The right change at the right time

Susan Tesch, MS, LMFT | Psychotherapy & Counseling

Susan Tesch, MS, LMFT | Psychotherapy & Counseling

Shame, Joy and Excitement

My own therapist emphasized to me that underlying feelings of shame, coming from a damaging childhood, colored my psychology enormously. We all have shame, but some of us may be drowning in it. Growing up with a sense of inner defectiveness is excruciating and people usually have no choice but to cover over those feelings both to themselves and to others, so as to to “look good.” Part of the work of therapy is encouraging a client to turn towards these buried feelings of shame and find a better place of acceptance in relation to them so that that person isn’t stuck in a costume of always “looking good” at the expense of feeling fraudulent or empty. 

In preparing for a course to professionals on the importance of shame, I began reading Sylvan Tomkins’ work which makes a connection between shame, joy and excitement. It works like this: If you run up to someone, happy to see him, and he doesn’t respond excitedly, you will immediately feel foolish (shame). Without thinking, you might blush, your eyes will turn downcast, and your shoulders will slump. That’s shame.

Think of the way babies are always smiling and laughing and how toddlers run up to parents excitedly. Then think of how the child must feel when a parent doesn’t respond to that excitement or joy. The child must repeatedly endure the precipitous drop from joy or excitement into shame. Over time, this becomes internalized as a state of being. I wonder how many of you reading this grew up in homes with a parent or parents who didn’t respond to states of joy/excitement. The more I’ve thought about this and done research on the importance of joy and excitement in development, the more I’ve begun to notice that most of my clients were undersupplied with the nourishment of joy and excitement in childhood.

When I’m in session, I pay attention to my clients’ eyes and when I see them light up, mine do too. It’s exciting! It’s fascinating! I unabashedly enjoy revving up a good feeling in my client. I like my work; I like the clients I work with, and it helps both me and my client get through some of the tougher times in therapy and in life to know this. Without the leavening of joy and excitement, life is unbearable.  I’ve come to feel that it’s vital that therapy include these lively experiences! I guess that means that at times I’m having a great time being a therapist! I can’t help it! If you’re looking for a somber therapist a la “The Sopranos” and come to me, you may be disappointed!

While I take a very serious approach to therapy and don’t shy away from helping a client confront and manage painful experience, I’ve also come to feel that amplifying joy and excitement in session is equally important. Joy and sorrow are kindred emotions of great value in responding to life’s ups and downs.

Going Off Insurance Panels

For about sixteen years, I’ve been a “Preferred Provider” with large health insurance companies in Washington, which means I’ve agreed to diagnose, bill and provide other information, according to their terms. The insurance company has paid the majority of the psychotherapy bill to me directly, while the client has paid me a smaller amount. The advantage for a provider in this agreement is that she receives many more referrals from a larger client base than she would have otherwise. The advantage for the client is that he doesn’t have to pay as much for his therapy as he would have otherwise. Up until very recently, I’ve felt these advantages have outweighed the disadvantages for both therapist and client, and thus I’ve stayed on insurance panels. However, my feelings on this have gradually shifted, and consequently, I’m no longer “in-network” with insurance companies.

As “Mental Health Parity” laws have come into effect, insurance companies are now required to pay for mental health benefits in an unlimited way; they can no longer set limits at–say-twelve or twenty sessions per year as they used to do. Thus, in order to offset the expense of paying for unlimited sessions, insurance companies are attempting to limit the therapy based on “medical necessity.” Rather than just requesting a diagnosis, as they did in the past, they are now asking for notes and detailed information over the phone and online describing what’s going on in a client’s therapy that proves the therapy is “medically necessary.” This has made me increasingly uncomfortable. I feel very protective of my clients’ privacy, and I also feel that I ought to be the authority of my own practice, rather than handing over that authority to an agent in an insurance company.

Once I began to acknowledge to myself my discomfort with insurance companies overseeing my clients’ therapy, other problems about accepting insurance began to occur to me. Why is it that each company sets a slightly different “discounted rate” when everybody is getting the same thing–a 50-minute session? Why is it that somebody who pays cash, which is very simple transaction, paying my “full fee,” but somebody for whom I have to bill insurance, which requires more work and time, getting a “discounted rate”?

Most importantly, I began to feel that accepting insurance directly takes the control of the therapy out of the client’s hands. It lends towards more passivity in the client. I had to admit I didn’t feel good about that compromise to the work of therapy, and from there my decision was inevitable.

This is a big move for me, and it is based on the conviction that it’s in the best interests of the treatment.

Though I admit to not liking dealing with insurance companies, I’m not a purist, and, as I  wrote above, I’m still willing to provide a diagnosis and whatever else may be required as an out-of-network provider for individuals who would like to seek insurance reimbursement themselves. At least in this case, both my client and I are still in control of the therapy.

Additionally, I’ve made the decision to keep my fee lower to offset the additional expense to the client of seeing somebody who’s not in in his network.

I know for some of you reading this, my not being on your insurance panel will be a non-starter. However, if you’re still considering meeting with me but are hesitant because I’m not on your panel, consider that it may not be much more money per year to see me out -of-network than if I were in-network. And even if it is more expensive, I believe that you’ll come to find that you get what you pay for–privacy and control over your own treatment, and a therapist who’s in charge of her own practice and has your best interests at heart.