Dr. Osbo — Who Needs Therapy Part 2: Tips for finding a therapist

For those of you who keep track of such things, I did say a couple months ago that I would talk about the DSM-IV diagnosis controversy. I have decided to postpone that conversation for awhile, as there are some upcoming forums I will be attending that will help me speak about this topic in a more up-to-date manner. Until then, I am going to continue with further thoughts on the process of therapy including a primer on what to expect and what to look for in a therapist.

To begin, I will digress briefly on the general reputation of therapy and its practitioners. It has been my observation that the general public does not hold a favorable view of therapists. This is a pervasive phenomenon, I think, that goes beyond the “gatekeeping” complaint leveled by some in the transgender community. In movies and literature, there is a frequent depiction of the “shrink” as pathetically inept, manipulative, greedy, exploitative, crippled by personal psychopathology — you know, the “What About Bob” scenario. Even the term “shrink” (for headshrinker) suggests something evil and coercive. It’s no wonder the average person might find the search for a competent mental health provider a daunting task. Consider how tough it might be for a transgender person who has been mistreated and misrepresented by psychiatry for decades, and is now in the position of needing a therapist’s counsel and/or approval for surgery!

In partial explanation, I would point out that our culture generally views psychological manifestations of dis-ease as much more unacceptable than physical ones. Emotional distress is popularly thought to indicate failure, weakness, or deviance, while people with physical symptoms are more likely to be seen as recipients of bad luck, and deserving of sympathy and comfort. Therapists, by trade, elicit our shameful, dependent, weak, guilt-driven feelings, and we rather hate them for it. To see them as helpful is to admit to our own helplessness, so we denigrate them, thus preserving our sense of being captains of our own ship – no great revelation there.

I think it’s best to start with the premise that therapists are human beings with feelings, too (only we call them “countertransference” and take them to our own therapists’ offices – if your therapist doesn’t do this, consider it a red flag). I’m reminded of Kareem Abdul-Jabar’s response in the 1980 movie Airplane, to an obnoxious little boy complaining about the Lakers “not really trying, except in the playoffs: “I’m out there busting my buns every night – do you think it’s easy?” In my case, it’s sitting for 12 hour days, witnessing and trying to be fully present – to lend courage, discover untried resources, and otherwise call upon my many years of training and experience in order to help people, without the benefit of any prescription pads or magic wands. More often than not, these are people who have dug themselves into very deep holes of despair, isolation, and relational stagnation before admitting to themselves or their loved ones that they might need some help. No, it ain’t easy, and with so-called “managed care” breathing down your neck, demanding quick and dirty solutions, it’s harder than ever.

Whew! That felt better. Thanks for listening! Now, what was my point? Oh, yes, what I’m trying to establish here is my belief that transgender people need to be mindful of the same things any other potential client might need to know in choosing a therapist, only a little more so, given the general lack of experience and knowledge that most providers have in this area (and this is something that I and other trans-knowledgeable therapists have been trying to correct through community outreach work). There are two main parts to the task. The first is more or less administrative. How do I go about finding a therapist? The second is more nuanced, and involves some understanding of what therapy is supposed to be about. I will take that topic up in Part 3 of this series on “Who Needs Therapy.” For trans clients, I will add some caveats to each of these pieces, that “more so” of which they need to be particularly aware.

How to find a therapist? That’s a tricky question in today’s climate of insurance-controlled medical care. The best way is to get a referral ““ through your physician, clergy person, friend or neighbor. Unfortunately, many people rely on their health insurance to reimburse their therapy costs, which often run $100-$150 or more for a fifty minute hour, depending upon the area of the country in which you live. Many insurance plans place restrictions on mental health visits, including which providers you can see and how many visits in a calendar year. Only recently have laws been passed for mental healthy “parity”, that is, coverage equivalent to that for medical conditions. If you plan to use insurance, check ahead of time as to what kind of outpatient mental health benefits you have and what the restrictions are for in-network vs. out-of-network coverage. If the person you would like to see is not allowed by your insurance, or if you have no insurance, you might still be able to negotiate a reduced fee with a therapist, but you have to ask ““ we are not likely to offer it up front.

As far as credentials are concerned, there are good therapists who are psychologists as well as social workers and marriage and family therapists. It will help if they are licensed by their particular state licensing board, especially if you are interested in getting insurance reimbursement. If they do not fall into one of these categories, it is not necessarily a dealbreaker (e.g., one of my very knowledgeable colleagues has a doctorate in Sexology), but you would want to know more about their therapy training and clinical supervision. I have not mentioned psychiatrists, who can be very good therapists, but tend to be more medically oriented (i.e., medication prescribers) and are usually more costly if you choose to see one for a regular 50 minute hour. Apart from these guidelines, therapist quality, like mostly everything else, follows a Normal Distribution (Bell Curve), with great ones and horrible ones at the outlying edges (2.5% in either direction) and the vast majority in the average range. Finding an excellent one will depend on your own research and conversations with people you trust, and your personal experience talking with the therapist on the phone and in the office. More about that later, but suffice to say that this is a matter in which you really need to trust your gut, and it is perfectly acceptable to decide that any particular therapist is not a good “fit” for you.

Once you’ve located a therapist, give him or her a call and tell them you are interested in some therapy for (whatever problem you are experiencing). Ask them if they’ve had experience in working with this issue, and if they could tell you something about the approach they use with this type of problem. In this short conversational exchange, you will start to get a feeling for the therapist’s personality, warmth, knowledge, and openness. Check with yourself to see how comfortable you feel talking about your issue with this person. Ideally, the therapist should be neither overly warm and chatty nor all-business formal. This is somebody you will be disclosing your deepest thoughts and feelings to, so it ought to be somebody who feels safe and accepting, but who will challenge you, too.

If you decide to make an appointment, check with the therapist in advance about the business arrangement, i.e., how he/she expects to be paid and what the charges are for various services. For example, some therapists charge for phone contacts over a certain minimum time spent, or for letters that they write on your behalf. And some therapists want to be paid at the time of the session, while others will send a monthly statement or bill insurance directly. Try to find this out in advance, so you will not waste your precious therapy time on such things. You can also discuss confidentiality issues, which can be particularly important with transgender clients. Be sure to let the therapist know if the number you give for them to reach you is a private one, or if they need to be discreet in identifying themselves.

If your issue involves gender identity, I cannot overstress ow important it is for you to find out about the therapist’s knowledge and experience in this area. He/she does not necessarily need to be a card-carrying member of WPATH, but should have some knowledge of what the Standards of Care are and be able to talk about his or her experience in using them as guidelines. Ask what books they are familiar with on the topic, or what conferences or seminars they have attended. If your therapist does not seem to be familiar with community and informational resources on transgender issues, you are taking a risk, no matter how experienced they are in general therapy work. If you already have a therapist that you like and trust who is not trans-knowledgeable, ask them if they are willing to attend a conference or get supervision from an experienced gender therapist. This will probably save you time and possible further psychological pain as you work towards finding greater comfort in your gender identity.

In next month’s column, the final Part 3 of this series, I will talk in general about the process of therapy and how clients can gain insight into and assistance with their transgender issues through working with a therapist. Until then, Happy Valentine’s Day, Groundhog Day, and SuperBowl Sunday!

Category: Transgender Body & Soul