When You Can’t Afford Help

The cost of mental health care can seem daunting. Whether it is a lack of insurance coverage, high deductibles, job loss or other money woes, finances often lead many people to suffer rather than seek treatment. With a little creativity, however, there are often ways to get help.

First, let’s look at some low-cost options for professional treatment:

Public and private mental health agencies. Most agencies offer an income-based sliding scale, and accept public assistance such as Medicaid. Many have caring and competent therapists, along with the resources to handle issues like medication, crisis intervention and serious or persistent mental illness.

Colleges and universities. Graduate students in psychology are one of my favorite resources for therapy. First, their fees are extremely reasonable: in my area, local university mental health clinics charge as little as $15 per session. Second, graduate interns are often up on the very latest clinical skills and supervised by top experts in the field.

Pre-licensure candidates. Most states require thousands of supervised hours to become a psychotherapist, and clinicians working toward licensure are often eager to see clients at little or no cost. State associations of fields such as social work, mental health counseling or marriage and family therapy may be able to help you locate clinicians in training, as well as larger mental health practices.

Pro-bono therapy. Many private therapists honor an unspoken professional obligation to treat a certain number of people at little or no charge. Don’t be afraid to disclose your financial situation to therapists and see what is possible. Also, your local mental health association (a consumer advocacy group distinct from mental health agencies) may be able to arrange treatment options you can afford.

Finally, here are some resources that can help or support you in addition to formal professional help:

Crisislines. Crisis counselors are available 24 hours a day from anywhere in the United States at 800-273-TALK (8255). You do not need to be suicidal or desperate to call: their job is to listen empathetically, direct you to resources, and help you take next steps in any situation. Crisis counseling is NOT psychotherapy, and not designed for the treatment of ongoing mental health issues. But trained volunteers are always there to talk with you.

Support groups. Live or online support groups can be a source of both information and fellowship. Support groups are also not meant to take the place of therapy, and are not for everyone – specific groups can vary widely depending on their participants or leadership.

Community-based programs. Many areas offer low cost therapist-led training programs for mental health skills such as managing your anxiety or controlling your emotions – check your local community activity listings. My own Anxiety Camp program, for example, teaches people in upstate New York how to deal with fears and phobias in an intensive weekend program costing less than $100.

The common thread through all of these ideas is: don’t give up when the cost of care seems overwhelming. Ask questions, explore resources, and keep trying. Your good mental health is worth it.

What is a "relationship-friendly" therapist?

When I meet with a couple for the first time, I inform them that I am a "marriage-friendly" or "relationship-friendly" therapist. Do you know what this term means?

It sounds like one of those apple-pie-and-motherhood phrases, sort of like being a student-friendly teacher or a patient-friendly doctor. In reality, it is a buzzword with a very specific meaning in our profession. And it is an important distinction among therapists if you ever seek counseling with your partner.

Relationship-friendly therapists serve the relationship, not just the individuals in it. It means that, except in cases of abuse, I will never explore whether a couple should break up or not. As long as they are both there to work on improving the relationship, I am there to work on it with them.

This orientation springs from the larger marriage-friendly therapist movement nationwide, which has several noted clinicians associated with it. There is even a registry of such therapists. (I am not a member - it is rather expensive, and my practice is pretty full already.) And it is important to understand that many very good counselors choose not to follow this orientation, because it isn't right for everyone.

Why do I choose this approach? Primarily for the comfort of the couples I serve. People often feel safer knowing that I will never, ever encourage them to break up. They know that I will always focus on helping them both reconnect, no matter what happens, as long as no abuse is taking place.

By comparison, many therapists have a relationship-neutral orientation that focuses on what is best for each partner. There is absolutely nothing wrong with this. But many couples avoid counseling for fear that the counseling process itself may lead to separation, and I explicitly take this fear off the table by privileging the relationship itself as my client.

I also follow this approach because it works. Many couples come to therapy because they have lost hope of solving their problems alone, and I have watched amazing transformations take place when they learn new relationship skills in a safe space with a counselor who will never give up on them. Even in situations that, on paper, may have seemed difficult or even hopeless at first.

Here are some other things worth knowing about relationship-friendly counseling:

We respect your choices. A relationship-friendly therapist will not proselytize either of you to stay together. If you thoughtfully decide to leave your partner, this is your right and your choice, and we do not seek to change your mind. We do, however, explore what we can do to help.

It may not be the right approach for you. For some couples, one or both partners actively want to examine whether their relationship should end. There is nothing intrinsically wrong with this. In cases like these a relationship-friendly therapist would be a poor choice, given our focus on saving and improving relationships, and there are many excellent counselors who are better suited to exploring these issues with couples.

