Twelve years ago, I lived in New York, way out in the bowels of Brooklyn. I was free falling into my first major depressive episode as an adult. An emotional paralysis was drawing near—I was desperate to run into the arms of a reputable psychiatrist. There was no doubt in my mind that I needed to get on anti-depressants in addition to attending weekly psychotherapy sessions. I remember my father, who was gathering names for me from his psychiatrist, calling me everyday and saying, “don’t worry, help is on the way”.
My father was working on this from his home in Houston, using his San Diego based doctor to get New York City referrals. The day I got an email with some names was a very good one indeed. Dad felt strongly I should see a man this time after working with female clinicians for years. There was no additional information aside from a name and phone number for each clinician, with one exception: the guy at the top of the list was younger than the rest of the pack. Too demoralized to put any real energy into this, I started with him.
He called me back! In hindsight I realize that this was my second major hurdle cleared; the first one being simply receiving that list. I used to run track in middle school, so I like hurdle metaphors.
We set up a “consultation”. In NYC, what this means is that I’ll be asked to fork over anywhere from $450 to $600 (at least) for the privilege of being told whether or not the doctor will take me on. At the risk of sounding like a “treatment-resistant” patient, after all the work I’ve done through the years, it bothers me to have to pay a new doctor to give me the familiar, entirely consistent through childhood and adolescence, diagnosis of Major Depressive Disorder.
The other privilege of this 45 minute expenditure is a breakdown of how much ongoing treatment is going to cost me. The so called ‘nuts and bolts’ or ‘business side’ of things. All the psychiatrists I saw in New York offered sliding scales. I’m sure that makes therapists feel good and it is, of course, a good thing to do. But the bottom of that scale is always around $150/200. That’s still out of reach for many of us at $600 or more a month.
Let’s go back to the fact that I was a very depressed 24 year old. I’d just retired from a modeling career, characterized by ambivalence and far less income than one might imagine. I was dipping my toe into higher education. The only money I had was from PELL grants and babysitting. Neither of my divorced parents, with non-profit careers and 2 other children, was in a position to spend hundreds of dollars a month. At the same time, they both–but especially my dad–INSISTED I work with this young doctor, who I think had proposed a discount price of about $250 per session, which comes out to $1000 a month. This was so far beyond my means; it felt like a punchline.
We were going to have to take the humiliating step of asking a “well-resourced” family friend to fund the treatment. I was uniquely privileged to have this option and don’t think I DON’T KNOW IT. Despite the ensuing difficulties regarding the arrangement, I’d be nowhere without the financial assistance I’ve had from my mother’s family and friends. I feel both gratitude and righteous indignation that such privelage is necessary to receiving ongoing mental health care in this country.
In this case, my dad assured the family friend it would be a loan. I’m sure he had every intention of keeping to that agreement but turns out it was wishful thinking. It would not be a loan because my father, who had suffered multiple strokes a few years prior, was not regularly employed and soon fell behind in the payments. I remember clearly the phone call in which he told me I would need to take a break so he could catch up on the mounting debt. My fear had not been the product of a neurotic pattern of expecting the worst. With my chest tightening, I stood listlessly watching the two small boys I babysat run around the children’s section at the West Village Barnes and Noble.
I comforted myself with the knowledge that the family friend would likely not take a hardline stance and pull me out of treatment until my dad got current. Graciously he continued to subsidize the care, knowing now reimbursement was unlikely. That generosity saved my life.
But there’s no denying that this added pressure to the work and heightened the depression and anxiety I was being treated for. There was a fresh awkwardness present with my benefactor, who was paying for something critical to my functioning. At any moment the rug could be pulled out from under me if he had a change of heart. Stemming from a mutual sense of obligation, I began doing things for this family in return: we fumbled through dog-walking and baby-sitting arrangements over which I had no right of refusal. My therapeutic relationship felt incredibly tenuous: I lived in constant fear that I’d get cut off from a doctor I’d grown increasingly fond of.
Years went by, and while I never was cut off, my relationship with the family friend became increasingly strained. Money is a complicated thing.
When I got my first post-college job, I was able to start paying for the treatment myself at a bigger reduction, a milestone of which I remain proud.
Those years of working, going to school full-time, and being in psychiatric treatment were grueling. Even though money was a constant source of anxiety, I did manage to live my life: I had relationships, formed friendships, and got my degree. The treatment was painful, tedious, electrifying, and everything else worthwhile therapy is. And I did, after many years, feel better.
But it all came at such a harmful price because I simply could not afford it. It is a fact that I never would have gotten the help I needed if our family friend had said no to the loan proposal.
And as we all know, major depression doesn’t get cured. I’ll always be seeing a doctor from time to time, even if I don’t need the weekly support.
How much better would we all feel knowing really capable psychiatrists in New York, and elsewhere, could be accessed even when you’re living paycheck to paycheck?
Enter Tele-Medicine. COVID forced a wholesale transition to virtual care that destroys the most common barriers to treatment; geography and prohibitive costs.
With far lower rates and access requiring only a tablet, phone or computer and a wi-fi signal, you’re in business. I’ve been doing FaceTime sessions for over a year now like everyone else and I don’t feel the need to ever see my doctors in person ever again! That’s not my choice to make but it gives you a sense of how much I like the modality. Being at home opens up new intimacy and vulnerability that I think has been conducive to the work.
It’s an exciting time for the mental health field. We are living through a historic inflection point: it’s very unlikely clinical care will return full-time to the office when the pandemic is behind us.
The other day I did a tele-session from my bedroom (fully clothed, and seated!). Could any of us imagined having our therapists in that intimate space?
Those of you nodding yes may be thinking carnally. That’s a whole other thing and I will refrain from commenting.
I hope everyone’s enjoying getting to know their therapists in a far more intimate way than we could in a sterile office. Often sitting in an uncomfortable chair. With our legs crossed.
And don’t forget to feel excited for new, lower fee structures if you’re open to using one of the many tele-therapy apps that are multiplying at lightening speed in anticipation of massive COVID related PTSD.
PS: Special thanks to the doctors who gave me the world: money would never have been enough.