How can we expand access to therapy?
Solving the reasons why people with a mental illness are not receiving treatment
This is the latest in a series of articles about the mental health crisis in the U.S.
Here's what we've learned so far:
Medication and psychotherapy are the most common treatments given to U.S. adults with a mental illness.
But more than half of U.S. adults with a mental illness are not receiving treatment.
These are the top three reasons why people are not receiving treatment:
Could not afford the cost of care
Not knowing where to go for services
Believing they could handle the problem without treatment
Two possible approaches
To make sure that everyone with a mental illness who wants to get treatment is able to, there are at least two obvious approaches:
Solve the reasons why people are not receiving treatment in order to expand access to the existing treatment options.
Come up with other treatment options that aren't subject to the same reasons why people are not receiving the existing treatment options.
Expanding access to the existing treatment options
In this article, we'll focus on expanding access to the existing treatment options.
In order to expand access to the existing treatments for mental illness, we want to solve the reasons why people are not receiving treatment.
First, let's evaluate the two most common treatments: medication and psychotherapy.
Medication vs. psychotherapy
Medication and psychotherapy are both effective treatments for mental illness.
The most effective treatment is medication and psychotherapy together.
Individually, psychotherapy is preferred over medication for several reasons:
Psychotherapy is proven to be as effective or more effective than pharmacological treatments.
The results of psychotherapy last longer.
Pharmacological treatments have adverse side effects.
Psychotherapy is more cost-effective in the long term.
Despite the reasons to prefer psychotherapy, medication is more commonly used.
Let's focus on therapy
Because of the reasons why psychotherapy is a better treatment option than medication, let's focus on expanding access to therapy.
Not to mention, Americans are already over-medicated.
Prescription of "antidepressants for subsyndromal levels of depression" is among the 10 most frequently prescribed medication classes for U.S. adults.
According to a 2005-2008 CDC study, "About one in 10 Americans aged 12 and over takes antidepressant medication."
Meanwhile, the debate about the effectiveness of antidepressants is ongoing.
In any case, the pharmaceutical industry is already working hard to increase prescription drug usage. In 2016, drug companies spent $6 billion on direct-to-consumer prescription drug ads.
So motivating more Americans to take prescription drugs seems like it would be redundant at best, and harmful at worst.
For all these reasons, let's focus on therapy.
To come up with ideas for how we can expand access to therapy, we'll study the reasons why people are not receiving treatment for mental illness, in general, and then propose solutions, in the context of therapy specifically, to solve those reasons.
Cost of therapy
"The cost of therapy depends on a number of variables, including the training and experience level of the therapist and the location of the therapy—the average fee in some regions is considerably higher than in others. In the U.S., the fee for a single session frequently falls between $100 and $200, but many providers will offer lower fees, while some charge more. The ultimate cost to a client also depends on whether health insurance is involved."
"The rate you pay will vary and depend on things such as your location and the therapist’s specialty, experience, and credentials. That said, the average cost for individual therapy services in 2021 was $75-150 an hour. If you live in a place like New York, however, that range jumps substantially to $200-$400."
"Most traditional therapy ... is priced between $75 and $200 per session or more, depending on your mental health provider."
The average cost of therapy is anywhere from $75 to $400 per session.
If you go to therapy once per month, that's anywhere from $900 to $4,800 per year.
If you go to therapy once per week, that's anywhere from $3,900 to $20,800 per year.
One reason why therapy is so expensive is that many therapists don't accept insurance.
Insurance acceptance rates are lower for psychiatrists, compared to physicians of other specialties. In 2009–2010, only 55.3% of psychiatrists accepted private fee-for-service insurance versus 88.7% of physicians of other specialties.
According to Michael Klein, a psychologist practicing in San Francisco, there are two reasons why some therapists don't accept insurance:
Money: "The reimbursement rates don't provide a living wage."
Paperwork: "For an hour of psychotherapy you spend a half-hour on paperwork."
Solution
The obvious solution to the high cost of therapy is to lower the cost.
There are some lower-cost versions of therapy that already exist:
Telehealth and online therapy (e.g., Talkspace and BetterHelp)
Community mental health clinics
Therapist training centers
The SAMHSA National Helpline (1-800-662-HELP) offers free referrals to connect you with state-funded treatment options.
There are also some alternatives to therapy that are more affordable:
In terms of addressing the problem directly, Alice LoCicero presents two possibilities that would meet the financial needs of therapists while also increasing affordable access to therapy for patients:
"1. Communities could subsidize community mental health centers, where clinicians could have real jobs, rather than be part of the gig economy. Those real jobs could start at the median income for the area and go up with experience. Full-time clinicians could be expected to do 30 hours of some sort of service, which might include supervision, seminars, community outreach, and clinical direct service, with 5-10 hours reserved for phone calls, notes, and consultation with peers.
