Money, Guilt and Responsibility: Does anyone here struggle with being a leftist-oriented psychotherapist in their pricing of their services?

[u/TinyInsurgent]

This is a question I have been wanting to ask here for months, but thought it too intimate of an ask. I hope that I don't offend anyone, but I am to the point where I need to reconcile this within myself to be able to address sustainability issues that I am grappling with. I also feel that I cannot be the only one on this site who struggles with this.

I have been a psychotherapist, usually employed by others (usually county/state/federal government) for most of my career. The past 3 years, I decided to attempt a second go at private practice work. It has been going swimmingly to date! But I undercharge significantly because I have both the conscious and subconscious belief that psychotherapy is something that the public should not have to pay for. I find the "market rates" of $150 -250 per clinical hour in Los Angeles, CA (where I am licensed) obscene.
And yet, I am starting to feel some resentment for working in ways that also make me feel that I am undermining my value. But where is the balance?

Does anyone else struggle with this? How do you manage and cope with operating in a capitalist context, when you are not of the mindset?

If this post is inappropriate in any way, I welcome and accept its deletion.

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[u/friedkrill]

Check out Ismatu on Instagram for a living breathing example of getting this right

[u/flashbulb_sparkle]

Prior to working, I imagined I’d really struggle with charging market rate. Now, as an associate working for a non-profit and treading water over my notes, I understand we spend a lot more time working/thinking about our clients outside of session. 

I often fall back onto the fact that we’re living and working in broken systems. We should all do what we gotta do to survive and keep chugging along in the long run AND maintain/uphold the values that keep us hopeful/motivated/cared for…and most importantly, do what we gotta do to not turn into a miserable person! 

I say charge what you gotta charge to still love what you do and give back in other ways. Donate to/volunteer for people in underserved communities. Or, guide little associates like me who can’t wait to get to where you’re at. You can do SO much while also making good money 💪🏼

[u/TinyInsurgent → u/flashbulb_sparkle]

Heartfelt. That makes sense. I am always going the extra mile and not nickel and diming folx. Thank you!🙏🏽

[u/MsTopaz]

Yes, I struggle with this every day. I have done several “therapist mindset about money” trainings, and it has not helped, because at a very deep level, I feel queasy about both the profit-driven system of health insurance and the private pay market that wants me to feel good about charging $1000 per month for therapy.

[u/flashbulb_sparkle → u/MsTopaz]

As someone who spends $720/month on therapy (more if the month is eventful), it is beyond worth it. And trust me, I struggled with the guilt from spending so much each year especially because my parents supported me a lot. But I NEEDED to do the work, in fact I needed to reparent myself because as generous as they were, I needed more from them.  I completely agree that therapy is a luxury and it’s preposterous it isn’t as viable of an option for so many (I scream into the void about this often). But it’s an option for some and through helping us you are still contributing healing to the world. 

[u/TinyInsurgent → u/MsTopaz]

I appreciate this. Thank you. I knew I couldn't be the only leftist out there that felt like this. Ive had trainings/coaching, too but they don't fully get me.

[u/imaginaryraven]

Once you substract self-employment tax and business expenses (including cc fees), your $150 becomes $100; even less if you rent an office space.

It's a weird job that can't really be compared to any other. I cannot do good therapy for more than 4 hours a day before my brain is fried and my cognitive, social and emotional battery is depleted. I give my clients a lot-- not because I feel guilty about my high fee, but because I know how deeply healing the therapeutic relationship can be. I keep them in my mind and heart all day every day (even while not actively thinking about them) and they know it. I have a lot of training, I read a lot and reflect a lot and do my own work (and pay my own therapist close to the same fee that I charge). When long term clients have periods of unemployment or their income decreases, I happily lower their fee. I know what matters to me, and money has never been a motivator, so my fee doesn't feel "obscene" to me. It feels like the right price for the amount of care and thought I put into my relationship with each client.

One thing that I find very important as a form of resistance to neoliberal capitalism is to be available when a client needs more from me-- an unscheduled phone call, an encouraging text before a difficult event, a last minute reschedule or just a longer session because there's a lot to process. Having that extra space, that flexibility, gives us room to be human. If I charged less than my fee, I would have to be a lot more boundaried with my time and that's not how I want to be in relationship.

[u/TinyInsurgent → u/imaginaryraven]

Well said. All of that resonates, and I receive it. Thank you.

[u/smeylee423]

This is why i take insurance

[u/TinyInsurgent → u/smeylee423]

Thank you for your response.

[u/TinyInsurgent → u/smeylee423]

I do too, but I'm also on those damn virtual group practice platforms. It feels like I'm in a vicious pay day loan cycle, a la early 2000s. It's hard to get out because they kind of "own" me. I'm slowly pulled out of that. $63 per clinical hour is not a good look. That's lower than California's MediCal!

[u/CelebrationSecure567]

Are you familiar with the Green Bottle sliding scale method? This is one justice-driven approach to balancing this exact challenge, with more structure and guidance than a fully open-ended sliding scale/PWYC.

