Tips for Working with Guilt

by: Abby Birk, LMFT

Guilt is an extremely common emotion that gets brought up in therapy sessions by almost everyone. When we feel guilty it can feel all-consuming. The thought spirals that accompany guilt can pin us down for quite a long time. We feel incapacitated by it. We feel beholden to it. We burden ourselves with it. I've decided to write this blog post about guilt, hoping to offer some alternative ways to work with guilt when it shows up for you.

What is guilt?

Guilt is a core emotion for most humans, meaning, we all have felt it at one time or another, across most cultures and nations. You might be wondering why we even have to have an emotion like guilt, what is it's purpose?! Why did it survive the millenia/million years of evolution?!

The theory is that guilt serves as an alarm for when we step away from our values or what is important to us. Meaning, that when we do something that violates our values, belief, or meaning system, guilt results. Guilt's alarm system can be helpful in many cases. Guilt moves us towards remorse which can lead to repair, reconciliation, connection (which evolutionarily meant a greater chance of surviving in a group with other humans). When we do something "bad" according to our beliefs, guilt tells us that we violated our own code and need to course correct and take a different path or action next time. And so the feedback loop continues, moving us closer and closer to a meaningful, aligned life where our actions line up with our values resulting in more satisfaction, purpose, fulfillment, and happiness. And who doesn't want more of that?!

Guilt is not shame. Guilt tells us when we've done something "bad" or "wrong" according to our values. Shame tells us "we are bad". See the difference? Guilt is behavior/action based. Shame is personal and character based. Guilt can be useful, at times. Shame sucks. Shame is an important emotion to learn how to manage so it does not rule your life and run the whole show, cause it will try to. But same with guilt, if we have a strong moral code filled with many "goods" and "bads" and "rights" and "wrongs" we are going to experience a lot of alarms (aka a lot of guilt). Sometimes guilt is helpful, sometimes it is not. While shame can be useful for the same reason guilt is: to help us recognize when we act out of alignment with ourselves and help us course correct and stay connected with others, it is most often not helpful due to it's tendency to attack our character and go for the most vulnerable parts of ourselves that easily believe we are no good, worthless, bad people. I won't be talking about shame today, but Brené Brown's work researching and healing shame is life-changing and worth a peek, if your interested in shame as a topic.

Helpful vs. Unhelpful Guilt

Just above, we identified there are two types of guilt: helpful vs. unhelpful. The first step to working with guilt is to discern which type you are feeling. How do you tell? Good question. Usually it requires checking in with yourself with these types of questions:

Did I intentionally choose to act in a way that violates a value that I hold?

Did I accidentally or mindlessly act in a way that somehow violates a value that I hold?

Did this action hurt someone (emotionally, physically, psychologically, etc.)?

Did this choice hurt me?

If someone else were to do this same action/behavior would I think it was hurtful or not okay?

Do I feel remorse, regret, or apologetic?

If you answered mostly yes to these questions, then you are most likely experiencing helpful guilt. If you answered mostly no to these questions, then you are most likely experiencing unhelpful guilt.

Do I feel this way because I am not living up to someone else's value or expectation of me?

Do I feel this way because someone else has an opinion about this that influences me and my view?

Do I feel like I am disappointing or upsetting others, but the choice/action/behavior itself is not inherently bad or wrong or hurtful?

If my friend or loved one were to make this choice/action/behavior, would I think they made a mistake?

Do I feel like this because I was taught this was bad/wrong but I don't truly believe this was bad/wrong?

If you answered mostly yes to these questions, then you are most likely experiencing unhelpful guilt. If you answered mostly no to these questions, then you are most likely experiencing helpful guilt.

After you have a better understanding of what type of guilt you are working with, you can then take steps to address it more effectively.

What To Do with Unhelpful Guilt

There are a few tricks to use when experiencing unhelpful guilt that I use with clients, who seem to get some relief from using them. First, challenge the reason for the guilt. Sometimes it is appropriate to challenge the belief, value, or assumption that your guilt is telling you that you violated or acted against - especially if it is unhelpful guilt, which means that you probably didn't do something that needs to be repaired or corrected or apologized for.

