[HN Gopher] Finding a therapist who takes your insurance can be ...
___________________________________________________________________
Finding a therapist who takes your insurance can be nearly
impossible
Author : rntn
Score : 116 points
Date : 2024-08-25 16:12 UTC (6 hours ago)
(HTM) web link (www.npr.org)
(TXT) w3m dump (www.npr.org)
| impendia wrote:
| Both of the therapists I've seen made it clear up front that they
| refuse to deal with insurance companies, and expect payment up
| front. The health insurance industry would make Franz Kafka
| proud.
|
| That said, I was surprised when I mailed a bunch of bills to my
| insurer, and requested reimbursement. I figured I was probably
| wasting my time, but why not see what happens.
|
| Anyway, they mailed me a check. The bills were higher than what
| my insurance would cover, but my insurance decided to cover a
| substantial portion.
| 23B1 wrote:
| Yep. A lot of people are unwilling to fight their insurance and
| the insurance providers are depending on this. Same with
| billing departments in the various healthcare systems, etc.
| pedrosorio wrote:
| > I mailed a bunch of bills to my insurer, and requested
| reimbursement (...) Anyway, they mailed me a check
|
| This is not what I'd describe as "fighting your insurance".
| impendia wrote:
| I've had frustrating experiences with my insurance before,
| but indeed in this case I just mailed in a form.
| nradov wrote:
| There's no reason to be surprised. This coverage benefit was
| probably clearly stated on your summary plan description. These
| are short, simple documents that most health insurance plans
| are legally required to distribute to members.
|
| https://www.dol.gov/general/topic/health-plans/planinformati...
| impendia wrote:
| Perhaps someone else would not have been surprised in my
| shoes.
|
| But, rightly or wrongly, reading my health insurance
| documentation feels to me like staring into the abyss.
| Indeed, I admit that the expression "clearly stated" provokes
| exactly the sort of dread I'm describing; it feels like the
| sort of thing a hospital or insurance company would say while
| sticking me with a massive unexpected bill.
|
| Whether my reaction is reasonable or not, I can't say, but I
| do feel deep empathy for the therapists out there who balk at
| dealing with insurance companies.
| senkora wrote:
| Thank you for inspiring me to read my health insurance plan's
| SPD. I learned some stuff.
| 23B1 wrote:
| Also hard to just find a therapist, let alone one you like. The
| simple fact is that there's plenty of demand and zero supply.
| This is why you see so many 'personal' and 'life' coaches now
| btw. It's an absolute cluster.
| falcolas wrote:
| In every other respect, I have excellent insurance. But the shit
| they put my therapist through seriously makes me wonder why she
| even bothers. Every story in that article echoes her own
| experience with insurance.
| firesteelrain wrote:
| This is very true. My Wife has seen a therapist for dealing with
| her dad's death and her mom's new boyfriend situation as well as
| mom's irrational behavior. Luckily I have been saving in an HSA
| for nearly ten years. Paying for it is no big deal. My company
| also had free sessions as part of our company provided employee
| assistance program.
| AndrewKemendo wrote:
| The key legal and economic goal of a privately owned health
| insurance company, is to become entrenched as a legally required
| intermediary between patients and the "medical cartel." So
| functionally the optimal approach for an insurance org is to
| ensure that they are only required to reimburse for expenses that
| are mandated by law. Then the trick is to reduce the number of
| mandatory payments through regulatory capture and obfuscation.
| See: Medical Biller role at each hospital and lack of consistency
| transparency etc...
|
| Therapists are not considered part of the medical cartel because
| they are not required to go to medical school or pass the
| licensing process for "Doctors." They can't increase the service
| costs unilaterally into longer term revenue. This is why it's
| trivial to find a covered psychiatrist - because they legally
| prescribe medicine which is the best possible outcome for an
| insurance carrier - their equivalent to SaaS margins.
|
| So therapists aren't legally "Doctors" and as a result they do
| not have the legal avenues to create an invoice that a health
| insurance company would accept as mandatory to pay by law. So
| there's only downside to an insurance provider for this.
| nradov wrote:
| That's not really accurate from a legal or health plan
| perspective. Therapists aren't physicians but they do have
| somewhat similar (though lower) legally mandated licensing
| requirements.
|
| https://www.bbs.ca.gov/applicants/
|
| Therapists are considered healthcare practitioners. They have
| NPI numbers. They can submit claims for professional services
| to payers using NUCC 1500 forms or X12 837P transactions, just
| like physicians.
|
| Therapists can choose to join health plan provider networks,
| just like physicians. On most health plans even out-of-network
| therapy is covered, but the patient financial responsibility
| may be higher. Mental health parity with medical benefits is
| legally required (although some payers aren't fully compliant).
|
| https://www.cms.gov/marketplace/private-health-insurance/men...
|
| There is a legitimate shortage of licensed therapists in many
| areas because education is expensive and reimbursement rates
| are low. Most therapists still work in small, independent
| practices rather than as part of large health systems so
| dealing with insurance billing is a huge hassle and overhead.
| Thus many therapists don't join health plan networks and
| require patients to pay directly.
| jaybrendansmith wrote:
| This is absolutely true, all of it. The insurance companies do
| not have the incentive to do what is best for the patient. I've
| been shocked at how little they were willing to cover, with very
| little justification, even when extreme depression and suicide
| was a possibility. Just think, they are willing to spent north of
| $1 million on a patient for complex cancer surgery, but are
| unwilling to spend 20k to pay for therapy that is proven to
| prevent a suicide.
| warkdarrior wrote:
| Cancer when left untreated costs the insurance a lot of money,
| even if only for palliative care. Suicide on the other hand is
| a one-time event with minimal, if any, insurance cost. It's a
| trivial business decision.
| feoren wrote:
| Someone who has killed themselves is no longer paying you a
| monthly premium.
| Kamq wrote:
| In the US, the insurance is probably through (and mostly
| paid for by) the employer. As long as the employer hires a
| replacement, they're back to where they were.
|
| As depressing as it is, I bet there's a table out there
| that covers this (and the risk that the replacement is
| poached from some other company that pays the same
| insurance company).
| donatj wrote:
| Our current and our previous major insurance companies both have
| covered therapists listed along side other types of doctors on
| their website.
|
| Made it super easy for us to find one. My wife saw one literally
| in walking distance from our house.
| Spunkie wrote:
| My insurance just flat out says therapists are excluded from
| coverage.
