What to Look For and Questions to Ask
(This is a whole chapter on the subject which didn’t fit in my book on the Mood Spectrum. It’s long…)
If you’re looking for a mental health specialists, or thinking about trying to switch, I hope you’ll find this material helpful. You can start by thinking about what kind of treatment you’re after, and how much of a specialist you think you might need. Here are your choices, by increasing level of training and specialization:
|Therapy But No Medications||Medications But Minimal Therapy||Therapy and Medications|
|Internet Chat Groups||Primary Care Doctor|
|Church Pastor||Primary Care
|Psychiatric Nurse Practitioner|
|Counselor||Busy Managed Care Psychiatrist||General Adult Psychiatrist|
|Licensed Therapist: (LCSW, MSW, Ph.D.)||Consultation with a Specialized Psychiatrist||Mood Disorder Specialist|
As you can see in this Table, there are many different providers whom you might try. For each type of specialists–prescriber of medications, or therapist, or both–there are increasing levels of specialization. The table also illustrates that one of the first decisions you’ll need to make is whether you need access to a medication approach. Should you start with psychotherapy, or medications? We’ll look at medications and therapy in later chapters. At this stage you just need a sense of which you’d like to emphasize at first, in order to look for treatment. You can start with psychotherapy and then add an additional provider to do the medication part; or vice versa. If you get lucky and find a good psychiatrist or psychiatric nurse practitioner, you may be able to get both in one place.
If you’re just starting out to try to get some help with your symptoms, you may first need to focus on figuring out just where on the Mood Spectrum you have been swimming. Therapists may be better diagnosticians than primary care doctors. They have more mental health training. However, they cannot prescribe medications. Since they are only able to do therapy, sometimes there is a risk that they can’t “see” hypomania very well. Remember the old adage “When all you have is a hammer, everything looks like a nail”? In the mental health business, when all you do is therapy, everything might look a bit more like plain depression, as that is what most therapists are best trained to address (unless you find a therapist who has experience with one of the bipolar-specific psychotherapies).
Psychiatrists are generally trained to use both psychotherapy and medication approaches, and have a lot more experience with the Bipolar end of the Mood Spectrum. Theoretically they should be the best diagnosticians. However, in my experience, psychiatrists also have some of the strongest diagnostic biases of any of the providers listed in the table above. So starting elsewhere is not necessarily a huge set-back, in terms of diagnostic accuracy. As you hopefully already understand, you are one of the most important factors in diagnostic accuracy, through careful consideration of your personal history, and careful explanation of your history to whomever you see.
Finally, in many parts of the United States , finding a psychiatrist – especially one whom you can see within a few weeks – can be very difficult. You could end up starting with one of the other providers listed above just because you can’t get to a psychiatrist easily. Placing your name on waiting lists, when you call psychiatrists, is probably wise: you might not need her when her office calls in a month or two or four, and can then decline the opportunity; but if you’re going to end up needing her help, you’ll want the clock running while you’re trying to manage in other ways. Let’s look now at how you’d pick any provider; then we’ll look specifically at picking a therapist, and picking a prescriber.
Tips for choosing any provider
Here are some tips that apply to any provider you choose. These may be utterly obvious, or unnecessary for you. But in case you need a step-by-step, read on.
Of course you’ll only want to do this with people whom you trust not to go blabbing all over the place that you’re looking for mental health help. You might be similarly cautious even if you were looking for a gastrointestinal specialist because there is a history in your family of colon cancer and you are seeing blood in the toilet bowl after bowel movements. In other words, you might use the same level of caution for any serious health problem.
However, we must admit that society still struggles with problems that seem to arise from somewhere higher than your eyeballs. So be careful whom you pick for this step. On the other hand, you may be surprised to discover how many of your friends have some sort of experience with mental health providers! After all, at any given time, about one in every 20 adults has Major Depression (you might hang out with people whose rate is lower, but some people could be living around people whose rate is even higher). And some other mental health conditions (even without including alcohol problems) are almost equally as common. So, your friend may not have seen a therapist or psychiatrist herself, but she may know someone who has. She may even know who her friend saw, and perhaps even whether he had a good experience there. That’s what you’re looking for, just hearsay at this point, if that’s all you can get.
