Second Thoughts on Sliding Scale Payment

Charity
While having coffee last week with my friends Christina and Peter, fellow writers from my Thursday afternoon group, we were discussing how a young philanthropist here in Chapel Hill had helped raise funds to rebuild a beauty salon burned during the riots in Ferguson. The young man’s efforts struck me as very personal: he did not donate or solicit money from others for a general fund or cause; instead, he worked on behalf of one particular individual, the salon owner. This prompted me to wonder whether millenials as a whole feel less comfortable than their parents donating to big faceless organizations like the Red Cross and want instead to feel a more immediate connection to the object of their generosity.

A little research the next day confirmed my suspicion. I found several articles discussing a major shift in the patterns of charitable giving, including this one from NRP where a young philanthropist described a pervasive attitude he had encountered among his peers.”They all said, ‘I don’t trust charities. I don’t give. I believe these charities are just these black holes. I don’t even know how much money would actually go to the people who I’m trying to help.'”

In another of these articles, I also read that millenials “value feeling connected to peer and professional networks and they want to be able to share the causes they care about with friends and colleagues.” It’s not just about narcissism, as I suggested to Tovia Smith in her segment on Boston Strong for NPR earlier this year. It’s about putting a face to the recipient of one’s donations of time or money and forging a personal connection, then sharing that connection with others.

In a roundabout way, this train of thought brought me back to the issue of sliding scale payment in psychotherapy. My post on this topic, written more than three years ago, remains one of the most popular on this site. In that post, I set forth my reasons for establishing one consistent fee that I charge to my clients and which I do not negotiate. I still agree with what I wrote, but the post seems incomplete and misleading. In truth, I reduce my fees all the time, but not for people I don’t know or have only just met. In other words, like millenials, I need a personal connection before I will “donate” part of my fee to help another individual.

Sometimes I feel a bit ashamed of this character trait, as if I’m lacking in compassion or humanity. I find it difficult to care about abstract or faceless groups. Discussions of “poverty in Africa” or “multiple sclerosis” do not touch my heart. On the other hand, I suspect I’m not alone in this respect, which is why print ads that solicit charitable donations for, say, children born with birth defects often depict one specific child with a visible and often pitiable deformity. In my more cynical moments, I also think that for many people who ostentatiously care about their causes, such caring mostly embodies a self-statement: I am such a good person because of my feeling heart.

If a stranger contacts me for psychotherapy sessions and asks me to reduce my fee, I still decline, but if one of my on-going clients suffers a financial setback, I do not hesitate to help. A long-term client who lives very close to the margin was recently forced to take a 10% pay-cut and I offered to reduce my fee or even see her for free if necessary. I have come to care about her as I inevitably do for all my clients; for this reason, I could not abandon her just as she faced hard times. She insisted that she should drop out and make way for someone who could pay my full fee, but I would never choose to take on a stranger in lieu of a person I care about, just for the sake of the money.

There are limits. If a client is struggling financially because he or she has major entitlement issues, I probably wouldn’t reduce my fee because I would be indulging that sense of entitlement. If a client has an unconscious rescue fantasy that involves being an infant whom I will rescue, I’d probably interpret the fantasy and keep my fee the same. Understanding all of the psychological implications is a challenge, but the client I mentioned who had to take a pay-cut is a hard-working single mother who has never asked for a handout. She also went through a truly horrendous childhood and has suffered a number of setbacks in her life that make her, at least for me, particularly sympathetic.

At the opposite end of the spectrum, I have therapist-clients in major cities charging much more than I do – sometimes twice as much. Should I charge them more because they can afford more? I feel deeply uncomfortable with that idea and have never raised my fee because a prospective client is wealthy (although I know professionals who do just that). On the other hand, it did not sit well with me that younger therapists would seek my expertise and pay me half of what they charge their own clients. After thinking long and hard about it, I finally decided to raise my fee for new clients just beginning treatment.

By and large, I don’t raise my fees for existing clients. One client who stopped treatment for complicated reasons about a year ago recently resumed treatment. When she reached out to me, I didn’t tell her that my fee for new clients had substantially increased since she stopped coming because I knew she wouldn’t have been able to start up again. I’m charging her what she used to pay even though I could have filled the hour with a higher-paying client. I care about her and have enjoyed our work together, and I don’t mind reducing my fee or taking less from someone who over time has come to matter to me.

