by Patti F Boyle

This is about how we pay for therapy, or, rather, how medical insurance pays for some therapy, sometimes. I know, boring topic. So, out of consideration, I’ll be as brief as possible. In fact, I am prefacing with “highlights” so you can skip reading the big part if you want.


1.   If you use your insurance for payment or reimbursement for therapy, you will have a mental health diagnosis on your medical record.

2.   The amount you must pay out-of-pocket before insurance benefits kick-in is called the deductible. Deductibles can be as high as $10k, so check with your insurer so you know what your deductible is.

3.   Insurance plans may also require you to “co-pay”, or share medical expenses, for each appointment you have with a medical provider or a therapist. Check with your insurer about co-pays as well.

4.   If you paid your deductible and want to use your insurance benefits,  and you want your therapist to bill your insurance directly (so you pay nothing at the time of your appointment), you need to choose a therapist who is “in-network” with your insurance provider.

5.   An “in-network” therapist is a professional who has signed a contract with your insurance provider.

6.    An “out-of-network” therapist has chosen not to contract with insurance providers.

7.   The fee for “out-of-network” therapy is often reimbursed by insurance.

8.   If you are looking for couple/marriage counseling, it is usually not covered by insurance. This can be true for family counseling as well. Again, check with your insurance provider and your therapist.

9.   In general, always call your insurance provider to ask questions about your coverage, and do it at least twice to make sure each representative is giving you the same information (there is a lot of confusion and misinformation in the medical insurance world), and talk to your therapist about insurance as well.

Big Part

To begin with, all health insurance plans must include mental health benefits, and to qualify for insurance payment, the “patient” must be diagnosed with a mental health disorder.

For many people, having a mental health diagnosis is of no concern, but  for professional or personal reasons, it can be a concern; therefore, please know that if you use your insurance for payment or reimbursement for therapy, you will have a mental health diagnosis on your permanent medical record.

While all medical insurance plans must include mental health benefits, these benefits will vary depending on the plan. Most insurance plans require we pay a set amount of out-of-pocket cash before insurance benefits or payments kick in. The amount we must pay out-of-pocket before our benefits kick in is called the deductible.

Deductibles can be as high as $10k, so check with your insurer so you know what your deductible is. Please note that your therapist will not know what your deductible is or if you have reached it. If you haven’t paid your deductible and your therapist bills your insurance for payment, your therapist will not be paid by insurance and will send a bill to you.

In addition, some insurance plans require a “co-pay”, which means they want you to pay for part of your healthcare when you visit a professional for an appointment. Co-pays can range from less than $20 to more than $60, or are a percentage of the total fee for the appointment. When you call your insurance about your deductible, ask about co-pays too.

Once you paid your deductible and have decided to find a therapist who accepts and bills your insurance, you will need to look for an “in-network” therapist. A contracted or “in-network” therapist refers to a health care professional who has agreed to certain terms mandated by an insurance company and has signed a legal binding contract; in essence, an “in network” provider is employed by the insurance company. This also means your diagnosis and the therapist’s notes about you become available to your insurer and any insurance employee who lays eyes on your record, and that a representative from your insurance company has the right to drop-in on your therapy session for the purpose of ensuring quality care. Of course, this rarely occurs, but contracted therapists are required to give insurance companies these rights. Again, for some this is of no concern, for others it can be a concern.  

 An “out-of-network” therapist has decided that being bound to an insurance contract is not beneficial, and they opt-out. But working with an “out of network” therapist does not mean your insurance will not pay, at least in part, for your visits. There is a good chance it will, but you will need to make a claim for reimbursement (more on this topic below). If you choose to make a claim for reimbursement, your diagnosis and therapy notes become available to your insurance company; if you do not choose to make a reimbursement claim, your diagnosis, therapy notes and therapy sessions stay exclusive to you and your therapist.

