The Caritas Counseling Center is nowhere near where you live. It is in Uganda.

The people who go there are not sophisticated.

They are not rich.

They do not have a mental disorder.

But they do have problems in their lives, and they’re looking for help.

That’s what therapy is for. Well, one of the reasons.

When I was much younger, I didn’t know what therapy was and I didn’t know what my options were. Now I’m a therapist myself and, while I know what it is, I feel that many people still have the same questions that I had. I’m writing this so that you will have the kind of basic information that just wasn’t available for me.

(And yes, I’ve been in therapy. Hundreds of hours. And I still go when I want to improve my life.)

As I’m fond of saying, “People are complicated…so it (i.e., the answer) depends.” This is also true for the subject of mental health care, so please regard the following Q&As as just the starting point for getting your questions on the subject answered. And much of the information below is, in truth, only the brief opinions of one mental health professional (which, for simplicity, I’ll abbreviate to the commonly-used generic term “therapist”).

Q: What’s the difference between “counseling” and “therapy”?

A: In my opinion, counseling and therapy are just different words for the same process. I call myself a counselor because I believe people are more comfortable with the word; other mental health professionals call themselves therapists or psychotherapists. All three words are informal and imprecise. You should also look for what formal credentials (e.g., academic degrees, licenses) a therapist has.

Q: What is therapy?

A: There are many ways (and reasons) to do therapy, so no one description can be entirely accurate. Let me give a partial answer to this question (the questions below will fill in more details):

In therapy, a trained professional meets with one or more clients, usually for a 50-minute “hour,” usually once a week, for an extended period of time. Clients usually seek a therapist’s help because of some concern or problem in their lives—perhaps regarding a crisis, a relationship, how they feel every day, or the quality of some aspect of their lives. (Some people use therapy to help them further their personal or spiritual growth.) The therapist (most are women) uses her academic training, ongoing professional development, professional experience counseling others, and own life experience as resources to help clients meet their goals.

Q: Can therapy be for more than one person?

A: Most counseling is individual counseling, one person seeking help for his or her problems.

If the problems are primarily about how two people in a relationship act or toward each other, then both of them can attend couples counseling (also called marriage counseling).

If the problems significantly involve how members of a family act towards each other, then some or all of the people involved can attend family therapy. This can include just the immediate family (parent(s) and children), extended family, or in some cases, members of the family system who are not related by heredity.

Group therapy is a very different kind of counseling that involves one or two therapists guiding a discussion among a group of people who may share a concern (e.g., women dealing with breast cancer) or may not (men’s groups). One reason that group therapy exists is that people learning from each other is often more effective than an individual or couple working in isolation with a therapist.

Counseling and therapy are just
different words for the same process

Grief counseling is the term used to describe counseling that centers around a significant loss. Usually, that loss is serious illness or death, but it can also be other things that are causing distress—for example, the death of a beloved pet or the loss of community from moving to another city.

Grief counseling takes many forms. Either one or several people may be the client. Those attending can be the ones with the loss (e.g., a couple dealing with one partner’s terminal diagnosis), or they may be people who are affected by someone else’s loss (family members after the death of a parent or child). Grief counseling may be done in a one-on-one configuration or a group configuration (group counseling of people with similar grief situations).

Grief counseling differs from all other forms of counseling described so far in that the counselor may not have an academic degree and state-issued license. I don’t know about other states, but the state of California (where I practice) allows this because such grief counselors have extensive training and are under the supervision of a mental health professional who does have the required degree and is licensed by the state.

Q: Why are there so many “types” of therapists? What’s the difference?

A: This is a very complicated subject, and what follows covers many but not all possibilities. It is as accurate as I can make it, but please do your own self-education on the subject.

I use the word type here as a shorthand to refer to a mental health practitioner’s credentials, licenses, and areas of expertise. The following list moves from higher to lower levels of expertise, scope (what services they are qualified to deliver), and price—though there are always overlaps and exceptions. (Remember, too, that everyone in this list is licensed by the state as being qualified to provide a specific set of services.)

Psychiatrists

Psychiatrists are the highest level of professional because, in addition to their mental-health training, they are also medical doctors. This means they are the only mental health professionals who can prescribe medications for problems related to mental health. (Obviously, personal physicians and other medical doctors can also prescribe medications.)

Because of this, other types of therapist will refer clients to a psychiatrist if they believe that medication may be appropriate. It is solely the psychiatrist who decides whether medication is appropriate and which medication to prescribe.

In addition, a psychiatrist is the only type of therapist who can formally diagnose a client as having a mental disorder (details).

Pre-license training

Just as psychiatrists (and medical doctors in general) undergo an extended period of training in which they treat patients under the supervision of someone with the qualifications to do so, the same is true for all the types of therapist described below.

