Whether via the private or public health care system, the task of finding a therapist can be daunting. You have to approach it from two different angles: 1. Finding your way through your health care (or lack thereof), and 2. Seeking out a professional whom you can afford, has space for you, and can give you the kind of help you need. As I’ve always contended– forcing a person who is struggling to make it day to day to advocate for their own care in a broken system is cruel. But it’s our reality currently so I hope that this can help make the process a little easier, and I will step off my soap-box for now. *Please note that no advice given here should be taken as an absolute as all plans and providers and marketplaces have their own rules and can vary significantly. Additionally, because there are so many moving parts to mental health care, this article is loaded with links to try and help pare down the excessive amount of information it takes to understand how to effectively navigate the system.
On health care: Insurance can be so confusing! Picture it as a tree– at the top you have your two options: private vs. public health insurance. Underneath each branch you have your various plans with their caveats, both financial and coverage-related, we’ll compare those later. The private insurance branch which is sold by companies like Aetna or Blue Cross, generally to large companies and organizations, then purchased by individuals as part of a group plan, or individually through your specific state’s health insurance marketplace (the latter’s monthly premiums may be subsidized based on your income). The other branch is public health insurance which is funded by the government and is generally for low-income families, individuals, the disabled, and seniors. So if you have a full time job, a part time job that offers coverage, belong to an organization (like a university or union) that offers coverage, or are self employed you would more than likely fall under the private insurance branch through your group plan or via your state’s marketplace. If you fall under a yearly income threshold based on your state’s limits, are unemployed, disabled, a student, or a senior, you would likely fall under the public health insurance branch. Here’s a good tool to help determine where you land with your income.
How private insurance *generally works: Here is a relatively accessible overview of how private insurance works. Under this branch we have two more branches: group plan providers which are acquired through employers or organizations, and your state’s health care marketplace if you are self employed or a small business. Whichever branch you fall under, here’s the short of the long: you must enroll during the open enrollment period (unless you have a qualifying life event) usually during the Fall, you will pay a monthly, quarterly or semi-annual insurance premium (which may be either partially or fully subsidized by either your employer or the state), you will likely have an out-of-pocket plan deductible before your plan will begin covering services for you (which does not include your premium payments), you will also likely have a co-pay each time you see a provider (many plans now cover preventative care visits at no cost, however).
Coverage: This is where it gets super convoluted and difficult to understand. I will only make a basic attempt at explaining this because I don’t want to overstep my base of knowledge as every private provider works differently. What I recommend here is utilizing your resources, by that I mean is grab a pen and paper and call the insurance provider/broker/marketplace, etc. and have them lay it out for you in as plain of English as you need them to, that’s what they get paid for. Another good resource often offered with employer group plans is an Employee Assistance Program (EAP), and they can help point you in the right direction when searching for mental health options and providers. Make sure you understand the basic terms that will be used and the following generalizations, such as the higher your premium the lower your deductible and vice versa, and that if you intend to see the doctor often you are likely better off with a lower deductible plan whether through a group plan or the marketplace. Here’s a good article on high vs. low deductible plans.
State Marketplace/Exchange: When it comes to state care, AKA the ACA, AKA Obamacare, here is the best place to start. If you find the marketplace/exchange confusing, I still recommend picking up the phone and calling for explanation. Some cool things about it are that the plans are required to provide the 10 essential health benefits (mental health coverage being one of them!!), and they have simplified the offerings to some extent with a tiered plan system: platinum, gold, silver and bronze. Starting from the top to the bottom, platinum covers more of your expenses but has a higher monthly premium, bronze has a lower premium but your services will cost more. When I was working full time self-employed and seeing a psychologist and/or psychiatrist anywhere from 1-4 times a month, I went for the silver plan and a portion of my monthly premium was subsidized by the state based on my income.
HMO vs. PPO: Under each branch, group or marketplace, you finally have two more branches of coverage option: Health Maintenance Organization vs. Preferred Provider Organization. Here’s the difference between the two and what they generally offer. Each plan has what’s called a network. The HMO network is self-contained meaning all your eligible providers already exist within the network and anyone you see outside of the network will not be covered. They generally want you to go see your primary care physician to get a referral to any kind of specialist, but they keep the coverage simpler with lower out of pocket costs, deductibles and premiums. A PPO network will allow you more providers in-network and will potentially partially cover some out of network providers (like if you have a doctor you really love but have to switch to a plan they don’t accept), but in exchange you’re going to pay higher costs.
How public insurance *generally works: Here is a good overview of how public insurance works. To me, public insurance can be simpler in ways but can take longer to navigate, and the behind the scenes administrative part of it can at times be frustrating (for example the time my Medi-Cal was cancelled due to an employee accidentally inactivating both my health and dental insurance instead of just my dental insurance and I had to spend a few hours calling around to get to the bottom of it, escalate it to management, then it took a week to have it reinstated). One tip, public care resources can feel like less of a one stop shop than private which is why I always recommend starting out with your local county public health care office when you need help. You will have a case worker, they will determine your eligibility and help walk you through finding a provider and explaining your options. There are 2 branches under which you can fall in the public system: Medicare which is for seniors and the disabled, and Medicaid (called Medi-Cal here in California) for low income children, families and individuals. Being a student and working part-time, I qualify for Medi-Cal and what was really great about it is I got to stay with Kaiser, which is a pretty decent HMO group offered in CA and a few other states. Options are more limited than private health insurance but care is available and when I can’t find a resource on my own, I find calling my county office or case worker a valuable resource to finding what I need.