“In” and “out” of network therapists are both credentialed and licensed. On insurance websites, insurance companies often speak to the high quality of their providers, including therapists, but the vetting process is basic and involves ensuring the therapist is licensed and has no criminal record or serious complaint lodged with the Department of Health. There is no interview or series of serious and significant questions in which to respond, and to become an “in network” provider, a therapist simply agrees to the contract being offered. In some cases, therapists are willing to contract with insurance companies, but the insurance company has closed its “panels” because it is thought there are plenty of “in-network” therapists; thus, some therapists who want to be “in-network” are kept “out”. Whatever the case, rest assured that “in” and “out” of network therapists are equal in terms of general qualifications

If you want to know if a therapist is “in” or “out” of network, contact your insurance provider, either online or by phone (the number is often listed on the back of your insurance card); however, be aware that provider lists are not always updated, and your best bet is to speak to your  chosen therapist for accuracy.

As noted earlier, when you choose to work with an “out-of-network” therapist, there is a good chance you can get reimbursed for the cash money you pay out-of-pocket, but you may have to wait a few weeks to get your cash back. Again, to be brief, I have listed the process:

1)  You pay your therapist their fee upfront;  2)  The therapist gives you a statement or “superbill” that has all the various numbers and number codes that insurance companies want to see (including your diagnosis); 3) You fill out a “claim form” (most likely this is an online task), and submit it; 4)  You wait for your reimbursement.

Generally, paying an “out-of-network” therapist and making a claim for reimbursement is pretty straight forward and there is no mystery around how much therapy will cost. The trouble is we are required to do the work of actually making a claim, and, remember, once we do make a claim we give our insurer the right to our therapy records.

All of the above applies to people who work with a therapist one-to-one, or to those seeking substance abuse treatment, or for hospitalization. All of the above does not apply to people seeking marriage/couple counseling or family counseling.  Although some insurance plans cover family counseling, few, if any, include couple or marriage counseling. There are certain circumstances that would allow for therapists to use a billing “code” that may generate insurance payment, and if you want to know more about these circumstances, please ask a therapist.

In good faith, the Affordable Care Act mandated that mental health services be included with medical insurance, but accessing coverage for counseling has become yet another quagmire to untangle. It is frustrating to search for a therapist only to find the insurance benefit you thought you had does not apply,  or to seek an in-network therapist only to find they are all full,  and to find out later you could have chosen an out-of-network therapist had you known the possibility of reimbursement. And perhaps the most upsetting outcome of using insurance to pay for therapy is  receiving a bill for hundreds of dollars from your therapist who you felt was "on your side". Your therapist was and is on your side. Unfortunately, it appears the insurance industry is not.

In conclusion, I want to express my astonishment that you have read this far.  I could barely tolerate writing about this very boring topic, but out of consideration, I wrote to clarify some of the confusion.  Generally, insurance coverage and paying for therapy is, at best, resting in the back of our minds, but I sincerely hope  this explanation has helped - and will help, in the event the topic sneaks around to the forefront.



Full disclosure: I do not contract with insurance companies for ethical and personal reasons.




State of the Union for Practice PLLC

By Thomas Auflick

This month marks the two year anniversary for my partner, Patti F. Boyle, and I providing mental health and relationship counseling services through our business, Practice, pllc. I am proud to say that the state of our union as business owners and professional partners is strong. Each year we have seen continual growth in our business. As a counseling business in the Seattle area, I see this as a significant accomplishment as the choices for counseling and therapists are vast and abundant here. With our competition we are also faced with the challenges of an industry that has strict ethical guidelines on advertisement and self promotion. We are a part of a very humbling business that has brought out a great deal of inner growth for my own emotional, psychological and spiritual being. As I have waited for our business to grow in the face of business challenges within the field, I have had to have a lot of faith and fortitude of mind. With much appreciation, growth continues to build and success abounds for our business.

All of this comes in an area of business that deals with a subject matter (Mental Health) that is generally ignored or shunned by the majority of the public, and quite often, by those suffering from its very existence. Like dentists, a great deal of people often avoid our services until the pain and suffering is overwhelming and they see no other options. Not to mention the access and affordability of going to see counselor is not always provided within the healthcare system. Though the Affordable Care Act has provided greater access for the population to healthcare benefits, we, as mental health providers, have seen reduction in what insurance companies will pay us for services and an increase in red tape that allows us to bill. Often counselors option out of the insurance process, charging directly to clients their fee for service, and operating outside of the insurance realm only as out of network providers. In this case clients are saddled with the burden of billing and are still responsible for paying up front the counselor's fee. Here, the counseling business has a tendency toward a gentrification process that dissuades many and allows quality access to only certain individuals.

