A Step-by-step Guide to Finding a (Good!) Therapistpost by squidious · 2018-07-18T01:50:00.581Z · LW · GW · 5 comments
The process of finding a good therapist is unlike the process of finding most professionals. If your dentist nags you to floss more every time you see them, it's annoying, but unlikely to really affect the quality of their work. In therapeutic work, however, most of the work comes from the bond between therapist and client. If you find yourself worried about your therapist judging you or don't trust them to bring up important parts of your life, you won't be able to get the most out of therapy. Of course, this can make the process of starting therapy intimidating! It is very important to know that you can always talk to your therapist about changing what they're doing or referring you to someone else -- something I've written about previously in my guide to termination. Here, I'll instead talk about the first in these two bookends on therapy: finding a therapist.
The first thing to remember in finding a therapist is that if you have a bad experience, it is more likely that the therapist is a bad fit than "therapy doesn't work for me". Finding a good therapist is more like dating than it is like finding a mechanic, because of the emotional trust and freedom from judgment that I mentioned above. This means you may have to try a few times before finding The One, and once you do find someone good, there is no guarantee that they will be affordable, available, or local. Part of the reason I am writing this guide is that I am hoping the advice below will reduce the number of tries it takes to find someone who works for you.
What are your needs?
In order to find someone who works for you, you have to know what your needs are. The most obvious needs here are the practical: fees, location, timing, insurance, and accessibility. If you don't have much to spend on therapy, you may be confined to clinics and whatever your insurance covers. However, it is important to know that if you're working through insurance, they are required to find you someone who meets your practical and therapeutic needs, or else they must cover someone who is otherwise out of network. So if you're looking for an OCD specialist and nobody on your insurance has availabilities, they are still required to help you out. Working with insurance can be frustrating, for both therapist and client. Fees are often so high because a therapist working with insurance may get less than half of what they charge. Associates, Interns, and Trainees often have much lower fees, though they are significantly less likely to take insurance because they are prelicensed.
When it comes to therapeutic needs, we usually have a sense of what issues we're struggling with. However, there is much more in this category that many are unaware of before starting therapy for the first time. For starters, there is a difference between having expertise, knowledge, or familiarity with the important issues. On some directories, therapists may list any and all issues they have familiarity with, even if they don't have training or expertise. Checking their personal website (if they have one) may provide more information, but otherwise, this may be an important thing to ask in an email or over the phone. Someone who is struggling to come out as trans may need a gender specialist, while someone else who has already transitioned and is looking to work on something else may only require that their therapist be familiar with trans issues.
One of the most difficult areas to assess in ourselves is what we need the therapist to be doing in the room. There are so many theories and techniques, and often times, the websites that therapists advertise on don't explain what any of them mean or what they look like. Most people have a clear image of old school therapy (lying down on the couch and talking about your dreams and childhood), but this is only one school of therapy (psychodynamic, specifically). If you look at what sorts of introspection and regulation interactions and activities work for you, often times those are linked to therapeutic techniques. What many people think of as a "pros and cons list" is called Cost Benefit Analysis in Cognitive Behavioral Therapy, and if reflective listening feels most helpful, Rogerian Therapy (also called Person-Centered Therapy) is based in just that. If you have found a CFAR technique that works well for you, I can almost guarantee that there is a therapeutic technique that it is based on that you may find works as well.
There are a few parts of the therapeutic process that are not often spoken about, but can make a huge difference. One example is that some therapists allow you to text them to schedule and reschedule appointments, and this can make a big difference for someone who has phone anxiety. There is also who leads conversations and how much, and focus on solutions vs introspection. A therapist who listens and tries to prod on introspection isn't going to help someone who wants guidance and solutions, just as a therapist who leads and looks for solutions isn't going to help someone who needs to work through their emotions first.
