Important Note: Before you begin reading, it is important to share that this may stir up all kinds of feelings and thoughts, and some of those feelings and thoughts will likely be challenging. Though we therapists cannot have a public discussion of specific fees here in the United States as it violates antitrust laws, I do think it is an important topic to discuss without specifically sharing one's exact fees.
Expanding the Dialog: One size does not fit all
While the subject of clinical fees and valuing one's worth is not a new concept, I thought it would be helpful to write on this topic because I find that it is typically not discussed from a comprehensive business point of view.
I read and observe clinicians and coaches writing and sharing some pretty strong opinions on this subject. However, what is often not taken into consideration are variables such as: client demographics, generational trauma with respect to money, personal preference, clinical experience, and societal influence.
Many business owners (especially women) have been taught not to discuss money and have been shamed into silence from an early age. Additionally, beyond the anti trust laws, there has been a veil of discouragement on having open and supportive conversations about money in the clinical community. Conversations that take into consideration many points of view.
Please Don't Shoot the Messenger
I have also felt subtle pressure on occasion to keep my thoughts on my business philosophy to myself because it differs from the current popular group think. I have experienced a reverse sort of shaming that feels like, "Mari, your thoughts on the topic of fees feels different than my thoughts. Your business model is now stirring up emotional stuff for me, and I'd like you to please just hush up." While I am puzzled by colleagues who are not open to looking through other business lenses, to each his/her/their own as the saying goes.
While my business fee structure is not the end all be all, now in my mid-50s it is my (key word my) model that I have refined over 30 years that has worked beautifully for me. I honor and value that you are working hard in your corner of the world, and appreciate that you will have your own thoughts, feelings, and perspectives on money management, business practices, and fee setting.
If you have read my other blogs or worked with me as a coach, you know I am a generous and kind straight shooter, so here is the real deal-i-o: If you choose to move forward in reading this blog, I hope that you will not personalize anything that I am sharing. If you find the following information challenging, then I hope you will lean in and explore that a bit. As business people, each one of us has gone through or is currently facing and healing financial fears and inadequacies in our entreprenurial journey - no one is exempt.
My sincerest hope is that by offering a different perspective with information that has worked well for me, and inviting other clinicians to share their own perspectives, we can begin to change the discourse on how we "should" be discussing money, fees, and so forth in the clinical community. If you feel triggered in reading through this, I hope you will hold this gentle reminder close to your heart, and do what you need to do to take care of yourself.
If anyone is still reading along, let's move forward and take a closer look...
Charging One's Worth: What the heck does that really mean?
A tired old chestnut that is being tossed around is a strongly held notion that therapists must charge between $200-$300 per session or they are devaluing the profession.
The other assertion I hear is that a therapist should never ever use sliding scales or accept insurance and, if they do, somehow they are not honoring their worth. What is not being discussed is how this message is creating shame for some in our community.
The result is that I have therapists sharing their pain in coaching sessions, or via email and via face book messages. The predominant question I hear on this topic is, "What does having a fee over $200 a session and not accepting insurance have anything to do with my worth and value as therapist or business owner?" It is a question worth considering.
Part of the coaching work I am doing these days is to have healing conversations about this topic. Conversations that support inclusiveness vs. exclusiveness. Conversations that look into what fears that therapist may have that is blocking abundance. And conversations to balance the idea that some therapists who have a higher fee, or fee for service practice must have it all figured out, while others who don't are failing miserably.
For example, without going into my specific clinical fees (in order to honor the US law), I have always had a fee for service practice and have never worked with insurance panels. I have increased my fee judiciously only 3 times over the last decade for my individual sessions as my experience grows and evolves. My fee is now the highest in my area, as well as being at the high end of the average therapy fee nationally.
However, now and then I still have colleagues tell me that given my level of expertise and experience, I "should" raise my therapy fee well over the $250 range, especially since I work with clients from the entertainment and sports industries.
My response to this: "Thank you, I appreciate your feedback and confidence in my expertise. However, I will not be charging that amount, no matter how wealthy my client is. I am happy with my current fee. It respects my business model and supports my clients. Perhaps I will raise it in the future, or perhaps not."
And guess what? This does not impact my value or worth one iota.
Sliding Scale? Yes please!
