fter years of profound physical and verbal abuse Tamara was determined to move forward. “I’d been carrying a ton of baggage since childhood and I wanted to throw it overboard” she says. “I was willing to take a beating and do the hard work.”
A social worker friend recommended a therapist and Tamara dove in. Several sessions later she was frustrated — and out a considerable sum of money.
“It was a total flop” Tamara sums up wearily. “The therapist was too focused on my feelings — she kept repeating and summarizing my words. I’m very self-aware. I’m in touch with my emotions and didn’t want to get mired in the past. My goal was to acquire tools for more positive daily interactions.”
After several sessions Tamara tactfully expressed her dissatisfaction requesting a more results-oriented approach. When no changes were forthcoming she gave up.
“I’m burned out” Tamara says. “I so badly wanted this therapy to work. I was willing to give it my all. But now I’m drained — and I don’t have the money or energy to try again.”
The Therapeutic Shidduch
Sadly Tamara’s story is typical. For numerous therapy-seekers the search for an effective professional proves to be a harrowing journey rife with wrong turns acute disappointment — and in the worst cases permanent damage.
“Finding a good therapist is like finding a shidduch” says Dr. Yisrael Levitz director of the Family Institute of Neve Yerushalayim a post-graduate training center and clinic offering a broad range of mental health services toJerusalem’s religious community. “Say ‘I will!’ after minimal checking and you’re bound for trouble.”
But before considering the qualities to look for in a competent mental health professional consumers must understand what psychotherapy is — and isn’t.
“Psychotherapy is not advice-giving” Dr. Levitz clarifies. “It’s more a process by which individuals learn to better understand their thoughts and emotions and become freer to cope more rationally with the painful issues in their lives. Good psychotherapy should help an individual regain the bechirah that’s been lost due to overwhelming emotional pain.”
Untrained therapists often ply clients with intuitive advice. It may or may not be wise counsel Dr. Levitz says but it’s not therapy.
“As soon as you tell someone what to do, you actually restrict their bechirah. The goal of therapy is for the client to emerge independent, with the tools to make good decisions on his own.”
Frum people are especially prone to mistaking therapy for counsel, because they’re used to approaching rabbanim with halachic and hashkafic questions. Dr. Michael Tobin, a Jerusalem psychologist with over 40 years experience, and who has trained and supervised therapists since 1992, notes that confused clients must be gently educated.
“A therapist is not a rav, and therapy is not daas Torah,” he says, noting the opposite is true as well.
More Training = Better Therapist
The first and most crucial element in the search for the right therapist is determining that the therapist has a strong academic background and received competent supervised clinical training.
“Acquiring academic knowledge without supervised training is like learning how to swim on land,” says Dr. Levitz. “It’s only when you jump into the water and are taught the proper strokes that you become a competent swimmer.”
Hands-on experience is important in all professions, but in psychotherapy, it’s the deal-breaker.
At Neve’s Family Institute, for example, postgraduate therapists (who have completed several years of graduate education) spend at least two more years acquiring intensive supervised experience, as they provide low-cost therapy to the religious community.
It’s unfortunately too easy to stumble upon inadequately trained therapists. Certification “factories” offer a year or two of education, then label their graduates as qualified, potentially causing serious harm.
“We usually get the carcasses they leave behind.” Dr. Levitz sighs. “Especially with marriage counseling — probably the most challenging form of counseling — there’s no way a person can become skilled in two years. Let the buyer beware.”
Shaindy learned this the hard way. Tight on cash, she sent her son Mendy to a “certified therapist” who advertised very affordable rates. After two years of therapy and no progress, Shaindy dropped the arrangement.
“My son wasted two precious years,” Shaindy recounts. “When we finally found the right therapist, Mendy was practically an adolescent, much more resistant to therapy.”
Weeding out amateurish therapists is challenging because, unlike the “doctor” title, the term “therapist” is frequently self-conferred, accorded at will without objective criteria.
Once, a rav asked Dr. Levitz to ascertain the competence of a certain therapist. In a five-minute phone conversation, the seasoned psychologist learned some disappointing truths.
“What’s your experience?” Dr. Levitz asked.
“I’ve helped hundreds of people. I’m very good at what I do.”
“What’s your education?”
“I used to ask Rav Wolbe what to do.”
“What kind of approach do you use?”
“Shittat atzmi [My own method].”
In other words, the fellow had no approach at all; he made it up as he went along.
“Would you ever see a doctor who practiced the ‘me approach’?” wonders Dr. Levitz aloud. “Even alternative medicine is based on defined concepts.”
