Keeping them in treatment for the mortgage

The ethical standards I learned in graduate school describe termination as a logical conclusion to a defined process. My professors talked about clinical goals and measurable outcomes. They spoke about the thinning of the therapeutic alliance as the client gained autonomy. I sat in those lectures and I believed every word of the theory. I believed that I would always prioritize the clinical needs of the person across from me over my own bank account. Then I opened a private practice. I signed a lease on an office. I bought a house with a mortgage that requires twenty-five billable hours a week just to keep the lights on and the grass cut. I realized quickly that the clinical literature assumes the therapist is a monk or a salaried employee of a massive hospital system. The literature ignores the fact that I am a small business owner.

I look at my calendar on a Monday morning and I see the gaps. I see the three o’clock hour on Wednesday that has been empty for three weeks. That empty hour represents one hundred and fifty dollars. Over a month, that is six hundred dollars. That is a car payment. That is a significant portion of the grocery bill. When a client says they feel like they are doing better, my training tells me to celebrate their progress. My training tells me to begin the conversation about ending our work. But my mortgage company does not care about the client’s progress. My mortgage company cares about the check I send them on the first of the month. I find myself searching for a reason to keep that client on the schedule for another eight weeks. I tell myself I am being thorough. I tell myself we are working on characterological issues that require long term maintenance. I know I am lying.

I worked with a man for four years who came to me initially because his wife threatened to leave him. He was a high functioning executive with chronic anxiety and a tendency to shut down during conflict. We worked through the immediate crisis in six months. His marriage stabilized. He started communicating. He stopped the late night drinking. By any objective clinical standard, he was ready to graduate. He was ready to go back into his life and use the tools I taught him. But he liked coming in. He liked having an hour where he was the center of the universe. He paid my full fee out of pocket. He never missed an appointment. He never questioned the utility of the sessions.

I watched him sit in my office for three and a half years after he reached his goals. I knew he did not need me. I knew our sessions had become a high priced social habit. We talked about his golf game. We talked about his frustrations with his board of directors. We talked about his children’s college applications. I justified it by calling it supportive therapy. I told myself that I was providing a stabilizing influence in his high stress life. The truth is much simpler than that. He was my most reliable source of income. He was the reason I could afford to take a vacation in August. He was the reason I did not have to worry about my marketing budget. I kept him in treatment because I was afraid of the hole his departure would create in my budget. I prioritized my financial security over his clinical independence.

I am not the only one doing this. I know because I talk to you. I hear the way we talk about our caseloads. We talk about the “good clients” and the “difficult clients.” When we say a client is “good,” we usually mean they show up on time and pay their bill. We rarely mean they are making rapid clinical progress. A client who makes rapid progress is a financial liability. A client who makes rapid progress leaves a hole in the schedule that I have to fill with a new intake. Intakes are exhausting. Intakes require paperwork and diagnostic assessments. A long term client who stays in a state of mild, manageable dissatisfaction is the golden goose of private practice. They provide the recurring revenue that makes the business model work.

The billing codes enforce this behavior. The insurance companies do not have a code for “therapist helped the client solve their problem in ten sessions.” They have a code for a forty-five minute session and a code for a sixty minute session. The system rewards duration. It rewards the accumulation of hours. If I am efficient, I am punished financially. If I am slow, if I linger, if I allow the treatment to drift into a vague exploration of childhood history that has no bearing on the current crisis, I am rewarded. I get to keep the client. I get to keep the income. I am essentially being paid to be inefficient.

I do not see this discussed in continuing education units. I do not see it in the ethics seminars. The ethics seminars focus on dual relationships and social media boundaries. They focus on the obvious sins. They do not talk about the slow, quiet sin of the extended treatment plan. They do not talk about the way I feel when a client tells me they want to move to bi-weekly sessions. I feel a flash of resentment. I feel a tightening in my chest. I am not thinking about their growth. I am thinking about the seventy-five dollars a week I am losing. I am thinking about how I will explain the dip in income to my spouse. This is the reality of the profession that we keep hidden behind clinical jargon.

I call it “working through the resistance” when a client suggests they are done. I tell them that the desire to leave is actually a defense mechanism. I tell them we are just getting to the “deep work.” I use my authority as a senior therapist to convince them that they are more fragile than they actually are. I manufacture a need for my services. This is a form of gaslighting. I am using my clinical expertise to undermine the client’s confidence in their own health so that I can continue to collect their money. It is a predatory behavior that is baked into the very structure of how we earn a living.

I remember a woman who came to see me for a specific phobia. She was terrified of driving on bridges. We used cognitive behavioral therapy. We used exposure techniques. In three months, she was driving across the bay bridge without a second thought. She was thrilled. She was ready to stop. I looked at my bank account. I looked at the two other clients who had just terminated because they lost their insurance. I told her that her phobia was likely a symptom of an underlying attachment wound. I told her that if we did not address the root cause, the phobia would simply manifest in another way. She believed me. She stayed for another year. We spent fifty sessions talking about her mother. Her mother was a perfectly fine woman. There was no attachment wound. There was only a therapist who needed to pay for his daughter’s braces.

I am not saying that long term therapy is never indicated. I am saying that the decision to continue is never purely clinical. It is always a negotiation between the client’s needs and the therapist’s overhead. When we pretend that the money does not matter, we are being dishonest. We are creating a culture of silence that allows us to exploit the people who trust us. I want to name this incentive because I think it is the only way to mitigate it. I have to admit to myself that I have a financial interest in my clients staying sick. I have to admit that I am a vendor selling a service. If I do not admit that, I cannot guard against the temptation to oversell.

I see younger therapists entering the field with six figures of student loan debt. They are under more pressure than I ever was. They are told to go into private practice because that is where the money is. They are told to build a “thriving practice.” No one tells them that a thriving practice often depends on a foundation of clients who should have left a year ago. No one tells them that their clinical judgment will be constantly warped by the balance in their checking account. We send them out into the world with a set of ethical guidelines that are useless in the face of a looming rent payment.

I have started forcing myself to do something I hate. I have started bringing up termination before the client does. I have started asking, “What are we still doing here?” It is the hardest question to ask when the answer might cost me a thousand dollars a month. I have to look at the client and see a person, not a line item. I have to acknowledge that my desire for a new car is not a clinical indication for continuing treatment. I have to be willing to be poorer if it means I am being more honest.

The profession’s silence on this issue is not a neutral stance. It is a form of complicity. By ignoring the financial incentives of private practice, we allow the most cynical parts of our business to flourish. I am tired of the pretense. I am tired of the way we pretend that the room is a vacuum where money does not exist. I am a therapist, but I am also a capitalist. I am a healer, but I am also a biller. I have to hold both of those identities at the same time. If I don’t, I am just a sophisticated liar. I am just someone keeping them in treatment for the mortgage.