NPR: Psychotherapists Gravitate Toward Those Who Can Pay

[deleted547631]

http://khn.org/news/psychotherapists-gravitate-toward-those-who-can-pay/

“A minute I spend training that person is a minute of my life wasted,” Humphreys said. “That very well trained person should be taking care of very, very troubled people. When they don’t, everyone who needs that care loses out.”

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[erg923]

http://khn.org/news/psychotherapists-gravitate-toward-those-who-can-pay/

“A minute I spend training that person is a minute of my life wasted,” Humphreys said. “That very well trained person should be taking care of very, very troubled people. When they don’t, everyone who needs that care loses out.”

**** this guy.

The idea that he feels he can decide/dictate who is deserving and who is not (or is less so) really defeats his whole holier than though argument, in my opinion.

 

[Ceke2002]

**** him.

The idea that he feels he can decide/dictate who is deserving and who is not (or is less so) really defeats his whole holier than though argument, in my opinion.

Yeah, he might have had some good points, but I couldn't really hear his argument over the sounds of 'BAAAAWWWWWW'

 

[SmallBird]

I read this article a while back and disagreed with it then also. In my third year I worked with a very privileged population. They had a broad spectrum of mental illness, and I was able to be helpful to them - overall, much more helpful than I have been in a community mental health setting, where my contribution is of limited value given the sustaining psychosocial factors which prevent recovery, and the horrifying bureaucracy which severely limits the capacity to establish a frame for psychotherapy.

Almost more frustrating is his insistence on finding US-specific explanations for this phenomenon. Private practice psychiatry is alive and well everywhere - it is financially sustainable and clinically rewarding.

 

[erg923]

Nothing demonstrates a feeling of supremacy more than fundamentally believing that certain people, or populations, are more worthy or deserving than others.

 

[splik]

although i am critical of the trend for psychiatrists to not want to treat the mentally ill, for psychotherapists patients who can pay and with minor problems and less psychosocial adversity have a much greater capacity to benefit from psychotherapy

 

[DD214_DOC]

What a stupid headline

 

[deleted343839]

“We don’t seem to have this problem with cardiology or oncology,” Humphreys said.

Oh, right, because subspecialty medicine has always been about high-volume services propped up by midlevel providers.

 

[michaelrack]

The article confuses psychiatry with psychology several times

 

[Doctor Bagel]

Another thing to say is that the difficulty of treating someone in terms of intellectual effort/knowledge required doesn't always correlate with how severe someone's illness is. Treating high functioning people with anxiety and possibly some personality related issues can sometimes be much more challenging than treating someone with schizophrenia who needs a clozapine trial. Also, right, who's to say whose suffering matters and whose doesn't? I'm sick of these people trying to shame us into following certain career paths.

 

[MacDonaldTriad]

Plastic surgeons don't have any ethical issues with treating the top of the socio-economic population. Why is the finger pointing at therapists?

 

[Doctor Bagel]

Did any of you see this article? http://ww2.kqed.org/stateofhealth/2...ts-therapists-also-battle-insurance-red-tape/

I love the statement from the CEO of the insurance organization saying therapists should adjust their rates down to be good members of the community. Why should people be asked to accept less than market rate? Insurance companies aren't these great altruistic entities that de-value their own profits.

 

[splik]

Plastic surgeons don't have any ethical issues with treating the top of the socio-economic population. Why is the finger pointing at therapists?

this is completely different - there isn't a shortage of plastic surgeons working with needy populations - in fact it is actually quite difficult to find a job doing burns or reconstructive stuff and much easier to find jobs doing tit jobs etc.

that said there is a multitude of factors that contribute to therapists not working sicker/higher risk/poorer pts including satisfaction. there was an interesting study looking at how therapists were less likely to take black-sounding pts than white ones. the study was somewhat flaws but almost certainly true

 

[keifernny2]

When we pretend that medicine is not a business we do a disservice to both our patients and ourselves.

 

[PsyDr]

The source from this doesn't even believe it. He works as a research scientist, not a clinician. Oh, except for the year he worked in policy in the White House. So I guess everyone lost out? Or he wasted that training? Or the people with degrees in healthcare policy wasted something. Or.. I don't know.

