There are several reasons I don't accept insurance
The personal and professional costs of refusing to accept insurance can be significant, however, in my opinion the personal and professional risks, and costs of accepting insurance are far greater - astronomical. Besides the unmanageable legal and regulatory morass entailed in executing and abiding by a contract with an insurance company, there are complex, irreconcilable moral, ethical, legal and philosophical conflicts that I choose to avoid. Think of me as a conscientious objector. The insurance model is the medical/disease model. Not accepting insurance is an affirmation of dissent - dissent from the disease model as applied to the mind.
"The disease-model, however, is ultimately not helpful, as well as being unfounded. For all its attempts to incorporate social factors, the [model] renders depression meaningless, because biology effectively trumps other influences. It conveys the message that we are powerless to change ourselves or our situations. When things go wrong, it persuades us we need a pill to put them right. This approach may appeal to some people ... But it is important that everyone knows how little evidence there is to support it." British psychiatrist Dr. Joanna Moncrieff
Pseudo science Physical diseases are that which can be demonstrated empirically. There is no test or procedure known to medical science that can be used to establish “mental illness.” Decades of scientific research have yielded no physiological pathology.
Diagnosis If you choose to use insurance for counseling or psychotherapy, you must accept a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders. Diagnoses are based on subjective normative judgments (which are based on personal, social, cultural, and political values not objective criteria) and opinions about a person's behavior and whether it conforms to what is expected or wanted in any given society or situation. Besides being conceptually incoherent and invalid on the basis of science, being diagnosed with a mental disorder has potentially significant adverse affects on opportunities for employment, insurance, licenses, and the right to keep and bear arms given the loss of privacy and confidentiality.
Privacy and Confidentiality are the cornerstones of effective psychotherapy. United States Supreme Court in Jaffe v. Redmond (1996):
"Effective psychotherapy ... depends on an atmosphere of confidence and trust in which the patient is willing to make a frank and complete disclosure of facts, emotions, memories and fears. Because of the sensitive nature of the problems for which individuals consult psychotherapists, disclosure of confidential communications made during counseling sessions may cause embarrassment or disgrace. For this reason, the mere possibility of disclosure may impede development of the confidential relationship necessary for successful treatment."
If you choose to use insurance you waive your right to privacy, confidentiality, and freedom of choice. Private and sensitive information will be disclosed to hundreds to thousands of unknown people such as gatekeepers, utilization and review reviewers, and even employers. Few barriers exist to an employer's use of its employees' medical and insurance claim records. In addition, with the growth of the information broker industry, not to mention hackers, there is no rational basis on which to believe that one's mental health records are safe from inappropriate and unauthorized intrusion. The loss of privacy & confidentiality sabotages the purpose and effectiveness of psychotherapy.
Conflicts of Interest Another major ethical conflict concerns loyalty. If I accept insurance, I become, in effect, a double agent. I'm an agent of the insurance company, and your advocate for health and well-being. Insurance companies incentivize professionals to breach their obligations and fidelity, fiduciary obligations, to clients; they offer an array of financial incentives and rewards, penalties and sanctions, along with other inducements to alter and limit care to suit their goals, objectives, and business interests, not yours. Decisions may be made that are adverse to you without your knowledge, input, or consent. It's immoral and dishonorable to model dishonest behavior such as saying people are sick (i.e., that they have a 'disease') when they are not, and unethical and illegal to collude with clients to misrepresent problems in order to be reimbursed for services. Such behavior diminishes the dignity and credibility of the profession, and erodes public confidence in its knowledge and practices.
Money, Pay, & Reimbursement Nonwithstanding the fact that discussion of money in our culture is taboo, and, correspondingly, that the matter of fees in therapy is a highly charged emotional issue, money is one of the most important parameters that defines psychotherapy. Money is a boundary in the sense of defining the business and professional nature of the psychotherapist-client relationship. The fee and fee arrangement are important determinants of the nature of the therapeutic process and set a boundary for the therapeutic relationship; money is one of the parameters that define and differentiate psychotherapy from friendship and other intimate relationships. It may be helpful when considering the issue of money to be mindful of the reality that the way we treat and relate to money is influenced less by logic and more by deep-seated beliefs that we are often unaware that we hold.
Professional Judgment The way managed care clinicians are paid often distort professional and clinical judgment. Employees of the insurance company become the de facto judges of what you need and how much you need, effectively usurping professional judgment and autonomy. With a primary emphasis on cost containment, your needs are invariably compromised. Many insurance companies routinely trump psychologists' judgment by determining methods (brief), and requiring chemical therapy - the use of so-called "anti-depressants" - as the first line of treatment. This absurd, unconscionable ethic continues in spite of the 50 years+ of well-documented lack of evidence of efficacy, and, more importantly, the evidence of harmful, potentially violent adverse effects on cognitive, emotional, and interpersonal functioning. The continual intrusion of managed care procedures, rules, and requirements is coercive, detrimental to the development of an effective psychotherapist-client relationship, and contrary to the rational, ethical, and humane practice of psychology.
Required Acceptance of Nonsense There's no way around it, an agent-therapist must medicalize the human condition and associated problems in living. Report people as sick when they are not. Agree to diagnose phony disorders/diseases ... and justify your reasoning. Contend with the temptation to over diagnose and over treat in order to be compensated. Treat human beings as problems to be fixed as quickly as possible. Focus on superficialities without addressing underlying problems. Use interventions that are erroneously thought of as techniques, and that are ineffective. Contend with company directives that produce a gross misunderstanding of what therapy is and how it works. Insight-oriented psychotherapy a not a "medical treatment." The best therapists would not accept such conditions.
Dehumanization The crux of the matter is that construing the psyche as physical/material/mechanical results in the loss of human agency, moral agency in particular, and with that identity, choice, and responsibility. Human beings are moral agents who, as such, have the capacity to think, make meaningful choices, and act in accordance with their values. If a person is depressed, there is a reason to be depressed. Anxious, there's a reason. To medicalize human thought, feeling, and action is to objectify and dehumanize humanity. All unwanted behavior is not sick; to say all unwanted behavior represents illness is to pathologize human existence, and, more importantly, to confer authority on the medical establishment to “treat” and control people. Not surprisingly, given a misunderstanding of human suffering, the efficacy of medical treatments are not borne out by the evidence, and, contrarily, in some cases, cause irreparable harm (suicide, homicide).
An open invitation
The medical model as applied to the mind is a woefully misguided approach to the human struggles and agonies that people bring into counseling. Therapy is an open-ended, collaborative, human encounter. I invite you to consider the choice of consulting with one of the few remaining independent practitioners who has chosen to cease to be involved in the immoral, unethical, absurd policies and practices of managed care.
"The best return ... invest in yourself." ~ Warren Buffet