How to take the first steps of starting therapy, including finding a therapist, understanding how payment works, and knowing what to expect in sessions.
As both a provider and consumer of mental health therapy, I know that the decision to begin mental health therapy and face one’s problems head-on can be difficult and daunting. I also know, through the experience of myself and of many of my clients, that this decision is only the beginning of a long road filled with many obstacles on the way to getting good help. This has always been the case, as finding the right therapist can be a bit like blind dating, only more expensive and without the dinner. In the midst of this pandemic, however, the demand for therapy has gone up tremendously, while the number of therapists hasn’t exactly had a chance to catch up. Nowadays, it’s not just a matter of finding the right therapist, but finding a therapist who has availability. Other barriers to beginning therapy include cost; accessibility; stigma; and plain old lack of knowledge. I’m writing this guide with the hope that it can assist people who would like to start therapy but don’t know how, or who have been having trouble finding a therapist. I’ll cover payment for therapy; accessing therapy; finding a therapist; and picking a therapist.
Payment
Let’s start with paying for therapy. Therapy can be expensive, and attending weekly sessions adds up quickly. The first step you might want to take is looking for a therapist who is in-network with your insurance policy; finding such therapists is discussed further below. Seeing someone who’s covered by your insurance is often the most affordable option, but also limits the selection of therapists available to you, since many therapists choose not to accept insurance. If you see someone who is paneled (in-network) with your insurance company, you’ll be responsible for your copay, and may have to cover the first number of sessions fully if you have an applicable deductible. Once any deductible is met, the cost for you to attend a session is the price of your copay. It’s possible, though not typical, for insurance to limit the number of sessions available for coverage.
There are many therapists who compromise between accepting insurance and taking nothing at all by accepting out-of-network payment, which means they’re not paneled with your company but will work with you on submitting the necessary paperwork for reimbursement. If you have kick-ass insurance, your plan might cover out-of-network providers partially or fully, although it has been my experience that most insurance plans do not have this benefit. If yours does, and the therapist accepts it, you will pay your therapist upfront and the insurance company will reimburse you a certain percentage of the cost.
The final insurance option is called single-case agreement. This is when your insurance company doesn’t generally cover out-of-network, but your chosen therapist provides a service not offered by any in-network therapists. Sometimes, you can make a case to your insurance company to create an exception to their rule, and they will agree to cover this specific therapist for you. This is unlikely to work if you’re seeking therapy for something like anxiety in a metropolitan area, but if you’re looking to treat a less common diagnosis (such as selective mutism) in a less-saturated area, it’s definitely worth a try.
While many therapists accept in-network insurance, many do not, and these therapists will have a set rate for their sessions. Typical cost per session depends on a number of factors, such as where you’re located, the length of each session, and how long the therapist has been in practice. It’s not unusual for a therapist in New York City to charge $250 or more per session, while therapists in more rural communities might begin their rates at $60/session. Note that it’s always worth asking if the therapist offers a sliding fee scale if you can’t afford the cost of a weekly session.
Finally, if insurance isn’t an option and fees in your area are unaffordable for you, try searching Open Path, a website that features therapists who have agreed to see clients at the sliding fee scale of $30-$60 per individual session, or $30-$80 for family or couples sessions. You’ll be asked to pay a lifetime membership fee of $59 in order to access the Open Path directory of therapists, and then you can search by location, specialty, race, online therapy, and more.
Accessing Therapy
All of the above assumes you’re looking to see a therapist in a private practice, but that is not the only way to access individual therapy. It’s important to know the different options available to you.
1. Treatment Centers:
Mental health treatment centers can offer comprehensive services, usually with more affordable options. These can go by many names — agencies, clinics, outpatient treatment centers — but the general idea is the same: a one-stop shop for mental health services. Many will accept a wide array of insurances and offer sliding fee scales, and often have a full staff including prescribing clinicians, case workers, and a number of therapists with different specialties. They’ll often offer a variety of treatment forms, including individual, family, and group therapy. Sometimes these clinics are devoted to treating a specific population, such as LGBTQ+ individuals or survivors of domestic violence. Additionally, most universities have on-campus counseling centers for their students, which is included in the price of tuition. Treatment centers usually have an intake process, which might include a phone call conversation, or an intake session to assess your needs and goals for treatment. If no therapist is available right away to begin working with you, you may be placed on a waitlist until the next availability opens up.
2. Private/Group Practices:
These are the therapists who strike out on their own and either start their own practice, or join another therapist’s small practice. While some small group practices might have a prescribing clinician on staff, most will not. Therapists in private practice, in aggregate, tend to charge more per session than agencies do. The drawback of increased price can be balanced out by the increased likelihood that your therapist is highly-trained, well-established, or otherwise a well-regarded clinician who can take the risk of private practice because they have confidence about their ability to retain a steady caseload. As someone who worked for years in agencies, though, it is important to me to note that clinics and agencies do have excellent, devoted, and passionate therapists who choose to stay in those practices because of their dedication to increasing mental health accessibility to all socio-economic classes.
