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Thu, Sep. 1st, 2016, 01:57 am
[pshrinkery/healthcare, Patreon] Why You Can't Find A Therapist, No, Really

[Read in black and white]


So there was this radio segment, back in May, for KQED's California Report, called "Sorry, The Therapist Can't See You — Not Now, Not Anytime Soon" by April Dembosky. It's about the difficulties people in California have in getting access to psychotherapy. The whole thing is a half hour, and you can hear it at Soundcloud.

In the segment "Frustrated You Can’t Find a Therapist? They’re Frustrated, Too", which you can read a transcript of at that link, Dembosky explores the fact that the problem's not that there's few therapists...
Insurance companies say there’s a shortage of therapists.

But it’s not that simple. Especially in urban areas, there are lots of therapists. They just don’t want to work with the insurance companies.

[...] Nearly half of therapists in California don’t take insurance, according to a recent survey from the California Association of Marriage and Family Therapists. The same is true of psychiatrists. There are two reasons why, Klein says.

“One, because the reimbursement rates don’t provide a living wage,” Klein says. “You can’t own a home and drive a car and survive on what in-network providers pay you.”

Most insurance companies pay therapists in their networks between $60 and $80 per session. In the Bay Area and Los Angeles, therapists say the market rate for therapy is more like $150 or $200 a session.
That's the moment at which I think Dembosky misses the turn.

I think something rhetorically bad and subtle happened, and Dembosky wasn't hip enough to the insider baseball of mental health insurance coverage to recognize it.

In reality, the one we all live in, the actual market rate is completely irrelevant to the discussion of how much insurance companies do and should pay therapists for therapy. But that's something both therapists and insurance companies know. Invoking "the market rate" is a rhetorical maneuver, something both insurance companies and therapists do to justify their arguments about appropriate compensation. But both insurance companies and therapists know that this rhetorical "market rate" they argue about is a fiction. Since insurance company compensation of psychotherapy is often set as a function of the "market rate" – actually the insider term is "usual, customary and reasonable rate" (UCR rates) and the function is usually a percentage – insurance companies who pay therapists make up numbers that are low so they can pay less, and therapists who take insurance make up numbers – basically "sticker prices" none of their patients actually pay, since they all have insurance paying – that are high so they'll be paid more. Insurers and therapists locked in this rhetorical battle know "the market rate" whereof they speak – and over which they vie – is nonsense, but it's the nonsense the terms of the fight is expressed in.

But as I said, the market rate, whether the actual one or the fictional, rhetorical one, actually has nothing to do what what Dembosky is trying to reveal.

The issue is not that "most insurance companies pay therapists in their networks between $60 and $80 per session" while there's some (according to therapists) market rate of "more like $150 or $200 a session".

The problem is that $60 and $80 per session. Dembosky accepts – no doubt it's what the therapists she talked to said – that the problem with "$60 to $80 per session" is that it is so much less than the market rate. But the core problem isn't comparative.

It's arithmetic.


When I asked, in my poll earlier today, what people thought psychotherapist compensation was like, several people attempted to start from what they guessed was the per-session rate and multiply out by something like 40 hours per week. Good try! (Wrong – but reasonable!)

But not one person who did that guessed a per-session rate less than $100 per hour.

That "between $60 and $80 per session" Dembosky hears about in San Francisco is what I'm seeing in Boston, too. I work for a clinic that pays me a cut of the take, and because my compensation is a percentage of what they're paid by the insurance company for my work, I get to see what they're getting paid. Now, I have few patients and they take very many insurance products at that clinic; I only know for the insurers of the patients I've treated, which is a small subset of the larger whole. But of the insurers that have paid for my work, the highest has been Massachusetts Behavioral Health Partnership (MBHP), a MassHealth (Massachusetts Medicaid) plan: it pays a hair under $86. I understand from some hints dropped that MBHP is the highest paying insurance in the state. The lowest has been Neighborhood Health Plan (NHP), which is paying a hair under $56. So $56 to $86 per session: the range is just a bit wider, but essentially the same.

By the way, we're discussing 90834. That's the Current Procedural Terminology(tm) (CPT) code for "Psytx pt&/family 45 minutes", translation: "individual psychotherapy for patient with or without family present, 45 minutes". (Used to be 50 minutes, until Jan 1, 2013.) Initial (diagnostic/assessment) sessions get paid under a different code with a higher rate, because they take more time; group therapy and family therapy are other codes, with differing rates. But 90834 is the vast bulk of psychotherapists' billing to insurance companies, so that's what is always implicit in these discussions. Nothing nefarious here, but just making it explicit. So now, you can go do your own research.

So psychotherapists are being paid $60 to $80 per (90834) session by insurance companies, not the $100 to $300 per session that some commenters guessed therapists were being paid, generally. In fairness, I didn't ask you what you thought insurance companies paid, I asked you what you thought therapists were paid, and for those of you who have paid cash on the barrel-head yourselves, it never crossed your minds that insurance companies might pay way, way less than a therapist charges patients directly.


Now, most people, when they hear "$60 to $80 per (90834) session", think, "Well, that's not bad. Sure, it's not $200/hr, but it's nothing to sneeze at."

libraryhungry.blogspot.com cannily caught the problem there:
I'm surprised by how many people are conflating "hours of work per week" with "hours of paid sessions per week."
Therapists who take insurance aren't working for $60 to $80 per hour, they're working for $60 to $80 per session.

