A few years ago, I appeared as a guest on a great podcast called “The Money Sessions,” hosted by my good friend, Tiffany McLain, on which therapists talk money. She interviewed me at length about my relationship to money in my practice – the fees I charge, how I go about raising (and lowering) fees, my thoughts about monthly fees, cancellation policies, and all sorts of other subjects. If you have an hour, listen to it. If you’re more of a reader, you can read an AI-generated transcript of it, below. [AI note: I used GPT-4 to transcribe the recording of the podcast, and I used Claude to convert the transcript from a raw block of text to the cleanly formatted text that follows. The transcript isn’t perfect, but damn, it’s good.]
Tiffany: Hey, welcome to this week’s episode of The Money Sessions, where we have real, honest, raw, direct, often uncomfortable conversations with therapists in private practice about money and charging for the work that we do as therapists. I am your host, Tiffany McLean. I am the founder of the Lean In Make Bank Academy, where our goal is to have every therapist be earning 30 to 50% more per month minimum while seeing fewer clients, so they have more time to invest in clinical training, more time to take care of themselves, more time to spend with their families, so you can really show up and create a sustainable private practice that takes care of you and the clients you serve.
Today’s episode might go down in the annals of podcast history as one of our top episodes because we’re talking to a guest that’s unlike any guest we’ve had on the show before. We’re talking with Josh, who is a social worker, psychoanalyst, who came from Wall Street. So Josh [last name], that’s a name of somebody who worked on Wall Street, right? Josh. Josh initially started his career, well, he initially started doing social work, community mental health, and then he went to Wall Street and started creating some kind of investment firm after that, right? So this is somebody who comes from that professional trajectory that so many therapists vilify or they’re afraid of becoming. If I charge premium fees, I’m going to become that terrible 1% Wall Street wolf, right? So it’s very interesting to hear from a human being who worked on Wall Street and experienced all of the professional successes that that entails, and still left to pursue a career in social work and then private practice as a psychoanalyst.
So in this episode, we get to hear the ways Josh thinks that is so different from the ways many therapists think about money and private practice. He’s going to talk about what it was like for him to charge premium fees, how he sets up his fee structure, which is really interesting, and I think you’re going to get a lot of value out of it. I certainly did. He’s going to talk about his cancellation policy or to be frank, the lack thereof, right? He has a policy that if you reserve your time with me, that is your time. And we really dive deep into what that looks like clinically, how he thinks about it, and what it looks like to actually enforce in the therapy room together with his patients.
We are going to talk about his family of origin. He describes himself as a white Jewish man, the son of a gay father and a socialist feminist mother, and how that impacts his desire to give back. But, and this is interesting, he has zero ambivalence or conflict about earning good money. So this is exactly the kind of guest you need to hear from, especially if you’re somebody who’s conflicted, anxious, guilty, worried about the possibility that you doing well financially means you’re hurting those around you or you’re becoming a greedy capitalist pig, right? This conversation with Josh will help you think more deeply and more clearly about some of these questions and conflicts, okay?
And if you are someone who is struggling with charging appropriate fees in a clinically ethical way, I highly encourage you to check out our workshop, Four Steps to Raise Your Fee Guilt-Free. You can check out that free workshop, go register for it if you go to www.heytiffany.com forward slash workshop. And we will put that in the show notes. Once again, www.heytiffany.com forward slash workshop. In this workshop, we’re going to talk about the three mistakes therapists often make when setting and raising fees in private practice. Plus we’re going to walk you step-by-step through the exact framework that we teach our students to help them earn 30 to 50% more monthly in their private practice while seeing fewer clients by addressing the conflicts, the insecurities that hold us back when charging premium fees. And we’ll show you how to ethically and confidently set and get fees that actually allow you to have a lifestyle that you want to have while continuing to work with the clients you’re passionate about serving.
All right, get registered for that workshop at www.heytiffany.com forward slash workshop. And now without further ado, let’s dive into this conversation with Josh [last name].
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I’m still here. Is it okay if I call him the Wolf of Wall Street? I think there’s a difference between saying what your fee is and like fully committing to it. I believe in this like law of attraction, but you also have to take action. I don’t think I do enough to help other people despite being, despite being a therapist. I was worried that I’d end up only serving wealthy people. You know, I was being so delusional about my actual cost. I wasn’t actually paying myself a real salary. Now that I am charging more, I’m not lying to myself. This is ridiculous. Completely broke. Like another fucking asshole wants my help. It’s massive. I want to do what she’s doing. Like she’s doing this.
Tiffany: All right, folks, welcome to this week’s episode of the Money Sessions. I am here with Josh [last name]. Josh, welcome to the Money Sessions.
