Challenges & Choices: Finding mental health services in Ontario
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The right help for you will depend on a number of factors, including:
- the mental health problem(s) you are facing
- the seriousness of the problem, and whether you need help for a short or long period
- your understanding of how to improve your state of mind
- what is available where you live and your ability to travel (e.g., in terms of cost and time), if there are no services close to your home
- your spiritual values and beliefs
- whether your therapist is able to respect personal characteristics, such as your age, gender, sexual orientation, religion, race, cultural and ethnic background, ability and income, and is able to respond to your needs
- the type of care that you feel most comfortable with.
- the language you speak, and your therapist's ability to communicate and work with you.
- whether you can afford to pay for therapy.
One type of treatment or one type of therapist may not always be able to provide you with everything you need. For instance, you may visit a spiritual adviser to talk about difficulties you are having. You may see a psychiatrist for a medication prescription. You may go to yoga or exercise classes to help you relax and feel less stressed. You may see a nutritionist to help you explore how various foods can influence your mood or thinking. Or you may find it useful to talk with your family doctor or a friend.
People go to psychotherapists to discuss the problems they have identified. They may get therapy one-on-one, as part of a couple, family or group. There is scientific research proving the effectiveness of both medication and psychotherapy to treat mental health problems, as well as proof of their effectiveness when used together.
Question: How do I know when a problem is serious enough that I should find professional help?
Answer: It depends on the person. Generally, people seek professional help when their problem is really interfering with their lives (e.g., relationships, work, school) and their ability to function and enjoy themselves.
Psychotherapists are mental health professionals who use "talking therapy" or counselling to help people with things such as self-esteem, changing beliefs and ways of thinking, communication and relationship skills and working through difficult issues from the past. People generally see psychotherapists when their problems affect their day-to-day living. These problems may be negatively influencing their work or school, their relationships and their ability to enjoy life. A psychotherapist can offer support, help you better understand your problems and help you learn new ways of coping.
If you're looking for a therapist, you can ask:
- your family doctor
- a nurse
- a community mental health worker
- a social work or outpatient psychiatric department of a hospital
- an employee (and family) assistance program through your work
- a religious or spiritual leader or organization
- a community information centre
- a social service agency (e.g., mental health association) or
- a self-help group.
Often the best way to find a therapist is to get a recommendation from a friend, family member or a health care provider whose opinion you respect. When you do get referrals, try to get more than one at a time, and get on several waiting lists, if necessary.
Question: How can talking to a therapist help me deal with my problems? Isn't it just as good to talk to a friend whom I already trust?
Answer: In some cases, speaking to a friend who will listen and be supportive may be enough. However, if your problem persists, it may be helpful to speak to someone who isn't connected to your life--someone who can offer a safe and neutral point of view. Therapists offer the advantage of being trained and having practice talking in ways that have proven helpful.
Don't be afraid to ask therapists questions to find out if you are comfortable with their style and approach. Below are some sample questions.
- What educational and professional training do you have?
- How many years of experience do you have working as a therapist?
- Do you have specific training or experience working with my particular issue (e.g., trauma, divorce, childhood sexual abuse)?
- What is your approach to therapy for my specific problem?
- Are you a member of an association or professional organization?
You may want to consider whether you want a therapist of the same gender, sexual orientation or ethnic background as you. There may also be other characteristics that you want your therapist to have in common with you, or to at least be sensitive to (e.g., issues of race, culture, age) or other factors that you see as important to your identity and way of viewing the world. As well, it's a good idea to find out how many sessions the therapist will provide and how much the therapy will cost. (See: How much will therapy cost?
Question: What if I'm not comfortable with my therapist or with how the therapy is working?
Answer: A trusting relationship between you and the therapist is key to successful therapy. If you are feeling uncomfortable with your therapist, it's possible that your personalities may not be the right fit. Or the therapist may be offering a form of therapy that is not useful to you. However, it's equally possible that your discomfort could be related to bringing a difficult issue out into the open or the anxiety of speaking to someone new.
To determine the source of your discomfort, it's important to discuss your concerns with your therapist. If you have had therapy before, it's also useful to tell your therapist what worked and what didn't work with other therapists. This will give your new therapist an idea of what you want from the therapy and if he or she can provide it.
But don't stick around in therapy if it's not working. You can fire your therapist! But if you do, make sure that there is someone else who will be able to see you. Your therapist may be able to refer you to another therapist.
