It may be in your best interest not to use health insurance to pay for counseling for relationship issues. Here’s why:

  • [details]  Insurance requires you to be diagnosed with a significant medical problem
  • [details]  Insurance often won’t cover relationship issues, including sexual issues
  • [details]  Insurance pressures therapists to behave in ways that are unethical
  • [details]  Only one of you gets a diagnosis
  • [details]  Therapists are required to treat the diagnosis, not you
  • [details]  You can’t get your diagnosis out of your permanent medical record
  • [details]  Diagnoses have consequences
  • [details]  Insurance paperwork can overwhelm your therapist
  • [details]  Insurance pays little for mental health services
  • [details]  Using insurance can mean worse results for you
  • [details]  My not taking insurance benefits you

Insurance requires you to be diagnosed with a significant medical problem

It’s important to understand that health insurance is designed to cover medical issues: it’s a product that pays to heal you when you’re sick. It is not intended to help you become a better person, a better partner, or happy.

When your therapist bills your insurance company, the therapist provides a diagnosis for you that is entered in your permanent medical record. The therapist also signs a legal document stating that your treatment is a “medical necessity.” As you might imagine, diagnoses that require medical treatment are often quite serious, and they have consequences.

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Insurance often won’t cover relationship issues, including sexual issues

Many insurance plans do not cover marital therapy, couples therapy, or relationship therapy of any kind. This is because health insurance follows the medical model, where health problems are seen as being within one person. This model is not a good match for problems that occur between people, such as communication difficulties, sexual issues, and emotional or physical abuse.

This insurance company policy is pointless and counterproductive. There is a great deal of research showing that relationship therapy is one of the most effective ways of treating “individual” issues such as alcoholism, depression, and anxiety. The refusal to cover this kind of therapy means that you are deprived of the full range of useful treatments.

Many insurance plans do not cover therapy for sexual issues, even for individual clients. This means your insurance won’t pay for treatment of low desire, inability to have orgasms, premature ejaculation, erectile dysfunction, pain during sex, and a variety of other problems even though these issues are listed in the official diagnosis manual.

There is no rational reason for refusing to cover these issues. They cause people as much suffering as compulsive hair-pulling, stuttering, and fear of public speaking, which are covered by all insurance plans. The real issue is that our culture does not place a high value on healthy sexuality, and this is reflected in insurance policies.

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Insurance pressures therapists to behave in ways that are unethical

You may be saying, “Hey, wait a minute! We’ve seen a therapist for relationship issues, and our insurance covered that.” Well, no, it didn’t. What happened was your therapist gave one of you a diagnosis (which is now in that person’s permanent medical record) for some other problem, and said they were treating that.

Ethics specialist Dr. Daniel Watter notes that many therapists “treat couples for sexual desire discrepancies and/or relationship problems. While few would argue that such therapy is not useful, it is often the belief that these situations are the result of partner incompatibility–not psychopathology.”

In these cases, the therapist should give the diagnosis “Partner Relational Problem.” However, insurance companies won’t pay for that. So the therapist needs to find a diagnosable problem in one of the partners. Popular choices are a mood or anxiety disorder. While a clever therapist can justify many different diagnoses, this is an ethical gray area because the therapist is purposely choosing a diagnosis other than the one they think is most accurate.

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Only one of you gets a diagnosis

The person whose insurance is being used is the only one who will get an official medical diagnosis. (It’s theoretically possible for a therapist to diagnose each person in the relationship, but I’ve never heard of anyone doing this because the paperwork would be crippling.)

This is a serious issue. First, diagnoses have consequences. Second, the therapist is required to treat the diagnosis, which means the therapist will spend some time each week thinking and writing about how they are treating the diagnosed person. This can have subtle and not so subtle consequences as the therapist comes to think of that person as the one with the “real” problem. This can also happen within the relationship, as the diagnosed partner gets an unfair share of the blame.

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Therapists are required to treat the diagnosis, not you

You might think, “OK, so my therapist gave me a diagnosis. That takes care of the insurance, and now we can focus on the real issues.” Unfortunately, it doesn’t work that way.

Insurance companies require your therapist to create a comprehensive treatment plan. Of course, this is an ethical responsibility for any therapist. The catch is that the insurance company, for obvious reasons, requires that the treatment plan be designed to treat the official diagnosis. And remember, only one of you gets a diagnosis and health insurance pressures therapists to misdiagnose. So, the treatment plan covers only one of you, and only for the diagnosed problem.

It gets worse. Therapists are also required to document each therapy session with a “progress note.” In this documentation, insurance companies want to see which techniques the therapist uses in the session, and how these techniques help treat the diagnosis of the “official” client. Insurance companies reserve the right to audit a therapist’s records, and to deny payment for any treatment that is unrelated to the diagnosis.

Therapists want to be paid, so they’re careful to write treatment plans and progress notes that follow the rules. This often leads to a form of “double bookkeeping,” where the therapist is doing one thing in the session, and documenting something else. At the least, this raises serious ethical questions. At the worst, it’s insurance fraud. In either case, it’s a waste of time and energy.

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You can’t get your diagnosis out of your permanent medical record

While writing this page, I consulted with a psychiatrist who has a current caseload of several hundred patients. I asked him, “How do you get a mental-illness diagnosis out of someone’s record, once it no longer applies?”

