The Mythical Therapist

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.

Joe is the author and the owner of AfterPsychotherapy.com, one of the leading online mental health resources on the internet. Be sure to connect with him on Google+ and Linkedin.

Good and Bad Reasons to Take an Antidepressant

Many people take antidepressants, not because they’re depressed, but because doing so helps them to avoid confronting important feelings or problem areas in their lives.

The Mostly-Bad Mother

Thoughts about preserving the “good” bits of the mostly-bad mother.

Defense Mechanisms V: Idealization

Idealization reflects a drive to escape from an internal experience felt to be unbearable and to connect with something perfect. This defense mechanism may take aim at another person, an actual experience or one’s own self.

44 comments

    I value my therapist with the highest regard and respect. The difference I have experienced in my life as a result of my work with him is priceless and I would not consider asking him to reduce my rate any more than I would ask any other professional to reduce their rate. I would rather cut back on other purchase to be able to pay his full fee. He is highly skilled and deserves the competitive fee he charges.

    As you can see, there are many readers who disagree with that point of view, but I thank you very much for sharing it here.

    Thank you for this post. The business of being a working therapist is something I think about a lot, especially now that school loans have come due. In my experience, the selfless therapist myth is pervasive. I think part of it has to do with the unique nature of the work, which entails, at its core, an intimate relationship that is both real and unreal. It’s a strange arrangement, and one that patients are unlikely to encounter anywhere else in their lives. Friends, family and other intimate relations “care” for free. I wonder if confusion about the true nature of the therapeutic relationship has something to do with the myth? I was curious what you thought.

    You’ve hit the nail right on the head. It’s a unique relationship that involves intimate emotional caring with payment. I don’t think it’s possible to do good work with your clients if you don’t care about them. And yet I also need to be paid for the work I do. It’s an important subject to take up during treatment, and in my experience, it comes up again and again.

    I think the biggest fallacy about therapy is that it’s just sitting and talking and caring about the patient (that it is & especially moreso when your theoretical orientation bends that way 99.99% of the time). But the majority of therapy is using tools and skills that therapists-in-training learn … it’s like saying – anybody can stick a needle in someone’s arm & draw blood so nurses and medical doctors shouldn’t get paid.
    No one says firefighters shouldn’t get paid well yet therapists handle the emotional and mental well-being of their clients (well co-handle as well as guide). It’s overly idealistic of people to want someone to pay $100K+ for an education and career then ask for free services. Further, IMO patients/clients paying for their therapy is another way of enabling them to be responsible for their own mental and emotional health. Lastly, people value things that have a specific value attached. Free, with its absence of value, is not value enough to not waste time, money, and good therapeutic skill on someone not ready, willing, or able to invest in their mental and emotional well-being (99.9999999% of the time … plus this is why its suggested therapists do a certain amount of pro bono work – right?)

    RJ – you wrote “It’s a strange arrangement…”, and no doubt it is. However there is another situation where it occurs. Christian clergy provide counseling services to their congregation members, and often to anyone else who asks, for free. Well, ‘free’ in the personal, immediate sense. Compensation often comes in other ways, to the church or through estate bequests.

    But the odd intimacy of counseling is very much mirrored in the clergy. A medical emergency, death, suicide, trauma, depression, arrest… clergy get a call by someone in the family. And the good ones and often the bad ones show up at the door, in the hospital, wherever. Sometimes they are really not wanted (grandma or crazy Aunt Susie made the call). Sometimes they are worse than useless, but sometimes, surprising everyone, they are comforting and helpful.

    Psychologist are not alone in their ‘odd’ intimate relationships with almost strangers.

    Thankyou for sharing your experiences as a therapist. I felt grateful to be reminded that regardless of whether a therapist or not it is important to allow another to meet their own needs first. It means that I can get on with meeting my own needs whilst be open to them re-engaging first. Not every session needs to be a block-buster. I also felt sad that as a society we often value our bodies more than our minds and our souls.

