Why Does Therapy Cost So Much?

Why Does Therapy Cost So Much?

Stephen MacGarry MNAPCP

For many clients the process of therapy seems incredibly expensive, and to some extent they are correct. This leads to the inevitable query among clients (and therapists) about how much it is fair to be charged for a therapy session. For newly minted therapists it can feel daunting to ask a client for more than what seems like an hours wage, however there are a number of extra factors that play into the decision on the fee amount. According to the NAPCP code of ethics therapists are encouraged to contribute of their time without charge where possible. However the therapist must also ensure that their practice remains viable in order to best serve clients. For some therapists this means that they allow a certain number of free sessions per week, for others (myself included) it means that fees must be calculated to allow for free or low cost sessions in addition to other costs inherent to operating in private practice. I hope that this short article will help clients to understand the reasoning behind the apparently high cost of private therapy as well as helping fledgling therapists to calculate appropriate fees that take account of the need for affordable, low-cost and in some cases free therapy. 

In order to calculate a reasonable fee for a psychotherapy session the first task is to work out what income is appropriate for an average therapist. According to Talent.com the average salary for a psychotherapist in Ireland in 2023 is €45,982 per annum. However, in order to reach that figure, the therapist generally has at least 6 years of college, and another 2 years of clinical practice working towards accreditation after that. The therapist also has a limit to the number of clients that can be seen in any week, most therapists can work between 20 and 25 client sessions per week. This limit does not make being a therapist a part time job, it reflects the requirements of the profession. In an average week, many therapists will spend 20 hours with clients, an additional 10 hours with administration tasks, at least one hour with a clinical supervisor, and another few hours reading and researching the best available interventions for their clients. The therapist must also hold professional memberships and obtain at least 30 hours of continuing professional development per year.

The figure of €45,982 is income calculated after costs, in a business sense the self-employed therapist is paid their salary as a total profit from their practice. With that in mind the additional costs of business have to be accounted for. Many therapists operate from shared practices with sessional room rates. This means that the therapists must pay the owners of the practice a fee for each hour booked in a room. Assuming a fee of €12.50 per hour for the room, a therapist operating 20 sessions per week will have an annual room cost of €13,000. They may also have to pay referral fees on top of that but for the purposes of this article I will assume that the therapist obtains referrals from their own sources. These room fees are due whether or not the client attends the session which can result in difficulties for therapists who do not charge for missed or cancelled sessions. In addition to the €13,000 for a premises from which to practice, many therapists also offer online sessions which require paid video conferencing software but for this exercise I will also ignore the costs involved in that.

Costs to the therapist for professional memberships, supervision and CPD also need to be factored into the cost of each session. Membership of the IACP (the most common membership for counsellors and psychotherapists in Ireland) costs approximately €350 per year for accredited members, and many therapists maintain more than one professional membership. Supervision is usually calculated at one hour of supervision per 20 client hours, which means it's usually at least once per week. Costs for supervision vary but the average appears to be about €70 per session, allowing for holidays that is probably going to come to about €3,000 per year. Doing the minimum 30 hours of CPD, which many therapists exceed, will cost approximately €500. So allowing for those expenses that is another €3,850.

In addition to all of this, due to the current lack of registration for counsellors and psychotherapists in Ireland, therapists must also charge VAT once they exceed €37,500 in turnover. As a service, counselling and psychotherapy are currently subject to a rate of 13.5%. So in order to reach a salary of €45,982, the self employed therapist requires a pre-VAT turnover of €62,832 or €71,314 including VAT. We also have to note that not all sessions available per year will generate revenue, in fact in order to facilitate closures for holidays, certain appointment times might not be filled and other issues, most therapists can assume that each of their 20 weekly sessions will only generate a fee 40 weeks per year.

So with this brief summary of the costs of operating a therapy practice we can say that in order to earn a salary of €45,982 per annum, therapy sessions should cost an average of €89.14 in private practice. Entry level psychotherapy salaries in Ireland, according to Talent.com should be in the region of €29,250 which translates to a fee of about €65 per session on average. Hopefully, when regulation is introduced for counsellors and psychotherapists in Ireland, the cost of providing therapy will be reduced by the VAT amount making it easier for both clients and practitioners. 

As I am not an accountant, this is a simple guide and as such I am open to correction by anyone more qualified who wishes to weigh in. 

Why Should Psychotherapists Charge for Cancellations

 Why Should Counsellors and Psychotherapists Charge for Cancellations?

