Frequently Asked Questions
About Big Sky Counseling, Inc. & My Approach
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I’ve worked in inpatient acute psychiatric settings, outpatient home-based settings, psychiatrists’ offices, my own private practice, and doctors’ offices. In addition, I’ve taught graduate social work courses at OU, and I regularly conduct facilitations and trainings for healthcare providers, therapists, and others. I have been featured in interviews about mental health issues with reporter Olivia Martinez on Oklahoma City’s Telemundo television station (KTUZ channel 30).
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I practice from a psychodynamically-informed, relational approach. Psychodynamic psychotherapy states that there are things about ourselves that motivate us—desires, fears, traumas or other wounds, and strong feelings—that we may not be aware of consciously. The goal of psychodynamic psychotherapy is to understand these deep motivators and to know ourselves better as a result. When we know ourselves better, we feel more in control of our lives. We can make choices that reflect our deep values, and we feel good about them.
The relational component of my approach refers to my view that relationships, rather than techniques, are the primary instruments of healing in therapy. That means that I don’t tend to focus on homework or techniques that people use in specific situations, but instead on the dynamics of your relationships and how to understand and improve those.
I do know—and I often utilize—techniques for mindfulness, meditation, relaxation, communication, and conflict resolution, and I use these to help control symptoms so that we can continue to work on deep patterns and feelings. Relief of symptoms is a byproduct of a therapy that works; not the only goal!
Of course, getting some relief is the goal for most people at first—it’s often what spurs people to call me. But, as I explain in our first session, long-term relief of symptoms comes only with a deep awareness of ourselves and what motivates us or gets us stuck. We’ll work on getting some relief up front so that we can work on the issues that will bring long-term relief over time.
I practice from these perspectives because I have observed that when we know ourselves more deeply and understand what motivates us, we feel empowered to change the things that have made us feel stuck and helpless. When we understand our needs and others’ in relationships, we find that our relationships become deeper and more fulfilling, without the obstacles or toxic patterns that have gotten in our way in previous relationships.
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Great question! Here are a few things to think about when you meet with me that will help us understand if we’re a good fit:
How does it feel to be in the session with her?
How easy does it feel to talk to her?
Do I feel like I could trust her?
Does it seem like she knows what she’s doing?
Do I feel like she’s interested in me?
Could I trust her with the parts of myself I’m most ashamed of showing to others?
Do I like her?
Do I feel safe with her?
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When COVID-19 hit, I switched to videoconferencing from in-person therapy, which is what I’d always done before. I have a medically vulnerable family member whose health has always been impacted by what I’m exposed to, especially respiratory illnesses. With COVID, it became essential to take extra precautions.
Like many other therapists, I was afraid that much of the closeness of the co-created therapeutic space would be lost. I wondered how my patients would be able to tell if I’m a warm, safe presence if they’re not literally in my presence.
My experience has surprised me. In some ways, a greater level of intimacy is possible, since people can choose to engage in therapy from a space that is familiar and intimate to them. If you think about it, part of the physical therapy space has always been kind of artificial: “Come sit in my fake living room and open up all your most vulnerable places to me.” This has always been a steep barrier to overcome! Telehealth frees folks to engage in therapy from wherever they already feel comfortable, rather than having to physically leave a comfort zone and develop feelings of safety about a completely new space.
Without having to worry about drive times, gas prices, traffic, etc., patients can fit therapy into parts of their day that work better for them. They need less time off work and appreciate the ease of clicking a link to start therapy rather than driving across town or to another city entirely.
Telehealth frees you to engage in therapy from wherever you feel most comfortable. It also eradicates concerns about coming to an office when you might be contagious or you might just have allergies, but who knows which? Now you can log on and get the help you need from wherever you need to be!
Nervous or unsure about telehealth? I get it. I was there, too. Call or send me an email to my secure encrypted address, and we’ll set up a video consult! If after trying it you still feel it’s not for you, I’ll help you find other options, but you may be surprised at how natural it feels!
About The Therapy Process
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There are lots of good, healthy things we can do to help ourselves live well, including eating well, getting plenty of sleep, exercising, practicing some form of meditation, spirituality, or other meaningful activity, hanging out with supportive friends, working hard at work that feels purposeful, etc. And I support all efforts to build a meaningful, fulfilling life—I firmly believe that searching for what helps you is in itself a great use of energy!
