Introduction
Seeking out psychotherapy to address persisting emotional difficulties, especially when you have never had personal experience with it, is almost always a last resort. Leaving aside unconscious factors captured by the term “resistance,” the cost of competent treatment remains one of the easiest excuses to cite when avoiding needed care. While this list won’t help you address any negative feelings you have about therapy and/or what it costs, my hope is that it will:
- Help people who are ready for treatment and struggling with how they can afford it; and
- Gently take away poor excuses for avoiding something that is needed.
Remember that therapists like to help. That’s how we got into this profession.
Don’t let the cost get in the way of the help you need. If you’re willing to do some legwork, there’s a therapist out there for you.#mentalhealth#therapy pic.twitter.com/xTGVlbxrYX
— Michael Kinsey, Ph.D. (@mindsplain) May 17, 2020
1. Ask for a Lower Fee and Present a Budget
Many therapists will consult at no cost with prospective patients to determine whether the fit is right and decide if both parties can agree that the work has the potential to be fruitful. Fee is one key elements to be established in this session. Ask your therapist if they ever work on a sliding scale, and what the lowest hourly rate they would accept is.
It’s not always easy for therapists to answer what the lowest fee they would take is, since a lot depends on what each patient can afford. Fee is not only compensation to the therapist, but leverage for change. Money gives patients a stake in progress. If you ask for a below-market rate, then as your therapist, I would want assurance that you are paying what is uncomfortable, but doable. Bringing a budget to the consultation accomplishes several important tasks when discussing fee:
- It shows you are motivated and committed;
- It is evidence of your ability to plan, conscientiousness, and sense of responsibility (i.e., will you come regularly? Pay on time? Cancel with plenty of notice?); and
- It assures the therapist that your desire to pay less does mean that you are prioritizing therapy less than you prioritize happy hours, frequent and exotic travel, and/or other indulgent non-necessities. As one of my therapists put it, the fee should “pinch” and come with a reasonable set of sacrifices if you are not paying full price. It is not meant to thwart any and all travel, leisure, or indulgences.
By being transparent, therapists will also recognize your willingness to open-up and share something personal and often shameful. Many (if anything, too many) therapists are agreeable and help compulsively; if the consulting therapist does not agree to what you can afford, then they may very well help connect you to someone who would agree to your terms.
2. Community Clinics
If you live in or near a major urban area, you are almost certain to have a low-fee clinic clinic whose mission is to serve the community with psychotherapy and/or psychiatric services. In New York City, there are too many of these clinics to list. Not all of these are of equivalent quality, but a small amount of research and/or travel could be the difference between finding an outstanding therapist vs. a resource-strapped mess. Don’t assume that because something is low-cost or even free that you will not be able to get the help you need.
In my experience, the downside of these clinics are that there are often waiting lists, and you may be assigned to a trainee. The problem with the latter is not necessarily quality of work, but rather that trainees rotate through clinics on a yearly schedule, which means you may have frequent changes in therapists. Not ideal, but not the end of the world if you don’t have the resources for a private-pay option. As a former trainee, I can attest that I (along with many of my peers) put my heart and soul into those treatments and stand by the work I was able to do on a time-limited basis.
As for the waiting list, all I can say is better late than never. If you are really in dire need of treatment, I know that many community clinics often have the capacity to expedite the intake process when risk is high. If your need is not urgent and you persist in looking for other options, there is nothing lost putting your name on a waitlist in the meantime.
3. Psychoanalytic Training Institutes
The first treatment I found when I moved to New York was through the New York Psychoanalytic Society and Institute. This is an institute that trains professionals in psychoanalysis. I ended up meeting with my analyst 4 times a week. I was a student and worked out a sliding scale fee of $10 per session (with what I know now about how difficult great and affordable therapy is, I’m embarrassed that I was able to get such an amazing treatment for so little).
My analyst was a young psychiatrist who was fully licensed and brilliant. It was a steal. I’m forever grateful for having this experience and I can’t recommend psychoanalysis highly enough. In New York City there is a treasure trove of these institutes where fully qualified professionals, who have already completed close to a decade of formal training and commit to spend another 4 years and countless hours further enriching their minds and lives. Everyone admitted to these institutes, in order to become a fully-fledged analyst, is required to complete several “control cases.” These are usually done on sliding scales and are taken very seriously by the provider. To see if any such opportunity exists to be a beneficiary of this training process, click on the link to the American Psychoanalytic Association low-fee clinic page here.
