How Can I Afford The Therapy I Need?

Curated by Claudia Shannon / Research Scientist / ishonest

I struggle with severe depression. I'm so glad that seeking treatment is becoming less stigmatized, but the financial ramifications of living with mental illness are often missing from the discussion. I'm 25, which means I will get kicked off my mom's insurance in less than a year. I hope I'll feel a little better by then, but even so, I'm terrified at the prospect of cutting off my relationships with my therapist and psychiatrist. My professional field is unionized and I was hoping to join by the time I turn 26, but work dried up due to COVID and slowed my progress [toward qualifying for the union]. Thankfully my industry has started to pick up again, but I still won't be ready to apply before my birthday. Even worse, I had to quit my last gig when a particularly terrible depressive episode began.

I don't want to stop working, but I cannot continue with this pain. My therapist thinks it's time for inpatient care, but it costs a fortune even with insurance. As an alternative, we're thinking that I could take a month or two off work to double our sessions and work with my psychiatrist without side effects interrupting my job performance. (In the past, I've had moments where I had to hang up on my boss to go vomit, which has not exactly helped my professional reputation.)

I know this is the right thing to do for my health, but I fear emerging from this terrible period only to face a drained bank account and ruined credit. Plus, it's such a shitty time for everyone that part of me thinks I should just grit my teeth and be happy that I have the luxury to consider these options at all.

I've worked since I was 16 and have always been good with money I'm very frugal, and have luckily built up that mythical emergency savings account with six months of living expenses. This seems like the emergency I've been saving for, but it took me years to save that money, and I'm hesitant to give up that cushion when losing my insurance is hanging over my head. I was thinking I could use that savings to help pay my providers directly until I can go on my future union's excellent plan, but that timing is hazy and I'm not confident it'll be enough if I also have to draw from those funds to cover a few months of rent. I'm single and moving in with my family is not an option. I have to figure out how to handle this on my own. Please help.

I'm so sorry that you're struggling with this, and I wish I could tell you exactly how to get through it. Instead, there's only one thing I can say definitively, which is, please don't tell yourself to grit your teeth and be happy just because others have it worse than you. Gratitude for what you have is a good thing, but denying the seriousness of your mental illness is not. Depression is a debilitating disorder, and your best path forward is to embrace every tool at your disposal and fight like hell for your recovery. I'm glad that you have a treatment team you trust and insurance that covers them, even if it will run out by the end of this year. I'm also glad you're planning for your financial future, but don't let it detract from getting the help you need right now.

That said, your financial health and your mental health are intertwined. I spoke to several leaders in the mental health field about your options, and they all agreed that you should bring your financial concerns to your therapist to determine your next steps. Digging yourself into crippling debt to pay for your mental health care would be counterproductive, and so is ignoring your psychological needs in the name of budgeting this isn't an either/or situation. Your therapist should understand that, and be equipped to recommend options within your financial scope. Be upfront about what your budget is, said Dawn Brown, a director at the National Alliance on Mental Illness. Especially if you have a relationship with your providers, they should be able to help you.

Of course, you're also in a weird spot where budgeting is difficult. I agree that severe depression qualifies as an emergency, one worth dipping into your savings to address, but I also understand why you want to preserve that rainy day fund for other foreseeable needs (like health care if you have to pay out of pocket, or rent if your work dries up again). This is why it's worth getting very specific. Sit down and do the math. Research how much it would cost to pay your therapist and psychiatrist out of pocket if you had to. (Or what it would cost to buy your own insurance plan that would cover them, which is another possibility when your current insurance runs out.) How long could you do that? What if you also had no income during that time? How many months could you support yourself and your health care with your savings?

If you have a friend you can talk to about this, even someone who will sit with you (remotely) while you crunch these numbers, that'll make the process less daunting. Alternatively, you could ask your therapist to devote an extra session or two towards assessing your budget and what you need to realistically prepare for. Don't underestimate the power of having a spotter who can put your anxieties in context, and tell you if they're realistic or not.

