The person on the couch isn’t the only one with problems.
1.“Your childhood was bad? Wait till you see your bill.”
Among those who seek psychological help in the U.S., 40% undergo therapy with a social worker, psychiatrist or psychologist, according to JAMA Psychiatry, a peer-reviewed medical journal published by the American Medical Association. All that talk doesn’t come cheap. There is no set charge, but therapists say rates can vary from $75 to $250 an hour. In fact, Americans spend around $10 billion a year on all kinds of psychotherapy — from relationship counseling to cognitive-behavioral therapy — according to research reviewed by Bruce E. Wampold, clinical professor of psychiatry at the University of Wisconsin-Madison.
One therapist’s fees for different clients can also vary wildly, experts say. When shopping around for a therapist, there’s nothing wrong with negotiating, says Simon Rego, director of psychology training at Montefiore Medical Center in New York City. Many clinicians offer a sliding scale for those with limited funds, he says. Sometimes, therapists dedicate a certain number of slots per week to low-income clients, he says, and there are counseling organizations that offer pro bono services to veterans and victims of natural disasters like Hurricane Sandy. In other cases, Rego says, therapists expect potential clients to haggle. “Some therapists claim a sliding scale as a rubric to negotiate,” he says.
There’s evidence though that good therapy is a bargain at any price. In clinical trials, psychotherapy has been shown to be effective in treating depression, anxiety, marital dissatisfaction, substance abuse and even sexual dysfunction, Wampold found. And relapse rates can be lower with some types of psychotherapy than with medication, according to research by Steve Hollon, a professor of Psychology at Vanderbilt University. For major depressive disorders, a 2009 Department of Veterans Affairs study on psychotherapy’s effectiveness suggests a combination of therapy and antidepressants as a first line of treatment.
One in five Americans in any given year will have a mental health disorder and two-thirds never receive treatment, says Paolo Delvecchio, director of the federal government’s Substance Abuse and Mental Health Services Administration’s Center for Mental Health Services in Rockville, Md.
2. “I may not have any training.”
While qualified psychologists, psychiatrists and licensed clinical social workers all require years of training, there’s very little stopping anyone from taking a night course in astrology or philosophy and calling himself a therapist. Therapy is an umbrella term that covers many professions and problems. It’s more of a descriptive term than a professional one, says John C. Norcross, a professor of psychology at the University of Scranton. In fact, anyone could advertise as a “therapist,” put it on a business card, set up a website and wait for people to call. “Seek mental health services from someone licensed to practice by the particular state in which you reside,” Norcross suggests.
Experts recommend that consumers who need mental health care turn to a psychologist, psychiatrist, or licensed clinical social worker. Psychologists must have a doctor of philosophy (Ph.D.), doctor of psychology (Psy.D) in counseling or clinical psychology or doctor of education (Ed.D.), and pass a state-level licensing exam. Psychiatrists have to earn a doctor of medicine (M.D.) and complete a medical residency. Licensed clinical social workers (LCSW) need a master’s degree (MSW or MA), and must meet medical clinical exam requirements. Licensed counselors also need a master’s degree (MA or MS) and pass a national licensing examination. The American Psychological Association, American Association for Marriage and Family Therapy, American Psychiatric Association, National Association of Social Workers and American Counseling Association can make referrals, as do state licensing boards and many health insurance plans list in-network mental health professionals.
For therapeutic services slightly outside the realm of mental health, though, another type of professional might be appropriate. For instance, some life coaches practice as therapists, says Julie Hanks, owner and executive director of Wasatch Family Therapy in Salt Lake City, Utah. (A life coach draws on techniques from psychology and career counseling, but working as a life coach requires no formal training.) Life coaches can be well-suited to helping people decide their next career move or improve their productivity, and plenty of informed consumers choose them over therapists for personal projects, business mentoring and creative endeavors. Many life coaches clearly state that their services are profoundly different from therapy or counseling. Nonetheless, Hanks says, she’s been surprised by how many clients have told her they weren’t aware their coaches weren’t trained to treat mental health problems.
