MyTherapistNewYork

We do not accept insurance- And here is why…

Right now there is a discussion on one of the mental health groups on LinkedIn about the problems with the DSM and using insurance in therapy.  I wanted to share a few of the exchanges here in response to a post by Hilding Ohrstrom, LCPC:

To DSM or Not to DSM, that is the question…..

Earlier in my career, I used to think the DSM process was a terrific one that helped to ensure we were talking the same language. I am no longer convinced that is true. Now I see children taking atypical meds when nothing else has been tried, anxiety misdiagnosed as ADHD, children diagnosed with bipolar, seniors medicated with anti-psychotics because they disagree with nursing home staff, normal grief mis-diagnosed as major depression, recurrent severe, drug dependence misdiagnosed as bipolar…..and the list goes on. It seems to me that if the DSM process is so central to the work as it has seemingly become, that the assumptions underpinning it should be re-examined. Otherwise we may be doing the equivalent of putting brakes on a truck that has no engine or transmission. There are many books on shelves. That does not mean they are good books, just that they exist!

My response:  I used to be leery of the “coaching” model, where people with who knows what as training could be doing “therapy”. The longer I’m in practice, though, the more I find myself moving away from the medical model, and more to the “coaching” model. I’ve made my rates all on a sliding scale, am moving away from working with insurance (and educate my clients as to why), and I focus on doing good, evidence-based work with my clients that has little to do with anything in the DSM. I feel like 10 years of practice has led me to the conclusion that, at least in my own experience, that people largely aren’t mentally ill, but when stressed, find all sorts of unhealthy ways to cope. I don’t need to call it adjustment disorder and get 60 bucks from an insurance company, when I can do the same work without putting it into a medical/pathological paradigm.

New Zealand Psychologist Amberley Meredith responds:  Michael I quite agree with all you have to say, even down to the leery view of coaching I once had, I now see what gifts it has to offer us and I am afraid bits of paper saying someone is a psychologist has never meant they are a sound and well balanced clinician. You get dodgy people in all trades and services, a far better measure of someone’s skill is not in what they study, but in what they know, how they feel and their people skills.

I think mental illness is exactly as you say, it is not more than a breakdown in the body of energy and this energy has some how become corrupted or interrupted, this then impacts the transmission of signals in the body that then impact on our cells, which impacts on our ability to create proteins that create behaviours, which create feelings. I have been loving the work of Bruce Lipton and neuroplasticity of late and the concepts of retraining our brain and cells through changing our environment and thoughts to create a better existence for ourselves. It is so far removed from the ‘pathology & diagnosis paradigm’ and just like the cosmic joke when they thought the atom was the smallest thing and they had done all that was needed (until they split it), I think pharmaceuticals are and will go the same wat, it is a great cosmic joke to think they are the ultimate and final stage of cure/control.

Why would we need a DSM if there was no mental illness to diagnose in the first place?

I continued with: … people sometimes have a need to say oh, it’s not my fault, I’m a/ or I have______ (blank being alcoholic, bipolar disorder, sex addict, PTSD, etc).
I can see how using a label can alleviate some symptoms, but on the other hand, it seems like people then just get stuck with that label and don’t do much to “cure” themselves.

I’m not saying mental illness doesn’t exist. I am saying there is much too much emphasis on pathologizing rather than coping. Needless to say, I don’t put much stock in the DSM or 12 step, as those “treatments” seem to only deal with symptoms, not underlying inability to cope with, well, being a living human being.

Easier to say, “Hi, this is my daughter with aspergers or adhd”, rather than feeling like you have any part to play in this child’s ability to cope and thrive.

Amberley Meredith responded:

Diagnosis is an anchor, it’s not a sail that can take you wherever you want to go, like the Harbour of good health. The anchor weighs you down and makes you stuck, immobile. Reality is constantly moving, if you are not moving and are stuck then you stay where you became stuck, i.e. if you were well, then got sick, then anchor in the diagnosis of being sick you will stay moored in sickness, as opposed to being like reality and moving into wellness.

It’s not to say your reality is not true, it is not to say the pain and feelings don’t exist of course they do. But you can choose to say “I am worthless and would be better off dead, I have depression” or you could choose to say “right now my feelings are showing me that my life is not what I want, therefore I am going to work out what I do want and then work out how to achieve it”. Reality is not a static diagnosis; it is a living breathing thing that can change in any given moment.

There is no such thing as mental illness, there are just a periods in your life when you are not feeling great, when you are adopting some poor coping mechanisms and your feelings are signals telling you this and that you need to make some positive changes.

The DSM probably started out with all the best intentions, just like the chemists who created most drugs, however, big business got in the way and now global corporations have far too much influence and control. I believe drugs have a place… largely in making drug companies more money and the DSM is their new sidekick.

I find it immensely funny and noteworthy that I lost my own copy of the DSM about 7 years ago and have not since replaced it. I think this tells me quite a lot. Our world loves to define, classify and systematize things in order to understand them. But the essential problem with this approach is that it makes the thing static and unable to evolve organically. Which humans do, they evolve, they change. How can we use rigid systems to describe life, that is constant flux and a state of transformation? It is wholly inappropriate and irrelevant.

