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Finding the right type of therapy

What are the types of things that you look for when ordering new equipment? Function, form, cost, and need may be some of those factors. With a new truck, should it be a crew cab or not? The list of wants versus needs versus input could be endless and unhelpful to use as an overall strategy. Some of us spend exorbitant amounts of time researching unimportant things (like how much time I spent researching what phone to buy the last time I needed to replace mine). 

Decision making can be difficult and complex. Identifying the right fit for therapy could more challenging if I also enter in the factors of urgency and pressure, like if I’m in immediate crisis and/or I have a pressure from loved ones to seek support. Where do you go to find that help? Well, there’s another potentially lengthy list. Let’s look at some ways to try and make this process a little easier, from understanding the terminology to navigating some key sites, and lastly help with some thoughts around how to make the decision that fits your needs. 

What has been clear to me since doing this work is that the terminology, lovingly described as psychobabble in the world of mental health practitioners and a language that I take for granted, is confusing for others. Let’s try and clear some of that up. 

The terms
There is a difference between psychotherapy and counselling that has more impact than meets the eye. Despite often being used interchangeably, psychotherapy is a protected act. This means that while anyone can label themselves as a counsellor, the psychotherapist title is held only by those with a combination of education and experience that meets the criteria for either the College of Registered Psychotherapists (CRPO) or the Ontario College of Social Workers and Social Service Workers (OCSWSSW). These colleges are the regulatory bodies for those workers and those workers have professional titles of either registered psychotherapist (RP) or registered social worker (RSW). One small piece to add is that unlike the RSW designation, which can be obtained following a person’s education, the RP will require ongoing supervision under a clinician with five years of experience or more for a time. This means that you may see their designation as (RP-Q), registered psychotherapist (Q), or registered psychotherapist qualifying. This person is still able to conduct therapy, but they are signalling to clients that they have not yet demonstrated and provided the hours of therapy and supervision to be able to practice independently.

There is another tier of note that often causes some confusion: psychologist and psychiatrist. A psychologist is a doctorate level practitioner who is a member of the College of Psychologists of Ontario (CPO). The main differences between a psychologist and a RSW or a RP is that they can conduct extensive assessments and provide a diagnosis. A psychiatrist is a medical doctor (MD) who specializes in mental health medicine. These doctors, on top of providing you with a diagnosis, are able to prescribe medication. They are the only practitioners within mental health specifically that can do this. Typically, at least in Ontario, a psychiatrist is someone who you may be referred to for a single session assessment and they may then provide your main medical professional (doctor, nurse) guidance on prescribing medications as well as clarifying any diagnosis your practitioners may have sought. They are most often associated with a hospital or outpatient setting. Though psychiatrists could practice privately, it is not often you find this. 

This means there are only two practitioners that can provide you with a medically meaningful (and legally permissible) diagnosis: a psychologist and a psychiatrist. If you require support through an agency – such as WSIB in Ontario – you will require a diagnosis from one of these practitioners. You cannot get a diagnosis from a social worker or a registered psychotherapist. I have had many people over the years reach out and ask if I can give them such a diagnosis as a registered psychotherapist. I have heard many people say, well, my therapist diagnosed me with PTSD or depression. RSWs and RPs can conduct some assessments, but these are not tools that can give you a formal diagnosis. In my own practice, I am clear about this, adding that we can “lean strongly in a direction” based on symptom review and assessments within my scope. But, as I also inform clients, I cannot and will not be giving any diagnosis. Unfortunately, there are some in my field who feel confident providing a clear “diagnosis” to a client, but are clearly acting out of scope. Be informed and recognize that they are providing you with their “best guess” and that this is not to be taken as a diagnosis.

There is so much more to say about these titles and the roles, but the most important piece that you should look for when seeking support are that the individuals that have those titles are in good standing with those colleges. All colleges have a database of individuals and will show their standing.   

We know their titles… now what do they do?
The “what” a therapist does is a large grey area that is difficult to encapsulate in a single article. When I speak with other clinicians and students, I like to remind them that therapy is both a science and an art, meaning that there is a lot of research to back many of the approaches that we use. The way to present this idea and work with it in a session is the art of it all. Nailing down the “what” might be a bit nebulous, so we’ll stick to big picture items, starting with modalities.  

A modality is the filter with which a therapist will view a client’s problem presentation. I’m trained and certified in cognitive behavioural therapy (CBT) for many different disorders, and I typically see my client’s experiences through the lens of that modality. This means that I share with them the language and outlook of this approach, which includes teaching about how their mind works, the different systems present and at play, and the importance of emotional experiences on thought formation and behavioural expressions. Then, through sharing, exploring, informing, and experimenting, the client grows to learn and understand things about themselves, others, and the world that they may have previously overlooked or discounted. This is just one modality in a very long list that a therapist can work from. Let’s explore some so you have a bit of an idea of the major approaches being used with firefighters. 

