“You don’t use any harder substances, do you?” I winced as I heard myself ask the question. After years of motivational interviewing (MI) training, I know that close-ended yes-or-no questions often shut down a conversation. I also know that phrases like “harder substances” carry a judgmental undertone. Yet I caught myself doing the very thing I know to avoid. Was I losing my MI touch?

Motivational interviewing is an approach to discussing substance use that illuminates the ways in which how we discuss behaviors can help or hinder change. Developed by William Miller, PhD, and Stephen Rollnick, PhD, MI has garnered a strong research base and reputation. What follows is an exploration of five commonly asked questions about an MI approach to substance use.

What if I’m not trained in (or uncomfortable) working with substance use?

While it makes sense to refer a client with severe substance use issues to another provider or to a higher level of care if treating these issues is outside the scope of your training, my response to this question is a follow-up question: How are your beliefs about substance use informing your approach to treatment?

Studies suggest that approximately 25–50 percent of outpatient clients use substances, regardless of whether substance use is explicitly targeted in treatment (or if we even know it’s happening). My suggestion for clinicians who feel uncomfortable working with clients who use substances is to understand where this discomfort originates. Motivational interviewing asks us to take a non-judgmental approach, increasing our awareness of judgments and unhinging ourselves from them. It’s a mindfulness-based practice that’s founded on awareness of our own biases. Exploring our beliefs can help us shift toward a MI framework where substance use, like any other behavior, is a problem-solving strategy.

How do I conduct motivational interviewing?

Clinicians do not do MI to clients; we facilitate MI with clients. This shift in phrasing is key for emphasizing the collaboration that is central to MI. While this may seem like an overemphasis on semantics, it’s important to note that MI’s effectiveness is rooted in the words we use about change. In fact, research has shown that a higher ratio of “change” statements compared to “sustain” statements made by clients is a key ingredient contributing to MI outcomes.

All of the strategies taught in MI trainings are meant to help clinicians arrange conversations so that the client states their reasons for change. While I recommend learning and practicing these techniques, such as OARS (open-ended questions, affirmations, reflections, and summarizing), remind yourself that they are simply tools for enhancing change talk and decreasing sustain talk. It can be challenging to stick to these strategies when integrating MI into other treatment approaches such as cognitive behavioral therapy (CBT).

When it feels overwhelming to stick exclusively to MI strategies, instead try using MI as a framework for mindfully focusing on what clients are saying. If the client states reasons for not changing, try switching strategies or simply reflecting what you are observing. For example: “When I asked about drinking just now, I noticed your demeanor change”. If the client states reasons for changing, reinforce these using reflections and delve deeper into reasons for changing using open-ended questions.

Follow-up question to ponder: What strategies have you found that work best for you to maximize change talk in sessions?

What if my client doesn’t want to change?

Motivational interviewing is designed to help clients resolve ambivalence about changing. The goal is to strategically reflect back discrepancies we see between a client’s values and behavior. Confronting these inconsistencies can be a very emotional experience, and clients typically state many reasons for NOT changing. Enter the dreaded resistance and sustain talk.

A framework that I repeatedly come back to is the Stages of Change model. This model posits that behavioral change is a slow and continual process over time, and is a lens through which we can view each behavior we’re targeting with clients. In fact, I often map out my client’s target behaviors using this model in treatment planning. For example, a client with major depressive disorder may be in the action stage for changing jobs, the contemplative stage when it comes to alcohol use, and the pre-contemplative stage for a late-night gaming habit.

I strongly believe that when we feel informed and empowered about what to do in session, judgments and frustration with a client’s resistance to change subsides. So my follow-up question is: Why does it make sense given the client’s conceptualization that this behavior isn’t changing?

What if I DO have judgments about my client’s substance use?

Judgments are a natural function of language and provide us with a shorthand for describing our experiences. I often tell clients that judgments only become a problem when they’re running the show. The key to embodying the spirit of MI is awareness, noticing when judgments arise, and striving to ask ourselves where they’re coming from.

