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Where to Get Mental Help

Stephen Barrett, M.D.

Professional help is appropriate when a mental, emotional, or behavioral problem significantly interferes with someone's ability to function, or when symptoms exceed an individual's tolerance. Therapists vary considerably in their training and professional standards.

Practitioner Types

Psychiatrists are physicians (M.D.s or D.O.s) who have completed at least 3 years of specialized training in psychiatry after graduation from medical or osteopathic school. Child psychiatrists have a minimum of 4 years of psychiatric training, including 2 years in adult psychiatry and 2 in child psychiatry. Geriatric psychiatrists are psychiatrists who have acquired additional certification by passing an examination in geriatric psychiatry. Certification is available from the American Board of Psychiatry and Neurology.

Psychologists have undergone training in the study of human behavior. The major recognized specialties are counseling, clinical psychology, school psychology, and industrial-organizational psychology. In most states, licensing or certification for independent practice as a psychologist requires: (a) a doctoral degree (Ph.D. or Psy.D.) from an accredited training program, (b) additional years of supervised clinical experience, and (c) passage of an examination. The National Register for Health Services Providers in Psychology, published by the Council for the National Register, lists licensed psychologists whose doctoral degrees and supervised experience meets the Register's standards. A few states allow persons with master's level training to work as associates or assistants under the supervision of licensed or certified professionals.

Psychoanalysts are practitioners who have undergone personal psychoanalysis and completed several additional years of part-time training in the theories and specialized techniques of psychoanalysis. Most are psychiatrists, but some are trained in psychology, social work, or another nonmedical discipline.

Social workers are licensed or otherwise regulated in all states. Certification in clinical social work or another specialty is available from the Academy of Certified Social Workers (ACSW). This requires (a) a master's or doctoral degree from a school of social work accredited by the Council on Social Work Education, (b) 2 years or 3000 hours of postgraduate experience under supervision of a master's level social worker, and (c) passage of a written examination. The NASW Register of Clinical Social Workers lists clinical social workers who meet the requirements for Qualified Clinical Social Worker (QCSW) or Diplomate in Clinical Social Work (DCSW). Both of these require 2 years of supervised clinical work plus either licensure, certification based on an examination, or membership in the National Association of Social Workers (NASW). The DCSW credential requires an additional 3 years of professional experience plus completion of a clinical assessment examination. NASW also offers two other credentials: (1) School Social Work Specialist, which requires 2 years of postgraduate supervised school social work experience, plus an examination; and (2) Academy of Baccalaureate Social Workers (ACBSW), which is similar to ACSW but does not require a master's degree.

Certified clinical mental health counselors must have a master's degree in counseling or a related discipline plus 2 years of experience after receiving the master's degree. They must also pass a written examination and adhere to a code of ethics. Currently 41 states plus the District of Columbia license or certify counselors. Those working in states that do not regulate counselors typically seek certification by the National Board for Counselors.

Specialists in psychiatric nursing are registered nurses (R.N.s) who usually hold a master's degree from a program that lasts 11/2 to 2 years, but the term "psychiatric nurse" may also be applied to any nurse who has worked in a psychiatric setting. The American Nurses Association certifies psychiatric nurses on two levels. Certification as a psychiatric and mental health nurse requires a bachelor's degree in nursing, 2 years (with a minimum of 1600 hours) of experience in a mental health setting, current clinical practice, and passage of an examination. Certification as a clinical specialist requires a master's degree in psychiatric nursing (or equivalent training), 500 hours of supervised clinical experience, and passage of an examination. The Directory of Specialists in Psychiatric Mental Health Nursing provides names of clinical specialists in psychiatric nursing.

Marriage and family therapists are licensed or certified in 42 states. Clinical membership in the American Association for Marriage and Family Therapy (AAMFT) requires appropriate master's- or doctoral-level training plus 2 years of clinical graduate experience with couples and families under the supervision of an AAMFT-approved supervisor. Training programs in the United States and Canada are accredited by AAMFT's Commission on Accreditation for Marriage and Family Therapy Education.

