How Finding a Therapist is Like Visiting a Dating Site (Only Worse)

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You didn’t want to. In fact, you tried everything to avoid it. Nothing worked. Now you will do the thing you never thought you’d do: go to therapy.

Here is what you weren’t told about the people who guard the gate to the counselor’s couch.

You didn’t know the entrance was guarded? Few therapy-virgins do. Most people have a better idea of how to buy a car than how to obtain a counselor. What’s more, car research is interesting and test-driving is fun. When you are in the market for an auto, your head is relatively clear. You know your budget. You understand safety ratings. You owned a car before and drove it thousands of miles.

The search for a head-shrinker is different. You are depressed, anxious, confused, grief-stricken, or all the above. Perhaps a crisis is occurring. Perchance you lost your job, your dog, your lover, or your parent. Losing your mind is next. Now you must get a grip and research a therapist.

The best of us are not at our best under the pressure of pain. Patient study is compromised. You want help now. You ask a friend or your primary care physician for a referral. Or you call the insurance company because your informational booklet so advises.

Ringing them up is a bit like phoning your mum and asking her to fix you up on a date. Her list of priorities in making a match is different from yours. To the good, we hope she cares. But her agenda is not your own and her judgment is suspect. Indeed, she resembles the gate-keeper to whom you will speak when you call the number on your insurance card.

Let’s say you or your employer purchased medical coverage through Fly Right Insurance Group of Historic Transylvania, aka FRIGHT. Remember when your brother told you he was afraid of FRIGHT? He was right.

FRIGHT’s rules are typical of most, but not all of those created by the insurance industry.

The voice on the other end of the toll-free number asks you a few questions and appears most concerned about where you live and work, how far you are able to travel, and getting to the next person in the phone queue. Unless you are suicidal, that is, in which case you are told to go to the ER.

The process of personal disclosure you’ve begun will most likely continue, with the counselor’s assistance, once you are in treatment: the world of Big Brother welcomes you. Your initial conversation can be recorded, coded, and kept in your medical file. Indeed, the U.S. government can take a look at some of your therapy records if it believes national security is at stake.

I am not making this up.

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The insurance employee offers you a few names or directs you to the “providers” listed on their website. Beware the word “provider.”

The noun suggests FRIGHT views therapists as no different from any other member of the service industry — for example, a man who is going to “provide” you with a paint job, a shoe shine, or dry cleaning. FRIGHT seems preoccupied with the commercial transaction involved in obtaining treatment — the cents and dollars at stake.

The word also seeks to knock the doc off his pedestal. “Doctor” is almost a mystical noun, complete with associations to being a good parent, an all-knowing chief of the tribe (“medicine man”), and a wonderful soul who can be trusted with your life. A provider, by contrast, is just another guy trying to sell you his work. No knock on those who shine shoes, but I imagine you’d want your insurer to be more concerned with the quality of the therapy service than the brilliance of your shoe shine. Their choice of terminology makes you wonder whether they do.

In general, the panel of practitioners is limited. The insurance firm’s protocol is the same when you sustain a car accident and need to take your vehicle to a repair shop. In both instances you are given a reduced group from which to choose. In the former case, you receive the names of those therapists with whom FRIGHT has a contractual agreement. The same is true of auto repair establishments. A similar written commitment applies to them.

It is important to understand why FRIGHT created its own panel (network or list) of shrinks. Equally, you will be curious why those same counselors (or auto body shops) agree to the insurer’s conditions. For each party, financial concerns drive the process. While insurance companies usually indicate that the contract’s conditions have been “negotiated,” FRIGHT and most other insurers operate on a “take it or leave it” basis.