Throughout all of my work with clients, substance-using or not, I always return to the question, “What is the function of this behavior?” Considering the function judgments fulfill, perhaps they show up when we’re feeling powerless. More than likely, judgments indicate that we sense some threat, such as fear that a client will be hurt if they continue with their behavior, or fear over our own ability to facilitate change.

My question in response to the above question is: What is the function of your judgment and what would you have to sit with if you were to “drop the rope”?

Is motivational interviewing only for clients who don’t want abstinence?

The focus of motivational interviewing is meeting clients where they are with their substance use goals. If the client’s goal is abstinence, then discussing steps toward maintaining abstinence is entirely consistent with MI. However, as mentioned previously, we must work to unhinge ourselves from any judgments we have about where a client “should” be in terms of their substance use goals. I often remind myself that any change that gets a client closer to their values-based goals is positive change.

My final question for you: How can you infuse an MI approach in all the work you do?

After posing the cringe-inducing close-ended question to my client, I paused. “Wait a minute,” I said. “Mind if we loop back around? What other substances have you used?” We’re all fallible, and the basis of MI is mindful awareness of how we’re discussing substance use. It’s important to remember that clients are not fragile and there is no expectation for perfection in motivational interviewing. Much like behavior change, growing our skills as MI therapists can be slow and circular. Facilitating MI is a journey and a value to strive for, rather than a destination or goal to achieve. Subsequently, the Motivational Interviewing Network of Trainers does not offer a certification, encouraging therapists instead to seek lifelong training in the practice of MI.

The following resources offer additional MI reading and training:

• Motivational Interviewing Network of Trainers
• From counselor skill to decreased marijuana use: does change talk matter?
• A Meta-Analysis of Motivational Interviewing: Twenty-Five Years of Empirical Studies
• Motivational interviewing: Helping people change

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If you are a mental health professional and would like to explore joining the Lyra network, learn more about how we work with providers and apply today.

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ABOUT THE AUTHOR
Dr. Hollie Granato is an assistant professor at University of California, Los Angeles in the David Geffen School of Medicine and staff psychologist at Harbor – UCLA Medical Center where she is currently assistant training director for the clinical psychological externship training program. Dr. Granato specializes in Motivational Interviewing (MI) and Dialectical Behavior Therapy (DBT).

When Erin* first learned that her young son was showing signs of autism and would need to undergo testing, her stress and anxiety surged. Later, when he was diagnosed, those feelings intensified as she juggled assembling a care team for her son with daily childcare coordination and her full-time job.

Finding herself in “a state of panic,” Erin knew that she needed help from a mental health care professional to deal with the turmoil she was experiencing. “I needed to find someone to talk to before going through a total meltdown,” she says.

Her husband’s health plan, a major insurance carrier, seemed good on paper. Little did she know that in many insurance networks, finding a therapist is at minimum a tedious task of calling offices and at worst, impossible to find anyone accepting new patients in a reasonable timeframe.

“I must’ve contacted at least 15 different providers,” Erin recalls. “Most, if they responded at all, said they weren’t accepting new patients.” This only increased her anxiety and needlessly delayed her care.

Julie, another woman juggling work and motherhood, is searching for a therapist to help her cope with postpartum mental health issues. For postpartum depression, getting treatment quickly is crucial. Delays can lead to complications for both the mother and child. But after calling a number of therapists on a list provided by her OB-GYN, she became increasingly discouraged as one after another informed her that they wouldn’t accept her insurance.

“It’s pretty frustrating because a lot of therapists don’t have websites and you’re just kind of calling these numbers and waiting,” she says. “I get disheartened and then am like, ‘Maybe I’ll just forget about it.’”

