Here is a topic that professional advisors love to talk about and that doesn't feel uncomfortable at all: Money!
Let's get it public and acknowledge that talking about money is no fun in the consulting profession. Because the nature of our business is sensitive. We do not sell public "goods", we offer a service. And this service is no ordinary service like controlling or grooming your dog. We work with you to heal some of the most painful parts of your life. We'll help you cope with tragedy. In some cases we try to keep you alive. Due to the sensitivity of our work as professionals, we can often feel “bad” when we bill you for this service.
We often talk to my therapist friends about our fees and everything related to them. We go into this profession to help people. Still, reality comes into play and we need to balance our hearts with our checkbooks. We have to reconcile that in order to use our skills we have to pay our bills.
Speaking of bills, as therapists we certainly have a lot of them. Some standard: undergrad, graduate school, or both student loans, the costly liability insurance required to operate, the license fees, the professional development courses required, our HIPAA (Health Insurance Portability and Accountability Act) secure phone lines, email and practice management software, marketing and Advertising costs, office rent, material for customers – it all adds up. This does not affect the normal cost of living, which we must all take into account, such as other bills, mortgage payments, health insurance and groceries.
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As counselors, we know that we have to make money to live, but this feeling of guilt about increasing our fees or charging a client after a particularly emotional session is real. Something I try to remind my therapist friends (and myself) about is that at the end of the day we are a business. It feels gross to say that because what we're doing feels like more.
However, when I think of all the people who work so hard and see such positive changes in their lives, it helps me calm down. To stay in this business and stay available, to use my skills to help people who are changing their lives for the better, I need to keep my lights on and pay my bills. I love what I do and I am glad that I can continue to do it. I worked hard for these skills so that you could work hard to get better.
Nevertheless, this question can and must be examined in a deeper context: Why is psychotherapy not more affordable?
Why is psychotherapy not more affordable?
This is an important and complicated subject. At the beginning, as mentioned above, therapy is a service like any other. Therapists do a job, and to do that job they have to pay a fee. But why can this fee appear so high?
When you think about the structure of therapy and compare it to similar industry services – such as CPAs, lawyers, and other professionals who pay you to provide a service rather than a product – it starts to make sense. Instead of selling a product, we sell time and know-how.
We do not question why lawyers charge so much for their time. We understand that they had to go to school to become the best at their craft. In return, we pay for access to this knowledge. The same goes for professional counselors and other therapists. We had to go through extensive training and education (and accumulate significant debt) to master the skills to serve you in the office.
Nevertheless, this argument can be shaken when applied to therapy because it is assumed that therapists should have more compassion for the needs of the population. Good mental health should be a human right, so why not take people off and offer these services at discounted prices so that more people can benefit from them longer? After all, this is mental health – shouldn't everyone be given the tools to lead a better life?
Without a doubt, mental health services should be accessible to everyone and financial barriers are a social problem. What is not always understood is that therapists also fall victim to this mystery. We do not benefit from the fact that society does not value mental health services.
Believe me when I say we wish we could offer a reduced fee to all of our customers. What makes this impossible is that most of the therapists with the highest fees are in private practices. There is no product they can sell to make their profit, so their time and service are their only source of income. With no salary and a steady paycheck from a company, they rely solely on their fees to run the cost of running their business, as well as other income to pay their bills and support their families. That puts them in a bind.
What can be done?
This constraint could be removed if our society gives priority to mental well-being and mental health. For example, if the government had programs to support psychologists and increase our incomes, we could lower our fees and more people could be seen without our need for assistance. If programs were created to provide mental health benefits to individuals so that services did not have to be paid for out of pocket, it would be another great way to make therapy available for all. If insurance companies raised their tariffs and paid a livable reimbursement rate for therapists (more on that later), more of us would accept insurance and our customers would be able to pay less.
I hate the way mental health is being devalued in our country. Those of us who are therapists got into this field because we want to help people and we are aware that we cannot reach whole areas. If we did, we couldn't be in business long and no one would benefit from it. I am confident that the change will come. The louder people are that they are demanding mental health rights, the more likely we are to get them.