The obvious question to then ask is "how many sessions per week can a therapist actually do?" It's an interesting question, but in many ways the wrong question. People get fascinated by the question of how much time does it take to actually do one psychotherapy session. It's not unreasonable to wonder: the amount of time a therapist has to spend on things outside the session – paperwork, collateral contacts (i.e. conferring with the patient's PCP, psychiatrist, endocrinologist, Methadone clinic, etc.), phone calls, arguing the insurer into paying for services rendered, waiting on hold to argue the insurer into paying for services rendered, etc. – can be huge, and none of it is compensated separately. It is explicitly, contractually included in the per-session fee. When you accept an insurer's terms, you agree that part of what you owe them for that money is all that stuff. They pay you by the session, but they're not just paying for the session. So it makes sense that people would fixate on how much time all that stuff actually takes.

But – and I say this as someone who has stayed at a clinic doing paperwork to midnight – that's a very secondary or tertiary concern.

The actually relevant question is subtly different. It's "how many sessions per week does a therapist get to do?"

There's three dimensions to the answer: schedule preferences, patient density, and non-attendence.


In another part of the same radio segment, "Single Mom’s Search for Therapist Foiled by Insurance Companies", Dembosky relates a little investigation:
To find out, we decided to conduct our own survey and called all the psychologists — 100 in total — that were listed on the Blue Shield website for Natalie’s plan in San Francisco.

Here’s what happened:

[Original cute graphic here.] We called 100 psychologists in San Francisco.

Of those, 22 never called back and 2 had wrong numbers. That left 76.

48 said they weren't taking insurance or accepting new patients. That left 28.

And only 8 had appointments after regular work hours.

The end result: 28 psychologists actually had appointments. And only eight of them had slots available outside regular work hours. Eight out of 100.

I have a whole separate post in the pipeline about the use of her phrase "regular work hours". But let's take it as given, and observe how Dembosky considers any psychotherapy appointment availability during "regular work hours" as effectively non-existant.

She's not wrong to – a psychotherapy appointment you can't go because your livelihood won't permit it is not actually a psychotherapy appointment for you – but let's look at the logical consequences of her assumptions. How many outside-of-regular-work-hours appointment times are there in a week?

When people ask about availability of appointments "outside of work hours" they usually mean weekday evenings. While Dembosky says "outside regular work hours" at the end, she describes it above as "after regular work hours". When people think of psychotherapy sessions when they're not at work, they usually think of them as being after work.

They do not, however, mean "Wednesday at 11pm", right? No, they mean something conveniently after work, for a workday assumed to end at 5pm, and have a bit of a commute to the therapy appointment. In other words, the latent assumption of when therapy should happen – the "when" had in mind by prospective clients calling therapists, looking for appointments – is 6pm to 8pm, Monday through Thursday. Since the actual therapy session takes a little under an hour, most therapists schedule them on the hour (and use the in-between time for paperwork, bathroom breaks, and checking phone messages). So, one appointment at 6pm and one appointment at 7pm, on each of four days of the week.

There are eight possible patient sessions between 6pm and 8pm, Monday through Thursday. Eight.

Let's call those the premium slots. Obviously, nobody is making a living on eight sessions a week; therapists have to try to book patients into other, less desirable, time slots.

Well, there's other times that are "outside of work hours". Maybe the therapist can convince patients to take appointments on Friday nights (another two slots), or at 8pm weekdays (another five slots), or at 5pm weekdays (another five slots). That gets us up to a total of 20 slots, half high demand, half lower demand, but still, technically "outside of work hours".

When else? Well, some therapists offer appointments before work hours. That generally means 7am weekdays. I gather those five slots are about as in-demand as 8pm weekdays. You could offer 6am and 8am weekdays (10 more slots), but they are in even lower demand. So weekday mornings yet you 5 second-tier slots, and 10 third-tier slots.

Note that working to 9pm (when an 8pm session ends) and working at 6am is kind of interesting. Few people try to do both.

What other outside-of-work times are available? Weekends. Some therapists offer Saturdays. I understand these are second- or third-tier desirability; there's basically 8 on Saturday and 8 on Sunday (9am to 5pm).

Finally, you could offer sessions after 9pm on weeknights and after 5pm on weekends. Those are fourth-tier desirability.

So, "outside of work hours" actually means: 20 slots after 5pm, 15 slots before 9am, and 16 slots on weekends, for a total of 51 hypothetical "outside of work hours" slots.

And look what working that schedule would be like: at work by 6am, having an unprofitable 8 hour gap, then working another four hours to 9pm. It is not possible working that schedule to get eight hours sleep per night. If you have any sort of commute to your workplace, either you chill your heels at your office or clinic for eight hours, or you double your commute. No days off at all – it's a seven days a week schedule. It means never seeing any of your own family who keep conventional hours themselves.

In short, it's impractical. So most therapists combine some "outside work hours" slots with slots during work hours.

This is, of course, incredibly frustrating to patients who want to see a therapist "after work hours". Those premium slots – 6pm to 8pm, M-Th – go like hotcakes, and then all the therapists have left to offer are less convenient, less desirable "outside work hours" slots, or slots during work hours.

I'm frankly astonished that of the twenty eight therapists they found taking patients, more than a quarter had evening slots. That's amazing.

Dembosky's team had to call 100 therapists to find eight who had evening hours? A little worse than one in ten? A couple of years ago, my 4pm Tuesday slot opened up, and I sat down with the clinic's waiting list. I called down ten names before I got to someone who still wanted therapy, and could meet at 4pm on Tuesdays.