Sexual therapists specialize in the treatment of sexual problems that can be helped by simple techniques and increased communication between sexual partners. They may or may not be able to deal with underlying emotional problems that require additional psychotherapy. Certification is available from the American Association of Sex Educators, Counselors, and Therapists (AASECT), an interdisciplinary interest group. This requires: (a) a master's or doctoral degree, (b) licensure or certification in an appropriate professional discipline, (c) 90 hours of specialized education, (d) 90 hours of sex-therapist training, (e) 500 hours of supervised therapy, (f) 100 to 200 hours of individual or group supervision, and (g) 12 hours of structured group experience focused on attitudes about sexuality. Certification as a sex counselor has similar requirements but can be obtained with a bachelor's degree. AASECT publishes a register of those it has certified. Because sexual therapy is neither defined nor regulated by law, anyone can adopt the title of "sex therapist" or "sexual counselor." For this reason it is important to check the reputation of a prospective therapist. Those practicing at university-affiliated clinics can be presumed competent. Information about other therapists may be obtained from your family physician, the local medical society, or a local family service agency.

Substance abuse counselors offer evaluation, counseling, case management, and various other services to individuals who abuse alcohol or other drugs. Some counselors have entered the field without a college education. However, associate, bachelor's, or master's degree programs are required for many jobs. To become a National Certified Addiction Counselor (NCAC), candidates must hold current state certification or licensure as an alcoholism and/or drug abuse counselor, have 6000 hours or 3 years of full-time of supervised experience, and pass a written examination administered by the National Association of Alcoholism and Drug Abuse Counselors.

There are many other types of mental health practitioners whose activities are not defined by law or regulated by licensure. Included in this category are caseworkers, social-work aides, clergymen, art therapists, music therapists, dance therapists, school counselors, crisis-intervention personnel, and a wide variety of self-proclaimed therapists. Some have sound training, but others do not.

Psychotherapy

Psychotherapy can be defined as any type of persuasive or conversational approach designed to help patients. Although there are hundreds of techniques and schools of thought, most have in common a wish to understand the patient and help the patient change emotional or behavioral patterns.

Psychodynamic treatments are based on the premise that childhood experiences exert an unconscious influence that actively shapes people's current feelings and behavior. In analytically oriented psychotherapy, also called exploratory therapy, patients say what comes to mind (free association) and are helped to understand their feelings, mental mechanisms, and relationships with people. Insights are used to help patients develop healthier ways of dealing with feelings and life situations. This type of therapy typically involves one or two 50-minute sessions per week for a few months (short-term therapy) or years (long-term therapy). It is especially appropriate for people who communicate well and are motivated to change. Psychoanalysis is a more intensive form of psychodynamic therapy in which free association is done while lying on a couch. It usually requires three to five sessions per week for several years. Few people can afford its high cost. Interpersonal therapy focuses on current relationships in order to help people deal with unrecognized needs and feelings and improve their interpersonal and communication skills. Used mainly for depression, it typically involves 12 to 16 sessions.

Supportive therapy is a conversational approach intended to maintain or restore an individual's highest level of functioning. Therapists give advice and reassurance, make suggestions, and discuss alternative behaviors and problem-solving techniques. Depending on the nature of the problem, treatment ranges from a single session, or a few sessions over a period of weeks or months, to long-term care over many years.

Cognitive therapy, which typically involves 15 to 25 weekly sessions, is aimed at relieving symptoms rather than resolving underlying conflicts. It is used for the treatment of depression, anxiety disorders (mainly panic and phobias), anger management, personality disorders, and marital therapy. Therapeutic efforts center on decreasing faulty perceptions and negative attitudes. This is done by identifying how the patient reacts to life situations and helping the patient test the validity of these reactions. For example, someone who assumes that bad things never happen to good people might feel intensely unworthy in the face of an adverse event. The therapist attempts to modify this tendency by persuading the patient that adverse events occur for many reasons, most of which have nothing to do with the worth of the person.

