Choosing the wrong mental health practitioner may cost you a lot more than those hourly fees.
1. "My title may not mean much."
With roughly 25 million American adults receiving some form of mental health treatment, job opportunities abound for anyone with a notepad and an available ear. If you're looking to start therapy, you know that a psychiatrist (an M.D. who can prescribe medication) or psychologist (typically a Ph.D.) has probably mastered his discipline. But with many other confusingly labeled providers, you can't be sure. Mental health counselors or marriage and family therapists, for example, are generally required to complete a master's degree and a prescribed regimen of supervised work with patients.
Before picking a therapist, investigate the credentials of any candidate. Get referrals from your primary-care doctor, visit the Web sites of the American Psychological Association and the Association for Marriage and Family Therapy, or check with a district branch of the American Psychiatric Association. To learn your state's requirements or the status of individual therapists, try your state's licensing and medical boards. Question therapists about what degrees they have and whether their continuing education goes beyond weekend workshops and conferences.
2. "My fees are negotiable."
The more education a therapist has, the more he usually charges. In a comparison of fees by industry newsletter Psychotherapy Finances, marriage and family therapists charge around $60 to $90 per session; psychologists, $70 to $100 per session; and psychiatrists, $90 to $150 per session. Rates go even higher in pricey areas such as New York City. If you have only partial insurance coverage or pay out-of-pocket, your bill can run high.
You can, however, request a reduction in the rate. In fact, some practitioners see it as, well, therapeutic. Christine Ryan is a case in point. Several years ago the San Francisco editor was seeing a therapist who disclosed, two years into treatment, that she would be raising rates. The therapist asked Ryan to think about the increased charge and discuss it later. The upshot: Ryan, who was thinking of increasing the frequency of her sessions, negotiated a break in the price hike to offset the cost of an increased schedule. "She approached it as a learning opportunity," says Ryan. "And it really underscored that this was the right therapist for me."
Another way to save money is to find a therapist who offers a sliding scale of fees based on need or who charges lower rates for hard-to-fill time slots, such as midmorning and midafternoon.
3. "I don't know anything about your condition."
If you're suffering from a particular problem, you'll want to see someone with special expertise in that area. A diabetic wouldn't sign on with a lung specialist, right? If you have anxiety attacks, you'd be best served by a therapist who works with patients who have the same problem.
Unfortunately, therapists often take on patients they're not trained to deal with. "Not every therapist is well trained in every disorder," says Richard Dana, a psychologist in Needham, Mass. "Someone who is referred with obsessive-compulsive disorder may find that his therapist was not really trained in that area." According to Herbert Klein, editor and publisher of Psychotherapy Finances, many therapists lost substantial income during the '90s, when businesses shifted to managed-care insurance. As a result, some therapists simply don't feel they can afford to turn away patients.
Quiz your prospective therapist about specializations and experience. For confidentiality reasons, he can't provide the names of clients as references. But you can describe your issues or symptoms and ask whether the therapist has worked with patients like you and how long it usually takes for them to complete their treatment.
4. "I use one approach — even if it's not right for you."
Therapy comes in many flavors. Among the classic approaches, cognitive-behavioral focuses on changing the patient's thought and behavior habits; psychodynamic stresses the role of early relationships; and interpersonal focuses on current relationships. Then there are the newer, less mainstream approaches. For example, Emotional Freedom Techniques (EFT) stimulate the body's meridian points, as in acupuncture, and Eye Movement Desensitization and Reprocessing uses objects waved in front of the eye.
"Different problems need different techniques," says Tina Tessina, a psychotherapist in Long Beach, Calif., and the wrong approach may, at best, waste your time. Worse, therapists may shoehorn patients into their theoretical boxes, creating new problems. Michael Broder, director of the Albert Ellis Institute in New York, points to the once faddish repressed-memory syndrome. "If you're a repressed-memory specialist, you can convince a patient they were molested even if they weren't," he says.
Before starting therapy, ask your provider about his method. It's also always wise to set up a specific trial period — anywhere from one to several sessions — to see if it works for you.
5. "I'm a pawn to your managed-care company."
Managed-care companies have clamped down relentlessly on therapy, requiring extensive reporting by practitioners and "a lot of time devoted to paperwork justifying treatment," says Daphne Stevens, a clinical social worker in Macon, Ga. What's more, patients generally sign a release at the outset of treatment giving the managed-care company the right to see their records and discuss aspects of their care with the therapist.
Several years ago Stevens started seeing a suicidal patient who was in the throes of an emotional crisis. After six months of therapy, "the managed-care company started asking when I was going to wrap it up," she says. When she insisted that the patient still required treatment, the insurer said okay — as long as Stevens checked in after every session. Finally, Stevens worked out a fee agreement that allowed the patient to pay out-of-pocket. A less charitable therapist might have let a patient go untreated.
You can't do much about your managed-care company's access to your files, but you can discuss your concerns with your therapist and ask to see any correspondence he has with your care manager. At least you'll be able to know what's being said about you.