I happily provide a sliding scale for clinical clients who really need this. I don't mind offering a modest slide, it has served me and my therapy clients well over the years, and is still within a very respectable fee structure. I refer out about 15-20 clients a month who cannot afford my fee even with the slide to clinicians I trust and respect. This is an ethical support to the client in need, as well as a nice support to my colleagues who are wonderful clinicians, but are still growing their clinical skills and practices. As colleagues will tell you, I have populated more than a practice or two (or ten) in my clinical career.
Over the years I've heard it all when it comes to the rhetoric and outrage with providing a sliding scale. And, yep, a few years ago as a new therapist, I espoused this same message with the other vocal zealots. I adamantly expressed my own outrage over the sliding scale. Fist in the air, NO more sliding scale was my loud mantra!
And then, one day, I realized what a dumb ass I was being. When I slowed down for a minute and took into consideration my past business ownership experience, this was my a-ha moment and my evolution in turning the corner with respect to the infamous sliding scale...
My first career was over 30 years ago as a 21 year old hair stylist and make up artist where I offered coupons to clients in order to build my client base. Eventually I built a very profitable business in that industry. During those early first years in business ownership, I kept my fees competitive and in line with my expertise. And I raised my fees as my experience grew.
I sold that business a few years later, with a long client list, for a nice tidy sum while some of my more high priced colleagues ("I don't get out of bed for less than $500 a cut) slowly saw their businesses dwindle, or were always on the hustle for the highest paying clients.
Over those years more than a few of their clients ended up coming my way because they could receive the same beautiful beauty service, or hair and make up for their wedding day at $450 vs. hair and make up at $800.
And much to the disgust of some of these hair stylist colleagues, I also did a homeless hair day 2x a year where myself and my team offered cuts and shampoos (there are some hilarious, gag worthy, and heart warming and heartbreaking stories as you can well imagine). And, though media attention was not the motivating reason in providing this to the homeless, and as word got out, the media tuned in which also supported my business efforts.
This was the model that worked well for me as a hair stylist and business owner. As a young person in my early 20s, I pretty much made it up as I went along. And I learned just as much from my mistakes (and there were many) as I did from the successes.
My second business in my 30s was as an interior designer and founder of Eden Designs and Interiors. And once again, I offered discounts and created client packages as part of my business model. I refined this business model by using what I had learned in my first business. I had a long wait list, and my fees were much higher than some designers (again, in line with my evolving design skills), yet lower than the designers in Brentwood or Beverly Hills because that client demographic was different than my client demographic.
Over the years as my reputation grew, clients from Beverly Hills reached out to me. While I did not raise my rates based on their zip codes, I also did not offer discounts because they could afford my full design rate. Instead, I built in a travel fee that I openly shared with the client (I am one hour east of Beverly Hills and with Los Angeles traffic, that can add up to 2 hours in each direction).
You know what that is called in my world? Ethical business practices.
No sliding scale as a therapist? What freaking cool aid did I drink? Once I stopped bleating and braying along with the rest of the herd and got very still, I realized that not offering a sliding scale simply did not make sense to me as a business woman.
So like the proverbial black sheep, I walked down a different path of my own making. I re-thought the concept of valuing my time and fees as a therapist, what that meant to me, examined any fears, considered decades of business experience, and then added a sliding scale to my private practice business fee structure.
It's a BOGO World After All
From time-to-time I observe therapists adamantly stating that, "No other industry offers a sliding scale or discounts so why should therapists!"
Oh really, is that so?
No matter what direction our business compass points us in, I believe we can all agree that we are certainly not the only industry that offers discounts (and by the way, that tired old saggy jeans argument needs to be taken to the Goodwill already). I used to march to that message as well, but these days I respectfully disagree.
Think about Taco Tuesdays, or Early Bird Specials, or BOGO (by one get one), or any number of ways consumers save. What about groupon for accountants or attorneys, or discounted airfare, vacations, early sign ups for retreats or conferences, or spa discounts, or yoga, or medical procedures, and coupons, and you-name it- ons.
While I fully get that therapy is more sacred and important than Taco Tuesdays (well for some that is), my point is that we are a nation accustomed to bargaining and looking for a sale. I understand that what we offer is more valuable than buying two shoes for the price of one (as a shoe lover, I might have to re-think that), but discounts are a part of our social exchange.
My bigger point here is that our client may not understand the value of investing in clinical support, especially if they are new to therapy, on a budget, have their own money shame, fear, etc. Like us, some of our clients have been socialized to think about how to save money, or that therapy is not a necessity like food or rent, that it is a disposable support. We need to know what our client's mindset is. And part of that knowing includes considering trauma, ethnicity, poverty, institutionalized living and so on.