Behavioral therapy (also called behavior modification) aims to replace maladaptive patterns with healthier ways of behaving. The therapist first analyzes the behaviors that cause stress, limit satisfaction, and affect important areas of the patient's life. Treatment techniques can include: (a) systematic desensitization (mastery of fears through gradual exposure to circumstances that provoke anxiety), (b) relaxation training, (c) exposure (gradual exposure to a feared object or situation without use of a relaxation technique), (d) flooding (maintaining exposure to feared situations until the anxiety dissipates), (e) reinforcement (rewarding behavior that is more mature), (f) modeling (copying a behavior demonstrated by the therapist), (g) social skills training, (h) paradoxical intention (temporary encouragement of behavior the patient wishes to stop), and (i) aversive therapy (associating an unpleasant stimulus with undesirable behavior). Behavioral therapy usually involves fewer than 25 sessions.

Biofeedback is a relaxation technique that can help people learn to control various autonomic functions. The patient is connected to a machine that continuously signals the heart rate, degree of muscle contraction, or other indicator. The patient is instructed to relax so that the signals decrease to a desirable level. The patient may ultimately learn to control the body function subconsciously without the machine. Biofeedback was popularized before it had scientific support, and it is still abused by fringe practitioners. Nevertheless, it has gained a measure of respectability [1]. It has been used to help patients control pain, anxiety, phobias, hypertension, sleep disorders, and some stomach and intestinal problems. Specialized techniques have been used to treat abnormal heart rhythms, epilepsy, Tourette syndrome (multiple tics), fecal incontinence, and Parkinson's disease. Most people who go through biofeedback training use it to acquire relaxation skills that could also be learned without electronics. Most qualified practitioners are psychologists, but some have backgrounds in other health disciplines.

In group therapy, several people, usually eight to ten, meet with a therapist for discussion. Groups may be homogeneous (composed of people with similar problems or backgrounds) or heterogeneous. The discussion may focus on specific topics or may deal with whatever comes up. Group discussions often help people feel less alone in their feelings and provide a "laboratory" for analysis of an individual's behavior in a group situation. Reticent individuals may find group sessions, in which they can sit and listen, preferable to individual sessions, which may be relatively silent.

In marriage counseling, husband and wife meet individually or together with a therapist to help them identify current marital conflicts. Acting as a referee, the therapist helps the couple communicate more effectively to negotiate solutions to their dispute. In family therapy the therapist meets with the family as a group to help resolve current family conflicts. Sexual therapy is most appropriate for couples who basically get along well but have a problem with sex. Couples with a sexual problem whose general relationship is poor will probably be better off with marital counseling or individual psychotherapy [2].

Hypnosis is a temporary condition of intense concentration during which suggestibility is greatly enhanced. This state may be used to increase the patient's control over a symptom or behavior. Hypnosis is not a treatment in itself but may accelerate the treatment process in properly selected cases. It has also been used for anesthesia during childbirth and dental procedures and for relief of headaches and other painful conditions. Because not everyone is amenable to hypnosis, the therapist should have adequate training in both the procedure and the selection of patients.

Expressive or creative activities, such as art, music, drama, poetry, or dance, are included in comprehensive treatment programs at hospitals and partial-hospital facilities.

Drug Therapy

Drugs are commonly prescribed for the treatment of anxiety states, depression, psychosomatic disorders, and psychoses. These drugs can affect both mental and physical functioning. Some take effect at once, some take several days to work, and some continue to work long after their use is discontinued.

Antianxiety agents (sometimes referred to as minor tranquilizers) are used to treat anxiety states, psychosomatic disorders, and alcohol addiction (during the detoxification process).

