By Bea Armstrong, MFT –
A woman – or a man – decides that she needs psychotherapy. An issue in her life has become chronic and unsolvable. Help is required and the prospective client acknowledges that.
So that person starts to look for a therapist – seeking referrals from friends or others, checking the Internet, and talking to professionals, such as doctors.
And while there will be several requirements taken into consideration – expertise, location, gender – money is usually one of the determining factors…
How much does the therapist charge?
But don’t think that the fee – even if it is a “high” one – is automatically a deterrent to someone contacting that therapist. On the contrary, some prospective clients want “the best there is” for the work that they want to do and will look for a high fee, along with years of experience regarding their issues.
Naturally, this approach will vary from client to client.
This is one reason that it is essential to have a clear understanding of the meaning of the fee and money in our psychotherapy work. If we choose to not think about the meaning of money, we will miss a lot of information that clients provide.
In my last article on fee setting – “Fee, Fi, Fo, Fum: Climbing the Beanstalk of Fee-Setting Issues, Part I” – we explored the meaning of money and the fee in psychotherapy for the therapist.
Now, I want to turn the spotlight on what it can mean for clients – and how we can use that information in our work with them.
Before the First Contact
Even before you are aware of a prospective client, he is gathering information about you. And if you have a website (and you should!), that person knows what your fee is, because it’s listed on your site (it is, isn’t it?).
Listing your fee helps a client determine where and how you fit into their mindset about paying for therapy – their budget, their needs.
As I said above, your fee doesn’t automatically eliminate you. In fact, it can be a discussion point in their initial talk with you.
Is your fee flexible, i.e., does it slide? Are you on any insurance panels? Or, if they are comfortable with your fee, they might only ask what forms of payment you take: cash, checks, credit? Are they defining a high fee with excellence and more than willing to pay that fee?
The crux here is that you need to be comfortable talking about your fee, as well as other money issues that will arise. And be comfortable as well with the choices you have made around your fee.
In 2013, Simon Yisrael Feuerman, PsyD, wrote about two therapists with completely opposite approaches to fee setting in a blog post for psychotherapy.net:
“A close friend of mine is a wonderful therapist, a child of the 60s, a gifted man, large-souled, big-hearted and wise. His practice nourishes him and is saturated with life … ‘I won’t ask my patients for more, at least not if I can avoid it,’ he says. ‘Often I will wait years to do it.’ [raise his fee]
“… And yet what fascinates me is that there are practitioners equally effective who take the opposite point of view. They are practically bullet-proof around money. They regularly raise fees with no compunctions. One colleague, a psychoanalyst and social worker, charges $200 per session and raises the price every two years in $25 increments.
“Both of these therapists have large practices and enjoy their work. Both of them claim that they work in the best interests of clients. In fact, my high-flying colleague insists that she raises her fees in order ‘to help’ her clients…
“‘Clients form an unrealistic dependency and attachment to me,’ she explained. ‘When I raise them, it allows them to separate from me by getting angry at me. It helps me too to be sure, but it is also a gift to them.'”
As Feuerman writes, neither therapist is “right,” or both may be, depending on how you look at it…
He notices the seeming irony when he says, “Where else do you have a field in which the ‘giving’ or ‘self-sacrificing’ therapist who is easy on the rules, winks at missed sessions, lowers the fee at the drop of a hat, can often be counter-therapeutic?”
As he summarizes: “If you’re whole-hearted about what you do, as in the cases above, it usually works out just fine no matter what you do. If you are conflicted, it won’t and you, your practice, and your patients will suffer.”
It should go without saying, but I’ll say it anyway…
Unless you know your money history and are comfortable with money, you won’t be able to help your clients explore that issue.
These two aspects of the fee in psychotherapy – the therapist’s beliefs and the client’s – are impossible to sever.
Here are some questions that you should be able to answer about you and money – and then can use with your clients. They come from “Money Issues in Therapy” – a talk that Thomas Manheim, M.S., gave at CAMFT’s 2003 annual conference:
- What was your family’s financial situation when you were born?
- What was the family’s attitude toward money as you were growing up? Who did you first learn about money from?
- Did you have any jobs when you were a kid? If you did, what did you do with the money you earned? Were there any rules in the family about how you could spend your money? What happened if you broke the rules?
