By Veda Shastri
“Find help,” “Get help.” These phrases are plastered through many a web-campaign and infomercial as awareness campaigns across the country encourage individuals to reach out for help to address their mental health problems. Many of these direct people to help-lines and online registries of healthcare providers. But beyond that, actually accessing help can be much more difficult. Despite the increased awareness and insurance coverage, patients continue to suffer.
Mental Health America, a non-profit dedicated to early intervention and prevention of mental illness has released a report that finds “over 42 million Americans suffer from a mental health problem, with over 8 million reporting suicidal thoughts.” Its report ranks Louisiana, Texas, Alabama, Mississippi and Nevada at the bottom when it comes to access to treatment and insurance, while Vermont, Massachusetts, Maine, Delaware and Iowa are the states with the best access.
The demand for those that can help is growing. According to the Bureau for Labor Statistics, “Employment of mental health counselors and marriage and family therapists is projected to grow 29 percent from 2012 to 2022, much faster than the average for all occupations. Growth is expected in both occupations as more people have mental health counseling services covered by their insurance policies.”
While more individuals reach out to seek help, there are still many gaps in the system.
In August, Altar Sorkac had just returned to Providence, RI from a trip to his home country of Turkey. He had pain in his limbs, and extreme levels of anxiety and fatigue. He was also struggling with the recent memory of suffering a panic attack while on vacation. “I wasn’t able to work well, I would always be in pain, I would come home exhausted, not able to move a muscle, I wouldn’t even be able to eat much. I would try to go to sleep right away,” he said describing his symptoms.
A 29-year-old post-doctoral fellow in Neuroscience at Brown University, Sorkac was aware of the range of medical and behavioral issues that could cause his symptoms, and so he admitted himself into urgent care at his local hospital in Providence. After a battery of physiological and neurological tests revealed nothing emergent, he was told to follow-up with a neurologist.
“When I called the Neurology Foundation for an appointment, they could only find an opening a month later. At that point, my anxiety was really, really high,” he said.
Despite describing his panic attack and debilitating anxiety to the medical practitioners in urgent care, no mental health services were offered or referred to him. As he waited for his appointment with a neurologist to roll around, he feared that he could not tolerate his mental health symptoms for much longer. “I thought I would go ahead and see a psychologist while I waited to see a neurologist. Nobody recommended anybody to me. I went online and checked different psychologists’ web pages.”
He went through the ratings of different psychologists online, and filled out an informational form for one that he deemed appropriate. In it, he specified that he was a neuroscientist, experiencing physical and psychological symptoms, and that he needed help. Sorkac’s initiative paid off. Later that day, he heard back from the psychologist and started therapy later that week. The neurologist Sorkac finally saw concluded that his physical symptoms were originating from his anxiety, and that it was indeed mental health care that he needed.
“My friends told me to exaggerate my situation on the form, so that someone would give me an appointment right away. I didn’t exaggerate, but maybe my situation was so dire, they called me right away,” he said.
Sorkac’s case called for immediate mental health attention, yet the onus was on him to identify it and find access. He was able to secure care but others are not so successful.
Those who are struggling with accepting the need for early intervention, often suffer while trying to gain access to a counselor. A patient who is going by the name of Arya to protect her identity had a discouraging experience with even getting an initial counseling session.
“The institution of healthcare did not help me at all,” she said. “I asked for referrals and received 5 names of therapists. I left voicemails for two of them and never heard back from them. A third therapist picked up the phone, and when I introduced myself and told her I’m struggling with anxiety, she said she wasn’t accepting new patients and hung up on me. It was the most disheartening thing. I left a message for a 4th therapist. I also sent her an email. She emailed me back after 2 weeks. At some point, I thought, this is not going to work out, I’m not going to find someone.”
Eventually, the last therapist called her back, and she started the counseling process. But the likelihood of people falling through the cracks of the system at this point is high. The same patient noted, “I worry about people who are in a dire state, and are trying to call and are getting the response—‘my panel is full, I can’t accept new patients at this time.’ What is that person going to do?”
