Jordan was seeing me weekly for several years to help him manage his divorce, relationship with his children, and decisions about his career. It became apparent after the first year of therapy that he had started to use alcohol to reduce his anxiety. Slowly and steadily, his use of alcohol increased until he had reported several blackouts and came to two sessions with bruises on his body, not remembering how he got them. It was after one of these sessions that he asked if he could reduce the frequency of his sessions because he couldn’t afford to keep coming on a regular basis.
Karen was a psychologist who came to see me due to the stress of her job working with survivors of sexual abuse. She was having nightmares as well as intrusive thoughts during the day, almost every day, about one or more of her clients. She had three children at home, two of them adolescents, who were challenging her authority and depleting her emotional resources. Karen was the primary caregiver to her children and managed household chores and expenditures. In her initial phone call, she explained that she wanted to see me monthly. The time and expense of driving to my office from a far northern suburb, coupled with needing to pay for child care, she explained, made coming more frequently impossible.
Rob had been seeing me for 10 years. He began in a psychotherapy group I was facilitating and later transitioned from the group to seeing me bi-weekly for individual psychotherapy. As time progressed, he was diagnosed with multiple sclerosis and in the last three years, had become disabled and no longer able to work. He had no private disability insurance and was living on monthly social security disability payments. He wanted to see me weekly, but could barely afford seeing me twice per month and was afraid he would need to discontinue altogether.
Scott was a new, enthusiastic social worker, seeing me for consultation around a couple he had been working with. He’d been seeing them at a reduced fee because neither of the clients in the couple had health insurance and both were aspiring artists, working part-time jobs. For several weeks they had been talking about how difficult it was to afford therapy. Not wanting therapy to be an additional financial stressor for the couple, Scott offered to cut their fee in half in order for them to continue to see him weekly.
Marcus and Rachel were seeing me for couples therapy to deal with issues around sex. Rachel was a survivor of sexual assault and felt very disempowered in her life and in her relationship with Marcus. Marcus had an outgoing personality and a powerful presence. He was frustrated by Rachel’s lack of affection toward him and felt she was consistently withholding in many ways, including sex. After a few months of therapy, Marcus began a session by telling me they had decided to stop because they couldn’t afford to continue.
Money is Hard to Talk About
Money is hard to talk about. When someone shares with us that therapy is not affordable, it doesn’t feel like we’re being sensitive if we challenge that assertion. We often feel we’re not left with many alternatives and, taking the statement of affordability at face value, we often reduce our fees, reduce the frequency of our sessions, or try to refer our clients to a resource that may be more affordable. While all of these may be viable options, if we don’t explore the possible hidden message behind affordability, we may be acting prematurely and may miss what is really being conveyed to us.
It May Be About Priorities
Before I agreed to see Jordan less frequently, I asked him if he’d be willing to talk a little more about his finances. “I just want to understand how you are feeling stressed financially,” I explained. When he agreed, I continued. “If you had to guess, how much would you say you spend on food each week?” Jordan gave an estimate that seemed a little low. “And how much would you say you spend on weekly transportation?” He gave another estimate that seemed reasonable. “And how much would you say you spend on alcohol—including when you go out with friends for drinks?” There was a notable pause. He was calculating silently. Head bowed, he answered: “About $150.” “Each week?” I continued. “Yes,” he said quietly.
While I think Jordan had a sense he spent a fair amount on alcohol, I don’t know that he ever allowed himself to calculate his expenses. He sat quietly and I knew I had an opening that may not arise again soon. I tentatively asked him: “Did you know that you are spending more on alcohol than you are on therapy each week?” More silence. Neither of us spoke for what seemed a very long time. I continued: “Do you think it makes more sense to decrease the frequency of your therapy sessions or decrease the amount you drink and spend on alcohol?” “OK” he said. “I get it.”