- What did you observe or learn from how your parents handled money?
- Did your family have secrets about money?
- What were their sayings about money? (i.e., “Another day, another dollar,” “A penny saved is a penny earned,” “It is easier for a camel to go through the eye of a needle, than for a rich man to enter into the kingdom of Heaven.”)
- If you had or have young children, what one lesson would you like to teach them about money?
- How have your beliefs about money either caused problems or brought you joy?
- If money were not a consideration, what would your dream job be?
- What are the three most important things that money will buy you?
Money Beliefs Affect Behavior
We know that what we experienced in childhood, unless challenged, we take with us into adulthood. Positive and negative.
Suze Orman in her Financial Guidebook: Put the 9 Steps to Work gives succinct examples of this that I’d like to share.
- Childhood memory: Suze’s mother told her not to tell anyone that she did not have a dollar to go to the swimming pool, because if her friends knew she didn’t have money, no one would like her. Her fear: If I don’t have money, no one would like me. Adult behavior: Suze charges gifts that she can’t afford to give to her friends so it appears that she has money.
- Childhood memory: When Tom was 9, his bike was stolen and was never replaced because his parents told him that he was irresponsible about the things that money could buy. And he did not deserve to have his bike replaced. His fear: I’m totally irresponsible regarding money and anything money can buy. Adult behavior: Tom does not earn or save money, never buys himself anything and lives like a pauper.
- Childhood memory: Anna received a smaller allowance from her father than her older brother and younger stepbrother did. Her fear: I will never have as much money as others because I am not worthy of receiving it. Adult behavior: Anna never asks for a job promotion or pay raise and doesn’t make as much money as she is capable of making.
We know in our work as psychotherapists that there are many contributors to our sense of self as adults, but these examples above make a point. Money beliefs can influence a sense of our value and what we can allow ourselves to have. And that goes for us as therapists as well.
Client Approaches to Fee Setting
The last time I checked, there were 325,232,938 people living in the U.S. And the numbers kept climbing as I watched. The National Institute of Health (NIH) states that about a quarter of the adult population of 240 million experience mental health problems. That means that 60 million of U.S. adults experience problems, of whom 60% of those, or 36 million, do not receive treatment. 45% of those cite cost as a barrier to mental health care.
What are these people looking for? And if cost is such a barrier to getting mental health services, why would some prefer fee-for-service?
There are three main approaches to how clients pay for psychotherapy:
- Insurance coverage via provider panels; and
- Community mental health centers.
Let’s take them in order and see what clients are predominantly looking for in each case.
1. Fee-for-service: What do clients see as the advantages to pay out of pocket?
Choice: Patients who try to stay in an insurance network may not always find a provider with whom they are comfortable or who has experience dealing with the types of issues the patient wants to address. In some areas of the U.S., in-network access to therapy is extremely restricted, requiring patients to travel as much as two hours to see someone.
Flexibility: Insurance companies can still restrict reimbursements on certain kinds of treatment, such as online therapy, group or couples’ counseling. Self-pay patients may also opt for longer sessions if the need arises, whereas patients covered by insurance must stay within the negotiated time slots.
Privacy: When patients use insurance, therapists must include a diagnosis to release benefits. That diagnosis becomes part of the patient’s permanent medical record. If someone is uncomfortable with the number of people who have access to that record, they may opt to direct pay. Paying out of pocket means no diagnosis is required, nor is medical information shared.
Timeliness: In overstretched networks, patients may have to wait long periods of time to schedule therapy with a provider who accepts their insurance.
Convenience: Paying out of pocket not only allows the patient to see someone more quickly, but self-pay patients are often given the option of arranging more flexible session times.
But even given all of that, clients may have some resistance to paying out of pocket that is unconscious.
This resistance frequently shows up with the client downplaying her financial assets. The idea being that the fee is not easily paid and there are no surplus funds if the therapy becomes lengthy and/or the therapist wishes to increase the fee.
The source of funds is often mentioned, as in “I don’t know what I would do if I didn’t get a bonus this year.”
The message is, “I can pay the fee, and I will even pay it without really complaining, but it does restrict me financially, which I don’t like.”
