IT IS AN almost universal thought, one that comes welling up from the down-and-out moments of our lives: “Maybe I ought to see a psychiatrist.”
Many times the thought was only a fleeting thing, here one moment and gone the next. People joked about psychotherapy and the analyst’s couch, but the majority still harbored a built-in resistance to the idea. Deep down inside, most of us probably believed that anyone who went to a “shrink” had to be a little “nutty.”
Times have changed. With the increased pressures today and the stronger emphasis on mental as well as physical health, that once-fleeting idea has become concrete action for thousands of Dallasites. A rising divorce rate, an increasingly transient society too often devoid of close friendships, a breakdown of traditional religious concepts, economic hard times, high unemployment and heightened tensions within families are sending more and more of us in search of professional help for our emotional problems.
Unfortunately, this is happening at a time when it is becoming increasingly difficult to make an intelligent selection from the burgeoning ranks of those who deal in psychotherapy. If you’re seriously in the market for a therapist, you may find yourself facing an exceptionally complex and confusing situation.
It’s easy enough to check out a family doctor or a dentist since all of them are licensed by the state. But there are a double handful of different types of practitioners who call themselves “psychotherapists” and no organization that represents all of them. There is no licensing board to tell who is qualified and who is not. You can find plenty of names under “psychotherapists” in the Yellow Pages, but how do you determine which one is to be entrusted with your mental health? What you end up with could range from a bona fide psychiatrist with an M.D. degree to a well-trained psychologist with a Ph.D., an experienced social worker with a master’s degree or Madame Zelda, the palm reader.
Most of the vital decisions about choosing a psychotherapist are left for the health consumer. But going it alone can be extremely risky business, so we’ve asked several local psychotherapists to help establish a set of guidelines for making those decisions. Before making any decisions or commitments, these experts suggest that you ask yourself these several pointed questions if you’re considering – or already undergoing -psychotherapy.
Should I seek psychotherapy in the first place?
Most of the time, there are certain, readily identifiable symptoms associated with mental stress -anxiety, insomnia, over or undereating, depression, withdrawal or anger. Most of us suffer one or more of these symptoms at some point in our lives. But when there are no physical causes for these problems and when you’re unable to find a method of coping with them on your own, you may be experiencing the kind of extreme demoralization that requires outside assistance, says psychiatrist-author Dr. W. Robert Beavers.
Even so, this doesn’t necessarily mean that psychotherapy is the only solution to the problem. If you can focus on the cause of your disturbance and share your pain with someone else -a close friend, a trusted relative, your minister or physician, even a friendly barber or understanding bartender -you may avert the need for professional psychotherapy, But if you feel completely alone, isolated, unable to communicate your problems to anyone you know and yet are unable to contain the emotional stress building inside you, psychotherapy may be the best available alternative.
People also seek therapy when they are going through a severe personal crisis that temporarily shatters their coping mechanisms. A marital breakup, the loss of a job, the loss of a loved one or a cherished possession, friction between a parent and child -any of these can cause severe stress and the inability to deal with the problem. Once the crisis is past, the individual’s coping mechanism will begin to function again. In the meantime, talking things over with a therapist may speed a return to normalcy.
But a person needn’t be suffering mental stress or battling a specific problem to benefit from therapy. Many consult a psychotherapist simply to make their lives more satisfactory overall. You could have a happy marriage, a nice home, a good job and plenty of money in the bank and still feel that something is missing in your life. At this point, you may need to dig deeply into yourself to discover that particular skill or talent that lies buried and unexpressed. A therapist can help recognize these personal resources and help chart avenues for personal growth.
Who provides psychotherapy?
In 1976, the State Board of Examiners in Social Psychotherapy was established in Texas by state law. However, the highly controversial board ceased to exist on August 31, 1981 because it was not reinstated by the Texas Legislature. Critics of the board claim it met a “merciful death” because it only served to confuse the issue of “who is a psychotherapist” even further, while supporters say it was killed to prevent growing competition in the field.
According to Dr. Larry Golden, associate professor of psychology at Texas Woman’s University, almost anyone can hang up a shingle and start practicing psychotherapy -even if the practitioner has no specialized training or experience, professional standing or even a high school diploma. Fortunately, there are ways to make sure you aren’t consulting a charlatan. In Texas, psychiatrists, psychologists, professional counselors and social workers are all licensed by their respective boards. And while they are not specifically licensed to do psychotherapy, they are obligated by law to obey the codes of ethics of their various fields.