| theGnuMe wrote:
| You must have a grandfathered plan because the ACA mandated
| access and equal reimbursement for mental health vs medical.
| PretzelJudge wrote:
| A PhD in psychology takes 6 years to complete plus another year
| for licensing. A PsyD is a little bit less, but typically you pay
| high tuition during that time, whereas most PhD programs are free
| (with a small stipend). So, you make little to no money (or pay
| money) for a long period of time and then you are presented with
| a choice to take or not take insurance. If you choose the former,
| you:
|
| - Get paid half as much
|
| - Have to deal with filing claims, which ultimately becomes an
| additional expense, since chances are you have to pay someone to
| do this for you.
|
| - Get your money later instead of now.
|
| - Have to keep meticulous notes in case you ever get audited by
| the insurance companies, who can refuse to issue payments if your
| notes don't meet their standards.
|
| - Have to lose patients when their coverage runs out
|
| Meanwhile, there's overwhelming demand for therapists in many
| cities and plenty of people who will pay cash. I truly believe
| that many therapists are not in it for the money... but if they
| are going to make less money, let's at least figure out a way to
| handle the bureaucracy so that their jobs are more enjoyable.
| BeetleB wrote:
| You don't need a PhD to get a license...
| nothercastle wrote:
| But very few non phd therapists practice evidence based
| medicine
| r00fus wrote:
| Most therapists I've spoken to aren't PhDs and the one we
| do work with isn't noticeably better for outcomes.
| hiddencost wrote:
| lol you have that backwards. The LCSWs tend to be evidence
| based, the PhDs are busy working on their book promulgating
| their theories.
| nothercastle wrote:
| Lcsw are more like someone you go talk to when you are
| having a bad day not so much when you need to manage
| chronic pain, anxiety or ptsd.
|
| Insurance understandably does not want to reimburse much
| for that.
| meroes wrote:
| And yet you produced zero evidence. The irony is off the
| charts.
| notepad0x90 wrote:
| if the government directly subsidized healthcare instead of
| relying on the insurance middlemen to perform its duties, this
| wouldn't be an issue.
| JumpCrisscross wrote:
| > _if the government directly subsidized healthcare instead
| of relying on the insurance middlemen to perform its duties,
| this wouldn 't be an issue_
|
| Most psychiatrists I know refuse to take Medicare because it
| has the same paperwork and pricing issues.
| CPLX wrote:
| Medicare is not direct. Direct would be if the therapist
| worked, on salary, as a therapist, and received a paycheck
| from the government.
| lolinder wrote:
| That isn't what "directly subsidized" means, though,
| that's "directly run". A subsidy is a strictly monetary
| arrangement, not one where the government actually
| becomes the employer.
| nradov wrote:
| It would still be an issue. Even countries with socialized or
| heavily subsidized healthcare systems tend to have long
| waiting lists for therapists and strict limits on the number
| of sessions. Services are rationed everywhere.
| nanoxide wrote:
| The issue is similar in Germany, where the vast majority has
| mandatory insurance: Too few therapists for too many people.
| Even in large cities you might wait months, if they even have
| waiting lists. It's much easier if you pay by yourself.
| jononor wrote:
| Same in Norway, which has a directly subsidized phealthcare
| system for all.
| ransom1538 wrote:
| Canada: Sure you will never see a doctor, but, when you do
| it is free!
| suzumer wrote:
| Do you live in Canada?
| lolinder wrote:
| I take it you haven't ever interacted with the IRS beyond
| filing the standard deduction? Or interacted with
| Medicare/Medicaid?
|
| The only issue raised by OP that would go away if it were
| managed by a US government bureaucracy instead of a private
| company would be people running out of coverage, and that
| only if healthcare were subsidized universally.
|
| And to preempt the comments saying it doesn't have to be this
| way: it doesn't matter what if US government bureaucracies
| are incompetent by the design of politicians or by necessity,
| the point is that _they are_ , and the idea that this case
| would be the exception is just wishful thinking.
| beedeebeedee wrote:
| Government support should start a few steps before payment
| and filing taxes. The solutions that would fix this problem
| are analogous with having free education instead of student
| loans
| lolinder wrote:
| Now we've moved on from talking about direct government
| subsidy to talking about completely government-operated
| medicine.
|
| And for that, I'd like you to point me to a state with
| government-operated medicine that _doesn 't_ have a
| therapist shortage. Because I'm hearing from several
| people in this thread that their countries have the same
| problems.
| beedeebeedee wrote:
| No we haven't- these problems aren't only reducible to a
| few categories (i.e., free market vs government
| operated). The shortage of therapists indicates at least
| an awareness of discontent among many people, and a
| desire for help (whether just listening, coaching, or
| deeper interventions). Those relationships used to
| involve family and friends, but we understand that a
| therapist is better suited because of better training and
| less conflict of interest. We don't need trained
| psychologists for all of those relationships, and much of
| it could be solved through other relationships that
| provide comraderie and fraternity- even in a racquet
| club, finding other people to help you understand the
| world and support you. That provides an alternative role
| for government to intervene, instead of the government-
| operated medicine boogieman. In this case, the government
| insuring that more people have leisure time to join
| clubs, go hiking, spend less pressured time with family
| and friends, would go a long way to improve the problem.
| That is a different approach from the financialization of
| cultural life that pervades most government approaches,
| but it would be much less costly and reap greater rewards
| notepad0x90 wrote:
| The IRS and the USGOV in general is much more lax on
| preventing citizens from having free money. I get tax
| return refunds I shouldn't, plenty of people cheat the
| system and get away with it. For profit insurance companies
| are harder to cheat. If an insurance company refuses a
| claim, what are you going to do? go to another insurance
| company that will do the same thing? If the government
| refuses a claim, you can vote for the other guy. The
| government is comprised of "we the people", so it is in the
| best interest of the people for it to take place of
| insurance companies, which are certainly not comprised of
| "we the people".
|
| You should also understand that I am not suggesting that
| insurance companies should be banned. If you don't like the
| USGOV subsidy, you or your employer can still subsidize
| private insurance for you. But now, insurance companies
| have to compete with the government!
| wbl wrote:
| I fucked up my taxes one year. I filled out the form
| letting them know I had made a mistake and paying the
| amount and that was the end of that.
| lolinder wrote:
| I messed up an insurance deadline one year. I called in
| and they sorted it out.
|
| I didn't say the IRS was worse, I just said it wasn't any
| better.
