by Jennifer Martin Rieck, LPC
There is a lot of discussion in the world of counseling, therapy, and mental health about the acceptance of insurance payment for services. Many people don’t know about the lengthy process that clinicians must go through to apply and be added to different insurance panels in order to bill for services and be reimbursed by insurance companies. With the benefit of increased affordability for clients and increased referrals generated by being an in-network provider, many clinicians are making attempts to participate in insurance plans. However, psychotherapy originated at a time when medical insurance wasn’t even on the radar of therapists. During the reign of Sigmund Freud, originator of the school of practice we now know as psychotherapy, in the late 1800’s and early 1900’s, insurance was just coming onto the scene. In fact, group insurance really didn’t even exist in America until the Civil War when it was used to cover injury of travelers by steamboat or railway.
Along with insurance companies becoming more involved with reimbursement for mental health services, have also come stipulations around who can be reimbursed, for what, and how. Out of this ongoing joint pursuit of clinicians and insurance companies to provide what are deemed “medically necessary” services, meaning services that are required and essential for the health of the individual, have evolved sets of stipulations for diagnoses, practices and procedures, and even time and session limitations. Naturally, these stipulations cause a certain level of frustration for clinicians who may hold a different belief about the necessity of diagnosing someone at all, who feel that more sessions and long-term work are more effective than short-term work, or who ascribe to theories outside of what insurance companies recognize as evidenced-based treatment. Evidenced-based treatments are treatments which have scientific research demonstrating effectiveness for the treatment of what the client is being seen for. All of this has led to a certain “struggle” between clinicians and insurance companies to come up with a system of agreement between the two.
Goal-Setting in Therapy
One prominent and interesting aspect of this intersection of mental health and medical insurance has been the requirement for specific and defined outcome measures to indicate improvement and effectiveness of treatment. Goal setting is something that perhaps has always been on the mind of many clinicians, but has become a necessity for planning and implementing treatment since oversight of insurance companies has become routine. When an individual is seen for psychotherapy or mental health counseling, one of the first things that the clinician and client do is explore the problem the client is experiencing and define the goal or outcome that the client desires. This is a collaborative effort on the part of the clinician and client, but really serves as a signpost to direct the therapy, as well as a benchmark for knowing when therapy has completed its original purpose.
As a clinician, I have sometimes struggled with a certain sense of confinement at having to narrow my client’s experience and expectations down to something as narrow and specific as a one sentence goal. Lately, however, my perspective has changed a bit. When thinking through my own life recently, I have discovered that I often have many, many goals in my life at any one point in time, and they are almost always useful and meaningful goals for me. However, I have noticed recently that even though I have become very intentional about making decisions by asking myself if my choices are in-line with my goals, many times when I have decisions to make about my life, one choice might support one goal but directly contradict another goal.
“Many times when I have decisions to make about my life, one choice might support one goal but directly contradict another goal.”
Exploring Goals and Priorities
For example, there was a time in my life where I struggled with anxiety, particularly around facing the disappointment of individuals in my life who didn’t support my decisions. At that time, I was being faced with needing to make significant decisions that were already causing me to experience anxiety and I just couldn’t handle any more anxiety. I made the decision, at that point in time, that lowering my anxiety was my primary goal. Because of this, I had to make some hard and fast boundaries with individuals who were making the decision more difficult for me to make. My goal, in that case, was protecting my mental health, which is a really good goal for someone who is feeling really impaired by a mental health struggle. If I have a client who is coming in for counseling, specifically for depression or anxiety, the goal very often is simply a demonstration of reduction of symptoms of anxiety or depression. All of the work that we do in the office, and all of the homework that they do during the week, is focused on reducing anxious or depressive symptoms.
Recently, however, I have had some things going on in my life that have been causing me to experience increased anxiety again. Because of the discomfort of anxiety, and the experiences I have had in the past with feeling overwhelmed by anxiety, my first instinct was to create a goal similar to my last one, one where I prioritize getting rid of the anxiety. I have had to stop myself and re-evaluate this idea, however, due to the fact that I am at a different place in my life and my goals and priorities are different. At that time in my life I was needing to make some really difficult decisions, that were absolutely necessary, and that I couldn’t make while simultaneously experiencing so much anxiety. At this point in my life, I am striving to grow in my profession and to become a successful therapist. This goal requires that, rather than avoiding the anxiety I experience, I face the anxiety and grow from it. This goal requires me to view the anxiety as a pressure and challenge that can help me to reach my goal of becoming a successful clinician, rather than as a feeling that will overwhelm me and stop me from meeting my goal.
As I’ve been thinking through all of this, I have realized that the key to an effective goal is really prioritizing. We often have many, many good goals for ourselves at any given point in time, but without an intentional evaluation and organization of our goals by priority, we can find ourselves making decisions that take us in circles away from one goal and towards another and back again, never getting us where we want to go. During this time in my life, I have had to prioritize my goals in order to see which one should trump the others. This way, when I am faced with a decision, I can determine to choose the option that is going to move me toward the goal I most highly prioritize, even if that temporarily sets me back when it comes to reaching another.
“When I am faced with a decision, I can determine to choose the option that is going to move me toward the goal I most highly prioritize, even if that temporarily sets me back when it comes to reaching another.”
Tips for Setting Goals
Tips for goal setting:
Make a list of all the primary goals that you have in your life. It might be useful to include the main reasons for the goal, just so that you can remind yourself of the value of the goal if you are ever struggling with the actions steps to meet the goal.
Under each goal, write down three or four action steps you can take to meet that goal.
Next, rearrange your goals by priority. Make sure that the most important goal to you is at the top. Realize that sometimes decisions may seem to move you away from one goal, but they should always be moving you towards the higher up goal.
When faced with a decision, evaluate all available options and make sure that you are choosing the option that will move you towards your highest priority goal.
Remember that setbacks are not the same as starting over. Sometimes it seems that when we fail, or make a decision that doesn’t move us towards our goal, that we have failed. However, starting again is not the same as starting from scratch. Each time we practice intentional decision-making we are strengthening our ability to do so again. Eventually, we will get to our goal or at least get really, really close, and sometimes really close is good enough.