Thoughts on Insurance & Diagnosis

I wanted to dedicate a post to talking about my perspective on diagnosis and the nature of the American insurance system; the relationship between insurance companies and the mental health field, and how professionals are required to operate when they work with insurance.

Diagnosis: Good, Bad, or Both?

I want to start by saying, diagnosis can be a powerful force for good, there are important diagnoses that are empowering people to more fully understand what they struggle with, and helps them find ways to increase their mental and emotional wellness. And on the other hand I believe that there are times that diagnoses do not benefit the client, if they are given to patients without proper attention to the actual presenting symptoms of the client, or given in a way that pathologizes a client for reacting in a totally valid way to things like injustice, grief, trauma, oppression. The United States as a country has trauma deeply embedded throughout its past and present, and there are tragic social, systemic-level problems that lead people to seek mental health treatment. Sometimes the problem is not just about the client, but about the conditions they and/or their family have lived in.

Modern Medicine Changes Lives

So I, like most of my peers, hold these nuanced views on diagnosis, and believe it certainly plays an important role in the mental health field. I highly respect the competent professionals in the field of psychiatry who are truly changing lives with their utilizing diagnosis and helping people find huge improvements with diagnoses like schizophrenia, bipolar, depression, and anxiety to name a few, with the help of medication. I am grateful for the wonders of modern medication for people whose condition warrants it and who choose to try it. I am not in the practice of prescribing medication; that is not my role in the field of counseling, but I can refer a client to a psychiatrist if they may benefit from it and the client is open to it.

What is a Counselor?

Counseling has developed historically as a category of mental health professionals who do not operate as heavily using the medical model of mental health as psychologists and medical doctors. We assist people in talk therapy using dialogue, and a wide array of interpersonal therapeutic interventions, from EMDR to empty chair techniques, to animal assisted therapy, to play therapy with kids, expressive arts therapy, and among the dialogue-focused counseling theories there are many schools of thought with their unique approaches. But as a counselor, the way I operate is different from professionals who work within the medical model. Because counselors have a special role in walking alongside a client in their own personal, unique journey. We are helpers who see more than just a diagnosis, we hear the whole story, and we engage with our clients as fellow humans, not as patients. We know that each person is complex, and it is important that counselors be given the freedom to work in this way with our clients. One reason I enjoy utilizing talk therapy skills, is I appreciate how much each client’s story and circumstances is unique to them, and I think it is important for people to have a space to process these in a nuanced way.

As I said above, people’s problems often do not originate with them, so it is not always about addressing a diagnosis, but it is often more accurate to call out the person’s environment, circumstances, and/or the human injustices that contributed to their presenting problem. Talk therapy is also an important way for people to process things like trauma or adverse experiences in an embodied way, hearing the response of the counselor and integrating growth gradually, week to week. I think it is a very human experience, and that is important to have these spaces where you allowed to be human, not asked to be productive, entertaining, or faking feelings. Where you are allowed to grow and recover on your own time.

Insurance and Counseling

That leads me to the question of working within the insurance system as a counselor. Clearly when people pay inordinate amounts of money every month for them and their family to have insurance here in the United States, you want to use it whenever possible. I am in that same boat with you.

The fact is, many counselors do not work with insurance, or they only work with one or two companies. There are many reasons why, and it is frustrating and not clear, as a client, why the counselor does not accept your insurance, or any insurance. So i wanted to write this post as a small offering that explains my personal perspective.

First, as an LPC Associate, it is not straightforward for me to panel with insurance companies. There are other common factors that lead counselors away from accepting insurance: Some people’s workloads would need to be very high in order to take away a salary that meets their needs and pay off their student loans, that they would experience burnout at worst, or at best be practicing from exhaustion, or even resentment, when they should instead be grounded and rested enough to attend to clients with their full attention, for hours each day. It can be draining work, and their therapeutic skills can deteriorate if the therapist does not have a healthy balance between their work and the rest of their life. A counselor who is unable to really see, hear, remember, and make time for you fully, is not what any client wants. Insurance also dictates how, and for how long, a client receives mental health care, and demands time from the counselor’s schedule to communicate about reimbursement and other subjects.

My Obstacles to Accepting Insurance

For me, the biggest factor in my choice not to panel with insurance is that I do not ever want to be in a position where I am diagnosing someone with a DSM diagnosis if: a) I have not had adequate time to assess them first b) if they do not fit the criteria of the diagnosis as stated in the DSM, or c) if I assess that their problem/symptoms are not caused by a mental disorder. This a matter of my personal integrity as a counselor and as someone who believes in fundamentally changing the way society takes care of people and supports their needs. Because of my niche and my counseling approach, addressing personal history with humanistic talk therapy, it is all but impossible for the following conditions to be met: a) I confidently diagnose a client with a DSM diagnosis on the first session (which is a requirement), b) with a reimbursable diagnosis (not all of the things listed in the DSM are going to be covered), that I c) feel is a responsible diagnosis that does not pathologize the client and d) have enough sessions covered to adequately address their concern with e) freedom to practice humanistic counseling, not focusing on CBT-based interventions which may not be the most appropriate approach for that client.

Large-Scale Changes I Advocate For

I recognize that access to counseling is limited when the client is not able to recieve a diagnosis that is reimbursable from their insurance company. This is why I advocate for a universal healthcare system and for universal access to therapy regardless of diagnosis or insurance carrier. Counselors, psychiatrists, Social Workers, Psychologists, and all other therapists and mental health professionals are all coming to terms with the same reality: that systems, oppression, and trauma cause adverse mental and emotional health symptoms more often than biologically-based disorders do. I believe it is time to reimagine access to care that does not require clinicians to operate outside of their ethics, and does not require us to pathologe a person for reacting in a rational way to unjust life circumstances.

Lastly, I would be thrilled to see substantial changes in future editions of the DSM that would allow clinicians to attribute client’s problems to Complex Trauma, and for insurance to make that diagnosis reimbursable. Presently, the PTSD diagnosis is meant for instances when the client faced things like death or sexual violence in a particular way with very particular symptoms, and does not make space for the spectrum of complex trauma… which is just as valid. If the DSM includes the spectrum of trauma that brings clients in to therapy, and if our healthcare system can make treatment reimbursable for that full spectrum of trauma, that would go a very long way to make therapy accessible. Things like discrimination, oppression, emotional and psychological abuse and trauma, unstable support system, poverty, family traumas… these need to be accounted for in the DSM and insurance companies would also need to choose to reimburse for them.