In 2019, Lydia Bugg was working from home when a man tried to break into her house. She fought off the intruder on her porch by hitting him and screaming until he ran away. Shaken by the incident, Ms. Bugg knew what she needed to do next: see a therapist.
“I couldn’t feel comfortable in my house,” she said. “I really didn’t feel comfortable in public.”
A friend told Ms. Bugg that if she didn’t get treated for post-traumatic stress disorder, or PTSD, right away, her symptoms could worsen. But in Nashville, where she lived at the time, no therapist she approached would take her insurance.
Ms. Bugg had Blue Cross Blue Shield, the most popular health care plan in Tennessee. But each therapist told her the same thing: “The way that Blue Cross Blue Shield pays people doesn’t allow us to actually have the time and resources to help you,” Ms. Bugg recalled.
Therapists in private practice have many reasons for not accepting insurance. If they do, they cannot negotiate with the insurance company for a higher wage, ask for a raise or be paid more commensurate with their experience. Despite a federal mental health parity law passed in 2008, insurance plans aren’t actually required to cover mental health treatment.
Undeterred, Ms. Bugg found a cognitive behavioral therapist who specialized in PTSD. The therapist was “hugely helpful,” she said. The therapist’s fee, $170 per session, was not.
“That was a lot of money for me and my husband at the time,” said Ms. Bugg, 35. To make it work, she went to therapy sporadically, going only when she could afford it.
But seeing the therapy bills come in felt, “retraumatizing,” Ms. Bugg said.
Ms. Bugg’s situation — the cost of therapy becoming a source of psychological distress — is not unusual. Increasingly, therapy is recommended as a crucial treatment for people with mental health disorders and a kind of mandatory finishing school for well-rounded adults. Less discussed is how the cost of therapy is out of reach for many Americans.
Those who do manage to begin therapy often cannot afford to keep going: A 2022 survey of 1,000 adults in therapy from Verywell Mind, a website overseen by mental health professionals, found that nearly a third stopped going to save money and almost half were worried about continuing to pay.
Weighing the Costs
Americans routinely list personal finances as a top source of stress in their lives. Trying to address mental health concerns through costly therapy sessions can create its own anxiety loop for people seeking professional help.
“They have to decide: Is that cost worth the treatment effect, the benefit that I’m receiving from attending these sessions?” said Jeremy Coleman, the chair of the American Psychological Association’s Committee on Socioeconomic Status.
With rising costs of living, Dr. Coleman said, this can be a difficult decision. People who need and want therapy often struggle with the question of whether they can put a price on their mental health.
These are the kinds of problems that one might want to discuss with a therapist. But talking about money can be difficult, even with a professional listener.
“‘Hey, this service that helps me, I don’t have the money for it anymore’ — it’s a tough conversation to have with your plumber, let alone your therapist,” said Laura Ulrich, a 27-year-old in Richmond, Va. Even when a practitioner accepts insurance, the cost of therapy can be untenable.
In 2021, Ms. Ulrich’s therapy co-pay was $25. But she was earning $15 an hour working as a barista at Starbucks, and the therapy fees became a strain.
It’s common for clients to say they’re worried about continuing to pay their fee, said Laura Freeman, a licensed marriage and family therapist in private practice in Alpharetta, Ga. But if clients have anxiety around money, they’re unlikely to say anything. “Either they will just keep paying it and live in that distress,” Ms. Freeman said. “And then if they can’t, then they just ghost.”
When clients do bring up their financial distress they may be reminded that their therapist, however empathetic, is running a business. Nina Lee, a 33-year-old filmmaker in Atlanta, remembered a time when she confessed her financial worries to her therapist.
“I was crying to her, like, bawling about being so stressed, I can’t see her,” Ms. Lee said. “And I remember her just being like, ‘Well, you know, when you can afford it, I’m here.’ And I kind of was like, ‘OK, well, if I kill myself before then, thank you.’”
Eventually, Ms. Lee qualified for membership under the Writers Guild of America, got union insurance and found a great therapist who accepted her insurance.
What clients often don’t understand, said Maggie Mulqueen, a therapist in private practice in Brookline, Mass., is that private practice therapists are at the mercy of insurance companies.