Although it’s important to find a qualified professional, Hanks says, the degree does not make the therapist. “What it boils down to is the quality of the connection between the client and therapist,” she says.
3. “Will you ever stop talking?”
While therapists are paid to listen to a patient for about 45 to 60 minutes at a time, it’s not always easy, especially since people in therapy can get so wound up in the minutiae of their day that they ramble on instead of tackling real issues. “I’ve been bored out of my mind occasionally,” says Hanks, the Salt Lake City therapist. But there’s an upside to her only very occasional boredom: It clues her in that something isn’t working. Then, she says, she knows to ask herself, “What do I need to do differently with this client?”
Sometimes it’s the therapist, rather than the client, who isn’t giving real issues the attention they deserve. Marci Robin, the beauty director of lifestyle and cosmetics site xoVain.com, recently wrote about her experience with a therapist who fell asleep during her session — while Robin was crying. Shortly before arriving at her therapist’s office in New York, Robin had been assaulted by a group of boys who hit her with a cup filled with ice. “As I spoke, I noticed her drifting off,” she says.
Such incidents are relatively uncommon. But therapists, like anyone on the job, can succumb to drowsiness and distractions. “Patients who have seen other therapists have reported this to me,” says Mirean Coleman, a clinical social worker and senior practice associate with the National Association of Social Workers. “I have also been informed by patients of therapists who texted or played games on their cellphones during therapy sessions.”
And of course when there’s a third party in the mix, he or she can be the reason conversations wander. In couple’s therapy, for instance, it’s not unusual for the more dominant partner to attempt to hijack the session. “There are some people who are a bit narcissistic and enjoy hearing themselves talk, and the therapist never really gets an accurate sense of what goes on in the relationship,” says Fran Walfish, a therapist in Beverly Hills, Calif.
4.“I need you more than you need me.”
After a few sessions, therapists often recommend additional treatment. But insiders say clients should watch for signs it’s time to move on. “If you feel like your therapist needs you financially” — for instance, if he or she is pushing for more sessions even though you feel better — “get another therapist,” Hanks says. Although the majority of therapists go into the profession because they genuinely want to help others, she says, a weak economy can make it difficult for a therapist to let a client go. Therapists who are struggling to keep their practice afloat — or who don’t have a potential client to fill the available time slot — might be particularly inclined to try to squeeze extra money out of their clients. “A good therapist does not want their clients in therapy forever,” she says.
What’s more, even a good therapist might not be the right therapist for a particular person. Clients reporting little or no change in their emotional well-being within their first six visits for cognitive therapy tend to show no improvement over the entire course of therapy or end up dropping out, according to multiple studies over three decades by psychologists Barry Duncan and Scott M. Miller, both of whom are also licensed therapists. “You should feel that you are on your way within a month, says Miller, Cummings Professor at the Department of Behavioral Health in Arizona State University. A long-term client-therapist relationship with no early change can encourage inaction and co-dependency, he says. The length of time a patient should be with a therapist should be based on the treatment goals and progress of each patient, says Coleman from the National Association of Social Workers. “If a patient fails to meet their initial and revised treatment goals, then other alternatives should be considered.”
5. “Maybe I’m the one who needs therapy.”
There’s no shortage of patients who complain that their therapist has as many issues as they do. When it’s time to say goodbye to a client, for instance, some therapists themselves can exhibit signs of co-dependency. When Kathy Morelli, a family counseling therapist in Wayne, N.J., told her New York-based therapist that she was getting married, was moving to New Jersey and wouldn’t require her services anymore, her therapist wasn’t exactly tickled for her. In fact, she didn’t see why Morelli should have a problem going 25 miles out of her way. “She thought I could commute into the city to see her — at night,” Morelli says. “She made a big stink about it. It was very weird.”
