Why your therapist won’t tell you what to do

One question us therapists often hear from our clients is, “What should I do?”

It makes sense that a client would want our advice. After all, we are often the only people in our clients’ lives who know all of the intricate matters of their hearts. We sit with the ambivalent feelings, desires, and conundrums our clients find themselves encountering. And, because we aren’t interwoven in our clients lives in the way that a friend or family member is, we aren’t directly impacted by the decisions our clients make. In short, we get the full picture without being in the picture. So, why shouldn’t we give them advice? 

Let me answer this question by painting a picture of a hypothetical client scenario. In this situation, a client has been dissatisfied with her relationship for quite some time. She feels that her partner cannot connect with her on an emotional level, and their sex life has been lackluster for the past year. She explains the full details of her situation to her therapist and asks, “What should I do?” Her therapist says, “Well, it sounds like this may not be the best relationship for you. I think you should leave.” 

What are the possibilities coming out of this? Let’s consider a few. 1. The client leaves her partner but later feels she has made a mistake. 2. The client leaves her partner and is thrilled about making the decision, but she is robbed of her confidence in her ability to make her own decisions and relies on her therapist for all future major decisions. 3. The client stays in the relationship and no longer trusts the therapist's opinion. 4. The client finds that she actually resents being told what to do and ghosts her therapist, losing faith in therapy and never getting the therapeutic help that would have helped her confront her deeper underlying reasons for seeking help in the first place.

As you can see, there is no winning when we provide advice to our clients.

In fact, this can do more harm than good. When providing an opinion, we may also fall into the unethical trap of imposing our own beliefs and values onto our clients – a direct violation of our ethical code. We also strip our clients of the very empowerment they come to therapy to build. While providing an answer to our clients’ problems may temporarily provide relief from uncertainty, it also reinforces reliance on the therapist to provide a sense of certainty. We want our clients to stand in their own power and trust in themselves – and to believe that no matter what the outcome of their dilemma, they will be able to handle it. 

So, what do we do when our clients ask us, “What should I do?”

We have several approaches we can take. We can help our clients to think through the pros and cons of each choice. Through this process, we may collectively uncover possibilities our clients had not thought of before. We might even go deeper than the surface level questions, challenging catastrophizing, black-and-white thinking, and other cognitive distortions. Perhaps we’ll find that the situation is not as bleak as it seems. If a client seems to be intellectualizing a choice, we might focus on expressing feelings and underlying needs. Contrary to popular belief, feelings and needs play an important role in decision-making and should not be ignored. Finally, we might explore how similar situations in the past are connected to the client’s emotions and beliefs about the current situation – or even confront the concepts of uncertainty and control more abstractly. 

We therapists are certainly flattered that our clients think our opinions are worth seeking on-high stakes decisions. But we also care about our clients enough to not tell them what to do. What we can do – and what is ultimately far more helpful – is  help them gain more insight into themselves. And this in itself is so powerful. Because when our clients know themselves better, they can make better-informed decisions that are aligned with their own goals, values, and beliefs.  

Book with Author Kaitlin Lowey: https://SouthTampaTherapyBOOKAPPT.as.me/KaitlinLowey

Why I Only Accept 50% of Insurance Clientele & 50% Self-Pay In My Private Practice (50/50/❤️ MODEL)

WHY I ONLY ACCEPT A FEW NEW INITIAL INTAKE INSURANCE APPOINTMENTS

USING MY MORAL COMPASS AND COMPASSION FOR HUMANITY, I’M CHOOSING TO CREATE A 50/50/❤️ MODEL:

50/50/ ❤️= 50% SELF PAY 50% INSURANCE ❤️SLIDING SCALE FEE

Sliding Scale Fees help advocate for affordable mental health care and create an opportunity for highly qualified INTERNS to co-counsel clients in need. I interview interns extensively, decide selectively, and supervise very closely and yet very trustingly. I will be an active participant in each session.

I initially started accepting insurance 15 years ago when I felt a strong need to support my community, who needed financial support, to get consistent help. Despite hearing horror stories from colleagues about insurance paperwork and clawbacks, I joined a few insurance panels. I loved every minute of being a therapist! I hated everything about the administrative process when it came to dealing with insurance companies. Don’t get me wrong, I love my insurance peeps! We have connected over the years and I will continue to support my clients who choose to use insurance as they should!