But I don’t feel compelled to reduce my fee for strangers when I don’t know them and haven’t had time to develop a personal connection. I don’t believe I have a duty to make financial sacrifices in order to help “humanity” or “people in general.” I need a personal connection before I will give, so I guess you could call me a middle-aged millennial.

P.S. — I finally realized that WordPress deletes comments in my queue if I don’t approve them within a certain number of days. I apologize to those of you whose comments to this post were deleted and I promise to approve them in future in a more timely fashion!

Joe is the author and the owner of AfterPsychotherapy.com, one of the leading online mental health resources on the internet. Be sure to connect with him on Google+ and Linkedin.

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24 comments

    You have to be one of the, if not THE MOST balanced and objective person in your profession. One needs to be careful all the time because there are many people with money who misrepresent things just for their love of the damned dollar and for the sake of paying less than a FAIR cost factor for services provided.

    In my profession, I have noted this as a common reality that like it or not, seems to run in specific “cultural” lines and sub races though stinginess and selfishness does not discriminate in who it infects. Having been in business over 20 years above board and years even before that in a charitable capacity spare time activity, I have learned to sort out the sheep from the goats and target such dishonest, stingy people for de-listing.

    I sell a service with a higher injury and fatality rate than either firefighters or enforcement police workers and while it is true there are what I call “hackers’ in the mix who will do the work cheaper, you get what you pay for. With my zero accident WSIB rate, no claims either for injuries or for commercial liability property damage, with two certified people doing the work, with bonded and criminal free RCMP fingerprint checks and OPP name matches, and a long list of clients who I have had for decades, I offer a professional trouble free, operation.

    I am in full agreement with Dr. B and follow a much similar tact, refusing to accept the plea that the customer has little money when I have to wade through beer cases, old pizza boxes, and can see the satellite dish and big screen system in the living room when I enter residences to collect my fees.

    I had one cheap stingy manipulator try to wheedle me down. He claimed he had a set income and needed a reduction since he was retired. Well he was right. He was retired and living in a million dollar house on expensive exclusive waterfront property.

    I bet that set income equated with several grand a month, but I have no tolerance for stingy people and delisted the miscreant.

    Another time, I had a call on a Saturday from a woman who lived a good hour away, who wanted me to go to her estate for a consultation. She whined when I told her there was a fee for that but claimed my ad said I would do it for free. I corrected her and told her that she was trying to evade the message that said estimates for IDENTIFIED work were free, not consultations that in her case, would take me the better half of a day. When she continued her whining I asked her how I was to survive if everyone who called me wanted a free consultation , to drive an hour each way, and spend another two hours minimum on the estate? I asked her if she had ever worked for nothing? I asked her if the tooth fairy would pay for my gas.

    She abruptly said that “This is not going to work” and I quickly told her, “No it is not because I am not a fool who caters to cheap and stingy people who want something for nothing.” I hung up and never heard from her again.

    The world is composed of two types of people, freeloaders or producers. I have picked enough tics out of my miserable carcass to know I want no attachments from the subhuman ones.

    Hang tough Dr, life is exciting.

    I don’t mind if people ask for a fee reduction; it’s only natural to want the best deal you can get. It’s the sense of entitlement (as demonstrated by the woman who wanted your consultation services for free) that bothers me.

    No, you are not alone as I feel the same way and I’m not a millennial either. I need a more personal connection as well regardless if whether someone agrees, disagrees or even understands. It’s been a guiding principle in my life, despite the fact that I’ve endured a lot of criticism by people who want something from me or they want me to align myself with their cause and serve as their echo chamber. It is why I chose the course I did in college (environmental studies) and even joined Greenpeace–I had a specific, concrete purpose which gave my life meaning and that is something few people know about me, but then they are not interested in that about me either as they want to talk about themselves (they only cared about my age, reproductive status and sexual orientation).

    I often feel as cynical as you do and it is a topic of conversation that I limit to one good friend who I feel that I can be honest with–we both tend to feel that peoples motives are not as altruistic as some would like to claim.

    I’ve actually experienced a lot of criticism by some people because my focus was on animal work and not people. I’d often hear the following, “People are more important than animals,” and it struck me as an offensive judgement. I recall meeting a single woman who told me the same and she worked at an animal shelter. It strikes me as odd why someone would feel compelled to volunteer to work at an animal shelter and then make those kinds of comments. Why not just volunteer to work with people and not animals. (Problem solved.)

