Therapists are there…but hard to find

psychotherapy-chair-vintageWe wanted to share this with you, which we found posted by Social Work Today. The original article was published at

There are a lot of people suffering from a mental health condition who need therapy. And there are a lot of therapists who want to help them. But both sides believe the insurance companies that are supposed to bring them together are actually keeping them apart.

Insurance companies, for their part, say there’s a shortage of therapists.

But it’s not that simple. Especially in urban areas, there are lots of therapists. They just don’t want to work with the insurance companies.

Take Michael Klein, a psychologist practicing in San Francisco for more than 20 years. He considers it his spiritual calling to help people calm their social anxiety and to help couples stop fighting and build trust.

“With the right kind of support, they blossom,” he says.

Klein doesn’t accept insurance. In fact, nearly half of therapists in California don’t take insurance, according to a recent survey from the California Association of Marriage and Family Therapists. The same is true of psychiatrists. There are two reasons why, Klein says.

“One, because the reimbursement rates don’t provide a living wage,” Klein says. “You can’t own a home and drive a car and survive on what in-network providers pay you.”

Most insurance companies pay therapists in their networks between $60 and $80 per session. In the San Francisco area and Los Angeles, therapists say the market rate for therapy is more like $150 to $200 a session.

“The second thing is the paperwork. For an hour of psychotherapy you spend a half-hour on paperwork,” Klein says. “I got into this field because I don’t like paperwork,” he says, laughing.

On that first point — money — insurance companies acknowledge that they may have to raise their rates to attract more therapists, particularly in rural areas. But they also say it’s on therapists to compromise.

“I think it’s unrealistic to expect either the state of California taxpayers or for health plans to just pay providers whatever they ask to be paid,” says Charles Bacchi, CEO of the California Association of Health Plans, a trade group for the insurance industry.

“That’s not sustainable,” he continues. “So you’re either in the system, and you want to be part of our health care system. Or you want to do concierge service outside of it and just pretend our health care system doesn’t exist. That’s your choice as a provider. Our job is to find providers that are willing to be part of the solution and willing to provide coverage to those of low and moderate income.”

That’s exactly how San Francisco psychologist Jonathan Horowitz feels. He wants to take insurance, but he has hit roadblock after roadblock. He sent out 10 applications to insurance companies and got nowhere.

“I might knock on Cigna’s door and say, ‘Hey, are you guys accepting any new therapists in 94105?’ ” he says, referring to his ZIP code. “And they might say, ‘No, we’re not doing that. We’re totally full.’ ”

Six different companies told Horowitz their networks were full.

So even though a patient might call seven therapists in her insurance network and not be able to get an appointment, insurance companies are telling new and willing therapists that there’s no demand for them.

“I definitely think it’s to control costs,” Horowitz says. “That’s very clear.”

He says he tried for a year, and one company finally said yes. Sort of. Horowitz never got a formal notice saying his clinic was admitted to the network.

“It was just like, ‘Oh wait, it looks like we’re suddenly getting a couple referrals from them. I wonder if we’re in their directory,’ ” he explains.

They were. Sort of. The clinic was listed in the directory. But the therapists who work at the clinic weren’t approved yet, meaning there was no one who was allowed to see the clients calling the clinic.

So Horowitz tried to call the insurance company to clear things up. He tried many, many times. I sat with him during a recent attempt to navigate the automated phone system:

Insurance company automated attendant: First I’ll need your provider identification number. If you need a moment, say, hold on.

Horowitz: Hold on.

Sound familiar? Turns out therapists get the automated run around as much as patients do. Horowitz persevered.

Insurance company: OK, please say or enter your PIN.

Horowitz: My PIN? Is this my PIN? (He enters a few numbers.)

Insurance company: I’m sorry I couldn’t find an account using the info you gave me. Do you already belong to the network?

Horowitz: I think so?

Insurance company: Sorry, yes or no.

Horowitz: Um, I don’t know … yes?

Insurance company: All right. And have you already requested a credentialing application?

Horowitz: Yes.

Insurance company: Sorry, could you repeat that?

These experiences didn’t bode well. “Honestly, I got a really bad feeling about it,” he says.

Horowitz figured, if this is what it’s like just finding out if he’s in the network, how’s it going to be when he has a problem with a claim?

“I could just see that getting out of hand really quickly,” he says. “So at that point we just said, do we really even want to do this?”

Furthermore, he says, the reimbursement rate was even lower than he expected, and the billing was so complicated that he was going to have to hire someone to do it. He says he couldn’t afford that.

“We made the decision that we’re just going to cancel the contract and continue to go with cash,” he says.

Easier said than done. Horowitz hasn’t been able to get through to anyone on the phone to cancel the contract. In the meantime, prospective patients are finding his name on the directory and are calling for appointments. Horowitz says he just has to say no.


A millionaire who helps children


Li Lijuan, 46, was once a millionaire, and spent the better part of the last two decades housing orphaned children. But even though she’s since lost her fortune, she is still dedicated to supporting fostering the kids, Yahoo reports.

