We often hear from our patients, “I’ve seen several psychologists before, but none of them of have been helpful until I started working with the OC Anxiety Center (formerly, Anxiety Research Center). Why doesn’t everyone do what you are doing?”
It’s a great question, and one that is complex to answer. The short version is that most are not specifically trained to treat anxiety disorders, and/or may not be using research based, clinically proven treatments. Unfortunately, as a field psychologists and therapists do not help the general public understand who to seek for what problems, and I apologize for this. This leaves us with this question: “What do I look for in a therapist or psychologist, and what should I expect in treatment?”
Here’s a few suggestions. I emphasize that there are exceptions to the rule of course, but this is what we have found in general.
1. For anxiety disorders, choosing a psychologist who is trained in cognitive behavioral therapy (CBT) is essential.
Research indicates that the two most effective approaches to anxiety disorders in general are CBT and medication. In regards to CBT, this goes beyond someone who has a weekend course or has taken continuing education credits in CBT, but had his or her graduate training in this area. You can ask a psychologist what their theoretical background is, and the answer should be something like “Cognitive behavioral approach”, “Behavioralist”, “Cognitive therapy”, or “Acceptance and Commitment Therapy”. There’s a few variations, but at the core should be changing cognitions and behaviors in a systematic way.
2. For more difficult situations, choose a provider who is a specialist who uses research proven approaches.
Think of it this way; if someone you love has been diagnosed with cancer, do you seek out your family doctor for care, or do you try to find an oncologist? If an individual has a less complex issue, it may be acceptable to seek the help of a generalist, but unfortunately I’ve come across too many people who have seen several therapists and/or psychologists who say they treat “X”, but are not truly skilled in that area. One suggestion is to look at their curricula vitae (i.e., resume), check their website, or ask about their background to evaluate their areas of study and expertise: too often I see claims from therapists who “specialize” in everything from anxiety disorders to marital issues to alcohol abuse. To me, that’s a generalist. Look for specialized training: internships, externships and postdoctoral fellowships in the area of interest, research publications and presentations. Affiliations with organizations and people who do research and practice in the area of interest. Typically for anxiety disorders, this requires someone with at least a Psy.D. or Ph.D.; while there are a few exceptions, most Master’s level therapists (as opposed to doctoral level psychologists) are not specifically trained in clinical issues. Almost all of those with a Marital and Family Therapy licensures (“MFT”) are great at marital and family issues, but do not have specialized training in anxiety disorders. As an example, I spent my undergraduate career learning about behavioralism, my graduate career learning and researching cognitive and behavioral approaches, my internship and externship in OCD, BDD, phobias and depression, my postdoctorate in teaching, researching and learning more about Panic Disorder, GAD and phobias: all of my required 3,000 clinical hours for licensure were in anxiety disorders. My academic posting as a professor included research on PTSD and cultural issues regarding all anxiety disorders. Most MFT’s do not have this type of training (they have two years of academics and one year of internship. I had five years of academics, a year of internship followed by an externship, two years of a postdoctoral fellowship and nine years as a professor before opening ARC); conversely I have very little training in marital and family issues, and refer patients out to a MFTs for these types of issues because they would be better at it than I would.
3. For those with OCD, Panic Disorder with Agoraphobia, Specific Phobias, Body Dysmorphic Disorder and Trichotillomania, it is essential to find a psychologist who not only uses CBT, but is well versed in Exposure with Response Prevention (ERP).
Without the use of Exposure and Response Prevention, it is unlikely these issues will be treated in a way that will significantly reduce symptomology. Research has found that ERP is one of the vital aspects of treatment for these disorders. Without it, it is similar to going to a personal trainer to gain muscle, and while talking about and discussing the proper techniques of weightlifting, the trainer never demonstrates them to you, and you never lift a weight. It is important to understand the problem, but it is just as important to actively engage in the getting rid of the symptoms. Talking about it is not enough.
4. When speaking to a psychologist about treatment, the psychologist should discuss with you how they approach the problem and how the two of you plan to deal with the problem together.
A psychologist should always start with an assessment to understand what the problem(s) is. It’s not uncommon for there to be multiple issues; for example, a person who is housebound because of the fear of panic attacks is likely to be depressed due to the inability to see friends or hold a job. Once the two of you decide on what the primary issue is, goals should be set, a general outline of treatment should be presented, and a general timeframe should be given. It should be noted that the timeframe may vary, but there are guidelines. For example, treatment for panic disorder with agoraphobia should take approximately 12 to 15 weekly sessions, but may vary. Conversely, it should not take 30+ sessions for this disorder, nor should it take 6.
5. Treatment should be active.
Attending a weekly meeting will not significantly decrease your symptomology. The weekly session is to teach, review previous homework, practice new skills and assign more homework for the following week. Most of the work is done by you, outside of the therapy hour. A therapist simply talking with you for an hour will not help change much; the change occurs through active participation and hard work. Typically in treatment there is reading, practice, homework and review.
Overall, treatment for anxiety disorders is very analogous to personal training. When I decided to use a personal trainer to get in better shape, I talked to several trainers to understand how they worked, what their methods were, and what results they got. After choosing an individual that fit me well, the first session consisted of him watching me perform my current workout (assessment), and explained to me what changes we had to do, and why (education). We then discussed the desired change (goal setting), and the number of sessions and content (research-based protocol). From then on, each week started with him reviewing the techniques he previously taught me, ensuring that I had properly learned the technique and making any changes necessary. Next, he would demonstrate a new skill for me and have me practice with him, and then alone to show that I understood what the skill was (skills training and therapist assisted practice). Finally, he would assign me homework for the week based on the new skill (individual practice and skills training). After several sessions we would reassess to examine if we were still on track for our goal, and make any changes necessary. And sure enough, a few weeks later I noticed a difference, and a few months later I was stronger, faster, fitter and happier. At the OC Anxiety Center we seek the same for your mental health.