I too, have health insurance. I get it, we have health insurance for a reason, pay high monthly premiums, and should be able to use insurance when we need it!

Regardless, I will show-up powerfully for ALL of my clients.

I feel good about my choice to create a 50/50/ ❤️BALANCE in my Private Practice!

As a healthcare member and a private practice provider, I’ve had the unique experience of seeing both perspectives of the healthcare system in the US.

As my specialty has continuously evolved, I have realized that mainly accepting insurance no longer make sense for the advanced work that I do. Ultimately, my decision came down to acting with integrity and practicing what I preach to my clients.

Here are some key points to help you understand my decision to create this model for my Practice:

LACK OF PRIVACY & CONFIDENTIALITY

When insurance companies pay for your treatment, it also means that their employees (clinicians or not) will audit my treatment plans and read what we talked about in my session notes. These employees are paid to save the insurance company money by searching for fraud and determining whether you're overusing your insurance coverage. In turn, the insurance company may decline authorization of additional sessions because you're not progressing fast enough; our work in psychotherapy does not qualify as "a medical necessity": or because my treatment approach isn't recognized by the insurance company as an "evidence-based treatment" (that's code for short-term, as in 6-8 sessions).

Hell, some insurance providers don't reimburse for 60-minute sessions anymore!

This doesn’t seem right.

I recently got audited by an insurance company. This audit took me countless hours, staying up late at night, time away from my family, unnecessary stress and scrutiny to provide tedious paperwork and specific details to prove that my clients needed the services provided. This is just not okay in my book. I totally understand documentation for integrity but demanding extra proof during a pandemic when I am already submitting the necessary information and feel overwhelmed and overworked helped me create the awareness and opportunity for me to reflect on MY CHOICE to accept insurance.

At first, I reactively felt angry resulting in thoughts and hopes that the insurance company would fire me! However, when I pause and feel to respond intentionally, I honestly and truly feel honored to hold space and care for ALL of my clients and I would feel disappointed if I were unable to offer insurance as an option.

In conclusion, I believe that everyone has a right to confidentiality of your medical records. You also have the liberty to progress through treatment at a pace that's best for YOU - one that allows you sufficient time to process everything that you're experiencing. Things unfold differently for each person, especially when our world seems chaotic (Global Pandemic)! If the insurance company fires me, they rip the therapeutic relationship apart that my clients and I have securely built over the years. Emotional injuries and attachment issues can be easily re-traumatized within seconds.

DIAGNOSIS OF ILLNESS

Insurance companies operate on a medical model, which means they require a diagnosis to establish that you have "a medical necessity" to seek services in order to pay providers. To justify that you have a "medical necessity" I have to assign you a diagnosis to be reimbursed for our work together when there may not be one that really fits what you're going through. The vast majority of insurance companies don't consider relationship issues like couples or family therapy, developmental/attachment trauma, existential issues, life-transitions, personal development, or self-improvement as "medical necessities" because there are no diagnoses for these in the DSM-V.

And even if there are appropriate diagnoses, there are some diagnoses that insurance companies don't consider debilitating enough to pay for. So, if I know what diagnoses are and are not paid for, l'd have to label you with a more severe diagnosis they will pay for, but one that may not really reflect your situation. I am not ok with this either!

You're probably wondering, "What's the harm in that? A little truth-bending never hurt anyone." Well, that's just it - it can. It can come back to bite my clients in the ass... your medical record. While that might not be such a big deal right now, it may become one later on if you want to: get life insurance, work in the financial sector managing other's assets, regularly handle firearms, or seek employment in any sector in which your decision-making might be called into question due to your emotional state. Call me crazy, but I feel that people should get the help they need without fear, stigma, or reprisal for making their mental health and personal growth a priority.

FRAUD

If I engaged in the aforementioned truth- bending, I'd essentially be committing insurance fraud. There are providers out there that are willing to walk this fine line and take this risk. In my opinion, the penalties and professional consequences of insurance fraud are huge, and frankly, not worth it. I have a strong need for peace of mind that comes with integrity.