Some therapists may be members of professional associations that also have stringent requirements for membership, such as the American Association of Marriage and Family Therapy. “In the absence of licensure requirements by the state,” Golden says, “professional organizations can also serve as good recommendations for practitioners.”
It’s also important to note that only the psychiatrist who holds an M.D. degree can prescribe drugs, which may be required for some psychological disorders. For this reason, reputable therapists -regardless of what type of practitioner they may be – will refer patients who need medication to a physician for drug treatment.
But look beyond specialized degrees, professional affiliations and licenses in selecting a therapist. If possible, ask someone you trust for a recommendation. Seek suggestions from your minister, personal physician, lawyer or close friends. If you have no such personal contacts, the Dallas County Medical Society, 526-5090, will provide names of psychiatrists, and the Dallas Psychological Association, 386-4362, will give you names of psychologists. If you’re interested in the services of a social worker, copies of the Private Practice Referral Directory are available by sending $1 to National Association of Social Workers, Texas Chapter, 815 Brazos, Room 300, Austin, Texas 78701.
Perhaps the most important thing to remember is that the whole point of psychotherapy is for you and the therapist to develop a working relationship in which you can unlearn maladaptive behavior patterns, develop a sense of autonomy, self-worth and belonging, and find a network of friends you can talk to and confide in, says Beavers.
One of the best ways to learn if you and your prospective therapist will be compatible is to ask questions. Don’t be afraid to take the initiative and speak up. The questions you ask will not only help to establish the credibility of the therapist, but can also have solid, practical applications as well. For example, one important question to ask at the outset is “Will my insurance pay for my treatment?” Some health insurance plans won’t pay for psychotherapy at all. There are plans that cover certain types of therapists but not others. It’s best to familiarize yourself with your insurance program even before the first visit to a therapist.
If they are truly qualified to practice psychotherapy, most practitioners will willingly answer inquiries about their backgrounds and education. “I get people who call me and ask: ’Where did you get your degree? What experience have you had?’ ” says Bernice Waldman, a social worker with six years’ experience as a psychotherapist. “I don’t mind them asking such questions. I know they are informed consumers. Others say they found me in the Yellow Pages; you’d be amazed at how many say that.”
Dr. Florence Wiedemann, a clinical psychologist and Jungian analyst with nine years’ training in human behavior, suggests that a person visit more than one therapist before making a final choice. “The most important thing is for the patient to feel good about working with the therapist,” she says. “At the end of the first visit, I ask the patient, ’How do you feel about me? Do you think I can help you?’ Then I ask myself, ’How do I feel about this person? Can I help this person?’ If the answer to all these questions isn’t yes, then I refer the patient to someone else.”
In the first session, both patient and therapist should try to determine if they make a good team. As an evaluation technique, you might ask yourself such questions as: “Do we seem to understand each other, at least part of the time? Does this therapist want to control my life or help me develop autonomy -and which do I really want? Am I willing to try to remove difficulties without relying solely on the therapist? Do I want quick answers without assuming a partnership role in my treatment? Do I see qualities in this person that are admirable and likable? Do I imagine that this relationship could become enjoyable?”
And it’s extremely important for a client to trust the therapist, Golden says. But at the same time, the person who needs therapy should realize that he may be frightened of the change that therapy encourages. Some patients persist in certain negative behavior patterns simply because change is frightening, Golden says. Therefore, it may be the change itself, rather than the therapist, that the patient feels uneasy about. “The person should take a good look inside himself,” Golden says.
“Sometimes a negative reaction to a therapist is related to a reluctance to change.”
What style of therapy do I want?
A lot of people -especially those whose only contact with psychotherapy has been through books and movies -have the idea that all psychotherapists operate in much the same manner. This couldn’t be further from the truth. Each practitioner has his own individual approaches, techniques and characteristics, but generally speaking, therapists can be divided into two broad schools. As Beavers sees it, all therapists are either “control-oriented” or “growth-oriented”; both approaches have their advocates and critics, their advantages and disadvantages. “I see them as different, rather than inferior or superior,” he says.
Beavers explains control-oriented therapy this way: “Many people wish to be rid of their emotional pain without concern for increasing their functioning ability. They want a therapist who controls the situation by either coercion or persuasion. In our culture, gleaming instruments, expensive furnishings and the placement of the therapist in a higher position than the sufferer all serve to increase the therapist’s overt power. The controller focuses on indoctrination-not dialogue. He wishes to minimize the objections or back talk from his patients and defines questioning or efforts to engage in a more equal discourse as resistance to treatment.
