Recently I saw comments in a discussion about therapists and insurance in which the commenter condemned therapists who go private pay for being financially inaccessible. Two of their statements stuck out. One was their statement that “you didn’t get into this career for the money.” The other is that healthcare is “supposed to be” free or low cost. These two statements embody the contradictions of Progressive Neoliberalism, and perhaps capitalism in general, that are frequently stated but rarely interrogated.

Neoliberalism has been the decades-long governing philosophy to defund public services and depend upon private business to fill the gaps. Instead of having a national healthcare service that employs all health providers and pays us from taxes, we have this system of bureaucratic layers in which I as a private individual am providing the therapy and contracting with a private company who decides how much to pay me for my work on behalf of another private company that hired it to broker their employees’ healthcare needs. (That’s three layers of businesses that need to be paid, incidentally.)

Progressivism is the movement to improve our conditions through reform and innovative technology and policy. It’s the idealism from which springs the statement that healthcare is supposed to be free. The contradiction that emerges when you put progressivism and neoliberalism together is saying healthcare should be free but having no infrastructure set up to pay for the labor and costs of that care. It is unworkable for a private individual to exist in that contradiction, providing cheap labor while trying to manage their own lives.

This progressive-neoliberal contradiction extends to a lot of facets of life that we think “should” be public services. In Seattle, we say that housing is a human right, but housing is run by private individuals and companies. So the laws that we pass to protect renters do not come with any commensurate protections or supports for the landlords who are obligated to follow those laws even if it hurts their business. This has driven a number of smaller landlords to get out of the business or sell to larger corporations who can afford to absorb the cost of bad tenants or the costs of breaking laws to protect their bottom line. Perhaps inadvertently, these progressive policies end up strengthening large corporations.

You can’t use capitalist methods to provide free or accessible public services. You need something like a co-op or government agency that is well-funded and exists to provide these services without the profit motive. The best private solution that I’m aware of is the Therapy Fund Foundation, a nonprofit that raises money to pay Black clinicians their market rate so that Black clients can access care at no cost to themselves. I’m happy this exists and I support it financially when I can, and I don’t know of any similar solutions that would include me as a white man. The Open Path Collective is a group of therapists committed to providing therapy at a deep sliding scale, which is another great option to expand access to low-income clients, but it requires the therapist to be willing and able to work far beneath their rate, which ends up coming back to this core problem.

Therapists are supposed to provide a human right at accessible costs and I guess just shut the fuck up. But I can’t think of any other job or industry where you’d happily settle for not getting a raise beyond an occasional cost of living increase for the entirety of your career no matter how much you increase your skill. Being a therapist is my full-time job. My income comes from the client service I provide, and a couple royalties whose amounts afford me a couple extra beers a month. I pay for my own business costs, my own business taxes, my own housing, my own healthcare, my own food. I am also a human being who can only work so much in a week before the quality of my care degrades, and I want to do things like have vacations and enjoy the time I have on this earth with my loved ones. And I’m in a privileged position; many of my peers have student loans and kids on top of those costs. Were I to provide free or low-cost therapy, I would have to get a different full-time job so I could afford do therapy as a hobby on evenings or weekends.

I can’t imagine other jobs where you would tell someone “well you didn’t get into this for the money” and think that is the end of the conversation. Actually, I can. I imagine teachers get this a lot, and people working in mission-driven nonprofits. Helping professions and nonprofits offer their own unique flavor of exploitation that’s wrapped in the language of passion. We’re told that simply doing this work is the privilege and we should be happy with the wages we’ve got. That we’re the selfish ones for wanting to be paid for all the energy and heart we expend. What’s the long-term product of that? Either burnt out martyrs or people who leave the profession and go into fields where they’re allowed to care about their paycheck. Neither of which results in good care.

In summary, the Progressive-Neoliberal contradiction is the belief that public services should be accessible and free without advocating for government infrastructure set up to ensure it, instead placing the burden on private individuals and then blaming them for having human needs and limits. It’s wanting socialist outcomes using capitalist means, which in practice results in strengthening large corporations and squeezing out small businesses and individual providers. This does not improve access to quality therapy for clients in need of it.