How and on what criteria should you choose a therapist?

There is a great deal of confusion about the titles, skills and therapeutic approaches that differentiate the various categories of mental health professionals. A "shrink" may in fact be a psychologist, psychiatrist, psychoanalyst or psychotherapist, or belong to several of these professions.

The choice of professional

Here are a few points to help you find your way around, before we talk about selection criteria based on your needs and preferences:

Psychiatrists have medical training. They are therefore oriented towards clinical assessment with a view to diagnosing psychopathologies, and are the only ones authorized to prescribe medication. Some psychiatrists also have psychoanalytical training, but as a general rule, few practise psychotherapy.

Psychologists have a university education in psychology with a specialty that may be clinical (psychopathology), or have nothing to do with mental health (social, cognitive, developmental, organizational psychology, etc.). Some psychologists also have psychoanalytical training, but not all are trained in psychotherapeutic techniques.

In France, the title of psychotherapist is reserved for psychologists or psychiatrists, and covers a wide range of technical skills (body therapies, cognitive-behavioural therapies, transactional analysis, gestalt, psychodrama, systemic family therapy, hypnosis, EMDR...).

Psychoanalysts work on the discovery of the unconscious and its modes of expression (symptoms, somatics, dreams, repetition scenarios, etc.). Training to become a psychoanalyst is regulated by the International Psychoanalytic Association (IPA) and its constituent organizations. A psychoanalyst may not be trained as a psychiatrist or psychologist, and the title of psychoanalyst is not regulated by the French state. Psychoanalysts generally follow a threefold training program: a theoretical curriculum (3rd cycle university diploma), training in psychopathology with clinical experience, and their own analysis followed by theoretical training in Freudian, Lacanian or Jungian psychoanalysis. They carry out ongoing research, and have set up a system for monitoring their practice.

Who should I consult?

Depending on the disorder you suffer from, it's a good idea to have some idea of the degree of urgency and severity that a professional will be better able to treat, depending on the type of treatment. The choice of treatment approach and professional depends on a number of factors:

• Clinical context and type of pathology
• Degree of symptom severity
• The need for pharmaceutical treatment
• The patient's capacity for introspection
• Personal goals and the quality of the relationship with the therapist
• Economic criteria

Many patients suffering from common mental disorders are first referred to a general practitioner. Some GPs tend to prescribe medication straight away (antidepressants, anxiolytics), while others refer patients to a psychiatrist or sometimes to a psychotherapist. Unfortunately, GPs are not always the best placed or most knowledgeable about therapies, or about the skills of professionals practicing psychotherapy.

It's worth remembering that only GPs or psychiatrists are authorized to prescribe drugs.

As a general rule, personality disorders, psychoses (e.g. schizophrenia), severe mood disorders (suicidal thoughts or acts, severe depression) and eating disorders (anorexia, bulimia, etc.) should initially be referred to a psychiatrist, who may decide on treatment and refer the patient to a specialized psychotherapist or psychoanalyst.

Less severe cases of mood disorders, anxiety or generalized malaise, as well as obsessional or phobic problems, bereavement, or relationship problems (couple, family, work) are sometimes best addressed by a clinical psychologist with training in behavioral psychotherapy (CBT) or a psychoanalyst. The special case of eating disorders is best dealt with by a specialized psychotherapist with training in nutrition.

As far as the economic aspect is concerned, it's important to know that Social Security only covers consultations with psychiatrists, and in certain cases (and within certain reimbursement limits), with an approved psychologist. It is therefore advisable to seek advice before consulting a psychologist. Analytical sessions are generally not reimbursed, unless covered by a private mutual insurance company.

The choice of therapy

Cognitive-behavioral therapies are generally briefer, with a more pragmatic, didactic and less analytical approach. The aim of these brief therapies is to treat the symptoms of suffering over a relatively short period of time. Unlike analytic therapies, they are more concerned with how a problem will be solved than with its causes and origins, with priority given to relieving suffering.

Counseling is a term that is difficult to translate into French, but which can be associated with the idea of psychological support. It meets the needs of those who are looking for one-off psychological help to resolve, in a relatively short space of time, problems that do not necessarily stem from a pathology. These problems may be linked to a specific relational context with which you have to cope, and for which you are forced to adapt without feeling prepared.

The difference between cognitive-behavioral and analytic therapies lies less in the clinical context than in the approach, philosophy and purpose: analytic therapies (psychoanalysis or psychodynamic psychotherapy) take a longer time to work through, and are designed to deal with the origins of unhappiness that everyone may encounter at some point in their lives. Depending on the individual and the circumstances, this malaise may manifest itself in the psychological, somatic, existential, affective, sexual, relational or social spheres.

Psychoanalysis requires a commitment of time and money, as well as a capacity for introspection that not everyone can afford. In recent years, new therapeutic techniques have been developed under the name of psychodynamic psychotherapy (also known as psychoanalytic psychotherapy). These techniques are still little-known and little-practised in France, but are highly developed in Anglo-Saxon countries, and have been the subject of numerous research studies which have demonstrated their effectiveness. Psychodynamic psychotherapy is a brief therapy that shares the same theoretical foundations as psychoanalysis, but with a more flexible therapeutic framework and method. In psychodynamic therapy, the therapist helps the patient introspectively to analyze and interpret the unconscious conflicts reactivated during therapy, while intervening to a greater extent than in psychoanalysis. This technique is primarily aimed at symptomatic improvement within a more precise clinical framework, but it can also contribute to a profound and lasting change in psychic functioning.

The importance of relationships

It's essential to understand that in psychotherapy, the relational aspect and the quality of listening and empathy, as well as the way in which the relationship of trust between patient and therapist is established, are undoubtedly the most important factors in the choice of a therapist, regardless of the professional title, skills and academic background of the person you consult.

The quality of the initial contact, the ensuing feeling of trust and professionalism, and the intuition that can be gained from the preliminary session or the first consultations are often a better criterion of judgment than the C.V. or title of the person in front of you.

In other words, listen to your intuition, and inform yourself about the modalities and principles that are specific to the different therapies to try to understand what might work best for you.

Therapy requires a great deal of emotional commitment, and the relationship with the therapist is therefore fundamental. Trying out a few sessions provides a more reliable personal experience than simply relying on the opinion of a third party or a doctor.

Analysis or not?

If you feel that the origins of your unhappiness, depression, relationship difficulties or anxiety have long-standing origins and causes that you'd like to understand, you should know that psychoanalytic treatment brings meaning to the psychological suffering that prevents you from moving forward. Analytical treatment enables patients capable of introspection to modify their relationship with their life history and buried desires, which are the practitioner's primary aim during sessions.

Finding the right therapist means first and foremost finding one with whom you feel comfortable. But the converse has its limits: not feeling at ease with someone doesn't make them a bad professional. On the other hand, just because an analyst is empathetic doesn't mean he or she is a good analyst. More prosaically, according to French psychiatrist Serge Tisseron, it's better to choose a psychoanalyst of a certain age, because"young shrinks need money, so they take on too many patients... Traditionally, psychoanalysts would see patients three times before deciding whether or not to start an analysis. This is no longer done, and it's a pity".