Aside from CBT, there is also:

Cognitive process therapy (CPT): This is a derivative of the CBT model but was designed specifically for the treatment of PTSD and trauma. CPT takes the view that traumatic experiences result in significant altering of the way we view ourselves, others, and the world. Through those experiences we either overprotect (overcompensate, become hypervigilant, get closed off, etc.) or under protect (ignore impacts, reason away causes and ignore ways to further protect). CPT helps to make sense of those experiences and challenge us to normalize and make meaning from them so we land in a place where the trauma no longer has this overprotective or under protective reaction in us. In the end, we hope that someone has accommodated the experience in a way that makes sense but is free from the reactions mentioned above that get in the way of living. 

Dialectical behavioural therapy (DBT): This modality was created by Marsha Linehan, who noticed that the CBT model for a certain subsection of her clients wasn’t helping with some of the major issues that she was seeing. She created a model that took some of the fundamental understandings of CBT and added and modified pieces to make them more appropriate for these presentations. This resulted is a modality that looks at four main components: emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness. 

Eye-movement desensitization and reprocessing (EMDR): This approach is much newer in its use but has found to be of some benefit when it comes to managing trauma symptoms. The idea is that through the use of bilateral eye movements (or more recently bilateral stimulation with vibrating paddles, for example) while processing the trauma memory itself has helped people greatly in the reprocessing of traumatic experiences. While it has a developing research base on its utility, I’ve experienced quite a few vocal voices discussing it as if it were a “cure” for trauma. I caution against this view. It’s a tool, and like all tools, may not work for you. 

Bio/neurofeedback training: This approach is about understanding the physical ways that mental health can manifest. Through training with this modality, we grow to understand better the way our body will react to stressful situations, and by how actively relaxing or focusing on the breath, we are able to restabilize the physical body, which in turn helps to restabilize our mental health experiences. There are a lot of different ways biofeedback is used (I use heart-rate variability in my own practices) but there are others like breathing, focusing on muscle contraction and release, and sweat that help give immediate feedback to what is happening. 

Neurofeedback training is the reading of certain brainwaves that have been identified as important and relevant when looking at arousal and under arousal states. After identifying problematic waves (usually through a short screening called a “mind-map”), the clinician will then work with training the brain through specific training protocols that inhibit certain wave expressions and reward others. This takes place in a few different ways, sometimes through sounds and music, others through games, that progress when your brain falls into the “right” brain wave levels. Clinicians that you see will likely use rather expensive but intensive programs and machines, but there are some entry-level devices that you can get that do related things. The MUSE device is one. 

There are so many other modalities that a therapist can use, such as internal family systems, mindfulness, acceptance and commitment therapy and so on. But nothing grinds my professional gears more than hopping over to Psychology Today, one of the most used sites in searching for a therapist, and reading about a therapist that says they conduct every modality they can spell and treat every diagnosis you can get. It’s frustrating, and here’s why. Just one certification in CBT for the treatment of anxiety disorders is 72 hours. That’s almost two weeks of eight-hour days. That’s a significant amount of time training, to mention nothing of the cost associated. That’s for one small subset of diagnosis from one small range of possible approaches. I randomly pulled a therapist that identified 19 areas of speciality and 12 different modality approaches! Imagine that each training is equivalent (it’s not always) — that’s 864 hours of training! Sure, it’s possible. But given the cost associated with each of those courses measured over the amount of hours, that’s a significant amount of both time and money that one person would have to commit to becoming certified in all those modalities. One last metric is practice length (identified by their college’s registration) and we can see that it is highly unlikely that one has certifications in all those areas.

And that’s the point.

When you are scanning through a registry like this it is vital to remember that they are not disclosing one’s certification in these areas. Simply, they are indicating that they may know a tool or two that comes from that modality and maybe even only occasionally use it. That’s different than saying they are certified in a modality. Because the truth is that you don’t need any certifications in particular modalities to offer therapy. Full stop. Once registered with a college you’ve achieved the minimum required to practice. 

We’ve explored the terms and some of the modalities. What do you do with all this information?

The most crucial piece of advice I can give is that you need to start this process well in advance of desperately needing it. When you are struggling to the point where a crisis is at hand, wading through all the necessary things to find a therapist is excruciating slow. There are many barriers, including costs and finding out insurance information. If you become involved with WSIB, that means you’ll also need to add to this journey by finding a WSIB approved psychologist to review your claim and then, if approved, find a WSIB approved therapist to support you. This means, sometimes, switching from a therapist that you have found to another one you may not know. This may be less than ideal for you. 

Start at the first inkling that your mental health needs attention and keep these basic summaries of roles and what they can provide in mind. 

Nick Halmasy is a firefighter with Selwyn Fire Department and a registered psychotherapist who has spent a decade with the fire service. He is the founder of After the Call, an organization that provides first responders with mental health information. Contact him at nhalmasy@afterthecall.org.