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Category: Doctors

How To Choose a Good Psychotherapist

By Deborah Serani, Psy.D.

It is a difficult, yet brave and courageous moment when someone makes the decision to pursue mental health therapy. But more difficult than the decision to go to therapy is the decision of who to go to for therapy.

So, how does someone find a good therapist?

Types of Therapists
First, it is important to think about the type of therapist you think is best for your presenting symptoms and issues. There are many kinds of mental health therapists, but sometimes understanding “who does what” can be confusing. Here is a list to help identify the specialties and degrees therapists can hold.

In the United States, Doctors of Philosophy (Ph.D.), Doctors of Psychology (Psy.D.), or Doctors of Education (Ed.D.) must complete at least four years of post graduate school, however, only those who have been licensed can call themselves Psychologists. Licensed practicing psychologists are specifically trained in the mind and behavior as well as diagnosis, assessment and treatment of mental, emotional, and behavioral disorders. The treatment provided is “talk therapy”. It is important to know that not all psychologists are experienced therapists. Some specialize in areas such as statistical research or industrial psychology, and may have little experience treating people. Therefore, it is important to inquire about the caliber of clinical experiences. Psychologists do not prescribe medication.

Social Workers
Clinical Social Workers (C.S.W.) usually have earned at least a Masters’ Degree, which is two years of graduate school, and some Social Workers obtain a doctoral degree (D.S.W.) . Clinical Social Workers credentials may vary by state, but these are the most common: B.S.W. (Bachelor’s of Social Work), M.S.W. (Master’s of Social Work), A.C.S.W. (Academy of Certified Social Workers), or D.C.S.W. (Diplomate of Clinical Social Work). Although there are exceptions, most licensed clinical social workers generally have an “L” in front of their degree (L.C.S.W.) communicating that they are a Licensed Clinical Social Worker. Clinical Social Workers also receive training in the prevention, diagnosis, and treatment of mental, behavioral, and emotional disorders. Their goal is to enhance and maintain physical, psychological, and social functioning in who they treat.

A Psychiatrist completes a medical degree (M.D.) like any other physician, followed by a four-year psychiatry specialty. Psychiatrists prescribe medication yet sometimes do psychotherapy with patients. Psychiatrists, unlike Psychologists, have the background and experience to understand how the body and the mind as a whole react when psychiatric medication is given, and have extensively studied the total body including brain biochemistry, tissues, glands, and organs, leading to a fundamental understanding of how these all interact and react to the patient’s environment in mental health and mental illness.

Marriage Family Therapists & Professional Counselors
Licensed Marriage and Family Therapists (L.M.F.T.), and Professional Counselors (L.P.C.) usually have two years of graduate school and have earned at least a Masters’ Degree such as: M.A. (Master of Arts), M.S. (Master of Science) or M.Ed. (Master of Education). Marriage and Family Therapists have additional specialized training in the area of family therapy.

Certified Counselors
Certified Counselors are typically trained in drug or alcohol abuse specialties. A Certified Addiction Counselor (C.A.C.) or a Certified Alcohol Counselor, (C.A.C.) may have a I, II, or III added to their degree signifying the level of training in counseling (CAC-I, for example). A C.A.C. Counselor may or may not have a master’s degree. Counselors are trained for supportive therapy. C.A.C’s work within the field of alcoholism and substance abuse, providing education, consultation, counseling, aftercare, recovery and advocacy.

Religious/Theology/Pastoral Counselors
These are counselors who are clergy, pastors or who have a Master of Divinity (M.Div.) degree, or a Doctorate in Theology (Th.D.) from a seminary or rabbinical school, with additional training in therapy. These spiritual counselors are trained in both psychology and theology and thus can address psychological, religious and spiritual issues.

Counseling Nurses
Psychiatric Nurses and Nurse Practitioners comprise a growing segment of mental health treatment professionals. They display the credentials R.N. (Registered Nurse), R.N.P. (Registered Nurse Practitioner) or M.S.N. (Masters of Science in Nursing). A Psychiatric Nurse is a registered nurse with a master’s degree who has been trained in individual, group, and/or family psychotherapy. The Psychiatric Nurse and the Nurse Practitioner view individuals from a holistic perspective, taking into account both physical and mental health needs while focusing on human behavior.

Word of Mouth To Yellow Pages
Now that you know the kind of therapists with which you wish to work, how do you choose one?Here are a few ways that can provide leads to a good therapist.

Word of mouth: Asking a friend or relative that you trust can be a great way of finding a reliable therapist. When a clinician is highly regarded, there is usually a buzz in the community about him or her.