    I’m not happy blindly giving to others and I seldom do as it doesn’t make me happy in the least. Trying to guilt people into giving is not a prescription for happiness either. It may work when someone is promoting their cause to use that kind of pressure tactic, but I feel that it is manipulative and that eventually backfires. I also feel anger and hostility towards people being intrusive and backing me into a corner about how I give–how much, etc., and especially being judgmental. It also doesn’t heal depression when you’re directed to “give until it hurts” or to “take care of” and “do” for other people to take the focus off of oneself as that is merely keeping busy to distract one. (That is another subject). Likewise, I’ve met far too many people who have a “USE” for me and want me to accommodate them as their own personal Mother Teresa.

    Within the past year I’ve read several articles about the subject of giving which started with stating, “Be happier and spend more money on others” which cited recent research. I disregard such articles as I’ve found that for me that philosophy doesn’t ring true. Then I found another article which also cited research which discussed that giving to others does not automatically increase happiness and it focused on relatedness, competence and autonomy–the relatedness part of what you describe as more personal. BINGO! I’ve always needed a greater, more personal connection, but there is more to it as well. I also need to see how my GENEROUS actions have made a difference. I don’t under-estimate the importance of autonomy either which is satisfied when I feel that my actions are freely chosen.

    I know a woman who runs a program here in Chapel Hill in conjunction with the local social services department. Every year, they ask for all the children in foster homes to provide a wish-list for Christmas, then they ask benefactors within the community to buy the gifts on that list. The gifts are then wrapped and given anonymously. As a donor, you never know the name of the child nor does the child know who actually provided the gifts. I understand that they want to eliminate any sense of indebtedness, but it has always struck me as highly idealistic: you’re supposed to want to give but to get nothing in return, no experience of gratitude and no pleasure of seeing how happy you made that child. Is there something wrong with enjoying those things?

    It’s not just young people who are suspicious of charities – I think people of all ages are now. In this country in the past year or so there have been several scandals relating to charities – directors paying themselves large salaries, running up huge expenses on hotels, trips abroad etc Some of these organisations are paid large sums of tax payers money with little or no accountability. Donations went down hugely – I don’t know if that has changed

    I have mixed feelings about charities. I used to work for homeless/ mental health charities and in a way I wasn’t surprised to hear about the mis-appropriation of funds as all of the charities I worked for were run by people with high levels of narcissism. Some of leaders were incredibly entitled and deep down I don’t think they really cared for their clients. However the ‘ordinary’ staff in those charities were usually badly paid and had to put up with abuse from clients and managers – I guess the payoff was lots of gratitude from clients. Some of the managers were badly paid too. Some staff and managers worked incredibly hard and were utterly dedicated to the clients – overly dedicated in some cases.

    I don’t think I could go back to that sort of work because of the sort of people it attracts – bullying was rampant. I used to move from job to job frequently because it was easy to get work – I kept hoping to find somewhere that was run by a good manager or management committee. I never found one because I don’t think they exist.

    My experience (of one job in the charitable sector – in a London (UK) nursery was very similar to what you describe (Fiona). Bullying managers. Miserable workers.Neglected children. Unfortunately I have found this across the board in education – state, private and charitable. My own view is that where there are vulnerable people there are narcissists and where there are those who care for the vulnerable there are the takers who abuse the caring disposition of their employees (not to mention the clients – the even more vulnerable, such as nursery-aged children or the mentally unwell). All in all these types of workplaces are a parasite’s paradise! But what can be done to change this deeply unsettlling state of affairs?

    After seeing my therapist Dr. Puchbauer for two years, she made a mistake that caused my insurance to be unable to pay her. I asked if going forward I could continue to pay her the same rate she had been getting from my insurance ($87.50) but she refused, saying that I was too much work and her full fee was $120 and I’d have to pay that or find a therapist who could take my insurance. This cut me deeply bc it was a red flag that she cared nothing for me, and it was discussed for months afterwards with her being incredibly defensive, culminating in her telling me that I am not special, I am just another client, one of many, that she only sees me twice a week and that’s it, that she can’t care about me the way I want her to. I still see her bc in out first year together she did some I’ll advised reparenting/holding therapy and I developed an attachment to her that I can’t seem to break. But it’s very difficult having a therapist I know cares so little about me that she would purposefully create a situation where it would be impossible for me to keep seeing her, and then shrug and tell me she can’t lower her fee bc I’m not special I’m just another client. So I see her now every Monday and Wednesday, and we don’t fight about this anymore, but I sit before her knowing that I don’t matter to her; her heart isn’t true, bc she used to tell me she loved me, but when it got rough, she tried to dump me without a backwards glance. How can a person change so much?