For example, if I decide to set a boundary with my mother-in-law when I visit their house, that I am going to stay in a hotel, to accommodate my need for alone time and more personal downtime and space while I'm with family over the holidays and my mother-in-law starts yelling at me that I am selfish and I am ruining the holidays for everyone, and my poor younger step-sibling is going to see less of me and I am bringing down the mood for the whole family by not agreeing to stay at their place -- then the guilt I might feel as a result of her reaction does not mean that setting the boundary or even the boundary I set was wrong or bad. It probably just means that my mother-in-law didn't like the boundary I set. Therefore, it is appropriate to challenge the assumptions leading to the guilt by reminding myself:

It is not bad or wrong to set appropriate boundaries that help me and others meet my needs better.

It is okay to feel upset after my mother-in-law responded like that, it does not mean I did something bad or caused her or others harm. Etc.

Not everyone is going to respond well to me when I set boundaries, doesn't mean I am responsible for their emotions.

Setting this boundary does not make me a bad daughter-in-law/step-sister/family member. Being a daughter-in-law/step-sister/family member is important to me and by setting this boundary I am able to show up more authentically and with more energy and care, which is how I want to show up in these roles and engage with others. This truly aligns more with my values than just doing what people expect of me.

Many value/belief systems and moral codes are taught to us by our caregivers, education institutions, religious institutions, and cultures. Some of these beliefs we grow to hold dear and integrate as our own as we become adults. A lot of these beliefs we grow out of and yet still carry with us and still live our lives by them. Sometimes this is a part of surviving our family or surroundings, sometimes it is not intentional. By challenging the value, teaching, or thought that is the reason underlying the guilt, we get more clarity on our own values and make more informed choices moving forward as to how to course correct in the future.

What To Do with Helpful Guilt

Helpful guilt is tough. Because it's there for a reason. It's a message meant to guide you in a better, different direction for the purpose of better alignment and fulfillment. When you experience guilt for a "good reason" or a reason that makes sense and is valid, then theses courses of action may be important: take accountability, repair if possible, seek connection, and then forgiveness (from yourself and/or others). This isn't a foolproof formula. Sometimes repair won't be possible, someone may not want to be in a relationship with you after you've behaved or acted in a way that has hurt them, sometimes forgiveness will not be forthcoming. What do you do then? Take care. Take care of yourself while you feel this difficult emotion. Just like sadness, regret, grief, or anger, guilt responds well to self-compassion.

When you are feeling a hard feeling, you can always be kind to yourself while you are feeling it. Feelings don't last forever (as sensations in your body). They come and go, ebb and flow, are stronger some days and don't come up in the same way for years, in some cases. Trust in the process of feeling your feelings through without plunging into the depths of shame, self-blame, or self-loathing. If that is your tendency, start with observational statements: I am feeling a lot of guilt because I believe I did something that hurt someone else or violated my value of not inciting harm to others. I am feeling a lot of shame and anger at myself. This is really hard.

And then, take care:

What do I need while I am feeling this emotion?

How can I punish myself less and take care of myself more through this difficult time?

What is a meaningful and appropriate way I can make amends/ seek out connection or support/forgive myself for being human?

What coping skills can I use in this moment to help manage the intensity of these feelings?

One Last Skill

In A Murder At The End of the World a murder-mystery multi-episode drama series streaming on Hulu at time of this writing, there's an incredible quote about guilt (I'll paraphrase here): "Guilt is a lot easier than the truth." I believe this quote means that most of the time it is easier to blame ourselves and lean into the guilt we are feeling rather than face reality as it is.

In the example used above, it could have been easy or familiar for me to give into my mother-in-law's guilt-inducing reaction to my boundary setting and blame myself for upsetting her and just agree to her demands, making myself uncomfortable for the rest of the visit and showing up less and less authentically. What is harder is stating reality: My mother-in-law reacts poorly when I set my own boundaries and try to care for my needs above other's needs. My mother-in-law's reaction is hurtful. My mother-in-law's response is more manipulative and controlling than it is concerned or caring.

I encourage my clients to face the hard truths of their situations and challenge the worn paths of self-blame, self-loathing, and self-denial. Hold space that it can be more than one thing happening at the same time. It's worth stating the truth and recognizing things are the way they are and that you feel some type of way about it (grief, anger, sadness, resentment) and guilt might just be "easier" or more familiar than feeling those other tough emotions and facing your reality head on.

In parting, I hope you take what you will and leave what you won't, so that you can have more clarity and feel empowered to respond to guilt in a more informed and useful way.  Good luck out there, don't forget to be kind to yourself!

