Burns, emotional scars linger long after the body has healed.

It was late, almost midnight, a few nights before Thanksgiving. Heather Whiles, then 20, home for the holiday from Columbia University, was cruising down Route 125 on her way from North Andover to Boston to see a friend.

She was sober, but tired, and fell asleep at the wheel.

The rest is a blur. She hit an embankment, uprooted a tree, then passed out when her car burst into flames. Two young men joyriding in a truck stopped to help, as car windows popped and gas sprayed everywhere. “They woke me up by screaming,” she says. “I crawled out a window.”

Burned over 70 percent of her body, she remembers nothing of the helicopter flight to Brigham and Women’s Hospital. Or of the pain and terror that doctors could control only by keeping her heavily sedated in a semi-sleep state for two months. Or of the surgeries every few days to strip away burned skin and cover her wounds with grafts and artificial skin. Or of the six weeks she stayed at Braintree Hospital to work with its burn rehabilitation team.

Today, she looks good – pretty, in fact. She wears a wig to hide the burns on her scalp and a full-body custom-made pressure garment – under her clothes – to keep scarring and itching to a minimum as she heals. She still faces two more years of reconstructive surgery.

Yet she feels her trauma “has made me amazingly strong.” In fact, she wants to go to medical school and become a burn surgeon.

“There’s a million tragedies in the world,” she says with conviction, “and only two ways to handle them: ‘Oh, woe is me, how can I have such bad luck!’ Or to be empowered.”

Empowering people like Whiles who in years past might have died from their injuries is now the cutting edge in burn care.

A half-century ago, in the Coconut Grove fire that killed 492 people, only one man survived with burns over 20 percent of his body, notes Dr. Colleen Ryan, a burn surgeon at Massachusetts General Hospital and the Shriners Burns Institute.

By the 1970s, doctors were saving half of patients with 30 percent burns, according to national figures. Today, half of all people burned over 70 percent of the body survive. And in burn centers, the survival rate, regardless of the depth or percent of body surface area burned, is as high as 94 percent.

The other good news is that fewer people – 1.25 million a year, down from 2 million annually two decades ago – are getting burned these days, thanks to smoke detectors, nonflammable clothing and better occupational safety standards, says Peter A. Brigham, president of the Burn Foundation in Philadelphia.

But along with the remarkable medical progress – much of it attributable to more aggressive surgery to remove burned skin, better skin grafting and earlier use of ventilators to protect damaged lungs – has come a huge, unexpected challenge: How to heal devastated psyches that are often as seared as the skin.

“People who would have died 10 years ago are now being saved,” says Marion Doctor, a clinical social worker at Children’s Hospital in Denver. This means burn teams now have the moral responsibility “not just to save their lives but to offer assistance in getting on with their lives.”

In the past, says Dr. Bob Demling, director of the Brigham and Women’s burn center, “our ability to save lives has exceeded our ability to return to society these individuals as functional, confident human beings.”

But increasingly, mental health specialists are finding ways to help people put their souls back together as their bodies heal, a process that, Demling says, has “very predictable phases, including denial, dependence and hostility.”

Some of the steps in this process are specific to people with disfiguring injuries, burn researchers find, but some are applicable to anyone with a major trauma, whether it’s visible to the world or not.

Dr. Patricia N. Watkins, a psychiatric consultant to the Columbia Augusta Medical Center in Georgia, has identified seven stages that burn patients go through, sometimes over and over.

The first is the “Will I live?” question. It hits people as soon as they become conscious of their injuries. While family members may quickly grasp that an injury is survivable, it often takes longer for the badly burned patient to believe that’s possible.

The next hurdle is believing pain will be controlled. Burn treatment often involves daily cleaning of raw wounds to prevent infection, a process that can be so painful that patients can get trapped in a vicious cycle of pain and fear.

