[PretzelJudge]

A PhD in psychology takes 6 years to complete plus another year for licensing. A PsyD is a little bit less, but typically you pay high tuition during that time, whereas most PhD programs are free (with a small stipend). So, you make little to no money (or pay money) for a long period of time and then you are presented with a choice to take or not take insurance. If you choose the former, you:

- Get paid half as much

- Have to deal with filing claims, which ultimately becomes an additional expense, since chances are you have to pay someone to do this for you.

- Get your money later instead of now.

- Have to keep meticulous notes in case you ever get audited by the insurance companies, who can refuse to issue payments if your notes don't meet their standards.

- Have to lose patients when their coverage runs out

Meanwhile, there's overwhelming demand for therapists in many cities and plenty of people who will pay cash. I truly believe that many therapists are not in it for the money... but if they are going to make less money, let's at least figure out a way to handle the bureaucracy so that their jobs are more enjoyable.

[jdgoesmarching]

LPCs, MSWs, LCPCs, LMHCs make up a much larger portion of therapists over PhDs and PsyDs. All take much less schooling.

[pas]

for anyone else wondering WTF is going on :P

LPC - Licensed Professional Counselor, 24 states + DC

LMHC - Licensed Mental Health Counselor, 7 states (NY)

LCPC - Licensed Clinical Professional Counselor, 7 states (IL)

LPCC - Licensed Professional Clinical Counselor, 6 states (CA)

...

MSW is likely Master of Social Work

( https://www.psychotherapynotes.com/decoding-counselor-alphab... )

[smeej]

Where are you getting state counts, and what do they mean here?

As far as I know, most states have procedures for licensing several of these categories, and a couple more besides (Licensed Marriage and Family Therapist, for example).

[pas]

The state counts are from the linked website. (As someone from Europe I have zero idea about any of this. I was just fascinated by the "TLAs".)

[QuantumGood]

Another OAAI member, I see (Overuse of acronyms and initialisms) /s

[timr]

I know someone who is in training to be a therapist. It still takes an absurdly long time and a lot of money to get any of those degrees. In New York, for example, there's a mandatory multi-thousand-hour internship that essentially treats you as indentured labor for several years -- and this is after getting a masters, which you usually pay for. The average case ends up substantially in debt, for a field where private practice pays mediocre salaries.

(Hot take: the masters was the truly offensive part of the equation -- most of the content was total bullshit / pseudo-intellectual woo. At least you're getting supervised practical training in the internship, even if your salary is low.)

[marcuskane2]

> most of the content was total bullshit / pseudo-intellectual woo. At least you're getting supervised practical training in the internship

If you're lucky enough to get an unusually good internship.

Won't most of the interns be shadowing someone who is just practicing the same bullshit/pseudo-intellectual woo the elder therapist was taught by the same programs a few years earlier?

[timr]

I don't know, but it seemed to be a pretty different level of thinking from the outside. When you're providing a service, you're grounded by the customer.

Depressed/anxious/whatever people don't generally want to have navel-gazing conversations about gender fluidity and the metaphysical dialectic (or whatever; I'm making up something woo-y). They want to feel better.

[leoqa]

Yeah my wife is a MFT and it’s wild how long the process has drawn out before she made money. School, internship, practicum (actually just another internship), license exam, associates licensure requires a supervisor- either you pay them to supervise you or you have to work somewhere that will hire associates.

[spicyusername]

Anecdotally, as someone who is considering a career change out of tech, I am constantly shocked at just how long and how expensive it is to change careers to do anything else.

I shouldn't be surprised, given how much training it took me to get into this field, but being paid nothing and spending years in training was much easier to tolerate at 20 than at 40.

[notepad0x90]

if the government directly subsidized healthcare instead of relying on the insurance middlemen to perform its duties, this wouldn't be an issue.

[mnky9800n]

No this doesn't work. In Norway there is typically a minimum 6 month wait. Or you can see a private person who takes money today. Same in Germany, and the Netherlands, and basically everywhere else I lived that has subsidized healthcare. It's one of the things that falls through the cracks in my experience.