Li made her fortune through her garment business and smart investments. She used her money to create homes for over 75 children over the past 20 years. Many of the children were abandoned by their parents because they had serious illnesses or disabilities. Because of this, they’re not legally orphans and instead Li is considered their foster parent.

To read the full article, including Li’s heartbreaking descent into debt, click here.

Is hoarding child neglect?

According to The Washington Post in a story from Indiana, it is, especially when the collections being hoarded are cats.

A child was removed from this environment and placed into foster care. About the condition of the home the local animal shelter director said-

In describing the conditions of the house to local news media, Peckinpaugh said it was impossible for him to stay inside without protection for more than 10 seconds. He described it as the worst case of hoarding he has ever seen, he told a local NBC affiliate.


Reentry into Care

lonely-childThis is a snippet of a very important study conducted by Elsevier. This is especially crucial to CASA, who keeps track of successful case closures. In our most recent numbers we’ve found that nearly 60% of children are successfully returned home to their parents. Nearly 30% of the remaining children are then adopted into their forever families. These percentages remain higher than the national average. Keep doing your awesome work, advocates! You’re so needed!

1. Introduction

When children enter out-of-home care, in the vast majority of instances, the service plan is to return them safely to their family. Yet, reunification fails in a substantial proportion of cases. This is an enduring concern to local, state, and federal child welfare administrators, who strive to keep the failure rate below strive to keep the failure rate as low as possible, especially since it is included as a performance measure in federal performance reviews. Reunification failures may result in reentry without abuse (e.g., when early warning signs of parental inadequacy are observed), abuse but no reentry into care, reentry into foster care (most often into another foster home), and greater likelihood of later placement instability and admission into group care.

Although rates of reentry vary widely, the available evidence has demonstrated that reentry to foster care after reunification is not a rare event. In one study of reunified families in Illinois (Goerge, 1990), one third of all children who were returned home during the 1980s, reentered foster care. Similar results were reported in a study of Texas reentry rates that showed that 37% of children who were reunified reentered foster care in Texas within 3.5 years (Terling, 1999). Wulczyn (2004) further reported that nearly 30% of children from 10 different states who were reunified between the early 1990s and early 2000 reentered care between those years. In the context of a randomized trial to evaluate a therapeutic foster care program, Fisher, Burraston, and Pears (2005) observed that over 50% of children reunified or adopted following placement in regular foster care reentered care within 24 months.

Most studies of reentry into foster care have relied on administrative data collected during the routine operation of child welfare cases. This single-source reliance often means that models explaining reentry are not well-specified, and some findings are explainable by idiosyncratic administrative rules (e.g., by the coding of drug-exposed newborn cases as physical abuse in the state of Texas, as detailed in Terling, 1999).

Nonetheless, some findings from administrative data emerge with notable consistency. Courtney (1995), studied reunified foster children in California and found that six groups of children had faster rates of reentry than their comparison groups: (a) children with health problems; (b) children from families receiving Aid to Dependent Children; (c) children who spent three months or less in care; (d) children who were placed in nonrelative care; (e) children who had a greater number of placements during their first spell in care, (f) and African American children. Correlates of reentry in Terling’s (1999) study included abuse type, prior child welfare services (CWS) history, parental competency, race, criminal history, substance abuse, and social support. Notably, in Terling’s study, assessments of risk made by caseworkers were not found to be related to reentry.

A shorter duration in foster care appears more likely to be followed by a reentry into care. McDonald, Bryson, and Poertner (2006) recently studied the relationship between reunification and reentry rates for 33 Oklahoma counties occurring in 2002. Consistent with prior research (e.g., Wulczyn, Brunner, & Goerge, 1999) McDonald et al. found a relationship between early reunification (less than 6 months spent in out-of-home care) and higher reentry rates; counties with the greatest number of cases in which reunification took place within the first 30 days reported lower reentry rates. Jonson-Reid (2003) found that children with a postreunification report of maltreatment or reentry were more likely to have been in care for a shorter time (i.e., less than three months in out of home care).

In general, foster care reentry research has included children of all ages. Although several studies have included age groups as predictors in their analysis, few studies have stratified their analyses by age. For example, Courtney (1995) found that children between 7 and 12 years had lower reentry rates than infants, but that this age group was indistinguishable from preschool children or adolescents. Wells and Guo (1999)disregarded the likelihood that there might be discontinuities in the relationship between age and reentry, and treated age as a continuous variable. They showed that the likelihood of reentry increases nearly 10% for each year of age at exit from foster care.

Reentry is also likely to be related to the number of prior foster placements. For example, Fisher et al. (2005)found that a positive association among foster children between number of prior placements and the likelihood of permanent placement failure. Children with multiple prior placements were much more likely to have difficulty achieving a lasting permanent placement.

