When I quit my job, I expected to leave my problems at the office. Instead, I was more anxious than ever before. As an uninsured freelancer, I asked friends-without-benefits to recommend sliding-scale therapists who might pity me enough for a discount. Without one, the going rate for therapy is between $75 and $150 but can top out over $200 in cities with a higher cost of living, like New York.
It turned out to be a bit of a riddle: Sliding-scale therapists offered only $100 a session as their lowest reduced rate, video chat therapy ran closer to $75, or I could put my name on a waitlist at a local psychotherapy school, where I could see a student therapist $40 per appointment. I opted for a student, as it was the most financially sustainable choice. “There’s at least a three-month wait, and we really recommend considering other options,” the receptionist told me. I put my name on the list anyways, and immediately spiraled into a panic about how my willingness to wait for therapy might somehow disqualify me from receiving it. I was an anxious mess.
As mental health awareness increases, so does the awareness of how much treatment can cost. Although 76 percent of Americans think psychological health is as important as physical health, 74 percent do not believe adequate mental health services are available to everyone, a massive mental health report revealed in 2018. The same findings showed that a quarter of respondents had to choose between therapy and basic necessities like food and rent, and people who live in lower-income neighborhoods and rural income areas are even less likely to have access to therapy in general, let alone services they can afford.
In some cases (like me and my student therapist), there may be other resources that social workers, nonprofits and clinicians can help people access such as Medicaid, student rates and special programs. But once therapists complete their training, they have little incentive to offer low-cost treatment to the underinsured beyond the personal satisfaction and public reputation of helping those in need. The American Counseling Association goes as far as to advise against sliding-scale services, arguing that they’re discriminatory against people who make a lot of money, because they have to pay more for the same service. For everyone else, there are suicide hotlines, emergency rooms and psych wards to serve as safety nets for people in crisis. But anyone who wants to proactively work on their mental health without insurance is met with the same harsh reality: Therapy is for rich people.
Steven, a 37-year-old copywriter, found this out when he was let go from his advertising job. While employed, he went to therapy to manage his anxiety for a co-pay of $40 with insurance. But when his coverage lapsed and his COBRA premium was too expensive, he no longer had access to the same care. “I felt like I was losing my mind, but I didn’t want to take some pharmaceutical to deal with it,” he tells me. “I couldn’t afford COBRA, so I tried the private marketplace, which had basically no mental health coverage. I was fucked entirely.”
As I did, Steven asked friends for therapist recommendations who might give him a break while he searched for steady employment. But after he reached out to upwards of 20 candidates, he could only get one down to $100 a session. “I was lost and stressed out,” he recalls. Eventually, he handed over $500 cash for five weeks of intensive therapy, a mental health Z-Pak of sorts, but that was all he could do. “I had to stop going, which chipped away at my progress.”
This isn’t the way psychotherapy was originally intended to be doled out. Before Bernie Sanders, the earliest advocate for therapy-for-all was actually Sigmund Freud. “The development of the sliding scale and the desire for open treatment for everyone, started with the very beginnings of psychology,” therapist Mark Pines explains. “Freud had asked as early as 1918 for free clinics to be made available for everyone.”
Freud, of course, is the founder of psychoanalysis, a form of therapy that attempted to bring unconscious thoughts to the surface and interpret what they mean. But its emphasis on individualism also helped to perpetuate capitalism — namely, the fallacy that if people work hard and pull themselves up by their bootstraps, they won’t ever have to worry about being sad (and if they can’t, it’s because of a repressed memory from their childhood, rather than their environment or economic inequities). French Sociologist Émile Durkheim’s research and subsequent book Suicide debunked this notion as early as 1897, concluding that capitalism made people more disconnected, dehumanized and depressed, and that societies shouldn’t minimize the role they play in collective psychological health.
Over 100 years later, though, not much has changed. If anything, the gap between people who can afford therapy and the people who cannot is only getting wider. “I get it. It’s a business, but it fucked me,” Steven says, acknowledging that the $500 he did spend was money well spent. “It’s worth it to prioritize your mental health.”
It’s not any individual therapist’s fault that the flawed system they work in doesn’t always allow them to give uninsured and underinsured patients a break. Although therapists with their own practices can make upwards of $100,000 a year, entry-level therapists make as low as $20,500. Meanwhile, therapists who can afford to offer lower rates have little reason to do so, and less established therapists might go broke doing the same. Sites like Open Path Collective are working toward making therapy more accessible to every income bracket, mostly through teletherapy (video chatting gives therapists the flexibility and low overhead, mostly by not having to rent an office, that makes it easier to offer a lower rate). But virtual therapy has limitations, such as technical difficulties, privacy and confidentiality concerns and the lack of connection of talking to a screen.
Other therapists are rebelling against the traditional system and refusing to accept insurance, because providers limit the amount of sessions patients can have in a year and many people often need more treatment than insurance is willing to pay for. Not to mention, they undervalue the work therapists do, and therapists generally make more money going it alone. “Insurance companies pay very little to providers, and the small amount they do pay doesn’t justify the work that therapists do,” explains therapist Jackie Krol. “Our field is a very serious one, but insurance companies unfortunately don’t see it that way.”
Krol does offer a sliding scale, but like every therapist Steven and I reached out to, her lowest rate is $100 a session.
And so, most uninsured individuals who want to see a therapist face-to-face for less than that will have to settle for a student therapist. Such was the case for Meredith, a 32-year-old interior designer who while seeking treatment for damage caused by an emotionally abusive relationship wound up at the Chicago Psychoanalytic Institute. Her therapist, Jon, was a 50-year-old student on his third career. Although he was ultimately helpful, his inexperience and age made the process awkward at times. “Therapists aren’t supposed to become emotionally involved, but I could always see Jon rooting for me,” Meredith tells me. “I chalked this up to his newness — and maybe the fact that my perspective may have been his first glance into young dating millennial life.”
Years later, Meredith moved to D.C. where she worked for a toxic boss for four years, until one day she couldn’t take it any longer and abruptly quit. At an all-time low, she called Jon. He answered, and told her she needed medication, which she could only get from a public health clinic or the ER. After her sister accompanied her to three separate clinics, she received a prescription for generic Zoloft, a decision she suspects the doctor made based on her lack of insurance and affordability, and a referral to a psychiatrist for follow-up. On her way out, the receptionist gave her a voucher that allowed her to fill the prescription for $25. (Zoloft without insurance typically costs about $35.)
Still, when Meredith asked about therapy, the clinic doctor told her that unless she was not an immediate danger to herself or others, they couldn’t help. “There was either $250 a session for rich people problems or a locked ward where you don’t belong,” she remembers. “There was no space for ‘I’m hurting.’”
As for me, my student therapist called me a month into my three-month waiting period. Only four sessions in, my therapist Michelle is empathetic, calm and occasionally overwhelmed by how much I can take over a conversation. Because she’s a student, Michelle videotapes our sessions to review with her supervisor and has to get verbal consent from me every time. If that doesn’t creep me out enough, imagining them going over my performance when I’m not around definitely does. (Sometimes I fantasize about pulling her boss aside and asking, “Did I win therapy?”) But I’m largely content with being a part of Michelle’s learning curve. It’s what happens when she graduates that I fear most.