The Real Cost of Therapy

Photo by Adeolu Eletu on Unsplash

How much do you charge? 
This is a very loaded question, indeed.  I’m going to give you straight answers to how much therapy actually costs, and why.  If you are a consumer of health services, you’ve likely asked it many times between doctors, dentists, and insurance plans.  Therapy is no different, yet it is unique in many ways.  Knowing your role in securing treatment and its cost can help you achieve a win-win.

Why are you writing this?
More than a therapist, I am an advocate.  This post has been a long time coming, and clinicians rarely talk about money on a personal level.  When there’s a good reason to do so, it’s an opportunity for growth.  This post is intended to help:

1. Consumers of mental health services make the best decisions for themselves with fuller knowledge of what they’re getting.
2. Professionals (colleagues and students) to understand the dynamics that exist to create a win-win.
3. Advocates of mental health who fiercely support their neighbor’s mental health and need tools to communicate and steer people to the best option that exists for their current circumstances.

Business theory.
When a good or service is offered, utility and/or providing for a human need or want occurs.  In fact, this is why the term “goods and services” uses the word, ‘goods.’[1]  In less than ideal circumstances, either the service is not provided (or provided poorly), or the exchange is NET negative (i.e., the provider loses money or the consumer can’t afford a service important to them).  
IDEAL: Good Service Provided <--> suitable exchange (money) = both parties win

How much is an average therapy session?  
Here are common rate structures:

• Free (through no copay insurance- highly uncommon- plans or state-run and non-profit services)
• ~$20-75+ for practicum/interns (little training or early in their training, but way more advanced than talking to your friend who “took some psychology classes”).
• ~$50 - $125 for a non-specialized therapist and/or online only therapy
• ~$150-250 per hour in urban areas and/or for specialists
• $300-600+ for clinicians who are truly at the top of their fields (think of hiring a celebrity to do a commercial vs. someone unknown from a talent agency)  [2]

What is a realistic win-win?
We live in the real world.  And while we can seek to change things we can change (see below under the “Systems that be” section), acceptance of what we can’t is a crucial part of mental health.  Work within the reality you exist.  

• Free therapy usually means it has been massively subsidized (or you are paying for it in another way, like insurance or a benefactor).  
  • However, to keep overhead low and have a NET profit to stay in business, they may not possess one or more of the following:
    • Expert level status (10+ concurrent years treating a specific condition)
    • Specialization (more than 50% of cases)
    • Additional amenities:
      • Great location
      • Easy access (right off main roads or highways, downtown, etc.)
      • Telehealth or other options, like home visits
      • A snack bar, great coffee, ambiance
• Interns and Practicum Students for $20-25 per hour can be wonderful for those with little financial wherewithal and/or if you need a listening ear with only some training- but be realistic in expectations.
• Online therapy is a great option that is often affordable and accessible, even possibly accepting your insurance.  Limits are a lack of the in-person experience or in-person exposure therapy with objects or places.  
• Generalists may be more likely to accept insurance or only charge rates in the range of insurance reimbursement.  However, the same limits apply as to the first bullet point.  
• Specialists are great if you have a very specific problem you need to address very specifically (like OCD, PTSD, Schizophrenia, etc.).  If you can afford them, it’s not a bad place to start, and if they’re being honest they can tell you how you can achieve results- even if it doesn’t include them.
• Famous clinicians are so cool!  If you can afford it and want to, go for it!  The Gottmans, Edna Foa, Sue Johnson, Steven Pinker, Daniel Kahneman, Reid Wilson.  

There will always be exceptions to the rule, and the above is no different. For example, some people offer excellent services through charity, passion for helping, faith, or other reasons.  Of course, this doesn't mean that anything is free- these services are simply subsidized through that person and often additional income streams like books and speaking fees.  A great example in Dallas would be the experts Drs. Harville Hendrix and Helen LaKelly Hunt.  They offer free community-based marriage building seminars and trainings (Safe Conversations).  Dr. Reid Wilson offers a free 2 day intensive every year at the Annual Conference of the International OCD Foundation   Many churches and places of worship do the same.  

