Tuesday, November 10, 2009

Sliding Fees



A lot of psychiatrists and other mental health professionals tell me they slide their fees, giving reduced rates to patients who can't otherwise afford to come. I want to ask: How do docs decide to do this? At clinics, scales are based on income (perhaps by family size), and just income, with a pre-set structure. But in private practice, this isn't usually the case (I don't think), and I wondered what other people do. In general, I've hesitated to slide my fees very much and this gets hard. Some of the patients I see live life without many luxuries-- rented homes, used cars, rare vacations. Sometimes it's a choice-- they choose not to work (when they could), and sometimes they are struggling quite hard to make ends meet, and yet they don't utter a word of concern about my fees. If anyone brings it up, it's me. Other times, patients are very verbal about their financial issues, how much they plan and calculate exactly what they can afford, and are very concerned about my fees and exactly what they can or can't afford. What's hard is that some of these same people are "strapped" because their life styles include many luxuries--boats, luxury cars, nice trips, a fine bottle of wine here or there, expensive tuitions, and maybe unexpected expenses. They come less then they should, or would like, because my fee is high. Maybe they've bitten off more then they should have (especially in the current economy) and are going through bankruptcy proceedings, or are simply worried about what the future might bring. Being tight on funds and the perception of what one can afford is based on many things, and so I'm putting this out not to get my own answers, but to ask how other people deal with this? Years ago I had a friend who was seeing a patient at a greatly reduced fee, only to discover that he lived in a much nicer house then she could afford-- it put some tension into the therapeutic relationship, I'm sure.

34 comments:

moviedoc said...

Odd how that sliding board goes down only. What if your patient is wealthy? Might you raise your fee. An internist I know covers the costs of indigent patients with revenue from her boutique practice.

What you leave out is that this issue rarely comes up except for "long term" psychotherapy with weekly or more frequent visits. I only do med management, opted out of Medicare, have no insurance contracts, and charge a fee for med preauthorization. But I have kept my basic fees low. When you treat for free or lower your fees it raises questions about what you get out of the relationship. I like to avoid that. I also think providers who contract with insurers tend to inflate their fees to exceed what insurance will allow. That's not fair to patients who pay cash.

Then you have Dr. Karasu and others claiming to get $600 for a 45 minute psychotherapy session. My blog has several posts on related problems. No easy answers.

Novalis said...

I've never done private practice, but I agree--sliding scales sound good in the abstract, but it seems that in practice they could be problematic. Would one require proof of income, tax returns, and/or itemized lists of debts and assets? Much would have to be taken on faith.

If one wants to be able to provide services to the (relatively) indigent, it seems more straightforward to devote a few hours or more per week to a a community health clinic or similar setting.

Marie said...

I had been seeing my psychologist for 6 months for weekly therapy sessions in conjunction with medication to treat for depression.

When my husband lost his job and our insurance changed, I couldn't afford to continue weekly therapy. I was relatively stable and decided to take a break to save money.

My therapist asked if the reason was financial, and offered to lower the rate temporarily. I appreciated his willingness to do this, and have gone back several times during this stressful time at the reduced rate. (On an as-needed basis.)

I'm sure there are people who would take advantage of the situation, but I'm not one of them. I think my therapist knew this about me before he offered the reduced rate.

moviedoc said...

A related question I find is tougher: Your established patient loses her job, is depressed and suicidal and now not only has no income but no insurance. You will likely be held responsible if she kills herself. If you allow her to let her balance accumulate, the increased debt may get her down more. If you treat for low/free she may feel guilty. Also, if you defer payment, according to the FTS you become a "lender" and must comply with the "Red Flags Rule" for preventing identity theft.

Sunny CA said...

When I was a college student a friend referred me to her therapist who charge a special rate for college students. It was still very expensive for me but I did not have insurance and I am sure it was very low relative to the going rate. Perhaps she filled an otherwise open schedule or was new to the business or maybe she thought it was a good deed or likes young adults. My current psychiatrist has offered to lower rates in case I can't pay. My financial circumstances certainly are not good. I feel it is unfair because he's worth his fee and I would not ask that of him unless I was desperate. I would be highly resentful if he were extending the reduced rate to people who have a boat, dine out, a summer home, etc, when I live frugally to afford the visits.

