How do I find off-the-books therapy?

July 30, 2009 9:29 AM

A while ago, I asked about the implications of accessing mental health care and possibly having a diagnosis tied to me. From the answers, I've concluded that in my specific situation, any help I need will have to be "off the record." Because that's my decision, this has made it hard to obtain care. How do I go about finding it anyway?

I'm located in the United States, and have the usual litany of Ask Metafilter issues: self-esteem, challenges with interpersonal relationships, maybe a dash of depression and anxiety. I don't believe I have any "major" issues (bipolar, schizophrenia, sexual or substance abuse, violence, etc.) I'm primarily looking for talk (rather than pharmaceutical) therapy, although it's plausible that what I really need is something like a life coach.

I actually have (good, even) group health insurance, but the disincentives from the previous question are so great that I'd really not rather make use of it. In a word, I'd rather go untreated than have a record of any of this.

Can I pay for therapy and counseling in cash, on some sort of sliding scale, as if I were uninsured? Use an assumed name? How do I make this as untraceable as possible, while still getting effective care?

I'm open to suggestions for informal counseling as well, although since I am a staunch atheist, religious figures and support groups associated with a religion aren't something I would consider.

posted by anonymous to health & fitness (11 comments total)

Can I pay for therapy and counseling in cash, on some sort of sliding scale, as if I were uninsured?

Yes. Call and make sure, obviously.
posted by desjardins at 9:32 AM on July 30

On preview, seconding desjardins.

Does your employer have an Employee Assistance Program? Most of the places I've worked offer one as part of a large passel of benefits; most of the time I'd get the brochure and just chuck it to one side. However, therapy and counseling has always been one of the things listed, and I don't believe you go out of pocket for the sessions at all (the company has paid for it already). You get a list of providers, call to make an appointment and that's about it.

The caveat is that the EAP may only cover, say 12 total sessions or something along those lines.

FWIW, the religious figures in my particular faith would be the first ones to tell you that they are not equipped for mental health issues...if something came to light during pastoral counseling, I strongly suspect you would be (gently) urged to find an expert.
posted by jquinby at 9:37 AM on July 30

Yes, many therapists take cash. I used to pay mine this way (well, by check, but I could have given her actual folding money) and then fill out the paperwork from my insurance for reimbursement. In my experience working in different fields - retail, editorial, general office-monkey stuff - the only time an employer has cared is when they need to see a doctor's note if you've been out more than X days, or for worker's comp purposes.

Talk therapy is an entirely unremarkable (again, IME) thing. Most people I know have done it or are doing it. A lot of people are on meds.

The one place where you may get caught is if you're filling out a security clearance or similar form: don't lie. Lying is bad. Getting caught in a lie will almost certainly make you not get clearance, and there might be greater consequences (getting fired).

I think you're overreacting, but I don't know where in the U.S. you live and I don't know what field you work in.
posted by rtha at 9:40 AM on July 30

My mom's favorite type of client is the cash-only one - she sees quite a few people who, for various reasons, don't care to trouble their insurance companies, and instead pay for therapy out-of-pocket. Were I you, find someone you might want to see, then just call and ask if they take cash, I 'd be quite surprised if they said no.
posted by restless_nomad at 9:41 AM on July 30

I pay cash for mine and she's so happy about it she's given me a discount.
posted by small_ruminant at 11:16 AM on July 30

If this is tl;dr skip to the end.

I've been trying to figure out what career path could be so sensitive to someone's having gotten therapy, and this is what I've come up with:

Politician
Doctor
Lawyer
Military (or other) Intelligence
Pilot

There are probably others that I'm not coming up with. I'm going to take it on good faith that you're very concerned about someone finding out, and go from there.

I work in a doctor's office, and we have residents here as well as attendings. I work upstairs from both a US Marines recruitment office and a statewide mental health advocacy organization.

I took a field trip, and here's what I found out:

Military: There are specific questions during the medical screening about past mental health treatment. It's only about diagnosis/treatment with meds, not therapy/counseling. They said that with depression or ADD, whether or not you'd be accepted depended on a) when the instance was and b) what specific meds a person was on. The next step would be a psych evaluation. Any other diagnosis/treatment such as anxiety, manic depression, etc. would be an auto-fail. This is all just for regular military service, not the top-echelon positions.