LOW RATES

In order to be "in- network" with an insurance company, I have to agree to accept a lower fee in exchange for the insurance company listing my practice in their directory of providers and sending me referrals. In the spirit of transparency, most of my clients find me through friends, family and through searching online. And each year, insurance companies continue to cut the rates they pay therapists for their work.

Here's an example with real numbers and real circumstances of how this happens: My fee is $170 per session. But I joined XYZ Insurance Co.'s network because I had a client in need of services. I chose to help and chose to agree to the insurance reimbursement rate of $60 per session. My client would also be responsible for a co-pay of $0-$40 per session depending on his plan, bringing the total to $60-$100 per session. That means I'm waiving at LEAST $70-$110 for each session. As a healthcare professional, I want to help! I have made these types of choices for the 20 years that I have been in private practice. I will keep choosing to advocate for my clients who have insurance because I also have insurance for myself and my family.

Would you be willing to forgo ~65% of your salary?:-/

I will also continue to set boundaries with ALL of my clients and companies that I choose to work with. If you no-show as a self pay or insurance client, I will treat you the same and ban you from being able to book an appointment until we have a meeting. I get it. I want to understand one another and use empathy. Life happens. I want to turn toward these curveballs

Additionally, insurance companies have been increasing their members' premiums, deductibles, and co-pays in the last few years claiming rising costs of care. You'd think that that would translate to higher reimbursement rates to care providers, but it doesn't...at least not in the mental health fields. In fact, insurance reimbursement rates have actually decreased over the same period of time. You're probably wondering, "How do the therapists and psychologists that take insurance afford to?

For such insurance-based practices, taking on more clients than is clinically prudent is the only way to make up the difference and keep their doors open. This then leads to another problem...

BURNOUT & EXHAUSTION

Here's the reality, many providers that accept insurance overbook their schedules in order to turn a modest profit after rent, utilities, malpractice, and other expenses.

Additionally, these providers often only offer a 30-50-minute session to maximize the number of clients in a day (10 vs 8) and the chances of insurance reimbursement (remember, most insurance companies don't pay for 60-minute sessions anymore). Also, if you use the 60 min codes, you are flagged for audits which take hours and hours to complete.

DELAYED (OR NON) PAYMENTS

Despite the insurance companies agreeing to a set reimbursement rate, these companies require therapists to jump through a bunch of hoops to get paid. It is common practice for most insurance companies to reject submitted paperwork to delay payments. When they're not seeing clients, these therapists are drowning in insurance paperwork and resubmitting billing claims in order to get paid, or spending hours on the phone contesting unpaid claims.

On average, it takes an additional 1.5 hours of UNPAID work outside of the session to get paid for sessions. And remember, the therapist is already making less by agreeing to take insurance. (In my previous example, it would cost $255 of my time ($170x1.5) to get paid my $60 reimbursement rate from XYZ Insurance Co.)

The alternative is to pay a medical billing company 8-10% of the claims' costs to do the aforementioned, but that increases expenses and cuts into that modest profit I mentioned before. But let's say that I or my medical billing admin ARE able to see the claim through the labyrinthine insurance payment process, the payment will finally arrive in my bank account anywhere between 3-6 months after the session took place IF everything goes smoothly.

RETROACTIVE CLAIM DENIALS (AKA CLAW BACKS)

Now imagine that, after all that trouble, that insurance company asked you to give the money back, even years later. Yep, this really happens and, unfortunately, it's a common practice among insurance companies. They'll audit your claims and paperwork for several years back. If they find any mistakes or inconsistencies in the therapist's paperwork they missed when they originally approved the therapist's claim, the insurance company will request that the therapist return the fees she was paid.

Pretend that your employer sent you a bill requesting that you repay the income you'd earned 3 years ago. Would that seem fair to you? I didn't think so. Claw backs can amount to thousands of dollars that can bankrupt a small business like a private practice. Many insurance- based clinicians live in fear of such retroactive audits.

Before reflecting and reassessing the insurance-based private practice I founded, I recently heard from a friend and colleague that a major insurance company requested thousands of dollars be returned by the end of the month. Talk about stressful!

All together that's a recipe for a tired, overworked, and stressed out therapist.