    Hello again . One thought that comes immediately to mind is that the med school administrators should be honest with their students and give them info about what kind of income they can be expected to make in the various specialties available to them, from heart surgeon on “down” to family internist . Discuss where “psychiatrist” fits into that model .
    Second , the psychiatrists that pull in the largest incomes are those , as you mentioned, who become strictly medication consultants . They charge a hefty fee to see a patient for about 20 minutes, and leave the actual talk therapy to the social worker or family therapist . If the psychiatrist wants to do the talk therapy, he will not be able to see three patients in one hour and therefore two things will result: he won’t make as much money, and he will be competing with other talk therapists for clients: psychologists, social workers, marriage and family therapists , etc. who charge less and may offer sliding scales.
    The result in today’s world is that the “talk therapists” do most of the therapy and refer their clients who need to be evaluated for meds to psychiatrists for just that portion of the therapy. This has resulted in a paradigm in which the psychiatrist who expects to make a good income as he expected to make after spending the time , effort and money to become an MD can end up with a frustrating choice: either focus exclusively on medication management , or accept the fact that if he handles the ” talk therapy” part , he will be competing with other types of therapists who charge less. And to top it all off , for many years there has been a movement to allow non MD therapists to receive training in psychotropic medication and be allowed to prescribe meds.
    The med schools need to make this situation crystal clear to students when they are deciding on a specialty!
    Having said all this , I am wondering dear Joe , in what other situation you found yourself being expected to “give” more of yourself than should be appropriately expected? How is this frustrating situation in which you find yourself as a psychiatrist , feeling somewhat resentful, trigger the feelings of an earlier situation in which you felt the same feelings , and were possibly trapped with no way out?
    This is your second blog on this topic. What are you working through?
    Thank you for your service to others and for your starting a blog site in which you offer a place for your readers to obtain much needed information about many useful psychological topics — for free! We are most appreciative.

    I think the people you speak of need a good deal of therapy. There are ways of working through resentment. What would you say to these people if they presented as clients?

    i appreciate what you are saying totally and think this is the most difficult thing for anyone in therapy, and for anyone that works as a therapist,

    cost its meant to be a safe place where you can explore your most deep wounds, that are based in the most childlike (i dont like the word infantile, culturally it is often used at others to shame them, so it has become a bit of a weapon word in society) places in us.

    BUT the hard thing for the client is to learn that yes we can finally open into those strong feelings have been pent up and suffocated and imprisioned for so long and have been begging like a starving naked child alone and in the dark,to be heard, and now they can finally see a safe place being offered BUT there are massive limits and control needed when they come out!and the child part of us can take over , and thats where a really good and well trained therapist is needed so that those feelings can be negotiated safely

    personally i think its always going to be one of the hardest things in therapy, on the one hand providing a safe place for these massive childlike HUGE deluge of emotions and needs to come up,

    on the other hand keeping the client aware of “reality” the reality of the “contract” whilst this is going on, i dont know how therapists do their job if im honest! but i suppose thats all part of the long training and clinical hours that are part of becoming qualified,

    i think its totally understandale and expectable that clients go into the mythical therapist thinking, as we are opening into such childlike emotions that rush out and can take over if they are deepwounds, desparate for getting their needs met, and these feeling can take over real life now,

    thats all part of a grieving process to realise that we have to look after our own wounded child ourselves? and that we are all really orphans?

    me too ! I’m at the time of life and career that I’ve had enough, long enough to slide my scale both up and down , sometimes way down, when the “match” w/ a client is ” Right “= we fit well , and I think I can really help someone who otherwise couldn’t get first-rate therapy. I don’t need to work for money now-a days , and I like both to work for money, do good and feel good about what I’m doing. Money is not the only appropriate compensation for our services , and very carefully managed exchanges of services can also be considered and can become important material for treatment — decades of careful exploration of the potential Complications of such non-traditional transactions were necessary , including some unsuccessful exchanges , for me to learn enough and feel clear and confident re that. I’d rather have explored creating variations on equitable exchange than be stuck within the rigid boundaries of tradition — and I felt quite pleased and gratified when APA ethics finally recognized the utility and wisdom of such non- traditional practices.

    You’re talking a lot about the money lately, and your justification for it. You sound like you came of age in the Reagan years, when money was the focus of most college students. I live in West Los Angeles as well, except I’m on disability for bipolar disorder. I can not work, but I am surrounded by BMW’s, Mercedes and new apartments that rent for $3500 a month. I can only imagine how much a psychiatrist here would cost.