Josh: Hi, Tiffany. Hi, welcome.
Tiffany: So you and I, we’ve known each other online for years and had many email exchanges, but I don’t actually have any idea. How did that start? Do you remember?
Josh: I believe that one or the other of us said something that one or the other of us was interested in on the Unbehagen Google group.
Tiffany: That’s right. That’s right. So we were, I’m no longer, I’m no longer on that listserv, but there was this really intense psychoanalytic listserv with all of these deep, thoughtful, crazy, mentally masturbating conversations from a whole bunch of New York analysts. And it was over that mental masturbation that you and I bonded. Isn’t that the way?
Josh: That makes sense.
Tiffany: Okay. Thank you for that reminder. I was like, how do I know Josh? Wow. I forgot about those years.
Josh: Yeah, that was probably six years ago. That’s crazy. Five or six years ago.
Tiffany: Is that group still going? Do you know?
Josh: Yep.
Tiffany: Wow. Okay. And it’s very similar to how it was when you left.
Josh: I can imagine.
Tiffany: Okay. All right. Okay. So tell us, Josh, and folks listening, Josh is a very interesting guy, as you can imagine, because six years later, we’re still in communication, albeit it’s not as much as it was in the Unbehagen days. But you’re a fascinating guy and I’m glad you’re on the show. Can you tell folks a little bit about you and your practice as it stands today?
Josh: Sure. So I’m 51 years old. I became a therapist about six and a half years ago after a career in finance. I was inspired by my own personal experience as a patient in psychoanalysis. I run a small group practice in Manhattan. I have about 10 other colleagues working with me. And to the extent that I have a specialty, it’s in sex and sexuality and shame. I have a particular interest in both ego-syntonic and ego-distonic manifestations of the dynamics around those issues. So I do work with kink and polyamory. And I do work with what some people call sex addiction and more confounding challenges like paraphilias, pedophilia, non-consensual sex, sex offenders.
Tiffany: I wish if this was another podcast, if we had another subject, we would go down. I have so many questions about that. And I imagine our listeners do too, but we’ve got to stick to the business. And I imagine these things will come up. So one of the things that is fascinating about you and you brought it up just now is that this is your second career path. This is your second professional life. Talk to us a little bit about what you did in finance, what your experience was back when you did that.
Josh: Sure. I was a private equity investor. I had a brief stint at a private equity firm. I then went and worked in city government running a group that helped to develop the Bronx. And then I went back to private equity and started a firm with a friend of mine that was focused on making private equity style investments, but in companies that we thought could improve by being better service providers to their customers, to their employees, to their communities.
Tiffany: Yeah, this is fascinating. So one of the things we talk about a lot on the show is how therapists are so conflicted about making money because they’re like, I want to help people. So we actually get to talk to you who had a career where you were making buku bucks. What, when you left at the height of your career, what kind of money were you pulling in?
Josh: Let’s just say that I made enough that when I, between when I left finance and when I started social, when I started practicing as a social worker, as a therapist, there were five or six years in which I didn’t earn any money. And I was okay with that.
Tiffany: So you were, you were doing just fine financially.
Josh: I was doing okay financially. Yeah. And I was at the, and we were at the beginning of our firm. So we had not yet made the buku bucks that my business partner, whom I abandoned has made in the years since I didn’t stick around to pick up the big checks.
Tiffany: Okay. The really big checks. We want to talk, we want to talk about all of this. Oh man, I’m trying to stay on track, but you’re making it difficult.
Okay. So, um, you left a career where you were making good money and stood to make just mind blowing for many therapists amounts of money. So here’s an interesting feature of my career. Every job that I’ve taken has paid less than the previous job when I took it.
Josh: I’ve been on a steady upward trajectory for most of my professional life, but each, each, each job move that I made represented a walk away from money to less, even though I then made up for the loss over time.
Tiffany: Yeah. How, um, how do you make sense of that fact?
Josh: I have, um, I mean, I imagine we’ll get to this later, but my parents, my father in particular wisely taught me that money doesn’t make you happy and that you should never do something for money. Um, if you can avoid it. And so I’ve always done what was most interesting to me and I’ve chased the people who were most interesting to me and that’s worked really well in the long run financially, even if it didn’t work in the short run financially.
Tiffany: Interesting. So, okay. So thinking about this idea of, of, um, not chasing the money, but chasing the people, the people who spark your interest to bring you joy. Um, and coming from a place where you, you made a lot of money. When you first went into, um, setting fees in private practice, how did you think about setting fees given your history?
Josh: So I confess I didn’t think a lot about it. Um, I set my first patient’s fee at $200, um, which at the time was about three quarters of what I had been paying for my therapist recently. Um, I think I’d been paying two 50. Um, and my second patient I saw for $15 a session.
