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When Choosing a Counselor, which way do I go?

by Julie Fischer, MSE, Licensed Professional Counselor

And you thought deciding whether or not to see a counselor was tough. Brace yourself! An even more difficult decision awaits...which counselor do you see? How do you find a counselor that's a good fit for you?

For starters, perhaps an insider's view of the world of counseling would be helpful. Health Maintenance Organizations (HMOs) and insurance companies have made this world much more complicated than necessary. Let me try to decipher some of what you may know, and educate you about some things you may not know.

Despite the strict guidelines of your particular HMO, which limit you to a handful of counselors, you DO have a choice of providers for your counseling process. Not only can you decide from among those providers covered by your HMO or insurance, but you can find private practitioners who will take you on as a client. There are many professional counselors who are not "providers" for an HMO (some like me, by choice). Considering these providers significantly broadens your choices when it comes to finding a counselor that is a good fit for you. So, even though they may not be "covered" by your HMO, many counselors in private practice would take you on as a client, and work with you regarding the cost per session to make it affordable for you without utilizing your HMO coverage.

There is in my opinion, a number of reasons you may want to consider seeing a counselor who is not part of an HMO-driven counseling agency. First and foremost, HMO's are primarily about money – saving and making as much as possible. While I understand the business side of counseling and the need to make money, I also believe that any business which delves intimately into people's hearts, minds and souls should have more in mind than the bottom line of making money. And, though the counselors working within these systems may be very competent, kind-hearted and altruistic, the "good ole boys" at the top of the HMO's are not; their main concern is making money! This inevitably creates problems for many of the counselors trying to deliver quality care within this system. I know because I once was one of these counselors. Try as I might, I just couldn't provide the type of quality counseling I knew was possible within the parameters of this large money-making "HMO machine". My focus on ethics and the welfare of the clients, versus the HMO's focus on turning a profit, seemed to too often knock heads.

Secondly, the quality of service at some of the larger HMO's can be compromised. Again, not necessarily because of the counselors themselves, but because of the constraints they are made to counsel within under the direction of an HMO. Take for example, a scene I witnessed while working in one such environment. A counselor was getting ready to go out into the waiting room and greet her client -- a woman she had seen several times before. I overheard the counselor say she felt rather uneasy, because without the receptionist there to guide her, she had no idea which woman in the waiting room was her client! This counselor had so many clients in her caseload, she could no longer remember what her client even looked like! Unlike a counselor in the HMO system, a counselor in private practice has complete control over her/his schedule. Therefore, your chances of getting quality counseling (which includes your counselor recognizing you, as well as your specific issues!) are greatly improved.

Because of the large volume of clients herded in and out of HMO agencies, not only is each counselor's caseload incredibly large, but the number of clients per day is equally excessive. While I was working in such an agency, it was common to have seven clients scheduled in an eight hour day. I learned very quickly, that with the intense work of counseling, it was virtually impossible for me to deliver the same kind of quality counseling to my seventh client, as I had to my first.

One last point to consider when working with an HMO agency is scheduling. Depending on the system and your choice of counselors you may have to wait a long period of time before getting in for an initial session (anywhere from two weeks to one month); and some clients report waiting even longer to try and book a second session. Is this good counseling? Is it even ethical? No. Is it a necessary evil within a huge HMO system? Yes.

As a result of these kinds of schedules on a daily basis, many counselors "burn out". Some choose to "get out" (of the system, that is) before they are the next burn out statistic. Others begin to become unhealthy themselves by working within such a system, thus creating unbalanced, stressed out counselors, who are trying to help equally stressed out clients. Kind of a "crazy-making system" that in many ways harms the counselors and the clients they see. The only folks who benefit from such a system are the folks (usually white males) at the top, reaping all the financial rewards.

HMO's desire for time and money-saving therapy have led to the creation and endorsement of some therapy practices that are questionable at best and unethical at worst. For example, counselors within these systems are encouraged to use "brief therapy." Said to bring about changes quicker by focusing only on the problems at hand, the real gem of brief therapy for the HMO is that counselors can move large numbers of clients in and out the doors in assembly-line fashion, thus saving money and time in "unnecessary" future sessions. Much like a band-aide over a gaping wound, the result for the client is temporary relief, followed by continued pain down the road.

Another time and money-saver for HMO's are drugs. The use of anti-depressants and other medications continues to sky-rocket. According to the July, 2001 issue of Natural Health, "On average, every American swallowed more than $460.00 worth of prescription drugs last year." Pushing medications is advantageous to the HMOs because dispensing and filling a prescription is much cheaper and more efficient than paying for several hour-long counseling sessions.