Antipsychotic agents (sometimes referred to as major tranquilizers) are used mainly to treat psychotic reactions (thought disorders manifested by hallucinations, delusions, or loss of contact with reality).

Antidepressants are available to counteract severe depressions (those manifested by loss of appetite, weight loss, severe insomnia, feelings of hopelessness, or psychomotor retardation or agitation). These drugs usually require from a few days to several weeks to take effect. They are not appropriate for countering the minor upsets that are part of ordinary living. Some antidepressants and antipsychotic drugs can be prescribed as a single bedtime dose. This method reduces the cost of the medication, may aid sleep, and reduces the likelihood of annoying side effects.

Antimanic agents, most notably lithium products, are used for bipolar illness (sometimes called manic-depressive psychosis).

Anti-obsessive-compulsive agents are used to treat patients with uncontrolled repetitive thoughts or actions.

Antianxiety agents and several other types of drugs are commonly prescribed for insomnia. Although occasional use of a "sleeping pill" may be appropriate, habitual use is not. People with frequent insomnia should seek professional help to correct the cause or to develop better sleep habits.

All psychoactive drugs have the potential for adverse reactions, some serious and some not. In each case the value to the patient must be weighed against the nuisance or danger involved. The most common side effects are drowsiness, agitation, dry mouth, tremor, and muscle stiffness. Some of these disappear with reduced dosage, continued use, or medication to counter them. Others are a reason to switch to another drug.

One complication of particular concern is tardive dyskinesia, an involuntary movement disorder characterized by twitching and tongue-thrusting, which can occur with a prolonged high dosage of antipsychotic medications. Although uncommon, it is often irreversible. Because the dangers of psychosis far outweigh the risk of tardive dyskinesia, there is no reason to withhold antipsychotic medication from individuals who are psychotic. However, it is poor medical practice to prescribe these drugs for nonpsychotic anxiety.

Americans have been accused (with some justification) of being a "drugged society" because of their high use of alcohol and medications such as Valium (an antianxiety agent) and Prozac (an antidepressant). Although most people who receive antipsychotic medications probably need them, it is clear that physicians often prescribe antianxiety agents or antidepressants when it would be more appropriate to help patients identify and correct what is troubling them. Physicians are not entirely to blame for this, however; patients often press for instant and total relief.

The danger of addiction to psychiatric drugs has been grossly exaggerated by the media, particularly in the motion picture I'm Running as Fast as I Can. The central character in this film is an anxiety-ridden woman who takes huge amounts of Valium, suddenly stops taking the drug, and becomes severely ill with convulsions. Although addiction develops occasionally with normally prescribed dosages of Valium and similar antianxiety drugs, the ordinary precaution of tapering off a dosage, rather than stopping suddenly, will prevent a withdrawal reaction from occurring.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT), also referred to as EST (electroshock therapy) and shock treatment, involves producing a convulsion by giving a brief stimulus to the brain. To receive the treatment, the patient lies down and is rendered unconscious either by an electrical stimulus or by a short-acting barbiturate given intravenously. To protect against injury, a curare-like drug is also given so that the patient's muscles do not contract during the convulsion. Electrodes are applied to one or both temples and a small amount of current is transmitted to induce the convulsion. After the treatment the patient usually remains unconscious for about 15 to 30 minutes. A series of treatments may cause memory difficulty that clears up in a few weeks except for memories of some events during the months close to the period of treatment. However, the ability to remember other things or to retain new information is rarely impaired [3,4].

ECT can be dramatically successful in certain types of severe depression and is sometimes helpful in severe psychotic reactions. However, it is seldom appropriate unless medication alone fails to produce results.

Selecting a Therapist

There are several reasons why finding a suitable therapist for a mental or emotional problem may be more difficult than finding one for a physical problem or for general medical care:

Four basic questions should be considered during the process of seeking mental health treatment: (1) What type of help is wanted? (2) Which practitioners can provide such help? (3) Are they available in the community? and (4) How much can the patient afford to pay?

