Psychotherapy, like religion, is often shrouded in mystery. All too frequently it is approached on blind faith. For the enlightened individual in the 1990s the process of looking for the right therapist should be no more mysterious than choosing an accountant or attorney. At all times in your search for a therapist you should remember that you are a consumer--and proceed in an informed and intelligent manner. A good psychotherapist is not someone who possesses some absolute truth, but rather a trained professional who should always have your own best interests at heart.
People choose to enter into psychotherapy for different reasons. Often some kind of crisis will lead an individual to decide that it's time for help. Crisis may attend the end of a relationship, the death of a loved one, a diagnosis of HIV or AIDS, job loss, problem drinking, or some other drug problem. At its most serious, such a crisis can involve suicidal thinking.
But crisis is not the only reason why people turn to a therapist for help A feeling of being out of control of one's life, being unhappy or lonely and not knowing what to do about it, or a vague sense of growing dissatisfaction-- any of these can cause people to want to make basic changes. Therapy is one way to bring about such changes. Nevertheless, it is crisis that sparks the move to therapy in most cases, and a person's judgment is not normally at its best during a crisis.
Many people use the terms counseling and psychotherapy interchangeably. Counseling is generally a short term process geared to solving a specific problem. A common goal of counseling is to reduce anxiety, usually without attempting to explore or resolve the underlying reason for the anxiety. In this respect it is only one way to handle symptoms. Counseling is having someone to talk to and hold your hand during emotionally strenuous times. Counseling often involves a lot of problem solving and, is one important component of psychotherapy.
Psychotherapy, or therapy for short, can be brief, but is in general longer-term than counseling. It is a general term used loosely to describe an interpersonal process that occurs between the therapist and client (or patient) to help treat nervous, emotional, or psychiatric disorders. Therapy usually aims toward bringing people more in touch with their feelings--and toward learning to act in accordance with these feelings. It may examine recurring negative patterns and unconscious motivations. It can actually be a process of slow personality restructuring. At times the therapist may even increase the client's anxiety intentionally in order to help him or her expand self-awareness.
One good way of finding the right therapist is to ask by good way of finding the right therapist is to ask your personal physician for a referral. This of course proceeds on the following assumptions: You trust your doctor, he or she knows that you're gay; and you are pleased with the degree of sensitivity and expertise with which you have been treated. Physicians regularly refer their patients to psychotherapists. Over the years they receive considerable feedback about many therapists, and this ordinarily gives them a good perspective to make such referrals, just as they would to dermatologists or other specialists.
Most people living in or around New York City know at least one person who is in therapy. If you like the changes that this person may be experiencing, then talk to him or her about the possibility of consulting their therapist. Be prepared for the fact that if you do see a friend's therapist, he or she will not discuss your friend's psychotherapy with you.
You can always contact the Gay Switchboard or consult the Gay Yellow Pages to find a therapist who is either identified as gay or lesbian or lists themself as sensitive to lesbian and gay issues.
It is crucial to bear in mind that there are some very inadequate therapists, gay, lesbian, or straight. So it is usually best to proceed on the basis of personal referral. Certain lesbian or gay therapists can in fact be shortchanging their clients by not providing as sophisticated treatment as is required. Certainly to view the dynamics of sexual orientation, coming out, and oppression are important issues for all lesbian and gay patients. But just how they tie into broader psychodynamics is equally critical--and must be explored and worked through in order for therapy to be truly effective. In other words, be wary of the psychotherapist who sees things in purely political terms. Otherwise the same goals could be achieved in a "consciousness-raising" group.
Never forget: you are a consumer seeking to purchase a service! If possible, obtain two or three referrals. and have several consultations before deciding where to make a commitment to treatment. Do not allow yourself to be pressured if you're not sure how you feel about an individual therapist. Therapy is a very personal decision--and something on which you spend considerable time and expense. Trust your instincts. If you have doubts or questions, express them. How the therapist responds to your concerns should be very helpful in resolving how you feel about working with this person.