Tiffany: One five. One five. Yeah.
Josh: So all along I’ve had a mix of very high and very low fees relative to some of my peers. And I think coming from my background in finance, I’ve always very closely monitored my fees. I have a spreadsheet that I update with every change in a fee that shows what I’m charging each of my patients and what my average patient is paying me and what my average fee per session is. Um, and I’ve steadily maintained goals to increase.
So my first goal was to get my average fee per session up to $100 that took me a couple of years to do, even though my first patient was at $200. Um, and then since then I got it up to 150 and now my average fee per session is on the order of $200. Um, I didn’t increase my top fee for several years. Um, I left it at $200 for a while. Um, but then in recent years it went from 200 to 225 from 225 to 250 and from 250 to 300.
Tiffany: Excellent. So one of the things I’m, I’m listening to is that even though you didn’t really think too much about how you were setting fees initially, uh, you were always very clear. You were not money avoidant. You looked at your money, you knew what your average fee was. You knew what it meant to take on a $15 client or a $200 client and you had goals that you tracked even while you maintained a sliding scale fee range.
Josh: Yeah, that’s correct. That’s correct. I, it’s always been important to me to be able to see people at low fees. And the only way I can do that is if I see people at high fees.
Tiffany: I love it. So, so many therapists we talked to are have the sliding scale and they’re afraid of charging premium fees, but they’re not looking at their money at all. And when they make a decision to take on a sliding scale person, it’s not out of intention. It’s out of fear, anxiety, guilt, and shame. When you did it, it sounds like you were very intentional when thinking about, can I take this person on at this fee? Uh, does it not make sense at this time?
Josh: Yeah, for the most part, though I will add that I am not immune to saying yes to a patient I shouldn’t say yes to.
Tiffany: Uh huh. Oh man. Okay. We are going to dive into that for just a moment because I can’t help myself. Um, what are the, when you say that, what are some of the clinical implications or the relational implications you can imagine, especially given your psychoanalytic thinking mind can come up when a therapist does slide their fee based on feelings of desire, guilt, shame, any of those things.
Josh: It never ends well for me. Yeah. My, my experience is that I inevitably resent and have to contend with lots of counter transfer, negative counter transference directed toward patients who I take on for bad reasons. And the fee can exacerbate that for me, in my practice, it’s never been the fee alone that has made me resent a patient, um, or a treatment. I have no ambivalence about several of my very low fee treatments and I have substantial ambivalence about occasional high fee treatments. So the fee doesn’t either establish resentment for me or inoculate me from negative countertransferential reactions. Um, but I would say in general, if I take on a patient for bad reasons, it inevitably is very challenging for the treatment.
Tiffany: I appreciate one of the things you said about that, that I really appreciate is that, um, you spoke about the fee when thinking about taking on a patient for the bad, a bad reason. The fee is just a symbol of the other things that are going on clinically. So it’s not really about whether you take someone on for $15 or $200 it’s what might be represented or symbolic in that fee, which has a whole bunch of other emotions, feelings, dynamics behind it.
Josh: The patient whose low fee I most resented paid me $250 a session.
Tiffany: Wow. I love it. Excellent. And this is what we want therapists to really start being able to think about. One, look at your money honestly, which is hard for therapists to do for a variety of reasons. And, um, it’s not so concrete as the money. We, we talk about money in concrete ways a lot because there is a reality to our financial situation and there’s clinical ramifications for the choices we make when setting fees. And that’s what I’m hearing from you as we think about this together.
Josh: For sure. So, uh, when you started charging premium fees, did you have any anxieties about that?
Tiffany: I did. And they were, I think, uh, limited to what my peers would think of me, whether they would be envious or judgmental. Um, and I think some of that materialized in both directions, both with respect to envy and with respect to respect to judgment. Um, those, those were my fears. And to a certain extent they were realized.
Josh: What, what, can you share with us an example of a confirmation you had that there was either envy or judgment around your fee?
Tiffany: You know, the envy is much, uh, more hard to, uh, identify concretely. It doesn’t tend to manifest in ways that are explicitly articulated. Um, I mean, I have a colleague who, uh, has ex, ex, explicitly said to me that he envies me, uh, in certain ways, but more often the judgment actually does get articulated.
Josh: Explicitly and I’ve people have said to me essentially, where do you get off charging X dollars a session given where you are in your career? I only charge Y dollars and I’ve heard that from a few people
Tiffany: That is so many therapists worst fear that a colleague will literally say to their face. Where do you get off? We have fears about it and a lot of therapists keep their fees low so as to not have to face that kind of judgment or those kinds of questions What how have you been able to keep doing what you need to do and want to do in spite of comments like that? What do you do with comments like that inside?
