Boston psychologist Natasha Holmes hasn’t had an official opening for a new patient in a very long time.
After the pandemic began, she made space for new clients, especially at the peak of COVID-19, when so many people needed help. But eventually she ran out of hours in the day when she could see patients and do her job well.
“There was just a significant increase in the number of people reaching out,” said Holmes, founder and CEO of And Still We Rise, a group of Boston-area mental health care professionals who specialize in working with women, and BIPOC, queer, and trans communities. “It has been very busy. And it’s hard to find a therapist.”
If you’ve looked for a therapist — as an individual or for a couple — you know this is true.
The shortage has changed the way I do my work as an advice columnist. I used to tell people that my Love Letters column was for entertainment and light support. If a letter writer’s problem or bad feelings seemed persistent, I’d recommend they find a therapist. But in 2021, I can’t just say, “Hey, go find professional help.” It’s not that simple.
And when friends, colleagues, and acquaintances ask if I can recommend a good counselor, I don’t have answers. As of spring last year, none of my go-to professionals is taking new patients, and many have stopped adding to their wait lists.
Though it’s not unique to Massachusetts, the scarcity of therapy is a significant issue here, and not just in hospitals, which have been overwhelmed by patients needing psychiatric care. There are some obvious reasons for this supply and demand problem.
Of course, COVID-19 has meant a lot of us have been suffering at the same time, and many are struggling with the reality that, despite the vaccines, we’re not going to be done with the pandemic any time soon. We’re still dealing with trauma, big choices, and change amid a worldwide crisis.
COVID-19 also made some of the stigma attached to therapy go away, I think, swelling patient demand. There were people in my life who’d resisted therapy, or who’d stopped counseling long ago, who suddenly decided, “Well, it’s time to get help, and I don’t feel weird asking for it.”
For others, getting help became more manageable in the logistical sense. Most therapists switched to online appointments after COVID hit, and therapy is easier to fit in when you don’t have to figure in travel time.
It didn’t take long, though, before mental health professionals with openings reached their limit with caseloads. And even if they had openings, they didn’t necessarily take insurance, making them inaccessible to a large swath of people in need. (Why don’t those therapists take insurance? More on that later.)
Massachusetts Psychological Association president Martin R. Pierre said there are about 6,000 psychologists in the state, 1,700 of whom are MPA members. While he doesn’t have hard data, “Anecdotally I could say that an overwhelming majority of [psychologists] are full,” he says. “They’re stretched to the limit. The waiting lists are approximately 5 to 15 clients. This changed at the height of the pandemic.”
This summer, I called Danna Mauch, president and CEO of the Massachusetts Association for Mental Health, and told her I wasn’t sure what to advise people seeking therapy anymore. Mauch said people in the industry are asking the same question.
“The rates of people reporting that there’s been a disruption to their mental health and well-being have nearly doubled from pre-pandemic among adults. And for some kids, it’s actually higher — young adults, 18 to 24.” Even pre-pandemic, she said “We did not have enough treatment professionals,” and the system for finding them was opaque.
This problem is so big that her organization started a campaign called #JustAsk, which offers links to resources, including community health centers, support groups, hot lines, and private clinics, and also reminds people they can reach out to their friends and family for support. That’s better than nothing, I guess.
Limits on insurance coverage continue to play a big role in patients’ ability to access behavioral health care. Mauch said that even before the pandemic, a huge issue for mental health professionals has been that insurance companies often don’t reimburse them what they actually charge. A therapist may bill $200 an hour, for example, but only get paid $75 by a client’s insurer. That disconnect can drive practicing therapists to refuse insurance altogether and, according to Mauch, can even dissuade would-be therapists from pursuing the field.
Results from a spring 2020 MPA survey, “Massachusetts Psychologists’ Experiences with Insurance Plans,” showed 83 percent of respondents were in- or out-of-network health insurance providers, Pierre said. But they might not take MassHealth, for instance, or your insurance, whatever it is.
A 2017 Blue Cross Blue Shield of Massachusetts Foundation-funded study, “Access to Outpatient Mental Health Services in Massachusetts,” found that 45 percent of outpatient mental health providers didn’t accept MassHealth, 38 percent did not accept Medicare, and 16 percent did not accept commercial insurance.