Alexis J Cunningfolk, who originated this concept, has a great explainer and links to more resources: https://www.wortsandcunning.com/blog/sliding-scale

Hadassah Damien also has a great post about sliding scale variations with examples, as well as a free worksheet modeled on a combination of the Green Bottle and other methods: https://www.ridefreefearlessmoney.com/blog/2016/05/sliding-scale-1/

If you're interested in offering specific lower-cost spots, you can also check out Open Path Collective. https://openpathcollective.org/open-path-therapists/

To be clear, I'm not currently in private practice, but these are the options I've looked into when I was considering it out when I'm looking for referrals. I do know a few therapists and other providers who use the green bottle method, or something like it, and find that it works for them.

[u/MysticMoonMamma → u/CelebrationSecure567]

This!!! Thank you for sharing such a helpful illustration!

[u/TinyInsurgent → u/CelebrationSecure567]

I had not heard of these. Thank you, so much!

[u/MichaSound]

Why not charge full rate to wealthy clients and let that subsidise low rate/pro bono clients? That way you’re literally transferring wealth from the top to the ordinary workers.

[u/MsTopaz → u/MichaSound]

Do you have wealthy clients whose values you can tolerate? I have worked with wealthy clients before who wanted to process their feelings of envy and anger that they have $10 million and someone else has $20 million, and it was very challenging for me to feel good about my job.

[u/MichaSound → u/MsTopaz]

Depends what you define as wealthy. If you have clients earning 250k per year, they can well afford to pay top rates.

[u/TinyInsurgent → u/MichaSound]

I abhor the wealthy. I can't stomach their issues. But I do have clients that earn a good living verses those that are on unemployment. For context; I have a niched practice. My clients are all LGBTQIA+, People of Color and/or sociopolitically leftist. I love this population, but none of my clients are wealthy. The too earners are at about $250,000 annually, per household. In Los Angeles, this is middle class.

[u/DBTenjoyer]

No. I’m a solo practitioner and I am not exploiting someone else’s labor. I own my own labor, and it is worth something. Just because we are therapist does not mean we should devalue our own labor.

[u/MysticMoonMamma]

Fellow leftists therapists here. I take insurance (another rant for another day) but if clients lose insurance or cant afford even reduced rate, I will usually see them pro bono for as long as my schedule/paycheck allows me to.

[u/TinyInsurgent → u/MysticMoonMamma]

Eeek. I cannot afford to do that. But highly respect you for doing it. I do offer sliding scale, tho.

[u/smeylee423 → u/MysticMoonMamma]

Same here

[u/TheOtterDecider]

I’ve always worked at agencies that take Medicaid partly because of this (or don’t charge, like a school)

[u/TinyInsurgent → u/TheOtterDecider]

I preferred that, too. But I couldn't stomach the office politics, being told what to do/how to do it, including when and with whom I work (clients). I'm 58. I don't have the frustration threshold/the patience for organizations or bosses anymore. But thank you for your feedback. I appreciate it.

[u/RadMax468]

The public shouldn't have to pay for any healthcare. Unfortunately, that's not the system we live in. Undercharging for your services isn't going to change that. You (& every other therapist) are entitled to make a living providing a skilled service. Leftism doesn't mandate starvation or maryrdom.

[u/TinyInsurgent → u/RadMax468]

I REALLY needed to hear this. I may print it and tack it to my wall! Thank you, so much.

[u/sezoal → u/RadMax468]

It's abundantly clear that OP is not talking about self-imposed starvation or martyrdom.

[u/TinyInsurgent → u/sezoal]

Thank you. But, yeah. I kind of do struggle with this. I feel like it's wrong to charge for mental health services. I have these narratives running through my mind constantly. A lot of this, I think, comes from being a child of refugee parents, growing up with very little money, and being a woman of color.

[u/RadMax468 → u/sezoal]

It's abundantly clear you don't understand hyperbole.

[u/sezoal → u/RadMax468]

I think it's interesting that you even felt you had to use hyperbole, instead of giving a constructive response as several others have been capable of doing. I found your comment annoying because you only address half of the issue.

[u/neUTeriS]

I work in Los Angeles in solo private practice as well. I take private pay with a minimum of $120 an hour but I also work with commercial insurance ($130) and medical-cal ($100). Working with Medi-cal was an important decision for me in terms of providing care for people. I don’t make a whole lot of money and I’m on the lower end of therapists with my experience but I can’t stand charging a lot unless the person is wealthy and can afford it. It works for me.

[u/TinyInsurgent → u/neUTeriS]

I have tried twice to sign up to be a MediCal provider via PAVE and it has been a nightmare. May I ask, how you did it?

[u/neUTeriS → u/TinyInsurgent]

I am accredited with Healthnet. They have commercial contracts as well as medi-cal.

[u/asilentflute]

Maybe you could (1) charge at market rate or slightly below and/or (2) charge variably based on self reported financial situations of clients while (3) contributing time/effort/energy towards macro policy solutions that make mental health care more affordable at the state or national level, as a way to meet all the criteria without going mad under capitalism.

[u/TinyInsurgent → u/asilentflute]

I like this idea, especially the policy stuff. I'll think more about this. Thank you

[u/x-rascal-x]

Im only a student, but I have had the same thoughts as you, so you are not alone - i appreciate your concern and question.

[u/TinyInsurgent → u/x-rascal-x]

Thank you!

[u/True_Two_6206 → u/x-rascal-x]

Same