Funny Girl, Serious Bills

My Barbra Streisand Obsession & the Uncomfortable Truth About Therapy Costs—Because Why Not?

This is how I feel when I talk about money & therapy. Photo by Bernard Hermant on Unsplash

In my outside-of-therapy world, I’ve been listening to Barbra Streisand read her 48-hour autobiography, My Name Is Barbra on audiobook (yes, you read that right - 48 hours of Barbra). My husband likes to rib me a bit because he recently listened to a 40-hour biography about Winston Churchill and feels that that was far more worthy of 40 hours of attention, given that he was a remarkable world leader and all, but I can’t help that Barbra is more interesting to me than Winston. (Sorry, Winston - I’m so grateful for your contributions and service.)

Plus, because it’s read by the author, it is as if I get to hang out with Barbra every day - she sits on my couch, chats with me as I wash dishes, and joins me on my daily walks around the neighborhood while she tells me about her life, sometimes sprinkling in audio clips of her songs and conversations with other celebrities. (You can see how this would be even a little more engaging than Winston, right?) 

Without getting into all of my thoughts and feelings about Barbra Streisand (don’t tempt me with a good time!), it's fascinating to hear the story of a cultural icon whose career has spanned over six decades. You have to have a hefty dose of self-confidence and grit (and maybe a dash of the delulu) to make it in Hollywood for that long, right? 

In one of her anecdotes about her early career, she explained that when she struggled to muster the confidence to advocate for better pay in a creative project, she would sometimes imagine that she was playing a character who was negotiating for the money and this would help her feel more brave. 

Isn’t this brilliant? And validating to know that even Barbra-freaking-Streisand had to resource herself a bit to ask for what she thought she deserved? 

This anecdote happens to fall right into my lap as I’ve been thinking a lot about the cost of therapy and my work in this weird field. I mean, who among us isn’t thinking about money and the economy right now, right? 

So today, we’re chatting about money! (Yay?) Because I’m merciful, I’ll give you the TL;DR¹ now - charging money for therapy is tricky. 

Why, you ask? Well, here are some of the primary reasons:

1. Therapy is valuable.

Therapy is valuable because it can make a profound impact on people’s lives. It can truly mean the difference between surviving and thriving or life and death, depending on the situation and mental health symptoms.

2. It is expensive to become a therapist.

In order to become a clinical licensed mental health therapist/counselor,² you have to shoulder a TON of up-front costs, typically including graduate school, unpaid/underpaid internships,  licensure exams, licensure fees, liability insurance, supervision, trainings, certifications, marketing, overhead costs for office space, office decor, Wi-Fi, and HIPAA-compliant software client scheduling, clinical notes, and treatment plans, and self-employment taxes.³

And a lot of these costs happen before you have your first full-rate client, because graduate interns and pre-licensed counselors usually provide sessions for free or at a reduced rate compared to the market average due to their experience and licensure status. Which, to a certain degree, makes a lot of sense. I do, however, feel very strongly that interns should get paid something for their work which is, I know, wild.

The main takeaway here is that given the amount of start-up costs for new therapists, it takes years, if not decades, to truly turn a profit. 

3. The work of therapy can be kind of nebulous.

It can be hard to perceive the process, depending on the modality/interventions that the therapist is using. If it seems like we’re just sitting there listening to you and having a little chat, that’s super fair, but we’re not really.

Internally, we’re actually running your words, presentation, affect, and emotions through different theoretical approaches, assessing constantly, making connections, considering the best intervention that we’ll use next, and thinking of all the questions we need to ask, all while keeping in mind both your ultimate therapeutic goals while not trying to push you too much, remembering all of the different names of people you’ve mentioned, and trying to keep our faces and mouths from saying things that we don’t intend to say. (Which can be difficult, friends. My facial reactions in therapy are often not…subtle.) 