We as therapists must be willing to educate our communities on the value of what we provide. Yet, even after all of our hard work, beating the drum on the value of therapy, providing a service of ethical excellence, this still may not change the deeply ingrained beliefs that some of our clients hold (and yes, that includes our "ideal" client).
We can get all sensitive and pouty when someone provides another point of view, we can personalize, we can Facebook message our colleagues about our hurt feelings, or we can keep our chin up and keep on truckin' like professionals. I find that when I am feeling all itchy and upset in my spirit, then that is a message for me to sit with. Growing pains, like 'em or lump 'em...we all have them when creating and refining a business model.
I'm not sure why it is so hard for some members in our community of healers to simply give an atta' girl or atta' boy for another therapist's business model, even if it differs from one's one way of conducting a practice. As long as it is an ethical business model, why does reading another point of view trigger such feelings of shame, anger, or competitiveness? Not one therapist, coach or organization has it all perfectly figured out. How about we all learn from each other instead of criticizing, assuming the worst, gossiping, judging or withdrawing from one another when the business model or message doesn't match your point of view?
I'd like to see this shift.
You say Insurance, I say no thank you
Now, on to the much debated topic of insurance. For those who have heard it is not smart or cool or wise or whatever to work with insurance clients, let me state here clearly that there is not a single thing wrong with being on insurance panels. I have never worked with managed care and made that choice from day one given my specialization and other reasons that would fall into a whole other blog). However, I respect that there are colleagues who choose to work with insurance clients.
For me, a small slide and a comparable fee that takes into consideration my expertise, years of experience, my diverse client demographic, and so forth simply made more sense for me.
Let's stop here to take a deep breath. In for seven out, for seven. Ahhhhhh. If this information that I am sharing is stirring up some feelings in you regarding your business model, a model that does not include a sliding scale or insurance, then I stand in support of what feels best for you. I celebrate how you choose to structure your fees. I don't use insurance because it doesn't feel good for my model. I use a sliding scale because it does. Chin up buttercup, I am not writing this to anyone person in particular. I am writing this to the community as a whole.
Bottom line: In addition to being clinicians of excellence, if we want a consistently full practice, we might need to be creative and a bit more flexible (and always ethical) about how we manage our fees. And that may include offering a small sliding scale at times. Or it may include accepting insurance.
Keepin' it 100: What's your Model Mari?
For transparency and full ownership: I have a modest slide for my clinical clients, and I also have a slide fee for group therapy as well. If a client works with me and pays my full fee for weekly individual therapy they will be paying several hundred a month. If they are in my group therapy, then they will be paying an additional several hundred per month. Some of my clients can easily afford this without a second thought. However, some of my clients struggle to make this work.
As a support for my clients who see me for individual and group, and work hard to budget in that money each month, I extend a lower fee in group by $20, and a lower fee for individual by $20. If this is still a challenge, then I offer to see them every other week.
For clients who have received the slide for weekly sessions, and are ready to reduce meeting to every other week (e.g. they no longer need weekly), I ask that they pay full fee. And for clients who do occasional check ins, even if they were on the slide, I ask for full fee. I also keep one pro bono spot open in my groups (I close at 7 members, 6 are paid) for women and men in need of support who cannot afford therapy at all.
Each year in January I increase fees for those clients who have been on the slide for the year prior to make room to support other clients who made need this support, and/or are doing much better financially. If a client is going to be working with me, healing issues around money is important and many of my clients begin to experience more financial freedom as they move through their healing work. If they are still in dire straights, they get to keep their lower fee. And I don't think that de-values my worth as a therapists by one red cent.
Fees and Fears and Frustrations...Oh My!
Could I demand a higher fee at this stage of my career? Sure I could. Is the reason I don't because of fear or low self worth? Nope, not by a long shot. I've done my work in healing those old money demons.
That said, it is a great question and one that I help clients examine in my coaching work. In fact, let's move a bit deeper into this topic of fees and fears and frustrations to see what is really going on with some therapists. We will start with the ever popular topic, "Charging a Full/Higher Fee."
Every therapist needs to figure out their average client fee on a regular basis. So, keeping in mind anti trust laws and discussing specific fees, everything I am listing is hypothetical. I will not be stating my exact fee here, and if you comment below, please do not state yours either so that we are not violating anti trust laws (or what is called fee setting per the US law).
