[Another from the World Mental Health Month collaboration last year – again, here for posterity…]
Here is the problem with therapists: by the time you need one, you are in no state to find one. You ask around, someone makes a recommendation, you make that phone-call with sweaty palms in case they can’t see you until Wednesday. Then you go, and for your entire first hour, you try to explain who you are, while you watch a stranger measure you up for craziness. Then you decide you don’t actually like them at all, but you’ve already been once and paid the money and even if they got your crazy-size wrong, at least you know how to get to their rooms, which is one less mountain to crawl over when you go again.
The first therapist I went to actually made me feel worse. I felt so dismal at the time it was hard to tell, and I couldn’t bring myself to find someone else and start again. She probably wasn’t terrible, we just didn’t fit. And that matters. Now I have a therapist who is so wonderful and brilliant that I haven’t needed to see her for over a year, but I want to make an appointment anyway because she’s awesome.
I think everybody should have someone they can see when stuff goes wrong. Good friends willing to listen are awesome in many ways, but they have shortcomings as counselors. One, they are seldom without their own ideas or interests in what you should be doing. Two, they vary widely in the capacity to listen well (a surprising number of people actually can’t listen at all). Finally, not all of us feel comfortable dominating a conversation for a full hour with our own concerns. I still have to restrain myself from asking my therapist how she’s doing. But the contract of therapy makes this OK, or rather mandatory, and I need that.
Therapy doesn’t have to be lying on a couch ruminating to a stranger about your childhood for years on end. Ideally (in my view at least), it’s a skillful and compassionate conversation, giving you space to reflect, gain more insight into yourself and your situation, and figure out what to do about it. It’s not self-indulgent or feeble, and it’s no less practical than seeing a tax consultant or a dentist (nor is it necessarily less difficult and uncomfortable, although you don’t generally have to stare up your therapist’s nostrils). Supportive counselling has been proven to be as effective as medication for many people with mental health diagnoses, and has very few side effects (Note: I’m all in favour of meds when appropriate – see Beginner’s guide to happy pills)
To me, it seems obvious that you should find the right person to talk to before there’s a crisis, so that they know who you are and what you’re really like before you’re teetering on the edge. That is generally not a good time to give a life history, nor have judgments made on your baseline levels of sanity and sense. Ideally, I think we should all go for a six-monthly mental health check-up in the same way as we go for blood pressure and cholesterol tests and prostate exams. We should get Vitality points for it.
So what do you look for in a therapist?
First, it helps to know what different healthcare workers are actually qualified to do. This may seem obvious, but my medical aid apparently doesn’t know the difference between a psychiatrist and a psychologist (terrifying but true). There’s a fair amount of difference in qualifications, scope of practice, and importantly, price. Simply put (note – true for South African context):
- A psychiatrist is a medical doctor, who has completed a four-year postgrad specialisation in psychiatry. Only doctors can prescribe medication, although you don’t have to be a psychiatrist to do so. Different psychiatrists have different interests and some have done additional training in particular kinds of therapy, but it’s worth knowing that their training tends to focus on medical interventions rather than counselling, and as medical specialists their hourly rates are pretty steep.
- A psychologist generally has an undergraduate and masters degree (sometimes also a PhD) in clinical psychology, although you also get educational psychologists, organisational psychologists, industrial psychologists and so on, who might also be appropriate for your needs. Psychologists don’t deal with meds; talking therapy is their main job.
- A social worker has a social work degree, which includes substantial counselling skills and a practical grounding in all kinds of social issues, from child protection to care of the elderly to addictions. They usually specialise in one or other field, and like psychologists, can register in specific categories with their professional board – clinical social workers are most often those offering psychotherapy. Medical aid rates for social workers are substantially less than those for psychologists, although this is no reflection on their level of expertise (FYI, my therapist is a social worker).
- Other kinds of counselors, registered and otherwise, abound. Chances are however, that your medical aid will not pay for them (no matter how good they are), unless they fall under specific categories (usually the above three, but check).
At the end of the day, the qualities, skills and experience of the individual therapist are what matter, and these vary between people even with the same formal qualifications. However, you should be sure that the person you see (a) has the appropriate skills for your needs (and will acknowledge their own limitations and refer you on if needed), (b) is ethically bound by their profession’s code of practice, and ideally is under the oversight of a regulatory body such as the HPCSA and (c) will be affordable and/or covered by your medical aid plan, if you have one that covers therapy.