Professional Referrals: Contacting your general physician, or inquiring with school guidance and special service staff if you are looking for someone to work with your child are good ideas. Contacting local psychological, psychiatric or counseling organizations can be very helpful in pointing you in a direction as well.

Insurance Company: If you have an insurance company, another suggestion is to call them directly and ask them to give you a few names of therapists in your area, and ones that specialize in the disorders or issues with which you are experiencing.

Church or Temple: Many churches and temples have outreach programs where the person in charge can help you find a therapist.

Yellow Pages: Many times I get calls from people who look me up in the Yellow Pages. With nowhere else to turn, people cold-call with the hopes of finding a good therapist. This experience can be frustrating and may lead you down a bumpy road of contacting therapists who do not specialize in what you need. If possible, try one of the other strategies listed above to help you find a good therapist.

The Initial Phone Call
Once you have a few names, find the time to call each one and talk on the phone with him or her. You can get a great feel for a professional during this informal chat. If you make a connection on the phone, arrange for an appointment to consult with the therapist. I call this “the meet and greet” consult where I get to meet the potential patient, assess the symptoms and issues and make sure that my training and expertise are appropriate for the necessary treatment. This is a time where the potential patient gets to know me as well, how I will work and also learns about my approach to treatment and the parameters of therapy. Though comfort and connection are necessary factors, so too are making sure that the therapist of your choice is educated, seasoned and a specialist in what you are seeking.

Questions to Ask:Most therapists will welcome the opportunity to answer any questions that you may have. Here are some of the most important ones to consider:

1. What is your professional training and degree?

2. How much specialized training and experience have you had with what I am seeking help for?

3. What theoretical school of thought do you follow?

4. How long are the sessions?

5. What is the cost of each session?

5. How does insurance work with mental health therapy?

6. What is your policy on cancelled appointments?

7. Have you been in therapy yourself? If so, how long?

8. Is it possible to reach you after hours in the event of an emergency or crisis? If so, how?

9. Do you receive regular supervision on your cases or belong to a peer supervision group?

10. What professional organizations do you belong to?

Good Therapy
Once these bases are all covered, and you settle into treatment, you should slowly begin to feel an expansion within yourself. Your awareness will widen, your feelings may swell, and you may find yourself thinking in new ways about your situations and experiences in life. Therapy may be tough on occasions, but in time, you should start learning techniques to help change, shift or remedy symptoms. That is how the arc of good therapy progresses. Last, but not least, always, ALWAYS, be sure that the professional you choose to work with is a licensed mental health practitioner

Device Company Payouts Mostly Royalties

Regarding, “Device Companies Post How Much They Paid Orthopedic Surgeons” today’s Health Blog revealed that the millions of dollars paid to orthopedic surgeons are mostly in the form of royalty payments (74% of total payouts), at least, for Zimmer:

Zimmer’s CFO broke down his company’s payments during a talk today at a Piper Jaffray health-care conference. According to a slide in the CFO’s presentation, 74% of the outlays were for royalties, 11% for consulting, 10% for “research & clinical” work, 4% for “education & other” and 1% for travel and expenses, Dow Jones reports.

Source: Health Blog

If the docs did indeed own the intellectual property that device companies are licensing to use, then royalty payments make perfect sense. Still, from the blog comments, some remain skeptical of the rationale behind such high payouts.

Bullied by Pharma Co? Fax Senator Grassley

Doctors can now fax Senator Chuck Grassley at 202-228-2131 to report on drug companies that the doctors perceive to “push too far” and are being “bullied” by drug companies. Doctors can remain anonymous and send information by mail or fax. This effort came at the heels of the Avandia investigation earlier this year, where manufacturer GlaxoSmithKline was accused of pressuring Avandia critic John Buse to change his story about Avandia risks. The company said it wanted Buse to correct factual errors Buse made about the drug, while Buse said the company used intimidation tactics.

I wonder if Grassley knows what floodgate he’s opening up by creating a service that allows anonymous tips on what is very much a subjective behavior (i.e. what one perceives to be intimidation or bullying or “hardball tactics”), and whether the senator is actually equipped to conduct investigations into every complaint filed. Source: WSJ Blog.

Device Companies Post How Much They Paid Orthopedic Surgeons

Major device companies that have been investigated by the government and entered into settlement were required to post how much they paid to orthopedic surgeons for consulting services. Wall Street Journal’s Health Blog posted the links to the company websites disclosing payment sums:

Stryker Consulting Payments (check out Richard Harrison Rothman in Philly)

J&J’s DePuy must have deep pockets because several orthos earned almost 3 million dollars in consulting fees (PDF file)

Biomet (check out Adolph V. Lombardi)

Smith & Nephew (check out Richard Laskin)

Many of these surgeons earned tens of thousands of dollars in consulting fees, but some received hundreds of thousands of dollars, and a few earned over a million (there was one ortho who earned almost 3 million dollars in consulting fees). WSJ blogged about the investigation on September 2007.

