A Short Guide to People Who Can Help With Your Mental Health

[Written by an American. Generalities probably apply to Canada and UK, specifics certainly do not]

>Can prescribe medicine related to mental health concerns
In the U.S., virtually all psychiatrists do not do psychotherapy on a long term basis. They’re expensive, usually have long waiting lists—I’m told it’s something like an expected three month wait to see a psychiatrist in my city—and specialize in medication.

If you are making an appointment to see a psychiatrist, this is frequently considered evidence that you are looking for medication. This can cause weird misunderstandings when people think of a psychiatrist and a psychologist as identical and psychiatrists anticipate that people who come to see them are coming to see them for their specialty. Patients can (and do!) occasionally get the impression that they’re hopeless and must go on medication or that the entire mental health establishment is focused on pushing drugs.

Psychiatric Nurse Practitioner/Mental Health Nurse Practitioner
>Can prescribe medication related to mental health concerns.
I’ve only run across these in hospitals, but this article suggests they also operate in private practice. In my experience they do slightly more therapy than the psychiatrists I know and work with, though their primary focus does seem to be medication management.*

Clinical Psychologist
>Cannot prescribe medicine.
Has a Ph.D or a Psy.D. Worked a variety of successive internships to collect enough hours (1,500 to 6,000, varied by state) to become a licensed psychologist. Almost always have specialized training in administration of specific kinds of therapies, like Cognitive Behavioral Therapy or Motivational Interviewing.

My impression is that psychologists are low variance in terms of skill at administering one-to-one therapy and diagnostic work. They’ve all received lots of hours of practice before being licensed, and while there are many ways to be a clinical psychologist who does therapy, there aren’t as many ways as say, a social worker. Psychologists are also more likely to be able to sort out a diagnostic label, if that’s relevant or important for you. Others on this list could, but might not use diagnostic labels as frequently or be as comfortable getting a really specific, precise diagnosis.

Social Worker
>Cannot prescribe medicine.
Most social workers who are providing one-on-one therapy have a Master’s degree**. Social work is weird because the list of things a social worker could be doing as their job is…….very long.

  • being available to talk when someone is in hospice
  • working in school with kids who are struggling (behaviorally, emotionally, academically)
  • doing therapy in a standard couch + office + “and how does that make you feel” setting
  • investigating reports of abuse or neglect
  • coordinating other therapists and psychiatrists for clients
  • talking to people who recently were diagnosed with a terminal or chronic illness
  • helping people get into detox programs by making a lot of phone calls
  • doing assessments of children entering juvenile detention
  • helping new immigrants or refugees adapt and find services
  • going to people’s homes to assist with counseling
  • helping people deal with other bureaucracies
  • accompanying clients to appointments (such as Social Security offices)
  • leading groups (support, therapy, social skills, etc)

The main differences I notice between social workers and psychologists are:

Variance: social workers are high-variance; I happened to spend both of my training internships doing individual therapy and training in Cognitive Behavioral Therapy. It would have been equally possible for me to graduate having never done one-on-one therapy and without specialized training in a single modality.

Advocacy & Case Management: Part of the reason for the high-variance nature of training is that some social workers never particularly want to do one-on-one therapy. They might prefer ‘case-management’. Ever needed to figure out how to get into a treatment center and also have follow-up services when you left? A case manager might coordinate all the people at the treatment center plus follow-up appointments, plus check in on your progress. It’s always been an expected part of my non-case manager role that I do some of this. Sometimes therapy is put on hold to figure out how a client is getting treatment for their health concerns, or sorting out billing. This seems to be a cultural difference between social work and the rest of the list.

Mental Health Counselor
>Cannot prescribe medicine (seeing a theme, yeah?)
Like a social worker, has a master’s level degree, plus two more years of work in the field to get an independent (not-requiring supervision) license. I usually see the license called an LMHC or CMHC. Can do similar roles as any of the non-prescribers listed above. Less of an advocacy focus than social work.

Marriage and Family Therapist
>Cannot prescribe medicine.
Though all previous listed professionals could do couples’ counseling, this category specializes in it, and other family work. Master’s level degree plus two years of training to get a license for independent (non-supervised) work.

*Know more? Feel free to add in the comments.