So, hypothetically, if you have a fee of $185, do you actually get that for every single client? If so, hurray! If not, then that is not your accurate fee. Thus, this is not an honest portrayal of your fee structure. An ethical assessment includes your average client fee.
For example, each quarter I meet with my CPA. We go over my PNL statements (PNL = Profit and Loss), set my quarterly goals, look at any potential red flags, and take a look at what I am grossing for an average hourly fee compared to the number of clients I see.
For those of you who glaze over with numbers, this is a very, very easy formula, so stay with me. If we are true boss babes and bros we do not shy away from this kind of information.
How this works:
Add up your clients fees for one week like this (I'm using these numbers as a hypothetical example as a way of demonstrating this simple tool without pissing the law makers off):
We will name our therapist Ima McCounselor. Ima sees 10 clients a week at $185 a session, with a sliding scale to $150, like this:
Client 1: $185
Client 2: $185
Client 3: $185
Client 4: $150
Client 5: $165
Client 6: $150
Client 7: $150
Client 8: $160
Client 9: $160
Client 10: $185
Ima's total weekly therapy client fees = $1,675
$1,675 divided by 10 week clients = $ 167.50
Thus, Ima's actual average hourly fee is not $185, it is $167.50. So Ima is unintentionally being dishonest when she proclaims from the rooftops that she is making $185. Ima needs to do her math.
Now, using a hypothetical round number, for those clinicians who share that they charge $225/per clinical session, fantastic! If they can do this without insurance, even better. If you are using insurance, then you must take into consideration the time involved outside of session to work with insurance billing and calculate that into your average. If you do not, then again, this is not an accurate portrayal of your fee. If a therapist can keep their practice consistently filled to their liking (as a "full" practice means different things to different therapists) at $225 or higher a session, without using managed care or a sliding scale, without having a niche, and has the expertise, reputation, and experience to back up the fee, wonderful!
(Side Note: We all know by now that the client/therapist relationship surpasses the letters behind one's name or the years under one's belt. But please read on for a more nuanced look at other factors that influence a client...)
However, what I have found is when you pull back the curtain and do the numbers to find your average fee, most therapists find that they are making at least $20-$40 less than their stated highest fee and, at the end of the day, are actually fairly in line with other clinicians in their area. Not all, but many. So, Ima is not the only one who is not actually making their claimed "high fee."
Another popular notion is to work with less clients for a higher fee. This is not a new idea. This is an idea that has been around for-ev-er. It's called working smarter not harder. Some therapists are financially able to do this because of a second income in the home, many are not. While working with 4 clients a week at $225 may be the sweet spot for some, it is not the sweet spot for all. I need and want more than what that would net per month. Just because a colleague shares they are making a certain high fee, doesn't mean that they are meeting their income goals.
Fly on the Wall: A Coaching Call
So, how does one stand firmly in valuing worth while using wise assessment in setting a solid fee with fee increases? I thought it would be helpful to answer this question by taking you into a hypothetical (though not all that unusual) coaching call. Again, this is a hypothetical conversation role playing what usually transpires around managing expectations, valuing one's clinical skills, honoring clients, while setting fair fees and keeping in mind antitrust laws and sharing fees.
In this example below, I am the one asking the questions with a new coaching client that we will call, Hope. Hope is my "avatar" client, she is someone who very realistically would reach out to me. So, let's see what is happening with Hope:
Mari: "Hi Hope! I am so glad we are meeting today. I reviewed your 360 form, and see that your top goal is to figure out the ebbs and flows of why your practice is not staying as full as you would like. Let's start there today and roll up our sleeves.
I see that you are 2 years into private practice, congratulations! And that you are a solo practitioner, 34 years old, married, one small child, no employees, and that you charge $225 per individual session, and that you do not work with insurance. Is that correct? Yes? OK good, thanks.
Do you know what the "average therapy fee" is in your area, and the average percentage of clinicians in your area working with insurance, and what is the median household income in your area/for your client?" (I will also caution about our antitrust law as well).
Hope: "Thanks Mari! Yes, that's correct. Hmmm I think about $150 is the average fee in my area. And I'd say about 50% of the therapists work on insurance panels. BUT don't even go there with me, I WILL NOT do that. I have no idea what the average income is around here, is that important?"
