Up-selling Psychotherapy: Are Therapists Even Allowed To Do That?

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Plants growing from jars of coins
Psychotherapy is an Investment

Up-selling is a term borrowed from the business world. While the concept seems counter-intuitive to a therapist salary, many of us are additionally small business owners. The fact that we are in a helping profession, doesn’t mean our psychotherapist salary doesn’t matter to us. We use our work in the helping field  to make a living, which is strangely complicated for private practice therapists. The amount we charge, if we slide our scale and for who and when and how much, if we charge for missed sessions or late cancellations, the frequency of sessions, and how long we see clients, all effect the therapeutic relationship as much as it effects our income. It often feels like a direct conflict, and because the field is inherently full of do-gooders, we almost compulsively err on the side of our clients pocket-books.

That is not necessarily bad, but sometimes, our paranoid fear that we might be putting our financial needs above the priorities of the work, result in failures to offer clients the clinical services they need. 

Here are some examples of how that looks.

  • Our client tells us that for financial reasons they want to go to every other week. We know that significantly reduces the potency of the work, but because it also hurts our income we worry we have the wrong motive, so we go along with the frequency reduction rather than argue the case for weekly sessions.
  • Our client has done a great piece of work in therapy during the 5 months we have been working with them. They announce they are done with therapy. It is true that it is a fine time to terminate therapy, but we have also learned enough about them to know what good work they could continue to do if they stayed in therapy longer. But we also hate to lose them for financial reasons. We worry about our motive, so we agree to the termination, without a discussion of ways therapy might be of value to them going forward.
  • We have been working with a couple for the past few months and it becomes clear that one of the partners needs to do some individual work along side the couples work, We have a colleague who we know could use to build their practice and would do well with the client. But now we are worried we are capitalizing on our clients needs so we don’t refer them to do the individual work, or we do, but we take a break from the couples work to protect the clients finances, without even exploring if that is necessary.

Reasons People Want to Reduce/Quit Therapy

Here is what makes this even a tad bit more complicated. Resistance. Many contemporary therapist don’t like to think about clinical resistance, in part because in Freud’s day everything was considered resistance. But if the work we are doing with clients is deep work, then we are asking them to rummage around their unconscious, into memories and feelings that most of us avoid on a daily basis. When the work is the hardest, dread is a normative response to the idea of therapy.

When a client reports to me that they have decided to reduce therapy to every other week, or that they want to terminate therapy, the first thing I do is think about the last session. Did we tap into a particularly painful truth? Did they feel hurt, angry, overwhelmed by something that happened in the session? When they explain why they want to go to every week I listen very carefully to their words, extracting them from the concrete world and applying them to the realm of the unconscious. So if they say things like “I just cant afford to do this anymore” I try to hear that beyond concrete finances and hear the possibility they are frightened by implications of our work. If they say “I just don’t have the resources to pull this off” I wonder about the emotional toll our work is having. If they say “I don’t have the time for this” I hear the impatience in this nuanced work.

Now I don’t mean to say I don’t take things like financial needs into consideration. But there is still the question about what changed. And why every other week or terminating are the answer as opposed to maybe me sliding the scale and moving to 3 weeks on and 1 week off. Or if something big did indeed happen to compromise their finances, why aren’t they asking about possible group therapies? Same with the time issue. What changed? Why aren’t they interested in involving us in the conversation rather than having already decided what to do without consultation with their therapy partner?

We are Psychotherapy Ambassadors

Here is the thing. I believe in psychotherapy. A lot. I go to therapy and have for most of my adult life. It is a brilliant tool, like no other. When a client wants to reduce therapy to every other week, I know what they are going to lose and I don’t want that for them. I know what they are going to lose in a way they are unlikely to understand. It is my job to lay that out for them, to help them think about what the work looks like at every other week versus weekly. It is my job to help them understand what has happened that has stirred up resistance, or reluctance, or a kind of upset that is making them want to take some steps back from therapy.

Sometimes it is good for clients to terminate therapy. But usually, I know that way before my client does. I start to see it on the horizon and introduce it as a topic. Or at least, when the client brings it up, it sounds right. If someone brings it up out of the blue, sometimes I come to see it as resistance, but sometimes it is because they simply don’t know about the ways to make use of therapy. They may think that because they have some relief from their presenting issue, and no longer know what to talk about in sessions, that maybe they are done. I usually have a good sense of the different layers of work they might use therapy to work on in their lifetime. It is my job to help them know different ways they might want to use therapy, inviting them into the longer-term nuanced work.

A Therapists’ Salary Matters, But So Does the Relationship

I have lots of ways I protect myself from ever having to rely on any one client’s session fee. I work very hard to have a real savings account, have other sources of income, and more clients than I need to pay my bills. But even when this isn’t possible, I trust myself. I know that I care enough about the therapeutic relationship to not compromise it for money. I am not saying I do not make my livelihood my priority. I do: In the fee I charge, in my cancellation policies, and my sliding scale agreements. But I don’t worry that I am somehow going to strong-arm someone into being in therapy, or being in more therapy than they need, for money. If money mattered enough to sacrifice my integrity, I would have chosen a higher paying profession.

 

Smith is the founder/director of Full Living: A Psychotherapy Practice, which offers clinical services with seasoned, cultural competent clinicians throughout Philadelphia and the surrounding areas.

Clink on these links for other posts that might interest you:

Is Your Client Irritating You? Boring You? It May Be Useful Countertransference

Does my Therapist Care About Me? Is That What I Pay Them For?

Attending to the Unconscious in Psychotherapy Session

Your Client Wishes You Were Friends; It’s Oedipal

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