PART IIIIMPORTANTQUESTIONS
17LOCATING A THERAPIST
America is overcrowded with helpers; there are so many helpful people out there, they are literally bumping into each other, and must be regulated by laws and organizations to keep them from helping so much that the average client in need of help isn't torn to shreds.Paul G. Quinnett,The Troubled People Book
This chapter assumes that you have used one of the two methods described in Chapter 7, "Self-Diagnosis: Mapping Your Way to a Therapy," and have now chosen an approach to therapy that seems most promising in relation to your goals or problems and your personality. You now face the practical problem of how to locate a therapist with the professional expertise to offer you the kind of help you desire.
There are three factors that you need to take into account in order to find a suitable therapist:
1. the degree of seriousness of your problem or need
2. any financial limitations you may have
3. the resources available where you live (or how far you are willing to travel if you cannot locate the help you want in your area)
The seriousness of your problem or need may fall into one of three general categories:
Very urgent need: You are severely upset, perhaps suicidal or dangerous to others. Or, you are suffering from extreme changes of mood or personality, major depression, delusions, or hallucinations. In either of these cases, you should see a professional immediately. You or a friend or relative should contact your family physician for a referral to apsychiatristor call a crisis intervention center for a referral to a psychiatrist. (Crisis intervention centers, sometimes calledsuicide prevention centersorcrisis hot linesare listed among the emergency numbers on the inside front page of your White Pages directory; otherwise, dial 911 for assistance.)
Serious personal, marital, or family problems or goals: You, you and your spouse, or members of your family need help soon but can wait for an appointment, if necessary, for a number of weeks.
Moderate need: There is no urgency. You are interested, before you consider formal therapy, in exploring some alternatives—perhaps by talking with a minister, priest, or rabbi or by trying one of the adjunctive approaches to therapy (such as therapeutic exercise, meditation, relaxation training) on its own, without individual therapy.
This chapter is intended primarily for people in the well-populated middle category, people who have serious problems or goals and are able to weigh alternatives carefully and without extreme pressure.
The seriousness of the problem and the cost of treatment go hand in hand. The range of treatment alternatives is shown in the table below.
Condition Cost Treatment by:---------------------------------------------------------------------more serious more expensive Psychiatrists| || | Psychologists| || | Social work counselors| || | Adjunctive therapists:| | biofeedback, bioenergetics,| | exercise, meditation, etc.| || | Religious counselors| |less serious less expensive Self-help
In general, the less serious the problem, the lower the potential cost of treatment. Also, the more serious the condition, the more advisable it is to have at least a preliminary evaluation by a psychiatrist.
Similarly, the settings within which therapy is available vary widely:
Condition Cost Setting:---------------------------------------------------------------------more serious more expensive Hospitals| || | Residential treatment| | centers| || | Private practice| || | Agencies: private, state,| | county| || | Academic sources:| | individual counseling for| | enrolled students| | vocational guidance| | counseling| | classes or workshops| | adult extension or| | continuing educationless serious less expensive programs
FINDING A THERAPIST WITH APARTICULAR SPECIALIZATION
During a time of increasing specialization in health care, many psychotherapists have unfortunately been attracted to eclecticism—that is, knowing a reasonable amount about a number of different forms of therapy, but resisting specialization in any one of them. For some individuals, especially people interested in wide-spectrum growth and personal development, an eclectic therapist can be very beneficial. Eclectic therapists believe that they are able to bring a wider scope of understanding to bear on a problem and a more flexible outlook. If you have fairly well-defined needs and interests, however, eclecticism makes it difficult to locate a therapist who has formal training and extensive experience specifically in treating, for example, depression, alcoholism, family conflicts, or adjustment problems. No therapist today can be an expert in the whole range of humanemotional problems and in the many specialized techniques that have been developed to help.
REFERRALS
There are a number of ways of going about locating a therapist. You can start by asking for a recommendation from any of these sources:
* your family doctor, who will most likely suggest a colleague, another M.D., a psychiatrist
* your minister, priest, or rabbi, who again will suggest someone he or she happens to know or to have heard of
* personal friends
* referral services
All of these alternatives are, however, limited by the scope of acquaintance of the person or service you have gone to. Referral services commonly are run by groups of subscribing psychologists (or social workers), so if you call one, you will be referred to a participating psychologist (or social worker). Sometimes referral services (which usually charge nothing for their referrals, unless you request a preliminary consultation) maintain a listing of the areas of specialization of their professional members, and this information can be helpful.
If you have a specific approach to therapy in mind and want to find a therapist with strong credentials in that approach, there are two usually more promising roads to follow:
BY MAIL, OR E-MAIL (GOOGLE ANY OF THENAMES OF ORGANIZATIONS THAT FOLLOW):
First, depending on your own judgment of the seriousness of your problems or goals and the extent to which the cost of treatment is important to you, you can request a list of therapists in your area from these organizations:
American Psychiatric Association1400 K St., NWWashington, DC 20005
Canadian Psychiatric Association225 Lisgar St., #103Ottawa, ON K2P 0C6
(for psychiatrists)
American Psychological Association1200 17th St., NWWashington, DC 20036
Canadian Psychological Association558 King Edward Ave.Ottawa, ON K1N 7N6
(for psychologists)
National Association of Social Workers7981 Eastern Ave.Silver Spring, MA 20907
Canadian Association of Social Workers55 Parkdale Ave., #3l6Ottawa, ON K1Y 1E5
Corporation Professionnelle des Travailleurs Sociaux du Quebec5757 Decelles Ave., Ch. 335Montreal, QC H3S 2C3
(for social work counselors)
Ask for a list that shows their specialties. If none is available, ask for the address of the branch office nearest you, which you then can contact for this information. If writing by mail, be sure to enclose a stamped, self-addressed envelope to ensure a response.
