Is Good Therapy Only For the Rich?

An acquaintance recently asked me to recommend a marriage counselor for her. I gave her the names of some trusted colleagues, but warned her that they work in private practice, so it would likely be costly. I also offered to look at the list of those who accept her insurance, to let her know if any names looked familiar. She opted to call the private names first. This friend and her husband are hard-working professionals, but they have significant expenses and not unlimited funds. When she heard their hourly rates, she echoed the frustrated sentiments of so many clients and would-be clients:  

Why does therapy have to be so expensive?

The short answer is: It doesn’t.

But of course, there’s a lot more to it.

It can be terribly frustrating to do the legwork of finding names and making nerve-wracking calls, only to find out that the help one seeks is unattainably beyond budget. I’ve even heard some go as far as to bitterly suggest that it is “unethical” or “greedy” for professionals to charge such high fees for these services.

So, I thought it might be helpful to publicly shed some light on this common grievance.

One important piece of information for the prospective therapy-consumer to know is that therapy need not cost a fortune. Licensed psychotherapy by a trained therapist for a diagnosable problem is available on most health insurance plans, often via telehealth options, and in many clinics and agencies for a fraction of the cost of private therapy. Any potential client should know this or be apprised of this when exploring treatment options.

If this is true, why would someone opt to see a pricier professional?

It really boils down to the basic economics of any good or service industry, but here are some of the mechanics of how it works in this field, beginning with reasons someone might opt for a specific professional:

Testimonials: Some people are willing, or even prefer to spend more if the provider was recommended by someone they trust—such as a referral service, a friend who had a good firsthand experience with that therapist, or a mentor who knows both parties well. Therapy is a deeply personal endeavor and requires a significant investment of time and trust, so some people feel more comfortable working with a clinician who was recommended and endorsed by someone they know.

Public figure/ personal exposure: Sometimes clients have seen a particular therapist lecture at an event, or on video, or have read their written material, and felt that the content, wavelength, and style resonated with their personalities, and the therapeutic work they are seeking to do.

Years of experience/ expertise: Some people want to see someone with many years of experience, or who has done extensive, advanced training in a specific sub-field, so they would invest in a specialized practitioner, rather than a more general clinician.

Status /popularity: Another motivation, for some, is the perception that more expensive automatically means better—more experienced, more talented, or at least more exclusive. Sort of like “designer therapy.” (Whether this is actually true or not is debatable, and probably varies extensively by situation and each professional; popular and expensive do not guarantee competent or compatible.)

But many clients and prospective clients feel resentful or aggravated by the fact that therapists “have the nerve to charge so much.”

In truth, rates in most fields are generally determined by the interactive natural laws of a free market and human nature. For example, you can buy a garment for $10, $100, $1000 or more. Some consumers may believe they are getting more durable, beautiful, or finer merchandise for the higher price tag. Others may believe that high-end couture is a scam, and believe there's no correlation between price and quality; often the more expensive apparel is actually more delicate. Either way, we generally have a range of fees and prices we can choose to pay for any particular product. This is true of almost any good or service. Sometimes you "get what you pay for," (subjectively) and other times it’s entirely unnecessary to splurge on a name brand to get good quality.

In a utopian world, maybe we would all have enough knowledge and money to get whatever goods or services we need or want, in whatever quantity or quality we desire. That would (probably) be great. But in reality, we all have constraints—time, money, geography and availability. Yet there is usually some variety and selection for nearly any purchase. Most of my readers and I live in countries and in communities where almost everyone can access some form of medical and mental health care when needed, even without funds or health insurance.  

We tend to prioritize our spending. I see families pay for schooling, summer programs, housing, weddings, and other celebrations that they objectively could not afford, but they do it because it was something they felt they needed or wanted to do, as per their communal norms or social status. Conversely, I’ve seen wealthy individuals opt out of expenditures they could easily afford because they simply decided it wasn’t worth it to them. These are the choices we make, and we are free to make them as we see fit, based on our values and finances.

I’ve seen clients who took money out of savings accounts, or even borrowed funds because it was important to them to see a specific clinician. (When speaking with people who are considering making this choice, I try to emphasize that there are less expensive ways to get therapy and try to offer them names of colleagues and clinics.)

Now, from the other perspective: Why would a therapist “have the chutzpah” to charge a high rate for his or her time?

Well, again, it’s mostly supply and demand. With real estate, for example, your home may have an official “estimated value” but in real life, your house, product, service, or time is essentially worth what others who are interested in it are willing to pay for it. If a new, unknown therapist were to hang out a shingle and start charging $1000 an hour, she would probably attract a total of zero clients.