“Anxiety drops dramatically” with good pain medication and psychological support, says Demling, at Brigham and Women’s. The key, he adds, is for burn teams to “break through that barrier of insecurity and anxiety and free up the ability of the patient to actively participate in rehabilitation.”

The challenge then becomes to find meaning in the tragedy.

Curiously, guilt, or at least taking responsibility if the accident was in some way caused by the patient, can help, says Watkins. In fact, the people who often have the toughest time making sense of their trauma are those who were simply victims of bad luck, being in the wrong place at the wrong time.

And while many people suffer because they think their injury must be punishment for some wrongdoing, says Watkins, people also get burned for doing something right – like saving the lives of others – and they, too, may have trouble making sense of it all.

Watkins recalls one woman who was burned over 20 percent of her body when she went into a burning building to try to rescue her father, after she had rescued her kids. “She was sitting there crying, saying, ‘What did I do wrong that I got hurt and he died?’ “

Finding an emotionally comprehensible explanation for the burn is crucial, Watkins adds. Without it, a person may develop post traumatic stress disorder, the way combat veterans and rape victims sometimes do. With an explanation that helps them come to terms with their injury, people are freer to participate in and take pride in their own rehabilitation, even simple accomplishments like enduring the pain of taking a shower.

With each step forward, though, comes a more realistic recognition of the losses, even with burns that are not normally visible to others, says David Chedekel, a psychologist at the Shriners Institute. In fact, recent research suggests that burns “that are not visible can cause as much distress as others,” he says.

Dealing with these losses – including the death of other people in the same accident – can often be accomplished by letting people talk and byproviding a safe place “to express the pain, the anger, the fear,” says James Beauregard, a clinical neuropsychologist at Braintree Hospital, which has one of the nation’s leading burn rehabilition programs.

Because severely burned people may go through dozens of surgeries to close wounds and reconstruct damaged tissue, psychological healing is often a two-steps-forward-one-step-back process as the medical interventions continue.

“Just getting through all the surgeries requires an immense amount of fortitute,” says Demling. “You have to want to get better at the price of looking worse temporarily. That is a real challenge, both physically and psychologically.”

The final emotional step is often the question of identity: Can I be the same person as before? This can be a tough one, especially for young people whose scars are impossible to hide.

But a number of things can help. For Heather Whiles, it was the gift of friendship from Jessica Cirrone, a 23-year old Framingham woman who is also recovering from a bad burn. Both women say that talking together, as well as visiting patients at earlier steps in the recovery process, has been very helpful.

Mental health specialists are also finding ways to help people with bad burns ease back into society. With small children, for instance, some burn centers send teams to their schools to prepare classmates for the return of the burned child.

Others gain confidence in camps for burned children, like those started by Marion Doctor in Colorado in the 1980s.

But whether you’re 8 or 80, re-entry is never easy in a society that puts great emphasis on looks. “One day you don’t have burns, the next day, you do, and you are scarred and disfigured,” says Doctor. “You have to adjust to the non-burned world.”

The miracle is that so many people do. Burn surgeon Ryan has watched in awe as former patients “go back to work and life. People have an innate courage in facing this adversity. It does come out in some people. They do remarkably well.”

“Nobody really knows how the mind works with tragedy,” adds Demling, the Brigham surgeon. “But it is clear that psychological trauma must be treated as aggressively as bodily injury, and with the same level of sophistication. You must deal with both.”

Heather Whiles, he says, has been “very motivated. But if we hadn’t paid attention to the psychiatric impact of this burn, she would have had a harder time getting to the positive point where she is. You see Heather and you see the work of a lot of professionals to bring the true Heather out.”

Whiles herself credits the nurses and other burn team members who have helped her, but also says that ultimately, recovery “is completely internal. You have to reach down and pull yourself up by your bootstraps.”

And she is convinced she will. “Some people talk about how cruel people are to you. But I think you only open yourself up to as much cruelty as you accept.

“I have shown people my back, my head, my hands. Human nature is wonderfully compassionate, but you have to give people a chance.”

