Consumer Guide for Seeking Professional Help

There came a time when the risk to remain tight in the bud was more painful than the risk it took to blossom.

~Anais Nin

People typically seek professional help when their best attempts to cope with and/or adapt to stressful life events have failed; when feelings of overwhelm and/or defeat, coupled with disabling physical, emotional and behavioral symptoms, interfere with their ability to effectively do life, i.e., participate in work, school, relationships, sleep, capacity for enjoyment and other activities of daily living. (See section “What is Trauma”)

Irrespective of one’s choice of clinician, program or type of therapy, the ultimate goal of trauma treatment (in fact, the goal of all psychotherapy) is to help improve one’s quality of life; to feel and function better on a somewhat sustainable basis. This doesn’t mean that therapy will not be difficult or painful; it means that the therapy process includes the development of safety, support and skills for stabilization for managing those difficult and painful times.

Where to Begin  

Even for a well-resourced, healthy consumer, navigating the mental health system is a significantly challenging task, but for a traumatized person, it’s often an overwhelming one. So, if there is someone you trust, who is willing and able to assist you, accept the support.  You may also find the general information provided below regarding trauma treatment, the clinicians providing it, and the modalities most frequently employed helpful at the outset.

Getting Ready

Lots of folks hate this advice (it’s particularly difficult to heed for those who have been traumatized), but, here it is anyway. If you do not have a primary care physician, now is a good time to find one, as a complete physical examination is warranted prior to beginning therapy. There are a host of reasons, but here are my top two:

1. Medical conditions must be ruled out in order to perform an accurate psychological assessment- a prerequisite to offering an appropriate treatment recommendation.

2. If medication is or becomes necessary, a complete physical examination is usually required.

And a few foundational statements regarding trauma therapy:

Inherent in the medical model lies a significant risk factor for anyone with a trauma history: the doctor/patient relationship, itself. What?! Why?! Unfortunately, that relationship is a hierarchal one. It’s as if an all-knowing, all-powerful, presumably healthy expert has taken on the burden of healing a frightened, much less powerful, not-so-knowledgeable, sick patient. Even if that ridiculous premise were true, due to the disempowering nature of trauma, survivors are poorly-served by that type of relationship.

Take away: Whether choosing a psychiatrist, psychologist, social worker or counselor, steer clear of authoritative clinicians.

Unlike the medical model, the trauma model is an empowerment model that recognizes the therapeutic relationship is requisite to healing.  Although the clinician should possess and provide many things-professional training, skill, useful information, empathy, insight, intuition, etc.-it is the client who is the expert on the client  and the primary agent of change.

Take Away: The therapeutic relationship is paramount to successful treatment. If it isn’t collaborative it’s doomed to failure.

Choosing a Clinician

Screen out the Unavailable and Unaffordable

Be advised that during your search you will find that for various reasons-full caseloads, scheduling conflicts, prohibitive fees, insurance issues, etc.-many clinicians will be unavailable to you. Although it is almost never personal, it can be disheartening. So, if possible, try to keep a certain level of detachment until you’ve located and met with one-or several-available qualified clinicians.

When seeking advice on How To Choose a Clinician the following are standard suggestions:

1. If you are comfortable and they are available, it’s best to begin your search with personal references, i.e., ask trusted relatives, friends, neighbors and co-workers about personal experiences with particular clinicians.

2. If you are not comfortable asking, or there are none available, you might ask your (regular or newly found) primary care physician for a recommendation.

3. Psychology Today’s website (as do many other websites) has a Find a Therapist search page.

4. Regardless of whether you will be using an insurance plan to offset the cost of therapy, anyone is free to search out clinicians from insurance companies’ panels.

All perfectly appropriate suggestions - adequate for most inquiries. Unfortunately not an inquiry into a relatively esoteric field. Hopefully this is a temporary situation, but presently within the field of psychotherapy, there remains a dearth of knowledge, education and training in the treatment of trauma; trauma therapy remains a specialized treatment. Over the past few years, I’ve received hundreds of calls and emails from across the country requesting contact information for clinicians skilled in working with trauma. Sadly >95% of the time I was unable to provide that information. Consequently, I’ve begun to compile a national registry. Perhaps it would be of value in your search.