You can see from this that the more people you ask, the more opinions you can gather. If you get lucky, you’ll get a really strong endorsement of at least one therapist. If you get really lucky, you’ll hear about that same therapist from two different people. Obviously, that would be a great therapist to contact. If your friend has seen this therapist, you can ask her if it would be all right to drop her name when making your initial call; any name recognition helps distinguish you from just any other person calling for help. If this therapist is really good, she may have a waiting list. Occasionally you’ll run into providers who indicate that they are not taking new patients at all. But for therapists, that can’t last too long: if they’re that good, some of their patients are going to get better and finish therapy! However, be respectful of limits the therapist is setting: over years, the people who can get well do so, and those who continue to struggle can still need help. The latter group begins to represent a bigger and bigger part of a therapist’s practice, and can lead in part to this “full up” problem, after a period of time.
Ask Your Primary Care Doctor
In the old days, before “managed care”, most primary care doctors had a list of their favorite therapists. If they’ve been in practice in your town for a while, they’ll have heard which therapists get good comments, and which do not. They may even have some thoughts about which therapists get better results,which of course is even better than getting good comments. So, your primary care doctor is a great resource for recommendations.
Start by making a copy of the list of therapists your insurance will allow you to see, if you have such restrictions in your policy. Call the patient services representative (usually an 800 number on the back of your card), but have a magazine in your lap when you start this: you may be on hold a while. Hand that list to your doctor’s nurse, with a note asking very politely if your doctor could just circle any therapists on the list with whom she’s had good experience, and put an “x” through anyone they’d recommend you avoid. Promise not to share that information with anyone, and make it clear you’ll stick by that promise. You can understand how politically sensitive it is in the medical community to “nix” somebody, and that anyone who does so takes a professional risk. You may not get any “x’s” for that reason. If the list is short or if you do not intend to use insurance to pay for seeing a therapist, obviously you could just ask for your doctor’s recommendations, much like asking your friends.
Your church pastor might be another source of information. As you may have discovered, there are also referral services on the Internet. However, at this writing, these services are not very credible: I just searched for my own zip code, for any therapist of any kind, any gender, etc. Although there are at least 20 therapists in my town (many of them good ones), none of them appeared on the computer list. Of the three who did, the nearest was almost an hour away.
Think about it: if you are a good therapist, you’ll get a good reputation in your area eventually. If you’re really good, you’ll have plenty of clients coming to you. You won’t need to be presenting yourself on the Internet. Those who do place their names on Internet lists may actually be less competent (but they could also be smart, “early adopters” of this means of findin g c lients). At this writing, on the West Coast at least, there seems to be little value in going to the Internet to find a local therapist.
There are many online therapy programs, some research tested, some not; some free, some not.Renton To my knowledge no one has developed a bipolar-specific psychotherapy and made it widely available online, yet. At least a few groups are working on it. One group in the UK, led by the remarkable Dr. Danny Smith, and another in Australia, led by the equally remarkable Dr. Michael Berk, has a research version under study.Lauder
BUT… thanks to the Australians, whose health service funded the work and the research, there now exist free, online programs for treatment of depression and anxiety. These are sophisticated interactive versions of the most widely-studied treatments for these basic problems, cognitive-behavioral therapy (CBT). And these programs have so far been equal in effectiveness to seeing a live therapist (believe it or not), if you complete the online program. That’s a very big if. Only a small percentage of patients succeed at this.Twomey You have to be disciplined and motivated.
If you’re not feeling disciplined and motivated (depression itself gets in the way, right?) then you still could use the online programs to be the guts of your treatment if you don’t have access to a therapist experienced in CBT. Use the therapist to be your coach and motivator and use the online program to provide the technical stuff. (This approach has not been tested, but it makes sense to me. There are a lot of people out there who might be able to find a therapist of some sort — or even a trusted friend — who cannot find a CBT specialist. I figure this is unlikely to be worse than seeing an unskilled therapist….)
