A woman phoned last week and asked, “Are you accepting new patients at the moment?” It’s not the first time someone has asked a question like that.
I always reply, “Yes, of course”, but at the same time I always wonder what’s behind the question.
Part of what’s behind it is that some therapists create long-term dependency in their patients. Once those therapists have a certain number of patients to see every week, they cannot accept any new patients for the foreseeable future. If you have had therapy like this in the past, or if you know someone who has, then your expectation might be that most therapists hang on to their existing patients and don’t like to accept new ones.
CBT, in contrast, works in a matter of weeks or months so that patients are constantly being discharged, almost always permanently cured of whatever it was made them seek therapy. As a result, although there might be a waiting list, there is always room for new patients.
Another part of what’s behind it is that not all therapists who think they can do CBT really can. Some set up in private practice but never manage to establish a good reputation. They go out of business and stop accepting patients.
Word gets around when a private CBT practice cures people, and over time the number of patients who self-refer because of a personal recommendation rises. This also applies to individual GPs, but not to private psychiatrists and psychologists.
I don’t fully understand GPs’ approach to referrals. Typically, some individual GPs will refer patients regularly, some hardly ever, and some absolutely never. Occasionally a GP will phone or write and express surprise that a private CBT practice exists in the area, even though another GP at the same surgery regularly refers patients here. It’s as if they don’t talk to each other.
Or sometimes a previously unknown GP refers a patient, the patient does well and is soon discharged, but there is never another referral from the GP. It’s as if some GPs don’t take any interest in the outcome, or don’t have the imagination to consider CBT for their other patients.
As a patient, this means that your GP might not suggest CBT even if you could benefit from CBT. And if you yourself suggest CBT, you cannot necessarily rely on your GP to be supportive or knowledgeable about it.
Private psychiatrists and psychologists lose out financially by referring patients for CBT. Psychiatrists lose out a little, so referrals from them are uncommon. Psychologists lose out a lot, so referrals from them are very rare.
A few private psychologists are themselves accredited CBT therapists and of course there is no need for them to refer. The rest will almost always try to treat you themselves anyway rather than refer you to a specialist therapist. You can end up getting CBT from someone who is not very good at CBT (though perhaps extremely well qualified in other things). The reason for this is financial.
If the psychologist refers you for CBT, then you are almost certainly never going to go back to the psychologist. The psychologist makes much more money by continuing to see you, even if that does not do you much good.
Psychiatrists, on the other hand, tend to specialize in diagnosis and medication. Your first session or two with a psychiatrist are costly, because (in theory) you are getting the benefit of the psychiatrist’s expertise to arrive at an accurate diagnosis. After that, psychiatrists generally prescribe medication with regular review. If they refer you for CBT, it’s in addition to the medication reviews.
So a psychiatrist who refers you for CBT still expects to make money from your medication reviews. Referrals for CBT from psychiatrists, therefore, are not as rare as from psychologists.
As a patient, you have to be careful to use medical specialists for what they are good at. A private psychiatrist or psychologist who has real expertise might be worth seeing for an expert opinion on your condition. But you cannot always rely on experts for actual treatment, unless they happen to be accredited as therapists too.
I have probably written before about how health insurance works. An insurer is on percentage, so it is in the insurer’s interest to increase your costs.
Suppose, for example, using ball-park figures for illustration, the average cost of CBT treatment is £1000. (Ten sessions at £100 each.) And suppose a health insurer charges an appropriate premium to insure you against that cost, making 1% of that cost as profit — that’s £10 a year profit.
Now suppose the average cost of CBT treatment can somehow be increased to £2000. The health insurer again charges an appropriate premium, and again makes 1% profit — that’s £20 a year profit. Higher treatment costs mean more profit for the insurer.
To increase the cost of CBT treatment, an insurer might insist that you have a psychiatric assessment first. You pay, say, £400 for the assessment. The psychiatrist will almost certainly prescribe medication and recommend monthly reviews at, say, £100 each. After six months the medication has not done much for you, and you are referred for CBT. The total cost to you is £1000 for psychiatry followed by £1000 for CBT. The insurer has doubled the cost, and doubled the profit.
As a patient, your situation depends on whether you have health insurance. If you do, then you have already paid the premiums and you have nothing to lose by going along with the psychiatric assessment. It’s not scary and you might even learn something about your condition. But if your policy limits the total amount that you can claim, beware of spending a lot of that money on medication reviews — it could probably be better spent on therapy.
If you don’t have health insurance, then there is no need for you to go along with the insurers’ claims procedures. You can self-refer, or ask your GP to refer you, directly to a therapist without involving a psychiatrist first.
The way insurers work has influenced the current healthcare debate in the United States in many ways, one of them particularly relevant to this post. The number of Americans without health insurance is often quoted, and the assumption is that all of them are vulnerable because they are not insured.
Some of those uninsured Americans, however, are deliberately uninsured because they understand how health insurance works. They have savings and investments that they can use to pay for treatment if they need it, and they know that by paying cash they can get their treatment more cheaply that way.
It’s just like my example above, where an insured patient in the UK might have to pay £2000 to treat a typical mental health problem, while an uninsured patient would only pay £1000 to treat the same condition. Unsurprisingly, there are people in the UK too who choose to pay into a savings scheme, not an insurance policy, to provide for their private healthcare.
Some of the tricks, then, in finding a good CBT therapist are to find someone who has a good reputation locally and a regular turnover of patients who have been cured of their conditions. You cannot always rely on GPs, insurers, or other healthcare professionals to make decisions for you — they might have their own reasons for doing things in a certain way that is not necessarily in your best interest.
When you phone for your first appointment there’s no need to ask, “Are you accepting new patients at the moment?” It might be me you’re phoning, and I might be shaking my head and thinking, “Not again!”