    The primary problem is that psychotherapists should be reimbursed at the same rate for their time as any other health practitioner who went to graduate school and completed an internship. And yes, there is a disparity between in internist and a surgeon and yes there is a difference in their residencies too. There was a Mental Health Parity Act passed under President Clinton, which may have unfortunately had some unintended consequences. Personally, I think that psychotherapy should be considered a “preventive service” like mammograms, annual wellness visits, etc AND that deductibles should not apply to these services just like they don’t apply to some basic preventive services. Why do you ask? Because by working through issues, a bout of depression, a bit of anxiety, etc, it can prevent a hospitalization (or a lifetime of hospitalizations), a lifetime of drugs and their side-effects, unemployment, and most importantly in many cases by helping people actually deal with their problems as they come we might be able to prevent them from passing them onto the next generation (their children, abusing their children, being absent from their children, being unable to care for their children while they’re in a psychiatric ward, etc). Unfortunately, those who most need therapy are also frequently those who can least afford it. Does this mean that all therapists must become “volunteers” for a certain percent of their practice? No. This means our society must stop treating people with either mental illness or mental “issues” as throw aways, and start reimbursing therapists like any other health professional.

    Well said, and a very interesting perspective. You’re right — if our society valued mental services in the way you describe, none of the issues I’ve discussed would come up.

    The point is when we are empotionally or psycologically injured we are not bleeding
    outwardly; so if you are on a tightbudget it is something you have a hard time putting at the top of the list. Also when you go in with a broken arm you can be pretty sure the guy you see can fix it. I have seen therapists with my kids at various trying times and have been shocked at how often they felt no real accountabilty for some meager measure of progress ior insight I might hope for. And even when therapy is a total FAIILURE…. IT COSTS THE SAME. A SKILLED AND COMPASSIONATE THERAPIST IS WORTH HIS WEIGHT IN GOLD. when you are a low wage earner you may have to take WHAT YOU EARN IN 8 HOURS TO PAY FOR ONE HOUR OF HELP. that’s hard to swallow.

    It is unique of you to bring up your fees, but don’t you think it rather naive at this stage to try to rationalize the value of your services? It reminds me of my sister, who is a school teacher. She’s so happy to get the summer’s off, but she got irritated when I asked if her students had learned anything. Seems you might have been looking forward to the perks, more than the reality.

    It feels like you are puffing yourself up to justify your actions. A bit narcissistic. I think most therapists care about their patients. I was impressed with some of your previous articles, but quite honestly Im not sure why you felt the need to bring the sliding scale up. If you offer it, great, if not, then why make a blog post about it? What does it have to do with life AFTER THERAPY?

    One thing I am learning about narsisism, is that when we puff ourselves up to feel better about ourself, or to fight against a perceived threat (In real life or in our mind), that we are doing it because we are not confident with who we are and seeking narsisistic supply.

    Also, let’s get real here, you didn’t sacrifice all that time in school, you made a investment.

    When you are confident in a healthy non-narsisistic way we don’t need to puff ourselves up to prove our worth because we already know it. We neither need to lower another person down to know and express our worth. We are at peace with ourselves and others without having to make ourselves right or anyone wrong.

    What I find fascinating is that I have gotten more comments on the topic of the sliding scale than any other post I’ve written, more gratitude and understanding from therapists for discussing the issue and more hostility from lay readers. It certainly touched a chord!

    Why is this even a topic? Psychology is a profession and, just like any other profession, you pay in order to access their skills and insight. I wouldn’t go to a lawyer or a physiotherapist and expect them to work for free. And everyone has financial commitments and aspirations to achieve, even psychologists!

    The reactions are not remarkable. They are merely contrary. You brought up the subject. Are you feeling defensive and trying to justify how much you charge? This suggests that you got into this field primarily for the money you anticipated earning.

    Thanks Joe for the post. It seems that herapists are often idealized in a multitude of ways in our culture. My wife, for instance, sometimes wants me to treat her like one of my clients–where all I am in compassionate and empathetic, never argue, and have wonderful active listening skills. However, she doesn’t always recognize that I am not a therapist 24-7, since I do have many needs that must be met outside of work. I cannot only give to others without meeting my own needs. Sometimes people think that therapists have their stuff together, that we magically possess some superhuman characteristics and are flawless. I do appreciate shows like “In Treatment” which I think did a good job of showing the human side of the therapist–his flaws and all. Therapists are not saints but sinners.

    I must say that I feel guilty at the idea of taking money for what I do. I don’t understand why yet. But it does feel like a form of prostitution–the client pays the therapist for services rendered. It is silly for me to think this way, because I know that I have worked hard in school and at my agency to improve my clinical knowledge and skills. I also know that the relationship I help build with my clients is a unique venue for them to grow, learn, and change. I am new to private practice, so hopefully over time I’ll feel less guilty about taking other peoples’ money for the work I do. Maybe deep down I believe I don’t deserve to be paid?