Aqua said...

Hi,
What if the depressed suicidal person who lost there job commits suicide because the one support she has (her pdoc) is unavailable to her because of financial difficulties?...that seems more likely.

Re: how do you know if a person is telling the truth about there income for sliding scale?...you don't. but I don't think it matters...here's why...

I used to work at a bureaucratic bank...it often felt to me and to clients, that the plethora of rules and regulations to ensure the bank managed risk made all the good people intensely frustrated... like we were annoying and punishing everyone because a very small # of people were/are dishonest.

Yes there were those who tried to lie,cheat and try to steal other people's money by lying/cheating etc., but in the thousands and thousands of people I served I bet much less than 1% were dishonest. I bet it cost more money (in dissatisfied customers, lost business, time etc.) than all the bureacracy to protect everything saved.

More proof that most people are honest came when my husband and I started a cut flower business on our farm in the city. We placed huge buckets of flowers out on a flower stand and charged $20 for a whole bucket. No one manned the stand...it was done on the honour system. People dropped $ in a lockbox and the took their flowers with them. Each year we had tons of business and maybe a maximum of 5-10 buckets went missing without payment each year...sometimes extra $ would show up in the box...so some of those may have been paid for too.

Sometimes I would be up at the stand and a customer would pull in and say they didn\t have cash on them. I'd tell them to take the flowers and drop the money off when they could. They always looked flabbergasted. Every single person I did this for returned and paid for the flowers another day.

My point is...don't set up rules about payment based on how dishonest people might be. Expect that most are honest and you will be pleasantly surprised.

moviedoc said...

Great point about the suicidal pt, Sunny CA. The patient you describe has become dependent on the doc. You describe the doc as a "support." I try not to foster dependence. My role is not to "support" someone, but rather to treat an illness. IMHO this societal view of psychiatrists as "supports" is a regrettable outgrowth of psychoanalytic psychotherapy, perhaps misapplied.

There certainly are many honest people in the world, but not enough in Paris where publicly available bicycles are regularly stolen and shipped to other countries according to a recent report.

Another predicament: I treat addiction. Many of my patients have spent thousands on drugs obtained illegally from dealers who do not likely use a "sliding scale." Then they want me to discount their fee. I consider this what we call "enabling" in addiction. A further problem with patients taking Suboxone is that they will claim to need 2 tablets a day, but sell one of them to someone else.

Jessica said...

my psychiatrist charges $225/45 minutes medication management + therapy session. for about 2 years, i saw her for severe, recurrent, treatment-resistant depression twice weekly, now once. i am not in a high-pay profession and elected to take on a second, part time, job rather then switch to a doc on my insurance. i was uncomfortable discussing it and never mentioned why I'd chosen to taken on another job other then that I enjoyed it (true, but irrelevant). Eventually, i got sick from the stress and constant work - you can only work 18 hours a day for so long. when i told her that i needed to cut back on therapy if not switch to just med. management, say, once a month or so, because i needed to drop the second job; i couldn't physically keep it up. she was shocked that i hadn't discussed it with her before and very surprised at how surprised i was that she would extend a sliding scale. end story: did accept a sliding scale, which increased later on as i was promoted.

the thing is, it's something about the whole mental-health-clinician and patient/client/whatever imbalance. In my profession, i see individual clients as well as provide consultation and would cheerfully (and do) adjust my fee based on the individual circumstances.

but for some reason, i-and many others - feel that psychiatrists and psychologists in private practice have a god-given right to charge obscene amounts of money, irregardless of circumstance.

i don't think this is a good thing.

Aqua said...