If you seek a professional counselor or other therapist and find that finances are not working, I encourage you to ask if the therapist is able to offer a graduated or reduced fee. Until then, I know it's a disappointment to see this price tag. We don't like it either.
Why many therapists do not take out insurance
There are therapists in private practices who take out insurance, but that will not always be the case. Previously, I addressed some of the reasons for the fees therapists charge. Now I'll explain why we don't always accept insurance as a way to cover these costs.
If a therapist wants to take out insurance, this form of payment is associated with considerable expenditure of time and money. First of all, therapists must apply to the health insurance companies in order to be able to take out their insurance. This process is complicated and tedious. It can take anywhere from four months to a year for approval to be granted. An insurance group will only allow a therapist if it recognizes a need for the therapist's services in this area that has not already been taken over by another provider. It is often rejected because there are already enough providers in the field of therapists.
If you are one of the elect, the process gets more complicated from then on. You have to sign a contract with the insurance group and agree to a fee schedule. While I can't share the specific fees that health insurers pay to therapists, they are almost always lower than a therapy session. In fact, it can be between a third and a half of what a therapist would normally ask for his services.
In addition, therapists are not actually paid for providing the service to the client. After the session, therapists must go through a time-consuming medical billing process to file a claim with the insurance company to claim payment for the service provided. The insurance company may decline the claim depending on a number of factors. In this case the therapist worked for free. If an insurance company approves the application, it pays the therapist weeks later.
Psychiatric therapy agencies and group practices with dedicated medical billing and coding teams have time to devote themselves to this complicated process. Providers who work with these agencies also usually receive a fixed salary so that the delays in insurance payments are not so acute. Therefore, in these situations you are more likely to find providers who take out insurance.
In contrast to this, therapists in private practices usually forego these challenges, since the expenditure of time and money does not make the most efficient business practice. Self-payer with resident therapists is just a lot easier. In addition, insurance companies require therapists to diagnose their clients in the first session and submit them to the insurance company, otherwise the benefits will not be covered. Not all therapists (or clients) agree with this practice of diagnosing, so this is another obstacle to accepting insurance.
No surprise, this is a broken system. There should be alternative, affordable systems to make therapy available to all who want it and to all therapists who can offer it. Some therapists try to lower the financial barrier by doing pro bono work or offering sessions at reduced fees.
Reduced fees and pro bono work
Therapists are encouraged by their code of ethics to offer some of their sessions at a lower cost or, if possible, to offer some services pro bono (free of charge).
Since the number of services we can provide at a reduced price or free of charge is limited, there is usually an upper limit to the number of customers who can receive this service at any given time. This will depend on the finances and decisions of the individual therapist, but most therapists will have a line on their business page indicating whether they are open to "sliding fees". This means that therapists work with clients to find out what they can afford.
Sometimes this sliding scale includes guidelines such as a fixed number of sessions or a fixed frequency, but talk to your therapist about what he can do for you.
Pro bono services work in a similar way. Therapists can offer some services for free, either directly or in a more general setting, such as services for charities, schools, or churches.
If a therapist currently has no vacancies for discounted work, do not lose hope. Whenever these clients graduate or expire, these places may become available again, so keep asking your therapist to be placed on a waiting list for such services.
If you are a therapist and do not currently offer these services, I strongly recommend that you reconsider. I offer several discounted places on my case number and I am glad that I am doing this because, as already mentioned, the therapy should be accessible to everyone.
Talking about money as a therapist is no fun, but it is necessary. If finances are an obstacle to your access to services, I encourage you to speak honestly with a prospective therapist. We really want to help and most therapists will work with you to give you the help you need. Now that you have a glimpse into how this area works financially, I hope you have the confidence to seek help if you are a potential customer and to provide help if you are a practitioner.
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Further reading for consultants:
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Stephanie Cox is a licensed Florida Mental Health Advisor specializing in the treatment of children, families, and adults with mild to severe mental health and relationship problems. She holds a degree in Psychology from the University of North Florida and an MSc in Counseling Psychology from Grand Canyon University. Contact them via:
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