Due to the number of requests I’ve received for psychotherapy via telephone or Skype, I’ve begun to reconsider my decision not to engage in those practices. I haven’t made up my mind, but the question has raised the issue of fee setting and how to handle it should I take on new clients. I think there’s a lot of confused emotion about payment for psychotherapy services rendered, on the part of both therapists and clients. I’d like to give my view on the subject; my policy is not the standard, nor is it particularly popular, but it’s the only one I have found that works for me as a practitioner engaged in emotionally difficult and highly demanding work.
Let’s begin with some questions: If your car broke down and you needed it for your commute but couldn’t afford the repair, would you ask your mechanic to cut his charges? Would you ask your dentist to reduce her fees if you needed a bridge and paying for it would present a financial hardship? How about your accountant? Would you ask him or her to work for less than the standard fee because paying full price would wipe out your meager savings? I suspect the answer to all these questions is ‘no’. Even if you did ask, you’d likely be told something like, “My fees are in line with the profession,” or “I charge what I need to charge in order to cover my own costs.” These seem like perfectly reasonable positions; why then do we expect therapists to work on a sliding scale?
Let me give you just one example of a problematic situation I actually encountered, one of many similar examples I could provide. One of my clients, paying less than my full fee, announced his plans to go on a trip to Europe that summer. These are the questions that immediately arose for me: If he could afford a trip to Europe, why couldn’t he afford my full fee? Was it my responsibility to keep my fee low so that he could afford such a trip? Had he been entirely straightforward when discussing his financial situation when he began treatment and we first set the fee? If his finances had improved since then, should he have told me so and offered to pay my full fee?
I believe most therapists who work on a sliding scale have encountered nearly identical situations. Many of them might even have felt resentful about it. The sliding scale is a major problem for the professional who depends upon the income from his or her practice to survive; particularly for the clinician practicing psychodynamic therapy, it introduces all sorts of conflicts and confusion into the treatment and distorts the transference. After struggling with this issue, I finally came to the conclusion that my fee should be my fee and remain the same for all clients. My reasons are two-fold: first, if you maintain your professional boundaries as a therapist, then your own emotional needs and issues don’t enter into the treatment. While you derive meaning and satisfaction from your work, therapy is entirely about the client’s emotional needs, not your own. You do have personal financial needs, however, and those are met by the client paying your fee. In other words, the actual therapy is about the client’s needs, the fee is about your own. If you’re working for less than your usual fee, do you give less to your client? Of course not. Why should the client’s needs be met but not your own?
Second, while clients often become emotionally dependent in psychodynamic therapy and develop a parent-child transference, you are not, in fact, their parent and it is not your job to look after their financial needs Your job is to give them the best treatment you can. Many clients and therapists are confused about this issue. Quite a few of us entered the profession because of an unconscious wish to cure a parent or in order to feel needed (rather than being needy ourselves); these factors might distort how we set our fees so they need to be understood and sorted out. The truth is, I need to earn money to support myself and my family; being appreciated for the work I do and feeling good about myself as a therapist are all well and good but they don’t pay the mortgage. My expenses won’t go down just because half the clients in my practice are paying reduced fees.
Because our profession is over-crowded, the issue becomes more complicated. When I used to practice in California, where the barriers to entering the field were fairly low, there was a large number of marriage and family therapists (with Master’s degrees) competing for clients, along with the clinical psychologists and psychiatrists. Many of these therapists were “hobbyists”, as we used to call them — largely women whose children had left home and whose husbands had lucrative professions. They went back to school in midlife to develop a career but earning money wasn’t much of an issue; they had small part-time practices and charged very low fees. For those of us who depended upon our practices to earn a living, they posed a problem. A potential referral might comparison shop and find a therapist willing to work for a substantially reduced fee; you might have to cut your fee in order to compete. That’s how the law of supply-and-demand works: too many therapists, even if minimally qualified, competing for a finite number of clients. Once you’re well-established with a professional reputation, you don’t necessarily compete with those same therapists. In the beginning, I had to reduce my fee like everyone else; later, I decided what my fee should be and I charged everyone the same.
What if an hour comes open in my practice and I have two prospective clients, one who can pay my full fee, and another who asks me to reduce it? Would you fault me for taking on the full-fee client and referring the other person to my local counseling center, where interns work on a sliding scale? I think I’m worth my fee; I work hard and earn every penny. I’ve had clients who feel I’ve saved their lives and offered to pay me more than my usual fee. I’ve declined, of course. My fee is my fee and I deserve neither more nor less.
Finding Your Own Way:
I suspect some of you may have strong feelings about what I’ve written. I invite you to consider what I’ve said about the fee and let me know whether you agree or disagree, and why. Maybe you feel that therapists have “so much” and the troubled client deserves a fee reduction in order to get what he or she desperately needs.
If you’re a therapist, I’d love to hear about your experience with the sliding scale, especially if you’ve had a conflict such as mine, where you began to suspect a client could pay much more than he or she originally represented. How did you feel? How did you handle the situation? Have you ever had clients who lied to you about their financial situations in order to pay less than they actually could? What did you do?