A Double Bind for Therapists

If you’re a therapy consumer and you have not yet read this ProPublica article about why so many therapists and prescribers are leaving insurance panels, I highly recommend you do so. If you’ve ever struggled to find a therapist or have been surprised by the out-of-pocket costs of high quality therapy, this article does a good job of providing an overview of the problems presented by insurance plans. As a therapist, I used to think it was important to shield clients from the darker side of insurance shenanigans but now, I try to be as transparent as possible about the role insurance plays in my practice to raise awareness about how undervalued and underpaid we are by the healthcare system in the US.

You see, I didn’t enter a PhD program in Counseling Psychology to work with only the segment of the population who feels comfortable paying $250 per session out of pocket. I entered the profession to be of value to many different kinds of people. Much of my training was with refugees, asylees, and people with undocumented status. But one of the reasons I find myself in private practice serving a generally privileged niche who have the means to pay for my services is that community mental health agencies and non-profits do not pay psychologists an actual adult salary, one that allows for a comfortable living and savings. What does this have to do with insurance? Well, I’m providing the context that practitioners like myself need to balance our desire to help others with our financial needs and goals. Another way of saying this is, I can’t afford to have a full week of clients who use insurance to pay me. Insurance reimbursement rates are not what the market value of high quality therapy with a PhD-level psychologist is in the real world. So from a financial perspective, the people I see who are using insurance to pay me are getting a discount.

The double bind in this is that I want to see people who use insurance. That should be the norm. People should not have to pay out of pocket for good therapy. At the same time, insurance places demands on me and presents risks that are difficult to manage. For instance, writing a note for a person using insurance is very specific and tedious. The ProPublica article I linked above described hundreds of clinicians who lost money because of erroneous and unfair clawbacks. That hasn’t happened to met yet but sometimes I wonder if it’s only a matter of time. And when it does happen, would it be worth the hours and hours of debating an insurance company’s bureaucracy to get the money back? There are no good answers for how to manage such a dilemma. It’s just best avoided in my opinion.

Harrowing Tales of “Bad Therapy”

All this has me connecting some dots. I’ve heard from so many clients and friends and family members that their experiences with therapists have been negative. One common theme is that a lot of people I know have met with therapists who have been unprofessional during sessions, such as doing virtual sessions in a coffee shop, eating or vaping during a session, taking care of a baby or child during the session, talking about themselves a lot (too much). Another common theme in these stories is the therapist is not present, such as not remembering anything about the person, saying the same things over and over, not getting emotional attunement right, giving overly specific advice.

Maybe there are some bad therapists out there, maybe there are even a lot of them. I don’t know. But I think there’s an important connection between the financial prospects of working as a therapist and the quality of services and presence they offer. If a therapist is making what amounts to minimum wage after taxes, even though they have a Master’s degree, how does that change your expectations about their performance as a therapist? I personally would rather work at McDonald’s than do this incredibly valuable and intensive work for a pittance.

My Insurance Panels

I’m currently taking Aetna in California and Texas through Alma. It’s going well so far and I’ve not yet experienced the things discussed in the ProPublica article. Fingers crossed for an uneventful foray into insurance.