I’m not sure I need to be here. At 29, I’m healthy, newly and blissfully married, and professionally satisfied. I’m thrilled to be living back in Colorado after a stint in New York City; I don’t have childhood trauma, financial problems, or addictions. Yet, at 8 on a sunny morning, here I am: in therapy.
For the past few months, I’ve felt funky. Initially, I justified my cloudy disposition: This is just an adjustment phase, I reasoned, a normal reaction to the transition of being new in town, with a new job and new partner. It’ll pass on its own. But by the time I made an appointment with Kelley Gray at Grace Counseling in Littleton, I’d begun to doubt myself: After all, I’d been working in my pj’s from a one-bedroom apartment all winter—sometimes going a whole day without seeing another human. In the evenings, I’d beat myself up for another unproductive day, and catastrophize things as small as oversteaming the broccoli we’d planned for dinner. Suddenly, I was a failure. At everything. Even though I “knew” that wasn’t true, I’d lost hold of my emotions. And while The Sound of Music always brings me to tears, vegetables usually don’t. Maybe this melancholy was something to worry about.
I slink into the office, my nerves on edge and my embarrassment rising. I wonder how long it’ll take me to feel like a complete head case in the therapist’s presence. I sigh and move farther inside the lobby. Gray, a cute thirtysomething blonde, meets me and leads me into her office. “Here,” she deadpans with a wry smile, “come sit on my cliché therapist couch.” I’m immediately disarmed by her humor.
Over the next 50 minutes, I’m comforted by how this woman interacts with me. She’s more like a pal—granted, a pal with active-listening skills—than a therapist. There is the requisite box of tissues (which I did reach for a few times), but otherwise the atmosphere Gray crafts is reminiscent of an intimate conversation with your favorite aunt.
She asks carefully placed questions, emits a gritty realness, and gives sensitive, helpful feedback when I tell her about my oddly placed crying, negativity, and isolated days. Although I can feel my normal self still in there, I tell her, it’s in a corner of my gut with something heavy on top, preventing it from getting up.
She diagnoses me as “mildly to moderately” depressed.
I’m not shocked. Instead I’m relieved. She understands what I’m experiencing and tells me to go easy on myself, which makes me feel like anything but a head case.
“Depressed brains are very inclined to just believe the worst, swallow it whole,” she explains. “When you’re thinking depressed thoughts, you just can’t believe them—you need help sorting through them.”
I need to tell more people what I’m going through, she says. But when it came to my depression, I was too proud and embarrassed to reveal how sullen and defeated I felt—not to mention guilt-ridden about burdening someone with the information.
“Would you feel that way if a friend came to you with this?” she asks me. I smile and shake my head. “If I can hear you say something—and I don’t throw up in the trashcan or fall out of my chair—maybe other people won’t, either,” she says. It was a simple way of making me realize that what I was telling her wasn’t all that surprising, that other people would understand.
Our session melts away quickly, and I leave knowing I will come out better and happier on the other side of this blip of depression. I leave armed with Gray’s positivity, empathy, and sound advice for how a better attitude and better choices will eventually turn my days around. I’m just going through a hard time. And that’s OK.
As I drive away from Grace Counseling, I give a quick call to my husband. “As I suspected,” I sigh, “I have a bit of depression.” I exhale. He doesn’t fall out of his chair.
Days after my session, I thought about how therapy almost didn’t happen for me. What if I’d let all my unknowns, about who to see and where to find him or her, keep me from going? In our outdoorsy culture, it’s easy to find a mountain to climb or a bike to ride to beat back the blues, but what about when a long run isn’t going to give you the mental tune-up you need? What should a normal person do to get the care he needs? I decided to find out.
WHO DOES WHAT
What type of mental health care professional is best for you?
Psychiatrist (M.D.): A medical doctor with training in the diagnosis and treatment of mental and emotional conditions who can prescribe medication and “look at your mental health in light of your physical health,” says Matt Vogl, community programs manager at the University of Colorado Depression Center. He or she may or may not offer psychotherapy or alternative/complementary methods of treatment.
Psychologist (Ph.D. or Psy.D.):Counselors with advanced degrees in psychology, they are trained to make diagnoses and provide individual and group therapy. They can’t prescribe medication.
Marriage and Family Therapist (MFT): A counselor with a master’s degree, trained to diagnose and provide individual and group counseling.
Licensed Professional Counselor (LPC): Counselor with a master’s degree in psychology, counseling, or a related field who has passed a national exam and completed 2,000 hours of supervised clinical work.
Certified Addictions Counselor (CAC): Training in addictions with level I, II, or III certification given according to national standards and contingent upon the hours of supervised work completed.
