The Question of Sliding Scale Payment in Psychodynamic Therapy

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?

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.

Latest posts by Joseph Burgo (see all)

This entry was posted in Points of Departure, The Psychotherapy Relationship. Bookmark the permalink.

197 Responses to The Question of Sliding Scale Payment in Psychodynamic Therapy

  1. L says:

    At the current agency we have a sliding scale but we start at a certain amount and go up from there. The starting point is pretty high so I don’t mind working on the sliding scale because of that. We are also only supposed to have 10% of our case load as low-fee clients who fall below our sliding scale, and again, that is up to you if you take low-fee or not.

    However, I used to work at an agency where the sliding scale started at $0 and went up from there. As a new therapist at that agency, they only referred very low-fee clients to me. Needless to say, I left to join another agency.

  2. hari says:

    i think bartering goes on alot in different trades, offers are made for work to be done just like tendering for a job, and i think thats fine to ask for a “deal” if im honest,

    there are accountants who work at all different price ranges in the business, aswell as lots of other trades,

    but i get your point about the client going on a european trip! wow, how cheeky,

    i have sacrificed alot for my therapy and i have foregone alot to pay for it, cos it comes asone of my top priorities in my life,

    its totally up to you how you set your fees, i would personally do so much percentage of my sessions as lower fee sessions, whatever i could afford to do, or chose to do and view it as giving to charity,

    but i totally get that my own therapist has several kids and has to pay the mortgage and if i miss a session with less than 3 days notice(rarely) i dont begrudge her being paid for the missed session as she still has to pay her mortgage!

    i suppose this profession is seen in general by alot of people much more as a vocation like nursing or doctor etc than an academic profession such as lawyer, accountant etc, but then again even our accountant at the charity i work for, does do work for us for free when we cant afford it,

    i have seen lots of real poor cases of people that deffo arent going to be going on any luxury holidays anytime soon, they cant even afford to buy a new settee when theres has broken, or definitely not afford a car, or clothes from anywhere but charity shops and im really glad that there are low cost counselling centres out there that can help people like this that genuinely want to work on their emotional health but are in such dire situations financially

    cos our society does need emotional health help, and alot of people in real poverty have tremendous mental health issues,

    but its up to each person as to decide if and how they want to help in that area,

    i dont think my counsellor does a sliding scale, but she does do supervision free for a low cost counselling centre

    to conclude i dont think its wrong for someone who is genuine dire circumstances financially, to ask for a “deal” on their session price, they deserve emotional help just as much as someone with the cash to pay for it, but whether they get a deal or not is totally the choice of the therapist.

    if you dont ask you dont get!

    • Joseph Burgo, Ph.D. says:

      That seems reasonable. I’ve done a lot of pro bono supervision over the years and taught classes for free, not to mention all those years I worked getting hours for my license when I worked for as little as $1 per session (of which I received 30% or 30 cents). I feel as if I’ve given back quite a lot already but I respect those who feel they need to continue do a percentage of their work on a reduced-fee basis.

      • S says:

        First off; it is a free market and you are free to charge whatever you want. You don’t even need to go out of your way to justify it as you have in this post–if you have people willing to pay your fee, then your fine. I agree with your right to charge whatever you want.

        It is however anyone’s right to negotiate a fee based on whatever reason they choose. It may be to stretch their dollars further, it may be real financial hardship, it may be that they don’t think you are really worth the full fee. But it does not matter. It is their right to ask or negotiate for whatever reason they have. You are the one with the choice as to whether or not you take them on as patient.

        Economics tells us that value=benefits – cost. That value is determined by the folks willing to pay for your value, real or perceived. And if they want a lower rate, maybe they see the value as lower than you believe it is. It is absolutely their right to negotiate that fee and if you accept a lower fee, and then gripe about how they spend the rest of their money then you are the one with a problem.

        Now enough with the, “we work so hard” routine. Being a psychotherapist is no harder than most any other profession. In fact There are few professions where there is less accountability for outcomes, success, progress, or results than a psychotherapist in private practice. You are required to be present. Listening and making observations about the problems of others is hardly a day of hard work. Unless it’s hard for you to stay awake.

        So charge whatever you want–it is your right. And if you take a discounted fee, do so and recognize it was your choice to do so.

        Hope you have the courage to post a dissenting opinion.

        S

        • Joseph Burgo, Ph.D. says:

          I do, and I agree with much of what you say. I agree that everyone has the right to negotiate a fee if they can and that we therapists have the right to determine what we’re willing to work for. I believe in free market economics. However, you can pay a beginning therapist with many open hours $25 per session and that doesn’t mean you’re getting the same thing as you would if you were to pay more to an experienced therapist with a waiting list. Of course, paying more is no guarantee of quality, but one of the advantages of having worked for a long time and gained a lot of experience is that you have something that sets you apart from many other, newer therapists with whom you’re “competing”.

