Mindfulness: why you should try it

Mindfulness has gone mainstream

A few years ago, I took a trip to Cambria, a small, quiet town along the Northern California coastline. Soon after I arrived at my lodging, I realized there was no internet or cell phone connection. I spent the next couple of days feeling restless, anxious and cut off from the world. I felt I was missing out on my social media feed and wished I could visit my favorite apps on my smartphone. I then realized how much I was preoccupied with things that had nothing to do with my current experience. After a few days of meditation and quiet bike rides, I started to calm down. I am no mindfulness guru. However, learning about mindfulness and how it affects the brain has been simply fascinating. 

Mindfulness refers to practices that help to cultivate an awareness of the mind and body and living in the immediate environment. It helps us connect with the present moment without any filters or lens of judgment. Mindfulness meditation is historically rooted in Buddhism and the concept of being present is an important concept in many spiritual practices including Christianity, Hinduism, Islam, Judaism, and Taoism. However, many contemporary mindfulness practices are secular in nature. The therapeutic application of mindfulness became popular in the US in 1979 when Dr. Jon Kabt-Zinn’s developed the Mindfulness-Based Stress Reduction (MBSR) Program which was based on his studies of Buddhism. At the University of Massachusetts Medical Center, patients who went through Dr. Kabt-Zinn’s program had significant reductions in anxiety and depression symptoms.  

As a psychiatric mental health nurse practitioner, I incorporate mindfulness when working with clients. However, mindfulness can be used in many situations outside the clinical setting. Regular mindfulness practice can help decrease stress levels, increase focus, improve self-worth, and support mental wellness. Functional neuroimaging studies demonstrate strong evidence that mindfulness meditation is associated with structural and functional changes to the brain. These new discoveries have contributed to the popularization of mindfulness practices in recent years.  

On October 1st, 2019, the term ‘mindfulness’ was rated at 100 points on Google Trends. This indicated that more people were searching for the term than any time in the last 15 years. The prevalence of mindfulness practice is also on the rise across the United States. According to the National Health Interview Survey, the number of people using mindfulness yoga practices in the US workforce increased by almost 50 percent (6 to 11 percent) between the years 2002 and 2011. In addition, more schools, hospitals, and businesses are implementing mindfulness programs. MindUP, an organization founded by actress Goldie Hawn in 2003, has created curricula to teach children about empathy and emotional self-regulation through mindfulness practice. In a 2016 Washington Post article, Principal Carlillian Thompson of the Robert W. Coleman Elementary School in Baltimore, Maryland, said that mindfulness practices helped the school’s “378 students leave behind the stresses of their lives, including problems at home, violence on the streets and conflicts with friends, so they can get ready to learn.” In addition, there is a growing number of online and peer-reviewed articles in which mindfulness-based interventions have been used to manage stress, anxiety, depression, chronic pain, and even substance abuse. Furthermore, there has been an exponential proliferation of apps dedicated to mindfulness and meditation. In a 2017 press release, Apple stated that “never before have we seen such a surge in apps focused specifically on mental health, mindfulness, and stress reduction.” The fact that more people are downloading these apps is a testament to the value mindfulness practices may provide.

Growth in the use of mindfulness coincides with record-high prevalence of stress and mental health issues. According to a survey of 41 million Blue Cross Blue Shield insured patients, the rate of major depressive disorder increased by 63 percent for teens and 47 percent for millennials between 2013 and 2016. Dr. Laurel Williams, Chief of Psychiatry at the Texas Children’s Hospitals, attributed these changes to the increased busyness of our lives, more time spent in front of our screens, decreased social networks and decreased sense of community. 

Being distracted and multitasking is the norm

The advent of the internet and smartphones has brought tremendous changes in every area of modern life. People now have access to unlimited amounts of knowledge in the palms of their hands. This has led to great advances in different industries including entertainment, retail, transportation, education, and health care. However, because we are connected 24/7 we are constantly distracted and multitasking has become the norm. According to the Pew Research Center, there are over 5 billion user mobile devices and over half of these devices are smartphones. In the United States, 95 percent of teens have access to smartphones and 45 percent are “almost always” online. The flood of information from online sources across multiple devices competes for our attention at the expense of sustained focused work. This can lead to a loss of satisfaction in our daily lives and decrease our sense of mental wellness and fulfillment.

Our behavior is shaped by our use of technology

The ability for the brain to change based on external stimuli and our body’s internal environment is called neuroplasticity. The internet and smartphones gain and sustain our attention through its effects on the brain’s cortical-striatal dopaminergic system, which governs how we link goal-directed activity to reward. When using our phones, each click, scroll, or notification provides a small dopamine surge when we are rewarded with a new message, picture, or video. One article asserted that “it is the social expectations and rewards of connecting with other people and seeking to learn from others that induce and sustain addictive relationships with smartphones”. In addition, the instant gratification and feel-good sensations obtained from our devices offer a quick and reliable way of avoiding or even soothing negative emotions such as loneliness, sadness, frustration, helplessness, disappointment, or low self-worth. Studies suggest that repeat of the cycle of negative emotion avoidance and reward-seeking behaviors lead to structural changes in our brains which make our actions more fluid and automatic. The behavior then becomes less intentional and more impulsive. We then become less mindful, pun intended, of the goals of the behavior and less sensitive to the changes which need to be made to address new goals. When we use technology to address negative emotions, these negative emotions go unaddressed often leading to behavioral dysfunction, decreased work performance and increase risk of mental health issues. 

Think of the last time you reached for your phone, swiped and clicked through a number of apps, before realizing you had no intention of using it. You put down your phone only to pick it up a few minutes later to repeat the process. The teenage brain is particularly vulnerable to these impulses. Mindfulness practice can be used to counter the effects of living in a distracted world and help us better hone in on our emotional needs. 

The prefrontal cortex and the default mode network

Mindfulness meditation leads to changes in the areas of the brain related to emotional regulation and attention. The prefrontal cortex of the brain is involved in self-control, emotional regulation, planning, and problem-solving. It is divided into different regions associated with specific functions. The ventral medial prefrontal cortex (VMPC) modulates the impact of emotions on judgment. The VMPC also regulates the amygdala, the fear center of the brain. In one study, showing negative images to experienced meditators produced decreased activation of the VMPC and amygdala compared to non-meditators. This means meditators are better able to tolerate distressing stimuli with a decreased response in fear or alarm. Also, functional magnetic resonance imaging (fMRI) of long term meditators showed decreased activity in the dorsomedial prefrontal cortex, which modulates how one perceives and internalizes an experience. Think “I am sad” versus “I am experiencing sadness.” The latter is more likely to occur with meditators. Other studies showed increased activation in the parietal lobe, which modulates external attention, and anterior insula, which modulates awareness of physiological sensations coming from one’s body. It was concluded that mindfulness decreases the impact of emotions on decision making and helped improve attention through the strengthening of attention networks in the brain.

Mindfulness meditation was also associated with decreased activation of the default mode network (DMN). The DMN is a system of interconnected structures within the brain that are activated when we are not focused on the outside world. The DMN plays an important role in social cognition and self-referencing thoughts. It modulates our ability to correctly anticipate, and pick up behavioral cues as well as take on the perspective of another person other than ourselves. FMRI images of meditators showed lowered activity of the DMN suggesting changes in the processes of automatic thoughts. It was concluded that Mindfulness meditation seemed to change one's subjective, automatic thoughts towards a more objective and contemplative perspective. This allows for better judgment and planning. At the same time, mindfulness meditation increases our awareness of the present moment and enhanced decision making under stressful situations.

 More research is needed to clarify what specific types of mindfulness exercises can be used to target which issues. There are also concerns that the application of mindfulness has been overhyped and may not be as effective in certain situations. However, it is evident that mindfulness leads to decreased emotional reactivity, and as a result, increased tolerance of negative emotions. This may translate to lower levels of perceived stress. The above studies were based on a variety of mindfulness practices and the benefits may not always be achievable for all mindfulness practices.

“No problem can be solved from the same consciousness that created it.” Albert Einstein

As one who practices mindfulness meditation, I recommend it to everyone. It is free and requires only a few minutes of your time. It’s as easy as stopping what you are doing right now. Now slowly, take a deep breath in, and then out. Observe your breathing, feelings, body sensations. Notice where your thoughts go. Gently refocus on your breathing and body sensations. Observe and accept them, without judging or attempting to change them. Then simply proceed with your day.  

It may not give you the power to fly, but it can increase your sense of focus, emotional regulation and overall sense of mental health wellness.  Now imagine what you could do with that. 

References:

Stahl, B. and Goldstein, E. (2010). A mindfulness-based stress reduction workbook. Oakland CA: New Harbinger Publications, Inc.

Kachan D, Olano H, Tannenbaum SL, Annane DW, Mehta A, Arheart KL, et al. Prevalence of Mindfulness Practices in the US Workforce: National Health Interview Survey. Prev Chronic Dis 2017;14:160034. DOI: http://dx.doi.org/10.5888/pcd14.160034

St George, D. (2016). How mindfulness practices are changing an inner-city school. [online]. Available from: Washington Post.

Perez, S. (2018). Self-care apps are booming. [online]. Available from: https://techcrunch.com/2018/04/02/self-care-apps-are-booming/.

Fox, M. (2018). Major depression on the rise among everyone, new data shows. [online]. Available from: https://www.nbcnews.com/health/health-news/major-depression-rise-among-everyone-new-data-shows-n873146.

Veissière, S.P.L. and Stendel, M. (2018). Hypernatural Monitoring: A Social Rehearsal Account of Smartphone Addiction. [online]. Available from: Frontiers in Psychology.

Silver, L. (2019). Smartphone Ownership Is Growing Rapidly Around the World, but Not Always Equally. [online]. Available from: https://www.pewresearch.org/global/2019/02/05/smartphone-ownership-is-growing-rapidly-around-the-world-but-not-always-equally/.

Anderson, M. and Jiang, J. (2018). Teens, Social Media & Technology 2018. [online]. Available from: https://www.pewinternet.org/2018/05/31/teens-social-media-technology-2018/.

Firth, J., Torous, J., Stubbs, B., Firth, J.A., Steiner, G.Z., Smith, L., Alvarez-Jimenez, M., Gleeson, J., Vancampfort, D., Armitage, C.J. and Sarris, J. (2019). The “online brain”: how the Internet may be changing our cognition. [online]. Available from: World Psychiatry.



Arnold Fosah is a Psychiatric Mental Health Nurse Practitioner and a co-founder of Neb.