[notepad0x90]

a) we're rich in the US compared to even Norway b) it's better than what we have, private options will always be there, they just won't be the only options with government competition.

[PretzelJudge]

No we are not. The US has a much higher GDP per capita than most of Europe, but not Norway.

[notepad0x90]

But a higher overall GDP (per-capita aside) than even Norway right? We're already spending more than any other country on the planet on healthcare.

Look at the table here: https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...

The US is spending 50% more per-capita than Norway already and we are worse off. This doesn't include private insurance money which is insane amounts already.

[krageon]

Yes, but then if you have the kind of systemic issues that need mental health care an extra six months isn't going to break the bank. It's unpleasant and a long time, but it's a pretty far cry from the US nightmare scenario

[mewpmewp2]

Yeah or even something like mental health it is impossible to get anything. I also pay for everything mental health related despite having universal health care.

[lolinder]

I take it you haven't ever interacted with the IRS beyond filing the standard deduction? Or interacted with Medicare/Medicaid?

The only issue raised by OP that would go away if it were managed by a US government bureaucracy instead of a private company would be people running out of coverage, and that only if healthcare were subsidized universally.

And to preempt the comments saying it doesn't have to be this way: it doesn't matter what if US government bureaucracies are incompetent by the design of politicians or by necessity, the point is that they are, and the idea that this case would be the exception is just wishful thinking.

[notepad0x90]

The IRS and the USGOV in general is much more lax on preventing citizens from having free money. I get tax return refunds I shouldn't, plenty of people cheat the system and get away with it. For profit insurance companies are harder to cheat. If an insurance company refuses a claim, what are you going to do? go to another insurance company that will do the same thing? If the government refuses a claim, you can vote for the other guy. The government is comprised of "we the people", so it is in the best interest of the people for it to take place of insurance companies, which are certainly not comprised of "we the people".

You should also understand that I am not suggesting that insurance companies should be banned. If you don't like the USGOV subsidy, you or your employer can still subsidize private insurance for you. But now, insurance companies have to compete with the government!

[dghlsakjg]

I had Medicaid when I was an adult student. Worth pointing out that it was administered by the state of Colorado and not the feds, and was post ACÁ.

It was, by far, the best insurance I have ever had in the US. It was effectively a gold insurance plan with no deductible, a $2 copay, drug and dental coverage.

It was very easy to sign up for, and the paperwork was literally the exact same as buying marketplace insurance.

I found it to be a better experience, and better administered than any other American health insurance I ever had.

If I could have paid money to stay on it when I got a job I would have.

[mauflows]

My brief insurance experience with Medicaid was the best I ever had. It was through State of NY. I happened to break my wrist during that time. It was easy to find a doctor, low/no copays or deductible, and they were comparatively easy to contact.

Every other insurance company I've dealt with has actively cost me money, time and unnecessary pain through ineptitude or beurocracy. My FAANG healthcare was good, but had relatively fewer health issues

[beedeebeedee]

Government support should start a few steps before payment and filing taxes. The solutions that would fix this problem are analogous with having free education instead of student loans

[lolinder]

Now we've moved on from talking about direct government subsidy to talking about completely government-operated medicine.

And for that, I'd like you to point me to a state with government-operated medicine that doesn't have a therapist shortage. Because I'm hearing from several people in this thread that their countries have the same problems.

[beedeebeedee]

No we haven't- these problems aren't only reducible to a few categories (i.e., free market vs government operated). The shortage of therapists indicates at least an awareness of discontent among many people, and a desire for help (whether just listening, coaching, or deeper interventions). Those relationships used to involve family and friends, but we understand that a therapist is better suited because of better training and less conflict of interest. We don't need trained psychologists for all of those relationships, and much of it could be solved through other relationships that provide comraderie and fraternity- even in a racquet club, finding other people to help you understand the world and support you. That provides an alternative role for government to intervene, instead of the government-operated medicine boogieman. In this case, the government insuring that more people have leisure time to join clubs, go hiking, spend less pressured time with family and friends, would go a long way to improve the problem. That is a different approach from the financialization of cultural life that pervades most government approaches, but it would be much less costly and reap greater rewards

[KptMarchewa]

Next time, for comparison, choose a country where half of the political spectrum does not deliberately gimp goverment's ability to do things just to prove government can't do things.

