Building upon Talia Weiner’s ethnographic work on the therapeutic fee (2019), I consider how we clinicians encounter class-based notions of therapeutic and financial deservedness throughout clinical training, especially early on. Using personal and professional reflections, I explore how shame is unconsciously evoked in trainee clinicians and well into later practice, gradually socializing our beliefs toward the felt necessity of charging very high fees—fees that render psychoanalytic psychotherapy unaffordable for most.
Juxtaposing vignettes in which I am both patient and psychotherapist, I consider the explicit and unspoken rationales for charging high fees circulating within psychoanalytic culture. I recognize fears of class contamination and regression, as well as fears of having one’s unresolved issues exposed by maintaining low or moderate fees, tracking how these themes surface in clinical encounters. Since these fears reinforce the pressure psychotherapists feel to charge more and more, I argue for intensive clinician self-reflection on the matter, on the one hand, and for a transparent, non-shaming approach to money talk with our patients, on the other, all toward challenging the insidious notion that money comes to those who deserve it.
My focus on the fee makes tangible the powerful role of shame in shaping clinicians’ attitudes toward the practical business of psychotherapy, learned through cumulative experiences in training and beyond. The cultural shaping of attitudes toward the fee occurs within the context of clinicians’ identity development, which is in flux and malleable during training and early career years. When I say “cultural,” I’m talking about the practices and norms, both spoken and unspoken, within psychoanalytic psychotherapeutic culture.
To position myself: I’m a precariously classed, white-presenting, partnered, mother of young children; I’m elitely and highly educated, living in one of the most expensive cities in the world.
My father grew up poor poor in Brooklyn, the child of Jewish immigrants. My mother grew up in Queens, nothing fancy. I was born into a moment of short-lived, vibrant family prosperity in the 1980s. This period set up an unrealized expectation of upward mobility that hangs over my personal reality and the economic reality of the 2020s, creating shadows I feel as alternately taunting and still somehow promising, as if linear class mobility will be right back at any moment (the staying power of the American Dream!). It is against this backdrop that I write.
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I originally shared these thoughts in a panel at a Division 39 conference (the psychoanalytic division of the American Psychological Association), and I am keeping the talk relatively intact while expanding upon some of the relevant intrapsychic and relational dynamics that are at play during psychotherapists’ development.
Our attitudes toward money and class in are insidiously molded during our development as psychoanalytic clinicians. The implicit induction of class-related shame seems to be a relatively common part of the process of learning what it means to be a “proper” analytic therapist. First, let me illustrate how this socialization introduces ideas about fees and value by sharing two uncannily similar examples from my experiences as a patient, and one from my experience as a clinician. I’ve learned through sharing with colleagues that these experiences are common, both during training and beyond.
Ten years ago, while in my psychology internship at a psychoanalytic clinic, I was strongly encouraged to switch to a personal therapist from the analytic tradition of the clinic in which I was training. I was making 17k a year for a full-time clinical internship in New York City and was gasping for air, but I was all in on the idea that to fully practice what I was learning, I needed to experience a personal therapy in the right vein.
I spoke briefly on the phone with the analyst who had been recommended by a supervisor (she’ll work with you on the fee, he said, vaguely). When I told her that I would need a sliding scale fee to proceed with therapy, she agreed to see me but only at 2pm because this was a time that was less in demand than her prime-time spots. She said this bluntly, as if stating the obvious. I felt my cheeks warm. It wasn’t as if I hadn’t before grasped the concept of time as a commodity, but I had never been so plainspokenly presented with the idea that a therapist could have the equivalent of the nosebleed section.
During our first meeting, after getting the general details of my challenges, the analyst clarified that she would only offer a sliding scale for a short time given that, with my prestigious education and credentials, I should be able to figure out a way to bring in more income and pay more for therapy. She suggested that in our therapy we work on what was holding me back. I left with a fuzzy, sinking feeling. Part of me knew that her perspective didn’t make sense—given the exploitive psychology internship structure and the expensive city I was living in, how could I be saving money?—but part of me attached to this pathologizing idea: there was something deep within that was causing me to be broke, an unexplored lacuna was drawing me to work in settings that paid little, keeping me from having some lucrative side gig while I worked with patients all day, worked on a dissertation on the weekends, and generally tried to keep my relationships intact.
I suppose she was reading me as rich in social capital that I was mishandling. I wasn’t supposed to be in this position, it seems, and she was going to help raise me up to the class status I should be occupying, one closer to hers where “we” belonged. She crossed her legs languidly on the creamily upholstered chair, thick catches of oil paint jutting out—stormily, it seemed to me—from the canvas behind her.
