Posted by Dr. Ettensohn 

The Affordable Care Act (ACA) has made health insurance widely available. Insurance plans are now required to provide at least some coverage for mental health services, including therapy sessions. These changes will no doubt result in many more people being able to access needed care, perhaps for the first time in their lives. With this increased access to mental health coverage, you may wonder why anyone would choose to pay for therapy out-of-pocket.

While paying privately for therapy may not be right for everyone, there are some definite drawbacks to going through insurance, and some surprising benefits to paying out-of-pocket.

Some drawbacks of using insurance for therapy:

Session Limits – Insurance companies have a vested interest in reducing their costs. It is often cheaper for them to create obstacles to treatment (that then need to be appealed by providers, patients, or both) rather than to simply authorize adequate treatment up front. Often, people will only have a handful of covered sessions in which to address and work through longstanding issues. The resulting pressure on both therapist and patient can interfere with effective therapy.

Limited Scope– Because of session limits and other insurance requirements, many therapists are learning to narrow or limit the scope of treatment. This may seem like a good thing, because it provides incentive to keep therapy ‘on track.’ However, in real-world treatment settings where problems are often complex and interconnected, the pressure to “focus” treatment can cause important issues to go unexplored.

In addition, time pressures can seriously interfere with a clinician’s ability to detect subtle dynamics that may play a big part in a patient’s problems. There is a very old (and valuable) saying that a therapist should strive to maintain “even hovering attention” during session. This contemplative stance helps a therapist to notice subtle changes in the patient’s mood, posture, tone, or narrative. It also helps the therapist to notice subtle changes in the way he or she feels with respect to the patient. This phenomenon is called counter-transference and can have huge treatment value. The freedom to explore, to associate, and to notice fine detail is endangered when the work of therapy needs to be wrapped up after only a handful of sessions.

Loss of Privacy – Many insurance companies require therapists to diagnose their patients in order for treatment to be authorized. Not surprisingly, this can have important consequences. Once the diagnosis is recorded and sent to insurance, the therapist has no further ability to control the dissemination of that information. It becomes a part of a permanent record. Some diagnoses carry stigma, can be used to justify decisions about life insurance coverage, or may impact security screenings for some forms of employment. In addition, there are circumstances under which an insurance company can audit a therapist’s treatment notes.

When therapists treat patients privately, they retain discretion over whether or not to provide an official diagnosis. The best way to ensure the highest level of privacy is to pay for therapy out-of-pocket.

Intrusion in the Therapy Relationship – Therapy works best when it is a collaborative and private relationship between therapist and patient. Involvement of third party payers, such as insurance companies, necessarily intrudes on that relationship. It places the power to make critical treatment decisions in the hands of someone who may not even know the patient.

The benefits of paying out-of-pocket:

Depth – Mental health issues are often complex and based on multiple underlying causes. Brief, symptom-focused treatments do not usually address these underlying issues, leaving patients vulnerable to relapse after treatment has ended (for discussion of supporting evidence, see here). When you private-pay for therapy, the duration of treatment is dictated by your individual needs. You and your therapist are free to explore and work through any underlying causes, making symptoms less likely to return after therapy has ended.

Quality of the Relationship – How much do you trust someone after only knowing them for five or ten hours? Typically, not very much. Learning to trust someone enough to let them in takes time. Therapists have long known this and volumes have been written about navigating the early trust-building phase of therapy so that the often more impactful later phases of treatment can be reached. This is where lasting change is often achieved. When you pay out-of-pocket, you give both you and your therapist a chance to build the trust that will be so vital in helping you to work through difficult issues that may lie further down the road.

Increased Value – Like anything in life, therapy has more emotional and psychological value when it requires some level of sacrifice to obtain. Budgeting and paying for therapy out of one’s own pocket makes the relationship more significant. It carries more weight because of the patient’s personal investment in the process.

Moreover, paying privately adds dimensionality to the treatment. Issues of affordability, sustainability, and worth must be negotiated and addressed – providing rich opportunity to explore self-worth, trust, dependency, and many other facets of a person’s relationship with themselves and others that might otherwise get overlooked. Negotiating and working through the practicalities and psychological dimensions of payment and cost can significantly increase the depth and effectiveness of therapy.

Is private-pay therapy right for you?

Despite the benefits, many people simply can’t afford to pay out-of-pocket for therapy services. While private-pay may not be right for everyone, many therapists reserve a few low-fee spaces in their practices, both as a way of giving back to the community and in order to work with individuals who have complex cases but can’t afford the treatment they require. If you honestly can’t afford to pay full fee, I would suggest calling around and asking for a lower fee. You might be surprised at how many therapists may be willing to work with you for less than they typically charge.