[lolinder]

We're commenting on an article from a US news outlet about the situation in the US. I wasn't going to start talking about a random other unrelated country when people are proposing solutions for this one.

Also, I attempted to preempt these comments. They're not clever or new or even particularly accurate:

> And to preempt the comments saying it doesn't have to be this way: it doesn't matter if US government bureaucracies are incompetent by the design of politicians or by necessity, the point is that they are

[ToucanLoucan]

> I take it you haven't ever interacted with the IRS beyond filing the standard deduction? Or interacted with Medicare/Medicaid?

raises hand

I have! I've actually worked a shocking amount with the IRS, not because I'm a criminal but because I'm working class and wasn't educated on how to file taxes more complicated than a 1040-EZ, presumably because it was never expected I would make that much money or own my own business.

Strictly my experience, I would much, much rather deal with the IRS than my insurance company. Yes, they're intimidating at first, but ultimately every person I've worked with both at the IRS and my state agency has been calm, professional, and frankly to a degree I found surprising, extremely understanding about how badly I fucked up my taxes on a number of occasions. I was never treated like a criminal; they explained what I did wrong, how they found out, what I owed, and how to prevent those issues in the future. And I was given interest-free payment plans with a one-time administrative cost to setup, that I now pay monthly. I'll be fully 0'd out in about 2 years.

This contrasts sharply with my experience with my insurance company! My insurance company tries to get out of paying for every last thing they can manage. My dental insurance has a maximum pay out of a measly $5,000 per year, which seems completely backwards to every other insurance I have ever had, but what do I know. You know how fast you can crush 5 grand in dental work? And paradoxically it still has co-pays, so apparently I'm paying so they will cover most of some bills, up to a predetermined maximum. Additionally, since I own my own business, I do have the luxury of choosing my own insurance, which most people can't, and for that luxury I pay simply princely sums each month to insure both myself and my spouse. I've picked the best for my area (at time of comment) and have to spend many many days of unpaid labor every year re-evaluating that choice, both because circumstances and networks change coverages, and because every single year my insurance goes up despite both of us, by and large, being quite healthy, and I get fucking annoyed about it and want to see if I'm getting my money's worth. I wouldn't say I am by a long shot, but the alternatives cover less, and cost more, so I'm still paying.

Frankly, and I don't mean this as a personal attack against you, but I have to assume people who talk like you have never interacted directly with the IRS, and are instead absorbing that opinion through the same cultural osmosis I did, because I too was initially terrified to the bone when I got my first letter from them several years after starting my company, and honestly, they are incredibly over-hyped. The only way to truly get the IRS to take you to to task is to, for years on end, purposely try and weasel out of paying taxes.

I would LOVE, absolutely LOVE, the ability to get my healthcare funded via an organization templated off the IRS.

[lolinder]

To be clear, I'm not talking about the cultural fear of the IRS, I'm specifically referring to the idea that patterning insurance after the IRS would solve most of the issues that OP brought up:

> - Have to deal with filing claims, which ultimately becomes an additional expense, since chances are you have to pay someone to do this for you.

> - Get your money later instead of now.

> - Have to keep meticulous notes in case you ever get audited by the insurance companies, who can refuse to issue payments if your notes don't meet their standards.

This description could be lifted up and dropped in to be describing my tax situation each year. Meanwhile, I've never interacted with the kind of nightmarish insurance companies that some people have, so I'm strictly comparing two relatively painful bureaucracies, not nightmare stories about either one.