Under law, a clinician or counselor can only be held responsible if they have treated a patient. But what if they refuse or ignore mental health treatment? Under the code of ethics laid out by the American Psychological Association (APA), in the section on Fidelity and Responsibility, it states, “They are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists strive to contribute a portion of their professional time for little or no compensation or personal advantage.”
The pressure on counselors to respond to calls for help is heavy. “I try to call everyone back within 48 hours,” says Michelle Roover, a psychotherapist who works in private practice as well as at a community health center in the Boston area, “and sometimes when I speak to people they say I’m so glad you called me back, I’ve already called 10 to 15 people who didn’t respond.”
Marushka Glissen, a specialist in Internal Family System therapy in private practice in Newton, Massachusetts, echoes this thought saying, “If you’re a sole proprietor, sometimes people can’t keep up.”
Clearly, counselors do not enter the profession without wanting to help treat and identify mental health problems. So then why is it difficult, even for patients with the requisite insurance, to establish themselves onto new patient lists?
A critical problem seems to lie with how health insurance companies bill therapists. The responsibility lies with the therapist to fill out the paperwork to be reimbursed for the patients that they see, and often it can be a hassle. It may vary, but generally, with a new patient the insurance company gives approval for 12 sessions. “After that, you have to explain why you need to continue to see the patient,” says Roover. If the patient has a very serious mental health condition like bipolar disorder, that falls under what is referred to as the “parity requirements,” Roover explains, “you are pretty much guaranteed that you can continue to see the patient. But if not, you have to justify why the patient continues to need help.”
Given these factors, many therapists in private practice choose not to see patients with health insurance. Both Roover and Glissen said they believed that if a potential patient mentioned they were willing to “self-pay” (pay cash) instead of going through insurance, that individual would be more likely to be taken on as a new patient. “There are therapists who put a limit on the insurance clients that they see. You do set limits on insurance and people who can only pay a small amount of money,” said Glissen.
She added, “I know that certain [therapists] past a certain age may think about retiring because the insurance companies have started to make it so difficult for therapists to get reimbursed.”
As problematic as it can be in private practice, in community health clinics, the red tape is even more damaging. Roover, who practices at a community health center in Newton, Massachusetts said that there is “a lengthy waitlist for those trying to access mental health care at the community health center, sometimes even 3 months.” In addition she notes, “there is a lot more paperwork for the clinicians because of the requirements for Medicare and Medicaid,” and many are slowly moving into private practice.
In fact, when Medicare was enacted in 1965, it reduced benefits for mental health care by reducing the amount it would cover for therapy or psychiatric hospitalizations than it did for other medical services. After a change in the law in 2008, Medicare now covers a larger part of the bill. It is only since the regulations issued by the Obama Administration in 2013 under the Mental Health Parity and Equity Act (MHPEA) that insurance companies have been required to cover mental illnesses in equal vein as physical illnesses. Advocates argue that even more has to be done to change the law and public policy so that insurance companies cannot find loopholes to limit access to mental health care.
As it currently holds, the fractures in the mental health system have a trickle down effect, preventing people in need from getting the care at the right time.
“I can imagine that because it is such a convoluted and broken system, there are a lot of people who probably need therapy, they are in jeopardy and probably don’t get it if they feel like they can’t afford it or even negotiate the system,” says Glissen.
Making your way into the counseling system requires a certain level of organization and persistence for potential patients, at the same time that they are struggling with their mental health. “Finding a therapist, for a short period of time, is going to add more anxiety to your life, which is not something you can deal with at that point,” advised Arya.
Altar Sorkac’s psychologist referred him to a psychiatrist to prescribe medication, and he has been continuing with therapy coupled with medication over the past few weeks. He said that he joked to his friends, “in the United States, they just wait for you to heal by yourself until they see you, and if you’re still not healed, then they see you.”