Recommended Trauma Informed/Trauma Sensitive Clinicians  

Take Away: Trauma therapy is a specialized treatment, necessitating more training and skill than many clinicians currently possess.

Screen out the Unqualified

It should go without saying that the combined abilities of hanging a shingle and collecting cash in no way qualifies a person to be a clinician, BUT in many states, anyone with those abilities is free to do just that, AND to refer to him/herself as a therapist or counselor. Happily, I haven’t worked directly with any of those people, but have worked with hundreds of clinicians. They come from myriad backgrounds, education and disciplines. Some started in medical school, got licensed in their state (M.D.’s and D.O.’s), then specialized in psychiatry. Others received non-medical doctoral degrees (PhD’s, PsyD,  Ed.D, Th.D.) and then got licensed in their state as clinical psychologists. Many earned master’s degrees in psychology-clinical, experimental or educational (MA, MS), others in social work or divinity (MSS, MSW, M.Div.). Some of those with their master’s degrees practice without any further specialization or licensing; others continued specialized training and then got licensed in their state as either licensed clinical social workers (LCSW’s), licensed professional counselors (LPC) or licensed marriage and family therapists (LMFT). Some clinicians obtained bachelors degrees in psychology, nursing or social work (BA, BS, BSN, BSW) and practice without any further specialization, while others continued specialized training in substance abuse and then got certified in their state as drug and alcohol counselors (CAC, CCDP).

Suffice it to say, entrée into this profession is as diverse as the field itself. However, simply knowing a clinician’s route into the profession is not a predictor of his/her or competence. I can assure you that there are some truly great psychiatrists and some truly lousy ones; some truly great psychologists and some truly lousy ones; some truly great pastoral counselors and some truly lousy ones; some great social workers... you get the picture.

Take Away: Credentials are evidence of education and training, not of clinical acumen or personal fit. It’s probably wise to use a lack of credentials as a screening device for eliminating unqualified clinicians.

What Types of Therapy Does the Clinician Offer?

The story goes, that if I were to observe a session run by a talented, newbie clinician, I could easily spot his/her theoretical background and clinical orientation, i.e., early on in one’s career, those are fairly obvious. Interestingly, if I were to observe the same talented clinician twenty-five years into his career, I could probably not determine his theoretical background and clinical orientation.  The explanation is that talented experienced clinicians develop much more eclectic approaches; pull from multiple disciplines; utilize efficacious techniques regardless of their origin; and modify clinical modalities to fit the client rather than trying to modify the client to fit the modality.

I think that it is fair to say that clinical approaches are not nearly as important as the clinician him or herself. As Stephen Porges, PhD states, “That's why you can respect a master clinician regardless of what training they've had or what their degree is, because they will have that sensitivity and be of great benefit to their clients, while a person with multiple degrees from the finest institutions and all the specializations, if they manualize, without the empathic or reciprocal interaction there is going to be very limited opportunities for success.” Robert Scaer, M.D. concurs, “Perhaps attunement is without which nothing, the sin qua non that you have to have to achieve whatever else these techniques provide.”

It’s quite clear that a collaborative therapeutic relationship with an attuned clinician is paramount to successful trauma treatment, but what constitutes good trauma therapy? What techniques and modalities are specific to treating traumatic disorders? According to van der Kolk, the key to effective trauma treatment lies in the nature of trauma itself:

Trauma is about immobilization and disconnection... You want to move and you want to fight; but you can’t. It’s about being betrayed and hurt; screaming out for help; but nobody comes. ... So (in treatment) anything that helps people move purposefully where they were helpless before and anything that helps people to feel connected, where they were disconnected before is helpful. ...Everybody who does trauma therapy needs to be an expert in self regulation... because regulating yourself is the foundation of all trauma therapy. It starts with regulating the body. ... Then there is going into the trauma...that’s a tricky issue, because indeed, the nature of traumatic memory is that it’s split off, ... as Freud said beautifully in 1893, ‘like a foreign object’ isolated somewhere, then it pops out. So these foreign objects need to be integrated into the larger whole. There are many different ways to do that. ...The clinical challenge is how to keep people safe and quiet enough so their bodies can tolerate what they feel, and their minds can tolerate what they know. ... Then you need to know a good trauma processing technique....Trauma needs to be processed, so you need to be able to go there in some can go there somatically- as in Somatic Experiencing and Sensorimotor- you can go there in your mind as in hypnosis or you can go there in this interesting hypnopompic state that EMDR induces.