Unfortunately, situations like Erin and Julie’s are common. Despite the one in five people with a mental health condition in the U.S. in a given year, mental healthcare remains the only underutilized area of healthcare in the country. That’s largely because the path to getting care is often riddled with obstacles, including:

• Insufficient insurance coverage and high out-of-pocket costs, with many high-quality providers not accepting insurance at all
• Lack of evidence-based care delivered by providers in insurance networks
• Lack of awareness about available care options
• Unavailability of providers who claim to accept insurance

We call the phenomenon of insurance directories filled with providers who are not accepting patients “ghost networks.” The dearth of accurate provider information affects other areas of health care, too, but is less severe. For example, researchers conducting a secret shopper-style audit of primary care doctors in California in 2015 were only able to make appointments with 64 percent of the providers contacted. But in a similar 2015 study assessing the accessibility of psychiatrists in three major U.S. cities, the results were far worse. Researchers could only get an appointment with 26 percent of 360 psychiatrists from Blue Cross Blue Shield’s in-network provider list. And 16 percent of the directory listings were wrong numbers – instead of psychiatrist’s offices, some of the numbers listed were for a McDonald’s restaurant, a jewelry store, and a clothing boutique.

The study’s findings support previous research revealing that two-thirds of primary care physicians were unable to get outpatient mental health care for their patients, as well as research showing that only 55 percent of psychiatrists accept insurance, versus 88 percent of physicians in other specialities. For children and teens seeking mental health care, the situation is even more dismal; researchers in another survey found that they could make appointments with just 17 percent of the child psychiatrists contacted in five U.S. cities.

Low in-network reimbursement rates discourage provider participation

At the heart of the problem is health insurers’ practice of reimbursing mental health care providers at far lower rates than other care types. According to a three-year analysis conducted by healthcare actuarial firm Milliman in 2017, therapists and mental health prescribers in the U.S. are paid 34 to 100 percent higher rates out-of-network than in-network.

Barbara Griswold, LMFT, a Bay Area-based therapist and author of “Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance,” says insurance companies routinely reimburse her at half the rate she receives from cash-only clients, and that in some networks, her reimbursements remained the same for decades, despite being based in one of America’s most expensive cities.

“It’s a real cut in pay the more insurance clients you take on, so at some point, the providers on insurance networks may say, ‘I can’t take any more insurance clients,” she says.

With such meager reimbursements, not to mention the lack of payment for time spent doing additional paperwork to process insurance claims and follow up on claim denials, there’s little incentive for providers to participate in insurance networks, and a growing number are opting for cash-only payments. Meanwhile, better awareness of the efficacy of mental health care and waning stigma around seeking treatment is driving up demand for this care as the number of providers per capita is dropping, says Joe Parks, MD, medical director at the National Council for Behavioral Health.

“There’s so much demand for psychiatrists now that about 45 percent are able to charge cash-only,” Parks says. “If you can keep busy all day and get paid three times as much [as in-network], why wouldn’t you?”

This creates a vicious cycle in which many established providers opt out of insurance networks. As a result, the remaining providers in insurance networks are even busier and harder to access.

Outdated directories

Compounding the problems of low in-network payments and the demand for care outpacing provider availability is insurance companies’ failure to regularly update their provider rolls, and providers’ lack of incentive, since these directories are sources for low-margin patients, to keep them up to date.

“Many of the providers listed are retired, dead, or only working part-time,” says Parks.

Griswold believes that many providers remain on network directories despite not seeing insurance patients for various reasons. In some cases, it amounts to a lack of communication – a provider may fail to submit formal resignation paperwork or to alert networks after they’ve moved, for example. In addition, the financial instability of maintaining a private practice, especially in pricier urban areas with higher concentrations of providers, make it harder to give up a relatively reliable stream of insurance clients, she says.

“A lot of therapists consider leaving the network, but worry, ‘What if, in the future, I need those insurance clients to fill my practice, because $60 is better than $0,’” Griswold says. “That’s why a lot of providers just kind of hang out and ‘ghost’ – they’re there but they’re not there.”

What can be done?

Insurance companies should be held accountable for accurate directories, reasonable access to care, and a network of providers who deliver evidence-based care.