Re: "your job isn't to support?" what about the patients with treatment resistant m. illnesses? I think the only reason I am still here is because, while I haven't become better despite a huge amount of medication trials, and all kinds of different therapy and therapists...at least my pdoc cares enough about me to keep trying and provide supportive therapy until we find something medication or otherwise, that helps me.

I know for a fact I am not the only person who requires ongoing supportive therapy. Most of the people I have met with severe and persistent mental illnesses require some kind of ongoing support from their psychiatrists or therapists. Also, just because someone "supports me" does not mean I am dependent on them. There are lots of kinds of support.

...personally the idea that "avoiding dependence" is always a good thing baffles me. I know for me learning to depend on someone, learning that there are dependable people who care, vicariously through my pdoc has probably been the most important lesson I have learned. Now I can go out in the 'real' world and have a bit more faith this kind of caring really exists...a lesson that part of my childhood stole away from me.
...aqua

Sunny CA said...

"Aqua" was the one who mentioned suicidal patients needing their pdoc even more in times of financial collapse, not me, but I thought it was an excellent point. I don't know about the overall honesty of mankind but I think it would be tough having a good relationship with one's pdoc if one is lying about financial matters to get a better rate.

I myself have a psychoanalytical pdoc and I do find myself feeling a lot better as a result of seeing him, but not at all wanting to end therapy. Perhaps it would be called "dependence" by some, but it feels more like a strong bond to me, plus he always brings up things that make me think and reflect and I feel that I benefit. He brought up the possibility of my terminating a while ago and I declined which he was fine with. I no longer "need" him but my life is better when I see him in my opinion. Does anyone ever get to the point with psychotherapy that they feel that they have completely figured themselves out and they no longer need self-exploration or that they can do it themselves? I still feel my pdoc understands me better than I understand myself. I still feel that the self-exploration is productive. I also do feel more secure when I maintain the relationship because it was not that long ago that I felt a marginal commitment to being alive. Maybe that is dependence, but if so, so be it. I am growing.

April said...

I was seeing my shrink for several months before they realized he was out-of-network (long story, miscommunication). When I told him I couldn't afford his $200/hourly rate compared to the $40 co-pay I thought I had been owing, we reduced my visit frequency. Sliding fees never came up. The office was really nice to let me pay the balance (which took over a year b/c I'm poor).

The Crazy Music Lady said...

not going to hop into this whole debate as to whether or not your therapist should support you or not, that's totally dependent on whether or not you see them for therapy or med management (oops, I guess I just did).

Regardless, the way my mother's clinic manages their sliding scale is through documentation for the Department of Revenue. Works out unless you're a drug dealer, I suppose.

Rach said...

We don't seem to have this problem in Canada, as I've written many times before.
Not to say that our system is perfect - it doesn't even toe the "good" line, but considering the fact that I'd be approximately $40,000 in the hole if I was paying for my shrink out of pocket.

Does the APA have some sort of policy regarding this? Or is it everyone for themselves?

Tigermom said...

It seems very true that the people who I feel can least afford to pay my fees never say a word about them and people who talk abut spending money on a variety of "indulgent" things talk about my fees quite a bit. And in the same breath as their new this or that.

We all make choices. Choices with consequences.

If a patient asks, I often do adjust my fee and recently I have added a time frame after which we will reevaluate the fee.

I have patients who are basically stable but have family members with costly medical and or psychiatric needs. I tend to cut those people a break.

I charge more for a first visit since it is longer and much more work for me. So if a new patient asks for a break, I am more inclined to decrease the initial fee and keep the follow up fee the same.

I balance not only the patients' needs but also whether or not I can treat the person without resentment about the fee. A grouchy therapist helps no one.

Sarebear said...

I love the pic, giggle!

In a comment on a recent post, I mention how I may be sort of ruining the only things I have to look forward to, like celebrations, by using them to ask for money to pay dr. bills, and thus, where is the quality of life that said treatments are supposed to be for, anyway?

Which may or may not be one of the prompts behind this post, I don't kid myself that I'm that important.