At the time, my caseload comprised patients who were largely on Medicaid and paid nothing for therapy. Throughout the robust clinical supervision I received at this clinic, there was no mention of how these patients should figure out a way to pay more for their therapy, their class status considered static. Counter to Weiner’s observation of working class patients being deemed more appropriate for time-limited treatment, in this training site, analyzability transcended class. These patients were considered excellent candidates for and received quite long-term psychoanalytic therapy and we trainees were encouraged by the administrators to figure out ways to bill and speak with managed care in order to help extend treatment. In this training site, the psychoanalytic appropriateness of the patients was not class bound, but the supervision and expected clinical focus was never on identifying obstacles to class mobility.
In contrast, in this interaction with the analyst, I was diagnosed with underperforming my status because, unlike my patients at the clinic, I was the paying type. The analyst seemed to suggest that being too lenient with the fee for too long would let me linger in my underachievement, too dangerously close to that other type of person that we work with in clinic spaces.
Now I’ll fast forward a few years, once I was well into my own private practice.
I sought out a recommended analytic therapist to help me sort out some things early in a pregnancy. As we mulled over the factors influencing my decisions about having children, the therapist lingered on my mentioning of financial concerns and asked me what I charge my own patients. I answered, an amount at the lower end of what a psychologist in Manhattan charges, and he explained that with my background I should clearly be charging more and, to that end, we could work on this if I chose to continue working with him. I’d then have enough to pay his high fee and presumably live a financially stable life with the babies I was still deciding to have. There was no pausing to discuss my partner’s income or any other relevant contextual factors—his attention went to my unrealized earning power. He had to do something with the disparity in our fees—the fact of it was sitting between us in plain sight—and he chose to make sense of it by diagnosing a problem with my recognition of my own worth. To not do that would let the discrepancy in our fees linger uncomfortably, opening up all sorts of questions: Was he charging too much? Was he indeed a more valuable therapist than I was? I recall this therapist’s gently inquiring posture, as well as the way that he conveyed to me, through subtle but powerful self-disclosure about where and how he lived, that there was a more comfortable life waiting for me once I worked through whatever was holding me back.
The message was coming together: Charging a moderate fee is like getting caught with your low self-esteem showing.
Talia Weiner ethnographically considers a paper on the therapy fee used in the training of social workers, observing that it is only when the fee is too low that it becomes uncomfortably visible, forcing “the therapist and patient into an uncomfortable recognition of their economically mediated transaction.” Weiner tracks psychotherapists’ unconscious disavowal of the political and social-structural factors that shape their reasoning about who is entitled to long term psychotherapy, and at what cost. In the anecdotes I’ve shared, the “low fees” in question are the ones I’m paying the therapist and the ones I’m charging my own patients. These fees call attention not only to the fact of an economically mediated transaction but also to the discrepancy between the value of the two therapists in the room. In psychoanalytic spaces, the tension this discrepancy creates in the clinical interaction is often not considered in social-structural terms but is instead framed as the consequence of one interlocuter’s psychological problem, and their failure to fulfill their economic destiny.
Of course, there are other dimensions of interpersonal and intrapsychic friction that can arise in money talk in the private practice realm. Others’ perceptions (or our projected perceptions) of our fees as too high can rattle us because they suggest grandiosity, that we might be characterologically troubled enough to demand so much for our services. A desire to avoid these perceptions conflicts with a desire to situate ourselves as elites who have come far from scraggly training days. A high fee can mark psychological health and a seeming resolution of conflict, conveying that we are a finished product of years of training and so thoroughly analyzed that nothing is holding us back from charging the highest rate the market can bear.
It’s no surprise, then, given the bulky meaning of the fee, that we may mount an unconscious defensive strategy when the fee becomes too visible an object, or too much of a relational third. The strategy often involves pathologizing low fees or motivate attempts to make our relatable patients more like us, as demonstrated in the two anecdotes above.
To be clear, I’m not referring here to the entire population of clinicians who are dedicated to working in free or reduced fee settings nor to the robust psychoanalytic community that is working relentlessly to increase accessible psychoanalytic services for all. But it’s also important to note that many of these psychotherapists come from socioeconomic backgrounds that comfortably afford them this dedication. After being offered an appealing psychoanalytic postdoctoral position attached to a low fee clinic, I asked the director how people afford to accept the position. She looked at me directly and said, “I’ll be frank with you, a lot of our postdocs have spouses that are in finance, or sometimes their parents are still supporting them.” Well, then.
