One of the most common questions I get from couples is, “Can we use our insurance for this?” Or they’ll tell me, “Our last couples therapist billed insurance—why don’t you?” It’s a great question, and I’d like to walk you through the honest and ethical reasons behind my answer: I don’t take insurance for relationship or couples counseling.
Insurance Is Built for Individuals, Not Relationships
To use insurance for therapy, three things are required:
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An identified client
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A mental health diagnosis
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A treatment plan that directly addresses the diagnosis—for that one client
In individual therapy, this works well. For example, if an individual is struggling with symptoms resulting from trauma, I can diagnose them as having Post-Traumatic Stress Disorder (PTSD) and use an evidence-based treatment like EMDR. That’s clear, ethical, and reimbursable by insurance.
But in couples therapy, things are different.
Relationships Aren’t Diagnosable—People Are
In couples work, the relationship—not one partner—is the client. But insurance companies don’t recognize relationships as billable “clients.” They want to know which person has a diagnosis, and how treatment is helping that individual.
Even when they allow “family sessions,” they still require an identified patient. So a couple might attend therapy, but I’d be forced to frame it as though I’m treating one partner’s anxiety, depression, or trauma, with the other there to help. That’s not couples therapy. It’s not how I practice, and more importantly, it’s not honest.
The “Relationship Distress” Diagnosis Doesn’t Count
There is a diagnostic code for relationship issues: Z63.0 – Relationship Distress with Spouse or Intimate Partner. But insurance companies won’t reimburse for it. And if I were to diagnose one partner with a mental health disorder just to access coverage—when that’s not what I’m treating—that would be misleading at best, insurance fraud at worst.
So Why Do Some Therapists Bill Insurance Anyway?
You may have seen a couples therapist who did bill insurance. That doesn’t necessarily mean they were doing something wrong—but it does mean they were likely using a workaround:
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Diagnosing one partner and coding sessions as either “Individual Psychotherapy”, or “Family Psychotherapy, with Individual Present”
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Focusing, at least in their clinical notes, on that one partner’s symptoms with the other in a “support role”
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Hoping the insurance company never audits the records
Some therapists genuinely believe this is ethical. Others believe the outcome—stronger relationships—justifies the workaround. After consulting with trusted colleagues, trainers, and insurers, I’ve chosen not to go that route. It just doesn’t align with my ethics or how I practice.
Why Paying Out of Pocket Might Be Worth It
When you pay for couples therapy privately, here’s what you’re getting:
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No diagnosis required—you’re not labeled with a disorder
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True confidentiality—no insurance audits or claims on your record
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Access to specialized care—from therapists trained specifically in couples work
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Freedom in approach—I can use the methods that best serve your relationship, not just what insurance approves
Couples therapy is an investment, not just in your relationship—but in your emotional, relational, and even physical well-being. And while it may cost more up front, the clarity, honesty, and quality of care you receive can make all the difference.
If you’re ready to work on your relationship, I’m here for the both of you—no diagnosis required.
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Want to learn more about couples therapy or schedule a consultation? Feel free to reach out!