    What you say about your wife is really interesting. It made me think of something I often try to explain to clients who idealize me. It’s a lot easier to be compassionate, empathic and a good listener, even if the face of deep pain or hostility, when you only have to do it for 50-minutes at a time. In an odd way, my clients get to see the very best of me. I am definitely a much “better” person during sessions than I am in the rest of my life, because I don’t look to the relationship with my clients to gratify my own emotional needs and therefore don’t feel a lot of the emotions that would otherwise come up for me. That’s not true in any other relationship I have. Maybe it’s something like what I do for my kids, but that’s a full-time unremitting job; as a parent, I’m nothing like the way I am as a therapist. Sometimes I wish I could be.

    This brings into focus one of the oft-confusing parts of therapy. In most ongoing “business” relationships, the terms and conditions are well spelled out initially. A childcare provider, for example, would tell you the fees, late policies, hours of operations and the expectations of paying (or not) when your child is ill or on vacation, etc. If you didn’t pay the bill, there would be a discussion and most likely, your child would lose his/her spot. The provider would also tell you how many kids she has, her discipline policies, philosophies, etc. I can think of several other examples like this, that are important, personal and caring…but still a paid service.

    In therapy, rarely are things spelled out really well. The fee might be set, and a meeting time, but so many things are left ambiguous as potential “grist for the mill.” Anticipatory guidance about when the need to call might come up and if there is a charge for that, etc. etc. I’m of the opinion that therapists are as reluctant to bring money into the business aspects of the discussion, as are clients. It has been my experience that the bill is folded and waiting on the chair, and I leave payment on the side table, almost like it is this secret side-piece that has to happen but we aren’t going to acknowledge.

    It is complicated, on both sides.

    Interesting and very apt analogy, especially if you think that what a therapist does is to care for your “inner child” (although I’m not keen on that expression). Those actual kids become attached to their caregivers, too, and would probably suffer if they had to leave due to non-payment by their parents. Would you think that the caregiver was harsh and unfeeling if she couldn’t continue to see your child for free, or call her narcissistic because she thought she was good at her job and deserved to be paid for it?

    And I agree that the discomfort about money is on both sides. See Shaun’s comment.

    I hope you’re discussing this issue with her. In similar cases, I’ve often “floated” clients until they get back on their feet. If I know it’s a question of immediate hardship and we have a relationship of mutual trust, I’m happy to let him or her run a balance and pay when times are better.

    The answers are “no” and “no” — but if there was a sudden financial hardship I would hope we could work something temporarily out, if at all possible. But this goes to another myth – that service people, therapists included, have this savings account from which to draw upon until the “paying customers” actually pay. Cash flow is an issue for everyone. If you ask the average person what would happen if their paycheck was delayed, it would, for the most part, impact them negatively.

    I also think the average client doesn’t understand that for every hour face-to-face, there is probably at least another 1/2 hour of paperwork that gets done. Rates have to encompass all of this, plus taxes, rent, etc. It *is* a business. Is it narcissistic for the grocer to charge for the fruit he has grown?

    I work with young children and it does push my buttons when we have these sorts of discussions with parents. I really do love the kids and I do think about them a great deal. But I also have to feed my own family. Our values are a little screwed up, IMO, when we pay actors and athletes millions but we (society) don’t want to pay for therapy for a traumatized 3 year old.

    Where is my soap box???

    I hope you’ll understand the great time lapse on this response/ But it takes lot of ingesting of ideas for me before I can even give my opinion/ And remember this is all that this is/ The military taught me the importance and the priority of opinion as it relates to it’s value in the main scheme of things/ We all have one/
    Be patient and tolerate and try to imagine what a sleeping innocence is and what it looks like. It can be a child or an baby animal or or a plant for that matter. If I haven’t lost you already then I say it’s the picture of innocence that I’m looking for. Beyond that I know it’s a reach but I’m going for the idea of forgiveness/ We have to somehow forgive the world for being what it is and accept our role in making it that way/In a perfect world there would be someone or something standing or waiting nearby watching us as we grew up and older as time passed/ And whatever that something or someone was it or they would be constantly reminding us that no matter how hard we try or how much time and effort or money we put into where we think we’re going, we may or may not receive what we consider our just rewards/ Don’t take it from me as a fact, consult your own experiences/
    We live in such a competitive environment that it’s no wonder we all don’t feel short changed for what we do and receive for doing so. More so who do we hold responsible for that. No one forces us to choose what we chose . If what we have is not enough it’s our responsibility to do something legally about that ability to choose. Yes it might mean reinventing ourselves but at least we have the freedom to do that/
    Nothing determines happiness and success like happiness and success/ But who can say what it is for someone else/ I know I’m not the only one that realizes that this is the period we’re full into/ That gray area where new situations are defined/ So I say step up and define something/ Let’s not just be stuck only with our opinions/ As valuable as they are we are smarter than our opinions. This one included.