M: "OK sounds good, no worries Hope, I'm not here to try and force you to do anything you are not comfortable with, but I will ask you to lean into some challenging parts of your business during our coaching call today, so hang with me. I just googled and it looks like your area is upper middle class income, and that your client, if they live in your city, will be making about $75,000 annually, so that is good for us to know.
Also, your fee is $225, which is $75 more per session than the other clinicians in your area as far as you are aware of. We cannot fee set as therapists as that is illegal, but we do need to consider what is fair and equitable for clients so are conversation is going to be focused on your experience and expertise. Will you please share with me what informed your business decision to charge this fee?"
H: "I offer EMDR and I believe in charging my worth, I need to value my time. NO bargaining or sliding scales! I think a client in my area can afford to pay that. I was told to decide on how much I want to make each year and then to raise my fee so that I could make that number."
M: "Yes, charging one's worth is so important, I truly agree! So, let's do the math here, if a client is seeing you weekly, they would be paying $900/month. If they are making $75K a year, they are taking home about $4,000 a month, so that is about 25% of their income that they would be spending on therapy with you.
Are you the only EMDR therapist is your area?
H: "Wow....25% is a lot when you put it like that, but I guess numbers don't lie, right. No, I'm not the only EMDR therapist, in fact, there are several of us who provide EMDR in my area."
M: "OK, good to know this Hope. And are you the most experienced EMDR therapist in your area, or do you provide a higher quality of EMDR or therapy, do other's provide EMDR though insurance?"
H: "I'm not sure, I think there are a couple who have been doing this for a few years, in fact one of them has a consulting group for EMDR therapists in the area, I really respect her work a lot! Yes, some use insurance, but that won't be me."
M: "I love that you have a colleague in the area that you trust and respect. Let's hold good boundaries around the laws on fee setting, if you had to give an educated guess, do you know what her fee is?"
H: "$175 is what she has listed on her website, and she offers a small sliding scale, but I don't want to do offer a sliding scale. It is old school thinking and cheapens our industry."
M: "OK got it, and is she brand new to this work too?"
H: "No, I think she's been doing this work for about 8 or 10 years. And she is ONLY fee for service like me."
M: "Thanks, OK that is helpful to know. So then we can see that you are charging $50 more than her and she has been doing this work 9 years longer and is considered an expert in the area, is that right?"
H: "Yes, people really respect her - she is very good. I learn a lot from her too!"
M: "Wonderful! OK, let's keep moving along here and figure out these gaps in your client schedule and income. Are there other therapists or organizations that hire you as a consultant and expert in this modality or method?"
H: "No, but one day!"
M: "Yes, definitely one day for sure! OK, hmmmm...are you hired to speak as an expert on the topic of EMDR anywhere?"
H: "No, not yet, but I would like to get paid to do this! How can I start lining up paid gigs like you do Mari for $5,000-$10,000 a gig?"
M: "Let's hold a good space for you getting paid for your EMDR expertise one day soon. For now we will book mark on that topic and let's stay focused on filling these gaps as this is your stated goal for today. OK, hmmm..do you have a book that you have written? The reason I am asking all of these questions is because I am assessing what is going on in your practice, and so that we can team up and figure out what sets you as a higher fee therapist in your area and add that to your marketing information."
H: "Well, I believe I am just as good as most, and probably better than others. But no, I'm not hired as a consultant, nor do I speak as an expert, and I want to write a book...but haven't found the time. Can we talk about a book today?"
M: "I think it would be a great idea to get that book started one day! But for our purposes today, let's stay focused on your stated goal. I know this can be a challenging topic and it makes sense that you might want to discuss other more fun topics. But, part of my work is to support what you wanted to get done today. I hear that you have already set your mind to $225 per session. So, is the higher fee because of your years of working with clients, or other businesses you have owned, or some other work I am not aware of, and this is why you have the highest fee?"
H: "Well, I've been doing this work for about 2 years. I feel like I do a great job, my clients tell me I do, and I deserve to charge a fee I am worth. But no, this is my first business and this is my first therapy role. BUT I have a lot of life experience. "
M: "I agree 100%. Charging one's worth is so important. And having life experiences to draw on as a clinician is truly so valuable. And listen, there are plenty of therapists out there who have been doing this work for 20 years and are burned out or just not really all that skilled. Again, help me better understand as a fairly new therapist with 24 months of experience, how did you decide to set your fee at $225? The reason I ask is, as an example, I really like my OB GYN, I really love that she is an expert and has many years of experience, and has a holistic point of view, and I am happy she has a vagina and understands first hand about women's health because she is a woman, but....I don't care too much beyond that in terms of her life experience, only as it relates directly to my specific care. Make sense?"