Starting Therapy

This is part 9 of a guidebook on how to find a therapist. Check out the introduction to get started.

You should schedule a first appointment with at least 2 people. Just one other therapist as a point of reference will be really helpful when evaluating a therapist. Maybe you’ll have to pay another $150 upfront, and the process will take another week or two. But in the long run, if you find the right person, you’ll get better much faster, and you won’t waste any money on therapy that isn’t helping you.

This is really important. Meet at least 2 therapists in person.

You’re almost done! So now you’re going to meet a therapist. During the first session, the therapist will ask you a lot of questions to properly understand your situation. This may take up the whole session, and you may not get to ask questions about things you think are important. So at the beginning of the session, I would lead by saying “I’d like to keep the last 10-15 minutes to ask questions.”

When evaluating the therapist, remember - go with your gut. Do you like what’s happening?  Do you like this person?

Finally, you pick between all the therapists you’ve seen, and now you start seeing one therapist.

Treatment Plan

After the first 1-3 sessions, it’s important to discuss a treatment plan with the therapist. Here are some questions to think about:

  • What are the issues you and the therapist will work on?

  • What will be the format of each session? For example, talking, mindfulness, coping skills, other exercises.

  • What will you have to do outside of the sessions as part of the treatment?

  • What will be the indicators of progress? For example, an improvement in your mood from week to week, handling certain conversations or situations in your life better, or making certain lifestyle changes.

Not all of these questions can be answered immediately - as mentioned earlier, therapy is not like taking cough syrup! It’s difficult to determine how many session you will need up front. It may take multiple sessions for you and the therapist to clarify exactly what your challenges are and goals. And as you start working towards your original goal with a certain approach, you may uncover other issues which need to be addressed, or the therapist may introduce new techniques.

However, at the highest level, therapy is medical care and a big part of your life. Just as you would create a plan and set expectations for a surgery, you should at least think about therapy with structure.

Giving Feedback

Right off the bat, the therapy may not be perfect. You like the therapist and the therapy is pretty good, but there are a couple of things that could be better. Often, you and the therapist may not have alignment on the issues you want to work on. You might want to address an issue that’s not being talked about. Or, the therapist may want to talk about something you don’t think is important. 

This is harmless and usually due to miscommunication. Feel free to give the therapist feedback at any time. During the last 10 minutes of the second session, you can say very straightforwardly, “I like what we’re doing, but I wanted to give you some feedback. I don’t think topic X is that important, and I’d like to spend more time talking about topic Y instead.” This may be uncomfortable, but it’s totally okay. This is their job, and they shouldn’t take it personally.

Switching Therapists

Finally, after 3-4 sessions, if you’re really not enjoying yourself, it’s okay to stop and look for someone else. Go with your gut! Remember, therapy has been shown to be really effective, and if it isn’t working, it’s often the lack of fit between you and the therapist.

Summary

  • Schedule a first session with at least 2 therapists!
  • Tell the therapist you’d like to keep the last 10-15 minutes of the session to ask questions.
  • Go with your gut - do you like what’s happening? Do you like this person?
  • It’s okay to give feedback if specific aspects of the therapy aren’t helpful.
  • If you aren’t enjoying yourself 3-4 sessions in, stop and look for someone else.

We Can Help

Neb can handle this entire process for you and find you the right therapist, free. If you’re interested, please check out our website.

Conclusion

That’s it! We’ve covered: why do therapy, what therapy is, types of therapy, finding the right therapist, insurance, searching for therapists, the phone consultation, and actually seeing a therapist. If I had to summarize this entire article in five bullet points, they would be:

  • therapy is awesome!

  • therapy and finding a therapist take a lot of time and effort

  • find a therapist you like

  • reach out to 15-20 therapists

  • do phone consultations and first appointments with multiple therapists

Self-care is one of the best things you can do in life. If you have any questions, please feel free to email us at hello@neb.health. Good luck!

The Phone Consultation

This is part 8 of a guidebook on how to find a therapist. Check out the introduction to get started.

When finding therapists, the main method of communication is phone. 99% of the time, you will go straight to voicemail. Don’t get demotivated by this, it’s standard. Leave a short voicemail - say your name, that you’re looking for a therapist, and your number.

Also, try to reach out to each therapist in as many ways as possible. On Psychology Today, you can send a message, so you should do that. Also, you’ll often find a link to a personal website.

Go there and either submit a form or find their email address and send them an email.

Therapists may take up to a week to return your call. Often, they’ll return your calls in the evening. I’ve personally gotten calls as late as 8:30 PM, so be prepared. When they return calls, you may see no caller id - you should answer these calls.

A lot of therapists will also not return your calls, especially if you’re calling about insurance. They may also call you back just to let you know they aren’t taking new clients.

If they’re available, phone calls they return are free consultation calls. They’re between 10-20 minutes long - take your time. They’re for you to explain your situation, and for you and the therapist to see if you both are a good fit for each other. The therapist will expect you to talk about why you’re seeking therapy. What they’re not meant for is providing therapy then and there over the phone, so don’t get too in-depth into your issues. 

Questions To Ask

  • “What kind of clients and issues do you usually work with?” We recommend asking this question before telling the therapist about your situation. This is because if you talk about your situation first, some therapists may convincingly say they’re a good fit even if they’re not. If you ask the therapist about their work first, you get to see if they mention your issues.

  • “I’d love to know a bit about who you are as a person. Could you tell me a bit about yourself?” You can really connect with a therapist based on their experiences and perspectives, which will make the therapy a lot more effective. On the other hand, once you discover you don’t like who the therapist is as a person, the therapy will no longer be effective, and it’s good to know that beforehand instead of a few sessions in.

  • “What is your style of therapy?”

  • “Have you worked with people similar to me before? How many?” 

  • “What is your availability?”

  • “Do you offer a superbill?” If you want to use out-of-network coverage.

Payment

Finally, you have to talk about finances. The therapist may bring up finances, otherwise you should discuss it last. Like we said earlier, a lot of providers offer sliding scale - lower prices for people who can’t afford therapy. The therapist may mention a minimum price - for example, “I offer sliding scale down to $100 a session”. Others may dedicate a certain number of their appointments to sliding scale clients, but not mention it unless it’s brought up.

We recommend directly telling the therapist your budget regardless of what they say - for example “I can only afford $90 a session - does that work for you?” Obviously, you have no control over the therapist’s decision, and nothing you say will change that. But, some therapists may already be willing to work with you, even if they don’t mention sliding scale or your budget is below the minimum they mention. The only way to find out is to ask.

Scheduling The First Appointment

If everything goes well, the provider may try scheduling an appointment at the end of the call. Remember, talk to at least 3 people on the phone! Don’t schedule an appointment with the first person you talk to and end your search. It’s really important to be able to compare to other therapists.

If you know you want to see them in person, go ahead and schedule an appointment. If they might be a good fit, but you want to talk to more people first, you don’t have to schedule an appointment - you can say something like “thank you so much for your time - I’d like to think about it and I’ll reach out to you.”

Tip: ask the provider what the best way is to contact them - phone, email, or their website.

When deciding whether a therapist is a good fit, remember - go with your gut. Do you like the therapist?

For more information, you can read our article on how to have a phone consultation.

Summary

  • You will go to voicemail 99% of the time.
  • Reach out each therapist in as many ways as possible.
  • Expect to get calls within a week of calling, during the evening or night.
  • Therapists will do a free 10-20 minute consultation call to understand your situation and for both of you to see if you are a fit for each other.
  • Questions to ask:
    • What kind of clients and issues do you usually work with?
    • I’d love to know a bit about who you are as a person. Could you tell me a bit about yourself?
    • What is your style of therapy?
    • Have you worked with people similar to me before? How many?
    • What is your availability?
    • Do you offer a superbill?
  • Regardless of what the provider says, directly tell them your budget and ask whether it works for them.
  • Talk to at least 3 therapists on the phone!
  • Go with your gut. Did you like the therapist?

We Can Help

Neb can handle this entire process for you and find you the right therapist, free. If you’re interested, please check out our website.

Next: Starting Therapy

Click here to go to the next section.

Searching For Therapists

This is part 7 of a guidebook on how to find a therapist. Check out the introduction to get started.

You know what you’re looking for, and how your insurance works. Now you need to reach out to therapists. 

First, like I said, you’ll need to reach out to at least 15-20 therapists. Also, it’s much harder to find a provider in-network than a provider that takes cash.

Finding In-Network Therapists

But, let’s say you do want to find a provider in-network. What you absolutely shouldn’t do is call therapists you find online, that don’t provide any insurance information, and ask if they take your insurance. A lot of people do this. The answer will always be no, and it’ll be a very frustrating experience.

There are two ways to find therapists in network. First, most insurance companies have an online directory of in-network providers. Google the name of your plan + “provider directory”. There may be a separate page for mental healthcare providers. You can also call your insurance company at the number on the back of your card, and they’ll tell you where the online directory is. Use this tool to find a list of therapists in your area.

The quality of this list will be low. There will be duplicates, therapists who aren’t taking your insurance anymore, or who aren’t taking new patients, or have moved or retired. Be prepared to call at least 50 numbers to find an in-network therapist.

If your insurance company doesn’t have a directory, you can call them to get a list of nearby providers. Finally, your primary care physician may have a few in-network therapists they can refer you to.

Finding Out-of-Network Therapists

If you’re looking for an out-of-network provider, you have a few options.

The first place to start is Psychology Today. You can search for therapists by zip code and specialty. Focus on the 3 specialties in green on the right hand side, and any specialties or styles of therapy mentioned in the bio.

Tip: the number listed on a Psychology Today profile may be disconnected. However, therapists often have a link to their website on their profile, so go to their website to find their current number.

You can also use Yelp, and you can go through the first few pages of search results on Google. I would just search for “therapist” + your city. For example: “therapist san jose”.

Clinics

You can also get a few more results by searching for “mental health therapy clinic” + your city. Some of the numbers you call when reaching out to in-network therapists will actually be clinic front desk numbers as well. When speaking with the front desk, ask to do a free consultation call with the therapist you’re interested in - don’t schedule an appointment immediately. You can sometimes find a list of the clinic’s therapists on their website. You might want to see if there’s a therapist who seems like a good fit and ask about their availability when speaking to the front desk.

Affordable Options

If you’re uninsured or can’t find a therapist in-network and can’t afford to spend more than $75 a session, here are some options in the Bay Area. These options cater to people who need therapy but can’t afford it, not people with high incomes unwilling to pay.