Anyway, now I also wonder about a potential downside of the mental health parity act, in a market where there's not enough psychiatrists, and the demand is potentially going to go up January 1, am I going to be able to find one at all willing to take on a new patient, which I was already wondering?

I'm not up to looking for one yet, but even if I started TODAY, the search would talke months; last time it took 6, and I ended up with a bottom of the barrel psychiatrist. If I call off the list of names from my insurance, to me that's the only result I see happening again - the only psychiatrists who'd take me on are the ones losing patients fast enough to need new ones; the ones who are not that great of a psychiatrist in the first place.

Anyway, good post, altho if I was that last shrink you mention, with that patient in the nicer house, therapeutic tension is an understatement lol.

At the moment I owe my psychologist 1000, from months when I couldn't pay, and that is $530 more than I was in debt to him at the turn of last year, which means I'm going to have to make a hard decision and see him only once a month until I get that balance down; it's not fair to him.

The problem is, I've got more problems than ever, a ton of anger floating around from this last psychiatrist mess, and today my husband abandoned his support of me in my arthritis diagnosis for the first time, because I hurt to bad to go to parent teacher conference, but more important, because I hurt too bad to go to the elbow doc appointment for our duaghter. From which they were then going to a family party straight from the docs.

I feel so betrayed by him, and more isolated than ever, and like I've got NO ONE, but I've got hard decisions to make.

The money thing is an issue of personal responsibility, and the doc has never pressed me on it, it's been me who has brought it up. He's been really good about when I couldn't pay, but I've also been of the mind that I am personally responsible. He knows though that if things get bad I can go to my clergy and there is a situation where we can set it up where my church might pay for my treatment for a time, like they did a while back.

I hate to go that route though.

But . . . . It just seems like so much is crashing down on me right now, emotionally, medically, everything. I need at least three surgeries and I still have no idea what treatment whatever the hip doc is looking for on the mri's w/contrast of my hip sockets, is going to need, if any. My husband and my daughter may also each need a surgery before the end of the year, and they will only likely be able to only fit one of my surgeries in before the end of the year (everything is currently paid at 100%, unti Jan 1).

And apparently, just making dinner, which I did yesterday, a now rarity for me, set off a day of bad arthritis pain today. Like they said, it was going to get to where everyday activities would be affected. This sucks.

I need my therapist more than ever.

Of course, his building is old and has no elevator and I have to go up one flight of curving stairs to get to him . . . . . ugh.

BUT, I've got bills on the brain.

Sorry for going on.

Thanks for the post, and for listening, as blogfriends, and anyone else.

Sarebear said...

Aqua, your message regarding support, I totally agree. I am so far one of those who hasn't found the right combo of meds, at least as far as my depression is concerned, and my anxiety perhaps, altho that last I think is more treatable by the therapy than the depression is, but support is needed for everything.

AND, Every year seems to reveal a new physical medical diagnosis that has of course a devastating emotional impact on me, and have had life-changing effects these last few years. I certainly didn't start therapy thinking I'd be needing support for coping with a lot of medical issues, but I sure have all that added to the mix now!

Still reading further replies.

Roy said...

When I had a private practice, people would sometimes call looking for a psychiatrist and ask me what my rates were. After telling them (back then it was 120/45min), a small number (<5%) would say they could not afford that. My standard follow-up question was "What can you afford?". They always came back with something acceptable and I said I would take that. That was my sliding scale. (Hmm, I never thought to ask if they could afford more.)

A practice from back in the days of psychoanalysis was to charge 10% of the patient's annual salary for a year's worth of 4 days/week analysis. That made it a sliding scale. Not sure how/if they verified income.

Lu said...

Roy, really? That is quite a bargain. Too bad that rule of thumb doesn't seem to apply anymore. I (the patient) would be making out like a bandit. Amazing that 10% of a person's income annually used to be considered a reasonable amount to pay (for those privileged to have 10% discretionary income). A conservative estimate I just made has me paying 18% of my annual income to the PsyD for 2 sessions per week. And that's with a 30% discount. How may people have that much money, and why do psychoanalysts worry so much that patients are taking advantage of them monetarily? Man! I'm going to stop feeling guilty about taking that discount now.

