We live in an era that has been inescapably shaped by the COVID-19 global pandemic. Indeed, the anxiety and depressive symptoms of Americans rose by over 25% through the pandemic (CDC, 2022). While telehealth surged during the pandemic, there continue to be challenges for many individuals and families regarding the affordability of mental health care. As a result, many of the conversations about mental health care have shifted towards improving access and affordability as well as reducing barriers to care. These are not new conversations; however, there is renewed interest in pushing for greater access to mental health treatment, especially for communities and individuals that have been historically marginalized. While researchers continue to demonstrate that psychotherapy is beneficial for many clients (Wampold & Imel, 2015; Barkham et al., 2021), how can one reap the benefits if they don’t have the ability to afford the service?

For over sixty years, there has been a persistent and pervasive narrative regarding how payment impacts the effectiveness of psychotherapy. Many traditional perspectives of payment for psychotherapy suggest that fees are necessary to motivate clients to change, and that the absence of payments will be detrimental to the therapeutic process. Cognitive dissonance theory, a common framework for evaluating the relationship between payments and therapy outcomes, suggests that charging money for therapy will allow clients to better engage in the therapeutic process given their investment (Davids, 1964). Simply, clients may invest more personal energy into the process due to the financial commitment to therapy (Goodman, 1960; Gumina, 1977). Freud (1958) contributed to this rhetoric, stating that “It is a familiar fact that the value of the treatment is not enhanced in the patient’s eyes if a very low fee is asked,” (pg. 131). This traditional way of looking at how payments impact therapy outcomes has consistently placed financial burden on clients and suggests that payment is a necessary aspect of the therapeutic process. This thinking further marginalizes clients who have fewer financial resources and who face financial barriers in accessing mental health care while also contending that low-income clients who are not paying for therapy will not see beneficial outcomes. 

Paying for psychotherapy has historically been a meaningful barrier for marginalized communities (Whaley & Davis, 2007). Low income, BIPOC (Black, Indigenous, and People of Color), and LGBTQ communities have faced serious challenges in being able to afford and find access to psychotherapy services. Cook et al. (2017) examined trends in racial/ethnic disparities regarding access to mental health care and found significant increases in disparities in Black, Asian, and Hispanic groups compared to their White counterparts on the three measures of mental health access and utilization (use of any mental health care, any outpatient care, and any psychotropic medication in the past year). Consistently, in a population study of Canada, Netherlands, and the U.S., it was discovered that many more U.S. respondents, especially those coming from low-income backgrounds, reported financial barriers in seeking mental health treatment as compared to individuals in Canada and the Netherlands (Sareen et al., 2007). These examinations of mental health care access for individuals from historically marginalized populations provides further evidence that these tangible barriers do not affect all individuals in the same way. 

As compared to historical perspectives, modern research has shown that fee paying does not necessarily have a significant relationship to outcomes and usage of psychotherapy services. Clark and Kimberly (2014) found that the amount of fee paid did not predict outcomes or attendance in therapy for low-income individuals attending a marriage and family training clinic. Some psychotherapy providers utilize a sliding fee scale to help ameliorate any potential negative effects (dropout rates, outcomes, attendance rates) that fee paying can have on clients. At the same time, research has shown that even sliding scale fee paying does not necessarily have a meaningful relationship to client outcomes and experiences. Johnson (2020) found that there was no significant relationship between a fee that was based on a percentage of income and dropout rates, while Aubry et al. (2000) saw that sliding scale fees set by income showed no evidence of influencing use of services or treatment outcome at follow-up. This literature suggests a movement away from the historical perspective of fee paying on therapy outcomes, in that sliding fee scales and other forms of dynamic payment still do not seem to have any relationship to engagement in therapy and client outcomes. 

Considerations Moving Forward

Much, if not the majority, of the data that comprises studies that examine psychotherapy outcomes and accessibility in relation to fee paying focuses on clients who are actively paying. One recommendation for future studies is to put a greater focus on communities or individuals who are not paying for therapy; what do outcomes, attitudes, and attendance look like for clients who do not have to worry about financial considerations for psychotherapy? Does the absence of fee-paying offer individuals greater opportunity to engage in the therapeutic process? Addressing these questions could provide further insight into the role of fee-paying in therapy and challenge the dated perspective of fees on therapy outcomes. Additionally, new technology companies, like SonderMind, have created very large research-practice groups where data from clients, providers, and payers can advance our understanding of this issue at a larger scale.  

Additionally, we can better understand fee paying as a matter of social justice and a call to action for our communities. Can we live our mission as ethical and multiculturally oriented psychotherapists if we are complicit in a system that makes mental health care inaccessible for some of our most vulnerable populations? In what ways can we actively resist these inequitable structures? This continued discussion can help clinicians and researchers alike break the rhetoric of payment being a necessary part of the psychotherapeutic process, challenging barriers to access for marginalized and low-income individuals seeking mental health treatment.

If you are feeling overwhelmed with this information, or stuck on how you can be helpful, you are not alone. We recognize that fee paying for psychotherapy can build or break the livelihoods of providers and organizations. We live in the complex economic system of capitalism that often undermines the inherent value of human worth. Providers should be compensated for the good work they do with clients. However, we believe there is likely a middle ground that advances      accessibility, affordability, and utility for clients, particularly our most vulnerable ones. As such, here are some practical considerations we can offer.

At the organizational level, ask the question: how many clients can we provide treatment without fees? Organizational structures typically operate on thin margins; thus, we understand this is not a small feat. However, organizations should entertain this question and find ways to help work towards some feeless treatments. At the individual provider level, ask yourself the same question – would you be able to take on a few (one) clients for free? How might you advertise the ability to take on a few clients without fees, and where would advertise that information? While one person, or one organization, may not be enough to move the meter on population health, that does not mean this is a fruitless effort. If we can achieve a critical mass of people who are committed to equity and access, it seems very possible that we could move that meter in meaningful ways. To support these efforts, it would be ideal to have a network or community of psychotherapists/organizations who engage in this practice to elevate attention to this needed issue. A network could also be a platform to help raise money to support therapists to provide more sessions at no financial cost. Crowd sourcing has been productive in many other areas, such as politics, cancer support, etc. 

It isn’t practical to expect that clinicians take on the full burden of providing payment free services without the support from policy changes that can help to compensate providers. 

As a broader body of psychotherapists, how might we continue to think through the ways in which we can advocate to lawmakers and insurance companies to address the embedded structural inequities pertaining to things like deductibles and copayments? This tension is important to understand, and it ultimately references a greater systems level issue for clinicians’ ability to advocate for their clients. In saying this, we hope this article continues to provide discussion around how we, as a community of researchers and clinicians, can imagine new policies and a shift in economic priorities that develops a world that can fully support providers and clients without fear of financial repercussions. 

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Caity Roe, BS

Caity Roe is a Master's study at the University of Denver's Counseling Psychology department. She is pursuing a research specialization within the MA program.