A guide to starting your mental health journey

I wanted to start seeing a therapist long before I finally did. For many years, my biggest obstacle was a near-total lack of free time, then a lack of insurance coverage for mental health care, then a range of positions that made seeking mental health care a professional liability. Even once I finally had a job with decent benefits and a list of therapists recommended by trusted friends, it took months to overcome another big obstacle to picking up the phone: my fear that during my first conversation with a prospective provider, I’d end up crying on the phone to a stranger. I’m not alone. In scientific studies, people who’d benefit from mental health care give rich and varied reasons for not seeking it, among them thinking it’s unnecessary, fear others will think less of them for getting it, and cost. At the same time, the US mental health care system isn’t structured to make treatment broadly available: Last year, 160 million Americans lived in areas with provider shortages and insurance denials, and in 2021, only one-third of people diagnosed with a behavioral health condition got the care they needed. Recent efforts to strengthen laws aimed at improving access might eventually help, but it’s not going to happen overnight. If you’re considering getting care for your mental health needs, just getting started can feel daunting, and the landscape of payment, providers, and your progress can feel like a minefield. It’s especially hard to begin if you embark on this journey when you’re at a low point. I speak from experience: I did wind up having the teary conversation I’d dreaded. But it turned out to be more clarifying than mortifying, and the therapist on the other end of the line was a keeper. People face a range of common obstacles when seeking mental health care. Here’s how to navigate a few of them. How do I start looking for help when I’m not sure what’s wrong with me? People across the spectrum of okayness access mental health care at different times in their lives, and there’s huge variation in what leads them to do so, says Megan Rochford, who oversees the National Alliance on Mental Illness’s (NAMI’s) national helpline. No matter your situation, keep in mind that you don’t need to know what you need to start getting care. If a sense of shame is keeping you from seeking mental health care, know that you’re not alone and help is out there, says Rochford. Calls to helplines like NAMI’s and the care that licensed professionals provide are confidential, she says, and their goal is to give you what you need to be your best and strongest self. Furthermore, getting mental health support might not look the way you imagine it: The vocabulary of modern mental health care goes beyond therapists’ couches and medications and includes options like community care models (including healing circles and peer support) that feel more welcoming for some people. Although the people you consult as you’re seeking care might be the experts on the resources available to you, you’re ultimately the expert on your own experience, and you get to decide what feels right for you, says Niya McCray-Brown, a licensed professional counselor who directs community engagement at the education and advocacy nonprofit Mental Health America (MHA). Some people find themselves seeking mental health care in a moment of crisis. For example, they’re losing control of their ability to work, go to school, or be present for loved ones, or are in danger of harming themselves or other people. In these cases, finding care is urgent — and it’s now a comparatively straightforward process, said Rochford: The 988 suicide and crisis lifeline, which rolled out nationally in July 2022, provides around-the-clock emotional support to people in distress and, if needed, connects people with services and facilities in their area. If you are in crisis, you can dial 988 from any phone, access the chat feature from the 988 website, or text MHA to the number 741741. For people who aren’t in crisis, the symptoms that lead them to seek mental health care may include both emotional and physical sensations. Many people seeking mental health care for the first time offer reasons including feeling particularly sad or overwhelmed, sensing constant worry, or being unable to turn off an internal voice, says Marnie Shanbhag, a psychologist based in Winter Park, Florida, who works for the American Psychological Association. Others report trouble concentrating, trouble sleeping, or low energy. People may also seek care to help change or get through specific moments in life, said Rochford. You might want to understand why you make certain choices or how to think through a problem you’re facing. Maybe you want help managing some unhealthy coping skills, like relying too much on alcohol or drugs, or working through some conflicts in a romantic or family relationship. Or perhaps you’re interested in seeing if you’d benefit from medication or getting a diagnosis. The toolkit for treating mental health concerns is large, and you don’t need to know exactly which tools you need in order to start getting care. However, it can be helpful to have an objective in mind, says Rochford: “Give some thought to what your goals are, and then give some thought to how to best go about meeting those needs,” she says. Websites like NAMI’s and MHA’s can help you put words to feelings or symptoms that are difficult to describe. There are also lots of mental health “warmlines,” free and confidential support lines that provide help over the phone: NAMI runs a national helpline, and many states run their own warmlines. These are different from hotlines like 988 in that they’re geared less toward supporting people