[epistemic effort: I went to like six therapists that didn’t suit me before I figured this out]
If you’re like me, you’re crazy and prone to researching your own craziness, which means you probably have strong opinions about your psychological treatment.
If you’re treating your craziness with drugs or lifestyle interventions, it’s usually pretty easy to tell whether you’re getting the treatment you want: you just look at the name of the drug you’ve been prescribed or observe whether or not you’re going to a yoga class or sitting under a lizard lamp. On the other hand, in my experience, it’s very easy to get a therapist who claims to be providing the service you want, but who isn’t really.
If you’re looking for a CBT therapist, you might go to Psychology Today’s Therapist Finder and look for therapists who claim to have expertise in CBT. The problem with this is that many therapists are eclectic, which means they use techniques from a bunch of different schools of therapy. To be clear, there’s nothing wrong with eclectic therapy: it can offer a lot of flexibility, so that if something isn’t working for you your therapist will feel free to try something else. To some extent, a therapist who only does CBT is like a psychiatrist who will only prescribe one drug. And some people believe the active ingredient in therapy is a kind, empathetic, high-status person who listens to you talk about your problems and helps solve them: eclectic therapists can provide this service was well as anyone else.
However, eclectic therapists– in my experience– typically list every kind of therapy they sometimes use as a kind of therapy they provide. That makes sense– after all, they do provide all of those kinds of therapy, at least sometimes. But if you’ve done the research and you really think your depression would be responsive to CBT and CBT alone, the profusion of eclectic therapists who say they do CBT means it’s a lot harder to find a therapist who will just do vanilla, manualized CBT. And it’s very easy for a person to believe they’re getting standard CBT when in reality they’re getting eclectic therapy.
How do you avoid this problem?
First, try looking for an organization that advances your preferred form of therapy; they may have a directory of therapists. For instance, Behavioral Tech’s website has a list of therapists they’ve trained in DBT. I currently go to a therapist listed on this website and she does DBT straight from the manual. (It’s great.) Not all therapists who practice a particular school of therapy will be listed on any website; even if the closest person is far away, consider calling them to get a referral.
Second, familiarize yourself with what your therapy is supposed to look like. If you’re going to a therapist for DBT and you’re not in a skills group, you don’t have to fill out a diary card, and you’ve never done a chain analysis, you’re probably receiving eclectic therapy, not DBT. If you’re going to a therapist for CBT and you don’t have to fill out innumerable tedious worksheets, you’re probably not actually in CBT. For manualized therapies, consider purchasing the actual manual– it’s costly, but you’ll know what you’re supposed to be getting and be ready to jump ship if you’re not getting it. If it’s impossible to find a list of therapists who actually perform your favorite therapy, you can brute-force it by going to every therapist who claims to practice [insert therapy here] and then dropping any therapist who appears to not actually do so. (For efficiency purposes, it is probably best to have intakes with two or three therapists at a time; the therapists will not be angry at you for doing this, although it can get really expensive.)
Note that it is likely that non-eclectic therapists will be more expensive, farther away, and less likely to take your insurance than eclectic therapists.
I’d like to reemphasize that there’s nothing wrong with eclectic therapy. It’s helpful to lots of people! That’s why there’s so much of it! But I do think more people should know that just going to a therapist who says they practice CBT/ACT/DBT/psychodynamic therapy/whatever does not mean you will actually receive CBT/ACT/DBT/psychodynamic therapy/whatever.
Thing of Things 
As a Person Who Is Pretty Much Incapable of Independent Research, are there some kinds of good ways for me to figure out what I need a therapist to do? Like, I have the feeling ‘I think I need my therapist to do something/guide me through doing something rather than mostly listening to me talk’, but I’m not sure how to get beyond that, and that’s not really enough to go on.
(Also, are there any ‘here are the therapies that exist and 101 about each of them’ type resources you know of?)
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* As far as having the feeling “I think I need my therapist to do something/guide me through doing something rather than mostly listening to me talk,” if you having something specific you want your therapist to try you can try asking the therapist to do that specific thing.
The therapist could refuse. The thing you request could be something that no therapist should do (like prescribe a medication if they don’t have the expertise to do so). It could be something that particular therapist doesn’t think they in particular should do. If the thing would be helpful to you then, in this case, you should consider requesting a therapist who will do such a thing. If a therapist is professional they should have no problem helping you find the right therapist for you. It could also be something that your therapist thinks won’t help you. If that is the case you two might be able to have a useful discussion on whether it would be helpful, why you think it would be helpful, et cetera.
The therapist could accede. You two try what you requested and it benefits or it doesn’t. Depending on the outcome you two can continue, stop, or adjust your request.
That’s pretty much it. If you want a particular therapist to try something in particular then the best thing to do is to ask. That act in itself is very unlikely to do any harm. If you have a general request then you can ask that too. A good therapist is willing to work with you to figure out what is best for you. The better feedback you give, the better your treatment is going to be.
