Back From the Brink: A Family Guide to Overcoming Traumatic Stress, by Don R. Catherall, Ph.D.
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12
SEEKING
PROFESSIONAL
HELP
Finding the Right Therapist and
the Right Treatment
Throughout this book, I have referred to the usefulness of psychotherapy for trauma survivors and their loved ones. Many of you who read this book will want to see a professional therapist to help you manage the recovery process and possibly root out deep‑seated issues. So in this chapter, we will address the issue of finding an appropriate professional therapist. There are several factors to consider: the cost, the therapist's personal qualities, professional discipline, and theoretical orientation.
The cost of psychotherapeutic treatment varies
according to the therapist’s profession.
Psychologists and psychiatrists in private practice are the most
expensive. Social workers in private practice are less expensive but will still
charge more than most clinics. Some clinics charge nearly as much as private
practitioners, while others offer a sliding fee scale that is adjusted
according to the patient's income. Some private practitioners also offer
sliding scales. The more expensive private practice people are not necessarily
better, but with them you'll have the most control over who you'll be seeing.
In clinic settings, you're likely to be assigned to whoever has an opening.
One of the least expensive ways to get treatment is
to go to a community mental health center. These are often subsidized by
government funding and can afford to offer services below the going rate.
Another good source of inexpensive treatment is a clinic that serves as a
training facility. You'll likely be treated by a trainee, but this does not
mean that you'll receive inferior therapy. If the facility is run responsibly,
the trainees will be supervised by experienced therapists. Often you will receive
good treatment here because of the extra time the trainee puts in discussing
your case with a supervisor. But your therapist's fees and how experienced he
or she is are only part of your evaluation. You should also be concerned with
what kind of person your therapist is.
No one kind of therapist is best suited for
everybody. But there may be a kind of therapist who is best for you. You are
looking for a good fit between your
therapist and yourself. Even a young, inexperienced therapist can be just right
for you if you're comfortable with and have confidence in that individual. In
the final analysis, you're looking for someone whom you can trust enough to let
yourself be vulnerable. Remember, you make the final decision on whether to commit
to this therapist or not.
But there are some general personal characteristics of therapists that make them better or worse for dealing specifically with traumatization, and so you should interview a potential therapist to determine whether he or she is right for you. (Here, for the sake of clarity, I will refer to the therapist as female.)
Acceptance
of Traumatization as a Legitimate Problem
Believe it or not, some therapists don't
"believe" in traumatization. Most of these "nonbelievers"
think that only individuals with personality problems should be identified as
having PTSD. They're not particularly interested in your trauma and may view it
as an excuse for problems that were already there. So they downplay the need to
talk about the trauma and focus instead on the current problems in your life or
on your childhood. If your therapist doesn't believe in traumatization, then
you probably won't get the kind of help you need. Find another therapist.
Many therapists who do believe in traumatization do not consider it important to talk about the trauma itself. Some feel that reliving the trauma retraumatizes the patient and doesn't contribute to recovery. They prefer to focus on the current situation. Clearly, I have a different view, but I respect their opinion. I have found that some people do not profit from extensive reexamination of the trauma. In any case, these therapists have different ideas from mine about how to be most helpful but they accept the premise that the traumatization is a legitimate problem.
Knowledge about Traumatization
The diagnosis of PTSD was developed only two decades
ago, and many clinicians are not very familiar with it. Your therapist may know
of the diagnosis but have little knowledge about the specific nature of
traumatization. So ask her about her familiarity with PTSD. Lack of familiarity
with a relatively new diagnosis is no sin, but she should be willing to
acknowledge it. Does she have some idea what occurs in a case of traumatization
and what needs to happen in order to recover from it?
After reading this book, your knowledge of
traumatization and the recovery process should be relatively sophisticated.
So don't be afraid to interview your prospective therapist. Your therapist
doesn't need to be an expert in the treatment of PTSD, but should be open to
recognizing the special aspects of the disorder. If she's open but not very
knowledgeable about traumatization, give her this book to read and come back
the following week.
Has she treated other people with trauma disorders?
Has she had personal experience with traumatization? None of these is required
to qualify the therapist, but the more experience she has had with
traumatization, the greater the likelihood that she can help you with yours.
