Therapists are in short supply and we can’t fix the problem — but we’re still here to help legal professionals in Massachusetts.
For most of my 23 years at Lawyers Concerned for Lawyers, I’ve been encouraging lawyers to get past the internal and external obstacles and reach out for help when burdened by stress, depression, anxiety, addictive behavior, trauma, etc. And for most of that time, when a lawyer came to see me and we agreed that a referral would be helpful, I’d come up with a short list of potential clinicians and within a few calls would line up a good match. Well, those days are gone.
Even before but certainly exacerbated by COVID, it has become a herculean task to find a therapist with an opening for a new client/patient, especially a therapist who is “in-network” for the individual’s health plan. A decade ago, a stream of therapists approached LCL, many of them coming in for a personal interview with our staff, in hopes that we’d consider them as resources for the lawyers and law students we see. Now, well, at least they return our calls — which they don’t always do for their prospective clientele.
Based mostly on my own impressions rather than a systematic study, here are some of the factors that have brought about this change.
For years, we mental health professionals have sought to decrease stigma and encourage people who are in emotional distress to ask for help. I think progress has finally been made on that front; I see this especially in the attitudes of young law students (a welcome change), but it’s also true for younger people in general, and now further bolstered by the appearance of TV commercials for online therapy featuring celebrities such as Michael Phelps.
Although this trend began years before COVID-19, the pandemic (and accompanying isolation and financial disruption) has only augmented the prevalence of mental health symptoms and demand for help. And the increased availability of tele-health formats (which only recently began to qualify for insurance coverage, especially during COVID) has also removed barriers.
From my perspective, it appears that the number of people seeking mental health training at a doctoral level (mostly psychologists) or at an advanced master’s level (independently licensed social workers) has not kept pace with community need. We have seen a great increase in the proportion of licensed mental health counselors (a more recently designated license in Massachusetts), who are mostly younger and, as a gross generalization, seem to have less training — and it is very challenging to get an initial appointment with any licensed mental health professional.
Why are more people not entering this field? If one accepts insurance coverage or gets a salaried position, it is not well-paying. A talented young person functioning at a professional level will do a lot better going into fields like finance, sales or a medical specialty.
Managed care, which came on the scene in the late 1980s and 1990s (now simply a fact of life to consumers), brought about a radical decrease in “allowed” fees. And assisting individuals who are burdened by depression, PTSD, addictions, etc., is hard and stressful work. I might make an analogy here to immigration lawyers: They deal with so much pain and feeling of personal responsibility, driven by a sense of mission, but financial reward is quite limited.
Departures from Managed Care Panels
As the demand for therapists has increased, they have naturally wondered why they should settle for something like a 50 percent discount by maintaining contracts with managed care networks, or with Medicare. In medical and health insurance circles, mental health has long been a “stepchild,” covered in a more limited way (a problem mitigated in recent years by “parity” legislation). When mental health professionals decide not to remain in-network for managed care plans, they can see many fewer patients while maintaining the same level of income.
While people seeking therapists several years ago might have sought names of well-recommended professionals from friends or doctors, now they feel lucky if they find someone with an opening as they go through an HMO list that gives them little or no information about potential treatment providers. If you’ve tried this, you also may have noticed that there are quite a few people on these lists who left the managed care panel (or even retired from the field) years ago, but who somehow still show up on the lists, as if to present the appearance of more provider options.
At present, insurance companies seem to be developing collaborations with virtual therapy entities such as Teledoc and Talkspace. Such companies are also doing their best to recruit therapists, emphasizing flexible work hours and no need for an office or to bother with claims and billing. I have no personal experience with these and no feedback thus far from clients using such services. However, ‘The Therapy-App Fantasy,’ an article from The Cut (March 2021) explores in detail the limits and challenges of such services. For example:
Of course, many users aren’t paying out of pocket because, for many apps, users aren’t the customer at all. These apps, like Ginger and Lyra, focus on selling their services to employers or insurance companies. For an institutional client, a therapy app checks the box of providing mental-health care. It also addresses employees’ unhappiness and stress without requiring any change to their actual work. Although Talkspace built its business marketing directly to consumers (their ads were, for a time, ubiquitous on the New York City subway), the company is now pursuing institutional clients as well — like employers or the City of Reno. My own workplace began offering Ginger last year; this year, it added Talkspace as an in-network provider on our insurance plan.