 

[splik]

just read the article didn't realize he was at Stanford where they don't even take Medicaid in their psychiatry clinics, where no one goes to train to take care of the seriously mentally ill, where I'm not even sure they know how to

 

[Therapist4Chnge]

Plastic surgeons don't have any ethical issues with treating the top of the socio-economic population. Why is the finger pointing at therapists?

Because YOU/WE are supposed to care more.

 

[erg923]

just read the article didn't realize he was at Stanford where they don't even take Medicaid in their psychiatry clinics, where no one goes to train to take care of the seriously mentally ill, where I'm not even sure they know how to

word...

 

[calvnandhobbs68]

this is completely different - there isn't a shortage of plastic surgeons working with needy populations - in fact it is actually quite difficult to find a job doing burns or reconstructive stuff and much easier to find jobs doing tit jobs etc.

that said there is a multitude of factors that contribute to therapists not working sicker/higher risk/poorer pts including satisfaction. there was an interesting study looking at how therapists were less likely to take black-sounding pts than white ones. the study was somewhat flaws but almost certainly true

Could say it about derm though, same kind of problem as psych except the shortage isn't as bad (generally, there's some areas of the country where its very hard to see a dermatologist). What's up with those greedy private practice dermatologists opening up cash only/out of network offices when Medicaid patients wait months to see a dermatologist?

 

[Ceke2002]

When we pretend that medicine is not a business we do a disservice to both our patients and ourselves.

But it's a calling, money should be the least of your considerations, don't you know you can be just as effective a therapist when you can't pay the rent on your office space, and your mortgage is in arrears.

 

[Doctor Bagel]

But it's a calling, money should be the least of your considerations, don't you know you can be just as effective a therapist when you can't pay the rent on your office space, and your mortgage is in arrears.

Argh, the thing that bugs me is that people who say stuff like this often come from money, so yeah, they don't have to worry about it. I doubt this dude above in the article has six figures of student loans (hey, no one his age does because school was cheaper then anyway). Also why is it so wrong to care about your life, doing work you enjoy and caring about your income? Do you give up that right when you go to medical school? Which BTW, most of us are scarifying a lot to do medicine anyway both financially and personally.

 

[Mad Jack]

Argh, the thing that bugs me is that people who say stuff like this often come from money, so yeah, they don't have to worry about it. I doubt this dude above in the article has six figures of student loans (hey, no one his age does because school was cheaper then anyway). Also why is it so wrong to care about your life, doing work you enjoy and caring about your income? Do you give up that right when you go to medical school? Which BTW, most of us are scarifying a lot to do medicine anyway both financially and personally.

Loving the autocorrect on sacrificing, because it's still true in a poetic sense.

 

[whopper]

I spent 10 years working in systems where I made less money out of a devotion to help people, teach, and learn from the best. This included the state mental health system and universities.

I caved in for the money after I had kids. I choose not to put them in a situation where they cannot enter college due to avoiding horrendous debt or gain that debt. Someone could call that selfish all they freaking want. My kids matter more than me.

And it just wasn't about my kids or the money. The last academic institution where I lived too many things were going on I couldn't tolerate. E.g. working in a jail where patients needing to go the hospital will not be taken cause the county refused to reimburse them among several other problems. I probably would've stayed at least a few more years and caved in later had I been happy at that place. I was not happy.

There should be more incentives placed in for mental health providers to do the communal thing. Insurance reimbursements ought to be more. I also was very disillusioned with many of the residents I've seen who just want to enter private practice without trying to further improve their skills or at least do some communal work especially among the residents who I know don't have the debt cause they came from wealth or other countries where you don't have to pay medical school tuition.

 

[Doctor Bagel]

Loving the autocorrect on sacrificing, because it's still true in a poetic sense.

Ah, pretty awesome. Scar tissue that I wish you saw ...

Actually training wasn't that horrible, but I don't feel like I owe society much for it. Otherwise, I wouldn't have these six figure loans with crappy interest rates. If I actually get 10 year forgiveness with PSLF, I might feel differently.

 

[deleted736562]

I don't think there's a need to be this defensive? This is more about how the overall healthcare system functions than individual physicians.

