Ask a Therapist: Why Is Therapy So Expensive?

And Is COVID Situated to Make That Scenario Even Worse?

by Liz Covey, LMHC

Nearly every day, therapists in private practice steel themselves for the inevitable: an email inbox that overflows with new patient requests from people who have been desperately looking for long weeks or months for an opening to begin to work on psychological issues or problems that are either long-standing or pandemic-related, or more commonly, both. Clients seeking to use their health insurance for therapy are likely to find themselves in a deadlock these days thanks to staffing shortages. If a potential client uses the state Medicaid program, Apple Health/Molina, the chance of finding an opening is even slimmer, since the amount of red tape plus lower pay mean even fewer therapists are available to these patients.

And if no one is available in-network, prospective clients will likely find themselves on the open market for therapy and can be startled by the price tag. Private pay therapy in Seattle in 2022 can cost between $100—$250 per session. Many therapists offer sliding fee scales, meaning that they reserve spots for lower-fee work, but these are limited so they can be even harder to find.

This has many today asking: Why does therapy cost so much? Let's consider some of the factors that contribute to this high fee:

A Medical Field

One of the most important factors for the high cost of therapy is that this profession began in the field of medicine and therefore built just as medicine has in our country: to serve people with the means to pay for it. This mostly translates to "by and for wealthy white people." To wit, only about 3% of psychology professionals nationwide are Black. So expensive therapy is not a flaw in the system, this is exactly how the system was built to function. Since doctors pioneered the practice, there was historically a hefty bill attached to the experience. Today, however, "doctors" are usually Masters-level counselors. And in Seattle, this profession is now closer in pay to what an experienced firefighter or school administrator earns than an MD.

High Cost of Entry

Private therapists don't tend to have much agency in setting guidelines for the profession so much as they pull the available levers for making a living in this line of work. The barrier for entry to the field is high: two expensive college degrees followed by years of no- and low-paying jobs before acquiring a license. And accepting insurance can lead to longer hours spent billing impersonal healthcare corporations which can be frustrating and confusing and ultimately lead to even lower rates of compensation.

An Atypical Schedule

This profession can be misleading in terms of supposed income because an hourly rate is nearly always presumed to apply to a 40 hour workweek, but therapists do not work a conventional 40 (paid) hour work week. According to many consulting websites targeting private practice therapists, the ideal therapist caseload was determined to be 15—20 clients per week, as care for patients is just one part of the job. Therapists also need to complete office work, return emails and calls, and stay on top of billing and record-keeping. Further, caring for people with close attention for a living has a cap on the worker's amount of available energy that is surprisingly low. In fact, malpractice insurance premiums could increase if a therapist sees too many clients per week.

The Cost of Doing Business

On top of a case load, private practice therapists are expected to pursue continuing education to meet licensing requirements and other tasks associated with maintaining a professional network, which sustains referrals as well as develops one professionally. Many therapists pursue teaching, presenting at conferences, consulting, podcasting, or writing to fulfill this need, most of which is unpaid time. Plus, private practice therapists are running their own small businesses, which comes with its own set of expenses, including office and technology expenses, private health and disability insurance, retirement contributions, and the benefits of sick, leave, and vacation pay.

Cost of Living

Suffice to say, most therapists in this expensive city are not working a light 15-hour client work week but rather are seeing people in the 20—30 client range in order to pay the bills here. Hopefully at this number, which is nearly double the proposed industry ideal, they are still afforded a life that is low enough in stress and high enough in satisfaction to have enough efficacy in a role that requires one to have skills in empathy, compassion, and stability.

COVID Era

The private market is also being squeezed thanks to the pandemic, with its monumental strain on everyone, leading to an uptick in therapy seekers and a downtick in providers. Many therapists have left the profession due to burnout and personal reasons related to the pandemic, causing a shortage in the market, which amounts to rising rates. In part this is simple economics, but it also speaks to the worsening conditions of the job today and the long-term strain of working with people in perpetual crisis while also living through it yourself. It is not an exaggeration to say this job is ten times harder than it was just a couple of years ago.

I hope this helps to illuminate that even though the out-of-pocket expense for therapy can be heavily shouldered by clients, therapists aren't likely to be swimming in profits.

I personally believe that private practitioners could be cared for by the State in the ways of health care, paid leave, disability, and retirement security, sparing them the need to extract those expenses from their clients. Furthermore, if therapist compensation and ease of reimbursement in State-funded programs like Apple Health/Molina were increased, therapy could be much cheaper — and thus more accessible — for those with less financial means. As it currently stands, many therapists working in community mental health work today (such as at organizations like Sound Mental Health, which serves populations who rely exclusively on Medicaid) end up paid rates approximately equal to minimum wage, compromising their own health and stress levels.

The problem of the therapy fee, therefore, lies with our nation's crippling politics of individualism at all costs, and within a broken health care system that neglects to take care of us all in crucial and fundamental ways, deferring the work of the health of the psyche to an expensive rented hour with a professional who herself is a cog in this machine that isn't working.

My personal prayer is that we can demand change from our policymakers who can create and fund programs that would enable us to shift our values from health for those who can afford it to health for all who need it. After all, if COVID has taught us anything, it is that we need each other to be well and that we need to fund collective programs toward that end.

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Featured image by Benjavisa Ruangvaree Art/Shutterstock.com. Image editing by Emerald staff.