Greg Thorkelson, MD with Ryan Reagan, PhD(c), LPC
It would be nice if we were fated to fall into this type of relationship seamlessly. Unfortunately, finding a therapist who is a good match can be a challenge. There are the systemic barriers—do they take my insurance, do they have openings, does their work schedule sync with my work schedule? Even when the stars align and you get your appointment, and nobody is running late; you sit down and you’re excited because this person came highly recommended—yet….something…just…doesn’t…click. What to do?
First, this is not unusual. Remember, high school? Every year there was that one teacher that you just could not get yourself to like. It can be like this with therapy, and it may have zero to do with anything you or the therapist did. It was just a mismatch. Now, fortunately attendance is not mandatory, you don’t have to find a way to tolerate this person for the remainder of the school year. This is good because we are not talking about education. We are talking about therapy, and this is a different type of relationship. It might be one of the most productive and beneficial relationships you ever establish.
Trust is the cornerstone of the relationship. While it can take time to establish trust, if you have attended a few times and the relationship just feels off, then trust your gut. There are other therapists. This may matter more than you initially think. Past research has demonstrated that the most significant factor in successful therapy is the relationship. Put another way, it mattered less if the therapist used CBT, Psychodynamic, or another method. What mattered most was if there was a strong connection between the client and therapist.
One source that was used in writing this post quoted a client who continued therapy because they were “worried about hurting their therapist’s feelings.” While there is no way to determine if this is a common sentiment, this is not a reason to continue therapy. It will not be productive. Therapy should really be about you receiving the best possible treatment. A qualified therapist receives extensive training and supervision around relational issues. Although therapy can mirror some of the same dynamics that happen in other relationships, you are not “dumping” your therapist even if it feels a little bit like that.
It is important that you feel comfortable with the therapist since you may be discussing very personal issues. You may want to consider whether the gender of the therapist is important to you. For the therapist this is probably not a concern, but if there are matters relating to sexuality, intimate partner violence, or abuse this could be uncomfortable. The age of the therapist may also be a consideration. While a young therapist may be exceptionally good but may not have the life experiences that help you relate, such as divorce, having children, being diagnosed with a serious illness.
It is also well known that individuals who seek counseling for substance use disorders often request therapists who are in recovery. This raises another important point. Some experts recommend asking the therapist if they have done therapy. Many therapists are forthcoming and often went into the field because they had positive experiences with therapy. Some counseling programs even encourage students to undertake their own therapy.
Questions to Ask.
There are additional questions that you may want to consider. Does religion matter to you? Some programs are affiliated with churches and charities, although there are generally policies in place to prevent proselytizing. On the other hand, some are drawn specifically to counseling for spiritual or religious matters and may want a therapist competent in this area. Some of the more recent trends in counseling incorporate content that is derived from Eastern spiritual practices including meditation and mindfulness. You may want to consider whether this is something that you desire or wish to avoid.
What kind of issues are appropriate for therapy?
It might be helpful to distinguish what is appropriate for counseling or therapy, and furthermore why we have two different terms. Counseling and therapy are often used interchangeably. Therapy tends to connotate the word reparative or rehabilitate. In physical therapy we are looking for something to be restored, specifically mobility. Counseling may be thought of more as a process that involves exploration—as in vocational counseling for job interests. Pre-marital counseling is another example. Both address a concern that requires brief and specific intervention, whereas therapy may take time to restore the balance sought.
Asking for help can be a difficult thing. A previous post on Nexus’ blog for mental health addressed this issue. One question to ask yourself is “am I in distress?” Distress is not the same thing as stress. Every one of us encounters stress, often multiple times a day. Distress is more like a state, meaning the stressor is consuming a lot of mental space, time, or energy just to manage. Sometimes this is brought on by relationships or work conditions that would not qualify as a “disorder.” A closely related question might be “is my performance suffering?” In cases of school or work there might be indicators that something is amiss.
One of the more challenging areas is substance use. It is not always clear to someone using substances that the use has crossed into more dangerous territory. For some, it will be legal consequences that first indicate a problem. For others it may be family, coworkers, or friends that first express concern. Either way, there is zero harm in having an assessment. And that goes for any other reason you might be considering counseling or therapy. Many therapists offer brief consultations to determine next steps. This is an opportunity to ask questions and determine if the therapist “fits” what you may be looking for.
It may not be possible to determine if it is a match just over a phone consultation, but this may help you narrow down the field of prospects. You can certainly let the therapist know that you have contacted a couple therapists and are looking to see which might be the best fit. You may want to ask them if they have specific experience with certain diagnoses. Almost every therapist has familiarity with depression and anxiety. However, not every therapist will have experience with OCD, substance use disorders, or eating disorders. Some conditions benefit from very specific treatment, in the same way that a general practitioner might refer out to a cardiologist for specialized care.
Different Types of the Therapists and Credentials
If you are unfamiliar with counseling and therapy, it can be confusing to sort through the alphabet soup that follows the name of each provider. Providers will list a variety of credentials, some of these indicate membership in a particular organization, or a state or board certification in a specific area—for example a state my designate a specialist in substance use disorders may list CAC for Certified Addictions Counselor. The first set of letters generally indicates the education background or licensure. The most common ones that you will see:
M.D. or D.O.—these are medical doctors and will be practicing in psychiatry. They can prescribe medications. You may also see DNP, CRNP or PA listed along with doctors. These are nurse practitioners and physician assistants that generally practice under the doctor. These providers can also prescribe medications. It is less common for these professionals to practice therapy in the present healthcare industry.