Rach said...

OMG, 10% of a person's annual salary for 4x/week analysis?!

I'm never going to be able to afford psychoanalysis.

Dinah said...

Lu said: "How may people have that much money, and why do psychoanalysts worry so much that patients are taking advantage of them monetarily?"

To the psychiatrist it's a balance: we work to pay our own bills, kids' tuition, overhead, mortgage, perhaps a psychoanalyst in the wings, and the younger folks have up to a quarter of a million in educational loans. The desire for a reasonable income and a pleasant standard of living (and remember, I've personally decided that nice vacations are a better means of dealing with stress than mass murder) gets balanced around a desire to continue treatment for patients who can't afford it.

Moviedoc's point is interesting: I too feel funny reducing fees for someone with a $100/week cannabis habit or a $400/month cigarette addiction. It feels enabling to slash fees so someone can continue to afford those things, and people make choices.

The government reduces fees for all medicare patients-- the current rate is $117.44 in my area for a 50 minute session. I follow the law, I don't make it, but it does feel funny to have patients with greatly "reduced fees" who have many luxuries while poorer ones pay full fee.

So far, lots of input, but no solid answers. I found it interesting that Tigermom will take a decreased fee for someone she hasn't yet met. I won't do this: I don't participate in insurance and so I figure that someone who is strapped for money can see an in-network provider, and I don't know what I'm getting myself into with someone I haven't met. I've had people tell me about all the psychiatrists who fired them, and asked if I'd reduce the fees before I've even met them.

The peace I've come to is to not raise fees on patients who are in treatment and don't talk about luxury cars, vacations, expensive restaurants, and to do some work aimed specifically at the indigent: I work in a clinic where I'm paid much less, I volunteered for a couple of years at a homeless clinic, and I volunteer for a Pro Bono group where they screen the patients for financial issues and I trust that the patients need help.

Lu said...

Dinah, sorry. My intent was not to put psychiatrists or psychologists on the defensive about their fees; my comment was purely a reaction to the tithing situation mentioned by Roy. I know that psychology professionals have a complicated situation on their hands when it comes to fees. I don't understand why it's so fraught for them, but then it's not really my business to worry about it. (And rest assured I haven't taken a nice vacation in years, although I agree that it would help with my stress, too.)

Anyway, no offense meant.

Child Psych said...

I use a sliding fee scale similar to one from an agency I worked at for patients who can't afford my full fee. It's based on household income and size of family. I find that this keeps the relationship business-like without creating second-guessing or resentment on either side. The reduced fee is almost always much much higher than a co-pay in-network which leaves the parents to decide whether they want to spend the extra money to see me.

itsjustme said...

My insurance only covers so many visits per year (Unfortunately, the parity act won’t help me. I work for a small company.), so I now have to pay my psychiatrist’s fee completely out of pocket. Well, I got into a major financial crisis which was entirely my fault. I make a fairly decent salary. I just made some really, really bad decisions that got me into a whole lot of trouble. I called my shrink to tell her that I would no longer be able to see her weekly and that I would just come when I could afford to do so until my insurance started up again in the new year. She said that she thought we should continue our weekly sessions and offered to cut her rate significantly. And I do mean significantly!!! I was completely shocked; speechless in fact. That was so kind and generous of her. However, if I had it to do all over again, I would refuse her offer and stick with my original plan. Since then, she’s brought up our “arrangement” a couple of times and I feel like she’s kind of throwing it in my face. I’m really grateful for what she’s done but the comments are making me uncomfortable. I never asked her to cut her fee nor did I expect her to do so. I feel that she shouldn’t have made the offer if she wasn’t okay with the situation, which it seems to me that she isn’t. As Tigermom said, “A grouchy therapist helps no one.” I don’t feel right bringing this up to her or cancelling my appointments, so I guess I’ll just endure the next month and a half until my insurance kicks in again.

Synna said...