If an organization doesn’t offer exactly what you need, give them a call anyway - they can often refer you to someone more suitable. 

If you don’t know what to do for whatever reason, call the Substance Abuse and Mental Health Services Administration (SAMHSA) 24/7 hotline at (800) 662-4357. For any situation, they will be able to provide you with information and/or referrals.
  • Reach out to at least 15-20 therapists!
  • It’s much harder to find an in-network therapist than out-of-network. You may have to call 50+ numbers.
  • Do not call therapists you that don’t provide any insurance information and ask if they take your insurance.
  • Ways to find in-network providers:
    • your insurance company's online provider directory
    • calling your insurance
    • asking your primary care provider
  • Ways to find out-of-network therapists:
    • Psychology Today
    • Yelp
    • Googling "therapist" + your city
    • Googling "mental health therapy clinic" + your city
  • Affordable options exist for people unable to pay more than $75/session. Scroll up for a list.
  • If you don’t know what to do for whatever reason, call the SAMHSA 24/7 hotline at (800) 662-4357. For any situation, they will be able to provide you with information and/or referrals.

We Can Help

Neb can handle this entire process for you and find you the right therapist, free. If you’re interested, please check out our website.

Next: The Phone Consultation

Click here to go to the next section.

Finances And Insurance

This is part 6 of a guidebook on how to find a therapist. Check out the introduction to get started.

Most Therapists Don’t Take Your Insurance

When it comes to mental healthcare, insurance works very differently than physical healthcare. It’s not like going to a doctor’s office, where they take almost any insurance. Most mental healthcare providers don’t take your insurance.

This is for a couple of reasons. Reimbursement rates are much lower than for physical healthcare. Also, guess what, it’s also really frustrating for mental healthcare providers to work with insurance.

Most mental healthcare providers are cash only. The market rate is between $120-200 a session. You may find a provider in-network, but be mentally prepared to have to pay out-of-pocket for therapy. 

Sliding Scale

But, a lot of providers offer what is known as sliding scale - depending mainly on your income and ability to pay, providers will lower their rates.

Online, you’ll see providers say that they offer sliding scale. But, what you won’t see is how low they’re willing to go. We provide some resources for affordable therapy in the next section. However, outside these and similar resources, almost no therapist will go lower than $75 a session.

Honestly, it’s awful there isn’t transparency about pricing. Searching for an affordable therapist and negotiating will be stressful. But, you may have to, and you may find a provider who’s willing to work with you at a rate you can afford. I’ll talk more about negotiating and affordable options that later.

In-Network Insurance

How health insurance works may seem complicated, especially if you’re younger, so I’m going to spend some time explaining how it works.

First, let’s say you see a provider in-network at their office, maybe in a plaza somewhere. They have a private practice or are part of a group practice. This is as opposed to a clinic or hospital. In insurance terms, this is known as an “office visit”. 

For an office visit to an in-network therapist, you only pay a copay. To confirm, ask the therapist or clinic whether they put something like “office”, “doctor’s office” (even if the provider is a therapist and not a medical doctor), or “outpatient provider’s office” down for the “place of service” field on the reimbursement form they submit.

Out-of-Network Insurance

Online, you’ll see a lot of therapists say they “accept out-of-network insurance”. This is a very misleading phrase. You will have to pay these therapists in cash, upfront. They don’t ever work with your insurance company.

But, out-of-network insurance is a way to possibly get some money back from your insurance company. How much, if at all, varies wildly. But it’s possible you can get reimbursed around $30-75 per session by your insurance.

This is how it works: 

  • Your therapist will provide you with what’s called a superbill, an invoice that contains information required by insurance companies.

  • Then, you fill out a form, either electronic or paper, and submit it along with the superbill to your insurance company. This is called submitting a reimbursement claim.

  • For the first several sessions, you won’t get reimbursed, but you still have to submit claims in order to eventually get reimbursed. More on this later.

  • You’ll get a check in the mail 3 months later. Yes, that’s a long time. How much you get back will vary each time, and your insurance company might not cover anything out of the blue.

Now, let’s say it’s not an office visit to an in-network therapist. There are four numbers to pay attention to: the deductible, coinsurance, maximum reimbursement rate for therapy, and out-of-pocket.

This applies to any out-of-network provider. It also works the same way for in-network, but if you’re going to a clinic or hospital. There are two sets of these numbers, for out-of-network and in-network, don’t confuse them when you’re asking your insurance company for details.

Deductible

First, there’s what’s called a deductible. You have to spend a certain amount of money out-of-pocket before insurance kicks in. The deductible includes spending on all healthcare services, not just mental healthcare. The out-of-network deductible may include spending on in-network care, and vice-versa. The deductible may also include copays.

You also have to consider the maximum reimbursement rate for therapy. Different insurance companies call this different things, such as: the maximum reimbursable amount, maximum allowed amount, or the contract rate.

When calculating how much of your deductible has been met, or how much insurance will cover, they use this amount as the maximum for the service. The exact maximum reimbursement rate isn’t known ahead of time. You can access an estimate by logging into insurance website. It can vary on a day-to-day basis, so expect fluctuations in your exact reimbursement amounts. 

Let’s use an example:

  • your deductible is $500.

  • the maximum reimbursement rate is $75 a session.

  • your therapist charges $150 a session. 

If you see your therapist 3 times, you will have to pay them $150 * 3 = $450. You might think $450 has gone towards your deductible, and you only need to spend $50 more. This is not correct. Because the maximum reimbursement rate is $75, $75 * 3 = $225 has gone towards your deductible.

How much the therapist charged you doesn’t matter, only the maximum reimbursement rate. In this example, you would have to see your therapist 7 times and spend $1050 before insurance kicked in. 7 * $75 = $525, which is more than the deductible.

By the way, the way to tell your insurance company you’re meeting your deductible is by filing the reimbursement claim I described earlier. You have to file a claim for each session from day 1. It’s just that you won’t get any money back until your deductible has been met. 

Coinsurance

Now, let’s say you’ve met your deductible, and insurance has kicked in. For out-of-network care, insurance won’t cover the full amount. They cover a percentage, which is known as coinsurance. This coverage again extends only to the maximum reimbursement rate, not what you pay your therapist.

Let’s use the same example as before, and imagine you’ve met the deductible:

  • You pay your therapist $150.

  • The maximum reimbursement rate is $75.

  • The coinsurance is 50%.

Insurance covers $75 * 50% = $37.5. The end result is you pay $150 - $37.5 = $112.5 per session.

Out-of-Pocket

Finally, there’s what’s called the out-of-pocket. If, in a calendar year, you spend the out-of-pocket amount on your healthcare, you get a lot more coverage. Like the deductible, spending on all healthcare services, counts towards the out-of-pocket. Similarly, the out-of-network out-of-pocket may include spending on in-network care, and vice-versa. The out-of-pocket may also include copays.

For out-of-network therapy, if you’ve met the out-of-pocket, generally 100% of the maximum reimbursement rate is reimbursed.

Let’s use the same example, and say you’ve met the out-of-pocket:

  • You pay your therapist $150.

  • The maximum reimbursement rate is $75.

  • The coinsurance is now 100%.

You pay the therapist $150 a session, but get back $75 * 100% = $75 from insurance. The end result is you pay $150 - $75 = $75 a session.

HSAs And FSAs

You should have no problem using a health savings account (HSA) for out-of-network therapy. Just keep a copy of the therapist’s bill.

You can also use a flexible savings account (FSA). But, your claim might be denied and you might have to dispute this. Ask your HR what to do.

Checking Your Coverage

To get all the information needed, call your insurance company at the number on the back of your insurance member card. 

Questions to ask your insurance company:

  • What is the name of my plan?

  • What is my copay for in-network office visits for outpatient mental health therapy?

  • What is my out-of-network deductible?

  • Do copays count towards the deductible?

  • Does in-network spending count towards the out-of-network deductible?

  • How much of my deductible have I met this year?

  • What is the out-of-network coinsurance for outpatient mental health therapy?

  • What is my out-of-network out-of-pocket?

  • Do copays count towards the out-of-pocket?

  • Does in-network spending count towards the out-of-network out-of-pocket? 

  • How can I find the maximum reimbursement rate?

  • Do I need a referral for in-network or out-of-network outpatient mental health therapy?

  • How do I submit a claim?

  • (About a specific therapist) is a therapist in-network with me?

Summary

  • Most therapists don’t take your insurance.
  • Therapy costs $120-200 a session.
  • A lot of therapists offer sliding scale - lower rates for people who can’t afford it.
  • You can file reimbursement claims with your insurance company to get anywhere from $30-75 back per session, even if the therapist doesn’t take your insurance. This is called out-of-network insurance.
  • Deductible - the amount of money you have to spend out-of-pocket before out-of-network insurance kicks in.
  • Maximum reimbursement rate - the maximum amount per session that: counts towards your deductible and out-of-pocket, or that you can get reimbursed for.
  • Coinsurance - the percentage of the cost per session, up to the maximum reimbursement rate, your insurance will reimburse you for.
  • Out-of-pocket - the amount of money you have to spend after which your insurance covers 100% of out-of-network costs, up to the maximum reimbursement rate.
  • You can use HSAs and FSAs to pay for out-of-network therapy.
  • Call your insurance provider to get all the information you need.

We Can Help

Neb can handle this entire process for you and find you the right therapist, free. If you’re interested, please check out our website.

Next: Searching For Therapists

Click here to go to the next section.

Process Overview

This is part 5 of a guidebook on how to find a therapist. Check out the introduction to get started.

We’ve covered the most important things you need to know about therapy and the right therapist. Now, let’s talk about how exactly to find a therapist. I’ll start by outlining the process.

How To Find A Therapist

  1. Write down exactly what you’re looking for in a therapist.
  2. Go online, find 15-20 candidate therapists, and call all of them. Email or message as many of these therapists as possible.
  3. Over the next week, these therapists will return your calls.
  4. Have free 10-minute consultation calls with at least 3 therapists.
  5. Shortlist 2 therapists and see both of them for 1 session.
  6. Pick 1 therapist to keep seeing.
  7. 2-3 sessions in to seeing the therapist, give them feedback if necessary and reevaluate.
  8. If needed, start over and find a new therapist.