Therapists will refer clients to a psychiatrist if they
believe that medication may be appropriate

For example, in California, before any of the therapists below are granted a license to practice, they must work as interns under the supervision of someone with the appropriate qualifications. This process includes accumulating at least 3,000 hours of what is called supervised professional practice. A majority of this time is spent seeing clients, with significant additional time spent talking with a supervisor about individual clients and other aspects of counseling. (For example, I spent over 1,800 face-to-face hours seeing individual clients of all ages, as well as couples, and families. The rest was supervision, training, and my own therapy.)

Psychologists

Psychologists are therapists who have a PhD in psychology or one of several similar degrees (details). Many of the jobs that psychologists are qualified for fall outside counseling (e.g., doing research, teaching at the college level). As therapists, psychologists are qualified to administer specialized psychological and developmental tests (which are needed for various reasons). Also, their PhD gives them expertise beyond that of the levels listed below.

The types of therapists listed below are roughly equivalent, except as noted. They have similar licensing requirements. Their educational requirements overlap with each other but also have significant differences. Depending on each therapist’s approach, counseling with one type of therapist may or may not “feel” different from counseling with another.

Social Workers

The focus of social workers is helping people by connecting them with locally available resources—family, social, community, and government. Once a social worker is licensed (gaining the title Licensed Clinical Social Worker, or LCSW), she is qualified to do a range of jobs, including counseling.

Marriage and Family Therapists (MFTs)

MFTs are qualified to counsel individuals, couples, and families. Their scope of practice (i.e., the range of services that their license permits them to perform) centers around helping people improve the quality of their relationships with others. (For example, California law describes this as “achieving more adequate, satisfying, and productive marriage and family adjustments…includ[ing] relationship and premarriage counseling.”)

Practically speaking, there is a disconnect between the title and the reality. In today’s society, most MFTs counsel individual clients (because that is the kind of counseling that most people are seeking), while a minority of MFTs specialize in counseling couples and/or families. MFTs can do individual counseling because the kinds of problems that people bring to counseling involve other people in some way. (It could be argued that an MFT should not counsel a hermit with depression, but I doubt that anyone has ever lost her license over doing so!)

By the way, don’t be confused if you see the acronym “LMFT.” The “L” stands for the word “Licensed”—“MFT” and “LMFT” mean the same thing. Very occasionally, you may see the acronym “MFTI.” The “I” stands for “Intern,” which refers to an post-degree person working on her MFT license who is seeing clients while being supervised as specified by the laws of the state where she practices.

Licensed professional clinical counselors (LPCCs)

The title “Marriage and Family Therapist” has been around for several decades, originating at a time when the most counseling was either marriage counseling (as it was called then) or family therapy.

LPCC (alternatively, Licensed Professional Counselor, or LPC, in some states) is a new relatively type of therapist, a category that was created to better serve the current marketplace. LPCCs receive less academic instruction and, without additional training, are limited to counseling individual clients.

MFTs concentrate on helping people improve
the quality of their relationships with others

It is important to note that LPCCs are as qualified to be therapists as MFTs. They take fewer academic courses because they are not learning about topics related to couples, family, and group therapy. If they become qualified to counsel couples, families, or groups, it is because they have taken additional training equivalent to that received by MFTs. In addition, they must do the same 3,000 hours of supervised professional training as MFTs and licensed psychologists and social workers.

Q: What should I look for in a therapist?

A: Neither I nor anyone else can give you a definitive answer to this question. However, given my self-imposed constraint of brevity, I will tell you what I believe are the most important things to keep in mind.

In the past half-century, much research has been done to shed light on what factors most often contribute to successful therapy. All of the studies that I have studied conclude that a significant, if not dominant, factor contributing to successful therapy is the quality of the relationship between the client and the therapist. For example, one relevant study claims that the “theraputic alliance” accounts for 30 percent of theraputic success, while “techniques unique to specific therapies” account for only 15 percent (see the first part of this page for details).

What does this mean for you? I believe that you should pay as much attention to how you feel talking to a given therapist as you do to her training and experience. Ask yourself:

• Do I feel comfortable sitting in this room, with this person?
• Is she treating me with respect, as an equal?
• Do I feel that she is listening to me supportively and without making judgments?
• Do I feel that she is trying to understand at an emotional level what I’m going through?
• Could I see myself—maybe not now, but someday—telling her about really personal things I’ve thought or done, even things that other people would judge me for?

Answering “yes” to most if not all of these questions is a good sign that you will benefit from counseling with this therapist.

Q: What if I don’t have a good feeling about the therapist I’ve chosen?

