As with most family bust-ups, this one will cost us. Status, money, authority: it’ll all be diminished if you leave the comfortable home the DSM has provided. However, to judge from the pitches I receive in the mail, snail and otherwise, the market is already anticipating our split; entrepreneurs are at the ready to show you how to build a practice free of the insurance companies—for a fee, of course.
But alluring as the prospect of getting continuing education credits for going to a seminar on business practices may be, I’d be glad to tell you—free of charge—what I know about how to stop playing Diagnosing for Dollars. It’s not all that complicated, and while I can’t tell you I’m out of the game completely, I’ve taken some steps that make the situation feel less bad to me.
The Devil’s Pact
The occasion to dispense with the diagnostic ritual generally presents itself right away, as soon as your client asks, “Do you take my insurance?” My answer is almost always “no.” Sometimes that’s the simple truth: the policy in question pays only network providers, and I’m not in any networks. But even in the case of point-of-service plans or plans with out-of-network benefits, it’s still no. The client pays me. If he or she wants to try to get reimbursed, I can help with the paperwork. But the financial part of the relationship—like every other part of it—is between us. And, I add, that help with the paperwork will come at a cost. I’ll have to diagnose him or her with a mental illness. They don’t call it medical insurance for nothing.
This often brings people up short, especially when a couple asks the insurance question, and I ask which of them is going to be the mentally ill one. Most people who consult therapists don’t think of themselves as sick—although this has changed over the last 20 years or so, as more and more of our clientele have heard about those “chemical imbalances” that doctors are so fond of invoking. Sensible people are rightfully wary of placing a mental illness in their medical dossier. And while some of this reaction is undoubtedly the result of stigma, some of it reflects a desire for integrity, for not claiming to be something they’re not. This is surely a yearning we want to encourage.
Still, there are plenty of people who don’t mind being diagnosed, or who can’t afford the luxury of integrity, and thanks to the foresight of men like Bob Spitzer—whose expansion of the DSM was meant in part to reassure therapists afraid that their access to insurance funds would get lost as psychoanalytic language was purged from the DSM—there are diagnoses that hardly seem objectionable at all: generalized anxiety disorder, adjustment disorder, and Asperger’s, for instance, and others, like bipolar 2 and major depressive disorder, that have lost much of their stigma in recent years. This is where it comes in handy to have spent the money on a DSM, so you can take it down off the shelf and read the diagnostic criteria to make sure the client knows exactly what mental illness they’ll have (or at least will have had) for the rest of their lives and what its symptoms are. You can even give him or her a choice.
There is something delightful about turning a diagnosis into a collusion against the insurance companies—one that can help those of us with sliding scales to operate our own private socialist systems and enable people with little money or no insurance to get therapy. That’s surely not justification, however, for allowing diagnosis to remain in the shadows, or for evading the fact that it’s essentially a corrupt practice—especially not if the corruption primarily benefits us, which, of course, it does. My starting rate is $140 per hour. What exactly is it that justifies that rate? My masters and PhD degrees didn’t cost me anything like what a medical degree costs. My malpractice insurance is well under $500 a year. My equipment consists of a couple of chairs, a couch, a clock, and a box of Kleenex. What justifies my rate is the fact that the market will bear it, and the market isn’t really free: insurance, as healthcare economists love to point out, insulates it from the rough-and-tumble of supply and demand.
It’s hard to know what we would be worth in a truly free market, which is to say if we no longer availed ourselves of our association with the medical industry. People pay plumbers and auto mechanics upwards of $90 dollars an hour; usually that’s because the need is urgent and short-lived. But they pay clergy far less, and bartenders work for tips. I suppose we could take a page from the evidence-based medicine book and ask people to pay us depending on our performance in any given hour, but it’s likelier that we would end up doing more of what most of us are occasionally doing now: figuring out a fee that works for client and therapist alike.
You’ve probably already worked out a method for determining a rate. You may use an income-based scale. Or maybe you state your fee and then ask a client how much he or she can afford to pay. A surprising number of people give an answer that seems fair. However, as I discovered when a man with a modest-paying job who’d negotiated a 40-percent reduction let it slip that a rich uncle had given him millions of dollars, you can get hosed. When this method fails—often because the client doesn’t know where to begin—I sometimes ask what kind of car he or she drives and what the payment is. Kia drivers pay less than BMW drivers. Or you can ask how much money they spend every week at happy hour.