How Therapy Works - A Transparent Look
You may be wondering if therapy is right for you and be overwhelmed by the price tag, the different ways of accessing care, and the commitment. It helps to understand why the model of therapy is the way it is: the structure of therapy itself, the costs, and systems behind the scenes affecting care.
The goal of this post is to be transparent about how therapy works in practice, why it’s scheduled weekly, the costs, and how the insurance systems act as barriers to care, resulting in therapists asking clients to pay out of pocket.
Why Therapy Is Usually Scheduled Weekly
Therapy typically happens on a consistent weekly cadence - same day and time, week after week. On a practical note, the regular schedule allows your therapist to hold space for you in their calendar reliably, but that consistency also translates to the effectiveness of therapy:
It allows for trust to be built over time. Meeting regularly helps clients open up more and more quickly develop a working relationship with their therapist.
Regular meetings allow for space to talk about urgent issues and get deep. The weekly sessions give you space to address whatever issues arose from the week, while also leaving room to explore the more core longer-standing issues when there’s nothing pressing from the week prior.
Therapy can build upon itself. Weekly sessions make it easier to follow up on unfinished threads of conversation, revisit “food for thought”, and check in on between-session reflections or homework from the prior sessions.
The weekly cadence is more than just logistics, it’s what makes therapy work.
Understanding the Cost of Therapy
The cost of therapy can be prohibitive, especially when you’re paying out of pocket for weekly sessions. It’s understandable that people balk at the price tag, or feel frustrated when a therapist doesn’t take their insurance. Understanding what’s happening behind the scenes can make the costs make more sense.
Why Many Therapists Charge Clients Directly
Most therapists who accept insurance are reimbursed significantly less than their private pay rate, being paid sometimes 60-70% less than what they’d otherwise charge. And that insurance payment doesn’t factor in business taxes, self-employment taxes, and individual taxes, let alone the cost of maintaining licensure, so therapists ultimately net even less than the insurance reimbursement provides.
In order to make a sustainable living while accepting these lower rates, many therapists end up needing to see double or triple the number of clients each week as compared to a full self-pay practice.
Charging self-pay rates gives therapists the ability to pause, breathe, and reflect after a session instead of immediately moving to the next appointment. This extra time can also allow therapists to consult with colleagues on complex cases. The additional time and money allows therapists to invest in trainings to better serve their clients, and maintain their licensure. Lastly, for those that need more care coordination (e.g., such as those with high needs needing referrals to hospitals or residentials, or children and teens who need coordination with schools), self-pay allows therapists to actually provide those services as insurance does not reimburse for care coordination.
The Hidden Costs of Using Insurance
Paying out of pocket also protects you from something insurance billing doesn’t: privacy and controlling your own treatment. When using your insurance, your therapist must share your session notes with your insurance company, which then gets to decide if your treatment is “medically necessary” and whether they’ll continue to pay for it.
This conditional relationship comes with strings attached including requiring questionnaires or assessments before each session with the caveat that if your symptoms are too low by their standards, they will not reimburse. They can also limit how often you are being seen, and even restrict treatment on the kinds of issues for which you’re seeking therapy.
Insurance companies can also issue clawbacks, a situation in which they retroactively decide that previously approved care isn’t actually covered, and demanding therapists repay years of reimbursed session fees after the fact. This risk shapes how insurance-based practices operate and provide care, and why many therapists choose not to participate in insurance networks at all.
What This Means for You
The goal of sharing this information isn’t meant to discourage you from seeking therapy, but rather be transparent about the broken system both clients and therapists are working in. My hope is in knowing why sessions are weekly, why self-pay rates exist, and the risks of insurance billing involved can help you make a more informed decision about the kind of care you’re seeking that aligns with your goals and budget.