Addictions Anonymous 34: Therapists Of All Sorts
This article belongs to Addictions Anonymous column.
In general, there are two kinds of therapist qualifications: (1) earned degrees and, (2) licenses and certifications. Some clinicians, of course, may have both.
A high school diploma is nice, but not likely to be found on a therapist's office wall since it is certainly not a qualification for treating psychological problems. There are, unfortunately, people out there without even this minimum education, uneducated charlatans in private practice taking money for their clumsy efforts. Telephone psychics may be the worse examples of the uneducated, boiler room crowd, but there are plenty of others. Let's assume our prospective helper made it through high school and can read, write and do enough arithmetic to figure out your bill.
Junior and community colleges now offer various Associate Degrees. These are usually awarded at the completion of a prescribed two-year course of study that may be in the arts, human studies, or sciences. Some colleges offer technical degrees such as nursing assistant, inhalation therapist and so forth. Conceivably, you could find someone with an Associate Degree in psychology or human development who might specialize in addictions. However, they would probably not be in independent practice; such a clinician would most likely be working under the supervision of a more qualified professional in a group practice and might well be a recovering person or peer counselor with additional certifications. Other holders of an Associate Degree may be found working in large organizations in human resources or personnel departments.
A peer counselor, by the way, is one who has recovered or is recovering from the illness he or she proposes to treat. The word peer means equal; in this case, equal in terms of having the same disorder. A paid peer counselor is, by definition, a professional who gets paid and has all the ethical and legal responsibilities of a professional counselor; this is someone who has additional documented and supervised experience in the field, and who is certified in the specialty. The scope of a peer counselor's treatment is, of course, very limited, so that is why treatment supervision and client assessment by a more generally qualified practitioner is necessary. In my own experience, it is very rare to see an addict enter treatment with just one problem; it is equally rare to see a peer counselor concentrate on anything more than one problem. That, I think, is just the way it should be. Peer counselors are essential in the total team effort, and it is not hard to see their contributions. What is hard to believe is that some few decide they are experts on everything, and these few may block or discourage clients from going to others for help with other problems.
If you find a recovering peer counselor working alone without the support of a professional team and with no advanced academic training, I would suggest you walk away. A sponsor in a Twelve Step group will do a far better job of helping you while following the guidelines of that organization. And, of course, the price could not be lower since it's free. It is a violation of Twelve Step principles for recovering addicts to take money for helping fellow addicts. It is also against principles to use a meeting as a way of finding clients for a paid practice, for turning their recovery into a business, or for telling their personal story in public just to recruit business.
As a side note in the discussion of earned degrees, I was recently surfing around the Internet and found about a dozen companies offering fake academic degrees. Some use names similar to those of famous universities, and it would require close study to tell that they are fakes. Again, let's just stand there and read those pieces of paper on the office wall carefully.
A Bachelor of Arts (B.A.) or a Bachelor of Science (B.S.) degree indicates the completion of a four-year college program in which the student had both a major and a minor subject of study. While there are employment opportunities for the holder of a four-year degree, these probably would not be in independent practice. Most states now recognize and license sub-professional clinicians such as Psychology Assistant or Physicians Assistant who work under the supervision of a fully licensed psychologist or physician.
Many nurses become excellent psychotherapists; the R.N. behind the name stands for Registered Nurse. Such a person may have completed work beyond the basic college degree, in which case they may show a Bachelor of Science (B.S.), a Master of Science (M.S.) or even a Doctor of Philosophy (Ph.D.) in nursing. A Clinical Nurse Specialist is a nurse with advanced experience and training that would qualify him or her for independent practice in certain areas such as addiction or in other medical specialties.
Social workers are often found either in a group or independent practice, and you may find a Social Work Assistant with just an Associate Degree; but most social workers have training to the Masters level with at least two years of study and practical experience beyond the four year Bachelors Degree. There are many specialty areas within social work.