If you want more individualized support for working with guilt, we have therapists with openings at Riverbank Therapy! Click here to schedule a free 20 minute consultation.

Guided Visualization Meditation to Build a Sense of Safety

by Abby Birk, LMFT

Recently, many of my clients (and I) have desperately needed to revisit our regulation skills. Skills that bring us back to a sense of calm, ease, relaxation or restoration in our bodies. In today's world, this state of being can be elusive between the go-go-go pace of life and the incessant call to be more and more productive. The need for intentional mindfulness and somatic regulation keeps increasing as we fall more and more into the trap of "I just don't have the time" day after day.

Below, I've written out the script I use to walk my clients through a visual meditation called Safe Place, to cultivate safety and security in the here and now. Many have their own version of this skill; here is the one I utilize in my sessions. My hope is to demystify these types of skills and make them accessible for practical, everyday use. As you continue, I recommend reading through (or listening to) the entire script at least once before trying it on your own with your eyes closed or gaze lowered.

Listen to the audio below:

Or read the script here (and maybe record it for yourself, or have a loved one record it for you!):

Find a comfortable seated, reclined, or supine position. Whatever position you choose, make sure you are not holding any tension to support this position, rather lean into and feel the support of your chair, floor, or object you are resting on, in, or against. It's best for grounding purposes (if you are in a position that allows it) to rest the soles of your feet on the floor. Let yourself get weighty and heavy as you allow your body to rest fully supported. You may place your hands wherever you'd like, on your thighs, in your lap, or on your heart and chest.

Now draw your attention to your breath. Do not seek to change anything yet, first observe with gentle curiosity the quality of your breath, the parts of the body that move or don't move as you breathe, the speed or sound of your current breath cycle...

As you observe, you might notice your breath starting to change anyways, that's okay. You can soon begin to intentionally lengthen your inhales and exhales. For this visualization meditation, we want to focus on elongated our exhales more than our inhales to better turn on our vagus nerve and calming parasympathetic nervous system.

Take a few rounds of deep breaths with longer exhales.

Minds wander, that's what they do. Label your thoughts as "thoughts" or "thinking" and return back to an aspect of your breath that can provide a bit more focus: the quality, speed, depth, length, feel, temperature, movement, etc.

Now you will select a safe place that you can imagine or think about for the rest of this exercise. It can be real or imagined. A place you've been to or never visited. It can obey the laws of physics or not. Whatever place you choose, you are in control here, you decide what is in the scene and what is not: if there's anyone with you, the weather, the way you feel here. You are completely safe and at ease in this landscape of your choosing. Take a minute to select a place or try a few different images to see which serves you today.

You will then explore your safe place through your 5 senses, starting with sight.

As you imagine looking around in your safe place, what can you see? How far can you see into the distance? What living things are around? What colors? What's the weather like? What buildings or people or nature fill up your space, if any? What surrounds you, what do you sit or stand or lay on? Once you've taken time observing, take some deep breaths simply enjoying the sensations that arise just by being in this place and looking around you.

When you're ready to move along, we'll continue our exploration through our sense of touch. What textures make up your safe place? Is there sand running through your fingers? Water? Are you surrounded by cozy blankets or laying on a fuzzy rug? Petting an animal? There are no wrong answers. Take stock of what you can feel on your skin, temperature, breeze, weather, etc. Take a few deep breaths once you're done observing with your sense of touch to enjoy the sensations that arise from the textures of your safe place.

Next, imagine closing your eyes in this place, identifying all that you can smell. If there are no naturally derived smells in your safe space landscape, you can invent some: maybe pulling in some of your favorite smells from different parts of your life like perfume/cologne, essential oils, warm drinks, nature, candles, etc. Take a few more deep breaths enjoying how the sense of smell in this place interacts with your body to create more safety and relaxation.

Now, you can continue imagining your eyes closed as you pay attention to the sounds that exist in this safe place. Further ground yourself into this landscape by singling out various sounds around you. Maybe you prefer your safe place to be silent, that is okay too! Whatever you find, just give yourself time to experience it fully and pay attention to how your body reactions to what it can hear in this space.

Lastly, we will engage with your sense of taste in this space. Like smell, you may have to manufacture a taste in your safe space if one is not naturally derived. You may pull from favorite foods, flavors, crisp, clean autumn air or the taste of the air after rainfall. Let yourself enjoy, with a few deep breaths, whatever flavors show up in your safe place.

