A lot of thought goes into deciding whether or not to accept insurance as a mental health provider – it’s a layered and important issue. Ultimately, I have chosen to operate as a private pay therapist in order to offer the kind of support I believe my clients deserve. Hopefully, this post offers some insight into my decision-making process.

The biggest drawback to not working directly with insurance companies is, in my mind, the challenge of accessibility. In an ideal world, mental health care would be available to every person who desires it with no financial barriers. Sadly, even with insurance, this isn’t currently possible due to our dependence on the medical-Industrial complex, a system that focuses on pathology and profit rather than genuine growth and healing. The insurance system works incredibly well at providing as little coverage as possible for its policyholders while taking advantage of healthcare workers. I also choose to not engage with the current diagnostic system when possible. It’s heavily influenced by ableism and colonialism so I prefer to diagnose only where necessary and with a collaborative approach.

Part of insurance demanding a diagnosis to cover treatment means that diagnosis becomes part of your record, which can impact future coverage, life insurance, and lead to higher premiums. Insurance companies then also have access to progress notes and treatment plans, which they use to dictate the kind of care I can provide. Insurance often demands short term treatment options, which sounds ideal on the surface, but can fail to address deeper issues in a client’s life. Short term therapies such as cognitive behavioral therapy (CBT) can be helpful in learning coping skills and managing symptoms, but fall short in addressing the root causes of mental health concerns. My therapeutic approach for these deeper struggles is based on creating a safe, healing relationship with my clients. This kind of relationship is rarely possible through short-term treatment. We have evidence that the most powerful factor in therapy, behind the work a client puts in, is the therapeutic relationship. If I were to allow insurance to dictate the kind of therapy I provide, I would be doing my clients a disservice.

In order for me to create and maintain my side of that crucial therapeutic relationship, I have to make sure my needs as a human are met. Being able to have greater control over my income is a big part of that. As much as I wish I could provide therapy for free, we live in a society where money is necessary for survival. I need to account for my own cost of living, the cost of running my business, and how many clients I can feasibly see per week when setting my rates. If I need to see more clients that what is sustainable in order to make enough money, I will quickly burn out, which is no good for me or my clients. In order to avoid burning out, I spend a lot of intentional time caring for my own mental health and overall wellbeing. I aim to show up to sessions grounded and ready to listen with intention, connect with you, and offer reflections and challenges. If I’m not on top of my own self care, I’m more likely to miss details in your story, struggle to stay present with you, and fail to notice the nuances of what is being said or not said. While I’m human and will never be able to do all of those things flawlessly, being able to choose a sustainable number of clients per week makes those important parts of being a therapist more accessible.

With all of this in mind, the unfortunate reality is that insurance across the board does not reimburse at a rate that allows for a sustainable caseload while accounting for cost of living and the cost of business. Insurance dictates what they pay therapists, regardless of what we set our session rate at, and we rarely get to advocate for rate increases. In the Minnesota metro, insurance companies typically reimburse between $75 and $125 per individual session, with the majority being in the middle of that range. Reimbursements are even less for couples and family work, if it’s even covered at all! To make it even more challenging, insurance companies often fail to pay for sessions within the mandated 30 days due to unnecessary administrative complications. They can also decide to take back payments for sessions, sometimes after several years, which healthcare providers call “clawbacks”. This is perfectly legal for insurance companies even though it’s akin to you having to pay back parts of your paycheck months after you were paid for work you did.

These realities of insurance reimbursements fall far short of what is needed to cover the expenses of this field. Another private pay therapist offers a detailed breakdown of those expenses, if you’re curious. She is based in the Pacific Northwest so there are some differences in costs, but some of the biggest factors remain the same: rent for a physical office space, paying off expensive degrees and certifications, costs for ongoing professional training and consultation, saving for unpaid hours of work and vacation or sick time (we only get paid for our time with clients, but we do a lot of work behind the scenes to provide the highest level of care we can), and more. The rate I set for my sessions takes all of this into account – it’s not the same as a typical hourly wage.

Choosing to be a private pay therapist allows me to be a better therapist overall. I can focus more on client care, furthering my knowledge and expertise, and staying more connected to my goal of helping people. I understand not everyone may be in a place where they can afford a full-fee therapist and this is an unfortunate side effect of our exploitative health care system. There are resources for reduced-fee therapy – one such resource is Open Path Collective, which is a directory of therapists committed to reserving a few of their weekly sessions for folks paying a reduced rate. I’m happy to discuss this further with any potential clients, including how you may be able to access out-of-network reimbursement through your insurance, which often reimburses more to clients than what they would otherwise pay insurance-contracted therapists. I hope that we will one day experience higher and more sustainable reimbursement from insurance in order to close the accessibility gap for therapy and, in the meantime, I regularly participate in advocacy opportunities encouraging insurance companies to make that a reality.