This may have been the problem if you've ever been to therapy that you felt didn't "work" with a provider from your insurance company. I should know. I started to experience the symptoms of burnout after two years of insurance-based practice. And that's when I realized, "Crap! I'm doing the things I tell my clients not to do!" Talk about incongruence!

So I changed my business model for the sake of the well-being of myself and my team to preserve the quality of care we want to provide every client. It breaks my heart to REDUCE ACCESS to care for people in need, but I realized early on that we can't help anyone if we're stressed/burned out or have to close our doors. I am choosing the 50/50/❤️ MODEL to advocate for mental health and well-being for all!

This makes sense to me!

WHAT ARE THE BENEFITS OF PRIVATE SELF-PAY AND/OR A 50/50/❤️MODEL FOR MENTAL HEALTH CARE?

No Labeling - You don't have to carry an unnecessary diagnosis on your medical record. Although, if you’d like to create awareness and assess for diagnostic criteria, I would invite this curiosity and self exploration.

Confidentiality & Privacy - You and your psychotherapist are the only people that will know you're in therapy. You get to choose who you disclose this information to. Session notes are private records so there won't be intimate details to “prove medical necessity/ diagnosis info”.

I am highly confidential and keep minimal notes. I naturally remember our sessions together because I truly care and our therapeutic relationship is genuinely important to me.

Self-Determination - You get to work with a psychotherapist that is free to use the best therapeutic approach to help YOU meet YOUR goals. You and your psychotherapist are the only people involved in the decision about the length of your care. You won't have to seek additional authorization to continue your work or return to psychotherapy, if you have new goals you'd like to explore.

Quality Care & Attention - You'll get a psychotherapist that's alert and engaged during your session, remembering the details of previous conversations. You'll have the help of a professional that's invested in your process of growth because they've taken the time to do the same for themselves. She will be able to use the healing methods that are most appropriate for you.

You might be thinking that this is just one therapist's rant against insurance companies. Don't take my word for it. Feel free to do your own research!

If you tried psychotherapy and were disappointed with the results or the treatment didn't seem to "fit" after working with a provider from your insurance company, I hope you have a better understanding of what might have been happening behind the scenes. We urge you to reconsider getting some support now that you do. There are great providers in the healing professions on both sides of the insurance divide that can help you.

I HOPE YOU HAVE A BETTER UNDERSTANDING ABOUT WHY I HAVE DECIDED TO CHOOSE THE 50/50/❤️ MODEL!

50/50/ ❤️= 50% SELF PAY 50% INSURANCE ❤️SLIDING SCALE FEE

Call or TEXT with any questions:

📱#813-240-3237 or ***Book Now: —> ❤️

The Art of Comprise and Core Needs

Core Needs Exercise

“Seek first to understand, then to be understood” -Stephen Covey

 What is a Core Need?

A core need is something that you need to feel like yourself in any situation. When a core need is met you are able to be more present to what is actually happening, rather than being over-focused or desperate about that need. The desperation can be a symptom or a signal that a core need is not being met, and your mind is trying to address it by giving it your mental/emotional attention. 

Consider, for example, that you are taking a long hike in the hills and after a few miles you reach for your water bottle and it isn’t where you thought you put it. Your mind will be driven to search for it, because on this hike adequate hydration is a core need. If you can’t find the water bottle and the sun is bearing down on you, then most of your actions are going to be focused on getting that water to meet that core hydration need. It is going to bug you, compel you and drive you until you can address the water issue. Once the water core need is met, you will be able to continue the hike and be more present to the fuller experience of your surroundings.

Here is another example: You work hard all day with mental problems and when you arrive home, your head is still mulling over those problems. There is an argument with family members soon after you arrive home. When you step back and look at what is actually happening, you discover your head is still in work mode from the day while you are trying to connect with your family members. 

Therefore, you might have the core need of “transition time". To address that core need, one option might be a 30 minute buffer time to change clothes, acclimate to being home, and allow your head to power down from the flow of mental problem-solving.

Let us say you don’t get that buffer and you put yourself in the middle of the family. Most likely you will be pulled inside in two different directions: trying to disconnect mentally and emotionally from the work of the day and trying to connect in the present moment with the family. This often results in feelings of frustration and fights about things that usually are not stressful, because you are torn inside with competing interests. A 30-minute buffer and transition time--especially if the family understands your need and it makes sense to them--would make it more possible for you to “feel like yourself” at home and be more present to what is actually occurring there.