Integrating all 5 senses in this imagined location allows for further grounding and experiencing of this beautiful internal resource. It allows your brain to fully simulate what it is like to exist in that safe, secure, relaxed state.

Take a few more breath cycles allowing yourself to simply exist in this safe place, remembering to see how your body feels. You will end the meditation with a body scan -- checking in slowly from head to toe (as if you were going through a scanner) for any sensations, feelings, emotions, etc. that arise. Then, you can wiggle your toes, eyelashes, and fingers: opening your eyes to fully come out of the meditation.

Remember, you are the author and originator of your own safe place, which means you have access to this space whenever you need it. Come to ground, regulate, relax, or restore yourself anytime you'd like! Visit when you need and just because you can, even allowing yourself a visit once daily or weekly. The more often we practice skills like these, the better utilized they will be when we actually NEED them in a difficult moment. Your safe place can change however you'd like or remain the same, time after time; don't forget, there are no rules, no "right" or "wrong" way to do this exercise. The important part to keep in mind is that YOU have full agency and autonomy over your safe place. View this guide as an invitation of cues to further ground you in your own experience -- which is all you, baby! Allow this guide to remind you of your own internal resources that you can avail yourself of anytime you'd like. Enjoy!

If you’d like to meet with a therapist to build a safe place together, or to further process stress in your life, Riverbank Therapy has therapists with openings, in person and virtual! Click here to schedule your free 20 minute consultation.

5 Tips for Sharing Big Feelings

by Bobbi Smith, LICSWA

“Big Feelings” is my term for the feelings that aren’t fun to feel- sadness, grief, pain, worry, etc.  It’s true that joy, love, contentment, and other positive feelings are just as big, but it tends to be easier to share those with others.  We may worry that if we share something negative we will be a burden, ruin someone’s day, or make the feelings bigger.  But it’s important to talk about them.  It actually builds community and connection.  Other people have Big Feelings too and sharing them helps make relationships more authentic.

 Often, we can share our big feelings, but end up intellectualizing them instead of really feeling them.

“Intellectualizing” means turning feelings into thoughts, either to explain why they’re happening or to try to find a way out of them by turning them into a fully mental experience.  Intellectualizing can be helpful because it can help us think through conflict without blaming anyone or can help us understand ourselves and our experience more.  It becomes a problem when someone uses reason and logic to avoid uncomfortable emotions.

Here are 5 tools you can use to share your Big Feelings with those around you more effectively:

1)  Choose who to share with

This step will require discernment about who might be someone you can trust.  Here are some tips for how to identify a trustworthy person to talk to:

• They show interest in you by asking how you are doing or how your day was

• When you respond, they show they are listening by acknowledging what you shared or offer their own experience in kind

• They don't often share stories about other people

• They don't tell other people's big secrets without permission

• They talk about their role in a situation, not just other peoples

• They acknowledge their Big Feelings:  sadness, anger, grief, worry

• They don't say bad things about groups of people as a whole

• You have all ready talked about some other things, so you have an established relationship

For more information about how to tell who is trustworthy, please look into the BRAVING framework by Brene Brown.  It is really helpful!  

2) Take a sip of your Big Feeling

This is a concept called titration.  Titration means to slowly acknowledge little doses of the feeling instead of being overtaken by it.  Think of it like this:  Your feeling is inside a big pot.  The big pot represents everything there is to feel.  You are simply taking a spoon and slurping the taste (unless slurping is too rude).  That’s it.  You don’t have to jump in the pot, you don’t even have to eat a full bowl.  Start with one spoon and slowly sip.  We are wading into this pool- not jumping in.  

3) Lead with the feeling

This is the part where you confide in someone else.  This might have a quality of breaking the ice.  It might even have a quality of bringing up something taboo.  You might be going against the grain.  There’s some risk involved, but ultimately the prize is worth it.  Leading with the feeling means focusing on the feeling itself instead of the story you have about it or the meaning you’ve made of it.  This is the hard part.  Here are some tips for breaking the ice:  

• When someone asks you how you are, take a sigh before you reply- this will signal to the other person that you’re not doing well even before you use words.

• Use a familiar greeting: “I don’t know dude, I’m just feeling a lot of…”

• Be direct:  “To tell you the truth, I’m…”.  