**It’s possible to be a social worker with a Bachelor’s degree, but this generally involves more case management and very little direct therapy.  Except in my state, where you do not have to have a degree at all.

8 thoughts on “A Short Guide to People Who Can Help With Your Mental Health

  1. Anecdotally, three months sounds like a particularly long wait time to me (although not unheard of). In SF, I had to wait a few weeks to get an appointment with a good, popular psychiatrist (who does therapy, which, as you say, is unusual). People I know who got private psychiatrists in New Haven generally didn’t have to wait more than a month as long as they weren’t committed to seeing one particular psychiatrist. Maybe your city is particularly bad?

    It also might be worth mentioning that wait times can be much shorter in a time sensitive situation. I knew someone who set up an appointment with a psychiatrist within a few days several times in NYC because they needed a prescription renewed but didn’t have a local psychiatrist. They had to basically be willing to see anyone with space, though.

    It might be worth adding that general practitioners can prescribe psychotropic meds including antidepressants and antianxiety meds. I think a lot of people don’t realize this. This often isn’t the best option because they may know very little about mental health or about the meds they’re prescribing to you and may not be able to give you good advice. But you’re not going to get THAT much advice from the median psychiatrist who sees you once for intake and then every three months for a 10-15 minute medication management appointment. If you’re confident that you want a specific medication (e.g. you’ve been on it before and responded well; you’ve done a ton of research and know you want to try something basic) and don’t want therapy then this can be an option especially if wait times for a psychiatrist are real long.

    Costs obviously depend a lot on whether you have insurance and what your insurance is but I find that people often overestimate the cost of mental healthcare if they are insured so it might be worth advising people to look up their specific costs before assuming they can’t afford a psychiatrist. FWIW, I think my plan is good but not great and my 45 minute weekly appointments with my psychiatrist have a <$30 copay.

  2. Should a GP ever be considered for mental health issues, or is it more useful to go directly to someone in one of these categories?

    1. I think it’s definitely reasonable to start with a GP (especially when you live in a city with a long waitlist and it seems like fast is more relevant than getting Exactly The Right Thing).

      Things that seem to make GP best:
      1) you have a reasonably common concern like panic attacks, depression, anxiety [and are unlikely to be bipolar, docs are still concerned about ‘kindling’ where antidepressants exacerbate mania]
      2) You have a good sense of what you might like to try and what side effects you aren’t willing to tolerate or you have done some research. For instance, I cannot tolerate drugs that have a side effect of weight gain at all, so I tend to go in armed with a sense of what available drugs I’d be willing to try.

  3. How common is it for social workers who are practicing as therapists to a) primarily be trained in macro social work or case management; or b) prefer to be in a field other than therapy?

    1. I spent some time reading the Council of Social Work Education report and here’s some envelope calculations and information, though I don’t think it converges enough to completely answer your question. Of the social workers enrolled in 2013, it seemed like 80% were focused on clinical work or generalist practice, with the remaining 20% working in program development, management, etc. (source: page thirty one)

      According to from the National Association of Social Workers here, it seems like roughly two thirds are doing direct practice; which is something like therapy or brief counseling or group therapy. I would expect some of “direct practice” is like, having a single conversation with lots of different people about how they should use fewer drugs, and I know a good chunk of some direct practice locations is case management. It also seems as though about 25% are doing administration or case management.

      That being said, I’m not sure how to rectify the question of people who get a degree in clinical work but end up spending their degree’s internships doing all case management but go on to get a clinical job based on their degree; therefore becoming people I would describe as “being trained in case management”. (This is a common enough problem in my program, which is clinical-training only, but often places students in case management jobs, sometimes for both internships)

      I am also really not sure about B, but I suspect it’s uncommon, due to the preponderance of (1) case management jobs and (2) amount of work involved in billing and/or fee-for-service therapy work.

      1. Thanks, Kate! This was super helpful. I’ve always wondered about this and even if there’s no data that directly covers it, just your impression from your program is a big update.

        “I suspect it’s uncommon, due to the preponderance of (1) case management jobs and (2) amount of work involved in billing and/or fee-for-service therapy work.”
        -Do you have a sense for whether there’s a big salary difference between the two?

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