Starting Therapy (Part III): Fees and Payment

Photo by Jude Beckon Unsplash

In this part of the framework and guidelines for starting therapy, I will discuss some of the logistics and rationale for fees and payment. This part is a bit more technical, but remains rooted in specific values concerning therapy and the therapy process. There is a whole other aspect to fees and payment that surrounds the meanings that they carry, but that is a topic for another time.

I determine my standard fee based on a fair market rate for a licensed psychologists in my geographical area and near my level of experience. This set fee amount requires no negotiation, regardless of frequency or circumstances. I occasionally raise this fee based on various factors, such as increases in cost of living and doing business, as well becoming a more experienced therapist as years go by. Whenever there is a standard fee change, I will give you notice of this at least one month ahead of time, if not more.

What about those who legitimately cannot afford to be in weekly therapy at this standard fee? I understand that there are many individuals for whom weekly therapy at the standard fee is simply not possible, or may cause excessive hardship, so I offer discounts for certain weekly time slots. I have tried many different configurations of fee and frequency over the years, and found that mutual agreement on a fee that allows sustainable weekly sessions is of paramount importance for successful work. Therefore, discounted rates are for a weekly standing appointment, and are charged as a flat monthly amount rather than a per session fee. I do not have an official sliding fee scale (which would place you at a specific fee based on specific income), but leave all discounts up to the unique circumstances of each person. A rule of thumb, however, is that if your household income is below $6400 per month and you feel that paying the standard rate for weekly appointments is not plausible, we should discuss an alternative arrangement. If you are earning more than this, let’s talk about the other financial or personal circumstances that make the standard fee implausible for you, and decide whether a discount is appropriate. Other factors may be unique expenses, dependents, unemployment, or the like.

I also often discount for regularly scheduled multiple sessions per week. Even for those who can afford the standard fee for weekly sessions, multiple sessions every week may not be financially viable. Therefore, if you’d like to move to a two or three session per week schedule, we can adjust to a weekly or monthly fee that discounts the additional sessions. One of my primary professional values is the capacity for deeper work together, and if you’d like to pursue this, I am open to discussion about how to make it workable.

After our fee is set, how do we manage payments? My policy is to collect payment at the “time of service.” This helps prevent you from building a debt and me from having to collect on debts. It also brings payment into the “here and now” rather than putting it off in the distance where we don’t have to think or talk about it. We can do payment per appointment or per month. If you are paying per appointment, we will handle payment at the beginning of each session. That way, payment does not interrupt us at the end of a session or lead to going over our time (time spent on payment is part of the 45-50 minutes, not extra time added on). If you are paying with a debit/credit/HSA card or mobile payment, I can take all major credit cards. The card must be present, I do not store cards on file or do remote card number entry. If you pay with cash or check, just set it on the table or hand it to me when you come in*. I may be a bit of a dinosaur in our digital world, but I prefer check payments, as they do not bring the processing fees and the sharing of the transaction with a third party into our relationship. If you are not already at a flat monthly rate, I recommend paying for sessions monthly if you are able, typically on the first session of the month. This is especially helpful for card payment because then we only spend time running a card once per month.

You may have deduced by now that my practice is “fee for service.” That is, I am not currently on insurance panels and do not bill insurance. The reasons for this are explained in my FAQ. If your insurance will reimburse you or apply your payments towards your deductible, I can provide you a superbill with the required codes on it (usually at the end of each month or quarterly). If you’d like a superbill, let me know and we can talk about the pros and cons of sending this documentation to a third party and the potential addition of a psychiatric diagnosis to your health record.

As you may have read in the disclosure and consent forms, I have a policy regarding charges for late cancellations or missed appointments. For those at the standard fee, sessions canceled with at least 24 hours notice are not charged. However, within the framework of weekly sessions in a depth psychotherapy approach, a pattern of cancellations becomes a topic for gaining understanding and insight into your feelings about the work we are doing, or more broadly, the underlying patterns or feelings that lead to the cancellations. For appointments cancelled with less than 24 hours notice, I may charge for the session unless the schedule permits us to reschedule later that week. Fee setting and payment can be fraught with anxiety and avoidance (from either of us)! It is really important for us to have a frank discussion about money matters. Your feelings and associations to fee and payment are important parts of exploring and understanding, so I encourage you to bring them up when they come to mind.