Typically your initial contact with a therapist will be over the telephone. If you left a message with a service or on an answering machine, how promptly was your call returned? Did you feel comfortable talking with this person over the phone? Begin by telling the therapist how you got his or her name. Ask whether he or she is accepting any new patients. (Why should you begin to pour your heart out, telling your problems, to someone who may not even be able to see you for a single consultation?) But most therapists can usually find an hour for a ~one-shot. consultation. Therefore a friend's therapist whose practice is filled may be able to see you once--and after discussing why you are there, be in a good position to refer you to someone else. Be prepared to pay for each consultation.
During your initial interview with any therapist you can certainly expect to be asked many questions. But at the same time, you should remember to ask questions too. Are you comfortable? If not, how come? Do you trust this person? Do you feel understood? These last points are crucial if therapy is going to work. It is important for you to discuss all these feelings with the therapist. It is also critical for you to evaluate whether you are satisfied with the therapist's response to your questions and concerns.
It is perfectly natural and understandable to feel awkward and uncomfortable during the first session with a therapist. Such feelings do not necessarily mean that this is not the therapist for you. But if they persist, consult with someone else after you have discussed these feelings with the person you are working with.
Some therapists suggest an initial "mutual evaluation period" of four to six weeks to determine whether or not the "fit" between client and therapist is correct. If you're not certain that you wish to begin treatment with someone but want to try it out, you can always be the one to suggest such a trial period.
Two obvious questions are whether you wish to be in therapy with someone who is gay or straight, and whether it ought to be a man or a woman. Your therapist need not be gay in order to be effective. But the therapist must not be homophobic or heterosexually biased. It is incumbent upon you to ask enough questions of him or her to satisfy yourself about how they view lesbians and gay men. You should not have to spend your time or money educating a therapist about lesbian/gay lifestyles.
Will you feel comfortable talking about sexually explicit matters with someone of the opposite sex? If you don't feel that this is an issue for you, then the gender of the therapist is probably not important.
You will need to ask any perspective therapist many questions before deciding whether or not you want to set up an initial appointment with him or her. Affordability is one of the very important components of choosing the correct therapist. If the therapist does not state what his or her fee is during the first phone call then you should ask. If you have medical insurance that reimburses you for part of the cost of therapy you will want to ask the therapist if he or she has the necessary credentials in order for you to be reimbursed. If you are on a fixed income then you will need to inquire about whether or not the therapist accepts Medicaid, Medicare or will accept assignment. Assignment means that you sign a certain section on the health claim form indicating that you want the insurance company to pay the therapist directly.
In addition, if you are seeking therapy while you are employed and can afford a particular fee, how negotiable will the fee be if you ever lose your job, have to go on disability or public assistance? It would certainly not be in your best interest to begin therapy, feel that you are doing important work in your treatment only to find out if and when you are unable to continue to pay the original fee that this therapist will not continue to work with you at a reduced fee. This is very important to discuss during the initial phone call or initial visit. If you are not comfortable with how the therapist responds to your questions, or if he or she does not state categorically that there is the potential for flexibility in the event of an emergency situation, then you may not wish to even schedule an initial appointment with this person.
Fees are, of course, an important consideration when choosing a therapist. A growing number of therapists ask clients to sign fee contracts. These contracts explain how the therapist expects to be paid. Some wish to be paid in advance, at the start of each month, others agree to being paid after each session. Some therapists prefer to be paid at the end of each month of treatment. The contracts also usually explain a particular therapist's policies regarding cancellation and rescheduling of sessions.
As important as therapy is, paying for it should never develop into a new source of major anxiety. When inquiring about a therapist's fees, if it's more than you can afford, remember to ask if a sliding-scale fee is available. If the fees are not flexible and regular therapy with that particular therapist would be a financial burden, then ask him or her to refer you to a colleague who charges less.
Therapy need not be expensive. There are ways of economizing. Seeing a therapist at a hospital, clinic, or training institute will probably be less expensive than with a private practitioner. At a hospital or training institute you may be seen by someone who is not yet licensed, certified, or finished with training. Through this individual may have less experience in working with patients, this does not mean that they will be less empathetic or skilled in helping you. Such therapists in training are subject to professional supervision themselves.
Recent graduates who are just beginning their own private practices will generally charge less than someone who has been out of school for awhile with completed postgraduate training. You could also suggest beginning every other week instead of weekly or several visits weekly if your budget is tight, though clinically speaking this may not be the best idea. The beginning period of therapy is a crucial one, and regular weekly contacts are preferred in order to insure the establishment of a good working relationship.
