January 20, 2023 • 20 mins
You could be battling anxiety or depression or psychosis, sleeplessness or overeating—no matter what the problem, there’s a therapist who can help. But who? Do you need a medical doctor, a clinical social worker, a psychiatrist—or something else? Dr. Saltz offers guidelines to help you choose.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:05):
Bees are challenging times, but you don't have to navigate
them alone. Welcome to How Can I Help? I'm Dr
Gail Saltz. I'm a clinical Associate Professor of Psychiatry at
the New York Presbyterian Hospital, a psychoanalyst, and best selling author,
and I'm here every week to answer your most pressing questions,
(00:26):
hopefully with understanding, insight and advice. I am often telling
you on this podcast when it's time to find a
therapist and get treatment. But today I'm answering a question
from a listener who knows that she does want to
go to therapy, but is wondering how to find a
(00:47):
great therapist. First off, you may be wondering how do
you go about finding a specific person to treat you
in therapy? But to back up at the start is
the question of what type of mental health professional you
should be looking for. How do you decide between a
(01:08):
medical doctor or a doctor of osteopathy, a nurse practitioner,
a clinical social worker, a psychologist with a PhD or
as i d, or a marriage and family therapist. All
of these people can be psychotherapists, but there are training
(01:28):
and expertise differences that you should know about. In fact,
the word therapist is completely unregulated in that sense, it
doesn't really mean anything except that this person feels they
can talk to you. You don't need a license or
(01:49):
any particular training to call yourself a therapist. So really
the question is what credential do you want to look
for in your therapist. Psychiatrists are medical doctors, either an
m D or a doctor of osteopathy, and they are
(02:10):
specializing in the diagnosis and treatment of mental illness. But
unlike all other categories of therapists, they can prescribe medication
if it is needed, but they can also do psychotherapy.
It could be preferable to seek a psychiatrist if you
(02:31):
are experiencing severe depression with suicidal thoughts. If you are
having severe anxiety or panic attacks. If you have severe
symptoms of post traumatic stress disorder. If you have bipolar
disorder and are having mania or severe mood swings. If
(02:51):
you are having psychotic symptoms such as delusions or auditory
or visual hallucinations. If you are having great difficulty managing
anger and as a result of that anger, have violent behavior.
If you have moderate to severe substance abuse or alcohol abuse.
(03:14):
If you are having a complicated medical psychiatric condition such
as diabetes or chronic pain that is now coupled with depression,
or if you have advancing dementia. Psychiatrists can provide an
accurate diagnosis, therapy and medication when necessary and can collaborate
(03:38):
with your internist, or if they are only providing medication,
they can collaborate with another therapist that you see for
therapy only. Psychiatric nurse practitioners can also provide a diagnostic
evaluation and even medication when they work alongside psychiatrists. Of
(04:02):
all the therapists, psychologists that is a pH d in
clinical psychology or a side d degree have the most
extensive graduate training in various psychotherapies, and while they are therapists,
they can also provide psychological testing for people, for example,
(04:24):
who want to evaluate whether they have a developmental disability
or a type of dementia, or attention deficit hyperactivity disorder,
and even other conditions when basically more information is needed
in order to be able to clarify a diagnosis. Licensed
(04:45):
clinical social workers have a master's degree as opposed to
psychologists who have a PhD or as i d, and
this master's degree is usually accompanied or often accompanied I
advanced training in psychotherapy. In addition, they have a special
(05:05):
expertise in navigating the social services system, which can be
very complicated and can often serve as what's called a
case manager when a patient with medical needs requires assistance
with being at home or assistance to resume their life
when they are medically ill. Marriage and family therapists have
(05:32):
a master's degree as well, and they are trained primarily
to provide couples therapy or marital therapy or family counseling,
and with special training, all of the people that I've mentioned,
all of those professionals can provide group or family and
(05:52):
couples therapy if they've had this special training. But even
as these different professionals provide therapy, the question is what
type of therapy. Some they specialized in short term therapies
like cognitive behavioral therapy and interpersonal therapy, which have been
(06:13):
shown to be as effective as medication, with in fact
a lower relapse rate for the treatment of mild to
moderate anxiety disorders and depression. Somewhat longer term treatments, but
based in understanding unconscious conflicts in the mind that are
driving the issue and working to make them conscious as
(06:36):
the treatment is what's called psychodynamic psychotherapy, which has also
been shown to be effective for anxiety, depression and also
for people with what's called a personality disorder, which is
basically a type of repeating the same thoughts and behaviors
(06:56):
over and over again in a maladaptive way that are
really messing up your life. Even though there aren't as
many efficacy studies done on psychoanalytics, psychotherapy which tends to
be a longer term therapy where you meet more frequently,
multiple times per week. This type of therapy may be
(07:19):
more effective for you depending on your symptoms. It's especially
helpful for long term, repeated maladaptive patterns of feeling and
behaving that you've just been unable to change. In other ways.
