Introduction
I have an unusual preference, when it comes to payment by my patients: I prefer to be paid a flat fee, monthly, regardless of how many sessions take place. Once a treatment is established, once I’ve been working with someone for a while, I typically suggest that we move to this model: that we convert whatever per-session fee they’ve been paying to an annual fee, paid monthly.
Most (almost all) therapists charge their patients on a per-session basis. In, or before, a first session, the therapist will tell their patient, “My fee is $x.” Sometimes, there’s a discussion, and the fee is raised, or lowered. And then, as treatment progresses, the patient pays the therapist that fee either at or after each session, or weekly, or monthly.
Insurance companies, which figure prominently in the American therapy landscape, encourage this configuration, as does the American Medical Association (the AMA): the AMA establishes “current procedural terminology” (CPT) codes for every medical procedure imaginable, and insurance companies reimburse clients, or pay medical providers, on the basis of the “procedure” performed by a clinician, as indicated by the CPT code. Every therapist knows that 90834 is the CPT code, for example, for a 45-minute in-person psychotherapy session. In other words, according to the AMA, a 45-minute in-person psychotherapy session is a clinical “procedure.”
The conception of therapy as a “service” or a “procedure” that takes place exclusively in the time and place of the session simply does not correspond to my understanding of what I do, of how therapy works: I don’t dole out therapy in 45-minute increments. I think about my patients between sessions; they think about me, about the work we are doing. The project of psychotherapy, at least as I practice it, takes place over a long period of time, in and out of my office. It features missed sessions, illnesses, vacations, work travel. All of that? It’s an essential part of the therapy. As is the patient’s trip to my office, their time in the waiting room, their trip home after, and so on.
Ask a person how long they’ve been in therapy, and they don’t say, “Thirty-four sessions.” They say, “Three months.” Ask a therapist how long she’s worked with a patient; she won’t say, “Two hundred sessions,” she’ll say, “Two years.”
How does this work?
I have met with Tim once a week for a number of years. Several years into the treatment, I suggested to him that we convert to an arrangement along these lines. At the time, he paid me $200 per sesssion. My suggestion to him was that we estimate how many sessions a year we missed due to holidays or vacations (my cancellation policy requires patients to pay for all other sessions) – eight, we guessed – and then, divide the cost of forty-four sessions (that’s fifty-two weeks in a year, minus those eight missed sessions) across twelve months. That worked out to 44x$200=$8,800/12=$733.33. For that year, Tim paid me $733.33 each month, instead of amounts that some months were $400, or $600, and other months were $200, $800, or even $1,000. After a year, when it came time for me to implement my annual increase, I suggested that we increase the fee to $825 a month – about a 12.5% increase – and a much less arbitrary-seeming number. In the years since, we’ve increased by 10-15% a year, always landing on a relatively “round” monthly number.
This arrangement provides Tim with a number of benefits: practically, of course, it’s easier to budget for a fixed monthly expense than for one that fluctuates significantly. But more important, it provides Tim with a palpable sense that he and I are engaged in a long-term project together. Together with my cancellation policy, it eliminates the structural economic incentive for a patient to cancel each individual session, and cements his commitment to engage in therapy into the economic configuration of our relationship. And, it takes both of our focus off the misleading idea that the session is the unit of value, rather than the relationship.
