There are two things to think about— chemistry and competence. Studies show that the best predictor of good outcome in treatment is that the people involved in it like and respect each other and work well together. Don’t stay with a therapist you really don’t like as a test of your endurance or in the hope that resolving the problem with him will somehow make you a better person. Every therapeutic relationship will have its occasional ups and downs (which you are likely to be contributing to in ways that may be enlightening), but these must occur on a foundation of trust and engagement if they are to be weathered well. It is probably a good idea to interview several clinicians before picking the one you want to work with and to go with your gut in choosing among them.
Competence is much more difficult to determine. There is an ever growing array of different professional disciplines offering treatment for psychiatric problems. Competence varies widely both within and across disciplines. Many mental health clinicians are the best people our species is capable of producing—among the most competent and most caring of individuals. But there are also many well meaning but incompetent therapists, some outright charlatans, and even a fair share of the mean-spirited who have mistakenly wandered into the most helping of professions.
There is no surefire way of finding someone who knows what he is doing, but a few tips may help. First off, get personal recommendations from your friends who have been helped as well as suggestions from medical schools, professional associations, and patient support groups. The fact that someone comes highly recommended does not always prove that he is competent or right for you, but it is better than a complete shot in the dark picking at random from the yellow pages. Next, ask questions and expect good answers. Most of what mental health clinicians do is pretty straightforward and can be stated in commonsense language. If the clinician cannot articulate a plausible diagnostic assessment, treatment plan, and clear answers to your questions, this may reveal a fuzziness of thinking that you can do without. And you can check the answers you get by going to references, the Internet, or getting a second or third opinion from other clinicians. Again, by all means possible, be an informed consumer.
Selecting the discipline of your clinician creates its own set of issues. If you need medication, it will have to be prescribed by an M.D.—usually either a psychiatrist or a primary care physician. There are some primary care physicians who are terrific with psychiatric problems and medications—but these constitute a tiny minority. Most primary care physicians have had little training, experience, or interest in dealing with mental health problems, and tend to prescribe psychiatric medications in a haphazard way that ignores their indications, risks, interactions, and side effects. For example, beware any primary care doctor who prescribes an antidepressant for you without asking if you have ever had manic or hypomanic episodes or if you have a family history of Bipolar Disorder.
Psychiatrists are more experienced with the use of psychotropic medications and are more likely to individualize the treatment regimen (both with respect to specific choice of medicine and the dosing strategy) to meet your particular needs. For example, the dosing regimen for antidepressants recommended by pharmaceutical companies has been simplified in order to make using them a “no brainer” for the primary care doctor. While easy to learn, this one-size-fits-all strategy often leads to problems. The standardized starting doses may be too high for you, resulting in a torrent of unwanted side effects. On the other hand, the recommended upper doses are usually overly conservative, leading to some people being under medicated. Many of the initial side effects (agitation, sedation, dizziness) can be minimized by a more gradual increase in dosage. Psychiatrists are more able to manage unwanted side effects and have more experience in adding additional medications to augment the effects of the first medicine. Finally, as trained mental health professionals, they are able to incorporate psychotherapeutic strategies into the treatment.
While most psychiatrists have had extensive training in medications and are usually good at prescribing them, there are some (especially the older guard) who may be more comfortable with psychotherapy and may be less knowledgeable as psychopharmacologists than is desirable. On average, however, we believe that you are much better off having a psychiatrist prescribe your medications than relying on a primary care doctor.
How about choosing a psychotherapist ? Beyond the crucial issue of getting the right interpersonal match-up, some therapists are much smarter, better-trained, practical, sensible, and experienced than others. To some degree this is related to the persons discipline—psychiatrists, psychologists, and social workers usually have more training and experience in psychotherapy than do other professional counselors—but there are terrific and terrible therapists in each discipline. We would recommend avoiding any therapist with an ideological ax to grind who is trying to fit you into a favorite theory. Beware especially of experts who specialize in Dissociative Identity Disorder/Multiple Personality Disorder, the recovering of repressed early memories of sexual abuse, hypnosis, sand play, or crystal gazing—all of these are likely to do you much more harm than good.
Stick to a mainstream person whom you like, who you can tell likes you, and who makes sense to you. Most of the therapy should probably focus on your here-and-now problems and on finding a better way of dealing with them. Discussing the past may be important in determining the enduring patterns of your behavior and how they may interfere with your current relationships—but this exploration should not become an end in itself or an excuse for settling for what you have got. If you are in therapy and have any doubts about it, a second opinion consultation is almost always helpful.