And I think the title is horrible. What Humphreys is talking about is mental healthcare in general (therapists + psychiatrists).

 

[Doctor Bagel]

I'm still actually amazed by the comment that it's easy to do psychotherapy on "some executive at Google." It makes me think this guy has never actually seen a patient. Also thinking about physician suicides and well being within our own community, it seems especially troublesome to imply that people who have money and good jobs don't have significant mental health concerns of their own. Lastly, therapy isn't fun. It's painful and hard. Going to a therapist is not like going to get a massage.

 

[splik]

I'm still actually amazed by the comment that it's easy to do psychotherapy on "some executive at Google." It makes me think this guy has never actually seen a patient. Also thinking about physician suicides and well being within our own community, it seems especially troublesome to imply that people who have money and good jobs don't have significant mental health concerns of their own. Lastly, therapy isn't fun. It's painful and hard. Going to a therapist is not like going to get a massage.

in fairness therapy is fun if you're narcissistic, and control the therapy so it's just you and your monologue and a dutiful therapist nodding like a lap dog. also this isn't necessarily about rich vs poor (though it would be ridiculous to argue that mental illness is not harder to endure if you are poor) but it is certainly true that many private psychiatrists exclude people who actually have serious problems from their practice. now that may be quite appropriate given that solo pp is probably not the place to treat people with schizophrenia or who are recurrently attempting suicide, it doesn't mean it isn't unfortunate that psychiatry has abandoned the mentally ill (which has been the case since at least the 1940s).

it is also fascinating to note the level of cognitive dissonance snd lack of awareness of it in this thread from psychiatrists and psychologists alike. much better to be honest and note this is s problem, there are legitimate reasons for this etc than to make ridiculous claims such as "who's to say one persons suffering is worse than another" or to pretend this is simply about rich vs poor. Rather, it is a fact that many psychiatrists find it more personally, intellectually and financially satisfying to treat patients who are similar to themselves, or they want to do psychotherapy which is a treatment best reserved for those without mental illness (so much so David Barlow suggests psychotherapy be the term used for those seeking insight, growth, development and self improvement and "psychological treatment" be the term used for talking as an intervention for mental disorder) rather than constrain themselves to rapid fire visits where there are relegated to a role as "prescriber" u differentiated from their nurse practitioner colleagues and undervalued and underappreciated

 

[splik]

I should also point out that there is a market for pp psychotherapy treatment of severe mental illness. because of my antipsychiatry credentials I periodically have family members contacting me begging me to see their child with psychosis and take them off their meds and treat them with psychotherapy. there are wet very few psychistrists who do this (and I don't either) Thoug there have been psychiatrists who have charged large sums for this kind of work in the past and I do think it is different from "treating" people who don't have mental illness which is what a lot of shrinks aspire to treat

 

[Doctor Bagel]

in fairness therapy is fun if you're narcissistic, and control the therapy so it's just you and your monologue and a dutiful therapist nodding like a lap dog. also this isn't necessarily about rich vs poor (though it would be ridiculous to argue that mental illness is not harder to endure if you are poor) but it is certainly true that many private psychiatrists exclude people who actually have serious problems from their practice. now that may be quite appropriate given that solo pp is probably not the place to treat people with schizophrenia or who are recurrently attempting suicide, it doesn't mean it isn't unfortunate that psychiatry has abandoned the mentally ill (which has been the case since at least the 1940s).

it is also fascinating to note the level of cognitive dissonance snd lack of awareness of it in this thread from psychiatrists and psychologists alike. much better to be honest and note this is s problem, there are legitimate reasons for this etc than to make ridiculous claims such as "who's to say one persons suffering is worse than another" or to pretend this is simply about rich vs poor. Rather, it is a fact that many psychiatrists find it more personally, intellectually and financially satisfying to treat patients who are similar to themselves, or they want to do psychotherapy which is a treatment best reserved for those without mental illness (so much so David Barlow suggests psychotherapy be the term used for those seeking insight, growth, development and self improvement and "psychological treatment" be the term used for talking as an intervention for mental disorder) rather than constrain themselves to rapid fire visits where there are relegated to a role as "prescriber" u differentiated from their nurse practitioner colleagues and undervalued and underappreciated