Still, in the midst of our challenges in the field of mental health counseling, Practice, pllc continues to proliferate. I am proud of the work Patti and I do as therapists. I am especially proud of the work we are able to do together in the therapy room as co-counselors. Our unique partnership that started in graduate school has created a synergistic model of co-counseling that we offer as relationship and couples therapists. As we have moved into a new office this last year with greater space availability, we are excited to soon offer group counseling services where we will continue create more opportunities to work together as co-counselors in the therapy room.

In my individual work I continue to assist people with their personal and professional development through easing symptoms of anxiety and depression. My 20 years of experience in the realm of vocational consulting has given me a unique perspective on the existential and personal importance of career in relationship to mental health. In simple terms career defines us and is critical in maintaining a quality life of health, happiness and wellbeing. I am passionate about the quest of helping people find balance, meaning and contentment in their personal and professional development. In addition, I continue to be inspired and excited to work as a couples counselor. I am honored to work for the Gottman Institute and am recharged by their message throughout the year as I assist in the production of their couple’s workshops, The Art and Science of Love. Each event with the Gottmans brings me new insight into couples counseling. This year I will continue on my journey to becoming fully certified as a Gottman therapist and look forward to providing greater levels of service.

I want to thank everyone for your recognition of our anniversary with Practice, pllc. Your comments through LinkedIn are greatly appreciated. Patti and I expect to see continued growth in our business and as professional mental health counselors. This is a career that is more than a job; it is a calling in life. I am grateful for the opportunity to share in the evolutionary process for all who take on the challenges related to self and relationship. The levels of success and wellbeing in life are infinite.

How Trump’s High Level of Emotion Attracts and Repels Followers Simultaneously

How Trump’s High Level of Emotion Attracts and Repels Followers Simultaneously
by Thomas J. Auflick, MA, LMHCA

In his article, “Why is Donald Trump so Insulting in the Debates?” Dr. Robert Mather illuminates the emotional process related to Donald Trump’s debate tactics. From a psychological perspective, Dr. Mather details the emotional arousal incited by Trump that hinders the cognitive process of his fellow debate participants. Trump fires incendiary insults at his opponents that short circuits their intellectual abilities and drags the debate into a dogfight off political issues and into a chaotic emotional realm. On the grand stage of his campaign, Mr. Trump operates with precision to play skillfully on the temperament of the political psyche making his stymied opponents look weak while he stands strong. He spins this emotion-charged rhetoric onto the public in order to garner his following in a process that Dr. Mather describes as an “emotional contagion.” Against all odds, punditry, media and traditional political processes, the Trump campaign has garnered an emotionally charged base of loyal followers and at the same time creating a passionate opposition.

In my work as a couple’s counselor, I utilize the research of Dr. John Gottman to educate my clients. Dr. Mather describes “working memory capacity” as a spectrum of our consciousness that changes when affected by arousal. When working with couples, I educate them on physiologically heightened states or what Gottman also describes as diffuse physiological arousal (DPA). We know DPA, as an excited emotional state, elevates our vital signs and changes the neurochemistry in our brains to disrupt analytical processes, or our ability to think straight. When our heart rate elevates to over 100 beats per minute (bpm), adrenalin is released and we regress into a more primitive state of thinking. In these highly charged emotional states, we may not even hear or process the words spoken by others. Simple brain science tells us that DPA moves us from using the large mammalian brain (cerebral cortex) to the small lizard brain (limbic cortex). When we are charged in a DPA state, we operate on a basic emotional level and become susceptible to “emotional contagion” and “behavior confirmation,” as described by Dr. Mather where emotions are transferred to others and escalated to absurd levels.

Our emotions provide the sweetness and bitterness of life. They give us meaning to our logical selves and protect us from the dangers that surround us. Evolution has given us the counterbalance to our emotional selves by allowing the development of our cerebral cortex that truly makes us unique and separate from one another by defining our individual personalities. What draws us together is the empathetic nature we all share, meaning we all know how emotions affect one another, and we relate to each other on this basic level. When I counsel couples, I teach mindfulness and relaxation in order to calm physiological arousal, allow vital signs to relax, and provide cognition for understanding and rational processing of their individual perspectives. Through counseling interventions, I help the big brain trump the little brain.

