Lowering Fees in Hard Times: The Meaning Behind the Money

Lowering Fees in Hard Times: The Meaning Behind the Money

by Melissa Groman

One therapist's good, hard look at the question of negotiating therapy fees with clients.
These days therapists are hearing about the bad state of the economy not only from the news, but also from their clients. And many of us have been affected ourselves by the economy in one way or another. In discussing how world financial events affect therapists with a group of colleagues recently, up came the topic of priorities, money and how we help both our clients and our practices prosper.
The topic of fees and money in our work is central and worthy, as well as rich with possibilities for understanding much about our clients, how they communicate, what they need and fear, and how they deal with change. But of the many facets to the discussion of money and therapy, the subject of
how we therapists view therapy and the meaning behind the money is most compelling.
how we therapists view therapy and the meaning behind the money is most compelling.
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Raising Questions

As practitioners we must wrestle with several ideas and feelings all at once. First, what exactly is our creed? We are supposed to be helpful, but what is really helpful when it comes to setting and maintaining fees, particularly in times of financial hardship? Many therapists intuitively feel that we should be generous, even at our own expense. So how do we unscramble all the pieces to make good clinical decisions and take good care of ourselves and our practices?
Is therapy a luxury? Is it a necessity? Who decides this and how? Some therapists tell me that they feel guilty charging any fee when clients are having a difficult time financially. Others have shared with me that they are having difficulty paying the fee for their own therapy and supervision.
How involved ought we be in a client's decision to begin or continue treatment? Should we encourage clients to stay? Is that too "sales-y"? Do we slide our fee? (Does the massage therapist or physician?) Do we really believe in what we do? Is it possible that coming to therapy actually helps people prosper? And make more money? Why are we hesitant to conduct business as usual?
I certainly don't think we should encourage clients to come to treatment that they cannot afford. But I am asking us to consider what "afford" means. What is our work worth to us and why? And what is it worth to our clients?

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I think we must be clear about what our work is worth, and confident about the legitimacy of our fee, even when we decide to lower it. We need to be watchful of our own anxiety when we respond to a fee problem. Lots of therapists are actually confused about what the fee is for exactly.
Do we charge for our time, our analytic ear, our guidance, our expertise, our ability to endure and stay with difficult feelings?
Do we charge for our time, our analytic ear, our guidance, our expertise, our ability to endure and stay with difficult feelings? It depends on who you ask. Some therapists may even feel relieved by charging a lower fee. They link their own self-worth, value and effectiveness to appeasing the client in this moment of stress. A lower fee feels like less pressure to push for change, and more freedom to just be with the client, which is, in many cases, the best intervention anyway. Ironically, we tend not to recognize the legitimacy of empathic listening alone as valuable and fee-worthy. Some of us operate under the idea that we need to be masters of theory or savvy interventionists in order to earn our keep. Do we underestimate the value of providing a good ear and the healing power of helping clients to talk openly and be understood?
Many of us could use a bit of help unpacking our own money issues, and may squirm at the thought of negotiating a fee. But discussing fees is not as tedious as many of us might think. Simple questions such as, "Should I consider changing the fee?" "How might it feel if the fee were lower?" or "How is it going with your finances and paying the fee? Let's talk about that" can help get a good dialogue started. And there may be a difference between the therapist suggesting a lower fee and the client asking for one. If we sense that money is what is in the way of someone continuing therapy—the resistance to it—then we may choose to inquire about it like any other matter in therapy.
One therapist I know asks her clients what they have in mind to pay. She also asks how frequently they would like to come. She is committed to consulting with clients about their ideas and wishes, especially when it's about the therapy itself. She likes to model a "feel free to say everything" way of working. Her touch is light, curious and exploratory. And oftentimes money is not really the issue at all, but rather a conversation starter, or a way for the client to communicate to us that something is off kilter in the therapy. Perhaps we have said something wrong, or hit the wrong note with a client. Many clients don't know how to tell us this directly. We cannot understand unless we explore it a bit.
I am reminded of a line from Woody Allen's Manhattan, when he said to his ex-wife, "My analyst warned me about you. But you were so beautiful I got a new analyst."
I am reminded of a line from Woody Allen's Manhattan, when he said to his ex-wife, "My analyst warned me about you. But you were so beautiful I got a new analyst."
So there is much to be gained by talking things over in sessions with our clients. Oftentimes money concerns are a perfect way to hear more about what a client needs, how they feel taken care of, what their parents did with money and what effect that has had on them. We may miss the boat on some good work if we merely chalk up financial problems to the economy and leave it at that.
When we lower a fee, we are sending emotional messages to the client. What, then, are these messages? Are they always what we intend?
Possible Answers
Possible AnswersSometimes, of course, a duck is a duck. Someone loses a job, or does not have the means to afford a higher fee. But I have seen many different solutions to these would-be obstacles to treatment. Some people come less often; some have to take a break for a while. Some do shorter sessions. One therapist I know does online counseling, and since it's more convenient for her, she feels she can charge less. Some therapists do reduce fees when the need is clear, and with the understanding that when things get better the fee will be returned to its regular status. Others save a few sliding-scale slots as part of their overall caseload and reserve them for a population they feel most needs it, such as young adults or single parents. There are many possible answers, but I think we have a better chance of landing on the best ones when we are conscious of the unconscious and allow for some good discussion all around.
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The Importance of Communication