Music fills the days at the John Eliot Elementary School in Needham.

When recess is over a teacher may put something soothing on the classroom CD or tape player, perhaps a Baroque piece whose steady rhythm evokes the 60 beats a minute of a heart at peace.

When kids study the solar system and make splatter paintings of the heavens, they listen to “The Planets” by Gustav Holst.

When they study the Colonial period, they write their own songs about the Boston Tea Party, says principal Miriam Kronish, who is also a musician.

And when they take the state MEAP exams in reading, science, social studies and math, these music-drenched kids soar like the voice of soprano Kiri Te Kanawa. The highest possible score on those tests is 1,600; on the latest tests, no child from the John Eliot scored less than 1,570.

This virtuoso performance fits with other data showing that older kids who’ve studied music – or the arts in general – score higher than average on both the verbal and math parts of the SATs, according to the College Board, sponsor of the tests.

Is there really a connection between the magic of music and the way the brain develops?  There appears to be, says a growing chorus of neuroscientists and psychologists.

Music, of course, should be enjoyed for its own sake, not for whatever it may do for brain cells. But there is compelling evidence that making and listening to music, starting as early as possible, may also build brain power.

In fact, some researchers now speculate that early exposure to music may help preserve some of the millions of brain cells a baby is born with that might be lost if they were not used.

“Music is as much a part of the human condition as language – we are born with the machinery to make and appreciate it,” says Dr. Mark Tramo, a Harvard Medical School neuroscientist. “It’s all there. All we have to do is turn it on.”

By the time a baby is born, the cochlea, part of the inner ear, is already equipped with a rubber-band-like membrane that can vibrate in response to sound waves.

Sound waves, which consist of air molecules vibrating at different frequencies, are created all the time – whenever a car screeches, a steak sizzles or a violinist plays an “A.” The “amazing” thing, says Tramo, is that specific sets of nerve cells respond to specific frequencies. For instance, some nerves respond to the middle A on the piano, which vibrates at 440 Hertz, or 440 cycles per second. Other nerves respond to middle C, about 262 Hertz.

“The miracle is that the physics of the sound vibration and the physiology of the ear and brain match so well. We’re born ready to hear – and love – music,” he says.

Babies as young as four months old appear already capable of understanding musical structure, according to a series of ingenious experiments by psychologist Carol Krumhansl of Cornell University and others.

In a typical experiment, the baby is placed in a dark room. When a light goes on, the baby turns her head toward it. As soon as she does, music comes on and stays on until she turns her head away.

Babies quickly learn, says Krumhansl, that the music plays only when they are looking at the light. Once the infants make the connection, the researchers play minuets by Mozart. Sometimes, they are played just as Mozart wrote them. Other times, they are played with long pauses between notes, a disruption that “sounds terrible” to adults, Krumhansl laughs.

The babies think so, too. When Mozart is played right, babies look at the light for long periods. When the musical structure is broken up, they look away. Stanford researchers have documented the same effect with Bartok and Bach.

“Babies are born with a sense of music,” Krumhansl says, adding that studies suggest that even young babies know a cadence – a set of chord patterns that often signals the end of a piece – when they hear one. And they prefer consonant music, with its pleasant-sounding chords, to dissonance, which often sounds harsh or out of tune.

Furthermore, it is becoming clear that specific types of music training can enhance certain intellectual skills, say Frances H. Rauscher, a psychologist at the University of Wisconsin, and Gordon Shaw, a physicist at the University of California at Irvine.

In their latest study, published in February, Rauscher, Shaw and their team took 78 three- and four-year-olds from working-class families and divided them into four groups. One group had six months of private piano lessons; another got computer lessons, a third, singing lessons and the fourth, no training. Unlike the kids who learned piano, Rauscher notes, those given singing lessons were taught little about musical concepts.

By the end of the study, the piano students scored 34 percent higher than the others on a test of spatial-temporal reasoning – putting a puzzle together to gauge their ability to process information in sequence and space.

