Breaking The Clouds

10) How is treatment for mental illness covered by health insurances? How much does it usually cost?

A: First, there are several types of treatments for mental illnesses depending on diagnoses and severity of illness. These include commonly used approaches such as psychotropic medications and psychotherapy as well as less commonly used methods such as electroconvulsive therapy (ECT), psychoanalysis, hypnosis, etc. They can be inpatient treatment or outpatient treatment. Different treatment modalities can be applied together or separately. Focusing on the commonly used approaches, medication management and psychotherapy can be practiced together or separately, depending on the therapist’s expertise (see Answers to Question #4, 6. and 7). When they are practiced separately, a medication management session lasts from 15-20 minutes on average and costs almost as much as a psychotherapy session; a formal psychotherapy session usually lasts 45-50 minutes. When they are practiced together, depending on the type of therapy, the session can be 30 to 45 minutes and the cost can be the same as therapy or a little more per session than either type of treatment alone. Keep in mind that the rate can vary by specific practitioner. It may also change over time.

Second, to my knowledge, most health insurance plans cover medication treatment and psychotherapy sessions to some degree. However, many plans limit the number of sessions covered per year and often count medication treatment as part of total mental health sessions allowed for one individual per year. As seeing regular doctors, a per-session copayment is almost the rule. One can discuss with the doctor about the treatment plan and session limits once started. It is quite possible that a patient will need more sessions in a year than covered by the insurance company. In other words, it is not uncommon that a patient needs to pay out of pocket to some degree. Your doctor/therapist can discuss treatment choices with you after evaluation. Psychoanalysis is essentially not covered despite its usefulness for certain patients, which is one of the reasons for its popularity decreased significantly in the US in recent decades. Many of them mostly see patients for psychotherapy.

Third, like medical doctors, there is a difference in coverages for providers who are inside the insurance network vs those outside network — If one wants to pay less out of pocket, it is important to contact your insurance and find out the list of providers. Many doctors and therapists choose not to be a part of an insurance plan due to low payment from insurance companies, unfortunately, including many of the best doctors and therapists. In general, psychologists and social workers charge a lower per-session rate than psychiatrists, but the cost can vary widely depending on other individual factors, such as the experience and popularity of the practitioner, the location, and affiliation (with a hospital or community mental health center vs private practice, for example). Therapists still in training usually charge a much lower rate than fully credited and established ones, but this does not mean their care is necessarily less good, because they always have an experienced professor/mentor who supervises them on each case. In some hospitals, the trainees’ therapy sessions were recorded with the patient’s consent and then supervised by senior faculties. A therapist in training may also be very conscientious with updated knowledge. Seeing a therapist under training at a teaching hospital or clinic can be an economical way to get high-quality treatment. Community mental health centers, some hospitals, and many psychotherapists charge patients on a “sliding scale.” In other words, the rate they charge a patient is pre-arranged according to the patient’s income. Therefore, the cost of mental health care for each person depends on his or her specific needs and financial considerations. Lastly, with doctors and therapists in private practice who have to cover many overhead costs by themselves, don’t be surprised for a small percentage increase of the fee which usually reflects the inflation, but the insurance plans are not necessarily agreeable.

Given all these variables, I can’t give specific numbers here for the costs of treatment. As a rule, it is important to keep good communication with your doctor/therapist about any concerns related to treatment including payment. Unlike other types of medical care, the discussion about the payment of treatment can be a psychological therapeutic issue. Most doctors and therapists will not charge an unreasonable rate both for ethical and practical reasons.

9) If someone has the tendency to procrastinate, should s/he consider seeking psychological help?

A: Procrastination happens to many people once a while. Very few people can say that they never procrastinated in their lives. However, if one procrastinates frequently, this can cause troubles in life, especially if procrastination causes serious delays in work or health-related issues. There may be numerous reasons to cause procrastination, such as not having enough energy or concentration as a result of physical or mental illnesses, or psychologically resist the pressure or obligation to do certain things. Thus, I would suggest that, if the procrastination is frequent and severe enough to interfere with a person’s daily function, such as getting work done or finish homework at school, or always late to appointments and affect relationships with friends and family, one should seriously consider getting some professional help.

(For the reader’s convenience, this article will be translated into Chinese in a separate entry.)

8 ) What should I do to help someone who seems to have depression or other behavioral symptoms but does not want to see a psychiatrist or psychotherapist?