6. "Our conversations aren't really confidential."
If you think conversations between therapists and patients are always private, they're not. Court decisions have found that the confidentiality of records should be determined on a case-by-case basis. Should you find yourself in a court case in which you've raised the issue of emotional health, your records can be subpoenaed by the other side. It's common in child custody cases. "Those records can become part of the legal fodder if parents are divorcing," says Leah Klungness, a psychologist in Locust Valley, N.Y.
In addition, the federal Health Insurance Portability and Accountability Act, or HIPAA, which was originally meant to safeguard patient privacy, was amended in April 2003 to remove a patient's right to give consent before certain "covered entities" — providers, insurers and health information clearinghouses — could access his medical records. As a result, confidential information about you can easily be disseminated without your ever knowing.
What to do? Ask to see what's in your records so you know what information could be passed on. While your therapist can't change what he has written, ask that he put in positive factors as well, such as your efforts to change.
7. "I'm crazier than you are."
Therapists sometimes receive some form of therapy themselves before treating patients. It is a requirement for becoming a practicing psychoanalyst, for instance. But that doesn't mean the person you see is necessarily a beacon of mental health. "Some therapists may have their own set of emotional problems which, in some cases, could interfere with successful therapy," says Los Angeles psychologist Yvonne Thomas.
The real problems arise when a therapist has unresolved emotional issues and takes them out on you. One writer in Santa Fe, N.M., for example, recently saw a psychologist who, she says, came late to every session. Once, when the therapist was a half hour late, the patient finally called her on it, and the therapist responded by angrily lashing out. "She told me this is an issue she was trying to work on, and I had no right to criticize her for it," the writer recalls. If you feel your therapist is exhibiting inappropriate behavior, bring it up. "A person should feel comfortable confronting the therapist and trying to have the problem improved," Dana says. If that can't happen, move on.
8. "I'm a drug pusher."
Antidepressants and other psychotropic drugs have helped millions of people. But they're not right for everyone. Managed-care companies, however, encourage psychiatric consultations where patients can be prescribed drugs, in part because it's often cheaper than long-term therapy.
Just because you're put on a drug, though, doesn't mean it's the right one for your condition. When she was in college, Steffanie Roulet, a researcher for a public relations firm in Cleveland, took part in a study in which a psychiatrist diagnosed her as bipolar and prescribed the drug Depakote. She continued to take it for 10 years, until she was laid off from her job and lost her health insurance. What happened? Not only did she feel better emotionally while she was off the drug, but she no longer suffered the shaking hands and nausea she'd developed. When she started therapy again a year later, she was put on a different drug, which she says helped her without side effects.
Your best move: Before you start working with a therapist, ask him to describe his philosophy about prescribing drugs. If he suggests that you go on drugs, ask what the rationale is for the recommendation, how the two of you can monitor the treatment and whether he has been pressured by insurers. If you don't feel comfortable with his answers, consider getting a second opinion.
9. "I'll exaggerate your diagnosis."
To qualify for insurance coverage, patients must be given a specific diagnosis, drawn from the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. The level of coverage may depend on the seriousness of the diagnosis, as determined by the DSM. This can lead to DSM-inflation. In order to make sure their patients receive coverage, therapists may assign a more serious diagnosis when given two similar options. Some states, such as California and Massachusetts, allow certain psychiatric disorders to receive the higher benefit level assigned to medical visits. "So (therapists) might give someone the diagnosis of 'panic disorder' when the milder 'adjustment disorder with anxiety' may also be appropriate," says Steven Sultanoff, a psychologist in Irvine, Calif. It matters because a diagnosis of depression, for example, could make it difficult to get disability insurance. Often, underwriters will not write a policy while a patient is receiving treatment or will require a clause denying benefits if the cause is mental-health related. "Some companies have said the patient must wait six to 12 months after treatment to apply," says Dana.
To avoid diagnosis backlash, discuss the diagnostic options before you begin therapy. Many practitioners are not inclined to put labels on their patients for a variety of therapeutic reasons but are forced to provide one before insurance companies will cover their services. Pay for your treatment out-of-pocket, and the need for any diagnosis — and certainly for an inflated diagnosis — may disappear.
10. "I'm going to drag this out — and you'll never be cured."
If your health plan doesn't impose treatment limits, you have more freedom to resolve your problems — but you might also find your therapy goes on too long. "Unless you have a serious problem, you should see some improvement within a few weeks and considerable headway in a couple of months," says psychotherapist Tina Tessina. At the same time, don't delude yourself that your last visit signals a cure for whatever sent you there. "These tend to be chronic relapsing conditions," says Dr. Darrel Regier, executive director of the American Psychiatric Institute for Research and Education.
Discuss with your therapist how long your therapy is estimated to last. Then, set up a schedule for evaluating your progress to determine if it should continue. If you feel things are dragging on without much progress, discuss your concerns with your therapist, and if you don't get a satisfactory answer, consider moving on. Stick to your guns even if your therapist contends you are "blocking" progress because you fear change.