What Therapists Won’t Tell you About your Request To Reduce your Therapy Fee
This week I was contacted by a new start up who, on the surface, seems to have a wonderful mission. They seek to address the accessibility issue to mental health treatment by problem solving the insurance maze. It is a good attempt at a solving a very large issue. When I spoke with them about whether or not I would take any cases, the conversation came down to rate per session and the level of psychiatric need of their clients. The rate they wanted to pay a psychologist was too little for it to be a viable option for most providers (without sacrificing) and they couldn’t answer my question about who their clients really were. I would be open to sliding my fee for a new immigrant to the country struggling with a domestically violent spouse but not for someone who just wants to complain about their boss.
While they have done a good job solving the problem on the consumer side, one of the real issues to accessibility for psychotherapy has to do with a therapist’s ability to earn a living wage from insurance cases. Most therapists simply cannot until they move out of direct client care and into administration of a larger group practice or build a private pay practice. The joy of private practice and helping people disappears when you realize you were making more money tutoring in graduate school. It’s not supposed to be this way and I, would argue, that if therapists cannot make a comfortable living without killing themselves with the number of people they are seeing, are they actually capable of truly helping you? A burnt out therapist is really of no use to you.
What struck a chord with me during this conversation was not the disappointment that the, yet again, a start up company hasn’t really spent much time in the professional’s shoes to learn why some of the best therapists and psychologists simply choose not to take insurance for behavioral health (or some of our best hospitals for that matter). It was in the entitled assumption that in our best effort to help, we would automatically choose to slide our fees. When I informed her that I, at this point in my career, would very rarely choose to do that for someone (unless there is a personal referral from a trusted source or they make a very good case AND I think I can help), I was accused of not wanting to help people struggling with a mental health crisis. It was a very out of touch comment as and far from the truth. Every single person I know in the mental health profession wants to help but we are stuck in a broken system with you — not against you. Since most therapists don’t talk or teach about why they choose to slide a fee, I figured I would actually write about it from the professional side and what it has been like on the personal side. Transparency on fee setting is always an area of ethical concern for psychologists.
My Lesson Learned in Graduate School About Fees
In graduate school, I learned the most important lesson of my training while working at Bellevue Hospital. My twenty something patient was suicidal and needed a great deal of mental health treatment. Her fee was already low based on the hospital policies but after a few weeks of treatment she came to session crying. She said she could not longer afford psychotherapy.
I went to my supervisor that day and made a huge case for why her fee should be reduced. I based it on her demonstrated commitment, her need for treatment, her prognosis and that we wanted to help her. My supervisor simply said to me, “Come back next week when you know how she spends her weekends.” I remember thinking my supervisor was a complete ass. How could he not see that this woman was in pain and suffering?! How could he be so insensitive? I was pissed and hell bent on proving him wrong.
So in our next session, I did what he asked me to do. I asked how she spent the last two weekends. Her face lit up and she was excited. She then she said, “OMG have you tried the martinis at that new place in Soho?! They are like $19 a piece but it is so worth it.” When I asked her how many she had last weekend, she said she had five that she paid for.
In that moment, I knew exactly what my supervisor was trying to teach me. I sat with my client and we actually did the math. Her sessions for three time a week therapy came to $80 per week (it was a public hospital program). Her martini habit came to $95. She drank her therapy budget in one Saturday night. I told her that not only did we need to decrease her alcohol usage because it was part of her treatment plan (and that is what she came into treatment for) but that we needed to learn to manage her finances and COMMIT to making treatment a priority. She admitted that she never calculated the numbers before and seeing how much she spent on alcohol seemed ridiculous.
Fortunately this client got the message the first time. We did not slide her fee further but the discussion of finances opened up important conversations about her lifestyle which lead us to talk about the importance of committing to psychotherapy — something she struggled to do for years with other therapists (whom coincidentally have never said no to her regarding sliding their fees). This incident also opened the door to discussing a family history of poor financial planning and fear for the future — something she had not explored in all her other years of therapy but was a really important topic to cover.
The assumption that your level of pain should automatically require a reduction in fee really is an ego based argument. Psychotherapy is about two things: 1) the relationship with your therapist; 2) your commitment to yourself. Therapy starts to work when both of these criteria are well established and it is really hard to establish them if you have the mindset that your suffering requires you to pay as little as humanely possible without consideration of the reality of your current situation.
In sum, therapists, really great therapists, will not automatically slide their fee — especially in a major city in the US. Sometimes sliding that fee is actually not of benefit to you and we actually follow ethical guidelines on how to determine your therapy fee. The discussion of the fee, is therefore, a very important part of your treatment and I strongly believe it is at the therapist’s discretion whether doing so is 1)based on real financial necessity; and 2)provides real therapeutic value. Both client and therapist should openly discuss what comes up around the fee discussion and make appropriate decisions based on those discussions. Complete transparency is often needed on both sides.
My Personal Experience in Therapy
As a consumer on the other side of therapy, I’ve had the experience of therapists who were willing to slide their fee and those who were not. The two therapists who have helped me the most were NOT willing to initially slide their fee. I recognized that the investment into our work was important and made the adjustments necessary to meet their fees so I could work with them. As we got to know each other and when times got tough due to life circumstances, both these therapists offered to help — and I said no but was extremely grateful for the support. I happily made sacrifices elsewhere. I wanted them to know that I respected their work through our long term financial commitment.