BY TELEPHONE
A second way to locate a therapist with specialization in a particular area is through careful use of your telephone directory. This may take you some time, and also some preliminary calls, but it can give you a good deal of information:
Psychiatrists
Psychiatrists are listed in the Yellow Pages under "Physicians and Surgeons." In larger metropolitan directories, you will usually find separate headings after the general listing, according to specialties. Look there for "Physicians-Psychiatrists" or similar heading. Many psychiatrists today will list their special focus there—for example, psychoanalysis, psychoanalytic psychotherapy (brief analysis), marriage and family therapy, hypnosis, chemical dependency treatment, child and adolescent therapy. If you want to see a psychiatrist and do not find one who indicates the specialized approach you want to try, then you will need to make some calls. Most psychiatrists' secretaries or receptionists are happy to tellyou what the doctor specializes in. If the list of his or her areas of specialization is impressively and overly long, perhaps it is best to look elsewhere for a more realistic professional.
If, after locating a psychiatrist with the background you are looking for, you want to double-check his or her credentials, ask the secretary if the psychiatrist is a member of the American Psychiatric Association (or, if in Canada, the Canadian Psychiatric Association), whether he or she completed a program of study at an institute of psychotherapy or psychoanalysis, and whether he or she is board certified. (Remember, any M.D. can call himself or herself a psychiatrist, but not all have the full qualifications of a certified psychiatrist.)
Clinical Psychologists
Clinical psychologists are listed in the Yellow Pages under "Psychologists." Their specialties are often identified—e.g., marriage and family therapy, group therapy, bereavement, alcoholism, eating disorders and addiction, psychological assessment (testing), learning disorders, sexual dysfunction, depression, panic syndrome. Again, if the list below a given psychologist's name is unreasonably long, you may have come across either a genius or someone who favors advertising. Psychologists less often mention the particular approach to therapy they use, but some do; for example, behavior therapy, Gestalt, hypnosis, or "analytical approach" may be listed. Again, it will probably be necessary to make a few telephone calls.
If, after locating a psychologist with the background you are looking for, you want to double-check his or her credentials, you can frequently find a copy in your public library of theNational Register of Health Services Providersor, in Canada, either theCanadian Registry of Health Service Providers in Psychologyor theInternational Directory of Psychologists. They list licensed psychologists with Ph.D.s who have completed internships of supervised therapy. Psychologists will often print their state license numbers in their telephone directory listings.
Social Work Counselors
Social work counselors are listed under "Social Workers" in the Yellow Pages. Usually, their listings are less specific than those for psychiatrists and psychologists. Most commonly, you will see listings indicating "licensed MFCC" (marriage, family,and child counseling), "MSW" (master's degree in social work), "LCSW" (licensed clinical social worker), etc. State licensing numbers are often also given.
TheRegister of Clinical Social Workers, published by the National Association of Social Workers, lists members whose degrees and supervised training were in counseling; it is available in many public libraries.
Specific credentials you may also see in directory listings include the following:
For therapists withAffiliation: specialties in:---------------------------------------------------------------------Membership in American PsychoanalysisPsychoanalytic Association(all members are M.D.s)In Canada: Membership inCanadian PsychoanalyticSocietyMembership in InternationalPsychoanalytical SocietyMembership in NationalPsychological Association forPsychoanalysisTraining from Center for Studies Client-centered therapyof the Person, La Jolla, CATraining from Gestalt Therapy Gestalt therapyInstitute of LA (or San Diego,San Francisco, New York,Boston, Chicago, Cleveland,Dallas, Miami, Hawaii, etc.)Training from Institute for Rational-emotive therapyRational-Emotive Therapy(which maintains a register ofpsychotherapists who havereceived training in RET.Address: 45 E. 65th St., NewYork, NY 10021.)Training from the Institute for Reality therapyReality Therapy (in LA, withbranches in other cities in theU.S.)
Membership in North American Adlerian therapySociety of AdlerianPsychologyMembership in Association for Behavioral psychotherapiesthe Advancement of BehaviorTherapyMembership in American Marriage and familyAssociation of Marriage and therapyFamily TherapistsMembership in Biofeedback Biofeedback therapySociety of AmericaMembership in American HypnosisSociety of Clinical HypnosisIn Canada: Membership inCanadian Institute ofHypnotismMembership in American Treatment of sexualAssociation of Sex Educators, disordersCounselors, and Therapists
HARDER-TO-FIND THERAPIES
It can be especially difficult or confusing to locate therapists with certain orientations, either because these approaches are less widespread or because you do not know which kinds of health-care professionals make the greatest use of them.
Frequently, an effective way to locate anexistential-humanistic therapistorlogotherapistis through religious organizations. Call to ask for the names of ministers, priests, or rabbis with training in psychotherapy or counseling. These individuals, in turn, will often be able to put you in touch with either existential-humanistic therapists or logotherapists who may or may not be affiliated with the religious organization in question.
Emotional flooding therapistsare usually found among psychologists, whose telephone directory listings will normally indicate whether they offer one of these therapies. The same is true for psychologists with experience indirect decision therapy.
Biofeedback therapistscan be found in private practice; they will also be found at pain and stress centers (which are often run by hospitals on an outpatient basis). These offer private or publicly funded programs to help people with chronic pain orstress-related difficulties. A number of counseling agencies have begun to include biofeedback therapists on their staffs.
