A Blueprint for Choosing the Right Psychotherapist
How to pick a clinician suited for the growth you seek
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.
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.
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.
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.
- Licensed Clinical Social Workers (LCSW) have a master’s degree and present with extensive post-graduate supervised work experience. The LCSW mental health therapist tends to take a holistic approach, assessing emotional and psychological traits as well as societal and environmental factors.
- Psychologists have a doctoral degree (Ph.D. or Psy.D.) in the field of psychology. Clinical psychologists diagnose and treat mental, behavioral and emotional illnesses. They can also administer psychological tests.
- Psychiatrists are medical doctors (M.D.) who emphasize the impact that biology and neurochemistry has on behavior and mental health. Hence, they specialize in psychopharmacology and typically collaborate with psychotherapists to stabilize symptoms with psychotropic medication.
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 refers to the clinician’s philosophy and the guiding principles that inform the treatment process.
- Psychodynamic therapy is a lengthy psychological process rooted in psychoanalytic principles and a strong therapeutic bond. In an article on Thriveworks, I explained that deep excavation of one’s history and the processing of powerful emotions is characteristic of psychodynamic work.
- Psychoanalysis is the creation of Sigmund Freud. It is a method to explore unconscious processes through dialogue, dream analysis, and free association, so as to heal neurosis and internal conflicts. Freud personified the mind as comprised of id, ego, and superego and posited that our human defenses (i.e. — denial, repression, etc.) are a result of conflicts within these facets of the mind.
- Coaching emphasizes goals and ambitions in the present. Through a supportive, solution-focused partnership, the coach guides a client towards actualizing inner resources and potentials so as to design the desired future.
- Cognitive Behavioral Therapy is rooted in the belief that mood is affected by thoughts. Patterns of thought and cognitive distortions are examined, tracked and dismantled so that one can effectively manage and replace self-defeating messages with more flexible, life-affirming ways of perceiving and behaving. CBT is structured, short term and goal-oriented.
- Dialectical Behavioral Therapy is an evidence-based and skill-based approach. It is considered a subtype of CBT. Developed by Dr. Marsha Linehan specifically for treating personality disorders, DBT incorporates Buddhist principles, such as mindfulness and radical acceptance, and teaches emotional regulation and distress tolerance as a means of enhancing relatedness to self and others.
- Humanistic therapy emphasizes the actualization of the self. Existential philosophy permeates humanistic treatment, as self-directed choice and the application of self-will is considered conducive to growth, to ‘meaning-making’ and ultimately, to freedom. Gestalt therapy, founded by Fritz Perls, is a humanistic approach that employs experiential processes such as role-play to address what is directly perceived and felt about various past and present situations.
- Jungian therapy was developed by Carl Jung, a colleague of Sigmund Freud. Jung expanded on analytical principles by including spirituality and creativity as fundamental to human drives, specifically the drive to individuate and strive for wholeness. Jungian analysis is also known as depth psychology as it explores both the unconscious and transpersonal (i.e. — collective and archetypal) aspects of the psyche.
- Eclectic therapy integrates various methods and orientations (multi-modal) in service of the individual needs of the client. Essentially, eclectic therapists tailor their approach and interventions in accordance with what best accommodates the presenting concerns and needs of the patient.
Therapeutic techniques refer to specific strategies and interventions which galvanize healing and growth.
- Dream analysis — The father of psychoanalysis, Sigmund Freud, referred to dreams as the “royal road to the unconscious.” Interpreting the metaphorical symbols and content of dreams assists with crystallizing unconscious desires, wishes, and conflicts. Jungian dream analysis posits that dreams reveal valuable creative insights and wisdom that assist with individuation.
- Art therapy utilizes creative expression through various art disciplines such as drama, music, sculpture, painting, and drawing to unearth repressed material so that healing can occur. Through art-making, what eludes words is conveyed through the “language” of imagination.
- Sandplay work, developed by Dora Kalff, borrows from Jungian psychology and involves the hands-on use of sand trays and miniature toys to assist with accessing one’s inner archetypal and symbolic world. This nonverbal form of creative expression reveals a miniature world that’s emblematic of the creator's inner world and transpersonal wisdom.
- EMDR aka Eye Movement Desensitization and Reprocessing, developed by Francine Shapiro, facilitates the processing of acute and complex traumatic memories so that distress is relieved and resolution is achieved. A disturbing memory is coupled with bilateral movements of the eyes so that both hemispheres of the brain are stimulated. This bilateral stimulation is said to allow for full successful assimilation of trauma.
- Somatic therapy is a holistic form of healing which addresses the mind-body connection. When the autonomic nervous system is impacted by trauma, painful physical symptoms can manifest. Somatic therapy assists with regulating the ANS and the limbic system so that one can alleviate painful sensations and experience safety and enhanced agency.
- Hypnosis aka hypnotherapy is a natural trance state of deep focused awareness in which the subconscious is more readily accessible and open to suggestion. Hypnosis assists with reframing perceptions, alleviating physical and emotional pain and tapping into creative resources that catalyze positive change.
Treatment modalities refer to the methodology of the process.
- Individual therapy, family therapy, couples therapy, and group therapy are the most common modalities of treatment.
- Video sessions have become a very helpful adjunct to the treatment process when travel or child-care responsibilities hinder in-person sessions. It is well-founded that communication technology can decrease isolation and loneliness, particularly in the elderly, those in isolated rural communities, and individuals challenged by disabilities that necessitate a sedentary lifestyle. (Lindsay H. Shaw and Larry M. Gant. CyberPsychology & Behavior. July 2004). Although telehealth has been around for decades, many clinicians are still unsure about the clinical, ethical, and legal issues that emerge as distance therapy becomes a more accepted practice.
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:
- How do you feel about the location, the office space, the assessment process?
- Does the therapist’s relational style match with what feels right for you? Do you prefer a therapist who is interactive and engaged or a therapist who is more neutral and detached?
- Does the therapist respond satisfactorily to questions you have regarding the therapist’s clinical training and experience, treatment expectations, or other concerns?
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.”