After all, an informed client is an empowered client.
Just like doctors, lawyers, engineers, and mustards, therapists come in many varieties. For the purposes of our discussion, let's clarify what we mean by therapist. Technically, the term is "psychotherapist," but clinicians tend to use that label with caution, as it sounds a bit, well, clinical. However, it is appropriate, given that there are many other kinds of therapists out there - speech therapists, occupational therapists, physical therapist, even massage therapists.
Even among psychotherapists, there are a number of different kinds. The good news is that they all are trained to help you. The (potentially) bad news is that the way they go about offering help can vary. The following list is not all-inclusive, but it should give you a basic idea of the differences:
Psychiatrists (MD) are the only ones on this list who have graduated from medical school and can actually prescribe medication. They usually have an MD after their name, indicating they are a medical doctor. Psychiatrists practice in all sorts of different places - hospitals, community agencies, and in private practice. Generally speaking, they are trained in some form of psychotherapy, but medication is often a critical component of their care.
Psychologists (PhD, PsyD, LPA) practice at both the masters and doctoral level. One critical distinction between a psychologist and a psychiatrist is that psychologists can't prescribe medications. Movies and TV shows get this wrong all the time. The character is seeing a psychologist and at the end of the session, the psychologist writes a script for Xanax or something and the client goes on their way. Sorry, no. Only medical professionals can do that - doctors, physician's assistants, nurse practitioners etc.
A psychologist's forte (or at least one of them) is testing and evaluation. School psychologists, for example, are often involved in the creation of IEPs that are developed based on testing that the psychologist performs. At the agency or hospital level, they write psychological evaluations based on tests that can cover dozens of different issues - IQ, ADHD, PTSD, personality disorders, level of depression or anxiety or schizophrenia, etc. There are many different types of psychologists with many different types of specializations. Generally speaking, psychologists tend to see clients with severe mental illness or personality disorders.
Marriage and Family Therapists (LMFT), as the name implies, deal with issues related to marriage and family. This is not to say that an LMFT only works with groups and not individuals. However, it is fair to say that LMFTs have been trained in what is called "systems theory." A family or a marriage or a couple is a "system." The idea is that individuals are influenced in both subtle and overt ways by the system with which they interact. Patterns tend to exist amongst generations in families - alcoholism is a pretty good example. Sexual abuse can also be a generational thing, as can spousal abuse and domestic violence. If regular therapy is basic math, MFT is calculus. The therapist is not just going to be looking at you and your presenting issues. They're going to be looking at your entirely family. Some LMFTs will even request that your family members attend a meeting or two.
Licensed Clinical Social Workers (LCSW) and Licensed Professional Counselors (LPC) are actually pretty similar. Many LCSWs and LPCs might disagree with that statement, but as far as education and training goes, it's hard to tell them apart. I'm a Counselor myself, and I have a hard time distinguishing between the two. An LCSW has more training when it comes to the coordination of social services, and LPCs focus more on a wellness model for their clients, but in practical application, the two are quite similar. Social Workers have been around for quite some time, whereas LPCs are fairly new. Many LPCs and LCSWs tend to specialize - some, for example, work with small children and some maybe exclusively work with adults, or teenagers, or couples. Mood Disorders, PTSD, depression and anxiety, and addictions are all examples of specializations.
Licensed Clinical Addiction Specialists (LCAS) round out the list. They work with clients who have drug and alcohol problems. This is often an additional certification that someone like an LCSW or LPC has earned after literally thousands of hours of training and supervision. So, for example, John doe, LCSW, LCAS, means he's a licensed therapist with additional training in drug and alcohol addiction.
Has all of this left you confused?
Fortunately, this information is all readily available as part of a therapists Informed Consent, which you will often get before you even sit down for your first session. Depending on where you go, you will often get a batch of paperwork to read and fill out. It's a good idea to read this information. Part of the Informed consent is called a PDS, or Personal Disclosure Statement. It should tell you exactly what type of therapist they are, what they specialize in, and what type of clients they see. If not, I have a simple suggestion:
Ask them! You have a right to know this information, and a therapist should have no problem answering any questions you may have. This may seem obvious, but you'd be surprised how many clients are afraid to ask basic questions that they have a right to know.