“With this approach, certainty is expected of the healer. There is no discussion of alternatives or the provision of choice for the ill person. The expert knows what the problem is and what to do. The role of the sufferer is to be passive. The one severe drawback of the approach is failure to deal with the root cause -the lack of satisfying, coherent, self-defining experiences with others.”
Growth-oriented therapy, on the other hand, strives to equalize the overt power between therapist and patient, since the major weapon used to alter behavior and attitudes is an empathetic relationship with the patient, Beavers says. “These methods flourish in a relationship of mutual responsibility and wither in an atmosphere of unilateral control. Interaction is designed to treat the cause, to provide needed self-confirming and self-defining relationship experiences that increase self-confidence, self-awareness, socialization and good morale. The patient need not subject himself to an authority, but instead participates in dialogue about viable solutions to his problems. In this relationship, the therapist is not responsible for, but responsible to the patient.”
Some people find the idea of taking responsibility for their actions too frightening; they prefer the controller approach. Many others cannot tolerate the reduction in personal power involved in submitting to controller techniques. Beavers believes strongly that therapist and patient should match in this regard. “The therapist’s virtue (and probably good results) consist of matching desire of the patient with the treatment approach. The therapist’s sin (and probably poor outcome) consists of ignoring the patient’s choice and giving the treatment the therapist prefers, rather than negotiating with the patient.”
Some therapists are “switch hitters,” Beavers says, which means they are able to function in either the controller or growth-oriented style. Others adhere strictly to one style or the other. In these cases, when patient and therapist don’t match, the therapist should feel comfortable in referring the patient to another therapist. Likewise, the patient should feel comfortable in asking to be referred or in accepting the therapist’s referral.
Although many people think of psychotherapy as strictly for individuals, it is a field with multiple possibilities, Beavers says. You might also consider whether you prefer individual, group, couples or family therapy. Incidentally, research has shown that if you are experiencing marital or family problems, there is a much greater chance for improvement if you involve your spouse and other family members in treatment.
How long do I go, and how much does it cost?
Patients usually see their therapists for at least an hour each week. Some therapy lasts only one visit – usually when a person has experienced a one-time crisis that can be worked out sufficiently in a single long talk with another person. Long-term treatment may last three years or more. The average treatment length is about a year.
“When you think that it usually takes 35 or 40 years to get a life messed up, a year doesn’t seem that long,” Wiedemann says. “In only 50 hours or so, you can change a lifetime.”
Private therapists usually charge from $30 to $100 per hour, which means that your 50 hours can cost you up to $5,000. But services are also available at mental health clinics on a sliding fee scale of $5 to $50 per hour.
Generally, either the patient alone or the patient and therapist together should decide when treatment should be completed. “A patient should not be held in a relationship by obligation,” Beavers says, “and he also shouldn’t be ’kicked out,’ either as a reject or a finished product, as defined by someone else.”
The proof of successful psychotherapy lies in the conclusion of it, regardless of all that has gone before. As Waldman puts it: “I tell clients that termination is the most important therapy and that they should not cheat themselves or me out of it. A lot of their endings have been involuntary, such as divorce or the loss of someone close. Here is their opportunity to choose an ending, and it is a really important opportunity for them.”
What can I expect from my therapy?
First of all, Wiedemann says, you should expect a therapist who is well-trained in the study of human behavior and is motivated to help people. You should also expect a therapist to be someone you can trust and count on, someone who will guide you through the experience you are caught up in.
Beavers adds: “To fellow human beings who come in search of emotional health, we should offer respect, human dignity and the possibility of increasing competence, experiencing community and finding certainty.”
The patient can usually expect to gain from psychotherapy in direct proportion to what he puts into his own treatment. “If the person comes in regularly, on time and takes insights away from therapy that he can use in everyday life,” Waldman says, “then therapy will be most beneficial. If the person wants something done to him that will miraculously change his life, that person is in for a big disappointment. I don’t have a magic wand that I can wave over them for instant changes.”
Don’t stay in therapy indefinitely without evaluating it, Wiedemann says. After three months ask yourself: “Is this a healing experience, or it is making me more dependent? Is this worth the time and money? Am I getting well?
If you can’t answer these questions toyour satisfaction, it doesn’t necessarilymean you should give up on psychotherapy. It probably does mean you shoulddiscontinue your present treatment, shoparound for a therapist who is more compatible and attuned to your needs, andvow to work harder yourself in quest ofyour own “cure.”