Unhappily never after, part 3: finding a therapist when you already need one

Note: I wrote this guide in 2019 to fill, IMHO, a serious gap in individual education around mental health. There’s tons of info on finding therapists, but very few directed for when we already feel overwhelmed and horrible, when doing the thing we need most is hardest. This is a revised, abbreviated version of the guide. Also: I’ve made reasonable attempt to include functional and relevant links. None of these links should constitute endorsement; they are provided for information only. Also, nothing in this guide should be considered medical advice. Always speak to your physician or health care provider when starting or changing treatment. If you are in crisis, please call 911 or your local emergency services.

In Part 1, we looked at how to determine what you need to know about your health coverage. In Part 2, we brainstormed what you can do if you have no coverage, or if your coverage bites. Here, in Part 3, we’ll briefly define the various kinds of therapies out there, and the therapists who deliver them.

Because you’re trying to just get help ASAP, you may not have a lot of choice over the type of therapist you see, or the style — modality — of therapy they use.

When you are feeling better and have the time, you can look for a therapist with intention, and look for the best match for long term.

But for the moment, this section will, at least, help you understand what you may experience with whomever you can see now, especially if you don’t have a ton of experience with therapy or mental health.

This list can’t, of course, include every single type of therapist, nor every type of therapy. There are lot of different types of therapists and many, many styles of therapies. I’m including the most commonly encountered practitioners, using the most frequently heard terms to describe their practices. These are just some of the professionals that work with adults and mental health — I am not covering those who specialize in working with children or just substance use disorders, for example.

I’m also just hitting the highlights of each; my descriptions are far from complete.

Depending on your state or country, the education, qualifications, and experience needed for each role may differ for licensure or certification. Titles and capabilities may vary.

A brief roster of therapy practitioners

Psychiatrists are medical doctors. Like your primary care physician, they went to medical school, but then specialized in the diagnosis and treatment of mental, emotional, and behavioral illnesses. They are qualified to prescribe medication. Many psychiatrists do actual therapy, usually psychoanalysis however, it’s rare that you would see a psychiatrist as your primary therapist for ongoing needs, unless you are also on medications (and even then, it’s rare). For an “acute episode” (like what you’re feeling now, though it’s far from “a CUTE episode,” sorry, couldn’t resist), you may begin with a psychiatrist, then move to another, less expensive (frankly) professional once you’re more stable.

Psychiatric nurse practitioners are nurses with advanced medical training, masters degrees, or PhDs. In most states, nurse practitioners have the same diagnostic, treatment, and prescribing rights as a psychiatrist (they may need to consult with or get sign off from an MD). You will see the letters “ARNP” after their names, which stands for advanced registered nurse practitioners, and differentiates them from other nurses. Nurse practitioners rarely perform therapy, though there are always exceptions to the rule.

Psychologists have masters degrees or PhDs in psychology, counseling, or a related field. Depending on your state, they may have masters degrees. They’ve completed intense supervised internships and advanced training, and, in many areas, can diagnose mental, emotional, and behavioral illnesses. They may or may not be able prescribe medications. Psychologists may practice any modality of therapy (some types require special certification), and often combine types depending on their preference and the needs of their client.

Clinical social workers have, at least, masters degrees in social work, and completed supervised internships in mental health. Not every social worker is a clinical social worker. Clinical social workers can diagnose and provide therapy of almost any type (some types require special certification). They will usually sport the letters “LCSW” after their name, to designate that they are licensed clinical social workers. What’s special about these providers is that their social work training gives them a social justice perspective, and understanding of the intersections between mental health and race, class, gender, sexuality, and so forth.

A licensed/professional mental health counselor/therapist (some combination of those terms. I’m going to call them therapists here, for ease) has at least a bachelor’s degree, if not a masters degree, in psychology, counseling, or social work. Depending on the location, they probably have additional training, have completed internships, have certifications, or have a certain length of experience — states and countries differ in what they require for credentialing, and whether therapists can officially diagnose. Therapists are the professionals we usually think of when we think of therapy, and most likely, the folks you will see on an ongoing basis. They usually have a few areas of specialty, in terms of which kind of therapy they’ve trained in.