Therapy is special, though. Whereas all the things we do to be well are great, very few of those things actually change our way of seeing ourselves or change our lives long-term, even after we’ve stopped participating in them. Psychotherapy is the best tool for developing the deep self-awareness and self-compassion that pays long-term, increasing dividends. It’s an investment, not only of time and money, but of intellectual and emotional energy. I often hear from clients that they feel more tired after we’ve begun working on entrenched patterns and areas of their lives that have felt unsatisfying for many years. Like any good investment, that time, money and energy pays off; in the case of psychodynamic therapy, it continues to provide benefit for years after treatment ends!
People often come to therapy because they’ve tried changing in other ways and have been unsatisfied with the results, or because they feel intuitively that they need to work out their problems within a caring, safe relational space.
We need compassionate witness to our pain in order to heal. It’s not enough to just know you’re hurt; that’s like being wounded and bleeding internally. The therapeutic process provides a safe space where that pain can be shared with someone who is compassionate as well as trained to contain and understand that hurt, and who can help guide your healing process.
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As much as I wish I could give a sure answer here, the only answer that makes sense is “it depends.” Typically, the longer something has been a problem, the more time it may take to understand it fully. Sometimes, though, a problem seems to erupt right when we’re most ready to handle what it can tell us about ourselves, and the “aha!” comes sooner rather than later. Most people who enter therapy are prepared to spend 6 months to several years understanding the root of the cycles they’ve felt trapped in and figuring out new ways to live and feel well.
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Sessions are 50 minutes long, and fees are paid at the beginning of each session. Occasionally, it may be useful to meet for longer than 50 minutes. We can arrange to meet for 75 minutes or a double session (1 hour 40 minutes) if necessary. We can discuss pricing for those sessions when you schedule.
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Great question! Again, to some extent, it depends. If you’d like to see progress more quickly, more frequent sessions will be necessary. That usually means weekly sessions, but I’ve had great success in meeting with people twice or three times a week, as well. One advantage with multiple days per week is that we can really build momentum in the work and feel progress being made. This approach also allows us to work in some specialized ways: for example, if someone has deep trauma that they’d like to work on, but they’re worried about feeling unstable while we’re doing that work, we can work on the trauma one day and work on self-regulating techniques, centering, mindfulness, and/or relaxation during our other session.
I do understand that financial and time considerations may make that difficult. Before you assume that you can’t do something, though, at least let yourself imagine prioritizing your emotional wellness and investing in yourself in a way you might never have done before.
As you improve and feel more stable, you’ll feel ready to take longer breaks between sessions, which is a natural part of the therapy process. Eventually, you may come monthly, or just every now and then for a check-in.
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This is a topic that a lot of us—patients and therapists alike—find particularly challenging. Even with the best of intentions, things happen that are sometimes out of our control. The problem this presents for therapists in private practice is that we are then put in the position of taking financial responsibility for the “life happens” moments of our patients. What I mean is, we can’t bill insurance for sessions that don’t take place, and if we don’t charge for missed visits, we take a financial hit. During flu season and vacation season, this can add up to create considerable instability for us.
I maintain a moderate patient load so that I can provide the best quality of care. I don’t overbook my schedule as doctors do, so when we have a scheduled appointment, that time is reserved for you alone, as if you have “rented” that space. You are my priority during the time I have reserved for you.
Missing appointments also create disruptions to your therapeutic progress. Sometimes having a financial incentive to keep that therapy appointment gives us the push we need to show up when our avoidance or resistance is telling us to leave something alone that needs to be dealt with.
It can be hard to prioritize therapy, especially with so many things demanding our time, attention, and financial investment. Please work to make therapy a priority; I will be happy to help with this in any way I can.
When you miss a visit, the following policy applies:
In addition to holidays and times when I am out of the office, each patient will receive 4 weeks’ worth of sessions that may be missed (planned or unplanned, for any reason) each calendar year without a charge being applied. This means that if you come weekly, you can miss up to 4 sessions (planned or unplanned, any reason) without incurring a fee. If you come biweekly, you can miss 2 sessions per calendar year without incurring a fee.
