My spouse and I had the good fortune to attend a portion of the New York City Fringe Festival in April of this year. We enjoyed many plays, ten in five days, as well as a plethora of authentic New York bagels. The plays were of varying quality, as one might expect from a Fringe Festival, and many of them included therapists as characters. This is a fraught situation for a person such as I who (as you, no doubt, have ascertained from my previous blogs) is quite critical of what is conveyed about mental health matters. I worry that audiences will witness inappropriate therapist behavior and begin to accept that behavior as typical of therapists—and thus make help-seekers vulnerable to professionally unacceptable and potentially harmful therapist actions. I also worry that, if audience members do recognize the professionally depicted therapist behavior as unacceptable, they may avoid needed help for fear they will encounter such behavior.
My concerns were lessened a bit by the first play, in which an unseen therapist was successful in helping a distressed young woman who finds solace from her troubles and self-doubts through regular infusions of junk food. Another play was a solo performance capturing the struggles and symptoms of bipolar disorder. The depiction of bipolar disorder was quite good, but the woman’s therapist did not measure up. In his initial meeting with his client, he demonstrated considerable insecurity and began by talking about himself rather than listening to his client. This is a major no-no for a therapist. I had to use great restraint to silence my groans, although I did indulge in some significant eyerolling. A third play focused on a young couple trying to decipher coded messages from a serial killer. The wife was said to be “a psychologist” (although there is also a reference to her not finishing college). She attempts to profile the killer, using astrological insights provided by a friend. Cue more eyerolling. I assure you that my training as a Clinical Psychologist never involved astrological considerations. (I have been forced to go to Astology.com on my own to learn about the “mutable fieriness” of my Sagittarian nature.) A fourth play involved a therapist (I believe he was called a “doctor”) conducting hypnotic inductions as part of therapy with a man who had attempted to kill a child, a therapist (Spoiler Alert) who turns out to be one of the attempted murderer’s alternative identities. A murderous therapist? Not an image to instill confidence—and not an accurate one.
In addition to my concerns about the influence of such portrayals on audience beliefs about therapist behavior, I started wondering, not for the first time, what people generally understand about the terms themselves–“therapist” or “psychologist” or even “doctor” and what those terms do and do not signify in the context of treatment of mental health conditions. I worry that limited understanding of what such terms do and do not indicate about background and training may undermine people’s ability to select appropriate providers for their needs. I thought, then, that I might try to clarify the therapist designations from the above plays.
Let me start with the broad term, “therapist.” Most “therapists” are credentialed/licensed under specific professional titles by the states in which they practice. Titles include psychiatrist, clinical psychologist, clinical social worker, marriage and family therapist, and licensed professional counselor, among others. Their licensure/certification typically requires specified (usually post-graduate) degrees (M.S., M.A., Ph.D., Psy.D., M.S.) from programs with appropriate curricula and training experiences that prepare trainees for work with people with mental health conditions. The title of “therapist,” however, is NOT a regulated term in most states (including Connecticut). What that means is that almost anyone can call themselves a “therapist” without any specific form of training or any licensure or certification by the state. (For more detailed information about mental health credentialing, you might wish to consult the following website: https://legalclarity.org/can-you-legally-be-an-unlicensed-therapist/).
“Psychologist” can also be a misleading term. Although many people automatically think of diagnosis and treatment when they hear someone designated as a psychologist, there are, in fact, many different kinds of psychologists, not all of whom are trained to address mental health conditions—or to be “therapists.” In fact, most psychologists are not. Developmental psychologists, for example, are concerned with how humans grow and develop throughout their lifespans. Social psychologists study the ways we are affected by others around us. Industrial/Organizational psychologists focus on human behavior in organizations and the workplace. The American Psychological Association has 54 Divisions representing different psychology specialties, and only a small number of them involve diagnosis and treatment of mental health conditions. When someone has a degree in “psychology,” even an advanced degree, it does not mean that that person is equipped/trained to provide therapy/treatment for mental health conditions.
The term “doctor” may seem clear enough, but, alas, it is not. Here, again, not every M.D. is fully trained to deal with mental health conditions. They may be surgeons, pulmonologists, cardiologists, and many other “ists” but not psychiatrists, who do have more extensive training in diagnosing and treating mental health conditions. Also, there are “doctors” other than M.D.’s. I am a “doctor,” for example, by virtue of having earned a Doctor of Philosophy (Ph.D.) degree, and I am addressed as “Dr. Wahl” in professional settings. The “doctor” in the Ph.D. designation, however, is a residual of its early use to identify people as general “scholars.” At the time I received my degree, for example, it was still required that one demonstrate scholarship by being able to read at least one foreign language. (Somehow, I did manage to meet that requirement, in French, although I have retained little of the language, apart from some choice curse words, basic travel inquiries (“Où sont les toilettes?”), and the suggestive title of a 1974 Labelle hit. [Here’s your Baby Boomer test/Google search for the day.] Although Ph.D.’s are granted in applied fields (e.g., Clinical Psychology), most Ph.D.’s are awarded in other academic fields where teaching and research are the main professional activities. A Ph.D. “doctor,” then, may or may not have any interest or training in the practice of therapy.
The point of all this is that people seeking mental health aid need to go beyond generic labels—therapist, psychologist, doctor—lest they end up being poorly served by people without adequate or appropriate training in mental health matters. Checking for appropriate licensure or certification is a good start. One might also consider the specific degree (and thus type of training) of the therapist. As noted, there are many different professions that are licensed/certified to offer mental health services; their training, however, is not the same. Clinical Psychologists are more likely to have had extended training focused on diagnosable mental health conditions than are Counseling Psychologists, whose training focus was more likely on what one prominent professional termed “problems in living.” Clinical Social Workers are likely to have more knowledge of community and organizational resources while Psychiatrists have more expertise in medicine and pharmacology. Level/length of training is something to consider as well. Doctoral degrees generally indicate more years of education and training, hopefully conferring a broader knowledge of mental health issues, metal health interventions, and relevant scientific findings. More time for knowledge accumulation may also permit more detailed consideration of ethics and law as related to mental health conditions.
Of course, the above are broad generalizations, and, as such, they do not capture the complexities of training and expertise differences—and overlaps–across the many mental health disciplines. It would take a much longer essay to do that. The generalizations offered also may be subject to some biases I bring as a Ph.D. Clinical Psychologist. (Shocking, I know.) I think, however, that my main point remains valid. Not all therapists’ training is the same, and their training affects what they can offer. I must acknowledge that some uncredentialed therapists may be quite skilled, that some credentialed therapists may perform their jobs poorly, and that extra years of training do not necessarily guarantee that a therapist will be “better” [whatever that means—something I may discuss in a future blog] than another therapist who earns a degree in fewer years. But it is a safer bet to go with “therapists” who have been thoroughly trained to deal with mental health conditions and whose training and readiness to practice therapy have been reviewed and approved by appropriate authorities. Good therapy is invaluable, and there are lots of good, thoroughly trained, state-certified therapists. However, we do need to be careful that non-specific designations, like “therapist,” do NOT lead us to inaccurate assumptions about the nature and extent of that provider’s training and expertise—and certainly NOT believe that Fringe Festival plays (and most other fictional works) are accurate in their portrayals of therapy and therapists, however entertaining they may be.
Otto Wahl, Ph.D.
MHCT Development Committee Member