Medical: The consensus of the doctors here is that with a small amount of caution that getting therapy or treatment for mental health problems is a GOOD thing to do. So the caution they recommended was to make sure the provider a person chooses would be outside the care system they're working/studying in, and to keep it on the down low (their words, heh.) They said that there were no questions on any board exams or licensing things about mental health specifically, other than whether a person had had a substance/alcohol abuse situation. And also whether there was any medical reason that the applicant wouldn't be able to carry out the job duties. So, like, someone with an untreatable hand tremor shouldn't be doing microsurgery. The docs did say that when it comes to getting jobs later, residencies, etc. that if word got out under the radar that a person applying had had mental health problems that the people hiring might turn the person down. They also said that getting treatment would make that person a better provider.

MH Advocacy group: I spoke with a therapist-turned-lobbyist. She said that the best way to go about accessing care with this concern would be to make an anonymous call to therapists and ask these questions up front:
1) How will you protect my anonymity and confidentiality?
2) How do specifically protect my records?
3) When the course of therapy is over will you give me all copies of my records?
4) If someone subpoenaed the records, what would you do? Do you destroy them after a certain point? Would you refuse to hand them over on principal?

She said that yes of course you could pay with cash off the books (ask first), and that in theory you could use an assumed name. She did say, however, that if you used an assumed name and the therapist found out that they'd be looking at some other mental health issues.

Her takeaway message was that:
1) Advance screening of therapists will greatly minimize the already very low chance that word would get out from your records.
and
2) There's no way to guarantee 100% that seeking treatment would have no negative effect, because you don't have 100% control over other people.

tl;dr

Safeguard your anonymity/confidentiality, pre-screen therapists, and don't go into the military.

Hope that helps!
posted by Stewriffic at 11:39 AM on July 30 [4 favorites]

Even if you pay cash for mental health services, it's still something you will be required to disclose to a future insurer if you ever need to buy individual insurance in the US (group policies through an employer are different and do not require this generally). If you choose not to disclose, they can sue for fraud and rescind your policy when you actually get sick, even for something seemingly unrelated, like a broken arm.

The way private individual insurance law stands, ANY treatment you ever had for anything can't be hidden from an insurance company you have a policy with. There is no way to keep it off the record if you find yourself needing to buy an individual policy at any point in your future.

That said, HIPAA laws still protect your medical record from being disclosed to pretty much anyone else without your consent. If insurance isn't what you're concerned about, go ahead and pay cash.
posted by slow graffiti at 11:44 AM on July 30

I'm not sure what sort of privacy issues you're worried about. But whatever they are, I suggest talking to your therapist about them — in a "Hey, we should discuss this as equals before we do business" way, not in a "Let me tell you about my anxieties, doctor" sort of way.

Me, I'm not too worried about privacy, but twice I've had a therapist bring it up at our first meeting. What both told me was that they wouldn't volunteer any information about me, but that under certain circumstances their records could be subpoenaed. One said he was willing to avoid keeping written notes if I was worried. The other said she intended to keep written notes because she didn't work well without them, but wanted to let me know so that I could find another shrink if that was a problem.

The moral of the story, I think, is that there are therapists who are aware of the stigma against mental health care, are aware of the particular ways in which it can make trouble for the patients, and have thought about how far they're willing to go to help with that.
posted by nebulawindphone at 12:06 PM on July 30

Therapists love cash. They hate insurance companies.
posted by kathrineg at 12:15 PM on July 30 [1 favorite]

Oh and my advice is to never disclose it, ever, to anyone associated with your insurance company (including your HR). You have a group policy, one of the many benefits of that is that you are covered no matter what conditions you have, as long as you're a member of the group.

If you need to get an individual policy for any reason, you might feel the need to disclose it on your application, but even if you get fired today your COBRA won't run out for more than a year.
posted by kathrineg at 12:20 PM on July 30

2nding EAP. They HAVE to keep it anonymous. That way you can get in to see someone, and they can steer you into the right direction.
posted by 6:1 at 3:29 PM on July 30