Therapy

What the Heck Is a …? A Guide to the Most Common Mental Health Professions

Once you have had some experience working with different professionals within the field of mental health, differences between each discipline’s values, style, approach, and skillset can be easy to detect.  However, if you are reaching out to a mental health professional for help for the first time, it can be overwhelming to differentiate between the different types of professionals, who may be best equipped to help you, and what practitioner will offer the treatment you have in mind.  

I’ve provided an editorialized guide to the most common professions within the field to mental health, along with some resources that provide a little less opinion.

Psychiatrist

Degrees: Medical Doctor (M.D.), Doctor of Osteopathy (D.O.)

Years of Training: 7+

Description: Psychiatrists are usually placed at the top of the mental health hierarchy because they are the only clinicians in the world of mental health that are medical doctors (although, they are not necessarily the only mental health practitioners that can prescribe medication).  All psychiatrists are trained first as doctors (usually 3 years) before applying to obtain specialized training in a psychiatric residency program (usually 4 years).

Psychiatrists are considered qualified to provide the full range of mental health services, although typically psychiatrists do not provide all forms of treatment.  Psychiatrists tend to receive most of their training in the most “medical” areas of treatment, such as diagnosis and assessment, biochemistry, neuroanatomy, prescribing medications, and administering electroconvulsive therapy.  Contrary to popular belief, most psychiatrists do not receive much training in psychotherapy or psychological testing.  

While some psychiatrists will focus on developing skills as therapists, especially those who obtain additional training in psychoanalysis, psychiatry has increasingly become synonymous with psychopharmacology (i.e., prescribing psychotropic medications).  A psychiatrist who primarily functions as a psychopharmacologist can be easily ID’d based on how often they schedule appointments with patients, and how long these appointments last. Psychopharmacology, once a regimen is established, typically does not require more than 1-2 meetings per month lasting 30 minutes each.  Psychotherapy, however, is optimally provided every week for 45-50 minutes.

Comments: As a psychologist, I have great respect for the intelligence and drive possessed by most psychiatrists.  Getting through medical training is not easy, and it can often be helpful for patients to have someone familiar with basic medical principles when screening out medical and substance-induced symptoms.  Medication can also be an incredibly powerful tool in providing immediate relief (although individual differences in responses to medications can lead to people giving up too soon on medication due to negative side effects or extended periods before medications take effect).  

On the downside, in my experience, psychiatry is a discipline prone to a number of unhelpful biases.  Some psychiatrists are prone to seeing people as brains rather than minds. As prescribers of medications, it is tempting to get into the habit of focusing too much on neurotransmitters and ignoring other relevant aspects of the person.  To use one example, many psychiatrists, especially at community clinics, are likely to place a greater emphasis on what the correct medication is without giving proper weight to whether or not the patient will actually take it. 

Another example of unhelpful biases comes with (the lack of) diagnosing personality disorders.  Personality disorders are both highly stigmatizing and notoriously difficult to treat with medications.  I don’t even want to count how many patients with clear cases of borderline personality disorder I have diagnosed and/or treated who had previously been given a diagnosis of bipolar I or bipolar II disorder.  Psychiatrically, these conditions are all treated very similarly. However, the wrong diagnosis can hinder progress in psychotherapy, which nearly all people with personality disorders need–whether or not they are also receiving medication from a psychiatrist.  I don’t believe this to be done in animus, but I do find this to be a common-enough oversight to warrant mention here.  

In my experience, when patients develop strong negative feelings with their psychiatrist, these feelings most often stem from feeling ignored, dismissed, and/or “poisoned” by their psychiatrist.  This is not necessarily an indictment of the quality of work done by a psychiatrist, but over-emphasizing medications without proper weighting to psychological issues may naturally result in misunderstandings, misattunement, and adversarial dynamics developing between doctor and patient.

Another bit of insider experience I’ll toss out there has to do with the nature of medical training.  I have come across a great number of passionate, hardworking psychiatrists who care deeply about their patients and providing the best possible care to individuals who are both difficult to deal with and profoundly suffering.  These docs tend to be the ones who endured countless hours of grueling, unrelated medical training in order to reach a position where they can help people with mental illness lead healthier and more productive lives.

