Why Am I Choosing To Not Work With Insurance?
To say that people have mixed feelings about insurance is an understatement. On the one hand, it affords us the ability to receive our needed medical and mental health services at a reduced fee, but this comes at a cost that often escapes words. This latent, unarticulated cost is so powerful that it not only inspired a young man to murder in cold blood, but that the slaughter even summoned fervent support. The “Free Mangione” movement represented an ardent protest–rooted in a profound feeling of injustice–against the crimes committed by an exploitative healthcare system. What level of injustice could have ever been so heinous that we could support cold blooded murder? What exactly have we robbed ourselves from?
Insurance companies place latent incentives on behalf of providers and patients that impose barriers to the therapeutic endeavor. These barriers include:
Incentivizing providers to engage in diagnostic and case formulation practices that subtly misconstrue clients' experiences in ways that meet arbitrary templates defined by external standards and regulations.
Disseminating categorical notions of human suffering that create unnecessary conditions for shame, frustration, and burnout on behalf of both patient and provider alike
From such ideas, creating slightly misleading expectations for treatment (i.e. wanting to “fix”, “be fixed”, or amputate a part of experience before understanding it)
Financial uncertainties that create frustrations and confusions that lead to burnout.
But there is a mystery here, because we are the ones who place incentives on ourselves. Why might this be so? While I will have much more to say on this topic in the future, I hope what follows will suffice.
We are each vulnerable and limited, and are afraid of this fact. I have noticed that we–and I deeply include myself here–yearn for and need categories in order to reduce complexity and help us make sense of the world. Yet, there is a way in which we seek safety behind the objects of our own creation, sacrificing complexity, nuance, and dimension for a sense of certainty that is not without consequence. What is this consequence?
I have noticed and felt that third party managed care companies incentivize me, in very subtle ways that often escape my attention, to justify the need for therapy, as if the person who is suffering isn’t entitled to receive therapy. Not only, if treatment is successful, reimbursement is denied and the patient is expected to terminate. And if it is not successful, treatment is considered a failure and I have felt the desire to want to terminate and help someone find another provider that the “evidence based” says would be better suit, without recognizing the fact that I may be colluding in a subtle dynamic in which the person I have tried to help is either suffering in ways that I don’t realize or tends to push people in ways that they don’t know. In both cases, the incentive is to end treatment.
This is notwithstanding the cognitive and emotional tax I have experienced in actively reconstituting—through a kind of mental gymnastics—a patients’ experience in order to get permission from an entity from which I need not seek approval. It has impacted how I have understood and shown up in my relationships: feeling subtly distant and avoidant in ways that I don’t want to. Yet, it has also protected me acknowledging a mutual uncertainty and limitation that, I believe, is terrifying in ways that words will never be able to capture, but which is an inescapable reality. I want to face and sit with this reality–to be present to the ways in which we both are impacting each other, in ways that we perhaps don’t realize–rather than run away from it.
More thoughts on this. To add some more language to the previous idea, I have noticed that the medicalization of human suffering has created subtly misleading ideas and expectations that have protected us against a universal and profound sense of uncertainty that we all experience. How could it ever be possible to reduce what it means to be depressed to 9 boxes of arbitrary criteria? Or even what it means to “have” OCD into 3 criteria? Depression and anxiety, to draw from the work of Dr. Jonathon Shedler, are the psychic equivalent to fever: the byproducts of an immeasurable array of potential psychological processes, in the same way that a fever may be caused by a wide array of infections. Therapy is a process of mutual discovery, not didactic “treatment” in which one person knows and the other person doesn’t, and the word “treatment” within the realm of therapy is a slight misnomer, because psychological treatment does not involve applying an intervention in the same way that a doctor does, but by actively discovering what, how, and why we feel so distressed, grieving what happened, and emerging from such an experience with a deeper sense of understanding and agency.
There is a personal barrier that we each experience in our quest for relief and freedom that we don’t quite experience at the doctors office. At the doctor, we want them to tell us wholeheartedly what is wrong. But on the couch, we fumble over our words, are scrutinizing, judging, and ambivalent, wanting something that we don’t quite know how to put into words yet not quite sure that the person to whom we are reaching out for help is an ally or a persecutor. We want respite from the suffering that we hold dearly. We want help, yet we want to avoid going there.
I have noticed that we each experience our own vulnerabilities by virtue of being limited and human, and therapy—good therapy as I am now beginning to see it at least—is about understanding and putting words to those vulnerabilities so that we have a mutual understanding of what is going on and to have greater freedom over our decisions, improve our capacity to love and trust again, and find joy and meaning in our work and creative endeavors. Improving our capacity to love and grieve is far different from the remission of symptoms, for human flourishing and suffering cannot simply be reduced to quantitative measures in an assessment, and the subtle expectation that it can fosters imperceptible frustrations that I have experience, and now realize that some of my patients have experienced, that we only make sense of by blaming ourselves absent an awareness of such latent incentives imposed upon us.
Yet, I also recognize the pull to want to be diagnosed. We need to label—that is, to give words to—what it is that we feel is at the heart of our distress. As someone who has received multiple trainings in “gold standard” evidence based modalities, I have noticed that there is an unsatisfactory and slightly misleading in how we as therapists tend to understand what it means to suffer, because it requires that we face an an ongoing uncertainty that we each live with day to day but which we deeply want to avoid. While I don’t know exactly how, yet, to go about facing it, acknowledging it is the best place to start. I don’t want to devalue the utility of modern acronym modalities. They are deeply useful and obviously helpful for some people, some of the time. But I would rather use them in the context of a relationship that acknowledges what is going on in the relationship so that they may be more effective.
Thus, I am choosing to not accept insurance because I have noticed that these incentives negatively impact my ability to work effectively. It is my hope that in expressing and labeling these incentives and reasons, I am better able to inhabit a deeper presence and understanding and build a capacity to face the fears that I–and we–have about acknowledging the ways that we impact each other, so as to subvert the negative consequences of such incentives remaining unacknowledged.