*Another COVID caution - we are avoiding direct item contact and keeping distance, so I am discouraging everyone from directly handing me payment. Cash or check is now set for me to pick up after the session to be handled with appropriate cautions. I also have contactless credit card payment set up.

Starting Therapy (Part II): The Structure of the Session

As I mentioned in the my last post, to facilitate good work together, it is important to work within a consistent framework. At the most basic level, this starts with the decision to work together and the setting of a weekly appointment time, but I’d like get into some of the nuts and bolts of what this generally looks like.

We will meet for 45-50 minutes each session. This means that 45 minutes from the start of our appointment time, I will let you know it is time to wrap up. We may stop there or spend a few more minutes wrapping up within the 50 minutes. This also allows for natural fluctuations of a minute or two. You may have heard of the “50 minute hour”, which allows therapists to maintain an hourly schedule, with time for notes, a stretch, a bathroom break, and, most importantly, to make their next cup of tea before the next appointment. The principle that is most important, however, is that we have a predictable and consistent beginning and end to sessions. Sometimes this will be an immense comfort, sometimes it will be really frustrating - but no matter what, it will be consistent. I encourage you to bring up how you feel about the time boundaries of the session, we never know when that might open up new opportunities for understanding.

Scheduled sessions are assumed to be in-person, unless otherwise prearranged due to travel or some other extenuating circumstance*. I believe that in-depth, exploratory therapy is more effective when taking place in-person, or when we are “co-present.” So, if you are running behind or slept too late, for example, will will either meet for the portion you can be present for or it will be considered a missed appointment. I know that sometimes life happens, and if the schedule permits, may allow us to reschedule an infrequent late cancellation. However, consistent with my therapeutic approach, we may explore the meanings of missed appointments, especially if there are potential patterns developing. This ties to a bigger idea that the changes in the framework of the therapy can carry important information about your ways of living, relating, and feeling. If I do not hold these boundaries or fail to be curious about alterations to them, I believe I can do a disservice to the work we are engaged in together.

This all goes both ways, of course. It is my job to be at my office for our appointments and to be on time. If I am running late for any reason that does not allow us 45 minutes together, I will provide you the missed time. And if I ever “no-show” on you, I will not charge you for that time (and I am sure we will explore the meanings of that experience for you in our next time together). Thankfully, while “life happens” for therapists too, these occurrences are few and far between, if at all.

*I wrote the original draft of this article before COVID-19 hit us. I’ve kept the wording the same above, because in “normal” times, I stand by this value. However, during the COVID-19 emergency, we have been required at times to continue to work from a technologically mediated therapy, through either phone or video. For some, this has been minimally disruptive to our work, and even opened up new possibilities. For others, it has felt very limiting and changes the nature of our work together. For my policies and recommendations regarding remote therapy during the pandemic, see my COVID updates.

Starting Therapy (Part I): Framework and Guidelines*

Starting therapy can be a harrowing process, filled with all sorts of conflicting feelings: excitement or dread, anxiety or comfort, despair or hope, confusion or clarity. Often many of these at the same time! The final decision to call me or submit an inquiry on my website is sometimes the product of many weeks, months, or years of contemplation (and maybe avoidance!). Since this is a big deal, I’d like to help provide you some scaffolding for how to understand and approach therapy as we begin this process together. This is part I of a series of brief articles, introducing a basic framework and guidelines for starting out, as well as thoughts about the general duration of therapy.

Once we’ve talked briefly on the phone and want to proceed, our first scheduled meeting will be an “initial consultation.” This is simply a time for you to share why you’ve come and for me to get to know you. My main request of you will be “tell me what you’d like me to know about yourself” and we will see what unfolds. During this consultation, we may explore the things that brought you to contact me, the things you want to work on, some of your family and/or relationship history, past therapy experiences, or feelings about being here in the first place. We will decide if this feels like a good fit for beginning therapy together. After that, we will proceed with regularly scheduled 45-50 minute sessions. The first few sessions often continue this “getting to know you” process and give us an even better sense of the decision to work together.