Research has consistently shown that a stronger developmental perspective is needed in child welfare research (Berrick, Needell, Barth, & Jonson-Reid, 1998; Wulczyn, Barth, Yuan, Jones Harden, & Landsverk, 2005) because the predictive factors for reentry in one age group may not be explanatory for another age group. Children of different ages enter care for different reasons (Barth, Wildfire, & Green, 2006) and leave care at different rates (Wildfire, Barth, & Green, 2007). The interrelationship of these factors is likely to contribute to reentry.

Only a few studies have looked in greater depth at reentry, by using more detailed case histories or observational/ interview data. These analyses have allowed for the inclusion of more varied predictors in the reentry models. For example, Frame, Berrick, and Brodkowski (2000) examined reunification and reentry among 98 infants in Alameda County California. Although their review of case records showed that maternal criminal history was a key predictor of reentry, they found no clear relationship to several other expected predictors such as type of maltreatment, parental visiting, gender, or time in out-of-home care.

Festinger’s (1996) study of 210 children in New York and who were younger than 15 years at the time of entry into CWS is something of an exception. This study detailed measures of factors contributing to reentry, but obtained on a sample of children with a broad age range (with a median and mean age of about 6 years old). Of the 210 children sampled, only 27 experienced reentry during the 16 months after their return home. Festinger concluded that the reunifications that resulted in reentry were generally more problematic, and often took the form of limited parenting skills, poor social support, and a history of mental health problems and homelessness. Yet, none of these factors could be isolated as significantly different between reentry and nonreentry cases.

Fuller (2005) is among the few researchers who have examined reabuse following reunification (see alsoJonson-Reid, 2003). Fuller examined the factors that appeared to predict short-term (i.e., within 60 days) maltreatment recurrence among 174 families with children returning home from their first stay in substitute care in Illinois. Seven variables were found to be positively associated with maltreatment recurrence: (a) younger child age; (b) poor parental mental health; (c) more prior placements; (d) initial placement type (kinship care); (e) total length of time in placement (3 or more years was a greater risk for recurrence); (f) more children in the home at reunification; and (g) children returning home to a single-parent household at the same time as one or more siblings. Although Fuller’s study evaluated factors related to recurrence of maltreatment as opposed to subsequent reentry, it provides useful insight into factors placing children at risk of future CWS involvement postreunification.

Miller, Fisher, Fetrow, and Jordan (2006) studied the reunifications of children between 4 and 7 years of age through close observation and interviews with children who had recently returned home from foster care. Miller and colleagues found that parental substance abuse treatment (probably indicative of substance abuse problems), children in special education due to developmental delays, child’s use of therapy for psychosocial maladjustment, overall parent skill, parental use of discipline, and the quality of neighborhood were all related to reentry.

Several factors have either not received much attention or the findings have been null. Prior studies have not identified gender as a major predictor of reentry. Both Fuller (2005) and Courtney (1995) tested gender and found no advantage to including it in their final models. Although Jonson-Reid (2003) found interactions between gender, age, and race that appeared important, it was not possible to replicate the prior findings in the samples stratified by age or in a smaller sample, as reported below. Fuller’s (2005) study was the only recurrence or reentry study that examined the number of children living in the home as a risk factor for reentry. They found that children who were returned to homes in which four or more children were present were three times as likely to experience recurrence.

Only one study has tested the relationship between recent family experiences of domestic violence and reentry to foster care. English, Edleson, and Herrick (2005) noted that the child welfare worker rating at intake of the level of risk due to domestic violence had no significant relationship to rereferral in Washington State. This finding stands in sharp contrast to several studies that point to domestic violence as having a key role in reentry. For instance, Kohl, Edleson, English, and Barth (2005) found that domestic violence created a greater likelihood of entering foster care rather than being served at home; however, there are no published reports that have followed children in households with domestic violence to reunification or reentry. Marsh, Ryan, Choi, and Testa (2006) found that substance-involved families who make progress with co-occurring problems including domestic violence are more likely to experience reunification.

Cumulative family risk has also been inadequately studied as a contributor to reentry. Although family risk and child-level risk are different, it is reasonable to expect that these factors are related. Appleyard, Egeland, van Dulmen and Sroufe (2005) observed that cumulative risk for an individual child had a linear relationship to later behavior problems. Nair, Shuler, Black, Kettinger, and Harrington (2003) found that, among substance-abusing women, high numbers of parental stress factors were related to measured child abuse potential.

Many explanations are possible for the contradictory and tentative nature of existing findings. It is possible that there are very different dynamics within age groups that were not distinguished; unmeasured factors that would have, if included in all the models, provided more consistent results; and problems of power that reduced the chances of identifying significant factors.

The goals of the present study were to understand foster care reentry dynamics for a discrete group of children (elementary school age children) who have been reunified by considering factors that have routinely been tested in multivariate models (e.g., length of time in foster care before reunification), case characteristics rarely tested in reentry models (e.g., clinical level of behavior problems), as well as some additional factors which our clinical experience indicate may have an impact on outcomes (i.e., family size).