Relevant to my current work in primary care, when an online therapy approach was tested in that setting, the online program was better than the usual approach there. And just over half of the participants actually made it through the online program. Kivi
Picking a Therapist
For the therapy role, you want someone who is very easy to talk to, as well as technically skilled. H ere are the four criteria which will likely determine your choice, each to be considered in turn below:
- Recommendations (if you can get some)
- Technically suited to your needs
- Feels right, or close enough
If you can, you’ll want to use the sources of recommendations listed above. But suppose you can’t get any recommendations to go on? You may have to start with the list of therapists your insurance will pay for you to see. If that factor does not structure your options, you might end up really starting from scratch: the phone book. Call a bunch of them, starting with those whose offices are easiest for you to get to, choosing first from those with an MSW, LCSW, or Ph.D. if there are a lot of them. Leave a message like this:
[NAME and CONTACT INFO’] Hi, my name is John Jones. I’m looking for a therapist. My telephone number is _____. It’s okay to leave a message there.
[REQUEST] Could you please let me know if you are taking new clients, and if so, how soon I might see you? I think I have both depression symptoms and something a little more like bipolar II, though I’m not certain about that. The depression is pretty bad at times. I’m looking for a diagnosis and psychotherapy. I might add medications later, perhaps not. I’ll be interested in your thoughts on that issue. (Or: I’m already on x and y medications for this through Dr. Z).
[HOOK] If I may ask, do you have much experience working with people with bipolar spectrum symptoms? If could let me know very briefly what general techniques you use, I’d appreciate it. Thank you. I look forward to hearing from you.
The hook is to elicit some clue as to their orientation and their experience. You don’t want to make too big a demand at this stage (as I can attest, being on the receiving end myself, often). But you’d like to hear something that you might use to rank one therapist higher than another, all else being equal. You want to give them just a little room to talk, so you can get a sense of what they sound like thinking aloud. You may be able to rank therapists, even with no prior recommendations to go on, based on how they sound when they respond to these questions.
You might find the name of the greatest therapist around, only to discover that she’s not taking new patients, or your insurance doesn’t cover her. Her excellence is now moot. When your recommendations – or the results of your own research — match up with a therapist who is taking new patients, you’re ready to evaluate her or his technical skills.
Technically Suited to Your Needs
If you are in a large city and have lots of choices of therapists, you’ll want to know about the bipolar-specific psychotherapies:
|Bipolar-Specific Cognitive Behavioral Therapy|
|Interpersonal and Social Rhythm Therapy|
|Family Focused Therapy For Bipolar Disorder|
However, technical skills are not the only thing you’re looking for. The feel of the message or conversation should suggest this person also has the personal characteristics of empathy, compassion, and perhaps (this would be trickier to determine over the phone) some wisdom as well! You’re looking for a connection that feels right, and that feeling should start to develop over the telephone before you even get to their office. I hope you can find several such candidates in your search process. Which is more important, a therapist who “feels right” or one with the right technical skills? This may have more to do with your particular needs than where you are on the Mood Spectrum. In general I think most therapists would agree that a good “fit” is more important than getting the right technique. There are several research studies comparing results obtained by therapists using different techniques, which suggest that the empathic connection with the client is more important than the technique used. Most therapists become “eclectic” – using bits and pieces of multiple techniques – as they mature in their profession. So if you are fortunate to have a lot of choices, the “fit” factor may be at least as important as the “technique” factor.
Picking a Psychiatrist
Nearly all the above comments apply to picking a psychiatrist — especially if she or he will also be doing the psychotherapy, if that component of treatment is needed. How much therapy and what kind is a very individual decision, although in general the research suggests that co mb ining psychotherapy and medications gets better outcomes than either alone. Here are those four factors that will guide your choice, adapted now for psychiatrists and psychiatric nurse practitioners in particular.