Don't be afraid to ask her about it.
What kind of person is this therapist? Do you get
the feeling that she could stay connected with you in the midst of powerful,
disturbing emotions? You can't tell a therapist's personal strength from her
appearance, only from interacting with her. But ask yourself whether she seems
to have the kind of strength of character upon which you can rely, even when
you are experiencing something that will be very disturbing to both of you.
When you talk to this person, do you get the feeling that she really understands? Empathy is a necessary characteristic for all therapists, but some are better at it than others. The only way you can evaluate your therapist's empathic ability is by your own feeling. If you come away without feeling understood and supported, you may have a therapist who is not sufficiently empathic. Being empathic doesn't mean that the therapist will always agree with you, but it does mean that she's able to see and understand the situation from your point of view.
The capacity to listen is closely related to
empathy. It is what therapists are trained to do, and most do it very well. If
you get the impression that your therapist is not listening carefully, it could
be an indication of a problem. Good listeners can paraphrase what you are
saying and demonstrate that they are following your thoughts. You must be able
to tell your story and feel that your therapist listens well and understands
how you see things. After the interview is over, ask yourself if you felt
comfortable enough to tell your story. If not, something didn't work right.
This is not necessarily cause to find another therapist, but it should be the
first order of business for your next session.
As I have suggested, a significant trust relationship requires that the participants be able to discuss the feelings between them. Is your therapist going to be able to hold up her end of a trust relationship? In an initial interview, one indication you'll have is how she handles the questions you ask. Does she answer them directly and openly, or is she evasive? Bear in mind that the therapist has her own agenda for an initial interview and may be trying to get her own questions answered. So don't confuse evasiveness with the therapist's efforts to maintain control of the interview. Overall, however, did you feel that you were talking to a "real" person or to an actor who was hiding behind the role of professionalism?
A Consumer Orientation
Many people get so anxious when they first go to a professional therapist that they are more concerned with what she thinks of them than with what they think of her. It's all too easy to view the therapist as having all the answers while you take a sort of passive, obedient child role as the patient. But keep in mind that you are the consumer, and you are deciding whether to purchase this person's services. It's a very personal service, and the final decision is yours (although the therapist must also decide whether she can work with you). If you have a very positive feeling at your initial interview, you may make a decision at that time. But you may find it helpful to wait until you've had time to digest your impressions before you commit yourself.
A number of different kinds of professionals perform psychotherapy. The primary ones are psychiatrists, psychologists, and social workers. In addition, a number of nurses with graduate degrees also perform therapy, as do other professionals who are trained therapists. Some renowned family therapists have been anthropologists, communications theorists, psycholinguists, and cyberneticists. I know family practice physicians and clergymen who have been trained to do family therapy. In fact, anyone can call herself a psychotherapist, since it is a generic label and not protected by law (in most states), like the label of psychologist.
So if you are uncertain about your therapist's
credentials, ask about her training. Professional training is a must. All
psychiatrists, psychologists, and social workers have professional training.
Many people are uncertain about the differences among these disciplines, so
here are some guidelines to help you.
Psychiatry is a medical specialty, just like
surgery, orthopedics, and cardiology. Thus, all psychiatrists are physicians,
and they hold the M.D. degree. All physicians must finish four years of medical
school and pass medical board exams, then do residencies in their area of
specialization. If your therapist is a practicing psychiatrist, she has
completed a residency in psychiatry, usually consisting of a one‑year internship
and three years of residency training. Many psychiatrists perform fellowships
and receive additional years of training, usually focused on some specific
aspect of psychiatry. Some take their specialty board exams and are board
certified in psychiatry. They're usually not required to be board certified to
practice psychiatry, but it's expected for many official positions. If your
psychiatrist displays her diplomas and certificates on the wall, you can learn
a lot about her training by reading them.
Psychiatry training occurs in a hospital setting.
Psychiatry residents are hospital staff members and are given primary
responsibility for psychiatric patients in the hospital. As physicians, they're
trained in the use of medications, and they can prescribe them as soon as they
pass their medical boards at the end of medical school. So when they start
their psychiatry residency, they are qualified as medical doctors even though
they may have little or no experience with psychiatric problems. Usually,
their experience is limited to a six‑to‑eight‑week rotation
on a psychiatric unit during medical school.