Dr. Mulqueen takes some insurance plans, but, in many cases, accepting insurance “doesn’t make any economic sense for me,” she said.
Billing insurance adds huge amounts of unpaid administrative work and is “sometimes a nightmare,” said Terrence Stewart, a licensed clinical social worker in Houston who accepts many forms of insurance.
One problem, many practitioners say, is that training programs for therapists often offer little instruction on how to talk about money with clients, or what to do when clients cannot afford therapy. The American Psychological Association’s code of conduct offers little guidance about fee setting, though some professional organizations, like the American Counseling Association, encourage practitioners to do pro bono work. Some therapists, noting high rates of professional burnout and increased demand for services, encourage one another to charge more to protect themselves.
Making Therapy Affordable
There are a number of ways to search for affordable therapy, each with its drawbacks: community mental health services for those who qualify, consulting your insurance company if you have one, using a digital platform that offers lower cost therapy or trying group therapy. But for those who love their current therapist but cannot afford to continue on, there are other options besides stopping therapy or paying and feeling increasingly anxious.
One way is for the therapist to directly address the business aspect of the therapeutic relationship in the first session, Dr. Mulqueen said.
“I’m very upfront,” she said. “I say: ‘This is my business. This is my livelihood.’” One reason for therapy sticker shock is that most people are used to annual or infrequent visits to a doctor’s office but are not educated on the financial realities of regular therapy, she said.
At the same time, Dr. Mulqueen tells her patients that “therapy should not cost so much that you can’t ever go out to dinner or that you can’t have a social life.” Her fee is $300 per session, but she takes some insurance and often negotiates sliding scale payments, for example, when clients lose their jobs.
In Ms. Freeman’s private practice, she devised a sliding scale for people with incomes below a certain threshold, which she is quick to offer when they bring up a major life change like losing a job, getting divorced or becoming a parent.
But not all therapists have flexible fees. “No one ever made that offer to me,” Ms. Bugg said of the therapists she approached after her home invasion.
Learning to ask for what you need — including for a sliding scale fee — “should be what therapy is about,” said Sharon Glassburn, a licensed marriage and family therapist in New Haven, Conn., who offers lower fees and pro bono therapy in some cases. But, she cautions, clients should be aware that the therapist may not be able or willing to meet their needs.
Therapists have their own bills, liability concerns and struggles with insurance reimbursement, she said, but some could be more flexible and creative when it comes to meeting clients where they are. Another way to limit the financial stress of therapy is for the therapist and client to meet less frequently, and also to establish a clear end date.
Damonde Hatfield, 35, started seeing a therapist to deal with work stress, and to process his grief over losing two grandparents to Covid-19. As a case manager working with the homeless population in Los Angeles, his work entitled him to three therapy sessions through an employee assistance program. He felt perfectly matched with his therapist, and was thrilled that they were making progress together. But when his free sessions ran out, he couldn’t afford his therapist’s fee of $150 per session, and she didn’t take his Kaiser insurance.
“I felt hopeless,” he said. It was difficult to tell his therapist that he could no longer afford to see her. She was understanding, though, and they agreed that he would reduce his visits to sessions twice a month. This isn’t a perfect solution — “It feels like the sessions are rushed,” Mr. Hatfield said — though he preferred it to quitting therapy or changing therapists.
What the therapist didn’t suggest was capping their sessions. “I would love an end date,” said Mr. Hatfield. “I think therapy is a journey. I think we’re always learning about ourselves. But honestly, if I have to pay $150 every two weeks, I don’t think I would want to do that for the rest of my life.”
“The end goal isn’t for the therapist and the client to be working forever,” said Mr. Stewart, the therapist in Houston. “The goal usually is for the client to succeed in therapy enough so that the things they learn in therapy, they can apply independently.” Therapists should discuss session limits as early as a first intake phone call, said Dr. Coleman.
Even therapists debate whether the high cost of therapy outweighs its benefits. Recently, Mr. Stewart set up an appointment with a new therapist who he believed took his insurance. But on the day of their session, her office called: His insurance wasn’t going to cover the session. He would have to pay the out-of-pocket rate, $360.
“I’m not about to pay $360 for therapy,” Mr. Stewart said.
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