Biofeedback therapists in private practice, as well as pain and stress centers, are listed in telephone directories. Try looking under "Biofeedback Therapy and Training" and under "Psychologists" for those who indicate that they offer biofeedback.
Relaxation training(and sometimes also meditation) is frequently offered by biofeedback therapists (as well as by many psychologists and social workers).
Therapists who usehypnosisare often listed under "Hypnosis" in telephone directories. You will usually find a wide variety of educational backgrounds represented among therapists in these listings. Some are in private practice; some work for agencies. You will probably see an array of credentials advertised, perhaps ranging from therapists without degrees, to those with Ph.D.s and M.D.s. Here, especially, is an area in which to exercise consumer caution. Unfortunately, hypnotherapy is well populated by therapists who lack professionally recognized credentials. It is wise to remember that Ph.D.s can be granted in all sorts of fields—in education, theology, librarianship, etc.—as well as psychology. Some "therapists" practice with a Ph.D. after their names, yet their Ph.D.s may be in fields totally unrelated to counseling and psychotherapy. Ph.D.s who arelicensed psychologistsand who are members of the American Society of Clinical Hypnosis offer professional credibility as hypnotherapists. The certification of therapists trained in hypnosis is still unsettled in many states, where anyone can hang out a shingle. Since many licensed psychologists, psychiatrists, and some certified social workersdoreceive professional training in hypnosis, these are the professions to which it is most reliable to go for hypnotherapy.
Meditation techniquesmay be learned on your own (see Chapter 15), or you can seek out commercial or religious organizations that teach meditation. They are sometimes found in the Yellow Pages under "Meditation Instruction." Transcendental Meditation (TM) programs have been popular and are widespread. Yoga instructors (raja yoga rather than hatha yoga) also teach meditation.
Relatively few psychologists or social workers have actually received training in the use oftherapeutic exercise, since this area is relatively new and its proponents are still small innumber. However, most psychologists and many social workers are aware of the exercise programs advocated by Kostrubala and Glasser (see Chapter 15) and can help you plan intelligently.
ABOUT THE COST OF TREATMENT
Most health insurance plans offer at least partial coverage for psychotherapy and counseling. Consult your policy to find out what providers (psychiatrists, psychologists, or social workers) you may go to for covered treatment and for how long. (If you have special concerns about confidentiality in connection with treatment under an insurance plan, see Chapter 19.)
As we noted earlier, it is possible to obtain treatment from many psychiatrists, clinical psychologists, and social work counselors at reduced cost, if you have definite financial limitations (see Chapter 4).
Many clinical psychologists and social workers indicate in their directory listings in the Yellow Pages if fees are set on the basis of a sliding scale-on the basis, that is, of ability to pay. It is worth a telephone call to find out. Many public and some private counseling agencies also set fees in this way. Reduced fees from psychiatrists are more likely through agencies that offer psychiatric care than from psychiatrists in private practice. For public agencies, look in the White Pages under the name of your county; then look for the heading "Mental Health Services" or "County Mental Health," or the equivalent. You will frequently find one or more mental health centers or clinics listed. In the Yellow Pages, look under "Clinics" for a listing of private and sometimes also public clinics. It is usually clear from their descriptions whether they offer psychotherapy or counseling or only treatment for physical illness or injury.
Again, it may be worthwhile to mention that the costs ofgroup therapy, whether through a clinical psychologist or a social work counselor, may be expected to be substantially less than the costs of individual therapy. (On the appropriateness of group therapy, see Chapter 13.)
ONCE YOU HAVE LOCATED A THERAPIST
If you believe you have found a therapist whose background, fees, and location meet your needs, I recommend that, when youtelephone for an appointment, you ask for an initial consultation. This will make it clear, in the therapist's mind and your own, that your appointment is for a trial session. (The fee is normally the same as for a regular appointment, but check on this.)
When you go to this first session, it is very tempting to launch into what is troubling you. If you can hold yourself back in order to ask a few preliminary questions about the therapist's background, experience, approach, and a likely duration of treatment—in other words, encourage the therapist to talk to you a little bit about himself or herself—you will get a better idea of thepersonbehind the professional title. This will help you decide whether you want to continue with future sessions. However, it may take several weeks, or even months, for you toknowthat the relationship will in fact benefit you.
18SHOULD YOU BE HOSPITALIZED?
There are two main reasons for psychiatric hospitalization:
1.You would be better off away from home. Many things can play a role here. Perhaps there is too much family conflict at home, too much emotional strain, for you to improve. Or, your family may simply not be calm enough to handle the crisis. Or, perhaps you have too many strong and upsetting associations at home—e.g., if your spouse has just died or your daughter just committed suicide at home. Or, you may just have too little privacy at home; you feel forced to maintain a stiff upper lip in front of children, your spouse, or other family members, but you simply can do this no longer.
2.Your condition may be too serious to be treated appropriately on an outpatient basis. If you are no longer in touch with reality, are unable to communicate coherently, are hallucinating or have delusions, you cannot be relied on to take care of yourself. If you are psychotic, your behavior may hurt others or yourself. If you are suffering from a major, incapacitating depression, you may become suicidal. Finally, if you are unable to control an addiction to drugs or alcohol, inpatient care is more likely to be effective.
You may, of course, have reasons toresisthospitalization. Most likely, your resistance will be based on fear—of the unknown, ofthe later stigma of having been hospitalized for a psychiatric condition, or of theinnerstigma: that you must have been terribly ill (or "weak") to justify hospitalization. Furthermore, if you have been hospitalized before, you may recall that the hospital's supportive environment encouraged you to feel dependent on it and to resist returning to normal living, and you may fear falling prey to this again.
