You can't miss the headlines. Every day it seems as though another celebrity dies from suicide, while the epidemic of deaths related to opiates rages on. Recent articles and television series focusing on "deaths of despair" highlight the role of alcohol abuse, opiate dependency and suicide in increasing death rates in the United States and other industrialized countries.
Despite the high rate of distress, people often avoid seeing a psychotherapist or utilizing mental health and substance abuse resources. According to the Anxiety and Depression Association of America, nearly 20% of people will experience debilitating anxiety disorders, yet only a little over a third of them will seek treatment.
There are several reasons, including lack of information, financial obstacles, access issues, privacy concerns, societal beliefs, and personal attitudes that may account for the reluctance. By identifying and addressing these barriers, you can help yourself and others to finally access help and supportive resources.
Lack of Information
I don't know where to start.
If you have insurance, you can look up "mental health and substance abuse" resources on your insurance webpage to find providers or call and speak with your plan's customer service representative. You will probably end up with a list of professionals within a few miles of you. You can either choose to call the entire list or winnow it down according to your preferences with respect to location, hours, gender, or professional credentials. Most insurance plans allow prospective patients to interview a few therapists before making a choice to ensure the best fit.
There are also a number of online directories such as Good Therapy, Psychology Today, PsychCentral, and Find a Therapist that offer searchable databases of practitioners with various specialties. Physicians, religious leaders, friends, and family members can also provide referrals and recommendations for professionals in your community.
I don't know who's who and what all these titles mean!
The variety of credentials can often be confusing, and it can vary from state to state. In general, professionals who have M.D.'s appearing in lists of mental health providers are likely to be psychiatrists who provide medication to relieve psychological symptoms. Most do not perform psychotherapy, but they may work in collaboration with a psychotherapist. Professionals with Ph.D., Psy.D. or Ed.D. are doctoral-level professionals, meaning that they have at least four years of graduate training. Other psychotherapists include family and marriage counselors, who might have titles like MFC or LMFT, and social workers with titles like MSW or LCSW, and often have master's level degrees with at least two years of training.
I don't know what to expect.
Many websites such as Psychology Today, Good Therapy, and PsychCentral offer tips on interviewing professionals and consumer-oriented articles about psychotherapy. These review topics such as ethical practices, different therapy approaches, financial issues, and treatment goals.
The potential costs of psychotherapy can be another factor that creates fear and uncertainty. Here are some common concerns that sometimes interfere with getting help and strategies to address them.
I don't understand how insurance works for psychotherapy.
It is important to understand what coverage you have under your plan if you want to use your insurance benefits. As with any covered medical expenses, it is common to have both an annual deductible that would apply to services as well as a per-session copayment. Many, but not all, deductibles begin at the start of the calendar year. Knowing how your deductible works will spare you financial surprises.
I have a high deductible on my health insurance plan.
Even if you have a high deductible plan, it is still usually less expensive to use insurance than to pay out of pocket for psychotherapy, since the overall costs of "private pay" services can be very high. You still benefit from seeing a psychotherapist who is in your plan's network since their maximum session fees are capped by their legal agreement with the insurance company.
I don't have an insurance plan, or my plan has limited or no benefits.
There are options beyond the private practice model, including low fee or "sliding scale" (income-based fees) such as local community clinics, counseling centers and clinics associated with graduate training programs in psychology or social work. These agencies will typically be staffed by graduate trainees and master's-level staff working toward their licensure, so you may encounter some turnover in staffing over time.
Many hospitals, churches and health-related agencies often offer workshops and lectures in areas such as stress-management, yoga, and mindfulness training. While these are not psychotherapy, these methods and techniques can have helpful mental health benefits.
It is still too expensive!
Sometimes you can negotiate a reduced rate with your psychotherapists for sessions held at off-peak times, such as mid-morning, or you can decrease the frequency of meetings to every other week to reduce costs. Some psychotherapists are willing to waive portions of copayment fees in situations of financial hardship. If you are seeking psychotherapy to resolve problems in relating to others, you might also explore group psychotherapy as an alternative to individual sessions. Group psychotherapy not only costs a fraction of individual psychotherapy, but it can also have a similar or better efficacy for interpersonal issues.
When the Barriers Are Due to Access
Barriers to seeking psychological services can also be about age, geography, or accessibility. These are genuine impediments, and the solutions involve alternatives to the ways that psychotherapy is traditionally structured.
I live in a rural area and the nearest city is over an hour away.
If you have to travel long distances to receive care, ask if your psychotherapist would consider holding extended sessions on a bi-weekly or monthly basis. Extended sessions can be from 90 minutes up to several hours. Tele-therapy may also be an option. Research the options carefully so you understand the billing and privacy practices, and continuity with the same professional over time.