Often we gain support most easily through tactics of emotional persuasion outlined in the “Elaboration Likelihood Model of Persuasion” as described by Dr. Mather. Trump’s tactics operate through emotional coercion that put his opponents off balance and draw his supporters more closely to his position of strength. His practice in debates and speech is both inflammatory and infectious, yet we learn and resolve nothing analytically. We come to a place of disconnection intellectually and connection emotionally. The little brain dictates our feelings and leaves our intellect behind. In this process, people are both attracted and repelled at the same time.

The 2016 United States presidential campaign demonstrates a process gathering strength from an internal combustible emotional state that feeds upon itself. From a psychological perspective, the effect of Trump’s campaign presents an emotional gravitational pull that infects people with similar feelings and attracts those who are already in that state. Donald Trump masterfully disrupts emotional stability to gather cohesion and simultaneously conflict with a strong opposition infused with outrage toward that his tactics. Being able to inspire such enthusiasm presents as a great strength to gathering support, but this leaves many questioning the Trump phenomena. In order for everyone to make sure they actually hear and not just feel we might just take a moment to breathe, check our heart rate to see if it’s below 100 bpm, and then, do our best to separate the emotion from the message or, at least, understand that the emotion is the message. By all means, we should make sure we all use the big brain in this process.  


This is a commentary on the Skeptic Ink article "WHY IS DONALD TRUMP SO INSULTING IN THE DEBATES?" You can read the full article: http://www.skepticink.com/gps/2016/03/04/1553/

Dad's Postpartum Depression

Postpartum depression and anxiety have probably been around since the birth of humankind, yet these have become topics of public knowledge only within the last 15 years.  A common assumption about women who become moody or anxious during pregnancy and after giving birth is that hormones are responsible for her sudden change in perspective, yet new research suggests that hormonal changes make only a small dent in the well of pre- and postpartum feelings (ScienceDaily, 8/2014).  Now, as the mechanisms producing knowledge about human behavior slowly grind forward, new research is revealing that men are also afflicted with emotional turmoil during their partner’s pregnancy and after the birth of their child. 

After reviewing 43 studies, Dr. Liana Leach, from The Australian National University (ANU) Centre for Ageing, Health and Wellbeing, found that 1 in 10 men suffer anxiety and depression before and after a child arrives. Although depression is generally difficult to understand, Dr. Leach  believes new and soon-to-be fathers feel “left-out” of the childbearing process since mother and child are integrally linked, and there is often no support for a father’s concerns (ScienceDaily; 11/2015). 

"Nobody is asking about the father and how he's doing,” said Carrie Wendel-Hummell, a University of Kansas doctoral candidate in sociology; "people typically focus on the mom and the infant, so not only is it more difficult for men to express their emotions, nobody is opening up that window for them either" (ScienceDaily, 8/2014). Wendel-Hummell points to the general absence of family-friendly leave policies in the workplace as one factor contributing to a new father’s stress, which obligate fathers to continue a day-to-day work routine while coping with the emotional and physical demands at home. Men don’t seek help “because they think 'it's not so much about me,” said Dr. Leach, and “health care during the perinatal period should be about the whole family” (ScienceDaily, 11/2015).

Fathers experiencing anxiety and depression after welcoming a new baby into their world should come as no surprise, but hearing a new dad admit he is having trouble just might. While women have been asserting themselves in what is, and has been, a “man’s world”, it seems men are reluctant to admit they are a part of what has long been assumed the world of mom and baby.

Fathers are significant in every aspect of family, including the link between mother and child. Perhaps it’s time for fathers to express their own feelings and needs when a baby comes along, and break the cultural norm that keeps them chained to the expectation of stoicism, and separation. If you are a new or soon-to-be dad, believe you are important enough to speak-up and reach out for help when you need it.  “No man is an island…”   John Donne prophetically wrote, and this includes you, too, Dad. 


 Australian National University. "Mental health risk for new dads." ScienceDaily. ScienceDaily, 24 November 2015. <www.sciencedaily.com/releases/2015/11/151124112134.htm>.

American Sociological Association (ASA). "'Super-parent' cultural pressures can spur mental health conditions in new Moms and Dads." ScienceDaily. ScienceDaily, 18 August 2014. <www.sciencedaily.com/releases/2014/08/140818012229.htm>.