Some people may take for granted that therapists can pick and choose who they see and under what conditions. Not all therapists will see every patient that walks through their office door. There are a variety of reasons a therapist won’t see you, and most of them have to do with professional ethics.

For instance, most therapists seek to avoid “dual relationships” with you or their other patients. A “dual relationship” is one where the therapist isn’t just your therapist, but may also be a friend, lover, business associate, or some other role in your life. Therapists seek to avoid dual relationships, so if they are already your friend, business associate, or whatnot, they will refuse to become your therapist as well (this also works in reverse — your therapist should never offer to become your friend, lover, business associate, etc).

Although this may feel like rejection, you shouldn’t take it personally. Therapists will often avoid seeing certain people for these reasons to ensure the patient is treated with proper respect and dignity. Here are five reasons why your therapist won’t see you now…

1. You’re not on an insurance panel they belong to.

As much as we don’t like to think about it, therapists need to make a living as well and they do so by charging for the psychotherapy they provide. Many therapists accept health insurance for reimbursement, but they don’t always accept all insurance. So if the health insurance you have isn’t health insurance your therapist takes, you’re out of luck. Or you can pay their full rate out of your own pocket — anywhere from $75 to $150 per hour.

A small minority of therapists will take patients on what’s called a “sliding scale” fee, too. This is where the therapist discounts his or her hourly rate based upon your annual income. It never hurts to ask.

2. Your therapist has an existing relationship with you, your family, or a shared mutual friend.

As mentioned in the introduction, a professional therapist will almost always seek to avoid dual relationships — especially where they have a pre-existing relationship with you in a nonprofessional capacity. While this may seem not to make sense (“Who better to listen to me than my best friend the therapist who already knows all my secrets?”), you have to imagine the worst-case scenario. What would happen if your best friend, who is now your therapist, tells you something you don’t want to hear or vehemently disagree with in therapy? Who then do you turn to? Dual relationships rarely end well, so that’s why therapists are taught to avoid them.

This is also a good time for a reminder that therapists nearly always seek to avoid entering into a relationship of any kind with a past client as well. Because therapists share a unique therapeutic bond with that person, it has the potential to harm the patient if a new type of relationship is transposed on top of it later on. While different professional ethics vary on this topic, most therapists seek to avoid any kind of relationship — whether it be a friendship, romantic interest or business partnership — with an ex-patient.

3. Your therapist is seeing someone else in your family, a close friend, or has a close relationship with one of those people.

Unless the therapist is specifically doing family, child or couples counseling, most therapists try to avoid seeing people who know one another in a close or intimate manner. Doing so can cause all sorts of troublesome problems for both the therapist and the patient, as the therapist will hold secrets about the two parties that they may have a hard time not inadvertently divulging.

This can be especially difficult if you were first seeing a therapist and recommended the therapist to a close friend or family member. The therapist ends therapy with you and starts with a new patient, who is your friend or family member. The therapist may not agree to see you again while they are seeing this other person. It may not seem fair, but therapists may do this in order to keep their boundaries well-defined and avoid conflicts of interest.

4. You have a personality trait, physical trait, or component of your history that the therapist chooses not to work with.

Therapists are human too, and while they are carefully trained to recognize their own foibles and “issues” while conducting psychotherapy, there are times where it simply isn’t going to work for them. Good therapists recognize that they can’t work with certain clients as early on as possible in the client’s therapy, and refer them to a colleague for continuing treatment. It could be as something as simple as body odor, or as complex as you remind them of their mother.

Therapists will probably not share with you the specific issue that prevents them from working with you. Some feel ineffective working with certain types of people or those with certain kinds of problems. I know therapists, for instance, who refuse to see anyone with a personality disorder, because of the complications it can bring to treatment. A therapist may just not feel safe around a certain type of client, or clients who have certain types of concerns.

5. They’ve worked with you in the past and feel they’ve done all they can for you, or don’t have room in their schedule now to take you on.

Sometimes therapists feel like they’ve already done all they can for a person after therapy has ended and don’t see the point in opening the door again. This may feel like they are not being fair to you, or that they should take on past clients no matter what. But therapists sometimes have to make a decision about who to see, and whether the person will benefit from additional psychotherapy.