Note: It is not ethical for a therapist to see you outside of therapy. It is not right for the therapist to be your friend or for you to end up giving therapy to the therapist! And it is WRONG for a therapist to make any type of sexual comments or to behave sexually. If you have any concerns about your therapist, call his or her governing or regulatory college and tell them what happened.
There are many different types of therapists who vary in the amount and type of training they've received. Following are some more common types.
Family doctors, or general practitioners (GPs), are often the first health care professionals someone will turn to when they have a mental health problem. A family doctor may prescribe medication, talk briefly to you about your concerns or refer you to a mental health specialist. Some general practitioners offer psychotherapy as a full-time practice.
General practitioners don't receive much psychotherapy training as part of their general medical degree. So it's important to ask them if they had additional training in psychotherapy after completing medical school. Therapy from a general practitioner or family doctor is covered by OHIP. Doctors who call themselves a "GP psychotherapist" have a special interest in psychotherapy. However, they aren't required to have additional training to be part of their professional organization, the GP Psychotherapy Association.
To find a family doctor in your area, you can call the Find a Doctor service available through the College of Physicians and Surgeons of Ontario at (416) 967-2626 in Toronto or toll-free at 1-800-268-7096. Or view their Web site at www.cpso.on.ca
To get a referral to a GP psychotherapist, please visit the GPPA's website at www.gppaonline.ca
Psychiatrists have a medical degree and five years of psychiatric training. Because psychiatrists are medical doctors, they are licensed to prescribe medication and provide psychotherapy. Their services are covered by OHIP. As medical doctors, they are more likely to identify connections between psychiatric and physical health problems. Some clients report that psychiatrists tend to be more focused on medication than on talking therapy--perhaps because of their medical training. However, some psychiatrists put emphasis on psychotherapy in their practice.
It is often very difficult to find a psychiatrist who is available to see you without a long wait, particularly if you live outside a large city. In fact, in some under-serviced communities, there may not be a psychiatrist on staff at the nearest hospital. These hospitals instead rely on visiting psychiatrists from larger cities or videoconferencing. Through videoconferencing, psychiatrists are able to assess and follow up with clients even though they are in different locations.
If psychiatrists are not available, psychiatric residents (medical doctors who are in training to become psychiatrists) may be available. Residents spend at least five years training to become a psychiatrist after they graduate from medical school. The work they do as psychotherapists is closely supervised by staff.
To find a psychiatrist in your area, you can call the Find a Doctor service listed above under Family doctors/General practitioners. You can also get a referral from your family doctor or visit an outpatient psychiatric clinic.
Psychologists have at least nine years of university education. They also have at least one year of supervised practice. To be able to register with the College of Psychologists of Ontario, psychologists must pass oral and written exams. They have a lot of training in doing assessments, which includes making diagnoses and providing therapy. Psychologists have a PhD or PsyD, but their fees are not covered by OHIP, and they cannot prescribe medication. However, the services they provide through hospitals, community agencies or private clinics or offices may be available without charge. Their fees may also be partly covered under extended health insurance plans, the Workplace Safety and Insurance Board (WSIB) or other private insurance programs.
To get a referral to a psychologist in your area, ask your family doctor or call the Ontario Psychological Association at (416) 961-0069 in Toronto or toll-free at 1-800-268-0069. The association will provide names of psychologists in private practice in your area. They can also provide details about the services they offer, the language they are offered in and the focus of their work (e.g., eating disorders, family violence, learning disability assessments).
Professionals from a variety of other fields (e.g., social work, nursing, occupational therapy) may also provide therapy. Depending on the field, their training may range from a diploma to a PhD. Many of these professionals supplement their education by taking extra courses and counselling training from universities or hospitals. Some take advantage of community-based workshops, training programs, seminars and conferences.
Social workers and nurses are particularly common in a psychiatric setting. They also tend to be available more often than doctors. Social workers are trained to focus on how a person's social environment affects his or her health. (By social environment, we're referring to a person's housing, family, work, financial situations, social supports, education, gender, etc.) (See: How much will therapy cost?
To get a referral to a social worker in private practice, you can call the Ontario Association of Social Workers at (416) 923-4848 in Toronto or view their Web site at www.oasw.org
. The association will try to match you with three social workers from the age group (e.g., child, adolescent), specialty (e.g., marital counselling) and language you desire.
Question: Is what I say to my therapist private and confidential?
Answer: Trust is the basis of a good relationship. Part of this trust involves knowing that what you say to your therapist will be kept between the two of you. Therapists must keep your information confidential. However, there are a few exceptions to the rule. If they suspect that you may seriously harm yourself or someone else, or in some court proceedings, they are obliged to report their suspicions. If, for instance, a health practitioner suspects that you have abused a child, they must contact the Children's Aid Society. If the client has a condition, including a mental health problem, that would make it dangerous for him or her to operate a motor vehicle, then a physician must report this to the Ministry of Transportation.