There are additional but less common forms of therapy, particularly
(07:40):
for a history of trauma, such as something called E
M D R hypnosis and bio feedback. In reality, most
therapists are trained to use what's called an eclectic approach,
which basically combines several methods, and they will tailor the
therapy to meet the individual patient's needs. A very common
(08:05):
and often effective way to seek out a reputable therapist
is to get a referral from a friend or family member.
Reaching out to a loved one is an important first
step in beginning to overcome the stigma associated with mental illness.
Another common way is for your medical doctor to provide
you with a few names that participate with your insurance plan.
(08:30):
This can be very important because you're out of pocket
expenses can be much lower when you use an in
network therapist. You need to double check with that therapist, however,
and your insurance company to confirm your benefits and make
sure the therapist is still in network. Insurance companies do
(08:52):
provide an online list of therapists that participate with the plan. However,
be careful as these lists can be found to be
unreliable because sometimes they include names of therapists who are
no longer with the plan. Insurance issues have been found
in many studies to lead to delays and treatment and
(09:15):
worst outcomes. Mental health organizations can provide an excellent online
search engine with biographies to help you find a therapist
in your area who treats your condition. For example, the
American Psychological Association or the American Psychiatric Association or even
(09:37):
the American Psychoanalytics Association. In addition, you can check with
a local psychiatry department at a medical school or university
hospital for a referral. Once an appointment is made, it
is normal to feel nervous about meeting your therapist for
the first time. Many therapists will offer a free initial
(10:01):
consultation or a short phone call to gauge whether there
is a good fit between the therapist and the patient.
So with that, right after the break, we'll get to
my listener's question. Welcome back. Let's get to my listeners
(10:30):
question and see how can I help, dear doctor Sels.
I have been feeling increasingly worried over the past month.
At first I thought it was related to my daughter
who broke her arm, but her arm has been in
a cast and actually seems to be fine, and yet
(10:50):
I keep worrying about that. But now I've also noticed
that I started worrying about a host of other things
as well. It shifts to day what is worrying me?
And also it's now happening during the night that if
I wake up, I start worrying and I can't get
back to sleep. I feel jittery a lot of my day,
(11:14):
and it's hard to concentrate on anything because the worries
just keep popping up in my head. I think I
need to see a mental health professional, but I don't
actually know who to see, or how to find them,
or what to be looking for to find someone who
is good for me and my problem? How do I
(11:35):
find a great person? I would agree with you that
it does sound like you should seek out a person
to see you. Because you are describing the symptoms of
an anxiety disorder how severe it is. It's hard for
me to tell with this little information, which is why
it's good for you to go have an evaluation. But
(11:59):
what I and say is that anxiety disorders do respond
very well to both cognitive behavioral therapy and to psychodynamic psychotherapy.
These therapies can be done by psychologists who have specific
training in them, and I would specifically look for the
psychologist who treats anxiety disorders. Once you have seen the psychologists,
(12:25):
they can also assess whether therapy alone will prove useful
or whether you should additionally see a psychiatrist for some
medication to be used in conjunction with the psychotherapy. Most
psychologists have psychiatrists they typically work with for medication. But
to your question to find a good psychologist near you.
(12:49):
You can start with your family doctor, who may have
suggestions of people they have successfully sent patients to before.
Anxiety disorders are common and patients often first tell their
doctor about their symptoms, so doctors are often referring for
treatment and tend to have a list of people they trust.
