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Navigating Mental Health Care

by Joseph B. Nelson, M.A., L.P.

Navigating the process of seeking mental health care and then getting it is a daunting task for many. Even if it feels like you are adrift and have reached the point where you need therapy, making that final decision can still be uncomfortable. A range of questions may fill your head, from “I know I’m sad, but I’m not really that bad off, am I?” to “I feel nervous and edgy all the time. I wonder why, and what it means? Am I crazy?” You may even find yourself thinking, “Maybe it’s all related to my blood glucose” or “I wonder what everyone will think if they find out that I’m seeing a psychotherapist.”

These types of thoughts can make you feel as though you have no direction or simply prevent you from picking up the phone, and it may take a long time before you finally decide to seek help. In fact, of the 13–14 million Americans who experience depression each year, only about half get treatment. That figure is up from just one-third 10 years ago, but it still leaves millions of people out in the cold. While there may have been a stigma associated with seeking out psychotherapy in the past, we now live in an age where high levels of stress are commonplace, and the resulting depression and anxiety are clearly serious problems. But people don’t have to go down with the ship anymore—these problems can be treated effectively. Meeting with a mental health professional for a session to screen for emotional problems can determine if psychotherapy may be a life preserver for you. This is good idea if you have some of those thoughts and questions mentioned earlier. Particularly for people who have diabetes, such a consultation is becoming an accepted part of regular health screenings.

In the course of getting mental health treatment, however, there can some big questions. How do I find the right therapist? Is this covered by my insurance? What’s my role in sessions and at home? How long will I be in therapy? This article presents some basic information to point you in the direction of getting all of your questions answered and getting the help you need.

Who can help?
The first big question is “Who do I go to see?” There are a variety of mental health providers who can be helpful: psychologists, social workers, licensed mental health counselors, and psychiatrists. The first question to ask about a given practitioner is “Is this person licensed?” This is important because it assures you that the provider has had a standard of training that qualifies him or her to provide help. The second question is equally important: “What type of training has he had?” This question is usually best answered by simply asking the person directly. His answer should give you a sense of how he views and treats emotional problems and what you can expect to happen in psychotherapy sessions.

Some other questions to ask include: Does the person know anything about diabetes? Is he willing to learn? Does he understand the interaction between emotional issues and diabetes control? It is a good idea to have some questions ready when you first speak with a mental health provider since you are, in effect, interviewing the provider first to find out whether he or she will meet your needs. Remember, you are employing this person to help you navigate unfamiliar waters.

It is also very important that you feel comfortable with the provider you select. Your relationship should be based on trust, as it is with any good captain and navigator. If it is, you will be more open to accepting the guidance your therapist has to offer. To establish this dynamic, you will have to have a sense of comfort and ease of communication. You should feel that you have the ability to connect to your therapist without too much difficulty. Such feelings are not always easy to measure, but like good art, you’re likely to know it when you see it, or in this case, feel it.

In addition to credentials, comfort, and connection, it is important to recognize that therapy is a confidential process, so make sure that you and the therapist discuss the nature and limits of confidentiality. Feeling secure enough to express yourself freely is a vital part of this trusting relationship. However, if your health insurance is covering some of the cost of your therapy, it will have to be made aware that you’re seeking mental health care and will most likely require your therapist to submit a diagnosis (such as “depression”) for you.

There is a possibility that you will have little say in who you see, since some HMOs and other insurance companies require their members to see designated mental health providers. This is not necessarily bad, as long as you are able to see a therapist who is properly trained and licensed. If the therapist you are referred to isn’t, you should ask for someone who is. Since insurance companies vary so much in their coverage, you may have other limitations regarding who you can see for help. Questions about this issue can be answered by your insurance company.

Other options for initial assessment providers include Employee Assistance Programs (EAPs), which are often available through the workplace. EAPs offer free short-term counseling and then, when appropriate, referral. Walk-in counseling centers also exist in some communities. These establishments will often offer short-term counseling for reduced fees. Another resource in many communities is United Way’s First Call for Help. This service differs from community to community, but is still worth a call if you are just starting out. Also through the United Way, a free national health and human services program, from which callers will be able to obtain information and referrals by dialing 2-1-1, is in the works. The program is already active in 22 states, so check www.211.org to see if your area is covered.

A few other resources for finding a therapist include religious institutions, which often offer pastoral counseling and may be able to apprise you of additional local treatment options; hospitals (especially those connected with a university or medical school), which usually have specialized departments of psychiatry, psychology, nursing, and social work; and not-for-profit or professional organizations. The Depression and Bipolar Support Alliance Web site maintains an “External Referral Services” page (www.dbsalliance.org/Resources/ExternalReferrals.htm) with links to and phone numbers for a variety of organizations that can help you locate a therapist. The American Psychiatric Association Web site (www.psych.org/dbs_state_soc/db_list/db_info_dyn.cfm) also lists contact information for local district branches in every state, which provide referrals, and the American Psychological Association can connect you to a referral system in your area if you call (800) 964-2000 and provide your zip code. Finally, your local American Diabetes Association (ADA) office will also be able to provide names of mental health professionals who are involved with them in some capacity. These professionals are likely to be knowledgeable about diabetes as well as mental health issues. You can find local chapter contact information on the ADA Web site (www.diabetes.org) or by calling (888) DIABETES (342-2383). In your search for a mental health provider, all of these organizations can act as buoys to guide you to a better understanding of where to go in this new area.

