Capitalism Ruined Therapy

Phew - this blog is one that has me sweating as I write it and especially as I imagine putting it out into the world for other people to discover and read. So, let me give you some context for where this blog came from; after all, money is one of those topics that we are not supposed to talk about. Having been in practice for several years now, I'm seeing the same two seemingly conflicting themes showing up with the communities I'm a part of: first, mental health therapy is too expensive; and second, therapists are struggling to make ends meet. 

It's become a sort-of-sort-of-not joke with myself and my closest people that whenever anything unpleasant happens, the cause is capitalism. And those two conflicting themes are actually very well explained by capitalism as a cause. This time it's not a joke. So, let's dive in and tease it apart a little bit.

Theme 1: Mental Health Therapy is Too Expensive

According to research from Mira (2023), the average cost for one therapy session in Louisiana at $140. It's worth noting that Mira is not an unbiased source on this topic as they are a service provider, so a quick scan of some other data supports the idea that in the United States, the average therapy session ranges from $100-200. Typically folks in larger cities are likely to see higher prices than those in more rural areas. But what about insurance? Folks with a private insurance plan may or may not find that their insurance covers mental health, which means any mental health treatment comes directly out of your pocket. Plans through the Affordable Care Act are required to cover at least some mental health treatment. What that means will depend on the specific state and plan. A survey from VerywellMind.com (2022) found:

• the majority of people had at least some out-of-pocket cost for their therapy, even when they are getting assistance from an insurance plan and/or Employee Assistance Programs.
• nearly 40% of people required the help of other people to afford their therapy costs.
• nearly half of participants worried about being able to afford their therapy on a long-term basis
• nearly half of participants reported they would have to discontinue therapy services if costs increased (definitely explore that article for more details on this and more data).

For those folks whose insurance does provide some coverage for mental health therapy, it's also important to note that frequently these plans are not cheap. Accessing affordable insurance plans may also mean decreases in coverage.

And the cost of the actual therapy session isn't even the end of costs. There's also secondary costs involved, like having to leave work, the drive for in-person sessions, childcare costs for the session time (and/or drive time), and more. Even with the increase in the availability of tele-mental health, access remains difficult for the average American.

The Pros and Cons of Insurance-Supported Treatment

I think it's also worth a brief conversation about the potential benefits and downfalls of using insurance benefits to access mental health care.

The first obvious benefit is the (hopeful) cost reduction. With insurance covering at least part of the session, that can make access possible and at least more bearable. The potential problems with this are also important to explore. Insurance limits which clinicians they are willing to support, even if the clinician is the best/better fit for a client and/or client issue, which means that in order to use Insurance benefits to pay for therapy, a client may be limited to clinicians who are not ideal. Additionally, since fewer clinicians are on insurance boards to provide care, this can lead to long wait times for folks who need therapy through their insurance. Insurance also requires access to diagnoses, which can cause some unease with clients who would rather their mental health issues remain private. It is also possible that Insurance would put a limit on the number of sessions they are willing to pay for, regardless of best practice and client need.

In theory, Insurance should be helpful in attempting to find a clinician as clients are less responsible for weeding through a huge list of clinicians and can focus only on the ones who are able to provide therapy for that Insurance company's clients; however, I have heard numerous times from people seeking both medical and mental health treatment that often the list of in-network clinicians provided by the insurance company is out of date, meaning that clinicians who are approved are actually no longer accepting clients, are no longer located in the area, and sometimes even are no longer practicing or even living. It can be frustrating to call clinician after clinician and to hit a dead-end every time.

A little known benefit of having insurance that covers mental health care, though, is the potential for reimbursement.

I have had clients successfully manage providing paperwork to their Insurance company independently in order to be reimbursed for some of the cost of treatment, even when I am not an in-network provider. The potential for reimbursement sometimes helps to buffer from the out-of-pocket costs of finding a clinician that is the right fit.