All of these are good reasons to proceed cautiously. Only the first fear can be reasoned with in an objective way, by understanding what psychiatric hospitalization is really like, something this chapter will help you to do. Certainly, the other fears also may have some basis.
Discriminationdoesstill exist against former psychiatric hospital patients. They may find it difficult, for example, to enter military service or serve in an important political capacity.
The inner stigma can be even more damaging, if you are a highly self-blaming person. If you are going to hold hospitalization as yet another black mark against yourself, then you may want to avoid hospitalization unless it means you are withholding treatment from yourself that really is essential to your well-being.
If you have been hospitalized before for psychiatric care, the last reason is very likely the most important one for you to weigh carefully. In the light of your past dependency needs, you must decide whether the problems you now face are serious enough to motivate you to walk into a situation that in the past you found difficult to leave.
Most hospital admissions for psychiatric conditions today arevoluntary. Usually, either your own judgment leads you to accept hospitalization, or you are persuaded by family, friends, family doctor, minister, or psychiatrist that doing so is in your own best interest. Involuntary hospitalization is legally difficult and occurs primarily in cases in which, over a period of time, there is evidence that a person's behavior is not responsible, that he cannot take care of himself, or that he may injure himself or others.
WHAT HOSPITALIZATION IS LIKE
Several kinds of hospitalization are available to individuals who are emotionally troubled:
* private or public hospitals in which there are special floors or sections for psychiatric patients
* hospitals that treat only psychiatric problems
* inpatient programs that specialize in stress management or the treatment of depression, alcoholism, drug abuse, and other problems
Typically, fifteen to twenty-five patients of both sexes will reside in a hospital unit. Often a ward is divided, with men living on one side and women on the other. In private and many public hospitals, private and semiprivate rooms are available, depending on your ability to pay or your insurance coverage.
Frequently, patients dress in everyday clothes rather than in hospital gowns and pajamas. There is usually a common dining area where patients can eat at tables seating two to four people. Day rooms are common—large areas with comfortable chairs and couches, a television, stereo, books, and games.
If you were admitted to a hospital unit specializing in psychiatric care, you would probably see a psychologist or psychiatrist two or three times a week in individual sessions. It is likely, since your condition was serious enough to warrant hospitalization, that you will receive medication during at least part of your stay (see Chapter 16).
If you are a voluntary admission, you will be asked to sign consent forms for treatment that is recommended to you. You do have a right to refuse treatment you do not want.
A complete physical examination is routinely required to rule out underlying physical disorders. You may also be asked to take some written psychological tests, most being of the multiple-choice variety.
Group sessions in hospitals are common. In forming groups attempts are made to choose people in ways that will be mutually beneficial. In part, these periods "in group" help to offset feelings of being alone in a strange environment.
Activities are planned to combat monotony. They may, for example, include arts and crafts, sports, dancing, and day trips to museums or the movies.
Staff members with whom you would have the most personal contact are members of the psychiatric nursing staff. Often, when former patients are asked who helped them while in the hospital, instead of mentioning the therapist, they name amember of the nursing staff. Psychiatric nurses have received special training in psychiatry and often are a major source of human warmth and caring.
Depending on your progress, you may be encouraged to return home during the day, or overnight, or for a weekend. As it becomes clear that you are improving, these periods may be lengthened to see how you handle the transition from the hospital, before being discharged.
Although hospitals expect patients to choose to remain until they are discharged, few hospitals actively confine voluntary psychiatric patients to prevent them from leaving early—and then generally only in cases judged to be very serious. The only restrictions and rules you would likely encounter are those of any hospital: to respect the rights of others, to be considerate, to refrain from taking drugs unless they are prescribed, to smoke only in smoking areas, and to maintain socially acceptable behavior.
Inpatient hospital programs specializing in stress management, depression, eating disorders, and so on, are normally intended for one- to two-week stays. Residential treatment centers for problems requiring longer treatment—e.g., drug and alcohol rehabilitation programs—are less formal than hospitals. Often, residential treatment centers are located in the country and may consist of a cluster of cottage-like buildings. The program is usually under the direction of a psychiatrist.
Hospital care and residential treatment are very expensive. Most health insurance programs cover most of the costs of inpatient psychiatric hospitalization, for several weeks or months. Public psychiatric hospitals must be relied on by many people for longer stays, unless they bear the costs of private hospital treatment themselves. Physical conditions at state psychiatric hospitals have in general improved in recent years but still tend to fall short of private facilities, for lack of adequate public funding.
LEAVING
Probably the most difficult experience if you are hospitalized for a psychiatric condition is leaving, not entering, the hospital. There is frequently a sense of relief and comfort that comes once you have made the decision to enter a hospital. You have a"legitimate" reason for leaving your normal responsibilities; you may feel "rescued" from family or work situations you could no longer cope with. Once you have begun to feel more at home in the hospital setting, you begin to relax, to participate in activities with less restraint or reluctance. Then, as you improve, thanks in great part to the concentrated attention and care you are receiving, you realize that you must begin to think of reentering life "outside."
Returning to your familiar life can be frightening. It is usual to wonder whether it will, perhaps again, prove to be too much of a strain. Leaving the hospital frequently means returning home or going back to work, to shoulder the same burdens again, trying to pick up where you left off.