Primary care doctors know the local psychiatrists even better than the therapists, generally: there are usually fewer, and their medical connections help bring them into greater contact. So your primary doctor’s comments and recommendations carry even more weight when it comes to recommending a psychiatrist.
Since you are presumably looking for a psychiatrist with skills in bipolar disorder, someone who is more likely perhaps than the average psychiatrist to be able to identify and cope with the bipolar components of your Mood Spectrum symptoms, it would be great if someone pulled together a national list of such specialists. There was one, for a time, courtesy of a Harvard-based team, but that’s no longer available. For one thing, many very good doctors won’t have taken the time to list themselves here; in fact, relatively few doctors have. (Interestingly, there were only 5 M.D.’s on the list Oregon , and only 3 in Missouri ! But there were over 25 per state in Massachusetts , California and New York. Gives you a sense of what you’re in for with this search…)
(Skip this section if you have plenty of psychiatrists to choose from and they are taking new patients. Lucky you.) In rural areas you may have great difficulty finding a psychiatrist at all; and those whom you can find may not be taking new patients, or doing so very slowly, with a long waiting list. Why is this? There are a lot of factors involved. Among them: psychiatry has for years been the least chosen specialty for students completing medical school. We just haven’t had that good a reputation. The pay is comparable to a family doctor’s, but far less than things like radiology and surgery. However, the advances in understanding of the diseases we treat – depression, bipolar disorder, schizophrenia – are helping make our profession look like a true medical specialty, with similar scientific methods and similar standards for treatments. That should help. But for the next decade or so, the supply of psychiatrists is likely to be ample only in the urban areas where psychiatrists seem to prefer to live.
What are you supposed to do if you need a psychiatrist? Well, let’s think about who really needs a psychiatrist, anyway. First, there’s the diagnostic part. A good therapist can do that, especially if she or he has experience in the bipolar-specific psychotherapies (and thus can better distinguish nails from bolts that need a wrench not a hammer).
Then there’s the medication part. Primary care doctors are frequently very skilled at using antidepressant medications. They have been prescribing a lot of them for years. All that experience ironically places them ahead of many psychiatrists in terms of the nu mb ers of patients they have treated with antidepressants, and thus then kinds of outcomes they have seen. All those patients can count for a lot, if your primary care doctor is smart and can learn from experience.
The problem comes with the medications for the other end of the mood spectrum. The “mood stabilizers” and “atypicals” are medications we psychiatrists use a lot. There are quite a few and they differ more from each other than most of the commonly used antidepressants. From working with my local primary care colleagues, I know that many of them use these medications also. A few of them have become quite skilled at it: smart doctors can teach themselves a lot if they see enough patients with a particular kind of problem. Thus we can’t really speak about “all primary care doctors” regarding their ability to use medications for the Mood Spectrum. Some are very good at this, and some have basically no experience at all. Those who have good access to psychiatrists will have referred to them everyone who has more than “plain” depression, and thus not had the opportunity nor the pressure to learn about the rest of the spectrum.
So what are you supposed to do if you can’t find a psychiatrist? First, you need to research all of your options. Is there a psychiatric nurse practitioner whom you could see? Your insurance company, if you have one, may be able to help provide a list of specialists in your region. But that list may not include all of the possible prescribers – only those the company will pay for! Your state psychiatric association might be able to help you identify all the psychiatrists in your area: find it using the American Psychiatric Association’s list of District Branches and State Associations (mostly but not entirely alphabetical) at www.psych.org .
Suppose there just is no psychiatrist you can access, realistically: they are too far away or they are not taking new patients or the waiting list is 5 months long. If you have a primary care doctor, you may have to rely on her, at least for now. If after reading Part I of this book you think that your mood problems lie somewhere in the middle of the Mood Spectrum, not all the way at the “unipolar” end; and if you think a medication approach is going to be necessary or should at least be considered; then you and your primary care doctor are going to have to work together. This is not impossible, though it is not recommended and you should try all the avenues you can find to at least have a consultation with a psychiatrist before relying entirely on your primary care doctor (who will appreciate your efforts to take this responsibility off her shoulders).