And when it comes to following up with clients on medications (meds.), HMO's have devised "group med. checks". With no regard for confidentiality, clients are now told that if problems with their medications occur, they can sign up for a "group med. check" in which they can sit with any number of complete strangers and share their personal concerns about their medication. The result for the HMO --- a huge savings in time and money, because one therapist can meet with a large number of clients at one time. The result for the clients --- no confidentiality, no personalized time and attention--- in essence, no quality follow-up care.

Another long-term consequence for you to beware of when choosing a counselor is the whole "diagnosing" issue. All HMO's (and most private practitioners) utilize the "medical model" of psychotherapy. This means that you will be given a diagnostic label from the Diagnostic and Statistical Manual, Fourth edition (DSM-IV), which will go into your permanent medical records. And though there are pre-existing condition laws to prevent this label from affecting you when you switch insurance providers, I have heard many accounts in which people were denied insurance coverage because of these labels in their medical records. As a counselor in private practice, I choose not to buy into the medical model. I embrace a holistic approach to counseling, which does not include diagnosing, but focuses instead on facilitating the growth of a client who seeks improvement in her or his life.

And when it comes to permanent medical records, don't count on yours being completely confidential in an HMO setting. Most HMOs closely monitor your progress to prevent paying for more sessions than "necessary." They do this by receiving, in some cases, detailed information from your counselor about you, your life, and your "treatment plan." In this computer age, it is possible that confidential information like this could be accessed by almost anyone. This, I believe, is a violation of your guaranteed right to confidentiality when working with a counselor, but is required in any HMO system. As a private practitioner, I operate on a fee-for-service basis, which allows clients to pay on their own. Without any interference from HMOs or Insurance companies, I am not obligated to release any of your personal information.

All that being said, the choice remains yours regarding whether you look for a counselor within your managed care system or seek a private practitioner. I strongly encourage you to ask questions when you are choosing a counselor for yourself. Don't be afraid to spend some time interviewing your counselor. This person will soon know many intimate details about you, and so it is vitally important that you learn as much about them, as a professional, as possible. (If your request to meet informally with them and ask some questions is denied, this might be your first clue to steer clear of this counselor).

The following are some possible questions to ask the counselor you're considering seeing during your interview:

  1. What are your counseling credentials?

  2. It is important that the counselor you're considering have a minimum of a Master's Degree in Counseling or Social Work. Though other people may be skilled at listening and helping (friends, family members, priests, ministers, etc.) they may not have the therapeutic training or skills necessary to provide you with the best help available.

  3. What is your counseling philosophy?

  4. Your goal here is to learn more about how, specifically, the counselor works with her or his clients. If the response isn't meaningful for you, for example, if the response is "I use a Cognitive-Behavioral model", or "I most often use Transactional Analysis", ask her or him to explain, in detail, what that means in terms of how they might work with you during the counseling process.

  5. How many clients do you currently see?

  6. (In counseling lingo, What is your current active caseload?)

  7. How many sessions do you typically conduct per day?

  8. How far out are you booking?

  9. (How long will I have to wait to get in to see you?)

    Questions three, four and five will help you determine whether or not the counseling you receive will be the best quality possible, and whether or not you will be able to access counseling in a timely manner.

  10. What specific type of information will be shared about my counseling sessions? Who will this information be shared with?

  11. Ask to see the specific information that will be shared with the insurance company or HMO, so you know what will be placed into your medical record.

  12. What will you record as my diagnosis, and what does that specific diagnosis mean?

  13. Ask the counselor to rate the seriousness of the diagnosis she or he has assigned you, and how its presence in your permanent medical records might affect you down the road.

  14. Are you now in or have you ever entered into counseling as a client?

  15. This question is very important to ask, and a healthy counselor should respond with a resounding "yes". While a counselor does have specific training in life-skills, she or he doesn't have a "get out of life's problems free" card. Everybody has issues, concerns and opportunities for growth in life -- counselors included. If the counselor you intend to see doesn't value the process of counseling enough to engage in it her or himself, you might have a basis for some serious doubts about the overall health of this counselor. In fact most quality training programs require all their counselors-in-training to take part in counseling as a client to deal with their own life issues. After all, counselors can only help clients to be as healthy as they themselves are.
And finally...
Trust your intuition.
That "gut feeling" or inner knowing will let you know in no uncertain terms whether or not you are comfortable with a particular counselor. Just take the time to tune inward and listen. Not every client will be a match for every counselor. If the match isn't good for you, based on any of the above responses to your questions, or based on your intuition, don't be afraid to move on.

Best of luck in your search for a counselor, and peace to you along your journey toward wellness!

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