Statements from therapists that radiate arrogance (“I know what I’m doing,” “I’m an expert,” etc.) are red flags.
“Therapy can take a lifetime to master,” Dr. Levitz says. “A therapist should be confident but humble, open and authentic.”
Just as important as extensive training, however, is experience with the specific issue at hand.
Devorah Levinson of RELIEF Resources, a nonprofit Jewish mental health referral service, notes that therapists who “do it all” may not be the most effective. “Oftentimes, it’s the really good therapists who focus their energies on a distinct condition or therapeutic modality, becoming bona fide experts.”
If a therapist purports to specialize in a particular area, he should be able to show a minimum of three years’ experience dealing with that issue exclusively.
“This was my mistake,” relates Elisheva, a divorced mother of four whose well-meaning but nonproficient therapist nearly triggered a nervous breakdown. “I didn’t have the headspace to verify her expertise in post-divorce counseling. When I finally switched to a therapist whose specialty was divorce, the difference was astounding.”
Determining a professional’s degree of specialty is tricky. A referral from a reputable agency or recommendation from several professionals is usually the best option.
Still, warns Devorah Levinson, if therapy’s truly needed, one should never delay it because “it’s hard to find the right one.”
“Referral agencies like RELIEF are the Hatzolah of mental health. We saw that people weren’t getting the proper help quickly enough, so we did what we could to streamline the difficult search process.”
With a database of more than 3,000 therapists, RELIEF has developed an exhaustive screening process that includes an extensive questionnaire and submission of r?sum?s and copies of licenses, diplomas, supervision certificates, and other relevant documents. A face-to-face interview evaluates the therapist’s communication skills and manner, and calls to mentors and colleagues provide honest opinions on the individual’s skill and integrity.
After RELIEF refers a caller to a therapist, representatives follow up whenever possible, asking questions like “How was the experience?” or “What did you like or dislike about the therapist?”
This caller feedback (sometimes given anonymously) is crucial. Even in today’s more “progressive” frum world, many won’t volunteer the fact that they pursued therapy, which makes it difficult for a lone individual to solicit referrals. Agencies like RELIEF are in a unique position to critically assess a therapist.
For therapy-seekers in locations with no centralized referral source, their next best bet is to request recommendations from a recognized mental health expert in the area.
Whatever you do, warns Sharon, a US-based mom of three, don’t rely solely on a friend’s experience. Desperate for immediate trauma counseling, Sharon trusted a longtime friend and plunged into therapy with a neighborhood therapist.
“She didn’t understand me,” Sharon reflects. “I had terrible insomnia, and when I poured out my heart about the sleeplessness, she responded, ‘That’s no good! You need a good night’s sleep!’
“I’d leave the sessions more stressed than when I’d entered.”
The Feel Factor
Sharon’s anxiety-ridden experience underscores another vital element of effective therapy: The client must feel safe and comfortable.
“In most cases, a good rapport is fundamental,” declares Devorah Levinson. “Without it, you’ll see little progress.”
For a client to become empowered and independent, Dr. Levitz concurs, he cannot feel judged at any time — even in areas of halachah. “If a religious client relates that he wants to become a mechallel Shabbos, a religious therapist, as a committed Jew, might likely feel profoundly pained. The therapist may even have the urge to subtly ‘mussar’ him out of it. But a therapist would simply not be effective if he gave mussar, subtly or otherwise. He needs instead to help the client explore the psychological determinants for his decisions. By keeping the relationship judgment-free, it becomes safe to explore deeper psychological factors.”
Tova, a child-abuse survivor who went through two therapists before finding the right one, experienced this firsthand.
“My [third] therapist never hugged me or even touched me. But her love allowed me to really ‘hear’ her often-painful suggestions, especially when she talked about me being jealous or malicious…. Despite knowing my negative side very, very well, she accepted me… even liked me!” That acceptance, Tova says, was key to her emotional turnaround.
Complementary personalities are also likely to facilitate therapy’s success. Elisheva describes her second therapist as very laid-back. “I’m a worrywart, prone to acute anxiety. Just being around her relaxed me.”
Devorah Levinson of RELIEF tries to match personalities by picking up nuances over the telephone. “A rav called in search of a therapist for the child of a shul family. The parents had been noncompliant in the past, refusing to take their son to a psychiatrist, and now they’d grudgingly agreed to start therapy. I knew they’d need a firm, take-charge therapist who could elicit full cooperation, yet was also sensitive enough to address their concerns.”
