“If it’s inaccessible to the poor, it’s neither radical nor revolutionary.” —Unknown
Not all therapists want to be radical or revolutionary. That’s okay.
But if we do not evaluate financial and power systems critically and constantly—particularly those within the therapy profession—we run the risk of perpetuating the systemic factors that contribute to mental health conditions and the stigma that keeps people from seeking help.
Even before I launched my independent practice, I struggled with some of the rhetoric that exists in coaching and supervision groups for therapists. Although meant to be empowering, the idea of “charging what you’re worth” is a dangerous line of thinking, tying our identities to what we earn in capital. And for those of us who have historically served lower-income populations, it may also be offensive. Are the people I work with in therapy who earn minimum wage “worth” $8 an hour?
In considering this topic, I’ve identified three major hazards of maintaining the status quo as it relates to inflexible and/or high fees in private therapy practice:
- We perpetuate the wealth gap. In some circles, therapy has a reputation as a service for the materially wealthy, provided by the materially wealthy. Are we becoming increasingly out of touch with the basic realities of Americans whose financial situations don’t look like ours?
- We punish people in therapy for what life has handed them—crisis, tragedy, trauma, and more. Too often, the people who need our services the most can’t access our services when they need them the most. People lose their jobs and partners. People experience violence and assault. People are diagnosed with cancer or other health conditions. These issues and others that could eventually feel manageable with more support may instead lead to further crisis and exacerbated symptomatology if mental health services are inaccessible.
- We let insurance companies and capitalism dictate mental health care. This happens when, for example, a major insurance provider has a functional monopoly, reimbursing 200% as much as other insurance companies for the same service codes, to the extent many therapists panel only with them. We should not accept unfair industry standards, but we should also be accountable for the ways we might perpetuate industry practices that make it harder for some populations to access help.
Many therapists connect their spirituality to their work. Such therapists in some cases may feel “called” to accept lower fees, but I have overheard therapists justify high fees because they are doing their “soul’s work.” I must caution our community against attaching our souls to a price tag. Assess your own values, but beware self-serving beliefs framed as empowerment.
Many disciplines have entire sections of ethical codes dedicated to financial arrangements. Take some time to review or revisit the financial ethics of your profession and ask yourself how you might be upholding or neglecting them.
Codes tend to vary slightly from one discipline to the next, but take for example “Responsibility to Clients” from the American Association for Marriage and Family Therapy (AAMFT) ethics code. The first item is related to non-discrimination: “Marriage and family therapists provide professional assistance to persons without discrimination on the basis of socioeconomic status” (and other statuses not listed here). How can we, in our own practices, maintain and uphold this principle—so critical it is listed before all others?
How Therapists Can Increase Access to Their Services
The following are ways therapists may effectively and creatively increase access through their own fee setting. This list is not exhaustive.
- Set aside a few spots to see people pro bono. Regarding fees in therapy, Dr. Ofer Zur critiques: "There is a view among therapists that clients who pay more for therapy value it more and are likely to benefit more from clinical work. Some go further and suggest that the higher the financial and other sacrifices clients make for therapy, the more likely the client is to gain from therapy. These (most probably) self-serving beliefs are not conclusively supported by research. Some research has shown that those patients who are engaged in no-fee therapy neither value it less nor gain less than those who pay" (2016). Of course, seeing people for free may be easier said than done, especially when starting out in private practice. If even limited pro bono work is possible for you, be upfront about the frequency of sessions and come up with an agreed-upon rate for “crisis” sessions, if applicable.
- Donate a portion of your standard fee to a social service you value in underserved communities. This can be a way to “pay it forward” in a sustainable manner, as charitable giving may be tax deductible as well.
- Employ a flexible sliding scale. In an attempt to be accessible to the communities they serve, some therapists utilize a “pay what you can” approach with those who cannot pay the full fee. When balanced with insurance reimbursements and people paying the full fee, this model is commonly employed by socially responsible therapists in private practice.
- “Your hour is my hour.” This refers to charging people what they earn in an hour as the lowest fee on a sliding scale. I know of one well-intending therapist who tried to introduce this as standard policy in her practice, but noted it frequently became financially punishing in her setting. Still, there’s hope for this as a starting point for discussing fees, particularly when working with people employed hourly and people without benefits.
- Panel with Medicaid. Some states have more functional systems than others, with varying reimbursement rates, reimbursement schedules, and budgets. If making yourself more accessible via insurance is of value to you, ask how other practitioners in your area are making this system work for them.
- Start a group. If you cannot afford to see people for a significantly reduced rate, you might consider seeing multiple people with similar concerns together. This provides an opportunity for people to learn from one another, not just from the therapist, generating a larger pool of therapeutic resources. And even if several people are paying a low fee, you can set your group cap to help you earn as much as your hourly fee (or more). Furthermore, many insurance plans cover group psychotherapy codes.
As with the people we serve, the financial situations of therapists can vary greatly. Some have more flexibility than others to adjust their fees in the interests of accessibility. It is up to each of us to figure out to make these changes sustainably within our own practices.
It is a risk to enter and maintain a private practice, but many of us do so with supports and security other professionals with comparable experience and training might not have. I am not suggesting anyone martyr themselves, but it’s important to discern wellness from wealth. Staying mindful of the factors that impede that effort is likewise important.
- American Association for Marriage and Family Therapy. (2015). AAMFT code of ethics. Retrieved from http://www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/Code_of_Ethics.aspx
- Pajer, N. (2017, May 8). Why is therapy so expensive? Huffington Post. Retrieved from http://www.huffingtonpost.com/entry/therapy-expensive-insurance_us_5900048ee4b0af6d718992e7?ncid=engmodushpmg00000006
- Zur, O. (2016).Fees in therapy: Summary and guidelines. Retrieved from http://www.zurinstitute.com/feeguidelines.html