Couples and families need insurance coverage for therapy | Mental Health Perspectives - The Seattle Times
Recently, after presenting at a local Polyamory Lecture Series, I was chatting with some folks who had attended the lecture. They asked me what it might look like for their polycule (a group of people linked through their relationships, often romantic and/or sexual, to one or more members of a polyamorous group) to attend therapy.
They shared that two of them were under the same insurance plan, but they had another partner that they wanted to bring to therapy with them and weren't sure how that worked. Insurance questions are some of the hardest to answer as a therapist, particularly when working with couples and families, because coverage varies so much.
Under the U.S. insurance model, there is no insurance coverage for any couples, relational or family therapy, no matter what insurance provider you have. Some therapists will choose to work within the system by taking on a couple, giving one of the clients an individual diagnosis like anxiety or depression, then using a secondary diagnosis of relational challenges. But if the therapist uses the diagnosis of relational difficulties, which is what most couples come to therapy stating, medical insurance generally will deny that claim and tell the clients to pay out of pocket.
Medical insurance is rooted in a model of individual health care, and there is rarely an acknowledgment that difficulties can be systemic and occur between people. This is the main barrier I see to insurance providers covering relationship and family therapy.
As a Licensed Marriage and Family Therapist Associate, I am trained in systems theory. This is the idea that you can treat systems and not just individual people from a therapeutic perspective. What does that mean for therapy? It means that I can see couples, relationships and families of any kind and am trained on how to hold multiple people's perspectives, challenges and feelings in one room together. We get to learn how to help folks whose reasons for coming to therapy may not be because of an individual diagnosis or challenge but because they are having a relationship issue.
When I was in graduate school, we rarely spoke about the complications of insurance and how it works with diagnosis. Generally, therapists only learn about the billing aspects of therapy once we're out of school and employed at community mental health or group practice locations. I have had to learn about the ins and outs of insurance coverage myself through continuing education hours, supervision, reading articles and talking with other therapists about their experiences.
A lot of therapists who see couples, relationships, families or folks for sex therapy won't even try to take insurance and will only take clients who pay out of pocket. This is easier because you get paid immediately and don't have to deal with insurance denying claims or clawing back money that they've paid out because the diagnosis didn't fit their requirements. This is frustrating for a lot of clients who wonder why their medical insurance won't cover mental health.
The lack of mental health providers in Washington makes it even harder to find care. The 2018 Washington State Health Assessment found there was only one mental health provider for every 360 people in Washington.
A majority of psychologists surveyed by the American Psychological Association said that since the start of the pandemic, they've seen an uptick in patients dealing with anxiety, depression and trauma. Nearly half of the therapists said they have seen an increase in patients with substance abuse challenges.
There have been some changes to improve the availability of mental health care: For example, in May 2023, Washington state got rid of its previous requirement for marriage and family therapists to work two years post-graduation in order to allow more therapists to get fully licensed quickly.
The U.S. also now recognizes Marriage and Family Therapists and Mental Health Counselors as Medicare-eligible therapy providers. This should increase the number of providers available to see family psychotherapy and multiple-family group psychotherapy clients, and it will actually be covered by insurance for the first time. This is a great step, but I would like to see greater coverage of therapy under Medicaid as well, where people are limited to the list of available therapists.
Sometimes, the barrier isn't just the number of therapists available, but also those that are a good fit for certain clients. This can be especially challenging if a client is LGBTQIA+, polyamorous or any other marginalized identity and wants a therapist who is affirming of their identities and well-versed in their particular challenges in addition to being covered by their insurance. Sadly, a lot of the time potential clients tell me that they feel like they have to choose between a therapist covered by their insurance and a therapist that is a good fit for them but requires out of pocket payment.
There are three big things that I would like to see improved in the future. Firstly, I would like to see medical insurance providers present clear information on how to access therapy as well as be forthcoming about the fact that they currently only cover individual health.
Secondly, I would like to see all medical insurance providers expand their definitions of health to cover family and couples/relationship therapy in additional to individual coverage.
Finally, I would like to see more therapist availability options for folks in marginalized communities who don't want to have to choose between a therapist covered by insurance and a therapist that understands their lived experience.
These are all large systemic changes that will require advocacy, time and a lot of people to get on board. You never know when you might need therapy. If you and other people you care about want the option to go to marital, couples and family counseling someday, you can advocate for these forms of counseling to be covered by insurance.
Camille A. Saunders is a Licensed Marriage and Family Therapy Associate who graduated with her Master of Arts in 2021 from Pacific Lutheran University. She runs her own private practice at Camille A. Saunders Therapy Services, where she works with her clients virtually all over Washington state from her home office in Sumner. Saunders supports individuals and their partners who struggle with anxiety, chronic pain and illness, relationship issues, self-esteem and sex.
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