4. Therapy is partly caregiving work.

Therapy has many forms and facets, but over the past few decades, it has become increasingly inherently coded as feminine because the therapist seemingly serves in a caregiving or nurturing role for the client.⁴ And not to be the cynic in the room, but do we know what happens in America when we start perceiving that something is a “woman’s job” because it’s all about caregiving (other examples: teaching, nursing, childcare, etc.)? We don’t value it as much. Why? Because unpaid caregiving labor has been demanded of women for everyone, all the time, for the rest of time, amen.⁵

Ultimately, it can often feel uncomfy to put a price tag on a caregiving industry that is regularly undervalued. And here’s the tricky part - as much as we may love our careers, feel deeply called to care for our clients, or even identify as nurturing caregivers, therapists also want to pay our bills, maybe own a house someday, and not feel perpetually financially stressed. (WHAT?! The audacity of wanting to have financial stability?!) 

5. There is often an overlap between profound trauma, debilitating mental health struggles, and poverty.

This isn’t a big secret, but it’s very important to name this when we talk about the complexity of therapy. So when a therapist decides to charge more for their therapy services or only offer sessions as “private pay” (not take insurance), there’s a whole swath of people who desperately need mental health services and who cannot afford them. If you ever talk to anybody in mental health about the cost of therapy or even begin to hint at the idea that you might want to charge premium rates for your services or just not want to take insurance anymore, you will get shit for it. People will say that you care more about money than mental health accessibility. And as a therapist, aside from mistreating a client or breaking a law, this is the greatest sin. 

6. Mental health services are sometimes covered by insurance.

Insurance plans sometimes cover behavioral health services, so now we have insurance companies with all of their convoluted nonsense entering the chat. On the one hand, it’s truly awesome that insurance companies provide coverage of behavioral health so that more people have access to therapy. Yes, and amen. More of this please.

On the other hand, insurance companies make a ton of money and it’s usually on the backs of therapists accepting discounted rates, slow payouts, and dealing with a crap-ton of administrative labor and paperwork (which inherently takes time and therefore costs money). And insurance companies usually counter providers’ full rates with their own adjusted in-network rates, so providers end up getting paid a reduced rate for their services when clients use insurance.

Providers usually can get more clients if they accept insurance and they can have the moral pleasure of knowing that more people can have access to therapy, but they also make less money per client session, so they usually have to see more clients to meet their financial needs.  

7. Burnout is a reality.

Burnout emerges when people are overworked and under supported, and therapists are constantly burning out in the mental health field. I love my job and genuinely look forward to it every day, and I’ve signed up to sit across clients and hold their grief, trauma, and pain with them. It’s beautiful work, but it’s emotionally, mentally, and physically taxing to care for suffering people.

The average full-time caseload as a therapist is considered to be around 25 fifty-minute sessions a week because of how taxing the work is, and because of how much behind-the-scenes work is required outside of those sessions (maintaining notes, treatment plans, supervision/consultation, collaboration with other providers, continuing education, etc.). 

So let’s just use our imagination - what could be the antidote for burnout? What would enable therapists to have manageable caseloads to the point that they’re able to feel fully present in session, maintain all of their behind-the-scenes work so that they offer the best possible care for clients, and have the capacity and resources to honor their own needs so that they can sustainable, long-term careers in this field? 

Money. 

If we were paid enough (whether it’s by individual clients, insurance companies, grants, fundraising, or the wave of a magic wand), we wouldn’t have to cram our caseload full to bursting because we were worried about paying our bills, and our clients, as a result, would get better, more sustainable care.

I don’t bring this topic up to just whine about money or convey any sense of “woe is me” or a lack of gratitude. I bring this up because I think that ultimately, this is a public health issue, and a justice issue. 

I would absolutely love to generously provide reduced-rates to clients in need and care for my community in that way. I have personally needed reduced rates from my own therapists for most of my life because I could not afford it otherwise. But it feels kind of bonkers to offer reduced rates to my clients while also needing a reduced rate from my therapist. This has to stop somewhere, right? 