through a crisis and more toward connecting people with resources for future care. These websites and helplines can also help you get oriented to the array of resources people with mental health concerns can access. Although many people may think of talk therapy and medications as the cornerstones of care, there are also self-help and support groups, peer support and other community care approaches, and a range of nonmedication treatments that can be helpful in lots of situations. For certain serious mental illnesses that are harder to treat, electroconvulsive therapy may play a role, and a range of psychedelic drugs are showing a lot of promise. If you’re not sure how to proceed even after some research, consider running your concerns past your primary care provider, says Rochford. “It can be very helpful to talk to somebody you trust who can kind of serve as a compass,” she says. Primary care providers likely know of mental health providers in your area, and can often start and manage medications for mental health complaints. Plus, it’s wise to rule out the possibility that a physical condition is contributing to your symptoms. Ultimately, mental health professionals are generally pretty comfortable helping you find the right place to start, even if it means connecting you to a different provider with the best expertise for your specific need, says Shanbhag. For more information about mental health diagnoses and types of treatment and support, check out: * MHA’s Common Treatment Types and Managing Expectations * NAMI’s list of support groups and community care organizations * NAMI’s Resource Directory, one of many resource lists on the organization’s website How do I pay for therapy and other mental health treatments? Cost is always a concern when accessing any kind of health care; mental health care is no exception. If you’re insured, look at your plan details (or call the 800 number on your insurance card) to figure out what kinds of treatment your insurer covers. There may be a deductible — that is, a portion of the cost that you pay regardless of the total cost — and that amount may vary quite a bit between plans. Some plans also fully cover a certain number of visits with a provider before you start paying out of pocket. The upshot is that there’s a ton of variation between plans, so if you’re insured, avoid surprises by checking with your insurer before seeking care. Many insurance plans have a network of providers whose services cost less to people in the plan than providers outside the network. Typically, these providers live in your state — although in the case of some online-only providers, they may live in another state but be licensed in yours. Many plans will pay some percentage of the total cost for providers in their network, and a lower percentage (or nothing) for providers out of network. Even if you do have insurance, getting your mental health care paid for is often different from getting physical health care paid for. Many therapists give you their bill directly, which you pay and then submit to your insurer for reimbursement. If you don’t have health insurance, you still have options. If you want therapy, paying full price out of pocket may be an option. It’s costly, typically ranging from $100 to $200 for a session. Some providers offer therapy on a sliding scale — which means lower costs for people with less ability to pay — so it’s worth asking. Additionally, many online-only providers provide services to people paying out of pocket (some also accept certain insurance plans). There are also low- and no-cost options, both for therapy and for other types of treatment. Rochford suggests looking for universities with graduate programs training people to provide psychotherapy; these often offer treatment for free. Additionally, self-help and support groups are typically free to attend. For more information on the financial side of mental health treatment, check out: * This article on NAMI’s website * MHA’s Paying for Care page How do I find a therapist? For many people with a mental health concern, psychotherapy — treatment that involves talking with a therapist to help identify and change bothersome feelings, thoughts, and behaviors — is part of the treatment plan. Looking for a therapist, though, can easily lead to more questions than answers: The acronyms describing different treatment approaches and skill sets may be confusing to people, and it might not be clear how to determine the cost-effectiveness of choices upfront. To start a search, it can be helpful to begin by considering your finances. If cost is a priority and you’re insured, it’s worth starting with the list of in-network providers your insurer maintains. You can search online for the names of individual providers to get some information about the populations and issues they typically focus on in their practice, or you can call individual providers to ask whether they have experience dealing with people whose concerns are similar to yours. Psychology Today maintains a large directory where therapists can pay to be listed alongside details about their practice, as do several other websites, or you can simply plug their name and “therapist” into a search engine. Among the lower-cost therapy options available for both insured and uninsured people are the mental health services many local health departments and community-based organizations may offer. For people of faith, clergypeople may serve as a good resource, and for children, check to see if a school guidance counselor can provide some help. Although some therapists see patients only in person or online, many offer both as an option. “The pandemic changed the way we thought about telehealth,” says Jeff Ashby, a psychologist