I’m going to be honest with you - this process is time-consuming and tedious. If everything goes well, it’ll still take you 2-3 weeks. For any number of reasons, it could take up to a couple of months to find a therapist. It’s harder to find a therapist in-network or if you have very specific requirements. You might find the right therapist, but they have a waitlist. Or after a few sessions, you find out the therapist you selected just isn’t a good fit.

Like I said, this will be like applying to college or a competitive job. But, it’s absolutely worth it. Let’s go over each of the steps.

The Two Biggest Mistakes People Make When Looking For A Therapist

You may be surprised by the numbers mentioned above: reach out to 15-20 therapists, talk to at least 3 therapists on the phone, see 2 therapists in person. However, this is absolutely necessary.

The two biggest mistakes people make when looking for a therapist are:

  1. not reaching out to enough therapists

  2. seeing the first therapist they have a decent phone call with

Don’t make these mistakes. 

First, finding a therapist is a numbers game. It’s hard to find a therapist. A lot of people reach out to 2 or 3 therapists, don’t hear back, and then stop looking. That’s why you have to reach out 15-20 therapists.

Second, remember - the right therapist really matters! Especially for people who are new to therapy, it can be hard to know whether a therapist is right for you. Having just 1 or 2 points of comparison is really helpful. We’ve heard so many people say things like “I only found out how bad my first therapist was once I started seeing another therapist”. Instead of only finding out a therapist isn’t right for you several sessions in, or being stressed that you might not have chosen the right therapist, you can quickly compare therapists up front. 

That’s why we say talk to at least 3 therapists on the phone and see 2 in person.

Write Down What You’re Looking For

First, write down exactly what you’re looking for in a therapist. The reason is so you don’t have to make decisions on the fly, as you’re looking for or talking to therapists.

Like I said, we can’t know exactly what matters to you, but you probably have a couple of things you really care about. 

To recap what we talked about earlier:

  • What style of therapy do you prefer? Do you prefer CBT, which is structured, therapist-directed, and solution-focused, psychodynamic therapy, which is unstructured, directed by you, and about self-exploration, or you aren’t sure?

  • Do you have preferences when it comes to the therapist’s:

    • gender 

    • age 

    • ethnicity 

    • sexual identity

    • religion

    • anything else about the therapist

  • Do you need a specialist? Are you dealing with a unique situation, such as an eating disorder, ADHD, or parenting, for which you need a therapist?

Here are some additional criteria to keep in mind: 

  • When are you available to see a therapist? If you don’t have a point of view on this, you may end up picking an inconvenient time, and you’ll eventually stop going. Most therapists are open from 9-5 on weekdays, but some have evening and weekend availability.

  • How far are you willing to commute to see a therapist?

  • Do you want to use insurance?

  • If you don’t want to use insurance, or can’t find a provider in-network, how much are you willing to pay per session? I’ll cover finances in the next section. But, if you want to use insurance, know that you may not be able to find a provider in-network, and you should think about whether and how much you’re willing to pay out-of-pocket beforehand.  

Finally, write down anything else you want in your therapy.

You don’t have to have a point of view on every factor right now. Most factors don’t matter to each person, and even if you’re unsure about some factors now, you’ll quickly develop preferences as you go through the process. Also, you may discover some factors you think are important aren’t you start seeing a therapist.

You might not be able to find someone who meets all your criteria, but it’s good to know what you’re looking for.

Summary

  • It’ll take at least 2-3 weeks to find a therapist.
  • Don’t make the mistake of not reaching out to enough therapists. Call at least 15-20 therapists.
  • Don’t make the mistake of picking the first therapist you have a decent phone call with. Comparing therapists is really important. Talk to at least 3 therapists on the phone. See at least 2 therapists in person.
  • Write down what you’re looking for in therapy.
  • Questions to answer:
    • What style of therapy do you prefer?
    • Do you have preferences when it comes to the therapist’s:
      • gender
      • age
      • ethnicity
      • sexual identity
      • religion
      • anything else about the therapist
    • Do you need a specialist?
    • When are you available to see a therapist?
    • How far are you willing to commute to see a therapist?
    • Do you want to use insurance?
    • If you don't want to use insurance, or can't find a provider in-network, how much are you willing to pay per session?
    • Is there anything else that matters to you?

We Can Help

Neb can handle this entire process for you and find you the right therapist, free. If you’re interested, please check out our website.

Next: Finances And Insurance

Click here to go to the next section.

The Right Therapist

This is part 4 of a guidebook on how to find a therapist. Check out the introduction to get started.

The right therapist really matters, so I’ll cover several specific factors to keep in mind when evaluating a therapist. But before that, I want to make two very important general points about finding the right therapist.

You Need To Like The Therapist And The Therapy

First, the biggest factor when it comes to successful therapy is whether you like what’s going on. Do you like what’s going on in the therapy session? I say “what’s going on”, because you have to like both the therapist as a person, and the therapy itself, the style and the therapist’s expertise.

Each of you is a unique human being dealing with a unique situation, so we can’t make universal recommendations. What we can say is, if you don’t like the therapist or the therapy itself, if you feel that in your gut - it doesn’t matter how many articles you read saying “this is the right kind of therapy for you”. Or how many 5-star reviews the therapist has on Yelp. Or that they got a PhD from Stanford. The therapist won’t work for you.

On the other hand, they could be a brand new therapist, and you might not even be able to put your finger on why you like what’s going on. But if you like what’s going on, it’ll work for you.

We’re going to talk about some factors that make a lot of people like or dislike their therapist or the therapy. But there is an infinite number of factors that can go into your preference. You could like a therapist because of their great sense of humor. Or maybe you can’t even articulate what exactly it is you like about what’s going on. So we can’t even list out all the factors to consider. You may really care about something we haven’t thought of. Also, you won’t have preferences when it comes to most of these factors. Most people care about a couple of things.

If You Aren’t Sure, Try It Out

You may also not know what you like, which brings me to my second very important point.

If you aren’t sure about a therapist or a type of therapy, try it out and evaluate quickly. Just like in a relationship, the best way to see if a therapist is right for you it to try seeing them. You’ll quickly learn - within 4 sessions, and usually within 1 - whether you like what’s going on.

Now, let’s talk about factors that usually make people like or dislike a therapist. 

Types Of Therapy

First, at the highest level, there are two types of therapy. 


CBT

There’s Cognitive Behavioral Therapy, or CBT. The goal of CBT is to help you replace negative thought and behavior patterns with positive ones. It’s not focused on your past or who you are.

CBT is very structured. The therapist has an agenda each session. You’ll learn skills to better handle specific situations. For example, when you have a negative thought, how to respond to healthily. Or how to communicate better in relationships. You’ll learn these skills through exercises, such as journaling, worksheets, and role-playing. You’ll also have homework - you’ll be expected to do these exercises between therapy sessions. This form of therapy can be as short as 6-10 sessions.


Psychodynamic Therapy

The other type of therapy is psychodynamic therapy. Psychodynamic therapy addresses your challenges by helping you more deeply understand yourself and the root causes of your challenges.

You focus on becoming aware of and articulating your emotions. You will explore your past experience and how that’s made you who you are. There’s also a lot of focus on understanding the nature of your relationships. These include your relationships with yourself, your family, partner, and colleagues, and the therapist themselves.

Psychodynamic therapy is directed by you, the client. It’s a lot more fluid than CBT - you can change topics every session. The idea is everything - every interaction, thought, or emotion - contains some information about you. So if you come in and some very tiny comment someone made a few days ago is on your mind, your therapist will explore what that says about you. Because it’s open-ended, it can go on for many months.


Choosing Between The Two

Neither style of therapy is better, and a lot of therapists incorporate both styles. But, most people prefer one. If you want structure or skills, you might want to try CBT. On the other hand, reasons people don’t like CBT are because it’s inflexible, or because there are too many exercises.

If you want to understand why you are the way you are, you might want to try psychodynamic therapy. On the other hand, reasons people don’t like psychodynamic therapy are because it takes time, or it’s uncomfortable to face your issues.

Note that even if you have a mild preference for one style, the other style may be more effective for the issues you’re dealing with. You might also discover you like a style you thought you wouldn’t like, or vice-versa. You should discuss style with therapists you’re considering to make the best decision, but it’s important to be aware of the styles.

The Therapist Themselves

Aside from the style of therapy, you have to like the therapist themselves. Again, there are an infinite number of factors that can make you like or dislike your therapist, and you should go with your gut. But, empathy is really important, and someone who has had similar experiences to you may be able to better understand where you’re coming from.

I’ll use myself as an example. I’m ethnically Indian. I was raised Hindu. I’m a minority in this country. And I’m an immigrant - I spent my teens in India. As a result, I have a very different set of experiences, beliefs, and perspectives than say someone who’s white and was born and raised here.

A lot of Indian parents expect their children to become doctors or engineers. I can’t talk to my parents about sex or drugs. My dad watches cricket and Indian news at home. I’ve been vegetarian for 15 years. I lived in an extremely dense city with 6 million people and so I don’t like suburbs. Very rarely, I’ve experienced racism.

As a result, a therapist who’s white and was born and raised here, wouldn’t be able to appreciate a lot of my perspective.

I’m also a male, 25, and working at a technology startup.

So, you may want to find a therapist who can understand where you’re coming from because of their own similar experiences. Gender, age, ethnicity, sexual identity, and religion are specific factors that result in people often connecting or not connecting with a therapist.

Specialty

Finally, in a lot of cases, a therapist that specializes in working with your issues matters. Almost all therapists can help with depression, anxiety, relationship issues, work stress, and life transitions. Most therapists can help with trauma and PTSD, and issues related to the gender of the therapist.

But if you’re dealing with almost anything else - for example eating disorders, addiction, ADHD, sleep, phobias, parenting, becoming a mother, being adopted, kids and teens, if you want couples therapy - try to find a specialist.

We’ll talk about how when we get to searching for therapists.

Summary

  • The biggest factor when it comes to successful therapy is whether you like the therapist and the therapy.
  • If you don’t have a preference for a type of therapy or therapist, try it out.
  • CBT is structured, therapist-directed style of therapy focused on replacing negative thought and behavior patterns with positive ones. You learn skills and do exercises.
  • Psychodynamic therapy is a style of therapy focused on self-exploration to understand the root causes of your issues. You talk about your emotions, your past, and your relationships.
  • Gender, age, ethnicity, sexual identity, and religion are specific factors that result in people often connecting or not connecting with a therapist.
  • If you’re not dealing with depression, anxiety, relationship issues, work stress, or life transitions, look for a specialist.