A: First, it is common that patients with emotional or behavioral problems do not actually realize that they are having these difficulties. If so, it is important to talk to these persons with a genuinely caring attitude and gently point out your and others’ observation, and then suggest that they consult with a mental health professional. On the other hand, many patients do know that they are having thinking, emotional, and/or behavioral difficulties but still refuse to see a mental health professional. There are many reasons for their rejection, including fear of being judged or looked down on and not realizing their problems are affecting people around them. Thus, in addition to showing sympathy to his/her suffering, it is also important to gently inform the patient the impact of his /her symptoms on others, and discuss his/her reasons for resisting seeking care in an unthreatening and open way.

In order to find professional help, seeing a primary care doctor is probably a good start, because it is important to rule out any physical illnesses (such as thyroid diseases, brain tumor, anemia) that may cause the mood or thinking problems. Some medications or substances, such as alcohol and painkillers, can cause emotional and behavioral problems. Seeing a general practice physician can also seem less threatening and embarrassing for people who are afraid of the stigma against mental illness.

In recent years, the medical community had learned a lot more about the biological and genetic factors of mental illnesses, the mechanisms of neurotransmitter imbalance and receptor disregulation in the brain, and the physical consequences of mental illness (such as increased risk of cardiovascular diseases among patients with major depressive disorder). Therefore, it often helps to compare mental health problems with other health problems when you are trying to persuade patients to seek medical help. For instance, will the patient consider seeing a doctor if he or she has a stroke or brain tumor?

A primary care physician is a good source for getting referrals to a reputable and competent mental health professional. If a patient still does not want to see a mental health professional referred to them, the primary care physician may question and clarify the sources of the resistance.

If a patient expresses thoughts of or give indications for harming himself/herself or others, or is unable to take care of self for daily living, he or she should be sent to a hospital emergency room for evaluation and treatment. In the United States, if aperson is not a danger to self or others, health care professionals cannot force him/her to receive treatment. In other words, even the police cannot force a person to go to the hospital or to see a doctor if he or she is not a danger to self or others.

7. Q: Should a Chinese immigrant find a psychotherapist who is a Chinese?

A: There are essentially two issues here: Language and culture. They are separate but connected. In my opinion, there are pros and cons for seeking either a Chinese or non-Chinese psychotherapist. As a patient, one should at least be able to communicate general ideas, describe daily life, and convey common emotions and feelings in English to the therapist; at the same time, a therapist should at least have enough patience to try to understand what the patient tries to describe instead of simply assuming. If the communication works out well, this can be a good way to practice and learn the new language for a new immigrant. However, know that this type of communication may prolong the process of treatment to certain degree depending on the level of communication difficulties.

With regards to cultural background, a therapist’s lack of understanding of the patient’s foreign culture can indeed bring significant problems into communication and affect treatment results with some patients. However, a well-trained psychotherapist should be able to be open minded and minimize the problems. In fact, many American therapists are quite interested in and some are fairly knowledgeable of the Chinese culture.

More important, the goal of treatment is usually to help one better adapt to the society he or she lives in. To achieve this goal, the immigrant needs to adjust his or her thinking habits and become more flexible. Thus, a non-Chinese therapist may be more sensitive to the differences between a patient’s original culture and the American (or another country’s) society, thereby providing more effective feedback. A Chinese psychotherapist may be equally helpful depending on how integrated the therapist herself/himself is into the society.

Certain psychological approaches may work in one society but not in another, because of differences in generally accepted customs, social values and rules, etc . Although a psychotherapist is not supposed to impose his/her own cultural values on a patient by telling a patient what to think or do, he or she still has a significant influence on the patient’s way of thinking. Thus, one has to decide which is more important for him/her to obtain the treatment.

6. Q: How and where do I find a good psychiatrist or a psychotherapist?

A: Just like finding a good regular physician or other professionals, word of mouth is probably the best way, in my opinion. You can start with asking other doctors, especially your primary care physicians, for a referral.

In the U.S., most psychiatrists have similar clinical training and are more oriented toward psychopharmacologic treatment in today’s environment. Some psychiatrists routinely refer patients to other mental health professionals such as psychologists and social workers for psychotherapy. Your choice also depends on other factors such as subspecialties or specific types of treatment you are looking for. Some psychiatrists focus on certain disorders such as depression and anxiety while others may see more patients with schizophrenia or substances abuse disorders.

A psychotherapist in the U.S. is actually not required to hold a specific degree, but usually is a psychologist, a social worker, a nursing practitioner, a psychological counselors. Just like psychoanalysts, many non-medical and non-physician professionals, such as academicians/professors now can go through some training and see patients. Many of them are quite good, but their professional background as well as many other factors in their background can make some difference in their approaches to treating patients or clients.

