The idea that clients should pay at least a small fee for therapy in order for therapy to be effective has been around for a long time. But it doesn’t hold up as well as you might think.
This is one of those things that I learned in grad school and simply accepted as truth for a long time. And then I was startled when I actually looked into it. Not only does forcing clients to pay even a small amount for therapy not help outcomes, some evidence suggests it makes outcomes worse.
Where the idea comes from
The notion that at least some form of payment — even just a dollar a session — should produce better outcomes than free therapy is backed by cognitive dissonance theory. Researchers have theorized that people will like almost any product or service they paid for more than if the person got the thing for free, in part to resolve the cognitive dissonance that might otherwise come from paying for something that we don’t find valuable.
The idea that session fees can improve outcomes also has links to psychoanalytic theory. Analysts have long worried that giving therapy away would foster dependence. Freud himself — who did some patient work for free — wrote that without fees “the patient is deprived of a useful incentive to exert himself” in working toward therapeutic goals.
What the research actually says
When researchers have examined the relationship between therapy fees and outcomes, they have not been able to support the idea that paying for services leads to better outcomes than receiving services for free.
There was a wave of research on the topic in the 1970s and 1980s, partly in response to changes in the insurance industry (such as the growth of managed care). This research generally found that payment for sessions made no difference in therapy outcomes. One study actually found that paying for therapy produced worse outcomes than getting it for free, though that study used a small sample and was based on a single therapy session.
The topic has been largely dormant among researchers since then. While many researchers have looked at clinicians’ ideas surrounding money and how those ideas may impact fee setting, outcome studies comparing free therapy with paid therapy appear to have been largely absent from the literature now for at least 20 years.
There is, however, one recent exception. A 2014 study looked at more than 1,000 clients in a training clinic. As was the case in the studies from a generation before, this study found that the amount of fee paid did not correlate with therapy attendance or outcomes.
We want to believe
Despite the obvious need for therapists to be able to talk directly with clients about money — something that Freud himself underscored the importance of — many therapists express difficulty doing so. Fee discussions are often not a significant component of graduate training in mental health care, and money in general is a complex, emotional, and sometimes taboo topic.
Our desire to believe that paid therapy is more effective than free therapy may stem from our own cognitive dissonance. Therapists sometimes wrestle with the notion that charging any fees for the services we provide amounts to profiting from (or worse, exploiting) client suffering. We want to believe that having higher fees, or even any fee at all, is somehow to the client’s benefit. This can be especially true when we’re working with clients who struggle with both severe mental health needs and extreme poverty. Fees are often a barrier to treatment for those with such needs. If we no longer have the excuse that fees improve outcomes, how do we continue to justify charging even small amounts of money to folks who simply don’t have it?
There is a multitude of good and defensible reasons to charge fees, to charge more clients fees if you currently see some for free, or to raise fees for existing clients who are already paying.
But “it makes the therapy more effective” isn’t one of them.