 “It’s a very definite, causal thing,” says Shaw. “You use large parts of the brain when you’re doing anything at a high level, like processing music.”

Rausher and Shaw also documented the “Mozart effect” in college students. Several years ago, they found that just listening to the complexities of Mozart’s piano sonatas increased scores on temporal-spatial reasoning tests, while listening to relaxation tapes or music by Philip Glass, which is more hypnotic, did not.

But in the college-age kids, the “Mozart effect” lasted only about 15 minutes, notes Rauscher, while the brain-boosting effect of piano lessons for little kids seems to last at least a week.

There is also growing evidence of a “critical period” – roughly the first seven years of life – during which music training is most likely to help brain development, says Dr. Gottfried Schlaug, a neurologist at Beth Israel Deaconess Medical Center.

In one study of right-handed musicians, Schlaug used modern imaging techniques like MRI to examine the corpus callosum, the structure that links the two halves of the brain. To play an instrument that involves both hands, such as the piano, a person must transfer information quickly from one side of the brain to the other.

Schlaug found that in musicians who started playing before age 7, the corpus callosum is bigger than in those who started after age 7.

In another study of pianists, Schlaug found that the motor cortex – the part of the brain that controls movement, including movement of fingers – was more symmetrical in those who started playing before age 7 than in those who started later.

All the musicians were right-handed, which means that researchers expected the left side of the motor cortex to be well-developed because the right side of the body is controlled by the left half of the brain, and vice versa.

Surprisingly, among musicians the right side of the motor cortex was equally strong, especially among those who started early. Most likely, this is because, as kids, these musicians used the fingers on their left hands so much.

A German study of right-handed musicians who play string instruments – and use the fingers on their left hands to press on the strings – bolsters this idea. In the right motor cortex, the spaces between areas that control the thumb and pinky were wider apart than normal, especially among those who started playing early.

Perfect or absolute pitch – the ability to identify one tone without reference to others – may also be honed early. Chances are, Schlaug says, that “if you don’t get exposed to music before age 7, you don’t have it.”

So what can you do to keep kids’ music neurons humming?

“It’s use it or lose it,” says Tramo. “If you want to maximize your children’s intellect, give them music lessons.”

That philosophy underlies Harvard’s Project Zero program, led by neuropsychologist Howard Gardner, who has long believed that music is one of the basic forms of intelligence.

You can also fight for arts programs in schools and communities. Budget cutters often see the arts as frills, says Jim Simpson, executive director at the South Shore Conservatory, which teaches 2,000 kids a year in Hingham and Duxbury. But the arts “are not an adjunct,” he says. “They are an important intellectual development area.”

The bottom line, says Schlaug, is that “any kind of music, either listening or practicing, is able to shape the structure and function of the brain. So anything you can do to enhance a child’s attraction to music will help.”

 

For people with no symptoms routine screening can have a downside.

A little over a week ago, a group of cancer gurus, having pondered 40 studies on the potential value of screening men for prostate cancer, ended up much like a hung jury.

The preponderance of the evidence, they concluded, simply did not show, as many had hoped, that the benefits of testing every man over 50 for prostate cancer outweighed the risks.

There are possible, though unproven, benefits to catching cancer early. But these potential benefits don’t outweigh a more clear and present problem – that worrisome results on screening tests set men up for yet more testing, often followed by surgery and radiation that can lead to impotence and incontinence.

If these risks scare you more than cancer – which might not kill you for years – you may want to skip this test, the doctors suggest.

In January, a panel convened by the National Institutes of Health slogged through 100 studies and came to a similarly dreary conclusion about mammograms for women between 40 and 49.

Mammograms clearly save lives for women over 50. But 98.5 percent of women who get annual mammograms in their 40s get no benefit, says biostatistician Donald Berry of Duke University, a member of the panel. The others do benefit some – gaining on average 200 extra days of life, he says.