Hospitalization is often a positive, reassuring experience. Patients become aware that others do care and that, if life becomes especially stressful, therearesources of professional help and encouragement available to fall back on. Most hospitals encourage former patients to maintain contact through follow-up services of some kind. Leaving the hospital is made easier for many people, for example, knowing that the psychologist or psychiatrist is still there and that they will be seen on an outpatient basis. To help former hospital patients ease back into more normal lives, groups that were formed in the hospital sometimes will also continue to meet on an outpatient basis for a time.
The decision to be hospitalized is difficult for anyone. Hospital care may help turn your life around and put you back on your feet. Or it can, if you are your own worst critic, give you another burden to carry. It is important to try not to block potentially helpful treatment with excessive pride and to try to listen to people who care about you. If they are in favor of the decision, their convictions should be considered. If your doctor or minister agrees, this adds weight to their advice. Once you have listened, try to make your decision your own, not anyone else's.
19CONFIDENTIALITYYour Privacy
THE NEGATIVE LABEL OF EMOTIONAL ILLNESS
Society has attached an undeniable stigma to so-called emotional or mental illness. The public is afraid of conditions that are not concrete and physical and are less easily understood. Emotional or mental difficulties seem more "hidden" and mysterious. The body istangible, and we feel we have more control over it. Setting a broken leg, having your appendix removed, even open-heart surgery—they are not difficult for the public to grasp.
However, depression, anxiety, intolerance to stress, disorientation, unsettling fears, unusual behavior—these are much less readily understood by nonspecialists. There is a tendency for many people to judge rather harshly what they do not comprehend. When many individuals who are ignorant of psychology hear of someone in emotional distress, the inclination is often to condemn. Condemnation is frequently an expression of fear—fear of what is not understood.
During the last two to three decades, society has gradually become more psychologically aware and more intelligent about nonphysical problems. And yet, the stigma of emotional or mental illness has still not been erased. It will take time.
As a result, many people who are in serious emotional distress hesitate to go to a therapist. They are afraid of the negative label that others may apply to them, if information about them ever "got out."
Sometimes this is a justifiable worry. Some employers are bigoted and may discriminate against employees with known emotional problems (even though this is blatantly illegal). And some families, in which there is little psychological understanding and much fear, may withdraw from a family member who lets it be known that he or she is in emotional distress.
On the other hand, most people like to feel that they have a certain degree of compassion and openness—even those who are judgmental! If you are willing to face ignorant attitudes head-on, unflinchingly (and this can take a great deal of courage), you will frequently gain the respect of others through your honesty. They will perceive your unwillingness to judge yourself negatively and may even come to admire the strength and determination you have to improve your life.
If you are in emotional distress, you may have to face a dilemma: whether it isprudentto try to conceal your difficulties from people because you believe that some of them may judge you harshly and critically if they find out you are in therapy, or whether it is likely that they would understand, and perhaps even sympathize, if you were able to be open and had the courage and self-confidence to help educate others on a psychological level. Unfortunately, people in real emotional distress don't have the energy, the courage, or the self-confidence to fight social battles! It therefore usually seems to be a great deal easier to try to keep your own affairsprivate. But this is not always simple to do.
THE CONFIDENTIALITY OF PSYCHOTHERAPY
Confidentiality as it relates to counseling and psychotherapy is not a straightforward thing; much that has to do with confidentiality is still an unsettled and still debated issue. In reality, there are as yet few laws that fully and genuinely protect personal privacy.
There are two central questions relating to confidentiality that I want to raise here. The first is a question only you can answer. I will try to discuss some of the answers to the second.
HOW IMPORTANT IS CONFIDENTIALITY TO YOU?
Only you can answer this. It may be reassuring to know that, usually, the safeguards observed by therapists are sufficient to protect the personal affairs of clients. And it is unusual for any real or lasting harm come to a client if information about him or her is released.
Many individuals, when they are trapped in a prison of self-concern and self-involvement, are prone to exaggerate or magnify the ultimate significance of being "discovered" in therapy, believing that a release of information about them will be potentially explosive and damaging. Individuals who are emotionally very upset are inclined to focus on threatening aspects of therapy.
We have already looked at some of the ways that a heightened sensitivity to maintain secrecy about your problems can lead to self-imprisonment, to blocks that stand in the way of positive change (see Chapter 1). Most of the information you may want kept secret may not really be as damaging as you first were inclined to think. Much depends on howyourespond to information that might be released about you. Let's look at an example.
A little more than a year ago, George Malcolm became seriously depressed. He was forced to resign from his job, and then he received disability income for ten months. During this time he entered therapy. His experience helped him to understand a number of important things about himself that he had ignored in the past. He discovered that he had felt very unsatisfied in his previous job; he had buried his frustrations and had suppressed the anger he felt at being trapped in a situation he disliked. It was a situation he felt he had no control over because of his concern for his and his family's financial security. He was also worried about his mother, who would probably have to be admitted to a nursing home in the near future. Her situation was an added reason for George's financial worry.
He also came to realize that his marriage was suffering because of his insistence that his wife not work. She, on the other hand, felt overcontrolled by her husband: she felt that he stood in the way of her personal growth.
As a result of his increased awareness, George came to see that losing his former job was really a blessing in disguise. His marriage began to improve when George's depression for thefirst time put him in adependentposition; he needed his wife's emotional support, and she, in turn, began to see him as aperson, with weaknesses of his own, and not as she had idealized him.
George's depression allowed him to understand and appreciate his wife's previously frustrated sense of initiative. He now encouraged her to do what she had long wanted to do, to develop a career.