Others have come across different peculiarities in their hunt for a good therapist. Stacey Glaesmann, a clinical psychologist and former therapist in Pearland, Texas, wanted to talk to her therapist about postpartum depression. But her therapist had more important things to discuss, she says. Chief among them: God. “I thought, ‘What the hell?’ I had come to her to talk about being depressed, not because I was looking for religion.” Another therapist she went to appeared to be addicted to her cellphone and answered it during a session. “She didn’t even say, ‘Excuse me,’” Glaesmann says. “How rude can you get?” Of course, such incidents aren’t the norm, says Lisa Brateman, a licensed social worker and therapist based in New York.
6.“A morning run might work just as well.”
A little exercise goes a long way. In fact, the effect of regular exercise on mild to moderate forms of depression is similar to the effect of cognitive behavioral therapy, according to the co-authors of the book “Exercise for Mood and Anxiety,” Jasper Smits, associate professor of psychology at Southern Methodist University in Dallas, and Michael Otto, a psychologist at Boston University. The two authors analyzed the results of dozens of published population-based and clinical studies related to exercise and mental health to arrive at their findings.
There’s little consensus on how or why exercise helps, but Smits says the public health recommendation for daily exercise — 75 minutes a week of vigorous exercise or 150 minutes of moderate activity — should be more widely prescribed by mental-health care providers, especially as studies show that 25% to 40% of Americans don’t exercise at all. “Some professionals argue that exercise is the non-pharmacological antidepressant and may work in the same way as these medications,” he says.
7.“I don’t have to practice what I preach.”
Some university programs and state licensing authorities require mental-health professionals to undergo therapy, but it isn’t universal. Utah and California are among several states that don’t require therapists to receive psychotherapy before they practice. Hanks, who does require it of those who work in her practice, says it’s crucial for a therapist to lie on the proverbial couch in order to understand what the client is going through. “I can’t take a client beyond anywhere I have not been willing to go myself,” she says.
Plus, Hanks says, when a therapist needs mental-health care, seeking treatment from another therapist is considered preferable to self-treatment. “Therapists need therapists like doctors need doctors. We need a different point of view.” Tina Tessina, a psychotherapist based in Los Angeles, says therapy helps a qualified therapist remain an emotionally strong and independent observer.
Some experts suggest consumers ask potential therapists about their own experience in the patient’s chair and their mental health. Tessina even recommends that those in the market for a marriage counselor seek a therapist who’s happily married. Others say a therapist who’s experienced similar mental health issues to a patient’s — including a marriage breakup — might be more empathetic and wiser. On the other hand, some argue that the therapist’s personal life isn’t relevant to treatment. After all, a doctor who’s never broken a bone is still trained to set one. And many therapists have a zero self-disclosure policy with clients, Glaesmann says.
8. “Your secret is (sort of) safe with me.”
Most patients assume their sessions are confidential, but there are many instances where these sessions could be made public. The records of therapy sessions could become part of a divorce proceeding or employment dispute if a client alleges emotional or mental damages on the part of a spouse or co-worker. Or they could be disclosed if there is a legal dispute between the therapist and the client. Laws also vary by state, therapists say.
If a client expresses suicidal or — indeed — homicidal thoughts, therapists may also be legally required to report that. Nor is a serious crime necessarily protected by client-therapist privilege. Glaesmann says she was obliged to turn over her notes on one client to the local district attorney after the client’s wife found child pornography on his computer, she says. “That had not come up during our therapy,” she says, “but if it had, I would have had to report it to authorities, as viewing child pornography is a crime.” Katherine Nordal, executive director for professional practice at the American Psychological Association, says the group advises therapists to provide a patient’s record only if a court orders it or if they have obtained consent from the patient.
The Health Information Portability and Accountability Act of 1996 does provide some protections for minors. Under HIPAA, the therapist must get a signed disclosure from a client ages 12 to 18 before releasing the minor’s health care records to anyone, including parents; however, in some states, parents may not be denied access to their child’s health records. Insurance companies are only entitled to certain types of information when evaluating whether a person qualifies for medical insurance; this excludes psychotherapy notes and diagnoses, which have special status under HIPAA.
9.“I’ll be there for you, but your insurance might not.”