It has ethical implications for individual counseling. I sometimes describe couples counseling as a "one-way door." Once I work with a couple, it would be a conflict of interest to treat either partner for issues that involve their relationship. This means I will probably never serve as either person's individual counselor in the future.

This does not mean that I never meet one-on-one with partners of a couple: in fact, it is good to do this periodically, to check in and discuss issues that may not come up in joint session. Short-term individual counseling for specific issues that do not pertain to the relationship is OK too. But in general, I encourage partners to have their own counselors where appropriate.

Is relationship-friendly counseling right for you and your partner? Click here to learn more about this movement, and become an educated consumer. Counselors like me see it as an important tool for preserving and growing healthy relationships.

Thoughts on the Germanwings tragedy

When horrific tragedies like the recent Germanwings crash happen, people often ask mental health professionals what we can do about them.

My response? The answer is very similar to asking doctors if we can cure cancer.

You see, cancer treatment and mental health care have both improved tremendously in recent years, but a solution for many of the worst cases still eludes us. Whether it is metastatic cancer or the potential for violence, the answers often simply aren't there yet. So when the unthinkable happens, we instinctively grope for easy solutions that miss the mark:

-"We need better access to mental health care" (Many if not most recent mass killers had the best mental health care that money could buy - including the Germanwings co-pilot.)

-"We need better gun control"  (Nearly ever mass killer could still obtain guns legally, or used a family member's gun, or in this most recent case, was co-piloting an Airbus A320.)

-"We should do a better job of identifying these killers" (Even people with homicidal urges don't usually act on them - they don't like being dead or in prison any more than you do. But even if we could pick out the ones who might act, then what? Lock them all up just in case?)

By all accounts, this Germanwings pilot was skilled at acting normally, even on the day of the crash. Sadly, he would have needed to disclose a specific intention to harm himself or others before anyone could have done anything. Which, of course, he didn't. Like metastatic cancer, this is where we are still stuck.

So do we have an alternative to just waiting for the next tragedy to happen? Sort of. We can invest in research, and in particular, try to learn from the perpetrators who survive - some of whom have written or spoken eloquently about their struggles with their urges. (This would mean not executing them, by the way.) And while it may be small comfort to the families of the nearly 150 souls who lost their lives, we can go on with our lives knowing that situations like this are extremely rare.

We can also try to keep media reports from coloring our thinking toward the mentally ill. Every time a headline blares that this suicidal pilot suffered from depression or may have been a narcissist, it silently slanders the millions of people living with mental illnesses who would never harm anyone - which, statistically, is the vast majority of them.

I remain an optimist. We have learned more in the last century about treating mental health than in all of previous human history. Many previously intractable problems, such as severe personality disorders, are now highly treatable today. But bad things still happen that we don't yet have an answer for, and all we can do is carry on with our lives, hug our loved ones a little tighter, have faith - and keep learning.

The Wegmans Test

How can you tell how strong your relationship is?

As a marriage and family therapist, I use a number of assessment tools to test this. They tell me, in gory numerical detail, where a couple's strengths and weaknesses lie. But I have a much simpler one you can use on your very next trip to the grocery store: I call it the Wegmans test.

Here in upstate New York, Wegmans is an extremely popular local supermarket chain. Their stores are huge, and going there is a bit like grocery shopping at Disneyland. Here in my native Ithaca, NY the local Wegmans is roughly the size of two football fields, has everything from dry cleaning to a pizzeria, and is open 24 hours a day.

Which means that aisles at Wegmans are huge. Now, suppose you turn the corner into one of these aisles, and you suddenly catch a glimpse your partner off in the far distance. What is the very first thought that immediately enters your mind? That is the Wegmans test.

When I first see my spouse at the other end of the store, my first thought is always to smile and think, "Ahh ... there goes my beautiful wife." This powerful first relationship-defining thought is what lies underneath whatever ups or downs are going on between us that day. It undoubtedly governs the stance I take toward her when all else is at rest - the words I choose, the emotions I feel, and the level of partnership I bring to the relationship. It is likely the reason I am still deeply in love with her after over 40 years together.

Now, suppose you see your partner and your subconscious gut reaction is "Ugh, there is the curmudgeon I have to go home with." In all likelihood, your communications, your mutual problem-solving style, and your motivation to improve the relationship are very different from mine. And that, in turn, is why you are both so unhappy most of the time.