Thank goodness I worked at a clinic, and so there was a waiting list. Imagining that in private practice – self employment – and having to wait through nine prospective patient contacts before getting one that could take my one schedule opening. Imagine being self employed and losing out on nine leads because nobody wants the non-premium slot you have available.

The world is full of therapists – at least the US is – and they'd mostly all be delighted to only ever see patients between 6pm and 8pm, M-Th. But you do realize, to do that, we would have to charge one eighth of our necessary weekly revenues for each of those sessions, yes? That is, figure out what the therapist needs to earn per week, and divide that by eight.

Here, I'll help: Fanny Mae used to have a guideline based on actuarial studies of consumer financial stability: one week's pay (gross) is one month's housing. Their studies showed that if you don't earn your housing costs in one week – that is, if you are putting more than a quarter of your income to housing – you're not a good risk for a mortgage that big, because you are living too close to the edge, and can't really afford one.

Right now, in the urban Boston area, studio (one-room) apartments are going for about $1,500/mo rent. So to meet the Fanny Mae guideline to be able to "afford" a minimal apartment for one's self – no dependents – a therapist would have to have earn $1,500/week.

Fifteen hundred divided by eight is $187.50 per session.

(But that's actually bogus. I just conflated revenues with income. It's actually much, much worse.)

It most definitely is not $60 to $80 per session.

And here we come to one of the ugly bits of the industry nobody talks about.

Insurance companies want to keep the number of therapists they allow to "take" their insurance products to a minimum. The obvious reason is that if there's no therapists available to treat you, they don't have to pay for your treatment, and it saves them money. The non-obvious reason is to pressure patients into taking those non-premium schedule slots.

If insurance companies took every therapist, then every therapist would be able to rely on filling exactly eight slots – anything beyond that is dicey. Therapist doesn't have a premium slot available? Go to another one. By constricting the consumer's choices to a limited roster of therapists, those therapists are in the position to say, "Look, I have 4pm Tuesday open. Take it or leave it."

This is brutal on the prospective patients, but the underlying problem isn't going away. Therapists have limited high-desirability time slots because that's all there are. The only ways for therapists to make a living are either to be paid enough for high-desirability slots that they don't need to see patients at other lower-desirability slots, or therapists have to see patients at times less convenient, or rather quite hard, for the patients.

You can compromise to some extent, but the therapist who books patients 5pm to 8pm (ending at 9pm) still has only 20 slots available per week, so now we're dividing necessary weekly revenues by twenty. So does that make $60 to $80 per session work?

This brings us to the next problem.


Imagine you are a prospective patient, and you have talked to two therapists who both tell you they're taking new patients, and who both work the same 20 evening hours – all the rest of their scheduled work time is during work hours, so as far as you are concerned, that part of their schedule doesn't exist.

One of these two imaginary therapists just started, and has no patients in those twenty time slots. "Pick any one you like," he says. The other of these two imaginary therapists is booked up to his eyeteeth. He has one of those twenty slots open.

What do you think the likelihood is that you'll be able to make the schedule work out with the therapist with the one slot? What do you think the odds are that you'll go with the therapist with twenty open slots over the therapist with one?

Or put another way, from the therapist's perspective: if your only slot left is 8pm on Friday, what are the odds that you will be able to fill it?

Schedule flexibility increases the likelihood that a therapist can meet your schedule needs. But the flip side of that is the more a therapist's schedule is booked with patients, the less schedule flexibility the therapist has; and the less schedule flexibility a therapist has, the harder it is for them to book more patients.

So there becomes this really interesting question of whether a therapist working the 20 evening sessions actually can book that twenty-slot schedule tight.

There is this asymptotic scheduling problem where the more patients you have the harder it gets to book your remaining slots.

So a therapist can decide "I'm going to work N session-slots per week", but in doing so, they're not magically going to book N sessions per week. They may, if all else is equal, asymptotically approach N sessions per week, but booking fully to N is hard-to-impossible.

(As an aside? I may have hit N on my Tuesday schedule. I am veddy, veddy close to being booked solid, and have a patient maybe coming back after an absence, and I think she can take the one slot I should have coming open in two weeks. This is me bragging. But being realistic here: two parts 133t schedulemancy, three parts dumb luck.)

A therapist's ability to book as close as possible to N, for whatever N they pick, has a lot to do with the demand for their services in their locale.

There's a lot of things, aside from desirability of schedule slots, which mediate potential clients' demand for a therapist's services. The obvious one is "do you take my insurance?" and slightly less obvious, alluded to above, is "how many other therapists around here take my insurance?"

But then there's also just straight up population density. If you practice in a big city, there are simply more people around who might want your services. This is why rural areas are starved for therapists. Way out in thinly settled areas, there often simply aren't enough human beings around to keep a therapist busy.

If you're a therapist and all you have is 10am Monday free, your odds of filling that slot are way better if you work in a city of a million than a town of ten-thousand (so say nothing of a village of 500). People here get confused by the concept of "per capita". The per capita number of therapists may actually be higher in a big city than a small rural town – that is there may be more patients per therapist in the small town – but that's largely irrelevant. If there are 10 people who want a therapist in a town of 10k, and 1000 people who want a therapist in a city of 1M, the per-capital demand is identical, but my odds of there being somebody who wants 10am Monday just went up by a factor of 100.

