A Blueprint for Choosing the Right Psychotherapist

How to pick a clinician suited for the growth you seek

Rev. Sheri Heller, LCSW
Oct 15 · 13 min read
Photo by Chinnapong.

Back in the ’80s, I was in my late teens, living on my own and putting myself through college. I sought therapy through a special program provided through the City University of NY.

It wasn’t until 1992 that Dr. Judith Herman coined the term complex trauma in her seminal book Trauma & Recovery. Hence I didn’t have an analytic definition for what I was contending with. All I knew was that my insatiable emptiness, impulsivity, reckless behavior, addictions, staggering anxiety, depression, and states of derealization necessitated my seeking help. What that help would or should look like eluded me.

My mother spent much of her life beset by hospitalizations for schizophrenia. Her justifiable fears of psychiatry stymied my enthusiasm about pursuing treatment, but I recognized that in spite of my trepidation, I couldn’t go on the way I was.

When I began working with a psych intern, I thwarted his efforts to support and counsel. I was terrified of letting down my guard. Inevitably I did, and he compassionately stood by me for over a decade, generating stability, health, and growth. I am forever grateful for his presence in my life.

I got very lucky, but luck should not be the basis for selecting a therapist. Who you entrust with your mental health should not be a shot in the dark.

Narcissism and ineptitude can infiltrate all people and professions. Being a clinician is no different. I know because I am a therapist myself.

Clinicians are people and people are fallible — sometimes even thoughtless and irresponsible. Sometimes, even dangerous. In fact, the role of a therapist can be an opportunistic way to grandstand and virtue signal.

Knowing what to look for and what to fend off is critical to selecting a therapist. Being an equipped, knowledgeable psychotherapy consumer can help you navigate through the process of choosing a competent and compassionate clinician. Taking full responsibility as a patient means understanding the fundamental variables comprising the psychotherapeutic landscape.

Before you can assess a therapist’s character and skill, there are sundry logistics to address. I offer a tutorial of what these logistics are, as well as important questions to consider when seeking therapy.


Know What You Are Pursuing Therapy For

Pain is a great motivator. Some degree of discomfort, whether it be a sense of malaise to debilitating suffering, fuels the impulse to engage in treatment.

Perhaps nagging angst and sadness results in stifling inertia. This might be the impetus to seek therapy, so as to transition into a more life-affirming, inspiring place. Similarly, debilitating circumstances, such as a break-up or a life transition related to a change of residence or employment can take a toll, prompting the need for therapeutic support.

For most people, emotional distress that takes the form of a diagnosable psychiatric illness is the driving force behind seeking therapeutic help.

The most common psychiatric afflictions folks seek outpatient therapy for are mood disorders, Complex PTSD, personality disorders, and addiction.

Mood disorders

One’s mood is a predominant emotional condition or state of mind. Folks with mood disorders experience extreme, persistent depression, mania, and anxiety. These extreme states create pervasive distress, interfering with one’s ability to function.

Complex Post Traumatic Stress Disorder (C-PTSD)

C-PTSD is linked to early trauma and results from ongoing or repeated interpersonal abuse (emotional/sexual/physical, neglect/abandonment, domestic violence) over which the child or adult has little or no control, and from which there is no real or perceived hope of escape. Narcissistic Abuse Syndrome is a specific type of relational trauma pertaining to the chronic psychological abuse incurred from malignant narcissists.

Personality disorders

A personality disorder involves unhealthy, rigid traits which result in significant impairments in oneself and interpersonal functioning. There are ten types of personality disorders, which are diagnostically grouped in three ‘clusters’ — A (odd, bizarre, eccentric), B (dramatic erratic), C (anxious, fearful). These personality features are deeply engrained and exist on a spectrum, meaning there is a range from mild to severe.

Addiction

An addiction is a three-fold illness of mind, body, and spirit in which an insatiable need for a mood-altering transcendent experience is pursued through a chemical (i.e- alcohol, drugs), a person, or a behavior (i.e.- gambling, materialism, sex). A compulsive attachment to self-will and tenacious denial shield the addict from the consequences of his/her behavior. Hence the addict will typically not pursue treatment unless they have hit a bottom, or have a modicum of sobriety and are interested in doing deeper work.