* As far as finding “some kinds of good ways for me to figure out what [someone] need[s] a therapist to do:” for me it took a few therapists and a year (or maybe more, I can’t quite remember) to figure out what works for me. It was largely through trail and error. I imagine there is a more deliberate approach to finding what works for you but I don’t know what it is and it would likely require some experimentation. Right now, I think for at-least some mental health issues, the patient has to take some active role in their therapy in order for it to be effective. There are different ways to go about doing this. I’m sorry I can’t give you a general guide but trail and error is an example of something that worked for one person once.
* As far as “here are the therapies that exist and 101 about each of them,” I know of no good resource off hand. I did a few google searches and “a href=”http://www.counselling-directory.org.uk/counselling.html”>this seams to be the best resource for what you appear to be looking for. I’ve also found one, two, three, four, and wikipedia.
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I take a very different approach to getting a therapist to do what I want: I get the therapist to adjust what they’re doing for me. This may require an eclectic therapist.
I spend the first couple of months getting a treatment plan that will work for me. This isn’t a formal treatment plan but, functionaly, it’s like there is one. I talk about what has and hasn’t worked for me in the past, I ask questions, provide answers, make statements, and the like that reinforces a specific treatment pattern. I’ve had therapists and psychiatrists who told me that something I decided to do involving my treatment wouldn’t work but I stuck with it. I have had to leave one practitioner for another at times but I find a therapist who is willing to be flexible and allow me to shape my treatment to a large degree.
I do have to adjust to the therapist as well, certainly. The two best therapists I’ve had offered different experiences. With one, I had a pleasant working relationship and our sessions were enjoyable. With the better one, we mostly fought with each other in our sessions. It helped me a lot despite neither one of us particularly liking the dynamic. There were some common elements even if they did things differently and things I didn’t want to do but think were good to do like reporting on my eating habits. I should also emphasize that best and better here are in terms of what is best or better for me personally.
I don’t think I have the luxury of following the same path as Ozy. Zie pointed out the expense involved. I don’t have… sufficient resources to invest in my health. Beggars can’t be choosers and sometimes I have no choice but to either get the person I’m with to practice in a way that is helpful for me or go without.
I should emphasize that, for depression at-least and I’m sure for some other mental health conditions, the patient is required (by practical considerations) to take the initiative in their own treatment. There are different ways of doing this. Ozy has zir method and I have mine. Different therapies and approaches work better or worse for different people and in order to get what one needs, one has to be pro-active in some way. This can be difficult for those with mental issues, I know, and ways I or somebody else might be pro-active, someone else can’t be. For some things, patient initiative of some sort is required. Perhaps some day medical science will get to the point that therapy can be tailor made to a patient without requiring this initiative but I don’t think we’re there yet.
Lastly, related to the last point. Anybody with a chronic and/or significant health issue would have better results if they have some independent (of treating practitioners) knowledge of their health issues. I have been told complexly wrong information by doctors before and it is good to have enough awareness and ability to act appropriately in these situations. One should respect the statements of experts but one also has to have the ability to protect oneself.
Just as different people respond best to different therapies, different people should take different paths to getting to these therapies. The important thing is to have some method of finding and getting the help you need. It won’t necessarily be the thing that is first available to you.
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I’m curious, why was the fighting with your therapist helpful to you?
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The fighting itself wasn’t helpful but there was usually a little to most of the session in something I considered fighting. One of the reasons why I can’t effectively self treat is that having someone challenge or push me is useful. There are ways to do this without leading to fighting but, given both of our personalities and how they interacted, with this therapist it often lead to some type of fighting.
I am naturally a blunt person and like bluntness in others in interacting with me. I think this is unusual. A blunt allegation of “I think [thing] is harming you,” or “I think it would be good if you [thing]” can lead to a very useful conversation but can also lead to confrontational behavior. I can give my best reasons for [thing] and my therapist can give the best reasons against [thing] for example and sometimes, given the personalities of those involved, the most efficient way to have this conversation is through something I call fighting.
The other therapist was able to do this in a more pleasant manner but the better therapist provided me with more useful sessions so maybe that says something. The fighting was cordial and polite but with both of us being blunt and not holding back in our advocacy (even if sometimes it was devil’s advocacy). There were definitely firm confrontations and thus I qualify it as fighting. It often felt like it was.
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As a therapist, my sense is that more than anything, therapy is about healing through a particular kind of relationship. Fifty years of research tells us that what matters most to outcomes is the client’s motivation to change and the quality of the rapport between the client and the therapist, not the modality used. Finding someone with whom you can develop a good rapport is based on a lot of intangibles that only become clear over time, and so I agree that a huge amount of finding a good therapist is trial and error. There are a lot of mediocre therapists out there and a lot of clients won’t have the experience of what it feels like to work with someone who is a really good fit for them if they don’t shop around.
If someone knows enough about modalities of therapy (and their are hundreds of them) and about themselves to say that a particular modality works well for them then they can look through Psychology Today listings (or the websites for modalities, like DBT) for people who say they use that modality. But know that modalities (such as CBT, DBT, EMDR, IFS, MBCT, body-centered psychotherapies, psychodynamic, etc) are practiced in widely differing ways by different therapists, so knowing what modality a therapist uses won’t tell you how they use it (even if they only use one), or how it feels to work with them.