What all this means is that however many patient session a week a therapist is open to booking, they aren't going to get that many. They're going to have some percentage of schedule slots standing open, because getting patients into the corners of your schedule is hard. Therapists can optimize for this by sticking to the urban cores, and avoiding low population density areas – which we all generally do.

So I just answered another part of "why you can't find a therapist where you live" if you don't live in a big city.

To recap: there's a much more limited schedule of desirable slots for offering therapy than perhaps you realized, and then when a therapist tries to populate a schedule there's things that make it hard to fill.

To put it another way: Therapists can offer fewer (and less desirable) sessions a week than you might have realized. Second, of however many session slots they offer (i.e. their work schedule), they will book even fewer patients that that.

But wait, it gets worse.

A lot worse.


So let us say that, despite all the forgoing, somehow a therapist manages to book a forty-hour work week full of patients. Yes, actually has booked every one of forty slots in a week.

Therapists who accept insurance don't get paid for patients they don't see. Doesn't sound controversial, no? Allow me to explicate: all(?) insurances contractually forbid the therapist for billing the insurance company for missed appointments. Most insurance companies contractually forbid the therapist from charging the patient a missed appointment fee.

And that's just missed appointments – which, btw, are conventionally in the biz not just missed appointments, but appointments canceled with less than 24 hours notice – and those aren't the only appointments patients don't attend.

So far I have followed the conventions of how discussions of therapist compensation go: discussing patient bookings as if we were discussing the sale of magazines at a newstand.

But we are not selling individual issues – though that is exactly how insurance companies pay – we're providing ongoing services.

If I book a patient onto Thursdays, come late November, either that patient reschedules to another day – assuming I have an empty slot that works for their schedule – or I'm not seeing them one week. Or any other patient on Thursdays.

Therapists don't get paid holidays. Or paid vacation, or paid sick leave, or paid personal days. You see patients, or you don't get paid: that's true whether the patient pays cash or you're being paid by insurance companies.

But that's just therapist time off: the patients aren't usually too keen about keeping appointments on Christmas or the Fourth of July, either.

And they do things like go on vacations. They take individual weeks off therapy to deal with other things in their lives. Nobody expects patients to attend therapy every week (or on every day of their regular schedule); it would be absurd and unreasonable to.

But when your patient takes four weeks to go hiking the Appalachian Trail, their schedule slot is empty for those four weeks. It's not like they're doing you some sort of wrong. But what are you supposed to do with a slot that's just four weeks long? You can't intake another patient for that slot (unless somehow you know the patient only needs four weeks of treatment), unless you have some other provision in your schedule for the ongoing care of that patient.

So in other words, not only do therapists necessarily book fewer sessions than they offer, therapists necessarily see fewer patients than they book.

How many fewer?

That depends somewhat on your patients' insurance. There have been studies, though many have problems. I gather patients who pay out of pocket have the highest rate of attendance and patients with insurance they get through an employer have a slightly lower rate of attendance. I'm unclear exactly what that rate is.

But the one thing that has been studied the most, and is best known to practitioners, is the rate of non-attendance of people who get their insurance through the state, usually for being poor. Medicaid patients.

Medicaid patients attend, on average, about 67% of their psychotherapy sessions. Yes, studies consistently show that Medicaid patients do not attend one in three of their psychotherapy sessions.

This is not because poor people are flaky or bad at being patients or don't understand the concept of the appointment – though all those things can be true, too.

There are three big classes of reason. First off, the poorer you are, the less control you have over your schedule. If you have a low status job, you don't get to tell your boss, "No, I can't work late tonight", if you don't have disposable income, you can't just get a sitter for the kids. Second, not having disposable income means your ability to keep commitments is thwarted by how brittle the conditions of your life are to mishap: not having money to spend on car maintenance means your car is more likely to break down, and you can't just take a cab if the bus never comes. Third, sometimes – often, in mental health care – the reason someone is poor is that they have a disability, which makes it hard to attend appointments, either directly, by the symptoms impairing their ability to make the trip, or because they have so many medical appointments schedule management gets hard.

(So I've just answered the question "Why can't I find a therapist who takes Medicaid?")

This level of non-attendance is so well known in the mental health industry, that the assumption is simply that one third of sessions won't be attended. At clinics where therapists are hired "full-time", the terms of employment includes a minimum quota of patient sessions seen (billed) per week. The industry standard quota for a full time therapist is twenty-six sessions per week – because 26 is a third less than 40.

Yes, the industry assumption is that a "full-time" therapist is booking 40 patients a week, and seeing 26.

At this point, I hope you understand that the question of how much time it takes at therapist to do all the attendant work for a patient session is basically immaterial. If you're dedicating a 40 hour work week and only getting to bill for 26 sessions, it doesn't matter that it takes you one hour of every two to just do paperwork. That's okay: you have the time.


To see 26 patients a week, a therapist must book 40 patients a week. But to book 40 patients a week, a therapist must offer more than 40 slots a week. How much more? I'm not sure – I've never tried to do it.

But I know of a few therapists who simply worked 60 hour work weeks. Ten hours a day, six days a week. And yes, they attempted to book all 60 hours, though of course they could only asymptotically approach it.

As an aside, to spell out what is implied by a 40 patient sessions booked per week schedule: most insurances only allow one session per patient per week. (There are exceptions.) That means booking 40+ patient sessions per week means having 40+ patients.

And, actually, many insurances will only pay for every-other-week sessions unless the patient is very ill. To book 40 every-other-week patients per week, you need a caseload of eighty patients.