I have a disability.
People who have a disability, such as being hearing-impaired, visually impaired, or with restricted mobility, as well as residents of senior-care facilities, may be limited to providers who can come to them. Consulting the national and local associations that provide information, resources and advocacy for your particular circumstances may provide referrals for professionals in your area. Other solutions may include tele-therapy and online support groups and forums.
When the Barriers to Treatment Are About Privacy Concerns
Another obstacle to getting care can be the fear that deeply personal information will be shared with others, including employers, spouses, family members or the general public. Here are some of these concerns and strategies to allay them.
I am scared about privacy.
Psychotherapy, like other medical contacts, is usually covered under the provisions of the Health Insurance Portability and Accountability Act (HIPAA), which specifies how, when and with whom information can be shared. Psychotherapist are prohibited from disclosing your participation in psychotherapy or what you share in sessions.
Professional associations and many state boards regulating professions have clearly worded statements on their websites about patient privacy protections. You can also ask your psychotherapist, insurance company, and state licensing agencies about protections to your privacy.
Okay, but I hear that there are exceptions, and I am still worried.
While there are some very limited exceptions to the confidentiality provisions, these should be described by your psychotherapist before beginning treatment. These exceptions apply when there is an immediate and specific danger to you, or someone known to you. A second circumstance that might necessitate disclosure of protected information involves court-ordered records or legal situations. If you sign a waiver during a legal dispute allowing access to your medical records, it may result in the disclosure of both medical and psychological information.
Your psychotherapist can address your specific questions about confidentiality and identify ways to limit any information shared.
Could my employer find out?
Mental health conditions, like medical conditions, are afforded protection under the Americans with Disabilities Act (ADA), which prohibits employers from discriminating against an employee based on the presence of a medical or psychological condition. If you are able to perform your job with or without reasonable accommodations, you are protected by the ADA.
My insurance plan is provided through my job. Can my employer find out that I am in therapy?
When employers engage an insurance company to provide coverage for their employees, they may receive a summary or overview of utilization data, but they do not have access to protected medical information on individual subscribers in the insurance plans.
What if my employer is self-insured?
When an employer self-insures and pays medical expenses out of the company's operating funds, employers are instructed to erect firewalls to ensure that their employees' private medical and psychological information is protected. Sometimes employers contract with third parties to administer their plans. Those that fail to do so may be subject to legal consequences if protected health information is disclosed. If you are in doubt about your healthcare privacy, you may need to consider paying for some care on your own, obtaining an individual insurance plan and opting out of the company's, or exploring a different employment situation.
What if it comes up in a background check for a job?
Employers in some fields, such as law enforcement, national security, and other highly sensitive areas, may make an offer of employment contingent on passing a security background test. In these instances, hiring decisions are typically based on the ability to perform the assigned role, not on whether you have ever been in psychotherapy. Read more about this issue here and here or consult an employment law attorney.
It might jeopardize my security clearance in my current job.
Employers are increasingly recognizing that the risks are greater when their employees don't obtain needed psychological services than when they do. Employees in high-risk or high-security roles suffer increased risk for problems like depression or substance abuse when they perceive psychotherapy as off-limits. The high suicide rate for military veterans and the recent suicides in the New York police department illustrate this issue. Increasingly, when there is a disclosure of use of psychological services, psychotherapists are simply asked by employers to determine whether the condition being treated jeopardizes the necessary judgment and capacity to perform the job.
Forget my employer! What about my spouse?
If you are over the age of 18, psychotherapists are prohibited from contacting anyone or discussing the content of meetings unless you authorize them to do so by signing a consent form. However, if you utilize insurance as a beneficiary, the primary subscriber may receive an explanation-of-benefits form from the insurance company that indicates the date of an appointment and the name of the professional or practice. If this is problematic for you, discuss options with your therapist.
What about my parents? I am under the age of 18.
You can obtain psychological services without your parents' consent in certain circumstances, usually to address issues related to sexuality, pregnancy, and substance abuse. Check with the state psychology, counseling, or social work boards to get more specific information. In the event that you want to use insurance to cover services, know that your parents will receive an explanation-of-benefits form from their insurance. When working with adolescents, most psychotherapists make agreements with parents to limit disclosure to only issues affecting your immediate safety in order to protect your privacy. Discuss privacy concerns early on with any therapist.
I live in a small community. Won't everyone find out?
In some smaller communities, you may encounter your therapist at the store, gym, school, or other public settings. In these cases, many psychotherapists will not acknowledge knowing you in order to protect your privacy. Discuss ahead of time how you would like your psychotherapist to handle that situation.