“Insurers aren’t doing their job – they promised an accessible panel and they’re not delivering that,” says Parks.

For their part, regulators in some states, including California and Massachusetts, have fined insurance networks over their inaccurate directories and long wait times to see a provider. These state agencies can also help ensure network adequacy by conducting more frequent audits of insurance networks. Data from state audits should be made publicly available so that customers and potential buyers have a clear picture of what they’re getting.

And as one of the primary buyers of health insurance plans, employers, too, have an important role to play in assuring that insurers deliver on the services they’ve promised.

“Employers are paying for their employees to get coverage for mental health disorders, and the only point of having coverage is if you can actually get access to care,” Parks says. “And they’re not getting what they’re paying for because their employees do not have access.”

Employees can also advocate for themselves by letting their human resources department know if they’ve had to call a long list of supposedly in-network providers and still can’t get an appointment, he says.

Without a major shift in the way insurance companies reimburse mental health providers, a growing number of employers today are stepping up to bridge the gaps that exist between insurers’ promises and members’ actual ability to access in-network care. In a 2018 survey conducted by insurance brokerage and advisory firm Willis Towers Watson, more than half of employers said they planned to invest in employees’ behavioral health.

One person who has benefitted from employers’ growing awareness on the issue is Erin – she’s now seeing a therapist through Lyra after her husband’s employer began offering the benefit. The care she’s received so far has been invaluable, she says.

“I’ve never had such a good therapist, and I feel lighter and can better manage my emotions,” she says. “I’m so lucky we had the option of Lyra just to get away from some of the friction you’re dealing with [using] medical insurance.”

For those who continue to rely only on insurance coverage for their mental health care, the prospect of finding the care they need remains daunting.

Without active participation from insurers, regulators, providers, and employers, substantial numbers of people will continue to go without care when they need it, impacting their families, their livelihoods, and putting their very lives at risk.

*Names of patients have been changed.

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If you want help connecting with a therapist, Lyra can assist you. You can get started today if Lyra is offered by your employer. Sign up now.

For employers who want to learn more about how Lyra’s enhanced EAP addresses network adequacy and quality issues, download our whitepaper on quality or get in touch.

And check in frequently here or follow us on Facebook, LinkedIn, and Twitter for more insights into optimal well-being. Sign up now.

Like a lot of mental health care providers, Mariana Prutton became a therapist because she wanted to help people overcome their problems and live happier, healthier lives.

When she heard about job openings at Lyra a couple of years ago, Prutton was excited by the company’s dedication to tackling the problems inherent in the mental health care system, and its tech-enabled approach to connecting more people to care. Today, she meets with clients via live video, shares digital lessons and exercises, and tracks her clients’ progress, all through Lyra’s digital platform.

Recently, the now-senior therapist took some time to fill us in on her career path and her experience at Lyra so far.

How long have you been a therapist, and what drew you to this field?

I started working as a therapist six years ago. My undergrad psychology classes were what initially drew me to the field – they were always my favorite courses, and topics I wanted to learn more about. From there, I wanted to get direct experience to see how all of these academic theories and ideas actually worked.

In college, I got real-life, practical experience working with people with severe mental health issues. I really enjoyed working with people who had a variety of different life experiences and diagnoses. I worked in a mental health rehabilitation center and also with kids, teens, and young adults, so I had the opportunity to treat people across the lifespan with a variety of different issues.

What inspired you to apply to join Lyra?

I’d heard through the grapevine lots of positive things about Lyra in terms of decreasing the stigma around mental health and increasing access to mental health care. As therapists on the ground, we see how dysfunctional the mental health care system is, so I really liked that Lyra was trying to solve wider systemic issues like the lack of available in-network providers and high out-of-pocket costs.

What do you like about your role at Lyra?

One of the best parts about the job is definitely the collaborative nature of Lyra. I get to be part of a clinical consult group, do in-person trainings, and meet other therapists. All that interaction and training doesn’t typically happen in private practice, and it makes it easy to learn from one another. For example, one therapist in my cohort has a lot of experience treating clients with autism, whereas I don’t. Being able to call on her for resources and tips around working with that population has been really helpful.