Responding to a 2018 BCBSM Foundation study, nearly 36 percent of adults in Massachusetts seeking treatment for mental health and/or substance use disorders said they were told a provider was not accepting their type of insurance; nearly 11 percent were told a provider wasn’t accepting insurance at all.
It’s hard to blame the mental health professionals for bailing on the insurance system. Earlier in her career, when local therapist Monica O’Neal billed insurance companies, she remembers having to ask her landlord to wait on the rent because she hadn’t yet been paid for the work she’d done.
“To try to get paid with an insurance company, it’s easily going to be in an hour call and it’s just a wild goose chase,” she said.
Mental health care providers — including licensed social workers, psychologists, and psychiatrists — are in a constant battle with insurers about how and how much they get paid and when the money is coming, multiple therapists told me. That means less time for clients.
And for a person already experiencing anxiety or depression, finding a therapist who is both affordable and accepting new patients can be exhausting. Many ask friends, family, colleagues — and people like me who talk about therapy a lot. They google. Psychology Today’s website has a pretty good list of therapists in all ZIP codes. But not every therapist is on it, and the directory doesn’t always tell you who’s taking new patients.
In 2019, when he was a psychiatry resident at Massachusetts General Hospital, Jack Turban wrote a revealing story for STAT about trying to find a therapist for himself. Turban, now a child and adolescent psychiatry fellow at Stanford University School of Medicine, discovered that insurance company listings of available therapists often lead nowhere— inaccurate lists have been dubbed “ghost” or “phantom” networks.
When I called some insurance companies to talk about the problems, their spokespeople said they do their best to connect people with available therapists.
Emily Bailey, former vice president of behavioral health for Point32Health, the now-merged Tufts Health Plan and Harvard Pilgrim Health Care, said the therapist shortage has led her group to embrace new technologies, including apps like Sanvello, Talkspace, and Happify, which, she says, studies suggest can be clinically effective. Some of them offer things like life coaching and happiness exercises, access to support from other users, therapy via text messaging, or online professional therapy.
But Mauch said the technologies and studies are new, and that patients have to be careful about how the systems are regulated and whether the therapy they offer is from credentialed professionals.
(A disclaimer: A therapy platform advertises on my “Love Letters” podcast.)
For my part, I’ve been calling more mental health experts to consult for Love Letters when it seems like it could be helpful. I know they can’t diagnose anyone based on a 200-word letter to an advice column, and that Love Letters is no substitute for licensed help (like many advice columnists, I’m trained only as a journalist). But these days columns like mine might be the only help a person can find.
Sienna Hunter-Cuyjet, the clinical manager at And Still We Rise, said most therapists want to help as many people as possible, but that they have to set boundaries for themselves, too. Therapists in her group are seeing patients coping not just with the pandemic, but with racism and discrimination based on their gender or sexuality. The therapists are balancing those treatment needs with administrative work and with their own experiences during this time of crisis.
There are mental health professionals with And Still We Rise who are taking new patients, though, and the group plans to hire more new therapists, she said.
“All of us go into this field because we care about the person,” Hunter-Cuyjet said. “To turn someone away is just ... I don’t even know if I have the word to really describe that.”
Meredith Goldstein writes the Love Letters advice column. Send your own relationship questions to firstname.lastname@example.org. Catch Meredith Goldstein’s “Love Letters” podcast at loveletters.show or wherever you listen to podcasts. If you’re a licensed therapist willing to share your professional opinion in Love Letters, e-mail email@example.com.
Help getting help
Can’t find a therapist? The therapists and experts I spoke with had a few suggestions.
1. Consider group work. Sometimes group therapy is easier to find than one-on-one. Call your primary care doctor, your insurance company, even local hospitals to find out what group therapy services are available.
2. Say yes to any wait list. Some used to say, “Well, ugh, I can’t wait six months.” But even wait lists can be hard to come by now. Get on all lists you can.
3. Seek a referral. Mauch advises asking your primary care physician if they’re affiliated with any behavioral health practitioners.
4. Pierre recommends asking someone you trust to help with making initial phone calls, so the process is less daunting.
5. Do not underestimate your immediate needs. If you need assistance now, treat it like any other emergency and get help, even if it means an emergency room.