Recently I began a year of intensive training on couples therapy. I’m excited to expand to a new area of practice and will be back monthly to share my thoughts to the training experience.

Early in reading about couples therapy I came across the notion that ‘the couple is the patient.’ I found this baffling and a bit disconcerting! I know lots of people enter couples therapy hoping to save their relationships, but surely some of those relationships do not continue and in fact, some of the work must sometimes involve supporting people through saying goodbye. If the couple is my patient, does it mean I’ve failed if the couple ceases to exist? Furthermore, what does it mean for my relationship to the individuals involved if they are not my patients?

I’ve come to understand this maxim to concern primarily the field of attention and intervention in couples work. In individual therapy, my focus is one person’s lived experience. That experience, communicated through a variety of means during the therapy session, is the only access I have to that person’s world and the only place we (therapist and patient) can make discoveries or changes. Surely, I as the therapist become the stand-in for others in that person’s life through. Understanding how my patient and I interact can provide both important information and a place to play and experiment interpersonally. However, my role as a therapist, even one that counts my emotional responses in session as valuable information, is to prioritize my patient’s experience. I may have reactions, even strong ones, but I try to share them only when, and in such a way that, they are helpful and relevant to the work my patient is doing. A former professor used to tell us to ask ourselves “for whose sake?” when we considered an ethical quandary.

Obviously, the others in my patients’ lives whom they find themselves in relationship with are under no such obligation. They speak for themselves, and for their own sakes, and they interact in their own ways with the internal dynamics of my patients. This is one of the ways that a therapist-patient relationship differs from other relationships in our lives. It is also one of the fascinating aspects of couples work, in that partners are acting and speaking for their own sakes together right before my eyes. Here in the couples therapy room are the ways that each partner’s lived experience comes into sharp contact with the other’s. Here is the field where one person’s innocuous comment is, equally and at the same time, another’s searing critique. It is where patterns are developed to protect and preserve the individuals and the couple. It is the stage where we agree, often implicitly, on the roles we’ll assume in the relationship and the play that we’ll put on, in some variation or another, again and again.

This is what is unique and fascinating about couples therapy – the couple is, in real time, producing a version of their relationship dynamic that includes the interaction of their individual histories, defenses, and values. I get to see in real time how partners co-create the relationship pattern they are in, and when I intervene, I get to see how that pattern responds to a disruption. Couples are seeking treatment because their relationship patterns have become problematic, and so my task as a couples therapist is to help them disrupt the loops that have them stuck.

The same could certainly be said of individual therapy – people find themselves stuck in loops that they hope therapy will help them escape from. But in couples therapy, I get to see how each person finds themselves in relation to their partner, and together the three of us get to try to change the shape of the relational field and see what happens. We experience ourselves in particular ways in particular relationships; the self we are with our parent or our boss or our child or our therapist is different from the self we are with our partner. Partners in couples therapy have created a dynamic that is unique to them. They exist in relationship to each other in an unique way, and my aim is to help them explore and perhaps try to open up the space they find themselves in as a couple. This is the way I think that the couple is my patient.

My office has a lot of orchids. Two offices ago, I got two small ones as a gift to myself upon moving in. My current office has so much more light and window ledge space, and the old orchids were growing so happily here – even producing new blooms! – that I acquired a few more. Then I noticed some sad ones on the clearance rack at Lowes, and some neglected ones in need of repotting at a friend’s house.

My windowsill is just about maxed out with these plants in various stages of life. One of the sad clearance rack ones turned out to be incredibly robust and continues to hang onto two of three blooms its had since February. One, a striking deep purple that was in full bloom at the same time the clearance one was clinging to life, quickly lost its flowers and has gradually dropped every single leaf it had when I bought it. I repotted it, removing the dead roots and rotted substrate and giving it a nice airy new pot, but it only seemed to accelerate the leaf loss. Mournful, I moved it to a less-prominent spot in the window. Honestly, I was concerned that its haggard appearance would interfere with the peaceful tone I try to create in my office. During the last few weeks, to my surprise, it has produced a beautiful new leaf! Not nearly as big as the one that is still dying off by its side, but new and healthy and full of promise.