A Doctoral degree is based on study and experience beyond the Masters level. The Ph.D.—Doctor of Philosophy—is the highest degree you can obtain in course work, meaning that it is the most advanced degree awarded as a result of academic study and research. The Ph.D. involves the completion of original research reported in a doctoral dissertation. It is the last degree to be awarded in graduation ceremonies and, historically, the most ancient of all the advanced degrees.
An M.D.—Doctor of Medicine—is awarded following completion of a four-year medical school that comes after the four-year pre-med undergraduate college program. A year of practical internship is required, and most physicians complete further supervised experience in a residency program. If a medical doctor completes a residency in psychiatry, he or she has specialized in that field, but any general practice physician can, and often does, prescribe psychoactive medications for depression and other mental problems. In a few states, Ph.D. level psychologists with special training may prescribe such medication.
A college education, medical school, an M.D., and a residency in psychiatry produce a psychiatrist, but in recent years many psychiatrists have given up on talk therapy. They are likely to see four or more patients per hour. Prescriptions for medications are the common result of a visit to a psychiatrist, and you may not be seen again for follow-up for some time. If the psychiatrist is in a group practice, you may be seen for talk therapy on a regular basis by a social worker, psychologist, or other counselor in that same practice. Of course, some psychiatrists still do talk therapy such as Freudian psychoanalysis. This can be very intense and may go on for years, but such a practice is confined to the economically advantaged in our society. In spite of its cost, this kind of treatment has no documented effectiveness for addiction treatment to prove that it is superior to cheaper and shorter treatments.
People often confuse psychiatry and psychology since members of both professions are properly referred to as Doctor. The use of the title Doctor is quite proper in addressing someone with any kind of doctoral degree be it an M.D. or Ph.D.
Doctoral degrees are awarded in all fields of learning. Medicine, over the years, evolved from a lowly occupation with little effectiveness to it present status of great respect as its methods improved. At first, one became a physician merely through an apprenticeship. Then, at one point not very long ago, people right out of high school entered a medical college. Then, a two-year pre-medical course was added; finally, the four-year college degree became necessary to enter medical school even as post-doctorial work was being added at the other end after the internship.
A psychologist usually holds a Ph.D. or a Psy.D. (Doctor of Psychology) degree. These are degrees awarded after four or more years beyond the four-year college. The training of a clinical psychologist usually includes training in research as well as training in psychological assessment, therapy methods, personality theory, a practical clinical internship, and much more. In almost every state, in order to represent oneself as a physician, social worker or psychologist, one must also hold the appropriate license, and this is true in dentistry, law and so forth. The standards for state licensing are often quite high and require passing an examination and interview screening.
We cannot, of course, be lulled into confidence just because our prospective helper holds an advanced degree. We still have to ask, "Is the degree in a field relevant to the problems with which I need help?" Doctoral degrees are awarded in many fields such as religious studies, law, sociology, music, political science, etc. Be sure to check the field in which prospective therapist earned the degree(s). If the earned degree is not in a mental health related area, you have questions to ask, and the clinician has explanations to make. Training in law or theology, as examples, is no guarantee that the person has any knowledge or skill for work in an unrelated field such as psychotherapy.
Remember our battle cry—caveat emptor! I have a friend who earned his Ph.D. in sociology and did wonderful work on the sociology of problem gambling. Over time, however, he became increasingly interested in working individually with pathological gamblers. At considerable expense and sacrifice to himself and his family, he went back to school and earned a second doctoral degree in clinical psychology, and I have no doubt he will be an outstanding therapist.
On the other hand, I remember a gentleman who had earned three Ph.D. degrees, but none of them were in a clinical field. Although he was a fine mathematician, I wouldn't let him groom my cat let alone ask him for psychological advice; but there he was being an expert on addictions.
