No Ordinary Fee
Posted on 31st January 2022 at 21:42
In an ideal world, all therapists would be employed by the State so that their services would be accessible to all. This is not the case, especially not in Ireland where HSE employed psychotherapists are few. Even if it were possible, it is unlikely there would be posts for the thousands of accredited psychotherapists that exist in the country. Private organisations employ psychotherapists but ususally at lower rates than in the public sector and certainly not in recognition of the qualifications and training required. And so, most psychotherapists are self employed and accessible only to those that can afford the fee. The fee is considered expensive- ranging from about €60 to €120 per hour- and will vary depending on location, reflecting the overheads of the premises in which the therapist is located. Aside from premises hire and utilities, the fee has to cover professional insurance, taxes, electronic payment fees, professional body membership fee, supervision and personal therapy fees, continuous professional training , holiday cover as well as the therapist’s time outside the session to review notes and consult relevant reference material.
Most therapists are reluctant business people, preferring to focus on their clinical work. But unless they are in a position to employ a receptionist, most have to handle bookings and payments themselves. Due to the nature of the work involved, both can be messy. 'No shows' and last minute cancellations, can make the income unpredictable and thus unreliable, unless you have measures in place to cover this. In psychoanalytical psychotherapy, the ‘messiness’ around booking and payment is grist for the mill in terms of informative material, but is tiresome from a purely business perspective. It can operate as a barrier to a client starting or remaining in therapy.
Looking at fee per hour value, the psychotherapist provides good value when compared with the ten to fifteen minutes at the GP surgery or the half hour with say, the physiotherapist. However, you usually won’t be coming back on a weekly basis over a long period of time to either of those specialists.
Health insurance companies are not standard in how they cover therapy fees or indeed which professionals they cover. Their customers can’t always choose. The different approaches to mental health by psychology, psychiatry and psychotherapy is beyond the scope of this brief article, but a simple differentiation centres around ‘who knows’. When patients are referred to psychiatry or clinical psychology, they are evaluated using assessments and psychometric testing such that the psychiatrist or psychologist tells the patient what they think is wrong. With 'root cause' psychotherapy, it’s the patient or client who really knows but is unable to access the information. Accessing the information with the help of a psychotherapist takes time and immeasurable time at that, unless the issue is very specific. Psychotherapists don’t prescribe medication and are often referred patients from general practice and psychiatry, not only to treat patients but to help them wean off medication in due course. Pasternack  states that:
“Recognition of the role of unconscious forces and emotional factors seems to be avoided in many settings. There also seems to be cynicism on behalf of the insurance companies and health care administrators around the diagnosis, treatment planning and value of psychotherapy. The facts, however, document that the great majority of patients are helped by psychotherapy. Furthermore, other medical costs are reduced when patients have adequate access to psychotherapy.”
Accessibility aside, Sigmund Freud  suggested that some financial sacrifice on behalf of the client incentivised a better therapy, a view supported by many subsequent analysts, some even more rigidly than Freud himself. Not paying a fee could lead to conflicts and resistance such as the client feeling they are receiving a ‘lesser’ treatment, feeling obligated to the therapist and feeling inhibited to express anger, to name a few. For their part, in setting the fee, the therapist has to ensure that there is no guilt or desire to be liked in the transference with their client, as this will impact the process. That clients who pay for therapy benefit more than those who pay nothing (or whose fees are paid by a third party) has generated many studies with variable results depending on the approach taken. [5-7]
Psychotherapists themselves know what it is like to be the fee payer as to undergo therapy is a requirement to become a psychotherapist – an aspect that differentiates their seven year (minimum) training from their psychiatry and clinical psychology counterparts. Apart from the personal value, it ensures that the qualified psychotherapist has dealt with any potential blind spots so that these do not interfere with their client’s therapy. Most psychotherapists I know are very reluctant to increase fees even when they have to. When all is said and done, the only person that can really comment on the value of the therapy, is the patient or client that benefits.
1. Pasternack, S.A. (1988) The Clinical Management of Fees During Psychotherapy and Psychoanalysis. Psychiatric Annals.
2. Freud S: Further recommendations in the technique of psychoanalysis: On beginning the treatment. In: Strachey J (Ed. and Trans.) The Standard Edition of the Complete Works of Sigmund Freud (Vol. 12). London: Hogarth, 1958, pp. 131–146. (Original work published 1913.)
3. Menninger K: Theory of psychoanalytic technique, N. Y.: Science Editions, 1961.
4. Herron, W.G and Welt, S.R. (1994) Money Matters: The Fee In Psychotherapy And Psychoanalysis: The Role Of Fee In Psychotherapy & Psychoanalysis. Guilford Press
5. Pauley, D. (2019) The Therapeutics of the Fee in Psychoanalysis. Psychoanalytic Dialogues 29:5, 560-574, DOI: 10.1080/10481885.2019.1656977
6. Raney JO. (1982-1983) The payment of fees for psychotherapy. Int J Psychoanal Psychother. 9:147-81.
7. Shipton, B., & Spain, A. (1981). Implications of payment of fees for psychotherapy. Psychotherapy: Theory, Research & Practice 18(1), 68–73. https://doi.org/10.1037/h0085962
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