Like the men who go through invasive testing after prostate screening, many women with suspicious mammograms find out they’re okay only after more tests and often, surgery.

Now, if you happen to be the one whose life is saved by screening, you’re undoubtedly a true believer. And some medical groups, including the American Cancer Society, agree, reasoning that it’s often better to know what’s going on sooner rather than later. This may be especially true for people at high risk of a disease.

But for people at normal risk, faith in testing is coming under attack as evidence for the downside of screening grows.

“The problem with screening is that it can put you on a slippery slope. And if you know enough about that slippery slope in advance, you may not want to walk out on it,” says Dr. Harold Sox, chairman of the department of medicine at Dartmouth Medical School and president-elect of the American College of Physicians.

“Every screening test will have its downside, not only because of the potential risks of the diagnostic workup plus the therapy, but because it will flag many people as abnormal who don’t have cancer,” adds Dr. Barry Kramer, deputy director of cancer prevention and control at the National Cancer Institute.

The dilemma in screening huge numbers of asymptomatic people boils down to a deceptively simple question – is it worth it?

If the screening test is for a disease for which there is a treatment that clearly works without causing too many side effects, it probably is. If there is no treatment that prolongs life significantly, or if the treatment causes harm, it may not be.

Complicating this are other knotty issues – like whether catching something early really leads to more years of life or just more years of knowing you have the disease – the so-called “lead time bias” question.

Often, the decision to be screened “depends on subjective responses that vary enormously from one person to another,” says Dr. Albert Mulley, chief of general medicine at Massachusetts General Hospital.

Many women in their 40s swear by mammograms for the reassurance value – even though in this age group they miss up to 25 percent of invasive cancers. (Among older women, mammograms miss only about 10 percent.)

On the other hand, many men – half, in Mulley’s experience – respond with a firm “No thanks” when told about the tests and treatments that can follow screening with a digital rectal exam or a blood test for PSA (prostate specific antigen).

But it’s not just personal factors like family history or fears of a particular disease that make these decisions so hard.

It’s that, with depressing regularity, different panels of experts look at the same data and come to opposite conclusions.

Sometimes, of course, the data do finally line up one way or the other. Though cholesterol screening has been controversial, many people are tested regularly, believing that if their cholesterol is too high and they lower it, they can reduce their heart attack risk.

The data that clinched the case, the so-called West of Scotland study, came only about a year ago, says Dr. Daniel Levy, director of the Framingham Heart Study. The study showed that, at least among middle- aged men, lowering cholesterol with medication reduces the risk of a first heart attack. In this case, screening clearly pays off.

But many screening decisions aren’t so simple when you look at the evidence on treatments, the quality of the studies, and how much doctors’ groups vary in the criteria they say a test must meet to be worthwhile.

For instance:

Prostate cancer. The American College of Physicians, after examining 40 studies, concluded the decision to screen should be up to each man and his doctor. It’s a tough call because many tumors grow so slowly that men die of something else and because of the harm that can follow a suspicious screening test.

Younger men (between 50 and 69) may benefit more than older men because they have more years of life at stake. But even for them, screening yields on average only two extra weeks of life.

But the American Urological Association does recommend annual PSA and digital exams beginning at 50 for most men, and at 40 for African Americans and men with a family history of prostate cancer. The American Cancer Society recommends an annual digital exam and PSA test beginning at 50 for men with at least a 10-year life expectancy and for younger men at high risk. But the society is considering changes in this recommendation.

And a government-funded panel, the US Preventive Services Task Force, which painstakingly reviewed the data on dozens of screening tests about a year ago, gives a “D” to both these tests, meaning there is fair evidence to recommend against them.

Colorectal cancer. In general, the evidence for screening is good and growing. One test, which examines stool specimens for blood, seems to reduce the risk of death from colorectal cancer by a third, says Dr. David Atkins, senior health policy analyst at the Agency for Health Care Policy and Research.

