The intention of this article is to promote transparency and understanding around therapy fees. It seems therapists often don’t openly discuss with clients the reasons for their fee, nor the back-end work involved in providing that one hour (or 50 minutes) of therapy. I’m not sure whether this is considered radical, but it seems healthy (to me) to make this matter more transparent, and to reclaim it from the realm of the taboo. It seems like allowing the therapy fee to remain enshrouded in mystery can become another way to drive an unnecessary and awkward wedge in between therapist and client as human beings. While there are certainly many areas of the therapist’s life outside of session that clients do not need to know about, it seems to me that the parts of the therapist’s life outside of session that are directly related to the service that the therapist is providing do not need to be so secret nor so carefully guarded.
Certain therapeutic modalities, like EMDR for example, require even more time outside of session reviewing notes, completing comprehensive assessments and ensuring that everything is looking really smooth for beginning to do some deeper healing work. I would also like to add (to the foregoing) that many therapists do make use of one-on-one consultation (which they pay for, and which often ain’t cheap) as well as peer consultation in free peer consultation groups. In these instances, identifying information is never used, and as little about the situation is revealed as possible– just enough to elicit helpful insight from colleagues. This is always done with the highest level of respect and care. Add, also, to the foregoing, all the hours of administrative and business management work that goes into being able to offer therapy in a private practice setting. It’s a big job. There is a lot going on behind the scenes.
In addition to this, most therapists are actively paying off student loans that are directly related to the training and education required to be able to provide therapy. Therapists are also sustaining numerous monthly business expenses (such as office rent, private email accounts, practice management systems, and much, much more). Lastly, in order to provide therapy in a private practice setting, the therapist is choosing to take on a lot of personal, ethical and legal risk. There are parts of their job that they cannot get wrong. Someone’s life may depend on it.
All of these considerations reach special dimensions of poignancy in San Francisco, where the cost of living is currently higher than anywhere else in the United States. Most therapists in private practice in San Francisco are simply financially unable to accept most insurances because the reimbursement rates are so low that it is nearly impossible to make a living seeing insurance clients only. I have personally considered looking into legal action against insurance companies in order to force them to change their reimbursement rates, so that more people are able to use their insurance in order to access therapy, and therapists are paid a living wage for services provided to insurance clients. I know it seems grandiose. I haven’t found the time yet. There is more I could say here, but I am wary of waxing too “political”.
I sometimes wonder if the lack of financially tuned in healthcare infrastructure around mental health in particular has to do with the lack of understanding about, and lack of appreciation for the importance of, mental health services. Mental health professionals, and therapists especially, are working in an invisible and abstract realm. Perhaps it is difficult to respect or appreciate this, or even to view this as a real science or art form, in our still heavily Cartesian, Newtonian modern Western culture. However, it is a realm that has very real consequences in the physical world, and in people’s lives. In 2015, suicide was the seventh leading cause of death in identified males, the fourteenth leading cause of death in identified females, the second leading cause of death for people age 15 to 34, and the third leading cause of death for those between 10 and 14. This is only one of several possible physical tragedies and/or misfortunes that mental health professionals and therapists work everyday to help prevent.
Since the healthcare situation (concerning insurance reimbursement rates for therapists in private practice, especially in areas with a relatively very high cost of living) is far from the dreamlike, ideal scenario of clients/patients being able to use their insurance, while therapists are happily reimbursed at a rate that allows them to comfortably maintain their business and their own life, it falls on therapists and clients to work this out together. It has to be worked out in a way that allows therapy to be accessible and reasonably affordable for the client (approximately 8-9% of monthly take-home income for therapy fees is considered pretty typical), and in a way that allows the therapist to maintain their business. This often means having to cap off after a certain number of sliding scale clients (as much as we may really want to continue taking on more), and it sometimes means having money continue to come up as a clinical issue, or as an elephant in the room. I have found that people are still able to move past and around this in the therapeutic relationship, because people are amazing. But I believe they shouldn’t have to. The only aspect of this equation currently within my control is the choice to promote greater transparency around the reasons why therapy fees are what they are. I don’t believe it is clinically inappropriate at all to talk about this openly.
I’d be interested to know what other therapists and mental health consumers think! Send me a private email (via my Contact page) and let me know what you think! (Please be informed, it is totally your decision to reach out and tell me about any therapy experience you may have had. That is your private information, and yours to share or not to share. I offer my private email here as a way to respect your privacy. Therapists, feel free to comment below!)