Stephen MacGarry MNAPCP

Many therapists, myself included, charge clients for missed or cancelled sessions. Some therapists always charge the full fee, some therapists only charge for cancellations with less than 24 hours notice and other therapists have a range of different policies depending on whether the client is paying a full fee or a discounted rate for therapy. There are as many different policies as there are therapists and in the initial session the therapist will generally explain the rules for therapy including any cancellation policies that may be part of the therapeutic contract. At some point during the therapy, it is almost certain that the client will, for whatever reason, have to cancel a session and at that point there is often an awkward moment where the therapist must remind the client that there may be a charge for cancellations. Money has an undeniable importance in the practice of psychotherapy, and as such it is important that psychotherapists approach the subject in a matter-of-fact way. The symbol of money in the therapy room can often be intimidating for both client and therapist in the same way that the topic of sexuality can be. This natural reticence to speak of money in the therapeutic setting may well be born in the transference and countertransference that exist between client and therapist. In order for the therapy to be successful the therapeutic relationship must be robust in such a way that the therapist does not allow him or herself to become held to ransom by a client who may choose not to attend and financially punish the therapist for unfavourable interpretations.

It has been suggested that it is unethical for a psychotherapist to become financially dependent on clients and it is certainly the case where a therapist must not take advantage of a client for financial gain (NAPCP Code of Ethics). That is not to say, however, that therapists should not charge their clients, nor that therapists should be independently wealthy so as to avoid such conflicts. It is rather that the therapist must be aware that the stability of their practice depends on their ability to pay rent, insurance, and supervision in addition to any other costs related to their practice before they ever take a wage. The costs involved in therapy must be clearly laid out for the client with a clear and transparent fee structure and details of how cancellations will be handled. If, with that in mind, the therapist becomes hesitant to impose fees on a client for cancellations or other reasons stipulated in the contract, then they might also be worried that if they give an unpalatable interpretation that the client may take their money and find a different therapist. A therapist who has become so beholden to his or her clients cannot ensure that they operate from an ethical position and may find themselves colluding with the client rather than engaging in an effective therapeutic relationship. Freud (1913) himself spoke of the need to throw off false shame and voluntarily name the price of his time. In this way he also suggests that some of the resistances to therapy are unwound by securing appropriate payment for therapy. He suggests that non-payment by a client may lead to an unconscious (or even possibly conscious) resentment of the client by the therapist, while the waiving of fees by the therapist may interfere with the treatment by way of altering the transference of the client, impeding the development of the therapeutic relationship. 

In terms of ethical and safe practice, counsellors and psychotherapists usually have a limited number of hours that can be used in a week to see clients. Many full time therapists see a maximum of 20 to 25 clients per week with the rest of the working week taken up by preparation for sessions, supervision, research, reading, CPD courses and administrative tasks. This means that, for many therapists, they do not have an income other than the fees charged to clients and those fees must all be gathered in less than 25 hours of a 35 to 40 hour working week. The therapist reserves a specific time for the client each week and cannot simply take the next person in through the door in the event of a cancellation. The relationship itself relies on the provision of a bounded and secure space within the therapist’s practice, in this way the therapeutic relationship differs significantly from other professional relationships. The provision of safe and effective therapeutic services within an ethical framework requires that therapists maintain a certain level of self-care which also includes an ability to ensure that they are not under any undue financial stress. 

While many other professional services do not charge cancellation fees in the way that some psychotherapists do, certainly there may be charges for short notice cancellations, but in many cases if you have to cancel an appointment with your dentist, your GP or even your solicitor, they will likely not charge you for the privilege if given sufficient notice. Due to the specific nature of the relationship in counselling and psychotherapy the charging of cancellation fees is an ethically responsible position to take as it helps to ensure the longevity of a therapist’s practice and their ongoing ability to provide safe and effective therapeutic services to clients.

Managing Stress in the Therapeutic Space

 It is a known fact that stress has a significant effect on the long term physical and mental health of many people in our society. For many people, unhealthy stress has become an accepted part of life, many employers, either deliberately or coincidentally foster high stress environments by reaching for ever greater productivity even in the face of extraordinary circumstances. If there is one thing that working in a pandemic has demonstrated, it is how important it is for people to learn to manage their stress. By manage, I mean recognise, understand, and address the signs, symptoms, and causes of unhealthy stress.

Firstly, it is important to recognise that not all stress is bad, in fact we all need a certain level of stress in order to grow and develop. The very nature of the cause desire, Lacan’s “object a”, is based in the knowledge that we must all strive towards something that can never be reached. That reaching out is the most evident source of what might be called normal or healthy stress. It is the source of curiosity and a desire to connect with people and the wider world. Stress is a normal reaction to a dynamic and sometimes threatening environment, the systems involved in the stress response are the result of eons of evolution designed for the purpose of allowing humans to adapt and thrive in different environments and situations.

