It’s almost the beginning of a new month with bills to be paid so let’s consider money and therapy.

Therapists that I know generally do not like to talk about money and fees. Most of us came to this work out of a desire to help others. And we often become uncomfortable with the business aspects of being in practice. The training programs I am familiar with make no mention of the business aspects of practice. So most of us went into, and many continue, practice with too little knowledge of and attention to nuts and bolts issues like fees.

I don’t recall ever considering how much money I could or would make as a therapist. In fact I had no idea when I began. That wasn’t a factor in my decision. Certainly that insurance did not cover therapy when I began practice meant that fees were lower and expectations about income more modest.

I recall something the analyst Donald Meltzer said at a workshop I attended years ago. When he was asked about third party payment for analysis, he first said that we must remember that he who pays the piper picks the tune. And though he and his colleagues were at first envious of analysts elsewhere in Europe where analysis was covered by insurance, gradually he came round to seeing that they were not better off as they had to contend with the intrusions of authorities who could change the terms under which analysis was covered without warning. Then he said that anyone entering this field planning to drive a luxury car and make a lot of money should reconsider becoming a depth psychotherapist because this work demands sacrifice on the part of both patient and analyst and that often means adjusting the fee. 

Setting fees is not a science. Fees and the business aspects of private practice are not taught in graduate school. There is not very much written about fees either. So we have to have a sense of what other therapists in our area and with our training charge, what we are comfortable charging, and how to handle those who cannot afford full fee. As someone who works long term with patients,  I do negotiate fees to accommodate need. I went through a process of determining for myself how much is enough, what I am comfortable charging patients. 

Yes, greed plays a role

Greed is an issue here; greed in the sense that no matter how noble some of our motives for being a therapist are, it remains the case that it is how we earn a living. And if we don’t get paid, we don’t eat. Therapists who rely on the compassion of strangers to provide for them are most likely going to have to find a job to pay the bills. I know of only one writer who has been willing to talk about the issue of greed in psychotherapy — Barbara Stevens Sullivan has a chapter on it in her book, Psychotherapy Grounded in the Feminine Principle. Any time I have attempted to raise the issue among clinicians, I have been met with ferocious resistance and complete disavowal of even the slightest whiff of greed as part of what we do in charging for our time.

I learned from Sullivan about the place of greed in the Tibetan Wheel of Life; greed is one of the three root delusions at the center. For therapists, denial of the importance of money and being paid can be a potent source of problems. Being unconscious about the importance of money in one’s life places a person at risk of being in the grip of unconscious greed. Openly acknowledging the importance of being paid and the desire to have enough money to live well creates the opportunity to consciously think through the issues.   Once I became comfortable with the fact that indeed I do not do my work out of the pure goodness of my heart and that I do enjoy being paid for what I do, the whole issue of dealing with fees became much easier.

Like many, I had felt almost guilty charging for my time. And as a consequence, for a long time, I set my fees too low and I was lax in collecting and in dealing with issues with patients about money. In fact, in my own discomfort with the whole subject, I was modeling for them that money was a somewhat taboo topic and I was unconsciously encouraging them to be as reluctant about paying me as I was to acknowledge that I wanted to be paid. My plumber seemed to have no problems letting me know what he charged for the work he did and that he expected to be paid on time. Nor did my dentist or my attorney. So step one was acknowledging that earning a living is what I am about, as much and often more than any of the noble aspects of working with people. This is a tough thing for a lot of therapists. How can I be “good” and openly embrace my desire for money?

Then comes the problem of what is enough? If a new patient tells me she cannot afford my full fee, we work together to find what she can afford. The fee settled on needs to be enough without either being too little or too much. 

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  1. I’m surprised that the concept of “greed” arises as if it were synonymous with “requiring payment for services rendered.” As I understand it, “greed” is the word for taking more than one needs, while aware, but unconcerned, that that “extra” is coming from what someone else needs.

    I suppose that people who are taught young that asking for most of what they desire is “greedy” might have more trouble charging for their time. But truly, the best model I have find for the question of how to charge is “what do I need in order to be able to sustain the relationships I hope to maintain with my clientele?” Generally, this requires charging at a level which encourages everyone involved to return – you, and them! That state where people receive needed services, you do the work of your heart, and enough money changes hands to inspire respect for the work and permit balance in your life, is what most folks would call win/win.

  2. Greed here is a shadow element. Many therapists wrestle with guilt about what to charge, and do so more than most other professionals. Unconsciously wanting to be paid for helping people in distress can create guilt. The desire to be the “Good Object/Parent” figure gets in the way of making a clean contract about payment and fees.

    It took me a long time to become comfortable charging for missed sessions, something which is customary among therapists. Unlike a dentist or hairdresser, I cannot just slot someone else in when someone cancels at the last minute. My patients have a time each week that is their time so in a way the fee is like rent they pay for that time, t have it available to them without question each week. Yet even though I inform people up front about this policy, more than once I have been told that it is greedy. And my fear of greed, my denial of it as an element — not the sole element but a piece of it — in being paid made me struggle with this policy for a long time.

    In my experience women therapists, especially those who are not psychiatrists, struggle more with what to charge than do men.

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