Help me pick a therapist

In My Humble Opinion
1

So I’m having issues with depression and anxiety. All the cool kids are. I’m not suicidal or anything, just having a lot of problems being functional. I’m tired all the time, I sleep a lot, I struggle getting out of bed. I’m not doing things I need to.

I finally got my insurance straightened out and got a new doctor, went for a checkup. The intake screening was enlightening. It really pointed out the depression. The doctor did a bunch of screening tests and whatnot, we’re checking on my thyroid, etc.

Anyway, I got a referral for a doc for mental health, but he didn’t take my insurance plan. I have a list of therapists in my area, and checked and I don’t need a referral or a pre-approval for mental health issues, just have to use someone in-network.

Here’s where you get to help me. I’m trying to figure out how to pick a therapist.

Different types include:
psychiatrists: these are medical doctors who then specialize in mental health. They can prescribe medications.

psychologists: these are mental health specialists typically with doctorates but not medical degrees.

clinical social workers: these are social workers who have masters degrees in therapy and mental health.

I know that typically even though a psychologist or social worker may not be able to prescribe medication, they typically work with psychiatrists and can get prescriptions, so that shouldn’t be a showstopper.

Other factors I’m more interested in thinking about include style. I know psychoanalysis was big in psychiatry but is rather outdated as junk science.

What else should I ask about? What kinds of therapy or approaches are there?

I’m not interested in alt med approaches here. I don’t need fake medicines that don’t have anything in them.

2

I suspect most people will point you to Cognitive Behavioral Therapy, because it is effective for treating depression and anxiety for many people.

But some people don’t like it because it is so pragmatic and structured. Some people want their therapy to uncover the source of their problems, which CBT isn’t really designed to do. Also, some people don’t want advice. They don’t want a problem-solver. They just want a listening ear. There’s nothing wrong with that, but CBT is pretty much all about “problem solving”.

If you don’t know what kind of therapist you want, you can look for someone who describes themselves as “eclectic”. That means they have no problem drawing from different modalities (psychodynamic, CBT, etc.) to help their patients. With my psychologist, I have done a little bit of everything.

If you don’t want to be pressured to take medication, I would recommend going with a psychologist (or social worker). I’m sure not all psychiatrists are drug-pushers, but all the ones I’ve had are like this. My psychologist was supportive of my decision to go on meds, but she was also fully supportive when I decided to stop taking them.

3

In the US, very few psychiatrists do anything but prescribe meds. Expect 15 minute sessions.

IMHO, (admittedly, I am biased, because I am one) phD level psychologists have more training and tend to be more consistently good than LCSWs.

In terms of type of therapy, I agree with monstro. I use lots of CBT techniques, but I find that digging deeper requires a more eclectic approach.

Psychology today has a decent therapist finder website. If you would like to PM me your location and any details you want to share, I’d be happy to look at some local therapists for you on their site.

4

This is a great discussion about finding therapists: #414: What are the green flags for a good therapist? – CaptainAwkward.com

My personal experience: on the one hand, research suggests that there are too many “eclectic” therapists out there who operate by instinct and experience, rather than hard data on what helps people, and the data suggests that this is not really helpful. On the other hand, the therapist who has helped me hugely is definitely in the “eclectic” boat.

5

Most (many?) psychiatrists will not prescribe psychoactive medications without the patients also being seen by a therapist/psychologist for some form of talk therapy. The combination of talk therapy with medication is what most would recommend and it’s what I am currently doing. I’ve done talk therapy alone and medication alone and I definitely find the combo approach to be most effective.

6

Another option is a nurse practitioner in psychiatry. They will usually do talk therapy, and depending on what level of education they finished, can prescribe any drug you might need (IIRC, a few of the highly controlled substances like Dexadrine may require a doctor, and some people need a small dose of that to fine tune their anti-depressant). I used to help people find doctors and therapists as part of my job, but it’s been over ten years since I did that, and some rules probably vary by state, but NP-psychs do exist.