Josh: Um, I have lots of areas of vulnerability and shame and concern and this isn’t one of them. So those comments don’t land if someone says, where do you get off? My response is my understanding of how the world works is a little different than theirs. And I don’t feel particularly defensive about it. And I am not too concerned about that judgment. I mean I was, I’m worried about it interpersonally. I don’t like having that in my relationships with people. But I’m not concerned about it in terms of its implications for my psyche or my practice.
Tiffany: Really interesting and so talk to us about, we’re gonna dive more into your confidence with charging. How that feels that we were talking earlier ego syntonic earning good money is ego syntonic. Before we dive into that. Can you talk to us about your cancellation policy? What does that look like?
Josh: I don’t have one. So my patients, if I establish a slot in my schedule for a patient, my patient pays me for each session. They don’t pay me if they’re on vacation or if I’m on vacation as long as we’ve talked about their vacation in advance. And if something comes up and they need to try to reschedule, I’m happy to work with them to try to reschedule typically within about seven days on either side. And I haven’t really had it be a problem where I couldn’t find a time that worked for someone. But basically my, my cancellation policy is the same as Freud’s. It’s a leased space. Someone is, the, my unit of production is the hour or the 45-minute session. It has a cost to me to reserve that period for a patient and then the patient is incurring an obligation to me in exchange for my agreeing to hold that time for them.
Tiffany: So clear. So clear. Did you have that from the, from the outset or is that something you created over time?
Josh: I did not have it from the outset. I created it over time. And it became apparent to me as I was practicing and as some of my most plum spots were routinely being canceled in compliance with my cancellation policy. And then I found myself growing resentful of the patients who were doing that and that was toxic for the treatments. And part of how I rescued those treatments is by moving to a more clear and straightforward, from my perspective, policy that relates the patient’s decision or not to attend a session to my earnings necessity.
Tiffany: Say that one more time that last part.
Josh: So what the, what my way of approaching it does is it explicitly links or de-links the patient’s decision to attend or not to attend a session from my earnings. In other words, why should I make more or less based on whether a patient decides to come or not to come? And so my policy says, well, look, you make a decision when you begin therapy with me. If you want to meet on Thursdays at 4, we’ll meet Thursdays at 4. I’ll hold that time. You can then decide how you want to use that time. Maybe that involves going on a business trip that takes you away from our session. Maybe it involves doing something with your family or going to a medical appointment, whatever. That’s a decision that you are free to make. But I’m not sure why I should have to forego income just because that’s a choice you are making.
Tiffany: So this is one of the, of the things we talked about in our program. It’s one of the things I encourage therapists to adopt is a no cancellation policy that looks something like what you describe. And this is one of the things that is so, the most sticky that therapists wrestle with the most. So I’m gonna pick your brain on this a little bit more because your clear clarity I think will be very helpful for some clinicians who struggle with this. The anxiety around, there is a feeling for many therapists that when they enforce the cancellation policy that everyone has agreed to, that they’re in some way punishing their client. Oh, the client is sick or the client’s child is sick. The patient has a doctor appointment and they and they must go, they have a meeting that came up at work. The therapist feels like oh, who am I to punish them by charging them for a fee when when something comes up in their lives? How do you think about that? How would you respond to that?
Josh: So I think that we collectively don’t think very clearly about this and I think that part of why we don’t has a lot to do with insurance and the way that we’ve all been driven to commoditize our sessions. We think of sessions as being the unit in which we deliver therapy and we charge per unit. That doesn’t resonate for any clinician that I know. We all carry our patients around with us all week long. We think about them outside of the 45 minutes that we’re with them. We’re working on the challenges that our patients or clients are facing whether we’re with them or not. And so I tend to conceptualize the economic relationship between me and my patients as not being doled out on a per session basis, but rather as being an ongoing relationship. And the convention is that we bill for it by the session, but in practice it’s really a monthly or an annual fee that we’re charging and then we have sessions.
And so just to say, I’ll say two other things on that. One is I have several patients with whom my arrangement is they pay me a monthly fee or they pay me an annual fee that’s been divided into 12. And then we have one session per week or two sessions per week or four sessions per week depending on the patient. And that makes it a little bit clearer when there’s a missed session that it’s just something that’s happening in the context of a larger relationship and not a unit of value that I’m somehow not being given the opportunity to deliver.