Marriage therapists like me make a profession of helping couples get closer, starting with learning new ways to talk - and more importantly, listen - to each other. But I could teach you all the communications skills in the world, and none of them would help if that basic, underlying spark isn't there. In fact, more often than not it would be like trying to bring a dead fish back to life. That is why the Wegmans test is so important.

So what should you do if the two of you flunk the Wegmans test? For starters, ignore most articles on how to be a closer couple. Candlelight dinners, holding hands, and even good listening skills aren't going to cut it when you fundamentally get under each other's skin. 

Instead, be honest with yourself - and better yet, each other - about what you might both need to change to bring the spark back. It might be as simple as learning to respect each other's preferences, or as complicated as unearthing past hurts and traumas in therapy. Either way, the keys to a good relationship are waiting for you right there in the produce aisle.

Of elevators and exposure

An old joke describes someone who gets stuck in an elevator, and the emergency phone rings a long-changed number that is now a therapist's office. At first the therapist tries to explain that he can't help him, to which the person exclaims, "Can't you do anything for me?" After a long pause, the therapist replies, "How do you feel about being stuck in the elevator?"

There is some truth in jest to this joke for me. I am a psychotherapist who specializes in treating anxiety disorders, and decades ago I recovered from some severe and crippling phobias myself with the aid of good therapy. Nowadays I am a pretty happy guy who experiences very little anxiety on a day-to-day basis. But one issue I've never really bothered to deal with is that I am claustrophobic and don't like to ride in elevators. And yes, I have been stuck in them before.

In a way, I am almost glad to have one piddling fear left, to observe and work with what I prescribe for others. For one thing, it isn't very life-limiting. When I go to Manhattan and have a meeting on the 38th floor somewhere, up the elevator I go. But if I am at a five-story hotel, I will ask for a lower-floor room and take the stairs. Either way there is very little motivation for me to work on this fear, so I just put up with it or accommodate it.

But what if I suddenly needed to be taking elevators a lot? Here are some of the things I would do if I were treating myself for this problem:

1) Examine my thinking. My fear is ultimately caused - and sustained - by a great deal of self-talk, most of which is false. "If we get stuck between floors, no one will know and we'll die like rats." "I'll yell and scream and make a fool of myself." "I am taking a big risk."

All of these statements are rich in what we call cognitive distortions, or errors in thinking. Elevators have alarms, emergency phones, and even the sound of my voice to people on a nearby floor. My cell phone will often work from inside the elevator. I can count the number of times I've actually been stuck on the fingers of half a hand or so, and in each of those cases I was out again within minutes. So changing my self-talk to be more accurate and rational can help the way I feel.

2) Create a gradual exposure hierarchy. I generally prescribe approaching a fear in small steps, and learning to be fully present at each step. But how can you gradually expose yourself to an elevator? After all, once the door shuts you're in, right?

In reality, there are all sorts of steps you can take with an elevator fear. Do you feel anxious just standing near an elevator, or watching people get on and off? You can start there! Then try going in and right back out of the elevator, or perhaps just go up one floor. And there are different kinds of elevators: fast, slow, glass-enclosed, and the like. Taking a small step and learning to lower its anxiety will strengthen you for every other step you take.

For example, when I did my psychotherapy internship at a large super-regional hospital in Pennsylvania, its 10-story hospital wing had slow, creaky elevators that I hated. But its attached five-story clinic had brightly-lit high-speed elevators that were always full of people - and in time, I actually learned to ride comfortably on these elevators.

3) Practice, practice, practice. Which leads to my last point: practice, even at low levels, will inevitably chip away at your fears and create progress.

During my internship, for example, I got a chuckle out of one of my fellow interns as I described how we were going to get to a meeting on the eighth floor of the hospital: walk over to the clinic, take the high-speed elevator to the fifth floor, walk back to the hospital, and go up three flights of stairs. But there I was on an elevator - and eventually I took this elevator regularly with much less fear.

Will I get over my fear of elevators someday? Stay tuned. In the meantime, there are evidence-based tools I can use if I ever need them. And I can keep them in mind even as I make my way up and down the stairs.

Coming of age

2014 was, among many other things, a year of coming to terms with age – my own, and others. My mother, who suffers from dementia, has sadly declined to the point where it is difficult to carry on a conversation with her. My mother-in-law also experienced a severe cognitive decline affecting her judgment, and after falling once too often, is now in a care facility. And this past year I reached the great age of 60 and am now preparing for my own retirement, a couple of years after my own spouse’s transition to Medicare and Social Security.