If medication is desired, one should see a physician. Most nonpsychiatric physicians can competently prescribe antianxiety agents and antidepressants for patients who are not severely disturbed. For antipsychotic drugs, a high dosage of antidepressants, or any type of long-range treatment, it is best to consult a psychiatrist. Information about the training and credentials of psychiatrists can be obtained from the biographic directory of the American Psychiatric Association, the local medical society, or the psychiatrist directly. Certification by the American Board of Psychiatry and Neurology is a good indication that a psychiatrist is qualified to administer medication, but this certification is not as useful a guideline in selecting a psychotherapist. Some analytically oriented psychiatrists are not motivated to become certified because they believe the board is primarily oriented toward biologic psychiatry.

If a conversational form of treatment is preferred, names may be obtained from a personal physician, cleric, school counselor, friend, local medical or psychiatric society, local psychologic association, or the local Yellow Pages. Psychoanalytic institutes located in some major cities and the departments of psychiatry at medical schools and hospitals can provide names of psychiatrists and psychologists who specialize in psychotherapy. Psychiatrists who have trained at university hospitals are more likely to be primarily interested in psychotherapy than those who have trained at state hospitals. "Do you do psychotherapy primarily?" is a good screening question when seeking conversational treatment from a psychiatrist. Most national professional organizations publish a biographic membership directory, and most certifying organizations publish a directory of the professionals they have certified. Some of these publications are available at public, hospital, and medical-school libraries. Credentials can also be checked by contacting the national professional organizations.

Steve K.D. Eichel, Ph.D., who practices psychology in Philadelphia, Pennsylvania, has obtained certificates for his cat from five organizations: "certification" from the National Guild of Hypnotists and the International Medical & Dental Hypnotherapy Association; "registration" from the American Board of Hypnotherapy; and "professional membership" in the American Association of Professional Hypnotherapists. In each case, the only requirement was completion of a brief online questionnaire and payment of a fee—none checked any of the cat's alleged credentials. The cat also obtained "board certification" from the American Psychotherapy Association (APA). Although the APA asked for a copy of the cat's curriculum vitae, it did not ask for any documentation of credentials or check whether anything listed in the CV was genuine. Nor did it require any examination before issuing a certificate attesting to the having met "rigid requirements" resulting in her "designation as a Diplomate." The accepteance letter that accompanied the certificate stated that diplomate status "is limited to a select group of professionals who, by virtue of their extensive training and expertise, have demonstrated their outstanding abilities in regard to their specialty." [5]

The current cost of psychotherapy with a private practitioner is usually $60 to $150 for a 50-minute session. Psychiatrists tend to charge more than non-psychiatrists. In many communities, people who cannot afford private care can receive treatment at a mental health clinic where fees are based on the ability to pay. Most psychotherapy at community clinics is done by psychologists and social workers. A limited amount of counseling is available without charge to students through the student health service at most colleges and universities. Insurance coverage for psychotherapy is usually not generous. It typically covers 50% to 80% of the insurance company's allowable cost per session, with a low dollar limit on total cost per year.

Consultation with a physician is advisable whenever mental problems are associated with any of the following symptoms: blackouts; memory lapses (such as trouble recalling recent events); persistent headaches; significant unintentional weight loss; numbness; tingling or other strange sensations; generalized weakness; dizzy spells; significant pain of any sort; difficulty walking; shortness of breath; seizures of any type; inability to control urination; unduly rapid or forceful heartbeats; frequent, heavy sweating; tremor; or slurred speech [6].