Peer counselors are professionals in recovery from mental, emotional, and behavioral illnesses who, in most US states, receive formal training, testing, and certification to provide supportive therapeutic services which enhance/supplement traditional therapy, as opposed to providing straight up therapy themselves. You will never do therapy one-on-one with a peer (unless they are also licensed as any of the above roles, too). But I mention them because you’ll find peer counselors running groups, teaching classes and workshops, and other types of work which support recovery.

Advisers (or advisors) or coaches vary wildly in title and level of qualification. They may be certified or not, regulated or not, licensed or not. They may have special education or degrees, or not. Some US states require registration and licensure to provide anything resembling therapy— others don’t (you get the picture). This is not to say that adviser/coaches are quacks or charlatans. There are tons of folks who provide excellent therapeutic services with these titles, and many do have the education, etc., to provide therapy (some states use “adviser” to designate BA level therapists, for example, who are otherwise licensed and trained), while others, like peers, do supplemental work that enhances therapy, or run support groups, teach classes and workshops, and the like. Don’t be afraid to ask about their qualifications for what they provide.

Pastoral (or other religious designation) counselors may provide therapeutic service (such as “talk” therapy, groups, education, and so forth) as mart of their ministry. Some clergy have further training in clinical pastoral education or have secular degrees in psychology, counseling, or social work, which also qualify them to diagnose and provide therapy. Don’t be afraid to ask questions! It’s not rude, especially if you’re upfront with communicating why you’re asking (not really religious, unfamiliar with the faith or terms, and so forth).

Common types of therapies

There are, literally, hundreds of therapeutic approaches, philosophies, and styles. Most therapists have a few primary types they use (because they have preference for, training in, and so forth), but ultimately use an integrated approach that combines various aspects pulled from different therapies, depending on the needs, personality, and preferences of their client.

So, more than likely, unless you go to a clinician who advertises that they stick within one school of therapy, you’ll encounter some blend of these most — currently — common approaches (talk, skill-based, and combination) that are used for “short-term” treatment. This list hits just the highlights though, and is far from exhaustive.

I’ve also included a list of the types of therapists who usually perform these types of therapies.

This list will have all kinds of exceptions — for example, there are psychiatrists who do client centered therapy, psychiatric nurse practitioners who do gestalt therapy, and so on. I just tried to capture “typical” scenarios, of who does what, based on my own knowledge and experience.

I’m concentrating here on “short-term” therapies since that’s probably what you will find, looking for an ASAP therapist, and probably what you will need right now to get you feeling well enough to then seek out a long term therapy relationship. “Short-term” or “brief” therapies are usually highly structured, goal focused, and designed to be encompassed within 15 or fewer sessions.

“Talk” therapies

Psychotherapy, psychoanalysis, and psychodynamic therapy The psycho-s are what you think of, when you think of therapy, and what is most often portrayed in movies, TV, and books. While you’ll probably talk some about what’s going on with you in the present, these types of therapies focus on how your past affects your present. Psychoanalysis has come a long way from Freud’s day, but still delves into how your unconscious impacts your thoughts, feelings, and behaviors. Psychodynamic is a “time-limited” subset of psychoanalysis; true psychoanalysis can take years, while psychodynamic therapy is designed to last a certain number a sessions — usually 15 to 20. In these therapies, there is a distance enforced between the therapist and client. The therapist will not comment much on what you say, and will definitely not respond with emotion or opinion. It can feel cold when you start, and can stay cold-feeling if you don’t gel with your therapist. However, its effectiveness is sky-high, and therefore remains, for many therapists, the gold standard style.

