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Individual Therapy, Part 1

In this post, psychologist Josh Gressel starts to explain some of the mechanics of what it means to go to for therapy.

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.

This post is contributed by a community member. The views expressed in this blog are those of the author and do not necessarily reflect those of Patch Media Corporation. Everyone is welcome to submit a post to Patch. If you'd like to post a blog, go here to get started.

subgirl November 22, 2012 at 12:23 AM
Why might a therapist not call a potential new patient back at all? I called several times and left messages, the final one asking if the doctor was not seeing new patients to at least call me back and tell me that specifically (though all I can find says they are taking new patients.) but never heard from them. It is honestly the worst feeling. Honestly I wouldn't want to see someone that can't return a phone call, but I just dont understand ehy this happens. This is NOT the first time (just most recent) this has happened since moving to the east bay 6 years ago and trying to find a therapist (which I have yet to do. It has been a struggle to say the least).
Josh Gressel, Ph.D. November 22, 2012 at 03:33 AM
Hi Subgirl: 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.
MIKE ALFORD November 22, 2012 at 04:57 AM
You know the best way to deal with reality is to stand in front of a mirror look directly at the problem when you can figure out which is real you or the reflection. than you will have an idenity than you can see the truth and deal with it ! if you can do that you will be able to see the real problems and solve them yourself ----
lovelafayette November 23, 2012 at 05:15 PM
Your primary care or family doctor (PCP) is the place to start your search for assistance with what may or may not be mental health issues. Changes in mental status or mood, how you are coping can sometimes be due to physical problems or medication. See your family doctor first to eliminate conditions that affect the brain but psychotherapy cannot cure (ie. thyroid imbalance, cancer). If the issues truly are mental health in origin, then discuss with your PCP whether to start treatment with the PCP. Many PCPs are skilled at diagnosis (bipolar or depressed?) and therapy, AND all can prescribe medication which a psychologist/MSW/MFT is not licensed to do). Psychopharmacology (medication) is often the best, fastest and cheapest way to relieve psychic pain or disturbance, accompanied with monitoring by your PCP. Many patients only need someone to talk to; but for many patients studies show that a combination of meds, monitoring, and talk therapy is the approach most likely to succeed. Medication can also make talk therapy more effective and shorten the duration of treatment. Another benefit of starting with your PCP is that a referral from an MD to a therapist is unlikely to go unanswered; in my experience self referral "cold" calls are less likely to be returned.
Josh Gressel, Ph.D. November 23, 2012 at 09:13 PM
Hi Love: 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.
Chris J Kapsalis December 01, 2012 at 12:37 AM
I just want to say life is a constant effort to find your balance. For everyone. Wrenches are thrown in. Deaths. Illness. Age. Divorce.... No one is immune. But my point is there is no shame in seeking help to find this balance or help. There may be more shame in not seeking it. I never say never. My dad was district manager of a major insurance company and suddenly he was acting really dumb. We did not know it, but he had a brain tumor that nearly killed him. They removed it and I am not sure if he is the same, but surely not dumb. So I always also have to remind myself I am no one to judge, assume too much about anything. Yes, look in the mirror. When I am perfect I will have time to worry about other peoples issues.. I will never be perfect. Therapists are trained and I have seen a couple. You have to be honest, with them and yourself or it will all be for nothing anyway. Is anyone completely honest? Even with themselves? I don't think so.they try to see throw as well sometimes. I see so many judge others, on their high horses. You know someday that horse may fail you. Lets all try not to be too judgmental of others. My wife told me I am a hypocrite a few years ago. She is very wise. Ever since then, I think twice before I cast a stone. And still I fail sometimes of course.
Anne Mobley December 01, 2012 at 01:45 AM
It is too bad that those who really need therapy don't go get it. And some that do, don't tell the truth to the therapist at all, which is sad. Some can fool some of the people some of the time but not all the people all the time.
MIKE ALFORD December 01, 2012 at 04:29 AM
Now That is the a Real Right to the point a real straght Fact ! And I H ave Tried to Help Linda And bring the truth and the bare Facts of Reality To show her that she doesnt have to be so timid. she should just look athow much it could help her to seek out good and real therapy I have tried to really make her see the truth ! Well maybe she will get Help , only time and support will tell ---- we can only hope !
MIKE ALFORD December 01, 2012 at 04:36 AM
Chris A couple of months ago I met your dad I was down at Fullers He and your mom were just leaving --- He really took me by supprise he said Hi Mike Hows the campain going --- I didnt even know that he knew me But he sure seemed very alert and was very pleasent
MIKE ALFORD December 01, 2012 at 06:50 AM
What was just said ----- Isnt Excately True Here In Martinez --- Because Some really can Fool The people (here In Martinez) All the Time ! One Only has to look at our City Counsel, Planning Commission & the Lackeys that Keep them in office ---- Talk About Needing Therapy ! Need I Say More ! ----- Well Citizens Of Martinez Im Doing My Part --- 242 Straght Meetings ---- 242 straght Reality Sessions ! ----- Yes Im Giving At Least Three Minutes Of Truth & Reality At Each Meeting ------ I Guess You Could THERAPY ---- By Mike Alford -- Not To Worry Folks ------ No Charge To The City Of Martinez ! (JUST PURE FACTS)
subgirl December 07, 2012 at 08:45 AM
I'm not sure what's going on in the other comments, but Dr. Gressel thank you for taking the time to respond to mine. I am still struggling to find help and will be emailing you soon. I just wanted to touch base and let you know that I appreciated the honest reply. I got a virus or something and have been sick for several weeks now so everything got put on hold but I wanted to at least come back to this post and thank you for the reply. I've been truly shocked at how many therapists it seems there are in the area, yet so few compassionate people among them. It's been extraordinarily discouraging to say the least. As I said I will be emailing you soon. I truly hope you can offer some suggestions for directions to look or even maybe referrals. Thanks again. -subgirl
subgirl December 07, 2012 at 09:03 AM
Oh I also wanted to add that I have an excellent PCP that is great for colds and infections, but she is not at all equipped or trained to be a therapist or to prescribe psychiatric drugs for more than immediate short term needs. She has to have experience with so much that she just humanly cannot. One wouldn't take their child to a podiatrist or a vet for health care but they are doctors and practice medicine. I see therapy and behavioural health the same way. They are specialised and spend their career focusing in on one aspect of the human condition to better treat the needs of the patient. Ideally they would work with one's other doctors and healthcare would be a team effort. 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.

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