PhD or PsyD—these practitioners have completed doctoral level work. PsyD practitioners have completed their doctoral work in the field of Psychology or Counseling. PhD practitioners may or may not have specialized in clinical psychology. Usually, it will be specifically listed if they are a state licensed clinical psychologist. This is worth noting as many clinical psychologists may work in very specific areas like neuropsychology, where they typically do assessments and evaluations. Some may not even practice counseling. PhD providers who did not do their doctoral work in clinical psychology will often list licensure following their name. They may have completed doctoral work in social work, education, or another related field.
LPC—Licensed Professional Counselor. In Pennsylvania, this practitioner completed a master’s degree in Psychology, Counseling, or Education, and then completed two years of clinical supervision under an appropriately licensed practitioner.
LMFT—Licensed Marriage and Family Therapist. In Pennsylvania, this practitioner completed a master’s degree in Psychology with special focus on marriage and families, followed by two years of clinical supervision under an appropriately licensed practitioner.
LCSW—Licensed Clinical Social Worker. In Pennsylvania, this practitioner completed a master’s degree in Social Work, and then completed two years of clinical supervision under an appropriately licensed practitioner.
LSW—Licensed Social Worker. This practitioner has completed licensure for social work, but has not completed the clinical supervision process.
M(fill in the blank)—designates that the individual completed a Master’s Degree. This practitioner may be working as a therapist. Sometimes you will find M.Ed (master’s in education) or M.Div (master’s in divinity) providing pastoral counseling.
An individual does not require a specific degree to list themselves as a therapist. Licensure is a recognition by the state that certain educational and supervisory requirements have been met. This is done to promote accountability. In the above listing, medical doctors through LSW all have licensure and are listed on their state websites. This also permits the public to check for any disciplinary action or complaints that may have been registered.
Different Types of Therapy
You may notice that some therapists have specific training in a certain “modality.” This refers to an approach that the therapist takes to treatment. The list of modalities changes frequently, but some of the most common are cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), psychodynamic, marriage and family systems, psychoanalytic, humanistic, and existential. Again, research has demonstrated that the “relationship” is more important than the specific modality that the therapist uses. Some other areas of specialization are substance use disorders, relationships or couples therapy, family therapy, and religion-oriented like Christian counseling.
Different Formats for Therapy
The covid 19 pandemic required rapid adaptation in some areas of the healthcare system. Telehealth became much more practical as a result. Insurance carriers lifted restrictions to ensure continuity of care. It is unclear on whether these changes are temporary or reflect a broader shift in the delivery of healthcare. For some, telehealth may be a good treatment option. It permits client and provider to meet remotely which can reduce barriers imposed by childcare or employment.
On the opposite end, many who were receiving therapy or counseling prior to the pandemic felt that something was lost in the move online. There is certainly a level of intimacy that is lost when you are not meeting face to face. On the other hand, there are conditions that make socialization incredibly difficult and anxiety provoking making telehealth a possibility. Despite its effectiveness, group therapy has been a source of stress for many. Large providers continue to use group therapy, and it should be emphasized that despite the uncomfortable feelings that it provokes, it can be one of the best treatment options.
Length of Time
You might be wondering—how long does therapy go on? There is no uniform answer other than “you know when you know.” A good relationship between provider and client finds this space naturally. For routine outpatient treatment it is not uncommon to begin with weekly sessions, moving to biweekly, and then further reduction if necessary. Mental illnesses can be chronic and episodic, meaning that they require ongoing maintenance.
It is also the case that therapy may “plateau.” You may get that feeling that the “wheels are just spinning.” When it feels that there is no room for further growth then it is likely time for change. Change is the key word here. Sometimes changing therapists is a very good idea. Change brings new ideas and fresh perspectives, and one thing that therapy should always be doing is bringing about positive change. There is no harm in second opinions. In some large providers it is as easy as informing the receptionist or practice manager that you would like to consider a transition.
Most large providers take insurance. Insurance coverage can vary widely however, and you should always check with the provider prior to starting services. You can also contact your insurance carrier. Commercial insurances will often provide listings of providers who are credentialed to participate in their network. Additionally, if you have a therapist whom you have been seeing, or would like to see, some plans may be willing to do nonparticipating provider agreements if the therapist is not in network.
Insurance plans also vary in their structuring of benefits. Some may include a deductible that must be met before they start paying for sessions. This means that you are responsible for the bill prior to the plan covering services. There also may be copays for regular sessions. All of this can be discussed with the provider or the insurance carrier prior to starting.
Medicare and Medicaid services may have limited access to providers. Many large institutions do accept Medicare and Medicaid, but some smaller practices do not. For those that are lacking insurance you may be able to find services through charities or local colleges that have counseling programs. Some of the therapists working in these areas are graduate students working on degree completion. This type of service is probably underrated in value, there is generally not a financial concern hovering over the relationship and there is heavy oversight of the care being delivered.
Some practices are willing to work on a “sliding scale.” This allows for pay what you can arrangements. It is unfortunate that the patchwork nature of our healthcare system makes this quest so challenging, and while this can seem overwhelming there are a range of options available, and you will likely find a good match with a bit of work. Friends, family, doctors, ministers can also be very good sources for referrals. Therapy can be an incredibly rewarding and life transforming experience. Remember that high school analogy? You probably also had at least one teacher in there that made a lasting impact. You just may find that therapist too.
Here is a table that can help with organization. You may want to fill out ahead of time after you have done some research. This can help you narrow down your field of options. Works with my concern—the therapist has familiarity working with what you may need help with—family issues, substance use, depression, etc. Gut feel—have a phone or email conversation and see what your initial impressions are.