| ToucanLoucan wrote:
| > I take it you haven't ever interacted with the IRS beyond
| filing the standard deduction? Or interacted with
| Medicare/Medicaid?
|
| _raises hand_
|
| I have! I've actually worked a shocking amount with the
| IRS, not because I'm a criminal but because I'm working
| class and wasn't educated on how to file taxes more
| complicated than a 1040-EZ, presumably because it was never
| expected I would make that much money or own my own
| business.
|
| Strictly my experience, I would much, much rather deal with
| the IRS than my insurance company. Yes, they're
| intimidating at first, but ultimately every person I've
| worked with both at the IRS and my state agency has been
| calm, professional, and frankly to a degree I found
| surprising, extremely understanding about how badly I
| fucked up my taxes on a number of occasions. I was never
| treated like a criminal; they explained what I did wrong,
| how they found out, what I owed, and how to prevent those
| issues in the future. And I was given interest-free payment
| plans with a one-time administrative cost to setup, that I
| now pay monthly. I'll be fully 0'd out in about 2 years.
|
| This contrasts sharply with my experience with my insurance
| company! My insurance company tries to get out of paying
| for every last thing they can manage. My dental insurance
| has a maximum pay out of a measly $5,000 per year, which
| seems completely backwards to every other insurance I have
| ever had, but what do I know. You know how fast you can
| crush 5 grand in dental work? And paradoxically it still
| has co-pays, so apparently I'm paying so they will cover
| _most_ of _some_ bills, up to a predetermined maximum.
| Additionally, since I own my own business, I do have the
| luxury of choosing my own insurance, which most people can
| 't, and for that luxury I pay simply _princely_ sums each
| month to insure both myself and my spouse. I 've picked the
| best for my area (at time of comment) and have to spend
| many many days of unpaid labor every year re-evaluating
| that choice, both because circumstances and networks change
| coverages, and because every single year my insurance goes
| up despite both of us, by and large, being quite healthy,
| and I get fucking annoyed about it and want to see if I'm
| getting my money's worth. I wouldn't say I am by a long
| shot, but the alternatives cover less, and cost more, so
| I'm still paying.
|
| Frankly, and I don't mean this as a personal attack against
| you, but I have to assume people who talk like you have
| never interacted directly with the IRS, and are instead
| absorbing that opinion through the same cultural osmosis I
| did, because I too was initially terrified to the bone when
| I got my first letter from them several years after
| starting my company, and honestly, they are incredibly
| over-hyped. The only way to truly get the IRS to take you
| to to task is to, for years on end, purposely try and
| weasel out of paying taxes.
|
| I would LOVE, absolutely LOVE, the ability to get my
| healthcare funded via an organization templated off the
| IRS.
| YawningAngel wrote:
| It's also country specific. HMRC in the UK are pieces of
| shit I wouldn't scrape off my shoe
| lolinder wrote:
| To be clear, I'm not talking about the cultural fear of
| the IRS, I'm specifically referring to the idea that
| patterning insurance after the IRS would solve most of
| the issues that OP brought up:
|
| > - Have to deal with filing claims, which ultimately
| becomes an additional expense, since chances are you have
| to pay someone to do this for you.
|
| > - Get your money later instead of now.
|
| > - Have to keep meticulous notes in case you ever get
| audited by the insurance companies, who can refuse to
| issue payments if your notes don't meet their standards.
|
| This description could be lifted up and dropped in to be
| describing my tax situation each year. Meanwhile, I've
| never interacted with the kind of nightmarish insurance
| companies that some people have, so I'm strictly
| comparing two relatively painful bureaucracies, not
| nightmare stories about either one.
| KptMarchewa wrote:
| Next time, for comparison, choose a country where half of
| the political spectrum does not deliberately gimp
| goverment's ability to do things just to prove government
| can't do things.
| lolinder wrote:
| We're commenting on an article from a US news outlet
| about the situation in the US. I wasn't going to start
| talking about a random other unrelated country when
| people are proposing solutions for this one.
|
| Also, I attempted to preempt these comments. They're not
| clever or new or even particularly accurate:
|
| > And to preempt the comments saying it doesn't have to
| be this way: it doesn't matter if US government
| bureaucracies are incompetent by the design of
| politicians or by necessity, the point is that _they are_
| jdgoesmarching wrote:
| LPCs, MSWs, LCPCs, LMHCs make up a much larger portion of
| therapists over PhDs and PsyDs. All take much less schooling.
| timr wrote:
| I know someone who is in training to be a therapist. It still
| takes an absurdly long time and a lot of money to get any of
| those degrees. In New York, for example, there's a mandatory
| multi-thousand-hour internship that essentially treats you as
| indentured labor for several years -- and this is _after_
| getting a masters, which you usually pay for. The average
| case ends up substantially in debt, for a field where private
| practice pays mediocre salaries.
|
| (Hot take: the masters was the truly offensive part of the
| equation -- most of the content was total bullshit / pseudo-
| intellectual woo. At least you're getting supervised
| practical training in the internship, even if your salary is
| low.)
| pas wrote:
| for anyone else wondering WTF is going on :P
|
| LPC - Licensed Professional Counselor, 24 states + DC
|
| LMHC - Licensed Mental Health Counselor, 7 states (NY)
|
| LCPC - Licensed Clinical Professional Counselor, 7 states
| (IL)
|
| LPCC - Licensed Professional Clinical Counselor, 6 states
| (CA)
|
| ...
|
| MSW is likely Master of Social Work
|
| ( https://www.psychotherapynotes.com/decoding-counselor-
| alphab... )
| smeej wrote:
| Where are you getting state counts, and what do they mean
| here?
|
| As far as I know, most states have procedures for licensing
| several of these categories, and a couple more besides
| (Licensed Marriage and Family Therapist, for example).
| Arubis wrote:
| Finding an insurer that pays therapists a rate in line with their
| level of education and specialization can be nearly impossible,
| and time spent filling out the billing paperwork (often only to
| be rejected for payment or even "clawed back" after the fact)
| isn't billable.
|
| Many folks I know that have private clinical practices address
| the tension between this and ensuring that there's access for
| people that can't afford the full rate out of pocket by charging
| a really high rate for most patients and then doing sliding
| scale/pro bono work.