What does it mean to “begin therapy together”? This implies a good-faith agreement that each of us is making to work together over time to help you achieve genuine insight, growth, and change in your life. On your side, this investment breaks down to three basic things: attendance, payment, and certain attitudes (such as honesty, openness, and curiosity). Obviously, a signifiant process of growth and change cannot happen without being here! Consistency and continuity are central to this. This is why, in order to facilitate deeper work, we will set a standing appointment time for the same day/time each week. This is an hour of each week that you are essentially leasing out from me, which is also where payment comes in. My work with you is a portion of my livelihood, and I charge for that time in accordance with my level of training and experience. My investment is not simply just time with you each week, but in providing my undivided attention, a consistent attempt to understand you deeply, and to convey that understanding the best I can. However, in order to do this, it requires your openness, honesty, and curiosity. Besides showing up and paying for sessions, it is your role to bring in whatever is on your mind, and to try your best to push past the temptations to withhold information or censor yourself.

At the beginning of therapy, many people are interested in knowing how long it will take. I do not believe either of us can predict this from the outset. I do not work in “time-limited” models that aim to isolate specific concrete symptoms and treat those with directed interventions. These types of solution focused or cognitive-behavioral therapies have their place, but in my training and specialization, I have chosen to work with people who want to explore the roots of their difficulties, and are interested in working on the more unconscious parts of themself. But working at that level takes time. The process of deeper work is cumulative and requires persistence and consistency.

I have not really answered the question, and again you ask, how long will this take? My general recommendation is that, barring some significant life change (e.g. moving away from the area) you plan to spend at least one year in weekly therapy if you expect to make some discernible difference in the underlying difficulties that brought you in. Recent research has suggested that the lasting gains from depth psychotherapy (not only the gains while in therapy, but additional gains after the end of therapy) really show up after about 150 sessions (and that’s three years of weekly therapy - or 1 ½ years of twice-weekly therapy). I have found this to be generally true in my career so far. Although I have seen some people make significant changes in less time, personality growth takes time. There is a certain common sense to this - in order to make deep and lasting change at anything in life, it requires ongoing, consistent engagement. This is true in sports, professional skills, education, spiritual growth, and all sorts of dimensions of human experience. So - plan on dedicating at least a year to this process (frequently more, sometimes less). Ultimately, I believe that good psychotherapy is a rewarding journey in its own right, and can last as long as you want it to and as long as it is a meaningful process for you. When well-known author and psychiatrist Oliver Sacks died a few years ago, I was not surprised to find out that he had been working with the same psychoanalyst for nearly 50 years! This is obviously an outlier, and I don’t expect to meet with many people, if any, for 50 years, but it is not that unusual for curious, self-reflective individuals that approach growth as an ongoing, never-finished process to find depth psychotherapy rewarding for 5 or 10 years or more.

One last thought about session frequency before ending part I. While I hold weekly sessions as the “standard of care” for ongoing depth therapy, I truly believe that meeting more frequently generally leads to more substantial insight and growth. Meeting two or three times per week can result in much more space for exploration of your inner world, and a much richer therapy experience. It is not unusual if you feel stuck in your life at weekly sessions, that meeting two or three times per week can open up new dimensions in our work together. While I am trained extensively in psychoanalytic therapies, I am not a formally trained psychoanalyst (yet). Therefore, I do not meet more than three times per week for psychotherapy. What about less time (such as every-other-week or monthly)? In my experience, I have found that less than weekly therapy is generally not conducive to the level of continuity or intensity required for deeper growth. While meeting less than weekly is sometimes unavoidable due to finances or life circumstances (e.g. traveling a lot for work), if we are just starting out our work together, I will generally expect that we set up weekly appointments. (If, down the road, you have made consistent growth and want to decrease our frequency, that is another discussion.)

In my next article, I plan to talk in more detail about the structure of the session and some of the details around fees and payment.

*Some caveats: Practically speaking, there are as many unique approaches to therapy as there are therapists. Even the proponents and researchers of major therapeutic approaches don’t agree on exactly how therapy should look. So everything within these writings is my opinion and reflective of my unique individual approach to therapy. While most of these ideas reflect broader perspectives or consensus from specific approaches, I certainly do not assume to embody “the” approach to therapy.