Another person of my acquaintance has a Ph.D. in economics and, when the opportunity arose, he went to work counseling addicts without getting any additional training or experience. While learning how to handle money is important—that's what economists do—I hardly think economics should be the primary topic in psychotherapy. It is vital to know the field in which a clinician earned an advanced degree, and to know what practical experience, such as a supervised clinical internship, the person had. One horrible example most of us would recognize is a radio talk show host who specializes in emotional and relationship problems. She is often referred to as a psychologist or psychotherapist, but her Ph.D. is in biology with a specialty totally unrelated to psychology or mental health.
In 1971, nine years after I got my own Ph.D. at the
Later in 1971 I returned to
The moral of all this is that we are sometimes at the mercy of the therapist. We can ask all the right questions and still not get all the information we might need. So, generally, we fall back on word-of-mouth testimonials, community reputation and, of course, on our own reading of the credentials available to us for study.
Representation to the public
If you see a business card, you should know that properly earned degrees go after the name as in:
Julian I. Taber, B.S., M.S., Ph.D.
Normally, of course, one lists only the highest degree earned although, if I really wanted to brag and look tacky, I could do it the way it's done above.
Licenses and certificates go below the holder's name:
Julian I. Taber, Ph.D.
Certified Gambling Counselor, National Council on Problem Gambling
(I hasten to note that since my retirement, I have not renewed my rather expensive license in
Many therapists have an alphabet soup after their names because they try to replace earned academic degrees with certificates earned by practical experience and workshops.
Julian I. Taber, CGC-NCPG & DAHSPAD
This might impress a few and confuse most. It's gibberish. The licenses and certificates go below the name and should not be abbreviated to look like degrees, so study those business cards carefully, and ask about anything you don't understand.
You may see a paper on the wall that says the clinician is Board Certified. Examination boards are set up within professions to certify specialties in the profession, and these certifications can be tough to earn. Many different specialties in medicine and psychology offer board certification, and this certification process is conducted by peers within a parent professional organization such as the American Medical Association, The American Psychological Association, or the American Psychiatric Association. If someone is board certified by a major national organization of professionals, this is a good sign. He or she has the degrees, the proper licenses, and additional proof of ability and acceptance within the profession.
There are, unfortunately, organizations with lower ethical standards that sell Board Certificates with only a cursory review of someone's credentials. Often, they will grandfather someone on the basis of experience and excuse him or her from examinations. If the approving board is part of a well-known national professional organization, you can feel sure the certification was earned.
Working your way up through the mental health system
Learning to use any system takes time, and the mental health system is complex, expensive, and confusing. So, take your time and do your homework. Make your obsessive-compulsive streak work for you and just pretend you are using one of those racetrack tout sheets; you know, rate the horse, the jockey, the track, the weather conditions, post position—all the good stuff some gamblers use to give their money to the track most efficiently. Apply your best detective work to a good cause, your recovery.
Addicts and family members often feel they are in a crisis. When the addict reaches a hard bottom, panic often strikes. Extreme panic and anxiety prevail and cloud good judgment. Acts of desperation at the bottom are common. If someone is suicidal or in a medical crisis, we call 911 and get that person to an emergency room. It's very hard to judge the seriousness of a suicidal feeling in others, so get the suicidal person to the professionals, and let them do a proper work-up, even if you suspect the threat of committing suicide is not real. If it's real, better to be safe than sorry later. If the addict is just trying to con you with emotional blackmail, taking the threat seriously and sending him or her to the emergency room will call the bluff and show that this trick won't work on you.
Withdrawal in addiction can be a very serious affair; with some drug abuse patterns, it can be life threatening. If serious withdrawal is not to be a problem, I prefer the following order of interventions, a priority system that keeps in mind the idea that using the least amount of available treatment is probably the best idea.
As I said earlier, many people who get over-involved in an addiction simply decide to moderate or stop altogether. We don't know how many or what percentage of problem addicts do this. Recovering addicts, and many professional therapists, say this is impossible; but we have not until recently seen good research on the question since natural recovery people don't, by definition, come into contact with therapists or researchers. We have to go out and find them before we can interview them. I would suspect that natural recovery people either do not fit the full diagnostic criteria for pathological addiction, or have certain strong personality characteristics or social support systems that help them to re-direct their lives.