Insider Tip: If a therapist has an office assistant, like someone who schedules the appointment, they may not be the best person to ask. When in doubt, ask the therapist directly.
Why you need to know this:
Simply put, you want to find the therapist who has the best training to help you. This will be different for every client. If medication is a critical component of your treatment plan, a psychiatrist might be your best bet, as they are the ones who write prescriptions. Conversely, if you want to avoid medication, an LPC might be appropriate, as they cannot prescribe medications and therefore do not use medication as an intervention. These are just examples, and are not intended to be taken as absolutes. In my experience, though, I have noticed that many clients simply do not know about all the different routes they can take. My objective here is not to steer you in one direction or the other, but to hand you the map so you can navigate better on your own.
With the different types of therapists explain, let's move onto the second crucial thing you need to know.
Unless you are paying out of pocket, meaning that your insurance company or Medicaid is not involved, you will probably leave your therapist's office with a mental health diagnosis. The same basic thing happens when you go to your doctor. Doctors have a code for everything. Got the flu? There's a code for that. Carpal tunnel? There's a code for that, too. It's how doctors get paid. They submit these codes to your insurance company, and they get reimbursed for their services. That's not really that big a deal, though. Or is it?
If you use insurance, know that in many if not most cases, a therapist will have to submit a diagnostic code in order to get paid by the insurance company. Therapists use something called the DSM 5, which is an acronym for Diagnostic and Statistical Manual, Version 5. The DSM is a catalogue of every mental health disorder known to man. And if your therapist wants to be paid, they need to submit a diagnosis. Here are a few examples:
- 296.33 Major Depressive Disorder, Severe, Recurrent
- 307.51 Bulimia Nervosa
- 302.72 Erectile Disorder
- 292.0 Caffeine Withdrawal
- 300.02 Generalized Anxiety Disorder
- 309.0 Adjustment Disorder with Depressed Mood
As you can see, they can get pretty specific. Who knew caffeine withdrawal was a thing? At any rate, many therapists loathe having to give a diagnosis after only one session, but this is the mental health system for you. If you're having a bad day and you just need to vent to somebody, there is really no corresponding code. About the most mild diagnosis a therapist can bill for is the last one on the list, the adjustment disorder. Let's say you've just moved to a new town and you're feeling lonely and your sleep cycle has been disrupted because you're in a new time zone. That's an example of an adjustment disorder. Relative to some other conditions, it's not cause for alarm. Other diagnoses, however, can have long term implications, and not just on your mental health.
Why you need to know this:
While it is important for a clinician to accurately diagnose you, you have a right to know that many mental health conditions can affect you in ways that are not necessarily obvious. Depression, for example, is a debilitating mental and even physical condition, but a diagnosis of Major Depressive Disorder, which is oftentimes what depression is billed for, can affect life insurance rates, health insurance premiums, and might even disqualify you for certain types of jobs. Bipolar Disorder, for example, can be a career killer in the military. But that information is confidential, you say! Yes. Yes, it is. Except it's not.
None of this should prevent you from seeing a therapist, but as a client, you have a right to know that your insurance company will be notified of your diagnosis, unless you are private pay, which means that you are paying 100% of the fees associated with therapy.
Insider Tip: Generally speaking, it is unethical for a therapist to give a diagnosis that is in any way inaccurate or misleading. Therefore, a therapist is going to give the diagnosis that he or she feels is most appropriate. That said, if you have concerns about a diagnosis becoming part of your permanent medical record, ask them about private pay options. Regardless, please do not let these issues prevent you from seeking help. Many mental health conditions can be fatal if not treated. Suicidal ideation is often associated with anxiety, bi-polar disorder, and depression, among several others. Your safety and well being should always take priority.
Let's move onto number three.
Trust is a critical component of the therapeutic relationship. If I am your therapist and you are my client, you have to know that I'm not going to be blabbing about your personal life to the cashier at Walmart, or posting your status on Facebook, or discussing your history with anyone with whom you have not specifically asked me to do so. What is said in therapy stays in therapy. That's just a given. Or is it?
