Therapy services: Money talk - Counseling Today Archive

Here’s a topic that professional counselors love to talk about and don’t feel awkward at all bringing up: Money!

Let’s get it out there and acknowledge that in the counseling profession, money isn’t fun to talk about. That’s because the nature of our business is a sensitive one. We’re not selling the public “goods,” we’re providing a service. And this service isn’t a run-of-the mill one like doing your taxes or grooming your dog. We’re working with you to heal some of the most painful parts of your life. We’re helping you cope with tragedies. In some cases, we’re trying to keep you alive. It’s because of the sensitivity of the work we do as professionals that we can often feel “bad” for charging you money for this service.

Among my therapist friends, we frequently talk about our fees and all that comes with it. We go into this profession to help people. Still, reality comes in and we have to balance our hearts with our checkbooks. We have to reconcile that in order to use our skills, we have to pay our bills.

Speaking of bills, as therapists, we sure do have a lot of them. Some standard ones: student loans from undergrad, grad school or both, the costly liability insurance required to operate, the licensing fees, the required continuing education courses, our HIPAA (Health Insurance Portability and Accountability Act) secure phone lines, email and practice management software, marketing and advertisement costs, office space rent, material for clients — things add up. This doesn’t begin to touch the normal living costs we all have to consider such as other bills, mortgage payments, health insurance and food.

As counselors, we know that we need to make money to live, but that guilt when we have to raise our fees or charge a client after a particularly emotional session is real. Something I try to remind my therapist friends (and myself) of is that at the end of the day, we are a business. It feels gross to say that because what we do feels like more than that.

However, when I think of all the people who are doing such hard work and seeing such positive change in their lives, it helps to reassure me. To stay in this business and stay available to use my skills to help people who are changing their lives for the better, I have to keep my lights on and pay my bills. I love what I do and am glad that I can keep doing it. I worked hard for these skills so that you can work hard to get better.

Even so, this question can be and needs to be explored in deeper context: Why isn’t mental health therapy more affordable?

Why isn’t mental health therapy more affordable?

This is an important and complicated subject. To start, as stated above, therapy is a service just like any other. Therapists are doing a job, and to do that job, they need to be paid a fee. But why can that fee seem so high?

If you think about the structure of therapy and compare it with similar industry services — such as CPAs, attorneys and other professionals whom you pay for providing a service rather than a product — it begins to make sense. Instead of selling a product, we’re selling time and expertise.

We don’t question why attorneys charge so much for their time. We understand that they had to go to school to become the best at their craft. In turn, we pay for access to that knowledge. The same holds true for professional counselors and other therapists. We had to go through extensive training and schooling (and accumulate substantial debt) to master the skills to serve you in the office.

Even so, this argument can feel shaky when we apply it to therapy because there is an assumption that therapists should be more compassionate to the needs of the population. Good mental health should be a human right, so why not cut people a break and provide these services at discounted rates so that more people can benefit for longer? After all, this is mental health — shouldn’t everyone be given the tools for better living?

Without a doubt, mental health services should be accessible to everyone and finances being a barrier is a societal ill. What isn’t always understood is that therapists also fall victim to this conundrum. We do not benefit from society not valuing mental health services.

Believe me when I say we wish we could provide all of our clients with a reduced fee. What makes this impossible is that most therapists whose fees are the highest are in private practice. There is no product to sell to make their profit, so it is their time and service that become their only source of income. Without a salary and a steady paycheck from a corporation, they rely on their fees alone to cover the costs of running their business, as well as the leftover income to pay their bills and support their families. This puts them in a bind.

What can be done?

This bind is one that could be remedied if mental wellness and mental health were prioritized by our society. For example, if the government had programs that supported mental health professionals and supplemented our incomes, we could reduce our fees and more people could be seen without us requiring assistance to live. If programs were created to provide mental health allowances to individuals so that services didn’t have to be paid for out of pocket, that would be another great way to allow therapy for all. If insurance companies raised their rates and paid a livable reimbursement rate for therapists (more on that later), more of us would accept insurance and our clients could pay less.

I hate the way that mental health is devalued in our country. Those of us who are therapists got into this field because we want to help people, and we’re aware there are whole swaths that we can’t reach. If we did, we couldn’t be in business for long, and then no one would benefit. I am hopeful though that change is coming. The more vocal people become about wanting mental health rights, the more likely we are to see them given.