We Can Help

Neb can handle this entire process for you and find you the right therapist, free. If you’re interested, please check out our website.

Next: Process Overview

Click here to go to the next section.

What Is Therapy?

This is part 3 of a guidebook on how to find a therapist. Check out the introduction to get started.

You may know some information about therapy, but I want to cover this because finding the right therapist is a complicated, nuanced process. It’s like applying for college or a competitive job.

You don’t just go online and start sending out applications. Being informed about therapy and having realistic expectations will make your experience a lot better.

Overview

Let’s start with the basics. Therapy is a treatment for mental health issues that involves talking and working with a professional. It’s usually one-on-one, but you can do couples, family or group therapy as well. There’s a lot of talking, but you may also do exercises, such as journaling, role-playing or mindfulness. 

It’s usually 50-60 minutes a session. We strongly recommend starting out once a week. Expect to be in therapy for up to 15-20 sessions. The first 1-3 sessions (usually just the first session) are spent understanding your challenges, seeing if you’re a good fit for each other, and agreeing on goals for the therapy. Then you work towards achieving those goals.

Therapy Is Like A Healthy Relationship

If you haven’t been in therapy before, you may expect it to be like going to your primary care physician. When you go to see your primary care provider for a cold, he may not be in a good mood, it’s very rushed, and there’s no personal connection. But he prescribes cough syrup, you take it for a week and you’re better.

Therapy is very different. It’s like being in a healthy relationship.

First, it takes a while. Like I said, expect to go up to 15-20 times. You will see results, but they may not be steady.

Unlike seeing a doctor, you can’t just show up once a week and expect to get better. I know this is hard - life is hard. First, you have to put effort into changing yourself outside of therapy. Based on our personal experience, and the 30+ people we’ve talked to who’ve had mental health issues, you’re much more successful if you make lifestyle changes and don’t just show up to therapy.

Second, your attitude to therapy really matters. If you don’t have a positive attitude towards it, and you expect it to work really fast, it won’t work. We all have similar experiences when we try to make changes in our life. We want to work out or eat healthier. But when we start, we don’t enjoy the process, it feels like a chore and we fail.

Again, I know this is hard, but try to be committed. Try to have a positive attitude towards therapy, accept that it takes time and effort, and want to put that time and effort in.

Everyone gives advice and doesn’t tell you how to implement it, so I’ll give you one suggestion. What works for me is first thing in the morning I remind myself of what I want to do and why.

I go over the most important goals and changes I want to make in my life, and why. It just takes a few minutes.

Finally, just like in a relationship, the right person really matters.

Summary

  • Therapy is 50-60 minutes a session, once a week.
  • Expect to go for 15-20 sessions.
  • Therapy is like a healthy relationship.
  • Progress will be slow and unsteady, but it will happen.
  • You have to put in effort outside of the therapy sessions.
  • You have to try to have a positive attitude towards the therapy and be committed.
  • The right therapist really matters.

We Can Help

Neb can handle this entire process for you and find you the right therapist, free. If you’re interested, please check out our website.

Next: The Right Therapist

Click here to go to the next section.

Why You Should See A Therapist

This is part 2 of a guidebook on how to find a therapist. Check out the introduction to get started.

What A Therapist Can Help You With

First, just by reading this guidebook, you’re taking a step towards improving your health. That’s awesome. If you’re dealing with negative thoughts or emotions of any kind, a therapist can help you. Therapists can help you with a wide range of issues: 

  • depression

  • anxiety

  • ADHD

  • bipolar disorder

  • schizophrenia

  • social anxiety

  • fears

  • relationships (significant other, parents, friends, colleagues)

  • parenting

  • work stress

  • finding your life purpose

  • eating disorders

  • substances

  • video games

  • pornography

  • trauma

  • cultural issues (ethnicity, sexuality, gender)

  • life transitions (moving, changing jobs)

  • losing a loved one

  • anger

  • domestic violence

  • separation

  • high school

  • college

  • giving birth

  • sleep

  • infidelity

  • codependency

  • sports

What’s interesting about this list is most of the issues (which are bolded) are not mysterious clinical disorders. Therapists can definitely help you with depression, anxiety, and other disorders, but they can also help you with a wide variety of everyday issues. So it’s okay if you don’t have a diagnosable disorder, or if you aren’t sure.

You also shouldn’t feel guilty if you can’t articulate exactly what’s bothering you. This is expected, and one benefit of therapy is it helps you put words to what you’re experiencing. If you’re dealing with negative thoughts, emotions, or behaviors, a therapist can help you. 

Does Therapy Work?

Yes, without a shadow of a doubt. Therapy works. If you see a therapist, 80% of the time, you do better than someone who doesn’t. This has been shown across hundreds of studies with many thousands of participants.

Furthermore, therapy has been shown to work in a wide variety of situations. It works for all kinds of issues. It works for people of different ethnicities, genders, sexual identities, with different personalities and communication styles. It works for kids, teens, adults, the elderly, couples, and families.

There are no side effects, and the change is long-lasting and hopefully permanent, even after you stop seeing a therapist.

It’s Okay To See A Therapist

I’ve seen a therapist. 30 people in our personal networks - friends, colleagues, relatives - have shared with us they’ve seen therapists. Depending on the particular study, 32-40% of Americans have seen a therapist at some point in their lives.

All of these people have seen therapists:

Untitled design (1).png

These are people who are incredibly successful professionally, and to a lot of us, it seems like everything in their lives is going well.

Impostor Syndrome

When we hear about mental health, we often hear about the most extreme cases.

People who have struggled immensely with mental illness their whole lives. They have a severe mental illness like major depression, bipolar disorder, or schizophrenia. They often have multiple disorders. Their stories involve multiple hospitalizations, drug use, self-harm, suicide attempts, homelessness, incarceration, or suicide.

Some of you may have thoughts like:

  • do I even have a “real” mental health issue?

  • I don’t have major depression or bipolar disorder, and those are the kind of things that are mental health issues.I can get out of bed every day and go to work or school. 

  • I feel like a fraud seeking help, or talking to people about my challenges as mental health issues. 

Let me tell you my story. In college, I was addicted to video games. I played 18 hours a day.

I failed a semester and nearly didn’t graduate on time. Clearly, this was a significant issue. But I graduated on time, and then worked as a software engineer. I’ve quit video games, I didn’t see a therapist for this, and I’m pretty high-functioning.

And it’s video games, something so normal in our society. So many people play video games and seem fine. Honestly, I still feel weird calling it a mental health issue.

This line of thinking is flawed. Just like you don’t need to have cancer to be able to go to the hospital and tell your friends you have a physical health issue, you don’t need an extremely severe mental illness to be able to seek help and talk about it. You don’t have to define yourself by a mental health issue you’re dealing with. But if you feel you need help you should get it, and it’s okay to talk about it.

Summary

  • Therapists can help with a wide variety of everyday issues, not just diagnosable mental illnesses.
  • Therapy works. If you see a therapist, 80% of the time you do better than someone who didn’t.
  • It’s okay to see a therapist. 32-40% of Americans have seen therapists.
  • You don’t need a severe mental illness to be able to get help and talk about it.

We Can Help

Neb can handle this entire process for you and find you the right therapist, free. If you’re interested, please check out our website.

Next: What is Therapy?

Click here to go to the next section.

How To Find A Therapist

 

Let me tell you a bit about who we are and why we wrote this guidebook. My name is Dhruv Manchala. I’ve dealt with self-harm, video game addiction, social anxiety, and binge eating. A friend and I wanted to do something in mental healthcare. We spoke to 30 of friends and friends of friends about their mental healthcare experiences. One of the most common problems we encountered was the process of finding a therapist is really complicated and it frustrates most people.

We actually started offering a free service to find people therapists. We’ve talked to people about their mental health challenges and the kind of therapist they’re looking for. We’ve called hundreds of therapists, clinics, and organizations to find therapists for people. And we’ve called insurance companies on behalf of people to help them understand how their coverage works.

How To Use This Guidebook

This guidebook is based on our personal experience finding mental healthcare providers for people. It covers the entire process, from figuring out the kind of provider that’s best for you, to working with insurance, to searching for and reaching out to providers. We provide very specific, actionable advice.

Each section can also be read independently. You can use the table of contents at the top of this page to navigate to a specific section. At the bottom of each section is a summary, if you don’t want to read the entire section right away. 

We Can Help

Neb can handle this entire process for you and find you the right therapist, free. If you’re interested, please check out our website.

Next: Why You Should See A Therapist

Click here to go to the next section.

How to have a consultation with a therapist

Once you’ve found several therapists that you’re interested in, you’re now ready for an initial consultation. At this point, you’ve probably left or filled out a number of voicemails and contact forms. After a few days, you should expect that a number of therapists will call you back. What should you expect from the call back?

While not every therapist advertises this fact, most mental health care providers are prepared to offer some form of free consultation. This means that they plan on answering questions regarding their practice, questions of fit, and other questions you might have before paying them for their services.

A consultation benefits both the therapist and the client. It can help both of you save time if it’s clear a fit isn’t there. However, it’s important for you, the client, to be prepped for these consultations so you can make the best use of your time and money. 

When a therapist calls you back, they are generally expecting to have a proper phone consultation with you. Once you’ve engaged in your search process, you should expect to answer most, if not all calls until you’ve found your therapist. Therapists may return calls as late as 8:30 PM and the source may show No Caller ID. This article discusses how you should approach this initial discussion with them. 

What is a consultation?

Though this article will focus on phone consultations, some therapists also offer free in-person consultations. There isn’t an industry standard for a phone consultation, but generally you can expect to speak with a therapist for around 10-20 minutes. A consultation with a therapist is a short conversation to understand if the therapist is a good fit for you. This fit includes not only practice style and personality, but also other details like whether the provider’s availability works for you or if they’re within your budget. 

Generally, you should have phone consultations with several therapists. From the ones you enjoyed speaking with the most, you may move forward with a session. If possible, we recommend an initial session with two different therapists before you ultimately stick with one of them. You may not know which therapist you liked most during your phone consultations. It will be obvious which you prefer, between your two favorites, once you’ve met them face-to-face.

You can also give us a call for free and we’ll find therapist matches for you in one week. This way, you don't have to field calls with providers who aren't already available or taking your insurance. Check us out.

Keep in mind that this consultation is not therapy. This call is about deciding to engage in therapy with this particular therapist. Actual therapy won’t start until you’ve begun meeting the therapist for formal sessions. 