Stress becomes unhealthy when high stress levels become a permanent feature of daily life, feelings of impending doom, trouble sleeping, distress at the slightest problem or deviation from a plan, or digestive problems can all indicate that a person may be experiencing chronic stress and that they may have inadvertently reset their baseline stress levels so that they are constantly one step from panic. In this situation, every small problem becomes much more difficult to solve and the line between normal life and disaster becomes steadily narrower. High levels of stress trigger the bodies defensive systems, sometimes referred to as the fight-or-flight reaction. The body releases large amounts of adrenaline (epinephrine) and noradrenaline (norepinephrine) which impact heart rate, respiratory rate, blood pressure, blood sugar and also affect other aspects of bodily function. These changes have a single evolutionary purpose, surviving the immediate threat. They are not meant to be permanent changes, and in the cases where people are constantly exposed to high stress environments the risk of heart disease, stroke, diabetes, and a myriad of other health problems increases.

An important part of learning to manage stress, is first learning to recognise the signs of stress on your own body. This can represent a challenge initially as many people experience a level of separation from the internal processes of the body. This loss of connection to the body may be a result of the analgesic effects of certain stress hormones or it may be what Thomas Hanna called sensory-motor amnesia. This forgetting of the bodily sensations not only dulls our perceptions of stress but also prevents us from listening to our instinctual responses to different situations which can in turn lead to additional levels of anxiety as we become more uncertain in our reactions. Hanna also suggested that the disconnection from the body leads to reductions in movement and premature aging. By reconnecting with our own bodies, we regain not only the ability to detect the earliest signs of excessive stress but also a level of organic wisdom provided by the unconscious mind through its manifestations in the body.

In my practice I use various methods to help clients to reconnect with their bodies and identify the key stressors in their lives. By beginning to identify stressors, clients are able to take steps to minimize the negative impacts of stressful events or even in some cases to make changes to their lives that eliminate certain stressors altogether. At the most basic level, I help clients to learn behavioural triggers that can help them control the activations of the autonomic nervous system which lead to increases in stress levels and anxiety. Over time these behavioural triggers build on each other from breathing exercises to guided meditations and progressive muscle relaxation and other techniques which are used to relax and reconnect with the body. For many people, these techniques combined with an awareness of the physical sensations that accompany the activation of the stress response can be enough to make significant progress towards a lifestyle that is free from some of the negative impacts of stress. For others, these techniques can help to form the basis through which they can more fully engage with the process of therapy in the longer term.

Stress management classes can be arranged online or in person. Individual classes cost €40 online or €50 in person. Group classes are available from €100 per hour depending on numbers. Contact differentsidetherapy@gmail.com for availability and bookings. 

Different Side @ LIR Psychological Services

LIR Psychological Services is located at 118 Upper Drumcondra Road (opposite the Skylon Hotel). The comfortable treatment rooms allow for face to face meetings with therapists while also allowing for adequate physical distance during the pandemic. Hand sanitiser dispensers are located in the therapy rooms and I sanitise my room between clients to provide a small measure of additional safety during the pandemic. 

In my practice at LIR, I accept clients of all ages presenting with a wide variety of difficulties. I offer counselling and psychotherapy from €60 per session* and I also see a limited number of students for a discounted rate of €40 per session**.

If you want to book an appointment for therapy please contact me either by phone on  087 0993901

or by email to differentsidetherapy@gmail.com

Click here to learn more about LIR

Click here to learn more about my practice in The Self Center Clinic

*Cancellation fees are 50% of the agreed session fee. Fees quoted here are calculated based on weekly attendance and are reviewed on an annual basis.

** To qualify for the student rate, the client must be enrolled in education and funding their own therapy.

Different Side @ The Self Center Clinic

The Self Center Clinic is a newly refurbished psychotherapy clinic located at 5 Main Road, Tallaght. The clinic has comfortable rooms which are large enough to accommodate social distancing while still allowing for face to face therapy to take place. Hand sanitiser dispensers are available throughout the building and my rooms are sanitised between clients to provide an extra measure of protection during the pandemic. 

In my practice at The Self Center Clinic, I accept clients over 16 years of age* presenting with a wide variety of difficulties. I offer counselling and psychotherapy from €50 per session**. Sessions typically last for 50 minutes and are held on a weekly basis.

I offer one to one counselling and psychotherapy for a range of issues including anxiety, depression, stress, panic attacks, difficulties relating to sexuality and sexual identity, trauma and abuse.

If you want to make an appointment for counselling or psychotherapy, you can contact me on 

087 0993901 or by emailing differentsidetherapy@gmail.com

Click here to find out more about the other services offered by The Self Center Clinic

To learn more about my practice in Drumcondra click here

*Counselling and Psychotherapy for under 16's is available subject to additional terms and conditions.