The second thing I would say is we all think very clearly about this when it comes to our cars or our apartments. We don’t imagine that our landlords should give us rent back just because we chose to spend the night at a girlfriend’s or a boyfriend’s, right? The apartment is there for us to use and we choose whether or not we’re gonna use it. The therapy relationship is there for us to use and in the same way, I think if someone has a slot on my calendar, they have that slot on my calendar and that has a cost. And in truth be told, if a patient doesn’t show up and we don’t know why or if they cancel and have some kind of feeling about it, that inevitably is working on us. We don’t just say, oh, well, moving on. We’re thinking about it. We’re talking to our colleagues about it. We’re trying to understand what it means in the clinical relationship.
Tiffany: So this thing you’re saying about them renting space in your brain or participating to participate in a relationship where you are thinking about them as the unit of value as opposed to this one 45 minute session, I think that’s a really important shift. And you’re right that we don’t think about that clinically as a profession.
Josh: Yeah. Look, I mean I’ve, I’ve had this conversation a number of times with colleagues. It’s, it’s, I have the experience not infrequently in the world of seeing things in a particular way that is different from how other people see them and that leaves me either feeling crazy or onto something. And in this instance, I sort of toggle between feeling crazy and like I might be on to something. But it makes perfect sense to me and it makes such perfect sense to me that I really don’t know how to proceed otherwise.
Tiffany: And do you ever find, especially when you first started implementing this, did you get pushback from your patients?
Josh: So when I first started implementing it, I got pushback from a couple of patients for whom it represented a change. And that was interesting, the pushback was interesting. It provided interesting clinical material and it was useful for us in the context of the treatment. I lost one patient over it who declined to continue working with me over this issue. And in the time since then, I’ve had one patient who but for this policy would have seen me, but felt it was simply unreasonable and therefore he couldn’t see me.
I’ve had a few patients essentially reach a compromise with me, which is that they’ve said, look, that doesn’t feel reasonable to me, or at least not manageable or likely to feel successful for me. How about if we don’t have a standing appointment time? Can we instead schedule ad hoc and use something more like a 24-hour cancellation policy? And so I’ve done that on occasion with patients for whom the policy simply felt unmanageable. It’s not my preference because I think it’s far better clinically to actually have a regular time that’s yours. But if someone’s not prepared to commit to that time, then I’m not.
Tiffany: One of the things I want to highlight for listeners is your thinking about this. So when you implemented your policy, you spoke about it, you said it was really clinically interesting, and you’re talking about what it meant for them, how it fit into the relational dynamic, what it represented for them in other areas of their life. You didn’t just say, I’m doing this policy, no thinking, and that’s what it is is what it is, moving on. In all of our policies, there’s clinical thinking that needs to be a part of it, and that’s what I hear you talking about.
Josh: And not just thinking, but also feeling, because this does bring up real feelings, both in me, as you hear, and in my patients. And sometimes those feelings are feelings of hurt or anger or sadness, and sometimes they’re feelings of appreciation or recognition. It has a way of making me real to my patients, particularly those for whom it might be challenging to see me as a real person.
Tiffany: Absolutely. I love it. And yes, thank you for bringing in our gut. Oh yeah, we have a gut too. We have feelings as well. It’s not just thought. Absolutely, yes. And I’m glad you said that because the feelings are the part that the therapist gets so twisted up about, and then they have a hard time thinking about what might be happening because they feel so much anxiety, so much guilt, so much shame, so much resentment, whatever it is that comes up, it makes the thinking impossible.
So I really appreciate both leaning into the feeling and also being curious. What is this representing? What is this representing? But not shying away from or not enacting policies that make sense for your business and your life because you’re afraid of what feelings it may bring up in you and your patients.
Josh: Yeah.
Tiffany: So let’s shift gears a little bit and talk about how you’ve grown your practice. So you started out initially, like we all do, private practice. You made a huge leap recently and really invested in taking your practice to the next level. What did that look like for you?
Josh: So I knew that I wanted to buy an office. The economics of renting offices in New York are really challenging in that we’re in a field in which our earnings are pretty much capped, right? We only have so many hours a week and there’s only so many dollars per session you can charge. And we’re competing for office space with the entire New York economy. And so it felt to me like in order to have an office that was of the sort that I would like, I would have to pay a rent that my practice couldn’t justify.
And ironically, the purchase market for office space, at least at the time, was a little more favorable. And so I went on a hunt and I found a basement storage unit in a residential condo that was being used to hold bicycles and stuff like that. And I bought it for what in New York terms was a song. And I developed it and I made it into a really pretty, nice, welcoming, comforting suite of three offices that resulted in a much nicer space than my practice ever could justify paying a rent on, but could justify from a purchase perspective.
Tiffany: That’s a huge investment and a big leap of faith in yourself. Although I hear you saying the math works out that actually in the long run, it made more sense to buy than to rent.
Josh: And I was coming from a position of privilege because I had worked on Wall Street. Absolutely. Yes.