When the Barriers Are About Social Stigma
Sometimes the barriers have to do with outdated ideas about psychological issues. Here are some common fears and ways to address them.
Doesn't it mean there's something really wrong with me?
Historically, only those with the most severe mental health problems received any form of treatment, and that form of treatment may have involved hospitalization or institutionalization. The present perception is that the range of psychological issues includes those that are brief and situational concerns to more significant and recurrent challenges, and now conditions such as schizophrenia are often successfully treated with improved medications on an outpatient basis.
Everyone is likely to have overwhelming psychological distress at some point. By getting appropriate treatment for deep emotional pain, you are taking charge of your well-being. There is nothing noble or courageous in hiding from or denying your symptoms.
My family, social circle, or ethnic background will disapprove.
There are some communities, religious groups, and family systems that maintain strong prohibitions about discussing personal concerns with psychological professionals. Often, psychotherapists may be perceived as "outsiders" by members of these social systems. In some families, talking about personal and family issues is seen as betraying or shaming family members.
When the Barriers Are Related to Personal Attitudes About Seeking Help
Sometimes it is your personal attitudes that prevent you from getting help. Do you recognize yourself in any of these statements? If so, read on to hear an alternative view.
I wouldn't know who I might become.
Sometimes there is fear of being transformed in such dramatic ways that you might not recognize yourself. Rather than becoming less recognizable to themselves, most people in therapy actually feel that they become more fully themselves as they express dimensions of self that have always been there but may have been less known. There is likely to be greater continuity and consonance (harmony) in your sense of self than disruption or estrangement.
It might change the way I relate to others.
This is true. Being in psychotherapy can alter the way you see yourself and others. There may be significant benefits to your relationships with others as you learn to express yourself more clearly, understand your relational needs and feelings, resolve conflict more successfully and enjoy a deeper level of intimacy in your closer connections. Psychotherapy can also affect how you relate to others in ways that can challenge the dynamics of family, marital, or relational systems. As a result of psychotherapy, you may be less willing to tolerate a stagnant marriage or unsatisfying interactions with your family system. Bear in mind that some changes to your relational life that are prompted by therapy might have been inevitable anyway.
I might fly apart.
When there is an awareness of significant pain or vulnerability, there is often a dread of beginning to explore these raw emotional experiences. This is particularly true when there has been a history of significant trauma, relational abuse or abandonment. Avoiding treatment for these painful experiences simply prolongs the pain and allows the abusive experiences to replay in your present life. Find a psychotherapist who has the necessary training and understanding to work with trauma, and then spend a significant amount of time at the start of treatment building trust and identifying a tolerable pace for proceeding. Before you jump into the most painful chapters of your life history, it is important to do a lot of talking about safety strategies, self-care techniques, and crisis-management processes.
I yam what I yam (apologies to Popeye).
This is the belief that you are fixed and nothing significant will change as a result of participating in psychotherapy. Given that we are beings who have constantly evolved new social structures and adjusted to changing norms in our work, family and personal lives, this is a little hard to maintain. You might try psychotherapy and see if you truly learn nothing about yourself.
I tried it once and it didn't work.
If your only experience of psychological services was when your parents dragged you into family therapy at age 7, you might consider whether being in treatment now could be a little different. Similarly, even if your experience in past treatment was unsatisfying, you might want to consider working with a different psychotherapist or exploring a different type of treatment. The outcome of psychotherapy is heavily dependent on the nature and quality of the therapeutic alliance between client and mental health professional.
I like the excitement and drama of my life.
Living "la vida loca" may be exciting at first, but you might begin to see an accumulation of lost jobs and broken relationships in the rearview mirror. If this sounds like you, find a psychotherapist who can help you assess the costs and benefits of maintaining your relationship with chaos.
I deserve to suffer.
If you were scapegoated by your family, bullied in school, or repeatedly felt responsible for situations you could not control, you may have internalized this punitive and self-defeating belief. While we all encounter pain in the course of living, ongoing suffering is a condition that depletes your resilience and erodes any quality of life. Getting mental health treatment will allow you to perceive your circumstances differently and to arrive at new and better solutions for your problems.
Others deserve to suffer.
If you believe that your psychological state worries or concerns others and you derive some satisfaction from this situation, you may be missing some important facts. By trying to punish others, you are actually doing the most damage to your own present and future quality of life. Getting help doesn't mean others were right, it means that you are taking charge of your life and decisions.
Carol Povenmire, Ph.D., is a licensed psychologist with a practice in Pasadena, California.