Therapy, Coaching + Shaking up the Mental Health Care System

Therapy, Coaching + Shaking up the Mental Health Care System

Fall is a good time to talk about change....

It's also World Mental Health Day, so it's a good day to broaden our view. 

I just read an article called “Why Therapy is Broken,” published on Wire (please find the link below). As someone who has been in the field now for 30 years, I couldn’t agree more.

https://www.wired.com/story/therapy-broken-mental-health-challenges/

While I don’t agree with every assertion in the article, the spirit behind the need for a systemic shake up is certainly resonant. There are many frustrations shared by therapists and clients alike, including a global shortage of available clinicians, cost, and other logistical barriers.

Some of the health care applications such as Better Help or their equivalents claim to have a solution. Unfortunately, they are intentionally muddying the waters in various ways and remain accessible only to those who can afford to pay out-of-pocket.

In my summation, the problems with therapy in all parts of the world are couched in context (no pun intended….). Thematically, they seem linked to the following challenges:

• Stigma
• Money
• Time
• Subjectivity
• Time + Money + Travel + Consumer Demand = Accessibility

Let’s break these down.

Stigma: Any stigmatized condition is always going to be more challenging to both mobilize people to pursue treatment as well as to find ways to fund it. Mental health conditions have historically been viewed as a problem caused by the sufferer in many cultural contexts. Shame prohibits the person from pursuing treatment. Stigma is a barrier to funding or regulating insurance companies to cover it.

Money: Therapy is expensive. Pursuing a degree that allows someone to provide therapy is expensive. So, therapy is going to be expensive.

Most people around the world cannot afford treatment. Most people around the world cannot afford a degree that allows them to provide therapy.

In the U.S., insurance companies have long resented and resisted paying for mental health care. Unnecessary and expensive audits, creating a billing jigsaw with undefined hoops to jump through, offering unsustainable reimbursement rates, and simply refusing payment are some ways that insurers have continued to badger therapists. Many therapists have had it and will no longer work with insurance companies and have moved to a cash pay model.

As an aside, your insurance company is contracted with you to ensure access to medically necessary care. That means they need to contact a therapist if you have been unable to reach one and if they do not comply, you can report them to the insurance commission in your state and file a complaint.

For example, here is a link to Oregon’s insurance commission site, where you can easily file a complaint online:

https://dfr.oregon.gov/help/complaints-licenses/pages/file-complaint.aspx

In low and middle-income countries, things are even more complicated. Travel, time, and money are more significant barriers in developed countries. This is coupled with higher levels of stressors that are often related to the basics of day-to-day survival.

Time:

In the U.S., the therapy hour is prescribed as a 50-minute hour, with some insurers only being willing to pay for 45-minutes. What that means for the therapist and the client is that both must be able to dive into some deep stuff and get back out of it within in a very condensed period of time.

For people with trauma, this is an extremely challenging task. The very prospect of addressing the trauma story can be very disruptive. The days that follow a trauma therapy session can also  be grueling.

There is truthfully a need for more support, but it cannot be the therapist alone who offers it. It is not financially or emotionally sustainable to do so. There are also ethical concerns around porous boundaries that have to be factored in.

Subjectivity

There is certainly plenty of science behind psychotherapy. It can help when it’s done well with the right people, who have the right resources at the right time.

Also, there are standards of care established for providers, especially those in specialty practices.

However, some therapists are more flexible with time and money than others. Some therapists are trained in modalities that work with some conditions but not with others. Some therapists are more behavior-oriented and some are more insight-oriented. And honestly, the client doesn’t have choice that goes beyond the logistics (time, money, accessibility). So, the client gets the therapist that is available regardless of whether their training matches the specific needs of the individual.

Honestly, us therapists could also be better about holding ourselves and our clients accountable for each of our respective roles in the work. A lot of therapists are very gentle people who struggle with negative feedback or setting limits around their time. So, there’s also that along with many other layers of interpersonal dynamics that come into play within the therapy room.

Time + Money + Travel + Consumer Demand = Accessibility

Navigating time, money, and a recent explosion in demand (surpassing the number of therapists available) has really limited access to therapy. One of the benefits of stigma being chipped away at over time is that more and more people are pursuing help. There are just not enough providers to accommodate the increase.  

I named a few of the challenges in mental health care delivery. Honestly, I think there are more, but the main point of this article is to help to begin to challenge our current approach.

A solution to the shortage of helpers proposed by the World Health Organization is task shifting, which is delegating tasks that do not require an advanced degree to trained paraprofessionals.

Here is an article that discusses the expansion of task shifting and task sharing in healthcare: https://journals.sagepub.com/doi/abs/10.1177/20534345211039988.

Not to toot our own horn, but this is precisely the reasoning behind the launch of The Orenda Project’s coaching certification. Technology is used to equalize access on a global scale by removing travel and time zone-related barriers. Tasks can be shared and shifted between therapists and coaches thereby decreasing pressure on the therapist while increasing support to clients. There is the added benefit of providing increased opportunities to people in developing parts of the world, enabling those within a community to support their community.

There are a lot of possible solutions. Maybe the first one is that we open our minds, take a look at ourselves and how we structure care, and begin to shake up the industry a bit.

 Photo credit: Katt Yukawa