Why is therapy so expensive?

girlallowance-insideThere’s no getting around the fact that therapy can be expensive. Sure, you may pay less than you would for a hair cut and color or just a little more than you would for a massage, but most people don’t get their hair cut as often as they’re likely to go to therapy. I mean a dye job lasts what, six weeks? And most people see their counselors about four times a month.

The reasons therapy costs so much are:

  1. Schooling. In order to offer psychotherapy, your counselor needs an advanced graduate degree. Generally Counselors, marriage & family therapists and social workers need a masters and psychologists need a PhD.
  2. Licensing fees. Ongoing expenses include paying for our license and certifications as well as our professional memberships in organizations like the American Counseling Association or the National Association of Social Workers.
  3. Continuing education. Therapists need to have continued training to be sure we’re up on the latest research and that we’re staying abreast of what our professional ethics and the law require of us. States vary in their demands and the costs of training differs a lot, too, but most of us sink a few hundred a year into making sure we’re up to date. If we have other certifications — in, for example, hypnotherapy — we will need to take classes to maintain that certification, too.
  4. Insurance. We pay for professional liability insurance the same way that doctors do (fortunately our costs are a lot less). Most of us need the insurance to maintain our licenses.
  5. Rent and utilities. Even if we’re not in practice for ourselves, part of our income goes to keeping the office open and the lights on. Bigger cities, naturally, charge bigger rents and thus more expensive therapy. For those of us in private practice, rent is likely our biggest expense (I know it’s mine).
  6. Phones. Some therapists also pay for an answering service.
  7. The cost of doing paperwork. Those of us who take insurance (I do not) generally negotiate rates with each contracted insurance company. So you pay your co-pay and the clinician bills the insurance company for the rest of the rate initially agreed upon (and this is usually something the insurance company dictates; therapists can either agree or not). The paperwork required for insurance eats up a lot of time. Insurance companies differ in what they require and when and keeping track of it, submitting the billing, following up on payment (because insurance companies don’t always pay in a timely manner) and going back to the client if there’s something sticky takes up a great deal of office time, which could go to seeing clients so therapists bundle that time into their fees. Some of us farm these tasks out and pay a biller, which also obviously adds to the cost of therapy. For those of us who don’t take insurance, the paperwork demands are a lot less but ethically and legally we are required to keep certain documentation up-to-date. After a session with a client, we have to write up the session and again, our pay for this is bundled into the fee we charge the client. Note: Those of us who take insurance generally charge more than those of us who don’t because of the cost of doing business with the insurance company but most of us end up making about the same amount. People who take insurance spend more time on maintaining paperwork and those of us who don’t spend more time on marketing (since insurance companies do much of the marketing for you, giving your information to consumers who use their plan). A full-time therapist (i.e., someone who works a 40-hour week) isn’t seeing clients for all of those forty hours. Some of those hours are doing paperwork, getting training, meeting with supervisors or getting peer support, marketing, talking to insurance companies, printing out worksheets for the next session, reading research, calling to coordinate care with other providers, following up with clients who missed appointments or have questions or emergencies; etc.. Client fees have to also cover the invisible work of being a therapist.
  8. Miscellaneous supplies and fees. Therapist need to print out worksheets and forms, keep our furniture in reasonably good shape (and replace broken down chairs and sofas), maintain a working supply of pens and paper, and Kleenex. Most of us also need to pay for a web site and/or for inclusion in membership directories so clients know how to find us. If we work with kids, toys and art supplies need to be available and in good repair. Then of course there’s stuff like bank fees, the cut the credit card company takes, etc.

After all of these expenses are taken from our hourly rate the rest goes toward our salary. Part-time and contract workers at agencies and practices as well as those in private practice for themselves also have to pay taxes (about a third of their income), health insurance and retirement (not to mention banking for sick or vacation days) out of that what they take in.

And that’s why therapy costs so darn much.

There are options to make therapy more affordable:

  • Use your insurance. Not all insurance plans offers mental health benefits and not all insurance plans that do make it more affordable. (Plans with high deductibles may take a lot of time and money before you see any savings.) You will need to find a therapist who takes your insurance and then you will need to receive a mental health diagnosis that your insurance company will cover. Once you get that diagnosis, your insurance company will need to approve the treatment plan your therapist gives. All of this sounds very complicated but therapists who take insurance generally understand how to make it work for you. Make sure you are clear about what the diagnosis and treatment plan mean and what exactly will become part of your health record. Also note that most insurance plans do not cover couple or family counseling and may not cover certain diagnoses. Sometimes you won’t find this out until your bill gets denied so take some time to make sure it all makes sense to you and your therapist.
  • Use your Health Savings or Health Spending Account. If you have a HSA card, see if it will cover counseling and if your therapist is able to charge HSA cards. Most of the time these plans will only need you to submit a monthly or quarterly receipt but check first to see.
  • Seek out a practice or agency that uses a sliding scale. Sliding scales tend to be needs based and different therapists and practices require different documentation; some will want proof of income and others will not. Not all therapists will advertise their sliding scale so if there’s someone you’d really like to see and you’re not sure if a sliding scale is available, call and ask.
  • Explore group therapy. Groups tend to be much less expensive than individual therapy (that’s one reason I decided to create the Parenting Challenging Children group — it’s a more affordable way for parents to get help) and research shows they can be be just as effective. I especially like groups because I feel that community can be incredibly healing for those of us who feel isolated in our struggles.
  • Seek out a publicly funded agency since they often have more generous sliding scales. Depending on your income, using a county agency (in Central Ohio those are agencies funded by the ADAMH board, a list of which you can find here) may allow you to pay very little and sometimes nothing for counseling. Because they receive outside grants to fund mental health support for underserved clients they can subsidize their services. There may be a wait list and depending on where you live, it may be long but check in regularly since cancellations do happen and sometimes the intake person can get you in more quickly than originally promised. (Sometimes if you call in the morning they may have a last minute slot open up in the afternoon.)
  • See your therapist less often. While meeting every week may be ideal (it’s easier to create and stick to change when you can devote an hour each week to working on it), you can go every other week or even less often if your therapist agrees.
  • See an intern at the practice. Not all agencies or practices hire interns but those that do sometimes charge less since those practitioners have less experience. Interns are supervised by other counselors with specialized supervisory training although what this means will depend on the practice. If you’re using this option, ask them what this will mean exactly so you know what you’re agreeing to. (Note: Research shows that new therapists can be just as effective as more experienced therapists in part because newbies have lots of enthusiasm, which can make up for their lack of real world experience.)
  • Do the work. Counseling is not a race and how long it takes will depend a lot on individual factors but the more energy you put into therapy, the more you’ll get out of it, the more quickly you can create change and the sooner you’ll be leaving therapy. This means showing up for appointments (and avoiding the no-show fees! another way to cut costs), being honest with your therapist and reflecting on what you’ve learned between appointments.