I’ve been on panel with a single insurance carrier (Blue Cross and Blue Shield of Texas), for several years. In June of 2018, I decided to no longer accept insurance for couples therapy. I still accept it for individual therapy.
This was not a decision I made lightly. I knew my clients would feel some negative affects, and I worried it would hurt my bottom line. There are three reasons I did so: one philosophical, one selfish, and one clinical. Any of them, in isolation, wouldn’t have been enough. Together, they made it necessary.
Health insurance doesn’t actually pay for couples therapy.
We all act like they do. If you call them, they’ll likely tell you they cover it. But they don’t. What they’ll pay for is individual therapy with a family member present.
For the layperson, especially someone hoping to use their benefits, this may seem a small distinction. For me it’s not. I work from a Systems Perspective. I view the relationship, and any distress within it, to be the product of interactional dynamics (rather than internally driven behavior).
To bill insurance, I have to identify one person as the patient. They become the one creating the trouble. Further, I have to label that person with a mental illness diagnosis. That last part is also a philosophical struggle for me, as a clinician with a post-modern theoretical lens, but that’s a story for another day.
This aspect always bothered me, but it’s the rules of the game. In the post ACA world, mental health diagnoses became a lot less dangerous, so I grudgingly relented. When I explained the situation and my objection, it was rare for anyone to opt out of using their benefits.
It stopped being worth it to me.
Couples therapy is a different process from working with an individual. It’s a lot more work. With three people in the room, I’m tracking six relationships (yes, that’s a real number). I can’t just follow my empathy and align with a client, without balancing it with the other person in the room. While I’m doing that, I also need to maintain a strategic viewpoint of all the little parts no one is saying aloud, formulate interventions on the fly, and keep track of all the things we’ve already done.
It’s rewarding, and I enjoy it, but it’s a lot of work.
Part of the deal with insurance, that I think most clients don’t think about, is that I’m taking a significant cut in my hourly rate. It’s a contract I have with them. They send me clients, and I accept their “negotiated rate.” Contractually, I can’t tell you what that rate is, and I can’t ask the client to make up the difference. Without getting into further details, let’s say that the ROI is poor.
I have, however, agreed to it. For the work I put in to any individual session, I’m ok with it.
With couples, given the work load and stress, I’m not. I realized I was getting burned out. I didn’t enjoy my sessions anymore, and I gave serious consideration to not doing couples therapy anymore.
Given that my client load is 75% couples, I was in a bad spot.
It wasn’t working for the clients either.
As I said at the outset, the previous points weren’t enough. Then, I had a curious realization. My couples weren’t progressing. I use a structured, goal-oriented, behavior-based approach in couples therapy. It has more than forty years of research behind it and has the highest success rate in the biz.
There is a normal course of treatment I expect to see in my couples. Some move faster or slower, some have more severe difficulties than others, but I expect to see them hit particular benchmarks.
Except my insurance couples didn’t. This wasn’t universal, but it was darn close. My insurance couples would initially get better, make some strides, and then just stall out. They weren’t terrible; they weren’t regressing; they just weren’t getting better. They stalled and stayed stalled for (in some cases) years.
I forgot to mention that my approach is short term. I work with a couple for 6, 9, or 12 months—with rare exceptions. Some of my insurance couples were approaching 24.
It didn’t hurt enough.
I have a personal theory, an explanation for what I was seeing. Couples therapy sucks. If you’ve never been, let me just tell you, it’s hard. My job, in a nutshell, is to take a stable system and disrupt it. Then, in that unsettled state, I convince people to take actions or face truths they were avoiding–sometimes for good reason. Once I’ve convinced them, then they have to do it, over and over until the system stabilizes in a new configuration.
Sounds dramatic, I know, but that’s the mechanics of it.
My theory is that if all someone is paying me is $25, maybe it’s just worth it to them to keep paying me rather than make those difficult changes. At $165 an hour, I guess that stings enough that they’re motivated to get it over with.
For reasons I’m not clear on, none of the above is true for individuals. Maybe it’s the nature of my relationship with them; perhaps it’s that 24 months is typical for individual counseling, I’m not sure. What I do know, is that it works.
You want to use your insurance benefits for couples therapy.
Hey, I get it. I pay through the nose for my insurance. I want to get my money’s worth out of it too. Part of my job is to make unpleasant truths explicit, so we can accept their reality. This is one of those truths. It just didn’t work.