Theme 2: Mental Health Therapists are Struggling to Make Ends Meet

When thinking about all of the information related to Theme 1, it's easy to assume that therapists must be raking in the green. I have seen discussions about this very topic on various social media platforms with people even "doing the math" to prove their point. And, let me tell you, I wish their math were reality. I think most people realize, though, that income as a mental health clinician is not as simple as it may seem. Let me share a few reasons why:

• Therapists cannot mentally maintain ethical and quality practice while working 40 client-facing hours a week. In the standard 40-hour work week, full-time therapists are usually aiming to see around 20 clients (with some seeing as many as 30). This doesn't mean they are working only 20 hours a week, though. The remainder of their week is very full with non-direct service.
  • I think it's also important to note here that client-focused work is relational. We know from the research that is isn't the act of therapy that helps people get better. The factor that is related to client success is the relationship between client and counselor. Like any relationship, the counseling relationship takes effort and intentional time, and is stressful. It is draining to walk with clients through some of their darkest and most difficult situations. It is painful to see clients in pain. Even the best therapists with the best boundaries carry clients with them and are impacted by them just as they are impacting their clients. 20 hours of intense, deeply relational work is exhausting.
• Additional time during the week is spent managing the business side of their work. Progress notes, treatment plans, case management/linking to services, consultation...there are endless things that are not only important, but are also required for ethical care.

• Therapists are required to keep up with regular continuing education in order to maintain their license (and I would argue that effective therapists are not limiting themselves to the minimum continuing education - we should be seeking out education that helps us to learn and improve). A fully Licensed Professional Counselor in Louisiana is required to earn 40 hours of continuing education in a 2-year license timeframe, with a portion of those hours specific to ethics, diagnosis, and teletherapy. These continuing education hours are costly in terms of time and often in terms of actual money - I have seen trainings offered for therapists on specialized topics in the thousands of dollars range. I have also seen trainings offered at no cost (in terms of money, anyway), but not many.
• It's also important to note that licensed clinical therapists (i.e., social workers, counselors, marriage and family therapists, etc.) are Master's Level clinicians. This means that many working therapists are working with very high school debt and, especially when they first get into the field, are often limited to extremely low-paying work. There is a hierarchical system in place for clinicians in these fields that, frankly, is exploitative toward newly graduated and our most vulnerable clinicians. Thankfully there are people who are concerned about these practices, but as many exploitative structures, dismantling them is much harder said than done.

And it's this issue, in particular, that highlights the problems that capitalism has caused and the ways that capitalism has not only ruined therapy for clients, but also for clinicians.

Therapists universally get into this field because we have a strong desire to help, usually because of the trauma we have seen around us and more often because of the trauma we have survived ourselves. Clients come to therapy not to purchase a service or good. They come to therapy because they need help.

And yet our culture of capitalism means that in order for all of us to survive, our very lives depend on procuring money. Help cannot be focused solely, and sometimes at all, on the client and therapist thriving. What therapy becomes, especially in times of economic turmoil and uncertainty (like we are experiencing right now with inflation and global unrest), is triage. We are providing bandages and performing surgery so people can get back into the battle of surviving. We provide emotional support and skill building for living better within a capitalistic system; which means that clients often don't have the ability to dream about what might actually lead to flourishing within self-chosen and values-congruent lives of great personal meaning. It also means that the help that therapists imagine providing, the kind of help that their clients want and deserve, can tend to seem always out of reach. This leads to disillusionment and burnout.

Where do we go from here? 

Look, I still firmly believe in and hope for a future for all of us that allows for and assumes that we will all flourish. When I think of my clients, and I do think of them very often during my week, I don't lower my hopes to be more in line with reality. My clients deserve to flourish. I deserve to flourish. We all deserve flourishing.

With all of this in mind (most of it pretty depressing), I think it's important to mention that just because therapy is restrained by the confines of capitalism, that doesn't mean it's all bad and it doesn't mean that the therapeutic process is pointless. There is so much to be gained from having another human, who you also know is in this fight with you, really see you and value you and cherish you. There is so much to be gained in knowing that we are in this fight together. And we need one another - the client and therapist and also just in terms of being humans. We need one another if we are going to make any progress in turning this around and bringing hope and flourishing to ourselves, our communities, and to the larger world.

Those high hopes of flourishing for all look a long way off and I know the journey is going to be tough, but I'm really glad you and I are in this together.