Tiffany: I’m glad you add that part too for the therapists listening who are like, but he comes from a place of privilege. Well, yeah. And you just acknowledged it. And that’s important. Did you have any anxieties about making this jump?
Josh: Tremendous. Yeah. So, it’s a really strange space. I told you it’s in the basement of a building. In order to get to my waiting room, you have to walk down cinder block steps and then walk past the compactor room and past the laundry room of the basement. And it feels a little like you’re descending into hell. And I had tremendous anxiety about what my patients would think, what my colleagues would think as they approached my office. I had confidence that I could make the office space itself nice and welcoming and pleasant, but I was worried about the approach. And that caused me a lot of sleepless nights.
Tiffany: How did you reconcile it? How did you reconcile it?
Josh: I took a chance. I gambled that it would all work out okay. I figured that people spend five seconds approaching my office and then they spend 45 minutes in my office and then they spend five seconds leaving. And I figured that that would all work out. And I think it has. But it was scary as hell. I had nightmares and my analyst heard lots about it.
Tiffany: I’m glad you’re acknowledging how scary it was, even to the point of telling us that you had nightmares about it and that you brought it to your analysis for some period of time. I think when therapists hear these stories, especially when you acknowledge your privilege, they think, oh, it’s easy for him because, oh, it’s easy for that person because. And I hear you saying it was actually a terrifying decision that gave you a lot of sleepless nights.
Josh: It was a terrifying decision. And look, you know, in the long term, economically, who knows whether it will have been a good decision? Because I now am an owner of commercial real estate in the midst of the biggest commercial real estate downturn in a hundred years. Yeah. You have to take those risks.
Tiffany: You took that risk. And who knows where it’s going to go?
Josh: Yeah. Yeah. But I have a nice office space and that was the reason I bought it. So, you know, it works.
Tiffany: That’s right. We’re going to move on to the deep dive section as if we haven’t been deep diving already. Before we do, I always like to give therapists some kind of actionable steps or mindset shifts, especially and we’re going to get into this money piece next.
But if we have therapists who are listening who say something like, man, I can’t imagine really ever looking at my money, charging fees that are commensurate with the life I want to have, a cancellation, they have trouble enforcing their cancellation policy. What might you offer them in terms of a strategy or shift to get to a place where their practice actually works for them?
Josh: So I would say, one, set meaningful, ambitious goals, both on a per patient level and on a practice wide level. Two, set target fee hikes for your patients long in advance. I have a spreadsheet. I keep track of when my next increase is going to be and what it’s going to be for each patient. And I raise fees at least once a year, in some instances twice a year. Unless there’s some clinical or other external reason not to, in which case I never do. But having that spreadsheet, I look at it all the time. By the time the date rolls around, I know that it’s time for me to increase patient X’s fee and I don’t have the doubt or anxiety because I’ve been looking at that upcoming fee increase for a year.
So I would say, set target fee hikes long in advance. And the thing I said that I sometimes have not done so well, say no to new patients who don’t help you achieve your goals. It doesn’t mean don’t take on low fee patients. It means know how many such patients you want to have. Know at what levels you can afford to have them and know what times in the day you want to set aside for those sessions if you want to do it that way. And then stick with it. And conversely, don’t apologize for asking people to pay you what you need to make. It’s advice I give. It’s not always advice that I follow, but I do.
Tiffany: For sure, and look, part of my privilege is that I was exempt from ambivalence about this. Yes. And guilt in a lot of ways.
Let me read this. I’m gonna read what you wrote to me, cause I love it, I think it’s so clear as we dive into a little bit about your backstory. You said, I’m a straight white Jewish son of a gay man and a radical feminist socialist mother. I’m committed to making the world better and, but, unconflicted about making money. There are so many therapists for whom this being unconflicted about making money, it’s that in itself is absolutely radical. Like it’s unthinkable to them. Can you talk to us about both the dedication to making the world a better place, making an impact, and having that not be at all antithetical to feeling confident about making money and doing well yourself?
Josh: So, my family was comfortable. We weren’t wealthy, we were comfortable. As I said before, my dad taught me quite young that if a job was making me miserable, a raise wouldn’t make me happier. It would maybe make a dent in my misery for an hour and then I’d be back where I started. And I was very fortunate in that my parents raised me with a very healthy appreciation for my privilege, but without a sense of guilt.
So, there was a real awareness in my family that the world was unfair and a sense of commitment and obligation to make it better. I was, there’s a Jewish concept of tikkun olam, which means to be an ulam or mending the world. And I was raised to believe that we all, regardless of where we’re coming from, have an obligation to make the world a better place. And that is not inconsistent with making money.
