Unhappily never after, part 1: finding a therapist when you already need one

Note: I wrote this guide in 2019 to fill, IMHO, a serious gap in individual education around mental health. There’s tons of info on finding therapists, but very few directed for when we already feel overwhelmed and horrible, when doing the thing we need most is hardest. This is a revised, abbreviated version of the guide. Also: I’ve made reasonable attempt to include functional and relevant links. None of these links should constitute endorsement; they are provided for information only. Also, nothing in this guide should be considered medical advice. Always speak to your physician or health care provider when starting or changing treatment. If you are in crisis, please call 911 or your local emergency services.

Part 2 covers ways to get care if you are un- or underinsured. Part 3 describes the various roles and types of therapists, and a summary of some common therapy styles you may encounter.

Part 1: Introduction, insurance coverage in the US (private, Medicaid, Medicare), Canada, and the UK

Finding a therapist is a lot like dating.

Like dating, finding a therapist requires energy, hope, and persistence…which is horrible, because, if you are anything like me, by the time you realize you need to see a therapist of some sort, you’re pretty close to being fresh out of giving a fuck, much less full of energy, hope, or persistence.

The best time to actually find a therapist is when you’re hale and healthy, full of motivation, when you want one, as opposed to when you need one.

But if you’re reading this guide, zip and fortitude are in the rearview, and you’re feeling tired, desperate, and a little stupid.

Feeling that is totally understandable. Human. And though it doesn’t feel like it this minute, I promise you’ll get your proverbial mojo back, and therapy will help.

So, consider me your zip and fortitude. At least, for now.

This guide will break down how to get yourself in a therapist’s chair using as little energy as possible, so you can get over the hump for now. We’re probably not going to find you your dream therapist out the gate (like I said, it’s like dating), but you CAN find someone, at the very least, “good enough.”

Before we get going though, I want to ask you some questions.

Please be honest. No shame, no judgement.

Are you in danger right now? Like…

Are you feeling suicidal? Like you want to die, don’t care if you die, want to just blip out and disappear?

Are you feeling like you want to hurt yourself or others? Or both?

Are you not taking care of your basic needs? I mean basic-basics: not eating food with some semblance of nutrition, not drinking water or fluids, not staying warm and dry, not sleeping normally, not taking medications or other substances as they are prescribed or within limits otherwise normal for you?

Has your perception of the world and yourself changed dramatically, recently? Are you seeing, hearing, or feeling people or things that other folks you trust are not seeing, hearing, or feeling? Do you suddenly feel like you are being spied on, watched, or monitored?

If you said “No, I just feel sad, scared, anxious, out of control, down, confused, or stuck,” then skip the inset content, and move onto the rest of the guide.

But if you were able to say yes to even one of those questions, then please, please, please pause and take what I say here seriously.

If you said yes, then you are having a medical emergency.

Your brain and body are reacting to an illness.

You are not a bad person, a failure, a waste, or anything like that. This is not a moral failure. This is illness, and it may be serious.

Please call 911 or your local emergency services right now, and get to a hospital.

This is the same seriousness as if you were having a heart attack, stroke, appendicitis, or other life-threatening illness. Do not “wait and see” if you get worse or get better.

Please, even if no one else believes you; I believe you. Go call, right now. Then, tell them everything, even if it feels terrifying, embarrassing, shameful, ugly, weird, or angry. It’s OK. They will believe you, too.

I know this is scary. I know from experience. But you have to be brave, maybe the bravest you have ever been in your whole life.

Call for help right now.

Thanks for bearing with me there. It’s important to be able to tell when we are having an actual medical emergency, especially when the emergency has to do with mental health. There’s still so much shame and stigma around mental health, but the truth is that our brains are organs, just like our heart, lungs, kidneys, and so on, and, like the heart, lungs, kidneys, and others, the brain needs medical care sometimes, too.

All right. If you’re still with me, let’s proceed to the business of the day: finding a therapist.

This is going to possibly feel like an overwhelming amount of work.

I’m not being patronizing. I have been there. Getting up, dressed, and going through the motions of a day when you’re feeling unwell are monumental efforts.

And finding help for mental health, even if you have done it before, is kind of like starting all over, as a total beginner. Where to start, how to proceed, dread, embarrassment, fear. It’s paralyzing.

Even when you have loved ones ready and willing to help you…it can feel the same as when you don’t. It’s hard to even think about what to task them with to help.

Knowing you need help is a huge accomplishment, and I am very proud of you for that (again, been there). But then there’s a wide chasm between knowing and getting, because the getting requires doing, and when you are ill, doing is really difficult.

I couldn’t make the process perfectly smooth and simple, nor could I cover every possible scenario you could face.