4. Clinical Trials
Just like pharmaceutical companies do experimental trials of their medications, so do psychotherapy researchers. If you believe that you have a specific set of symptoms and/or diagnoses, you may search for clinical trials in your area for that particular disorder. This type of research often means committing to being “randomized” such that you don’t know if you will receive the experimental treatment or the “treatment as usual.” By participating in these, you relinquish some agency over the course of your treatment, but with the benefit of obtaining low-cost, free, or even paid psychotherapy. If you are located by either major universities and/or large teaching hospitals with departments of psychiatry, chances are that opportunities to receive low-cost treatment are available.
One resource for locating clinical trials for anxiety and depression can be found here.
5. Participate in Research
Going the route of obtaining treatment through a clinical trial is a direct way to get free or inexpensive treatment while helping advance psychotherapy research at the same time. One downside to this option is that you will inevitably have less control over who you work with and what type of therapy you receive. In many cases, researchers may not even be able to tell you much about the type of treatment you will be receiving in order to keep the study “double blind.”
A more indirect way to obtain therapy through research participation while maintaining more control over the type of therapy you receive is to use the money you make through research participation to pay for the therapy you want. Paid research can be found by going to psychology departments at major universities, searching online (e.g., craigslist), looking for flyers in teaching hospitals, etc. Some of this research pays quite well and can help cover costs of psychotherapy–especially if you have the time to participate in multiple studies. Focus groups are another type of research that pay quite well and can expand the amount you can pay for treatment.
6. Barter (being mindful of boundaries)
For many psychotherapists, a barter arrangement for services would be unimaginable, even though psychology ethics codes do not forbid it. The reason many therapists might balk is because boundaries around barter have the potential to introduce complex dynamics into the consulting room.
However, many psychologists have psychology-related projects outside their practice that could benefit from patient contributions. As a content creator, blogs, articles, testimonials, etc. can be extremely valuable to me, both in terms of money and in terms of saving time. I could easily imagine striking a deal with a patient who writes well but does not have the means to support an ongoing treatment where I accepted an article from the patient instead of a check. Famously, the author/psychotherapist Irvin Yalom co-wrote a book with a patient called Every Day Gets a Little Bit Closer: A Twice-Told Therapy.
I cannot recall if Yalom reduced or waived the fee in order to complete this project, but I like the fact that the barter arrangement of co-writing a book has the added benefit of promoting emotional growth.
If your psychologist is not a content creator, perhaps you have a different skill, such as online marketing, document creation/design, web design, social media management/consulting, etc. that could be adapted to take the place of a fee. Many types of service/goods exchanges are not appropriate for a therapeutic relationship. But just because many are off-limits does not mean that a fair and appropriately-boundaried exchange cannot be agreed upon.
7. Take Classes & Make Use of Counseling Services
Attending a college or university is huge expense in its own right. But what about if attending college and mental health problems stand between you and a more prosperous life? Why not have the cost of one offset the other?
Having completed my training in New York, I had the privilege of working in the Baruch College Counseling Center as one of my practicum placements. I loved working with the students there. I found most to be mature, smart, and highly resourceful. In my biased opinion, the therapy these students received was also top-notch.
At Baruch, not only was the school a part of the CUNY system, where costs were much lower than other schools, but the counseling center permitted therapists to work with students for the full academic year (some counseling centers place limits on the number of sessions). Even if the school you might attend places limits on session numbers, the counseling center will then offer practical referrals to ensure continuity of treatment. Health insurance is also obtainable at a reduced cost through universities, and therefore in-network providers off-campus are always feasible. What’s more, the CUNY and SUNY tuition can be free for New York residents who fall below certain income thresholds. In short, if you meet the criteria for a tuition-free place at Baruch College, you could get both free classes and free therapy.
Of course, I highlight Baruch because it is exceptional in this regard. However, the basic principle still applies: If education and mental health stand in your way, both can be obtained with the mindset to find schools, scholarships, and programs that can alleviate the cost of both while obtaining two invaluable experiences.