I talked to a colleague who had a 60 hour per week schedule, and he had something like 90 open cases. Ninety patients. Ninety life stories, ninety family trees, ninety evidence based treatment plans, ninety courses of treatment to keep track of. How did he do it?

Apparently – according to ex-patients of his whom I have treated – he didn't. He had no idea of whom he was talking to session to session, or what their lives were like.

Also, he burnt out and no longer works as a therapist.

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Thu, Sep. 1st, 2016 06:49 am (UTC)
siderea: Comment Catcher: Why You Can't Find A Therapist, No, Really

Comment catcher comment for catching comments.

Thu, Sep. 1st, 2016 11:19 am (UTC)
fabrisse: RE: Comment Catcher: Why You Can't Find A Therapist, No, Really

I'm pretty sure 26 is ~2/3 of 40 not 1/3.

The big problem I have with KP insurance is the 5 - 8 p.m. slots are scheduled for groups. And you know how I hate mornings? I still managed weekly therapy at 7:00 a.m. because it only made me take 1/2 hour off work. All the other appointments would have cost between 1 & 3 hours of sick leave. My boss let me work 1/2 late on therapy days, so no sick leave charged.

Thu, Sep. 1st, 2016 11:29 am (UTC)
fabrisse: RE: Comment Catcher: Why You Can't Find A Therapist, No, Really

Addendum: The other two issues which need to be addressed from the patient side are:
1) Bosses don't take therapy appointments as seriously as dental appointments (much less an oncology appointment) unless one has had a demonstrable mental break.
2) Health insurance will only cover 10 non-group appointments per year with an extension of up to 20.

By the way, the department of Health and Human Services is currently taking comments on how insurance covers mental health. I went into great detail on point 2.

Thu, Sep. 1st, 2016 11:28 am (UTC)
nuclearpolymer: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

This is a wickedly difficult logistics and schedule match up problem.

At first, it would seem like prime-time versus non-prime-time pricing would make sense, but then it seems like the people who could least afford to cope with an inconvenient time slot would get stuck with them.

Do you see any movement toward telemedicine for these kinds of services? Providers could treat patients outside of their own time zone, and match schedules from a large online pool. Or would video calls be so much worse than in person that it doesn't make sense? Not every patient or provider has video conferencing facilities, but one could imagine medical service facilities setting up spaces for such use.

I was going to ask you if the same dynamics of having trouble filling all the slots was relevant to other healthcare providers, and then I realized that there is a big difference between scheduling for a once-a-year providers and once-a-week providers. Someone is more likely to be able to take a morning off, or rearrange their normal routine, to see a once-a-year provider than a once-a-week provider. So now I'm trying to think what are other types of once-a-week providers...I guess things like visiting nurses or dialysis are often more than once a week and treating patients who aren't regularly working.

Thu, Sep. 1st, 2016 12:54 pm (UTC)

I had a long course of sports physio after an injury last year; that was once or twice per week for 6 months. From asking about different appointment times I gather that the physio I was seeing had booked almost all available appointments (The best I got was plausibly in my lunch break, mostly I had to take time out of work).

Thu, Sep. 1st, 2016 12:55 pm (UTC)
m_danson: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

Or would video calls be so much worse than in person that it doesn't make sense? Not every patient or provider has video conferencing facilities, but one could imagine medical service facilities setting up spaces for such use.

I did some mediation training via video conferencing both as a student and as an instructor. The program I was associated with accepted out of town, province, and country students so we tried to make it work (both using home systems and a classroom system). In the end (to the best of my knowledge), most out of town students elected to pay to come to the school for practice sessions or dropped out.

Some of the issues we encountered included:

- Technical reliability is expensive (and mostly wishful thinking). The connection is only as good as its weakest link and technical problems happened in almost every session (even with school equipment).

- If students had to go somewhere to use the equipment then they had the same scheduling issues as if they were coming in person. If they used home equipment, they had to both have it and be able to trouble shoot themselves (also, they still didn't do it during work hours). As far as I know, nobody called in from their place of employment.

- Ensuring security and confidentiality was a nightmare. We didn't ensure it. Beyond unsecure connections and not always being able to know who was in the room/chatting via text... video conferencing software often has recording functions. Sometimes these non-obviously default to "on".

- I'm in STEM. Most of the other people in the program were not. I was vastly surprised at the degree of technophobia or technical ignorance that is normal in a non-geek, non-stem population. (Generation and previous employment history also seemed to matter here.)

- Even if everything worked, there was still sometimes issues with body language. If someone is looking into the camera, then they usually can't see the video of the other person (and vice versa). Also, if the user can see themselves in video time they sometimes start acting like they are watching themselves in a mirror (which they effectively are). All of this can produce some weird effects on body language interpretation and presentation. Having one person on a laptop while the rest of a group is in person also creates some comfort preferences in who gets the most attention.

I think all of those have technical or practice-until-comfortable solutions. However, in my experience, the problems turned out to be larger and more complex than expected.

Thu, Sep. 1st, 2016 02:15 pm (UTC)
nuclearpolymer: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

The main scheduling advantage would be the ability to schedule an after normal work time slot for a client and a during normal work time slot for the provider by taking advantage of time zone differences, and by being able to match up across a much larger pool. I found that when I was looking for a language tutor, it was much easier to find one online due to those reasons.

But I definitely agree with you that the ease of use of video conferencing is still not great...though I hope that with so many consumers using apps like Google Chat, Facetime or Skype, that should improve. (As long as one is willing to accept less security.)

