‘We’re At Time’

In this fourth and final piece in the series, we explore the costs of therapy and the financial decisions people make when seeking help.

When Affordable Therapy Network founder Katie McCowan was in her final year of therapist training, she started experiencing mental health challenges and decided to seek therapy.

“I was in school, working as a waitress, not making a lot of money. So I found myself Googling ‘affordable therapy options Ontario,’” she says, referring to her inspiration for launching the Canada-wide online database in 2015. To meet her needs, she used one option (provided by her school) at $40 per session and also tried a private therapist at $140. But while the private sessions were helpful, they cost her a day’s wages. “$40 was affordable, but I wasn’t able to choose my therapist, and therapeutic fit is very important.”

McCowan realized that this was a common challenge and thought, “What if I built a website and listed therapists who offer lower rates so people can connect with them?” She began with her esteemed colleagues, since new graduates often charge less. Word spread. The network grew. And during the pandemic, demand exploded.

The website now lists more than 550 vetted therapists, all with sliding-scale fee options and about half offering subsidized spots at $65 or less (including some pay-what-you-can and pro bono options). “A wide variety of therapists list with us, and most offer a certain number of low-cost spots, maybe five or so, that are subsidized.”

While these lower-cost rates tend to be less than half the price of private therapy, considering today’s socio-economic realities, “I know that’s a stretch for a lot of people,” she says. Still, McCowan acknowledges that fees in the private industry are fair and appropriate. “Therapists don’t charge more than they should. There is extensive training, extensive supervision, and it’s quite challenging work.”

Financial insecurity and therapy
If you feel that life seems more expensive lately, you’re right. According to the Canadian Social Survey on quality of life and cost of living, the consumer price index rose 6.8 per cent in 2022 — the biggest jump in forty years — with costs for food (up 8.9 per cent), shelter (up 6.9 per cent), and transportation (up 10.6 per cent) increasing the most.

Such pressures have had a mental health impact on many people. Half of our population has been affected by “inflation, the economy and financial insecurity,” according to a post-pandemic survey from Mental Health Research Canada (MHRC), and are “showing signs of worsening mental health.” In fact, since the previous year’s poll, this group reported “higher self-rated anxiety (33%) and depression (32%), higher suicide ideation (31%) and alcohol (23%) or cannabis dependency (22%),” among other issues.

Indeed, not only can financial stress impact mental health, it can affect decisions about therapy and other mental health resources. In Canada, psychotherapy and psychology services may be covered (in part or completely) by private health insurance, such as insurance plans provided by an employer, or purchased directly by an individual. Mental health service providers offer more specialized care, which ranges depending on the severity of the issue. Certain services need a doctor’s referral, while some are self-directed and available online or by phone or text message. Others are public (funded by governments) or provided by charities, community groups, and other organizations. The Canadian Mental Health Association, for example, has branch offices to direct people to support, including free counselling provided in some of its 70 regions in 330 communities across Canada.

CMHA programs are “culturally safe and meaningful,” which is significant when looking at the impact of financial insecurity on mental health and access to supports, including therapy, for various populations. To cite just one example, the MHRC survey found that racialized persons, people from 2SLGBTQI+ communities, young adults (ages 18 to 34), students, and those who are unemployed, have low incomes, or are in financial trouble are more likely to report high levels of anxiety.

Fee scales to improve access
To help clients get access to mental health services, the Calgary Counselling Centre has had a sliding fee scale since it opened in 1962, says CEO Robbie Babins-Wagner, who is also an adjunct professor and special instructor at the University of Calgary.

“We have to make sure we meet the needs of vulnerable people, including those vulnerable financially because of health issues, mental health problems, or other social issues,” says Dr. Babins-Wagner, whose passion is “clinical practice and making sure clients get the results they deserve.” Babins-Wagner and her team employ scientific, data-driven research methods and tools, including “session-by-session” outcome measurement (with questionnaire tools in 24 languages) and financial modelling. “We use that data to try and understand how we’re helping people and improve what we’re doing.”

The centre assigns new clients to a counsellor “no later than noon the next day” after receiving a request and uses no formal means testing. “We ask a client what their income is, and we trust them,” she explains. “When a client says they can’t afford the suggested fee, we say, ‘Your counsellor will discuss that with you; the fees are not a barrier to service.’ The counsellor has the discretion to bring it down to, generally, as low as $8 an hour, but if necessary, we’ll bring it lower. We truly don’t want fees to be a barrier.”

The centre collects this data, Babins-Wagner says, “because we want to understand what’s happening for clients and where the pain points are.” Through an internal process using blind data, every time there’s a fee change, we “look at what the suggested fee was, what the client could afford. Then we put that in our database and run that data to see whether clients from certain income groups are struggling more than others and if we need to make changes. Those are the kind of changes we typically make to the fee scale, and we test it to see if it’s achieving the intended benefit, which is meeting client needs.”

With the economic challenges Calgary has endured since late 2014, she says the centre now reviews its fee scale every year or two instead of every five years “because we know we can’t wait, and people are being more impacted than we’ve seen historically. So, we use data and current conditions to look at these factors.”

Finding a way
Dr. Elana Bloom, psychologist and director of campus wellness and support services at Concordia University agrees that “navigating mental health resources can be challenging.” While her expertise isn’t related to affordability per se, she understands the issue based on her clinical practice and is familiar with the mental health resources in her province, particularly for the student population.

“In Quebec, individuals (including young adults) can access mental health and psychosocial services, including psychotherapy and crisis supports, at CIUSSSs” [integrated university health and social service centres and community-based organizations]. At Concordia, we offer an array of mental health services, including wellness programming and psychotherapy with counsellors and psychotherapists. If you’re not able to access services or resources in a timely manner, if there’s a wait-list, another option is to seek services privately.”

Dr. Bloom advocates an “expansive view of wellness and well-being” — where seeing a therapist may be part of a broader wellness strategy that can include self-care, social interactions, physical well-being — and “leveraging technology” to make the most of self-directed mental health tools and resources. “Being a psychologist myself, I believe in the positive impact of psychology and in seeing a therapist,” she says. “But I also think mental health is more than just meeting with a psychologist; it’s important to take care of our own mental health and well-being using many different resiliency-based strategies beyond going to see a psychologist or therapist.”

She also notes that services are available to meet the particular needs of specific populations, such as Indigenous, 2SLGBTQI+, and African, Caribbean, and Black individuals.

Therapy 2.0?
While young people (and the rest of us) are increasingly living their lives online — and this extends to therapy — not all mental health apps are the same. For example, people’s personal data has been shared for marketing purposes and, in one case, a crisis line number in an app was wrong. The Mental Health Commission of Canada discovered that error when consulting with young people to develop Canada’s first e-mental health strategy to improve e-mental health solutions, which will be released in early 2024.

To make sure mental health apps are evidence-informed and safe, the commission also launched a Mental Health App Assessment Framework. App developers, designers, and owners can use it to assess their apps and improve their safety, quality, and effectiveness. The framework includes information as well on safety, social responsibility, and equity and outlines the perspectives of diverse groups, ages, and populations.

In addition to digital options, McCowan says talking to your family doctor can also be important. “I think it’s easy to fall into a spiral where it feels like there’s no way out. Checking in with someone, having an outside perspective, someone offering you any kind of resources, any kind of support is super helpful.”

 Resource: Where to Get Care — A Guide to Navigating Public and Private Mental Health Services in Canada.

 Further reading: How to Break Up With Your Therapist.

Read the entire Money & Mental Health series.