Why You Should Pay Me Cash Instead of Using Your Insurance

David Flowers

Last Update 2 years ago

1. You want your counselor to work for you. Whoever pays the money is ultimately the employer. 

2. Privacy and confidentiality are assured when the insurance company is out of the loop (I'm sure as heck not going to breach your privacy!)

3. When you use your insurance for couples counseling, one of you has to be diagnosed with a mental illness. Do you think one of you is mentally ill? If not, I'd encourage you to think about the ethics and legality of that. If so, but you're seeking couples therapy, be aware your counselor has to document the session and write a treatment plan as if your mental illness is the main thing being dealt with in counseling. 

4. I charge enough to make sure I'm not constantly in knots about money, and enough to make sure I can make a living seeing 10-20 clients instead of having to see 30-50, which isn't uncommonly what therapists have to do to both make a living and pay their (frequently enormous) student loans. Together, this means I'm not constantly feeling burned out, stressed out, and checked out. It also means you get a counselor who can be truly present with you, and to whom you are 1 in 10 or 20, not 1 in 30, 40, or even 50.

5. When you pay me $200 for a session, you're simply paying for the enormous investment of time and money I have made to get to where I know enough to actually help you.

6. If you had to see an attorney, say, to pay for a divorce, or settle an estate issue for a parent, you'd pay $200/hour at minimum, and insurance wouldn't cover it, and you'd pay it anyway, because you needed the service. You'll always pay for the things you need and value most.

7. If you were marrying off a child, you might choose to spend $10-$20k or more, and that's not even required, you'd just want to pay for the party! The DJ alone could easily be $1000. For music. For one night that, as great as it's going to be, will be gone in an evening and nothing but a memory. $1000 is five sessions of couples counseling, an investment into the most important relationship in your life.

8. If you had to put a new furnace in your house, that's about $10,000. A new roof would run you about the same. You need heat, you need a roof over your head. And you need a healthy intimate relationship, as healthy relationships have been shown to contribute more to health and long life than not smoking! So you want to make sure you're seeing someone who is trained, is experienced, and knows what they're doing.

"One study, which examined data from more than 309,000 people, found that lack of strong relationships increased the risk of premature death from all causes by 50% — an effect on mortality risk roughly comparable to smoking up to 15 cigarettes a day, and greater than obesity and physical inactivity."

Source: Harvard Health Publishing

9. 82% of therapists who see couples haven't received particular training in doing that work, so they approach it much like they approach individual therapy. The first thing you learn when you do pursue advanced training in couples work is that approaching it like individual therapy will oftentimes actually do more damage! You want a therapist who has invested the time and money into learning how to do the work you're paying for, the work that can change your life for the better. And most therapists who have made this investment don't accept insurance. (See above!)

10. Don't compare a therapist who sees couples but has very little or no training in working with couples, who accepts your insurance so you only pay a $20 copay, to a therapist with extensive and costly training in working with couples who doesn't take your insurance. That's not an apples-to-apples comparison. Compare therapists with similar levels of training and experience, and you'll see most of us are in a similar range and don't accept insurance. (See above!)

11. The fact that there are no guarantees in couples counseling argues for paying cash for someone with a lot of experience instead of using insurance for someone less qualified. 

I can't promise any specific couple that coming to therapy with me will definitely restore their relationship. The system I use has a success rate of about 75%, but that's assuming a couple is attending sessions regularly and working hard on applying the new interventions they are learning at home. There are no shortcuts in relationship counseling -- you're going to have to ultimately do the work. So you'll want to prioritize finding a therapist who 1) knows what the work is; 2) knows how to show it and teach it to you; 3) knows how to assign homework that will really help you apply that skill at home in your normal environment. 

12. I have found a great deal of my work as a couples therapist is helping couples understand why they are struggling to do the work at home. You can learn principles of sound relationships in a book, along with the exercises you need to practice in order to change your habits and improve your relationship. But if and when you get stuck, you'll need someone who can help you figure out what's going on, and this will require the very training most therapists who accept insurance will not have.

13. Since I see couples exclusively, my sense of competence as a professional is based almost entirely on the extent to which I'm able to actually help couples get the results they want. So I have not only a financial incentive to help you, I have deeply personal reasons as well. When you see a therapist who accepts insurance and sees a broad variety of clients, they will also be concerned about their competence with anxiety, depression, eating disorders, bipolar, ADHD, or whatever other issues they work with. None of that matters to me -- I measure myself only by the standard of whether and how well I help couples.

14. There are of course exceptions to this, but generally the old maxim holds true that by and large, you get what you pay for.

15. It's usually more about how you think about the issue than specifically about the money. If you had a sick child, and there were only a few doctors who could treat them, and the treatment was quite successful but still not approved by the FDA and therefore not covered by insurance, you'd get the treatment, right? Of course, we'll do anything for our children, pull out all the stops, and we should!

I think people should do that for their relationships as well, and that might not mean choosing me as their therapist. Maybe a couple finds someone else they pay a similar fee to whose training and experience they feel better about. All I'm saying is I don't think this is an area where couples want to put the money first, I think they should put the relationship first and follow that priority wherever it leads.

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