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. But weighing all of that, I still made the decision. Here’s why:

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 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. This aspect always bothered me and feels slightly unethical by my standards.

Couples therapy is a different process from working with an individual. It’s a lot more work. With three people in the room, it is a more complicated dynamic. 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, 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 it is not great.

With couples, given the work load and stress, I’m not okay with taking such a rate cut. 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. But, I decided instead to stop taking insurance for couples therapy. This did reduce my caseload for a while, but now I find I have more energy to work with couples and find more joy in the work.