In fact, my parents helped me to understand that it is possible to use the money one makes to make the world a better place and it’s up to which one makes money to make the world a better place. Now, obviously, there are ways in which making money can make the world a worse place, right? I worked on Wall Street for a long time and I saw a lot of people who were sociopathic or who were destructive in the ways that they made money. And I’ve really tried hard never to do that. I don’t believe that making money is intrinsically bad, but I do believe that it can be.
Tiffany: This is, I’m really glad you highlighted the both and. One, on Wall Street, there were sociopathic people making money and there were people who were wanting to make an impact and genuinely empathetic and kind people who were also making money. It wasn’t one or the other.
Josh: Yeah, and look, you asked me about my employment history or my professional background. Prior to working on Wall Street, I actually worked in social services and I did a couple of jobs doing sort of social worky type things. I ran a shelter for developmentally disabled homeless people and I did a couple of other interesting things. And as I look back at the jobs I did prior to becoming a therapist, paradoxically or surprisingly, the one in which I feel like I had the biggest impact for the good in the world was on Wall Street.
It was a job in which I was building a firm that was investing responsibly in companies that might otherwise go out of business or lay lots of people off. And so even though I was making a pittance while working in social services and having a direct impact on people’s lives, I felt like I had a larger and more powerful impact when I was working on Wall Street in retrospect than I had when I was working in social services.
Tiffany: You saw my eyes flew open, huh? I’m sure there are a lot of people listening who like me were expecting you to say, and the best, the most giving work I did was with those homeless folks. That’s what I felt. But that is not what you’re saying. Can you clear up that contradiction or that, ah, for those of us whose eyes flew wide?
Josh: Yeah, sure. I mean, I think anyone who’s done agency work knows how maddening and difficult and frustrating and bureaucratic it can be and how powerless and irrelevant one can feel as an employee. And that’s not to say that I didn’t feel like the individuals with whom I was interacting were benefiting from the work that we were doing. It’s really to say that I felt very confident that if I hadn’t been there, someone else would have been and things wouldn’t have been significantly different.
Conversely, there’s a company in Chicago that employs 400 people today that might not still be employing 400 people had me and my firm not gotten involved.
Tiffany: That’s such a, you’re talking about such a difference in magnitude of scale when you talk about this kind of impact you can make when you allow yourself to be comfortable with and receive and work with money. Man, so it’s interesting too to think kind of micro to macro, macro to micro.
Many therapists, when we talk to them about earning enough to actually take care of themselves financially, and we’re really trying to emphasize these days, also desire. It’s not just like earn enough to live. It’s like, also, what do you desire? What kind of life do you wanna have? It’s okay to dream and go after that. And so many of them get hung up on, oh, but then when somebody calls and they really can’t afford my full fee, I’m a terrible person. I’m hurting others, and I’m buying into capitalism when I turn away that poor person who can’t, just because they can’t pay my 200 per session.
And it’s through how you think about that in a way that’s different than how those therapists are thinking about it.
Josh: So, I mean, one, there’s the overused metaphor of putting the oxygen mask on yourself before you put it on your kid, right? If I take on patients or if anyone takes on patients whom they can’t afford to take on, they’re not gonna be able to do it for long. If we wanna keep doing this, we have to be able to make a living at it. And so anything you do that subverts the likelihood of being able to make a living isn’t doing your clients or patients a favor in the long run, I don’t think.
I mean, as I’ve said, I do see lots of folks at a low fee and that’s important to me. And I think that we all, let me just rewind for a sec. When I was studying for the LCSW exam in New York, one of the questions concerned, what are you supposed to do if someone comes in and they can’t afford your fee? The answer apparently ethically is you’re supposed to provide the service, which I don’t understand. That is confusing to me. I don’t, I understand it on an individual basis. I don’t understand how that can be a policy that you apply across the board, because if you do that, then you have to go find another job, right?
If we all were required to serve everyone at five or 10 or $15 a session, we couldn’t possibly feed our families. And I don’t feel any guilt at feeding my family and earning enough to feed my family. So, and as I said, it’s hard for me. I don’t easily say no to patients and I end up seeing too many people because I say no to too few. And then I have a few too many hours each week. At a certain point, the hours make it impossible because there are only so many hours.
But that’s, I don’t have a good answer to your question as to what do you say to someone who feels guilty when someone comes in and they can only pay $100 and your fee is $200. I mean, the answer I think for me has been establish a mix of fees that I’m prepared to take and stick by it. And be generous at the bottom end and be entitled on the top.
