Finding a Therapist


FINDING A THERAPIST
Marlene Steinberg, M.D., 2003

I. Getting Started: Some Relevant Issues
Since the publication of THE STRANGER IN THE MIRROR, many people have asked me how to find a therapist experienced in the treatment of dissociation. Because there are a limited number of specialists in the field of dissociative disorders, and managed care insurances have restricted access to out-of network professionals, locating a provider who is experienced in the treatment of dissociation may require considerable effort. In fact, the majority of e-mails that I receive are from people who are having difficulty locating a treatment provider. Finding a qualified therapist is one of the most important decisions you will make with respect to your or a loved one's recovery. I hope that the information provided in this section will allow you to approach this process with greater ease.

An educated consumer is the best advocate for finding treatment for either you or your loved ones. Familiarity with recent advances in the field of dissociation, including the existence of specialized diagnostic tests and treatment will allow you to search for a therapist whose training is based on the highest standards of psychological/medical care. For example, if you needed heart surgery, you would never think of going to a general surgeon . Similarly, people with dissociative disorders are wise to seek help from a mental health professional who specialize in the treatment of dissociation.

Though Dissociative Identity Disorder (DID) has been recognized as a genuine psychiatric disorder (that is included in the American Psychiatric Association's Diagnostic Manual of Mental Disorders since 1980), there are some professionals who believe that a person who experiences symptoms of DID is not suffering from a real illness. If the therapist you consult does not recognize DID, the type of treatment that you receive may differ from accepted treatment standards . Due to misconceptions related to dissociative disorders, it would be useful to understand whether the professional you consult harbors such opinions which may affect your treatment.

What kind of events or experiences are likely to cause symptoms of dissociation? People who develop dissociative disorders are likely to have experienced and/or witnessed various types of traumas. There are traumas within one's home, either emotional, physical or sexual abuse. Other types of traumas include natural disasters, such as earthquakes, political traumas such as holocausts, hostage situations, wars, random acts of violence (such as the Oklahoma city bombing and the Columbine shootings), or the grief we feel after the death of a family member or loved one. Some mental health professionals specialize in the treatment of trauma survivors and post traumatic stress disorder. It is important to note that these therapists may or may not also specialize in the treatment of dissociative disorders . One way to find out what their experience is with dissociative disorders is to ask them about their experience directly (see questions listed in Section III. The Initial Consultation below.)

II. Recent Advances in Detecting Dissociation
Until the 1980's, there were no objective tests that reliably diagnosed the severity of dissociative symptoms and disorders. Fortunately, we now have various screening tools and diagnostic interviews that allow for early detection of dissociation, so that appropriate treatment can begin. The Structured Clinical Interview for DSM-IV Dissociative Disorders, (or SCID-D) (American Psychiatric Press, 1994) is considered the most comprehensive and rigorously evaluated diagnostic test for the identification of specific dissociative symptoms and the dissociative disorders. It is a series of standardized questions designed to help identify whether you are experiencing symptoms of dissociation and the dissociative disorders. Trained mental health professionals with a variety of backgrounds (including psychiatrists, psychologists and social worker) can administer the SCID-D. Depending on how you answer these questions, your therapist will tell you whether your symptoms are nothing to worry about or serious enough to merit professional help.

The five dissociative symptoms evaluated by the SCID-D include amnesia, depersonalization, derealization, identity confusion, and identity alteration. THE STRANGER IN THE MIRROR provides you with practical information about the five dissociative symptoms, and allows you to screen for their presence. Briefly, there are five main symptoms of dissociation evaluated by the SCID-D, and they occur along a spectrum (from mild or normal to severe):
  • Amnesia. This refers to gaps in the memory;
  • Depersonalization. This is the most common symptom of dissociation. In fact, the concept of depersonalization is captured in the title of my book, THE STRANGER IN THE MIRROR-you see yourself as a stranger and feel disconnected from yourself.
  • Derealization. This occurs when we feel disconnected from our surroundings, such as during moments of grief following the death of a loved one.
  • Identity confusion is when we feel as though there's a war inside of us about who we are.
  • Identity alteration is when we actually constructing different lives, either overtly or in a hidden fashion.

With the help of the SCID-D interview, therapists can now identify the five core dissociative symptoms (amnesia, depersonalization, derealization, identity confusion, and identity alteration) at the earliest stage so that effective treatment can begin. Mental health professionals throughout the United States and abroad have used the SCID-D and there are many scientific investigations describing its reliability and validity.