For those who need a low fee therapist, there are training clinics associated with universities where prelicensed therapists practice under the supervision of a more experienced licensed therapist. If you find someone who calls themselves an Associate Therapist or a Therapy Intern, they are probably prelicensed and in training. You will find prelicensed individuals at training clincs run by universities and in private practice, though they rarely take insurance. This is a good way to get therapy for cheap, while still receiving all of the experience of the therapist's supervisor.
Finding a Therapist
Two of the most common ways to find a therapist are through insurance or through a directory. Insurance websites don't actually have much information on the therapists beyond location and a few areas of expertise; websites like Psychology Today and Good Therapy allow therapists to explain their practice in ways that are specific to their target clientele. Because of this, not all therapists have their own websites, but many (especially newer therapists) will. Psychology Today's therapist finder lets you search by insurance, though it is less reliable as to whether the therapist actually takes your insurance than going through your insurance company directly. It also lets you search by specialty, modality, gender, and much more. As I mentioned above, a therapist's listed specialty may not actually be something they're certified in, so it's often best to ask directly if this is important to you.
Another way of finding a therapist is through referrals. Most commonly, people get referrals through their general practitioner or psychiatrist. Sometimes, you can get a referral through a friend, though this can pose a problem if you and a very close friend are seeing the same therapist, and some therapists may refuse to see someone close to a client due to the possibility of each coming up in the other's sessions. This is also why you usually cannot have the same therapist for couples and individual counseling, or for individual for you and your partner. I am currently compiling a list of professionals in the Bay Area approved by those in the rationalist community, and other communities often times have similar lists (for LGBT, poly, kink, fat-friendly, etc). Often times, the best referrals come from an existing professional. All therapists have referrals ready in case they end up with a client who can't see them anymore, for any reason. The better and more well connected the therapist, the better their referrals are going to be. Thus, advice I often give for finding a good therapist is to find someone who is the best match for you (ie someone who wrote a book on your niche issue or did an important research study on a technique you love) and ask them for referrals (unless you luck out and they are available and affordable).
Online therapeutic services are getting more and more common. Some websites function as referrals, like Reflect (which matches people in SF and the East Bay to therapists who match their personality via video chat consultations). Others allow you to chat directly with a therapist, like Better Help. Some, like 7 Cups of Tea, match you to a trained listener rather than a therapist, so they can provide therapeutic services for free. There are also websites like Mood Gym, a CBT self help tool that is particularly helpful in pointing out bugs. Many therapists also do video sessions. This can be very important for people with chronic illness, disabilities, or social anxiety; you can get help without even leaving the house.
Once you've found someone, you can sometimes figure out whether or not they're a good fit based on online profile alone. If you want a tech-savvy therapist who can recommend apps and online tools, a therapist who doesn't have a website or doesn't check email very often is probably not a good fit. A therapist's website or directory profile often has a blurb that is directed at their target clientele. These tend to contain phrases like "Do you feel lost in your life?" and "It can be difficult to find a safe space to express our feelings". If a therapist's blurb doesn't speak to you, that doesn't necessarily mean it'll be a bad fit, but one that does is more likely to be a better fit. Sometimes, the blurb can give us insight into ourselves. You may read a sentence like "Do you ever get anxious and push people away?" and realize that yes, you absolutely do that. This is a good sign that this person may be a good fit, because the blurb is meant to attract the kind of person the therapist feels confident they can work with.
Of course, you can't fully judge whether a therapist is a good fit without talking to them. While it is possible to schedule an appointment blind, it is not recommended unless you feel confident that they are the therapist for you (ie if you are already familiar with their work via books or a blog). Ideally, a consultation would happen over phone or video, but sometimes it is just easier to talk via email. It is important to note, though, that if you and the therapist have difficulty scheduling time for a phone call, you are likely to also have difficulty scheduling sessions.
In the initial consultation, you will both be learning about each other. Your therapist will be listening to your description of your symptoms and needs to assess whether they feel they can take you on as a client, and you will be noticing their responses to decide whether you trust this person enough to make an appointment. Notice how comfortable they are or aren't to talk to, and how the experience of the consultation feels. Do you feel heard? Judged? Understood? Ignored?