    I guess I expected her to WANT to help me stay, but what she wanted was for me to go and I couldn’t reconcile in my mind the fact that she didn’t care about me.

    Hi Dr Joe, Our fee policies have more overlap than I’d realized, tho I’m onea’the therapists who set fee in relation to what the client & I agree they can pay. First session is a fixed [mostly] fee somewhat higher than what I tell clients second session – that “most folks pay between X and Y, some pay a lot more and if you’re a starving grad student w/ 4 kids and we fit together well I set a very low or no fee”. Usually we’re both comfortable with the fee they propose, and if not, we bargain and negotiate – which gives clients first hand up-time experience with realistic management of differences in important relationships, and gives me valuable information about their Way in the world.
    Recently a Much over-burdened returning client wanted to pay half-fee, and I suggested 3/4. The former client may have merited 1/2 fee, and knowing how money is used in that family, I hoped paying more for their own treatment would be a strong step toward valuing themself appropriately in that family. The client quit contact and wouldn’t negotiate further despite my offer. In the everyday world things don’t always go the way I’d prefer – Darn! Dr Bob

    Thanks, Bob. I’ve never been comfortable with negotiating the fee upfront, before I come to know someone. How do you know what they can really afford? How do you know what the dependency/transference issues might be before you even start?

    Depending on who is describing generations, I am sometimes a millennial and sometimes a Gen-Xer based on my birth year. Interestingly I have traits of both. When it comes to giving charitably, I donate all the time to regular, big box type charity organizations. It is something that is very natural to me. I have on-going donations that come out of my checking account every month that I don’t even have to think about. These are planned for and budgeted on all on an excel spreadsheet. But when I have the occasion to give to someone I know, there is a greater sense of warmth. For example, recently my family was able to help out a family that just moved here to Southern California from Maine. They came with very little. We knew them through friends of friends, but hadn’t met most of the family until they arrived. We furnished a place for them, got groceries, helped them get their kids to school and enrolled in school etc. All of this took a lot of time and some finances of course. I find that I will easily give money to something but when it comes to my time, then I am more likely to “donate” to someone that I have a personal connection with, be it a similar cause, or something like this family. When it comes to therapy, there have been a few times where I have had to cancel without being able to give the 24 hour notice. Once was when my Dad had cancer and the hospital called and needed us there ASAP because initially it was thought he had one type of cancer which required one type of treatment and it turned out he had a completely other kind of cancer. I was supposed to see my therapist that morning and so I stopped in, only to give her the payment for the missed appointment, but she wouldn’t accept the payment. It did make me feel really bad because she wasn’t being compensated for her time. There was one other instance but I don’t remember the situation now. She is also very good at discounting her fee if I need to see her for a second time during the week for any reason which very rarely happens. It is helpful because I pay cash out of pocket, not through my insurance, and even though I’ve been with her 6.5 years, she hasn’t raised her rate. Also helpful because four or five years ago my company downsized and I took a huge pay cut (but kept a job) and am barely getting back to where I was five years ago. But that wasn’t her problem. She certainly could have raised the rate, but she didn’t. It’s rather baffling. I suppose at times it is easier to give then to receive kindness. However, my Mom has this great saying on her wall in her kitchen which says, “Do the kindest thing in the kindest way.” I just think that is a great motto. By the way, I like your site, Dr. Burgo, particularly I seek it out when my therapist is on vacation (like now). I did try to respond to this post once before but I don’t know what happened to my comment.

    When a severe depression left me unable to work full time, my psychiatrist of nine years – whom I also see for therapy substantially reduced her fee (to an absurdly low amount) so I could manage to see her twice a week. I still was unable to pay her regularly so she carried the bill. Previously I had always paid in full and on time. Now that I am back to work full time, she has raised her fee (still relatively low), I am seeing her once a week. I pay the monthly bill in full, plus give her a little most every week to decrease my balance. If there is a week I can’t give her a check, she never says a word. I believe she trusts that I will pay her when I can and I will pay her the remainder of the balance. Knowing that I was able to continue with her through this depressive episode that lasted a good part of this year (and required two inpatient admissions) and simply knowing that she trusts me has helped strengthen the therapeutic alliance.

