Decolonizing Therapy and the Ethics of Not Taking Insurance
An article that has spurred much conversation in the therapy field lately has been circulating. The article discusses the dysfunction and corruption of the insurance industry and its impact on those seeking and providing mental health care. After reading this article, I did not feel surprised. Instead, along with the sadness and anger that was familiar towards our insurance industry after working in the field for many years, I felt validated as a practitioner who has chosen to no longer work with insurance.
Interestingly enough, this article came out right as I was diving into Dr. Jennifer Mullan's impactful book Decolonizing Therapy, where she draws our attention to the colonial legacies prevalent in therapeutic work that contribute to ongoing oppression and create obstacles to true healing and justice. Dr. Mullan's book inspires deep recognition and reimagining for those engaging in therapeutic work on the individual and communal levels. In her exploration of the oppressive legacies prevalent in the field, she reveals harsh truths about the insurance industry and its role in historical and ongoing systemic oppression.
Deciding as a therapist not to work with insurance is one of the more radical aspects of the decolonizing approach. This connection may seem surprising, especially since, at first glance, it can seem exclusionary, limiting access for those who cannot afford to pay for therapy out-of-pocket. However, when looked at alongside the information we have about how and why the insurance industry works (especially regarding mental health care), it becomes clearer that this choice can be necessary for providers to offer quality care while also being an ethical stance against a deeply flawed system.
Insurance and Systemic Oppression
As it exists today, the insurance industry perpetuates harmful power dynamics that can often limit the options of those seeking care and the efficacy of their treatment. While federal laws require insurers to provide equal access to mental and physical health care, the enforcement of these laws is minimal, and mental health coverage is often highly restricted, delayed, or straight-up denied. Insurance companies prioritize profit over people to be a successful business, and this leads to them frequently limiting or denying access to necessary treatment, most notably for those with chronic mental health conditions that are costly to treat.
Dr. Mullan argues that genuinely decolonizing therapy requires us to recognize and resist systemic oppressions such as this. Refusing to hold up a system that puts profits ahead of people's well-being puts therapists in control. Removing the insurance industry as a flawed gatekeeper allows therapists instead to align themselves with the core values of decolonization, including autonomy, empowerment, and justice.
The Limitations of Insurance Dependency
As the article cited at the beginning of this blog describes, therapists who choose not to accept insurance often do so after facing insurmountable challenges within the system. They usually struggle to make this decision, painstakingly weighing the costs and benefits for those they care for to determine the best path forward. Insurers often interfere with the therapeutic process, which makes treatment challenging. They dictate the type, length, and frequency of sessions and sometimes pressure therapists to reduce care even when patients are at risk of harm. This interference undermines the therapist's ability to provide ethical, patient-centered care. Furthermore, therapists often need to work more hours or decrease the number of clients they see to instead communicate and advocate with insurance companies. This results in lost income, reduced mental health services, and increased stress for all involved.
In a decolonized approach, the therapeutic relationship and the client's needs are put far before any constraints imposed by insurance policies. By opting out of insurance networks, therapists can provide clients with treatment focused on true healing. This autonomy allows therapists to uphold the ethical principles of beneficence and non-maleficence, which ensures a practice guided by the client's needs rather than an insurer's demands. In many instances, the ability to offer responsive, individualized care free from external pressures and limitations makes all the difference.
Reimaging Access and Equity
In our current, deeply flawed system, some may argue that therapists are making mental health care less accessible by not accepting insurance. However, when we look through a decolonizing lens, we see that access and equity can exist in healthier ways that support individuals and communities. Accessibility is not just about financial affordability. It is also about the quality and appropriateness of the care received. If therapeutic care is affordable but poor and dysfunctional, there is a real possibility that it can do more harm than good.
When therapists are free from insurance constraints, they can establish creative and effective ways to make their services more accessible. For instance, they can offer sliding-scale fees and group sessions. Without the limitations imposed by insurance companies, therapists can incorporate innovative models of care that better meet the needs of diverse communities.
Furthermore, if we are to decolonize therapy truly, we must address the root causes of inequality, such as economic injustice and the lack of public investment in mental health. When therapists challenge the existing insurance model, they raise awareness of what is broken and join the call for broader societal and policy changes to make high-quality mental health care accessible to everyone.
Putting it into practice
Reimaging these structures is something I am focusing on right now in my practice. Recently, I have been working to build a practice that offers sliding-scale sessions for individuals who can't afford full-price therapy. I have started offering online courses to cover the costs and have felt proud to navigate this transition with my values intact. Maintaining the quality and integrity of the care I provide clients while ensuring that therapy is accessible to those who might otherwise be excluded will always be a priority for me. Reading Dr. Mullan's book inspired me to dive deeper into decolonizing my practice while recognizing that I am not alone in this and that we can all work to create more just and equitable mental health care.
Decolonizing therapy challenges us to rethink the ethics of mental health care and actively participate in dismantling the oppressive systems that have been while imagining and building the thriving, equitable mental health care yet to come. For therapists, the decision to work outside the insurance system is a powerful tool that aligns with decolonizing principles, offering autonomous, equitable, and client-centered care. This approach not only honors the dignity and agency of clients but also contributes to the broader work of social justice and collective healing.
In closing, I want to name and honor the complexity and consequential fatigue of living within harmful systems while simultaneously trying to detach and dismantle them. It is easy to drive ourselves into despair and apathy when we strive for perfection rather than doing the best we can right now. Balancing personal needs and systemic change requires a lot of nuance.
As I walk this path, I find that the changes I can make gradually and sustainably seed further and more effective shifts than the impulsive and often guilt-ridden actions that may feel initially more gratifying but don't have the same staying power. As a therapist, I am grateful to have the lens of balancing inner and outer work, for one can't heal without the other. I am immensely thankful to Dr. Mullan for writing Decolonizing Therapy and bringing further awareness to the harmful histories and systems impacting the mental health field. I especially appreciate her invitation for practitioners and clients to work individually and collectively. Please consider reading this vital work.
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