Why you should have a consultation

First and foremost, a consultation is about saving time and money. While therapy may feel different than paying for most services, ultimately you’re employing the therapist to help you. It is wise to have spoken with anyone you plan on hiring to answer questions you have. This also allows you to gut-check your fit with the therapist. Ultimately you want to be happy with your decision and this is another way to ensure you’re making a good one. 

From the client’s perspective, a phone consultation allows them to ask questions about the therapist’s practice and iron out logistical details. If you’re speaking with a therapist who operates independently, you’ll spend some time discussing fees and availability in addition to questions about their practice methodology and experience. If you’re speaking with a therapist who is part of a clinic or group practice, the front-desk staff can manage fee and availability questions so you can focus your phone consultation on more specific practice-related questions.

From the provider’s perspective, the free phone consultation is also equally valuable in assessing if they feel comfortable treating the client. Therapists are ethically obligated to let you know if they don’t feel like they can help you. If they don’t think they can help, they will politely decline an appointment or refer you to someone who is better equipped to help you. 

Questions to ask yourself before the call

Before you begin your call, there are several important questions you need to ask yourself:

What are my goals, hopes, fears involved with therapy?

It’s alright if you don’t have very specific goals. You may only have a feeling of being mentally unwell and you want help. You may also have specific issues that you want to address. Whatever the case may be, the better you can articulate how you feel during the call to the therapist, the easier it is to get a feel for whether they can help you.

What is my budget? What am I comfortable spending?

If the provider you’re contacting is in a clinic, you will start asking these questions with the front-desk. Questions about sliding scale may or may not be handled directly with the provider depending on how much the front desk handles for them.

Regardless of who you speak with, you should understand what the fees are. What you will have to pay out-of-pocket will be a combination of multiple factors including whether your insurance covers out-of-network specialist services. Some insurance plans will not provide any support until you’ve met a high deductible. Others may offer you coinsurance of 80%, meaning you may only be on the hook for 20% of the provider’s rate - up to the maximum reimbursement rate..

Another factor you should keep in mind is your financial circumstances. A lot of therapists provide some form of sliding scale. Therapy is an investment in yourself and so you should not merely aim for the lowest priced provider. However, therapy is also not an inexpensive service. Sometimes a therapist seems like a good fit but you really cannot afford to see the therapist at their rates. You should be open to them with what you can afford and what your circumstances are. Do you have large amounts of student loan debt? Is your income low? This information can help the therapist fit you into their sliding scale options.

During the phone consultation

There are three components to a consultation. Logistical questions, which may or may not be handled by a front-desk, questions about the therapist’s practice, and questions the therapist will have of you. These are not necessarily in order.

Therapist questions

The therapist will generally just ask you what brings you to therapy. During this time, they are assessing how you articulate your challenges and whether they believe they can help you. It is a good idea during this time to be broad about your issues. It is easy to dive into too many details but this call is not about receiving therapy and is more about evaluating fit. You evaluate fit as how the therapist listens to you as well as how they respond to your questions, so save some time for your questions. 

Logistical questions

These are questions pertaining to fees, availability, and any questions about the office, such as parking etc. You may ask these to the front-desk as well.

  • What insurance do you take? 

  • Do you provide a superbill?

  • What availability do you have? Will I be able to see you at this time weekly?

  • What is your cancellation policy?

  • Do you partner with other professionals like psychiatrists or nutritionists if necessary?

  • How do you accept payments?

  • How will I discuss things with you outside of appointments? Can I text you? Is email preferred?

Fit Questions

Here are some questions you want to consider asking. Remember, this isn’t a formal session so try not to ask therapy-seeking questions and focus on which questions are most important to you. Here are some questions you may want to consider asking:

  • Have you helped people with issues similar to mine?

  • Do you think I’m a good fit?

  • Can you tell me about yourself?

  • What type of treatment styles do you prefer?

  • How will I know therapy is working?

  • Will I be receiving homework?

  • How often do you expect me to come into the office?

  • Have you personally experienced my issues before?

  • How long have you been in practice?

If you perceive gender or sexuality to be core components of therapy for you, be sure to ask questions related to this. Most mental health care providers are white and heterosexual. If you are queer or a person of color, you may want to consider questions related to cultural competence. While it’s not shown that gender or sexuality largely affect the therapeutic process, trust does. If you don’t feel like you can trust the therapist because cultural competence, you should absolutely ask questions around the therapist’s history of working with people similar to yourself, their views on racism or gender identity, and whether or not they understand issues in society that pertain to you racially or sexually. 

Wrapping up the consultation

If the provider is in a clinic, you’ll do the scheduling with their front-desk usually so you can just thank them for their time and say you’ll talk to their front-desk if you want to move forward.

If you’re speaking with an independent provider, you’ll usually have an opportunity to schedule an appointment with them at the end of a call. They may also point you towards an online-booking option. If you’re not comfortable setting up an appointment at that time, you are not obliged to. You are welcome to say that you need sometime to think. If you think you might go with that person, you may ask at that time whether you can schedule an appointment via email or text to avoid playing phone-tag.

Regardless of whether you decide to schedule an appointment then and there, you should definitely keep your calendar ready and on-hand during the call. If you find yourself resonating with the therapist during the call, you’ll definitely want to ensure you’re scheduling a time that actually works for you.

If you don’t feel like the fit is there, don’t feel bad! You’re not going to hurt the therapist’s feelings. It’s better when you’re honest about your feelings as you will save your time and theirs.

Evaluating the session

While we won’t dive into it here, it is widely understood the most important factor for successful therapy regardless of the treatment type is what is commonly called the working or therapeutic alliance. Simply put, it is how well you get along and trust your therapist. This trust and belief in this relationship is foundational to benefiting from therapy. While it’s unlikely you’ll know what your perfect therapist fit is before seeing them, you should ask yourself the following questions if you haven’t yet seen them.

  1. Did I feel comfortable speaking with this therapist?
    While difficult, you should try and separate any anxieties you may generally have about therapy from the ability to speak with this person. If the way the therapist spoke made you feel uncomfortable, you may want to consider someone else.

  2. Do I feel like the therapist listened to me?
    Phone consultations aren’t easy, for you or the therapist. However, if you feel like the therapist isn’t listening to your questions or seems rushed, that can be a red flag.

  3. Do I feel like I’d like them as a person?
    This may sound silly but ultimately you have to trust and respect the person you’re working with in order to benefit fully from therapy. If you find that you dislike the person on the outset, it is unlikely that your feelings will change soon. 

Conclusion

Consultations are important for your success with therapy. The road does not end here. In our future articles, we’ll discuss how to have a great session with your therapist. 

If you want help with this process, considering using our therapist finding service. You can also give us a call for free or use our form and we’ll find therapist matches for you in one week. Check us out.



Why We Wait to Initiate Mental Health Treatment

We sometimes delay mental health treatment out of ignorance and fear

Mental illness has lasting consequences for the patient, their family, and the community. Mental illness decreases the likelihood of completing school and gaining full-time employment. It can also result in a poor quality of life and increases the risk of physiological illness. In one study, people with mental illness were shown to have a shorter life expectancy of up to 20 years compared with healthy individuals (1). Despite the availability of effective treatment, over half of those who need mental health treatment do not obtain help (2). Patients sometimes wait several years before requesting mental health treatment. In another study, patients with anxiety took 3 to 30 years before initiating treatment (3).

Delayed treatment means worse symptoms over time which increases the impact on the health and welfare of the individual. People delay initiating treatment due to a variety of reasons including availability and affordability of a mental health provider, insurance and the lack of structural resources to obtain help when needed. Below, we briefly discuss how stigma and the lack of knowledge about mental illness lead to delays in the initiation of treatment.

Stigma persists

Stigma refers to the negative feelings, behaviors, and expectations associated with people with mental health disorders. In recent years, many organizations, celebrities, political leaders and advocates have helped to increase awareness about mental illness. However, people continue to have negative beliefs about mental illness. Some of these include that people with mental illness are "stuck" and will not improve or recover, can not be employed, are violent or erratic, can “snap out of” their condition, cannot have healthy relationships or get married or that mental illness only affects adults. Some people simply do not believe that mental illness can happen to them (4). These notions are false and do not encourage people to initiate treatment. 

The facts prove the contrary. Half of mental illnesses show signs before the age of 14 and three-quarters of mental illnesses start before 24 years of age. Also, people with mental health issues are nonviolent with only 3 to 5 percent of violent acts being attributable to mental health issues. Furthermore, people with mental illness are a vulnerable group and are 10 times more likely to be a victim of violent crime compared to healthy individuals. With treatment, many patients improve and those with mild and moderate symptoms often go on to make full recoveries (4).

Cultural taboo

In some cultures, mental illness is stigmatized by even the most well-meaning members of family, friends and even faith communities. Family members with mild to moderate forms of depression or anxiety may be left isolated, or have to deal with accusations of insubordination or lack of appreciation of one’s privileges. They may be labeled as stubborn, lazy, weak, or stupid. In more serious cases such as bipolar disorder or schizophrenia, mental illness may be seen as a sign of bad luck, bewitchment, or demonic possession. Such views increase stigma, decreasing the likelihood that an individual would seek treatment. This is sad because it is usually the person who is in the most need of care who ends up being punished for what they themselves do not understand. As a result, symptoms may become worse and, as discussed below, more difficult to treat.

The mainstream media may increase self-stigma

The mainstream media and social media strongly influence our sense of reality. The media shapes our perception about people who seek mental health services as well as those who provide care such as therapists, nurse practitioners, psychologists, and psychiatrists. Popular movies like “Good Will Hunting” and TV programs such as “Dr. Phil” may introduce viewers to the idea of therapy and mental wellness. (5) However, some programs may have the paradoxical effect of increasing self-stigma and the discomfort of obtaining help for oneself. Self-stigma is when the negative feelings, expectations, and beliefs about mental illness are directed towards oneself. The person may, though erroneously, consider obtaining mental treatment as a threat to their self-esteem and a sign that something is wrong with them. One study found that seeing people with mental illness in movies and TV shows, not in therapy, who were successful suggested weakness in those who sought treatment (5). Also, there was a negative perception that anyone seeking mental health assistance was thought to have mental illness (5). Furthermore, the mainstream news media's coverage of gun violence and suicides strongly associates mental illness with violence and extreme behaviors. These negative perceptions increase self-stigma and prevent people from initiating treatment. 

