What You Pay For

I read an interesting post called What You Pay For, the other day on the blog What a Shrink Thinks.  While the shrink-author says many things that I take exception to, the one I’d like to deal with today is exactly what the title says:  What are you paying for when you pay a therapist or counselor (and for the record, I use the terms counseling and therapy interchangeably)? The blog author’s take on the issue seems to be that a client mainly pays to have the therapist keep their own issues out of the room.  I’ve been pondering that answer for a while now, and finding it lacking. 

Photo by Joe Houghton

In my experience as a therapist and as a therapy client, I’ve come to believe that the client pays for a lot more than someone to talk to who won’t try to get their own needs met in the conversation.  Yes, that’s an important part of therapy, and I would not want to be or to see a therapist that attempts to get their personal needs met during their clients’ sessions.  But let me add a few things to the list.  Here are some other things that I think the client (ideally, at least) should be able to expect from their therapist:

• The therapist’s time.  Most therapists would not have time to see clients if they could not make a living at it.  They would have to go do something else for a living. 
• A helper who knows how to help.  A therapist is not a friend or a family member or a concerned acquaintance, or anyone else who happens to be part of the client’s life when they find themselves needing help.  A therapist should have extensive training for and experience in helping people who are suffering.    
• A commitment to the client.  I think a client should be able to rely on their therapist to stick with them.  To keep their best interests primary.  Even when the going gets tough.  Even when life events and/or the work itself makes it hard for either party. 
• Caring.  OK, this is the part where people tend to say that therapy is like prostitution.  The client pays for the therapist to care, and if they didn’t pay, the therapist will stop caring.  I don’t see it like that.  I think that if the therapist and client agree to work together, then the therapist is making a commitment to try their very best to care for that client.  Usually it isn’t hard.  When you really try to understand another person, genuine caring typically emerges naturally.  And when it doesn’t, that lack points toward a direction for the therapy that should ultimately allow such caring to develop.  If the client stops paying after caring develops, then let me tell you that the caring doesn’t stop, even if the payments have to.

I think that the exchange of money for therapy is hard to accept (for clients and therapists both) for a couple of reasons.  First, most of the interaction in therapy is so intimate and social.  Research shows that we view money very differently in a social setting than we do in a professional setting.  Asking for money in a social setting is often quite offensive (e.g., imagine trying to pay your mother-in-law for your thanksgiving dinner at her house).  So, having a fee be part of this thing that is predominantly so social can feel just plain wrong.  However necessary it may to make the whole set up workable.

Also, I think clients can feel a certain amount of shame around not finding the help they need in their personal lives.  “I’m so pathetic that I have to pay you to listen to me, because no one else will. You wouldn’t listen either if I didn’t pay you.”  It breaks my heart whenever I hear this.  Here is where therapy most feels like prostitution, in my opinion. 

Having been both a therapist and a client, I have come to believe that this feeling is due more to shame on the client’s side, than to the willingness to listen on the therapist’s side.  As a therapist, I don’t feel like a prostitute.  Here I’m going to paint prostitutes with a probably unwarranted broad brush, and assume that they would all rather not provide the service they provide, if they had other options for acquiring similar money: As a therapist, I don’t feel like I’m giving up something that I’d rather not give up.  In fact, I feel the opposite.  I wish I could be in a position to provide therapy to whomever could benefit from my help, without regard to compensation. 

What do you think of the fee for service aspect of counseling?

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Peg Shippert is a psychotherapist in private practice in Boulder, Colorado.  She loves her work, and has a deep passion for helping survivors of sexual violence.   

What if I Can’t Afford Counseling?

Unfortunately, a sad truth about counseling is that it can be expensive.  In Boulder, CO, where I work, typical fees for a 50 minute session seem to range between about $90 and $150. If you don’t have health insurance that covers counseling, or don’t want to use it (for example, if you are a teen who doesn’t want to involve parents, or if you don’t want a of record of your counseling history), or if you’ve already used up the few sessions your insurance covers, then what do you do?

The first place you may think of for low-cost counseling is a community mental health center. If you have a serious mental health problem, and limited resources, it is definitely worth checking with your local mental health center to see if they can help.  Unfortunately, mental health centers are usually overtasked, and underfunded.  Therefore, it may take some time to receive services at a mental health center.  

But don’t assume that that is your only option.  People with less serious needs, and/or some resources, may find that it is also possible to find relatively low cost counseling from other providers.  One option is to look for counselors who accept sliding-scale fees. This means that the fees are adjusted depending on the client’s ability to pay.  Other counselors may offer lower fees for a limited number of sessions, for clients with temporary financial difficulties.  Some counselors who accept these lower fee arrangements may be less experienced, but still well trained and qualified to work with you.

One way to find counselors in your area who offer a sliding fee scale is to search the Psychology Today Find a Therapist web site.  You can search by zip code, or state and city.  Then check the profiles of the counselors you find who look good to you.  In each profile there is a Finances section that shows their typical fees, and whether they use a sliding scale.  If they do, then it might be worth calling them to see if they will accept what you can afford to pay.  If not, they may be able to refer you to someone who will.

If you are lucky, there may be counseling organizations in your area that help you find low-cost counseling.  For example, in Boulder there is a counseling cooperative, called Boulder Counseling Cooperative, to which you can pay a modest annual fee ($50 to $125) and then relatively low per-session fees ($20 to $35).  The fees you pay depend on your income, and the counselors are well qualified, licensed professionals. 

Have you found affordable counseling in other ways?  Write in and let us know how you found it.

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Peg Shippert is a psychotherapist in private practice in Boulder, Colorado.  She has a deep passion for working with survivors of sexual violence and other traumas.  She does offer a sliding fee scale.