The shrink promises to discount his fee in return for being on the list. There are three factors at play with respect to fee reduction: one benefits the insurance company, the second helps the patient financially (but reduces his choice of therapists), and the third is in the interest of those providers who agree to the insurer’s terms, but not without a cost to them:

  1. The insurance company’s payable portion of the fee is reduced. In other words, if the full value of a therapy session is $150 and the insurer pays 80%, FRIGHT would have to lay out $120 per session. But, if the charge is discounted to $100, the company’s outlay is only $80 ($100 x .80). The insurer saves $40.
  2. Similarly, the patient’s part of the bill is also reduced. He is responsible for only $20 (20% of $100) instead of $30 (20% of $150). In other words, the client saves money IF he goes to a provider on the approved list. If not, he discovers the policy will pay a lower percentage of the fee for out-of-network professionals. This has the effect of saving the insurer money on fee payments to those individuals and discouraging the patient from selecting anyone who has not been impaneled, costing him more to visit.
  3. Why would a therapist agree to a fee-cut on the order of 33%? (The size of this reduction is not unusual, by the way. It can be more or less). The answer is simple. He wants the referrals: a flow of new patients he anticipates from having his name among those recommended by the insurance company. By receiving more referrals he hopes to offset the reduced income due to his discounted fee.

All of this demonstrates that therapy is a business as well as a healing art, treatment is expensive, and the proliferation of shrinks (especially in big cities) causes competition among them. Economic times have diminished the ability to pay out-of-pocket for treatment. Both the insurer and the patient have an interest in reducing costs. The patient is constrained from being treated by anyone he might choose, but is compensated by a lower per session therapy cost and a lower insurance premium. The counselor would benefit if he could keep his fees high, but is willing to lower them if he can fill his schedule with more patients provided by the insurer.

None of this focuses on quality of care. FRIGHT does not make a strenuous effort to evaluate the skill of their “providers” (admittedly a difficult task). They don’t know whether the people they refer you to are the best in their field, average, or below average. Beyond the confirmation of the practitioner’s license to practice psychotherapy and an absence (probably) of discipline by legal authorities or ethics boards, you are on your own in determining his excellence.

For the most part, insurers take a therapist’s word for his expertise. He states his range of skills: diagnostic evaluation, cognitive-behavioral therapy competence, psychodynamic treatment experience, etc. The qualities are simply checked-off by the therapist from a list required by the insurer.

What you are dealing with, then, is something like the self-descriptions on a dating site. We know how trustworthy they are.

The dominating dictate of the dollar determines which therapists you are encouraged to consult by your insurer. Money is also a significant consideration for the therapist, who not only takes a smaller fee if he wants to receive potential referrals, but agrees to other conditions FRIGHT will impose on him once you walk through his door. He creates a description of himself according to FRIGHT’s guidelines. You are expected to take him at his word, just as you are expected to take your insurance company’s word that the list they have created is comprehensive and the professionals on their website are adequately vetted and good at what they do.

Incentives exist for both parties (the impaneled therapist and the insurer) which have nothing to do with your treatment. Those motivations go beyond your well-being and are sometimes in competition with your well-being. If you don’t pay attention to them, no one will do this for you other than your suspicious brother who warned you about FRIGHT.

I should point out that without such cost-saving mechanisms, the price of psychotherapy would be higher than it now is. Decades ago insurance firms discovered how they could artificially restrain costs and guarantee profitability by so doing. In the process, they dampened the increase in health care costs for their customers, but also limited their choice of doctors, ancillary health care professionals, and hospitals.

Many practitioners are driven to discount fees as a simple matter of economic survival. Most would prefer not to deal with insurance matters at all. A small number refuse to submit claims and have flourishing practices nonetheless.  Such, however, is not the typical reality of delivering the services for which treaters trained. Your therapist’s calling to help humanity probably did not include a vision of the red tape involved.

The intervention of insurance giants in the counseling marketplace and their influence on treatment is not limited to what I’ve described. Additional concerns come into play once you reach the inner-sanctum of the therapist’s office. The long, tentacle-like arms of insurance companies reach everywhere.

I’ll talk about this more in another post.

Boo!

The top image, Frightened Girl, is the work of Daigo Oliva. The Halloween photo is the work of Policia Nacional de los columbianos. Both are sourced from Wikimedia Commons.

Phishing For a Therapist

In the age of electronic scams, no one is safe, not even a therapist. I have now received three or four very similar queries from potential new patients that fit the same model. And I do mean model, since all of the phishing expeditions involve someone searching for a therapist to treat a swim suit model with anxiety problems.