Psychiatrists are usually trained to do
psychotherapy with a broad array of disorders, but since they're the only
therapists who are also physicians, many of them get involved with the more
severe cases—those requiring medications and hospitalizations. Most
psychiatrists in private practice are on the attending staff of a hospital. If
you are receiving medications for psychiatric symptoms, a psychiatrist should
always be involved. Other physicians are qualified to prescribe medications for
psychiatric conditions, but you're better off being monitored by a trained
psychiatrist who is familiar with these particular drugs and their effects.
There are a number of subareas in psychology, but it
is clinical psychology that
constitutes the training of the bulk of practicing psychologists. In order to
be called a psychologist in most states, the individual must meet various
qualifications, including supervised experience in a year‑long
internship. But the nature of a psychologist's degree can vary, and individuals
with degrees in other areas of psychology can usually be licensed as
psychologists as long as they get the clinical internship training. Most
graduate programs in psychology provide several years of training prior to the
internship. But this varies with different schools and programs. Some place a
greater emphasis on clinical training than others. Many psychologists receive
further (usually more specialized) training in postdoctoral fellowships,
performed in hospitals or clinics.
The degrees that psychologists hold can be confusing. Some have master's degrees, but most have doctorates—either Ph.D.'s, Ed.D.'s, or Psy.D.'s. The Ed.D. is from a department of education and is usually in counseling psychology. The Psy.D., a newer degree, is granted by programs that are oriented toward producing professional clinicians (as opposed to academics or researchers). The Ph.D., the more traditional academic degree, requires proficiency in research and scholarship. Thus, if your psychologist has a Psy.D., you can assume that her education had a strongly clinical orientation. If she has a Ph.D. or an Ed.D., she may have attended a program that emphasized scientific skills over clinical skills, but this is becoming less and less common as most programs now focus on both.
The clinical training of psychologists includes
psychological assessment (the use of such tools as intelligence and inkblot
tests) as well as psychotherapy. Whereas psychiatry education is focused on
illness, psychology training is focused more on studying how the human
personality functions. That's why the personality tests that psychologists use
are designed to tap into the basic processes that make up the personality.
Clinically, psychologists strongly emphasize learning, and they tend to
consider medication less often than psychiatrists.
Social Workers
The field of social work evolved as an applied profession, rather than as an area of academic study like psychology. Social workers correct sociological problems at the grass roots and help people who are having problems make the best use of societal resources. Most social workers have a master's degree—the M.S.W.—which fully qualifies them to practice. A doctoral degree in social work usually does not add more clinical training; rather, it emphasizes research and scholarly skills. There are different specialties in social work, some of which are oriented toward administrative skills and offer no clinical training. The social workers who are therapists have generally been trained in psychiatric social work, though it may be labeled differently at different programs.
Social workers usually receive one to two years of
clinical training in clinics or hospitals. They often put a stronger emphasis
on client advocacy and social issues than psychologists or psychiatrists. They
are licensed in most states and can operate independently. Many states used to
require that social workers be supervised by a psychiatrist, but these days,
social workers are recognized as competent professionals who do not need to be
supervised by another discipline.
Social workers are trained to look at the individual
within the community. To make a gross oversimplification, we might say that
where the psychiatrist looks for disease and the psychologist looks at the
personality, the social worker looks at the individual's situation. Social
workers are more likely to work with the family, the school, and other
community resources.
I should note here that there are more similarities
than differences among these three disciplines. Psychologists and psychiatrists
certainly do not ignore the individual's situation, and social workers are well
aware of psychiatric disorders.
Before I leave the topic of professional discipline,
I should reveal my own background so that you can evaluate my biases. I am a
psychologist, and I hold a Ph.D. in clinical psychology. I received three years
of training before my internship, two years of internship, and another year of
post-internship training. The three years of pre-internship training were part
time, as I was attending classes at the same time. All my training took place
in hospitals and clinics associated with hospitals, since I attended the
clinical psychology program at Northwestern University Medical School.
As you may or may not know, therapists have different theoretical orientations. In this section, I will give you a brief overview of the different theoretical approaches. Among the many theories of human behavior, these are some of the ones that are most often employed in treating traumatization.