Naturally, there can be an overlap of co-current disorders. For example, a person with severe depression may also present with a history of alcohol abuse. Sometimes there is also a ‘mask presentation,’ in which what seems like mania may actually be flooding due to unresolved traumas. All these factors will be assessed when you schedule your initial consultation.


How Do You Plan to Pay for Therapy?

We are beset by a broken health care system in the United States. Insurance reimbursement for psychotherapy is significantly lower than customary rates, resulting in droves of seasoned therapists withdrawing from insurance panels. For this reason, as the pickings become slim, expect that clinicians who have remained in-network will have a waiting list.

If your health insurance includes a provision for “Out of Network” outpatient mental health benefits, this means you can avail yourself of a fully licensed and credentialed clinician without the waiting period. However, you are responsible for full payment at the time of service and will need to submit an itemized statement to your insurance company in order to receive reimbursement. The percentage you will eventually be reimbursed is based on the contracted rate specific to your benefits package — after you fulfill your deductible, that is.

A deductible is the amount you have to pay out-of-pocket for medical expenses before your insurance coverage even kicks in.

Given that therapy is expensive and generally occurs on a weekly basis, many clinicians offer a sliding scale.

A sliding scale is a flexible fee structure offered to folks who present with financial hardship due to income or overhead costs. A sliding scale fee will only go so low. Still, a reduced rate can assist with meeting deductible expenses and can possibly make therapy a feasible endeavor if you don’t have insurance coverage.

Another insurance issue to consider—and related to cost—pertains to the disclosure of confidential information by the insurance company. This may be required by your health insurance carrier to process claims for services rendered. That means there is some inevitable risk to your privacy and sometimes to your future capacity to obtain health or life insurance.

If it is simply not tenable to pay for private practice psychotherapy, even with a sliding scale and out-of-network insurance, then you might want to consider a low-cost, community-based mental health clinic or a professional training institute for post-grad clinicians.


What Type of Therapist Do You Want?

One size does not fit all! There are a multitude of therapeutic approaches and therapist disciplines to choose from.

Generally, you will encounter mental health clinicians who sport a professional suffix such as LCSW, Ph.D./Psy.D., and M.D. Each discipline maintains specific standards for training and credentialing and ascribe to shared and exclusive approaches and orientations. All disciplines are subject to ethical principles that are enforced through board certification standards.

To maintain licensure and enhance clinical acumen, clinicians of all disciplines participate in continuing professional development. These trainings can consist of state-accredited webinars, university courses, and postgraduate certifications. Postgraduate programs afford clinicians a specialized focus on treating specific disorders, populations, and acquiring specific therapeutic skills.

There are sundry techniques and strategies that therapists use to stabilize symptoms and plumb the subconscious depths. Those techniques and strategies depend on the training the therapist has completed during college and then in continuing education.


What Type of Treatment Methods Are You Seeking?

There is an extensive range of theoretical orientations, techniques, and treatment modalities to choose from. Nailing down what resonates for you gives you leverage with discerning who you are best suited to work with.

Theoretical orientation

Theoretical orientation refers to the clinician’s philosophy and the guiding principles that inform the treatment process.

Therapeutic techniques

Therapeutic techniques refer to specific strategies and interventions which galvanize healing and growth.

Treatment modalities

Treatment modalities refer to the methodology of the process.


Choosing a Therapeutic Framework

You’ve figured out what you’re seeking therapy for, how you will pay for it, the type of therapist you want to work with, and what treatment methods interest you. Now it’s time to examine policies and expectations, clinically referred to as “the therapeutic frame”.

The “therapeutic frame” is essentially a blueprint of clear ground rules, expectations, and guidelines that inform the nature of the work and the client-therapist relationship. It maps out the beginning, middle, and end of the therapeutic process. What enables vulnerable sharing and safety are relational guidelines, boundaries, limits, and clear expectations. When we are given clear guidelines, and clarity about the procedures governing the work and the relationship, intimate authentic disclosure can safely happen.

