Money Matters

Q: As a female therapist in private practice, I know the value of my time is important to communicate to clients, but I’m uncomfortable talking about money with them. What can I do?

A: Few therapists receive specific training about the business side of a private practice, and for many of us, having a business mindset can feel antithetical to our role as helping professionals. But in my experience, being a good businessperson is essential to providing high-quality therapy. When clients mistreat us financially, feelings of resentment can interfere with treatment. And just as importantly, clients who believe we’re mistreating them financially may feel resentful.

While all therapists must address money issues in their practice—they come up when a client fails to pay a bill or misses a session—it’s female therapists who talk to me most often about struggling with deep discomfort when it comes to discussing money with clients. This may be the vestiges of how an older generation was raised. But as I see it, modeling best practices in these discussions can show clients that knowing one’s financial worth is an important indicator of self-care and self-respect, regardless of one’s gender. Since you find money conversations make you feel uncomfortable, practice talking about these matters with trusted people in your life so it becomes less difficult.

One female psychologist I know, who works in a metropolitan area and has been in practice for more than 30 years, makes a yearly habit of asking her male colleagues of equal training and experience what they charge, and then matches their fees. Last year, she raised her fee to $300 per session, and none of her clients balked. When she shares her fee with her female colleagues, she reports a few will say things like, “I couldn’t do that, because no one would pay me that much.” Or they insinuate that her fee is onerous, saying, “I’d never do that to my clients.” However, she says not a single man she’s consulted has expressed those concerns.

Another female colleague got an odd reaction from her co-ed peer supervision group when she brought up her desire to get off insurance panels. Initially, the group cautioned her that she’d limit her referral base with a higher out-of-pocket rate. But when she asked them how they handled their own fees, a hush fell over the room. She left disappointed. With whom could she discuss money issues, if not her closest colleagues?

Money and Caring

Some therapists and clients will conflate a high fee with a perception of being uncaring. But when a client challenges my payment policies, I’ve learned we usually manage to find our way through with an honest discussion about why these policies are in place.

For example, a graduate student I was seeing recently left me a voicemail at 4 a.m., wanting to cancel her 9 a.m. appointment. The heat was out in her apartment, and she’d been up all night. Since her budget was tight, she said she’d come in if I was going to charge her for the cancellation (half of my fee), even though she didn’t feel the session would be productive.

The act of putting this decision on me felt like a litmus test: Did I care more about her well-being or getting paid? In this case, I left her a message saying I wouldn’t charge her for the session and I’d see her at the usual time next week. But I started that next session by sharing my perspective that she was testing me to see how much I cared about her. This opened up an important dialogue between us, where she explored feelings about “paying to be cared about,” including that she wanted to feel special in my eyes. Paying for therapy led her to question whether or not my care for her was genuine.

Often these conversations aren’t as difficult as you’d expect, and can be valuable in themselves. One colleague told me that when she recently raised her rate, a client who’s a corporate lawyer said, “You should charge more. Do you know what people pay me per hour? They value my legal advice, and I value my mental health. People don’t understand how much mental health matters.” They went on to have an important session about how deeply he appreciated their relationship and how he internalized the value of something by its price tag.

Another colleague told me that a client just started paying her more after she’d failed to raise her fee for five years. It embarrassed her, and she sought supervision to understand why she’d been reluctant to increase her fee. Her discomfort dealing with money matters unintentionally put the burden on her client to manage the financial part of their relationship.

Is money inherently a gender issue? No, but our society is not gender blind. When it comes to matters of equal pay or social expectations regarding who pays for dinner, for example, many stereotypes still prevail. One of my male clients often comments how much he welcomes his ability to talk with me about pressing financial matters in his life. One day I asked him if he imagined he’d discuss money as openly with a male therapist. This led to an examination of how he feels competitive with other men, especially when it comes to money, whereas he expected me, as a woman, to be unfailingly supportive of him. Our exploration of this question opened up an important dialogue about how he respects men, but feels emotionally close to women. Having him examine these beliefs was essential for his personal growth.

What Are We Worth?

There are many factors that influence what one’s fee should be. Before deciding on your rate, research regional incomes, office rental fees, and insurers’ reimbursement rates. One of the great ironies in our profession is that insurance rates differ based on academic degree, not years of experience, and certainly not gender. A number of my colleagues set their fee based on the Blue Cross PPO rate. For example, an LICSW with 20 years of experience uses $170 as her fee, since that’s what she gets from insurance. An LMHC of similar experience stays at $120 because that’s what insurance pays her.

Early in my career, I hired a financial advisor to help me understand how to run my practice. He gave me two invaluable pieces of advice. First, he emphasized that I’m an hourly worker with no health or retirement benefits, vacation, or sick days. Therefore, my fee needs to account for the limitations of being self-employed. Second, he gave me a rule of thumb that I continue to abide by: budget for 10 months of work per year to manage the inevitable ebb and flow created by inclement weather, sick days, and vacations.

My conversation with him encouraged me to think more broadly about how I would set my fee. Over the years, as I gained additional training and expertise, I increased my fee to reflect my level of seniority. Although I accept some insurance plans, I don’t use their rate to determine my fee.

Talking Money at the Start

First sessions can be overwhelming for therapists and clients, and weaving in a discussion about payment policies isn’t easy. But failing to be clear about money from the outset can lead to resentment on both sides. That’s why I reserve the last 10 minutes of the first session to discuss the business side of my practice.

In my conversation with clients, I’ll state explicitly that my practice is my livelihood and go over billing and cancellation policies. I’m careful to emphasize that insurance can’t be billed for missed sessions. As a rule, I don’t charge for calls, texts, or emails between sessions, but many of my colleagues do. Whatever position you take, be transparent from the outset. I leave time in that first session for questions about any of this, and then I follow up at the start of the second session to see whether further clarification is needed.

Even if you provide this information in writing, I strongly recommend talking about it too, so clients know money is part of the treatment and future discussions are welcome.

When it comes to charging for the inevitable missed session, or clients running into financial troubles, policies can help us be consistent without being unfair. If you equate caring with pleasing clients—or are overly concerned that your clients might do so—then it can seem cruel to charge for circumstances outside their control, like traffic or missed planes. It can be stressful to uphold previously agreed upon policies if you aren’t clear with yourself about the importance of the policy. Again, the more readily you accept the fact that having a private practice involves dealing with money, the likelier you are to develop policies you can stand behind.

Addressing Money Can Deepen the Work

Clients are often more willing to share details of their sex lives than talk about their finances. And when therapists are uncomfortable talking about money, clients will sense that discomfort. But finances are a crucial part of everyone’s life. Making it clear that you’re open to talking about money is just as important as conveying a willingness to hear about any other area of a person’s life.

When we don’t make this clear and clients have personal successes, like an end-of-the-year bonus, or a raise or promotion, they may downplay or even not disclose these accomplishments out of fear of engendering envy. They may even be afraid their fee will be raised. But don’t we want to celebrate these achievements with them? When we have our own financial houses in order, it’s easier to celebrate their successes and, when necessary, challenge them not to hold back on money conversations.

I’ve also had clients go through difficult financial times. Exploring the anxiety and depression that accompany a financial loss can create a safe harbor for them. When changes in net worth or access to insurance impact them, my bottom line is to ask myself how I can best serve them without sacrificing my own needs. Sometimes that means shifting to a less in-demand hour and reducing their fee. Other times it’s a payment plan. Only rarely has it meant providing a referral.

I went into this profession because I care about people, not as a vow of poverty. Talking openly about money with each other and our clients is an empowering way to normalize what everyone knows: money matters.