Because George received disability during his depression, his insurance company had information about him on file. When George was interviewed for a new job a year after he became depressed, he was asked at the interview if he had been ill during the preceding year, when he had not worked.
George decided to be truthful and said that he had become depressed and that as a result of the experience had learned much about himself. In particular, he had learned what kind of work really interested him and gave him a sense of satisfaction. Although it had been a difficult period, George said that he felt he had gained a great deal from the experience.
George's prospective employer was impressed by George's honesty and evident sincerity. George got the job—in large part because of the attitude he took toward his depression.
WHAT LAWS PROTECT CONFIDENTIALITY?
To what extent is your privacy protected? What situations legally justify your therapist to release information about you?[1]
[1] Since the first edition of this book, the Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996, bringing with it a mass of complexities relating to patient privacy. There remain many still unsettled legal questions and issues relating to the so-called Privacy Rule, which there is not space here to discuss. If you wish to know more about the legal status and interpretation of patient privacy, see Wikipedia's article about HIPAA at: http://en.wikipedia.org/wiki/HIPAA.
These questions do not always have clear-cut answers. There may or may not be special laws in your state to protect the confidentiality of psychotherapy. The legal status of therapy is still ambiguous in many states. Even in those where laws have been passed, legal protection is sometimes not reliable unless your therapist is willing to face a jail sentence if need be to maintain the confidence you have entrusted in him. If you feel a situation is likely to arise that would put legal pressure on your therapist to release information about you (for example, in a child-custody hearing), you should ask your therapist what his or her commitments to confidentiality are.
"Leaks"
More frequently, confidentiality is broken due to informalityrather than due to an intentional release of information. For example, if you are referred to another therapist or to a physician, the chances are that information about you will be shared by your original therapist with the new therapist or doctor. You can ask your therapistnotto release information in this way, but if you do, the care you receive as a result of the referral cannot benefit from your first therapist's understanding of you. On the other hand, if you do permit your file to be shared with a new therapist or doctor, you will probably not know in advance know what his or her own policies about confidentiality are.
There is a second way that information about you may be released. Often, therapists discuss information about their clients with colleagues in an effort to provide better help for them. It is often to your definite advantage to have other therapists share their assessments and ideas with your therapist. But if you ask your therapist to refrain from discussing your case with professional colleagues, he or she will very likely agree to cooperate with you.
If you believe you have special reasons to be concerned about protecting the confidentiality of your relationship with your therapist, it will help him or her to know this, and it may be possible to request that special precautions be taken to protect your file from access by others.
Accidental or inadvertent breaks of confidentiality sometimes can also occur. For example, billings may be mailed to your address and then be opened by a spouse, child, or parent whom you may not have wanted told that you were in therapy.
Here is another example: If you enter group therapy, other members of the group are not professionally bound by rules governing confidentiality. Because they are not counselingprofessionals themselves, they will be less attentive to matters involving confidentiality—although most group therapists try, when a group is first formed, to get group members to agree not to disclose privileged information outside of sessions.
Exceptions
Beyond the kinds of possible breaks of confidentiality that are due to inattention, informality, and access of information about you by others, there are a number of legal exceptions to confidentiality.
Examination by court order is one. If a judge orders you to be examined by a psychiatrist or psychologist, his findings will be transmitted to the court and so be made public.
If a client reveals his or her intention and decision to commit a crime, a therapist is legally required to report this to authorities. If a patient plans to commit homicide, therapists are required by law to take whatever action is necessary to prevent the murder. In California, in addition to warning the police of the homicidal intentions of a client, therapists must also take steps to warn the intended victim, if this is possible.
If a patient is seriously suicidal—that is, has decided on a means to commit suicide, has decided when to do this, and cannot be persuaded to hold off while in therapy—the therapist is legally bound to take whatever action may be necessary to prevent the patient's suicide, including the disclosure of pertinent information to public officials.
Similarly, in cases of child abuse or neglect, the law requires that a client's confidential relationship with his or her therapist be set to one side in order to provide adequate protection and care for the child.
THREATS TO PRIVACY FROMHEALTH INSURANCE COMPANIES
There is another way that privacy can be invaded, and for many people it is little known and more significant than the breaks of confidentiality we have already discussed. It comes about as a result of recently formeddata banksthat are maintained and continuously updated by insurance companies. Information about insurance claims and payments not only are kept on file by individual insurance companies, but a number of national data banks have been established to provide insurancecompanies with information about the health histories of individuals.
For example, if you file a health insurance application or a claim for benefits with many insurance companies, they often will run a check on your health history through a national computerized clearinghouse that maintains insurance information. This information includes data about previous insurance claims you may have made. Insurance companies believe that they have a right to data of this kind, since the information protects them from having to pay for health care costs that come about due to "preexisting conditions," which many insurance policies limit or exclude. Too, if you have suffered from poor health in the past, and were covered by insurance, there are probably data about your health history on file in such a national computerized clearinghouse; by accessing information about you, an insurance company is able to form a judgment as to whether you are an excessive risk.
Like any information about you that has been compiled and is furnished without your consent, these data about your health history—maintained by agencies that service insurance companies—are subject to possible abuse. Information on file can and is used to protect the interests of subscribing insurance companies; your own interests may not be served in the process. Not only might you be denied future insurance benefits, but the information maintained about you is subject to whatever use the insurance clearinghouse believes is appropriate.
As yet, laws to secure a true measure of personal privacy have not been passed. This has been one of the goals of organizations like the American Civil Liberties Union.