My most recent orchid addition was by far the most dazzling: purple and yellow flowers tumbled down a gracefully curved flower spike. A few patients were reminded of a tiger. I thought of dragons. This week its last two blooms, wilted and muted in color, clung sadly to the end of the spike. A patient noticed and asked “What will it do now? Will it flower again?”

Dragon-tiger orchid in full bloom!

Of course I have the same question, and perhaps we shared the same wish that it would. I replied that it might or might not, but it would likely take some time. Orchids grow roots and new leaves during the summer and, if conditions are right, may bloom fall to spring. But of course I’ve heard lots of people say they could never manage to get an orchid to rebloom. My original orchids went more than a year without reblooming, and one of them still hasn’t.

I joked with my patient that growing orchids was a metaphor for therapy. Initially I meant this in a wry, self-deprecating way. We have worked together for a long time and have talked about how frustrating it can be when change comes very slowly, or not at all.

As I’ve learned more about orchids, though, I’ve learned how to notice small changes that indicate their health and happiness. I do feel concerned when a leaf starts to shrivel or discolor and I worry that I’ve done something wrong. At the same time, I know other indicators of growth to look for; I can notice the health of the roots and, if I’m lucky, spot new roots emerging that will make the plant stronger. If I can see new leaves emerging I know the conditions are right for the plant to continue to grow. Blooms are beautiful, and I’m delighted when they appear, but one of the oldest orchids that has never bloomed since I bought it is now bursting with new roots and leaves – really, it looks as if it’s jumping up out of its pot! There is no doubt that plant is healthy, even if it doesn’t have flowers.

This is the fuller, non-sarcastic metaphor for therapy. Progress is not always linear. Small steps are important and worth celebrating. Growth and thriving might look different from case to case, and sometimes thriving is not showy.

Therapists and patients can forget these points and grow disheartened, frustrated, or anxious. Life comes with setbacks, and one of the most powerful things a therapist can do is hold for themselves and their patients the conviction that one can emerge from even devastating losses. We can do that in part by making space to notice small steps toward change – tiny efforts to reach for what one needs. As therapists and as patients, we can be mindful that therapeutic growth might look different from one person to another and to remember that there is not one picture of health or happiness. It may be gratifying when a patient ‘blooms’ – whatever that means in my imaginary notion of the ‘good life’ – but therapy is not about making people become more pleasing to the therapist. Sometimes, even for the patient themselves, therapy becomes about recognizing other kinds of growth or health. Sometimes our image of the good life changes, and we recognize a new kind of beauty.

This is the fourth part in a series about searching for a therapist while navigating your insurance. You can start at the beginning here.

If your plan only offers in-network coverage, especially if the pool of therapists for your network is small, you may have trouble finding someone who has availability and/or expertise in issues relevant to you and with whom you feel a good fit.  Even if your plan doesn’t offer out of network coverage, you still have options!

Alternately, you may have out-of-network coverage but a very high deductible, or the help from your insurance is not enough to bridge the gap between your desired therapist’s fees and your budget. One of the following options may be of help.

Change plans

Does your employer offer a selection of insurance plans? If you know you want to invest in therapy, consider whether a plan that offers more generous coverage such as a PPO would make financial sense.

Keep your plan, but pay out of pocket

Here’s where you’ll want to crunch some numbers. Even if you have a choice of plans, if the cost for the more generous plan is significantly higher, or if it has a very high deductible, you may be better off keeping a less expensive plan and negotiating an out of pocket fee with the therapist of your choice.

Many therapists are open to some negotiation of their fees; avoiding insurance saves them time and effort as well, so negotiating a self-pay fee with a therapist with whom you have a mutual sense of good fit can be a win-win!