Childhood-onset mental illness gets worse over time

In the Diagnostic Statistical Manual 5 text, used by professionals to diagnose mental illness, there are hundreds of mental health disorders. The variety and severity of symptoms differ from person to person depending on age, gender, culture, genetic disposition, and environment. Many symptoms start subtly at an earlier age where behaviors may be overlooked or excused. Caregivers of children then may not quickly recognize symptoms until there is a significant decline in a person’s function such as poor grades, trouble making and keeping friends, difficulty obtaining and maintaining employment, divorce, or even the onset of a medical condition. Mild emotional or behavioral issues may gradually become entrenched habits. For childhood-onset mental disorders, caregivers may normalize the child's behavior and coping strategies such as social withdrawal and phobia which result in more treatment-averse attitudes later in life. Some studies suggest that this process of neural kindling can result in untreated disorders becoming more spontaneous, repetitive, severe and difficult to treat over time (6). Caregivers who do not know what to expect or who may themselves be stressed out may delay initiating treatment because they do not recognize the early signs of mental illness or how to take action to prevent it. Early intervention is important in preventing the worsening symptoms and improving the trajectory of recovery.

Hindsight is not always 20/20.

For many people who end up getting mental health services later in their lives, they often underestimate how long they have struggled with mental health issues. In cognitive psychology, this is an error in thinking referred to as telescoping (6). The telescoping effect refers to our tendency to inaccurately remember how often and how far back (backward telescoping) events occurred. As a result, the person may lack a sense of urgency in obtaining treatment and would tend to wait even longer to get treatment.

Lack of insight or anosognosia

Mental illness affects the brain which governs our thoughts, feelings, and behaviors. As a result, the same brain with aberrant patterns is not always capable of recognizing the faultiness of these patterns. An imperfect analogy is to consider how an adult caregiver may view their toddler throwing a tantrum. To the toddler, they are experiencing upsetting emotions without understanding the cause. However, the parent knows that they may be tired, hungry, in need of affection or simply searching for new stimuli to satisfy their curiosity and rapidly growing brains. Anosognosia is the medical term for the lack of awareness about a disease by a patient. As seen in the analogy above, this is not a case of denial or lack of will to change. Anosognosia is one of the reasons why many people may delay, resist, interrupt or even stop mental treatment altogether. It often leads to worsening mental health conditions, inconsistencies in treatment and frequent hospitalizations (7)

Lack of mental health literacy

The term mental health literacy refers to the “knowledge and beliefs about mental disorders which aid their recognition, management or prevention” (8). Mental health literacy is affected by a person’s social, economic and cultural backgrounds. In one study, it was noted that being female, more educated, financially stable and having more severe symptoms were associated with earlier initiation of treatment. Mental health literacy does not mean reading about mental health in a book but more importantly, the empowerment of people to use available resources, collaborate and organize to address or prevent mental health issues in families and communities. Important components of mental health literacy include knowledge about, (a) how to prevent mental health disorders, (b) recognizing early signs of mental illness, (c) help-seeking and treatment options, (d) self-help strategies for milder problems, and (e) skills to support others with mental illness or in a mental health crisis (8). The availability of resources that support mental health literacy empowers people to seek treatment early while the lack of these resources or the knowledge that they are available, prevents people from seeking early treatment. 

Knowing is not enough; we must apply. Willing is not enough; we must do.

- Johann Wolfgang von Goethe

Conclusion

In summary, stigma and our lack of knowledge about the process, prevention and the resources available for the management of mental illness can make people delay initiating treatment. Obtaining care is an act of self-love and self-care. Promoting mental wellness helps to better ourselves, our families and our communities by improving health outcomes, improving quality of life, increasing productivity, decreasing crime, lowering healthcare costs, and creating stronger economies. 

So there’s no need to wait. There are resources available.

Speak to a loved one or your health provider about obtaining help. Get involved with community efforts to decrease stigma and increase awareness. 

At Neb, mental health providers come to you so you don’t have to go into an office or clinic. Ask for information on how to find mental health assistance. See therapists at a nearby coffee shop, park or in the comfort of your home.

Other resources include the National Alliance on Mental Illness, Mental Health America, and Mentalhealth.gov. If someone you know is in danger related to mental health issues, please call 1-800-273-8255 for the National Suicide Prevention Lifeline

Arnold Fosah is a Psychiatric Mental Health Nurse Practitioner and a co-founder of Neb.


References

1 A review of the economic impact of mental illness. (Christopher M. Doran A B and Irina Kinchin A)

https://doi.org/10.1071/AH16115 

2 Many mental illnesses reduce life expectancy more than heavy smoking. University of Oxford.

http://www.ox.ac.uk/news/2014-05-23-many-mental-illnesses-reduce-life-expectancy-more-heavy-smoking

3 Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization's World Mental Health Survey Initiative

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174579/

4 Mental health myths and facts

https://www.mentalhealth.gov/basics/mental-health-myths-facts 

5 Media influences on self-stigma of seeking psychological services: The importance of media portrayals and person perception

https://search-proquest-com.ucsf.idm.oclc.org/docview/1492506234/fulltextPDF/6B6EC4C0AAA14908PQ/1?accountid=14525 Maier, Julia A; Gentile, Douglas A; Vogel, David L; Kaplan, Scott A.Psychology of Popular Media Culture Vol. 3, Iss. 4,  

6 Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization's World Mental Health Survey Initiative

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174579/

7 Assessing and improving clinical insight among patients “in denial”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4538978/

8 Mental health literacy: empowering the community to take action for better mental health

https://search-proquest-com.ucsf.idm.oclc.org/docview/901639932/fulltextPDF/C81214DABA724305PQ/1?accountid=14525


Why is finding a therapist so difficult?

It’s estimated that almost 1 in 5 people suffer from some form of mental illness in the United States. With such widespread prevalence of mental illness, finding a mental health care provider should be easy. Ask anyone around you however and they’ll tell you that finding a good therapist is really hard. It can feel time-consuming, emotionally draining, and expensive. Why is our healthcare system unable to provide us the simple access to mental health care we need?

Before we dive into some of the more systemic problems in accessing mental health care, let’s start with the obvious issue of stigma. Because mental health is deeply personal, it’s pretty unlikely that you’ll hear your co-workers rave about how great their therapist is. It is easy to feel alone in your concerns about mental health. Open up to your personal network and you may find cousins, friends, and co-workers who have already embarked on their own mental health journeys.

Among some households in America, mental health is not always well received. Some parents call their children weak when they express concerns over mental health. Others may think that their children’s mental health reflects poorly on them as parents. Some cultures may not have well-known concepts for more severe mental illnesses.  Family members with diseases such as bipolar disorder or schizophrenia may be treated poorly because they’re seen as afflicted by bad karma or evil spirits

Starting the mental health care journey

You’ve moved past these challenges and now you’re taking your mental health into your own hands. Now what? 

Mental health isn’t transactional. It is not like getting your arm put in a cast or getting stitches for a deep cut. While medication may be involved, a lot of mental healthcare is developing skills and altering neural patterns to change unhealthy reactions and patterns of thoughts into productive healthy ones. It is incredibly powerful, but it takes time. 

Much like an athlete who has to take care of their physical health and hone their skills through repetition, a person engaging in mental health does so through healthy behaviors and cognitive and emotional skill development. 

The most common way people start their mental health journey is by asking their general physician for a referral. If you’re lucky enough to have a physician who takes your concerns seriously, you’ll likely find yourself on a large waitlist behind hundreds of other Americans who’ve tried the same thing. Medical clinics and hospitals around the country do not have enough mental health care providers to meet the demand. This problem is so bad in fact that often you may not even be able to see a provider unless you indicate that you are dealing with suicidal thoughts. 

Say you, like many other people, don’t want to wait a month or longer to get the care you deserve. The next step in the process is to find a mental health care provider who will take your insurance. Sounds simple enough, except that nearly half of all mental health care providers in California alone don’t take any form of insurance! 

People are seeking mental health care and therapists want to help. Why are insurers, the entities that are supposed to bring them together, absent from the equation?

Problems with insurance

If you ask the insurance companies, they’ll say that there’s a shortage of therapists. While that’s true in the state of California as a whole, the answer isn’t that simple. In fact, while there are not enough qualified clinical therapists in rural areas of California, there are many mental health care providers in the more dense urban areas of the San Francisco Bay Area and Los Angeles. They just don’t want to work with insurance companies.

Therapists give several reasons why it’s challenging to work with insurance. 

First is an issue of money. Mental health care providers receive some of the lowest reimbursement amounts from insurers. It’s common for a therapist to only receive $60-$80 from insurance in places like San Francisco where the market rate can be $150-$200 per one-hour session or more. We’ve even heard cases of these rates being even lower depending on how the provider chooses to bill the insurance company.

Adding to this issue is the paperwork required by insurers when providing mental health care. When a provider files for insurance reimbursement, it can take up to an hour to fill out the insurance paperwork per hour of therapy provided. It then takes the insurance company 4-6 weeks after the appointment to pay the therapist. When looking at an hourly rate, a therapist charging $120 per session can actually expect to be making something like half that. Factoring in low reimbursement rates from insurance companies and we can start to see why therapists aren’t keen on working with insurance companies. 

Lastly, and perhaps the most frustrating to motivated providers, is the fact that insurers may not even accept the therapist on their panel. To be on an insurance panel means you are listed in the insurance network and can accept a patient’s insurance. The benefit for health care providers has traditionally been more referrals to be a part of these networks at the cost of providing care at slightly lower costs. When these therapists apply to be on the panel, the insurance companies tell them that there are already too many providers in that area already.

And yet, when speaking with people who have sought therapists within their own insurance network directories, they can’t seem to find any therapists who’ll take them. The listed therapists are completely unavailable, with waiting lists that are months long. Sometimes the providers may not even exist! 

It’s not that the therapist profiles are fictitious. However, there have been reported cases of mental health care providers listed on insurance networks who have retired or are no longer even alive! This problem has become common enough it’s engendered its own term: ghost network. A ghost network describes an insurance network that seems large and full of clinicians in the network but in reality is full of providers who aren’t practicing or actually part of the insurance plan. Our most recent searches on Kaiser’s network as part of our therapist finding service revealed that almost all of the therapists listed on the first 3-5 pages were either: 

  • not accepting Kaiser insurance any longer

  • not accepting clients at all

  • duplicates of previous results

Challenges with internet searches

The next step is often a generic internet search. I’ll just search for a therapist who takes my insurance! You may soon be asking yourself  “why does it say all these therapists on Psychology Today or GoodTherapy say they take insurance?” If what you’re saying is true, I would expect only a handful of them to take my insurance! 