Some therapists grant their patients credit. You can very easily go into debt to a therapist, especially in a time of crisis. You must examine your own feelings about this carefully before entering into such an arrangement. If you have medical insurance, read the policy carefully to determine whether outpatient psychotherapy is covered. Some policies limit coverage to treatment by psychiatrists or psychologists only. Other policies do not specify the discipline of the practitioner.
It is very important to ask any perspective therapist whether or not he or she has had experience working with other people living with HIV or AIDS. If coping with HIV concerns is only one of the reasons why you are seeking therapy then you should ask the therapist about his or her experience in working with people with what ever the concerns are that you have, e.g. being in recovery; eating disorders, ACOA issues, lesbian or gay issues, sexual dysfunctions, sexual abuse, incest, parenting, etc.
In a sense, this article is an attempt to demystify psychotherapy. There is not magic about the process of therapy or finding the right therapist. It entails some luck, lots of work coupled with common sense, and most of all your willingness to be informed, critical consumer of psychotherapy services. Finding the correct therapist can be confusing and daunting even when the issues are not as urgent and crucial as living with AIDS or HIV. If you are a person living with HIV or AIDS, there are some particular concerns that you need to explore with any perspective therapist.
You should also ask whether or not the person is licensed. (This is not to suggest that simply because a therapist has a graduate degree or is licensed by the state that he or she is a good therapist or the right one for you. There are many excellent people practicing psychotherapy who do not have a Ph.D., MSW, MD or RN, and many incompetent therapists with degrees.) Be prepared that a professional who is licensed will usually charge a higher fee than one who is not licensed.
You will want to inquire about how long the sessions are. (Currently most psychotherapy sessions run forty five, fifty or sixty minutes.) You should also ask how frequently does the therapist expect to see you. Usually therapy begins with once a week sessions, but in crisis situations more frequent sessions can be useful and appropriate. Will the therapist be available to you by phone if there is a crisis? Will he or she have some flexibility in their schedule if you feel the need for an additional session? If a medical emergency arises that prevents you from keeping your appointment, does he or she have the flexibility to reschedule your appointment? What is the therapist's cancellation policy regarding payment for missed appointments? If you are unable to get to his or her office will they do hospital or home visits or telephone sessions? I believe that these are all important concerns that need to be discussed before treatment begins so that you and the therapist can each decide if the fit or chemistry is correct between you.
Here are some questions to ask any prospective therapist:
In New York State, New Jersey, and Connecticut there ~is no licensing requirement or regulation for the practice of psychotherapy. In fact, anyone can literally hang out a shingle and claim to be a psychotherapist-- even if the individual has had no formal training. Various professionals and paraprofessionals practice therapy. and some of the more specific titles are regulated or licensed.
A psychiatrist is an M D who has completed at least four years of specialty training in psychiatry. Ordinarily, a psychiatrist should be affiliated with a hospital and have admitting privileges. A psychiatrist is the only kind of psychotherapist who can prescribe medication. The best trained psychiatrists have completed additional training in psychotherapy after residency. It is important to ask whether they have had such training since it not a requirement to become licensed. For the most part, psychiatrists work with in-hospital patient populations during their training. Psychiatric training also consists of learning to differentiate between neurological/ physical disorders and intrapsychic disorders--those that originate in a person's thoughts or feelings. Psychiatrists are typically the most expensive practitioners of psychotherapy, with fees ranging from $100-$300 per session. If your medical insurance covers outpatient psychotherapy services it will definitely pay for at least part of a psychiatrist's fee.
A psychologist needs to have either a Ph.D. or Ed.D. to be licensed by New York State. New Jersey. or Connecticut. There are different kinds of psychologists, not all of whom receive training in clinical psychotherapy. A clinical psychologist is an individual who has received extensive training in doing psychotherapy while actively working with patients under close supervision. This is a major part of the clinical psychologist's graduate training. This is contrasted to other kinds of psychologists who have specialized in laboratory research, educational counseling, or testing and measurements. So it is very important to ask a prospective psychologist about the Wnd of training he or she has completed. Psychologist's fees generally range from $75-$150 per session. The services of a clinical psychologist are generally reimbursable by insurance if therapy is covered.