Another, called flexible sigmoidoscopy, in which a doctor uses a viewing tube to examine the rectum and lower colon, reduces the death risk by 60 percent. Many doctors think it’s better to do both tests, though this is unproved.

And the consensus is in flux. Last week, the cancer society issued new guidelines, saying that at 50 everyone should have either a stool test plus a sigmoidoscopy, with repeat tests every year and five years respectively, or a total colon exam.

The total colon exams means either a colonoscopy – a viewing tube exam of the whole colon – or a barium enema, with these tests repeated every 10 years or 5 to 10 years, respectively.

Breast cancer. For women between 40 and 49, the whole issue of screening is a “mess,” says Dr. Jerome Kassirer, editor in chief of the New England Journal of Medicine.

In January, the NIH panel concluded it could not recommend regular mammograms for younger women. Last week, the American Cancer Society went the other way, strengthening its previous guidelines to recommend annual mammograms for women in their 40s. Yet another panel, the National Cancer Advisory Board to the National Cancer Institute, is still considering the issue.

The value of breast self-exams is debatable, too. The task force gives them a “C.” And a recent study of more than 267,000 Chinese women failed to find the exams reduced the death rate, though the women were followed for only five years.

Cervical cancer. Pap tests – at least every three years – rank among the best screening tools. Every year, Pap tests find serious, precancerous conditions in 300,000 women who need treatment. But the tests also pick up mild abnormalities in 2 to 3 million others, for whom the next step in not clear.

The National Cancer Institute is assessing the options: minor surgery, repeat Pap tests in six months or testing for human papillomavirus, which causes cervical cancer.

For any test, especially those about which experts disagree, the best course “is to engage your doctor in a discussion of the facts, particularly the facts of your own history,” says Dr. Larry Gottlieb, deputy medical director at Harvard Pilgrim Health Care.

This, unfortunately, is getting ever tougher, as managed care chips away at the amount of time doctors have to talk.

But it is “high time,” says Dr. David Rosenthal, president-elect of the American Cancer Society, “to rely less on blanket screening and put decision-making back where it belongs, into the hands of the doctor-patient team.”

Medical screening tests: Which are worth doing?

An analysis of the major screening tests by the US Preventive Services Task Force, a government-funded panel, found little scientific justification for routine use of many procedures.  The rankings apply to healthy, asymptomatic people at normal risk of disease. Tests were graded A to E.

A – Good evidence to recommend the test
B – Fair evidence to recommend the test
C – Insufficient evidence either way
D – Fair evidence against screening
E – Good evidence against *

 

Maybe your boss is driving you crazy. Or it’s dawning on you that your husband is acting just like your alcoholic father.

Maybe you can’t find a mate, or can’t commit when you do. Maybe you hear voices, or think about suicide. Or get so scared you can’t leave home. Or so depressed you can’t get out of bed.

Whatever the particular worry, you decide the time has come to embark on that quintessentially American solution to life’s woes: therapy.

The question is, what kind of therapy and with whom?

You’ve heard, of course, of psychoanalysis, and probably of psychodynamic therapy, too, where the idea is to understand your current troubles by tracing them to the emotional patterns laid down long ago in your family.

You may also have heard of cognitive behavioral therapy, through which you try to change unproductive thoughts and actions, regardless of who did what to whom 30 years ago.

And if you’re a denizen of New Age bookstores and the bulletin boards of the granola-and-tofu circuit, you’ve probably heard of the more far out stuff as well, like rebirthing, channeling, white goddess healing, aromatherapy or – the list is endless – even alien abduction therapy.

But with therapies mutating faster than the flu virus in a bad year and options ranging from the well-studied to the wacko, you could drive yourself nuts just trying to sort it all out.

But there are some useful guidelines to navigating the therapeutic seas, say both mainstream and not-so-mainstream shrinks. Berkeley psychologist Margaret Thaler Singer, for example, coauthored “Crazy Therapies,” a useful resource for anyone interested in the less traditional options.

