why it's so hard to find a therapist
as a therapist, i get asked this a lot. here's the lowdown:
insurance companies do not pay therapists enough.
that's it. that's the reason.
let me explain. there are three ways to pay for therapy.
cash. this is not realistic for most people. therapy is expensive.
seeing an in-network therapist (sometimes called a "preferred provider"). these are therapists who have signed a contract with your insurance company to see clients at a discounted fee. you pay a co-pay, usually somewhere between $10 and $50, and insurance takes care of the rest.
see an out-of-network therapist. this is a therapist who has not signed a contract with your insurance company. you pay the therapist's full fee up front, send the bill to your insurance company, and get a reimbursement check for a percentage of the bill (typically 50%-80%) a few weeks later.
still with me? okay, so the second option—seeing an in-network therapist—is the one most people try first. for some people, it's the only option. it's usually cheaper than going out-of-network, and many people's plans don't even offer out-of-network benefits, or offer benefits that come with a high coinsurance or deductible.
theoretically, insurance networks are supposed to be good for both therapists and insurance companies. the insurance company gets a discount, and the therapist gets a steady stream of clients. however, the rates insurance companies offer in-network therapists are shockingly low. this is true of every insurance company. sometimes, it's less than a third of a therapist's full fee.
as a result, many therapists have said no to insurance networks and only accept out-of-network and cash pay clients. why wouldn't they? would you take a job for a third of your usual pay rate, even if you were desperate (which most therapists aren't)? if you ran a small business, would you let a huge corporation buy your services for next to nothing, especially if you had other people willing to pay your actual rate?
add in the fact that a therapist's week includes many hours of billing, scheduling, accounting, and documentation on top of therapy. add in the cost of office rent, software, self-employment taxes, office supplies, insurance, internet, web hosting, credit card processing, cell phone. add in a mind-numbing crapton of hours spent dealing with insurance companies. add in the fact that all therapists have spent years eating ramen in grad school followed by years of mandatory supervised experience for low salaries in terrible conditions only to be offered these insulting rates once they finally open their own practices.
here's the kicker. in some cities, certain insurance companies won't even let new therapists join their networks. that's right, many insurance networks don't allow therapists to join if their geographical area is considered "saturated," meaning there are too many therapists competing in that area. this is almost never actually true—if it were, why would clients with plans from these "saturated" insurance networks struggle so much to find therapists? why would insurance-accepting therapists' waitlists be so long?—but it's a great way for insurance companies to limit their costs.
as a result, therapists in insurance networks are inundated with clients. many work for exploitative clinics and group practices that take most of their fees. many see enormous caseloads of clients to make ends meet. many lack adequate experience and training. so even if there are technically therapists who accept insurance out there, they're exhausted, underpaid, inexperienced, and may not be equipped to deal with specialized mental health concerns.
and that's why it's so hard to find a therapist.
i will close by giving you some recommendations if you're having trouble finding affordable therapy in this capitalist hellscape. please note that this advice is directed at americans.
if you have out-of-network mental health benefits, thank fuck! use them! if you don't know whether you have them or what they cover, call the number on the back of your card. getting reimbursed can be a hassle, but you'll have a much, much wider selection of therapists. you can see pretty much any licensed therapist, and all your therapist has to do is give you a bill to submit to your insurance company.
if you have out-of-network benefits but can't afford to pay up front and wait for reimbursement, services like advekit allow you to pay only your coinsurance rather than the full amount. it's free on the client end, and while the service takes a cut out of the therapist's fee, it's often worth it to retain a client (or get a new client). not all therapists are willing to use this service, but you can also use it to find a participating therapist.
if you have out-of-network benefits and you're having trouble getting reimbursed by your insurance company, services like reimbursify can help (costs money, but might be worth it).
if you need a letter of support for gender-affirming hormones or surgery, the gender affirming letter access project can help you get a free evaluation for surgery/hormone readiness. i'm a member. it's a great project.
many therapists offer sliding scale fees. if you can't afford a therapist's full fee, it won't hurt to ask. they can say no. a sliding scale fee is still sometimes more than insurance companies pay their in-network therapists, and none of it gets eaten up by a predatory insurance company.
if you have a therapist friend, talk to them. your therapist friend has therapist friends. your friend may know someone affordable who's taking clients.
if you go to college, your college's counseling center may be able to offer you therapy, usually for free.
if you work, check your benefits. your workplace may offer an employee assistance program (eap), which can provide you with a limited number of free therapy sessions.
some university training programs for therapists offer low-cost therapy to members of the local community.
you can see a therapist for $30 to $80 through open path collective if you're uninsured or underinsured.
group therapy/support groups can be an affordable or even free option. since covid, many of them have gone online, and often, they're able to accommodate group members in other states/cities.
directory sites like therapy den, psychology today, and goodtherapy allow you to search by insurance network, out-of-pocket cost, and many other filters. unfortunately, a lot of therapists don't update their availability or misrepresent their expertise. sucks, but these are the most comprehensive directories out there. you might also want to look at specialty directories, like wpath's provider directory for gender therapists or polyfriendly.org for nonmonogamy-friendly professionals.
you'll notice i haven't mentioned companies like betterhelp and talkspace. these companies pay rock-bottom rates—worse than insurance!—and treat therapists and clients terribly. avoid unless you have no other choice.
overthrow the government.
saving this for later bc you never know