Well there are two major things at play here. 

Firstly, a lot of therapist bios can be misleading. The bio may say something like Premera (Out-Of-Network) Insurance accepted. This doesn’t mean that the provider takes your insurance. The therapist will actually provide you a  statement for reimbursement. This document, otherwise known as a superbill, is basically an invoice describing the treatment you received. You must pay the therapist their full-rate up front in cash and then submit this superbill along with a form to your insurance for reimbursement. For insurance providers such as Cigna and Blue Shield Blue Cross, this claim will take 60 business days to be processed and for you to be reimbursed. 

Even if this isn’t the case at hand, therapist bios are often out-of-date or unhelpful to the general public. Your therapist may have accepted your insurance at one point and didn’t update their profile when they decided to stop accepting it. 

Therapist bios can also be confusing for the average person looking for help. You may find profiles where a therapist lists every single issue as something they treat. The profile may also list many different types of treatment methodologies such as Humanistic Therapy, Gestalt Therapy, or Intensive Short-Term Dynamic Psychotherapy. Combined with a barrage of information and acronyms such as LCSW, EMDR, CBT, or LMFT, it’s easy to be overwhelmed. These providers often have specialties that are only made clear once you’ve contacted them. Our recommendation is to avoid therapists whose profiles appear too general. If you see a provider who says they tackle everything from Asperger's Syndrome to Transgender issues, you may find that they’re not as effective at tackling your specific issue as someone who focuses on issues of anxiety, racial identity, or whatever challenges you face.

Regardless of whether you pay with insurance or out-of-pocket, it’s not uncommon to hear that someone has contacted 15-20 different therapists via phone or email, waited days or weeks to hear back, and finally found 3-5 therapists who are currently taking new clients. Adding up all this effort, it can take someone weeks to their first appointment, only to find out the therapist wasn’t a good fit. 

How to find a good fit

Problems of fit often occur when a person is unfamiliar with the process. This happens when the client doesn’t know what they’re looking for in therapy and they start seeing the first therapist they find. The person may not have been aware that they could ask for a free phone consultation to get an idea of whether the therapist was a good fit. Often a person will wait far too long to terminate or change therapists after they’ve felt like the fit wasn’t good. Remember, you are paying money to improve your well-being. If you aren’t getting the help you need, find someone else.

All told, the process can be really challenging, but with a structure in place, you can make this endeavor a lot less painful. And in the end, you’ll be happy you did so. If you’d like help embarking on your mental health care journey, you can read the guide we’ll be publishing soon!

You can also give us a call for free and we’ll find therapist matches for you in one week. We use roughly the same structure provided in our guide except we also help you understand your insurance benefits and walk you through phone consultations and how to think about your therapeutic goals. Check us out.

Technology Isn't As Good At Finding The Right Answer As We Think

I spend way too much time choosing music as I’m about to work out. It’s not specific to music or working out. I’ve found in a variety of situations, and across a variety of technology services - looking for a restaurant in a new city on Yelp, doing research for work on Google - I spend way too much time looking for the right thing. 

Most commentary on how people use too much technology focuses on open-ended, recreational consumption - Instagram, Snapchat, Reddit, gaming. I’m talking about something different. 

Utilitarian technologies, that are supposed to help find us the right thing quickly - companies like Google, Yelp, and Amazon, and more generally the search bar - have failed us. I want to explore exactly how this happens, why it does, and the effect it has on us.

Choice Overload

The idea that more choice is always better is embedded deeply in our culture. Technological advancement has relentlessly increased the diversity of possible products across all fields, and seems poised to continue. We as consumers have accepted this steadily diversifying diet of products being fed to us by corporations. However, that more choice is always better is also accepted by the intellectual mainstream. It's taken as gospel by classical economics and psychology. Science fiction classics such as Brave New World and Fahrenheit 451 imagine dystopian futures based on a lack of choice - of social status, and of information and views, respectively. Our current blockbuster film franchises, Marvel and Star Wars, continue to portray evil as centralized regimes with hordes of soulless, near-identical minions, and good as a decentralized, diverse, ragtag bunch of heroes.  

However, it's becoming increasingly apparent that boundless choice is not just unhelpful, but harmful. This alternative view dates back to at least 1970, when Alvin Toffler in his bestseller Future Shock, one of my favorite books, defined the term overchoice. I'll quote Toffler directly: "...when choice, rather than freeing the individual, becomes so complex, difficult and costly, that it turns into its opposite. There comes a time, in short, when choice turns into overchoice and freedom into un-freedom."

In a groundbreaking study by Sheena Iyengar in the mid 90’s, grocery store shoppers encountered a tasting booth with either 6 or 24 jams. 30% of shoppers who saw only 6 jams at the booth later bought jam from the grocery store, but only 3% of those who encountered 24 jams later purchased. Since then, a growing body of research has conclusively established that - if there’s too much information, or choices are hard to compare, or the decision-making process is poor - more choices lead to worse choices and less satisfaction, a phenomenon known as choice overload.

If we examine the design of these utilitarian products, such as Google, Yelp, and Amazon, we find that they - intentionally or inadvertently - most definitely cause choice overload.

The Anatomy of Search Results

First, each of these tools provides a massive number of choices. For a long time, Google has been known for its "10 blue links" on its first page of search results. yelp.com goes further and shows me 30 options on the first page of results for (ironically) The Best 10 Restaurants near Willow Glen, San Jose, CA. 

The number of organic search results is hardly the extent of the options our brains have to process. Along with the primary link to see more about the restaurant, Yelp search results each have another "read more" link, and some feature additional buttons - Find a Table, Start Order, and Join the Waitlist. Numerous ads, alternative searches, and filtering tools are also always present. Mobile apps enable even more interactivity, such as infinite scroll and horizontal scroll. 

In short, our brains end up processing dozens to over a hundred choices - in seconds.

Furthermore, the sheer amount of information provided for each choice overwhelms us. Results often each have a large amount of information. On Google, the title and description of each search result are on average 219 characters long, which makes a page of search results hundreds of words long. Amazon is even worse. Each search result consists of an image, the title, the star rating, the number of reviews, and the price, along with optionally the original price, details about Prime shipping, third-party sellers, and many other details - 7-8 pieces of information per choice. The word count for a random individual product page was 2,666. Amazon product pages can have 75% more words than this entire article.

Our decision-making process is also non-existent when we use these tools. It’s stunning how Google, over a mere 20 years, has instilled into an entire planet of people the conviction that the search bar is the be all end all of knowledge-seeking. The mere presence of a long text input with a magnifying glass icon at the right means all questions will be instantly and correctly answered like a modern day tarot reader or Nostradamus. As a result, we instantly reach for our devices and open apps when we have a question or need, without mentally articulating exactly what we want. Our questions of these powerful oracles have become worse and worse. Amit Singhal, the former head of Google Search, once said "The more accurate the machine gets, the lazier the questions become.” 

Combined with the massive number of choices and the vast amount of information on the screen, our thoughtless use of these tools leads to choice overload.

Engagement = Revenue

Just like the Facebooks and YouTubes of the world, whose motives for engagement are no secret, even these needle-in-a-haystack tools, which are supposed to help us find the right thing quickly, profit off of engagement. Google and Yelp obviously make money from ads, but subscription services also need people to use them frequently so they don’t cancel. Even Amazon Prime, seemingly the most utilitarian subscription service, really took off only when they bundled video - which is engagement. 

And the more we use something, the more likely we are to continue using it, even if it isn’t doing its job. This year, Facebook had a consumer satisfaction index of 67, 14% lower than the airline industry at 73. Yet Americans still used Facebook (excluding Instagram) for 38 minutes a day. 

Other “features” of these products also increase engagement more than they help us find what we’re looking for quickly. Take the 5-star rating system. The average rating of a business on Yelp in the US and Canada is 3.77 out 5, while it should be near 3 if ratings are well-distributed. We simply like seeing higher ratings left by other people. Another example is Google search queries with an objective answer known by Google, such as “time in New Delhi”. Google has actually briefly tested not showing any links and only the answer, but has reverted back to also displaying its usual search results.

Look, these tools are very powerful in many situations. Being able to find that video I watched last month about how Rwanda is becoming the Singapore of Africa, or check when a coffee shop closes, or quickly buy a reliable pair of shoe expanders, is great. I’m also not saying all features and imperfections in these products were introduced specifically to get us hooked. But certain aspects of these tools - which are supposed to help us find what we want quickly - and how we engage with them, make us use them more than required. This conditions us to use them next time, which leads to more revenue for these companies.

How It Affects Us

Searching for answers impacts our life negatively. For starters, it takes up a lot of our time - more than we expect. I’ve found that when I interrupt a task to find something - say picking music when exercising, starting to drive, or working - it always takes me longer than I expected. It also makes us feel worse. According to researchers, choice overload or overchoice makes us less satisfied with our decisions, less confident in our selections, and more regretful of our choices. Even more important than conclusive findings of researchers is our subjective experience. When I spend a while hunting for a song or restaurant, I feel anxious, and experience a sensation of constriction in my chest. I’m less focused immediately afterwards. How do you feel when you go down a search rabbit hole?

I want to conclude with a couple of thoughts. First, I don’t have any specific solutions to search more effectively. But I’m trying to generally use technology less, and more mindfully. For the past 8 days, I’ve been using non-essential technology for only 30 minutes a day - 30 minutes for messaging, reddit, articles, Google, music, videos, TV, podcasts. I genuinely feel happier. I’m more relaxed. I feel that less is going on, that I have time on my hands, and like doing more.

Second, I also work at a therapist online marketplace. We only have 10 therapists listed at the moment, but as we grow, we’ll have to very quickly make it easier for people to find the right therapist.  

- Dhruv

If you're interested in therapy, Neb lets you meet a therapist when and where you want - at locations such as coffee shops, parks, or your home, in the evening and on weekends. Check us out.

Know Your Therapist

Subscribe to our newsletter for information on mental health care and more!

When Tragedy Strikes: A Guide for Empathetic Leaders

When Tragedy Strikes: A Guide for Empathetic Leaders

Researchers in industrial organizational psychology tell us that leadership is a process of social interaction where the leader’s ability to influence the behavior of their followers can strongly influence performance outcomes. Despite popular culture portraying successful leaders as unfeeling authoritarians with unbending wills and magical product intuition, good leadership is about emotional management, not commanding orders.