I recently dropped my therapist who not only knows eating disorders inside and out, but also actually takes insurance. She was a unicorn in my area, someone that actually understood the intricacies and complexities of eating disorders and only required a $25 copay per visit. I had struck mental health gold. Until I was ready to move on.

This happens frequently for me. In the nearly two decades I’ve been in therapy, I’ve seen dozens of therapists. Some, I find after a few sessions, aren’t the right fit. I see others for a year or two and then reach a plateau and feel ready to move in a different direction with someone new. It’s sort of like dating, except way more expensive.

A few months ago, I felt I had reached a plateau with the unicorn therapist and I was also prepping to move to a new area of town. I used this as an excuse to take a break from therapy and start my search for someone else, maybe someone in my new neighborhood. Based on past experience searching for eating disorder–trained therapists, I knew the search would be difficult, but maybe things had changed during the past almost decade that I’d been out of the country.

Before I left the States to move abroad in 2013, I had been seeing out-of-network therapists (and paying out of pocket) for years, but not by choice. After trying a few in-network LCSWs who didn’t have any specialization in EDs, I bit the bullet and started forking over $150 a session for therapy, another $150 for nutrition counseling, and anywhere from $180 to $250 for 30-minute sessions with a psychiatrist. Sure, I would submit super bills to insurance in hopes that they would reimburse me, but I never actually expected to see that money again—and I never did.

The Eating Disorders Coalition (of which I have been an on-and-off member since 2008) has been trying to get equal coverage for mental and physical health for what seems like eons. We made a dent in 2008 with the passage of Mental Health Parity, but between then and now, little has changed.

Providers still don’t want to accept insurance, a symptom of a larger institutional healthcare disease. So as seekers of qualified, adequate, and informed care—care that we actually pay premiums to have access to—we’re left with limited options.

I believe in transparency, so I told the unicorn therapist that I was going to start looking for another therapist. In an effort to help me search, she provided me with one other name she knew in the area who accepted insurance, but this provider had a months-long waiting list. I sighed in resignation, but having been through this numerous times and having just received a raise at work, I decided to take my chances outside of my insurance network.

Below, I recount my journey to finding eating disorder healthcare in the United States.

Referrals

My search began with a list of therapists provided by my out-of-network nutritionist, who I had been paying $150 a session to see. Assuming rates would be similar or close to that amount for therapy sessions, I filled out a few intake forms and waited for responses.

The first provider I talked to was very well-versed in disordered eating, and the center seemed like a place that really understood how complex eating disorders can be. I felt a twinge of optimism as we booked our first session, a 60-minute in-person sit down in an office not far from my new address.

Then we got down to fees.
The provider charged $280 per session and did *not* accept insurance, but they did provide patients with a “super bill”—also known as a monthly list of services and fees complete with a codified diagnosis—which we would then have to submit to our insurance company for a reimbursement that would most likely not happen.

Knowing that I would be paying this amount out of pocket at least twice per month (maybe more), I had to put our conversation on pause. I expected three-figure rates, but not this high. Technically, could I afford it? Maybe. But if I signed on with this therapist, I would have to make crucial cuts elsewhere in my budget.

I was once again scratching my head, wondering how anyone is able to afford proper treatment for a disease that kills millions each year.

Fewer and fewer therapists are accepting insurance, which, although infuriating, isn’t necessarily their fault. According to an article by Margie Ryerson, a licensed marriage and family therapist:

When I worked with insurance companies, I needed to occasionally spend twenty to thirty minutes being questioned by an insurance representative about the necessity for continuing a patient’s therapy. These extra requirements were often time-consuming and were unpaid. That the insurance companies questioned my treatment protocol especially bothered me. It was in their best interest to keep treatment as brief as possible. Of course, at this point I realized that insurance companies were the ones profiting from this arrangement.

Going out of network means more work on the patient’s part, too. We have to keep up with super bills, paperwork, and we might even have to get on the phone with the insurance company, which in and of itself is a daunting prospect, especially for those of us with social anxiety. Dead end #1.

Zocdoc

I resigned myself to a self-search for therapists who specialize in eating disorders and accept my health insurance plan. I used Zocdoc to narrow my search to my geography, and was then asked to select a mental health specialty.

I scanned the lengthy list and saw I could select either anorexia, bulimia, binge eating, or emotional overeating. Only one of these. This list did not take into account that people with eating disorders are likely to be struggling with more than one of these subtypes and therefore should be allowed to select more than one.

Additionally, this list of four is hardly extensive. There are many more eating disorder subtypes that aren’t represented here. (Check out my Deep Dives to learn more.)

After completing these few steps, I was presented with a list of two therapists who had availability in the next week. Because my search wasn’t that urgent, I played around with dates.

Although I had made it clear that I was searching for mental healthcare providers in the form of psychologists, most of my search results were internists, another term for primary care doctors who focus on a wide range of medical conditions. I clicked through profile after profile, finding no evidence of eating disorder treatment experience or specialty. Dead end #2.

BetterHelp

My next move was to consult the virtual therapist network of BetterHelp. I have been seeing therapists virtually for a while, so I was no stranger to having frequent video chats with a provider. What’s more, their fees were something I could manage: $80 a week for a weekly live session, plus unlimited text, audio, and video messaging.

After completing an intake form, I was paired with a therapist, and setting up an appointment was incredibly easy.

I wanted to get to know more about this therapist so I closely examined their BetterHelp profile. Among their long list of subspecialties was eating disorders, but it was accompanied by a litany of other generic issues like adjustment issues and relationship problems. While co-symptoms like these are common, for my specific situation, I knew I needed someone who had specific education, training, and knowledge of eating disorders. No exceptions.

I messaged the provider directly and asked about their experience. Yes, they had treated people with eating issues but it wasn’t something they were trained to do. This was a red flag to me, so I canceled the appointment.

I then sent a direct message to BetterHelp’s support team explaining my situation. At the time, they did not have any available therapists whose principal focus was eating disorders, they said. (I just scanned my inbox to try to find the communication but unfortunately, it has been lost in the ether.)

I was saddened and disheartened. But I wasn’t surprised. I’d been down the road of therapists who only slightly understand eating disorders, and it’s a road to nowhere. Frustrated, I surrendered to the only viable remaining solution: Go out of network and pay out of pocket. Dead end #3.

The out-of-pocket limit we deem acceptable for therapy is different from person to person. The reason I feel it’s acceptable to spend $150 but not $280 is an individual decision based on many factors, beliefs, and levels of comfort.

Yes, it’s an investment in myself, one that I found to be non-negotiable at the height of my disease. But it might be an investment I can afford to put off for a few more months, relying on the tools I’ve developed throughout recovery to get me through any tough times that arise.

Again, it’s an individual choice, one that should be taken seriously with all options considered. To start your search for eating disorder treatment and support, please visit the Rules & Resources page or use the search function on Psychology Today.

To better understand how in-network and out-of-network health insurance works in the United States, click here.