There is also, importantly, the explicit social justice orientation of many social workers compared to psychologists, and I am writing from the perspective of a psychologist. Psychologists may have less conflict around charging high fees given that the profession does not explicitly purport to be concerned with class disparities or working with the underprivileged, though certainly some of us are. The field, with its extraordinarily lengthy training process, normalizes financial struggle while in training, as well as its swift end soon enough upon licensure.
In The Gift of Therapy, a book often given to new psychotherapists (and given to me by one of my first supervisees), Irvin Yalom writes of the matter of money:
I’ve always considered psychotherapy as more of a calling than a profession. If accumulating wealth, rather than being of service, is one’s primary motivation, then the life of a psychotherapist is not a good career choice.
Granted, Yalom moved on from psychoanalysis to existential psychology many decades ago, but his point of view was a common enough one across all of the psychotherapies when the book was written, in 2001. Over the past two decades, as psychotherapy has been deemed more urgently necessary, a human right, an indispensable way of knowing and healing the self across people of all socioeconomic classes (though certainly more completely among middle- and upper middle-class people), its commoditization has soared. When something is desirable and less stigmatized, and increasingly seen as essential to “well-being” (that vague, all-encompassing project of self), it has more market value.
I’ve recently worked with two younger millennial patients who are highly branded—slick website logos and mottos, marketing strategies—and have no trouble embracing a commodity mindset.
One of these patients, a newish, notably non-analytic psychologist, was struggling with being overly accommodating of her patients’ cancellations and rescheduling. She mentioned her fee, which I learned was almost three times the amount of mine. She couldn’t introduce a cancellation policy to discourage frequent last-minute rescheduling, she explained, because she might lose patients who value her flexibility. Because each patients’ fee was so essential to her overall income, any threat to her caseload was problematic for her. Contra Yalom, money was her top priority, and she limited herself to seeing very wealthy people with a particular symptom set. I hadn’t heard of a session fee that high and after a moment of shock—several prolonged moments of shock, really—I found myself appreciating her forthrightness. She performed no dance around why she deserved the fee or had to charge that amount in order to be respected in her field—she simply aimed to be wealthy and structured her practice around that pursuit. I expressed curiosity around a theme of accommodation of others as a more general issue in her life (this avenue didn’t yield much), struck by how her lack of analytic background and training seemed to make this fee setting an almost entirely unfraught process for her. She didn’t voice the identity concerns that plague many analytic therapists, especially during the transition from early to mid-career, when many of us feel pressure to increase our fees to mark ourselves all grown up.
In the treatment with this patient, I countertransferentially contended with being the “cheap” therapist and kept a careful eye on any urge to mount my own defensive attack against feeling lesser than—for not valuing my services more, for not commoditizing and branding myself enough. Most importantly, remnants of the consult with the analyst years prior during my training came to mind, the shadow of her suggestion that some deeper, unconscious issue held me back from earning more hovered obnoxiously over my shoulder.
When I brought the case up in my own supervision group, all psychoanalytically-oriented psychologists, the immediate response from my colleagues was (of course!) that I should raise my fees with her. The suggestion came with laughs as they all processed, with some disgust and disbelief, the very high fee my patient charged her own patients. My colleagues’ protective/projective response was to re-establish my status in the relationship by wishing me to charge something equal to or above the patients’ fee. It was their response, so uniform that it was comical, that made things so clear for me.
Raising my fee with this patient would only re-enforce this relationship between the fee and value that is precisely what I am trying to argue against.
I think it’s essential not to trick ourselves into thinking that raising our fee is for our patients nor that it necessarily expresses something about our own self-worth. Many of us charge a lot for sessions because we want to, or need to, or because we can. And many of us charge a lot for sessions because we feel that we should, based on training and clinical experiences like the ones I’ve described here. We should or else we’re shameful.
Being more aware of how these beliefs are socialized throughout our training and clinical careers may, I hope, loosen up the hold this imperative to charge ever higher rates has on us. This pressure to keep up with the Joneses’ fees relates to unconscious fears of class immobility, contamination, and regression, and to what we have been taught—implicitly and explicitly—about what fees symbolize about the therapist’s sense of self.
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I have a clinical practice with forty percent of my caseload at different points on a sliding scale and the remainder of slots at full fee. When prospective or current patients remark about my fee—some find it very expensive, as do I—I agree that it really is a lot of money, and we take it from there.