Paying out of pocket comes with the additional benefit of uncoupling your insurance company from your treatment. If you pay out of pocket, your therapist isn’t obligated to give you a diagnosis to justify your treatment to your insurance, and you and your therapist have complete freedom to determine the course of your work together without your insurer weighing in on the hows and whys.

If you do have a choice of HMO and PPO coverage for your health insurance, to make an informed choice you’ll need to estimate the cost of therapy for the year and compare that to your deductible and any difference in premiums between plans. You can get an idea of what therapists in your area charge by checking sites like Psychology Today that list therapist fees.

Use your HSA or FSA account

If your employer offers a Health Savings Account or Flex Spending Account, therapy with a licensed provider is considered a medical expense. You can use the pre-tax dollars from these to pay for therapy. If your provider accepts credit/debit cards you may be able to use your HSA/FSA debit card to pay your fee. If not, you can file for reimbursement from your account administrator.

Ask about sliding-scale, reduced-fee or pro-bono availability

Therapists know how hard navigating the world of insurance can be – it may be why they aren’t in-network! Many therapists are also committed to making therapy available to all people, regardless of need. To that end, some will offer ‘sliding-scale’ fees that are scaled to your income. Others may reserve a few spots in their practice for low-fee or pro-bono patients who otherwise couldn’t afford their services. If you find someone who seems like a great match for you but who isn’t in your network, you can try asking if they are willing to negotiate a reduced fee with you.

Ask about insurance exceptions

Similarly, if the therapist you’d like to see isn’t in-network and you can’t afford their fee, you can ask if they would be willing to request an exception from your insurance plan to treat you. Some insurers will grant exceptions on a case-by-case basis, usually in cases where you couldn’t find a therapist in their network who is appropriate for you. For example, if there are no in-network therapists near you that specialize in LGBTQ mental health, you and your therapist can ask your insurance plan to treat your therapist like an in-network provider just for your treatment only. If granted, your therapist would have to agree to provide treatment to you as though they were in-network. This includes accepting the contracted rate your insurer provides and filling out necessary paperwork, so it is somewhat like asking to be a pro-bono or reduced fee patient.

Try a clinic

Outpatient mental health clinics, such as those attached to the psychiatry departments of hospitals, usually accept more insurance plans than private practitioners, in part because they have a billing staff to manage negotiations with insurance. You might have less choice in terms of identifying the particular therapist you want, and you may be assigned to a trainee, but the trainees in clinics, especially those attached to reputable universities, often have their cases overseen by experienced senior therapists. Seeing them brings you the benefits of the new therapists’ enthusiasm and fresh training along with their supervisors’ wisdom and experience. In the Cambridge area, I recommend Cambridge Health Alliance’s Outpatient Psychiatry Department. In Newburyport, I suggest Harborside Counseling.

Look for research studies relevant to you

Some hospitals or training sites may offer therapy as part of a research study and may have funding to offer treatment at little or no cost. The Center for Anxiety & Related Disorders at Boston University and the Center for Anxiety and Traumatic Stress Disorders and Complicated Grief Program at Massachusetts General Hospital are examples.

I hope this guide has been helpful! If you have feedback or questions, please don’t hesitate to reach out over on the contact page.

This is part three of a series about navigating insurance while searching for a therapist. You can start from the beginning here, and check out ways to find an in-network therapist here.

With a PPO or other kind of plan that offers out of network coverage, you have the choice to see in-network or out-of-network providers and get some help from insurance either way. If you choose an in-network provider, you’ll pay only a copay for your visits, just like a regular doctor’s office visit. If you choose an out-of-network provider the process is a bit different.

Check your benefits information online or in the welcome packet you received when you signed up, or call the customer service for your plan, usually located on the back of your id card. You’ll need answers to the following questions to determine how your benefits work and what portion of payment you’ll be responsible for if you see an out of network therapist.