But I’ll attempt to break down the most common situations into manageable-feeling steps.

My hope is that by providing a clear(ish) map of what you need to cover, doing the getting feels slightly less impossible.

It’s impossible to cover every area of the world. However, some information is applicable everywhere, in terms of what you need to think about, know, and ask. Substitute your country or area’s department/ministry of health/human services or insurance plan with the ones mentioned.

If you get stuck, contact: The World Federation for Mental Health, a US-based, but globally-focused, non-profit which promotes access to mental health services. Though they do not themselves provide services, they often can point you to services in your country: The World Federation for Mental Health PO BOX 807 Occoquan, VA 22125 USA [email protected] https://wfmh.global

International Council of Psychologists, one of the oldest professional organizations for psychologists, focuses primarily on education. However, contact their Secretary-General, currently listed on their website at https://www.icpweb.org/contact-us.html for assistance.

Health insurance

If you do not have health insurance, or your health insurance doesn’t provide enough coverage for you, please skip to Part 2.

In the US, more than likely, your insurance will have some coverage. As of 2014, most individual and small group health insurance plans — aka “Marketplace” plans — in the United States are required to cover mental health and substance use disorder services.

Same goes for Medicaid Part B, Medicaid and Medicaid alternative (known as “Advantage”) plans: they may not offer an awesome amount of sessions, they may only cover certain types of therapy or specific species of professional therapists, but they have to offer something.

In Canada and the United Kingdom, the national health insurance policies for citizens and legal nationals, do include coverage for mental health services, including outpatient therapy — though you have to about getting referred in specific ways. Skip to the very end of this section for guidance.

OK.

Take a breath. Not so bad, right? You’ve already gotten started and you haven’t had to expend much energy yet. Which is nice because this next part takes a little effort, because you will probably have to speak to someone on the phone… …which, when we’re healthy, is, at worst, a slight tickle of a shadow of an annoyance. But, when you’re feeling awful sounds as appetizing as steaming shit.

I’m going to help you through it, though.

I can’t give you a perfect script, per se, because every plan is different, but I am going to break this down into a sorta outline, as best I can.

In the United States, with private insurance, employer-provided insurance, or a Medicare Advantage Plan (PPO or HMO)

If you have a physical insurance card, get it out of your wallet, flip it over, and find the teensy printed customer service phone number on the back.

If you don’t have the card, fire up the Interwebs and search YOUR PLAN COMPANY NAME + Contact us and look for the number for member/enrollment questions.

Take another breath and call the number. Follow the prompts that lead you to “questions about coverage” or “something else” or “speak to an agent.”

Sometimes mashing buttons, especially 0, will lead you to a human being.

You want to say, “Hello, I need to understand my mental health coverage.”

The representative will need either your member and group number (off the card) or your social security number and date of birth to locate your plan.

Ask them the following questions:

1. Do I need a referral from my primary care provider? 2. Do I have to see someone “in network”? If so, where is the searchable list on your website, or can you send me a list of mental health providers (in the mail, via email, or the like)? 3. Is there a limit to how many visits are covered? Per calendar year or quarter? How many? 4. Is there a copay or coinsurance* charge? If so, how much is the copay, or what percentage is my responsibility of co-insurance? *Insurance is super confusing. But in this case, knowing the difference between copay/insurance is helpful: copays are flat fees paid per visit or service, while coinsurance is a percentage of the cost you pay per visit or service, while your insurer pays the rest — usually after you have met your yearly deductible. 5. Are there any restrictions in my plan that I need to be aware of before I make an appointment?

Thank them and hang up. Then take a break. You did great. I know that was harder than it seemed like it should be.

In the United States, if you have (“Classic”) Medicare

There are some definite restrictions I can already tell you about. You will only be able to see certain types of practitioners (for example, psychiatrists or other doctors, psychiatric or clinical nurse practitioners, psychologists, and clinical social workers), and you’ll most likely have to schedule a “depression screening” first with your primary care doctor or clinic.

The good news is that depression screening is free, and you are allotted one per year.

Once you complete this screening, and are determined to be in need of mental health services, your primary care providers will jump in and help you schedule referrals and follow-ups.

After you meet your yearly Part B deductible (at 100%), you’ll pay 20% of the Medicare-approved amount for treatment.

I emphasized the words Medicare-approved amount on purpose.

If you want your bill to be predictable, you will have to call your Medicare provider and find out:

1. How much you have paid towards your deductible. If you have not yet met 100% of your deductible, you will have to make that amount in payment before the 20% co-insurance kicks in. 2. The dollar amount approved per visit. Medicare sets a price for services, depending on your location and the type of provider and visit/service.

