Special Edition Field Manual: Practicing in the Gaps

Providing Radical Therapy While Billing Insurance

Sometimes people ask me for the specifics - not the theory, not the philosophy, but the actual mechanics of radical therapy within insurance constraints. This is different from my usual writing. It’s a blueprint I developed across years in Texas public mental health. Consider it open-source code for therapists drowning in the contradictions.

“Adjustment Disorder” is a phrase I’ve coded dozens of times. It sounds neutral, clinical, even apologetic. But when I use it, it often means something sharper: Your life is unlivable, and it’s not your fault.

One client’s response when I explained it that way: “So, late-stage capitalism?”

Exactly.

I typed: Client presented with symptoms consistent with Adjustment Disorder, with disturbance of mood in response to contextual stressors.

What I meant: She cried when she got evicted. She stopped sleeping after her boss changed her hours with no notice. She couldn’t stop checking the locks at night. She was very tired of surviving, and she was exploring what that meant to her.

This is what it looks like to practice radical therapy inside the insurance system: I tell the truth in code. No euphemism. No upcoding. Clinical precision and mutual trust - inside an infrastructure built for containment, not care.

I. Inside the State-Funded System

I didn’t initially build this approach by rejecting public systems. I learned it inside one.

My first real training ground was a Texas state-funded rehab - a place I saw high-acuity, low-income clients with a barely functioning electronic health records system. We were audited frequently. I learned how to write notes for Medicaid while protecting the truth of what happened in session. I learned how to describe survival without pathologizing it. I learned that the smallest wedge of integrity matters when the system wants to devour nuance.

I never considered lying on my documentation. I also never considered letting it speak for me.

II. What I Don’t Do

There are things I refuse - not because I’m rebellious, but because I know my power. The system lets me decide what to write. I don’t let it decide who my clients have to be.

If the session runs over 53 minutes, I bill 90837. If it doesn’t, I don’t. I don’t embellish symptoms or stretch diagnoses to get a higher code. The time we spend together is what determines billing. That’s it.

Therapists are sometimes taught to make care “justify itself.” I believe the care is already justified. I meet the billing requirement, and I let the system pay for what it claims to value: time, presence, and stability. I don’t bend the rules. I play them straight, so they don’t bend me.

I don’t pad charts with V-codes. I don’t use Z-codes to make someone’s life story look more clinical. I diagnose minimally. I use Adjustment Disorder often - not as a placeholder, but as a refusal. Most of the people I see are responding exactly as you’d expect to an unbearable context. They don’t owe me pathology to get care. I won’t medicalize them just to satisfy a checkbox.

If a client needs a higher-level diagnosis for treatment access, I talk with them about what that means. I ask for consent, and if they don’t want it charted, I don’t push.

My clients always know what is in their chart. If I pull an existing diagnosis from prior care, I check that they’re comfortable with me including it. If I need to include something structural for context, I explain how I’ll phrase it.

It’s not a performance of consent. It’s a practice of shared authorship. My job is not to surprise anyone with their own chart.

III. What I Do Instead

I document as if a state auditor could walk in tomorrow - because once upon time, in my local mental health authority life, they did.

When that happened, I wouldn’t scramble. My notes were clean, truthful, defensible. I had protected my clients’ humanity and my own.

I document process, not pathology. If a client names structural violence, I don’t reduce it to “cognitive distortions.” If they talk about eviction, racism, gender-based violence, I don’t edit that out for the sake of “focus.” I chart what happened. But I do it in a language that lets both of us live.

I write things like: Client demonstrated insight into systemic contributors to distress. That means: They talked about how capitalism is killing them, and I believed them.

This is not rebellion. This is congruence.

IV. Clinical Integrity Is Not Compliance

There’s a difference between breaking the rules and refusing their logic.

I don’t bill dishonestly. I don’t falsify progress. I don’t play games with CPT codes. I also don’t let the system dictate what kind of therapist I am.

I am audit-fluent and ethics-forward. I am careful because the people I serve deserve care that doesn’t blow up when an insurance company gets curious.

They give me a form. I fill it out. I just don’t let it become my script.

This isn’t passive-aggressive compliance. It’s active integrity. It’s how I stay safe and dangerous at once.

V. Care Without Performance

My clients show up in good faith. That’s all they owe me.

They don’t need to be “falling apart” to deserve consistency. They don’t have to narrate their pain in ways that feel extractive just to keep care.

They are not here to prove their worth. They are here because they’re human.

In return, I show up with the clearest thing I can offer: a model of care that is transparent, boundaried, and survivable. I don’t coerce. I don’t manipulate. I meet the system’s minimums with maximal precision, so I can give my clients the space to breathe.

This isn’t heroism. It’s a replicable practice. I want more people to learn it.

VI. Practicing in the Gaps

I’m not “hacking” the system. I’m practicing in its gaps.

I am using the tools the system gave me - billing codes, progress notes, diagnostic frameworks - and I’m building something with them. Not perfect. Not utopian. But livable.

I am not teaching people to survive by abandoning themselves. I am teaching them what it feels like to be held without being shrunk. To be witnessed without being dissected.

The system isn’t built for this. But sometimes, if you hold your line just right, it lets you do it anyway.

That’s the opening I’ve chosen. That’s the space I guard. That’s the work I offer.

This is the first in an occasional series of more robust pieces. Most weeks, I’ll return to my regular programming of musings and micro-theory. But sometimes, the architecture of my mind pours out, and that is important to share, too, especially when it is a piece that might have difficulty finding a home elsewhere.