Money and Therapy; A Very Confusing Topic

I just wrote a long draft for this post, and it disappeared, so I am very frustrated. I will try a shortened version of what I had in mind.

I started by describing a lot of potential scenarios (in private practice as opposed to clinics or training institutes or agencies) for therapists and patients to raise questions such as the following:
1. What is it about the exchange of money for therapy that directly affects the therapy?
2. With insurance companies often paying the bulk of your therapists fee, does your copay to your therapist hold any meaning for you or your therapist?
3. Is there such a thing as too low or too high a fee?
4. What does it mean for the therapy for a patient to be paying a very low fee over a long period if time due to real financial hardship?
5. Is the therapy compromised or changed when an outside party such as a parent or friend pays for all the therapy?
6. What is it like as a therapist to be mistakenly seen as very wealthy by your patients due to some misconceptions about therapists in private practice and their incomes?
7. What is it like for a therapist to have a patient who makes over twice the therapist’s income?
8. Is it wrong for a therapist to let a patient who has money problems and is paying a low fee get very far back in payments to the therapist and owe months of therapy? Who should bring up the topic?
9. Is there something strange about this scenario: therapist goes to a supervision group and pays a monthly fee 30$ more than the fee s/he charges her own supervises in the supervision group she runs.
10. What makes most therapists say no to bi-weekly (2 times per month) instead of weekly sessions and what makes a few therapists accept this scenario as well as a low fee due to the patients’ financial hardship?

In the world of many therapists the whole topic of the fee and sliding scale and how to handle the negotiations of it is hotly debated. Some say if you don’t pay attention to the fee and how it is paid you are avoiding a lot of important issues. Others have a philosophy of really using the sliding scale fee and accommodating people other therapists would never work with. I confess I fall in the category of those, the ones who lower their fee to accommodate patients with little money and at times I accept a patient coming only twice a month. In most cases it is a patient who has been coming weekly for a long time but not always. There are other reasons I have accepted this type of patient besides money issues though I agree with most therapists’ opinion that much more can be accomplished with the regularity and structure of weekly sessions. I also would never run a supervision group that did not meet weekly as I think the group process works with weekly meetings and consistency and keeps the group functioning for support as well as clinical issues.

Many years ago I read in the New York Times magazine a profile of a British therapist. I don’t remember his name or why the article was on him but I do remember him saying, ” I strongly believe that therapy should not cost more than (don’t remember the amount but it was equivalent to about $80 which these days might be around $120 as this was written around ten years ago)…” anyway I was really struck by his point. He actually thought there was a limit to a decent fair fee for his services despite his education, training and experience. Sort of like saying an ice cream cone from a truck shouldn’t cost more than 3$. This was and is very unusual in our profession to actually say that it’s indecent to charge more than a typical amount such as $100-$120 per session as your highest rate. Putting a limit on the value of therapy. Most therapist’s focus much more on the difficult issue of, can this particular patient afford to pay my highest fee and if not what can they afford. On the patient’s side, I have seen people say I don’t want to pay you less than such and such as I don’t want you to feel disrespected so this is what I could afford to pay you.

I admit I had a conversation with someone about couples therapy and how insurance companies often pay too little for it. Yes, some therapists charge more for couples than individuals. The reasoning is that couples therapy is much more difficult to do, which I think is definitely true. In addition, most couples don’t stay in therapy that long with some exceptions. While it is not unusual to have a patient in therapy for five years or more, the average couple dies not remain in therapy that long. I could diverge into a discussion of couples therapy but that is for another post. I will add that it’s not unusual for a couple to go to a couples therapist and end up with one partner continuing with the therapist individually and thus stopping their couples sessions. It is one way people kind of accidentally find a therapist they like for individual…

Back to money. The idea of going to someone’s office to share intimate details of your life and expose your self in various verbal and nonverbal ways is hard for some people to wrap their head around. Usually the boundaries of not knowing much about your therapist helps with this scenario and makes the whole money transaction make more sense to most patients. I am going to a doctor of the mental, emotional and spiritual body so of course I am paying as I would for a doctor of the “physical” body. This is how I would explain the process to a curious and puzzled Martian.

People may notice they are sometimes treating their therapist like their mother (transference) but it helps to have the distance and strangeness of the personal information mostly flowing one way, from the patient to the therapist.

I admit or confess to sometimes wracking up a large bill with a patient who is on a low fee and having a very hard time confronting the patient about it. It certainly would be easier if the patient brought up the topic. Confronting someone who has a job they work hard at and are paid little for who has loyally stayed my patient when s/he could have found someone in network on their limited health plan and now owes me for quite a few months if therapy is not easy. I also have a patient who left therapy suddenly owing me about $300. She has paid off most of it but still owes enough that I need to chase after her every once in a while.

The majority of my patients not using their insurance pay me some fee lower than my regular fee and pay it on time.

The one insurance company I am in network with pays me a little more than half my regular fee. What does this mean? Probably that the insurance company undervalues my work in a much more insulting way than any patient is capable of doing. It says with your license, level of training and experience we agree to pay you almost half your fee. If course experience usually doesn’t mean much to the insurance companies nor do they raise your fee according to inflation and cost if living.

Raising your fee is another big topic which a lot of therapist’s struggle with.

Money and therapy: big topic to be continued in the next post!

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