Who Can Help? Choosing a Therapist

Excerpted from
How to Go to Therapy : Making the Most of Professional Help
By Carl Sherman

When you visit a physician, you know what she is-the "M.D." after her name may not tell you everything about her intelligence, experience, or areas of expertise But you can assume she's had the training and passed the tests that, by consensus and law, qualify her to treat your bodily ills, and indicate that she is legally and ethically obligated to follow a well-established code of conduct.

But when you seek mental health care, you find people who call themselves psychotherapists, psychologists, social workers, nurses, and counselors, among other things. It's a jumble out there-a jumble of names, titles, and degrees. Before you start looking into more complex questions of how "good" a therapist is, you need to know what she is. Keep in mind, however, that a title or degree will tell you so much, but no more

A psychotherapist is someone who is in business to do psychotherapy. It's purely a descriptive term; as a title it means nothing. Anyone can list himself as a "psychotherapist" in the Yellow Pages, hang out a shingle, or run a magazine ad, just as anyone can call himself a philosopher or healer. He needn't have a license and is accountable to no state board or professional association for his actions. He has not agreed to adhere to any code of ethics or principles.

This is not to say that an unlicensed psychotherapist cannot be well trained, brilliant, and highly scrupulous But then again, he may be a scoundrel, or a criminal (a psychiatrist or psychologist who has lost his license for unethical behavior can still practice as a psychotherapist). Front the title itself, you have no way of knowing. And if things go wrong-he violates your trust, uses unorthodox methods that cause great harm, or disappears in the middle of your crisis, you may have virtually no recourse

A psychiatrist is a licensed physician. She has gone to medical school and received the same basic training as your internist, and presumably knows a few things about the human body and the various things that go wrong with it. She followed her medical training with four years of psychiatric residency-courses and practical experience devoted to the study and treatment of mental illness.

Psychiatrists are the only mental health professionals allowed by law' to prescribe medications. Their training should also give them special insight into the complex connections between medical and emotional illnesses. But the title does not necessarily indicate competence in psychotherapy. Residency training programs differ widely in the amount of time they devote to this area, and some pay it little attention. (This is changing: as of 2001, psychiatric residency programs are required by the Accreditation Council for Graduate Medical Education to have their trainees demonstrate competency in basic types of psychotherapy.)

In the essentials of therapy-establishing an effective relationship with patients, and helping them achieve insight into their problems and work toward the changes they desire-a psychiatrist may be expert, or woefully inadequate.

A clinical psychologist also needs a license to use this title. He has advanced training-the minimum varies from state to state but generally includes a graduate degree and at least two years of supervised clinical experience. Most psychologists have doctorate degrees (Ph.D., Ed.D, or Psy.D.), although in many states those with master's degrees can be licensed as well.

A psychologist's training generally includes the study of theories of behavior and an acquaintance with research methods. His grounding and experience in one or more types of psychotherapy may be thorough, or fairly minimal. When you go to a licensed psychologist, however, you do know that he can be held accountable for his professional actions.

Note: Someone with a Ph.D. who calls himself a psychotherapist is not necessarily a psychologist. The degree may reflect training in an unrelated field.

A clinical social worker is also a licensed mental health professional. Some social workers practice in a hospital setting and have little to do with therapy Those who work directly with patients as therapists generally have the designation A.C.S.W. (certified social worker) or L.C.S.W. (licensed clinical social worker), for which they typically need two years of supervised experience after a master's degree and must pass a state examination.

While a social worker's psychotherapy training may be similar to a psychologist's, it is likely to put extra emphasis on a "systems" view of mental health, which pays more attention to the social forces impacting the individual, and on his relations with family, community', and other groups.

Marriage and family therapists are licensed in most states, but not all. A license generally means a master's degree, two years of supervised clinical work, and a state exam. These professionals specialize in treating couples and families, but may work with individuals as well. Members of the American Association for Marriage and Family Therapy have met training and education requirements and agree to abide by the organization's code of ethics.

Many family therapists are also certified or licensed as clinical psychologists or social workers. A psychologist who has a special interest in this area, for example, may undergo additional training and supervision after his initial certification.

A psychiatric nurse has a nursing license and should have additional training in psychotherapy. But there is no specific degree or credential that guarantees this. Most work in hospital settings, but some do individual therapy in outpatient clinics. In some circumstances, psychiatric nurses can prescribe medication under the supervision of a physician

Counselor is a loose term that generally refers to professionals, often but not always with a master's degree, who treat specific problems like substance abuse, stress disorders, or short-term crises, rather than more serious persistent disorders. Any clergyperson can do pastoral counseling, which may use the techniques and approaches of psychotherapy in a religious context, or consist of basically spiritual advice.

Most states have licensing for counselors. Those who hold licenses (including pastoral counselors) generally have similar training to social workers: at least sixty hours of graduate credits and two years of supervised clinical experience. Membership in organizations like the American Association of Pastoral Counselors or the American Counseling Association suggests a degree of expertise.