My worst experience in therapy was with one therapist who was all too willing to slide her fee but kept bringing up the fee discussion every other week and interrupting my therapy session. It did not feel therapeutic, it felt like she had made too much of a sacrifice to see me and she was resentful. We eventually struggled to have financial conversations that felt safe. This led to a breakdown in communication and me choosing to not go back after a few months. The final straw was in her insistence of being paid only in cash or check because she did not know how to accept a debit card or credit card payment and was not willing to explore how to use PayPal. This was not something, as a client, I could respect (as it was adding to my stress) and so I needed to move on.
I believe that in order for our personal development work to make a difference, we have to be willing to commit. Commitment means prioritization not simply fitting it in at the hope that it will be beneficial. It’s the difference between mindfulness and mindlessness and most of us need to get more mindful about how we are really living our lives. For the client that means a review of how money and time is being spent and for the therapist a review of boundaries and choosing what is actually realistic to provide to a client without sacrificing your own mental health. It is not okay to slide your fee so low and then turn around and be restful to that client.
What About People Who Really Can’t Afford Therapy?
Having said that, there are people in a real crisis who do need access to immediate mental health treatment. There are people who live in rural areas without access to therapists and there are people who do not have the knowledge to go out and find the right therapist. There are people in acute distress and cannot wait for an outpatient provider. It is for these populations that I would consider making alternative arrangements and almost every therapist I know would make these adjustments. But in my professional experience, it is these clients, the ones who are struggling the most AND struggle with access who are more likely to sacrifice everything else in their life to make therapy with the RIGHT person work. If you are one of these people, a good therapist will bend over backwards to happily help you.
I remember the mother of a teenage client I had during graduate school. The cost of therapy at a training clinic is always significantly less but even then, there can be a barrier to receiving the right kind of help. She was struggling financially and we offered to help her because her son was benefitting from treatment. She said no thank you. The next session she brought a thank you note and a pie explaining that she knows we are not charging nearly enough for the sessions but that she will find a way to make it work because the chance at her son having a better life was worth the sacrifice to her.
We did decrease her fee and explained that since her son was working so hard that she also needed to be free from the worry of paying for his sessions. We provided the psychoeducation about the importance of her presence for her son and not just adding a job to pay his therapy bill. We did our very small part to help a highly motivated family. We wanted, of course, to do more but this is what we were able to provide. These are the cases that make the job worthwhile.
How To Have the Fee Conversation with an Outpatient Therapist
As for the consumer — here is a better way to broach the conversation about fees (as you probably have a deductible to meet anyway).
- Know your finances ahead of time. A good therapist is going to cost some money but it is usually worth it IF you believe it is a good fit. You’ll need to adjust the sticker shock and think of it as an investment in your future well being. Don’t go to therapy simply because someone told you to — you need to go because you want to.
- Call your insurance company and ask about your behavioral health plan. Most people have no clue what their coverage actually is!
- Do your research! No therapist likes to be told, “Hi I was going through my list from my insurance plan and figured I would call you…” Therapy is about a relationship. Go to their website and do your homework.
- Make a phone call and leave a message for the therapist or contact them via email to schedule a brief phone call.
- Listen carefully to how the therapist runs their practice. Remember they are screening you to see if you are a good fit for their practice so you should do the same.
- Tell the therapist why you are interested in working with them and be specific.
- Inquire about whether they are willing to slide their fee. If yes, ask how much an initial session would be. If no, ask if they would be willing to reconsider after the first couple of sessions if it seems like a good fit. Give specifics about why you are asking for a reduced fee. Most therapists will likely agree to keep the conversation open if they see your willingness to commit to an initial consultation.
The act of going to therapy is not going to solve your problems. The commitment to yourself and the process of therapy, can however, change your life. Even the process of having the financial conversation can be a very life changing as most of us avoid discussing finances and they are a huge source of our stress and anxiety.
What to Do if you Can’t Afford Private Therapy
If a private therapist is not an option, one of the biggest untapped resources for great therapy is at a university training clinic. You have dedicated and enthusiastic young people under the supervision of highly trained professionals. The fees are often very low. You can also call these clinics and ask for a referral list. Many times their recent graduates are starting private practice and have reduced their fees to get started or they will know if hospital based programs with a lower fee structure.
As an example, I used to work at the Institute for Violence, Abuse, and Trauma in San Diego, California. Their clinical services division helped train forensic psychology students and provide low fee therapy and assessment services for people all over the United States — especially for those people dealing with abuse in a child custody case. We automatically assume that there is no hope available when the real issue is that we simply do not know where to find the help. While it would take far too long for clients to find us, when they did, we did our best to help.
Finding a therapist is not hard — especially now that we have the internet. Finding the right therapist you can afford can be a huge challenge. I have found that most people assume therapy is too expensive and so they don’t try to find one. Don’t let your anxiety fuel the illusion there is no help. There always is. You just need to keep your options open and get clear about what it is you want. There may also be another healing option you haven’t considered that would be a better fit than traditional talk therapy. Doing your homework and listening to your intuition on what you need can help you navigate the process much more easily.
And remember, you’re not alone. You’re friends and colleagues are probably looking for one too!
Dr. Jennifer B. Rhodes is a licensed psychologist, relationship expert and the forthcoming author of Toxic Insecurity: Our Search for Authentic Love. You can connect with her on Twitter and Instagram @jenniferbrhodes.