2. Another possible answer would be for insurance companies (or perhaps, ultimately, a national single-payer system such as Medicare for All), to increase payment rates. In order for a clinician providing 25 hours of direct clinical service per week to approach the San Francisco median income of $96,000, to give an example, such payments would have to be a minimum of $100/hour for those practicing in that metropolitan area. That would provide an income, after basic expenses, of $93,600, a decent income for a clinician, particularly one who is just starting out. But those rates would have to rise, at least pegged to the rising cost of living in any particular area."
Knowing where to go for therapy
It's not easy to find a therapist.
There was already a shortage of therapists before the pandemic.
At a hearing before the U.S. Senate earlier this year, Mitch Prinstein, Chief Science Officer of the American Psychological Association, testified:
"Even before COVID-19, the U.S. was facing a serious shortage of mental and behavioral health providers, including psychologists, with every state having documented mental health professionals shortage areas."
Then demand for therapy increased during the pandemic.
And now the shortage is even worse.
Even if there were enough therapists, the process of finding a therapist is difficult.
When I tried to find a therapist earlier this year, the first place I looked was the website of my health insurance provider. It was difficult to navigate the search results to find a therapist because:
I didn't know which therapists in the search results were objectively good, e.g., education, experience, reviews, etc.
I didn't know which therapists would be good for me personally, e.g., beliefs, personality, communication style, etc.
I didn't know which therapists were covered by insurance and what percentage would be covered.
After scrolling through several pages of results and cross-referencing other websites to find reviews, I actually did find a therapist that seemed like a good fit, but when I went to their website, there was a message on the front page: "I don't accept insurance. It's $400 per session." Or something like that.
My guess is that this therapist had already received a lot of questions about whether they accept insurance and what the cost would be, so they decided to make it obvious on the front page of their website. As for the cost, I can't remember the exact figure, but I'm pretty sure it was at least $300 per session. It was high enough that I was surprised. For context: I live in San Francisco, so therapy prices are probably higher here.
After my first failed attempt to find a therapist, I started asking friends for advice. They told me:
It's hard to find a good therapist.
It's hard to find a therapist at all right now (during the pandemic).
Insurance doesn't usually cover it.
You should try Talkspace or BetterHelp.
The only way to find a good therapist is to get a referral from a friend.
Based on my personal experience trying to find a therapist, I can understand why "not knowing where to go for services" is a top reason why people with a mental illness do not receive therapy for treatment.
Solution
I think tech can help with this.
I'm imagining a website that takes you step-by-step through the process of finding a therapist, allowing you to book an appointment in less than 10-15 minutes.
First, you fill out an intake form, including:
Location
Insurance information
Symptoms
Why you're looking for a therapist
Your beliefs
Your personality
Your communication style
Preference for in-person vs. virtual
Then, you get a list of therapists that are matched with you specifically, based on your answers to the questions on the intake form.
For each therapist in the list of results, you can see the exact cost that you will pay per session, including a breakdown of how much your specific insurance policy will cover.
When you click on a therapist, you see their schedule, and you can book an appointment with a click. The UI would be similar to booking a meeting with someone via Calendly.
Does a solution like this already exist?
Handling the problem without therapy
Perhaps people avoid going to therapy because of stigma.
Also, there are general reasons why people avoid any type of medical care, not just therapy. According to a 2014 study:
"Three main categories of reasons for avoiding medical care were identified. First, over one-third of participants (33.3% of 1,369) reported unfavorable evaluations of seeking medical care, such as factors related to physicians, health care organizations, and affective concerns. Second, a subset of participants reported low perceived need to seek medical care (12.2%), often because they expected their illness or symptoms to improve over time (4.0%). Third, many participants reported traditional barriers to medical care (58.4%), such as high cost (24.1%), no health insurance (8.3%), and time constraints (15.6%)."
This likely requires more research. There are probably various reasons why people believe they can handle their mental illness on their own without treatment.
Solution
Even with a limited understanding of why people believe they can handle their mental illness without treatment, there are at least two apparent approaches to the solution:
Understand why people believe they can handle their mental illness on their own in order to convince them to seek professional help.
Empower people with less serious cases to successfully treat themselves without professional help.
Most serious mental illness cases probably require professional help.
For less serious cases, if people have the right resources and support, can they successfully treat themselves?
Perhaps this is another opportunity for alternative remedies and lifestyle remedies.
Conclusion
To increase access to therapy as a treatment for mental illness, we've proposed solutions to the top reasons why people with a mental illness are not receiving treatment.
If we take the three proposed solutions from above and try to combine them into one solution that solves all three reasons, it might look something like ...
A free, easy-to-use website
That makes it obvious where to go for therapy
With recommendations based on your unique needs
In a way that reduces fear of stigma
In addition to traditional in-office therapy, the site could also recommend different versions of therapy (telehealth, online, community-based, self-care), alternative remedies, and lifestyle remedies. This way, there would be options at all cost levels, including free options.
DISCLAIMER: THIS IS NOT MEDICAL ADVICE
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