A psychiatrist will want you seeing someone about once a week for about an hour initially, because your drugs will be adjusted a lot, and you will have to try some things, and reject them before you find the drug or drugs that work for you. The psychiatrist wants you seeing someone who will monitor your mood, and make sure the drugs are working, but not inducing mania, or having such undesirable side effects that it would be better to try something else (eg, if you noticeably gain or lose weight over a three-week period, you probably need something else, even if your mood has improved, unless you had suddenly gained or lost a lot in the other direction before starting on meds).

If you go with an NP, make sure he or she has admitting privileges at a hospital, or is in practice with a doctor who does.

7

Or they simply won’t take new appointments without a referral from a therapist.

Psychologists have either a PhD or PsyD. Depending on where you live, new ones may have a harder time geting hired than LCSW/MFT/etc. Master’s level, because the doctors cost more. Generally speaking, there is nothing wrong with the master’s person, and actual experience may matter more than schooling. In other words, don’t reject someone simply by their degree.

Also look at their “philosophy.” CBT is one of these. Some may approach woo, or be inappropriate for your condition. I don’t have much use or belief in pure behaviorism. It’s not supposed to be easy, though, to go through therapy.

Nothing wrong with shopping around. If they don’t seem like someone you “mesh” with, try another. Just don’t go shopping around for docs because they say something you don’t like!

In some states, psychologists can prescribe IF they have specific training. It’s rare though, and probably not applicable to you. A psychiatrist (MD) might meet semi-regularly at the beginning, and once you find something that works they will become less frequent. Meetings might become “Hi. Doing well? Good. Here’s another 3 months.” Some psychiatrists do train for actual talk therapy.

8

Okay, another point of information, my mom was an LCSW and did therapy, so I am familiar with their existence. She’s been helpful, but some things you don’t want to get your parents doing.

And I did have a period of talking with a doctor when I was in high school. That was a lot of dealing with feeling unliked and social interaction problems. There wasn’t any meds then, it was all discussion and finding methods to become less isolated. It was moderately successful, but I don’t think it ever resolved my issues on that front, though it did help me get through high school.

I’ve heard of CBT, but I’m not familiar with what it involves. It does sound like something I’m interested in - I want to get better. I’m a science and rational type guy, not into woo.

I definitely think I need meds, at least for a while. This is a long term situation that has been building over time, I feel, but I’ve had degrees of it in the past. I think it was exacerbated because I was laid off in January, but that’s not the whole of it.

I will definitely give that a look.

Talk therapy is fine and probably important, as long as it’s based on something rational, and not “Tell me about your dreams” or reading the metaphorical bumps on my head. (The literal bumps is, of course, right out.)

Yes, I’ve been warned the drugs might take time to find something effective without bad side effects and narrow down the dose. I want to be optimistic, but I know it might take time. But I need to get this started now rather than later. It’s too easily later for me, especially right now.

9

A therapist seeing you in conjunction with a prescribing doctor will probably want to meet you once for a baseline assessment before you start on meds. Then they will just talk about how well you are handling daily tasks, to see if your functioning is better, worse, or static, and what events in your life affect your mood, and need to be considered in assessing whether a med is helping. They’ll be a sounding board if you need one, and may point out patterns you might not have noticed-- like every time you have to go in early for work, you report feeling excessively depressed later in the week: have you considered that missing a couple of hours of sleep might be a trigger for you? and maybe you should try taking some melatonin and going to bed early when you have an early meeting the next day.

10

Just a note from another “science and rational type” girl who avoided therapy for far too long because it seemed much too woo:

  1. The human brain is not a particularly science and rational type place to live. It’s sometimes useful to have a guide who is comfortable with the decidedly non-rational shit that comes up.

  2. A good therapist will keep their personal preferences out of your sessions. My therapist is clearly 1000% more woo than I am, but he understands and respects my science brain, and does not push that shit on me.