3. Online:
Pre-pandemic, online therapy was already becoming more common, and now, ads for services like BetterHelp and TalkSpace are everywhere (and now that I’ve written that, of course, even more ads for more services are popping up on my web browser). Therapy on these sites can range from video sessions to texting support, and while research is still underway to understand how online therapy compares to in-person, this option is clearly rising in popularity. During the pandemic, most therapists turned to telehealth to be able to continue providing therapy while maintaining physical distance, so video and phone call sessions are available with many private practice therapists these days as well. However, services like the ones mentioned above are entirely online, and offer a directory of therapists who exclusively work through virtual media. This option can be especially helpful for clients who live in more remote locations; travel frequently; or are simply more comfortable interfacing digitally.
4. Groups:
Group therapy can be useful as a stand-alone form of treatment or in conjunction with individual therapy. Groups are usually created for a specific population (individuals struggling with eating disorders, for example, or parents of children with developmental disorders) and can either be a therapist-led group or a peer-support group (see The CDS Clearinghouse for a directory of some of these). The former usually has a fee associated with it (far less than the price of an individual session), while the latter likely won’t. Like individual therapy, group therapy can have a range of formats, from highly structured with weekly homework to more free-flowing conversational support. Groups can be open-ended or have cycles with beginning and end points, and during the pandemic many are being held online.
A note about the actual physical accessing of therapy: Pre-pandemic, many therapists would never consider offering therapy over the phone or online. Now, however, many who have had to rely on these methods are choosing to continue offering it either to the exclusion of in-person therapy, or as an alternative option. From speaking with many therapists and clients about this, the preference for one form over another seems to be personal and widely variant. There are certainly benefits and drawbacks to each format.
Finding a Therapist
So how do you find yourself a therapist in any of those categories? Google will always have answers — but usually an overwhelming amount. Typing “mental health clinics near me” brought up 713 million results, which is just a few too many for me to sift through. Therapy is a personal process, and having someone recommended to you personally can be exceptionally helpful. Asking friends or family if they know of anyone who might be a good fit for you can be more valuable than any online search engine. Be aware that different therapists have different rules about seeing two different clients who are closely connected, so your sister’s therapist might be a great fit for you on paper, but they might not feel comfortable working with you. If you have any friends or family members who are themselves therapists — bingo! They’re likely to know the mental health landscape in their area fairly well, and have colleagues they respect and would recommend. They may also be willing to post in one of the many therapist listservs that exist to find a therapist who fits the description you’re looking for.
If you don’t feel comfortable asking your loved ones, another good resource is other professionals in your life. Many primary care physicians have working relationships with local therapists, and will keep a list of therapists to whom they feel comfortable referring their patients. If you have a religious or spiritual advisor in your life, like a rabbi or pastor, they can also be a valuable resource in finding a therapist.
Keep in mind that a therapist recommendation is not a guarantee. Just because someone works well for your friend does not mean they’ll work well for you; this is even more true when the person recommending the therapist hasn’t experienced them as a therapist firsthand. Ultimately, there’s no real way for me to know what it’s like to be the client of any of my colleagues, and trying out a therapist is the only foolproof way of finding one who fits.
Should you prefer to find a therapist through the reliable old Internet, the search engine that I most often recommend is PsychologyToday. PsychologyToday hosts an online directory of mental health providers that clients can search through using filters like location, gender, price, specialty, and insurance of providers. It is by no means a comprehensive directory, as there is a fee for providers to be listed, but putting in my zip code gives me 160 providers within one mile. Widening that to two miles adds on another 40 providers (to be fair, I live in a highly saturated therapist market, and I imagine zip codes in other states and areas will yield fewer results). The thing that makes PsychologyToday so user-friendly, in my opinion, is the headshot and bio that most providers choose to include on their respective page. This allows you to get a small feel for who you’re thinking of calling, rather than just the provider’s name and degree. PsychologyToday also includes agencies and group practices, as well as separate lists for psychiatrists and for support groups.
If you’re hoping to see a therapist through your insurance company, a comprehensive list of in-network providers is usually available on your insurance’s website. These do not usually include pictures or information about the therapist beyond name, degree, and contact information. Additionally, these lists are not always updated regularly, which can lead to therapists being listed even if they no longer accept that insurance, or long lists of therapists who do take that insurance but are not presently accepting new clients. Using your insurance panel’s list and cross-checking with PsychologyToday or even Google can be a fruitful, if time-consuming, method.
Picking a Therapist
Now that you have some names, how do you choose your new therapist? First and foremost is the importance of finding a therapist who “fits” you. Research shows that the rapport between a client and a therapist is the biggest predictor of success in treatment, and unfortunately that’s something that you can’t determine from reading your therapist’s bio online. You may need to try out a few therapists before finding your match.