An emerging model that permits and allows change is Existence Medicine, where people are seen as individual, human beings, treated with intimacy, breath and touch, acknowledging all levels of existence (physical, psychological, emotional and spiritual) and how the levels interact and affect one another. The premise is one of stimulating self-actualization, growth through understanding and change through compassion.

Categorization means you are putting limits around it, defining it, therefore it should be surprising that a classification of mental health like the DSM has its limits. I always cite the fact homosexuality was still in the DSM into the 1980’s as a mental illness, this book is not the final destination, it may be useful sometimes to understand what a cluster of symptoms might mean and how this cluster of symptoms might be helped. But also sometimes its just plain wrong.

That said I think the DSM is only part of a bigger problem. the bigger problem is the humans who are mis-using it.

I wanted to share a bit about what other therapists were saying about this topic to really get people thinking about the ramifications of being part of this system before insisting that their therapy involve a mental illness diagnosis and insurance reimbursement.  Thanks to Hilding and Amberley for letting me include their thoughts here.

Before using in-network or out of network insurance benefits for counseling/psychotherapy, find a therapist who works on a sliding scale.  Don’t be afraid to do some short-term, effective, work.  Don’t be afraid to ask your therapist how long they expect to have you in therapy.  We’re all in this together!

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We do not accept insurance for therapy-  And here is why.

People don’t generally expect therapy when making out their budgets.  They really don’t expect it when they have insurance coverage that covers medically necessary treatments.  For these treatments to be covered, the clinician must give you a medical diagnosis, which becomes part of an elaborate trail of paperwork (sometimes electronic) that includes any number of people involved in getting your insurance claim from the clinician to the insurance panel, and getting payment from the insurance panel back to the clinician.   While the system has its flaws that are too many to discuss here, it does generally work if you are lucky enough to have great medical coverage, and have something like strep throat.  It does not, however, have your best interest in mind when working with mental health clinicians like marriage and family therapists and mental health counselors.

I am an outspoken critic of the book that we in the mental health profession are expected to use in our work with clients called the DSM (The Diagnostic and Statistical Manual of Mental Disorders) put out every ten or fifteen years by the American Psychiatric Association.  (Interestingly, there are no statistics included in this book, despite its name.)  In it, are lists of what psychiatrists have voted to define (based on research?) as mental illness.  Nevermind that psychiatrists are medical doctors trained in biological brain diseases, not usually  psychotherapy, sexuality, couples therapy, substance abuse, eating disorders, autism, or any other topic included in the wide field of psychology.  Yet the entire field of psychology is forced to use codes from this book, to diagnose you with a mental illness, if you want to have insurance pay for part of your therapy, even if your therapy does not include treatment by a psychiatrist/physician.

Let me make it a little more clear to you by giving some real life examples.  You know all those gay kids killing themselves because they are getting bullied?  Well, if they come to therapy, I have to give them a diagnosis, probably related to depression or something called “adjustment disorder”.  So it’s not the little shits DOING the bullying that get the diagnosis, but the victim. Interested in couples therapy because your partner cheats on you?  Are you the one that calls the office to set up the sessions?  Then you are called “the identified patient” (or IP), and the “medical chart” at your therapist’s office will be opened in your name.  If you are the one with the insurance, then you are the one who will receive the mental illness diagnosis.

If you are hearing voices, or know someone who is severely depressed and fear for your safety or theirs, by all means, call 911 or check our your nearest psychiatric emergency room.  But by and large, these aren’t the folks who are going to therapy, many of whom just have problems coping with all the obstacles that come with being alive, and it is unfair for everyone involved to make them fit into a psychiatric/medical model.

Instead of using insurance for therapy, my solution has been to offer psychotherapy/counseling/coaching (whatever you want to call it) on a sliding scale.  This means that I accept a range up to what I consider to be ethically acceptable as the maximum fee (in NYC, my fee is $150, and if you do a bit of searching, you’ll find that some other professionals charge rates that are much higher).   Your rate is calculated based on the number of people in your household and your annual income, and starts at $40.

This is my calling, and my passion, and if I could do it for free, I would.  But I went to school for a long time to be able to practice my profession, and have to pay my bills, too. ( I do not want to be part of a system that emphasizes illness and not wellness, and truth be told, the amount that I would get paid from any given insurance company is not worth the hassle, anyway.) So to make my living (and pay back those student loans), I offer realistic therapy with results.  You track your progress.  You see if you are getting better at dealing with what you came in to deal with.  If you’re not getting better, why would you stay with the same therapist for years on end?  If your therapist can’t tell you exactly their plan for helping you, what are you paying them for?  If you ARE getting better, then why do you need to stay in therapy forever?  I believe so much in what I do, I have developed my practice as a training practice to offer therapists-in-training experience in offering effective, ethical, solution-focused and evidence -based counseling.  (And since 2005 have supervised no less than 30 new therapists, many of whom are now my competition.)

Chances are if you are reading this, you are not mentally ill.  Maybe no one has ever told you that before, even.  I do hope this series sheds some light on the subject of using insurance coverage for therapy, and I hope that you will want to read more about my practice and how we can help you be who you are.

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