Here is a more inclusive list of Treatment Modalities

Considering EMDR? What every Client Should Know

When You're Ready to Hire a Clinician

Psychotherapy is a professional service that you are seeking. Although the same considerations regarding price, convenience, location apply, sometimes what gets lost is the fact that as a consumer, you are entitled to hire and fire at will. You will be selecting, interviewing then hiring the professional who can best meet your needs. To better prepare you for the hiring process-including the interviews, here are a few things that you should know:

-Good clinicians continuously monitor and attend to the therapeutic relational process, which mandates a vigilant self awareness.  In professional jargon, as clinicians, we are responsible for attending to our own countertransference issues. In laymen’s terms, as clinicians, we are required to acknowledge and work through our own issues-ON OUR OWN TIME, IN OUR OWN THERAPY OR SUPERVISION SESSIONS-NOT DURING OUR CLIENTS’ SESSIONS!

-Good clinicians are well aware of the inherent power differential within the therapeutic relationship, i.e., because it is the client’s personal history, issues and frailties being explored and exposed, the client is necessarily more vulnerable than the clinician. It’s a very good idea for clinicians to explicitly acknowledge this imbalance, while simultaneously facilitating the development of relational and communication skills to empower the client inside and outside of therapy.  

-Good clinicians have firm-yet not rigidly inflexible-boundaries. They are validating, respectful, open, authentic and self-disclosing when appropriate, i.e., when the intention is to improve the therapeutic relationship or to meet a specific need of the client, not a specific need of the therapist. See above.

-Good clinicians are not threatened by an informed consumer; will answer as many questions as you have; and if unable to meet your needs will readily refer you to someone who can.

Take Away: This advice is offered to those seeking a clinician- a unique relational role that is distinctly different from that of friend, parent or romantic partner. Buyer Beware: confusing these roles can be extremely costly-financially and emotionally.

Below are some interview questions for your potential clinicians. My advice is to print out several copies and bring one to each interview. Interview Questions for Potential Clinicians. This first set are general questions that are usually explicitly covered by the clinician-verbally, on the clinician’s website or in an “About my Practice” document, but you should feel feel to ask anyway:

How long are sessions?

What is the fee per session?

What is your policy about missed sessions?

Do you accept my insurance?

Do you have a sliding fee scale?

The set is about policies that may or may not be explicitly covered:

Do you have a crises policy?

Do you have a policy about physical contact with clients?

Do you have a policy about contact outside of the session?

Does somebody cover for you if you are sick or on vacation?

The set is about qualifications, credentials and experience with trauma:

What are your credentials? And what do they mean?

How long have you been practicing?

Do you have a specialty? How or why did you choose that?

How much experience have you had in treating disorders of traumatic stress?

What is your approach to treating traumatic stress?

Have you been trained in any of these modalities?

     * EMDR (Eye Movement Desensitization and Reprocessing)

     * SE (Somatic Experiencing)

     * Sensorimotor Psychotherapy

     * Gestalt Therapy

     * Neurofeedback

     * DBT (Dialectical Behavioral Therapy)

     * EFT, TFT or other forms of Energy Psychology

     * IFS (Internal Family Systems)

     * AEDP (Accelerated-Exeriential Dynamic Psychotherapy)

     * Guided Imagery

     * DNMS (Developmental Needs Meeting Strategy)

     * Psychodrama

Has anyone ever successfully lodged a formal complaint against you?

Have you ever been sued or censured by a professional organization? (Although this may be a difficult question to ask, it is advisable to do so; you are entitled to the answer, as it may well impact your hiring decision. If the clinician is not licensed or credentialed by the state, then asking is the only way to get the information. However, if you have eliminated non-credentialed clinicians prior to live interviews, this information is readily available to consumers on the internet. Go to your own state’s Department of State webpage. Under the heading Licensing enter the clinician’s name. (Disciplinary actions, if any, will be noted at the bottom of the page. )

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