Ultimately, of course, picking the right therapist can be as tricky, and personal, as choosing the right mate, but here are some tips that may help:

If you haven’t had a physical exam lately, get one. There may be an underlying physical problem.

Shop around, which means visiting at least two therapists.  You may be surprised how different it feels to talk to a man or a woman, to someone older or younger, to a doctor or a social worker, or someone of a different race or religion.

After each try-out visit, ask yourself how you felt. Did the therapist listen, or just try to sell you on his approach? Did she treat you with respect? Did you just plain like this person?

Be wary of any therapist who offers the first hour free. That may be a marketing gimmick, not a serious mental health consultation.

You may be attracted to both mainstream and alternative therapies, but mainstream shrinks, at least, overwhelmingly recommend seeing a licensed professional. This could be a psychiatrist (an M.D.), a psychologist, a social worker, or another professional, such as a psychiatric nurse, whose training and credentials meet a minimum standard required to be licensed by the state.

Obviously, a license is no guarantee of competence or compassion. But it’s better than no license, and it should mean the therapist has studied the basics, like how the mind works, different types of mental illness, family systems and the like.

Be skeptical, by the way, of anyone who does not have a license but hangs out a shingle as a “psychotherapist.” Legally, anyone from your car mechanic to your mother-in-law to a professional who been stripped of his license can call himself a psychotherapist.

Ask what training the therapist has had, and don’t be too easily dazzled. A few impressive-sounding weekend workshops are no substitute for years of graduate school.

Don’t pick a therapist from the phone book, a holistic health catalog, grocery store giveaways or any publication that’s mostly a marketing tool. Or if you do, at least ask for references from people who know this therapist’s work.

Be cautious about referrals from friends. A friend can be a great resource, especially if she’s no longer seeing the therapist she suggests. But in general it’s a bad idea to share therapists – you’re better off finding your own.

The best bet is to get referrals from a health professional, hospital or a mental health organization.

Steer clear of any therapist who offers simplistic, one-size-fits-all therapy that assumes everybody has the same problem. Ditto, if the explanation seems to lack common sense or be unrelated to the problem you went in with. If you have marital problems, for instance, it probably won’t help to be told you’ve been abducted by aliens or were someone else in a past life.

If you do have a specific problem, it may make sense to see someone with a defined specialty like, say, sexual abuse – though neither you nor the therapist should assume you fit this category without considerable discussion.

March right out the door if your therapist touches you – other than a hello and goodbye handshake – or comes on to you, sexually or emotionally. Some therapists feel an occasional hug is all right, but others strongly disagree.

Discuss fees upfront. Ask how many sessions insurance will cover (the state mandated minimum is $ 500). Ask if you will be billed for missed sessions. If you have managed care, ask if the therapist will fight for full coverage, which some insurers may make difficult. Avoid any therapist who offers to barter services, like giving you therapy for a picture you’ve painted.

Ask about your therapist’s orientation. Does he believe it’s important to understand the familial roots of your pain? Does he prefer to help you find ways to cope in the here and now? Think about how this approach fits with your own beliefs.

Ask what evidence there is that your therapist’s approach works, but bear in mind that many of the mainstream approaches have been found to be roughly equivalent.

A task force from the American Psychological Association recently ranked therapies according to evidence of efficacy. Some techniques clearly work, the group found, including cognitive therapy for anxiety and depression, therapy that examines interpersonal relationships in people who are depressed, and family therapy for schizophrenics and their relatives.

Other approaches probably work, among them behavior therapy for some types of drug abuse, some psychodynamic therapies and relaxation techniques for anxiety.

There’s less agreement on the efficacy of psychoanalysis, despite its longstanding reputation, or some newer controversial treatments like EMDR – eye movement desensitization and reprocessing, a technique that relies on eye movement exercises to relieve for post-traumatic stress disorder.

Be wary of any therapist who seems to be controlling you, including sequestering you from family and friends.