Thu, Sep. 1st, 2016 08:01 pm (UTC)
londo: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

I'd expect that the time zone differences would be bad. It opens up scheduling options, but it adds extra social distance (in the normal ways re: body language and such) and also adds potential cultural distance, which seems like it would be a bigger deal than usual with a therapist.

I mean, as it is I know people in Boston constantly looking for a poly-and-kink-friendly therapist - I assume that finding one outside of this bubble is Real Hard.

Thu, Sep. 1st, 2016 02:13 pm (UTC)
fabrisse: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

Speaking as a patient, not a therapist...

I've done long distance therapy. It can be a useful stopgap. For instance, my mother is a major stressor and I had a scheduled phone appointment during a visit with her which helped immensely. When I've been in crisis, knowing that I can call (and once actually calling) were life saving.

But when I tried to do it longer term, pre-video, it didn't work well at all. I was able to put on a happy voice when I just wanted to get through the call quickly. I had times when I was doing well where my therapist didn't believe me. Even with the video aspect added, it's much, much easier to present a facade through a camera than it is in person. No one will see your foot twitch with anxiety, for instance; that can't be hidden in a face-to-face session.

Thu, Sep. 1st, 2016 02:42 pm (UTC)
dr_tectonic: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

Physical therapists? I have colleagues who work from home for part or all of the day fairly frequently because of PT appointments.

(This is in response to nuclearpolymer's comment; I mention it because the threading layout is being non-obvious.)

Edited at 2016-09-01 02:45 pm (UTC)

Thu, Sep. 1st, 2016 06:48 pm (UTC)
fivebluestones: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

Speaking as a couples therapist in private practice who does not accept insurance (and who has enormous compassion for those who do), I definitely use prime-time vs. non-prime-time pricing. Otherwise, I'd have nothing to do all afternoon. This way, people who care about pricing find ways to come during the day, and those who don't pay a substantial surcharge for the privilege. (Insurance companies don't allow variable pricing.)

Also, while I dislike the experience of teletherapy via video -- it's harder to read tone of voice and I get more tired -- I have noticed that London couples are another great way to fill those afternoon slots.

Mon, Sep. 5th, 2016 12:56 am (UTC)
mellyjc: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

One problem, at least in California, with the telemedecine idea, (outside of different ability to hold the space for someone in crisis, ability to make it safe to do deeper work and leave the stress of whatever work/home environment may be present, etc)

As and LMFT it is a state license. Meaning, I am not legally able to provide services outside of of California/in any other time zone. I do know of some counselors who practice internationally, with countries that do not regulate counseling practice. Otherwise, I'm legally advised that telemedicine with a client who is on vacation or residency outside of the state of California puts me as technically practicing illegally.

I haven't done too much of it myself, but I can envision, even outside of actual effectiveness, a diminished sense of return on investment with therapy of this nature.

What's scary to some of us is that this dynamic creates a push for change of title. Life coaching is an unregulated field- can (and usually do) practice via telemedicine. Anyone can call themselves a life coach, with NO training on how to handle a client in crisis with suicidality etc..but there is also less liability if something bad happens. And despite the lack of training, malpractice insurance, overhead from working online, etc, they seem to receive double per hour what licensed clinicians do.

And what's sad, is that this whole dynamic of having to settle for mediocre pay is totally ingrained into the field (or at least this license tract). Many interns work 3000 hours for NO pay, so receiving ANYthing seems like a miracle. Some think insurance is a must just to get clients, and working 3 jobs or 60 hours is just standard and accepted. But, working two other jobs, further limits a the availability to clients.

Mon, Sep. 5th, 2016 04:11 pm (UTC)
nuclearpolymer: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

I have often thought about how weird it is that there are some totally unregulated fields like that, where someone could be performing a similar service. Dunno if it is essentially analogous to the regulation of medicines versus the non-regulation of supplements.

Thu, Sep. 1st, 2016 12:02 pm (UTC)
cvirtue: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

I am so very lucky that the person I accompany to mental health appointments has a very flexible schedule, so we can see high-level specialists during normal working hours. Even if this person tends to freak out on the subway...

We also go to afternoon appointments more locally that have a lot of Medicaid/MassHealth clients (I assume, based on the prolific postering of MassHealth info sheets & infographics on the waiting room walls.) I see a lot of adults go in to their sessions with small children in tow. At some point, these kids will be too aware of what their parent is discussing, and then childcare will get very problematic. (My estimate is that the kids will start getting concerned by age 6 or 7, which is too young to leave them by themselves for an hour, even for a not-paranoid-of-everything parent like myself, and this is rare.)

Sat, Oct. 1st, 2016 05:16 am (UTC)

My child would have started getting concerned in my therapy sessions around age 3.5. This may not be standard, but I cannot imagine doing useful therapy with my child in the room past about 12/18 months.

Thu, Sep. 1st, 2016 12:28 pm (UTC)
lyorn: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

Hm, yes, I was wondering how one would get to 40 hours a week when answering the income question. Jobs at in-patient clinics came to mind, or working with people who do not have jobs (kids, refugees, unemployed, long-term sick, retired, dying). The therapists I know who do private practise and see one patient at a time are somewhere in the "5 to 8 per week" range.

Thu, Sep. 1st, 2016 01:03 pm (UTC)
herbivore: RE: Comment Catcher: Why You Can't Find A Therapist, No, Really

Next time someone asks why I work for a UCC instead of in private practice, I'm just sending this link instead of trying to explain it myself.