H: "Yes, makes a lot of sense actually. Well, how I came up with my fee. Um. Hmmm..I'm not sure, LOL! I guess because I joined a coaching group, listened to a couple of podcast interviews, and I read a blog that said I should be charging that amount! And a bunch of therapists on Facebook all say that we should be charging a lot more money. And when I broached the topic of moving my fee down a bit, they all lectured me on why I should never do that. And most of them are new too!"
M: "OK, makes total sense, we don't know what we don't know when we are new in business. I agree that historically therapists have undervalued themselves. The great news is that this has changed quite a bit in the last few years. You contacted me because you are having a hard time attracting and keeping clients. On the other hand, you share with me that clients don't stay in your practice even though you receive great feedback for the work that you do. This is good news in a very real sense because no matter how skilled a person is with marketing or fee setting, if they are not skilled as a clinician and cannot connect with the client, then clients won't stay. Clearly that is not the concern here with you. So, let me ask you this, what is the first thing that clients say when you share your fee?"
H: "That they can't afford it. But I am determined to charge my worth. No sliding scales!"
M: "Yes, I absolutely agree it is so important to value self. You know Hope, I think it may be helpful to share my perspective on fees and worth since that is a topic you are coming back to again and again today. I believe that the support that we therapists give is priceless because we help people to step away from suicide, we help people recover from addiction, and we help people heal relationships, to reduce anxiety and depression, to create lives they are proud of, to reach dreams and goals, to heal marriages, and so much more. Providing skilled therapy to help hurting people grow and heal is priceless work as far as I'm concerned. But, in the real world people have budgets, and services have prices, and not many people can give a quarter of their monthly earnings to a therapist, some can, but not every one. And, I would imagine that might even be hard for you to give 1/4 of your income to your therapist. So, here is the thing...why do you think your clients don't book a first session or stay on for more than a few sessions with you?
H: "No, I could never afford to pay my therapist a quarter of my income. Well....I think clients don't book or stay because they can't afford my fee. BUT, I really am going to stand my ground on this. I DESERVE to value my service, no discounts, no other industry offers discounts but us. Like you said, the work is priceless [long pause]. But, yeah, I can see what you mean...I guess.
M: "I am with you 100% on this. However, it is good to remember that pricing services is about a business model and system. We cannot do that without taking into consideration a number of factors including the larger social system. What I mean by this is that we live in a culture where people are socialized to price shop and compare. Many people base their choice on where to spend their discretionary income on word of mouth, or if the product they are buying comes with great feedback - think about our Amazon review culture we live in- or the service they are investing in (be it a hair stylist, a mechanic, an attorney, a doctor, or a personal trainer) comes with either A) Great references, or B) A high level of experience and expertise. And some people just want to get the cheapest. And some people don't have it in their budget. Make sense?"
M: "You still there Hope?"
M: "You OK?"
H: "Yeah. I'm just feeling a little shaken up and angry, but it is not fair of me to "kill the messenger" when what you are saying makes so much sense. I guess I am pissed off at myself because deep inside I was never comfortable with my $225 fee. I sort of felt peer pressured into it. I felt all pumped up at a coaching event I attended, but then when I got home, and I followed their advise, it was just crickets. No clients were calling. And even though I already have 5 clients and all of them are willing to pay full fee, I sense that two of them are a little resentful, and one has started canceling sessions after I raised my fees.
M: "Thank you for the trust in sharing that with me Hope. That must feel pretty frustrating. Did you talk to your coaching group? They can't read your mind after all, you need to let them know this.
H: "Mari, I did! But one of the coaches publicly shut me down and shared that they built a full practice in the middle of the recession a few years ago, and if they can do it so can I. No excuses were allowed. I felt a lot of shame. Plus I spent a boat load of money to learn the marketing system they were selling, so I felt like I had to do what they were saying. They told me I needed to build a bigger list, or blog more, or attend a conference, or start giving out freebies, or put together all kinds of different income funnels that were incredibly exhausting and time consuming. So, I guess I feel some shame that even though I have jumped through all of their hoops, it's not happening for me."
