I have thought about the price of therapy since before becoming a psychologist. I have reflected, read, and talked about it from the perspective of someone who has sat on both sides of the therapy room. Now that I have been self-employed for over three years, I understand why the average fee in the Netherlands is around €90 per session. At the same time, it is disheartening that the very same fee that allows a self-employed therapist to make a living poses a financial barrier for many of the people we want to reach.
I believe that therapy should be accessible for anyone who wants to start. However, the high fee of private therapy is out of reach for many. As the cost of living continues to rise, even reduced rates or sliding-scale options are unaffordable for people with an average salary. The cost-of-living crisis affects both clients and therapists: it has become more expensive to go to therapy, and it is also expensive to maintain a private practice.
The fee is a crucial element in private therapy. People decide whether they can start or not based on it, how often they can go, and for how long… Even though these are questions that affect the therapeutic process itself, matters related to money often go undiscussed. During my Master’s program, for example, we were not taught how to price therapy in a way that is fair for both the client and the therapist, or how to handle cancellations and late payments… I learned about these questions and situations through practice and consulting with other therapists.
The high rates of private therapy often give the impression that therapists must earn an attractive salary. The way therapists are portrayed in the media tends to reinforce this idea. In films and series, psychologists sit in their luxurious offices and have equally fancy houses. This affluent lifestyle is not the reality for most of the psychologists I know. In fact, it is not uncommon for self-employed therapists to have multiple income streams to sustain themselves. It is this less visible side of the profession that I hope to shed light on.
A close look at the numbers: The cost of GGZ and private therapy.
In the Netherlands, the Dutch Healthcare Authority (Nederlandse Zorgautoriteit, NZa) sets the maximum rate that may be charged for mental health care. NZa tariffs set the market rate, and they are the official reference point for all billing within the GGZ (Dutch Mental Healthcare). These rates can be found at the Zorgprestatiemodel. To give you an idea, the NZa rate of a 45-minute session with a GZ-psycholoog is €149,82 (Code CO0497), and a 60-minute session with a psychotherapeut is €205,96 (Code CO0635).
How much do I pay if I go to the GGZ?
How much you pay depends on what type of contract your GGZ healthcare provider has with your insurance. In every case, you will need to pay the mandatory deductible (the “eigen risico”, which is €385 per calendar year) if you haven’t reached it yet.
Dutch insurers work with two types of healthcare providers:
- Contracted providers: If your provider has a contract with your health insurer, your insurer pays your provider directly.
- Non-contracted providers: If your provider does not have a contract with your health insurer, you will receive the invoice for your treatment and need to submit it to your insurer yourself and request reimbursement. You may receive lower reimbursement, since the reimbursed amount depends on what percentage of the NZa rate your insurer reimburses for non-contracted care.
How much do I pay if I go to an independent therapist?
The basic Dutch health insurance (basisverzekering) does not cover the costs of therapy outside of the GGZ. Unless you have an international or additional private insurance that covers private therapy, you need to pay everything out of pocket. In the Netherlands, individual private therapy typically costs between €70 to €120 for a 50-60 minute session. That means every month you’d be paying between €240 and €480 for weekly therapy, or between 140€ and €240 for biweekly therapy.
Understandably so, many people can’t start therapy because it falls outside of their budget, or they might come every two or three weeks. Biweekly therapy has become so common that I almost forgot that weekly therapy has been the standard frequency for years, especially in the first weeks of therapy. In fact, in some psychotherapeutic approaches, such as psychoanalysis, it is normal to go multiple times per week. In my experience, meeting weekly creates a sense of continuity, and it allows us to build a connection and work through therapeutic material faster. When a long time passes between sessions, therapy may become something fleeting in your life, rather than part of it. It is a shame that regular therapy has become a luxury, only feasible for those who can afford it.
Why is private therapy expensive?
From my perspective, there are two main reasons why private therapy rates are high. First, a high fee is necessary to sustain a private practice and make a living as a therapist. Besides the many business expenses that come with being self-employed, we also need to account for potential sick leaves, inconsistent referrals, unpaid cancellations, our holidays, clients’ holidays, retirement… That is, all the expenses that are typically covered by an employer, and all the employment rights a contract secures for you. Second, having low rates could devalue the profession. If therapy fees are too low, people may perceive psychotherapy as less valuable, unimportant, or amateurish.