As you can see, core needs are by their nature inflexible: you NEED the water and you NEED your transition time or you will be hurting yourself physically and/or emotionally. 

So in working things out with others, it is best not to compromise a core need. You function best from where you are flexible. You may find that as you discuss the issue of work/home transitions with your family, that they each have a core need to be “greeted” when you arrive home. Since you would know you are going to get your transition time, you might be flexible to delay it a few minutes so you could check in on each member and say hello. If there is an agreement about your transition time—your family knows you need your 30 minutes and they are aware of the benefit when you have that time--they could encourage you and support you in taking that time after the greeting. Everybody wins with these agreements, and compromise does not sacrifice any core needs.

NOTE: Core Needs are more possible to identify when you are applying this process to an actual situation, such as: when I get home in the afternoon from work I need a transition time, rather than a generalized core need say, to get “respect.” It is more effective to explore the core need of “ respect” IN the situation of when you arrive home from work. Be as specific about a circumstance as possible and avoid generalizations and “always” and “never” narratives. 

____________________________________

This is the format for discovering core needs and flexible needs for each person in a relationship or just for your own insight into yourself.

Note:

• COMPROMISE happens in the FLEXIBLE NEEDS area of the circle. NOTE that there is a much larger circle for FLEXIBLE NEEDS than the CORE NEEDS. It is important to work to get the core needs circle as clear and accurate as possible.  CORE NEEDS content will be smaller than the flexible needs.  However, it may FEEL larger when trying to trick or convince someone to be flexible with a CORE NEED. This will create attention to the smaller circle and create a gridlock. 

• Understanding and discovery happens in the core needs. Not compromise. These are non-flexible. And if they are flexible and that is ok, then they are still important to you but are not core needs but flexible.

• Sometimes you think something is a core need and you may find upon discussion it is actually flexible. Sometimes you find a flexible need might be core as you get insight. Allow continuing understanding to happen as you work with this.

 It is often best to start learning this exercise using a very focused issue such as “where do we go on vacation’ or “what movie do we want to watch this weekend together.”  You can choose “our marriage,” as a focus but know that this is a broader focus and might need to be broken down into areas of the marriage such as ‘friendship” or “parent” and "sexuality" "affection" and other areas. It is ok to choose“the marriage” as the focus, just know that if you get bogged down to bring the target focus into a more specific topic about “the marriage.” Then this can be done with many conversations instead of one big one. Marriage is actually one life-long conversation.

Once you each have completed your two lists, set a time aside to each have a turn where you listen to your partner's circles, and only ask questions for your understanding THEIR point of view. Once both have had a turn WITHOUT criticism or commentary, THEN, move into a discussion and how a negotiation and agreements can be made with the flexible/adaptive areas.  This is to be done while valuing and protecting your partners core needs: the non-flexible areas. It is often amazing how many new options open up when a couple stops trying to change their own or their partner's core needs on an issue, and move to a discussion of the flexible areas.  Happy couples do more than that. They PROTECT and ADVOCATE for their partner's core needs. 

Use the GETTING TO YES questions A a guide to help come to a negotiated agreement regarding the issue or focus at hand:

Remember the principles of the Sound Relationship House below, especially avoiding the Four Horsemen! There are more instructive articles on the CORE NEEDS EXERCISE below.

“Seek first to understand, then to be understood”

"More than one thing can be true at the same time."

"There is nothing wrong with you, life it just far harder than you ever expected.

Yield to Win: Compromise like I am someone you love. The art of compromise exercise. Discuss the questions with your partner.

How Do I Make A Decision?

Many people who come to my office say they have a difficult time making decisions. I have developed a process to help my clients master this skill. I recommend that people follow these four steps:

1.    Identify the real issue. For example, you are trying to decide which movie to see, but you are having a hard time agreeing. As you talk about it, you realize that the real issue is that you simply want some time to be together in a quiet place where you can talk. Going to a movie does not address this issue.

2.    Identify the available options. In the above example, the options might include going to a quiet restaurant, taking a drive, or walking on the beach.

3.    Evaluate the available options. Discuss the advantages and disadvantages of each. Evaluate how well each option addresses the real issue.

