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When Chappell Roan called on the music industry to pay artists a living wage and give them health insurance during her Grammys acceptance speech in February, she sparked a debate about labels’ responsibility to the acts they sign, including the artist’s potential — and the label’s investment — that is put at risk if mental health struggles take center stage.  

Nearly three-quarters of some 1,500 independent musicians reported struggling with mental illness, according to a 2019 survey by the digital distribution platform Record Union. Even among unionized musicians and performers, rates of mental health problems and substance use disorder are higher than among the general population, according to Sound Advice, a book written by music journalist Rhian Jones and performance coach Lucy Heyman.  

Over the past several months, Billboard asked more than a dozen artists, managers, financial planners, music executives and therapists about creatives’ single biggest out-of-pocket health care expense, and the answer was consistently the same: therapy. 

Sobriety coaches, on-tour therapists and mental skills training offer potentially career-saving — even lifesaving — support for singers battling anxiety so intense it can rob them of their voices.

But they come with eight-to-10-figure medical bills, these sources say. And health insurance, for those fortunate enough to have it, often covers just a fraction of the cost.

“It’s $250 a session for someone who is good and qualified,” says Chief Zaruk, joint-CEO of The Core Entertainment, an entertainment company launched with Live Nation that represents Bailey Zimmerman, Nate Smith, Nickelback and others. “If you’re a beginner artist without a record deal, maybe a publishing deal, you’re making $2,500 a month, and you’re like, ‘Wait, I’m going to take more than a third of that and put it toward a therapist?’ They just can’t do it.”

Zaruk and Core co-founder and CEO Simon Tikhman provide their employees with 10 free sessions with a therapist, a life coach or business coach each year. Tikhman says they extend the service to many of their artists, including those just starting off, because, “If you help yourself now when you are playing in 200-300 person venues, it will give you the tools to help you manage [feelings of] overwhelm when you are in arenas.”

Ariana Grande, who has made millions of dollars of free counseling available to fans through a partnership with app-based therapy company Better Help, called on record labels in February to include therapy coverage in young artists’ contracts. 

At least one major music company explored the cost of providing those services, according to a former executive from the company who spoke on condition of anonymity. That former executive, who advocated that the company offer therapy as a recoupable expense, says internal researchers determined around 2020 that coverage was ultimately too costly. 

While therapy is expensive, the cost of foregoing needed mental health care is enormous, says Dr. Terry Clark, director of The Conservatory at Canada’s Mount Royal University.  

For more than two decades, Clark has studied how mental skills training is used to equip classical musicians and dancers with tools to cope with stage fright and anxiety after failed auditions. Some of the lessons involve setting goals and picturing oneself achieving those goals on stage, like an imaginary rehearsal where the artist can make mistakes and envision how the show could go on.

“Careers can go on a long, long time,” Clark says. “But if you burn yourself out and there isn’t a later, the cost is enormous when you look at what you’ve lost.”

In a recent interview with Rolling Stone, Lorde described successfully treating her paralyzing stage fright with the psychoactive drugs MDMA and psilocybin, a therapy commonly used to treat post-traumatic stress disorder, though that is still awaiting approval for use in the United States.

For others, substance use disorders can be part of their mental health struggles.

Kristin Lee, founder of the Los Angeles-based business management firm KLBM, says her musician clients’ biggest out-of-pocket health care expense is treatment for addiction and substance use disorders.

A number of organizations, including MusiCares, Music’s Mental Health Fund, Sweet Relief and Backline, provide financial assistance to help independent artists pay for mental health care. Lee estimates 35 percent to 40 percent of her clients get subsidized health insurance through SAG-AFTRA, and those who don’t qualify for it often pay $700 to several thousand every month for private insurance for themselves and employees.

“Touring is probably the absolute worst thing to do while you’re trying to be sober. It’s a rigorous way of life with no downtime, and it’s entertainment, so it’s supposed to be fun,” Lee says. She says some of her clients have hired sobriety coaches to go on tour with them at a cost of $70,000 a year.

Sobriety coaches are meant to be a resource a patient needs less over time, and so the cost eventually declines. Regardless, the investment for many is worth it.

“Rehab is expensive, too,” Lee says.