From there, you can look at your treatment options. And there are a lot! If your therapist strongly recommends the in-patient route, then that's what you should do, but it's worth bearing in mind that there's a huge range of alternatives for intensive mental health care. Many of them will accommodate your work schedule, too. I understand that trying to keep it together in Zoom meetings while you adjust to new medications or struggle to get through a particularly excruciating week might be impossible. But if you want to continue working and it seems like you do that's something your treatment team should support unless it's truly detracting from your health. Not only would it keep your income steady, but it would keep you on track to join your industry's union, which would help alleviate your concerns around health insurance. We always try to keep people in work or in school, if they can hang in there, said Dr. Brad Riemann, the chief clinical officer at Rogers Behavioral Health, a nonprofit mental health- care provider that offers inpatient care and operates in seven states. It helps provide stability.

Dr. Riemann also broke down the many different levels of care that you might consider. Starting with the most intensive: People who are deemed a threat to themselves or others are recommended to enter an intensive inpatient facility for a limited period of time (say, five or six days). At that point, the objective is to stabilize them, not necessarily to treat them. Once they are considered stable, they are usually moved to residential care, which is still staffed 24 hours a day but doesn't include the extreme (and expensive) monitoring that a typical inpatient facility offers. In a residential facility, the goal is to treat the condition, and depending on the facility and the program, average lengths of stay could be anywhere from 30 to 60 days, says Dr. Riemann. Residential programs can still be very pricey, but nothing like the cost of an inpatient facility. Most importantly, Dr. Riemann notes that all of the above is usually covered by insurance, at least to some degree, for a limited period of time. You'd need to take time off work to do either of these.

The next level down from residential care is known as partial hospitalization, which involves patients spending their days at a treatment facility and then going home at night. Alternatively, there's intensive outpatient care, or IOP, which usually involves multiple (or even daily) visits per week, for several hours at a time. Again, most insurance will cover both of these options to some degree. But the latter would probably allow you to keep working while undergoing treatment, albeit with some adjusted hours.

Of course, you could also just try bumping up your current sessions to multiple times a week. I always tell patients: Don't underestimate doubling the dose of the treatments you're getting. For some people, going from one hour of psychotherapy a week to two could be the magic trick, said Dr. Reimann. Any good treatment facility will put you through a clinical screening process before you check in, to determine the right level of care, he added. We don't want to under-treat anyone, but we also don't want to over-treat them and disrupt their lives more than necessary.

When evaluating your full scale of options, be sure to call your health- insurance provider to ask what would be covered. And follow your instincts! I know that mental illness can wreak havoc on your confidence, but if your gut is telling you something's off, speak up. If you're not a hundred percent sure about the recommendations of your treatment team, go back to them and ask for other possibilities, says Paul Gionfriddo, the CEO of Mental Health America, a nonprofit dedicated to addressing the needs of those living with a mental illness. Remember, there are two experts in the room: There's the therapist with clinical training, who has expertise that's a mile wide, but you have expertise in your own situation that's a mile deep. Recognize and respect your own expertise, and monitor how you're feeling throughout these conversations.

(I should also note that for some people, going on disability leave would also be an option, in which case their care might be covered by Medicaid if they didn't have health insurance. But the process of qualifying for disability can be arduous. And since you are an independent contractor with health insurance that isn't tied to your employer, this probably isn't a viable option for you right now.)

Finally, remember that the government should be providing more help soon for those who are suffering from job loss due to the pandemic. Sure, no guarantees, but there's a very good chance that the Biden administration will quickly pass more aid legislation that provides additional stimulus checks as well as enhanced unemployment benefits if your work dries up again.

None of this will be easy, and I completely agree that the financial burden of living with mental illness is far greater than it should be. But you are not alone in facing it. Lean on the support that is currently available to you, and don't be shy about asking for more and creating very clear boundaries about what you're comfortable paying for. And above all, remember that your mental health is a valuable asset. If your mental health improves, your quality of work improves, and so will your career and your financial prospects, Gionfriddo points out. It's one of the most important investments anyone can make.

The National Suicide Prevention Hotline is 1-800-273-8255.

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