When I worked as a therapist for a university counseling center, I didn’t think much about what my clients were paying for therapy. The exchange of money was the responsibility of the center. I could conduct my therapeutic work, oblivious to the business side. I was trained to be a therapist, not a businessperson, after all.
Back then, if a client no-showed to an appointment, we could talk about the reasons behind the “no show,” what it meant for her, and what it meant for me. Did she “no-show” to other important appointments in her life? Did she doubt the usefulness of the therapy? Was she angry with me? But when a client complained about having to pay a “no-show” fee, I could always hide behind the fact that it was center policy and out of my hands.
After five years, I left the university counseling setting and went full-time in private practice. I quickly learned that charging for my therapeutic services was my biggest adjustment. I didn’t have enough practice with asking for and receiving payment.
My private practice is in Washington, DC, where the going rate for 45 minutes of psychotherapy is somewhere between $160 and $200. I have heard of some senior clinicians charging $250 per session.
Though I thought even the low-end of the scale was excessive, I was confident that the services I provided were at least as good as the services offered by my colleagues. I thought to myself, “If that’s the customary fee they are charging, that’s what I will charge!” This was my livelihood, after all.
For psychotherapists like me without salaried positions, our options are to work for someone else (eg, group practice or counseling center) and take home about half of the fee charged the client, or start a private practice. I had to get comfortable with the business of practice.
I practiced saying aloud: “My fee is $160 per session.” Pause. Throat cleared. “My fee is $160 per session…” The practice wasn’t working (no pun intended).
I felt this panicky feeling of guilt rise up from deep in the core of my being when I stated my fee. I heard a voice that said, “This is not a fair price, Imran! You are advertising to the person seeking help, and then profiting off of their suffering!” I couldn’t gain the confidence I needed by myself. I needed help.
I talked to a number of trusted colleagues about the fee issue. These were colleagues who like me, got into the field genuinely to “help people.” I went to colleagues who I knew were also conscientious about the fees they charged.
My colleagues could justify the fee with a number of rationales: the years of schooling, the student loan debt, the investment in working on the self and one’s own therapy, and market comparisons to what physicians and lawyers charge for their time and expertise. They also pointed out that I’d have to consider that the $160 session fee also includes taxes, office rent, benefits like health insurance and 401K investments, the cost of required continuing education units, etc.
It was a good point. My take home of the $160 fee was at best, half. So 50 minutes of my time was a net value of $80 or so. OK, I thought, I am getting closer to feeling comfortable with the fee.
And yet, after months of charging the usual and customary fee, I couldn’t stop worrying about what my clients felt about paying me $160 for a weekly meeting for self-improvement. Throughout the day (admittedly even in sessions) I pondered on why psychotherapy is so valuable and worth the costs. I had to feel like the therapy was valuable to my clients to survive in private practice, which I really, really wanted to do.
I came up with a few reasons on why psychotherapy is valuable, and what makes it is so expensive. Below are the three “C”s when assessing the value of psychotherapy.
Confidentiality—A Unique, Safe Space
Psychotherapists are legally bound to keep confidentiality. When a person has been suffering privately with shame, therapy can be incredibly relieving and transformative. There are other professionals who are also supposed to keep your secrets confidential—lawyers and priests come to mind. But unlike a priest, your psychotherapist does not also partake in refreshments with your family at social gatherings after you have bared your soul to him. The therapy room is a unique space in the safety it can provide the client to articulate difficult feelings and to face very private fears.
Good therapists are incredibly consistent around the therapy hour. Therapy sessions start on time and end on time. There is minimal disruption to the boundary of the appointment hour.
Knowing that one’s therapist will always be there at the same time can create a positive thought-space throughout the week. If a distressing interaction happens at work or at home, a client can know that he or she will have a chance to talk about it with their therapist. If a client is curious about some aspect of himself and wants to explore it privately, he knows exactly when and where he can do that.
Friends and family can disappoint with arriving late, canceling at the last minute, or unpredictably making shared time together miserable. In contrast, clients can consistently rely on the fact that their therapy hour is theirs and theirs alone. Plus, the burden for keeping consistency in the weekly meeting is on the therapist, not the client.
Think about when we go on vacation: In general, our clients can count on us to talk to them about it at length and let them express their thoughts and feelings about our absence. Where else is an absence given so much nuanced attention?
Charting the Change Process
People often make intentions to improve their lives, whether that is getting in better shape, making healthier decision, stopping bad habits, or taking on a new hobby or interest. But people who successfully make life changes rarely do it alone. As social beings, having support for self-improvement is crucial.
Weight Watchers has been successful in helping millions of people lose weight and 12-Step programs like AA have helped millions more maintain sobriety. The programs’ successes are in large part due to their built-in social support.
Therapy provides a way to keep people accountable to their goals. Telling a loved one that you intend to stop smoking is different than telling your therapist that you intend to stop smoking. People pay their therapists to keep them accountable, in a gentle, non-punitive way. If a client stopped smoking for a month and then started up again, he knows he can talk out the feelings and frustrations around quitting smoking with his therapist.
Therapists know that behavior change happens when people are aware of the feelings behind a habit. It is not enough to have a theoretical concept to change behavior. Developing awareness of the feelings associated with a habit helps with the change process. Therapists help people do this.
Reviewing these three C’s has helped me feel into the therapy fee. There is still more work to do, both to make the experience more valuable for my clients, and to feel more confident in my interventions.
I learned early on in graduate school that the therapy room is a unique space. The therapy session is like no other person to person interaction. Charging money in the service of helping is necessary to keep the therapeutic boundaries around the relationship. Time, both in consistency and frequency, is another important boundary.
I wish that the usual and customary fee for psychotherapy was less than what it is. In that way, more people could access the benefits of therapy, and therapists could feel fairly compensated.
Therapists in my area who are not on insurance panels do not tend to see a lot of clients with limited financial means. On the other hand, therapists who slide their fee often feel uncomfortable doing so and risk feeling resentment towards the client.
My professional challenge is to continue to make my therapeutic services worth my clients’ time and money. Even more challenging…feeling I am worth it!
Image courtesy of Ambro at FreeDigitalPhotos.net