I'm a psychologist in private practice in Australia. For most of my work people can claim a rebate through our medicare system. The gap between my fee and the rebate is less than $20. For people with pension/healthcare cards (ie low income, single parents, disability, all as defined by the government) I will bulk bill them - no out of pocket for them, medicare pays me the fee direct.

I try to keep fees as reasonable as possible given the demographics of where I practice.

Tigermom said...

Dinah,

The reasons I reduce an intake fee for a patient vary. Usually I do it when I am seeing the patient as a favor to the referral source.

What constitutes a favor? Seeing the relative of a referral source or an indigent patient of someone who sends me a lot of non indigent patients, or a story that tugs at my heart strings. Pregnant or post-partum women, teachers, and public servants (police officers, and the like) tug for me, as example.

And like you Dinah, I actively figure a percentage of my work that I want to be pro bono work. I meet and sometimes exceed that percentage without trying.

Some of my regular patients will undergo unexpected financial hardship so I often negotiate a lower fee for these people. That combined with doing special favors constitutes plenty of low fee arrangements.

Anonymous said...

I see my psychiatrist on a sliding scale. It's a very low fee,and he's not making any money off of me.

I started to see him during my residency, and we elected to continue after he graduated. He uses someone's office in the evening for his private patients, so his overhead is very low.

He still sees himself as developing his practice and skills, so he tells me that he gets something out of it too.

When he graduated, he asked me what I could afford and I told him (feeling guilty) what would have been my co-pay if he had chosen to do insurance billing.

He also has an academic/ public psychiatry job, so he's not exactly relying on my income.

He wants me to have a decent quality of life and specifically said that he didn't want me to feel that I had to cut out a $5 yoga class.

My standard of living has gone up from my $19K job and unemployment of $800/week, since I moved in with my boyfriend and am not paying rent. We went to his brother's wedding and stayed in a hotel, and then, because of a deal, we took a 2 day trip to Quebec. I would not have been able to afford this on my own and wouldn't have done it. When I went to visit my boyfriend's family for the first time, my psychiatrist said, "Good, you need a vacation." It was a pretty low-ost one-- mostly gas and food on the way. Although we've talked about marriage, I don't feel secure enough in that relationship to give up on the reduced fee just yet, and I'm getting help from others with my $700/month student loans which had been in default following a crisis where I really wasn't functioning and could have been homeless.

At some point when I'm more financially secure, I will pay him more, although I think I'd cut back the frequency. He suggested that we up it at one point, and we then cut the session rate.

I do not think I could pay $600 or 700 per week unless I were making a lot of money, and when I look at rent of $1225 a month, $2400 for therapy really takes my breath away.

The job I recently interviewed for paid $30K before health insurance deductions. So, I think that would be about $25K after-tax.

Expenses-- $8400 for student loans
Medications --$600
Co-pays for other doctors $100
Food -- $50 x 52 =$2600
Portion of Rent and utilities --$8500

$20,200 total expenses. That leaves around $5,000. Assuming that the doctor takes 2 weeks of vacation, that leaves $100 per week for therapy.

The budget above doesn't even include clothes, and if I want to advance in a career, I would need to avoid showing up to work in tattered ones.

I forgot the $720 I'd have to pay for a T pass. I've got about $86/ week for therapy. I suppose that I could just go once o r twice a month or every 3 weeks, but I think that I would struggle, and I don't think that the variations in my moods and functioning would be as well observed.

Anonymous said...

To follow up, I could drop the contact lenses (they are something of a luxury)--though I wore an old pair for several months longer than I should have.

And a reduced fee membership at the Y is $40/month.

My PCP is on my case to take supplemental calcium and vitamin D, and that costs money too.

I'd like to take fish oil, but even the discounted stuff is not cheap, and the heart benefits seem to have stronger evidence for them than the mood ones.

Sarah said...

thank God for the NHS!