(For further information about these studies, see Resources for Professionals. For further information about the five dissociative disorders that can be assessed with the SCID-D, see Understanding the Dissociative Disorders. )

III. Finding a Qualified Provider
There are several options for locating a qualified provider. These include contacting family physicians, therapists, relatives or friends for possible referrals to professionals specializing in dissociative disorders. The Psychiatry and/or Psychology Department s of local hospitals and universities may have listings of professionals and their specialties, as well as mental health clinics. If you call a therapist who informs you that they do not specialize in the treatment of dissociation, ask them if they can recommend a colleague who does specialize in this area. Another resource is the International Society for the Study of Dissociation (ISSD), a nonprofit professional association that provides no-cost referrals. These mental health providers are listed geographically so you can obtain the name of those nearest you. The ISSD's telephone number is 847-480-0899 and their e-mail is: issd@issd.org. As the providers on their list are not screened by the ISSD, you might wish to consult more than one professional before choosing a therapist .

It is important to recognize that if you live in a large city, you may find numerous professionals who are experienced in DID treatment. On the other hand, if you live in an area that is remote, and lacks a professional who specializes in dissociation, you should not rule out commuting to someone who is qualified. Many people with dissociative disorders commute an average of one hour or more in order to obtain appropriate treatment , as I have seen with my own patients. I recommend that you select the therapist you feel is most qualified to help, rather than the one who is located closest to your home.

IV. The Initial Consultation: Questions to Ask
Once you have obtained the names of one or more therapists, you are ready to call for information about setting up an appointment for a consultation. Prior to your first visit, you will need to find out whether the therapist accepts your insurance and what the fee is for the session. Consulting with a provider can allow you to learn about the provider's experience and approach to treatment. While an initial consultation may include only one session, a more complete diagnostic evaluation and treatment plan may require several sessions, particularly if specialized testing, such as the SCID-D is conducted.

It is important that you find a therapist that you not only feel reasonably comfortable with, but one who is trained in working with people with dissociation. During your consultation session, don't be afraid to ask some of the following questions , as they can help you select an experienced therapist :
  • What training and credentials do you have?
    (Professionals licensed to practice psychotherapy include psychiatrists, psychologists, and social workers.)

  • How long have you been working with people who experience dissociative symptoms and disorders? What experiences do you have treating problems similar to yours?
    (If a person has recently begun to practice psychotherapy, you might ask if they regularly obtain supervision or consultations with a colleague.

  • Have you obtained any specialized training for the diagnosis or treatment of dissociative disorders? What type of specialized training have you had?
    (Specialized training includes reading books and publications focused on dissociative disorders, attending courses/workshops focused on the diagnosis and treatment of dissociative disorders, as well as supervision by an expert in the field. Experts have usually published many articles or books about diagnosis or treatment of dissociative disorders, have presented at many conferences, and have taught other professionals about the treatment of dissociation.)

  • What treatment approaches do you use in your treatment of dissociative symptoms? Do you believe you could help me? How would you begin the therapy process?
    (Individual therapy is the main treatment for dissociative disorders. The first phase of treatment entails accurate diagnosis is which allows the therapist to identify the specific dissociative symptoms that a person is experiencing. After the therapist has identified the dissociative symptoms, the therapy process can focus on helping the person to stabilize/reduce their symptoms so that he/she can function better personally and professionally. In addition to psychotherapy, medication can be useful in reducing a person's anxiety or depression associated with their dissociation. )

  • Do you advise people with dissociative disorders to use medications as part of their treatment? If you are seeing someone who is not a psychiatrist, you might wish to ask him or her if they work with anyone who prescribes medication.
    (While medication (including anti-anxiety and antidepressants) can be useful to help with coexisting anxiety or depression, it should always occur with psychotherapy. Medication can make the road less bumpy but the long term treatment/healing depends on specialized therapy.)

  • Are you familiar/experienced with the use of specialized screening and diagnostic tests for the dissociative disorders? If yes, which tests? (Screening tests include the Dissociative Experiences Scale and the Questionnaire of Dissociation. Screening tests do not allow for a definite diagnosis of a dissociative disorder. They allow a therapist to identify whether a person is experiencing dissociative symptoms. If you are experiencing dissociative symptoms, a definitive diagnosis of a dissociative disorder requires a more detailed clinical interview, or the use of a specialized diagnostic interview such as the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D).

  • Are you experienced in administering and interpreting the results of The Structured Clinical Interview for DSM-IV Dissociative Disorders, (or SCID-D)? If yes, what training have they had and how many times have they used this test?

    Professionals can obtain SCID-D training by reviewing THE INTERVIEWER'S GUIDE TO THE SCID-D (American Psychiatric Press, 1994) , reviewing audiotapes(see Resources for Professionals), obtaining supervision, and/or attending SCID-D workshops.)

  • Are you familiar with the treatment guidelines published by the International Society for the Study of Dissociation (ISSD)?
    (The ISSD publishes guidelines for mental health professionals working with people with dissociative disorders. Experts in the field have developed these guidelines.)

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        Disclaimer: This information is for educational purposes only. Dr. Steinberg is not responsible for the quality of the referrals given by any of the resources. Dr. Steinberg advises that you carefully evaluate the appropriateness of any referral and consult your doctor if you have questions about a medication or are experiencing side effects from your medication.

 
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