Ayala, a widowed mother of six, specifically looked for a “tougher” children’s therapist in the years that followed her husband’s death. “I knew I’d need that, because I was too soft on my kids. I just felt so bad for them,” she explains.
An expert therapist, however, can adjust his manner according to the client’s readiness. “He’ll be soft and hard, gentle and tough,” says Dr. Michael Tobin. “At each stage, the therapist must gauge how hard he can nudge his client into growth.”
Member of the Tribe?
Many therapy-seekers assume they need a religious — or at least Jewish — therapist who can understand their values. Is this assumption valid?
“If he’s ultra-qualified and frum, that’s ideal,” says Dr. Levitz. “But the priority has to be: Is he trained? Is he an expert?”
Devorah Levinson wholeheartedly agrees. “Some parents lament, ‘Why isn’t there a frum treatment program for people with anorexia?’ I reply, ‘The primary focus should not be that we want a frum program — rather, we want the best program.’ Once we find the most cutting-edge facility, most doctors and professionals are more than willing to accommodate religious sensitivities.”
What’s more, a true expert will have encountered enough religious Jews in his practice to become familiar with the frum lifestyle — and empathetic to our unique challenges.
Defined conditions like trauma, phobias, addictions, mania, depression, or personality disorders are often treated successfully by non-Jewish or irreligious therapists.
On the other hand, obsessive-compulsive disorder (OCD) frequently requires a good understanding of Jewish law because it emerges in activities important to the person — and Yiddishkeit is important to religious Jews. The OCD often manifests in mitzvos like hand-washing, Krias Shema, or Pesach cleaning.
Moishy, for instance, was able to find a qualified local therapist in his small town to help with his severe OCD, which expressed itself in kashrus. But he’d spend three-quarters of each session explaining concepts like milchigs and fleishigs — an expensive and tiresome transmission of Judaism basics.
Family and marital issues are also tricky in an irreligious setting. “A religious marriage involves practices that are often poorly understood or alien to the world at large and require an extensive knowledge of halachah. I’d be reluctant to recommend a secular therapist who is not sensitive and knowledgeable about halachic marital practices,” says Dr. Levitz.
Disdain can crop up regarding other aspects of frum lifestyle too. When her son’s therapist began making disparaging remarks about the chareidi school system, Shoshana was wise to back out. “I needed someone who’d help me work within the system. I didn’t want to feel defensive.”
For those who are self-conscious about therapy, “outsider” professionals might be preferable. “I didn’t want to bump into my therapist at the supermarket,” another woman says.
Whether you go heimish or not, Dr. Michael Tobin asserts, it’s a good idea to establish that the therapist has a stable personal life and hasn’t been through multiple marriages and divorces.
“The well-known saying goes, ‘A client gets no further than where his therapist is stuck.’ If your therapist is not worked-through, your progress will be limited.”
The therapist’s gender may affect comfort and efficacy too. Clients must be sufficiently self-aware to determine if an opposite-gender therapist will cause unease, or lead to inappropriate interactions.
Chaya, who pursued marital therapy, ultimately switched to a male therapist after noting her husband’s dissatisfaction. “My husband felt our original therapist, a woman, was partial to me, and that made him lose interest in cooperating,” Chaya recalls.
The Phone Call
Once you’ve amassed some recommendations, it’s wise to conduct a mini phone interview with each. “Be an educated consumer,” advises Devorah Levinson. “These therapists are selling a service. Ask questions, get information.”
Queries like “What’s your experience?” “What are your specialties?” and “This is my problem — how would you plan on helping me?” yield valuable clues as to the therapist’s competence and manner.
“The therapist should be able to explain — in layman’s terms — how he plans on helping the client,” says Dr. Levitz. “More important than the choice of approach is the existence of an approach. You want a man with a plan, not someone who is fumbling along.”
If the therapist sounds abrupt, harried, or dismissive, that might presage what your sessions will be like.
“I don’t have a secretary because I want to answer that initial phone call myself,” shares Dr. Tobin. “Most callers have been ruminating about therapy for a while — they’re anxious, they might feel a stigma. Now that they’ve taken the first step, I put them at ease about the therapy process, spend ten minutes getting a feel for their issues. Every potential client deserves that courtesy.”
Many callers want to know “How long will it take?” Because therapy is tailor-made, however, it’s hard to offer an accurate estimate until a proper meeting has taken place.
“Some people are in and out after three sessions,” says Dr. Tobin. “For complex problems, even three to six months would be illusory.”
Real therapy, the veteran psychologist ruefully notes, does not conform to the guidelines of insurance companies. “An honest, ethical therapist knows full well how challenging (though doable!) it is for people to change,” Dr. Tobin says. “They’ll be realistic about time-frame.”