Scott and I spent a fair amount of time discussing his couples case and his decision to preemptively offer them a reduced fee. While they had been discussing financial struggles and difficulty affording therapy, they did not request a decrease in frequency or fee adjustment. Scott acknowledged that he reduced their fee because of his own anxiety about their finances. I encouraged him to revisit this topic with the couple and to ask more questions about the meaning behind them talking about their finances and therapy. Interestingly, the couple told him that what they were actually trying to do was communicate the value they place on therapy and that despite financially difficult circumstances, maintaining therapy was important to them. They admitted being surprised when he offered to reduce their fee without discussion. I also invited him to consider how reducing their fee without them requesting he do so might feel even feel disempowering to them.
It Might Be About Self-Worth
I agreed to Karen’s initial request to see me monthly. After a few months of sessions, I learned that Karen had lost her mother at an early age and, as the oldest child in her family, was responsible for taking care of her younger siblings and doing cooking and cleaning. With more discussion, it became clear that her pattern of caring for others also manifested in her professional life, and in her home life as an adult. Her own needs were secondary at best, and the cost to her physical and mental health was great. As we discussed this pattern over the next few months, Karen realized that she was “going the extra mile” for everyone else, but wasn’t willing to do it for herself. Without any suggestion from me, she asked if she could come twice per month and maybe even come more frequently if she could make it work.
It Might Be About Dissatisfaction
Marcus and Rachel posed a different issue around finances. It seemed Marcus had made this choice to end therapy without much discussion. I asked how they arrived at this decision, and Rachel quietly voiced a desire to continue. I could sense Marcus’ discomfort. “Marcus,” I began, “Are there some other reasons you might want to stop therapy.” There was something about Marcus’ expression that made me ask the next question: “Is there anything about our work that you’ve not been happy with? Anything you don’t like about how I’ve been working with you.” Admittedly, I’d not checked in with them about our process.
Marcus jumped in. “Actually, yes. I feel like you’ve been more attentive to Rachel’s needs than to mine. It always seems like Rachel’s needs come first and that I’m the one who has a problem for wanting more.” Without realizing it, I had become another person who was “withholding” from Marcus. I took a moment to gather my thoughts, taking in his feedback, and considering it carefully. It was true. I had not been acknowledging his yearning for physical affection as much as I was attending to Rachel’s history of abuse. “I think you’re right, Marcus,” I offered. “ Maybe what’s been happening in therapy feels a lot like what happens for you at home. Maybe this is a place where we can explore the importance of considering both of your needs equally. Even Rachel seemed more relaxed. I continued: “Do you think we might give this another shot?”
It May Really Be About Money
I had a 10-year relationship with Rob. I knew his history and I had been a witness to his steady decline. We discussed his goals for therapy, the relationship we had developed over time, and his desire to continue to see me weekly. We had a very frank conversation about his financial circumstances and what he could afford. After further dialogue, we agreed to continued weekly sessions at a significantly reduced fee.
Money Means Many Things
In each of these situations, it seemed that money was driving the process, yet with further exploration, money became the point of entry to discuss the process of therapy more explicitly. Each discussion provided an opportunity for a “course adjustment” that, had the discussion of money been more concrete, might never have happened.
Of course there are circumstances where bringing money into the conversation is really about money. For instance, with Rob, without discussion and a fee adjustment, he would not have been able to continue his therapy with me. There are many other instances when I’ve engaged in a discussion about money and therapy fees, where the result has been an adjustment in frequency of sessions or in fees. And there have been even more instances when a discussion that began about money, led us down a very different path.
It is hard to talk about money. When someone says therapy is not affordable, it’s like playing a trump card. It may feel like cost prevails and punctuates the need to reduce the frequency of sessions, reduce the fee, or to stop entirely. Although it may be challenging and uncomfortable to ask why the issue of money has arisen when it does, the cost of not doing so may be great.
Thinking it over, I’ve been sad
Thinking it over, I’d be more than glad
To change my ways for the asking
—Paul Simon
by Jeff Levy, LCSW, CTRS