Why Some Therapists Don’t Take Insurance
Okay – so why are there so many therapists that I want to work with who are not working with insurance right now?
First, this is a totally valid question.
As someone who utilizes insurance for a lot of my own medical care, I think the desire to utilize insurance for mental health care is a fair ask. Even with this truth, I’ve had to make tough decisions when it comes to working inside or outside of the insurance industry.
My decision is influenced by the values I hold personally and professionally, as well as the quality of life I need to sustain my work as a therapist.
Some of the reasons I’ve decided to divest from the insurance/mental health industrial system are because I value:
Divesting from Broken Systems
The Client-Therapist Relationship
Self-Determination
Protecting My Bandwidth
Divesting From Broken Systems
Insurance companies have an interest in paying as little as possible for payer's care. This is the nature of how insurance works. The resources available to pay for a payer's care are dependent on other payers not needing to tap into the financial resources they pay into it. This approach is inherently flawed because it can never cover the number of people it is committing to protect.
This system incentivizes insurance company case workers to be hyper-vigilant about only giving benefit coverage to those who absolutely need the service. This process is a reflection of our heavily reactive, rather than proactive, culture. Hence, the US has some of the worst health outcomes in the world––insurance companies are looking to rule out certain sick people from receiving coverage so that they only pay for what they deem "critical."
This type of system is meant to throw band-aids on bullet wounds. It doesn’t allow for healing within the context of mental health to take place before they are ready to withdraw access to care from the people they are supposed to serve.
What a bizarre way to approach wellness, right?
By working outside of this system, I am honoring my value of integrity. Because I know that insurance companies are often working against the goals of my clients, divesting from this model creates an opportunity to dream of a system that honors integrity and whole-self healing.
Client-Therapist Relationship
When working with insurance to make sure mental health services are provided, therapists are required to submit documentation about the client’s progress. Even from the first session, insurance asks therapists to conduct a “Comprehensive Clinical Assessment.” This assessment (as required by insurance) asks therapists to get as much information about the client to make sure that the client is actually in need of this service.
Insurance companies ask therapists to prod around deeply sensitive topics within their first sessions, and will often only reimburse for up to 90 minutes of therapy. This doesn't provide much time for the client and therapist to get to know one another or to ground before wrapping up the session.
Imagine, having to talk quickly about the worst things that have happened in your life in a 90-minute window – all because your insurance wants to verify you have a reason to be seen? That is the furthest from what a survivor needs while trying to access support from a mental health therapist.
From that very first client/therapist meeting, insurance companies are setting rules that create a potential for mistrust and traumatization within the therapeutic space. That's not the best way to create a foundation for a therapeutic relationship, which recent studies show over and over is the most important factor in someone’s success in therapy.
Self-Determination
This process of “reporting back” to insurance companies can be challenging. Based on the right or wrong wording, a client can be seen as “too well” to continue with the treatment that was working for them, and suddenly, the coverage can end. On the other hand, if a client isn’t making “enough progress” insurance can decide that they no longer want to pay because the individual receiving care is not making good enough use of the insurance companies' investment.
This is a very harmful reality of working within insurance. There are times when I have been in the midst of some deep trauma work when a client’s insurance company decided they had made all the progress they needed to make.
In these moments, I am made to choose between seeing the client for free (impacting my financial stability), sending the client to a "less intensive" type of care, or having to begin an appeal process (which is laborious and often disappointing in outcome). You can likely see here how self-determination and the client-therapist relationship are closely connected.
This situation leads to pausing the therapy we were doing and orienting to a systemic flaw––turning on the "fight or flight" response to navigate the current threat. This style of "healing" is unsustainable even for the best of the best therapists.
Another self-determination benefit of navigating outside of the insurance industrial complex is being able to leave behind the label of your trauma or stress responses as being a "disorder." Of course, diagnoses can be very validating for some and have the potential to direct treatment. However once that diagnosis is in your medical records, it’s permanent for insurance companies to use when making decisions about your use of benefits.
My Bandwidth
I became a therapist because I want to help people connect to themselves and heal within the context of a relationship. To support people in doing that, I have to be extremely dedicated to resourcing my nervous system so that I may show up and provide a calming presence on which the client's nervous system can depend.
The insurance/mental health industrial complex creates obstacles and hoops to jump through that take an enormous amount of energy. When the insurance companies ask me to set up a phone call, I have to re-tell the trauma of a client to secure continued coverage. Not only does this cause me to feel that I am betraying the confidentiality of my client, but I am creating more moments of vicarious trauma for myself.
I signed up for a profession in which I am expected and willing to sit in the pain of trauma with individuals looking to heal. I did not sign up to re-tell these sacred and painful stories to strangers on the other line. I am open to holding space and containment for people who are walking through their sorrow. I have budgeted time and energy to lovingly stay in that space, but it takes a great deal of intention and work on my end to show up fully for that job.
Additionally, I have committed an extensive amount of resources of time, financial, and emotional energy towards being an incredibly trauma-informed provider. I hate to bring it down to money (in therapy school we were effectively taught that our own need for money to survive was irrelevant), but insurance companies lowball therapists regularly, underpaying them for the incredibly heavy work they provide and their commitment to providing quality care.
Ending my relationship with the insurance industrial complex has allowed me to prioritize the parts of my work that are the most important. Being present and resourced with individuals in front of me in session is important. I am my best version of me when I can rest up and show up for those on their healing journey.
If you have any questions feel free to reach out and we can schedule a phone or text consultation to discuss further.
If all of this information feels like another language to you, I invite you to check out my colleague Toni Aswegan’s wonderful blog post entitled Insurance 101.