Of course, you can give one or two sentences to provide context to the other person, but don’t get too lost in that.  Remember your spoon.  

If you’re unsure how to describe what you’re feeling, check out this blog on steps to feeling your feelings.

4) It’s okay to say “I don’t know what to do”

Intellectualizing can become so normative that it might be expected that you have a strategy to address the feeling you’re having even as you experience it.  How will you make it go away?  You don’t have to know yet.  You don’t have to have a sophisticated plan.  Just stay close to the feeling.  Experiment with different language to float the fact that you’re not trying to come up with a solution right now- you are titrating, not fixing.

5) Observe the conversation while it’s happening

Perhaps someone will respond with mutual recognition:  “Me too… I’ve been feeling the same thing.”  Perhaps not.  If they do, here’s a few things to pay attention to during the conversation:

• While you are sharing, keep returning to the pot with your spoon.

• Notice the words being used.  If you end up talking about theories or high level strategizing, or planning how if someone would act differently the feeling would go away, you are likely intellectualizing.

• Feel for deep and simple truths:  conversations that center on universal human experiences are often an indication that the conversation is anchored in the right place.  

• Notice the spoons they hand to you, and the contents of their pot, and respond in kind.  If you don’t know what to say, take a pause.  You can say:  “I’m so glad we’re talking about this.  It feels hard to talk about.”  “I really care about you, even if I can’t understand your experience.  I want to help.”

Conversations about feelings like this are vulnerable.  When you have shared your Big Feelings mutually and receptively with someone, there will be a natural shift in tone.  You might feel a bit tired from doing emotional work.  Also, the conversation might naturally change to humorous topics and become more spontaneous.  These are signs you have accessed your common humanity and might feel safer around each other.  

Lastly, if it doesn’t work, try again.

Any new strategy contains inherent risk.  There is a reason patterns become engrained.  It makes sense to avoid pain or rejection and risk.  If for whatever reason the person or people you open up to don’t respond or attempt to reform the ice, it’s okay to extend your spoon again.  They simply might not have noticed the first time.  

Try with another friend, a different group, or in a different situation.  Take a risk.  Without risk, there is no reward, and no growth.

Happy Ice Breaking!

If you’re interested in sharing and processing some Big Feelings in therapy, we have therapists with both in person (in Seattle) and virtual (across Washington state) openings here at Riverbank Therapy. Fill out our contact form here to get your free 20 minute consultation scheduled.

What is somatic therapy?

by Bobbi Smith, LICSWA

More and more, somatic therapy is being integrated into therapeutic techniques.  But what is somatic therapy?  And where does it come from?  In this blog entry I will attempt to give an overview of what somatic therapy means, and how to approach a therapist about integrating somatics if you are interested.  

As always, we start with context:  all the way back in the 1600’s (yes really) there was a French philosopher named Rene Descartes who was quite taken with examining the relationship between the human mind and body.  Since his work as a philosopher was pondering things, he began to think about the process of thinking itself, which he believed took place in the mind.  He theorized that the mind and body were separate organisms, and that the mind had dominion over the body.  This theory was known as Cartesian dualism, or sometimes mind-body dualism.  

Though there were always people that opposed Cartesian dualism, when what we now know as Western medicine began to form and institutionalize, it carried the legacy of Cartesian dualism with it.  Treatment of bodily ailments and treatment of mind ailments developed as distinct disciplines.  We don’t know if this is what Descartes intended, and can’t say for sure how he would react if he were alive to comment on it, but it unfolded this way anyway.

For generations, psychology has had the task of treating what western medicine firmly categorized as ailments that are located within the container of the mind, and therefore should be treated in that location, using the vehicle of thoughts to transfer a cure from the psychologist to the patient.  The most famous of these is “the talking cure” developed by Sigmund Freud.  In this approach, the psychologist would aggressively analyze the patients every word, which is 1. Deeply unethical and 2. Super annoying.

I’m getting to the somatic stuff, I promise.  

Let’s jump forward.  For decades now, some doctors, therapists and clients have questioned the utility of Cartesian dualism to truly address the complexity of mental and physical health conditions, and have been developing treatments that integrate both mind and body.  Soma means body.  Somatic therapy means incorporating some dimension of work with the body into treatment for ailments that used to be considered to be solely of the mind:  depression, anxiety, post traumatic stress disorder, and more.  

