Scheduling A Therapy Appointment
The mental health care system in the United States is less than perfect. There are stakeholders with competing priorities involved in the process of trying to find a qualified therapist to help work through improving one's mental health. Insurance companies have historically created barriers to receiving care, and still do in some cases, The Affordable Care Act and subsequent Congressional actions have helped increase mental health parity, which has eliminated issues such as session limits, and made care more affordable. However, this Jan. 2022 report shows that issues still remain.
Insurance companies also frequently offer low reimbursement rates, keeping many mental health providers out of the insurance market altogether, and maintaining a "private pay" only practice. My understanding is that this is even more common for psychiatry providers, turning many clients to general practitioners for treatment, who have less training and expertise in mental health care. Insurance companies often tie reimbursement rates to Federal medicaid rates, which, are not particularly enticing. If we are going to be honest about it, the United States is not historically known for taking very good care of its impoverished, and that includes in health care.
Medicaid (and Medicare) is an important program, but the low reimbursement rates and significant bureaucratic barriers, keep providers like myself from participating. When I expanded my private practice to full-time in September 2022, I spoke to a colleague who operated a non-profit mental health agency that accepted Medicaid. I told her I would like to be a Medicaid provider, and asked her opinion about it. I was surprised when she encouraged me not to accept Medicaid. She indicated that as a solo practitioner, the paperwork and billing expectations would be significant hurdles for my practice, and are written with larger group practices in mind. What is unfortunate about this is mental health care is a field that permits an individual, like myself, to operate a solo practice pretty easily, relative to many other fields - typically low overhead, no inventory or special machinery to worry about - just me and my clients in an office (or on computers!). Not many industries are like this, and there are many providers like myself who cannot bear the burden of time and learning complicated Medicaid billing issues, especially when we can operate efficiently without doing so.
So, the government makes it difficult for many providers to service Medicaid/Medicare patients and insurance companies often tie reimbursement rates to Medicaid (keeping many providers from participating with insurance companies), which both contribute to fewer available providers for large segments of the population.
Additionally, finding a provider is difficult. The market has not figured out how to efficiently match clients with providers who have availability. The process for finding a therapist tends to look like this -
1. Search one of any number of online databases for a provider, or contact your insurance company for names of providers in their network.
2. Contact one or more providers.
3. Wait to hear back.
4. Schedule an initial appointment.
Seems pretty straightforward. However, the problems most prospective clients can and do experience are many. Here are a few -
Therapist database profiles usually just ask if you are accepting new clients. For providers like myself, at any given time I may be full with a small waitlist, or can have a few available appointments. At the time of this writing, I have one weekly and one bi-weekly appointment available. But honestly, I’m not going to update that on my (several) online profiles every time my availability changes. That would be really annoying and it is just not worth my time. So clients are left contacting providers with whom they have no idea whether appointments are available (and when).
Insurance companies often keep names of providers on their list, long after those providers have stopped practicing or stopped participating with that insurance company. This can be somewhat circumvented, as I (for example) encourage people seeking therapy to cross-reference names on those lists with a simple online search to make sure those providers are still active. But still, an additional and annoying step. And let’s face it, on average, I would guess most people who are reaching out for mental health treatment, especially if it’s for the first time, have been ruminating for months on whether to start the process. The stigma and lack of general psychoeducation that contribute to this problem is fodder is an entirely other post. I digress…
Provider expertise is also an issue in this process. If you have ever looked through provider profiles, you will see that most indicate competence or expertise in a wide range of clinical issues, populations, and treatment approaches. This makes it very difficult for potential clients to be sure their provider has the proper training and experience to address their needs. But as a provider, I also find it infuriating to try and articulate my “expertise.” I have been a licensed psychologist since 2014, have worked for around 12 years at university counseling centers, two years in dual diagnosis (mental health and substance abuse), and in some form of private practice for nearly a dozen years. Can I say I have expertise in substance abuse issues having worked with that population for two years? Maybe, but I also am not a certified addictions counselor. What about as a clinical supervisor? I have been in that role many times throughout the last 10 years, but I have never published a paper or given a presentation about it. I have worked with and helped countless college students who have suffered from trauma, suicidal thoughts, and even eating disorders, but I wouldn’t call myself an expert in those areas. For certain issues, the answer is easy, for example, I am not trained in EMDR, so I don’t do any of that. But I do have some training in motivational interviewing, acceptance and commitment therapy, dialectical behavior therapy, and the Gottman method, but I am not certified in any of those treatment modalities. As a provider I agonize over how to represent myself on these profiles (and technically, doing so inaccurately is an ethics violation), so I can only imagine how difficult it is as a member of the general public trying to wade through the sea of clinical jargon and claims of expertise just to find a therapist.
Provider responsiveness can be a problem as well. Sadly, I hear frequently from clients that providers often do not get back to them. That should not happen, period. Now, to defend providers for just a minute, however, we have a lot to take care of. I, for one, might end up waiting a week to get back to prospective clients for three reasons - 1. I do not typically reply to such requests on the weekend. 2. I do not always know my availability at that moment. Sometimes I need to wait until the end of my clinical week to have a clear idea of what is available or when something might be available. 3, I cannot offer the same time to multiple people at the same time. Meaning, if you are the third client that week to reach out for what happens to be a single bi-weekly available time slot, I have to offer that to the first two potential clients and wait a fair amount of time (usually at least half a day) to hear back before I offer it to the next person on my list. So, it gets a little tricky. This is less problematic if you are trying to receive services at a group practice, however.
All that to say, scheduling an initial therapy appointment can be a good bit more challenging than it ought to be. Here are a few pieces of advice -
Know what you want to change in your life before coming to therapy. Have an idea of 1-3 goals you have for that change, with which you imagine therapy might help.
Unless you are really knowledgable about treatment modalities, don’t worry so much about picking someone with that specific background. I have had several clients initially say they wanted a “CBT therapist” because they basically heard from friends or articles that CBT is the best. It’s not. It’s good, but there is generally no “best” form of therapy. CBT gets a lot of attention because it is a philosophy that is easy to develop, teach, and administer for research purposes. Therefore, it’s the “easiest” treatment to show significant benefits in a head-to-head double-blind randomized control trial (the gold standard for research). Not to mention these are often developed and funded by the VA or other government institutions that have a lot of money to develop them. The bottom line is that unless you are looking for treatment for a pretty specific concern (e.g., phobias, eating disorders, sexual trauma, autism, a medically-involved concern, and probably a few others I’m forgetting) any legitimate form of treatment can help. Therapist and client fit is a much more significant factor for good outcomes than the specific treatment being offered. Therefore…
Pay attention to the clinician. Cross-reference profile info online about them, and from what you can learn, see if they might be the kind of person you would connect with. The relationship you build with them is going to be just about the most important factor to the success of the therapy.
Know your insurance benefits. Contact your insurance company or look up online how much your deductible, co-insurance, and co-pays will be for mental health treatment. Do not get started on this very involved process only to be priced out of treatment. For those who cannot afford treatment, there are organizations in Maryland that can help, like the ProBono Counseling Project.
An effective course of psychotherapy can be a life changing experience - in fact, that’s kind of the point. Hopefully this has helped provide some useful information and motivation to search for a provider, reach out, and schedule your intake appointment as soon as possible.