There is a second insurance-related issue that has to do with confidentiality. If you have group health insurance through your employer, it will be necessary for your therapist to complete reports about you in order for you to receive benefits under your insurance plan. (I am assuming here that your insurance offers coverage for counseling, psychotherapy, or psychiatry.) The reports filed by your therapist with the group health insurance company are sometimes filedthrough your employer, and sometimes employers require their group health companies to providethemwith information about health care supplied to their employees. In either way, the fact that you are in therapy and the general reasons for your need for therapy may come to the attention of your employer.
If your employer is a large company or organization, such information will probably be filed in your employer's business or insurance office and laid to rest; it will probably not come to the attention of individuals you actually deal with in your work. But it may. In a smaller company, there is a greater risk.
If you are really concerned about this possibility, ask your insurance officer how health claims are handled and whether health information is requested by your employer from the insurance company.
If you are then still concerned and feel that you need to avoid potential complications at work, you may prefer to see a therapist on your ownand refrain from using your employer's insurance coverage. If you see a therapist in private practice, your decision to pay your own bill may be expensive for you. If finances are a problem, bear in mind that you can frequently locate competent help through county, state, or private counseling agencies. If you go to an agency, remember that you will almost certainly be asked whether you have insurance coverage. If you admit that you do, you will have defeated your purpose in going to an agency on your own to protect your privacy. It is, after all, your right to obtain treatment thatyouelect to pay for.
MAGNIFYING YOUR NEED FOR SECRECY
After reviewing these ways in which confidentiality may be broken—by accident or sometimes excessive informality, by legal requirements, or by what to many of us constitutes an invasion of personal privacy by insurance companies—you may wonder to what extent information that you disclose in therapy reallyisprotected.
In fact, very seldom are thedetailsof therapy divulged to others without a client's advance consent. Most of us do not need to be worried by legal exceptions to confidentiality: most of us are not actually homicidal (though we may feel very angry at times!); most of us are not determined to take our lives (though we may at times feel very disheartened); most of us are not concerned that a court will order us to be examined by a psychiatrist.
I have tried to give a realistic picture of confidentiality in therapy. The fact that you receive mental health counseling or therapy may inadvertently be disclosed by such things as a billing that goes astray orby a fellow group member's inclination to talk too much outside of the group. If you decide to make use of insurance coverage, there are possible consequences you ought to be aware of.
I have tried to underline the fact that most people who enter therapy blow out of proportion the real significance of these possible, but comparatively infrequent, "leaks."
Karl A. Menninger, a renowned and original contributor to psychiatry, quotes one of his patients who shared her intelligent reflections with him:
"When I look back upon the many months I pondered as to how I might get here without anyone knowing, and the devious routes I considered and actually took to accomplish this, only to realize that some of the symptoms from which I suffer are respectable enough to be acknowledged anywhere and valid enough to explain my coming here, it all seems so utterly ridiculous. I looked furtively out of the corner of my eye at the people I met here, expecting them to betray their shame or their queerness, only to discover that I often could not distinguish the patients from the physicians, or from other visitors. I suppose it is such a commonplace experience to you that you cannot realize how startling that is to a naive layman, like myself, even one who thinks he has read a little and laid aside some of the provincialism and prejudice which to some extent blind us all. I see how there is something emotional in it; if the patient feels only depressed or guilty or confused, then one looks upon his consulting the psychiatrist as a disgraceful recourse; but if some of the symptoms take form in one of the bodily organs, all the shame vanishes. There is no sense to it, but that's how it is. I have written a dozen letters to tell people where I am, the very people from whom in the past six months I have tried to conceal my need of this."[2]
[2] Karl A. Menninger,Man Against Himself(New York: Harcourt, Brace and Company, 1938), pp. 455-456.
DON'T LET EXAGGERATED WORRIES HOLD YOU BACK
When you stop for a moment to consider how widespread personal problems are—20 percent of Americans have serious emotional difficulties—isn't there something silly, ridiculous, and, frequently, self-defeating in being overly concerned aboutkeeping others from knowing that, for a time, you were depressed, anxious, unsatisfied, and frustrated to the point that youdecidedto do something about these unhappy feelings?
To be sure, discretion is sometimes prudent. An employer, your family, or some of your friends may be so provincial or bigoted as to think that counseling is close to a misdemeanor. Ignorant or uninformed people do tend to judge hastily and to condemn. But often, if you do have the endurance, many of them are also willing to change their minds when they have the opportunity to understand a little bit about what they fear.
You cannot live for the approval of others. If you believe therapy may help you improve your life, don't allow yourself to be held back by exaggerated worries.
It usuallyispossible to keep confidential the fact that you have entered therapy when there are especially compelling reasons to exercise foresight and caution.Explainyour concerns to your therapist; he or she can then make every effort to help you.
20DOES THERAPY WORK?
Whether or not therapy works is a question that has hounded psychotherapists for more than thirty years, when evaluative studies began to cast doubts on its effectiveness. Since then, several hundred studies of the effectiveness of psychotherapy have been made. Some of them appear to show that psychotherapy is highly successful, and many have pointed to evidence that psychotherapy is no more effective than no treatment at all.
The ambiguity about this issue has been very troublesome to therapists and tends not to be openly discussed with clients, for obvious reasons.
Why reports about psychotherapy's effectiveness have been so contradictory and ambiguous has never been made clear. But understanding the reasons behind these opposing claims will give us a basis for optimism.