** Low cost/affordable counselling and psychotherapy can be arranged by contacting The Self Center Clinic. Cancellation fees are 50% of the session fee (sessions cancelled with less than 24 hours notice will be charged at the full rate)

Sex in the Therapy Room

Sex in the Therapy Room

One of the most challenging experiences that occurs in the course of therapy is when the topic of sexuality comes into the room. Exploring the topic is a sensitive matter that can challenge the most experienced therapists, even more challenging is when a client presents with an alternative or divergent mode of sexual expression. In many cases, these clients have spent years hiding the nature of their sexuality from co-workers, family and even friends. Many therapists even now flinch at the idea of treating a client who’s sexuality does not conform to the image of what the therapist considers to be ‘normal’. Part of this can be attributed to societal conditioning and the fact that sex, for many people, is still something of a taboo, however it must also be noted that up until relatively recently, in main stream psychology, any deviation from the ‘normal’ sexual aim was considered to be a paraphilia or in other words a perversion.

Perversion is a word that carries serious connotations, which of course are counter productive in many cases. It is a word that has been carried on from before Victorian times, before psychotherapy was even conceived of. Freud (SE7) made reference to the many different sexual appetites that form part of the normal spectrum of behaviour stating that he believed that some measure of perversion was present in all normal development, in other words Freud believed that everyone is into something. His understanding of the difference between a perverse act and a perverse structure is key to the work of psychotherapy when it comes to talking about sex. This is a difference that all therapists need to come to understand, and it revolves around one key principle, the desire of the Other. A sexual act that appears perverse to the understanding of one person can be part of a healthy sexual life between two consenting adults.

In the sense that the normal sexual aim can be supplemented by a divergent interest there should come as no surprise that certain sexual acts will be deemed more acceptable than others. In many cases, these things fall short of what should be considered pathological in a client. As Freud (SE7) suggested it is only when the normal sexual aim is supplanted that we should be concerned about the pathological nature of a sexual act. For example, there are many cases where people will have an unusual interest in feet, which to many may seem weird or disgusting, however as long as that interest does not become the entire aim of sexuality then we can reasonably judge that it is within the non-pathological realm and thus while potentially interesting from an academic perspective it is largely irrelevant to clinical work. Where this ceases to be the case is where such an interest begins to either impede the normal sexual aim or the interest becomes disturbing to its object. In terms of true pathological perversions as Stoller (1975) suggests, it is unlikely that the masochist will choose the sadist as an object, as the sadist cannot permit the masochist their enjoyment of the perverse act. The true perversion is the disavowal of the desire of the Other, it is the desire to deny the other its jouissance. As the joke says when the masochist asks the sadist to hurt them he replies “No”.

Problems of sexual difference often present themselves in therapy, sometimes the client may come to therapy as they feel that there is something wrong with them or they have experienced rejection by family, friends, or prospective partners on the grounds of their preferences and attractions. In some cases the client can even become afraid of certain fantasies as they conflict with what they think they should want by way of a sexual encounter. This fear can lead to a repression of the fantasy and even a level of sexual dysfunction as they struggle to find satisfaction in their sexual lives.

Endings

In my work, I place a lot of value on the ending of the relationship. The final session of therapy can become one of the most important and also one of the least common of all experiences for therapist and client alike. Many clients simply stop showing up, or cancel enough sessions in a row that therapists are forced to discharge them, others blow up and reject the therapist in a final attempt to overthrow the desire of the Other. All these endings are in some way acrimonious, leaving unfinished business between the therapist and the client mimicking the relationship patterns that exist for many people outside of the therapeutic space.

The final session of therapy is an opportunity for the client to experience something that is rare in life, a positive end to a relationship. It is hard to imagine ending a relationship simply because it has ended and leaving with no ill feeling between two people. Even in cases where someone has emigrated, in the modern world it is not an end to the relationship but a change of its primary format, you are still friends, just in different countries. The end of therapy however is an ending like no other, in the same way that the relationship of therapy is a relationship like no other.

During my training, I had the opportunity to work in a place called JIFACA where we saw children and adolescents on a voluntary basis. It was during this time, that the clinical director pointed out that the ending of the relationship in therapy is of vital importance, especially with younger clients. It may be the first, if not only, time that they get to experience a positive ending to any relationship. All previous endings are likely to be either acrimonious or forced by outside agents. The ending of therapy is theirs, and theirs alone, they must choose the time and manner of the ending and it can be a powerful experience.

The same is true of adults, the opportunity to choose a conscious ending can be terrifying as they imagine that the therapist will be angry or disappointed like the figures internalised in their unconscious minds. I think that in the process of therapy, as well as providing care for the client as they work through their difficulties, the therapist also has to attempt to ensure that the client has the opportunity to experience that good ending. We are, as I was once told, ending from the beginning...