By Bart Magee Ph.D.
January has arrived and along with it the yearly ritual of resolutions and making efforts to follow through on commitments for self-improvement. More and more, those commitments include starting therapy. We in the mental health community wholly support those intentions, but we also know that for so many (and if you’d tried it you know) finding and affording a therapist has only gotten more and more challenging.
The first part is where to start. Does one just start Google searching? Do you ask a friend, your doctor, your yoga teacher? It all can seem so random. And what kind of therapist will be the right one? Aren’t there lots of different kinds of therapy? How does one know which is best?
The next part is how to pay for it. Like the cost of so many things the cost of therapy has gone through the roof lately. Then there is insurance. Does it even cover therapy? How much of it? What will the co-pay be? Will a therapist take insurance? How do I go about getting reimbursed?
And then there is the question of all the new therapy companies that are advertising like crazy and promising easy access to therapy via remote sessions, texting and other on-line modes. Can these be trusted?
Are you overwhelmed yet? If you are, you are not alone.
In the spirit of not letting these questions and complexities get in the way of the resolve to start therapy, let’s break it down and sort through the process.
The Search Process
The first thing to remember is that the whole process can take time and persistence. We are in the middle of a provider shortage. Therapists are busier than ever, so finding someone with an opening can take multiple calls and inquiries. It’s about being there at the right moment. Ideally, you can get a referral from a trusted source. If you happen to know a therapist or someone in the mental health profession you can start there for direction. Those of us in the profession are aware of the challenges in navigating the system and we’re happy to help. For looking online, Psychology Today has a good, searchable website and most therapists have listings there. You start by entering your location. Searches can be modified by gender, insurance, issues, specialties, etc. The therapists listed all have brief statements about themselves and their practices. It’s also easy to send an email to inquire about availability, keeping in mind, again, that getting an appointment can take some time.
What if you are fortunate and find one or more therapists that do have availability, does one shop around? This is complicated. Scheduling a series of appointments with different therapists can foster confusion. It’s often very difficult to get a feel for the therapist in one appointment. And the same goes for the therapist. Getting to know you and your situation takes some time. It varies, but the general rule is it takes about three sessions for a consultation. At that point the therapist should have a good enough sense of your difficulties and should be able to provide some initial advice and direction for treatment.
What about all the different therapy modalities? That also can create confusion. It can help to learn some of the basics about each, however, what’s most important is finding a therapist who has experience working with the issues that you are struggling with. Many therapists have training in multiple modalities and can integrate approaches as the situation demands. The research on therapy outcomes has consistently found that the most important factor in therapeutic progress is the quality relationship between patient and therapist. That doesn’t mean it’s hunky-dory all the time, there can be conflict and struggle, but overall, the relationship is collaborative and works toward a shared sense of direction.
People who are members of traditionally underserved and marginalized groups, including, racial minorities, immigrants, and members of LGBTQ communities can face additional barriers to access. While the profession is slowly diversifying, and contemporary education and training (like the training at Access Institute) emphasizes multicultural competency, therapists still tend to skew white, straight and middle/upper-middle class. For people outside the mainstream, this means having to spending extra effort in the search process to find a therapist who has experience working with minority groups and the specific issues associated with those experiences. Fortunately, therapists who work in these areas are generally open about describing those interests and abilities.
Insurance Coverage (the dreaded topic)
We all need it and depend on it, but oh what a headache it is to navigate the insurance system. First the good news. Insurance is slowly getting better at covering therapy. Most plans have some coverage, but that’s where the good news ends. Coverage depends on which plan you have. The big difference is between PPO (Preferred Provider Organization) plans and HMO (Health Maintenance Organization) plans. If you have an HMO, to get reimbursed you are required to use a provider within the network. That will mean that the first stop will be to the company’s web portal where you can find a list of providers in your area. If you have a trusted source, you might have them look at the list to see if they know any of the providers on it. When you call, don’t be afraid to name-drop your source. That can also help increase the chances of getting a call back. PPO plans vary in their coverage. Bronze plans have higher deductibles and co-pays meaning that you’ll be paying full-fee until you reach those out-of-pocket limits. Silver plans have more moderate deductibles and Gold plans have little or none. If the therapist is “in-network” the deductibles and co-pays will be lower. If a therapist is out-of-network and doesn’t bill your insurance directly, they should be able to provide you with a bill with all the necessary codes that you can submit for reimbursement.
Unfortunately, for lower and even middle-income people, the benefits provided by insurance and not adequate and paying $200 and up per hour for therapy until the deductible is met doesn’t pencil out. That’s why I founded Access Institute and why our sliding-scale services continue to provide a vital resource for the community.
Whether it’s on the radio or social media, it seems like every other advertisement these days is for one of the on-line therapy companies. The messages promise easy access to treatment on-line along with texting and access to web-based tools, all at affordable prices. While that all adds up to a great benefit, the recent track record of these services is far from smooth. They can provide increased access to treatment, and many of the people served have never had therapy before. A key limitation has to do with the growth model of the companies, which can undermine quality of care. Another criticism has been around privacy and the sharing of personal data by the companies’ apps. And while teletherapy allows for increased access (particularly transformative for people living in rural areas) and convenience, it can be harder to develop a strong therapeutic relationship, which is key to making progress. I’ve seen this first hand in my private practice and at Access Institute. While some people do well with remote sessions, the emotional connection can be diminished. Remote work presents challenges both for the therapists, as it's harder to pick up on subtle cues, and for the patient, who can experience the therapist as more distant. If possible, an in-person model with a hybrid option offers the best of both worlds. It affords the more intimate connection of the in-person work while enhancing the continuity of care, so that factors like travel, illness, etc, don’t have to interrupt the treatment.
All of this only scratches the surface, but hopefully it provided a little clarity. The landscape of mental healthcare has changed tremendously in recent years and continues to evolve. At Access Institute, we continue to advocate for greater access to care, the reality of the system— with its complexity, high costs and scarcity— means that too many barriers remain, causing people to suffer without the support they need. As I said in the beginning, persistence and ability to navigate complex systems are often basic requirements to finding a therapist, at the same time, we know that experiencing mental health difficulties can make that an even greater challenge. That’s why it’s vital to support each other in the process— as we take care of ourselves, we are also looking out for others around us.