How We Pay for Therapy, or, Imagine a World Without a Fee
Clinical Impact Statement: Psychotherapy fees do not just evoke anxiety in budding private practitioners, but evoke broader racial, economic, and political tensions in society. Reflecting on these dynamics can create more room for psychotherapists to imagine how therapy intersects with politics, and how we should advocate for healthcare reform.
These were the contradictory messages I received about one of the most anxiety-provoking tasks of the budding new therapist and entrepreneur--setting your fees. The first time we set our fee often reflects how we feel about the act of charging for psychotherapy, not how your clinic, your hospital, or your supervisor are paid. But how you are paid. Feelings of guilt and shame swirl around the fee. We—especially those of us committed to social justice work as therapists—can be tortured by questions of ethics and equity. Who is being left out by my fee? Who is unable to afford my services? Do you take insurance as a way of offsetting the costs?
Most therapists come to their own conclusions about the fee. I certainly came to mine. I charge a high fee, which allows me to provide reduced fee slots. These slots are available for potential clients with whom there’s a mutual sense of being a good fit for one another, but who would otherwise not be able to afford psychotherapy.
My marketing makes my practice attractive to young adults of color, struggling with anxiety and relationships across the economic spectrum. In the end, I “stay true” to my values of social justice and serve the communities I want to serve. As I was taught by supervisors and private practice consultants, you can “be woke” and still make money, or as Anand Giridharadas echoes in his book Winners Take All, it’s a “win-win.”
So I thought.
I’ve been feeling an increasing discomfort with this system. I don’t just mean my fees, but our broader healthcare and economic system. My fees as an individual practitioner are essentially a method for wealth redistribution administered at a local level, with my practice taking on a role that the government should fulfill. They are a symptom of a systemic problem. We don’t have an equitable healthcare system that takes care of people equitably across gender and gender identity, sexuality, race and class. We don’t have full parity between medical and mental health, despite the latter’s clear economic impact on the former. We don’t have a system that addresses the racial inequality that complicates the economic inequality in mental healthcare access and provision. An inequality of intersections that produces an economy of symptoms.
No, what we have are hospitals and community centers drained of resources for the many—often poor, often Black and Indigenous People of Color (BIPOC), often LGBTQ—and the plurality of fiefdoms made up of private practitioners and group practices dotting the land for the few. Even among so-called “woke” practitioners like me, our patients can often lean higher on the socio-economic spectrum even when we serve diverse populations. Some of us yet find a balance between taking some insurance, including Medicare and Medicaid, and taking private pay clients. But the core of the issue—racial and economic inequality—remains the same.
The fee, and anxieties around it on both part of the practitioner and the patient, introduces an adversarial dimension into the therapeutic relationship that enacts social and political dynamics. Can I afford your fee, or am I excluded from your practice because of it? If I accept a lower fee to engage in psychotherapy, does that mean I will have less quality treatment? Am I more valuable, more loved, more “premium” if I can afford a higher fee? Am I a “lower” patient? These questions mirror debates in the chambers of congress, in the news, and our cultural ethos. Who is deserving of resources? Who are the cheats who “steal” our money and “live off” the system? Who needs to “work harder” in order to receive care? Who is unwanted? The patient needs treatment. The therapist needs to eat. Yet the therapist--as a stand-in for the state--has the privilege of determining the appropriate allotment of resources. Resources measured in love and money.
Of course, we care for our patients. Through their highs and lows, we grow to love them. But we never escape the fact that this love is attached to symptoms and money, their exchange and distribution. Being paid is part of the frame that establishes the therapeutic relationship--a relationship grounded in the exchange of symptoms for fees. There is, after all, a symptom economy.
We meet once (or more) a week at a certain time and place, with a certain person, for a certain amount of time (predetermined or open-ended, who knows?). Whether it is the patient’s money, health insurance, Medicare or Medicaid, money and symptoms set the frame, but it is time and the work of therapy itself that leads to love. When the therapeutic relationship ends, if it ends well one supposes, only one of these will endure. The other, dialectically, puts food on the table. Once you realize the relationship is tied to money, and the exchange of money is tied to the exchange of symptoms, you cannot look away from the fact that these symptoms are themselves produced by a system of racial and economic inequality. In the final analysis, it is the system that proliferates symptoms, creates the cycle for their exchange, produces the need for the therapeutic relationship, and puts food on the table.
Even when we offer pro-bono slots, we signal the imperium of capital by its very absence. We treat these patients because they cannot afford psychotherapy. Whatever empathy or understanding we exude, whatever our intentions, does not hide this fact.