Clients can expedite the process by arriving with a clear list of goals.
“Most people come with a vague sense of ‘my life is not working,’ or ‘the problem is my husband,’” Dr. Tobin relates. “While a skilled therapist will pinpoint the underlying issues rather quickly, it still takes time.”
Evaluating the Process… in Real Time
Even with the right therapist, you need to take inventory of your emotions after each session: Do I feel safe? Hopeful? Empowered?
“Overall, after most appointments, you should feel positive about your care,” says Devorah Levinson.
But “feeling positive” Dr. Tobin qualifies, doesn’t refer to a touchy-feely, life-is-hunky-dory sensation.
“Therapy is not relaxing,” he punctures the myth. “Change is hard, and feeling drained is normal.”
“It’s okay to be a little disturbed or stirred up by the therapist,” agrees Tova, a seasoned psychotherapy goer. “But this should always happen within the backdrop of the therapist caring for the client, and the client should feel that care.”
“Trust your instinct,” Tamara advises, looking back at her failed therapy experience. “I had a hunch it wasn’t going to be effective, but I so wanted it to work that I pushed on — foolishly.”
Red flags of ineptitude or substandard professionalism include a therapist’s answering the phone during a session (“I’d fire him on the spot,” Dr. Tobin says), looking distracted, forgetting something important he’s been told, or falling asleep. (Yes, it happens!)
“Expect 100 percent attention,” Dr. Tobin says. In this area, he’s a relentless, dogmatic supervisor. “Anything less is stealing. For every moment she’s in that chair, the client must feel she’s the most important person in the therapist’s life.”
“It bothered me that my original therapist didn’t remember key names or people I’d talked about, or what they had done,” relates Tova. “I had to repeat myself a lot.”
Tova also remembers a pattern of feigned understanding: The therapist would nod her head, but Tova — her client — could tell she wasn’t “getting it.”
“The therapist should be able to say, ‘I’m not sure what you mean, could you explain some more?’”
Beyond a pleasant, attentive relationship, at some point, clients must also see quantifiable results. “A nebulous ‘I think I feel better now’ means little,” Dr. Tobin says. “You want solid, describable accomplishments: ‘My relationship with my mother is healthier; I’m clearer about my life goals, etc.’”
For more measurable conditions like OCD or phobias, the key question is: Have symptoms decreased?
“The speed of change depends on the disorder and its severity, as well as the level of the clinician and motivation of the client,” Devorah Levinson says. “With moderate OCD, for example, if the client still washes hands every 45 minutes after two months of therapy, it might be a sign to reassess.”
Progress must also be continuous: If improvement has plateaued after several months, it may be time to move on.
“I was seeing a psychiatrist, and it was really helpful,” remembers Temi, who suffered from severe postpartum depression. “We identified childhood sources for some of my negative-thinking patterns, with the eventual goal of working to undo them.”
After a year, however, Temi felt her progress beginning to stagnate. “It was becoming a weekly kvetch session,” she says.
Temi switched to a more pragmatic licensed clinical social worker and made concrete behavior adjustments. But she doesn’t regret her psychiatrist visits. “Had I not gone through the first process, I could not have identified what I needed to work on. Each professional had his purpose.”
A bump in the therapy process does not usually warrant immediate termination; in fact, smooth sailing is the exception. The courteous — and worthwhile — thing to do is communicate openly with the therapist.
“There’s no room for discomfort here,” says Devorah Levinson. “By being up front, you’re giving your therapist the opportunity to better help you.”
A client who sees dubious progress might politely say: “We’ve been working for four months now, and I’m feeling a bit static. Can we discuss my goals?”
A good therapist won’t become defensive; he’ll appreciate his client’s motivation and alter his approach accordingly. And a really good therapist, Dr. Levitz adds, will preempt problems by soliciting feedback himself.
“He’ll ask ‘How did this go for you?’ or ‘How do you feel about our session?’ This communication is crucial, because the therapist’s and client’s perceptions often differ.”
It Ain’t Over Till It’s Over
Following candid discussion, if the client still feels unsatisfied, it’s probably time to part ways.
“But you have to be honest with yourself,” Devorah Levinson warns, citing a common pitfall. “Is your dissatisfaction coming from the discomfort of having to be in therapy altogether? Are you convincing yourself that therapy isn’t working because you hate the stigma or don’t like the ‘feel’ of being in therapy?”