It’s one thing for a therapist to suggest that you not see your family right now because you are exploring possible abuse or that you steer clear of drinking buddies if you’re trying to get sober. It’s quite another to tell you to trust only him and prohibit any contact with people who are important to you.

Be open to group therapy. For some problems, this may be ideal, especially if you fear interacting with people, if you’re anxious, have an addiction or have the general sense that you don’t understand why people treat you the way they do. Self-help groups using the Alcoholics Anonymous model may also be useful.

Be wary of any therapy that leaves you feeling increasingly discouraged. It’s common to feel worse for a while when you get in touch with painful feelings, but it’s a red flag if you go endlessly downhill.

If you feel you are getting worse, discuss this with your therapist. If you are not satisfied with the explanation, get a second therapist to evaluate your progress.

Things get tricky at this point. You shouldn’t switch therapists to avoid your own deeper problems, but you should consider making a change if a therapist is not helping. This is particularly true if your therapist is not licensed or practices therapy for which there is little evidence, like “entities” therapy, in which you may be told that spirits from the dead are in your body.

If your emotional problems are severe, you might also consider prescription medications. For this you should consult a doctor, usually a psychiatrist, or a psychiatric nurse.

As you embark on therapy, give yourself credit for the courage it takes to confront your problems. And remember that many people feel they have benefited from therapy – of different kinds.

In a survey of 4,000 people by Consumer Reports in November 1995, for instance, people felt they made similar progress whether they saw a social worker, psychologist or psychiatrist. The survey also showed – the party line of the insurance industry notwithstanding – that the longer they stayed in therapy, the more progress they felt they made.

Remember that no matter which flavor therapy you choose, the key is often the relationship with the therapist.

So take your time and choose wisely.

1. The sources for this story

The following people were interviewed for this column:

Anne Alonso, clinical professor of psychology, Harvard Medical School, past president of the American Group Psychotherapy Association.

David Barlow, professor of psychology and director of the Center for Anxiety and Related Disorders, Boston University.

James R. Council, psychologist, North Dakota State University, president of the psychological hypnosis division of the American Psychological Association.

Sharon Gordetsky, president-elect of the Masssachusetts Psychological Association.

Dr. Laura Kramer, a psychiatrist at Spectrum Medical Arts in Arlington, which combines Western and holistic treatments.

Robert P. Salvatore, a certified clinical social worker at LaMora Associates in Nashua, N.H., who specializes in EMDR (eye movement desensitization and reprocessing).

Margaret Thaler Singer and Janja Lalich, authors of “Crazy Therapies,” published by Jossey-Bass Publishers, San Francisco.

1.  For help in finding therapist

For a referral to a mental health professional licensed in Massachusetts, try the following organizations. Your choices may be limited by your insurance coverage. If you are in the midst of a mental health crisis, go to the nearest hospital emergency room or call 911.

Massachusetts Psychological Association, 617-523-6320.

Massachusetts Psychiatric Society, 1-800-831-3134.

Massachusetts Nurses Association (for psychiatric clinical nurse specialists), 1-800-882-2056).

Massachusetts Chapter of the National Association of Social Workers referral service, 617-720-2828 or 1-800-242-9794.

Massachusetts Association for Marriage and Family Therapy, 508-345-3600.

Massachusetts School Psychologists Association, 617-422-1755.

Massachusetts Mental Health Counselors Association, 1-800-944-0934. For referrals in other states, try:

American Psychological Association, 202-336-5700.

American Psychiatric Association, 202-682-6220.

National Association of Social Workers referral line, 1-800-638-8799 ext. 291.

American Association of Marriage and Family Therapists, 202-452-0109.

To learn if a mental health professional is licensed or if there have been any complaints against him or her, call:

Office of Investigations of the Division of Registration, 617-727-7406; or

For psychiatrists, the Board of Registration in Medicine, 617-727-3086.

To get a background profile on a doctor, call 617-727-0773 or 1-800-377-0550.