It is important to notice THAT with the client, rather than “fix it” by lowering the fee. Clients don’t have to enjoy paying for it, but they should expect to get good service for the money they are spending. You can ask: “What are you hoping to get?” “Have your expectations regarding paying for something not been met before? If yes, how?”
In terms of the fee, some patients take another direction and emphasize their wealth. Herron and Welt (Herron, William G. and Welt, Sheila Rouslin. Money Matters: The Fee in Psychotherapy and Psychoanalysis. 1992. New York: The Guilford Press.) write about a patient who was due to pay his therapist in a particular session. The patient had just sold his business for $2 million and had the check with him. Instead of handing the therapist the check for the fee as usual, he deliberately gave the therapist the $2 million check and laughingly pretended the mix-up was accidental.
Hopefully that therapist explored the meaning of this “accident.”
2. Insurance coverage
Experienced and highly trained mental health professionals, such as psychologists and marriage and family therapists who have been in practice for decades, can garner fees averaging well over $150/session. While private health insurance will pick up the majority of this cost if the patient is covered (generally requiring a co-pay of between $10 and $30/session), those who aren’t covered may find it difficult to afford therapy.
Historically, health insurance provided by employers placed severe limits on the type and extent of mental health treatment they paid for. But the passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equality Act of 2008, outlawed this disparity. However, loopholes exist and the new law doesn’t cover small business with fewer than 50 employees – most of us in private practice.
Also certain diagnoses can continue to be excluded, and providers may still need to get continuing authorization from insurance companies.
But since insurance does typically pick up a large portion of our fee, issues surrounding it might not be as blatant as in the fee-for-service examples. That just means we have to be more observant.
Comments during the sessions can relate to the rising cost of health care premiums in general, to having to care for others’ insurance (parents, adult kids, and so on) or to delays in getting reimbursed.
If these kinds of comments come up several times in a few weeks, I’ve learned to talk about them and their meaning w/the client.
Even if the client assures me there is nothing meaningful behind their comment, I still want to acknowledge it and let them know that I’m open to talking about whatever might be there – feelings or thoughts – about this issue. That willingness alone can be healing.
Sometimes a client’s coverage will change and that will bring up money issues, especially if the reimbursement is lowered.
And many therapists, myself included, prefer not to be on any insurance panels for a lot of reasons.
“The goal for most therapists is to get to the point when you stop taking insurance,” said Dr. John Grohol, founder of PsychCentral, the Internet’s oldest independent mental health social network. “When you stop taking insurance, you stop having to deal with someone questioning your treatment decisions, and you can stop doing all the paperwork.”
Some therapists are dealing with how to get off provider panels when they have been seeing clients with insurance coverage. That is a topic for another article, however.
3. Community Mental Health
Less expensive than private practitioners are public resources – many of which were set up during the 1960s to try and help move the mentally ill, who were confined to hospitals, back to the community. These community clinics, typically referred to as community mental health centers, are available in hundreds of communities across the country and they are often funded and run by a local government.
These centers rarely offer “free” psychotherapy, however.
Like the sliding scale model in private practice, these clinics charge fees to people seeking therapy, but those fees tend to be much less than what is found in the private sector.
Psychotherapy is subsidized in these centers by government funding (usually via local taxes and federal reimbursements, such as Medicaid). But the centers still try and recover some costs directly from those using the services. An individual could pay as little as $10/session if they had virtually no income, or it could be free if they are covered by Medicaid.
Patients who typically use a community mental health clinic are more connected to and even conversant about the importance of money in their lives. However, they might not be as aware of how their feelings, and ideas about money, transfer to the therapy or the therapist. And even when you make this apparent to them, they might see this as a real stretch on your part.
Again, just the idea that you are willing to talk about money and its meaning in their lives and in the therapy can be very healing for these clients.
There is so much more that can be said about the issue of the fee in psychotherapy. I expect that we’ll pursue the topic more in the future at the Therapy Marketing Institute.
How does the subject of money and your fee come up in the work you do with clients? And have you done your own work around your relationship with money? We’d love to have your input, so be sure to leave your thoughts and experiences regarding fee setting and money in psychotherapy below… We look forward to hearing from you!