Honestly, this is a hot-button issue in the therapy world and I didn’t feel super prepared for it in graduate school. I’m regularly asking this question of other mental health providers because I think we’re all trying to “make it make sense” in our corners of the world. (And today, dear readers, I asked you to hold this complexity with me - thanks for hanging in there.) 

How can you be a deeply empathetic, trauma-informed, justice-minded therapist while meeting your financial needs and facilitating a sustainable career in mental health? 

And if you decide that you need to raise your rates, limit your reduced rate/sliding scale offerings, or not take insurance, how do you feel comfortable doing that in the face of all of the nay-sayers who will tell you that you’re a shit person, preying on those with mental health struggles? How do you honor the value of your work and your own worth so that you can confidently make those changes? (And then how do you find clients who can pay those rates?) 

For me, this is where the Barbra Streisand anecdote comes in - whenever I think about increasing my rates, I get panicky and insecure. I’d have to pretend to be Freud himself or something to get the guts up to do this. I had to text my friends for support when I decided to increase my rates by $10 in the new year to keep up with the cost of living.

I’m only two years into this work, and I certainly don’t have the answers. But I do know that I like my work and that I’d like to be in this field for as long as I can, so it’s valuable to me to have this ongoing conversation. 

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In other news, a dear friend recently encouraged me to make pledges available on my Substack. She said that this would allow other people to support and dignify my writing, which is really just an unpaid side quest that makes me happy and gives me the opportunity to process through different things I’m thinking about in my 9-5 job. 

With that said *takes a deep breath and channels Barbra* - if you like reading these essays, if they resonate with you or spark new thought processes or you just genuinely find value in this Substack, you’re invited to sign up for a monthly or annual pledge amount to tangibly support “That’s Our Time” (you could also pledge monthly, pay once and effectively buy me a cup of coffee, and then cancel - you do you). 

I’ve set the pledge options at $7/month ($75/year) which is the cost of my favorite oatmilk latte at the coffee shop down the street and my preferred IPA at the brewery with the twinkle lights around the corner, and so that we can imagine that we’re having a drink while we chat about this stuff together. 

Eventually, I hope to have additional essays or perks included for different subscriber tiers, but I’m not there yet in my rhythm of Substack content creation. So at this point, a pledge would grant you membership in The Hype Squad, and you’d have the pleasure of knowing that you’re my favorite and that you’re helping to keep the lights on. :) 

And, I recently created these little Feelings Wheel stickers for my business, so if you make a pledge, I’d love to mail one to you! 

(I’ll reach out via Substack DM and ask for your mailing address and will promise to not be a weird stalker or anything. Truly.) 

Whether you decide to set up a pledge or not, please know that your readership is profoundly meaningful to me. Taking the time to support my work by reading and engaging with these posts (liking, commenting, subscribing, sending a post to a friend) is super impactful and always makes me smile. I’m grateful for you!

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Disclaimer: This essay is intended for educational and informational purposes only. Reading or engaging with this content does not constitute therapy, nor should it be considered professional advice or a substitute for therapy. Everyone’s experiences are unique, so what’s shared here may or may not resonate with you. For more details, please review the full disclaimer on my About page before reading. To learn more about my clinical work, please click here.

1. TL;DR - Too Long; Didn’t Read. You’re welcome.

2. “Therapy” and “counseling” (and “therapist”/ “counselor”) are pretty interchangeable, but keep an eye on the letters after the name to get a sense of what kind of therapist/counselor someone is and whether they have a license or not.

3. This can obviously vary a bit depending on the kind of licensed mental health provider - I can really only speak to my experience as a Licensed Clinical Mental Health Counselor Associate/Provisional Licensed Professional Counselor.

4. To be clear, this is not to say that there aren’t male therapists - there are! There’s also a lack of male therapists across the mental health industry, and we need more of them.

5. Do you see that little soapbox in the corner called “Unpaid Parental Leave?” Do you sense that I would like nothing more than to leap onto it and begin yapping? Thank you for acknowledging how I’m trying to stay focused over here.