Thu, Sep. 1st, 2016 02:15 pm (UTC)
fabrisse: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

Universal Commercial Code?

Thu, Sep. 1st, 2016 11:14 pm (UTC)
herbivore: RE: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

University counseling center. We don't take insurance, the student health fee pays for whatever services the student uses, and we work 8:00 to 5:00. It's not without its drawbacks, but it avoids almost all of these problems.

Fri, Sep. 2nd, 2016 12:54 pm (UTC)
fabrisse: Re: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

Thank you. I googled and that's what I got, but it didn't make sense in context...

Thu, Sep. 1st, 2016 08:02 pm (UTC)
londo: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

United Church of Christ?

Thu, Sep. 1st, 2016 11:14 pm (UTC)
herbivore: RE: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

University counseling center. (See above.)

Thu, Sep. 1st, 2016 02:21 pm (UTC)
jadia: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

I'm curious - do you have stats on your own practice regarding attendance rates?

Fri, Sep. 2nd, 2016 05:01 am (UTC)
siderea: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

Yeeeeit's complicated.

I have been working at two clinics and I have my own private practice. At one of the clinics, I have stats, but they are messy (for one instance, they're out of date). At the other, I haven't been keeping my own because they allegedly keep them, but I haven't figured out where they keep them, so that may be about to change.

I haven't bothered to compile stats on my private practice.

Thu, Sep. 1st, 2016 06:43 pm (UTC)

Ninety patients. Ninety life stories, ...

Ninety opportunities for a patient to hit a crisis and need a lot more therapist time and support. The odds on that -- and how the therapist will handle it -- I imagine vary wildly from patient to patient and therapist to therapist.

Fri, Sep. 2nd, 2016 12:05 am (UTC)

My 40k-in-Seattle estimate came about as follows:

50 weeks a year
$80/session; therapist gets half (and the rest goes to landlords and middlemen, as usual)
each session takes the therapist 2 hours (a visible hour and an invisible hour) = 20 sessions/full time week

50*80*(1/2)*20 = 40k

Sanity check: does this correspond with the lifestyle of therapists I know in big cities? (Yes.)

Fri, Sep. 2nd, 2016 12:14 am (UTC)
alexx_kay: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really


"any psychotherapy appointment availability outside of "regular work hours" as effectively non-existant."
'outside' should almost certainly be 'INside'!

"as a lot to do"
"as" should be "has".

Extra i

"some how"
I think that should be a single word.

"26 is a third of 40"
Rephrase due to math error.

"I gather patients who pay out of pocket have the highest rate of attendance"
Anecdotally (n=1) patients who are aware of the provider side of this equation (e.g., through reading your posts) are MUCH more likely to make it to appointments than they were previously.

Fri, Sep. 2nd, 2016 04:48 am (UTC)
siderea: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

Re editorial – thanks, all fixed!

Anecdotally (n=1) patients who are aware of the provider side of this equation (e.g., through reading your posts) are MUCH more likely to make it to appointments than they were previously.

Believe it or not, one of the things that inhibits therapists telling patients about this side of things is the fear that patients may skip appointments, either deliberately or unconsciously, to punish the therapist. There are types of therapist (in the psychodynamic tradition, particularly) who do things that elicit latent patient aggression/hostility towards the therapist, to be able to explicitly address it. I think they're particularly concerned about informing patients of the power money gives them to reprise against the therapist.

But I also think that's an expression of an unfortunately common neuroticism in therapists about patients. I think there's plenty of therapists who are a bit afraid of their patients, or feel insecure and defensive about what their patients might think about them. I mean, if your first thought about telling your patients about how the money works is, "But then they might decide not to pay me out of spite!" that's.... telling. Of something.

I have a different concern. As I wrote, I'm not (too) concerned about patients not making appointments due to not taking them seriously or reprising against me or any such emotional reasons. Often patients miss session for reasons largely outside of their control – and often enough, when a mental health symptom is involved – deeply humiliating.

When an adult with ADHD misses their appointment with me because they carefully put the appointment in their phone, but then lose the phone, I can pretty much guarantee their inner monologue about this sounds something like, "–I am such a fuck up I can't believe I did it again I'll never do anything right I flunked out of school because I'm so stupid and now I'm flunking therapy–" I don't want to tell that person that their missing their appointments hurts me in a bid to increase their motivation not to miss appointments. They already have all the motivation they need. I don't need to guilt-trip them; they're already doing a smashing job at doing it to themselves. At best, my doing so will just make them feel more bad about something they already feel terrible about.

Same thing when someone misses an appointment due to depression, or anxiety, or psychotic symptoms.

Same thing about physical conditions.

Same thing about poverty. Same thing about being in an abusive relationship.

I have some patients who know how the money works; I did have one patient in particular who I felt was missing appointments needlessly because (I surmised from something she said) she imagined that I was on salary and her not showing up was reducing my workload without reducing my pay. As it happened, she had herself worked as a hair stylist at a salon, which is exactly the same. So I explained it to her. "If the chair is getting cold, I'm not getting paid." Her eyes got very wide. And her attendance got very good.

Fri, Sep. 2nd, 2016 10:56 am (UTC)
lyorn: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

did have one patient in particular who I felt was missing appointments needlessly because (I surmised from something she said) she imagined that I was on salary and her not showing up was reducing my workload without reducing my pay.

