How To Find A Therapist

Having an outpatient therapist is a prerequisite for admission to the S.A.F.E. ALTERNATIVES¨ Intensive Program. We strongly believe that having a therapist to weather emotional storms and help sort through confusing issues is the best road to healing.

How do you find a therapist?  It's helpful to ask around.  A personal referral from someone you know is usually the best method.  You may want to consult your family physician, your gynecologist, or anyone else you know and trust in the medical field.  If you don't have a trustworthy source for a direct referral, you can always look in the telephone book under 'behavioral health,' where you will find names of clinics, hospitals and individual therapists. If you have insurance often times the customer service department (look for the number on the back of your insurance card) can give you a list of providers that accept your insurance.

Teaching hospitals and some clinics offer low-cost/sliding scale treatments. There, you may be assigned to a professional in training such as an intern or psychiatric resident who is supervised by a senior physician.  If you choose this option, know that you may have to terminate with that person once his or her training requirements are met.  The two of you can still have a productive and rewarding therapeutic relationship.  Be sure to find out what the transition process will be when their term is up.

Psychiatrists are medical doctors who are trained to diagnose any illness and prescribe medication. They have specific training in the treatment of emotional disorders and have graduated from a traditional medical school.  Some psychiatrists are doctors of osteopathy, fully licensed physicians trained in osteopathic medicine. This is a holistic approach to wellness based on the interrelationships between various body systems.

Psychologists are trained to conduct psychotherapy, though they are not medical doctors and cannot prescribe drugs at this time.  If you want to work with a psychologist, try to find someone with a minimum of a master's degree in social work or in clinical or counseling psychology.  Those with doctoral-level degrees (Ph.D. or Psy.D.) have even more experience and training.  Some registered nurses have also been trained and licensed to offer psychotherapy or counseling.  Some states offer counseling credentials to people with other types of training in related behavioral health fields.  Be sure to ask about a therapist's background and areas of expertise.

Therapy Models

There are several theoretical orientations in psychotherapy, and all of them can be helpful to the self-injurer. When interviewing therapists, ask which modality they use:

• Insight-oriented, or psychodynamic therapy focuses on understanding the motives for a person's behavior. Their choices are seen as complex outcomes of wishes, fears, memories, unresolved feelings and conflicts. The person may or may not be aware of the motives that drive their behavior. The premise of the therapy is that the more someone learns about their unknown inner world, the less they will feel compelled to engage in unhealthy strategies to cope with life.
• Cognitive-behavioral therapy starts from the premise that the way a person thinks strongly influences the way they behave and feel. Therapy focuses on helping clients recognize and change their automatic thoughts (their internal dialogues and statements about themselves), underlying assumptions (the beliefs they hold about what people are like and the way the world works), and cognitive distortions (errors in logic that lead people to draw faulty conclusions). The behavioral aspects of cognitive-behavioral therapy combines work on faulty thinking patterns with teaching, training, and guided rehearsal of new coping strategies. Patient and therapist work back and forth between the practice of new behaviors (often in the form of homework assignments) and the examination of belief patterns.
• Supportive therapy focuses on helping people manage the day-to-day practicalities of their lives. Rather than treating underlying or past issues, the supportive therapist offers advice and support for daily living problems. While therapy is usually limited to once a week, contact between sessions is often encouraged. The overall goal is to increase the person's stability and self-esteem.

The boundaries between these orientations are not rigid, and while most therapists profess to emphasize one approach, there is a great deal of overlap. For example, a cognitive-behavioral therapist will sometimes focus her efforts on exploring the causes and motives behind a self-injurer's actions, even though this will not be her primary target of intervention. Similarly, the psychodynamic therapist might challenge a patient's thought patterns, and at times help her devise more effective strategies.

Whatever the therapist's orientation, a self-injurer usually benefits the most from treatment that regards their behavior as an expression of their underlying issues. In other words, it is more helpful for the therapist to not view self-injury as the sole problem, but rather as the obstacle that keeps the patient from facing their issues and anxieties directly.

Self-injurers tend to have stormy relationships with people, and this turbulence can carry over into therapy. And such difficulties may also reflect problems with the therapist, who may recoil from self-injurers for a variety of reasons, from emotional aversion to legal liability.

Some therapists may suggest the use of hypnotherapy and cathartic methods, which can be counterproductive for self-injurers. Many self-injurers are tempted to try hypnosis to modify their behavior or forcibly remember painful feelings and memories, hoping it will speed recovery and help them control themselves. Our experience has been that many self-injurers who try hypnotherapy find it to be a very disorganizing and overwhelming experience, one that brings about regression, hospitalization, and more self-injury. We strongly caution anyone to consider this before trying the technique with their therapist.