The courts can also subpoena your therapy records and your therapist's testimony under certain conditions, such as a sexual assault case. So it's a good idea to discuss with your therapist what he or she will include in your records, and how they will be kept.
Your therapist should explain confidentiality (privacy) issues with you at the beginning of the therapy.
Anyone can call themselves a psychotherapist and advertise their services, even if they don't have training. So it is important to find out what kind of experience the therapist has.
Non-licensed therapists do not belong to an organization that makes sure they're doing their job right. No one ensures that they are competent and ethical in their practices. And if clients have complaints, there is no one to handle them.
For more information about what to expect from your therapist, call his or her professional organization. This organization will have guidelines about supervision, training and ethics for its members. If you have a complaint about your therapist, call the governing or regulatory college to which he or she belongs.
Question: Are therapists available in the evenings or on weekends?
Answer: Therapists can sometimes see clients in the morning before they go to work or at the end of the work day. However, it's often hard to get these time slots because many people want to see their therapists outside of regular office hours. It's unusual for a therapist to see clients on the weekend.
Psychotherapy from a psychiatrist or any other medical doctor is covered by OHIP, and will thus not cost you anything. Services obtained from other health care professionals (e.g., psychologists, social workers) may also be free if they are offered in government-funded hospitals, clinics or agencies. If psychotherapists work in a private practice, their services will not be covered by OHIP, and you will be charged a fee. These fees range from about $40 to $180 per hour. However, the fee will vary depending on the therapist's experience and training and the type of therapy. (Group therapy may be less expensive.) Some therapists offer a sliding scale, which means that they can offer a reduced fee based on your income.
Fees may also be covered through an extended health care plan or private insurance. (You may have a benefits plan through your work.) Some of these plans may only cover services up to a certain amount and for certain types of therapists (e.g., psychologists but not social workers).
If you are working in a large organization, you may have access to an employee assistance program (EAP)--sometimes referred to as an employee and family assistance program (EFAP). (For more information about counselling services provided through EAPs and EFAPs, see Reducing job stress
If you are a student, counselling services will most likely be provided by your high school, college or university. Some communities also have free clinics, support groups and drop-in centres that offer counselling.
Challenge: Many free services have long waiting lists.
Suggestions: Use a free service, such as a distress line, or go to a drop-in centre that has free groups. Get on several waiting lists at once. Tell them that if someone cancels, you can be available at the last minute. Keep checking in to find out where you are on the list. If you no longer need the services, ask them to remove your name from the list.
Just like finding a therapist, choosing a type of therapy will be different for each person. It will depend on your problems, the approach you feel comfortable with and how long you want to be involved in therapy. Being a certain type of professional (e.g., social worker, psychiatrist) doesn't mean that the therapist will practise a certain type of therapy. In reality, many clinicians use a combination of different approaches.
Therapists' style will also vary. Some therapists will give you a lot of feedback about how they think you are doing and suggestions of what they think might help you. Other therapists will tend to be quieter during sessions, and will let you draw your own conclusions. You can tell therapists which approach you prefer, and ask them how they work. Therapists may be willing to adapt their style to suit your needs. If they can't, they may not be the right match for you.
Question: How will I know if and when therapy is working?
Answer: Most likely when you start therapy, you'll have certain goals or ideas of what you'd like to be different. If you find that you are meeting these goals over time, chances are the therapy is making a difference. It's important to understand that results don't necessarily happen overnight. In fact, sometimes you'll feel worse at the start as issues are brought to the surface.
If you don't know if you are making progress in therapy, you should discuss this with your therapist. You may want to schedule times to evaluate how things are going in the sessions.
Studies indicate that only 15 per cent of successful therapies happen because of the model or technique a therapist uses. The most important factor for successful therapy is the quality of the relationship between the therapist and client.
Therapy can be short- or long-term. Because resources are often limited, you're more likely to receive short-term therapy, and then be linked to other service providers in the community.
Brief therapy (e.g., solution-focused therapy), as its name implies, is a short-term therapy that often lasts between eight and 20 sessions. Short-term therapies are frequently used to deal with a specific problem, such as death, divorce, parenting issues or a specific phobia, rather than problems that have lasted for years. The sessions tend to focus more on current rather than childhood or other issues from the past. And the therapist generally takes an active role in guiding the discussions. Sometimes clients are given homework (e.g., exercises to help them cope with stress or anxiety between therapy sessions). Brief therapies are particularly helpful for depression and anxiety.
