you dependent on it?
No, concerns about needing therapy in the sense of “allowing oneself” to become “stuck” in it come from within the person’s own personality and it is an important part of the treatment to understand the meanings and origins of these concerns. Actually, the goal of psychotherapy is to resolve the difficulties that bring a person into treatment, and to develop greater understanding of her/his feelings and behaviors, so that the person can live a freer and more gratifying life without treatment.
Can you be required to go into treatment?
Occasionally someone is required to go into treatment in order to keep their job or stay in school, for example. Typically a kind of surveillance is set up, such as requiring the therapist to confirm intermittently that the appointments have been kept. This is “policy” in several contexts, such as employers and school administrators. There is some misunderstanding about the validity of this practice for several reasons. First, “requiring” the therapist to report back undermines the treatment because there is a conflicting agenda other than fully confidential self-examination. A consultation or evaluation can be mandated, but this is not treatment, and it is essential to maintain this distinction. Also, people for whom treatment has been mandated often keep appointments only to appear to be in compliance with the order, while the real goals of therapy are avoided. The only way to determine whether there has been authentic change in a person’s attitudes, behaviors, and self-control is to require a follow up evaluation with a qualified mental health consultant (not the therapist). This can be required at a future time, such as when the person wants to return to work or school, or wants their parenting rights restored.
Occasionally the court orders an individual, such as a parent in custody litigation, to go into what the court calls “therapy,” although typically there is little followup to determine compliance. Experienced psychotherapists can often engage someone in treatment even though they started out resisting it. In any case, I do now provide a service that we call “mandated therapeutic intervention.”
Is there anything I should do to prepare for my initial meeting with a therapist?
Yes, but only if a client wants to use mental health benefits to help cover the cost of treatment. It saves a great deal of time to review beforehand the details of mental health coverage. This should include the deductible, whether there are out-of-network benefits and, if so, the proportion of the therapist’s fee that is covered by the plan; and the maximum amount of benefits within a specified time span. Clients should bring their insurance card with them at the first visit.
How do I know when I am ready to end my treatment?
Clients should feel free to discuss this with their therapist so that they can review their goals (what they have wanted to accomplish) and learn whether and how continued treatment is necessary and for what purpose. Sometimes people feel satisfied with their gains and feel confident stopping, or they want to “take time out” to try to manage on their own for a while. It is always an option to return for a consultation or for continued treatment.