(13:11):
You can also search the American Psychological Association's Members page
or actually on Psychology Today on the website for psychologists
that would be in your area. Then, after finding your area,
look for the area of specialty, so in your case,
put in anxiety. It will allow you to find someone
(13:36):
who feels this is something they specialize in treating, and
you can often also search to find the type of
therapy they use, so in their bio do they mentioned
CBT or psychodynamic psychotherapy specifically. Another method is to call
(13:56):
your insurance company for a list of psychologists who work
with that insurance in your area. Once you do identify
a psychologist, leave them a message on the phone asking
about their hours of availability, their fee, their modality of treatment,
and whether they can use teletherapy if that is important
(14:18):
to you. Many people will spend ten minutes on the
phone with you at no charge, answering your basic questions,
and this may give you an idea when you're on
with them. If this person is indeed a good fit
for you, it is important to feel comfortable about the
fit between you and your therapist. If after a few
(14:42):
sessions you do not, then it is okay to look
for someone else. Don't stay in a bad fit situation,
but do give it a little bit of time, because
to make progress with any mental health issue it does
take some time. Do choose someone you can afford, whose
(15:03):
available times can work, and who you can reasonably easily see,
because creating obstacles at the outset will make treatment more
likely to fail because you will tend to quit. What
should you be thinking about and asking yourself about someone
new you have met for therapy? Think about these questions.
(15:28):
Do you feel comfortable opening up to this person? Is
this therapist empathic and a good listener? Does this therapist
seem to have an agenda? Are they trying to have
you commit too soon to a schedule before they've accurately
assessed your motivation and the range of options that are
(15:48):
available to you. What are their credentials and levels of expertise?
Have they treated many other people with your particular condition.
What type of therapy are they offering you? They should
be able to explain why one type is better than
another for the particular condition that you've come to see
(16:11):
them for. How will they manage the fee and billing
and if needed do they offer a sliding scale fee?
How do they collaborate with your psychiatrists if you're seeing
a psychologist or even your primary care physician, as collaboration
(16:32):
will greatly improve the quality of care if needed for you?
Do they offer evening and weekend hours? And how often
are they recommending that you see them? Finally, what are
the agreed upon goals for your treatment and what do
they see as endpoints for therapy. As you proceed along
(16:58):
in therapy, try to keep in mind line that it
is normal to feel worse before you feel better because
everything is being brought to the surface. You may feel
as though you want to quit, but don't without first
at least discussing it with your therapist. You might experience
(17:19):
many positive and negative feelings towards your therapists. This is
called transference. These are actually feelings that you have for
other significant people in your life that are being transferred
onto your therapist. This is common and it is normal,
(17:40):
but it does need to be discussed with your therapists
because this is what leads to possibly wanting to stop
therapy inappropriately, but it also leads to information that you
can use in the therapy to help you. Understanding transference
leads to real progress in therapy. With some forms of therapy,
(18:04):
like cognitive behavioral therapy, you may be expected to do
homework such as journaling, keeping a log or diary, or
doing relaxation exercises. If you're not doing the homework, then
you and the therapists need to explore your resistance to
doing so. Understanding and tackling the resistance is the key
(18:27):
to improve it in any therapy. I hope that was helpful.
The goal of any therapy is to gain insight into yourself,
into your relationships, and into your condition. It's also to
have the ability to cope better with your anger or
(18:49):
depression or anxiety, and to improve your ability to care
for yourself and to use prevention strategies. When therapy is
done to and a relapse, you will want to work
with your psychiatrists if you're on medication to successfully taper
(19:09):
off of psychiatric medications. If and when it becomes possible.
Do not stop medication abruptly on your own. Most medications
can cause a withdrawal. It's not that you are addicted,
but it is that stopping the medication abruptly causes a
(19:30):
withdrawal syndrome, which can feel terrible. So do let your
therapist help you wean off medication. Once you and your
therapist feel that you have reached most of your goals,
then you should, in the therapy sessions begin to discuss
(19:51):
ending therapy, and remember that progress often continues even after
therapy has been discontinued. Overall, navigating the mental health system
can be overwhelming and frustrating, and as a result, many
people get put off from getting the help they need.
(20:12):
But you should know that help is always available and
that if you do put in the effort and don't
give up, most mental illnesses can be successfully treated. Do
you have a problem I can help with? If so,
email me yet? How can I help? At Seneca women
(20:33):
dot Com, all centers remain anonymous and listen every Friday too.