A survey by Consumer Reports magazine drew 4100 responses from readers who had sought professional help for emotional problems between 1991 and 1994. Most had conditions that were not chronically disabling. Almost all felt they had been helped, with those who initially felt the worst reporting the most progress. Significantly more improvement was reported with long-term therapy than with short-term therapy. Overall, the respondents felt that psychiatrists, psychologists, and social workers were equally effective, and that marriage counselors were less so. Those who relied on their family doctors were more likely to receive medication and be less satisfied than those who sought specialized care [7]. This result mirrors research findings that most people who seek treatment benefit from it and, for most problems, the most important factor in psychotherapy is the patient-therapist match rather than the type of treatment sought [8,9].

How much therapy is "enough" depends largely on the patient's personality and the nature of the problem. Obvious symptoms tend to diminish fairly quickly, but personality change usually takes longer. How can progress of therapy be measured? One sign is lessening of symptoms such as anxiety or depression. Another is mastery or better management of stressful situations that previously had caused difficulty. However, symptom-relief can be temporary, and other types of improvement may not be obvious until many months have elapsed. Hales and Hales [10] state that although there are no consistent indications that therapy is on course, there are "red flags" that suggest when it is not. These include a sense that the therapist doesn't understand the problem, difficulty communicating or confiding, dreading each session, feeling "stuck," and feeling that the therapist is behaving unethically. Negative feelings do not necessarily mean that the treatment is not working. People who feel they are not making progress should discuss their concern with the therapist. Ethical violations are a reason to switch therapists.

Hospital Care

Psychiatric hospital care is needed in four basic situations:

Many communities have day-care or "partial-hospitalization" programs where patients spend 6 to 8 hours per day in a therapeutic atmosphere. Some hospitals have night-care programs. In some communities, halfway houses ease the transition from hospital to community living.

Patients who are judged sufficiently dangerous to themselves or others can be committed involuntarily to either inpatient or outpatient treatment. Contrary to popular opinion, court decisions and state laws tend to define "dangerousness" rather narrowly. As a result, commitment against a person's will can be difficult to initiate or sustain.

Summary

Although excellent help is available for the treatment of mental and emotional problems, selecting a suitable therapist can be difficult. Some people respond best to a conversational approach, some to medication, and some to both. Before seeking treatment, it is advisable to understand the types of help available and the training that various types of practitioners undergo. Although most practitioners with accredited training are competent, some engage in practices that are unscientific or reflect underlying problems of their own. For this reason, consumers should also be able to recognize the common signs of inappropriate therapy as described in other articles on Quackwatch.

Questionable Approaches

References

  1. Biofeedback. Harvard Medical School Health Letter 15(10):1­4, 1990.
  2. Callan J. Your Guide to Mental Health. Philadelphia: George F. Stickley Co., 1982.
  3. Task Force on Electroconvulsive Therapy. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. Washington D.C: American Psychiatric Association, 1990.
  4. Devanand JP and others. Does ECT alter brain structure? American Journal of Psychiatry 151:957­970, 1994.
  5. Eichel SKD. Credentialing: It may not be the cat's meow. Greater Philadelphia Society of Clinical Hypnosis Web site, accessed Nov 14, 2002.
  6. Pies RW. Inside Psychotherapy: The Patient's Handbook. Philadelphia: George F. Stickley Co., 1983.
  7. Mental health: Does therapy help? Consumer Reports 60:734­739, 1995.
  8. Gabbard GO. Are all psychotherapies equally effective? The Menninger Letter 3(1):1­2, 1995.
  9. Seligman EP. The effectiveness of psychotherapy: The Consumer Reports study. American Psychologist 50:965­974, 1995.
  10. Hales D, Hales RE. Caring for the Mind: The Comprehensive Guide to Mental Health. New York: Bantam Books, 1995.

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This article was condensed from the Mental Help chapter of Consumer Health: A Guide to Intelligent Decisions, Seventh Edition (McGraw-Hill 2001), by Stephen Barrett, M.D., Manfred Kroger, Ph.D., William T. Jarvis, Ph.D., and William M. London, Ed.D., M.P.H.

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This article was revised on November 14, 2002.