Practiced (most likely) by psychiatrists, psychologists, therapists

Client-centered (CCT), person-centered (PCT) therapy Also called humanistic or Rogerian therapy (after Carl Rogers, the psychologist who pioneered the idea) CCT/PCT is also a form of “talk” therapy, but is less structured in format. You can talk about the past, present, or whatever you’d like during the session. Rather than determining how your past affects your current state of being, CCT/PCT looks to understand how your “self-concept,” or your own vision of your identity, your relationships, and your place in the world, affect you. CCT/PCT therapy feels considerably warmer than psychotherapy, as CCT/PCT operates on Rogers’ concept of “unconditional positive regard,” in which therapists show empathy and support for their clients, and will provide their own thoughts and observations into the session as dialogue. At CCT’s best, you will feel a healthy attachment to your therapist, as an otherwise neutral beneficent ally who can be counted on to give you supportive, but honest, feedback.

Practiced (most likely) by psychologists, clinical social workers, therapists, advisers/counselors, pastoral counselors

Gestalt therapy

Gestalt (from the German word for “form” or “shape”) therapy emphasizes talking through your perceptions to really get to the truth of how things are going in your life, overall (the shape of your life as a whole, for example), as opposed to how your past experiences will color how you feel your life is going. The idea is that we learn thought patterns from past experiences, and these patterns can be limiting or negative, and affect our well being. A gestalt therapist will constantly redirect you to what you are experiencing and feeling at the moment, and to propose solutions you can implement now to deal with these present issues and feelings.

Practiced (most likely) by psychologists, clinical social workers, therapists, advisers/counselors, pastoral counselors

Skill-building therapies

Cognitive behavioral therapy (CBT) CBT is the best known and most widely used skill-building therapy, and is often combined with other therapies or targeted for specific conditions (for example, there’s a specific CBT for insomnia called CBT-i). CBT is based on the idea that dysfunctional thinking patterns lead to dysfunctional behaviors and responses. CBT alone doesn’t try and determine the source of these dysfunctional thoughts — as in which/how/why experiences shaped you into having these types of thoughts. Instead, it looks only at the effects of having these thoughts, and how to change or replace these negative thoughts with healthier, more positive ones, which then, in turn, changes your reactions and behaviors. CBT is very solution-based, which makes it measurably successful. The results are awesome. But the fact that it deals with the symptoms over the cause makes it less effective for long-term therapy.

Practiced (most likely) by psychiatrists, psychologists, clinical social workers, therapists, advisers/counselors, peer counselors, coaches

Dialectical behavior therapy (DBT) DBT extends CBT with concepts of mindfulness, compassion, and self-acceptance to increase your ability to tolerate distress and discomfort. DBT teaches problem solving and emotional regulation, and customarily would not be used, straight up, as a short term therapy (most formal courses of DBT run, intensively, for 6 months to a year as very structured combinations of individual and group therapy). However, I mention it because many therapists pull out sections of DBT curriculum and adapt them for short term sessions that help you quickly develop and practice skills that provide relief if you are dealing with very serious issues of self harm, suicidal thoughts, eating disorders, and PTSD.

Practiced (most likely) by psychiatrists, psychologists, clinical social workers, therapists, advisers/counselors, peer counselors, coaches

Combo therapies

Acceptance and Commitment Therapy (ACT) ACT is a time-limited treatment that bridges talk therapy with behavioral-focused therapies. Its abbreviation does double duty, standing in both for the name of the therapy and the three core steps of the therapy: Accept, Choose, and Take action. In ACT, you build skills to react to life’s challenges, first by talking through and accepting your feelings, thoughts, and behaviors, then assess the choices before you of how to handle or address them, in terms of your values. By defining your values and desired outcomes, you choose what to do, and then, well, do it. Like CBT, ACT is solution-based, but it integrates time exploring the experiences that shaped your feelings and reactions (the whys). Most ACT therapists also include the unconditional positive regard principles of CCT, giving this therapy a reputation of also being as supportive as it is results-driven.