M: "I know it can feel a discouraging, but here is the thing Hope, let's look shame in the eye and ask it to pack its bags. You are the person paying your bills. Not me, not the other coaches, not your Facebook buddies. You. And when we really pull back the curtain, there are some coaches and other colleagues who do many other things to make money beyond a private practice when they are first getting started.
When someone says, "I built a practice in the middle of the recession in the middle of nowhere walking through 10 foot snow banks and so can you!" I'd be curious to know if they were also working another job, or taking on side projects like writing, or website building, or supervision, or agency work, etc. And, I'd also want to know what a "thriving practice" meant to them. How many clients did they consistently see on average? How long were they in practice? What was their actual average therapy fee, not just what they were advertising on their website, and what was their net annual income strictly from their clinical fees? Do they share those things with you Hope?"
H: "No. Sigh. I have no idea what the answers are to any of that. But, now that I think about it, I do believe that the coach was working at an agency part time, and had a part time business doing copy editing or website design, or teaching, or something when he first started his practice. And I think his fee was like $100 or $125 when he first started. I never really thought of it that way. I just figured I had to set my fee pretty high in order to value my worth. But you know what Mari, when I tell my colleagues in my area what my fee is, not to fee set, but if it comes up in a conversation or they read it on my website and mention it, I can see them sort of looking confused because I am so much higher than they are, but can't really back up my reason for being that much higher. Other than what I keep repeating which is, "I totally deserve to charge my worth!" I wonder if this is why they don't refer to me?"
M: "Well, I think that is really courageous and I appreciate your transparency. I think it is perfectly wonderful to command a higher fee if that works well for one's practice, aligns with one's experience, and supports one's business model. That said, I don't know that any fee, no matter how high, will ever really be a statement about my worth as a professional. And yes, we should strive to make a great living doing this complex and challenging work. And we should only work with the clients that we want to work with. And we should also make room to support clients who may not be able to afford us, or at least have excellent referral support for lower income client.
I would imagine that some of your colleagues either feel your fee is too high given your experience, and/or are not therapists who refer often, and/or are ashamed because perhaps they have a very low fee, or are insecure, or who knows why. Let's not get too wrapped up in worrying what other people are doing. Best not to compare. And again, I want to caution you about the antitrust laws and discussing fees in Facebook group or groups of therapists. I know I'm a broken record, but it is important to remember this.
Are you open to my suggestions on how we might find that sweet spot between valuing your worth and keeping your practice filled with the number of clients you would like to see each week?"
H: 'Yes please! That is why I reached out to you."
M: "Great! So, this is going to require you to dig deep, and look through another lens, and think about worth and value a bit differently. Are you up for that?"
H: "I am so freaking up for that!"
M: "I love your energy shift Hope! You have learned some great tools from your previous coaching so your investment was not wasted. There are some things we will dive into in our next coaching session to tighten up and refine your voice and website, your niche, and especially your blog. There are ways we can start branding you as an expert in your community while you grow your experience. There are ways we can build the relationships with other clinicians. And none of this is fancy, or a bright shiny new anything. And it won't require a bunch of coaching sessions or big money investment.
But, for the sake of staying focused on today's goals, and in order to get this train back on track, first thing we need to do is create a fee that is in line with what you bring to the table and so you have clients and income. What you bring to your clients is a lot, and is valuable! But...maybe not at $225/hour just yet - as your practice is showing you currently. Especially when we consider your current demographic and the other factors we discussed today. When you get very still in your heart, what is the fee that really works for you?"
H: "Hmmmmm....well....$165 has always felt like my number but I was told that was too low."
M: "Why this number? Let's really assess why this fee feels right for you. I want you to know in your business bones why this is your ideal fee for now."
H: "Because it is just above the standard in my area which also keeps it marketable and fair for clients, and still honors my certification as an EMDR therapist. And it is just below the more skilled and experienced EMDR therapists in my area."
M: "I like that Hope, this method helps you stay away from comparing prices or fee setting. Instead set your fee according to your training and experience, and by using good business skills in assessing why this is the right fee for you. A fee that respects your additional certification but also respects the client.
Now, what would need to happen for you to feel more comfy moving this up to say, $185 at a future date, maybe a year or two from now."