On finding a therapist: This part can be equally as tough but for different reasons. Whether via private or public insurance it’s hard to know whom to go to for what and how to get to who you need. If you’re looking for medication only, your general practitioner is usually a good start. If they don’t feel comfortable prescribing you what you’re looking for they can refer you to a psychiatrist. If you’re only looking for therapy, you can also ask your GP for a referral but there’s a few different types when it comes to mental health professionals, ex: psychologist, LMFT, peer support, counselor, nurse, etc. If you are looking for the dual approach of medication and therapy, you will likely have to see a psychiatrist and psychologist independently as they no longer co-exist within one professional as they used to.
Once you know who you want to see now you begin the search of finding the right professional. I am lucky living in San Francisco, I have an accessible concentration of professionals in my city, however I realize that those living in more rural areas run into issues of both accessibility and lack of professionals. Finding the time during your work day to go to the doctor can be tough, as can finding a professional who is accepting new patients or one who accepts your insurance. This is where I’d recommend keeping a spreadsheet of some sort, outlining the following: Name of doctor, location, hours, are they accepting new patients, do they have after hours appointments, can they do video or phone appointments (there’s now also apps out there to get remote therapy on demand– Talkspace, and Larkr are two), are they within an accessible radius of your home or work (maybe there’s a shuttle?), etc. The best approach to narrowing down who might fit the bill is again to call your insurance provider and make them work for you. If you have private insurance call their main customer service line and ask for help finding professionals in your area based on your criteria. If you have public insurance you can call your local county office, ask for the same thing and they can help by giving you a list of providers to call, or point you in the direction of a resource who can. Also one thing to keep in mind given that the demand for mental health care is blowing up right now (yay, keep seeking help!), many insurance providers are having to farm their mental health care out to a secondary provider in order to meet our demands. This can add a level of complexity to it but don’t sweat it, you can work their resources the same way you’d work the ones provided by your direct carrier. For example I see a therapist at Kaiser 1-2x a month, her case load is too large for me to see her any more frequently so she has given me a referral to a company called Beacon who is finding me another provider whom I can see more frequently.
Where rough meets tough: Let’s say you’ve found someone, they’re taking new patients, you can get to their office, they take your insurance, and you can afford the copay, but the only time they can see you is during the workday. You can take the time off of work to see them but don’t want to tell you boss for fear of the repercussions. That’s OK! Treat it like any other doctor’s appointment, let them know you have an appointment, it may turn into a regular thing and you will need the time off. By law they cannot ask you who you are seeing or why, frankly your self care is none of their business. You may have to forgo a few paid hours at work if you don’t have leave time you can take but I’ve always said the reality mental health is that it’s always at a cost. Whether it’s time, money or energy, mental health care equates to a resources expenditure. But it’s beyond worth it so please DO NOT FEEL GUILT OR SHAME over making the time to take care of yourself. In the end you may very well be happier and more productive at work because you took the time to get care! (Also please consider the remote therapy apps if missing work and/or logistics prove to be care-prohibitive).
Let’s say you’ve found a therapist but you’re not jiving with them. It can be really tough to open up and spill your innermost darkness and troubles to a total stranger. In order to heal we need to try and find a safe space within which to carry out the healing process. So if you find a therapist and you feel they aren’t hearing you, are not offering you workable solutions, are too old, too young, male when you’d feel more comfortable with a female or vice versa, etc. my advice is to NEVER GIVE UP, HELP IS OUT THERE, YOU ARE WORTH IT. Good doctors can be hard to find, they are not one size fits all. Don’t be afraid to ask for what you need whether that be from your therapist or your insurance company. Be firm but kind, be direct, and don’t take no for an answer. A pragmatic approach to care is the best; you have problems to solve, you likely have limitations on how you’re able to solve them, and you need a clear path to solving them.
When you go into the vast space of mental health, I recommend having some semblance of a plan, know what you want. My very first visit to my first therapist in my early twenties, I walked in knowing nothing other than I wanted to feel better and I needed help getting there. The first thing she did was give me a post it and ask me to sit there and think about and nail down the biggest thing I wanted out of treatment and to write it down. I still have that note and it’s a goal I’m still working to attain 13 years later. It’s a process; being mindful of that, as well as being kind and gentle to yourself, and remembering that you’re not alone will really help elevate your care and healing during what can be a confusing, difficult, and frustrating time. Logistically it can also help to work backward, knowing your transportation options to get to the doctor, what days and times you can go, how far you can travel, what you can afford, who you want to see, and what your ultimate goal is can help you to narrow things down from a different angle.
If you’ve made it this far, thanks for sticking around to read through. It’s a lengthy topic and I hope that I’ve been able to help provide some education and direction when it comes to setting afoot on this journey. The least but utmost important piece of advice I can give you is DON’T GET DISCOURAGED. This can be a really tough process, you won’t see immediate results, especially when it comes to medication, but you’re taking a crucial first step, don’t give up! It will feel discouraging at times, and you might want to quit but if it’s not working for you and you are able to change it, then change it. Use your resources, and be as relentless as you can in your quest for self-betterment because you and your wellness are 100% worth it.
Peace, love, and wellness.