Shop For A Psychotherapist To Avoid The Lemons

Originally published on May 20, 2011 2:30 pm

Turn on a TV talk show, and you'll think that everyone in America is in need of mental health counseling. But there are hundreds of different kinds of therapy out there, and it's hard to know which ones work.

Researchers have put a lot of effort into testing different forms of psychotherapy, and they have solid evidence of what works, particularly for common mental problems like depression and anxiety.

But despite that, people can't presume they're going to get the right psychotherapy, according to Alan Kazdin, a clinical psychologist who directs the Yale Parent Center and Child Conduct Clinic. That's partly because therapies don't have a lot of marketing money behind them, unlike new pharmaceuticals. As a result, "The public doesn't know about them and isn't demanding them," he says.

In the past decade, there has been a big push in the mental health community to use evidence-based therapies to treat common mental health problems like depression, anxiety disorder and obsessive-compulsive disorder. The STAR*D trial, for instance, found that cognitive behavioral therapy and interpersonal therapy were as effective as antidepressants in treating major depression.

Shop For Therapy Like You Shop For A TV

But not all therapists have adopted these treatments, and with hundreds of different forms of therapy offered, it's difficult at best for people to figure out what kind of therapy they need, and then find it.

People should be as practical-minded when they shop for therapy as they are when they shop for a flat-screen TV, Kazdin says. And they should ask therapists: Do you use an evidence-based treatment, which one, and how often have you used it?

"People are now much better shoppers when they seek surgery in hospitals," Kazdin says. "And all we need here is just that same informed nonprovocative questioning about, 'I'm paying for a service and I'm suffering. Am I getting the best I can get?' "

Web resources can help identify treatments that have been tested and proven effective. A searchable database from the federal Substance Abuse and Mental Health Administration (SAMHSA) is a good place to start. So are advocacy groups like the National Alliance on Mental Illness or the Depression and Bipolar Support Alliance. Once you know what kind of therapies work, professional societies like the National Association of Cognitive-Behavioral Therapists can help find therapists who have specialized training.

But shopping can be a challenge when you're suffering.

'I Wasn't Sure Where To Turn'

Janet Ohlsen found that out. Three years ago, she started to spiral downward into depression, anxiety and bipolar disorder. She was dizzy and couldn't think straight. Once, she told her husband she was going to do laundry; instead, she disappeared into the woods near her home in Erieville, N.Y.

Her physician prescribed antidepressants, but she reacted badly to them and more than once ended up in the emergency room. She diligently researched her various diagnoses and discussed them with her doctor but still had a hard time finding treatment.

"I wasn't sure what was wrong with me," Ohlsen, 54, says. "I wasn't sure where to turn."

A friend who was a clinical social worker recommended a therapist who does psychodynamic therapy. "I was lucky in getting a good therapist right off the bat," Ohlsen says.

Ohlsen has assembled a team to help her manage her mental health: her primary care physician; a psychiatrist who prescribes medication; and her psychotherapist, whom she sees twice a week.

"Counseling is the biggest part of this whole recovery — finding someone you trust, someone you click with," Ohlsen says. She and the psychotherapist have been working together on negative thinking, which is a hallmark of depression.

"I think a lot of people, mental illness or no, have a tendency to have immediate negative thoughts on everything," Ohlsen says. The therapist, she says, "forces me out of that."

She's now back to training for a triathlon and plans to help coach other women who are recovering from illness.

The Art Of Persuasion

Some therapists fear that the push for evidence-based techniques will restrict their ability to connect with their clients on a deeply human level, that they'll be doing cookbook therapy.

Scott Lilienfeld, a clinical psychologist at Emory University, says a good psychotherapist can do both. He's the author of the book 50 Great Myths of Popular Psychology: Shattering Widespread Misconceptions about Human Behavior and a frequent critic of ineffective or dangerous therapy. "Most good therapists are good listeners," he says.

That's critical, because psychotherapy done right is hard work. "A lot of psychotherapy is difficult," Lilienfeld says. "It involves getting people to change and try hard things, try new things that people have often been resisting. Part of the role of a good psychotherapist is persuasion. It's getting a person to understand why they should change."

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And if you turn on a TV talk show, it can seem like everyone in America's getting counseling. But how does one find help that's right for you? NPR's Nancy Shute reports on why it can be difficult to find good psychotherapy.

NANCY SHUTE: Scientists have put a lot of effort into testing psychotherapy, to see if it really works. As a result, they now have solid evidence on therapy for common mental problems. But Alan Kazdin, a clinical psychologist and director of the Yale Parenting Center, says you can't always find it.

ALAN KAZDIN: And in fact, we have very effective treatments for all sorts of things. And to try to get one of them, if you have a problem, is very difficult.

SHUTE: In fact, there have been thousands of randomized clinical trials done on psychotherapy. They've found behavioral interventions that work just as well as drugs, and with no side effects. One of the great success stories is cognitive behavioral therapy. It teaches people to replace negative thoughts about problems in everyday life.

KAZDIN: Cognitive therapy, for depression, is one of the most widely studied treatments. It has evidence going back to the late '70s, and much more evidence in more recent years. It's a treatment of choice for psychotherapy for depression.

SHUTE: And there are dozens of other good therapies for mental health problems. Kazdin is part of a movement to make those treatments part of all psychotherapy. But that movement is having a hard time gaining traction, and Kazdin's really not happy about that.

KAZDIN: It would be like, you know, having grape juice to control your cancer when in fact, there's chemotherapy.

SHUTE: So if you or a family member need mental health therapy, it's time to become a savvy shopper. Kazdin explains how.

KAZDIN: You interview therapists. Or if you're incapable of doing that because of some crisis, you have a relative help you. And among the questions would be the obvious ones: What do you do when you see patients like me - or like my spouse or my sister; and what is the evidence for that treatment? And then, is there anything I could read about that? And then I would go home and look all this up.

SHUTE: But when you're suffering, it can be hard to shop. That's what happened to Janet Ohlsen. Three years ago, she was doing triathlons. Then, she started losing control.

JANET OHLSEN: So things spiraled down quickly and - ended up in the E.R. about three times for craziness, sort of manic symptoms - running off into the woods and hiding and - you know, it's just insane.

SHUTE: Janet lives in a small town in upstate New York, where there aren't too many health-care choices. So she did another thing that people can do: She asked a friend, who is a clinical social worker, for advice.

OHLSEN: Fortunately, I met - or I have a very good friend, and she had recommended a therapist that she had worked with. It was perfect.

SHUTE: That therapist practices psychodynamic therapy, which has been shown to help with depression. As far as she's concerned, Ohlsen says that therapy has been a huge factor in her recovery.

OHLSEN: My psychologist is just wonderful, and she helps me for minimizing my actions and my tendencies to neglect my health and well-being, no matter what it might be.

SHUTE: Scott Lilienfeld disagrees. He's a clinical psychologist at Emory University. He says good therapy has room for both science and a human touch.

SCOTT LILIENFELD: Part of the role of a good psychotherapist is persuasion - is getting people to understand why they should change.

SHUTE: Nancy Shute, NPR News.


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