| nothercastle wrote:
| Keep in mind that most therapists only get to keep 50-60% of
| the paid rate. So if insurance covers 200$ an hour, they take
| home 100-120. Which seems decent until you realize they only
| have 5-6 or so billable hours a day and the rest is paperwork
| and insurance bs. Also a typical Ph.D had an additional 10 or
| so years of post secondary education income/opportunity loss.
| pipeline_peak wrote:
| >"The way to look at mental health care from an insurance
| perspective is: I don't want to attract those people. I am never
| going to make money on them,"
|
| Exactly why healthcare should be a human right and not a
| business. As someone who's grown more conservative over the
| years, this is where I draw the line. Unfortunately since people
| will always see mental health as secondary to physical, this will
| always be overlooked.
| feoren wrote:
| > As someone who's grown more conservative over the years, this
| is where I draw the line
|
| At the thing that personally affects you. Just like all
| conservatives: all problems are fake problems until they're
| real for you. Disgusting.
| pipeline_peak wrote:
| Never claimed it personally affected me. You can think it
| does because that's convenient and fits your narrative but we
| both know you don't know.
|
| Comments like these are lazy, destructive and downright
| judgmental. They only further explain why we can't get along,
| take care friend.
| jeffheard wrote:
| So let's set aside for just a moment the notion of single payer
| healthcare as an answer to this. Why hasn't a point of
| competitiveness between insurance companies ever been that they
| keep your workforce healthier, more productive, and easier to
| retain than the competition?
|
| The biggest cost to an employer is always their roster. The fewer
| sick days people need, the less burnout causes them to churn, and
| the healthier and happier people are overall, the lower the
| training, recruiting, and redundant staffing cost.
|
| It feels natural to me that in an employer paid healthcare system
| like the one we have in the us, the employer should demand the
| highest quality coverage possible by that metric as long as it
| reduces staffing overheads.
| galdosdi wrote:
| My guess is that despite the strong long term overall link,
| it's too difficult to draw a meaingful link between any
| particular executive decision on this and any particular
| outcome, causing a tragedy of the commons. I think it's a good
| guess because it's a powerful explanation for many other such
| questions about "Why don't they just ____?"
| coryrc wrote:
| My employer offers therapy solutions like Lyra, so somebody
| agrees with you. No reason for BCBS to be involved.
| Mountain_Skies wrote:
| By far the number one thing any employer I've worked for has
| done to reduce my number of sick days and visits to the
| doctor/pharmacy was remote work. Offices and gathering large
| numbers of people from over a wide area into a confined space
| by its nature is a vector for spreading infections. This is
| before even getting into issues like what a stressful commute
| does to the body and how it limits one's time that could,
| though not necessarily will, be used for healthier activities.
| But just the elimination of picking up colds, flus, and other
| infections from the office has had a significant impact on the
| number of sick days I've used. There also have been times when
| I was sick but not too sick to be productive. In the past I
| would have had to consider if using up a sick day and having no
| productivity was a good trade-off for not going into the office
| and possibly infecting others.
| janalsncm wrote:
| > competitiveness between insurance companies
|
| Maybe we should question this assumption that insurance
| companies intend to compete. It strikes me as very difficult to
| compare insurance companies. Some of them don't even keep up to
| date information about the doctors that are in network (you
| have to call the doctor to ask).
| nradov wrote:
| Payers (insurance companies) do compete aggressively, but
| they mainly compete on issues relevant to benefits
| administrators who make the decisions at large employers
| about which health plans to offer to employees. Those
| administrators need to hold down costs for self-insured
| employers, and having larger provider networks means higher
| costs.
| matrix87 wrote:
| > The fewer sick days people need, the less burnout causes them
| to churn
|
| I mean, does more therapy lead to fewer sick days though? Or
| more sick days?
| feoren wrote:
| Because those are long-term effects, and most companies have
| literally zero decision makers with any incentive to care about
| the long term. They all know the game. They're there to
| parasitize as much value as possible from the company or its
| common-stock holders in the short term and then fail upward and
| repeat the cycle. The long-term health of the company is
| completely irrelevant to everyone who matters.
| nitwit005 wrote:
| People switch insurance fairly frequently, so if you could pay
| to improve someone's health, the insurance company is not all
| that likely to see much benefit.
|
| Most employees at my current firm stay 2-3 years. That means
| that if you could "fix" a medical issue, it would often need to
| pay for itself in a year or two, which is unlikely.
|
| Unfortunately, the economics to seem to favor what the
| insurance companies are often accused of doing: finding excuses
| to deny treatment.
|
| Edit: Typo
| grecy wrote:
| Increasing employee pay would also boost morale, but it would
| be detrimental to retention - move money in their pocket means
| people have more options to quit outright or find a different
| job.
|
| The same applies to good healthcare - employers WANT their
| employees to be utterly dependant on them and just barely
| scraping by so they're stuck.
|
| Crappy coverage is a feature, not a bug.
| robswc wrote:
| I often wonder if therapy is "over prescribed" these days.
|
| I've struggled with various problems and therapy has seemingly
| always made it worse. We would "explore" things which caused me
| to dwell and dedicate so much brain power to "untangling" ideas.
| Eventually, I would always be "cured" after some relentless
| distractions and not the therapy. I truly believe the therapists
| wanted to help, and our progress felt real... but looking back,
| it was probably worse than doing noting.
|
| I bring this up because I believe some people need therapy, but
| many people are encouraged to seek it out for problems that could
| be overcome with other methods, causing a "therapist shortage."
| This has downstream effects, like the one posted here.
| DevX101 wrote:
| Agreed. There's a lot of therapy that used to be addressed via
| talking an issue out w/ friends/partners/family/church, or
| other built in cultural institutions. There's a lot of therapy
| that our in person social networks should be doing (and we
| should be giving). As we become more lonely and our social
| institutions fall, it opens the door for the therapization of
| our modern culture, which seems like a bandaid on a deeper
| problem. This isn't to admonish therapy, but ideally it should
| probably be for more severe issues.
| borroka wrote:
| I will go even further than that. Talk therapy is the scam of
| the 2000s. The trickle that brought what we call therapeutic
| language into everyday life, the constant references to the
| narcissism of a partner who, if we are honest, had the great
| fault of just not wanting us anymore, the masochistic lingering
| over traumas that are nothing more than everyday life, the safe
| spaces, the escape from responsibilities that should be ours
| but we have been taught to assign to society, has had
| disastrous effects on human relations and also on political
| discourse.
|
| On top of that, I have rarely, if ever, found people
| participating in talk therapy getting better. If it were a
| pill, no honest doctor would prescribe it.