Behaviorists do not relish theories that invisible
forces are operating inside the psyche. Rather, they focus on what can be
measured and observed in people's behavior. In a classic behavioral experiment,
Pavlov trained dogs to associate the ringing of a bell with being fed. They
would then salivate upon hearing the bell—the dogs were "conditioned"
to respond this way by the conditions in which they were fed. Behaviorists look
for the ways in which people, too, are conditioned to maintain certain
behaviors. Of course, they focus on more sophisticated rewards than being fed,
but the principle is the same. A behavioral approach focuses on changing a
person's external environment in order to change his behavior. With humans,
the external environment refers to a number of things, including other
people's responses to the person.
Behaviorists may try to change the way you respond
to your memories of the primary trauma through such devices as the
desensitization techniques described in Chapter 9. Most behaviorists would also
work on changing your current symptoms by helping you alter your environment.
Some behaviorists also work with the family, again trying to help people work
out problems by altering the ways they respond to each other. I think
behavioral approaches are most useful in dealing with some of the physical
symptoms that accompany traumatization. Other issues, such as the survivor's
loss of meaning, seem to be less responsive to behavioral methods.
Cognitive approaches focus on how and what people
think; their goal is to develop more rational thought. Some people are more
responsive to this approach than others. I think people who are more intellectual
can make the best use of this approach. It can be useful with issues like self‑esteem
(as we have seen in Chapter 10) and obtaining a more balanced perspective on
the initial trauma, but it doesn't seem to work in isolation. In order to make use
of cognitive tools, you need to feel supported emotionally. Thus, cognitive approaches
for traumatization work best when they're accompanied by a supportive trust
relationship.
The theory underlying most family therapy approaches
is called systems theory. Its
premise is that the behavior of an individual cannot be understood in isolation
but must be looked at from the perspective of how it fits into the entire
family system. An apparent problem in one family member may actually be serving
a function for other family members. For instance, a child with a behavior
disorder may serve to take the heat off of the parents' marital problems. Or a
wife's depression may serve to help her husband overcome his low self‑esteem
and feel better about himself by taking care of her. Family therapists
typically see individuals with problems in the company of their spouses or
families.
There are a number of schools of family therapy, combining
systems theory with practically every other theoretical approach. Family
therapy is a powerful tool in the treatment of traumatization because it allows
therapists to influence those important trust relationships in the family
(where most recovery takes place). Sessions with the family can help trauma processing
take place and help the family remove any blocks against that processing. But
if the traumatization is downplayed and erroneously viewed as an attempted solution
for some other family problem, a family therapist can fail to acknowledge the
importance of the trauma.
Family therapy means being in therapy with your
spouse or lover, with your children, your parents or your whole clan, or any
combination of the above. The therapy will inevitably deal with your
relationships with one another, even if the problem that brings you there is
associated with only one family member. The therapy may be quick and focused on
how to help that symptomatic member, or it may be focused on family problems
that are related to the individual member's symptoms. Usually, families with
traumatized members make use of family therapy to break down barriers and open
the kind of communication I advocate in Chapter 6.
Therapists who practice psychodynamic and
psychoanalytic approaches are primarily interested in the internal processes of
the individual and how those processes are manifested in relationships. Change
is to be brought about by developing insight,
wherein the patient comes to understand the hidden reasons underlying his behavior.
Psychoanalysis has the largest body of theory of all psychological approaches
and is sometimes criticized because of its strong reliance on theory.
Psychoanalysis refers to both a theory and a
technique that the psychoanalyst uses. In its purest form, psychoanalysis
involves lying on a couch and free‑associating with a therapist several
days each week. The therapist is called an analyst, and her job is to analyze
the psyche of the patient. Only in true psychoanalysis is the therapy conducted
in this way, however. Most psychoanalytic therapists are not analysts (it
requires additional training) and do not offer psychoanalysis per se. Rather,
they use psychoanalytic theory to help their patients achieve insight, but they
have modified the classic (Freudian) psychoanalytic method. They see patients
less frequently—usually once or twice each week—and may be considerably more
active, directive, and supportive than the classic method prescribes.