Every client is looking for something different in a therapist, and not every therapist is the right fit for every client. This can be a personality clash, a style mismatch, or a cultural gap too large to cross. Too often, people stay with therapists who don’t fit them because it’s genuinely difficult to “fire” your therapist, or because they think that they as the client must be doing something wrong, or because searching for the right therapist is a legitimate pain in the ass. And while I have stayed with therapists for longer than I should have for all three of these reasons, I implore you not to make the same mistake. You will end up frustrated about wasted time and money and possibly even disillusioned about therapy as a whole. If you are finding that sessions are not helping you, or that you are uncomfortable with your therapist, let your therapist know that this is not the right fit for you. It’s not unlike breaking up with someone after a few unenjoyable but harmless dates. Ideally your mismatched therapist will understand and perhaps even help you find a better fit for you; if they respond in a way that invalidates your decision, that is on them. You are seeking therapy because you need help, and if your therapist isn’t helping, it’s your prerogative to find a new one.
Though comfort and rapport can only be found through trial and error, there are ways to narrow down the overwhelming selection of therapists near you. One such method is through identifying a therapist’s specialty. While all therapists are trained broadly in similar ways, many therapists end up specializing in a particular diagnosis or population. Most therapists will have dealt to some degree with the more common presenting problems — anxiety or depression — but if you are entering therapy with a specific target issue, make sure your chosen therapist has experience in that area. Someone who spends all day every day working with people processing grief is far more adept at handling the nuances of loss than someone who generally treats anxious teens.
Another way to distinguish one therapist from another is the treatment modality, or therapy approach, they use. Common modalities include Cognitive Behavior Therapy (CBT); psychodynamic therapy; Dialectical Behavior Therapy (DBT); and psychoanalytic therapy, to name just four of hundreds. Each approach has a different theoretical underpinning, and each directs the therapist to shape sessions in a certain way. Each one, too, has a different amount of evidence to support it. Some therapists are strict about using one modality; others consider themselves eclectic, and will use different modalities for different clients or diagnoses, or combine pieces of different modalities to create their own mix. Take a little bit of time and read about the different therapy approaches that you’re seeing online; see if any of them appeals to you more than others. If you are looking for someone to give you concrete coping skills for your anxiety and your therapist wants to spend every week talking about your childhood, you probably won’t find sessions helpful.
Looking at a list of therapists, wherever you’re looking, you’ll notice the alphabet-soup jumble of letters following each name. The various credentials represented by these letters indicate different graduate-level education degrees: PsyD, PhD, LCSW, LPC, LMHC, LMFT. I could go into the differences between each of these, but essentially your options are a Master’s level therapist or a Doctoral level; in order to provide clinical services, a provider must also be licensed or under the supervision of a licensed therapist. You may want to confirm that your therapist has a relevant degree and is licensed, or in the process of being licensed, though if you find them on PsychologyToday or through your insurance company, that step has already been done for you. Research shows little to no difference in outcome of therapy between the different credentials; once again, alliance between therapist and client is the biggest predictor of therapeutic success.
Once you’re in therapy, and the therapist fits, make your needs known. Once again, this is easier said than done; it took me about a decade of being in and out of therapy to feel fully comfortable letting my therapist know when she does something I don’t like. The inherent power dynamic in a therapeutic relationship, and our societal norms around confrontation, can make telling a therapist that they’re doing something unhelpful really uncomfortable. The idea that the therapist is the professional and must know what they’re doing makes it even harder. However, therapy is an intensely personal process, and what one client finds comforting might feel invasive to another; what your therapist intends as guidance might sound like criticism to you. The only way a therapist can know that is if you tell them, and if your therapist is more committed to helping you than being right, they will take your feedback with gratitude. If you tell a therapist that what they’re doing isn’t working for you, or you’d like more of something they’re already doing, and they can’t or won’t accommodate you, that might mean it’s time to move on. A therapist is trained for two to six years in therapy, but you’ve known yourself your whole life. Give yourself the credit of knowing what you need.
Finally (as if I couldn’t go on for pages longer), doing good therapy work ideally means ending at some point. It can be difficult to know when you’re ready to “graduate” from therapy, and one useful option is to step back slowly from the process instead of ending all at once. Pay attention to how you feel going into your regular sessions and use that to gauge if you’re ready to slow down. If sessions no longer feel as urgent as they did, or you find yourself looking for things to talk about, ask your therapist if you can move down to less-frequent sessions (every other week, or monthly) and check in with yourself and your therapist about how this new level of support feels for you. Once you do feel comfortable going without regular sessions, you can ask your therapist about scheduling a check-in session at some point in the future to make sure that you still have that avenue of support open to you, or taking a break instead of ending permanently. Most therapists will welcome you to return to work with them in the future should new issues present themselves; it’s also okay to decide that, after a break, you want to try a new therapist.
While these initial steps can be intimidating, the benefits of therapy can be literally life-changing, even life-saving. When it works well, therapy is the rare opportunity to have someone join you, with compassion and genuine care, in the places within you that feel too dark, confusing, or shameful to share with the people in your life. When we are seen and heard with empathy, we can begin to make the changes that have felt too overwhelming to attempt alone.
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