If you’re looking for a professional counselor or other therapist and finding that the finances are not working out, I encourage you to ask if the therapist is able to offer a sliding scale or reduced fee. Until then, I know it’s a bummer seeing that price tag. We don’t like it either.

Why many therapists don’t take insurance

It’s true that you can find therapists in private practice who take insurance, but it won’t always be the case. Previously, I touched on some of the reasons behind the fees that therapists charge. Now, I’m going to explain why we don’t always accept insurance as a way to cover those costs.

If a therapist wants to accept insurance, there is considerable time and cost associated with this form of payment. To begin with, therapists have to apply to insurance companies in order to take their insurance. This process is complicated and lengthy. It can take anywhere from four months to a year to get approved. An insurance group will approve a therapist only if it recognizes a need in that area for the therapist’s services that isn’t already filled by another provider. It is common to be denied because there are already enough providers in the therapist’s area.

If you are among the chosen, the process gets more complicated from there. You must sign a contract with the insurance group and agree to a fee schedule. While I can’t share the specific fees that insurance companies pay to therapists, it is almost always less than what a therapy session costs. In fact, it can be anywhere from one-third to one-half of what a therapist normally charges for their services.

Additionally, therapists are not actually paid when they render the service to the client. After having the session, therapists must complete a time-consuming process of medical billing to submit a claim to the insurance company requesting pay for the service provided. Depending on a number of factors, the insurance company can deny the claim. In that case, the therapist has then worked for free. If an insurance company does approve the claim, they pay the therapist weeks later.

Mental health therapy agencies and group practices that have specific medical billing and coding teams have the time to dedicate to this complicated process. Providers who work with these agencies are also usually paid a steady salary so that the delays in insurance payments are not felt as acutely. That’s why you are more likely to find providers that take insurance in these settings.

In contrast, private practice therapists usually forgo these challenges because the cost in time and money does not make for the most efficient business practice. Self-pay among private practice therapists is simply a lot easier. In addition, insurance companies require therapists to diagnose clients in the first session and submit that to the insurance company or else services will not be covered. Not all therapists (or clients) agree with this practice of requiring a diagnosis, so this is another barrier to accepting insurance.

No surprise, this is a broken system. There should be alternative affordable systems in place to make therapy accessible to all people who want it and feasible for all therapists to provide it. Some therapists try to lower the barrier of finances by doing pro bono work or offering reduced-fee sessions.

Reduced fees and pro bono work

Therapists are encouraged by their codes of ethics to provide a portion of their sessions at a lower cost or, if possible, to offer some services pro bono (free).

Because we have limits to how many services we can provide at a reduced fee or for free, there is usually a cap on the number of clients who can receive this benefit at a given time. This depends on the individual therapist’s finances and choices, but most therapists will have a line on their business page stating whether they are open to “sliding scale” fees. This means that therapists will work with clients to determine what they can afford.

Sometimes this sliding scale comes with stipulations such as a set number of sessions or a set frequency, but talk with your therapist about what they can do for you.

Pro bono services work in a similar fashion. Therapists can provide some services for free, either directly or in a more generalized setting such as providing services for a charity, school or church.

If a therapist does not currently have any open slots for reduced-fee work, don’t lose hope. Whenever those clients graduate or phase out, those spots may become available again, so be sure to keep asking your therapist to be put on a waitlist for such services.

If you are a therapist and don’t currently provide these services, I highly encourage you to reconsider. I offer several reduced-fee spots on my caseload and am glad that I do because, as stated previously, therapy should be accessible to everyone.

Money talk as therapists is not fun, but it is necessary. If finances are a barrier for you to receive services, I encourage you to be honest about that with a potential therapist. We truly do want to help, and most therapists will work with you to get you the help you need. Now that you’ve been given some insight into the financial workings of this field, I hope you will have the confidence to seek help if you’re a potential client and to provide help if you’re a practitioner.

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Related reading, for counselors:

“Finding balance in counseling private practice“
“Pro bono counseling: How to make it work“
“I want what I’m worth“
“Exploring and changing money shame“

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Stephanie Cox is a licensed mental health counselor in Florida specializing in therapy with children, families and adults with mild to severe mental health and relational issues. She holds a degree in psychology from the University of North Florida and a Master of Science degree in counseling psychology from Grand Canyon University. Contact her via:

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.