Nevertheless, any form of recovery begins with that very important decision to stop, and the passionate desire to so. In spite of their bad reputation, resolutions and pledges sometimes work.
Any addict who can convert that old passion into a passion for normal living will make it in the real world. Resourceful ones will use any and all the help they can find.
I confess, for what it's worth, that I was an alcohol user through my mid twenties and was fortunate not to have driving accidents or get into serious trouble. When drinking threatened to cause serious problems, I just gave it up and never got tipsy again. Drinking seemed to be a part of graduate school at the time, back in the 1950s. Two of my favorite graduate school professors died of alcoholism, as did several of my fellow-students in the psychology department. I was the lucky one and I credit my wife as the one who suggested, shortly after we were married, that I stop. I did.
Then, after twenty-two years of two plus packs of cigarettes per day, in 1971, I finally threw them away and went cold turkey. I wish I had been able, at that time, to use the American Lung Associations stop smoking program, but that didn't come into being until much later. I call this kind of thing maturational moderation or natural recovery. I wish we knew more about it, but the fact is that most of us need special help of one sort or another to end a dependency when simple resolutions fail.
Of course, anyone with a significant addiction problem will have sworn off and failed many times. When all good intentions and resolutions fail, some more drastic action is called for.
When natural recovery on your own fails repeatedly, participation in a Twelve Step group would be my next level of referral for problem addicts. There are other self-help groups such as Rational Recovery, and the curious person may wish to investigate these groups.
Twelve Step philosophies, however, have grown and flourished since their beginnings many years ago. Some new members find they don't like these groups very much at the beginning and are confused by the drastic changes in thinking this program seems to demand. Some see it as too religious or as some kind of substitute for religion. There are many strong personalities to be found in self-help groups, and the stories and advice they share so freely may be intimidating to the newcomer.
If you're looking for excuses, they're easy to find.
Hey, nobody asks you to like your treatment, we just ask you to go get it. Most medical treatments have unpleasant, confusing features, but we submit because we want to live and be healthy. Twelve Step groups are definitely not entertainment, that's what addiction is. Twelve Steps mean real work and responsibility. You have to hang in until you really understand what they are trying to teach. It does work if it's taken seriously. It is more accurate to say that if you work the program then the program will work for you. Memebers of the group can't fix you, but they can show you what they did to get a better life.
The addict has to dive deeper than the surface features of addiction to find the basic philosophy that will nearly always produce a better quality of abstinence. Stripped of all the embellishments, the philosophy of groups like Alcoholics Anonymous is ancient and simple:
• Be willing to change and stay open-minded
• Learn to be humble
• Admit that some things (like addiction) are too powerful for you to control
• Admit that life has baffled, confused, and defeated your egotistical demands
• Confess past errors and mistakes without holding back any of the truth
• Learn to learn from the experiences of others
• Learn by sharing your experience with others
• Study your own personality and life to discover what you need to change or improve
• Live a simple life
• Put serving the needs of others ahead of your own desires
• Practice strict honesty in all your affairs
There are other very important ideas and concepts to learn, but this is the general nature of the personality re-development needed for abstinence and a normal life. These priorities probably already exist to some degree in those who achieve a natural recovery on their own, as they do in some measure in all of us, but we need to continue the endless path to maturity even as we grow older.
Oh! Did I remember to say that you couldn't fix what's wrong just by reading material like this? What you learn must be infused into the acts of everyday life. Go out and practice being normal. You may like it, but you learn to be normal by practice, not by book learning.
If one has given the Twelve Step philosophy a sincere effort and still cannot begin a good recovery, then a specialized treatment program might be needed in addition to the anonymous group. (I said in addition to, not instead of.) New programs are popping up all the time in all parts of the world these days, no meeting list would be valid for very long. A good addiction treatment program, in my opinion, will support and encourage continued attendance in the self-help group. There is probably a state council on your addiction in your state, and all the state councils as well as a National Council can be found in the phone book or on the Internet. These organizations can offer referrals to treatment programs.