CLAIMS AGAINST THE EFFECTIVENESS OF PSYCHOTHERAPY
If people who are emotionally troubled "get well" through psychotherapy in about the same length of time as those who are not given any treatment at all, we would be inclined to say thatpsychotherapy didn't help. Several studies have shown that the majority of people with "neurotic disorders" improve spontaneously, on the average, in one to two years.[1] When people with similar problemsaretreated with psychotherapy, the outcome is virtually the same: the spontaneous remission rate for all practical purposes is the same as the rate of success due to therapy. Psychotherapy doesn't seem to make a difference. We'll call this thespontaneous remission criticismand will come back to it in a moment.
[1] S. Rachman,The Effects of Psychotherapy(New York: Pergamon Press, 1971) p. 18.
Most studies of the effectiveness of psychotherapy make use of "placebo treatments": a group of emotionally troubled individuals is treated with one of the major approaches to psychotherapy by well-trained therapists, and another group of similarly troubled people is treated by untrained "therapists" who offer their clients a "therapy" that is simplymade upbut is carefully presented so as to be believable. And, again, it turns out that clients treated with the legitimate therapy improve, but not significantly more than those in the placebo group. We'll call this theplacebo criticismand will come back to it, too, in a moment.
A few studies have shown that psychotherapy can actually beinjuriousto clients. A disorderbrought aboutby medical treatment is called aniatrogenic disturbance.Iatrogenesisis the Greek word for "brought about by doctors." If the iatrogenesis criticism is valid, then therapy may be not only ineffective but sometimes actuallyharmful.[2]
[2] See, for example, Thomas J. Nardi, "Psychotherapy: Cui Bono?," in Jusuf Hariman, ed.,Does Psychotherapy Really Help People?(Springfield, IL: Charles C. Thomas, 1984), pp. 154-164.
Together, these three criticisms have made therapists feel very defensive—and rightly so. If fictitious treatment by a mock therapist works as well as treatment provided by a man or woman who has trained long and hard for a Ph.D. or M.D., wouldn'tyoufeel ill at ease—perhaps very much ill at ease!—charging your clients $75 to $100 an hour for your time for a service that is no better than none at all and may even cause your clients to get worse?
These are not trumped-up charges against psychotherapy that we can afford to ignore. Therapists don't like to confront them. Here are some of the results of research studies:
... [A]s compared with spontaneous remission, there is no good evidence to suggest that psychotherapy and psychoanalysis have effects that are in any way superior.[3]
[3] Hans J. Eysenck, "The Battle over Therapeutic Effectiveness," in J. Hariman, ed.,Does Psychotherapy Really Help People?, p. 59.
... [M]ost of the verbal psychotherapies have an effect size that is only marginally greater than the effect size for ... a "placebo treatment."[4]
[4] Edward Erwin, "Is Psychotherapy More Effective Than a Placebo?," inDoes Psychotherapy Really Help People?, p. 39.
Most writers ... agree that the therapeutic claims made for psychotherapy range from the abysmally low to the astonishingly high and, furthermore, they would tend to agree that on the average psychotherapy appears to produce approximately the same amount of improvement as can be observed in patients who have not received this type of treatment.[5]
[5] Rachman,The Effects of Psychotherapy, p. 84.
... [U]sing placebo treatment as a proper control (which it undoubtedly is), we find that the alleged effectiveness of psychodynamic therapy [i.e., psychoanalysis] vanishes almost completely.[6]
[6] Eysenck, "The Battle over Therapeutic Effectiveness," p. 56.
There is still no acceptable evidence to support the view that psychoanalytic treatment is effective.[7]
[7] Rachman,The Effects of Psychotherapy, p. 63.
... [T]here is no relationship between duration of therapy and effectiveness of therapy.[8]
[8] Eysenck, "The Battle over Therapeutic Effectiveness," p. 57.
Psychotherapy of any kind applies techniques that are based on certain theories, and these theories demand not only that there should be correlation between success and length of treatment, but also that the training and experience of the therapist should be extremely important. To find that neither of these corollaries is in fact borne out must be an absolute death blow to any claims to have demonstrated the effectiveness of psychotherapy.[9]
[9]Ibid.
The pessimism produced by these conclusions was summed up by Hans J. Eysenck, professor at the Institute of Psychiatry in London:
I have always felt that it is completely unethical to subject neurotic patients to a treatment the efficacy of which has not been proven, and indeed, the efficacy of which is very much in doubt—so much so that there is no good evidence for it, in spite of hundreds of studies devoted to the question. Patients are asked to spend money and time they can ill afford, and subject themselves to a gruelling experience, to no good purpose at all; this surely cannot be right. At least there should be a statutory warning to the effect that the treatment they are proposing to enter has never been shown to be effective, is very lengthy and costly, and may indeed do harm to the patient.[10]
[10] Eysenck, "The Battle over Therapeutic Effectiveness," inDoes Psychotherapy Really Help People?, p. 59.
WHY PESSIMISM IS UNFOUNDED
I hold all contemporary psychiatric approaches—all "mental-health" methods—as basically flawed because they all search for solutions along medical-technical lines. But solutions for what? For life! But life is not a problem to be solved. Life is something to be lived, as intelligently, as competently, as well as we can, day in and day out. Life is something we must endure. There is no solution for it.[11]
[11] Thomas Szasz, interviewed in Jonathan Miller,States of Mind(New York: Pantheon Books, 1983), p. 290.
We must grab the bull by the horns. Thousands upon thousands of people continue to enter psychotherapy. How long would any service last if it failed to serve the needs of its market? It is tempting to suppose that something constructive, at least sometimes, happens as a result of psychotherapy to justify the time, expense, and faith of clients. Or is their faith really misplaced?