In Freud’s Free Clinics: Psychoanalysis and Social Justice, 1918-1939, Elizabeth Danto (2005) outlines the progressive spirit of the grandfather of psychotherapy, psychoanalysis. She reviews the commitment of Freud and the first generation of psychoanalysts (many of them socialists, Marxists, and social democrats) to strengthen the social safety net and develop a “psychotherapy for the people,” essentially a form of “psychotherapy for all” in which the state provides for universal mental healthcare alongside basic material needs. Psychoanalysts of the time were expected to contribute not only part of their time to low fee or pro bono patients, but also a portion of their income to outpatient mental health clinics to provide equal treatment to the rich and the poor. Such clinics housed thinkers such as Otto Fenichel, who led seminars on psychotherapeutic technique side by side with reflections on racial and economic justice. Echoing Freud’s call in The Future of an Illusion, they imagined a world that was “no longer oppressive to anyone.”
Can we imagine such a movement for psychotherapy today? Psychotherapists across schools of thought complain about managed care. We share war stories of fighting and arguing with insurance companies, of procuring those needed sessions or that medically indicated in-patient stay. We write our parent organizations—whether APA, ACA, or NASW—to advocate for fair and equitable reimbursement. But do we ever stop to ask, or even dare to dream, for a better system? A system that removes the profit motive from healthcare provision? A system that makes psychotherapy, as Freud once wrote, as available as lifesaving surgery? A system that makes both freely accessible? A system that makes both--paradoxically--less necessary by slowing the cavalcade of symptoms produced by inequality?
Is it really that “radical” a thought for a Puerto Rican therapist who’s witnessed the divestment of literally trillions of dollars to corporations in the midst of a pandemic, billions of dollars in a militarized police force, bloating the wealth of CEOs into the trillions while poor, BIPOC, LGBTQ and immigrant peoples struggle? To raise the question of whether we can afford a “psychotherapy for all”? To go even further, to blasphemously advocate for less need of our services? That we can afford reparations for Black and indigenous peoples? That we can afford canceling debt and hold a universal jubilee across the student population and the people of Puerto Rico? That we can have race-conscious universal systems and population-specific programs that work?
Questions of psychotherapy and social justice must go beyond traditional discussions of accessibility and diversity. Yes, it is important to address mental health and cultural stigma. Yes, it is important to address clinician’s biases in terms of race, gender, sexuality, and class. But the problem of psychotherapy and social justice is not confined to what exists between people’s ears—whether patient or therapist—but the very world that makes racial and economic inequality possible. “Barriers to treatment” are not limited to local communal dynamics or the immediate structural lack of specific hospitals, clinics, or practices. It is grounded in questions of policy, economics, and power. Is community psychology important? Absolutely, more than ever. But what about a materialist psychology? A psychology of political economy? Of wealth redistribution? Of power and policy? In the time of COVID-19, one need not be a Marxist or a Democratic Socialist, a liberation psychologist or a theologian, a prophet or a martyr, to see how broken our mental, medical and economic system is in the United States.
Is there a lot we can learn about the patient’s lifeworld and ways of being from their reactions to the fee? From our own feelings around the fee? Absolutely. Exploring such feelings can be mutative and useful in psychotherapy. However, I maintain that a world in which psychotherapy is available to all will be no less rich in opportunities to explore fantasies and associations, to elucidate automatic thoughts, to practice skillful mindfulness, and analyze the chain of feelings, thoughts, and behaviors that link our moment to moment lived experience. A world in which psychotherapy is available to all may also be a world in which psychotherapy is less needed. And even then, there will be no lack of material to work with.
Will I continue to charge and raise my fees over time? Definitely, if I want to eat. Will I continue to offer psychotherapy at reduced fees for folks I can help? Without question, if I want to be true to my values. But I would be incongruent with those values if I did not also advocate for a world in which managed care did not dictate research and treatment, where private insurance was optional, where insurance did not chain you to a job, and where fees were a formality. Ideally, if I may allow myself a flight of fancy, to imagine a world without a fee.
D.W. Winnicott is famously quoted as saying, “there is no such thing as a baby,” outside the parent-infant relationship. We might add that there is no patient-therapist dyad outside of a matrix of social, cultural and economic relations. When our patients express feelings of alienation in intimate relationships, their experience of discrimination and oppression based on gender, sexual, racial, and class (among other) difference, we bear witness to the proverbial canaries in the coal mine.
Will we listen? Or play with platitudes, cash a check, and call it a day? I argue for a different kind of listening that listens to the patient and the world their symptoms point to—a world in need of radical change. And if listening in the therapeutic space is a form of love, then how is listening on this register not more so? If the reduction or end of symptoms signals an end to the therapeutic relationship, then saying goodbye becomes the deepest form of love--a willingness to let go while keeping the patient in our heart. The end of an economy of surplus symptoms, in turn, would signal the end of psychotherapy in its current form; letting go of the privilege associated with our place in the economy may also be a form of love. If helping the patient put their feelings into words to build a life worth living is a form of love, then how much more loving would it be to build a world worth living in?
You could almost call that therapeutic.
Cite This Article
Gaztambide, D. (2020). How we pay for therapy, or, imagine a world without a fee. Psychotherapy Bulletin, 55(3), 31-34.
Danto, E. A. (2005). Freud’s free clinics: Psychoanalysis and social justice, 1918-1939. Columbia University Press.