Two Guidelines for Keeping Your Therapy Business Afloat

Strategies for Making Sure Therapy Clients Stick to Payments

Lynne Stevens

Money is an underdiscussed topic in graduate programs, supervision and peer groups, yet every therapist I know has felt the awkwardness of seeming mercenary when insisting to a client who has fallen behind that he or she needs to pay. Unfortunately, most therapists were never coached about how to reconcile the closeness of the therapeutic encounter with the fact that therapy is also a business. It has taken me years to understand that therapy is not separate from the exchange of money. I am in this profession because I care and have skills and knowledge that can help, and I also need to make a living.

These days, I run into the problem of clients who don't pay far less frequently than I used to. I attribute this to two changes I've made. The first was convening a peer group to discuss money issues. We examined our family values and messages about both the importance of money and the secrecy that often surrounds money matters, while also looking at the impact of social messages about gender and earning potential. More than anything, doing this personal exploration is what prepared me to explore the topic with my clients. The second change I made was developing a few practical steps to make it more likely that my clients will pay on time: prevention, intervention and having a bottom line. Prevention involves setting clear boundaries up front about my expectations regarding payment. I give written guidelines to clients during the first session that explain how I run my business: I prefer to be paid weekly, but will accept payment monthly; I charge for missed sessions unless clients give me 24 hours' notice. My guidelines also extend to questions about sliding fee scales and how much notice I give before I raise my fee. I ask my clients to read and sign guidelines while they are in my office. The next week, I follow up and ask them if they have any questions or thoughts about them. Even though it's not legally binding, the document signals a commitment to take the business side of therapy seriously. Later, if money issues come up, I show them the signed copy I keep on file.


One client, Sherry, was four weeks behind in her payments, for which she offered a series of reasonable excuses. The next week, Sherry's session focused on a very intense description of an episode of childhood abuse. But when she got up to leave at the end of the session without paying me, I cleared my throat and said, "So, today is the day you need to settle up for the last few sessions, as we agreed." She was upset that I could care about money after she had just revealed her deepest pain. At that moment, thinking about money as a boundary made it easier to stick to my guns. Sherry's not paying was not only a violation of our contract, but a replication of old family patterns in which uncomfortable issues were not discussed and boundaries were regularly violated. My kind but insistent tone let Sherry know that I was not her mother or her best friend, and that money was a fact in our relationship as surely as the clock that told us when it was time to end the session. Although she was angry, she wrote me a check before she left.

At the beginning of the next session, Sherry talked about feeling humiliated that she had to pay someone to care about her. It gave us an excellent opportunity to talk about the therapeutic relationship, what she could expect from me and how I was different from a friend or parent. I saw this conversation as a deepening of the bond of trust between us. She admitted that my treating her like an adult by expecting her to pay had given her a positive sense of herself as being capable and mature even while she was exploring her childhood wounds.

Having a bottom line about our fees is hard for all of us in the helping professions. It doesn't mean cutting off anyone who doesn't pay like clockwork, but it does mean not being a doormat. I try to catch potentially disruptive money issues by dealing with clients' accrued balances in a timely way. I also address clients' resentment at being charged for a missed session that they forgot to cancel and explore their expectations of how "understanding" I will be when they tell me about financial hard times. I try to leave the door open as much as I can, while at the same time holding to my bottom line.

The only way I can make sure that money issues don't harm the therapeutic relationship is to be self-aware enough about my own issues around money, and then be willing to raise the subject with my clients when it comes up between us. I now welcome the opportunity to examine the meaning of money with my clients. Our clients are not going to lead the way. When money issues come up in therapy, it's up to the therapist to blaze a trail of openness, honesty and healthy limit setting.

This blog is excerpted from “The Bottom Line". Read the full article here. >>

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Topic: Business of Therapy

Tags: ACA | add | boundaries | conversation | cutting | ED | EFT | family | HEAL | limit setting | psychotherapy | sex | talking | TED | therapist | therapists | therapy | Psychotherapy Networker | money | clients | pot | meaning

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Saturday, January 9, 2016 12:51:47 PM | posted by Ike
I found this article coincedentally. Just a few thoughts:

Psychotherapy being a business is the major reason why I sometimes have doubts about psychotherapists intentions (from the perspective of a potential client). Of course, in the society we live in, psychotherapy (and other health services) are needed and have to be paid for by someone, since money is our medium of exchange and psychotherapists also have expenses to cover and probably also want to afford a comfortable life.

What makes me wonder however is that psychotherapists and other academic medical practitioners earn huge salaries and belong to the top-earners in society (corporate CEOs, top managers, investments bankers and such aside), while for example nurses and people who take care of the elderly are not adequately paid for what they do.

Also, the academic medical field and Psychology are very "elite". Often it's the children of the upper middle class whom will end up as psychologists, since they have the financial means and the support that is needed in order to a) get a proper education and preperation in order to earn good grades during their schooling days so that they meet the requirements for Psych School / university and b) the financial support to afford going to university.

Here is my point: if the intention was mainly to help people who suffer from mental problems and take care of their needs and learn more about the perception, actions and emotions of individuals, why does money then play such a huge role? Very likely at least some psychotherapists are primarily motivated by the social status and financial gains they have access to due to being in that profession, rather than by the idea of helping people who were less fortunate than them-bourgeoise-selves.

Don't take this as an attack please, I'm just curious for your viewpoint.


Tuesday, June 30, 2015 8:49:21 PM | posted by Roger Aveyard
Thanks, Lynne, for your very much appreciated article. I have always had problems with the money aspect of our profession and your insights are very helpful to me, and Im sure, others. Thanks. Roger A.