You have a right to know that there are limits to confidentiality. This is something that your therapist should discuss with you, but often this information is part of that packet you get when you first make the appointment. Many people sign and initial without fully reading the documentation, and this could lead to a problem. Clients need to have a frank discussion with their therapist about confidentiality, and this really should be an ongoing conversation. As therapy continues, new issues are bound to surface, and a client needs to know what a therapist can keep quiet about and what he or she cannot. Here are some points to consider:
1. Confidentiality is an ethical concept, not a legal one. The term privileged denotes something that is protected by law. If you are seeing a lawyer, you have what is known as attorney-client privilege. Basically, you can tell a lawyer that you killed somebody and they can't tell anyone. This is an important distinction. While a therapist is ethically bound to maintain confidentiality, there are times when the law requires them to break it. This varies from state to state, but one of the newer, more controversial issues, is whether or not a therapist is ethically obligated to tell your partner if you are HIV positive, if that is confessed in a session.
2. Confidentiality statutes vary from state to state, and from therapist to therapist. LPCs, for example, subscribe to the American Counseling association Code of Ethics. Psychologist have the American Psychological Association. And so on, and so forth. Because there are so many differences across the United States, my advice to you is simply to ask your therapist what the limits of confidentiality are.
3. A therapist can be compelled by a judge to testify in court. This happens a lot during divorces, especially when one or both spouses has seen a therapist. Those proceedings can get nasty. Again, it is wise to talk with your therapist if you think something like this will come up.
4. If you are a minor, confidentiality is essentially up to your parents. Clients under the age of eighteen should talk with their therapist about what can stay between them, and what goes back to mom and dad. Most therapists understand that it is difficult to forge a relationship built on trust if the client knows that mom and dad get a report of everything they say, so there's no reason you can't establish ground rules before you begin. When I work with kids, I tell them that I'm going to have to tell someone if they want to hurt themselves or someone else, but most everything else will stay between us. I tell their parents that, too. It seems to work just fine.
5. Suicidal intent or ideation, homicidal ideation or intent, suspected abuse of children or the elderly, and imminent threat to the client or someone else are all potential reasons why a therapist could break confidentiality. This list is not all inclusive. Talk with your therapist if you have questions.
Insider Tip: Some therapists are really good about going over this stuff; some are not. Advocate for yourself! Ask questions.
Let's move onto number four.
If you've ever seen therapy on TV or in a movie, it's usually not a super accurate depiction, namely because actual therapy does not make for good TV. More often than not, you see the client lying on a couch and talking about his or her dreams. What you are seeing is a Hollywood "interpretation" of Freudian Psychoanalysis, which is am example of a theoretical orientation. Freud believed that dreams offered insight into our unconscious mind, that the past dictated the future, that procreation was a driving force in our lives. He believed in other stuff too, but you get the picture.
These ideas, or theories, guided, or oriented, his belief system about therapy. Thus the term theoretical orientation can be loosely defined as a set of ideas to which a therapist subscribes about how to affect positive change through counseling.
More than 100 years after Freud literally wrote the book on psychoanalysis, there are a few dozen different theoretical orientations that therapists use in various different ways. There are way too many to list here, but suffice to say, it's a good idea that you know which one(s) your therapist uses. If you're curious to know if there is one that tends to be more popular with therapists, there is. It's called CBT, or Cognitive-Behavioral Therapy. Basically, the theory says that our thinking dictates the way we feel. If our thinking is screwed up, it follows that our feelings will be, too. So CBT is likely what you're therapist uses. But not definitely. Like I said, there are a few dozen different theories in current application today.
Why you need to know this: Not to keep picking on Freud, but let's say your therapist is a Freudian and he or she wants to do dream analysis with you. What if you have absolutely no interest in your own dreams? Or your childhood? Or your subconscious? This has the potential to create conflict between the therapist and client, and conflict tends to prohibit things like trust and rapport. Plus, some theories employed in counseling tend to work better than others, depending on your presenting issue(s).
This of course is merely an example. In reality, most therapists are not Freudians. It's still a good idea to know what their theoretical orientation is, because it has a direct effect on the following:
- The therapist's belief about the relationship between client and counselor
- The therapist's belief about the nature of change (which is why you are there in the first place, probably).
- Interventions that they use to bring about said change.
Theoretical orientation is important. It's like a navigation system for the therapist.
