The Three Money Realms of Private Practice

Have feelings about money? Of course you do.

Who doesn’t? Almost without exception, issues related to money and fees come up at some point during sessions with my supervisees and consultees who are already in or are heading into private practice.

I remember a teacher once saying that with money and sex, it is better not to ask if someone has an issue, but to simply ask what the issues are. We’ve all got them. And, like we know so well as therapists, if we’re not able to identify a problem, there is little hope of being able to work it through.

There are so many ways fees and money can challenge therapists, and they generally fall into one of the following three realms.

The first realm is the inner world of the therapist, where our own stories and beliefs about money, our work, and our worth reside.

We all have a money story, a set of beliefs we’ve internalized—one that is influenced by our culture, our psychology, our social location, and our family of origin’s behaviors and beliefs around money. The stories can be about scarcity, fear of success, fear of disappointing others or of being envied. There can be shame about one’s history with money or debt. Perhaps there is a history of martyrdom and self-neglect.

There might be internalized misogyny or a voice telling us it is not okay to want more; or a sense of entitlement stemming from a history of privilege. There might be conflict about either surpassing our parents, or not earning as much as they did.

Our feelings about money are influenced by disavowed longings and our attachment wounds.

Without identifying and working with our own money stories, they will continue to operate unconsciously. They will influence how we manage the other two realms: the business and the clinical.

Our best bet is to work on these unconscious dimensions in our own therapy and consultation.

The second realm is the realm of the business itself.

Clarity in this realm necessitates knowing and paying attention to the numbers, and sometimes making difficult decisions in the service of having a sustainable and thriving practice. While many therapists do not feel naturally inclined in this direction, it is an essential skill set if you want to run your own business.

Without clarity about the needs of the business—how much income needs to be generated to cover business expenses, what our business expenses actually are, and how to reach the income we need, we’re operating in the dark.

Our unconscious money stories and our shame are also in the dark. Staying in the dark about the needs of the business might relieve a short-term anxiety, but it is a setup for self-sabotage and resentment.

This is also the realm where the difficult realities of capitalism and the problems in the mental health system need to be confronted. There has been a lot of media coverage about the difficulty in accessing mental health care, and the struggle some patients experience finding a therapist who takes their insurance.

At the same time, there is the reality of reimbursement rates so low that the number of patients a private practice therapist needs to see can put them on the fast road to burnout.

How we negotiate the wish to be of service and the need to have a profitable business will of course look different from person to person, but there is no avoiding the dilemma.

The third realm is the clinical realm. Money—in particular the therapy fee—holds symbolic significance in addition to the concrete.

I’ve worked with people who could financially afford my fee quite easily, but who could not psychologically tolerate investing that much in themselves. So they would ask me to reduce their fee.

The issue was not the actual dollars, but what those dollars represented. Once this was explored and made conscious, we could think together about the concrete aspect of the fee in a new way.

To be able to engage in this inquiry with compassion requires a certain amount of internal spaciousness on the part of the therapist, space which can get collapsed if the therapist is flooded with their own money-related anxieties.

The fee is a part of the business arrangement we make to be able to provide therapy, but it can be much more as well. Being able to hold the multiplicity of meaning can allow for a deeper and more revelatory therapy.

The issues and challenges of each of these realms overlap and influence one another.

We wear many hats, sometimes several at once—therapist as person, therapist as business owner, therapist as clinician—each role with its own potential challenges around money.

Fortunately as therapists, we have lots of experience bringing a compassionate curiosity to such challenges.

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