Another unexpected perk is that I can choose the hours that work best for me and my clients, since I work remotely. Since video therapy enables clients to have sessions anywhere, I hold more early-morning and daytime appointments, which frees up my afternoons and evenings. And because I don’t have to factor in a commute multiple days a week, I get time back in my day to do things I enjoy, like walking my dog or going to a yoga class.

What are some of the more challenging aspects of your job?

One challenge is that clients often come in with misconceptions about therapy. A lot of times, people expect psychoanalysis, or that therapy should go on forever. So there’s some expectation-setting that needs to be done at the beginning to let clients know that a short-term, evidence-based approach can be really effective.

Another thing is that sometimes clients aren’t a good fit for video therapy, which tends to happen with more severe cases. So even if there’s a relationship fit, you still have to refer that person out so they can get the most appropriate care for their needs. That can be challenging if the client has connected with you.

What do you find most exciting or surprising about working at Lyra?

I think the most exciting thing is that Lyra brings together so many different types of people who are committed to improving mental health. You have people from a variety of backgrounds across engineering, sales, marketing and other teams working hard to improve how people get connected to mental health care, and improving the care experience in general. I love that there’s an onboarding training on-site where everyone can get to know each other and meet the people working behind the scenes on the product.

In other companies I’ve been in, people tend to get really burnt out and drained from being in a dysfunctional system, so it’s nice being around people who are inspired and motivated to make changes. It’s a true community and team effort, and we celebrate client success stories across teams since so many people have a hand in those stories in some way or another.

What are some of the typical mental health issues your clients are dealing with?

On any given day at Lyra, no two clients are the same – each person is dealing with their own unique struggles and issues. It’s different from my experiences in private practice or clinics where you’re often working on a particular issue. Having this much variety in my caseload has been a great opportunity to become more competent in specific treatments. I feel like I’m developing more expertise in a breadth of diagnoses and issues.

My clients are generally very motivated and engaged throughout the whole process. I really like working with people who are so willing to try different things and practice new skills to make positive changes in their lives.

What types of tools and techniques do you use to treat these issues?

Lyra has a library of high-quality resources that I can easily share with my clients. Being able to integrate digital lessons, exercises, and resources in a completely personalized way for each client means they get extra support and often make a lot of progress in between sessions. It really helps that you don’t have to give clients paper worksheets that they have to carry around and return to you – it’s all in the platform, so it’s just a more user-friendly process. Our clinical team is constantly working to build out the resources we can share with our clients so that therapy has the biggest impact possible.

The video lessons are also helpful because they help normalize some of the struggles clients are going through and offer tangible strategies that they can apply to their lives. The lessons help reinforce what clients are learning in therapy and keep those skills and strategies top of mind. It helps keep clients engaged and thinking about the things you’re discussing every week.

What skills are you investing in to grow as a clinician?

We have access at Lyra to continuing education trainings – live, recorded webinars – which help me grow my clinical skills. A couple of recent trainings that stand out in my mind were on intimate partner violence and exposure therapy for kids. Since I don’t specialize in either of those areas, it was so nice to do a deep dive with an expert into how to work with those populations.

My weekly clinical consult group has also been a great chance to learn from other therapists. It gives us a chance to share ideas and learn about other strategies or ways of approaching a situation – and we’re able to support each other through any problems we’re facing. I’ve found that the therapists who come to Lyra are excited about being better therapists and improving the care experience, and that includes professional development and collaborating with other people.

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Interested in joining a growing team of Lyra therapists like Mar? We’re hiring master’s-level therapists who are licensed in California, New York, Texas, Utah, and Washington.

CONTACT US
For additional provider openings and to explore joining the Lyra network, learn more about how we work with providers and apply today.

And check in frequently here or follow us on Facebook, LinkedIn, and Twitter for more insights into optimal well-being.