(e.g., psychodynamic psychotherapy, psychoanalysis) is less structured than brief therapy. The client has more flexibility to talk about a variety of concerns related to both past and present issues. The length of therapy is indefinite, and can last a year or longer.
Question: How long will I need therapy?
Answer: How often you will need to go to therapy depends on the nature of your problems. You may have a concern that can be addressed in a few sessions. Or you may have more complicated issues that require about 20 sessions. Some people get therapy off and on throughout their lives.
Therapy can be quite different depending on the kind of approach being used. Therapy may focus on changing clients' behaviours or their way of thinking about the world. It can focus on understanding difficult situations from the past. Or it can focus on expressing feelings that have come from old wounds, such as a history of abuse. Therapy can also be about supporting a client through a difficult time. Four of the most common forms of psychotherapy now being practised are cognitive-behavioural therapy, interpersonal therapy, psychodynamic therapy and supportive therapy.
Cognitive-behavioural therapy is considered by many experts to be the number one way to treat depression and anxiety. It focuses on helping clients become aware of how certain negative automatic thoughts, attitudes, expectations and beliefs contribute to feelings of sadness and anxiety. Clients learn how these thinking patterns, which may have been developed in the past to deal with difficult or painful experiences, can be identified and changed in their day-to-day lives to reduce unhappiness. They learn to have more control over their moods by having more control over the way they think.
Interpersonal therapy focuses on identifying and resolving problems in establishing and maintaining satisfying relationships. These problems may include dealing with loss, life changes, couple difficulties or conflicts, and increasing the client's ease in social situations.
Psychodynamic therapy involves exploring the client's beliefs and inner states, even when the client may not be completely conscious of them. Psychodynamic therapy assumes that because clients may not be aware of what is causing their unhappiness, the usual methods for finding relief (e.g., talking to friends or family, getting advice) may not be helping. The therapy instead focuses on finding the underlying problems that show up in various ways (e.g., difficulties at work, problems in a relationship).
Supportive therapy involves providing support and advice during a difficult period. This form of therapy can be short- or long-term. It focuses more on current problems rather than long-term difficulties. The overall goal is to reduce clients' discomfort level and help them cope with their current circumstances.
Individual vs. couple, family and group therapy
Whether you choose to see a therapist alone, with a partner, family member or as part of a group (with other participants you don't know) will depend on the kind of problem you want help with.
Family therapy is focused on changing the way families interact. It aims to increase understanding and improve communication among family members. It does so without placing blame on any one person. Family therapy is generally used when the family system is seen as contributing to one family member's difficulties (such as a child or adolescent's).
Or it is used when one family member's difficulties are influencing other family members, and they need help in how to cope and adjust to the situation. Both the "identified client" (the person identified as having the problem) and the other family member(s) can benefit from this kind of therapy.
If you are looking for a family therapist, contact the Ontario Association for Marriage and Family Therapy at (416) 364-2627 in Toronto or toll-free at 1-800-267-2638. You can also view their Web site at www.oamft.on.ca
Couple therapy helps couples to resolve problems and conflicts that they're unable to find solutions to on their own. Both partners sit down with the therapist and discuss their thoughts and feelings. This kind of therapy aims to help couples get to know themselves and each other better. If the couple wants to make changes, the therapist can help them do so.
If you are looking for a couple therapist, contact the Ontario Association for Marriage and Family Therapy at (416) 364-2627 in Toronto or toll-free at 1-800-267-2638. You can also view their Web site at www.oamft.on.ca
Group therapy allows people to work on their problems by interacting with others in a group setting. Participants share their thoughts and feelings and receive feedback, encouragement and support from other members. This process enables them to learn more about how others respond to them. They can also practise new behaviours in the safety of the group. Group therapy can be particularly helpful for people dealing with relationship problems or difficulties with intimacy, self-esteem or trust. Some groups discuss issues as they're raised at the weekly sessions. Others stick to an agenda.
Question: How long is each therapy session?
Answer: Individual sessions generally last between 20 to 50 minutes. Group sessions or family appointments can last longer.
Question: How do I know I am getting the best treatment?
Answer: Good treatment is often based on a proper assessment. (See Section 3: Getting an assessment, p. 21.) It also involves following clear goals you have discussed and decided on with your therapist. To reach your treatment goals, you need a therapist who has education and experience with your kinds of issues, and is someone whom you can trust and respect.
Challenges & Choices: Finding Mental Health Services in Ontario