| sneak wrote:
| Cognitive behavioral therapy, the most common type of "talk
| therapy" these days, shows effectiveness on par with
| medications in a broad range of studies with good
| methodology.
|
| It is important to remember that anecdotes are not data.
| borroka wrote:
| What kind of medications are we talking about, for what
| "issue" (suicidal thoughts or "my parents are disappointed
| because I did not go to college and I am feeling
| worthless") and what is the effectiveness, especially long-
| term, of either medication or talk therapy?
|
| I certainly present anecdotes, and I also live in this
| world and I notice and I observe and I evaluate. The
| comment I am responding to does even less.
|
| The second scam is, of course, couples counseling. I have
| sporadically watched Showtime's "Couples Therapy," and I
| know several people who have gone to a couples therapist.
| The cost of a 50-minute session with the therapist
| presented on the show seems to be $700. After watching
| parts of the program, I can give my prescription to all the
| couples featured, free of charge: You need to break up and
| find someone else. It may be a collection of anecdotes, but
| I have yet to see a couple "fall in love again" or "settle
| their differences" after expensive couples counseling
| sessions. It's time to move on.
| Veen wrote:
| Does that demonstrate that therapy is effective or that
| medications are ineffective?
| hirvi74 wrote:
| Not the GP, but I'll comment about ADHD, since that is
| what I have relevantly read research about.
|
| For ADHD, it appears that therapy < medication < therapy
| + medication.
|
| When compared head-to-head, therapy is almost as useful
| as medication, but the issue with therapy is that once
| the patient stops attending, the benefits tend to
| diminish rapidly.
|
| However, therapy tends to have less side-effects and less
| stigma. According to some research, medication efficacy
| also tends to diminish overtime as well.
|
| For other conditions, I cannot tell you. I feel like it
| would be too large of a brush to try and paint with. I
| could see conditions like personality disorders not
| benefiting from medication as much as therapy. Conditions
| like schizophrenia might not truly benefit from either.
| For conditions like depression and anxiety, I think the
| medications are efficacious if not perhaps less so than
| therapy, but do not quote me on this one.
| robswc wrote:
| CBT worked well for me. Unfortunately though after the
| first few weeks, doing the exercises and thinking about my
| problems seemed to reel me back into the gravitational pull
| of my problems right as I felt I was escaping. As you point
| out, its an anecdote and a sample size of one... but is a
| factor in my opinion.
| robswc wrote:
| Mostly agree with this. In my heart of hearts I truly believe
| many problems are best left to be abstractions and not
| "explored." When you explore your problems, you dwell on them
| and when you dwell on them, you're often not in a good place.
|
| It is all anecdotal of course but like you, I notice that my
| friends and family that constantly go to therapy never seem
| to get better... and often times worse. I don't think its a
| case of correlation either, I think they've just made a
| mountain out of molehill.
|
| Now, I do want to say there are _many_ people that absolutely
| need therapy. I think if you just can't function, you need
| professional help. That shouldn't be discouraged.
| kylehotchkiss wrote:
| I'm thinking aloud with you here and not dissuading anybody
| from taking care of their mental health but wow people really
| need to learn long term coping techniques. The amount of times
| I see the word "gaslighting" used to describe everyday
| interactions has really made the word meaningless in sincerely
| emotionally abusive situations. Tiktok brain telling everybody
| that they are screwed together wrong really should be addressed
| at a policy level.
| robswc wrote:
| I've noticed this too. Like you, I hate expressing the idea
| that therapy is "over prescribed", lest someone with real
| issues put off not going... but man, people over complicate
| things.
|
| Knew someone that went to therapy b/c they constantly thought
| the world would end any second. Why? Because they kept going
| on reddit/the internet where every top comment is "the world
| will end soon." They would talk about their "progress" and
| all sorts of techniques. Their life seemingly revolved around
| their new problem to the point you didn't want to hang out
| with them very long because it would come back to their
| issues. IMO, the "cure" to this problem is talking a long
| walk in a park or downtown and get the hell off the internet.
| Out of curiosity, I just checked and they're still posting...
| latest posts are about monkeypox and how it will kill
| hundreds of thousands... sad to see.
| kylehotchkiss wrote:
| The world ending would be less treacherous than living each
| day with the fear of it. Yeah, the cure is just to live in
| the moment. This is a coping technique. Kids need to be
| taught this stuff in school.
| zeroCalories wrote:
| I don't think the problem is that people can't be helped, I
| think the problem is that most therapists are bad at their job.
| I would not meet with anyone that has not gotten a PhD
| equivalent or gone to med school at a reputable place.
| robswc wrote:
| I can agree with this.
|
| Just a quick anecdote. One of my problems was public
| speaking. This was in HS so my parents and teachers
| encouraged therapy. Unfortunately, this now meant dwelling on
| my fear of public speaking 3 times a week. We went so "deep"
| with why I was afraid but tbh it was probably best to keep it
| as simple as "I'm afraid to mess up"
|
| I was "cured" of this fear by a damn video game. It was
| coming out the day of my presentation and 90% of my brain was
| focused on the anticipation of the game, only 10% left to
| worry about the public speaking. I got up, did the
| presentation on autopilot and then realized "oh, this isn't
| the worst thing ever" and never had a problem after. Sure, I
| get nervous but before I would actually throw up on days I
| knew I had to speak so... I consider it cured :)
|
| My therapist was a great and qualified person... but I think
| I would have never made any true progress... just dwell on
| and dissected my fear into adulthood.
| harimau777 wrote:
| For what it's worth, I have a family member who ran a non-
| profit mental health clinic. According to them, studies have
| found that advanced degrees have little impact on outcomes.
| From what I recall, he argued studies showed that the key
| elements for a successful therapist where following some sort
| of framework/plan (e.g. cognitive therapy, behavioral
| therapy, Jungian therapy, etc.) and to be contentious (keep
| records of each session, come into each session with a plan,
| etc.).
| nothercastle wrote:
| It's not the degree that matters, it's just that most
| people have no way to screen for properly trained
| practitioners of one of the above plans. A top school will
| be more likely to have trained the students in these plans
| correctly by experienced trainers
| opihnb wrote:
| About me: tenured faculty at APA and APS accredited
| clinical PhD program. Went to a top clinical program in the
| US.