On the other hand, medicine attracts many people who are drawn to the prestige of medicine but do not have a particular talent or passion for any one specialty.  Medical lore suggests that psychiatry has historically been a discipline wherein students who lack a certain drive and focus accumulate. Many unfairly criticize psychiatry for not being sufficiently rigorous for this reason.  I think it’s very easy to understand why relatively aimless med students would choose psychiatry over something like surgery. I believe that the best psychiatrists are among the smartest people in medicine. However, if you find yourself with a psychiatrist who does not seem to be living their best life, I may have just provided you the reason why.

Additional Resource: American Psychiatric Association

 

Clinical Psychologist / Counseling Psychologist / Neuropsychologist

 

Degrees: Ph.D., Psy.D.

Years of Training: 5-6+

Description: The term psychologist refers to any individual who has completed doctoral-level academic work and research in a sub-discipline of psychology.  Clinical (for simplicity, I omit neuropsychologists here) and counseling/school psychologists differ from other psychologists (e.g., social, developmental, cognitive, industrial, etc.) in that training includes pre and postdoctoral experience working directly with patients.  Predoctoral training includes multiple offsite yearlong placements (~20 hours per week), along with one yearlong full-time placement. Most states require one to two years of supervised postdoctoral work in order to become licensed as well. Clinical and counseling/school psychology training varies by program with regards to how much psychotherapy, psychological testing, and academic research are emphasized.  Psychologists tend to be the only mental health practitioners with competence in testing, and also tend to receive the most training and supervision in psychotherapy before licensure.

Comments: As a psychologist, my opinion here is extremely biased.  For any services besides medication management/psychopharmacology (or possibly psychoanalysis) and medical rule-outs, I believe psychologists, on average, to be the best equipped to handle most issues for which people seek treatment.  Many would disagree, I’m sure. I make this argument primarily based on the amount and focus of training. Exceptions exist, which is why I take care to say “on average” and “most.”

The problem with psychologists is that 1. There are not enough of them to meet the growing demand for mental health services; and 2. the cost of training prohibits many psychologists from seeing patients who cannot afford high fees or have excellent insurance.  It should be obvious that the places where psychologists are most needed do not often have the resources to adequately attract/hire them. The same is true for psychiatrists, although psychiatrists who focus on managing medication can sometimes see as many as four individuals in the time a psychologist needs to see one.  Thus, psychiatrists’ expertise can be better leveraged, though not without burdening them with heavy caseloads.  

Additional Resource: American Psychological Association

 

Licensed Psychoanalyst

 

Degrees: M.D., D.O., Ph.D., Psy.D., M.S.W., M.A., M.S., etc.

Years of Training: Years of professional training + 3-4 years

Description: Psychoanalysts are trained to approach psychotherapy and psychoanalytic treatment through the lens of the unconscious motivations, drives, and conflicts.  Think of the Freudian tradition. When psychoanalysis was first created, only medical doctors could become psychoanalysts. Training in psychoanalysis is now open to all licensed clinicians, both masters-level and doctoral; in more rare cases people from outside the mental health training to pursue the ability to practice as a licensed analyst.  New York is one state that provides this option.  

Becoming a fully fledged psychoanalyst is a rigorous process that includes approximately four years of coursework, one’s own personal analysis (i.e., as a patient, entailing 3-4 analytic sessions per week, in addition to completing several (the number varies, but typically four) “control cases.”  In control cases, candidates receive supervision from an experienced psychoanalyst who closely monitors progress in each one of the candidates’ active cases.

Comments: Again, I disclose a personal bias here.  My own therapies have all been with psychoanalysts, including one formal 4-times-per-week analysis.  Critics call psychoanalysis outdated and anti-scientific, however, I have found psychoanalysis to be the only model of psychotherapy that has the sophistication, nuance, and depth to provide patients who have been failed by other therapies a satisfying and intuitive understanding of how their problems came to pass and why they persist.  This is more than just my personal opinion. Psychodynamic treatments, a broader category of psychoanalytically-informed psychotherapies, are in fact well-supported by clinical trials and most importantly, have been shown to provide continuing returns long after treatment has been discontinued.