and professor at Georgia State University who researches stress and trauma. “What we discovered — consistent with previous research — is that a whole lot of issues can be treated using telehealth.” There might be some small advantages to in-person therapy: It allows your therapist to read your body language, not just your facial expressions, and makes building a therapeutic relationship a little easier. In part for that reason, Catharina Chang, a professor and counselor at Georgia State University, recommends having at least one or two in-person sessions before switching to virtual interactions. But the best modality for accessing therapy really is the one that gets you the help you need. “The important thing is that you get help, and have a way you can get the help,” she says. If that means using a virtual-only platform, that’s fine! Lots of text-based therapy platforms have popped up in the past few years. Although these platforms offer what feels like an easy way to access support, experts advise approaching them with caution. State psychotherapist licensing boards, which accredit therapists based on their adherence to evidence-based best practices, haven’t approved text-based therapy, says McCray-Brown of MHA. “I would just caution folks to understand the implications of that, both in terms of the quality of service that they’re getting and what payment options are available to them,” she says. In other words, you’ll probably be paying out of pocket for text-based therapy — and there isn’t yet great evidence that it actually helps. For more tips on finding a therapist, check out: * NAMI’s Finding a Mental Health Professional page * This helpful guide from NPR Shots What do all the degrees and job titles mean? If you’re choosing a therapist from a list, the array of letters following providers’ names can feel dizzying. It’s wise to keep a few things in mind as you look at credentials. First, there’s a difference between therapists who’ve been licensed by the state or states they practice in and those who haven’t. Licensed providers have to complete thousands of hours of supervised training before hanging up a shingle, have been extensively trained in diagnosing and treating mental health disorders, and are bound to keep your information confidential by HIPAA laws and ethical standards. None of this is guaranteed with unlicensed providers. The experts I spoke with suggested that unless you’re receiving therapy from a clergyperson under the umbrella of pastoral care, seeking out licensed providers is the safest route. Second, the paths to becoming a licensed therapist include getting a master’s degree (in counseling, social work, or marriage and family therapy) or a doctoral degree (typically in psychology). They also include a minimum of two years of supervised experience providing therapy. Although the degree alone doesn’t convey much in the way of a therapist’s fit or even their experience, a few differences may be of interest to potential patients: * Psychologists (i.e., therapists with either a PhD in psychology or PsyD and at least three to five years of supervised experience) are trained in assessing a variety of mental disorders, which may be helpful for people seeking a diagnosis or treatment of a particular condition. * Clinical social workers (i.e., therapists with a master’s degree in social work and at least two years of supervised experience) have experience in managing stressors related to housing, employment, and other social issues. When these issues overlap with mental health concerns, a therapist with this training can function as a “one-stop shop” in many ways, says Mirean Coleman, who directs clinical practice at the National Association of Social Workers. * Licensed professional counselors (i.e., therapists with a master’s degree in counseling and at least two years of supervised experience) have training in diagnosis and can provide one-on-one and group counseling. Some have focused training in rehabilitation and school counseling. * Licensed marriage and family therapists (i.e., therapists with a master’s degree in counseling and at least two years of supervised experience) also have training in diagnosis, along with additional training in family systems and how close interpersonal relationships work. * Psychiatrists are medical doctors with training in diagnosing and treating many types of mental illness. They less commonly provide talk therapy nowadays, but unlike most other therapists, they can prescribe medication. Typically, if a therapist determines a patient would benefit from medication, they refer them to a psychiatrist (or a psychiatric nurse practitioner) to prescribe and manage the medication, and stay on as the provider of psychotherapy for the patient. So as long as your therapist has experience in the issue you need help with, it makes sense to put more weight into whether you “click” with the person you’re seeing and less into what letters they have following their name. Beyond differences in their degrees, there’s a ton of other variations among therapists: * Many develop expertise in working with certain populations — for example, older adults, or LGBTQ people. * Some get special training in caring for people with certain diagnoses or experiences (like obsessive-compulsive disorder, eating disorders, or trauma). * Different therapists often specialize in several of a variety of treatment methods, like cognitive behavioral therapy (used for a range of conditions, including depression, anxiety disorders, bipolar disorder, eating disorders, and schizophrenia), dialectical behavioral therapy (a frequent treatment for borderline personality disorder), acceptance and commitment therapy (also used for a broad range of