How much clinicians make.
Income ranges wildly, from those famous clinicians to practice owners to social workers to private practice and more.  I don’t know anyone who’s getting rich off of therapy.  Most of us got into counseling/therapy as a helping profession in the first place.  I told my wife when we were dating I would very likely make less than her as a nurse at a prominent Dallas hospital, and I wanted to make sure she was okay with that.  Let’s just say she didn’t dump me.  :)  The median Master’s Level counselor in the U.S. makes about $50-75k per year.[3]  Besides gross income, clinicians have a lot of other factors that take off the top:

• Overhead/Expenses 
  • Office Rent is usually the largest single expense for most clinicians.  Most folks I know will pay somewhere in the vicinity of $500-3000 per month just for their office space.
  • Telehealth, Electronic Health Records, Marketing efforts, and more add to the expense.
• Degree/Licensure
  • Master’s degrees require college plus 2-3 years full time along with an internship usually an additional 2 years beyond this.
  • Psychologists (doctoral level) have an additional 3-5 years with school and practicum/internship above a master’s degree.
• Ongoing training
  • Base level continuing education is usually around 12-15 hours per year.  Those with certifications or other training (EMDR, CSAT) have their own separate upkeep.
  • Expert Clinicians are generally speaking/writing/training at conferences (1-3 per year for many), which is more time and cost.  Travel costs wrack up easily, and for those heavily invested in being at conferences, it can easily add $5-10,000+ per year in travel expenses and associated costs- all to stay up to date and invested.
• Self-Employment Tax, which Depending on income bracket, is much higher than when an employer covers a chunk of taxes.  Take about 20-35% off the adjusted gross income for total taxes in a year.
• Health insurance.  This may be the biggest expense of all for clinicians if they have to purchase their own health insurance, which can cost around $3,500-12,000 per year- just to have the insurance.
• Limited codes to bill.  Therapists have only a few billing codes they can submit to insurance; many only use one code based on the hour of therapy (90837).  Insurance is not typically known to give raises.  
  • Doctors have, as of this date, literally 70,000 codes to bill!  [Some of my favorites: Y93.D: Activities involved arts and handcrafts and W55.41XA: Bitten by pig, initial encounter, W61.62XD: Struck by duck, subsequent encounter.]
• Cost of living (L.A. and New York and Chicago will see many non-specialized therapists charging $200 or more per hour).
• Number of clients- what is feasible depends greatly, but most clinicians I talk to can see about 15-30 clients per week before they start burning out.  For every client hour, many clinicians have to spend at least an hour for administration, marketing, training, etc., that they don’t get paid for.

I’ll let you do the math.  

So yes, I get it.  Therapy can be expensive.  If my clients say “this is expensive,” I agree.  “Yes, it is.  You are making a sacrifice.  Thank you so much for your prioritization in being here.  My goal is to help you reach your goals and get you on your way as soon as is reasonably possible (unless you want to stay around longer).”

I hope this post is helpful in helping you make a decision or in supporting others considering decisions for therapy in our current world.  Remember the old truism: “you get what you pay for.”  Or maybe what somebody else pays for.


References:
[1]  https://en.wikipedia.org/wiki/Goods
[2] How do I come by those figures?  They’re rarely published, but it is my personal experience and through research and conversations behind the scenes. This makes it subjective, but I hope it helps.
[3]https://www.salary.com/research/salary/posting/counselor-salary, https://www.payscale.com/research/US/Job=Licensed_Professional_Counselor/Salary



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Addendum (i.e., for further reading)

It is worth noting that there are whole systems at play at any given points with healthcare. it is not the purpose of this article to get into these complexities, but I do want to at least acknowledge that they are there and need addressing in their own right.  

Depending on where you were born, your skin color, or any factor of diversity, you may face a substantially harder time in life pursuing things that come easier for others.  That sucks.  It’s unfair; it’s unjust.  I want you to know you are seen.  You are heard.  You have value, whoever you are.  

This is where advocating for the plight of the hurting and the poor is so key.  I hope you will join me in doing so if you can. Or if you are hurting and in need that you will check out one of the many resources listed on my page, https://www.justinkhughes.com/resources.html.  

I hope readers will be careful in making judgments or interpretations about the intentions of others (I’m talking to you, clinicians, consumers, and advocates). PERIOD. That underscores a basic principle of CBT and emotional health. 

Therapists as a whole struggle at times with charging anything.  I've been there, and I still wrestle with cases of extreme need and how to approach.  I remember when I helped run an intensive program for teens struggling with substance abuse.  One of the young teens once exclaimed, “For $20 per person, you guys are getting rich.”  We had about 15 kids a night, for 3 hours per day clinical and 1 hour admin., with about 4 staff members and an owner.  That’s $15 average per employee, or Costco’s minimum wage.  Some of my colleagues who charge the most are also most involved in advocacy and a number of outside free resources, be it free clinics that they put on, short-term workshops, educational content online, training of clinicians and lay persons, etc.  In fact, though I may be biased here, I think that some of those that charge the most are more involved in these efforts. If they're making a decent living what they're doing, it can actually free up their time, energy, and passions for more advocacy and help.  

Paying less or more does not have to be an inherent good or bad; it's often a question of many factors and considerations that you must weigh for yourself and with your loved ones.  As I tell all of my clients, advocate for your health! People who are assertive in their treatment get the best outcomes.