Recently Congress passed the No Surprises Act, which is supposed to correct a wrong that’s committed when a patient enters medical treatment and later finds that not all their health care providers are in-network with their insurance company. These unfortunate souls have been stuck with high bills they had to cover. The act is also designed to facilitate the ability of patients to shop around and get the most cost-effective medical care. I trust the law will accomplish these worthy goals, but in the process, it has mandated that I give clients a document which is impossible to provide.

The document I’m supposed to give is a “good faith estimate” of what it will cost to be in therapy with me without insurance. My clients have always known my per session private pay fee; that’s no secret. But, in addition, this law orders me to state what your diagnosis is, describe the services I’ll provide, the frequency of sessions, an estimate of how many sessions we’re going to need before we’re done, and total it up for you, all within three days of when you set your initial appointment. Not three days after we meet, but three days after you make the appointment.

Here’s the problem. I cannot in good faith give a good faith estimate. But I can explain why.

Diagnosis

Many prospective clients, when they first contact me, tell me the nature of the problem for which they seek therapy. They’ll say they’re anxious, depressed, their wife left, they’re drinking too much, or something like that. This is helpful information, but it’s not a diagnosis. A diagnosis is a label given to a condition that meets a strict set of criteria so that every medical professional can have the same thing in mind when you say you have, for instance, generalized anxiety disorder. Not everyone who says they have a problem with anxiety has an anxiety disorder. It could be a hundred other things in the diagnostic schema. Your anxiety may not even meet criteria for any disorder, but still be very troubling to you.

It’s impossible to give an accurate diagnosis before I meet you and do a thorough evaluation. In some cases, a thorough evaluation could take many sessions. If, for instance, you drink a lot and also have problems with anxiety, we won’t know until you’re sober for a few months if your anxiety is caused by your drinking or the other way around. That, in turn will affect the course of your treatment.

If you want to know your diagnosis, I’ll tell you when I think I know what it is, and you can tell me if you agree; but I cannot in good faith give a diagnosis before I know anything about you. An inaccurate diagnosis is misleading and can stay on your record for years. It can be impossible to get rid of.

The Services I Provide

There are four services I provide. Evaluation, individual counseling, couples’ counseling, and sometimes I write reports to third parties when clients think that will help. Evaluation, individual and couples’ counseling all cost the same rate per hour. I write reports for free if they are not too elaborate. If they are, I charge the same cost per hour as I do for sessions.

Except for the evaluation, there is no way of knowing what you’re going to need when we start working together. Often, when someone comes for individual counseling, I end up seeing family members to involve them in your therapy. When someone comes in for couples’ counseling, I like to have some sessions with the individuals privately, so we can talk about what’s hard to say with the other present. As for the reports, it’s always the client asking me to write the report when they need one. I almost never offer because it’s important to me to keep your confidences.

So, here’s my good faith estimate regarding the services I provide. You will definitely need an evaluation just so we can look at the big picture, but I don’t know how many sessions that will take. We will meet individually if you can profit from having a private place to talk. We will meet with family if that can help. I can write reports if you don’t mind other people knowing what I tell them.

How Frequent Will Your Sessions Be?

I like to meet with clients frequently enough that we don’t forget what we’re doing, but not so often that there’s nothing to do. You always have control of the gas pedal and the brake, so you can start and stop therapy when you want and go as fast as you want to go.

It generally works like this: we meet more frequently at first, to get us going, especially if you’re in distress and need to acquire and perfect new coping skills. As you start to feel better, learn those skills, and resolve the problem that brought you to me, you might stop therapy. I’ll invite you to see me again if you ever need to. I now have hundreds of clients who make an appointment or two every few months or years, whenever they need to talk.

Some clients who find they like therapy and want to deal with the underlying issues that lead up to their problem, meet regularly for longer, but less frequently, giving us time to reflect between sessions.

The point is that the frequency of sessions depends entirely on you and can change from week to week. To ask me to say, before we even meet, how frequent the sessions will be, may cause you to believe you are locked into a plan that should be flexible.

How Many Sessions Will You Need?

Predicting the future is the most difficult part of the “Good Faith Estimate”. I know a therapist is supposed to be an expert and able to predict how treatment is going to go. However, I’m enough of an expert to know our expertise is sketchy. I will not make extravagant claims of understanding something I don’t. Psychological trouble, no matter how mild or severe, is a feline thing. Like a cat, it hides, you never know what it’s going to do, and it never does what you want. I find it best to be adaptable and adjust as we go.

When client first tells me the nature of the problem for which they seek therapy, they seldom tell the whole story. Sometimes they aren’t aware of other factors that turn out to be important; sometimes they’re afraid to say. Very few people end up working only on the issue that brought them into therapy.

The next problem has to do with the concept of being done with therapy. To my mind, you’re never done with therapy in the sense that you will never need to go back and take another look at things. It’s quite all right to take a break from it, maybe for years, but the practice of self-examination must be permanent and sometimes you will need the help of others. Furthermore, if you have a chronic condition, such as an addiction or repeated episodes of depression or psychosis, then your overall success will be directly related to low long you stay in therapy. People who stay are less likely to suffer relapse.

There will be many therapists who can tell you how many sessions they will give you, not how many you need. I used to be one of them. I had a program. I had a set course of treatment that I applied to everyone who came by. There’s a place for that. It imparts basic manualized therapeutic information in what appears to be a cost-effective way. You may want to try it if you never have before. I don’t do that kind of therapy anymore because I think it wastes people’s time. I prefer to provide my therapy tailor made, not ready-to-wear. I want you to have something that fits you perfectly. The thing is, we don’t know in advance what that’s going to be.

The Grand Total

The No Surprises Act requires that I add up all the projected costs and give you the grand total. Even if we knew the diagnosis, the types of services, and the frequency and number of sessions, do you really need me to do the math for you? It’s going to be expensive, frighteningly so, but you should also calculate what it will cost you to NOT go into therapy.

You won’t be able to say for sure what it will cost to NOT have therapy. Now you understand how hard it is to estimate costs.

Not everyone is right for the kind of open-ended, eclectic therapy I offer. I’m OK with that and you need to be, too, if you work with me. If you do work with me, I’ll expect you to take a leap of faith into an unknown future. I’ll go with you. If you can’t take that chance, I understand. However, I do have one question for you.

Does an unwillingness to take a chance have anything to do with the problem that’s troubling you?