Devorah notes that compliance — i.e., sticking it out — is challenging, especially in frum circles. “People go to therapy when they’re in crisis, but drop out when things start looking up, or when they begin medication. Six months later, the crisis hits again — with a vengeance.”
While the stigma associated with mental health services has diminished in recent years, it still causes many people to forgo badly needed therapy. Mothers, who are especially ill at ease, or just unaccustomed to giving to themselves, tend to shrug off the need. Plus, therapy’s steep, often unreimbursed expense gives deliberating individuals yet another reason to abstain.
Ultimately, though, it’s a question of priorities.
“People will pay hundreds of dollars on vitamins, but don’t have money for therapy,” laments Devorah Levinson.
If someone with strep failed to see a doctor, he’d be negligent. Similarly, contends Temi, a former PPD sufferer, taking care of one’s mental health is a serious obligation. “It’s our responsibility to use the tools Hashem’s given us to make things better. We have to do our part.”
The myriad ABC permutations that trail a mental health professional’s name can be dizzying. Here’s a mini-primer on the significance of the symbols.
MSW: A social worker who’s earned a master’s degree, but hasn’t completed the required hours for licensing — and cannot practice privately.
- LCSW: an MSW who’s received her license (L) after extensive supervised clinical (C) training, and is qualified to give therapy or work in case management.
- LMFT: a licensed marriage and family therapist who’s earned a graduate degree in psychology and/or marriage and family therapy, plus supervised experience. She’s not qualified to deal with issues unrelated to marriage and family, like OCD, anxiety, or personality disorders.
- LMHC/LPC: a licensed mental health counselor who’s earned a graduate degree in counseling and/or psychology, plus supervised experience. Similar to LCSW, the MHC education is focused on therapy for a broad range of disorders, but it does not cover case management.
- LCAT: a licensed creative arts therapist who’s earned a master’s in art therapy, music therapy, dance/movement therapy, or drama therapy, plus supervised experience.
- PhD: a licensed psychologist who’s earned a doctorate, usually with a focus on research.
- PsyD: a licensed psychologist who’s earned a doctorate, usually with a focus on patient therapy.
Did you know? In all states except West Virginia, psychologists must earn a doctorate in order to get licensed and see patients privately.
Therapy is rarely covered in full by insurance — especially when provided by top professionals. Are there options for cash-strapped, in-crisis families?
- Insurance. Medicaid or decent private plans usually cover (at least partially) a qualified therapist for typical problems. Many senior and specialty clinicians, however, won’t take insurance: The reimbursement level can be less than half of what they usually charge, with the added requirement of incessant paperwork. “Using your insurance can be like going to a clearance shoe sale,” quips Devorah Levinson of RELIEF. “You might find something that will do, but it probably won’t be the right color or perfect fit.”
- Be savvy. Agencies like RELIEF help navigate insurance labyrinths to obtain funding, particularly if you have out-of-network benefits or can prove your need for a niche professional, like a male Yiddish-speaker who specializes in OCD. If that doesn’t work, RELIEF connects callers with insurance advocacy groups, who, for a fee, can help you obtain coverage from recalcitrant insurance companies.
- Delegate. The patient is probably in no state to battle stubborn insurance representatives. A concerned family member or caretaker should do the legwork instead.
- The clinic route. Newer, subsidized therapists at clinics like OHEL’s Tikvah Center in Brooklyn or Jerusalem’s Neve Family Institute offer a full range of therapy services for children, adults, couples, and families under the supervision of highly qualified supervisors. The Neve Family Institute has a generously subsidized fee schedule with a maximum per-session fee of NIS 100, and is known to never turn anyone away for lack of funds. The downside: You’re getting someone with less experience.
- Community giving. Many leading therapists accept a certain number of cases as “maaser” or “klal” clients. Ask the therapist to take you on pro bono. Additionally, agencies like RELIEF can refer you to organizations that run patient funds for specific issues, like teenagers in crisis. However, there’s no free ride. To get the most out of every dollar, these funds will usually subsidize half of eight sessions rather than four full sessions. Their goal? To ensure you’ll stay in therapy as long as possible, for optimal results.
- Be up front. Most therapists will be flexible about rates, particularly once you’ve already begun and shown them you’re in for the long haul. “One woman was so relentless, so serious about changing,” shares Dr. Michael Tobin, “that I was happy to give her a significant reduction.” Even in complimentary cases, Dr. Tobin concedes that he’ll still charge something — $5, $10 — just to assure motivation. “The more serious the financial commitment, the more serious the client’s commitment. That’s human nature.”
(Originally featured in Family First Issue 380)