Bob, who works at a cybersecurity firm in Massachusetts, decided to try Talkspace after his employer started offering it as a benefit. He wanted help with anxiety, but he wasn’t sure about therapy. “It’s still that cliché thing, but it’s very true,” he said. “Most guys don’t talk about things, ever.” Talkspace seemed more approachable — he had heard ads on the podcasts he listened to — and besides, it was free. After submitting his questionnaire, he was surprised to see that none of his top matches had any availability for the next three weeks. Beyond that, he had no access to their schedules. His office’s plan included one video visit a month; now he wasn’t sure if he would even get a chance to use it. He decided to message the first match anyway. The therapist wrote back and told Bob that he currently had 210 clients in his Talkspace caseload — so, yes, he was unavailable. (Talkspace calls this “impossible” and says no therapist on the platform has an “active caseload” of that size.)
It took Cait longer to run into problems. After meeting with her first match and messaging for a couple of weeks, she wasn’t sure she had found the right fit. She wanted to find someone more suited to her, a practice Talkspace encourages. “The relationship drives outcomes,” said Neil Leibowitz, a psychiatrist and the chief medical officer at Talkspace. “We’re pretty big on giving people the choice of therapists that they like, and if they don’t like their therapist, they should switch.” The second therapist Cait was paired with didn’t respond, so after four more days, she moved on again. She exchanged a few messages with a third therapist, but the woman never followed up after Cait asked when they could schedule. At this point, she had been on the app for a month and had only a ten-minute introductory session. When she contacted customer service, a rep agreed to a few weeks’ worth of a refund (and assured her that she should be hearing from a therapist daily, five days a week), then paired her with a fourth therapist. Cait was excited about this one — when she explained that she’d had trouble finding someone who communicated regularly, her new therapist said she checked messages even on her off days. That was the last Cait heard from her. This time, customer service told her Talkspace was experiencing high demand as a result of the pandemic and offered to put her account on hold. (Talkspace says that experiences like this are “rare” and that the company works with clients who have an unresponsive therapist to find a new one.)
There is also a role for sources of comfort and perspective that can be provided to and/or practiced by large numbers of people outside the realm of psychotherapy, and which are gaining popularity. These include mindfulness/meditation and yoga, as well as programs encouraging regular exercise and sleep hygiene. Such modalities are pretty much good for everyone but are not a substitute for the process of open, honest communication; the opportunity to verbalize thoughts and feelings not expressed via other relationships; and the sense of being heard and understood in the context of a confidential, trusted relationship, not to mention the kinds of perspectives, growth and coping strategies that can develop in therapy.
Now may also be a good time for rebirth of interest in group therapy, which allows for a different therapist-patient ratio. My own observation in recent decades has been that more people want individual therapy, and that the groups that have survived tend to be more topic-specific, structured and of briefer duration. Many or most group therapists do not take insurance, not only because of the more massive amount of paperwork involved, but because managed care’s allowed fees for this form of treatment have made the endeavor barely worth the effort. On the other hand, one need not be wealthy to afford to self-pay for group therapy.
At LCL, of course, the groups we run, though not group therapy, are free to lawyers and law students to connect, discuss, and find support among peers who relate to their problems. This can be tremendously helpful in the absence of or in addition to individual therapy.
In the long run, health insurance will have to provide better pay to mental health professionals in order to attract enough of them to the field, and to the managed care panels, to meet the demand. They seem to have finally realized, recently, that providing mental health supports reduces the need for much more costly physical health interventions, but that recognition has not yet translated into payments for services provided.
LCL MA’s Efforts
At LCL, meanwhile, we are doing our best to adapt to what has become a much more difficult mission in terms of referral. When attorneys and law students come to us for help in the current climate, the effort to find a therapist will require more of their own effort than in years past, when we could simply make a few calls. We can be less choosy about potential providers.
We are also working to develop more efficient ways of searching. When individuals present with problems that may be manageable without longer-term therapy, we are more likely to offer more than the limited number of consultation sessions that were standard for us a year or two ago, but was often followed by outside referrals. Don’t give up on the search — a good one can be hard to find but can make a big difference once found.
A Letter to the Editor on the Aforementioned ‘Long Run’
We thank the lawyer who wrote in to Massachusetts Lawyers Weekly, where this post was originally published, with a letter to the editor published on July 9th, pointing out that we cannot wait for the long run, as suggested earlier in the article. We wholeheartedly concur with their statement:
We can’t wait for the “long run” — this needs to happen now. And those of us who are employers need to make this clear to the insurance companies we choose for our employees that this will be a significant factor in our choice of providers.
Free & Confidential Consultations:
Lawyers, law students, and judges in Massachusetts can discuss concerns with a licensed therapist, law practice advisor, or both. Find more on scheduling here.
. . .
This post was originally published in the June 24, 2021 issue of Massachusetts Lawyers Weekly as “First toilet paper, now therapists.”