Things to ask customer service:

• Do I have out-of-network coverage for mental health/behavioral health? (If yes, continue. If no, see the post on finding an in-network therapist.)
• What is my deductible? How much of that deductible has been met for this year?
• When does my deductible reset? (e.g. Jan 1st or some other date?)
• What is my coinsurance to see an out-of-network provider?
• Are there any limits to the number of covered outpatient mental health visits in the year?
• What is the maximum allowable fee for a psychotherapy session (CPT code 90834 for individuals or 90847 for couples in most cases)?

Most insurance plans incentivize you to stay in their network by providing more generous benefits for seeing those providers. If you choose someone outside the network, you may be responsible for a deductible, which can vary widely from plan to plan. If you have a very high deductible, it may mean you’ll be expected to pay for all of your therapy out of pocket. Other plans may have small deductibles that will be used up in the first few sessions. Be aware, the rate that your insurance considers you to have paid down your deductible depends on their maximum allowable fee (sometimes called the usual and customary fee), not the amount your therapist bills you. If you have a very high deductible, it may be worth considering negotiating a self pay fee with your therapist rather than using your insurance and/or changing your insurance plan. More on this in a later post.

Once you have tracked down the above information from your insurer, you can calculate your likely out of pocket cost for therapy. That out of pocket cost depends on a few factors; your therapist will have his or her set rate, which may or may not be negotiable based on your financial situation. Your insurance plan will have their own set fee, the maximum allowable fee, that they will cover for a session. Your plan may also have a coinsurance – a percentage of the allowable rate that you are expected to cover each session. This works like a copay for in-network visits, but the amount is expressed as a percentage of the insurance-allowed expense rather than a flat fee. Finally, you’ll have the balance between the insurance payment + your copayment and the your therapist’s total fee. For example:

Your therapist charges $300 per session. You pay her and submit to your insurance plan for reimbursement. Their maximum allowable fee for your visit is $150, and you are responsible for a coinsurance of 20%. They will reimburse you $120, leaving you paying $180 out of pocket.

As you can see, choosing an out of network therapist can cost significantly more than a copay for an in-network person, but may be significantly less than paying the full fee on your own.

Why choose an out of network therapist then? Expertise, convenience, choice

Despite the higher cost, an out of network clinician might be the right choice for you if your needs aren’t a good match with the available in-network clinicians.

• Perhaps you want someone who has experience and expertise in a specific issue, treatment modality, or population that isn’t available in your network.
• Maybe you have a tight schedule and require an appointment during specific hours. Early morning, evening after 5pm, and weekend hours are in high demand and tend to fill up quickly, especially for therapists who are in-network with insurances.
• Finally, you might have a preference for a particular provider: someone you’ve seen before, or feel a particular affinity with, or who has been recommended to you by someone you trust.

In any of these cases, you might find your in-network options don’t meet your needs and out-of-network coverage can help bridge the gap.

If you would prefer to see someone out of network, but the cost is prohibitive, even with your out-of-network benefits, see the next post on expanding your options while managing costs.

This is part 2 of a series about navigating searching for a therapist using your insurance. Find part one, learning about your insurance coverage, here.

If your plan is an HMO with no out of network benefits, or after having considered your options you decide to restrict your search to in network providers, most of the financial information you need is likely on your card. Look for “BH” (behavioral health) or “OV” (office visit) to find your copay. This is the portion of payment you will be responsible for when you see an in-network provider.

Because you are limited to therapists in your network, It’s a good idea to start your search with a list of providers in your area who are covered under your plan. Most insurance websites allow you to search for covered mental health professionals near you. Using this tool will give you a sense of how large the pool of in-network therapists in your area is. The larger the list, the more choice you have, obviously, but also the fewer calls you may have to make to find someone who is accepting new patients and whose style, expertise, and schedule match your needs. By contrast, if the list is very small, be prepared for the therapists to have less availability and know that you might need to expand your search in terms of location, scheduling, or other therapist preferences.