I know that thought. Was more like, "therapist is probably tearing out her hair about me being a not-sick-enough, only-sorry-for-herself drama-queen fake whose babble she has to listen to for 30 minutes. Better for all involved if I just stay in bed instead of going." though.)

(As that was student counseling, I was pretty sure that she was on a salary, so I constructed another counter-argument to get going.)

Sat, Sep. 3rd, 2016 06:45 am (UTC)
brooksmoses: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

Yeah -- honestly, I find the fact that my therapists have had clear no-show policies that still require full payment if I don't cancel ahead of time to be very useful in avoiding that part of the guilt trip. But then mine have all been in independent practice where I was quite clearly writing a check with their name on it, so that part of the money flow was pretty obvious. And I'm lucky to be in a position where that payment doesn't hurt too much.

Mon, Sep. 5th, 2016 01:00 am (UTC)
mellyjc: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

This is what I see much more of (the guilt for asking reasonable pay thing).

I'm a little horrified every time I see on Facebook someone posting, "X client canceled, they totally told me to go ahead and charge the cancellation fee...should I charge them?"

Mon, Sep. 5th, 2016 12:37 am (UTC)
mellyjc: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

To say nothing of the fact that, in CA, there is the highest number in the country (last I checked) of LMFTs (as opposed to LPCCs or other licenses) and LMFTs are still not even accepted as medicaid payees. LCSWs can, but CAMFT is still fighting for LMFT approval, if I have my info straight. So, even if we wanted to accept the ridiculously low compensation, we CAN'T.

Medicare (called Medi-Cal, here, because California insists on being a special snowflake in many regards), pays different depending on county. When I researched it here, it was $76. My friend a few counties away at least gets $102. When the client shows up. The more I talk to her and the more I hear about the no-shows, the more glad I am that I don't take insurance that limits the charging for missed session fees. Even if I don't do it, (lately I've tried and apparently have received bum credit card numbers, hmmm) it seems to reduce the number of no-shows.

Thanks for writing this. It's a little technical for some people, but I'm inclined to want to link to it on my website somewhere. Looking forward to the additionals.
(Deleted comment)

Wed, Sep. 7th, 2016 01:43 am (UTC)
siderea: Re: Comment Catcher: Why You Can't Find A Therapist, No, Really

32? Dayum. Looks like they expect 50 patient bookings a week.

Thu, Sep. 1st, 2016 05:35 pm (UTC)

There's also, of course, the fact that $60 to $80 per session is not $60 to $80 of net pay to the therapist. I don't know your actual numbers, but if it's like anything else I've seen, overhead costs of 50% are a plausible ballpark, yeah? There's rent for the office space, and there's paying for various continuing-education class requirements, and bill-management software, and I'm sure there's ongoing certification stuff that's not free, and so on and so forth. Oh, and all the self-employment tax stuff that's not a part of normal corporate salaries, and health insurance.

Thu, Sep. 1st, 2016 06:07 pm (UTC)

That would be a fair summary of Part 2, yes. :)

Fri, Sep. 2nd, 2016 11:46 pm (UTC)

There's also the element of, we don't actually keep that $60-80/hour - we spend half of it on business expenses and self-employment taxes.

Tue, Sep. 6th, 2016 11:20 pm (UTC)
(Anonymous): Can these numbers be right?

In Ottawa, I believe the going rate for a psychologist is about $200 per hour. The city is full of civil servants who get $2000 in psychological services a year and who have a flexible work schedule and so can attend daytime appointments. The patient pays the psychologist and is reimbursed from insurance so if they miss an appointment they have to pay themselves out of pocket ( I assume though I am not sure of the policy if they submitted a claim).

I guess my question is whether Ottawa is a psychologist's utopia or am I missing something from your article where it appears Californian psychologists are just scraping by. Is it a licensing issue? Canadian psychologists have to have doctorates in clinical psychology.

Wed, Sep. 7th, 2016 01:54 am (UTC)
siderea: Re: Can these numbers be right?


Not all psychotherapists are psychologists.

One does not need to be a psychologist to be a psychotherapist in Ottawa.

Indeed, I expect an Ottawa psychotherapist who is not a psychologist to be along momentarily to have words with you.

Canadian psychologists do not all have doctorates, because Alberta is special.

An Albertan with a master's degree who is working toward her credentialing as a psychologist may also be along shortly.

I'm also pretty sure that even psychotherapists who are psychologists in Ottawa and have doctorates are not being paid $200 per session by insurance companies or other third-party payers.

Two thousand divided by two hundred is ten.

There's probably a third option besides Ottawa being the "psychologist's" utopia you think it is or that you have missed something from the article.

Thu, Sep. 15th, 2016 03:36 am (UTC)
qualmish: Re: Can these numbers be right?

OHIP appears to pay $80.30 per half-hour of psychotherapy. It looks like you could book patients every 46 minutes and still be able to bill $160.60 for each 46-minute block, such that a sufficiently motivated person could effectively bill $209 per hour. A psychiatric "consultation" does appear to be about $200, though outpatient "psychiatric care" is back to the $80.30-per-half-hour rate. It does not seem to mention who would be performing the services. ( http://www.health.gov.on.ca/en/pro/programs/ohip/sob/physserv/sob_master20151221.pdf ) (I am still extremely amused that OHIP pays for narcoanalysis.)

Mon, Dec. 19th, 2016 06:27 am (UTC)

Your essay is referenced in Sane Thinking About Mental Problems.