Social Workers are also licensed by New York State after having completed either an MSW or MS degree and passing a certifying examination. New Jersey and Connecticut do not currently license social workers. A New York State licensed social worker has the designation CSW. If there is an "R" in front of his or her license number, they are qualified to receive insurance reimbursements for providing psychotherapy. ACSW means that the social worker is nationally accredited as a member of the Academy of Certified Social Workers, and is qualified to conduct a self-regulated practice by the National Association of Social Workers. A social worker who is practicing therapy should have a number of years of postgraduate training in psychotherapy, although this is not a requirement for either an MSW or initial licensing. Social workers generally charge from $40-$100 for a therapy session.
Pastoral Counselors are either current or former members of the clergy or individuals with strong religious backgrounds who have entered this field. It is important to ask about their training since some pastoral counselors are trained in theology, some in counseling, and others in psychotherapy.
A Peer Counselor is an individual who has no professional training. He or she may function out of an institution such as Identity House, a gay walk-in counseling center in Manhattan. and would have some kind of professional supervision. Peer counselors are often either volunteers or employees of crisis centers such as those that serve rape victims. This is probably the least expensive way to find someone to speak with about a problem. In many cases there is no fee at all for such services. Perhaps a donation may be solicited. If ongoing short-term counseling is provided, the fee may run from $5-$10 a session. A peer counselor can see you either once or for three to five sessions of short-term counseling. He or she can also refer you to a therapist if you so wish. This is the basis on which Identity House functions.
Psychoanalysis is a specific method of psychotherapy. Any of the above professionals may become psychoanalysts, or they may more loosely draw upon this method to conduct psychoanalytically- oriented psychotherapy, as opposed to formal psychoanalysis. In order to use the designation psychoanalyst legitimately, one must have completed a postgraduate training program at a certified psychoanalytic institute. In a sense, this is the most traditional form of therapy. Sessions are held at least twice a week, and sometimes there may in fact be the proverbial couch--and the analyst may hardly speak to you. Until recently the entire field of psychoanalysis (and with it most of psychiatry) was pervasively homophobic. The most important psychoanalytic institutes still do not certify known homosexuals. Needless to say, a gay person should ask some searching questions before beginning therapy with any psychoanalyst.
Traditional psychoanalysis requires multiple visits each week for a number of years. With fees ranging anywhere from $45 to $125 a session for certified analysts, this can become very costly treatment. The cost may be somewhat less if you are in analysis with a trainee at one of the institutes.
Many therapists hold a staff position at a clinic or hospital and may only see private patients on a part-time basis. When interviewing a prospective therapist inquire about other professional affiliations in addition to their private practice. You can sometimes see a therapist either in his or her private practice or at a clinic or hospital where the therapist is on staff. There are benefits to either approach. Generally speaking, private practice is more expensive since almost all clinics have sliding fee scales based on an individual's ability to pay. The major reason that private practice is more expensive is that the private practitioner has to absorb all of the overhead costs for an office, utilities, and insurance.
When a psychotherapist is on the staff of a clinic there is usually a psychiatrist also on staff who can be consulted if medication or hospitalization becomes indicated. A staff psychologist is usually available to conduct psychological testing if such a need arises. The likelihood of having insurance pay for therapy is increased if you are a patient at a clinic rather than of an independent practitioner. On the other hand, there is more potential for flexibility in scheduling and treatment with a private therapist than with a clinic. One example would be the ability to see the therapist once every two weeks or at variable times if you so choose. Often the organizational structure of a clinic makes this kind of flexibility difficult.
As a gay person, another consideration is the certainty that if you begin therapy with an individual or at an institute know to be lesbian/gay sensitive, you are not likely to suffer homophobia or the hidden agenda of having a therapist seek to heterosexualize you.
Starting therapy is in many ways like beginning any new intimate relationship. There needs to be
some initial excitement, trust and intuitive feeling that this is a safe and nurturing place for you to
be. As time goes on, there should be an increasing number of tangible examples that this person
has your best interests as their priority.
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