He seemed surprised at the question. After a few moments of silence, he responded, “This is a pathology-oriented business. There’s no form or procedure for removing a diagnosis.
It just stays there forever.”

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Diagnoses have consequences

Your diagnosis is not just a number in your permanent medical file. It’s information that can be accessed by a wide variety of parties, and that can be used against you.

Once you have a diagnosis, you must answer “yes” if a job application asks whether you have ever been treated for a mental illness. Half of the Fortune 500 corporations acknowledge using employee medical records in making employment decisions.

A mental health diagnosis can disqualify you from working in law enforcement or the military. In rare circumstances, it can preclude you from getting a security clearance. Life insurance companies charge higher rates if you have certain diagnoses in your record.

People often come to therapy because their relationship is distressed. If the relationship then ends, the fact that only one of you gets a diagnosis may lead to an unjust custody arrangement. The American Academy of Child and Adolescent Psychiatry states that “in child custody disputes it is common for a parent’s psychiatric history to be used by the opposing side as an argument against granting custody to that parent.”

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Insurance paperwork can overwhelm your therapist

There are various estimates of the burden of paperwork; a conservative number is that it takes up thirty percent of a therapist’s working hours. Thirty percent! Now, some of that paperwork needs to be done no matter what. But the majority of it relates to insurance.

Increasing a therapist’s paperwork acts as a deterrent to billing and costs an insurance company nothing, so it’s not surprising that they pile it on. And it works. I’ve provided many client services for which I never billed because I couldn’t bear the associated paperwork.

Insurance companies want to pay out as little money as possible. Their compensation rules are complex, and have the (desired?) effect of making it difficult to know what’s covered, when, and for how much. Insurers compound the challenge by following the heuristic “if it’s possible to think of a reason to deny this claim, do so.” Of course, a therapist can appeal this denial, and even win. But it’s yet another hassle.

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Insurance pays little for mental health services

No therapist gets paid “list price” by an insurance company. The insurer sets the fees, based on the “usual and customary” charges in your area. How these “usual and customary” figures are arrived at is unclear, but the rates that result from this process are always quite low, and have actually been going down for years.

For a licensed professional like me, the range is roughly $60-$80 per 50-minute session; when the time to complete the associated paperwork is included, this comes to roughly $45-$60 per hour. This is, of course, before accounting for the other work, expenses, and taxes that running a small business entails. If you’re curious, here’s a decent description of the costs and expenses for running a counseling practice.

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Using insurance can mean worse results for you

Taking insurance means a therapist gets paid a low hourly rate. So, a therapist who wants to afford a middle-class lifestyle, much less a home, in the Boston area has to see many clients, which means doing much paperwork.

This has implications for your quality of care. For one thing, doing lots of paperwork for low pay wears on a therapist.  For some, this leads to burnout, a big issue in my profession. For many others, it leads to frustration, and who wants to see a grumpy therapist?

In addition, insurance-based therapists suffer from a chronic lack of time. This can force them to cut corners in critical areas, such as improving their skills, attending conferences, and keeping up on the latest research.

At its worst, it leads to “assembly-line” therapy. Each session is limited to precisely 50 minutes, no matter what comes up. The ten minutes between sessions are spent scrambling to use the bathroom and grab a bite to eat. There’s no time to prepare for, or even anticipate, the next clients. (“If it’s 4:00 on Tuesday, you must be the Andersons.”) Therapy is all improvisation: the therapist walks in and wings it.

If you’ve experienced a therapist who was distracted, or tired, or forgetful, or irritable, or just generally unprepared, you may have been seeing the side effects of taking insurance.

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My not taking insurance benefits you

I have a simple, if unusual, business model: I see half as many clients as many therapists do, charge enough that I can pay my mortgage, and keep what I earn because I don’t let insurance take their huge cut. Then I provide the rest of my services for free.

Seeing a manageable number of clients and avoiding insurance paperwork allows me to schedule free time between sessions. This  brings a range of benefits. For starters, it means I’m flexible about session length: if an important issue comes up near the end, we can find  time to properly attend to it.

It also means I have time to stretch and meditate, to help me recharge. I can even eat and pee. (No joke! Ask a busy therapist how often they have to skip one or both of these.) All this helps you: you want your therapist to be in a good emotional and physical place.

Then there’s preparation. After each session, I type up a long, detailed note. This is where I formulate and clarify my ideas of what’s going on for you, and what might be helpful. Before each session, I read over these notes and come up with a individualized plan for your session. When you walk through my door, you’ll find I’ve already put a lot of thought into your issues.

A big part of preparation is research. I constantly read about psychotherapy theory and practice. I keep an annotated database of the research literature. I create summaries of what I read, to hand out to clients. Much of this reading is targeted just for you. It’s not unusual for me to track down several research articles to answer a client question. It’s not unheard for me to read a whole book to provide better treatment for one couple.

What this means for you is a therapist who is cheerful, relaxed, and ready. My goal is to be present and focused 100% of the time for 100% of my sessions, and I come pretty close. You can tell the difference immediately: it’s obvious when your therapist is right there with you, minute by minute.

Not taking insurance also gives me the time and resources to help the world. I can see impoverished clients at a community mental health agency, give presentations to the public, write articles for this web site, and more.

By this point, you’ve probably learned more about insurance and counseling than you ever wanted to know! If any questions remain, get in touch; I’m happy to answer them for you.

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