You Are Not A Non-Profit.

Please do this for me; even if you never contact me and ask for a consultation or supervision, just do the following.

  1. Print out this page.
  2. Cut out the title to this blog post.
  3. Find a picture of your child, partner, parent or other loved one.
  4. Tape the title to the picture.
  5. Place it on your office desk, where you can see it every day.


This week in MA, we had further seismic tremors in the land of health care.  Two tremors in fact.  First, the news broke that our three biggest insurers Blue Cross, Harvard Pilgrim, and Tufts had reported financial gains this past year and strong investment income.  In addition, the story reported that the CEOs of these companies made salaries ranging from 780K to 1.2 million dollars.  News also revealed that BCBSMA’s board members collected an average of $68,000 last year to attend board meetings.  That’s roughly $1,100 an hour.

The other big insurance news was that Tufts and Harvard Pilgrim decided to call off their merger.  The reasons cited were that there wouldn’t be enough savings to offset the cost.  Translation:  They just wouldn’t make enough money to make it worthwhile.

What does this have to do with anything?  Lots.

First, the salaries and board stipends underscore that Blue Cross Blue Shield is a non-profit business.  That is why if you look at this list of BCBSMA’s Board of Directors, you will see top-ranking business-people and government officials.  Put simply this means that it can dispense its surplus to reward board members and top management.  They are a franchise, and in many cases, publicly-traded companies.

Second, and this is a reiteration of the first in a lot of ways, health-insurance companies are designed to make money, not just break even.  They are a Non-Profit not because they don’t make money, but because of the way they disburse the money made, to their managers and board members (who incidentally are some of the people who have legislative power when it comes to healthcare reform.)

Back to your picture and my post title.

You are not a non-profit.  You don’t even have to play the shell game with board members and management, because you are the management.  It is understandable and easy to get distracted by the rage and yes, envy, that one feels at these “fat cats” making so much money.  But let’s get real honest now.  Here, I’ll go first:

1. I’d love to make 1.2 million dollars a year.

2. I live in a capitalist system, not a caste system, which means that just because I was born in a capitalist system I don’t have to live here, or, I can try to alter the system to be more in keeping with my socialist goals.  But as long as I live in a capitalist system, money is an inevitable fact of my existence.

Now the hardest one, at least for me:

3. The minute I accept insurance reimbursement I become part of the medical establishment, and that means that the sickness and suffering of others is what creates a need for the commodity of psychotherapy.  In other words, I need a steady stream of unwell or hurt people in order to make my living. If I do my job well enough, people won’t need me any more, and I’ll need to attract other hurt or unwell people.  And even if I try to gussy it up in the form of “self-help,” I’ll still need people who need help.

Now I am not going to try to justify this to you, gentle reader, by saying I only make as much money as I need.  I don’t believe greed is good, but I do want an iPad, and I don’t need an iPad.  So I have to come clean and admit that I am not an non-profit.

I consult so often with therapists who take great pride in the amount of “slide” they have in their sliding scale.  They are willing to give up that money without a lot of regret.  Until they take out that picture of their family that I ask them (and now you) to put on the office desk.  Look at it, at them.  Those are the people you love, they are also being affected when you don’t charge full fee to someone who just got a new job, or when you don’t enforce your cancellation policy.  They are the ones who are depending on you to help keep your family afloat.  They are the ones who embody the best care you can give, and they will be with you and counting on you the rest of their lives in one way or another, often financially.

You are not a non-profit.  You need to make a profit, and you need to stop pretending you don’t, and minimizing the profit so that you can pretend.  I hate insurance companies and a lot of our healthcare system, and I am fighting for social justice when I am not working in my practice.  But these companies get it, they get that they are in business.

We need to get that too.


  1. Dear Michael,
    I read everything your post and I aways find your articles/messages helpful and thought-provoking. Thanks!
    With warm regards,

  2. Mike,
    All I can say is well said. I appreciate your comments very much. There should be no shame in making a living! We teach clients to ask for what they want but many therapists are afraid to do the same. Thank for this blog post.
    Renee Segal

    • You’re welcome Renee, and I agree that we are sending a mixed message to our patients if we feel ashamed to earn our fee. It reminds me of parents who spank their children for getting into physical fights at school. Huh?

  3. I think there is likely a relationship between the way therapists devalue their services by not charging and collecting proper/full fees, and wider exploitation of therapists by big health care, insurance companies and EAPs.

    I love all your posts – great writing and ideas – thank you!

  4. Mike, I once had a business coach who told me,”If you work to make money that you keep, you are not a non-profit.” Bingo. As I move my practice to more of a self-pay model, I’m looking for ways to give to non-profits and others who are in need. But I can’t go broke on behalf of my clients’ needs. We live in a capitalist culture and live by those standards. Thanks for spelling this out so clearly…

    • I do not accept any insurance at all. Full fee, pay at time of service is my standard. The way I give back, is that I provide psychotherapy at reduced or pro bono fees when I care to-because the great majority of clients pay full fee. I love taking a motivated student, single-parent, missionary, non-profit employee-or whoever I care to, because I can afford to. I can afford to because of the first two sentences. I allow myself a specific number of those clients and stick to it. At times, a client will wait (if not in crisis) for a reduced-fee spot. This is very satisfying for me:)

    • Thanks for weighing in yourself. I like your coach’s quote. And I think we need to do more than just break even, this work is challenging and emotionally draining at times. If we can’t afford to go out with a colleague for lunch, get a massage, or have a gym membership, our patients will end up with grumpy resentful therapists!

  5. It seems that a lot of therapists would fall under the nonprofit idea because they really don’t make a profit, which is fine, if they really are not interested in making more than their expenses. However, the problem with that idea is that many people only value what they pay for and if they don’t pay anything or only a small amount for therapy they will value what they get at that level. We can have a sliding scale when that would be the only way someone could receive therapy but it should be an exception not the rule so that people really comprehend that an exception is being made for them.

    • Carole, well put. I do think that a sliding scale should be the exception, not the rule. I also use those moments to review the financial picture of the patient’s life. This means a calculator comes out and we go through the monthly bills. This often opens up new areas of conversation and work.

  6. Mike–This is so clearly stated! Thank you.

  7. Thanks for reminding me. I provided a too-deeply discounted fee plan to someone yesterday (a recently bereaved student on leave from work and school) and regretted it immediately. The next words out of her mouth included her inability to reschedule with me for a month due to a month-long sojourn she is making to some sunny clime(!) I learn this lesson a little better with each experience. I am not a non-profit. I am not a non-profit. I am not a non-profit. my blog:


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