Practiced (most likely) by psychologists, clinical social workers, therapists, advisers/counselors, pastoral counselors

Solution-Focused Brief Therapy (SFBT) Like gestalt therapy, SFBT examines the present moment. However, SFBT is more formally focused on goal setting as its therapeutic center, and as you direct your attention to thoughts and feelings in the present, you then, under guidance of the therapist, identify your future goals for what you want to change or make better. Then, because it is “brief” therapy, you will choose a goal to work on. As you move through SFBT, you break your goal into clear, actionable steps that you can start to implement immediately. The ultimate point is that talking through the process of self-assessment, goal setting, and then planning will set these skills in place for you to continue to use after the therapy sessions have ended.

Practiced (most likely) by psychologists, therapists, advisers/counselors

Parting thoughts

Here’s my hope. Now, after slogging with me through these looooong articles, you know what’s covered, or not. You have a high-level understanding of who the therapy professionals are, and the types of therapy you will probably encounter. You’ve done some hard and exhausting work, and I promise you: you are in the home stretch. Don’t give up now.

It’s OK if you feel overwhelmed (still, again). There’s still a lot of stigma around mental health, and in my unsolicited opinion, it doesn’t help that stigma that finding care can be/feel so difficult. I’ll get off my soapbox for the minute (I’ll climb back up in my closing remarks), but I wanted to reassure you that if you’re still feeling like this is a mountain: it’s understandable, you’re doing great, and you are almost at the peak.

You just have to make the calls or send the emails. Whether you’re perusing a list of therapists that accept your insurance, scanning down a list of therapists from NAMI, or pulling up possibilities from a Google search, you need to pick someone and contact them.

My advice? Don’t just pick one, if you have the option. Pick three possibilities and contact them.

Why three? Sometimes, rosters are full, and therapists aren’t taking new patients. Other times, they have, for whatever reason, stopped taking a certain insurance even though they are still listed as accepting it. Maybe they only have openings at times that just won’t work for you. Or, it’s possible they are even on vacation at the moment. You never know.

So, pick three to contact and you increase your odds of finding someone who can work with you.

Great. Stop, stretch, and then plow onward. Call or email the three you identified right now.

Yep. Right now.

It doesn’t matter if it’s the middle of the day or the middle of the night. First contact is always (99.9% of the time) going to be with voice mail or an answering service when you call, and hey, email, you know it’s 24/7 and they’ll see it when they are available.

If you do it now, you won’t lose momentum, you won’t put it off because it becomes something you wind up dreading doing, and then, it’s out there, in the world, already in motion.

You only have to mention three things: your name, contact information, that you have X insurance/need sliding scale (if appropriate). It’s good to also mention that you’re hoping for an appointment or intake soon. Sandwich in some nicetities (a hello and a thank you), and that’s all.

Then hang up or hit send.

Now, you just have to hang on until you get a call or text back. This is a new, but still hard, part. You did all this hard work, and all you can do is wait.

Give the three therapists you contacted three business days to respond, max. If you haven’t heard from any of the three by then, give them one more round of emails or calls, then wait a full business day before moving on. It’s likely that you will hear something from at least one of the three within the first three business days.

When you’ve made contact and have an appointment: the rest is up to you. Depression and anxiety put up a solid fight to keep us in the house, in bed, or on the couch. You’ve got to be strong; you’ve come so far. You’re a champ, friend. Make it the last lap.

Bribe yourself if you have to. Just close your eyes and plow. Enlist a friend or family member to take you, nag you, or help in some way. Whatever it takes. Again, I’ve been there, feeling like my arms and legs are a thousand pound each, with sorrow threatening, at the same time, to turn me inside out. I’ve had times when I was sure if I moved, something worse would happen. And I’ve had times when I wasn’t even sure I believed anymore that I was worth saving.

You can do this. I have absolutely no doubts in you.