In my experience, it’s a minority of therapists who practice by using manuals in a highly structured way, or who only use one modality. In my experience, how much a therapist charges relative to their colleagues doesn’t correlate to whether they draw on multiple modalities or practice just one. Insurance reimbursement rates are the same for everyone based on a limited number of procedure codes for psychotherapy and those who don’t accept insurance set their fees based largely on personal factors.
When you study a lot of different modalities, they start to look like different paths up the same mountain. Something like dialectical behavior therapy is itself an agglomeration of earlier techniques, so it’s “eclectic” all on its own. Most of therapy is like this — sets of tools that help us train our minds to relate to our experience in a less-suffering way.
The things we call therapy modalities were created by seasoned clinicians who packaged a bundle of tools that they framed in some semi-coherent way theoretically. Generally though the theory came after the clinician stumbled around using a lot of different tools until they settled on the ones that worked best for them and then they put those into a bucket and called it “X Kind of Therapy” and wrote some narrative theory that they hoped would tie it all together (there’s generally very weak or no evidence to support one theory or another).
Across modalities there’s a ton of overlap in the actual tools. And we now have research that tells us that how closely a therapist cleaves to all the essential parts of a modality doesn’t determine outcome either — therapists delivering a very partial, loosey-goosey version of Motivational Interviewing (for instance) produce just as effective outcomes as therapists delivering a comprehensive, structured, by-the-book version of Motivational Interviewing.
The tools taught by most all modalities fit into categories like emotional regulation tools, cognitive reframing tools, interoception tools, relaxation tools, graded exposure tools, mindfulness tools, breathing techniques, communication tools, and so on. People don’t generally talk about therapy this way — as a series of tools that one can learn and that can improve one’s lived experience — but I wish we did. There are some important parts of therapy that aren’t just about learning tools, but those mostly revert to the intangible healing that’s provided by a safe and trusting relationship.
I’m just a data point of one, but I thought I’d offer this view from one therapist. I’ve also been a client of a bunch of different kinds of therapists over the years (I’m an old person!) and what sticks with me about those experiences as a client is that it was the quality of the relationship with the therapist that mattered most to whether it helped me rather than what modality they used.
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This is a bit off topic, but what does it cost to go to a therapist?
I get the general impression that it is really common for Americans, even if you are not particularly rich. Is it typically covered by insurance? Do you need to have a diagnosed mental illness? Is there a long wait time?
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Like a hundred dollars a sessopm, and often not covered by insurance. You don’t need a diagnosed mental illness unless you’re trying to get medication (and then it would be from a psychiatrist not a therapist). Wait time can vary. If you’re seeking out someone eclectic it likely won’t be a problem, but if you live in an area with, say, only three clinical sexologists and that’s the kind of specialist you need, you may be waiting awhile between sessions.
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I’m sorry if I’m talking to much on this topic. The answers to your questions, Jsfik Xujrfg, are complicated. What insurance will cover and what it won’t depends on the specifics of the insurance plan. Almost all will have a co-pay which can very from trivial (a dollar or two) to most of the cost. The specifics on what insurance covers does very widely (so many sessions in a year, so many sessions in a month, more or less depending on diagnosis and/or other services, insurance that will cover costs after the patient has already spent a set amount of money, insurance that will end after the insurance has spent a certain amount, et cetera)
Outside of insurance, there are often government and non-government clinics that offer free, reduced cost, or sliding scale services. I would guess that plenty of private practices that normally take insurance may offer this as well (or at-least help with the co-pay). These services vary widely in availability and in quality. Going one town over can sometimes lead to big differences in experience.
$100 for 50 min sounds like a good ball park but this could be noticeably more or less even for non-subsidized and non-insured care. Psychiatrists (who prescribe medicine) make a lot more then mental health therapists (most commonly but far from exclusively, licensed clinical social workers) but spend a lot less time with patients. Anything more then 15 min a month for a psychiatrist is usually reserved for patients requiring care labeled “intensive” or something similar. Therapy on the other hand tends to be one 50 min session once every week or two at most with a similar caveat. This can very much be different depending on the situation.
One of the things about America’s complicated health care system is that it is not always straight forward to answer what something costs.
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Is it normal for insurance companies to refuse to cover comprehensive DBT programs? The only one near me doesn’t take insurance directly, and my (otherwise generally good, including about mental health) insurance is refusing to reimburse for it.
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Personally, I find that going to therapy training programs with graduate students will usually get you something closer to the manual; they haven’t had multiple years to get set in their own weird blend of therapy, which means that if you come in and go “okay, I want to [this]” they will usually actually do so. Therapy training programs will usually also have multiple therapists, which means that swapping therapists is low-friction.
Caveat #1: Graduate students in training do not have any experience. They will follow the manual near-perfectly, after you give them a week or two to look up and acquire the material, but they will not always know what to do if you spring an unexpected problem.
Caveat #2: Graduate students in training must share their logs of counseling you with their teachers/supervisors. Confidentiality is still in force, but if you are not okay with logs being shared and discussed, you are going to need a not-in-training therapist.
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