I agree that there are tons of very real access issues in mental health that shake out in all sorts of ways. In my community, for example, patients with severe mental illness and private pay insurance have about the hardest time finding anyone to treat them because they don't quality for community MH, and no one in private practice takes patients like that (yes, for good reasons because a person on their own doesn't have the capacity to deal with that). I'm still troubled by the tone in the article though that one type of work is a "waste" or that one type of work is actually easy when in fact it's pretty hard. BTW, I work with SPMI folks all the time -- I honestly don't think they're the most challenging patients to treat most of the time. That's my other frustration with the article.

 

[F0nzie]

I'm still actually amazed by the comment that it's easy to do psychotherapy on "some executive at Google." It makes me think this guy has never actually seen a patient.

Many of these folks require therapists with a very high degree of skill and intelligence. From what I have seen in clinical practice average therapists cannot hang with highly intelligent executives. They are placed on the chopping block on from day 1 and lucky if they can secure a follow up. I have worked with many therapists but only know of 2 psychologists in my community that can truly play with the big boys.




Sent from my iPhone using SDN mobile app

 

[splik]

I agree that there are tons of very real access issues in mental health that shake out in all sorts of ways. In my community, for example, patients with severe mental illness and private pay insurance have about the hardest time finding anyone to treat them because they don't quality for community MH, and no one in private practice takes patients like that (yes, for good reasons because a person on their own doesn't have the capacity to deal with that). I'm still troubled by the tone in the article though that one type of work is a "waste" or that one type of work is actually easy when in fact it's pretty hard. BTW, I work with SPMI folks all the time -- I honestly don't think they're the most challenging patients to treat most of the time. That's my other frustration with the article.

each patient population has its own challenges so it's spurious to suggest that one is more difficult than another (I'm talking about people with some sort of mental illness rather than problems of living). I do think working with SPMI population is the most challenging if you are also doing psychotherapy with these individuals which is precluded in most settings. when you don't do psychotherapy then I agree it is somewhat difference but only if we are talking about someone with psychosis vs a significant neurotic disorder as opposed to someone who has nothing wrong with them (which I agree is flippant but can be put into context)

 

[Ceke2002]

I'm still actually amazed by the comment that it's easy to do psychotherapy on "some executive at Google." It makes me think this guy has never actually seen a patient. Also thinking about physician suicides and well being within our own community, it seems especially troublesome to imply that people who have money and good jobs don't have significant mental health concerns of their own. Lastly, therapy isn't fun. It's painful and hard. Going to a therapist is not like going to get a massage.

in fairness therapy is fun if you're narcissistic, and control the therapy so it's just you and your monologue and a dutiful therapist nodding like a lap dog. also this isn't necessarily about rich vs poor (though it would be ridiculous to argue that mental illness is not harder to endure if you are poor) but it is certainly true that many private psychiatrists exclude people who actually have serious problems from their practice. now that may be quite appropriate given that solo pp is probably not the place to treat people with schizophrenia or who are recurrently attempting suicide, it doesn't mean it isn't unfortunate that psychiatry has abandoned the mentally ill (which has been the case since at least the 1940s).

it is also fascinating to note the level of cognitive dissonance snd lack of awareness of it in this thread from psychiatrists and psychologists alike. much better to be honest and note this is s problem, there are legitimate reasons for this etc than to make ridiculous claims such as "who's to say one persons suffering is worse than another" or to pretend this is simply about rich vs poor. Rather, it is a fact that many psychiatrists find it more personally, intellectually and financially satisfying to treat patients who are similar to themselves, or they want to do psychotherapy which is a treatment best reserved for those without mental illness (so much so David Barlow suggests psychotherapy be the term used for those seeking insight, growth, development and self improvement and "psychological treatment" be the term used for talking as an intervention for mental disorder) rather than constrain themselves to rapid fire visits where there are relegated to a role as "prescriber" u differentiated from their nurse practitioner colleagues and undervalued and underappreciated

From a patient's point of view I both agree and disagree that therapy is 'fun'. I do enjoy therapy, even the difficult and challenging sessions, but I also wouldn't equate the enjoyment of therapy with say something like a relaxing afternoon at a beauty spa. Unfortunately I do think there are segments of the patient population for whom therapy is 'fun', because they are basically approaching it from the point of view of having this really awesome friendship where you catch up once a week and get to unload on someone whose entire focus is on you and how utterly fascinating you presume yourself to be (or the less cynical point of view that sometimes patients do approach therapy as 'fun' for the simple reason that they mistake therapy for friendship, and are working under the assumption that their therapist is a friend, albeit an idealised version of one).

