One of the key challenges when setting up and running a therapy business is the issue of money. Determining our fees and, more importantly, ensuring that fees are paid can be fraught with awkwardness and difficulty.
Most of us come to private practice having spent years working in the voluntary or public sectors where clients are receiving the service for free and so the switch to (finally) being paid, as well as having to take payment directly from clients ourselves can feel uncomfortable.
The fee you set will depend on your level of training and how much you have invested in it, the location of your practice (and perhaps the fees that peers in your area are charging), your own financial expectations and how accessible you want your counselling practice to be to a wide range of clients.
More importantly, the fee we set is an indication of how we value ourselves and what we offer as therapists and it’s here that many of us can struggle, often falling prey to the tendency to undercharge for fear of not delivering a good enough service for the money or being accused of being greedy or uncaring.
Asserting rules around payment can similarly trip us up, as we find our feet in private practice counselling and find our language to address this taboo subject.
Given how awkward we generally are around money, it is unfortunate that this is one of the main ways that clients can “act out” in the therapeutic process.
Whether it be turning up to the session without their wallet, cancelling at short notice (or DNA’ing altogether) and refusing to pay the cancellation fee, or directly challenging our price or payment policy – many of us are forced to learn the hard way how to talk about money and protect our own interests as therapists.
Since most of us have been drawn to the counselling profession because we have a deep compassion for others and a desire to help those who are struggling, the idea of protecting our own interests can feel a bit alien. Isn’t being an all giving, Mother Theresa type the gig?
And yet we all understand that irrespective of our therapeutic approach, therapy is a relationship and like all other relationships for it to be healthy both parties must be considered. Therefore, if our need to be paid for our counselling service is repeatedly not met or respected, it will become increasingly difficult for us to stay in the relationship and meet our client with the warmth and positive regard that is necessary for the process to be fruitful.
Holding our lines and honouring this most fundamental premise of the therapeutic agreement really is fundamental.
Here are some ways you can support yourself to hold boundaries around payment:
1. Be really clear about the rules from the outset
Communicating the rules at the start creates a reference point that we can readily return to should any issues arise in future.
2. Repeat, repeat, repeat and make sure there is a paper trail
We’ve always found it to be helpful to send a summary of our service rules to new clients prior to their first session so they have time to digest the information and can refer to it at any time. This can then be repeated verbally at the end of the consultation or start of the first treatment session to confirm that the client has read and understood the rules and for good measure the client can be asked to agree to your payment and cancellation policies when you obtain their consent to data collection and storage under GDPR. This way should a client challenge you on your cancellation policy, you’ll be able to direct them to the initial appointment confirmation email and signed consent form to remind them of what was agreed.
3. Take payment at the point of booking to protect yourself against losses from DNAs or late cancellations
In our experience cancellation fee invoices are rarely paid and so it places you in a stronger position if payment for a session is taken in advance. You can then use your own judgement on whether to refund if a client cancels at the last minute or is a no show.
4. If you choose to bend the rules for a client (for example not charging for a late cancellation as a gesture of goodwill) be sure to remind them of your cancellation policy for future reference
Outside of these protective strategies, leaning into any perceived payment games and what may be being unconsciously communicated through them can be really valuable to the therapeutic process. As Yalom says, “It’s all grist for the mill”
After all, money and its exchange is ‘loaded’, symbolising such things as power, control, ambivalence towards therapy or the relationship, or even a desire for a non-therapeutic relationship, e.g. non-payment could allow the client to maintain a fantasy of you being their friend.
Money can also represent energy and for some, love, so a client who is withholding or reluctant to hand over session fees could be communicating something about their own energy reserves, feelings about give and take in relationships e.g. a desire to be cared for, for free, or a subconscious wish to exercise power or control in the dynamic.
Case study
"Over the years a number of clients have expressed their discomfort with the payment element of counselling both implicitly and explicitly.
In the days of cash payments when the money was hidden in an envelope and not handed directly to me, instead being placed up on the mantelpiece or on a side table, tucked away out of sight, I would often wonder what it meant to the client to “have to pay” for this support.
Was there shame in the mix? Or did the money somehow threaten an important fantasy about our relationship? "
Even clients who would be loath to ever bend the payment rules are communicating something to us.
The client for example who offers to pay extra when we allow the therapeutic hour to go on a little longer than usual, is perhaps telling us about their difficulty in receiving care from others or that they feel undeserving of any time that they haven’t paid for.
How do we then manage payment issues without compromising the therapeutic relationship?
It is a sensitive subject, and the unconscious nature of the communication means that bringing it into the light prematurely could be damaging to rapport.
Supervision is the best place to start, so use it to discuss what might be going on for the client, the value of sharing your observations with them and the best way to broach the conversation.
Case study
I have been directly challenged once or twice about charging a fee at all, often accompanied by the accusation of only caring because I’m paid to.
I remember one young woman after a moment of silence angrily declaring how much that had cost per minute. She went on to accuse me of charging obscene fees and being immoral. In my shock, discomfort and naivety, I knee-jerked into self-defense, stuttering something silly about the market rate and that I was actually very cheap as psychologists go, etc. etc. It was a deeply uncomfortable hour that left me shaken.
After taking this to supervision though, we were able to return to the issue and explore what it meant to the client to be “costing” her parents this sum and how this felt when her older brother was being supported by the NHS for free.
This opened up a whole new level of depth to the therapeutic process and allowed her to release a lot of pent-up anger and sadness.
There was an important lesson for me here: that if I can steel myself against the awkwardness of talking about money and hold my own stuff, bringing any issues around payment into the light can deepen both the therapeutic relationship and the process.
If we understand that everything is a communication when we do this work, then when a client is challenging our payment policy explicitly or otherwise, we can (on our good days) take a breath and lean into the challenge.
What is playing out for the client who expresses resentment towards our price point when they have actively chosen to come to a therapist who has been clear about this price point on their website?
What does it mean to the client who accuses us of only caring because we’re paid to, that they have had to seek out private counselling?
How is the client who continuously pays at the last-minute feeling about therapy at the moment?
Hopefully by gently and compassionately giving these unconscious communications space, a deeper understanding can be achieved, any issues in the therapeutic relationship can be addressed and the healing can begin.
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