How can I help with me? Doctor Gale's Salts
Bees are challenging times, but you don't have to navigate
them alone. Welcome to How Can I Help? I'm Dr
Gail Saltz. I'm a clinical Associate Professor of Psychiatry at
the New York Presbyterian Hospital, a psychoanalyst, and best selling author,
and I'm here every week to answer your most pressing questions,
(00:26):
hopefully with understanding, insight and advice. I am often telling
you on this podcast when it's time to find a
therapist and get treatment. But today I'm answering a question
from a listener who knows that she does want to
go to therapy, but is wondering how to find a
(00:47):
great therapist. First off, you may be wondering how do
you go about finding a specific person to treat you
in therapy? But to back up at the start is
the question of what type of mental health professional you
should be looking for. How do you decide between a
(01:08):
medical doctor or a doctor of osteopathy, a nurse practitioner,
a clinical social worker, a psychologist with a PhD or
as i d, or a marriage and family therapist. All
of these people can be psychotherapists, but there are training
(01:28):
and expertise differences that you should know about. In fact,
the word therapist is completely unregulated in that sense, it
doesn't really mean anything except that this person feels they
can talk to you. You don't need a license or
(01:49):
any particular training to call yourself a therapist. So really
the question is what credential do you want to look
for in your therapist. Psychiatrists are medical doctors, either an
m D or a doctor of osteopathy, and they are
(02:10):
specializing in the diagnosis and treatment of mental illness. But
unlike all other categories of therapists, they can prescribe medication
if it is needed, but they can also do psychotherapy.
It could be preferable to seek a psychiatrist if you
(02:31):
are experiencing severe depression with suicidal thoughts. If you are
having severe anxiety or panic attacks. If you have severe
symptoms of post traumatic stress disorder. If you have bipolar
disorder and are having mania or severe mood swings. If
(02:51):
you are having psychotic symptoms such as delusions or auditory
or visual hallucinations. If you are having great difficulty managing
anger and as a result of that anger, have violent behavior.
If you have moderate to severe substance abuse or alcohol abuse.
(03:14):
If you are having a complicated medical psychiatric condition such
as diabetes or chronic pain that is now coupled with depression,
or if you have advancing dementia. Psychiatrists can provide an
accurate diagnosis, therapy and medication when necessary and can collaborate
(03:38):
with your internist, or if they are only providing medication,
they can collaborate with another therapist that you see for
therapy only. Psychiatric nurse practitioners can also provide a diagnostic
evaluation and even medication when they work alongside psychiatrists. Of
(04:02):
all the therapists, psychologists that is a pH d in
clinical psychology or a side d degree have the most
extensive graduate training in various psychotherapies, and while they are therapists,
they can also provide psychological testing for people, for example,
(04:24):
who want to evaluate whether they have a developmental disability
or a type of dementia, or attention deficit hyperactivity disorder,
and even other conditions when basically more information is needed
in order to be able to clarify a diagnosis. Licensed
(04:45):
clinical social workers have a master's degree as opposed to
psychologists who have a PhD or as i d, and
this master's degree is usually accompanied or often accompanied I
advanced training in psychotherapy. In addition, they have a special
(05:05):
expertise in navigating the social services system, which can be
very complicated and can often serve as what's called a
case manager when a patient with medical needs requires assistance
with being at home or assistance to resume their life
when they are medically ill. Marriage and family therapists have
(05:32):
a master's degree as well, and they are trained primarily
to provide couples therapy or marital therapy or family counseling,
and with special training, all of the people that I've mentioned,
all of those professionals can provide group or family and
(05:52):
couples therapy if they've had this special training. But even
as these different professionals provide therapy, the question is what
type of therapy. Some they specialized in short term therapies
like cognitive behavioral therapy and interpersonal therapy, which have been
(06:13):
shown to be as effective as medication, with in fact
a lower relapse rate for the treatment of mild to
moderate anxiety disorders and depression. Somewhat longer term treatments, but
based in understanding unconscious conflicts in the mind that are
driving the issue and working to make them conscious as
(06:36):
the treatment is what's called psychodynamic psychotherapy, which has also
been shown to be effective for anxiety, depression and also
for people with what's called a personality disorder, which is
basically a type of repeating the same thoughts and behaviors
(06:56):
over and over again in a maladaptive way that are
really messing up your life. Even though there aren't as
many efficacy studies done on psychoanalytics, psychotherapy which tends to
be a longer term therapy where you meet more frequently,
multiple times per week. This type of therapy may be
(07:19):
more effective for you depending on your symptoms. It's especially
helpful for long term, repeated maladaptive patterns of feeling and
behaving that you've just been unable to change. In other ways.