Most psychoanalysts are psychologists and psychiatrists, who have undertaken costly and rigorous training above and beyond medical and doctoral-level training.  They are, in my view, among the most erudite and scholarly individuals out there.

The biggest detractors of psychoanalysis are academics and insurance companies, each with too many self-interested reasons to criticize this mode of treatment to list here.  As one of my mentors, David Shapiro, Ph.D., often says, “It doesn’t seem to require much skill or training to understand how someone’s behavior is irrational.” Put another way, it requires a more sophisticated theoretical model to understand why someone’s irrational behavior makes sense.  Psychoanalysts work with a theoretical model that does exactly this.

Additional Resource: American Psychoanalytic Association

 

Clinical Social Worker (LCSW)

 

Degrees: M.S.W.

Years of Training: 2-3+

Description: Clinical Social Workers are masters-level counselors/therapists who have undergone a period of additional supervised training to meet state licensure requirements.  They are trained in both general and specific psychotherapeutic techniques in addition to the core aspects of social work, such as case management and providing advocacy (or locating advocacy programs).

Comments:

The up-front cost of training to become a social worker is far less than becoming a psychologist or psychiatrist.  However, just because social workers put in less time, money, and brainpower into their training initially, it does not mean that they will not pursue further training to catch up with the training done by clinicians with more advanced degrees.  In fact, many clinical social workers choose to train in social work because they know they can begin clinical work sooner while they earn an income that helps them to obtain more expertise.  Some of the most resourceful and grounded clinicians that I have encountered have been social workers, as they have been more responsible financially while they approach training with no less drive than any other mental health practitioner.

On the other hand, a sizeable percentage of clinical social workers chose social work as the fastest road to doing clinical work without considering the costs involved in taking a shortcut.  If you are trying to choose the best therapist, you may be best served by a clinical social worker; the problems is you’ll likely have to do additional work to screen out the less able, and less committed group.  

Don’t assume either that the better clinicians will be the ones charging higher fees.  Yes, some clinicians may charge the higher fees because it’s the only way to manage the demand for their highly-effective services.  But also bear in mind that another reason for charging a higher fee is a lack of self-awareness. Plenty of people in all walks of life will overvalue themselves because they avoid fully engaging with their own limitations.  You’ll find plenty of these among psychotherapists, with higher concentrations, I suspect, among those who trained as social workers. You’ll also find plenty of highly skilled and educated therapists as well. I risk writing this publicly since I make the assumption that the social workers reading this blog are less likely to be in the shortcutting camp.  

The main point I’m trying to make is that you place an additional burden on yourself to sort out the best from the mediocre by opting to focus your search clinical social workers.  Choosing a psychologist or psychiatrist does not eliminate the need to filter, but I do believe it reduces screening efforts considerably.

A final point I’ll make about the training of social workers is that training tends to emphasize social systems and structures.  This is either an advantage or disadvantage depending on your perspective. It’s an advantage because social workers tend to be especially savvy at helping people connect to resources in the community and are much more sensitive to factors outside a client’s control.  In some cases, I have found this to be a tremendous help to individuals or families who face too many existential threats (e.g., poverty, undocumented status, chronic illness, etc.) to fully benefit from a purely psychological treatment.  

Conversely, one of the primary reasons for ignoring such factors in psychotherapy, is that providing people with “help” has all kinds of hidden costs.  Every time anyone, whether a mental health professional or otherwise, provides assistance, the implicit communication is that what is being provided cannot be obtained by the individual being helped.  Each decision to provide practical help requires that the “helper” carefully weigh the pros and cons of the decision. Clinical social workers who have trained in psychoanalysis tend to be much more cognizant of this.  In some instances, practical assistance is absolutely indicated. In other cases, “help” may actually be over-indulging clients’ dependency needs, thus undermining progress.  

An honest look at what you are seeking help with can be helpful in determining whether a more “helping” framework is indicated.  If you tend to take on too much responsibility and overburden yourself with the needs of others, then a more resource-oriented treatment can be helpful (or at least not harmful).  On the contrary, if you have not properly “launched” (sadly, an ever-growing epidemic), then a less-involved form of treatment would be better in my view.