This is also the time to make sure they actually fit your needs, practical and otherwise. Online information may be dated, your schedules may not mesh, and they may have only taken a class or two in a technique that you need an expert in. If you have questions about fees, this is also the time to ask about that; many therapists have sliding scale fees and can make accommodations for those paying out of pocket, though a lot of these therapists won't advertise this unless there is an expressed need for cheaper therapy, so it's good to ask. Try and settle on a fee before you schedule an appointment, so you aren't shocked by the numbers once you're charged. Once you're talking to them, you should also find out what the easiest way to reach them is in case you need to contact them before the session. It is good to know how to get in touch with them if you have trouble finding their office or are running late.
Clients often forget key information during initial phone consultations. Remember to mention your name and age, as well as what you're coming into therapy for. Including a general sense of your weekly schedule and any concerns about insurance or ability to pay can also be very helpful. Depending on how much time you have for a consultation, you may not have time to get to culture and experience in therapy, but these should be brought up either in the consultation or within the first couple of sessions. Culture includes elements of identity, such as sexuality, languages spoken, military background, etc. Depending on your concerns, these may be more important to bring up in consultation (ie if you need an LGBT friendly therapist or if you prefer a therapist who can speak your mothertongue). Similarly, previous therapy experience, diagnoses, and psychiatric meds taken can give your therapist important information about what your concerns are and what does or doesn't work. Some of this stuff may be covered in the intake (also called biopsychosocial), but it's important to discuss it in session nonetheless.
Some therapists give you intake paperwork during the first session, while others send it to you before the first session. If you have the option, it's always best to get it finished before the first session; otherwise, you may end up spending half of your first session filling out paperwork and not get to talk to the therapist very much. Regardless of when you fill this out, note that it can be pretty intense and involve a lot of invasive questions. Some of these questions may seem totally unrelated to what you're coming in for, but in fact it may not be. Eating and sleeping habits, family history, child development, how you were parented, and events you experienced as traumatic (even if you feel they don't count!) can make a huge difference in someone's life. Depending on your history, the intake may involve revisiting old wounds. This is another reason it can sometimes be better to do paperwork before session; you can take your time and go at your own pace, rather than feeling rushed like you might in session.
What other forms you need signed depends on where you live and who you're seeing. There will most likely be at least an informed consent form, that tells you about some of the risks and benefits of therapy. There may be a separate form to consent to being filmed or recorded, or one to consent to therapy over phone or video. A therapist who uses online recordkeeping may be required to give you a packet of information on their privacy practices, and have you sign a form saying you received it. If you have other providers you see (ie a psychiatrist, couples/family therapist, social worker, etc) you have the option to sign a release to allow them to communicate. You can use this same form (Authorization to Obtain Information) to allow a previous therapist to speak with or send their notes to your current therapist. On top of this, child, couples, and family therapy may require other forms, like a specific informed consent for minors or a no secrets policy for couples, depending on the therapist and how they conduct therapy.
When scheduling a first session, make sure you are not rushing to or from therapy. Intense emotions can come up in therapy, so going to an important meeting right after is a bad idea, if it can be avoided. Relatedly, check in with your therapist about their cancellation policy and if they do phone or video sessions. This is often included in the paperwork somewhere, but it can be helpful to establish ahead of time. Most therapists have 24 hour or 48 hour cancellation policies, so if you cancel within the time window or don't show up at all, you will still get charged. In this sense, it is better to reschedule or have a phone or video session than to pay for a session you couldn't attend.
Lastly, it can be helpful to take notes during the week to remind yourself of things to bring up in therapy. Journalling helps a lot with this, as does keeping an organized schedule, but you can even just jot down a few quick reminders on your phone. This can include difficult events during the week, realizations about yourself and your progress, or goals you have for therapy. Not everyone has the ability to put in a lot of work outside of therapy, but a little can go a long way.
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