There are additional but less common forms of therapy, particularly
(07:40):
for a history of trauma, such as something called E
M D R hypnosis and bio feedback. In reality, most
therapists are trained to use what's called an eclectic approach,
which basically combines several methods, and they will tailor the
therapy to meet the individual patient's needs. A very common
(08:05):
and often effective way to seek out a reputable therapist
is to get a referral from a friend or family member.
Reaching out to a loved one is an important first
step in beginning to overcome the stigma associated with mental illness.
Another common way is for your medical doctor to provide
you with a few names that participate with your insurance plan.
(08:30):
This can be very important because you're out of pocket
expenses can be much lower when you use an in
network therapist. You need to double check with that therapist, however,
and your insurance company to confirm your benefits and make
sure the therapist is still in network. Insurance companies do
(08:52):
provide an online list of therapists that participate with the plan. However,
be careful as these lists can be found to be
unreliable because sometimes they include names of therapists who are
no longer with the plan. Insurance issues have been found
in many studies to lead to delays and treatment and
(09:15):
worst outcomes. Mental health organizations can provide an excellent online
search engine with biographies to help you find a therapist
in your area who treats your condition. For example, the
American Psychological Association or the American Psychiatric Association or even
(09:37):
the American Psychoanalytics Association. In addition, you can check with
a local psychiatry department at a medical school or university
hospital for a referral. Once an appointment is made, it
is normal to feel nervous about meeting your therapist for
the first time. Many therapists will offer a free initial
(10:01):
consultation or a short phone call to gauge whether there
is a good fit between the therapist and the patient.
So with that, right after the break, we'll get to
my listener's question. Welcome back. Let's get to my listeners
(10:30):
question and see how can I help, dear doctor Sels.
I have been feeling increasingly worried over the past month.
At first I thought it was related to my daughter
who broke her arm, but her arm has been in
a cast and actually seems to be fine, and yet
(10:50):
I keep worrying about that. But now I've also noticed
that I started worrying about a host of other things
as well. It shifts to day what is worrying me?
And also it's now happening during the night that if
I wake up, I start worrying and I can't get
back to sleep. I feel jittery a lot of my day,
(11:14):
and it's hard to concentrate on anything because the worries
just keep popping up in my head. I think I
need to see a mental health professional, but I don't
actually know who to see, or how to find them,
or what to be looking for to find someone who
is good for me and my problem? How do I
(11:35):
find a great person? I would agree with you that
it does sound like you should seek out a person
to see you. Because you are describing the symptoms of
an anxiety disorder how severe it is. It's hard for
me to tell with this little information, which is why
it's good for you to go have an evaluation. But
(11:59):
what I and say is that anxiety disorders do respond
very well to both cognitive behavioral therapy and to psychodynamic psychotherapy.
These therapies can be done by psychologists who have specific
training in them, and I would specifically look for the
psychologist who treats anxiety disorders. Once you have seen the psychologists,
(12:25):
they can also assess whether therapy alone will prove useful
or whether you should additionally see a psychiatrist for some
medication to be used in conjunction with the psychotherapy. Most
psychologists have psychiatrists they typically work with for medication. But
to your question to find a good psychologist near you.
(12:49):
You can start with your family doctor, who may have
suggestions of people they have successfully sent patients to before.
Anxiety disorders are common and patients often first tell their
doctor about their symptoms, so doctors are often referring for
treatment and tend to have a list of people they trust.