Before meeting for an initial consultation, clarifying the expectations and policies which constitute the therapeutic frame may determine your course of action—so it’s good to have an idea of what is typical and think about the commitment you are willing to make.

Unless you are a former client returning for sessions, committing weekly for 50–90-minute appointments at a designated time is generally a mandatory pre-requisite. Clinicians typically require canceling within 24 to 48 hours so as to not incur a charge. Under extenuating circumstances, such as illness or an unexpected crisis, the cancellation charge might be waived, with the understanding that you are to re-schedule.

Patterns of cancellations and lateness are a treatment concern, and many therapists will stop treating you if you develop a habit of not showing up on time.

The final stage of therapy requires a period of closure, formally known as “termination”. Sometimes, your participation in that termination process is a precondition for returning to therapy in the future.

Essentially, the frame can be flexible or “tight” depending on the preferences of the therapist and the needs of the client. Irrespective of the format of the therapeutic frame, it conveys the message that commencing with a therapeutic collaboration is a serious responsibility. Knowing what you are ready and willing to commit to determines what type of therapeutic frame is commensurate with what is realistic for you.


Going In for a Consultation

Hallelujah! You finally narrowed it down to a therapist you can afford and who offers the type of treatment you seek.

Scheduling an initial consultation is the next step in determining if this is the right therapeutic collaboration for you.

The consultation is for both you and the therapist to assess if you should work together. Knowing if you are a good fit is dependent on a number of factors, for both the therapist and the prospective patient.

During the consultation, the therapist may have a structured assessment process for you to complete. Alternatively, they may just casually chat with you about what you are grappling with, organically segueing into current and past history.

The therapist uses this information to determine if weekly outpatient therapy is the appropriate level of care for you. They will be evaluating if you are indeed a candidate for the type of therapy they offer. If it turns out you require a higher level of care or a different type of treatment, they will discuss that with you and usually make a referral.

Similarly, you will be figuring out if this is the person you want to take this journey with. Some questions to consider:

Keep in mind that you have the right to ask the therapist to explain what the treatment plan will look like. Discerning if this path of treatment resonates with you is key to knowing if this is the professional who should be facilitating your healing and growth.

Most importantly, do you feel comfortable with this person? Do you feel understood? Cultivating a strong therapeutic alliance directly impacts positive outcomes in treatment.

By the end of the session, you will either know or need more time to reflect on moving forward with scheduling ongoing appointments.


Be Prepared to Grow

Choosing someone to guide you through a journey of healing — and possibly even transformation — is a noble undertaking. It is a pledge to create meaning from your suffering and give definition to your being and your life.

As psychoanalyst Carl Gustav Jung said, “Every human life contains a potential. It that potential is not fulfilled, that life was wasted.” Addressing the vicissitudes of human suffering, guided by a caring therapist with an elaborate understanding of the human condition, allows for illusions to be stripped away and truths unlocked. Suffering can be assimilated so that healing can occur and actualization can unfold and potentials can be realized.

The right therapy with the right therapist is an opportunity to fulfill the inherent need to embody one’s true being. It can, as philosopher Jean Vanier wrote, “undo knots in us and permit life to flow again and aid us in becoming more truly human.”

Better Humans

Better Humans is a collection of the world's most trustworthy writing on human potential and self improvement by coaches, academics, and aggressive self-experimenters. Articles are based on deep personal experience, science, and research. No fluff, book reports, or listicles.

Rev. Sheri Heller, LCSW

Written by

NYC Therapist & Author. Complex Trauma & Addiction. Dual citizen, traveler, lover of art and nature. I appreciate the absurd. Sheritherapist.com

Better Humans

Better Humans is a collection of the world's most trustworthy writing on human potential and self improvement by coaches, academics, and aggressive self-experimenters. Articles are based on deep personal experience, science, and research. No fluff, book reports, or listicles.

Welcome to a place where words matter. On Medium, smart voices and original ideas take center stage - with no ads in sight. Watch
Follow all the topics you care about, and we’ll deliver the best stories for you to your homepage and inbox. Explore
Get unlimited access to the best stories on Medium — and support writers while you’re at it. Just $5/month. Upgrade