The psychoanalytic approach pays considerable
attention to the lifelong effects of early childhood experiences, reasoning
that current problems often relate to childhood experiences, such as the deep‑seated
blocks we examined in Chapter 11. The primary criticisms of the approach are
that insight does not necessarily produce change and that the treatment process
is unnecessarily slow. Psychoanalytic practitioners argue that problems take a
long time to develop and that lasting change is equally difficult to develop.
Although the critics are right that insight does not always lead to change, the
psychoanalytic counterargument is that insight allows the individual the choice to change. Doing it is still up
to the individual.
Clinicians have applied psychoanalytic theories and
methods to traumatization. Psychoanalytic theories help explain many aspects of
traumatization, and this book is founded on some of those theories. My only
caution about the psychoanalytic approach is that the clinician must be aware
of or willing to learn about the unique aspects of traumatization. If a
clinician views traumatization as only a minor vehicle for unearthing childhood
issues, she is making the same mistake as the family therapist who discounts
the trauma in favor of family system pressures. Very often, I find that
traumatization does unearth childhood issues, but the overwhelming nature of
the trauma requires that it be dealt with first and, once it is dealt with, the
childhood issues often become irrelevant. Sometimes, however, as in the
examples from Chapter 11, deep‑seated problems become the new focus for
therapy as the traumatization is resolved.
Eclecticism
I've described several approaches and emphasized some of their differences. Some people practice these approaches in purer forms than others. Those who take bits from one approach and pieces from another—and refuse to be categorized by only one—refer to themselves as eclectic. Most therapists are influenced by more than one approach but may accept one label as generally descriptive of how they operate. Thus, a clinician may call herself psychoanalytic, yet help parents employ behavioral strategies in dealing with their child's misbehavior.
Brief Psychotherapy
In brief psychotherapy, treatment is focused on a
few specific goals and is conducted with a time limit, such as twelve or twenty
sessions. The therapy may rely upon the theories from any of the other
approaches; it is simply limited in what it targets. In brief psychotherapy
there tends to be a very efficient use of the time and a lot of goals can be
achieved. The format doesn't lend itself well to vague goals; the more specific the goals are, the more likely
they'll be achieved. Thus, it is not the best approach to use to pursue total
recovery from traumatization, but it can be very helpful for pursuing specific
goals that are part of that recovery.
Many insurance plans provide for only brief psychotherapy by covering something
like twenty sessions per year. If you pursue a time‑limited therapy, be
sure to set realistic goals so that you don't frustrate yourself and come away
feeling that therapy can't help.
Group psychotherapy is therapy with a group of
strangers, sometimes for a fixed period of time, such as twelve sessions.
Groups are an unusual kind of treatment because some of the most significant
influence comes from the other group members—other patients—rather than from
the professional therapist. Groups can be a tremendous source of support,
particularly if you have become socially isolated. The best type of group for
people who have been traumatized is a group of other people who have been
traumatized. Traumatized people may feel less alienated if they can relate to
others who have been through similar experiences. The national network of Vet
Centers has run groups for traumatized veterans for the past decade. Many
veterans have found this to be their lifeline and the beginning of their
journey back.
Again, I should share my own orientation and
approach so that you know my biases. I operate according to a mixture of
psychoanalytic and family systems approaches, with a little behavioral
technique thrown in. A fundamental part of trauma therapy is the
de-conditioning of the fear response; this often requires highly structured
techniques for lowering arousal while the survivor accesses the memories. I
also place a premium on the development of insight, whether with families or
individuals. And, for people recovering from trauma, I place a premium on
support and the opportunity to share the burden. Much of what I do is what I
have advised you to do in this book, and my job is often devoted to removing
the blocks that are preventing patients from doing their jobs.
I, of course, leave it to you to decide whether you
need to see a professional therapist. If you're uncertain, go for a session and
see what emerges. Many people go into therapy and find themselves crying and
getting emotional about things that they didn't think they had a lot of
feelings about. If you do go to a therapist to deal with your own or your loved
one's traumatization, be sure to consider the personal qualifications of the
therapist. Find a good fit. Trust your gut feeling about your therapist. Be
open—talk with her about your feelings about her and how she conducts your
therapy. Therapy is not something that a therapist does to you; it is something
you do together.