On the other hand, consider a seasoned practitioner who has earned a strong reputation, invested in ongoing training and supervision, and perhaps lectured, published, or been involved in communal work. If she initially accepts a modest salary or sets affordable fees, she may have the good fortune to be promoted at work or to join a strong practice. She may be willing to see clients through insurance, or with a sliding scale rate, out of kindness or to fill her schedule or both. Once she has more incoming calls than available hours, then from an entrepreneurial perspective, it’s fair and logical to raise the rates. As she accepts new clients and graduates the earlier ones, her reputation builds and her overall value increases. As long as those slots are filling, she can continually raise rates—that’s how the business end of private practice works. It could be considered cruel or elitist, to restrict availability this way, except for the fact that for every professional who grows to expensive success, there are many more up-and-coming clinicians who are also trained, licensed, and more than willing to help, in clinics and newer practices, for lower fees. So it's not a question of "how you can charge that much when you're the only one who does this?" No one (or very few) are "the only one who does this."

Most professionals, no matter the field, understand the importance of investing in education and working hard at first in low-paying, entry-level jobs, to gain experience, build credibility, and ultimately earn the privileges of promotion or eventual self-employment. We call that paying our dues. Therapy is no different from other industries in that way. Capitalism motivates providers to strive for excellence, and consumers to reward skill. The ambitious pursue professional growth. (For those who are ideologically anti-capitalism, they could back their views by intentionally visit a free clinic, thereby patronizing supporting organizations whose structure aligns with those values: If you believe health care should be free or low cost, then go where it it's free or cost. If they say: "Well, the problem is that it's not always as good there," then they now understand one of the drawbacks of socialized care.)

But of course, sometimes reality can be hard to swallow.

One frustrated acquaintance grumbled, “I don’t understand why exorbitantly-priced therapists think it’s ok to discriminate against people who can’t afford their high rates!”

To me, that sounded something like the single man who says: “I don’t understand why all the pretty women whom I would date, think it’s ok to discriminate against guys like me just because I’m not good looking!” The “not-good-looking-man” himself is discriminating against “less-pretty” women and then expressing righteous indignation at others for doing the exact same thing.

Likewise, this consumer who dismisses more affordable care and laments the cost of higher end private practice is “discriminating” against more affordable therapists, snubbing their work by assuming that more expensive automatically means better, and then getting upset that this exact, paradoxical criterion then prices him out. It’s a vicious cycle that can be pithily summed up by Groucho Marx’s famous quote: “I don’t care to belong to any club that would have me as a member.”

Similarly, I remember once apologizing to a potential client for not having any openings at his requested time. He responded, tongue-in-cheek, “I would hope not; I don’t want to see someone who isn’t full.” (We scheduled for the following month.)

As self-educating consumers, our job is to research the practitioners not only by “what people say” informally but with more sophisticated, discerning analysis. Some therapists may technically be considered more exclusive, but are not necessarily the best suited to a given case, even if money is not the issue. One could also make a case that a lesser known professional can sometimes be more eager, respectful, humble, and accessible than higher profile ones. They may have more time, flexibility, attention, and genuine interest to offer their new clients than those who are busier and more established.

Kristina Kuzmic, in her moving memoir, Hold On, But Don't Hold Still, describes how when she was a destitute single mom struggling with finances, life stressors, and her mental health, she sought free therapy at the clinic in a local graduate school. Students there were being trained and supervised intensely while providing free therapy onsite. She credits this resource as a vital lifeline when she needed it most, which played a crucial role in her recovery and eventual success.

So many smart, empathetic, motivated therapists-in-training would love to have more opportunities to help this way- I hope that in time, more clients learn about this and consider the possibility.

When there are options for insurance coverage or private pay, I generally recommend trying to request a referral from another professional you trust (like your doctor, for example) or an impartial referral service and then doing an online name search. Aside from a therapist's professional website, many clinicians will have client reviews, books, podcasts, articles, blogs, or video lectures with their research or some therapeutic content available for public viewing. This can offer a valuable sampling of a therapist’s relational style, knowledge, and professional focus.

When making the initial call, it is also reasonable and appropriate to ask the therapist or practice representative some pertinent questions about the practice and policies before scheduling a session, to determine whether what they offer is suitable to your needs.

As far as negotiation: Some professionals don’t appreciate the question, but I don’t mind at all when people (politely) ask about the possibility of a sliding scale rate. (I happen not to offer one to new clients at this time, but I believe it’s a legitimate request.) Most therapists I know “give back” to the community in various ways by volunteering time, or seeing some low-cost clients, trainees, or lectures. But that is an individual choice; not the entitlement of any one client or organization to demand.

For many, in the quest to get help, it may prove necessary to try more than one therapist, and sometimes even several, until they find the right fit. There is no one simple solution to the problem of finding the right therapist, especially when cost is a concern, but there are more options than many realize. Regardless of reputation, expertise, or cost, the therapy connection is person-specific, and so it will always be a matter of subjective compatibility.

Over the last decade or so, we have seen more of both nonprofit organizations and businesses opening and expanding to address this need for more information, access, and resources for therapy referrals and treatment options. I'm hopeful that as communities and professionals, we will continue to think and work proactively to generate more and better solutions, to increase and enhance help and healthcare of all kinds for those who need it.

*If you want to learn more about setting yourself up for a good therapy experience, check this out.*

*One of the ways in which many therapists try to make therapeutic resources available at different price points is by writing posts like this and books like THIS:)

This article was originally featured in Ami magazine.