While most therapists will gladly open their doors to see an ex-patient again, not all will. It may be due to a conscious decision on their part, or simply that their schedule is full up and they have no room for “new” patients (even if you’re not really new).

This entry was inspired by Dr. Kolmes’ March 2010 blog entry, When a Therapist Says It Isn’t a Good Fit.

One would think that at one of the leading academic institutions in the world, Harvard would take an open-minded, flexible and personalized approach to helping their young charges navigate the new world set out before them. Especially those most vulnerable.

One would be wrong, of course. Harvard seemingly takes a bureaucratic, miserly approach to helping their students, forcing them to “voluntarily” take a leave of absence and then navigating a rigid set of rules to be let back in once they’ve undergone mental health treatment away from the university.

On a primarily residential campus where most students live far away from their family and doctors at home, it falls to the College to both assess and address mental health concerns. But Harvard is first and foremost an academic institution, and while the administration’s goal of protecting students is clear, the Ad Board’s limited scope and the lack of clear communication with students often transforms concern into discipline.

The “Ad Board” refers to the Administrative Board, the committee at the university that is charged with being “responsible for the application and enforcement of undergraduate academic regulations and standards of social conduct. The Ad Board acts on different types of petitions and cases, categorized as routine and special petitions, disciplinary cases, and academic reviews.” Why are decisions about letting a student return after a health or mental health concern placed in front of the same judge and jury who also hear disciplinary cases and students who cheat?

Why are students at Harvard who have a mental health issue considered the same as either a criminal or the ethically-challenged? This is an enlightened stance?

There are many challenges students face when they take the leave of absence. One of the challenges is how do you get back into school? In the case of Janie — one of the students highlighted in the article — she agreed to prove “six months of work and stability” before returning to school. In this economic environment, that was a poor choice, since jobs are impossible to come by. So no matter how healthy she may be now, she may not be able to return because she hasn’t fulfilled her side of the “contract.” It sounds as if the letter of the law is more important than the spirit — a problem when you’re dealing with the messy realities of being a young adult.

And of course, there’s the delicate part of how to pay for the treatment mandated by Harvard as a condition of return to the university. Once you withdraw from the college, you lose your health insurance. No health insurance means no way to readily pay for mental health treatment. They can continue supplemental insurance coverage if they choose, but they have to pay for it — an expense not all students can readily afford.

“It has been such a difficult conversation to have with students, to tell them [they] need to go away, and have therapy, but [they] don’t have any insurance.’” said Howell. “It’s a little surreal to ask students to go home to Kansas and away from the ready-at-hand resources and require them to get regular help that isn’t available.” [...]

When Lisa returned to Harvard, she sought care outside of UHS [the Harvard health service for students], citing mixed and, at times, negative experiences with the strained system. But after the 12 visits allowed under Harvard insurance, she had to pay her new therapist out of her own pocket. “It was expensive. Eventually I couldn’t pay for it anymore,” she said.

Great way to step up to the plate there, Harvard. I might expect this attitude from some backwater college, but not from Harvard.

This article is also remarkable because, in part, of the frankness displayed by a senior staff member at Harvard University. John D. “Jay” Ellison is the secretary of the Harvard Administration Board, the committee setup to review students who want to return to the school after taking a leave of absence.

“If we have a case where a student is considered capable of coming back, but can’t resume full studies, we hesitate.” said Ellison. “Harvard is an academic institution, not a mental institution or a halfway house.” [...]

“This may sound cold, but my job is not to care about the specific circumstances of a student’s case,” Ellison said. “I need to know what their requirements were, and if they complied.”

Cold? Nah, you merely sound like a bureaucratic robot. Suggesting that people who need mental health treatment belong in a “mental institution” or a “halfway house” is ignorant. Perhaps John D. Ellison doesn’t realize this, but most mental health care in this country is provided in an outpatient setting, once weekly, through an appointment with a psychotherapist. Maybe he thinks students go away to a “mental institution” when they leave Harvard, where they are strapped down and ECT is forced upon them?