    When I went to therapy my fee was paid by my healthinsurance (but I suppose this is different in germany). When I missed one of the one hourly session, I had to pay that session of my own pocket this was about 75 Deutsch Marks at that time. My own average income at that time (as a chef) was around 18 German Marks / hour. Quite frankly If my healthinsurance would not have paid most of my two years therapy I would have never been able to afford a therapy, but I would never have gotten the Idea to ask my therapist to cut the fee. Once you start a longerlasting patient/therapist relationship you do know the cost. You do know also you will tell your therapist your innerst secrets (well most of the time anyway) but you do know he is not your friend, he/she is somebody looking from the outside into your problems.

    If the therapist you working with does´nt do the trick you might have to change him/her or end the therapy but haggle with him about his wages?

    I appreciated your post. I could never ask my therapist to lower her fee because I feel its inappropriate. However, I do have to make a decision. I can no longer afford her fee because I lost my job. So herein lies the dilemma: do I sacrifice grocery money to go to therapy, or do I suspend therapy until I can find another job — whenever that will be? It’s a tough call to make. I feel like I am making progress and really like my therapist. But being financially prudent is in order at the present time. This reminds me of the health care dilemma – if you have insurance, you can get that susrgery you need; if you don’t, you won’t.

    I don’t think it’s unreasonable to ask any other professional to reduce their fee. I’ve done so with real estate agents, accountants, lawyers, etc. It’s up to them to say no and I don’t think asking your therapist the same thing is a mommy/daddy issue. It’s a perfectly reasonable question. And yes or no are both perfectly reasonable responses. After all, the answer is always no until you ask.

    Absolutely, you can always ask. It’s a mutual relationship and you both have to agree together on the terms.

    spark:
    >The primary problem is that psychotherapists should be reimbursed at
    >the same rate for their time as any other health practitioner who went
    > to graduate school and completed an internship

    I’m wondering where the “should” comes from? As Joseph noted, market conditions are king when it comes to market compensation. Plenty of people put in years of higher education and they don’t all receive the same compensation in their careers.

    Scarce resources cost more, “scarce” being a function of supply and demand. Professional historians, say, may be less in number than therapists, but they are also in less demand. (i.e. a city has less of them, but also desires/needs less of them)

    For whatever the reason, the balance of supply and demand for medical doctors results in higher salaries than for therapists.

    Resentment is probably unproductive … if someone wants to increase their takings (perhaps to what they “deserve”?), then they need to either sell a better product (“better” being “more satisfactory to the target market”), or target a higher-end market, or market the product better … that sort of thing.

    It’s interesting to me that clients are being advised to stop viewing this so emotionally – hey, you just need to pony up for an important service from a professional service provider. But the other side of the equation is the provider – OK, if you want us to view this as purely a business relationship, then accept that it is one, both ways :) We don’t (at the practical level) become more willing to pay higher fees when we hear about your sunk investment. Any more than we do at the grocery store.

    Interesting article. I highly respect my therapist’s skill and am deeply appreciative of the difference working with her has made in my life. My financial situation recently changed and she offered to reduce her rate for a time. I could not accept the offer in good conscience. When someone is that good they deserve their full rate.

    I agree, though it’s easy to understand why other people don’t. So many emotional needs and dependency issues come up in the therapy, it’s hard to see your therapist as a professional who earns and deserves her fee like any other professional, not someone like a parent who will make allowances for your periodic difficulties in the financial arena. That being said, I have offered to reduce my fee for a time, when a client needed to get back on his or her feet, and never regretted it. I always do it in a time-limited way, so that we agree in advance on exactly how long the fee will go down.

