QUICK GUIDE TO STARTING THERAPY
7 Steps to Beginning a Successful Therapeutic Relationship
By Kristin Stonesifer, LCSW
Many years ago, I needed help for my son, who was struggling with behavior issues and paying attention in school. I had no idea where to begin. None of my friends were having issues with their children (seemingly) and could offer very little help. Feeling alone, I contacted my insurance company and asked for help. The only information I was given was that my policy would cover 20 outpatient sessions per year. She was speaking Chinese to me.
After maneuvering through several providers, we finally found a psychiatrist to help us. Looking back, I was at his mercy, as I had no education or training about mental health. When he recommended a medication, I blindly followed his recommendation. After that experience, I am very much aware and sensitive to the vulnerability to those seeking mental health help and make sure that I explain as much as possible and give my clients options where appropriate.
As you begin your journey to better mental well-being, there are several steps to consider to make your experience more successful.
- Determine what level of care you need
When I heard the term ‘outpatient,’ I had no clue what she was talking about. Information is power, so here are the three basic levels of care in the mental health field in most areas:
Inpatient care: Inpatient care is appropriate for debilitating impairment in functioning, such as feeling or attempting suicidal, homicidal, or psychotic. Psychiatric inpatient care is the mental health equivalent of being admitted to a medical hospital. It involves staying at the facility overnight, generally for several nights until your mental state stabilizes. Another form of inpatient care is rehabilitation facilities, where a specific issue is addressed for 30 days or more.
Partial Hospitalization (Day Treatment): This level of care is appropriate for individuals struggling with severe impairment in functioning, whereby inpatient may not be necessary but more care is needed than once or twice a week with a therapist. Day programs vary widely but are generally a day-long program with no overnight stay. Some programs focus on mental health, such as depression and anxiety, and some programs focus on substance use. The programs tend to be group-oriented and are structured programs.
Outpatient care: This level of care is appropriate for most mental health issues, such as depression, anxiety, substance use disorders, trauma treatment, where the individual is not in crisis. Your situation may feel like a crisis but from a safety perspective, the individual is not a danger to themselves or anyone else in an outpatient setting.
Many insurance plans cover mental health services, but not all do. Contact your insurance company directly to determine what your benefits are. They may be able to provide you with a list of providers in your area.
- Determine your medication and talk therapy needs
If outpatient care is appropriate for you, deciding where to begin can be overwhelming. There is an array of serviced and an array of letters behind a professional’s name that can be confusing and meaningless to the layperson.
Two main subcomponents of outpatient treatment are medication and talk therapy.
Medication can be provided by a psychiatrist (a medical doctor) or by a nurse practitioner (a master’s level trained nurse). Medication is a personal decision and is not necessary when seeking mental health treatment.
Looking back on my own situation, I wish I had pursued the talk therapy route more for my son rather than relying on medication. After a few years, he developed neurological tics and gained and lost a significant amount of weight. As a mother, the tics were difficult to see and I felt tremendous guilt.
Many people are opposed to pharmaceutical intervention and many people have benefitted from medication. The choice is yours and neither choice is wrong.
Talk therapy is generally provided by a psychologist or by a master’s level trained clinician (LCSW/LPCMH). In some states, the letters may vary but usually clinicians who accept insurance must be at least master’s level trained.
In some areas, drug and alcohol counselors (CADC) may also accept insurance but may not have master’s degrees.
Like any profession, there are excellent CADC providers who have a certificate and there are ineffective psychologists. A professional’s level of training may not necessarily correspond to the quality of care you receive.
When looking for a provider, it can be difficult to determine who is appropriate, as it is not always apparent by a title what the professional does.
For example, if you have a heart problem, most people know to find a cardiologist. If you are having a baby, you find an obstetrician. It is a little bit more difficult with mental health.
Many clinicians choose to specialize and have attended specific trainings. For example, treatment for marriage, trauma, and childhood issues require a different, specialized skill set.
Before scheduling an appointment, it is helpful and productive to narrow down your particular needs (where possible) and find a provider who best matches your situation.
- Finding a provider
Asking for referrals may seem like the first place to start, but there is an important dynamic to consider.
While it is a compliment to the professional to receive a referral, it can potentially present a conflict of interest. Remember, therapy is different than recommending a dentist.