Sources: Mental Health America of Colorado, mhacolorado.org; Kelley Gray, LPC; Matt Vogl of the University of Colorado Depression Center
Definitions are good to have on hand, but how do you know if the person you’ve got on the phone is as qualified as she says? The state’s Department of Regulatory Agencies maintains a vast, if simple, database of psychotherapists.
—Where to start: Verify that the professional you’ve chosen is registered, certified, or licensed at dora.state.co.us/dora_pages/ProfessionVerification.htm. You’ll see a bunch of departments—DORA oversees everything from hairdressers to midwives—but therapists and psychologists are there, too.
—How their qualifications vary:
Licensed Professional Counselors (clinical social workers, marriage and family therapists, psychologists, professional counselors, and addiction counselors) have college or master’s degrees, sometimes even doctorates, and have passed a national competency exam in addition to completing an online form (a $210 fee). The public is alerted to those who may practice by the title(s) listed above via the DORA database—more on that below.
Registered psychotherapists may be any of the above five types of professionals, but their requirements are typically non-practice-related: For instance, they must have insurance and use a disclosure form. There is still government oversight of their practices and the ability to file grievances, but an online form ($160) is all he or she needs to be part of the searchable database.
Addiction counselors are not designated as registered or licensed, but as certified at level I, II, or III. Certification programs offer a level of consumer protection similar to licensing programs, but the barriers to entry are generally lower. The required educational program may be more vocational in nature, but the exam still tests a minimal level of competency.
—Why would I choose registered over licensed? “A lot of people groove on not having someone who’s licensed,” says Chris Lines, a DORA spokesman, “and it’s a choice we have here in Colorado that other states don’t have. Many seek a more nontraditional practitioner who isn’t necessarily into the books and scholarship.”
—Where are the psychiatrists? Psychiatrists are medical doctors. They are licensed through the state’s Board of Medical Examiners, which is also found through DORA. dora.state.co.us/medical
—When to think twice? In fiscal year 2008, DORA logged 375 complaints about mental-health professionals. Read them at dora.state.co.us/CheckDiscipline.htm.
—When you need help—fast.
Denver Health Psychiatric Emergency Services, including mobile crisis service (drug, alcohol, or psychiatric problems): 303-602-7221
Lis’n Crisis Hotline Denver Metro (suicide, depression): 303-860-1200
Denver Veterans Affairs (PTSD, suicide prevention, substance abuse, violence prevention, and more): 303-326-0645
Metro Crisis Services For city and county of Denver residents (any “client-defined crisis,” meaning if you feel it’s worth calling about, they’ll help): 1-888-885-1222
Four ways to begin your hunt for a mental health care provider.
Try… Asking your primary-care provider
“I think PCPs should be the gatekeepers of the entire health-care system,” says Dr. Abraham Nussbaum, an attending psychiatrist on the adult inpatient unit at Denver Health. Nussbaum says people struggling with things like depression or anxiety who have a primary-care doctor they trust will often begin there, and that it’s perfectly OK to do so.
Try… Getting a recommendation from a friend or family member
“That translates really, really well,” Kelley Gray says. When you make the call, she says, mention how you heard about him or her, inquire about schedules, and confirm he or she specializes in what you need. Even if you have a minute and a half on the phone, Gray says, “you will get an impression.”
Try… Seeking the advice of your religious leader
For people of faith, the comfort and confidentiality that comes with talking to an admired leader, who likely trained in counseling as part of his or her divinity degree, can be a great place to begin. “I’m thrilled if somebody has that rich network,” Nussbaum says. “If they can go to a pastor or spiritual adviser and have their needs met, terrific.”
Try… Inquiring at your child’s school
Because most parents are likely to discuss concerns about their child’s health with family, friends, and teachers before seeing a doctor, says Dr. Vincent Collins, a child and adolescent psychiatrist at Denver Health, his hospital teams up with the Mental Health Center of Denver to jointly provide 13 area public schools with on-site access to psychotherapy.
The Shame Game
Denver Health’s Robert House and Vincent Collins are colleagues and friends, doctors, and concerned citizens, spending much of their workdays treating, and bringing greater acceptance to, mental-health issues. Here, they talk about the stigma mental health often still carries.
5280 Health: Do you think Americans view mental health care differently than physical health care?
Collins: Yes, but that does seem to be changing as neuroscience informs us that at the heart of psychiatric illnesses are biological changes in the central nervous system. So as we better understand the biological difference between people who have psychiatric illness and people who don’t, we’ll have a better appreciation for the fact that this is more similar to asthma or diabetes or hypertension than it is dissimilar.