[glenstein]

>I'm specifically referring to the idea that patterning insurance after the IRS

Maybe I'm missing something, but I don't see anyone who brought up the IRS as a model example except for you. It seems like people are just talking more generally about steamlined than the current status quo experience, and there are so many ways to steelman that which have nothing to do with analogies to the IRS.

To your credit you did note that you wanted people to take you up on your suggestion of using only bad examples, but I don't think your insistence on that front holds water because this is the type of thing where the difference that makes the difference is going to be the very details you are asking everyone to gloss over.

[lolinder]

I was responding to GP, who definitely did say they would love to use the IRS as a positive example:

> I would LOVE, absolutely LOVE, the ability to get my healthcare funded via an organization templated off the IRS.

I'm not at all sure what you're getting at with the rest of your comment, because it doesn't seem to relate to anything I actually said. I'm insistent that we be realistic about what a US bureaucracy will inevitably look like and not expect it to produce less red tape than is already present. I said nothing about glossing over anything.

[YawningAngel]

It's also country specific. HMRC in the UK are pieces of shit I wouldn't scrape off my shoe

[wbl]

I fucked up my taxes one year. I filled out the form letting them know I had made a mistake and paying the amount and that was the end of that.

[lolinder]

I messed up an insurance deadline one year. I called in and they sorted it out.

I didn't say the IRS was worse, I just said it wasn't any better.

[glenstein]

Right but I think the point is that it is better at the end of the day. Since we're all sharing our anecdotes, I am familiar with someone who works in a municipality where their entire job revolves around billing and claims for EMS.

The amount of extreme cases of stonewalling, long holds, call transfers, inconsistent interpretations of policy, requests for faxes that get lost, requests for new paperwork, and general lack of urgency, across numerous companies in numerous states, is mind boggling, and easily an order of magnitude more extreme the IRS experiences I've seen shared here.

[nanoxide]

The issue is similar in Germany, where the vast majority has mandatory insurance: Too few therapists for too many people. Even in large cities you might wait months, if they even have waiting lists. It's much easier if you pay by yourself.

[taejo]

Afaik there are many therapists who are qualified and want to take public insurance (reimbursement rates are actually pretty good compared to those for MDs) but in the '90s there was a formula developed for how many therapists are needed per capita, and only that many therapists get licenses to take public insurance. Since the stigma around mental health was much higher then, demand now completely outstrips supply, and the competition for the licenses of retiring therapists is fierce.

[ransom1538]

Canada: Sure you will never see a doctor, but, when you do it is free!

[dghlsakjg]

Canada’s healthcare is managed at the provincial level. So you’re comment is pretty reductive and unrepresentative of many places.

This is my experience in BC as an American immigrant. It doesn’t apply to Toronto or Ontario.

Counselors are very easy to find. I had my pick and the wait was about a week. The province didn’t cover it in my case but my extended benefits did. Most of the ones I talked to offer pay scales based on extended insurance coverage, and many will provide pro bono care. Some counselors are covered by the province if you get a referral from a doctor.

The longest I’ve personally waited to see a general doctor is 6 hours at an ER on a weekend night, typically the wait is about an hour if you go to a clinic in the morning without an appointment.

For specialists, appointments are done on a triage system with a referral. If your case is urgent, or worsening you typically get seen asap. I’ve seen MRIs get done same day, or take as long as six months for non-urgent needs.

What I’ve never seen is someone wait a day with a broken arm to make sure they actually need to see a doctor because they can’t afford it. That’s something I saw twice in college in the states.

I’ve also seen people get referred to a specialist and never get seen because their insurance wouldn’t cover it.

Also seen people declare bankruptcy over medical debts in the states despite having insurance.

Canada’s healthcare system could be improved, but if you have ever dealt with low end insurance or uninsured healthcare in the states, you would understand how much better the system is here.

[HeatrayEnjoyer]

Better than never seeing one at all because you can't afford it.

[suzumer]

Do you live in Canada?

[Suppafly]

>Do you live in Canada?