The main issue I have with the article is that it feels far too much like the author is playing oppression olympics. Yes of course if you come from a disadvantaged background then your experience of emotional distress or mental health issues is likely going to be magnified by that, but at the same time that shouldn't mean we then assume that the wealthy person who is shelling out 400 bucks an hour to delve into their own life issues is suffering any less, or that for them a high priced therapist should be automatically viewed as a symbol of status. Rather than turn it into an issue of 'poor vs rich', 'deserving vs undeserving', 'worthier than thou' etc etc, and complain about how disillusioned you are that you're wasting your time training the next generation when they're just going to go off and choose the type of cashed up and easy practice they find the most rewarding and least stressful, how about working to make other options (like working with serious mental illness in a pp psychotherapy situation, or working with disadvantaged populations, or doing inpatient hospital rounds and attending a community outpatient clinic) just as appealing in terms of perceived reward.

 

[Ceke2002]

if it's fun it isn't working. that doesn't meant that it is supposed to be terribly painful either. removing ones long cherished and tightly held onto defenses hurts but you shouldn't feel worse than tour lowest ebb - if you do it means your therapist has done do
something terribly wrong, is a sadist or worse or grossly miscalculated what you could tolerate. I have been guilty of the latter myself.

I suppose 'fun' isn't really the word I would use, more like I derive enjoyment from a process that is working and where I can note growth and improvement - the enjoyment for me is more the end product of the process, not necessarily the process itself (although I'd be lying if I said I didn't find the actual process of therapy to be stimulating on an intellectual level). So no, on the days I have an appointment booked I don't exactly bound out bed whilst fist pumping the air and shouting 'therapy, alright!'

edited to add: And I've just noticed that I only put ' ' marks around one of those 'funs' in the last post, I thought I'd placed quotation marks around both to indicate a sense of 'for want of a better word'. I shall change that.

 

[st2205]

I periodically have family members contacting me begging me to see their child with psychosis and take them off their meds and treat them with psychotherapy.

And how many family members do you have that have children with psychosis?

 

[PikminOC]

this is completely different - there isn't a shortage of plastic surgeons working with needy populations - in fact it is actually quite difficult to find a job doing burns or reconstructive stuff and much easier to find jobs doing tit jobs etc.

that said there is a multitude of factors that contribute to therapists not working sicker/higher risk/poorer pts including satisfaction. there was an interesting study looking at how therapists were less likely to take black-sounding pts than white ones. the study was somewhat flaws but almost certainly true

Do you think malpractice risk and lawsuits play into this?

 

[PikminOC]

just read the article didn't realize he was at Stanford where they don't even take Medicaid in their psychiatry clinics, where no one goes to train to take care of the seriously mentally ill, where I'm not even sure they know how to

Ding ding ding

 

[DD214_DOC]

Gee, people who invest a significant amount of time, money, and effort into something naturally position themselves to reap the best return on said investment?

I don't see the problem, or why this is a surprise.

 

[SeniorWrangler]

Hate the game, not the player.

 

[smalltownpsych]

I suppose 'fun' isn't really the word I would use, more like I derive enjoyment from a process that is working and where I can note growth and improvement - the enjoyment for me is more the end product of the process, not necessarily the process itself (although I'd be lying if I said I didn't find the actual process of therapy to be stimulating on an intellectual level). So no, on the days I have an appointment booked I don't exactly bound out bed whilst fist pumping the air and shouting 'therapy, alright!'

edited to add: And I've just noticed that I only put ' ' marks around one of those 'funs' in the last post, I thought I'd placed quotation marks around both to indicate a sense of 'for want of a better word'. I shall change that.