If we can reschedule our appointment for the same week, it will not count against your allowance of missed visits, and no fee will be applied. There is no guarantee that I will be able to reschedule for the same week, but I will do my best. Letting me know as much ahead of time as possible makes it more likely that I can find another time for us to meet.
All no-shows and same-day cancellations, regardless of the reason for the cancellation or no-show, will be charged the full session fee. This means that if it is 10 minutes past our session time and I have not heard from you, I will charge the full session fee to the card you have authorized. I will attempt to contact you if I haven’t heard from you within 5 minutes of our designated starting time.
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I have a wide network of fellow professionals I can refer you to for specialized help with things like:
Nutrition
Neurology
Spirituality
Psychopharmacology (doctors who prescribe medication for things like depression, anxiety, etc.)
Testing for ADHD, bipolar disorder, learning disabilities, etc.
Hormonal imbalances and women’s health
Other issues as needed
If you would benefit from visiting with one of my colleagues who specializes in these areas, I will be happy to facilitate a referral.
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Another great question, and one that is often overlooked when starting therapy! Therapy, like all relationships, has a life cycle that includes an ending, which we call termination. Termination can happen at any time for a lot of reasons, including:
You can decide to terminate your therapy with me at any time and for any reason, with or without letting me know.
I obviously prefer to have a termination session so that we can recap what you’ve gained from therapy, what has worked for you and what hasn’t, etc. I can also help you find another therapist, if needed.
You may reach your therapy goals and decide that you no longer need therapy.
This is the ideal scenario, and the most common one in my experience. We will have discussed this extensively, and you may have been tapering down (e.g., from weekly to biweekly or monthly therapy) for some time.
You may lose your insurance coverage, or switch to a company I’m not paneled with.
You may become unable to pay for treatment.
Either of us may experience a change in life circumstances, location, or schedule that makes meeting impossible or impractical.
I may determine that you need a different level of care, therapeutic approach, or better therapeutic fit.
This is a difficult clinical determination that I try to make as early as possible in our treatment, so that the change in care causes the least possible disruption to you. In this case, I will provide you with multiple viable referrals.
There may be safety concerns that make termination necessary.
Typically this happens very rarely, and may involve a patient threatening to harm their therapist.
You may violate the terms of our therapeutic agreement, making termination necessary.
Violations of our agreement would include failure to pay, no-shows, failure to abide by a safety contract, etc.
If I terminate our treatment for clinical reasons or if you are no longer able to afford sessions with me, I will provide you with multiple viable referrals—therapists who have immediate availability, take your insurance or have a sliding scale, and who I believe are clinically a good fit for you.
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You can call me at 405-761-2514 and leave a message or email me at liz@elizabethfletcherlcsw.com. Since email is not a secure or confidential form of communication, be careful about what you include in an email. Although my email is end-to-end encrypted, if you email me from a non-encrypted account, your information may be vulnerable to hacking. Once we’ve established contact and have an appointment set up, I will securely send you a packet of forms to fill out before our first appointment.
Please read these forms carefully! They lay out all my policies and procedures, including policies about emergencies, finances, cancellations and no-shows, privacy and confidentiality, and insurance. If you have any questions about them, or if you don’t agree with something, please reach out and we’ll discuss it! I’m happy to go over anything that seems confusing or explain a policy that doesn’t make sense to you.
Insurance, Rates & More
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I only accept HealthChoice currently. Even if I do happen to take your insurance, you may decide not to use it for our sessions. Insurance companies require me to diagnose you with a disorder which remains on your medical record as a pre-existing condition forever. They require me to share information with them, and while I work to keep that information as general as possible, they have the right to ask for particulars, including your specific symptoms, their causes, and their severity. Many people find that unsettling and prefer to keep the information they share with me as private as possible.
Not working with insurance companies keeps costs more stable: there are no deductibles to hit you every January, and your payment to me changes only when I give you at least 60 days’ notice that it will change. Your insurance company can change your out-of-pocket costs every year, and you’ve probably experienced firsthand the disruptive effects of those changes. Being freed from insurance obligations also enables us to work on what feels most important to you in the way that you feel best suits your needs. Many insurance companies dictate the kind of treatment therapists can provide, the number of sessions you can receive every year, and the diagnoses for which they will cover treatment.