8. Use a Consulting Clinician’s Network
Therapists know a lot of therapists. Knowing this, and the fact that many therapists offer free consultations, and you have just instantly improved your chances of finding affordable therapy. As a member and participant in multiple psychological organizations, I receive emails daily from other providers looking for the right therapist for a patient with whom the sender has just consulted. It’s extremely common for patients with very particular budgets and specific needs to get connected with a therapist who meets those exact needs; all that needs to happen is for you to tell a mental health provider exactly what your needs are, then ask said provider to disseminate a de-identified email to all his or her colleagues.
Yes, sometimes it is really this easy.
9. Philanthropy
Therapists can be generous in the fee they offer because they want to help. You know who else can be generous to those in need? Everybody else. Gofundme is a great resource if you are truly in need. Understandably, you may not want to broadcast your depression or anxiety disorder, but you may get the help you need if you do. A great use of this resource is in response to a significant, public trauma. Perhaps friends and family learn that you have been assaulted, your wife or husband left you, your child is sick, or you’ve witnessed a tragedy. If people already know you must be struggling, then why not ask for help?
Receiving help is extremely difficult for many, I’m well aware. If you are one such person, consider being on the other side of things. Have you ever not known what to say or do when someone about whom you care deeply experiences a terrible loss? Wouldn’t it have been much easier to be around this person if this person had communicated exactly what s/he needed? Asking for help feels good for both parties. What’s more, it’s healthy for both people.
While Gofundme is a very public way of asking for help, I’m sure other options exist for seeking help without the fanfare. If discretion is paramount due to stigma or simply being a private person, ask people who are as trustworthy with secrets as they are generous. Nowadays we are all under so much pressure to not need other people. The problem is that we do need other people. Acknowledging this truth is a major strength and could just be the thing that gets you through a tough time.
10. Ask for a Discount in Exchange for a Different Form of Payment
Although I’m mildly embarrassed to share it, I’m a bitcoin afficionado and a goldbug. I value these stores of value over our national currency. I am happy to accept 50% of my standard (in dollars) if a patient is willing to pay in bitcoin or bullion. Does this happen often? No, but I hope it does. The therapist you want to see may harbor the same wish. That still might be a significant fee, but 50% off is a pretty generous discount if you ask me.
More commonly, patients ask if there is a discount for cash. Very often there is. Bitcoin, gold, and cash are all tools to get a therapist to lower his or her fee AND feel good about it. With this and other options on this list, you have the option of using several of these strategies until you reach an arrangement that works for both you and your therapist.
11. Explore Insurance Options
Nothing allows for affordable psychotherapy better than an excellent insurance plan. But even if an insurance option is the answer, you still have to have the plan, find the plan, know your benefits, and/or strategize to get the most out of your insurance coverage. If you’re like me, reading fine print and calling 800 numbers to figure out all of your options evokes feelings of dread and torpor. Luckily, others can help us with this task for a low cost. For example, the website Fiverr allow us to outsource tedious tasks like this for a low cost, and more importantly, the potential for a high reward. For example, a quick search of Fiverr yielded this result.
My own aversion to completing these tasks has a great deal to do with my sense of how competent I am at completing them. If you have more confidence to work the angles and research your way to having the most options, then you may even enjoy taking on this task.
Although much more could be written on this topic, essential questions to ask yourself are:
- What type of coverage is available to you through your employer, the public exchange, a parent, spouse or domestic partner?
- Is there a plan that fits within your budget as an expense–especially when considering other medical needs you may have?
- Who are the therapists that accept insurance in your area and which of these come highly recommended?
- If in-network providers are not an option, which plans/carriers offer the best out-of-network benefits?
Conclusion
The affordability (that is, the lack thereof) of top-notch psychotherapy is definitely a problem. Financial difficulties and stresses are often one of a confluence of factors drawing people into treatment. Conversely, the costs of training on top of ongoing expenses often prohibit clinicians from charging less than they do.
But I don’t believe that this stalemate between the sticker price of therapy and the resistance of the patient is one that can’t be broken by some creative thinking. Most therapists struggle to charge what they are worth because they tend to prioritize the needs of others over their own. If you are sufficiently motivated for treatment and are willing to create a plan for how to help a therapist say “yes” to an affordable rate, I have no doubt that you can strike a deal with an outstanding provider.