There is no specific credential, or certificate of specialty, in treating self-injurers. Psychotherapists of all types and orientations vary widely in the amount of experience they have with the problem. It may be helpful to ask the prospective therapist how familiar she is with the issue, and how many patients she has seen who have the problem. While you may feel more comfortable with someone who has broad experience with self-injurious patients, keep in mind that this quantitative criterion is no guarantee that the therapist is skilled or successful. A 'good' therapist may not be the 'right' therapist for you. Some therapists with little experience may do well with self-injurers because they are inherently good at what they do and can sense instinctively what their patients need.
The rapport between client and therapist is a very important.

Interviewing a Therapist

Finding the right fit between therapist and patient is a highly subjective process. You might want to consider a few issues before you start interviewing candidates. Do you want an older therapist, someone your age, or someone younger? A man or a woman? How important are location, distance, surroundings? How much can you afford to pay? Is the therapist willing to bill insurance or does she expect you to be responsible for the bill?

When meeting a prospective therapist for the first time, go in prepared with ideas about your needs and goals, as well as what you don't want from your therapy. You might want to jot down in advance a list of questions to ask, for example:

• How often will you meet?
• How does she treat self-injury?
• What if there is an emergency between sessions? Is she available for phone calls?
• Will she help set up a safety contract with consequences for self-destructive behavior?
• How are holidays, vacations, and weekends handled?
• Is her schedule flexible enough to work in extra sessions if needed?
• Does she bill insurance or is payment due up front?

When you meet a therapist for the first time, think about:

• How do you feel?  Are you comfortable, safe?
• Is this someone you can trust and confide in?
• Do you want to come back for a second meeting?

Trust your intuition about these issues, and realize that you don't need to make a long-term commitment to anyone after one meeting.  It's perfectly acceptable to schedule a second and third trial session, or a trial period, to test your initial impressions and decide whether the fit is right.

We have found a few ingredients that help make the relationship a positive one:

• A therapist whose demeanor is calm and serene will usually work well with self-injurers.  Someone who grows alarmed and fearful when a client injures is unlikely to be of much help.  While the therapist must acknowledge that the behavior is damaging and dangerous, she must express her alarm and concern in ways that benefit the patient.
  
  An example:  In one case of a therapist/client mismatch, a patient told us of a therapist whom she used to call routinely when she felt the urge to injure.  Each time the doctor felt obliged to call paramedics and have the patient hospitalized (doctors can be legally liable or stripped of their licenses if they know a violent act or a crime is about to occur and do not intervene).  While the doctor's reaction was understandable, the patient believed she could have regained control and avoided injuring if she had been able to talk to the doctor about feelings connected to her urges.  The doctor, who did not feel comfortable enough with the risk involved to delay the emergency intervention, ultimately decided that the fit was wrong.  She helped the patient make a transition to another therapist, someone who was more comfortable intervening in a way that could potentially avoid hospitalization.
• The ideal therapist is open-minded and empathetic, yet firm.  A nonjudgmental attitude toward the self-injurer and her behavior is essential to a successful relationship.  A therapist who sees self-injury as manipulative or morally wrong is probably not going to work.  Your therapist needs to see self-injury as a sign of desperate struggle, a symptom that needs to be understood.
• At the same time, no psychotherapy relationship can progress or succeed if you do not curtail your behavior.  You must demonstrate ongoing motivation to change.  It's unreasonable to expect your therapist to permit unlimited self-destruction.  You owe it to her to work diligently as a partner in the restoration of your health and safety.
• The therapist must have a reasonable degree of availability and must manage well in times of crisis.  When you are interviewing, ask about the therapist's understanding of your problem and the potential it raises for crisis intervention.  Make sure the therapist understands the difference between any suicidal thoughts you might have and your non-suicidal self-injurious behavior.  Disclose any suicide attempts.
• The therapist must respect the client's autonomy as an adult.  Self-injurers say their most successful experiences have been with therapists who do not infantilize them or try to rescue them from themselves.  From the therapist's perspective, it is very tempting to become parental, to tell the client what to do, to advocate round-the-clock supervision, or to take away dangerous objects.  In general, this will not help the self-injurer reorient herself to assume personal responsibility for her behavior and its repercussions.  Look for a therapist who wants to enlist your active participation in recovery, one who tells you straightaway that her goal is to help you become autonomous and self-disciplined.

Finally, if you are relying on insurance benefits to help pay for treatment, learn as much about your policy limitations as you can.  Know what your deductible is (the amount of charges you must accrue at the beginning of the calendar year before the insurance will begin to reimburse you), and if there is any co-payment (an amount you are expected to contribute toward each session's fee).  Ask the therapist whether she expects payment up front, or if she is willing to wait for insurance reimbursement.  Find out if you will be expected to pay for missed appointments.  Knowing as much as possible about the practical arrangements will help prepare you to make a commitment to the therapy and your recovery.

Ideally, your therapist should not be the only person on your recovery support team. We suggest you take an active role in enlisting others - friends, family members, and trusted clergy - to set aside time for you on a regular basis. This time could be spent talking about issues and feelings to support the work you are doing in therapy.