Teachers are often first to observe mental difficulties in a child. How have you seen parents react to such information?
House: My daughter is a schoolteacher, and she hears things like: “If you were a better teacher, or if the school was better in general, my son wouldn’t have these problems.” It’s looking for blame.
Collins: When I was a primary-care provider, I got considerable push back when I’d suggest a referral to a mental-health professional. There was a strong push to say, “Well, it’s the teacher’s fault.” That’s usually the manifestation it takes—that there’s got to be an alternative explanation.
Does the stigma affect how easily people can access care?
It does. One of the sources of frustration for us is insurance companies’ “carve-outs” [benefits that are excluded from coverage and paid under a contract with a separate provider] for mental-health benefits, which reinforce this notion that psychiatric illness is to be dealt with in a separate, and usually inferior, way to physical illness. What we can and cannot do is governed by what insurance will permit.
House: I would agree. The carve-out says, “Let somebody else manage that,” and that contributes to the stigma.
Does the stigma affect how money is doled out at the state or federal level?
House: I think so, because patients with a psychiatry problem do not have a big voice with the people who run your money and policy. Whereas if you’re going to cut veterans’ benefits, all the veterans—plus their advocates—speak out.
Is the national conversation becoming more open and positive?
Collins: As a consequence of the advocacy on the part of our entertainment figures, athletes, and politicians, the stigma seems to be diminishing. Our struggle now is the stigma that we carry around inside of us.
House: I think the younger people are more accepting, like adolescents talking with each other about A.D.D., for example. When I was that age, that wouldn’t have happened at all. I certainly wouldn’t have talked about it, and my parents wouldn’t have either.
What can we do in our daily lives to contribute to decreasing the stigma?
House: Normalize it. I have a nephew who dealt with that; here’s what worked for him. Engage in a conversation around it, so it’s not like, “Oh, my God—YOU have THAT?” When people find out they’re not alone, they’re more willing to talk and problem-solve.
Does everyone have to know?
Though mental-health experts say a decrease in stigma means people these days are more open about their mental-health struggles, in the United States, national privacy laws mean the choice to reveal those details is yours alone. Even if you’re receiving treatment through an Employee Assistance Program (EAP) that may cover part of your mental health care, your rights as a patient and employee state that such consultations are confidential and may not be discussed without your consent. Exceptions include an imminent threat to yourself or public health and safety, or suspected child abuse.
Does Obamacare Care?
How health-care reform may affect mental-health medicine.
Given Colorado’s mental health care issues, it’s clear the need for treatment will continue. But amid the politicking surrounding health-care reform, the important question has remained unanswered: What changes will the average Coloradan see when reform kicks in during 2014?
Most experts say it’s a near certainty that mental health care will be included in the government-backed insurance plans. However, no one seems to be able to say to what extent. “We know mental-health services must be part of the package of benefits being defined in health-insurance exchanges,*” says Moe Keller, vice president of policy and systems advocacy for Mental Health America of Colorado. The dilemma? The federal government has yet to lay out any baseline definitions.
Once it does define a minimum standard for mental-health coverage—and opinions vary on whether that will be before or after the 2012 elections—Keller says the question then becomes whether the national standard will be “lower” than our state’s existing standards. For instance, as it stands now in Colorado, if a person has mental-health coverage through his or her insurance (and works for a company with more than 51 employees), mental-health coverage must be equal in scope to the physical health coverage.
Worst-case scenario? If the national coverage is not as comprehensive as what we have in Colorado, our state’s Medicaid patients could be responsible for the entire cost of their treatment (as opposed to the current 50/50 state/federal split). On the private-sector side, if the state wanted to put such coverage demands into the packages offered by the insurance exchanges, “we’d have to pay the entire cost to our general fund,” Keller says. “That would be a pretty significant hit.”
*Government-regulated online marketplaces where private or public insurance plans (with different levels of coverage) are offered to small businesses or individuals without health care.
By The Numbers
335,000: The number of Colorado adults (10.2 percent) that are on medication or are receiving treatment for a mental-health condition or emotional problem.
228,417: The number of adults, comprising 7 percent of Colorado’s population, who met the criteria for depression in a 2008 study by the state health department.
12: Percentage of Colorado adults who have, at some point, been diagnosed with anxiety.
14.8: Percentage of Colorado women who experienced anxiety in 2008, compared with 9.8 percent of Colorado men.
25 to 64: Age range of Colorado males who comprise the greatest number of suicide deaths each year in the state.
6th: Colorado’s rank in the national suicide rates in 2007, the last year for which statistics are available.
30: The average age of onset for a mood disorder in the United States.
Early 20s: The age at which most people with a mental-health issue will begin treatment.