|
| Your family member is correct. However, the
| "framework/plan" in that research is _not_ necessarily a
| manualized empirically supported therapy, it 's having some
| kind of guiding theory about what's going on and a plan for
| how to proceed. Much more basic than the EST idea. Research
| generally doesn't show any replicable differential effect
| of therapy paradigm, especially after you control for
| publication bias.
|
| Many of those studies of experience and degree were done
| long ago though, and I'm kind of interested how more recent
| studies would hold up.
|
| In general though the most important things are having some
| working theory and plan about the client, rapport and
| comfort between the client and therapy, things like that.
| What makes therapy work is sort of nebulous and hard to pin
| down.
|
| There are studies, for example, showing that there are
| better therapists than others, but figuring out what makes
| someone a good therapist has been much more difficult, and
| to the extent researchers have done so, it doesn't really
| track well with the manualized protocol-driven paradigms
| that have dominated the scientific therapy literature for
| the last 30 years or so.
|
| It makes me wonder if what someone needs is highly
| individual-specific, and part of the trick to doing good
| therapy is figuring that out all around, and successful
| rapport stems from that.
| nothercastle wrote:
| Absolutely this. Only trust phds from top schools
| practitioners of evidence based therapies. Unfortunately
| there is a lot of quality dilution in the field and good
| practitioners don't get reimbursed any more than quacks
| harimau777 wrote:
| I suspect that the opposite may be true: That everyone needs
| talk therapy and this was traditionally provided by pastors,
| village wise men, extended family co-habitation, etc. Like many
| things in life, as our society has become more complicated and
| specialized, clinical social workers have become the
| specialists who perform that role for many people in society.
| robswc wrote:
| I could agree with this. I believe there is a benefit in not
| having "on-demand" access to a therapist and boundaries with
| the people you talk with.
| gruez wrote:
| >I often wonder if therapy is "over prescribed" these days.
|
| Relevant: "Bad Therapy: Why the Kids Aren't Growing Up"
| https://www.amazon.com/Bad-Therapy-Kids-Arent-Growing-ebook/...
| pas wrote:
| can you please provide a tl;dr? what's the main argument,
| what data is it based on?
|
| ...
|
| okay, I didn't want to be that lazy, so looked up the author.
| (Her name is interestingly not on the cover :o)
|
| Abigail Shrier, hm. okay, at least there's a wikipedia page
| about her. she seems to be a layman when it comes to
| psychology/psychiatry. and her 2018 book about "Transgender
| Craze" ... uh, okay.
|
| ...
|
| https://thingofthings.substack.com/p/bad-therapy-review-
| fift...
|
| """
|
| Much of Shrier's book is devoted to critiquing Internet
| Mental Health Culture, [...] I broadly agree with her
| critiques.
|
| [Her] preferred alternative to Internet Mental Health Culture
| is what you might call Fifties Dad Mindset.
|
| [...]
|
| Shrier explicitly says that the right response to "minor
| cutting" is to ignore it.
|
| """
|
| Amazing book.
| matrix87 wrote:
| simple, some people just make a religion out of it. it's a way
| of life for them. the same way some people obsess over the
| bible
|
| for some people, it's about finding solutions to specific
| problems, the scope is well defined, nothing wrong here
|
| for others, it's this monolithic worldview that asserts itself
| as an authority on problems and solutions
| Insanity wrote:
| Healthcare (in the US) is insanely expensive for physical health,
| often with insurance being "difficult". Hence not sure why anyone
| would be surprised that mental health is similar.
| logifail wrote:
| (Genuine Q) why do so many Americans [appear need to] have a
| therapist compared with - sorry, not sure how to put this - the
| rest of the planet?
| Nifty3929 wrote:
| It's not a question of need, it's a question of want, and
| available resources to support those wants. The US is
| sufficiently productive that it can allocate people to
| relatively less important tasks. If a country barely produces
| enough to eat, then there's no room for therapists. No knock on
| therapists - this is basically true of everything. The more
| productive we are, the more "extra stuff" we can afford to
| have/do.
| Red_Leaves_Flyy wrote:
| >It is no measure of health to be well adjusted to a profoundly
| sick society. J. Krishnamurti
| harimau777 wrote:
| I suspect there's a number of factors:
|
| If you are comparing to the population of the world as a whole,
| then I suspect that's because many people in poorer regions
| simply don't have access to therapy.
|
| If you are comparing to wealthy industrialized nations (e.g.
| Western Europe and Scandinavia) then I suspect that America's
| lack of work life balance, lack of social safety net,
| repressive moral culture, high gun violence, etc. play a role.
|
| I suspect that in some cultures people like pastors and family
| members play some of the role of therapists to a greater degree
| than in America.
| logifail wrote:
| > I suspect that America's lack of work life balance, lack of
| social safety net, repressive moral culture, high gun
| violence
|
| Are Americans in therapy directly affected by those issues,
| or - how can I put this - merely worried about those issues
| in general terms?
|
| The Economist wrote recently about how political views appear
| to affect mental health in the USA. The title feels
| unnecessarily inflammatory, for which I apologise, the
| article's content feels much more balanced.
|
| https://www.economist.com/united-states/2024/04/04/are-
| ameri... ( https://archive.is/iWAaP )
| tomjakubowski wrote:
| What do you mean by "directly affected?" The lack of a
| social safety net makes me worry about myself (and loved
| ones) and what might happen in the event of severe job loss
| or health misfortune. In my city I see people living on the
| streets almost every day - it is a recurring reminder of
| the thin line.
|
| Almost by definition, anyone who is directly suffering from
| the lack of a safety net -- because they are falling
| through where it would be, and living on the street -- is
| unable to gain access to therapy, because they wouldn't
| have money to pay for it.
| gruez wrote:
| From OP's linked article:
|
| >It is possible that liberalism does not just correlate
| with sadness but may exacerbate it. Musa al-Gharbi, a
| sociologist at Stony Brook University, has noted that
| educated, affluent white liberals have come to endorse
| the idea that America is systemically racist, leading
| them to view other racial and ethnic groups more warmly
| than their own. "This tension--being part of a group that
| one hates--creates strong dissociative pressures on many
| white liberals," he wrote in the journal American
| Affairs. Another hypothesis, advanced by Jonathan Haidt,
| a social psychologist, and Greg Lukianoff, a lawyer, is
| that liberals are performing a reverse cognitive
| behavioural therapy on themselves: promoting not
| resilience and optimism about incrementally improving the
| world but catastrophic rumination about problems such as
| climate change and fearfulness of disagreement even on
| university campuses. Such habits of mind can deepen
| depression.