Working with intelligent, engaged, and motivated patients is more enjoyable for both patient and therapist. Nothing wrong with that. It can still be challenging, but it's better than working with many of my cases. At any given time, there are a few patients on my case load that I really enjoy, but the majority is just another day working. Anyone who thinks it is an easy job has never actually done it.

 

[Ceke2002]

Working with intelligent, engaged, and motivated patients is more enjoyable for both patient and therapist. Nothing wrong with that. It can still be challenging, but it's better than working with many of my cases. At any given time, there are a few patients on my case load that I really enjoy, but the majority is just another day working. Anyone who thinks it is an easy job has never actually done it.

I can relate to this for sure. Of course there are times when I've had a particularly heavy session and I walk out feeling like my head has just been spun around backwards, but I just take time to decompress at home afterwards for a bit, and then I go back through the session in my mind and break it down a bit more and end up having some real 'Aha!' moments. Again that's where even the heavy sessions become enjoyable to me, it's like I know it's gonna be uncomfortable to talk about stuff at the time, but it's worth it for the rewards of insight I'll receive. And my Psychiatrist being mostly specialised in treating trauma survivors and/or personality disordered patients knows when to push and when to back things off, so we always work at my pace and what I'm ready for at any particular time. Just lately I've not been very well, and while we have been working on getting me back on top of a eating disorder relapse (it has been working, I'm at least stable again now) most of our recent sessions have been a bit lighter - more concentrating on talking about positive changes, and what else I can do to keep the positive changes going. I'm sure we'll get back to the 'so tell me about your terrible childhood stuff' soon, but I think a good therapist should be aware of when they need to push a patient to open up more, and when they need to back off and just give the patient a bit of a break with a few easy sessions.

 

[SeniorWrangler]

The problem is that it's overdetermined, as sociologists like to say: some of the neediest patients tend to have the insurance which pays the least and covers the least, are the least likely to show up, and the most likely to get the provider audited by the Federal government. I'm surprised at the amount of interpersonal therapy being described in this thread, I thought the field was dominated by CBT these days.

 

[Doctor Bagel]

The problem is that it's overdetermined, as sociologists like to say: some of the neediest patients tend to have the insurance which pays the least and covers the least, are the least likely to show up, and the most likely to get the provider audited by the Federal government. I'm surprised at the amount of interpersonal therapy being described in this thread, I thought the field was dominated by CBT these days.

Not in my neck of the woods. Almost all the psychiatrists I know who do therapy are dynamically oriented. CBT seems to more popular with non-physician therapists.

 

[Jules A]

Not in my neck of the woods. Almost all the psychiatrists I know who do therapy are dynamically oriented. CBT seems to more popular with non-physician therapists.

Its all about medication management here and more DBT than CBT done by LCSWs and LCPCs. Although I would guess there are a few more I only know of 1 psychiatrist 80+ something years old who still does their own psychotherapy in my area.

 

[Doctor Bagel]

Its all about medication management here and more DBT than CBT done by LCSWs and LCPCs. Although I would guess there are a few more I only know of 1 psychiatrist 80+ something years old who still does their own psychotherapy in my area.

That's too bad. Fortunately that's not the reality here, which means it doesn't have to be the reality for psychiatrists. Of course these psychiatrists should feel bad and all because they're wasting their training. My aunt who is a doctor said I was wasting my training as a physician by becoming a psychiatrist, though, so I guess we're already wasting things by joining this profession.

 

[masterofmonkeys]

So Humphreys doesn't take Medicaid, and apparently has never billed for therapy either. Jackass.

Even when we consider medicaid, they don't blink twice (here in FL at least) about paying for thousands of dollars worth of abilify a year, but I can't get them to pay for even an 8-12 week course of CBT (a thousand freaking dollars for YEARS of benefit). When I do manage to get them to, it's only through intimidation, posturing, and calling Sen Bill Nelson's office and holding the wetlands ransom.

The problem is that society and CMS/medicare/medicaid don't value therapy, but will happily fund compeltely unnecessary ortho procedures, expensive brand name drugs, and fat hospital fees