In response to my last post, one reader commented that when therapists come from a position of “bounty”, they will be willing to reduce their fees for clients who can’t pay. Whether you agree with this statement, it suggests that the therapist must first have “enough”, whatever that may mean in his or her personal circumstances, maybe even more than just enough, in order to feel bounteous. Therapists must feel that their own needs are being met and that they have enough left over to give to their clients. This seems unquestionably true, although I suspect my views on “enough” and “bounty” differ from this reader’s meaning. I also believe that “enough” will be a different amount for different people; it’s not a case of one-size-fits-all.
My decision to become a therapist was not based on a drive to help people, although I enjoy that aspect of it very much. I pursued training as a psychotherapist because I could think of no other career that would fascinate me so much, hold such personal meaning and also earn a decent living. I wanted to marry, have children, own a home and provide for my family. At that time, I lived in Los Angeles on the west side of town; I went to graduate school and built my practice there. Life in West Los Angeles was and still is expensive. “Enough” to afford those things in that area meant earning quite a lot of money; even if I had charged very high fees with a full practice, I never could have done it alone. Ours was a dual-income family, as were most families we knew at that time. A therapist living in a small town in Indiana might need quite a lot less than I did in order to have “enough”.
Then there’s my emotional need for compensation, to feel the reward for having worked so hard to get here. I spent six years in graduate school. During those years, I worked 35 hours per week in a law firm, saw clients in a low-fee clinic and attended classes in the evening; I studied all weekend. My education (including my training analysis and individual supervision) cost about $30k per year during the 1980s; my parents helped with about $5K and I earned the rest, in addition to supporting myself. I took out no student loans, though many students finished graduate school with large debts. I don’t claim to be a special case. Most therapists-in-training I knew worked as hard, sacrificed as much and earned as little as I did. My goal was to sacrifice and work hard during those years in order to have meaningful work and a nice standard of living later on. If money had counted less, I would’ve become a writer and lived hand-to-mouth — hard to do if you have a mortgage and a family to support.
I’m not one of those people who feel that doing the work is its own reward, nor do I see psychotherapy as some special professional case, different from other professions. At that time, a first-year lawyer, just graduated from law school (3 years) and passing the bar, would’ve earned $60K per year; a staff physician at a hospital, fresh out of medical school (6 years including paid residency) earned even more. Give my six years in graduate school, it seemed to me that a comparable income would’ve been in order. Unfortunately, the laws of supply and demand dictated otherwise, as discussed in my last post. I never earned a six-figure income, as lawyers and doctors regularly do. By no stretch of the imagination was I ever wealthy. With both our incomes, we had enough to live in a nice home and have a very nice (but not extravagant) standard ofliving. All the while, I was teaching for free, sitting on the board of my insitute for free, and supervising interns for free. Financially, we had enough, just, but I never felt as if I was in a place of “bounty”, either emotionally or financially, where I had so much that I could sacrifice my own needs to those of my clients. I’ve never known a parent of small children who felt bounteous.
I knew an independently wealthy psychoanalyst in England who charged his patients nothing. That’s one extreme; he really did come from a place of financial bounty. On the other extreme are psychiatrists who see four patients per hour for a med eval and bill the insurance company $100 a pop, never dealing with the question of the client’s ability to pay. Somewhere in the middle lie the therapists who must work in a competitive field, obey the laws of supply and demand and try to see that their own needs are met while tending to those of their clientele. Given the emotionally demanding nature of the work, it’s crucial to make that effort; in my experience, therapists don’t succeed very well.
First of all, in most metropolitan areas, our profession is over-crowded and we feel (with some justification) that we’ll lose the client if we don’t cut our rates. That’s the way the law of supply-and-demand works. (Once you’re well-established and have a good reputation, that pressure becomes much less.) On top of that, most of us are vulnerable to the expectation that we ought to take care of our clients; if they can’t afford to pay full fee, we owe it to them to reduce it. The “savior complex” is a common professional neurosis. Clients in great need and pain also place heavy emotional demands upon us; if you’re a compassionate person, even if you actually believe it’s acceptable to refer the financially-challenged client to a low-fee clinic and work with the full-fee clients, most people will feel some degree of guilt about it. I believe this has to do with politically correct and misguided notions about “selfishness” and “greed”, but that’s a post for a different day.
Many of my therapist-clients felt that kind of guilt; many of them also felt resentful working for very little money after six years of graduate school and $100K in debts. Some spoke with angry resentment about their own clients who expected them to work for minimum wage. As a result, some became depressed; others worked themselves to the bone, suffering emotionally and physically. Others moved on to find another profession. The work of being a psychotherapist is emotionally difficult and financially challenging — that’s the reality. And yet, there are readers such as the one who responded to my last post, who expect their therapists to reach some mythical level of self-actualization and emotional bounty where they’re in possession of such internal riches they want to give emotionally to their clients and at the same time cut their fees. It’s a highly idealized view, and one many people long to believe in.
I don’t. I believe that the ideal mommy/daddy therapist is a myth. Some of us care deeply about our clients and give enormously of ourselves; but we’re real people with real needs that we must attend to if we’re going to continue giving our clients what they need.