        • C says:

          I agree with “S” here as your post does seem a bit disconcerting for a licensed practitioner. It is a free market, YOU are allowed to set your fee at whatever YOU decide is fair. There’s really only one way to say that but you’ve really taken the time to try and justify it. Honestly, it’s a little embarrassing and comes off a bit trite. The world is chalk full of professions in which the services are negotiated on the daily. So, as “S” put so well, “charge whatever you want–it is your right. And if you take a discounted fee, do so and recognize it was your choice to do so.”

          -C

  3. Steph says:

    I’m ignorant on this subject – my questions will reflect this. Why *do* we expect therapists to work on a sliding scale? Is there a historical reason for this? I’m in the UK where physical healthcare is free, so I really don’t understand the reasoning. I choose my dentist according to their fees, their reputation etc. I’m not offered a sliding scale there, so I agree, why would I expect one elsewhere? And as a client, it seems wrong to be bartering with a potential therapist at the outset. I agree with setting a fixed fee, particularly for individual practices. For group practices, it seems sensible that different therapists charge different rates, but even those rates should be fixed for the therapist. I don’t ‘get’ the ideology behind the sliding scale. Regarding telephone or skype therapy, doesn’t the technology interfere with the process (eye contact, delays on skype etc) making it more difficult? Therefore perhaps therapy by skype should be more expensive because it requires an extra set of skills?!

    • Joseph Burgo, Ph.D. says:

      I think it’s very different when healthcare is simply covered; I assume National Health sets a range of reasonable fees for therapists and a professional can charge accordingly. As for the effects of Skype, I can’t yet tell you as I haven’t done it yet. I have a couple of long-term patients who no longer liver near me; after years of working in the same room, we moved to phone sessions and after a brief period of adjustment, I find it no different. These are people I already knew quite well before I began working by phone, however; what I need to find out is whether I will eventually come to feel as if I know new clients just as well via Skype.

      • Steph says:

        The NHS doesn’t set fee levels (this page partly explains: http://www.itsgoodtotalk.org.uk/what-is-therapy/cost ) and therapy here is not as widely used/accepted as I think it is in the US. I do wonder why the sliding scale exists for this profession, if not others. I mean, would anyone feel happier bartering for open-heart surgery? The bartering element mystifies me (and I don’t like bartering).

  4. Dee says:

    I have a friend who was raised to believe her family was upper crust. They did their best to portray it. She used to talk about how broke she was, although she opted to leave the workforce for a few years. She was the same person who used to disdain “pot luck” type get togethers. She didn’t want to to out for dinner unless it was steak and martinis!! Ethnic food wasn’t chic enough I guess. She drives a leased BMW, keeps relationships with the few people of means she knows who supply her with dinner, vacations, porcelein veneers. She also used hospice counseling, until, I guess they finally thought the free counseling should come to a close. Charge everyone the same. Sorry to sound so brutal, but people are wierd and wierd when it comes to money. Your time is worth money regardless of who the client is.

    • Joseph Burgo, Ph.D. says:

      I don’t think it sounds brutal; what’s interesting to me is our expectations of therapists, as if they’re not supposed to have the same needs as everyone else, or that they’re supposed to be more “altruistic” and self-sacrificing, putting the needs of their clients ahead of their own.

  5. Lifelong says:

    During my years in therapy my therapist’s agency worked on a sliding scale. I chose to pay the mid-point of that scale but being brutally honest, I could have paid more. Looking back, I was really quite angry that I had a need to spend my hard earned money on therapy, however that of course was not my therapists fault.

    Whilst it would be ‘nice’ to offer reduced rates to those who really could not afford it, I am in two minds about this also. For example, many people who can supposedly not afford it spend the amount of a fee, and more on cigarettes and alcohol each week. I guess it is all about choices.

    I think one fee, although on the one hand seems harsh, is as you say a charge for a professional service. We don’t expect our plumber, electrician, mechanic or doctor to reduce their fee because we can’t afford it – we have to pay the going rate.

    What I gained from my therapy I would have paid ten times the amount for if I was able to. The benefits are so huge and on going that even now, 5 years after finishing therapy, I continue to realise these benefits with new life situations I am faced with.

    My therapist did a wonderful job, and continues to support me by email, also welcoming calls to update where I am at. That commitment is lifelong too and I continue to find that simply astonishing – it is far more than just a job.