There are many traditions of what is called collectively somatic therapy- Sensorimotor Therapy, Somatic Attachment Therapy, Somatic Internal Family Systems, and more. There is no singular type that is agreed upon as the best approach.  Therapists that integrate somatic therapy into their practices are trained in and draw inspiration from traditions designed by many different healers, and that is a good thing.  Just like every other type of therapy, there is no one size fits all.  In addition, there are many, many traditional healing methods practiced across the world that include some type of body work, to which western somatic therapy traditions owe great honor.

The tradition I myself am mainly trained in is called Somatic Experiencing- I am not certified but simply studying it.  Somatic Experiencing was developed to treat PTSD, or what is now mostly called simply trauma.  The thesis behind Somatic Experiencing is that trauma can cause wear and tear on the autonomic nervous system, and so, trauma treatment should include the autonomic nervous system.  The autonomic nervous system is a component of the peripheral nervous system that regulates involuntary physiologic processes including heart rate, blood pressure, respiration, digestion, and sexual arousal. It contains three anatomically distinct divisions: sympathetic, parasympathetic, and enteric.  The autonomic nervous system lets us be relaxed, spontaneous, and socially engaged in a safe environment, or prepares us to fight, flee, or freeze in response to a threatening one.

Our human brains have evolved with add-ons to other species' brains, but we didn’t lose anything from them.  Basically, we have new apps but not a very different operating system.  As such, we have instincts to respond to harm or perceived harm in ways similar to other species.  Somatic Experiencing considers humans, aka homo sapiens, part of an evolutionary lineage that shares bodily features (such as an autonomic nervous system) and bodily instincts (such as fight, flight, or freeze) in common with other animal species that are evolutionarily older than us, and honors the innate intelligence of those similarities. In a threatening situation, animals either run to get away, fight off the threat, or if those don’t work, play dead (freeze) to appear unappetizing to a predator until it wanders away.

As animals, if an instinctual survival response sets off an alarm in our autonomic nervous system telling us to fight, flee, or freeze, it is important that that protective response is allowed to fully play out in service of its goal:  to get to safety.  If that response is prevented or constricted, the unresolved instinct can remain trapped in the nervous system as a chronic trauma response, or PTSD.  That can mean someone can feel trapped by the instinct to constantly fight, flee, or freeze, even if they aren’t in an unsafe situation anymore.  That is because even though our mind can cognitively register when a threatening situation is no longer happening, at the level of the organism (or body) there is no real proof of that, because all the nervous system knows is that it couldn’t do what it needed to in order to protect itself.  The nervous system doesn’t know time.

If that response were allowed to play out to its natural conclusion, our nervous system settles back into its baseline state, which is a proper flow in real time and proportional to what’s currently happening around us- not stuck in a chronic response.  We'll start in therapy by creating a safe container, building skills to cope with overwhelming emotions, thoughts, or body sensations. Then, when you're feeling ready, we may slowly approach your traumatic narrative, attending to body sensations along the way and supporting the discharge of trapped fight/flight/freeze energy.

One thing I love about Somatic Experiencing, and all types of somatic therapy, is that they acknowledge that human beings have evolved capacity for abstract thought, but otherwise are not fundamentally different from other animals per se.  Somatic therapy acknowledges the intelligence and healing instincts of other parts of our bodies besides just our minds.  Our bodies have instinctive reactions to what’s going on around us- and that means involving the body in therapy can have profound positive impacts on our sense of not only ourselves, but the world.  And who wouldn’t benefit from more wholeness and integration?

Most of our therapists at Riverbank incorporate somatic traditions into their treatment approaches. If you’d like to schedule a free 20 minute consultation with one of our therapists in-person in Seattle, or online for residents of Washington state, click here to fill out our contact form!

Insurance Superbills and Out of Network Therapy

Here at Riverbank Therapy, we provide courtesy billing for clients who want to use their in or out of network insurance benefits (read more about this below, and more about our fees and billing practices here). However, many therapists in the field opt to provide clients with superbills rather than doing courtesy billing.

Even if you don’t seek therapy at Riverbank, we’d love to support you in understanding what a superbill is, how they work, and what out of network reimbursement can look like with superbills. We want to support you in feeling confident navigating the financial side of therapy services.

What is a superbill?

