Field Note #1: Why is therapy so expensive?

In the zip code where I keep my office, near Rittenhouse Square in Philadelphia, a typical private-pay therapy session costs around $200, or roughly a gallon of milk per minute. A client who arrives five minutes late has, in effect, lit a $20 bill on fire.

Why is therapy so expensive?

The short answer is that most therapists cannot see more than twenty to thirty clients a week because the product they sell—the kind of attention they provide—is both capped and unscalable. A therapist has only so much presence to give, and each session requires another full measure of it.1

That presence takes its toll. Use me as an example. I’ve always been a hard worker with a decent supply of energy. I exercise regularly, sleep well, and am still relatively young. I am completely exhausted after seeing six clients in a day. Not emotionally devastated. Not struggling to keep stories straight. Not snowed under by logistics. Just plumb out of attention.

But wait a second, you might say. Even with six clients, you’re still only working four and a half hours. That’s barely more than half the average workday. What gives?

This objection confuses hours spent at work with hours spent working. Much of the ordinary workday is cushioned by meetings, interruptions, coffee and bathroom breaks, phone-checking, staring out the window, and the thousand small evasions by which humans avoid sustained focus.

Indeed, there is a reason some software teams cap pair programming—two programmers working together at a single workstation—at three or four hours a day. Pair programming is harder than ordinary programming not because the code is more difficult, but because the attention is continuous. When I was first introduced to the concept—I forget where—the person describing it said that newcomers often go home and take a nap.

Point is, I’d be willing to wager a fat wad that four and a half hours of maximal focus is much more than most workers achieve in a typical eight-hour workday. But I’d be curious to know what you think:

The rest of a therapist’s week is not empty. Email, notes, billing, scheduling, consultations, marketing, supervision, continuing education, and the general maintenance of a small business all have to happen somewhere. But, at least for me, these are not the real constraint. Attention is.

Without a doubt, that attention is worth something. Indeed, one-on-one, nonjudgmental, good-faith attention is becoming one of the scarcer resources in the world. I suspect this is mostly due to the modern proliferation of things designed to capture it.

The growing scarcity of whole-milk attention is one reason why, for all my criticism of the field, I still find something wonderful in the simple fact that therapy exists. In a society so often organized around efficiency, practicality, and the bottom line, I find it almost touching that we have preserved this strange little practice in which one person pays another for the privilege of reflecting openly and honestly on their life.

Nor are therapists just anyone. We are a particular kind of someone often especially worth talking to. Because we are not part of clients’ lives, we can usually listen with less defensiveness and respond with less self-interest. Because we are accustomed to sitting with people in difficulty, we don’t always have to solve their problems to relieve our own discomfort (unless you’re a CBT therapist). Because we get paid, we can make the time all about the client.

Therapists are not, as many people want us to be, doctors of the mind. We do not possess reliable technical knowledge of the psyche comparable to what physicians know about the body. At our best, we are nothing more and nothing less than experienced and paid listeners to the human condition. Still, that is worth something.

The question is: how much?

At $200 per session, therapy may still be worth it for some people. For someone in crisis, someone with means, or someone who happens to find exactly the right therapist at exactly the right moment, it may be money well spent. But at that price, therapy is not broadly accessible and therefore cannot serve as a primary answer to public mental health. At that price, we have to call it what it is: a luxury good.

I find myself increasingly uncomfortable with the fact that therapy is a luxury good. It doesn’t help that while therapy is increasingly priced as a luxury, it is also increasingly moralized as a necessity—something everyone can, or even should, do. It is becoming yet another sine qua non of modern life, alongside laptops, cell phones, headphones, and a skin-care routine.2

I’m also not particularly comfortable with how much I charge. Currently, my average session rate is $125, while new clients pay $150.3 Lately, I have been considering raising that to $175. I could use the money, with a child now and a home renovation underway. And I could almost certainly get it.

But at $175 a session, weekly therapy costs $700 a month. At $200, it costs $800. That is roughly half the average monthly rent for a one-bedroom apartment in the U.S.

At Pennsylvania’s minimum wage, which is still somehow $7.25 an hour, a single $175 session costs about twenty-five hours of labor before taxes. A client who sees me after work on Wednesday has just spent their entire week’s labor so far.

Who can afford these prices? By that, I don’t mean: who can put it on a credit card and worry about it later. Who can actually afford it? A country in which more than a third of adults cannot cover a $400 emergency expense with cash or its equivalent is not a country in which private-pay therapy is broadly accessible.4

Here’s the kicker, though: therapy is both wildly expensive for clients and not an especially lucrative career for therapists. According to the Bureau of Labor Statistics, the median annual pay is about $59,000 for mental health counselors like me, $61,000 for social workers, and $64,000 for marriage and family therapists.5 Those aren’t terrible salaries, but you might expect more from a profession that requires an advanced degree and charges so much.

To be fair, those salary figures lump together therapists working in agencies, institutions, and private practice. The much higher session fees I have been discussing apply primarily to private practice, where clients pay more and therapists generally earn more. But even there, supporting a family usually requires building an unusually successful practice and working near the limits of one’s clinical capacity.

When I think through my friends and colleagues in private practice, the vast majority are subsidized in some way: by a spouse who earns more (or whose job at least provides benefits), by inherited money, by a second job, by institutional employment, or, frankly, by prioritizing the health of the business over the health of their clients or themselves.

All this supports something my supervisor—who, by now, you must think a very wise man—told me early in my training: “If you want to build a successful therapy practice, marry someone with a good job.”

Fortunately, I’ve always been a good listener.

Meanwhile, the economics of therapy help explain the perennial fantasy of scaling it: turning it into a measure, workbook, app, manual, or course that can reach thousands of people without requiring thousands of hours of a therapist’s attention. Occasionally, these efforts produce something of genuine value. Most of the time, they produce absolute trash. This is because, at least for the time being, therapy cannot escape what it is: an unrepeatable conversation built out of sustained attention and a particular relationship.

That neither presence nor relationships can be mass-produced is both a blessing and a curse.6 Therapy is expensive because it requires one person to devote sustained, compassionate, and curious attention to another—and there are only so many hours of that any one person can provide. This limits a therapist’s earning potential, often requiring some other source of support, while also making the cost untenable for many clients. Therapy is a precarious business on the one hand and a luxury good on the other.

Which brings me back to the question underneath all this: what should I charge?

I am a licensed professional counselor with ten years of experience. My colleagues in this zip code charge around $200/session. The machines tell me I should charge at least $175. I want to make a living and be a decent person: someone who does not mistake what the market will bear for what he ought to charge.

What do you think?

Field Notes

• Field Note #1: Why is therapy so expensive?

• Field Note #2: On the Origin of Duties

• Field Note #3: The Cost of Doing Business