Invariably, even though individuals have the best intentions, bumps in friendships can occur and each may feel betrayed about what the other person is saying in therapy. Even though an ethical provider will keep confidences, it can interfere with the therapeutic relationship in ways that cannot be predicted for the individual.
Your insurance company is a resource that may be able to provide you with a list of names, but the list may be long.
A great way to narrow down the best therapist for you is to read online bios. Most providers and organizations have websites with bios. Begin here to compile a list of providers with the specialty you need.
Once you have a list, do an internet search of each name. Many professionals have social media pages where you can gather more information.
An internet search may also reveal any licensing complains. A word about complaints with licensing boards – while all complaints are not legitimate, many are. If someone you are considering has a complaint filed against them, don’t immediately dismiss the person. Many complaints are frivolous and unfounded.
- Contact the office of each provider on your list
Like most healthcare offices, providers are very busy people and are running on a schedule. Don’t expect to have a conversation with the provider and ask questions.
When you call the office, you will be speaking with an intake or reception staff member. Most intake personnel have a general idea of the provider’s area of expertise but may not be able to give you too many specifics.
When you call to make an appointment, you will be asked for basic demographic information, insurance information (have your insurance card available), and basic reasons for the need for treatment (“I have anxiety”).
At this point, the intake professional should be able to determine if the provider is credentialed with your insurance company. It never hurts to reconfirm this information because it is ultimately your responsibility to choose providers that are covered by your policy. Not all providers take all insurance.
As with other healthcare professions, the best and most in-demand providers will have longer waiting lists. For high-demand providers, make sure you attend the first appointment. If you miss the first appointment, you may not get another chance. I have a zero-tolerance policy in my practice. I have learned the hard way through the years that clients who miss the first appointment end up being unreliable with their attendance.
- How to prepare for your first appointment
Before your first appointment, you may feel nervous. Completely understandable! One main concept to keep in mind – mental health providers talk to people all day long for a living. It is likely that they have interacted with thousands of clients. It is unlikely that anything you say would be shocking. I can almost guarantee that what you think is crazy or shameful doesn’t even hit their radar.
Prepare two lists before your first appointment. On the first list, compile a list of medications you take and previous mental health treatment. Some providers ask for this information and some may request notes from previous providers (most do not).
For your second list, think about what your goals for therapy are. For some, it may be difficult to articulate – that’s okay. Your therapy experience will be more productive if you have a roadmap. You may develop or change your list as therapy progresses.
- What to expect at your first appointment
Make sure you arrive 15 minutes early. As with other healthcare providers, you will most likely have paperwork to fill out. Remember, mental health professionals do not ‘stack’ patients like doctor’s offices do. Many doctor’s offices will over schedule the number of patients seen every hour by 1 or 2 to account for no-shows. Mental health providers cannot stack clients and therefore run on a tight schedule. They have allocated a specific time for you (usually 45 or 60 minutes) and do not have room in their schedules to move or squeeze clients in.
Don’t expect miracles at your first appointment but do expect to accomplish something. A lot needs to be accomplished in the first appointment. The provider needs to explain various policies (or should!), the provider needs to ask a lot of questions, and, most importantly, the client needs to be heard. You should leave your first appointment feeling heard, with a diagnosis, with a specific plan for treatment, and feeling hopeful. If you did not feel comfortable and supported or feel like the provider seemed incompetent in any way, it is okay to look for someone else.
Remember, it is YOUR healthcare and you have a right to choose your providers.
- If your provider gives you homework, do your best to complete it
I always use the gym analogy for clients. I can buy you a gym membership, buy you a cute outfit, drive you to the gym, and sign you up for a class, but you must do the workout to receive the benefit. Homework is the workout, especially with marriage, trauma, and child therapies. New thoughts and behaviors require practice for incorporation in order to generate change.
There is no need to struggle with mental health issues. Many people don’t understand therapy or what therapists do. They don’t just chat with clients (that would be a paid friend). For a better understanding of some of the concepts that can create positive change, check out my new book, 30 Day Mental Health Boot Camp, which is a day by day compilation of my most successful therapy interventions.
A journey of a thousand miles begins with a single step. – Chinese proverb