I'm guessing they don't. As a US person we hear a lot of, presumably insurance company sponsored, anti-Canadian-healthcare propaganda and then dumb people repeat it online.

[missedthecue]

In the UK the NHS waiting list can up to a year.

[jononor]

Same in Norway, which has a directly subsidized phealthcare system for all.

[JumpCrisscross]

> if the government directly subsidized healthcare instead of relying on the insurance middlemen to perform its duties, this wouldn't be an issue

Most psychiatrists I know refuse to take Medicare because it has the same paperwork and pricing issues.

[CPLX]

Medicare is not direct. Direct would be if the therapist worked, on salary, as a therapist, and received a paycheck from the government.

[lolinder]

That isn't what "directly subsidized" means, though, that's "directly run". A subsidy is a strictly monetary arrangement, not one where the government actually becomes the employer.

[jerkstate]

Tricare is perhaps the closest thing we have to direct government healthcare, it handles healthcare for active duty military, it is part of the DoD and contracts out to providers directly (including therapists) and compared to other private insurers they are among the most difficult to work with. My partner is an independent psychotherapist and contracts with various healthcare providers and Tricare has by far the highest rate of spurious rejections, short paychecks, heavy audit requirements, etc and their resolution department is the hardest to work with.

So we already have evidence of how it goes when the government manages it directly and it’s worse than private industry.

[nradov]

It would still be an issue. Even countries with socialized or heavily subsidized healthcare systems tend to have long waiting lists for therapists and strict limits on the number of sessions. Services are rationed everywhere.

[victorbjorklund]

in sweden it is almost impossible to find a psycologist. Many years of waiting and that is only if you are an extreme case. If you are just average depressed you can just dream about getting one in your lifetime.

[BeetleB]

You don't need a PhD to get a license...

[nothercastle]

But very few non phd therapists practice evidence based medicine

[r00fus]

Most therapists I’ve spoken to aren’t PhDs and the one we do work with isn’t noticeably better for outcomes.

[Suppafly]

>But very few non phd therapists practice evidence based medicine

That's a good point, although people don't seem happy to acknowledge it. In my metro area, the biggest providers of mental health services are aligned with religious organizations or outright promote themselves as offering religious based therapy. It's frustratingly hard to get evidence based treatment free from religious influence.

[hiddencost]

lol you have that backwards. The LCSWs tend to be evidence based, the PhDs are busy working on their book promulgating their theories.

[nothercastle]

Lcsw are more like someone you go talk to when you are having a bad day not so much when you need to manage chronic pain, anxiety or ptsd.

Insurance understandably does not want to reimburse much for that.

[meroes]

And yet you produced zero evidence. The irony is off the charts.

[miki123211]

Okay, here's one thing I really don't get.

There are plenty of native English speakers in third-world countries. Presumably, some of them could become qualified (from a practical point of view, not a legal point of view) therapists. Therapy can be offered via telemedicine, over the internet. At least some of these people are far enough from US jurisdiction that they could probably offer this service to anybody who wants it over the internet, and just not care what foreign governments have to say about it. This feels like an easy way for people there to make relatively large (by their standards) amounts of money. Why isn't this happening yet?

[PretzelJudge]

Sure, if you just want someone to talk to. But most clinical psychologists are dealing with more severe cases. Would you want your suicidal teenager talking to a licensed therapist trained to deal with their case, or to someone overseas whose qualification is that they speak English?

[rafram]

Because people want therapists who’ll connect with them and understand their life experiences.

I’m sure there are fitness/“life” coaches working online from who-knows-where, though. That’s more or less a form of counseling.

[Suppafly]

The problem with this, and we see this in the US already with medical providers, is that even if they are 'native' speakers in their own country, they miss a lot of important nuance and conversational skills to work with US native patients. And that's before you even consider the cultural stuff that they just don't have a frame of reference to understand. Someone from a country where women don't have rights, or where normal things like divorce or abortion are illegal, isn't going to be able to offer useful therapy to someone from the US.