Health insurance companies can place limits on how many therapy sessions they’ll pay for, and they may be keen to wrap up the sessions before the client is ready. Relying on insurance to pay for therapy isn’t always in a person’s best interest, says Joseph Winn, a clinical social worker in Arlington, Mass. “The insurance company will make their determination regardless of what you, or your therapist, feels is appropriate,” Winn says. If a client disagrees with an insurance company’s decision not to provide additional treatments, he or she can appeal, says Susan Pisano, a spokeswoman for America’s Health Insurance Plans, the industry’s trade group. And people can continue treatment by paying out-of-pocket. Under the Mental Health Parity and Addiction Equity Act of 2008, insurers must also provide their clients a reason why they stop or decline payment for mental health services.
There have been some efforts by lawmakers to make it easier for Americans to get mental health coverage. The Mental Health Parity and Addiction Equity Act, which employers with 50 or more workers began adhering to in 2011, requires that when coverage for mental health and substance use conditions is provided, it be generally comparable to coverage for medical and surgical care. That means, for instance, that insurers can’t put a cap of, say, 30 annual trips to a psychiatrist for mental health if they haven’t put such limits on treatment for other conditions, like cancer or diabetes. President Obama’s Affordable Care Act, which takes effect in 2014, broadened the 2008 act to include all insurance and employers providing health care and is expected to extend federal parity protections to 62 million Americans, with mental health coverage deemed an “essential health benefit.” Some insurers treat therapists as specialists, which typically require a higher copay: $30 or $50, say, instead of $20.
However, experts say handling insurance is currently still cumbersome for practices — and that the best therapists are increasingly the ones who won’t even accept insurance. “Insurance has become so difficult and expensive to work with,” says David Reiss, a psychiatrist in San Diego. “While there some very good therapists that work with insurance, if therapists can afford to practice without having to accept insurance, they often will.”
10. “Time’s up. Here’s a pill.”
There has been surge in the use of medication to treat mental health problems, studies show. In 2005, a mere 11% of psychiatrists — who, unlike social workers and some other kinds of therapists, are licensed to prescribe drugs — used talk therapy with all of their clients, down from 19% in 1996, according to a 2008 study in the medical journal of the American Medical Association. Similarly, the proportion of patients visiting psychiatrists for talk therapy fell to 29% from 44% in the same period. Psychiatrists get reimbursed by insurance companies at a lower rate for a 45-minute psychotherapy session than for a 15-minute medication visit, the study found.
As talk time went down, pill-popping went up — a trend which some mental health professionals find troubling. The use of psychiatric drugs among adults increased by 22% from 2001 to 2010, and one in five Americans now take such meds, according to industry data compiled by Medco Health Solutions, a pharmacy benefit manager in Franklin Lakes, N.J. And it’s not just adults who are increasingly being prescribed drugs for mental health. Some 6.4 million children ages 4 to 17 have received a medical diagnosis of attention deficit hyperactivity disorder, an increase of over 40% in the past decade, according to recent data from the Centers for Disease Control and Prevention.
To be fair, the Food and Drug Administration policy states that it only approves drugs after rigorous clinical trials and that any potential side-effects are stipulated on the labels. And many people get prescriptions from their primary health provider rather than from a psychiatrist. But compared with medication, psychotherapy has fewer side effects and lower instances of relapse when discontinued, says Nordal of the American Psychological Association.
Talk therapy can be as effective in treating depression as the most recent generation of antidepressants, according to a 2011 review of 15 studies and published in the Journal of Nervous and Mental Disease by researchers at Metropolitan State University in St. Paul and Dartmouth College in New Hampshire. That’s not to say therapy and pharmaceuticals are mutually exclusive options — or even the only options. Many people solve their own problems on a routine basis through exercise, yoga and meditation, or by talking to their families or attending religious services. But a professional can still be helpful, says Scott D. Miller, professor of behavioral health at Arizona State University. “There are many paths to having a more fulfilling and less troubled life, and psychotherapy is just one of those,” he says. “Like with toothpaste, people have a choice.”