conditions, including obsessive-compulsive, eating, and substance use disorders), and eye movement desensitization reprocessing therapy (often used for treating post-traumatic stress disorders). It’s not uncommon for people with certain identities — like those with certain racial, ethnic, religious, gender, or sexuality affiliations — to seek out therapists who share that identity. “It’s natural, healthy, and valid that folks want to work with a clinician or work with a mental health care worker that has a similar experience to them,” says McCray-Brown of MHA. That doesn’t mean that a mismatch is a bad thing. In fact, says McCray-Brown, “you might be able to find a sense of confidence and empowerment in educating others about your experience.” Additionally, good providers should have enough cultural humility to validate the experiences you bring to the table as part of your identity. For people who prefer to see a therapist with some cultural overlap but are struggling to find one, it’s reasonable to prioritize seeing someone who otherwise has the skills and fit that works for you rather than waiting. Don’t let perfect be the enemy of the good here — but at the same time, don’t hesitate to ask for changes if your experience isn’t affirmed and validated, says McCray-Brown. For more information on types of mental health professionals, check out: * MHA’s Finding the Right Clinical Mental Health Care For You How do I decide if a therapist is the right one for me — and can I fire them if they’re not? The fit between a patient and their therapist is the most important thing in determining whether therapy will be productive, says Ashby. But it can be difficult to predict what kind of person you’ll click with in therapy. “Think about it as shopping,” he says. “There may be really talented therapists for whom you’re not a good fit,” and if that only becomes clear after you’ve been seeing them a while, you’re still absolutely within your rights — and not in violation of any norms — to move on to someone who’s a better fit. “Good therapists only want to work with clients who are good matches because no one wants to be unsuccessful,” says Ashby. As you start looking for a therapist, it’s key to remember that therapists are aware of the importance of fit between themselves and their clients, and they’ll know it’s totally normal for you to talk to a few people before settling on someone to work with. You shouldn’t be getting a hard sell from a therapist: Instead, you should get a clear sense that they’re well-qualified and open to working with you, but that it’s your choice to work with them. McCray-Brown suggests asking prospective therapists for a 10- or 15-minute consultation call to get to know them and their practice. Questions that can help you get a feel for how you might work together include: * What types of clients have you worked with before? * Have you ever talked to somebody who’s dealing with the things I’m dealing with? * What type of approach do you use in your therapy? * How often will we be meeting? * How long are individual therapy sessions? * How would you handle it if I had a crisis? * How long does treatment for a condition like mine typically take? For help finding local providers, have a look at: * MHA’s guidance on finding a therapist. How will I know when I’ve gotten everything I can out of therapy or other mental health treatment? Getting therapy for mental health problems can be uncomfortable even when things are going well. Chang, of Georgia State University, suggests checking in with yourself after the first visit to determine if the fit is right. She recommends asking yourself if you felt heard, if the therapist seems like someone you can open up to, and if you were encouraged to talk about the goals and outcomes you want out of counseling. As psychiatrist Richard A. Friedman recently wrote in the Atlantic, most types of mental health therapy — and many mental health medications — have a common goal: “to eventually end treatment because you feel and function well enough to thrive on your own.” While some people with chronic conditions may need pharmacotherapy and individual or group support indefinitely, the majority of people who seek mental health care should consider it to be something they will eventually no longer need, or need only sporadically. The duration of therapy — and other types of mental health care — varies among people and conditions. Sometimes, a few sessions fix whatever was wrong, but more often, therapy uncovers the tip of an iceberg, says Ashby. Sure, you might “hassle around and finally find somebody and see somebody for two or six sessions and say, ‘I think I got it, I think these are the aches and pains of life,’” and feel like you’ve got it sorted out, he says. But more commonly, people have been spending a lot of emotional energy holding issues at bay by the time they finally seek treatment for a mental health concern, and it takes time to unpack things. Even then, writes Friedman, therapy typically lasts a few years at most, not indefinitely. Rochford suggests talking to your provider early on about what it will look like when you’ve reached your goals. Then, as you work together to figure out what you need, you’ll both know what an endpoint might look like. Some people may be ready for a deep dive into something that’s been impairing their function, like a history of trauma and a current major depressive disorder, says Rochford. Others might just want a few months of work on reducing burnout, setting better boundaries, or having a stronger relationship. The goals of mental health care look different for different people, she says: “You’re the expert on what you need, what’s going to work best for you, what you’re ready for.”