A: The quality of the client-therapist relationship is very individualistic, just as the “chemistry” is between two people in friendship or in an intimate relationship. Meeting a therapist for the first time, you can never tell whether or not things are going to work out. Because of this, it is fairly common for people to try more than one therapist before they find one they decide to work with.

My advice is to give yourself at least three sessions to get to know the therapist and to begin working on whatever it is that has brought you to counseling. Then feel free to make a decision. Pay more attention to how you feel about this therapist than what your brain is telling you.

It is fairly common for people
to try more than one therapist

If you decide that you want to try another therapist, you can begin by saying something like this to your current therapist: “I appreciate the work we’ve done so far, but I think I’m looking for something different. Can you give me some referrals?” The therapist’s response should be cooperative and motivated by her concern that you end up with a therapist—not necessarily her—that you feel comfortable with. Any response less than this, especially one that is defensive or coersive, is a strong sign that you should find counseling with someone else.

Q: What should I do if I don’t like what the therapist is doing?

A: This is another one of those “It depends…” situations. I can think of three distinct cases.

• In the first situation, the therapist is doing her job well, and she’s doing something entirely appropriate. She may be pointing out something that makes you uncomfortable but that needs addressing. Or she may be encouraging you to try something that moves you slightly in the direction you need to go—because progress in therapy often occurs by making a series of small changes, each of which “stretches” you by asking you to do something that is slightly outside your zone of comfort.
• In the second situation, the therapist’s intentions are good, but she has made a misstep. This is inevitable for several reasons: everybody makes mistakes, and sometimes what one person says can affect the other person in unexpected ways. It’s her job to recognize this and to repair the communication that has broken down between you. If you can, try to tell therapist about how you are feeling as a result of what she has said—the more specific you can be, the better.

You should never feel unsafe in a session

• The third situation is far more serious because the therapist is doing something inappropriate or harmful. You should never feel unsafe in a session, nor should you feel pressured to do anything that feels unsafe to you. You should never get the feeling that the session is about the therapist, her problems, or her needs. The therapist should never be verbally or emotionally abusive towards you. Any kind of sexual proposition or advance is seriously wrong (details). In these and similar situations, you will need to decide how to respond. If in doubt, seek the opinion of a trusted friend or other advisor.

Q: How do I start the process of finding a therapist?

A: The previous questions give you a start on how to find whether a given therapist is a good fit for you. This question is about how to get to that first session.

Finding names to consider

One good place to start is by asking people you know (especially if they have had problems similar to yours), your personal physician, or a trusted advisor (e.g., minister). Most schools (from elementary to graduate) make some level of counseling available free of charge.

Certainly, the Internet is a good source for finding potential candidates. One way to start is to search online; enter “therapists” plus the name of your city and state. (I highly advise against searching by ZIP Code, which gives you too few options.) If you can be more specific (e.g., “couples therapy” or “psychiatrists anxiety”), use that instead. If cost is an issue, substitute the phrase “public mental health services.”

Professional associations and services are also places you can begin an Internet search:

• Linkedin.com is a nationwide database of professionals of all kinds.
• therapists.psychologytoday.com provides a database of paid listings.
• The California Association Of Marriage and Family Therapists maintains a searchable database of its members at counselingcalifornia.com.
• The American Association of Marriage and Family Therapists provides a similar database at therapistlocator.net.

(DISCLOSURE: I list my private practice at the first three locations.)

Calling the therapist

When you call a therapist, it’s a good idea to ask some questions before scheduling an appointment. Most therapists understand the value of doing this and will be as helpful as they can.

When you call a therapist who has a small private practice, you may need to leave a message; the therapist will call back (often within a few hours). If you call and are connected to a receptionist answering the phone, ask if the therapist would be willing to call back to answer a few brief questions.

When you call a prospective therapist,
ask some questions

If I were calling to find a new therapist, I’d begin something like this: “Hi, my name is Gregg Williams. I’ve been having some problems with depression, and I’m looking for someone to work with. Would you have a moment to answer a few brief questions?”

Here are some good questions to ask:

• “As I said, I’m having some problems with _____. How many people have you treated for this?” Follow up with questions like, “What mix of success and failure have you gotten treating such cases?”, “How long was therapy for these clients, if you had to give a range?”, and “Do you have any special training for working with _____?”
• “What are the main issues you see with _____? What’s your approach to treating it?”
• “If I come to see you, what would the first several visits be like for me? In other words, what does starting therapy look like? What can I expect to get out of it?”
• “I know this is a difficult question to answer, but how does therapy work?”

Actually, these are not “brief questions.” All but the first one are difficult to answer—especially when the therapist knows little about you. Pay attention to how she answers you, maybe even more than what her answer is. Often, you can tell a lot about a therapist’s style, professionalism, and ability to relate to others, just by listening.

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