Finding the best therapist can be confusing

(Sebastien Thibault for the Boston Globe)

A Dedham mother remembers when her teenage daughter became overwhelmed with anxiety and was using illicit drugs. When her daughter’s doctor suggested she see “a therapist,” the mother began investigating, and soon found a dizzying array of options — psychiatrists, psychologists, psychiatric nurse practitioners, and social workers, among others.

Some specialized in prescribing mood-altering medications, while others focused on psychotherapy that delves into the child’s past. Some focused on changing destructive behaviors, while others probed family and school stresses. Beyond that, there were also pastoral counselors, yoga therapists, and life coaches.

“I used to think all therapists were the same,” said the mother, who asked to remain anonymous to protect her child’s identity.

“See a therapist” has become standard advice to many going through periods of anguish. Whether they’re victims or bystanders coping with traumatic events such as school shootings and natural disasters, or individuals going through a divorce or losing a job, some 13 percent of Americans use mental health services each year. These clinicians are in short supply nationwide, though Greater Boston — and the Northeast in general — has more than in most parts of the country. Among the available providers comes a confusing blizzard of options — and terminology.

“Terms like therapist, counselor, or psychotherapist are not regulated,” said Elana Eisman, executive director of the Massachusetts Psychological Association, which represents some 1,700 psychologists in the state. “Anyone can use those terms.”


In Massachusetts, however, not just anyone can promote themselves as a psychiatrist, psychologist, mental health counselor, or marriage and family therapist — professions that are licensed and regulated by the state with established educational and training standards. And though most health insurers will cover treatment provided by most state-licensed mental health professionals, some are excluded, such as certain types of licensed social workers with less training and education.

Finding the best therapist is not an easy task. Many mental health advocates say that patients should look for only state-licensed practitioners. The oversight of the state board, they say, ensures the clinician meets eligibility standards, and exposes them to investigation and possible disciplinary action if they are targets of complaints.


Alternative mental health treatments generally fall outside licensing and insurance systems, for better or worse. John Kepner, executive director of the International Association of Yoga Therapists, describes his area as an “emerging field” that promotes physical and emotional well-being, and says many suffering from stress-related ailments have been aided by yoga therapists. He said his group is working on establishing professional standards.

Though state licensing may have its benefits, he said, he’s ambivalent about the spiritual principles of yoga getting entangled in the bureaucracy of government regulations.

“Yoga and licensing are uneasy bedfellows,” he said.

Another issue to consider is the privacy of confidential information shared during therapy sessions. While state-licensed mental health practitioners covered under insurance are required to comply with federal laws limiting the disclosure of private information to others, alternative practitioners may be excluded or fall in the “gray space” of these laws, said Mark Schreiber, a Boston attorney who specializes in, among other things, medical privacy laws.

Mental health advocates say people need to consider many questions when looking for a therapist — and whether it’s a psychologist with a doctoral degree or a mental health counselor with a master’s may not be the most pressing issue.

Given tight budgets for most people, Larry DeAngelo, a staffer for the National Alliance on Mental Illness in Massachusetts, advises that most people first see what their insurance will cover, what clinicians fall under the insurer’s plan, and if specific clinicians have room for new patients. Availability remains tight, he said, and the debate over what type of therapist someone wants to see can almost be a luxury.


“It’s like when people are desperately starving, and you ask — do you want a chocolate bar or ice cream?” DeAngelo said.

Though insurers have come under fire for low reimbursement rates for behavioral health clinicians — as compared with those providing medical services for physical problems — many insist they are committed to giving members broad coverage from a wide variety of professionals.

For instance, Michael Sherman, chief medical officer for Harvard Pilgrim Health Care, said his company, as a general rule, pays for treatment administered by state-licensed mental health clinicians with advanced degrees who can practice without supervision. By that standard, over the past decade, Harvard Pilgrim began reimbursing licensed independent social workers, mental health counselors, and marriage and family therapists.

According to many mental health specialists, anyone seeking therapy services should first see a primary care doctor (or a pediatrician in the case of a child) to rule out any physical ailment to explain the emotional distress. For instance, some hormonal or neurological problems can explain depression or mood issues. Once a physical problem is ruled out, then a doctor can often help advise the patient about what type of therapist is best suited for their specific issue — such as a psychiatrist who can prescribe medications if bipolar illness is a possibility, a social worker if school troubles loom large, or a marriage and family therapist if divorce is on the horizon.


Eisman, of the Massachusetts Psychological Association, said there is also the intangible of chemistry between a patient and clinician — no matter if they have a MD, PhD, or LICSW after their name. She said any good clinician has had his or her share of therapeutic relationships that just didn’t work, and often can facilitate a better referral if necessary.

“Therapy works best when you can talk honestly,” she said.

Patricia Wen can be reached at wen@globe.com.