Finding a Therapist: Part I

Part I: Psychologist, psychiatrist, therapist?

As a therapist, I am often asked for therapist recommendations.  Despite working in the field and knowing a whack of both budding and seasoned therapists, this question is not so easy to answer.  I have often found myself casting around, searching for my own therapist .  I think now of the German poet Rilke’s words: “At bottom, and just in the deepest and most important things, we are unutterably alone, and for one person to be able to advise another, or even help another, a lot must happen, a lot must go well, a whole constellation of things must come right in order to succeed”.  In other words, finding a therapist is no easy task.  Even for a therapist.

This is the first of a number of posts that hopes to address this difficult and important task.  It bears saying at the outset that I am writing from a Canadian perspective.  Much of the information and terminology I use will vary depending where in the country or the world you are reading from.  I have tried to address these discrepancies as they arise and I believe the bulk of the information provided in these posts will apply to you wherever you live.  Please also not that the term ‘therapist’ and ‘counsellor’ and ‘psychotherapist’ are used more less interchangeably throughout.

The first question to ask yourself, when searching for a therapist, is as follows: Is a therapist the right professional for me? A therapist is not a psychologist, a psychiatrist, or a life coach.  A therapist, also known as a counsellor or a psychotherapist, is distinct from the aforementioned professions in philosophy, education, professional psychotherapeutic training, and fees.

Psychiatrists have medical degrees.  They are doctors, and as such are able to prescribe medication.  Here in Canada, visits with psychiatrists are covered by provincial health plans.  A visit with a psychiatrist requires a referral from a family doctor, hospital, or mental health organization.  As a general rule, psychiatrists focus on the most severe forms of mental illness/psychopathology such as major depressive disorder, bipolar disorder, and schizophrenia.  People suffering from the aforesaid disorders almost always benefit from seeing a therapist in tandem with a psychiatrist, but a psychiatrist may be considered an indispensable part of treatment.

I have personally seen more than a handful of psychiatrists, and my experience has not been positive.  Philosophically speaking, psychiatrists are trained under a Western medical model and as such, are primarily focused on diagnosis.  The general tendency of psychiatrists to eschew the therapeutic relationship (more commonly known as ‘bed-side’ manner) as well as their lack of client/patient-centeredness is problematic, and I think it is a systemic issue that needs addressing at the level of training.  In other words, my experience with psychiatrists has often been alienating and even stigmatizing.  Having said this, one cannot dismiss the important role played by psychiatrists and I do not want to disparage the important work they do.  Particularly in cases of severe psychopathology, and in cases of less severe psychopathology where medication is warranted, working with a psychiatrist is absolutely essential.   (A quick word on this last point.  I feel it is important to note the importance of psychiatrists in the case of anti-depressants.  While anti-depressants have come to be widely prescribed by general physicians, my own experience has been that general physicians are ill-equipped to help patients navigate these medications.  If you are taking antidepressants or considering their use, I highly recommend a referral to a psychiatrist).  My personal and professional experience also leads me to suggest that if you are seeing a psychiatrist, you also find a good therapist.  Or perhaps you have found that rare unicorn, the psychiatrist with extensive training in psychotherapy, in which case consider yourself lucky!

Psychologists do not have medical degrees.  Most psychologists will have Phd’s in counselling psychology, clinical psychology, or a closely related field.  In Canada, a limited number of visits to registered psychologists may or may not be covered by extended health plans, employee assistance programs, hospitals, or other government subsidized programs.  If you pay out of pocket, psychologists generally charge in the neighbourhood of $200 dollars per hour.  This is the fee recommended by the BC Psychological Association (the licensing body here in the province of British Columbia), but you may find there is some variation.  While the wait times for psychiatrists can be prohibitive, my experience has been that it is often easier to get an appointment with a psychologist, particularly those who work in private practice.

Psychologists see patients/clients from across the spectrum, including those with severe psychopathology.  Psychologists, particularly clinical psychologists, are often trained within a diagnostic model much like psychiatrists, however most will have additional psychotherapeutic training.  Unofficially, my experience has been that philosophically speaking, psychologists fall somewhere between therapists and psychiatrists.

Therapists/Counsellors deal with less severe forms of psychopathology.  At least in theory.  Therapists see people struggling with anxiety, depression, difficult life transitions and stressful life events, relationship problems, emotional abuse, sexual abuse, physical abuse, domestic abuse, grief, divorce, suicidality, family issues, addiction, behavioural problems (particularly in the case of children), career questions, and more.  A therapist may be what you are picturing when you think of Freud and his patient lying of the couch.  A therapist may be what you imagine when you hear the words ‘talk therapy’.  As opposed to a psychologist or a psychiatrist’s focus on mental illness, a therapist focuses on mental health/mental well-being.   A therapist does not generally manage incidents of acute mental crisis, but rather helps clients to process difficult experiences both past and present, to problem-solve, to improve relationships, to develop and better understand the self. While therapists have extensive knowledge of psychopathology and the Diagnostic and Statistical Manual of Mental Disorders (DSM), they will usually also have training in a psychotherapeutic orientation of their choice.  In contrast to the work done with psychiatrists and psychologists, therapists often (though there are some exceptions to this rule) focus on the relationship between the therapist and client.  Creating a safe, trusting, nonjudgemental, and unconditionally accepting relationship is almost always one of the central goals of treatment.

Here in Canada, a limited number of sessions with a registered counsellor may be covered by extended health plans, employee assistance plans, or other government subsidized programs.  If you have to pay out of pocket, a registered counsellor generally charges approximately $120 an hour, though there is some variation and some registered counsellors may offer sliding scales.  Unlike psychiatrists and psychologists, here in Canada, the title of ‘counsellor’ and/or ‘therapist’ is not protected.  This means that many counsellors and therapists may not have graduate degrees.  Likewise, many may not be registered.  There is nothing to stop a person from hanging out a counselling shingle and proclaiming oneself a counsellor, but much more on this issue later.

Deciding whether or not you need to see a psychologist, a psychiatrist, or a therapist depends upon your individual mental health needs, your own philosophical orientation, and accessibility.  Often you may need to see more than one mental health professional at a time.  Perhaps you will also decide to see a life coach (more on life coaching to come) or an energy healer.

Once you have decided on the type of mental health professional you need, next comes the tricky work of choosing the individual. Stay tuned for more posts on this tricky business!