Insider Tip: These days, many therapists like to pick and choose from several different theories, the idea being that humans are too complex for any one theory to cover. This is known as eclecticism. A therapist should be more than willing to discuss this with you. a lot of clients never ask, so you may find that they are pleasantly surprised to get the question!
Basically, there are two types of experience. Personal experience and professional experience. Mental Health is one of those fields where your personal experience can be either a great asset or a great detriment, depending on how you use it. Professional experience, on the other hand, deals with education, training, supervision, and research. Anyone can take a course on schizophrenia, but that doesn't mean they know what it's like to be schizophrenic. But does that really matter? Does a therapist have to have personally experienced every condition they treat? Is that even realistic?
One of the more controversial areas of therapy where this question comes up is in addictions counseling. Can someone who has never been addicted to drugs or alcohol be an effective addictions counselor?
My own opinions about this have evolved over the years. I have been in recovery for quite some time, and during my first year of graduate training one of my professors posed this question. I was emphatic. Only an addict can help another addict! How could anyone have a different opinion?
These days, I understand that a therapist's most important tool is empathy, which one of my professors defined as "the ability to walk in someone else's shoes without actually being that person." As I thought about it more, my opinions began to evolve. It would be a lot to ask a therapist to have personal experience with every single mental health issue known to man. That would drive them stark raving mad! While I do think it helps if a therapist can draw from their own personal experiences, I'm no longer sure they have to have direct, firsthand knowledge of a disorder to treat it. That's asking too much.
So, to return to the addictions debate for a moment, consider the definition of addiction from Narcotics Anonymous. I'm going to paraphrase, but addiction is an obsession, which means I can't stop thinking about it, combined with a compulsion, which means I can't stop doing it, regardless of the negative effects, which leads to unmanageability in my life. Who here has never experienced an obsession or compulsion before, no matter how slight? If you have, then you have at least some idea what actual addiction is like. You know you just can't turn it off. There's no switch hiding behind your ear that can just be flicked off on a whim. This is partly what I mean by empathy - drawing from your own personal experience to relate to someone else.
Personal experience can be an extremely useful tool. It also has drawbacks. Therapists are human. They are subject to the same biases, cultural affiliations, and dogmatic beliefs as anyone else. They are, however, trained to set those things aside. But as I said, they are only human.
This is admittedly not really something you can find out about a therapist before your first session. You may never know. Ethical debates abound self-disclosure and its role in counseling. Some therapists believe it is key to building a relationship. Others do not. My point is, there's no reason you can't ask a therapist about their ability to work with you on a specific issue.
Professional experience, on the other hand, should be readily available to you. Again I return to the Informed Consent. In this packet of information, therapists usually list their education, certifications, and areas of specialization. At this point it is important to note that there are many excellent therapists who do not have specific certifications in areas in which they excel. I know one doctorate level counselor who is an outstanding play therapist, but he holds no official certification. That said, a therapist usually lists basic information about the type of person he or she sees, and for what. An example: "Dr. Awesome works with teenagers and adults in individual and group settings and specializes in depression, anxiety, anger management, and conflict resolution."
When shopping for a good therapist, please note that there are certain disorders that require specialized training. This is not an exhaustive list, but may include the following:
- Eating Disorders
- Personality Disorders
- Post Traumatic Stress Disorder
- Psychotic Disorders
Why you need to know this:
For the same reason you don't see a dentist for a broken arm. Doctors specialize for a reason. So do lawyers, engineers, teachers, and therapists. The mind is an incredibly complicated mechanism. When it malfunctions, you want to have the right person for the job.
Insider tip: A therapist's qualifications and experience are only part of the equation. Personality, culture, gender, ethnicity, age - these are all things that play a role in any relationship. Though at the very least you now have some idea of what to look for in a therapist. Ask them if they have experience with your issues. If they don't, ask if they can refer you to someone who does. In my experience, the counseling world is a fairly small one - the good clinicians tend to know of one another, and making a quality referral is not only the ethical thing to do, but the professionally courteous one as well.
A good therapist can be the difference between profound mental anguish and peace of mind. It takes work, but you can get there. But before you schedule your first appointment, please take the time to learn about your therapist and what he or she can - and cannot - do for you. Remember: a well informed client is an empowered client. I wish you well in your efforts. Send an email if you have any questions.
What do you think? Leave a comment below.