Now that you know that, you should then call the provider for which you received a referral, and find out how much they are actually going to charge per visit.

When you call, ask to speak with their billing specialist directly.

These are the folks who can validate that, indeed, $______ (dollars from above) is how much Medicare has approved, and then tell you if there’s a difference between what Medicare will pay and what the therapist will charge.

Billing specialists are also, in most cases, willing and able to work with you to set up payment plan if necessary.

In the United States, if you have Medicaid

It’s really hard for me to completely nail down every iteration this may take, as Medicaid is jointly funded by the federal government and individual states.

Most states regulate their own program, and just to make things more complicated, some states contract Medicaid operations to

companies who then issue “managed care plans” (that look, smell, and act like regular consumer health insurance, but aren’t).

In general terms, it’s unlikely that you’ll able to go to a traditional therapist in, say, private practice. Medicaid — usually — will only pay for services provided in group settings, or by those clinics deemed “community mental health centers.”

The “community mental health center,” or CMHC, is Medicaid-speak for organizations, usually non-profits, that provide outpatient mental health services — which may or may not include one on one therapy — and who are set up and approved to bill Medicaid.

CMHCs may be large or small, may cater to certain demographics, may be attached to universities, community centers, or hospitals, and may provide other services like job training or case management.

In my experience, some CMHCs do provide therapy, and though I know you are definitely feeling like not having to call every health center in your metropolitan area to find out which do, indeed, provide it. There’s no other, easier way to find out.

You can chance it, and go for whichever CMHC is closest or can get you scheduled for an intake the soonest, and I can guarantee that you will, at least, speak to a hard-working and sympathetic case manager (who may or may not have any clinical licensure) and you will have access to some psychiatric medication prescribers (most likely, nurse practitioners).

Even the CMHCs that do not offer therapy do run a schedule of some sort of therapeutic groups.

Groups are usually casual in nature and not very intensive, though run by qualified and enthusiastic staff.

Don’t read in my statements any judgement against CMHCs, which are indispensable in countless ways. I’ve worked in CMHCs, and believe they are (usually) staffed with incredible folks who want to help others.

But this guide is about finding a therapist, and it’s honestly a matter of funding and geography whether a CMHC has the budget to employ them…and enough employed to meet the need.

A good case manager should be able to help you locate therapy services, even if that means ultimately switching your services (the CMHC you receive services from is called your “tier”) from one community center to another tier. This adds extra time and steps between this moment right now and when you actually receive therapy.

It’s not a terrible choice or anything, but it definitely dilutes the immediacy that has gotten you to reading this guide.

So, to quickly ensure that you are able to get to see an actual therapist of some sort, however, you will either need to make those round of calls or skip ahead in the guide and read the section for folks with no insurance to find free or low-cost therapy.

In Canada and the United Kingdom

In Canada, you customarily begin with your primary doctor to receive a referral for mental health services. Depending on your provincial health insurance plan, some types of practitioners are covered, while others are not…or, some are covered, but only under specific circumstances, like being referred by your primary doctor.

For more help navigating the conditional referral system, contact a voluntary service, such as The Canadian Mental Health Association (CMHA), which has branches in most provinces. CMHA themselves don’t provide direct therapy services — they provide other types of support, education, and advocacy on mental health issues.

CMHA can help with referrals that are covered by your insurance or to help you determine if you are eligible for other routes to service (such as through community agencies that will provide care for you at no or low cost) You can find your closest branch of CMHA at https://cmha.ca/find-your-cmha.

You can always self-refer to therapists in private practice, if you can pay their fees. Skip ahead to section two, in that case, to learn about types of therapists and common types of therapy, and then the appendix for searchable databases and therapist listings.

In the UK, therapies provided through the National Health Service (NHS) are free.

You can start by talking to your primary care provider, who can refer you to a therapist.

Or, depending on where you live (most UK areas are covered, except Wales), you can self-refer yourself to a therapist through an NHS program called “Improving Access to Psychological Therapies” or IAPT.

You can search IAPT (often shortened to “Psychological Services” by NHS) services on the NHS website at https://www.nhs.uk/Service-Search/Psychological-therapies-(IAPT)/LocationSearch/10008.

In Wales, since you aren’t yet covered by IAPT, you will have to start with the NHS, but you can, in many cases, skip to calling directly for a referral: from NHS Direct Wales, by phone at 0845 46 47 (open 24 hours).

You’ve done some serious work. I am beyond proud of you! When you get a breath, move onto Part 2. In Part 2, we’ll look at options for the un- and under-insured. Then, finally, in Part 3, we’ll give a simple low-down on the different kinds of therapy out there, and who provides which type.