More than anything, I am confronted with the fact that if we are fortunate to live long enough, we often need the care of others. Walking through the halls of a nursing home surrounds me with an overwhelming sense of finality: no more trips to Paris, starting a new consulting project, or ducking out for a movie. Just one day after another in the same hallway, with televisions blaring, neighbors muttering incoherently, and activities that feel like being back in third grade, because you can no longer hoist yourself on the toilet or be left alone safely.

Right now, I can be smug that I will walk out the door after each visit and return to my normal life, as I hope to for many years to come. But I can’t forget that this was once the case for each of the dozens of names on these doors as well, including people I love. So what could I - and each of us - do to prepare for this day? Here are some of my thoughts:

1. Learn to live in the moment. For me personally, this will be the hardest part of my journey. I live incessantly in the future, and my good life often revolves around my next “thing.” But we all ultimately live from moment to moment. I see many good moments of connection between people in a nursing home, and I can perhaps best honor their worth by finding more joy in my own moments.

2. Have a voice in our own aging process. If there is one trait that seems to permeate an entire generation above me, it is denial. It saddens me when people insist they are fine when they clearly aren't, or refuse to have a discussion about possible next steps, and I ultimately watch decisions being made for them against their will. Few people suddenly wake up one morning with dementia or degenerative illness, and if that is my lot someday I hope to be part of the dialogue about my own care. 

3. Plan ahead. I hope that someday I will know when it is time to raise the white flag - and I am sure this will be much harder than it looks when the time comes. Especially for someone like myself who has no children to serve as truth-tellers and advocates. But if circumstances permit, I would much rather have a game plan than just hope for the best.

None of us knows what the future holds. I could be like my grandmother, who was lucid and funny right up to the end of her 96-year-old life, or my late father, whose last conversation was about his field of finite element analysis with a colleague in Europe. Or I could be run over by a beer truck tomorrow. (Don’t laugh, I live on a major highway.) Or my wife and I could end up like our mothers. Either way, I am glad to be growing older – especially given the alternative. And my goal for 2015 and beyond is to start learning to age mindfully and enjoy this mystery we call life, for as long as I possibly can.

Investing in yourself

Many years ago, after purchasing a vehicle, one of my co-workers sourly observed, "You'll never get rich buying new cars."

But actually, he was wrong. Years later, when I was starting a consulting practice, getting a new car - at a time when I had no income whatsoever - turned out to be one of the smartest moves I ever made. And perhaps one of the smartest moves YOU could make too. Allow me to explain.

Here's the backstory. In 1996, after a pretty good first year as a consultant, everything came to a very hard stop. All of my projects and clients ground to a halt at nearly the same time, and my income with it. From there, I couldn't get myself arrested. Three months later, adding insult to injury, my wheezy old car with six figures on the odometer needed major repairs.

With my tail between my legs, I went to my local dealer to try and trade for a passable used car while I got back on my feet again. Instead, the salesperson wheeled out one of the most gorgeous vehicles I'd ever seen - a brand-new, full size car with metallic paint, a sunroof, and a premium stereo system. And explained how leasing it for two years would only put a small amount of my assets at risk.

His numbers actually made sense. I could essentially "borrow" this beautiful car for two years for a modest cost, and then turn it back in if I still wasn't successful. I will never forget the feeling of having had no income in three months, no idea when I would ever work again, and driving off the lot in the nicest car I had ever owned.

Here is why it actually made good financial sense. Every time I got behind the wheel of this beautiful car, I FELT like a successful person. And ACTED like a successful person. Which made a real, tangible difference as I started knocking on doors, lining up gigs and clients, and planning my future. Soon I was back in business again, and I proudly paid that car off early and kept it for seven years.

Think about it. If you are trying to make an impression on others - for business or personal reasons - what would give you your best chance of succeeding: feeling hot, sweaty, and dirty, or feeling freshly showered and clean in a nice suit? Either feeling transmits itself to other people, and the same thing is true for the rest of your self-image. And what they perceive, in turn, ultimately governs your success.

I am not suggesting that you start taking stupid risks with your life, or your cash flow. But I do want you to rethink the hair-shirt view that self-denial is a necessity for success. What works for those types frankly wouldn't have worked for me - and I feel strongly that you should do whatever will make YOU most successful.

Nearly two decades later, I still drive around in a nice car, because I firmly believe that how you FEEL and how you ACT are major determinants of success. (My current ride is pictured above.) So whatever it takes to make you feel awesome - and then share that awesomeness with the world - seriously consider it as part of your life plan. Invest in yourself and your self-image, and I believe the rewards will often come back to you many times over.