One of the most important factors in mental health care is how much a doctor or a therapist cares for a patient/client, including how well the doctor/therapist explains things to you the client and whether you two actually “click.” Consider whether you feel what the doctor/therapist says makes sense to you, whether he or she provides you with useful insights, and whether these insights enable you to look at issues from a different perspective that you have not thought of before. Also consider how comfortable you feel during the interactions with the doctor/therapist. The only way you can know whether a doctor/therapist works for you is by actually trying. In most cases, you can tell whether a particular therapist or doctor “clicks” with you and whether the course of treatment he or she is taking is moving in the right direction for you after a few sessions.

5) How do I prepare for a visit with a psychiatrist or a psychotherapist? What should I expect? What if I get upset during the session and just want to run away?

A: There is no special preparation needed. However, the interaction with the doctor will be more effective if you are prepared to ask all your important questions and tell all your worries during the session. This helps the doctor understand and focus on your questions and problems. Depends on individual practices, the first session can last from 30 min to 1 hour and incur different fees. The doctor will ask you about your major complaint, just like your family doctor does. The doctor will also ask and record your history, including family history, your history of mental illness, medical problems, medications you are taking, whether you use any other habit-forming substances, smoking or drinking, etc. Most of the time the doctor is experienced enough to detect your discomfort during the discussion. However, people have different comfort levels in expressing their feelings. If you feel uncomfortable or getting upset during the visit, you should let the doctor know right away if possible. Running away or hiding will not help communication between you and your doctor and may hinder the doctor’s understanding of your problems.

4. Additional notes about whether one should visit a psychiatrist or a primary care physician when you are unsure.

In the United States, many people are insured with managed care plans. Most managed care plans require a referral from primary care physician before a patient can visit a specialist. This can be a safeguard because symptoms that appear to be depression, thought disorders, or other mental illnesses, may be a result of physical illnesses or adverse effects of medications used to treat other illnesses. Primary care physicians can help rule out these causes before making referrals to other specialists. If you have an insurance plan that allows to see a specialist without referral, you can choose to see a psychiatrist without first going through a primary care physician, because psychiatrists will also conduct necessary tests to rule out medical causes for psychiatric symptoms. If a psychiatrist decides that psychotherapy is needed but he or she does not offer in-office therapy, you will be referred to a psychotherapist.

3) How does a psychiatrist differ from a psychologist? Would a psychiatrist “force” me to take medicine? I’m afraid of medicines.

A: A psychiatrist is a medical doctor who has graduated from medical school with an M.D. degree and four years of psychiatric residency training, which also requires substantial training in general medicine. From the intervention point of view, psychiatrists provide treatment either biologically (such as prescribing medications) and/or psychotherapeutically (giving psychotherapy). Some psychiatrists may also undergo additional years for fellowships (specialties). One example is the subspecialty of child and adolescent psychiatry.

In comparison, a psychologist usually holds a PhD degree in psychology from an accredited graduate school. They are also called doctors and they usually have at least one year of training alongside psychiatrists in hospitals. However, most psychologists are not trained in medicine and, in most states, they cannot prescribe medications. Most psychologists have been trained in and can provide various types of psychotherapy and perform psychological and/or neuropsychological evaluations.

In the United States, by law no doctor can “force” anyone to take medicine. Only a mental health court is able to issue legally binding orders to treat a patient against his/her will, and the court’s decision is usually made only when the patient is a danger to self or others.

2. Q: I am unsure whether it will be a good thing to seek help from a mental health professional. I’m afraid that other people will think I’m crazy or look down on my if they find out.

A: As stated in the first question and answer, mental health professionals are there to help you with your problems/issues, just like ordinary doctors. Although there are a lot of stigma associated with mental health care in the society, one should understand that, in this country, there are laws against discrimination of mentally ill patients. In addition, doctors are legally obligated to keep everything you tell them strictly confidential, that is, the doctor cannot tell others about your condition or the content of your consultation with him or her to others without your explicit permission. Like other types of doctors, your mental health professionals may inform other doctors about your condition as necessary, because they are all on the same treatment team for you. That being said, the exceptions about confidentiality are if you are having dangerous thoughts that threaten the safety of yourself or others, i.e. suicidal or homicidal, then doctors are required to hospitalize you for psychiatric evaluation and treatment.

1. Q: I have had some troubles on my mind for while and am wondering if I should see a psychiatrist or a psychotherapist. I am not sure if it is a good thing to do. If I am not ill and do not need treatment, will a psychiatrist or therapist convince me I am?

A: It’s good to seek help in general. Mental health care professionals such as licensed psychotherapists and psychiatrists are there to help you with various kinds of troubles of the mind. They are doctors and make diagnosis based on your symptoms and their formal training, just like primary care physicians or other types of physicians. With training in science, practice, and ethics, no doctor will convince you that you are ill if you are not.