(13:11):
You can also search the American Psychological Association's Members page
or actually on Psychology Today on the website for psychologists
that would be in your area. Then, after finding your area,
look for the area of specialty, so in your case,
put in anxiety. It will allow you to find someone
(13:36):
who feels this is something they specialize in treating, and
you can often also search to find the type of
therapy they use, so in their bio do they mentioned
CBT or psychodynamic psychotherapy specifically. Another method is to call
(13:56):
your insurance company for a list of psychologists who work
with that insurance in your area. Once you do identify
a psychologist, leave them a message on the phone asking
about their hours of availability, their fee, their modality of treatment,
and whether they can use teletherapy if that is important
(14:18):
to you. Many people will spend ten minutes on the
phone with you at no charge, answering your basic questions,
and this may give you an idea when you're on
with them. If this person is indeed a good fit
for you, it is important to feel comfortable about the
fit between you and your therapist. If after a few
(14:42):
sessions you do not, then it is okay to look
for someone else. Don't stay in a bad fit situation,
but do give it a little bit of time, because
to make progress with any mental health issue it does
take some time. Do choose someone you can afford, whose
(15:03):
available times can work, and who you can reasonably easily see,
because creating obstacles at the outset will make treatment more
likely to fail because you will tend to quit. What
should you be thinking about and asking yourself about someone
new you have met for therapy? Think about these questions.
(15:28):
Do you feel comfortable opening up to this person? Is
this therapist empathic and a good listener? Does this therapist
seem to have an agenda? Are they trying to have
you commit too soon to a schedule before they've accurately
assessed your motivation and the range of options that are
(15:48):
available to you. What are their credentials and levels of expertise?
Have they treated many other people with your particular condition.
What type of therapy are they offering you? They should
be able to explain why one type is better than
another for the particular condition that you've come to see
(16:11):
them for. How will they manage the fee and billing
and if needed do they offer a sliding scale fee?
How do they collaborate with your psychiatrists if you're seeing
a psychologist or even your primary care physician, as collaboration
(16:32):
will greatly improve the quality of care if needed for you?
Do they offer evening and weekend hours? And how often
are they recommending that you see them? Finally, what are
the agreed upon goals for your treatment and what do
they see as endpoints for therapy. As you proceed along
(16:58):
in therapy, try to keep in mind line that it
is normal to feel worse before you feel better because
everything is being brought to the surface. You may feel
as though you want to quit, but don't without first
at least discussing it with your therapist. You might experience
(17:19):
many positive and negative feelings towards your therapists. This is
called transference. These are actually feelings that you have for
other significant people in your life that are being transferred
onto your therapist. This is common and it is normal,
(17:40):
but it does need to be discussed with your therapists
because this is what leads to possibly wanting to stop
therapy inappropriately, but it also leads to information that you
can use in the therapy to help you. Understanding transference
leads to real progress in therapy. With some forms of therapy,
(18:04):
like cognitive behavioral therapy, you may be expected to do
homework such as journaling, keeping a log or diary, or
doing relaxation exercises. If you're not doing the homework, then
you and the therapists need to explore your resistance to
doing so. Understanding and tackling the resistance is the key
(18:27):
to improve it in any therapy. I hope that was helpful.
The goal of any therapy is to gain insight into yourself,
into your relationships, and into your condition. It's also to
have the ability to cope better with your anger or
(18:49):
depression or anxiety, and to improve your ability to care
for yourself and to use prevention strategies. When therapy is
done to and a relapse, you will want to work
with your psychiatrists if you're on medication to successfully taper
(19:09):
off of psychiatric medications. If and when it becomes possible.
Do not stop medication abruptly on your own. Most medications
can cause a withdrawal. It's not that you are addicted,
but it is that stopping the medication abruptly causes a
(19:30):
withdrawal syndrome, which can feel terrible. So do let your
therapist help you wean off medication. Once you and your
therapist feel that you have reached most of your goals,
then you should, in the therapy sessions begin to discuss
(19:51):
ending therapy, and remember that progress often continues even after
therapy has been discontinued. Overall, navigating the mental health system
can be overwhelming and frustrating, and as a result, many
people get put off from getting the help they need.
(20:12):
But you should know that help is always available and
that if you do put in the effort and don't
give up, most mental illnesses can be successfully treated. Do
you have a problem I can help with? If so,
email me yet? How can I help? At Seneca women
(20:33):
dot Com, all centers remain anonymous and listen every Friday too.
How can I help with me? Doctor Gale's Salts
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