Initial Session Price Tag—$150? Or Free?

This post was co-written with Mitchell M. Handelsman, Ph.D., whose blog is “The Ethical Professor” and who co-authored the book Ethics for Psychotherapists and Counselors.

The initial meeting between potential clients and psychotherapists is of critical importance [Anderson & Handelsman, in press]. Shopping for the right therapist is an important investment of both time and money. Before making a commitment to the relationship, the potential client needs some answers to important questions.

In prior blog posts, where we talked about shopping for a psychotherapist and what to look for, we suggested questions potential clients can ask therapists to help make good decisions and ultimately answer the question, “Is this therapist the right therapist for me?” In this entry, we tackle the issue of the ethics of charging money for the first session.

Recently, we heard from a mental health professional and graduate student, Katherine Morris of Seattle, who wrote:

I am required to undertake a year of personal counseling during my doctoral training program (which I think is a good requirement) and have found the following among many, if not most of the psychologists listed by my health insurance provider.

Counselors and psychologists too often do not make any basic information about themselves available to the public, other than where they went to school and their license number, but that says almost nothing really. Instead, they try to make an appointment with the potential client, in order to answer the most basic questions, and charge the usual $150 just to answer questions like: "What is your theoretical orientation?" Why should prospective client pay $150 to each psychologist while they are looking for a "best fit"?

Our question is, “Is this practice ethical or unethical?”

Is this a red flag of future unethical behavior to come? Or is this a green flag representing good practice by a therapist who is also a good business person?

One way to look at this initial fee is that psychotherapists make their living talking to people, and they certainly have a right to charge for their time. Doctors can (and do) charge for checkups, even when no medical condition exists and no treatment results. Financial planners, accountants, and attorneys charge for consultations. It could be argued that charging for an initial session might encourage clients to take the interview more seriously.

Another argument that has been advanced (and not only by therapists!) is that a free first session might be too much of an inducement for some clients. (Consequently, some folks have recommended giving the last session for free.)

On the other hand, it could be argued that charging for a session that is mostly about answering clients’ questions and not about assessing clients’ situations, needs, or personality, might be—or give the appearance of being—a way to make a quick buck. This might be especially true in the age of the internet. As Morris says, “Why don't they have websites with information about their theoretical orientation and how they view human nature, etc.? Today there is no excuse not to have even a single webpage profile giving this basic information.” This might be especially true as clients are more and more being encouraged to shop around for therapists.

Thus, one option for psychotherapists to practice positive ethics is to provide really useful information on a web page. In the short term, this practice may cost psychotherapists the opportunity to make the odd $150. But in the long term, we believe such therapists will reap the economic, and emotional, benefits of having reputations as honest professionals who care as much about people as about their bottom line.

Of course, therapists are ethically responsible for providing accurate and useful information. Morris talks about one therapist in Seattle who “has a single advertisement page on Psychology Today, with no information about his theoretical framework, just a long list of what he 'specializes' in. In fact, the list is so long, he could not possibly be a true specialist in all of those things!” We are reminded of the “Car Guys” on NPR who laugh at garages with signs that say, “We specialize in all foreign and domestic makes!” Do therapists who have such advertisements realize how inane that sounds? Is it unethical to be inane?

The more (useful) information therapists provide on their web pages, the more justified they are in charging for their first sessions. After all, they can encourage and expect clients to have already taken some responsibility for their own therapy process. One option here is to charge a reduced fee for the first session—kind of “splitting the difference.”

To add one more layer of ethical excellence, some therapists will charge for the first session if the client continues, but not if the client decides not to return. We think this arrangement is a green flag; it benefits both parties—as long as the therapist tells the truth and is not motivated to say anything just to make the client come back. (However, the more information on the web page, the less the therapist can do this.) Prospective clients who are shopping for a psychotherapist may feel less like they are being taken advantage of, and therapists may feel that no matter what happens in the first meeting they are not compromising their financial needs by always having the initial visit free.

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Morris suggests (and reports using in her own practice with great success) one more option: A money-back guarantee. Pretty respectful of clients, huh?

Whatever their policy, therapists should be clear upfront about what the cost will be and what the options are. They also need to practice beneficence and respect clients’ autonomy by not evading clients’ questions about costs, potential length of treatment, treatment strategies, and other important factors.