If I am not on your company’s panel, but you would like to be reimbursed by your insurance for out-of-network provider services, I am happy to help you complete the forms to get reimbursed by your company.
If I am on your insurance company’s panel and you would like to use insurance, call the number on the back of your insurance card before making an appointment to find out:
If I am currently on that company’s panel
How much your copay is
How much your deductible is, and how much you still have to pay on it
How many sessions you are allowed per year
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The initial session/intake appointment is $185 for a 50-55-minute session, self-pay and out-of-network.
Individual therapy is $165 per 50-55-minute session after the first session, self-pay and out-of-network. A 75-minute session will be $245.
Couples and family therapy is $180 per 50-55-minute session after the first session, self-pay and out-of-network. A 75-minute session will be $265.
Missed appointments (see missed visit policy) are a full rate for 1 session. Other services (documentation outside of normal note-writing; emergency/crisis calls; letters; consultation outside therapy; other services) are priced individually. Pricing for those services can be found in my Information for Patients document or in a Good Faith Estimate for service costs if one is requested.
Payment is due at the beginning of the session or at the beginning of the day of the session in accordance with my financial policy, available in the intake packet or upon request.
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Therapy is an intense experience, both for clients and for therapists! Psychotherapists go through a great deal of costly training, including ongoing post-master’s-degree licensure, supervision, consultation, continuing education, as well as our own psychotherapy, to make sure we provide the very best care.
Because therapy requires such an intense psychological investment from the therapist, most therapists cannot work more than 18-25 billable hours per week. It is my responsibility to make sure that I’m 100% emotionally and intellectually available and engaged in every session. To do that, I need time when I’m not in session to think carefully about my cases, to take care of myself, to complete paperwork, to research and write to stay up-to-date on the most evidence-informed ways of helping patients, and to go to trainings and classes.
The amount I charge reflects the costs of doing business, which include rent, utilities, equipment, paying for billing software, websites, and services, accounting, insurance, continuing education, and licensure and professional membership fees, as well as vacation and sick leave. That amount may change from time to time, as the costs of doing business change. You will be informed at least 60 days before any change in my costs goes into effect.
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As part of the COVID relief bills passed in 2021 by Congress, the No Surprises Act (NSA) was passed and went into effect on January 1, 2022. Please see the linked information to understand the full scope of the Act.
What this means for my practice is that any person who is not using or does not have in-network insurance benefits must receive a Good Faith Estimate (GFE) of how much services are expected to cost and how long they are likely to last.
These regulations were designed to prevent surprise billing in hospital emergency departments and inpatient hospital settings, but they impact all providers, myself included. It is already part of my practice that patients sign documents indicating that they have read and understood my billing policies and fee schedules, both for sessions and for missed visits, letters and consultations outside of sessions, court fees, etc. I also verbally confirm with each person that they have read and understand this information and invite questions during our first session. I make information about fees and length of treatment available on my website in the Frequently Asked Questions section.
The NSA requires a more formal written communication. As with most big changes, what it winds up looking like is likely different from what it will start off being. But based on my and my consultants’ best understanding of the law and advice from my professional organizations, I will be giving each non-insurance or out-of-network patient the form we develop via DocuSign with all information I have access to fill in.
It’s important to remember that the GFE is only an estimate. The services outlined reflect my estimate of what services may reasonably be expected to be provided to you during the estimated duration of treatment. In the course of treatment, I may recommend services that would be scheduled separately and not reflected in the initial GFE.
Because the GFE is an estimate, actual items, services, or charges may differ from what you read there.
The Good Faith Estimate does not require you to obtain psychotherapy or any other service from me, nor does it obligate me to provide services to you. It is not a bill for services already provided.
The GFE is not a contract. It is an estimate of the total cost of treatment based on information I have available to me at the time that it is made. The fact that your fees may be more or less than those outlined in the GFE is not a “violation” of the estimate and does not constitute a breach of any kind.
As always, if you have questions about this or any other policy, please feel free to contact me!