| impendia wrote:
| Roughly speaking, I'd conjecture that it is because America has
| always been an idealistic country.
|
| As the Declaration of Independence says, "We hold these truths
| to be self-evident, that all men are created equal, that they
| are endowed by their Creator with certain unalienable Rights,
| that among these are Life, Liberty and the pursuit of
| Happiness." This is not a uniquely American sentiment, indeed
| the phrase was largely borrowed from the writings of John
| Locke, an Englishman -- but it does feel very American to me.
| (Moreover, the fact that about half the signers of the
| Declaration were slaveholders puts an odd twist on it, which
| also feels quite American.)
|
| If some aspects of your life are going well, and not others? It
| feels American to me to believe that you can have it all, that
| if you're experiencing problems then you should not grin and
| bear it, but rather that you can and should solve them.
|
| This is my personal conjecture, and of course is highly
| debatable.
| recursivecaveat wrote:
| This is a significant factor in overmedicalization in America
| I think. Therapy catches a lot of it since it is both broad
| in scope and difficult to objectify. It is a shame that so
| much money is wasted to provide worse outcomes in some cases:
| eg overprescription or overuse of inpatient stays.
| zo1 wrote:
| I'm not trying to jab or anything, but I think this is highly
| due to social media. Some people genuinely have issues and
| difficult mental problems, this isn't aimed at them, and they
| do need professional help.
|
| But there is a whole cottage movement of people advising people
| to go see a therapist to deal with all sorts of
| (controversially and arguably) benign stuff. Everything from
| bad breakups, to "toxic traits" they need to address, to family
| issues, to "issues" they got told is the cause of their dating
| woes, etc. I haven't been able to put a finger on it
| definitively, but it's present and is definitely influencing
| people.
|
| If I were to put my "right wing" hat on, I'd respond and say
| it's because of all those damn lefties urging people to "talk
| about their feelings and stuff". That might be a tad too
| dismissive, but there is something to it behind the pointed
| accusation; and we all know how heavily pervasive social-media
| is at driving the behavior of the American populace, aided by
| the heavily-left-leaning tech companies which actively don't
| allow the natural immune reaction society has to large-scale
| gaslighting.
|
| For all we know, people are being gaslight on a large scale,
| and therapy is trying to put a bandage of it because all these
| affected people can't reconcile the real world with the
| craziness of "The Narrative". Some people maybe just need
| someone to talk to too, you know? Maybe there is more of that
| in America because they're all forced to self-censor and
| repress themselves.
|
| </rant> This turned out to be a rant and I let my bias show.
|
| Edit. Now that I think about it, there is arguably even more
| censorship in the EU so maybe that's not it. Perhaps it's more
| blatant and people all know it's "forbidden" speech, rather
| than being forced or gaslight into thinking their thoughts are
| wrong.
| matrix87 wrote:
| If I had to guess, more money in selling people meds that they
| don't really need, profits get funneled into advertising and
| media outreach, positive feedback loops, social contagion sets
| in, etc
|
| Therapists don't typically prescribe medication, but they have
| a role in the pipeline of prescribing it
| cflewis wrote:
| It doesn't feel like a genuine question you followed it up with
| a snide jab.
|
| Assuming you didn't: as a non American who emigrated to the US,
| the answer is fairly clear. My home country (UK) pretends like
| if you need therapy you either mentally weak (time to man up!)
| or on the verge of an inpatient psychiatric hold. Marriage
| counceling is just a desperate prelude to divorce from people
| that can't see the writing on the wall. I would never _ever_
| tell anyone on the UK if I was taking psychiatric meds.
|
| America doesn't have the same stigma, at least in the coastal
| states. So people get help. People talk about getting help.
|
| Modern life stress is not limited to the US. It's just the US
| that talks about it the most. Mental illness is not limited to
| the US either, they're just more willing to use medications.
| And it saves lives. Had I been in the UK with mental illness I
| have (just the very commmon depression/anxiety power combo) I
| might be dead by now.
|
| I also take great exception to the idea that there has been
| some seismic change in life that has resulted in more mental
| health crises. They were just manifested via more normalized
| alcoholism and home abuse instead.
| neilv wrote:
| > _Several insurers told ProPublica that they are committed to
| ensuring access to mental health providers, emphasizing that
| their plans are in compliance with state and federal laws.
| Insurers also said they have practices in place to make sure
| reimbursement rates reflect market value and to support and
| retain providers, for which they continually recruit._
|
| Journalists could use an LLM to fetch the obligatory predictable
| responses from corporate spokespeople, to insulate the
| journalists' souls from that.
| skybrian wrote:
| The point is to give them a chance to respond. Then they can't
| come back later and say "why didn't you talk to us?"
|
| It's often not that helpful, but it's standard journalistic
| practice to give them a chance.
| bradleyjg wrote:
| Your house is probably not going to burn down, but if it does the
| financial impact would ruinous. So we pay a little bit each month
| to insure against this rare outcome.
|
| Some of health insurance looks like this, but many parts of it
| don't.
| screye wrote:
| Cherry on the cake is - People start looking for therapists when
| they're struggling the most.
|
| Navigating the Kafka-esque mess is hard enough when you're well.
| But if you're clinically depressed and struggling to get out of
| bed, booking an appointment can feel like an unsurmountable wall.
| nradov wrote:
| Yes, that is difficult. But someone who might be suffering from
| a severe mental health condition probably shouldn't start with
| looking for a therapist. Instead it would usually be better to
| make an appointment with their primary care provider and see if
| a referral to a psychiatrist is medically necessary.
|
| For lesser issues, many employers now offer Employee Assistance
| Programs (EAP) as part of their benefits package. This can be a
| relatively quicker path to get a few sessions with a therapist
| or counselor.
| halfcat wrote:
| Not only that, but even if there were zero barriers with
| insurance, finding a therapist is still hard.
|
| Because finding good people that you click with is hard,
| whether that's hiring employees, finding a romantic partner, or
| finding a therapist.
|
| The online therapy companies that provide an "instant match"
| haven't really solved this, any more than a temp agency has
| solved hiring top talent.
| kristianbrigman wrote:
| there is rula: https://www.rula.com
|
| you put in your insurance and location, and they find you a
| provider.
