How Rote Admin Requirements Can Actually Deepen Therapy

Most therapists I know groan when they talk about insurance requirements, SMART goals (i.e. goals that are specific, measurable, attainable, relevant, and time-limited), and treatment plans. They go glassy eyed at the mention of questionnaires and resent the endless justification of “medical necessity.” And it makes sense that therapists react this way—on the surface, these requirements and protocols feel like intrusions—bureaucratic forces that flatten complexity and pull therapy away from what feels alive, relational, and real.

Recently, a colleague spoke to me about these requirements as necessary evils at best, distortions of the work at worst. I surprised him by saying, “Actually, I disagree. I think reality is therapy.” He gave me a puzzled look. “What do you mean?” he asked. As a somatic, psychodynamic therapist with experience in community mental health before transitioning to private practice, I laughed and explained that I didn’t mean this as a defense of the insurance system, which is deeply flawed. I meant it as a psychodynamic stance.

The conditions under which therapy occurs, including insurance constraints, are part of the relational field. I treat documentation, treatment plans, and symptom measures as clinical material—symbols of a broader relational and social reality. Therapy becomes a place where clients can practice navigating systems without losing themselves—where anger, grief, resignation, and creativity unfold in response to constraints that can be named and metabolized in the therapeutic relationship.

Splits Matter

Therapy and the world in which we practice therapy are interconnected. When therapists treat insurance requirements as shameful or purely administrative, we risk recreating a familiar split that lies at the root of the issues and symptoms many clients struggle with. Often, clients are already struggling with beliefs around what can be seen, discussed, and acknowledged, and what must be hidden from view. From a psychodynamic perspective, splits matter. What’s disavowed tends to return in a different form: as anxiety, resentment, enactment, or burnout. Rather than reinforcing splits by ignoring or rushing through conditions of access that inform a client’s treatment, I bring them into the room, making the implicit explicit. This concept is central to psychodynamic psychotherapy. Making what’s implicit explicit can foster safety, deepen awareness, and create the conditions for integration in therapy. Making documentation, treatment planning, and symptom measures an explicit part of therapy isn’t an afterthought. It’s a clinical choice.

Working with Questionnaires. When I support a client in completing depression measures like Patient Health Questionnaire 9 (PHQ-9) or the Generalized Anxiety Disorder-7 (GAD7), I invite curiosity rather than compliance. “How does it feel to translate lived experience into numbers?” I ask. “Which questions fit, and which miss the mark? What aspects of your life become more visible here as you answer these questions, and are there any aspects of your life that disappear?”
The conversations that follow these questions offer rich material. Sometimes, clients notice and express how pressured they feel to present as “sick enough” to receive help but not so sick that they’re hospitalized or deemed untreatable—or to appear to be improving so that they can continue meeting treatment plan markers but not cured in a way that would result in therapy ending. They’ve heard the phrase “medical necessity,” which carries implicit judgments about whose suffering counts most and what improvement should look like. Making these explicit allows clients to voice fears: “What if I’m not sick enough to deserve help? What if getting better means losing support? What if my pain has to remain visible to stay legitimate?” Avoiding these questions doesn’t protect clients. Working with them can be reparative, helping them understand how suffering must be translated into psychological frames to be recognized and legitimized by institutions. Far from distractions in therapy, these issues are direct expressions of how clients negotiate power, worth, dependency, and survival.

Taking Notes in Session. Documentation can also become part of the therapeutic work. One of the ways I make documentation visible is by taking notes on my laptop during sessions. I know this is unconventional, as many therapists believe notetaking disrupts rapport, but I find it supports therapy. I begin sessions with my laptop open and in initial sessions, say “I take notes to help me stay connected to you and your treatment. Clinical notes are required by insurance, so these aren’t just my notes, they’re yours, too!” Often, this explanation leads to an in-depth conversation about trust and privacy. Usually, I close my laptop once I have a sense of where we’re going and then reopen it if the client says something important that I want to capture accurately.

Now, note-taking is part of our shared frame. It’s not a hidden activity I engage in after they leave the room. It brings clients frustrations with bureaucracy into our treatment, providing direct experience of how to work within a system that imposes constraints. For clients who struggle with trauma symptoms, or who tend to disengage, dissociate, or feel helpless in the face of obstacles, honesty about my process treating them within a larger system strengthens the therapeutic relationship and offers a corrective experience. One client said, “I like that you take notes. It makes me feel like you care and are really paying attention.” For many clients, careful documentation isn’t experienced as distancing. It’s experienced as attentiveness and recognition.

Collaborative Treatment Planning. I’ve found that treatment plans become reductive when they’re written about clients rather than with them. In my work, they’re collaboratively shaped into an evolving treatment roadmap. We talk openly about why certain goals need to be framed specifically to connect their struggles with an action they can take to feel better. A goal to feel less fearful during a medical procedure might look like, “Client will practice somatic coping skills learned in session to decrease anxiety prior to weekly dialysis.” Improving relationships can be worded as, “Develop skills to communicate emotional needs without fear of abandonment within 8 weeks and establish one meaningful supportive relationship or strengthen existing connection within 12 weeks.” We explore the tension between what the client wants to accomplish and what can be documented as reimbursable progress. This opens important psychodynamic questions. What parts of you are considered worthy of care? Which parts must be hidden? What happens when your truth must fit someone else’s language?

Rather than undermining authenticity, this process of working within a client’s particular treatment constraints deepens it. It provides clients with practice many of them need to learn to hold multiple levels of truth simultaneously: administrative language and lived experience. Learning to navigate these layers consciously is itself developmental. Helping clients identify and articulate their needs translates to empowering self-advocacy outside of the therapeutic container, which builds their self-confidence.

For clients who’ve been harmed by institutions, my overt care around the need for compliance around notes, questionnaires, treatment plans, scheduling, and insurance requirements models that these things can be navigated in a way that still takes care of them and our relationship. I’m not asking them to manage systems alone, and I’m also not colluding with them in the fantasy that we can opt out of systems that affect our lives, mental health, and livelihood. Instead, I demonstrate how it’s possible to stay engaged with constraints without compromising one’s dignity or checking out.

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Psychodynamic therapy is often mistakenly viewed as an emotional luxury that’s somewhat impractical for clients who struggle with issues related to basic survival needs. But the truth is, it doesn’t require fantasy conditions that are disconnected from our clients’ lived, everyday experiences. It requires honesty. When we bring the full context of care into the therapeutic relationship, including insurance constraints, we acknowledge that healing doesn’t happen in a vacuum. It happens in bodies, relationships, and systems. When my colleague called these requirements “necessary evils,” he was treating reality as separate from therapy. It’s not.

Reality isn’t the enemy of therapy. It is therapy.