Consultations are generally one or two sessions, and lead to a formal diagnosis and a set of treatment recommendations your primary care doctor can then follow. Most university medical centers with a medical school will provide this service. Many private psychiatrists do not, because it requires a lot of work “up front” without the opportunity to see how things turn out (and learn thereby). But if you can get such a consultation, even if it requires a lot of travel, it may be very helpful. Unfortunately, you are then really stuck with the potential biases of the doctor whom you see, so you’ll want to be prepared for that.
Technically Suited to Your Needs
Psychiatric Nurse Practitioners (PNP’s) and Psychiatrists are the only prescribing mental health specialists. How do they differ? The PNP’s have much less psychiatric training – but they often were psychiatric nurses before getting their NP degree. Many of the PNP’s I’ve worked with are excellent. Nurse practitioners are often the “cream of the crop” in their nursin g c lasses and in their professional settings. They also tend to have remarkably open minds to learning, compared to their M.D. colleagues. They be somewhat more open-minded in their diagnostic assessments as well – though of course these are broad generalizations and almost meaningless when it comes to evaluating a particular NP whom you might see. The main point here is that PNP’s can be excellent options and should be evaluated alongside whatever psychiatrists appear on your list.
There are two skills you’ll be trying to evaluate for psychiatrists and PNP’s: their ability with medications, and with psychotherapy. The latter evaluation is basically the same process described above for therapists. As for evaluating medication abilities, this is very difficult. If you already have a therapist, then her or his recommendations are very likely to be the best you can get. They are more likely even than your primary care doctor to know the psychiatrists and PNP’s personally, or have had experience working with them (e.g. sharing the care of a particular patient). If you don’t have a therapist, the same list of recommendation sources given above for therapists applies: friends, primary care doctor, pastor. If you have no such recommendations to go by, then just as for picking a therapist, you may have to start with those who are closest and who are available (taking new patients now).
Feels Right, or Close Enough
I hope that by the time you reach this step you actually still have some choice, more than one option. (In most of Oregon , this is not likely to be the case; and it could be worse in yet more rural states.) All of the comments on choosing a therapist, regarding the “feel” of the person, are relevant here.
In addition, here is one last thought on this subject. Getting a “second opinion” as to your position on the Mood Spectrum, and your treatment options, should be okay with the provider you pick. Even if it is not, you can proceed to get one. You would be under no obligation to inform doctor #1 that you had done so. If you like doctor #2 better, because of her opinions or her style, you could stay on there and politely inform doctor #1 that you have decided not to continue treatment at this time. There is one exception to this recommendation, however, as follows.
You should be careful about choosing to switch doctors. In the psychiatric business I very commonly end up telling people things they don’t really want to hear. Usually I will wait to do so, if I have the chance, until they have some reason to trust me. Hopefully the “cement” of having spent several hours with me will help them recognize that whatever I say is supposed to be helpful, and that they can take my comments in that light. But sometimes there is no opportunity to wait. You could end up hearing something you really don’t like in the very first session. You’ll have to be careful: do you want to switch because you just don’t feel comfortable with this person? Or do you just not feel comfortable with this person because she or he is telling you things you really don’t want to hear?
This caution about switching doctors becomes even more important if you’ve been working with a particular psychiatrist for quite a while. The longer you do so, the more opportunities there may be for him or her to make a serious error in listening or understanding. When that happens in therapy, people often start thinking to themselves: “maybe I’ve improved enough, maybe now is a good time to finish up the therapy, or move on to a different therapist”. It is crucial that you stick around to work through any such errors. Sometimes the biggest gains in therapy come out of these. You have to be brave and just tell the therapist “when you did X, I felt Y”. After that gets straightened out, if you still feel like finishing therapy or moving on to a different provider, you have to be brave again and tell the therapist so. Don’t just stop going. Give the therapist the opportunity to respond, and listen carefully to his advice. You don’t have to follow it, but you have to consider the possible truth in it.
Good luck with the process.