In some cases, suggesting or agreeing to lowering the fee may be communicating the idea that we agree that things are indeed pretty bad for the client, and they won't get better—that they are poor and perhaps helpless to figure out how to figure out their money situation. We may be sending a message of despair, not of understanding and support. Other clients may feel loved or cared for, but for some it may signal that we don't value the work, or value the client. Not always, but we can't be sure unless we really talk it through.
One therapist shared with me that after she lowered the fee, the client stopped coming. After several attempts to reach her, the client finally called back and said that she felt guilty and embarrassed paying so little and so decided not to come. It can work the other way as well. A lower fee may leave us resenting the client, particularly if it has not been thought through enough.
Some therapists like the feeling that they are being supportive or practical, loving even, when they are negotiating a fee. And it may be true, since being so is the heart of much of what we do as psychotherapists. Many of us, particularly from social work or social welfare backgrounds, have the idea that we must offer up at least some of our services as charity. This is a worthy ethic of the helping professions and our practices. However, should it be done habitually to the point where we have difficulty meeting our own obligations or goals? Not so fast, I think. Our relationships with clients are important. Our time with them is sacrosanct. We work hard with concentrated effort and dedicated time. We are not (well, I don't think so) merely the mani or the pedi that could be done at home.
Can we suggest that clients look at things this way, too? Dare we question the priority that therapy holds in their budgets? Or suggest giving up something in order to pay our fee? Should we question their leisure plans, hobbies or choices? Should we help them to view therapy as an investment in their marriage, financial recovery or success in life?
Do we really believe this is a luxury item or a vital part of our clients' well being?
Do we really believe this is a luxury item or a vital part of our clients' well being?
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Therapist Attitudes, Beliefs and Fears

And what about our fear of losing clients, of financial insecurity, or of ineffectiveness? It's difficult enough to have your own business and have your paycheck change from week to week. To have to bring in business concerns on top of doing therapeutic work adds to the pressure. How much do we know about our own worries and the effect they have on our decision making when it comes to fees? Some clinicians think they must slide to keep business.
People don't negotiate fees with the grocery store, cable company or the gas station. Most doctors and dentists don't negotiate either, though a friend of mine who is struggling financially told me that her doctor told her to keep her co-pay and not pay it. My friend felt very loved by this, and loving toward the doctor.
And a lot of lawyers I know do pro bono work, or barter. We can make this part of our work too, but should it really be our only way of thinking about our work? Why is it that many therapists' default thinking goes to the value being less rather than more? Or maybe it should be as one therapist I know says, like taxes. The more you make, the more you pay.
Some of us are jaded or heartened by our experiences with our own therapy. If we have felt understood, helped, and have made progress, we may tend to value therapy more. If we have had a less than fulfilling therapy experience, or have unresolved issues with our therapist, we may tend to transfer those feelings into our practice.
Many therapists model their practice after their own therapist, especially those of us who learn largely by emotional experiences and modeling.
Many therapists model their practice after their own therapist, especially those of us who learn largely by emotional experiences and modeling.
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Everybody prospers when we give ourselves permission to talk out our ideas to an open ear, and to study what's operating underneath. We do not have to act quickly. I think sometimes we want to resolve things fast. It's hard to stay with uncertain, uneasy feelings, and we so humanly go for the good feeling. But I think we miss out on a lot of important information when we do this, not to mention the opportunity to model patience, curiosity, tolerance for bearing some discomfort, and the value of talking, consulting, and understanding something more fully. Even in our business, we sometimes forget we can benefit from studying even, maybe especially, the basics.
Many therapists do try to make treatment available and manageable for clients as long as they themselves can afford to. And many of us sort out the facts from the feelings and make decisions based on what we figure to be best clinically. But money has so much meaning, and when we don't take at least a few minutes to be curious about what that meaning is to us and our clients, we may be short-changing everyone.
We need to know where we are coming from, and to unpack what's influencing our choices when we are working toward the best solutions in difficult financial times. It is key for our own self-care, the well being of our clients, the work, and even the economy.