So apparently this is Harvard’s enlightened policy. If you have a mental health issue and you actually make an adult, responsible decision to take some time off to deal with it, you have to prove you’re not fit for a “mental institution” but rather to resume your academic studies at 100 percent capacity. You must face the review of a secret committee that also hears the cases of a student caught cheating, and the one who vandalized a dorm. And you must wait and be patient, because the committee doesn’t really care about your personal circumstances, only whether you’re “fit” to return to Harvard. After all, you’re a potential liability, not someone they personally care about.

Kudos to Asli A. Bashir for some excellent reporting and weaving the stories of many students into a picture of a reprehensible system of treatment for Harvard students with mental health issues. Although a lengthy article, it’s worth the read.

Read the full article: Brain Break

A friend of mine who currently sees a psychiatric nurse for her medications wanted to switch to a psychiatrist so that she can try to get off of Effexor, a commonly prescribed antidepressant than can be extremely challenging to get off. She lives north of a major metropolitan area in the U.S. and has decent health insurance.

So she started the thankless process every American faces when trying to find a new specialty provider — making endless phone calls to the list of “approved” providers from her insurance company.

(As an aside, it’s amazing to me that in the year 2010, the only way to find out if a professional has openings — and when they are — is to physically call their office. With endless talk of electronic medical records and scheduling software, there’s still no simple, central place a consumer can go to get this information quickly and easily. Talk about a business opportunity!)

Anyway, she went around and around with the phone calls, over the course of a few days. Some providers either didn’t have front office staff, or they were busy, so she needed to leave a message. Then they had to call her back to let her know their availability. If she was on the phone for her own work, she would then have to start the fun game of phone tag, which is also fairly frustrating.

Finally, it starts becoming clear when openings are available. Six months. Five months. 4 1/2 months. Finally she found a psychiatrist who could see her in about 3 months’ time. For all the talk of having long lines or “rationed” treatment in other kinds of health care systems (such as Canada’s), you don’t have to look very far to see the same thing happening here in the U.S. The long lines have long existed here; it’s just that either people aren’t familiar with them, or believe that for some reason it’s acceptable for certain types of specialties (with little reasoning or rationale).

This issue has become the focus once again as psychologists have sought to extend their prescription privileges from the current two states to a third — Oregon. Some psychiatrists, like Dr. Danny Carlat, support such an extension because he believes there is a critical shortage of psychiatric prescribers in the U.S. If properly-trained psychologists can be allowed to prescribe a small set of medications, the thinking goes, it may help alleviate some of the burden on psychiatrists. While I am against such privileges, I understand the rationale behind the push.

Nobody seems immune from this recurring problem in the U.S. health care system. It’s nearly impossible for me to get into see my dentist for a regular cleaning unless I schedule 6 months in advance. Even the world famous Mayo Clinic isn’t immune. Their Mayo Mood Clinic has a 2+ month wait list to be seen, according to a colleague.

Treatment Only Works if People Can Get It

It’s great that we keep pushing people to seek treatment for their mental health issues, but what’s the point if that treatment isn’t readily available? Trust me when I say it takes enormous courage for most people to even take the first step toward treatment by agreeing to see someone. Imagine how deflating it is when, having toiled with the idea of seeking treatment for weeks or months, you’re told you have to wait another 3 or 4 months to see someone.

I suspect a great many of those people simply say, “Thanks, but no thanks.” Making a person who is already suffering wait longer in their emotional suffering isn’t just a bad way to run a mental health care system — it’s cruel and illogical.

As a bonus, this is the way that most people get their first interaction with a mental health provider — by being told they have to wait weeks or months to see them. In a psychotherapy relationship where the therapeutic alliance is a significant component of change, you can imagine what this must do as a “first impression” in that relationship. Whether or not the fault of the provider, patients don’t care. They don’t want finger-pointing, they want it fixed.

Unfortunately, there are no simple fixes or ready solutions to this continuing problem, which seems to have only gotten worse in the past 20 years. Treatment resources will always be constrained by the availability of someone willing to pay for them. If it’s not the consumer (and the consumer in the U.S. rarely shoulders the burden of the full price of the mental health services they receive), then it’s the government or a private insurance plan. In either case, it seems pretty clear from these examples — as well as countless others I’ve heard over the years — that neither has much interest in ensuring affordable mental health care is readily accessible and available. No matter how much additional pain and suffering the waiting causes.