Keeping a private practice
In the Netherlands, after graduating from your university, you can work as a basispsycholoog in a GGZ practice (very limited vacancies for non-Dutch speakers), get hired by an independent/private practice, or become self-employed and start your own. I had never contemplated the path of becoming a freelancer until that was the main (if not only) opportunity that I encountered on my path to becoming a therapist. When you are self-employed, you’re not just a therapist, you also have to manage a business and cover all necessary expenses yourself. To put it in perspective, here’s a summary of my business expenses: NIP membership, office rent, office supplies, supervision, my own therapy, courses and trainings, marketing, business insurance and complaints committee, business phone number, business bank account, tax accountant, and taxes. With all that in mind, something I really value about working as an independent therapist is that there is no intermediary between the patient/client and me. No boss profiting from the work of employees, no insurance company adding layers of bureaucracy while dictating the terms, and no profit-driven platform making millions by advertising therapy.
The value of therapy
The value of therapy is not easily translated into numbers. How do you quantify care and attention? How much is someone’s time and presence worth? There’s a tendency to undervalue the helping professions. Psychotherapy, like care work in general, involves a lot of invisible labour: Knowing when to speak and when to stay silent, paying attention to their body language, picking up on what is left unsaid, noticing how you are feeling in response to what is happening in the room, reflecting on the process in between sessions… You cannot see this from the outside, but a great deal is happening inside the therapist’s mind from the beginning of the session till the end. The visible work is equally valuable. Where else would we find a relationship in which someone is consistently there for us without us ever needing to reciprocate the help?
Unlike other professions, the process and result of therapy are not perfectly measurable or tangible. Sometimes we only see the fruit of the therapeutic work many months after the first session. As therapists, we ask people who come to see us to look inward and go to a place within themselves that might resurface very painful feelings, with the purpose of healing an invisible wound that we don’t know when it will scar over. The value of therapy doesn’t lie in results or quick solutions, but in having a compassionate witness to all parts of yourself.
How do self-employed therapists set their own rates?
In the absence of a clear way to quantify the worth of therapy, therapists look to other concrete markers to choose their own rates: market rate (how is therapy priced in our area), official guidelines (NZa tariffs in the Netherlands), how much did it cost us to become a therapist (university education and post-Master’s trainings), and how much does it cost us to maintain our practice. When you plug all of these numbers into a calculator, the number you get will inevitably be high.
The NZa rates are official guidelines determining the maximum fee healthcare professionals can charge. I believe it would also be necessary to have a minimum recommended fee set by a professional institution, as they do in Argentina, for example, where psychology associations set a “minimum ethical fee” to protect therapists and the profession from inflation. Having official parameters of what the minimum and maximum rates are for mental healthcare would not only help self-employed psychologists set their own rates, but it would also help maintain professional dignity and ensure therapists earn enough to afford professional and personal costs. Most importantly, it would help create a shared understanding of what therapy is worth.
Final thoughts
Money typically signifies safety. In our current social context, with living costs and unemployment on the rise, many people do not feel financially stable enough to pay for therapy out of pocket. The solution is not for self-employed therapists to lower their rates. If we did so, we would not be able to invest in our professional development or cover the necessary business costs, nor would we be able to make a living. As long as personal and professional costs remain high, therapist cannot afford to lower their fees. Paradoxically, private therapy is becoming unaffordable on both sides. Many people who need therapy can’t afford it, and many therapists who want to continue their training or invest in their private practice can’t afford to either.
The road to financial safety is a long journey for many therapists. Rising expenses aren’t always accompanied by rising income, an income that is tied to the number of sessions we can realistically have per week. Because of this, a lot of therapists look for other ways to increase their earnings without proportionally increasing their hours, such as creating courses and workshops, writing books, producing podcasts, building a social media presence… Sometimes this is done out of a genuine desire in such ventures, and sometimes it is born out of the necessity of starting a side project that will provide more financial stability. When I became self-employed, I did so because I wanted to be a therapist. Everything related to business and marketing was completely foreign and new to me. After all, I didn’t study psychology to become an entrepreneur. What I have learned from my own experience and that of other therapists is that some therapists can afford to make a living just from therapy sessions, and some cannot. Which group you’re in depends on many factors, such as living costs in your city, whether you can count on other financial support (family or partner), and whether you had financial security and stable living circumstances before going freelance (such as already owning a house or having savings).
