I want to shift directions today. After several months writing about relationships, I am going to switch gears and blog for a while on more individual issues. I am making this switch because I see individuals as well as couples, and because many people reading this also have questions about individual issues.
I will try to write about these issues with a minimum of technical terms. Do you know psychologists have created words called "ego syntonic" and "ego dystonic?" These simply mean something that feels good or bad, respectively. What's really scary is that this language starts to sound normal after several days in a professional conference.
Starting this topic is like standing before a blank canvass that stretches out for miles, and miles, and miles. There's so much potentially to say about it. What I think I will do, for my own sake if not for yours, is begin this process by telling you some of the things I tell clients who are coming to me for the first time. I always have to remind myself that the basics I consider givens are things that need to be spelled out. And in today's posting I will spell out some of the basic structure.
Most therapists work on a 45- or 50-minute hour. That is, if you have a 1 p.m. appointment, you will be done at 1:45 or 1:50. There are a number of reasons for this, mostly having to do with the logistics of running a therapy practice. I don't know if this story is true or not, but I also heard one reason therapists work on a 50-minute hour is because that's the longest Freud (who basically started the whole field of psychology and psychotherapy) could last without a cigar.
For the rest of us, it simply is necessary to have a few minutes to write case notes, shift gears, and go to the bathroom before the next person comes in. I sometimes wish someone could see what drastically different worlds we are exposed to from hour to hour. It's a little like being transported to completely different planets and the next person who comes to us rightly expects our full and undivided attention when they sit down before us.
Which brings me to my second basic point: I don't know of any sane therapists who see 40 clients in a week. I've worked at a lot of different jobs: some physically demanding and some mentally demanding. The reality of being a therapist is that each hour of therapy is equivalent to approximately 1.5 - 2.0 hours of anything else. So a therapist who's seeing 40 clients in a week is working the equivalent of 80 hours.
Clients who come for therapy may do so either via their medical insurance, which allows for a certain number of therapy sessions if the therapist determines they are "medically necessary" (I could spill a lot of ink on that term alone) or pay out of pocket. Copays using insurance vary from no copay (nearly unheard of anymore) to $50 per session. This depends on the plan, on whether the therapist is "in network" or "out of network" and a host of other things. The average copay for most people is in the $20-$40 range.
Next week I'll write about the kinds of things which make someone pick up the phone and reach out for help from a therapist.
Do you have a question about your marriage or relationship? Is there a particular topic on relationships or individual psychological issues you would like addressed in this blog? Ask Josh in the comments below or email him at josh@joshgressel.com.
Josh Gressel, Ph.D., is a couples and individual therapist based in Pleasant Hill, CA. Visit his website at joshgressel.com.
I'm probably going to upset any colleagues who might be reading this, but to answer your question: I don't think there is any good excuse for not calling you back. It is rude, insensitive and unprofessional. We (meaning therapists) need to always remember what an act of courage and vulnerability it requires to pick up the phone and make that call for help and even if we can't respond with an appointment, we should respond. Having said that, a piece of this has to do with many insurance companies having "phantom lists" of therapists -- names of people who are supposedly on the panel but who no longer take new patients in practice. The insurance companies haven't raised their reimbursement rates to therapists for 20 years, even while they raise their rates to patients by as much as 10% year after year. Many therapists stay on panels only as a hedge against a rainy day, or to continue to see a long term patient who could otherwise not afford to see them. So they get inundated with calls from people burned out trying to find someone within their plan but the therapist has no intention of seeing anyone from that plan if they can help it. Still, I believe if they are on the plan in name, they need to give those who reach out for help a call back. When you're ready to try again, e-mail me at the address listed above and I'll see if I can help in some way. Good luck and thanks for writing.
I agree with the bulk of what you're saying. I will be writing a separate post about who to see when (thanks for the idea) but for now let me say this: I believe the primary care physician (PCP) is a good place to start, especially if you have an established relationship with yours. With that said: 1) The reality of physician care today is that most PCPs are moving from one person to the next in 15 minute intervals. It is very hard to make anything but the most cursory mental health evaluations in that amount of time, such as screening out for suicide risk; 2) while it is true that PCPs prescribe 50% of the psychiatric medication, when any of my clients need medication I refer them to a psychiatrist, who is a medical doctor who specializes in psychiatric medication. A PCP must keep up with hundreds of different kinds of medication; a psychiatrist specializes in the few dozen kinds of psychiatric medication and their interactions with each other and has much more experience in tweaking them to each individual; 3) I do not recommend seeing your PCP for talk therapy. They simply are not trained for this, and while it is always good to speak with someone you trust, past an initial few sessions you will need someone who knows how to continue the dialog forward. Nearly anyone can be an effective therapist for a few sessions; the separation between minimally useful and mastery occurs down the road. Thank you for your helpful comments.
Also, my PCP doesn't do referrals to individual specialists. They would just pick a name from a list in a directory unless they knew someone personally. I, however, am able to, and have, spent weeks poring over documentation, histories, reviews, the provider's website, etc. to chose a few that would potentially "fit". This is the process for how I contact any specialist I am referred to by my PCP and yet therapists are the only ones that don't call back.