You’ve come to the realization that you can’t do your best work, take good care of your health, and make a livable, sustainable wage if you continue to take insurance.  But when you think of sending that Dear John letter to the various panels, the fears and doubts creep in…

  • What if I can’t sustain a self pay practice, and the insurance panels I fired won’t take me back?
  • What if my clients feel abandoned or tricked because I took their insurance when we began therapy?
  • Ethically, am I obligated to take their insurance as long as they are clients of mine?  It’s what I agreed to when we first began working together.
  • What will my clients who can barely afford their copays do? They can’t afford to pay out of pocket!
  • I know I’m a really good therapist, but am I $200 good?
  • Access to care is a value of mine. Aren’t I going against my own values if I go to a self pay model?
  • I couldn’t afford to pay my own self pay fees.  How could I ask a client to pay that?
  • I have a successful, six-figure, super busy private practice as it is.  What if going self pay is the worst decision I could ever make for my business?

As you mull over your own objections as well as the ones above, what are you aware of?  What’s you body saying to you right now?  Are there certain objections that feel like a punch in the gut or that make you feel sick to your stomach?  It’s no wonder! You’re programmed to survive, so your body is responding to the perceived threat of changing the way you earn money and telling you not to do anything that may put you in imminent danger. The survival instinct doesn’t really care that you’re under constant stress–physical, economic, and emotional– as an insurance provider.  Take a moment to thank your survival brain for trying to protect you.  Now just ask it to hang out in the background for a few moments as you consider the following responses to the above objections.

  1. What if I can’t sustain a self pay practice? First, let’s define what sustain means in dollar amounts for you.  Let’s say you’re used to making $100,000 a year as an insurance provider, and you see 25 clients a week typically and work 48 weeks a year to gross $100k per year. That’s an average of $83.33 per session and 1200 sessions per year.  If by sustain, you mean make as much money as you have while taking insurance, you have to see a lot fewer clients per year to make the same amount of money.  For instance, if your self pay rate is $175 per clinical hour, to reach $100,000 a year, you only have to have 572 clinical hours of sessions per year.  That means 12 sessions per week if you work 48 weeks a year. What comes up as you think about that?  You don’t have to stick to by-the-hour client services either.  What if you ran some groups?  Served as a consultant for other professionals in an area of expertise?  Develop some psychoeducational resources to sell online at Teachers Pay Teachers (for selling to educators or other therapists) or Gumroad (for selling educational materials to anyone who visits your website or social media business profile.) If you have more time on your hands, let the creativity flow!

  1. But what if my clients, both current and future, can’t afford to pay out of pocket?  It can be very easy to make assumptions about our clients’ abilities to pay, simply based on their occupation.  Did you know that teachers–yes, K-12 school teachers–along with CPAs, engineers, and attorneys, are on the most likely to become millionaires list?  “Okay, fine,” you say, “but some of my clients receive government assistance, so they really can’t afford to pay out of pocket. Some of them are really working hard, and I want to continue to work with them.”  Fantastic! With a self pay practice, you’ll have the time, space, and bandwidth to have a slot or two for sliding scale.  You’ll just have to be sure you continue to earn an average per session of $175 per hour to meet the above goal.  You may decide to see an average of 13 clients a week and charge $175 an hour for everyone except for your one sliding scale slot.  You may need to raise your fee to $185 or $195 to offset the cost of seeing a sliding scale client once a week. Depending on how you work, you may have room for two sliding scale clients every other week, or you may choose to work with one at a time on a weekly basis.  It’s your practice, and you know best what works for you.  

  1. What if my clients are mad at me because I am coming off of their insurance panel? What happens in the therapy room provides a great mirror for life.  You’ll help them process what’s underneath the anger! They may have abandonment issues that are being activated by this issue. Great! You know how to help with that!  

  1. I know I’m a really good therapist, but am I $200-an-hour good? Research has demonstrated time and time again that the most important factor in whether therapy is effective is the relationship the client and therapist have.  You can be the most “skilled” therapist with a particular therapy modality, but if you don’t have the ability to be fully present with your clients, your skill level will be irrelevant. In fact, how many times have you heard a client mention that a former therapist  fell asleep, took phone calls, or whipped out their hummus and tabbouleh pita and started chowing down right in the middle of a session? I’m not saying this to beat up on our fellow colleagues who are exhausted and stretched too thin due to clocking 8 to 12 clinical hours a day.  I am saying we all have a limit to the number of clients we can see per day and be at our best. Not only do we have a responsibility to give the best care possible to our clients, we owe it to them to stay in business–and to do that, we need to make good money and have plenty of time for self care and free time to enjoy life.  If that number is $200 per clinical hour for you to be at your best, you must work toward being comfortable with charging that amount.  I have oodles of ideas for how to get there, so shoot me an email at so I can share a few with you!

  1. Access to care is a value of mine. Aren’t I going against my own values if I go to a self pay model? On the contrary!  Nearly all the therapists I know who’ve changed to a self pay model have much more time, energy, and money to devote to helping causes that matter to them!  Cynthia and I are founding members of the Southeast Brainspotting Institute (SEBI)–a 501(c)3 non profit organization. Part of the mission of SEBI is to… “support and educate currently-trained practitioners, develop the use of Brainspotting in rural areas and with underserved populations, and ensure an inclusive and diverse Brainspotting community.” The work that SEBI does today for the southeastern United States brings us to tears.  It took four dedicated, passionate founding members over three years to get it off the ground and attract more Board members who could help take SEBI to the next level.  And I don’t even want to count the hours it took.  With a family to care for, I know for a fact I couldn’t have given so many years of my life to this incredible organization if I didn’t have a self pay practice.  

  1. I couldn’t afford to pay my own self pay fees.  How could I ask a client to pay that? I completely understand that your current financial situation would make it very difficult if not impossible to pay privately for a vital, life-changing service like therapy.  How much of your current financial situation is driven by insurance company denials, claw-backs, and low reimbursement?  If you didn’t have to work under the constraints of a tyrannical system that unabashedly devalues your work, how could your financial life change? 

  1. I have a successful, six-figure, super busy private practice as it is.  What if going self pay is the worst decision I could ever make for my business? This fear was the #1 thing stopping me from breaking up with insurance.  In 2014, I made it my goal to stop taking insurance entirely, but the fear of completely ruining my private practice by going self pay kept me frozen for years.  Literally years.  Finally in 2016, after doing lots of Self Brainspotting on my own and then having one 30 minute Brainspotting session with a colleague, I wrote and sent the Dear John letter to the last insurance company.  I’ve never jumped out of an airplane, but I imagine I felt the same thing in that moment when I pressed “send” on that email to Blue Cross/Blue Shield.  It was a one-two punch of exhileration and sheer panic.  Then an incredible calm came over me, and I knew it was going to be okay.  I would see to it.  Now, over five years later, I can honestly say that decision was one of the best decisions I have ever made in my life. 

Now that you’ve read through some of the most common objections and worries therapists have about having a self pay practice, what’s coming up now?  

If you still have doubts, I invite you to find a safe place do this Brainspotting exercise with me right now!    


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