So, beyond qualifications, what should you look for in the individual?
Firstly, you should like her (or him), and feel comfortable talking to her. It may seem obvious, but if there isn’t a rapport or connection between you, you aren’t going to trust her with your mess. This might not mean she isn’t a skilled therapist, there may just be reasons she’s not the person for you. Or you for her (therapists are people too). But remember she is a therapist, not a friend.
Therapists play a professional role with very particular boundaries. Some keep themselves very much behind a professional “front”, remaining as neutral as possible, and this goes with a particular therapeutic approach. Others show more of themselves in therapy, and ideally their own personalities and experiences become therapeutic tools. There’s no one “right” level of this (although if your therapist starts telling you about their problems, get your money back and find someone else), but you should feel comfortable with how they handle themselves. For me, it has mattered a lot to know that my therapist has herself been through some of the things I’ve struggled with.
Next, you should never, ever feel judged. Something I have found really helpful (and quite revelatory) is a quality or technique called “unconditional positive regard”. This simply means your therapist treats you like a worthwhile and decent human being, no matter how messed up you are or what you tell her. It might seem like a no-brainer, but it’s not always the case. Personally, I need to know my therapist likes me and considers my life and problems important (or at least is effective in pretending so while I am in front of her. It’s not actually that easy to fake).
Also, I don’t like to feel like I’m being therapized. I’m an occupational therapist (OT), and maybe there’s always part of my brain assessing (and yes, judging) what the person in front of me is doing. But that’s probably not just a professional thing – lots of people don’t like hearing “hm, and how did that make you feel?”. To me, the really skilled therapist’s skills are mostly unnoticed, because they feel natural and authentic.
Let me be cautious about emphasising comfort in therapy. There are times when good and effective therapy must be uncomfortable to get to the point. Your therapist should be skilled in knowing when and how to challenge you, and hopefully you can spot the difference between this kind of discomfort and other kinds (at least most of the time – sometimes the statements that most outrage us for being completely not true about ourselves turn out to be the most accurate).
Should a therapist tell you what to do? Absolutely not. But sometimes yes. I’m in favour of practically focused therapy, and (as an OT), all in favour of having things to do. Sometimes you absolutely do need guidance on how to deal with a situation, or what to do next. Prescriptive or bossy intervention, or jumping to solutions before you’ve got a handle on what the problem is, isn’t useful. Never giving any direction at all can equally be a problem. Better than directing you however, a therapist can help you with a range of tools for managing yourself better. Cognitive-behavioural therapy (CBT) and mindfulness-based practice are among the best known and most effective strategies, and there is growing evidence that they actually change the brain structures behind anxiety and depression. Gaining insight into your condition is essential for recovery, as is getting to know your own triggers and how to work around these in daily life. Therapy can also help you deal with unresolved grief and relational issues, which are often at the root of mental illness.
There is a lot more I could say here about different schools and philosophies of therapy, but to me, what I’ve said here is what really matters. We’re all different, and respond to different things, sometimes even from one time in our lives to another. Some approaches have been “proven” by clinical trials to work pretty well for particular conditions, but therapy is as much an art as a science, and can only work when the relationship between client and therapist allows it. Finding someone you trust and can relate to is usually more important than how many degrees that person has.
Hopefully this inspires you to go out and find a therapist immediately (and no, I will not be getting commission from anyone if you mention this blog post, although you’re welcome to suggest it). It can take time and be frustrating (not to mention costly) to shop around, so it’s worth asking for recommendations from people who know you – and of course, bearing all of the above useful points in mind. Personally, I think a speed-dating format would make therapist-finding more efficient and cost-effective, and I’m hoping medical aids will cotton on and pay me to set this up (although I might need to start with straightening out the psychiatrist/psychologist distinction for them first).
It is however really worthwhile: therapy, with the right therapist, really does work. You can do better than just surviving, and you don’t need to do it alone.
*IMPORTANT: This post assumes you have the cash and wherewithal to access a therapist, and the luxury of choosing whom you will see. In South Africa, this will be less than 20% of the population. State mental health services are terrifyingly scarce and poorly resourced, and as with most other health problems, those who most need the care are the least likely to get it. We desperately need ways to get more resources, including human resources, into public mental health care at community level. We have to figure out ways for the private and public sectors to partner for better and more cost-effective services across the board.