    This brings up an issue that goes off on a bit of a tangent. In private practice, it is customary that when a client misses an appointment, he or she still pays the therapist. If I cancel my appointment with my psychiatrist, I still must pay her the full amount. I am an LCSW-R who works in a large mental health clinic where the majority of clients are on either Medicaid, managed Medicaid or Medicare. Numerous appointments are broken (no call, no show) or cancelled each day and the clients don’t have to pay anything. This really hurts the therapists that are paid per diem, or per appointment. I am asking people’s opinion on this issue. Clients receive Medicaid because of their difficult financial situation. Would it be too much to ask of them to pay a small token fee – even $2 or $3 – if they break or cancel an appointment, just so they become aware that this is an action not without consequences?

    I don’t think this will get approved, but so many of your replies make you look arrogant. It’s as if YOU feel entitled and you come off looking like you think you are better than your patients. Even your latest comment that recipients of free health care don’t fully value it. That could be true for some, but not all. Do you sit on a throne in your office?

    I’m a UK resident who gets ‘free’ healthcare via the NHS: all residents contribute via National Insurance, which is a tax levied on salaries and income. One the whole, most respect it and don’t take it for granted, although there are a group that do.

    There is a problem with cancelled and missed doctor’s (GPs) appointments in the UK. A politician suggests a cancellation fee be charged for no-shows, and there’s furore about it, largely because it’s felt GPs should be ‘free to care, not check you can pay before they care’. More pragmatically, it’s said it would be very difficult to collect the money, which might be true for the larger hospital outpatients/A&E than it is small local doctor’s practices (GP surgeries) which are effectively small businesses.

    If charging here we would likely see more visits to A&E (which is already overwhelmed) and clients already in a muddle financially would be in more debt. Or there’s a fear that by no-showing you would miss folk who ‘could last out another week and avoid $5’. (Ireland primary care charges for doctor’s appointments – see what they see.)

    Or do you target serial offenders? One way (perversely) might be to pay your serial offender clients on completion of attending a block of sessions. While it seems to be a reward for bad behaviour, the outcome might justify the means… Compliance is cheaper for the clinic and society. There is plenty of evidence for this in UK juvenile offender units: wayward kids (who often struggle with mental health issues, low educational attainment and a disordered upbringing) are rewarded for attendance or good behaviour with tangible goods or small funds of money. It seems to work.

    Not all social groups are motivated by long-term gains and rewards, but the use of shorter-term tangible rewards is worth investigating, especially with folk whose life skills set doesn’t include the delayed gratification of e.g., education, career, thinking ahead to next month…next week, even.

    Reading your article, I realize that I am conflicted with regard to offering clients a sliding scale. Yes, I offer existing clients reduced fees, if they experience a loss of income. I both volunteer the reduction and also sometimes await their request for a reduced fee as an expression of their agency. I suspect I should be more consistent in this regard.
    With regard to new clients, I will offer a sliding scale, if I have time available on my schedule.
    Typically once the fee is set, that’s it, unless when at the beginning of our working together a sliding scale was offered with the understanding the rate would increase when the client’s finances improved.
    Your post causes me to inquire more closely into this aspect of my practice. Thanks.

    Joseph – Thank you for taking the time to examine these issues in your blog. I would enjoy engaging you more regarding this topic. I want to offer another angle from which to approach this question.

    I believe that there should be more vocal conversation on harmful/exploitative/unethical therapy and how to protect clients from abuse in the therapy context, as well as how to empower clients who have been harmed or exploited by therapists acting unethically. I think this is a widespread enough issue that the profession as a whole has responsibility to work towards addressing it. One way to offer more protections to clients in these kinds of therapy situations is to give them greater power to seek out consultations and insights from those who are not directly involved in the harmful therapy dynamic. For clients with higher incomes, this is much easier, as they can afford to call around and meet with people to find someone 1) qualified 2) comfortable working with a client in this situation 3) who the client can connect with. On a low or low-middle income, seeking outside consultation after or during another therapy relationship can be a huge burden. I think that clients would be more protected if they have more power of choice in terms of who they see for professional mental health care and if they are more empowered to seek out support if they suspect that something is not going right with their therapy. By offering a sliding scale rate to new clients, or by offering a free initial session (for which the client would be charged if he/she decided to meet with the therapist a second time), therapists can contribute to giving vulnerable clients more choice and support, and thus safety. I can see how this would be more of a burden for those therapists trying to make ends meet or those therapists who want to know where their charitable money is going, but I think there could be greater benefit in the protections offered to a very under-heard, very under-supported, and very real population of people impacted by therapist boundary violations.

    I think a free initial consultation sounds like a good idea. One problem here is that our professional ethics require that we not consult with clients who are already in therapy with someone else without that therapist being informed.

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