How do I pay?
The next big question is “How will I pay for this?” If you have insurance that includes mental health coverage, some of the costs associated with your psychotherapy should be covered. With the exception of co-payments or deductibles, most insurance plans pay for a certain number of sessions. But here is where navigation can become confusing. The federal government mandated mental health coverage in the Mental Health Parity Bill of 1996. While the intentions of this law were good, its scope was limited; as a result, standards for mental health coverage still vary from state to state. What this means is that you have to talk with your insurance company and read your insurance manual to determine how much therapy will cost you.

If you go to see someone in private practice, the fee structure will likely depend on the practitioner’s profession and training. Some therapists accept insurance, and some do a cash-only business. Those who do a cash-only business are likely to provide a receipt with which you can file your own insurance claim. Some therapists are willing to negotiate their fees, particularly if they do a cash-only business, so if you can’t afford their full fee it can’t hurt to ask them for a discount that would better fit your budget. If they are not willing to negotiate, they can at least help with a referral to another therapist who charges less.

Unfortunately, maintenance for upkeep of your ship isn’t always paid for by insurance. But even if your insurance doesn’t reimburse you for sessions with certain mental health professionals, the training and experience that a therapist has to offer may convince you to seek help from him or her anyway. For example, most insurance companies do not pay for marriage counseling or sex therapy, both of which deal with very important areas in adults’ lives. In these cases, therapy dollars are often well-spent on a specialist who can help steer you through some hard times.

When—and how often—will I go?
Limitations on the number or frequency of therapy sessions you can have each year depend on a few different issues. The first issue is the availability of the therapist. In some centers, therapists are so busy that patients must wait a long time for an initial consultation and then often cannot return for an extended period. This common frustration is generally caused by the system, not the therapist. Another limitation is the time of day of session availability. Many settings offer sessions only during daytime hours. Since people often work during those hours, this can make seeking help more difficult.

The last issue is the insurance company’s limitations on the number of psychotherapy sessions you can have. In most instances, the number of sessions is approximately 30 per year. This works out to one session about every other week, with a few weekly sessions during the initial assessment period. For most psychotherapy, this is an adequate number of sessions for effective therapy. If, however, the severity of your condition requires a greater frequency of appointments, this can usually be arranged through a request for additional sessions by the therapist.

What’s the plan?
The plan that you and your therapist develop will help you to understand how therapy works. This is a collaborative relationship. Effective communication between you (the captain) and your therapist (the navigator) is a joint effort. Formulating a plan of action will also help you to get an idea of the pacing of the sessions and of the process in general.

Your plan is intended to be a general guideline. Your progress in psychotherapy depends upon how each session goes, and is affected by how well you do the homework and by your ability to implement change in your life. Your part in this process is key—it is important that you be honest with your therapist and be invested in getting better.

Most people would say “Of course I want to feel better,” but the process of feeling better often means facing some difficult truths and making changes in our lives. This is where the concept of hard work in therapy comes from. To make the most of your therapy, then, it is critical that you do your part both in and out of sessions. Homework may involve specific tasks, such as speaking with a family member about a problem, or activities, such as keeping a daily journal. Make sure that you are clear on homework assignments, and that you are willing to do them. If you don’t understand or are not willing to do the homework, tell the therapist so that you can come up with an assignment that will work for you.

Taking the first step
When people are depressed or anxious, they often find it difficult to think about setting sail for any destination outside their comfort zone. Seeking therapy can be like venturing into uncharted waters, and fear of the voyage may be the greatest obstacle to making the call to seek help. Motivation may come from knowing that you are not available to your loved ones the way you want to be, or from having someone who cares about you notice that you are down. Still, for some people, the most difficult part of the process is just making the decision to ask for help. It requires not only courage, but energy, and those who are depressed often don’t have that energy. In some instances, a loved one might make the first call for you or help do the initial legwork involved in finding a therapist. Another option is to discuss your situation with your doctor or diabetes educator to see if one of them can help you get connected with a therapist. Most of the time, these options work well and can help you make that important initial contact.

Understanding the demands of living with diabetes requires that you care for yourself in so many ways. This is a challenging undertaking when you’re feeling well, but when you’re stressed, depressed, or anxious, the tasks can seem huge. To manage your diabetes you need good mental health the same way you need a good diet. When you are feeling positive about yourself and the world, going through life with diabetes can be much smoother sailing.

Planning the trip
Once you decide it is time to seek mental health care, check the following outline as a reminder:

Get the weather report. Get to know your insurance policy and its limits. Call a service representative for details, if necessary.

Find out who might make up the crew. Get the names of possible therapists and their credentials.

Hire a trustworthy crew. Interview the therapist to find out about him and how he works, and to get a sense of how you connect.

Understand how and when the crew will be paid. Have no surprises. Once you choose a therapist, discuss his fee structure and make sure that you understand what, when, and how much you are going to pay.

Get your maps. Discuss and develop the plan for therapy, including frequency of visits.

Set sail. Do your part. Show up, participate, and do the homework.

Dock and unload. If appropriate, have a plan for when to end therapy.

Sail regularly, to keep shipshape. Get a regular mental health checkup (once a year or when it’s needed) to head off problems before they occur.

Joseph Nelson is a psychotherapist in private practice in Minnesota.

Statements and opinions expressed on this Web site are those of the authors and not necessarily those of the publishers or advertisers. The information provided on this Web site should not be construed as medical instruction. Consult appropriate health-care professionals before taking action based on this information.