|
| also, some therapists don't take insurance (or recommend you
| don't use it) because supposedly if you do, then part of that
| agreement is that they tell the insurance company your treatment
| plan, which includes the diagnosis, that may be available to your
| employer. doctor/patient confidentiality seems like there are
| some exceptions here.
| monktastic1 wrote:
| Piggybacking on this to share my BIL's company
| https://www.meetnirvana.com/. It helps therapists look up
| patients' insurance details quickly and easily.
|
| Not just a shameless plug, either: I really believe in their
| mission, and did a short stint with them.
| theogravity wrote:
| I wanted to get short term therapy for a mental health related
| thing this year, and made the mistake of switching from my PPO to
| Kaiser thinking that Kaiser would cover therapy sessions since
| they appeared to have thousands of therapists under their
| network.
|
| It turns out that Kaiser will only cover you if you have a
| diagnosed mental condition (eg bi-polar / ADHD). If you don't,
| then you're completely out of luck. Instead, they refer you to
| use an app where you can get counseling via _text message_ , and
| it's only for 90 days.
|
| https://organizations.headspace.com/kp/faq
| lukevp wrote:
| Do you have access to an employee assistance program through
| work? We have made use of the therapy multiple times and it's
| been great. Totally free, 8 sessions per person per incident.
| You can kick off another set of sessions if there's another
| incident you need to discuss. It's not a long term solution but
| it's good to fill in the gaps and get you seen soon.
| theogravity wrote:
| I haven't thought about it at all. I'll definitely check it
| out, thanks!
| theoreticalmal wrote:
| It sounds like there's a financial incentive for therapists to
| diagnose patients with conditions they may or may not
| have...big yikes
| KptMarchewa wrote:
| Therapists don't diagnose, psychiatists do.
| nothercastle wrote:
| That is incorrect. Some do just depends on qualifications
| theogravity wrote:
| Psychiatrists / neurologists do the diagnosis. I'm not sure
| about a financial incentive, or at least in Kaiser's case. It
| would mean they'd have to cover that person's therapy
| possibly indefinitely which isn't much of an incentive.
|
| They're more incentivized to _not_ diagnose with a condition.
|
| I was considered not bi-polar and do not have ADHD by a
| psychiatrist and thus I couldn't get therapy covered.
| MichaelZuo wrote:
| There's an even deeper problem, which is that insurance as
| a system simply doesn't make sense for things that are not
| rare or that affect a sizable fraction of population
|
| If it's that common, then there's no need for a large
| bureaucracy of actuaries, accountants, agents, etc..., in
| the middle or to serve as your intermediaries.
|
| And a single paperwork error every five years, causing you
| to spend a few hours sorting it out, would more than
| outweigh all the tiny advantages that might theoretically
| benefit the customer.
| jeremywho wrote:
| This has been my view for a while. Basically health-care
| != health-insurance.
|
| People I've talked to can't quite to wrap their heads
| around that idea. Not sure why.
| margalabargala wrote:
| > might theoretically benefit the customer.
|
| As with any for-profit business, benefit to the customer
| is not a goal in and of itself, but rather an incidental
| side-effect of obtaining money from the customer, in that
| it is how the customer is convinced to give up their
| money.
|
| I would caution against assuming systems such as what you
| described are intended to help the customer. It sounds
| like instead, it is intended to help the company, by
| causing you to have to spend your (not their) time and
| potentially miss an appointment, saving the insurance
| company money.
|
| After all, what are you going to do, leave your employer
| for another one with a different insurance company over
| an insurance paperwork headache?
| djoldman wrote:
| Lawyers: where's the class action lawsuit on behalf of therapists
| alleging a pattern of denial of payment?
| halfcat wrote:
| Don't think it would help people get therapy.
|
| The big companies already have a pile of cash they've allocated
| for when they get sued, as the cost of doing business.
|
| So maybe a class action suit happens, and insurance companies
| have to pay $1 billion in damages. Lawyers get their cut, a
| bunch of therapists get a $1k check, and zero patients get more
| therapy.
| kmoser wrote:
| There must be a pain point beyond which insurance companies
| are willing to actually provide the services they promise.
| Perhaps jail time for execs might move the needle?
| 999900000999 wrote:
| The entire American Medical Industrial Complex is designed to
| extract as much money from customers as possible.
|
| Fun fact, therapy is usually not covered by Medicare at all( and
| when it is you can literally have a year wait). So you have a
| system in which working class person just have to get through it,
| and anyone with means will be told they have dozens of things
| wrong with them.
|
| Better Help sells user information. The venture capitalist tech
| bros have a new market.
|
| When I was at my lowest, broke , without any health insurance at
| all, I had a friend who listened to me complain about my latest
| eviction for hours at a time. That did more for me that any
| therapist ( who almost always watch the clock to cut you off ).
|
| I plan to pay for her children to go to college. I make a tech
| bro salary and it's not a lot of money to me.
|
| The Quest For Community and Tribe are great books on what's wrong
| with modern society. In my grandma's time the average person
| attended church ( I'm am atheist, but I value the community
| aspects), at least one social club, and she was a member of a
| union.
|
| How many community connections does the average person have today
| ?
| dottjt wrote:
| This is not to be taken as mental health advice (merely an
| anecdote), but yesterday I was thinking about needing therapy to
| deal with my issues and I had the thought to use ChatGPT. Wow, it
| was absolutely incredible in providing me with what I needed.
|
| I think therapy with a professional would be really useful if you
| have no idea what your problem is, but I think if you're able to
| put your problem into words then LLMs can be useful.
| hirvi74 wrote:
| I might have to give this a try one day. In my experience,
| therapy as a tool to improve one's life is overrated and not
| worth the money. But hey, that has been my experience over a
| long period of time with many different providers. Everyone is
| different.
| tonymet wrote:
| What does the business side of therapy look like ? How do they
| measure success ? I've seen patient surveys , but stated
| conditions are biased.
|
| Therapy doesn't seem like healthcare . People enter the system
| and receive care without recovery
|
| It just seems like legitimized drug dealing. Just make the
| psychotropics over the counter and save the world hundreds of
| billions
| smeej wrote:
| I got new insurance this year through my state's insurance
| marketplace. They said my existing therapist was in-network. This
| was news to her. I called and spoke to them. They insisted. She
| called and spoke to them. They insisted.
|
| So they've been paying her $150 a week for me instead this year.
| She doesn't know how she ended up being considered in their
| network as she practices solo, but here we are.
|
| The system is vastly more convoluted than I think anybody on any
| side actually realizes it is.
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