Copyright © 2009 Psychotherapy.net. All rights reserved.
Melissa GromanMelissa Groman is a Licensed Clinical Social Worker in private practice in New Jersey. She specializes in treating eating and cutting disorders and mending marriages. Melissa founded the Good Practice Institute in 2007, and provides clinical supervision, consultation and practice building coaching to therapists from across the country via telephone. Melissa writes creatively late at night when her husband and five children are finally and blessedly asleep. She can be reached by phone at 973-667-8777 or through her website www.goodpracticeinstitute.com or email: Melissgro@aol.com.
When I was a young adult, my therapist took MA payments, of, (I think) 25.00 for some of the time. Other times, I saw her for free. She was a a psychoanalyst in training and I nwas a student. Whe my father died and left a small amount of money, I paid her a few thousand of the ten I got, because I wanted to return the favor. 10 years later, I needed a therapist again. My second therapist saw me for free, for many years, then bartered, then charged. He changed the course of my life and I repaid him when I became a therapist, by referring at least 25 paying private practice clients, about half of whom were therapists, who also referred. At 60, I went through a divorce and went into therapy a third time.After about a year, I had`crushing financial problems and he continues to see me for free, our arrangement being that I will pay him, when I get n my feet again. As a therapist, in private practice and as a Community Mental Health Therapist, I alway have one or two pro bono, because I feel strongly that it is a good practice.
Lynne T., Nydick, Psychotherapist
From a clients perspective. I am in the fortunate position that I can afford to pay for therapy. Having said that I do know that I was paying way above what other therapists in my area charge. I am aware that my therapist is known to have said when questioned about her fees "I'm worth it". and she is viewed as a business woman she has never said this to me, however it did leave a bad taste and how I began to change my views on her motives and have found myself battling with how long she appears to keep clients going for in my case 4 years next month but i know others who have been consistent clients for 10 years and more. I'm now considering a change of therapist. I believe that all clients deserve as a minimum respect in being given notice of a fee increase. I paid for my session and received no change as I normally would, didnt notice but nothing was said until information sent by email and then told "my fees have gone up and so I didnt give you change today" I felt very hurt by this lack of consideration or respect for the service I was buying from her. Having said that she is a very skilled and experienced therapist it was not the charge but rather the sense of being shown little respect like "oh she can afford it so it doesnt matter" which makes me then question how she values me as a client/person who deserves respect, which she says I have a right to from others in my life. I hope that any other therapists reading this will consider how they approach their fee rises to which they are entitled to just as employees.
T. Molony
I think the author does an excellent job of addressing a very complicated and timely issue. As a psychiatrist with a subspecialty in Psychosomatic Medicine and an advanced candidate at the New York Psychoanalytic Institute, I have a diverse and interesting private practice including medication management, psychotherapy, and psychoanalysis. Like everyone, I see the economic fallout in my patients. Grappling with fees and what they mean is part of the work of therapy and what the fee means is often a guide to whether or not, or by how much, the fee should be adjusted. Might this work be unconsciously more difficult, obscured or obfuscated, when we treat "clients", symbolizing the "customer" aspect of being a person in need, rather than "patients", who are people in emotional and psychic pain coming to us for professional help?
David Goldenberg, MD
I’d like to thank Melissa Groman for her thought-provoking and comprehensive article on the issue of lowering fees in hard financial times. Although I have gotten more comfortable over the years with not sliding my fee as a knee-jerk response to someone telling me of their money woes, it can still pull on me. Yes, we ALL have issues around money and self worth and it’s interesting to me that one client can feel loved by us lowering our fees and another feel ashamed or even insulted. I’d be interested as well to hear about the fees that the insurance companies pay us therapists (that we accept!). There is one panel that I have been on for ten years that has never paid more than $50 per session! I justify staying on this panel because I do get referrals I wouldn’t otherwise but it is also my way of tithing/giving back to the community. That said, I resent being viewed by these huge conglomerates as worth $50 and I wonder why we as a group accept this. Perhaps this is another article. In any case, thank you.
Susan Pease Gadoua, Director Transition Institute of Marin
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