The Commodification of Mental Health and Wellness, and the Lost Art of Relationship

I’ve been a practicing therapist for 20 years now, and I promise you I’ve never been in it for the money. To be honest, if I’d known then what I know now, I’m not sure I would have gotten into this field at all. Being a healthcare provider is expensive, and it’s only getting worse. I have and continue to benefit from being a therapist in countless ways, but financial gain isn’t one of them.

I worked as a community agency counselor at the beginning of my career. This meant working long, high stress hours for very little pay with very limited resources. I left community agency work to start an insurance-based private practice. I had no start-up funds – it was just one day at a time. It never occurred to me not to take insurance at that time. Most therapy clients need months to years of weekly meetings to achieve their mental health goals. Who on earth could pay out-of-pocket for that?!! So I contracted with a wide range of insurance providers and other funding sources, and a few years later I closed my practice. Why? Because I literally couldn’t support myself and my children at the rates insurance was willing to pay. And I don’t mean I couldn’t afford to have nice things; I mean I couldn’t meet our basic needs.

I left private practice for several years of government service providing care to veterans. Much better pay and benefits than community agency work, but the same high caseloads and other limitations. Now my kids are grown and I’m back in private practice as an out-of-network provider. I needed to make this transition to protect my own mental health. Clients pay my full fee upfront and, if they have great insurance, get reimbursed after submitting receipts called “superbills.”  Do I feel good about what I charge people who are in pain and need help? NOPE. Not because I don’t think I’m worth it, but because a person can only afford what they can afford. I have some workarounds for people who can’t afford my full fee, but there’s only so much workaround that I can afford myself.

Obviously, I’m not alone in navigating this conundrum. Expenses go up and up and up while wages barely move. People are getting all kinds of creative to earn a living on the provider side of the house, and all kinds of creative to access mental healthcare on the consumer side. And consumer may be just the right word to describe this new commodification of mental health and wellness. I don’t believe wellness was ever something that was meant to be bought and sold, but here we are. Venture capitalists are all over it. Insurance companies, pharmaceutical companies, social media entrepreneurs, all competing for the biggest piece of the pie. And you know how Wal-Mart can offer lower prices than your local small business? Same principal, with the same range in quality.

A lot of people think that because I charge a lot for my services, I must make a lot of money. They’re wrong. There are many unseen costs associated with psychotherapy practice. In addition to basic expenses like rent, utilities, etc, ongoing expenses include: licensure and certification renewal fees, required continuing education to maintain licensure, liability insurance, multiple types of consultation (legal, business, tax, clinical, and educational), tax payments, HIPAA compliant medical record systems, therapy specific supplies, and specialized advanced trainings to maintain the highest quality of care possible. And this doesn’t include the years of education it takes to get a license to begin with, or things like personal health insurance that any small business owner has to cover independently.

In addition to the expenses listed above (and that is not a comprehensive list), much of a therapist's time is unpaid. We spend time preparing for each session, reviewing each client’s progress and needs, reflecting on how best to help, completing documentation, obtaining consultation/training, and reading books and other publications. Most of us conduct initial, free phone consultations with every potential client, many of whom do not go on to participate in paid services. And we take time for self-care, which is essential for any therapist who seeks to be fully present and engaged during psychotherapy sessions. No one pays me when I’m out of the office for any reason. And no one pays me when a client cancels a session for any reason.

Insurance dictates how much a therapist gets paid for their time and what type and duration of treatment can be provided. Billing insurance requires additional unpaid time, including time spent justifying care or disputing erroneously unpaid claims. Many providers need to hire additional staff to manage insurance claims and authorizations, which adds another significant operating expense. And sometimes insurance says they’ll cover a service, then after the therapist has already provided that service insurance just plain doesn’t pay.

Therapists who don’t have other sources of income (e.g., family, trust fund, money saved before becoming a therapist) have to get creative to achieve any quality of life, and I think that’s really compromising the quality of care available to all of us. More and more therapists are offering online classes, memberships, coaching programs... These can be great resources and I’ll never fault anybody for doing what they have to do to take care of themselves (as long as they’re not hurting anybody else), but those of us who need traditional therapy services may find it harder and harder to find a good therapist. Meanwhile, huge corporations like BetterHelp, Grow Therapy, Headway, and others are taking over the niche that used to be filled by solo private practice therapists. And whereas I used to recommend people look for therapists with specialized advanced trainings because I thought that demonstrated a commitment to ongoing professional growth, now newbie therapists are paying mega bucks for specialized trainings and, frankly, over-selling their expertise. Which they kind of have to, because the mental health industry has become a marketing game, and I think we’re all losing.

I wish I had some helpful advice to offer therapists that’s also good for the broader community, but I really don’t. As I said earlier, if I knew then what I know now, I might not be a therapist myself. For the broader community, however, this is my present take:

Take full responsibility for your own well-being. You may be suffering as a result of circumstances and experiences beyond your control, and you deserve all the help you can get. But we’re all in somewhat of the same boat, as far as that’s concerned, and healing really is an inside job.

If you can afford to pay out of pocket for therapy, do that. We need good therapists, and a lot of therapists who don’t take insurance are able to offer sliding scale because the people who can afford to do so pay full fee. Leave the free and low-cost services for people who couldn’t get therapy otherwise.

Use whatever resources are helpful to you that fit within your budget, maintaining awareness that no one outside of you will ever have all the answers for you. We’re all just figuring it out as we go, no matter how much training or experience we have. I feel strongly that a healthy therapeutic relationship is mutual. It’s absolutely different from a friendship or other personal relationship, but it’s still, above all else, about the relationship. Look for local community groups. Get off the internet.

Run through as many therapists as you need to until you find the person that’s a good fit for you. As you do so, please recognize that we’re people too, with all of our own stuff. Most of us work really hard and really care, and we actually get treated like garbage pretty regularly, often by people that don’t even know us. If your options are limited because of finances, don’t assume you can’t find someone really helpful to you, even if they don’t look so fancy on paper. Just keep trying.

Limit your consumption of mental health material. Find one or two books, websites, podcasts, or youtube channels and study them. Journal about them. Talk about them. Think about how those concepts do and don’t apply to you. Most of the material I come across is basically a new person saying an old thing in a different way. Keep your focus on you, and what and how you want to change. Money can absolutely buy a certain amount of security, which is enormously important, but money doesn’t buy happiness, and sometimes less is more. Stop scrolling. Start hearing yourself.

From my perspective, we need to get back to people helping people. The mental healthcare industry has undergone rapid change over the past few years, and that rapid change continues. I’m not saying that psychotherapy used to be great and now it’s terrible. In fact, there’s a long history of hurt and injustice done under the auspices of mental healthcare. What I’m saying is that we’re getting further and further away from the connection that has always been at the core of helpful therapy. We need to stop looking for quick fixes and magical cures, and start seeing and treating each other as valuable human beings again.