I honestly don't know what I would do if I had to pay anytime I had to see a doc (psych or otherwise)

EastCoaster said...

moviedoc--

I had a psychopharmacologist who didn't take insurance and had opted out of Medicare. He did have one long-standing patient who had been on Medicare who didn't have a ton of money. He continued to see her and charged her what her co-pay would have been if he still took Medicare, so there's some discounting by med-only people. He also billed one rate for 30 minute appointments and twice that for longer ones, but I think that when he ran behind I sometimes got 40 minutes of his time. It was only about $90 for 30 minutes (10 years ago), and his initial evaluation was always 3 hours, and it cost $270.

At that time my school insurance did provide out-of-network benefits, but no drug coverage, we got a 50% off discount at the school pharmacy--and they didn't carry some things, so when he had them, he'd often offer me samples. I'd always try to avoid them, because I did get a bit of help to pay my bills and I was proud, and he'd say that he was just checking my mental status. So very tactful.

athinkingman said...

I used to operate a slide - charging 1000th of a client's income (£30,000 income = £30 a session etc.) I stopped it for two reasons. First, it got difficult asking clients to demonstrate their earnings. Secondly, apparently every client only earned £10,000 a year!

Anonymous said...

I wouldn't pay $600 to talk to someone even if I had it. That's over $13/minute. That's outrageous. Sorry, I've never heard any advice worth that.

itsjustme said...

I have a question based on the last Anon’s comment. Dinah, Tigermom, Moviedoc, etc.; do you “give advice” to your patients? I went to a psychologist 7 or 8 years ago and all she did was tell me what I should do. “Go there, do this, etc.” She didn’t listen to me at all. If she had, she would have known that the things she was telling me to do were things that I would never ever do. I quit after 2 or 3 sessions. I decided to try therapy again about a year and a half ago and my psychiatrist is the complete opposite. She has never given me a single word of advice and even when I directly ask her opinion, she will only occasionally give me a straight answer. I appreciate the fact that she isn’t trying to force off-the-wall ideas on me, but sometimes I wish she’d put in her 2 cents. Where do you guys stand on this? I’m just curious as to what’s the “norm” since my 2 experiences have been so drastically different. Thanks.

moviedoc said...

I certainly give advice, but I don't do psychotherapy now. When I did I used the family systems model. Psychotherapies are sometimes divided into directive and non-directive methods. Analytic/dynamic methods tend to be non-directive, but have little science to support them as effective for treating mental illness. CBT is very directive, and probably very effective.

Anonymous said...

I never knew that a shrink would do a sliding fee scale. So I never thought to ask.

When I moved I could not find a shrink in my county who took Medicare. The community clinic only takes medicaide, if you don't have medicaide you are out of luck there. I don't understand why they won't take medicare.

So anyway I started seeing a PA for meds and when it came time to review my SSDI I got cut off and I was subjected to a CDIU investigationg due to lack of medical evidence. (I apealed and won)

For my appeal I found an 88 year old psychiatrist 25 miles from home who would take medicare. I only had to wait one week to see him. But he was a total ass and I always left his office very upset, but I put up with him because he took medicare and I needed ducumentation. I like old people but this guy could barley walk and he could not put his socks on properly, he really was too old for the job.

Then I found out that his notes were unreadable and would not do me any good in my appeal. So I dumped him. He was doing me more harm than good and he was useless for my apeal.

Then a hospital 25 miles away got a new pdoc and I got on the waiting list for her. I had to wait 2 months to see her but she is good and the hospital takes medicare and offers uncomphensated care that I qualified for at the 100% rate.

I lucked out becasue she is one of those few rare psychiatrists that I like and she takes my insurance and she thinks I am disabled.

But being the subject of a disabilty investigation complete with the State police coming to my house and talking to me and my neighbors and then trying to cut off my SSDI made my condition 200% worse. I'm still trying to get back to where I was before all of this happened.

http://www.voanews.com/Khmer/archive/2006-12/2006-12-07-voa3.cfm is all about these investigations that the mentally ill are subjected to. The Seattle CDIU branch is the worst:
http://www.wsp.wa.gov/crime/cdiu.htm