What is Therapy? Part 2: Why Opting for “Private Pay” Therapy Matters
- Amy Ratkovich
- Aug 24, 2025
- 5 min read
Dear Therapy Seeker,
Many people assume therapy should always be covered by insurance. After all, people pay for insurance, so why not leverage those savings? I get it.
But here’s something many therapists know: most of us don’t use our own insurance for therapy. Why? Because using insurance changes the frame.
You might think, “But how different can it really be? I use insurance for my doctor, and mental health is healthcare, right?” And yes — mental health is health. But therapy isn’t like going to the doctor. A doctor might order a test, prescribe medication, and you’re on your way. Therapy is different: it’s a relationship cultivated over time, where process and patterns matter more than quick fixes.
Insurance frameworks, however, require diagnoses, demand notes, and shape the way your therapist conceptualizes your case. Sometimes, they even become part of the therapy conversation itself — shifting focus away from your healing process.
In this blog, I’ll share the ways I’ve seen insurance distort therapy — not to convince you one way or another, but to give you the full picture. That way, you can decide for yourself whether your needs fall under “medical necessity” or whether private pay might be a better fit.
1. Privacy: Who Really Sees Your Story?
When you use insurance, your therapist must submit:
A diagnosis (from the DSM-5 or ICD-10).
Progress notes or treatment summaries.
Sometimes even detailed session notes during audits.
That means a third party — not you, not your therapist — now has access to intimate details of your inner life. It becomes part of your permanent medical record (Protected Health Information).
In cash-based therapy, your story stays in the room. Notes are minimal, private, and written only to support your process — not to justify payment.
Old school: before the age of computers, therapists kept notes in a locked cabinet behind a locked door! Yes, people wrote with parcment and quill! Some still do. ;)
Most notes today are digital, and while secure platforms are used, even the safest servers can be breached.
Pro tip: if privacy is a top concern, ask if your therapist offers paper notes. They can’t be hacked — though this is rarely an option unless you invest in private treatment.
2. The Importance of the Therapeutic Frame
In therapy, “the frame” refers to the container that makes the work safe and effective: confidentiality, time boundaries, and the therapist’s undivided focus on you.
Insurance disrupts that frame in subtle but powerful ways. Because your therapist has to think about billing requirements, diagnoses, and what’s “covered,” part of their attention shifts from you to the insurance company’s rules.
Think of it like this: you and your therapist are cooking together, but insurance is standing in the kitchen saying, “You can only use these ingredients, and I want to see your recipe notes every time.”
That third presence changes the flavor of the work.
3. Progress Notes vs. Process Notes
Here’s an important distinction:
Process notes are private reflections your therapist may keep to track themes in your work. These are protected, never shared, and often handwritten or kept outside electronic systems.
Progress notes are what insurance requires. They must document specific symptoms, goals, and measurable “progress.”
When insurance is involved, therapists are obligated to keep progress notes. That means sessions — and sometimes even the way questions are asked — get filtered through the lens of “what will satisfy medical necessity?”
Insurance-approved approaches must also be “evidence-based.” That often means CBT or manualized therapies expected to deliver results in a short time. In fact, EAP benefits are often limited to just a handful of sessions.
With private investment in therapy, we can focus on the truth of your experience, not on fitting it into a predetermined framework. We can get creative — longer sessions, walking sessions, somatic practices — things that insurance won’t cover, but that may be essential to your healing.
4. Dispelling the Myth: “Therapy Should Always Be Covered”
Insurance is built around the concept of medical necessity. Coverage is designed to stabilize you:
Getting back to functioning at work, school, or home.
Reducing symptoms that cause significant distress, like insomnia, panic attacks, or inability to concentrate.
That’s important — but what about therapy for:
Strengthening relationships?
Exploring identity?
Processing past experiences?
Cultivating resilience?
Making meaning and finding purpose?
These don’t always qualify as “medically necessary.” Unless distress or impairment can be documented (sometimes with measures like the GAD7 or PHQ9), insurance won’t pay.
Yet often the heart of transformative therapy is curiosity without agenda. That’s where growth happens. This kind of work — deep exploration, soul-level healing, and self-discovery — doesn’t fit neatly into an insurance model.
5. The Case for Private Investment in Therapy
When you invest directly in therapy, you buy freedom — for yourself and for the work. Private pay allows for:
Greater confidentiality.
Flexibility in session length and structure.
A wider range of therapeutic approaches.
Space to explore growth, not just symptom reduction.
Without insurance in the room, you and your therapist can follow what emerges: silence, metaphor, body awareness, unconscious themes — all things that don’t fit into billing codes but often make therapy transformative.
Conclusion
Insurance has its place — especially in times of acute crisis or severe impairment. But for many, the deepest work of therapy happens best when insurance isn’t involved.
Ask any therapist: which frame allows for the deepest work? Most will say the same — therapy is freer, deeper, and often more transformative when it’s just the two of you “in the room.”
My goal isn’t to tell you what to choose, but to give you the trade-offs so you can make an informed decision. If you want your therapy to be as confidential, flexible, and transformative as possible, private pay may be worth the investment.
Key Takeaways
Insurance requires diagnosis, notes, and oversight — which compromises privacy.
The “frame” of therapy is most intact when no third party is involved.
Progress notes (insurance) and process notes (therapist) are very different — only private pay allows for true confidentiality.
Therapy is more than medical necessity. Growth work matters too.
Private pay isn’t just about money. It’s about protecting the integrity of your healing space.
Curious whether privately investing in therapy might be right for you? Let’s talk. Book a free consultation and explore what kind of therapy frame feels best for your needs with no obligation.
References & Further Reading
Psychotherapy Notes vs. Medical Records (HIPAA guidelines ) Explains the special privacy protections psychotherapy notes receive under HIPAA, distinguishing them clearly from the progress notes insurers can access.
Private Practice and Self-Pay Context Highlights the importance and challenges of private practice settings, including how many providers choose self-pay
Insurance Often Limits Treatment to Medically Necessary Cases
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