Your insurance website may not include much information on the therapists themselves in their search tool – for that you may need to turn to therapist directories like Psychology Today or simply google the names that come up to find their professional websites. You can also try asking friends who have therapists they like – I have often suggested therapists for friends of patients!

Try to generate a list of a few possible therapists; if you have time restrictions (e.g. evenings only) or a small pool of in-network therapists you may need to have a longer list. If you can be flexible on time or have a very large pool of therapists from which to choose you may not need as many names.

Take some time to sit down and reach out to the therapists on your list. Some things you’ll want to ask about in your initial inquiry:

• Are they accepting new patients?
• Are they a provider for your insurance plan? (Sometimes provider directories are outdated or incorrect – it is essential to confirm network status with the therapist to avoid surprises later!)
• If you have scheduling requirements, do they have openings during the times you need?
• If you feel comfortable, you might share a very brief explanation of what you’re hoping to work on in therapy so they can determine whether they are an appropriate match for you clinically.

Once you have a match, you’re off! Bear in mind, again, that a sense of fit between therapist and patient is of utmost importance, so use the first session or two to get a feel for how well you work with the therapist you’ve chosen. If you don’t find a good match, try the process again or see the upcoming section on expanding your options.

This post was created and written in collaboration with Scott Bortle, Ph.D. 

There are many good resources for finding a therapist out there, but often the people who contact me have questions about using their insurance to help pay for therapy. Navigating insurance is frustratingly complicated and sometimes discourages people from reaching out for help at all! Let’s take a closer look at how your insurance works and how to use it (or not!) in looking for a therapist.

For a variety of reasons that I’ll address, you may conclude that the best option for you is choosing a therapist who is not covered by your insurance. The subjective sense of ‘fit’ between a therapist and patient is the strongest predictor of therapy success, and limiting yourself to therapists covered by your insurance may minimize your chances of finding that fit. We all know how expensive healthcare can be, but because you will be investing a lot of time and energy into your therapy I encourage you not to choose based exclusively on cost. I’ll explore some options for managing cost while maximizing choice later.

I’ll start by guiding you through the basics of health insurance as it pertains to mental health professionals. Particularly, we’ll review how insurance networks work and what they’ll mean in your therapist search.

Then, I’ll tell you how to search for a therapist in your network who meets your needs.

Next, I’ll talk about out-of-network coverage; why you might choose an out-of-network therapist and how to use your benefits to see the therapist of your choice.

Finally, I’ll consider options for maximizing your choice while managing costs. I’ll suggest some alternatives if you don’t have out of network benefits and/or can’t find a therapist meets your needs and is in your network.

Get to know your insurance. What therapists can I see?

Your insurance will likely fall into one of two categories: it will either offer out-of-network coverage or it will not. Every insurance company has a pool of therapists (a “panel”) who have agreed to see that insurer’s subscribers for a reduced fee and under their terms. These clinicians who have contracted with your insurance company are in-network for you. All others are out-of-network. If your plan allows you to see out-of-network providers, you can choose your therapist freely (with some caveats that I’ll discuss in the out-of-network section). If not, then you must choose from within the insurers network or they will not cover your sessions.

Take a look at your insurance card – does it contain acronyms like HMO or PPO? Most HMO plans (including most plans through Commonwealth Care or the state Marketplace) restrict their coverage to in-network providers. Most PPO plans do offer out-of-network coverage, though the details can change from plan to plan. In either case, you can call the number on your insurance card to ask about your coverage for mental health visits (sometimes called ‘behavioral health’), or look up information on your insurance company’s website under your specific plan.

If you know you only have in-network coverage, proceed to the next section, where I’ll cover how to find an in-network therapist match. If you have out-of-network coverage, keep reading – you can still choose an in-network person, but you’ll also want to ask some more questions of your customer service or HR person to learn about the particulars of your out of network coverage.

This series was created and written in collaboration with Scott Bortle, Ph.D.