As you may know, “Phishing is the act of attempting to acquire information such as usernames, passwords, and credit card details (and sometimes, indirectly, money) by masquerading as a trustworthy entity in an electronic communication” according to Wikipedia.

The email messages always follow a pattern similar to this:

Greetings from Transylvania!

My name is Dr. Sucker Fisher. I have been a plastic surgeon since 1993. I do face lifts and breast lifts. I have been looking for a therapist for anxiety for over a week now till I met an old friend yesterday that referred you to me, so I decided to contact you to know if you will be able to work on my client.

My client’s name is Ms. Lana Voluptuous, a swim suit model here in Transylvania who is struggling with anxiety. She will be coming to the U.S in three weeks time for a modeling job and will be residing in your area temporarily until the necessary arrangement for her job has been made before she leaves. She will be needing a one hour anxiety therapy session per day, three sessions per week for six weeks. Ms. Voluptuous asked me to come with her to the States, but I told her that my schedule wouldn’t permit this and also because I do not know much about anxiety therapy sessions, so I promised to help her get a good therapist in your area.

Please tell me a little more about yourself,  how long have you been treating anxiety? And would you be able to provide her with the anxiety therapy sessions requested? I need you to get back to me with the amount you charge per session and also let me know if she can pay you with a certified check drawn from a US bank.

You can view some of Ms. Voluptuous’s pictures from the following link: http://www.lanavoluptuous.com/ 

Thank you,

Dr. S. Fisher

Your Future Patients?

OK, now ask yourself what is happening here and what will happen if you, the therapist, engage in a correspondence with the phisher, Dr. Fisher?

There are several things within the email that suggest that the search for a therapist is not genuine:

1. Isn’t it a little suspicious that (unless you are an internationally famous therapist) someone in Transylvania recommended your services?

2. Why isn’t the patient making the request herself instead of through an intermediary?

3. If the alleged model decided to engage someone to do this search for a therapist, why wouldn’t it be her current therapist? Why would it be someone who professes to know very little about the treatment of anxiety? Given that she wants a very precise number of sessions per week, Ms. Voluptuous (if she is real) is clearly knowledgeable about treatment and is currently in therapy.

4. Why wouldn’t the model wish her present counselor to provide the new counselor precise and detailed information about her background and her needs rather than the very generalized description of her condition (“anxiety”)?

5. Why would any legitimate request for a therapist include a link to photos of the model?

6. Why would the above email include a request for more information about your background and ability to treat anxiety? First, the writer has indicated that he knows little about such treatment, suggesting that he would be unable to evaluate anything you might provide. Moreover, you might (like me) have both a website and a blog site that include information on your background. If he were serious about searching for a qualified therapist, he almost certainly would already have consulted those sites (and in my case, noticed that I am retired).

In the actual emails of this sort, the links to the photos are real. I imagine that the models in question would be surprised to find that someone is using their names and their photos to swindle unsuspecting therapists. The models are always quite beautiful. I imagine that the phisher is assuming that the enticement of working with a sexy young woman will lure some therapists to pursue the email exchange further. Such a therapist might rationalize that since there is the promise of being paid by a certified check there would be no risk of financial loss.

Not so fast. Once the email exchange progresses sufficiently, the “model” typically discovers that her next assignment (after her therapy sessions with you, but before you actually have seen her) will be in another country. You are also told that she is having trouble dealing with the company that is engaging her there and asks you to serve as an intermediary involving a financial transaction. Again, you will be reimbursed by a cashier’s check (which will doubtless be counterfeit).

Do many therapists fall for this? I can’t say for sure, but if they do, here is why:

1. They are being offered the opportunity to obtain a new client who will presumably be paying a hefty fee.

2. The client is very attractive.

3. They are flattered to think that their skill is so great that they are being sought by a minor celebrity from another country.

As P.T. Barnum is alleged to have said, “There is a sucker born every minute.”

In this instance, need I add that we are talking about men?

The top image is called Fishing by Carl Larsson. The photo below it is from the Miss Kandy Kontest, September 13, 2008. It was taken by Toglenn. Both images are sourced from Wikimedia Commons.