I believe the gap between the need for therapy and its inaccessibility reflects a crack in the structure of the mental healthcare system. One that affects both clients and therapists. It is not a perfect design. How could it be, when psychotherapy is still a very young discipline, less than 150 years old. I hope that one day, private therapy will be within the reach of anyone who wants to start. I hope that people who seek insurance-covered therapy do not have to wait for months, and that their treatment is not cut short. I hope that therapists who want to work in public healthcare can enter the system in the first place. I hope that therapists who want to start their own private practice can live from it. I hope that every therapist can make a good living without risking burnout or their integrity. I hope that one day I’ll see in a film a therapist I can relate to. And I hope the value of therapy doesn’t get lost within the imperfect system in which it currently exists.
In case you’re wondering…
Why aren’t there more international therapists in the GGZ?
Even if the Netherlands actively pursued internationalisation by offering many Master’s degrees in Clinical Psychology fully taught in English, it is hard to get into the Dutch mental healthcare system without a B2+ in Dutch. This limits the number of paths available to non-Dutch-speaking therapists when entering the GGZ. Hence why most international therapists work privately. That being said, there are some ways to get into the GGZ:
- If you want a job with a contract, you can work as a basispsycholoog within the GGZ. There are very limited positions where Dutch is not a requirement. It is also necessary to have a LOGO verklaring, which is another bureaucratic hassle in itself.
- Some practices within the GGZ might hire you as a self-employed professional. Logistically, this means instead of sending an invoice to your patients, you send it to the practice itself, which takes care of all patient management. I’ve heard of some psychologists working like this, but it is not very common.
- You can become BIG-registered. The basic Dutch health insurance (basisverzekering) can only reimburse you if the practice you go to has a lead practitioner (regiebehandelaar) who holds a BIG registration. The BIG-registered protected titles in mental healthcare are: GZ-psycholoog, Psychotherapeut, Klinisch psycholoog, Klinisch neuropsycholoog and Psychiater. There are two paths for non-Dutch natives to enter the BIG register:
- You can follow the standard Dutch path, which involves doing the GZ-opleiding, a 2 to 4 year post-Masters training fully in Dutch. If you have a B2+ level and want to do the training, there are two ways to get in. The most common path is to work as a basispsycholoog and wait until the practice you work at has a spot for you. Given the limited number of funded positions per year, competition is high, and waiting time can last years. There’s also the option of paying for the training yourself, which might reduce the waiting period, although the total cost is around €23,900.
- If you obtained your professional qualifications in another country, you can apply for your diploma to be recognised in the Netherlands. The competent Dutch authorities will decide if your qualifications from said country are considered equivalent. There might be additional requirements to fulfil Dutch standards, such as Dutch proficiency or periods of supervised practice. This is typically a long and potentially arduous process.
What options do I have if I can’t afford private therapy?
- Dutch Mental Health Care (GGZ): In order for your insurance to cover therapy, you need a referral letter from your huisarts (General Practitioner). The first step is to make an appointment with your GP, and they will refer you to either the Basis GGZ (BGGZ: Basic Mental Health Care) or the Gespecialiseerde GGZ (SGGZ, Specialized Mental Health Care). The BGGZ is for short-term treatment (5 to 12 sessions), whereas the SGGZ is for long-term therapy.
- Check with your employer: Some companies are able to offer psychological support or pay for your therapy. They might have an in-house psychologist, they might have partnerships with mental health platforms that connect external therapists to their employees, or they might have a yearly budget that employees can spend on anything wellness-related.
- Universities: Universities often have a student counsellor who can provide short-term counselling.
- In case of an emergency, there are free resources available:
- ACCESS NL has a counsellor on call from 8:30 to 20:30.
- The Suicide Prevention Line is available 24/7 at 0800-0113 or via chat
- The Listening Line is available 24/7 at 088-0767-000 or via chat
- You can find more resources here.
Dagen Efter / The Day After by Mamma Andersson, 2020