I hope that it goes without saying that I am painting with a broad brush and there are indulgent psychologists and appropriately withholding social workers.  The reality is that initially we need filters to narrow down our options when there are so many variables to factor into a decision like choosing a therapist.

Additional Resource: National Association of Social Workers

 

Marriage and Family Therapist (MFT)

 

Degrees: M.A., M.S.

Years of training: 2-3+

Description: Marriage and family therapists are also masters-level counselors/therapists who have undergone a period of additional supervised training to meet state licensure requirements.  They are trained in basic psychotherapeutic techniques as well as some more specific intervention strategies. The main difference between MFT’s and clinical social workers is the focus of training.  Academic work in social work is far more systems-based, whereas marriage and family therapy tends to appeal more to individuals who are interested in an expedited way to become a therapist (i.e., non-doctoral) and spend more time learning about psychotherapy and counseling as opposed to social/systems-level ways of providing assistance. 

Comments: My 2 cents on marriage and family therapists are essentially the same as my opinion on clinical social workers when it comes to choosing a therapist.  The barriers to entering the field as a masters-level clinician compared with a doctoral clinical/counseling psychologist are drastically fewer. Does this mean doctoral-level clinicians are always better?  Of course not. What it does mean is that there are way more masters-level clinicians to choose from, and I believe, a broader range on the continuum of excellent to poor. Recommendations, testimonials, or extensive face-to-face consultations (if these are offered free of charge) are all ways of finding the standouts.  

I fully acknowledge my bias as someone who has put in the additional years, cost of training, and opportunity cost associated with becoming a psychologist–not to mention the additional rigors of being selected to a doctoral program.  So take my opinion with a grain of salt if this offends.

I’ll say again that I have had the opportunity to work with talented, competent, dedicated, and hardworking therapists from social work and marriage and family backgrounds.  A great therapist, is a great therapist. A great anything is hard to find and should be valued and compensated commensurately.  

 

Alcoholism and Substance Abuse Counselor

 

Degree: A.A., B.S., M.A., M.S.

Years of training: 2 – 3

Description: Obtaining a certification as an alcoholism and substance abuse counselor varies in its requirements from state to state.  This qualification may be an additional certificate to a masters-level or doctoral-level professional license, or it could be a sole qualification, requiring as little as an associates degree and on-the-job training.  If a private practitioner has this certification, s/he is certain to have at least completed masters-level training. In a clinic or other outpatient treatment facility, alcohol and substance abuse counselors can work with substance misusers without having completed a masters or even a bachelor’s degree.  Even in a multidisciplinary setting, without a masters degree, counselors can only provide a small range of counseling services (e.g., goal-setting, skills training, motivational interviewing) and must be supervised by a licensed professional.

Comments: Substance misuse, abuse, and dependence is a challenging area in which to specialize for a number of reasons.  First, substance use is often accompanied by physical dependence. Second, substance use is typically only one of several mental health issues with which a client needs to contend when obtaining treatment, and third, many long-time substance users have consumed all of their social resources by the time they reach care, and thus are socially isolated, lacking material resources, and often homeless.  Those who choose to specialize in this area, in my experience, are often among the most committed to helping others and have some form of personal stake in the treatment, no matter what level of training. Many substance abuse counselors got into the work after battling their own substance use issues (or have watched friends, family, and/or romantic partners struggle with addiction). Experience with addiction has the potential to give a counselor more credibility than any degree.  Many clinicians, especially psychiatrists (because of potential risks associated with substance-medication interactions), are reluctant to work with substance users. However, what I have observed is that those who do the work are highly motivated and committed individuals. If substance use is a part of the picture, finding someone with this specialty or focus area can be an important predictor of how engaged the client will be.

Additional Resource: 

If the above information still leaves unanswered questions (sadly, what I have summarized here is not an exhaustive list), the National Alliance on Mental Illness (NAMI) provides an excellent guide to understanding who does what in the field of mental health.  To be taken NAMI’s site from here, click here.