Addiction damages family life enormously, and after years of suffering with an addict, most family members will have arrived at personal compromises with life that will have to be unlearned. They may have reacted to the addiction with addictions of their own, or they my have learned to protect and defend the addict from the consequences of addiction. Abstinence on the part of the addict can actually place even more stress on family members. There are organizations such as Gam-Anon or Al-Anon for family members of gamblers or alcoholics, so if meetings of those organizations are available, family members and loved ones should try those meetings themselves.
Family therapy, like Al-Anon, is for the benefit of all family members and should not be intended to help the addict stop. It is not a substitute for the individual treatment the addict must get, but it can help clean up the mess once recovery begins.
Sometimes severe emotional and personality problems in some addicts prevent abstinence and recovery. In addition to a major addiction, other disabling problems include depression, anxiety, low intellect, hyperactivity disorder, and the whole range of other mental disorders from schizophrenia to paranoia and beyond. Undiscovered physical problems such as a low thyroid function or diabetes can also make someone more susceptible to addictions.
Any other emotional, personality or health problems should be thoroughly assessed by a psychiatrist or psychologist. A fifteen-minute office interview is not enough, in my opinion. The better professional programs offer a team of different professionals, all of whom may be involved in the total assessment. The assessment should include a complete life and physical history before any kind of therapy begins. It may involve psychological and laboratory testing. This complete assessment is easily contaminated if the person is still actively using, or if the addiction problem is hidden and denied.
Addiction is mind-altering behavior, and total honesty with those who want to help is essential. Unless there is some kind of crisis, the assessment and any more sophisticated psychotherapy usually are best undertaken after a period of abstinence and participation in self-help. In my experience, psychotherapy works best after the first year of abstinence, not at the beginning.
Based on a brief office interview, many physicians will prescribe medications that can reduce depression or anxiety. Although it is easy for one to find oneself on these psychotropic or psychoactive medications without undergoing the complete assessment described above, I do not think this is an ethical practice. If medication is begun, it should be accompanied by monitoring and by weekly talk therapy with a professional psychotherapist.
There is no magic chemical bullet to cure problem addiction, and there may never be one to do the complete job by itself. Commitment, hard work, and consistent attention to detail are what make life better for most of us, not chemistry alone. Newer drugs are being developed all the time and there now are certain medicines that reduce addictive craving for some addicts. However, a reduction in craving is only the opening that may permit learning of better habits of living.
Difficult and complex as our mental health system may be, there are wonderfully skilled and highly dedicated people with all levels of experience and training waiting to help. Getting the help you need is certainly less frustrating, less expensive, and less complex than trying to improve your life through addiction. Compared to addiction, recovery does, unbelievably, require less frustration, less money and just a little simple reasoning.
All addicts gamble with their lives, and you never wish a recovering gambler good luck. At least I don't. So, I'll just say, "Welcome to the world of normal nerds. Happy to have you with us."
more in Life
Problems confront addicts when they decide to seek mental health services. They can be serious problems, but they are not impossible. Here are a few of the big ones:
In the days when I was working as a clinical psychologist in hospital programs where we treated addictive behavior, it was common to have members of Twelve Step groups bringing people in for help.
Vulnerable Groups Experience and research show that gamblers and other addicts entering treatment are not exactly like the general population on a number of important psychological dimensions. Rather...
I remind the reader who may be studying these choices that I have not announced my own preference in terms of which of the choices, A or B, I think is most appropriate to a mature and normal way of thinking.
No one really teaches us the whole story on how to live in the world. We learn some of what works and some of what causes pain. We learn what people like and dislike about our behavior. Unfortunately, we don’t have teachers who teach us how to live comfortably in the world, how to develop and keep the everyday euphoria that is our right. If we knew what to do to reduce self-inflicted misery, we would probably want to learn it because we need something better than the School of Hard Knocks.