H: "I'd want to get a couple's counseling certification, and I'd want to get some consulting/coaching on how to facilitate therapy groups and workshops, and then start offering those and getting skilled in that area. And I guess, well, even though a part of me hates to admit this, it would be wise to have 2-3 more years under my belt to grow my experience so that I have more credibility with clients and colleagues in charging a much higher rate."
M: "Such clarity here. Now, what would need to be in place, let's say 3-5 years from now to go from your current new fee of $165, to your future fee of $195?
H: "I'd want to start speaking and teaching as an expert. Get paid for consultations, be respected in my area and within my niche. And speaking of a niche, I thought it was working with women in transition, but after reading your blog on niching down your niche, I see that that is way too vague. And, I'd like to be paid for speaking, and write a book that would support my clients and possibility create materials like you have done on your therapist tool box store, and training that would support other colleagues."
M: "You know what I call that?"
M: "A very wise on ramp and ethical foundation to create a thriving practice with multiple income streams that will bring you abundance for many, many years ahead."
Fast forward 10 months later...email from Hope to Mari:
I wanted to take a moment to first of all wish you a happy holiday season. And to let you know that after meeting with you for 4 coaching sessions earlier this year, I refined my practice and fee structure based on our work. I am happy to report that I have had a full practice of 17 clients. While my fee is $165, I also added a small sliding scale and my average client fee is $155.
I also implemented our work and what you taught me about leveraged income and group therapy, and I now have a women's weekly trauma group. I charge $85 a week per client, and I already have a wait list for next module! I even started a small mentors group that meets weekly via SKYPE and I charge $10 a person to facilitate this and we have 8 people. I went from less than 1,000 a week to over $3,200 a week in the last 8 months! I am taking home $9,030! This has given me such a boost of confidence. I stopped racing around for the easy shiny carrot (using a Mari-ism) and I started speaking at local businesses for free to increase my visibility in my community.
And guess what? I just got booked to speak at a woman's group for guess how much? $1,500!!!! I am so so so happy, and so so so grateful. I work 4 days a week, and see on average 4 clients a day. It really is a dream come true. Thank you Mari! I know you are going to say it is my hard work that made it happen, and I agree, but I am grateful for your coaching support and our time together and all of the practical tools and good information that I learned from you and I wanted to share my progress! Once I stopped being so mad at you for telling me the truth, and I got out of my own way, and trusted my own business compass, I made it work!"
So, there you have it my fellow healers and colleagues, "Live" from the Counselor's Coach. I realize this may not be the popular current group think that is surfacing of late on fees and valuing worth. And I fully respect that you may have a very different way of approaching fees and business building, and that is 100% OK! Different strokes for different folks.
In closing, this is what I know from 30+ years of business ownership:
1. You can't build a reputation over night;
2. Clients do their research, they compare fees, and they compare expertise and experience;
3. Not every therapist or every coach can be an expert right out of the gate;
4. You grow a business over 3 years - not 3 months;
5. The word "thriving" means different things to different people;
6. Not everyone tells the truth about their fees;
7. People/Coaches sometimes have an agenda on the whole "charge what you are worth" that has nothing to do with your success, and everything to do with their own agenda (i.e. if they charge a really high fee for coaching for example, then why would they not lead loud and proud with this message for you to charge a high fee too? After all you need to be able to afford their high coaching fees, right?);
8. Anyone, not just me, or you, or the man on the moon, can build a successful business with the following: Experience, education and certifications, guidance, integrity, professionalism, flexibility, hard ass work, focus, dedication, gratitude, kindness, balance, reputation and trust (and for me prayer);
9. You can start making money over a short period of time as long as you have a business model that is realistic and consistent;
10. Always, always, listen to your heart and guts and not the roar of the crowd. Or the convincing of a coach, or a blog (even this blog). Trust and honor your own internal compass.
In closing, I would love to hear your thoughts on this topic in the comment section below (please keep in mind our anti trust laws on sharing your fees).
How did you assess and decide on your fee, and why did you choose that specific number? How do you determine when to raise fees?
Do you have a sliding scale? If so, what are your beliefs about this. And do you take insurance? If so, have you felt shamed or belittled by colleagues?
Gentle hint: Responding with, "I decided to charge my worth because my colleagues and coaches said so, and clients just paid what I told them to pay" is not a well thought out reason.
So, there you have dear reader, my philosophy on clinical fees. Yes, I went there. Someone needed to.
Kindly and in support,
Mari A. Lee, LMFT, CSAT-S