Tiffany: One of the, something I’ve been thinking about lately. So I’m gonna invite you to think with me about this is the ramifications of a sliding scale on the therapeutic relationship. So I have been thinking about what it does to the therapeutic relationship when I, the privileged, professional, benefactor therapist say, I will take you at $50 an hour. I have the means to subsidize your treatment and I will do that because I’m good. Those could be some of the dynamics. Do you ever talk with your patients and or how do you think about the inequality in I’m wealthy, you’re not. So I’m gonna pay for your treatment.
Josh: So I try not to conceive of it that way. I don’t think of myself as the benefactor. I think that, I mean, again, my lowest fee patients are not necessarily the ones with whom I have the most complicated relationship to the fee that they pay. I don’t feel like I’m giving charity. I feel like I’m building a practice that I want to have. And so those patients are helping me just as much as I am helping them. It feels very much like a fair trade. It doesn’t feel like a lopsided, subsidizing type relationship. Although to the extent that that comes up in the treatment, it does and it has to be tangled with and it’s real, right? People might feel that way. People might feel humiliated or ashamed by the low fee that they’re paying. And that’s important to respect and to interpret and to try to make meaning of.
Tiffany: I love that you are, that’s what you’re emphasizing too is, well, two things I hear you saying. When that comes up, you hold it in mind and you’re aware of and present of how this dynamic may be at play in their psychology and in between the two of you. And I hear over and over again, you are helping me and us get out of the realm of, you’re thinking about money differently, which is money is not the only exchange of treatment.
And I think that comes from somebody who, I think it’s helpful that you have worked on Wall Street, where you’ve had all kinds of access to money and that wasn’t the be all end all, that wasn’t where your joy was. In fact, you found money’s great for all kinds of reasons and you left it, even though you were making less money.
So one of the things I hear you saying is, when I’m taken care of financially, because I’ve set up my practice that way, there is an interesting kind of work that can be done with this human, regardless of whether they can pay 300 or whether they’re paying 15 or 50, whatever the case is. And I’m curious about their mind. I’m curious about what’s at play. And it is a benefit to me and my interests and who I’m going to develop into as a clinician, working with this person. So it’s not about the money because I’ve taken care of my money over here on this end.
Josh: Right, and just to take a metaphor that I used earlier, if you think of the treatment as being paid for on a monthly or an annual basis, I think maybe like what I’m saying is that I think of my practice sort of in the aggregate. And so I think of each of the individual people I work with as being a part of that and helping me to create an overall practice that I want to have. And so each person has a role to play in that. And part of the role they play is financial and part of it is clinical and intellectual and emotional.
Tiffany: I just had a mind blown moment. I’m thinking back to when you said, shoot, what did you say? I can’t remember exactly what it kicked off, but this is, oh yeah, you said sometimes you have ideas that you think are brilliant and that other people don’t have and sometimes they might just be crazy. But this one is fascinating. You’re saying, okay, if I want a $200,000 per year practice, the pieces that make up that practice are gonna be variable and different and the different ways that money is made is gonna be different. But my overall $200,000 practice is going to be the same. That is, I love that idea. I think I just created an entirely new framework for my course.
Josh: Well, I was just, as you were saying that, I was just thinking about a puzzle, right? And like a puzzle has lots of different pieces and some of the pieces might be bigger, some of them might be smaller, some are edge pieces, some are corner pieces, some are center pieces. You need them all.
Tiffany: Wow. Okay. We went way over the 35 minutes I theoretically thought we were gonna go. Josh, thank you so much. I know that people are going to be, have their minds blown, have different ways of thinking, likely be in touch. We don’t have folks on the show. I don’t think we’ve had any folks on the show who did come from a, we haven’t had anyone who came from a finance background and certainly not a Wall Street background. So I think this is gonna be fascinating for folks. If they wanna reach out to you, if they wanna learn more about how you work and what you do, where can they go?
Josh: My website, wolf-powers.com with a hyphen. It’s W-O-L-F hyphen P-O-W-E-R-S.com or email me or text me. Anyway, all my information’s up there.
Tiffany: Awesome. So I’ll also put your website in the show notes. Josh, thank you so much.
Josh: Thank you, Tiffany.
Tiffany: All right, whatever you’re doing, I want you to pause. If you’re driving, pull over. If you’re chopping a carrot, put that knife away. If you’re making sweet love to your woman, well, I mean, that’s kind of flattering in a weird way. You can just go ahead and you can keep doing that.
But for the rest of you, if you learned even just one thing of value today, please share this episode with even just one therapist who can benefit from the message. Here’s how. If you’re listening on iTunes, click on the episode and you’ll see a small purple circle with three dots. Click on those dots and you’re gonna see the option to share at the bottom of the list. Click that and you can just go ahead and share it on Facebook or you can even just text it to one therapist who you know needs to hear it.
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Look, it’s time to get the word out. We gotta spread the message. Thank you so much and we’ll join each other again soon.