    In your previous article, you compared therapy to dental work or getting one’s car fixed. You said: if people don’t get reductions in Those fields, why should they expect for therapists to work on a sliding scale? I have a few answers to that: first, many people skip dental work if they can, & they are poor. If they can’t it’s because they have No Choice. Likewise w/car repairs. Second, therapy is not a Necessity, it’s really a Luxury, in many ways. You have to be in a pretty stable position, financially, to be able to afford it. But even then, it’s extremely expensive, esp. the kind of therapy You practice, where it’s typically long-term, once a week, etc. You certainly Are entitled to your fee, but you are Not as crucial as a car mechanic or a dentist, except to those who are actively suicidal. You seem to have quite a nice life for yourself & you want to maintain that; fair enough. I just find it a bit intellectually dishonest, however, that you present therapy as crucial to Bare Bones, Basic, Material Survival as treating an impacted tooth or getting a car running again. You may Think this is so, but: excuse me – if a person doesn’t have a running car, they can’t get to work, make money & afford to eat, pay rent & even (perhaps) pay for therapy. If a person as a sore tooth, they could lose their entire jaw if they don’t get it treated. Once basic needs are taken care of, there ARE other needs – Crucial needs, in many way – but to equate therapy with BASIC needs of survival is not a fair thing to do, just because you want to get your full fee. Again, you Are entitled to it, & if patients can afford it, more power to them & to you. Just don’t present the argument that what you do matters as much as what a doctor does, when someone is having a heart-attack or a car mechanic does, when a car won’t run & a person is in direct jeopardy of losing their job. You aren’t THAT important; not when it comes to bare bones Survival. No doubt you will see this post as attacking you, but it’s really just anger w/therapists who place a value on what they do that is overly special. Only a well off person can say, with true honesty: my car mechanic and my therapist are of Equal Importance to my being able to SURVIVE. Most people NEED to do their JOBS, & they Can’t do them w/no car or if they are in physical danger from wounds. Inner wounds count just as much, but inner wounds take a backseat to BASIC SURVIVAL, (unless one is completely not able to function outside of a mental hospital). My anger over your post is that you try to equate therapy to BASIC SURVIVAL & I do think that’s a specious argument. Everything else you wrote, I agree with, in that article, however. You ARE entitled to your fee & therapy is Very Important, to many people.

    I don’t take your comment as an attack on me. Everyone is entitled to his opinion and I can’t expect everyone to see it my way. I do understand the reasons for your anger, I respect your opinion and I disagree with you.

    I see where you’re coming from in terms of distinguishing between basic needs for survival and other needs; that’s a very good point. However, the majority of people I know do not need a car to get to work (walk, bike, public transport) so I don’t think that’s a good example. It might be true for you, but not for everyone. Furthermore, what you say about the car mechanic and someone losing their job without a car can equally be applied to a therapist and someone who is struggling with stress and mental health issues – they don’t have to be on the verge of suicide or in a state where they need to be in a mental health hospital in order to lose their job. A much larger percentage of people suffer from mental health issues at some point in their life than you might imagine and many of those who loose their jobs through this could have prevented it through therapy (please note that I said ‘could have’ rather than ‘would have’ – I’m not suggesting therapists are miracle workers).

    I agree with what Meagan says above.
    Besides it is healthy to expect compensation for one’s work, and for the years spent qualifying for the profession. I feel that when emotional and psychological pain is so blidning, so crippling, not to mention sometimes life-threatening, that the therapist is a lifeline in a very real sense, and utterly necessary.

    Joseph says:
    “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.”

    This resonates with me.

    All the best
    Hermes

    Thanks, Joseph, for your clear-eyed and unsentimental treatment of a subject which has often become a taboo for us therapists! We talk about death and suicidal intentions and sex and abuse without batting an eye—but when it comes to money, we get all tongue-tied and feel like charging reasonable fees makes us money-grubbing mercenaries or emotional prostitutes. Like you, I came into this field because I love learning and because I am amazed and delighted at the capacity of individuals and families to grow and change—but I also wanted to make a decent living. I don’t have a sliding scale because I don’t need one to fill up my practice to capacity, and although I occasionally offer sessions for free I particular situations, I don’t feel guilty for charging my fee because I have worked hard and I believe I offer good skills and helpful techniques to my clients who choose to change. We have narcissistic needs as well as our clients, and we have no reason to be embarrassed for charging reasonable fees for offering a valuable, life- and relationship-enhancing service. Thanks for spelling it out clearly.

    I feel just the way you do, Darrell. Recently, I also realized (duh!) that I devote an enormous amount of time doing pro bono work through the writing and maintenance of this site. I don’t charge for my time in responding to the comments, or answering the many personal emails I also receive. Probably about 10 hours a week all told. I need to charge full fee for the other hours I work.

Leave a Reply

Your email address will not be published.