4.    Implement the decision. Make a choice and carry it out.

Even though most people make dozens of important and complex judgments every day, few of us have actually been trained to make good decisions. We started making basic decisions when we were young children, and we continue to follow the same simple process as we get older, even though the issues have become much more complicated.

We learned to make decisions by watching our parents and learning in school. Mostly we learned by trial and error. Our first decisions were pretty simple-to choose pizza or hamburgers, to play softball or soccer, to wear the pink headband or the blue one. These decisions pretty much boiled down to choosing between X and Y.

According to the authors of Smart Choices: A Practical Guide to Making Better Decisions, most of us continue to choose between X and Y without making certain that we are addressing the real problem in the first place.

A second common mistake is rushing into a decision, hurrying to get it over with. We rarely step back from the decision and view it in a broader context. While it is more difficult and time-consuming, it is better to take your time and be sure you are seeing the big picture and the key issues.

Strategies for Making Better Decisions

Here are some decision-making tips:

1.    Take your time making important decisions. Some situations require a deliberate and careful decision-making process.

2.    Once the decision has been made, carry it out without hesitation.

3.    If you can, delegate decisions to those who will carry them out. Authors Heller and Hindle (Essential Manager's Man-ual) advise managers always to be on the lookout for ways to push the decision-making process down a level. If you are making decisions for your family, consider how you can involve your kids in the process.

4.    Making decisions requires both intuition and logic. It's important to trust your gut, but be sure you are thinking logically.

5.    Unless the situation is pretty straightforward, it is a good idea to generate as many ideas as you can. Learn the principles of brainstorming (see box) and throw lots of options into the hopper.

6.    Look at the issues from different points of view. How do they look to the different groups they might affect? For example, if a teacher asks his students to wear Native American clothing tomorrow, will the kids' parents have the time to help them prepare on such short notice?

7.    Consider the immediate and long-term implications of each solution, including its impact on other people.

8.    Consider the worst- and best-case scenarios, as well as the possibilities in between.

Deciding Yourself versus Involving Others

Involving others in your decision-making process helps you avoid the tendency to rush into a decision, hurrying to get it over with. When you take the time to consult others, you force yourself to step back from the situation and see it in a broader context. While it is more difficult and time-consuming, getting the advice and support of others can help you produce better decisions.

Consider these points when seeking advice:

1.    Determine whom to involve in the process. If it's a simple, low-risk decision, you may not need to involve any one else.

2.    If you do ask others for advice and suggestions, be prepared to respond to their input.

3.    Determine who will need to approve your decision, and get that approval.

Consider these points when seeking support:

1.    Think about who might resist your decision, and have a plan to manage that resistance. For example, you want to allow your daughter to have her friends sleep over on a weeknight during the summer, but you expect your husband will object because he has to get up for work the next day and doesn't want his sleep disturbed. Think about how you could plan the evening in a way to avoid disturbing your husband.

2.    Identify ways to increase the chances that your decision will be supported. In the sleepover example, you could ask the girls' friends to bring sleeping bags, and set up the basement for them to sleep in.

3.    If your decision presents any risks, look for ways to minimize them.

Make This Work for You

Rules of Brainstorming

    1.    Write down the question you are addressing. For example, "Where shall we go on vacation?"

    2.    Think of as many ideas as you can.

    3.    Write down every idea, no matter how wild it seems.

    4.    No one is allowed to judge or evaluate any of the ideas in any way. This includes making faces, rolling eyes, and sighing.

    5.    The goal is to think of as many ideas as you can. Quantity is more important than quality.

    6.    After everyone is finished suggesting ideas, take a break.

    7.    After the break, discuss the ideas and edit the list. A solution will emerge.

Identify a situation in your life right now. Be sure to choose something important and challenging. Apply the steps we have been exploring to this situation.

    1.    Describe the situation.

    2.    What is the real issue here?

    3.    List the pros and cons of each option.

    4.    What do you need to consider when seeking advice?

    5.    What do you need to consider when seeking support?

    6.    What are the best options?

    7.    Who needs to be involved?

    8.    What should be delegated? To whom?

    9.    What resources would need to be secured?

    10.    What steps need to be planned, and what is their timing?