A superbill is a receipt from your therapist provided to you after a session has occurred. You can submit your superbill to your insurance carrier for potential out of network reimbursement.

For successful claims processing with your insurance, the superbill must contain at least:

• your name, date of birth, and insurance ID number,

• the date of service for the session,

• the CPT code for the session (for most therapy sessions this is 90791, 90837, or 90834), including any modifiers for the session if it was a telehealth session,

• your diagnosis (yes, even with out of network billing, you must have a diagnosis on the superbill for insurance reimbursement),

• the providers name, license number, NPI number, and tax ID number,

• the fee for the session, and how much you paid.

Some insurers may require more information on a superbill, but this is typically what is required.

Why is my therapist giving me a superbill?

Therapists who are out of network with insurance companies may choose to provide you with a superbill rather than doing courtesy billing (more on courtesy billing below).

Therapists often choose to do superbills because they do not have to navigate the complexities of insurance systems and incur less risk financially. With superbills, the therapist collects the full session fee from you up front, and then you do the legwork to potentially get reimbursed by your insurance company.

What if I don’t HAve or want a mental health diagnosis?

We understand that not everyone wants to have a diagnosis in their medical record. Much of what brings us to therapy is just a result of being a human, and labeling your experience with a diagnosis is not always helpful.

However, a diagnosis is required for in-network and out of network billing for services to be reimbursed by your insurance company. Sessions will not be covered by insurance without one. Unfortunately, this is how the insurance industry in the United States functions, regardless of how your provider handles billing.

If you don’t want to have a diagnosis on file, you will want to opt for “private pay”. This is effectively just paying out of pocket for therapy sessions and not involving insurance at all.

How do I submit a superbill?

Different insurers have different processes for submitting superbills. Most of them have an online member portal where you can fill out a claims form requesting reimbursement and include the superbill (with all of the information listed above, and anything additional your insurance carrier requires). Then you wait for them to process the claim and determine how much was covered by your insurance.

Some HSAs also require you to submit a superbill when using HSA funds to pay for therapy sessions. Check with your specific insurance plan and HSA to find out what is required.

How much will my out of network insurance cover when I submit a superbill?

This depends on your plan. See more on our Insurance 101 page for information about insurance plans, deductibles, coinsurances, and the difference between in and out of network providers.

When you submit a superbill, you’re doing it because your therapist is out of network with your plan. Your therapist should quote you an estimate of your benefits before your first session so that you have informed consent about what therapy will cost for you. Not all providers do this though, so we recommend also calling your insurance carrier to find out what your out of network coverage is.

Most out of network plans have a deductible that you have to hit before insurance begins covering anything.  For example, you may have a $3000 out of network deductible. This means you have to use $3000 worth of medical services before insurance will pay anything. (More on this on our Insurance 101 page). Once you hit your deductible, most plans have an out of network coinsurance. For example, after paying $150 per therapy session until you hit the $3000 deductible, you might then have a 50% coinsurance per session. This means you would pay $75 per session, and your insurance would reimburse you for the other $75.

However, if your provider is doing superbills, you would have to pay their $150 fee up front, even after you’ve met your deductible, then submit the superbill to your insurance, and wait for your insurance to reimburse you for the $75 (50% coinsurance) that they cover.

Again, we recommend reaching out to your specific insurance carrier to find out what your out of network coverage is.

How do I get reimbursed by my insurance company?

Most insurance companies mail you a check for the covered amount after you submit the superbill and they process the claim. This typically takes around 30 days after you submit the superbill.

What is courtesy billing?

Courtesy billing means that you don’t have to deal with superbills! Courtesy billing means that your provider submits claims to your insurance on your behalf, and then the provider waits for reimbursement.

For our above example, with a superbill, after you met your deductible, you would have to keep paying your therapist $150 out of pocket each session, then wait for your insurance to reimburse you for the $75 covered after your submit the superbill.

With courtesy billing, once you’ve met your deductible in the above example, you would just pay the 50% coinsurance ($75) up front to your therapist, and then your therapist would wait for insurance reimbursement instead.

We do courtesy billing at Riverbank Therapy. We find it to be easier for our clients and increases the accessibility of therapy. More information on how we handle this on here.

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WANT TO HEAR MORE ON THIS TOPIC? LISTEN TO TONI TALKS THERAPY EPISODE 2 ABOUT STARTING THERAPY!