British Doc Pisses People Off by Calling Out Fat

Dr. Hamish Meldrum is the head of the British Medical Association and has upset a lot of people because he wants to stop sugar-coating the obesity problem and start some serious prevention. Meldrum’s view is that obesity is not always a “medical” problem, but a behavioral one, and when doctors are too quick a write a prescription for a pill for a patient who should be best helped with dietary modification and behavioral changes around food, this prevents overweight people from taking personal responsibility about their weight problems. (more…)

DTC Advertising: Doctors Still Hate It But Industry Continues to Use It

New England Journal of Medicine recently published a paper looking at “A Decade of Direct-to-Consumer Advertising of Prescription Drugs”, where the study authors looked at pharma company spending on DTC advertising and physician promotion in the past 10 years (1996-2006). The authors also looked at the FDA regulation of drug advertising during this time. While drug companies’ promotional spending went from $11.4 billion (1996) to $29.9 billion (2005) where DTC ad expenditures grew by 330%, this made up “only” 14% of the almost $30 billion in drug companies’ promotional spend.

On the other hand, FDA’s warning letters fell from 142 in 1997 to 21 in 2006. The authors speculate this could either be due to drug companies becoming better behaved and playing by the rules, or due to the FDA being too short-staffed to follow up on all violative behaviors. I’m skeptical whether this reduction in FDA warning letters is mostly due to staff shortage at the FDA given how steep this drop was (142 to 21 per year); while I’d like to think that drug companies are finally being “scared straight” by the various scandals and class action lawsuits in the recent years, I’m also not so much of a pollyanna to believe that no violative behaviors are being produced. Still, it looks like DTC is here to stay, as much as many doctors loathe it with a passion of a thousand suns. (more…)

Updated Heart Attack Treatment Guidelines

This week the American Heart Association and the American College of Cardiology have published updated treatment guidelines for heart attacks (or, as the journal article titled it, “Update of the Clinical Competence Statement on Cardiac Interventional Procedures”). The entire update is currently available in full from the Journal of the American College of Cardiology (JACC) via this link (technical). According to Reuters Health, which reported on this update, the guidelines focus on identifying patients at risk early and the right treatment. In patients with “low risk”, medication therapy is recommended, and tests of cardiac functions are suggested. In patients with “high risk” intervention including angioplasty is recommended.

Religious Doctors May Not Be Called to Serve the Poor

gif_occu_c_043_ss.gif For many doctors (religious or not), the practice of medicine is more a “job” than a “calling”, even though there may be an undercurrent of “desire to serve”. Ask any job applicant, and you’ll get the typical answer: “I am applying for this job because I want to help people.” Doctors enter medicine for many reasons, one of which may be “to help people”, but this is different from being called specifically to serve a certain group of people. It does bring a reality check for those patients who believe that a doctor’s religious affiliation may have a greater influence on the altruistic motives of that doctor than a doctor who does not claim a religious affiliation. (more…)

How Much Vermont Psychiatrists and Endocrinologists Received from Drug Companies

Gardiner Harris of New York Times wrote about Vermont’s disclosure of the amount of funds that the states doctors received from drug companies. While the focus was on psychiatrists, because they received top total dollars, I was particularly intrigued that endocrinologists as a specialty followed a close second. Those of you familiar with the field (I briefly worked in the field when I was a pharma employee) know that compared to psychiatrists, endocrinologists are a much smaller group as a specialty.

moneyparachute.gif Still, I was concerned that psychiatrists earn so much money from drug companies because in general, doctors can earn money from drug companies mainly through consulting fees (including speaking fees) or from participating in clinical trials. In neuroscience, clinical trials tend to be very large and time-consuming to have any meaning behind the results. This means psychiatrists wouldn’t make much money per year from clinical trial participation alone, and the bulk of their revenues would come from “consulting” agreements. Consulting agreements usually comprise of speaking engagements and other “advisory board” activities. While we have many more drugs within the psychiatric therapeutic area than endocrinology, why wasn’t cardiovascular specialists a close second or even topping the list? The number of psych drugs could rival the number of cardiovascular drugs on the market.

Could it be that there is much more off-label (unapproved) use of psychiatric drugs than there is for cardiovascular drugs? This was implied by the NYT article, when it noted that psychiatrists who earned a lot of money tend to prescribe psych meds to children the most often. (more…)

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