When Kate Spade and Anthony Bourdain both died by suicide this summer, it felt like the entire internet was blanketed with messages of support for anyone contemplating self harm: call suicide hotlines, reach out to friends and family members, don’t be afraid to seek professional help.
It was a welcome step toward breaking the stigma around mental health issues in America, but all the Instagram posts in the world couldn’t answer a nagging question: Even if I’ve found the courage to seek help, how am I going to pay for it?
“I think that when you're struggling with a mental health issue it's hard enough finding therapy under the best circumstances, but when you have limited resources it can just be really unbearable,” a friend who requested anonymity said, describing what it was like to find therapy during various financial crises in her life.
Unfortunately, the availability of those services continues to vary wildly, from the number of visits covered to the doctors who accept your insurance to the copay per visit. As a result, people are three to six times more likely to choose out-of-network care for behavioral health issues than other medical visits, according to a 2017 study from Milliman, a risk management and healthcare consulting company. And when you see a doctor out-of-network, you almost always wind up paying more money.
“There are a lot of behavioral health providers that are in private practice that don't even take insurance because the reimbursement rate is so low,” said Inger Burnett-Zeigler, a psychologist at Northwestern University’s Asher Center for the Study and Treatment of Depressive Disorders.
Without insurance, she estimated an out-of-pocket range of $75 all the way to $300 or $400 near her practice in the Chicago area, with people of color and low-income communities being the least likely to access mental health resources.
Keeping those barriers and caveats in mind, I asked practitioners and patients for ideas on finding affordable therapy.
Find out about free services at work
You can get free assessments and short-term counseling through your company’s Employee Assistance Program (EAP), a service offered by most firms with 250 or more employees. Using your company program is confidential and can help with a wide range of issues—from pet loss to smoking cessation—in addition to mental health problems, even if you’re not eligible for your company health plan. EAP’s generally offer just a few sessions to begin with, but the counselor should offer referrals to long-term therapy options.
Even though most companies offer EAPs, they continue to be “one of the most underutilized services for free therapy that there is out there,” said Bill Prasad, a licensed professional counselor near Houston. That’s because many employees don’t know how to access the programs and worry that their manager might find out if they do. There’s also some lingering stigma associated with them since they used to be solely for substance abuse or serious mental health issues. But today’s EAPs are basically “a concierge service where you can go for an assortment of different problems,” Prasad said.
Ask questions before making an appointment
Before you set foot in any therapist’s office, call their office and ask if they participate in your insurance plan, then call your provider to double check. Next, find out what the copays are, how many sessions are covered, and how much late cancellation fees cost. If you qualify for Medicaid—eligibility varies by state but is generally available to people living at or near the poverty level—you can see a therapist who accepts Medicaid at no charge.
Finding an in-network therapist that is taking new patients can be tough, however, and seeing a therapist out of network will almost always be more expensive. However, you can try to negotiate. Some things to bring up include why you sought them out in particular (ideally because they specialize in the specific issue you are dealing with), who recommended them, and how much you can afford. While each therapist is different, you can often get a short phone session for free, and you can bring all this up then.
Be honest about your income and ask about sliding scales
If you’re seeing a therapist out of network and paying the full price yourself, it’s important to be upfront about what you can and can't afford. "People will adjust according to your income,” says Leyna Lightman, an independent curator based in Los Angeles who took advantage of sliding scales to reduce her costs for treating an eating disorder.
Non-profit health centers are especially likely to offer discounted rates. These include organizations like the Institute for Contemporary Psychotherapy and the Karen Horney Clinic in New York City and the The Painted Brain in Los Angeles. The Anxiety and Depression Association of America and Mental Health America also have directories of non-profit organizations and federally-funded centers across the country.
Another option is the Open Path Psychotherapy Collective, a national collective of providers who leave room on their caseload for patients that pay between $30 and $50 per session (up to $80 for couples therapy), plus a $49 one-time membership fee.
Be sure to mention if your financial situation changes, too. “I've also seen situations where therapists are working with clients and they're charging the clients their regular out-of-pocket rate, maybe it's $125 and then the client runs into some financial problems or the client maybe loses their job, and then the therapist reduces the fee for a while,” Prasad said.
Don’t rule out therapists in training
The least I’ve ever paid for therapy, without insurance, is $40 per session in 2015, as a participant in Beth Israel’s Brief Psychotherapy Research Program, where the therapist was a trainee supervised by a team of psychologists.This included an initial two-hour intake session and survey, plus 30 sessions of therapy (it’s now 20). I filled out a survey after each session, and a slightly longer one when the 30 sessions were over. After a three-month wait, I completed the program a second time with a different therapist.
I was going for help with a long-term issue and a new one: chronic panic attacks and a depression coinciding with a stressful job search that drained my energy, my self-worth, and my ability to complete what were previously basic tasks, like getting out of bed, paying my bills, even brushing my teeth. The intake interview and filling out surveys after each session was time-consuming, but it was also affordable and consistent, and gave me referrals when it was over to other sources for lower-cost therapy.
Pay with pre-tax money to save even more
In addition to lowering your upfront costs by seeking out lower cost options, you can shave another 10 to 25 percent off your bill (depending on your tax bracket) by paying with pre-tax dollars. To do this, you’ll need to open a health savings account available to people with high-deductible health plans or a flexible spending account provided by your employer and use those accounts to pay for out-of-pocket costs, including copays.
With a flexible spending account, you need to fund your account in advance during the annual open enrollment period (usually in November) and use the money within a year or so. Health savings accounts are more flexible in that you can keep using the funds indefinitely. If you don’t have either account set up, it’s still wise to keep track of how much you spend on therapy visits, so you can write the costs off come tax time.
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This article originally appeared on VICE US.