    • Joseph Burgo, Ph.D. says:

      And I’ll bet your therapist doesn’t charge you for those emails or phone calls, and yet this is time he or she takes out of a busy schedule to give to you. In my experience, many clients feel very angry about having to pay for their therapy, and it is an important issue to take up during treatment. It can express a number of feelings, among them: the wish to be taken care of, a feeling of entitlement, envy of the therapist, etc. If you think back on it, your decision to pay the mid-point of the sliding scale “cheated” your therapist out of money he or she might have earned. It’s a central problem with the sliding scale — everyone wants to pay as little as possible and people are rarely honest about just how much they actually can afford to pay. Once they have misrepresented their finances, it introduces an element of dishonesty into the treatment; after that, they may feel reluctant to mention certain expenditures or they may conceal details that might give the therapist cause to believe the client could pay more.

  6. Barry Grenon says:

    Sorry for using this forum in this way — not actually a comment, but a request. If you do decide to accept new clients for telephone therapy, I would be happy to be a guinea pig, whatever your rate is. I have been following your blog for a couple months now, and it is great. I have never had any therapy (well, one session during a thesis crunch in grad school), and am not really in acute need of it at the moment, but have long felt it would be of benefit — only not just any therapy, and not just any therapist. I live in a small city in Maritime Canada, so options are limited. Anyway, if you’re game, I’m game. Apologies again for using the comments section in this way, but could not find a straight email address anyway.

    • Joseph Burgo, Ph.D. says:

      If you ever want to contact me directly, the email address is AfterPsy@gmail.com. I probably should make that clearer on the homepage.

      I’ll let you know what I decide. In any event, it won’t be until September because the Internet connection here in Colorado is too weak for Skype to function well enough.

  7. Kaiti says:

    I see what you are saying, however, I wouldn’t compare being a therapist to being an accountant or a mechanic. I would compare it to being a doctor. One takes care of mental health, while the other physical health. And I believe everyone deserves access to good quality healthcare. So in this instance, I believe in means-tested fees, though they wouldn’t be the norm for me when I start working as a therapist. I have been in therapy, and I am currently a student of psychology, so perhaps my views are simplistic. Whilst I am still tweaking my position on this, my overall feeling is that I would have a base rate, and in some instances, I think I would make exceptions.

  8. Evan says:

    We have differing expectations of therapists to mechanics. And I think we should.

    If therapists want the kudos of being ‘professionals’ then they accept the obligations too. (Personally I think professionalism is pathological.)

    Why should therapists have a sliding scale? Because people are entitled to a healthy life. I think basic needs should be available to all. Things like health, housing and education. Wealthy therapists aren’t the only ones entitled to have their needs met.

    I think your problem is how to make the scale slide. I understand this. When I was a student of acupuncture I offered sessions for $10. The only people who took up the offer were those who had mortgages (and there were lots poorer people in my neighbourhood) so I stopped doing it.

    The question seems to be how we get people to pay the appropriate fee. This may mean that if it is impossible to do this and that rich people just use it to rip off people that it may not be viable. It is in some ways an honour system – and if there are enough people without honour then it won’t work.

  9. lee says:

    THE REALLY IMPORTANT VARIABLE IS THAT PEOPLE WHO CAN’T OR THINK THEY CANNOT AFFORD THERAPY FREQUENTLY UNDERESTIMATE THE IMPACT IT CAN MAKE ON THEIR LIVES SO THEY DO NOT DO IT. CONVERSELY BAD THERAPISTS MAKE YOU VERY SORRY YOU TRIED AND JUST WASTED THE MONEY. I HAVE HAD BOTH EXPERIENCES REDUCED FEES AND FULL FEE TERRIBLE RESULT. REDUCED FEES GET PEOPLE TO GO THAT OTHERWISE WOULD NOT, BUT, I THINK THIS IS THE PLACE FOR COMMUNITY
    SUPPORTED CENTERS SO IT IS PEOPLE, WHO WANT OTHERS TO HAVE ACESS WHO ARE PAYING THE TAB AND NOT THE THERAPIST. I NOW DONATE AND SUPPORT SUCH A PLACE BECAUSE IT IS IMPORTANT.

  10. Renee Segal says:

    I appreciate you taking on this topic. You are correct other professions don’t ever adjust their fees, except perhaps real estate. Your comment about the market demands are important. Since other therapists charge a reduced fee the potential for losing clients is possible. I came from an agency that did a sliding scale. I have done a bottom limit on what I will charge, if the client can’t pay it then I refer to an agency. This has worked for me so far but after reading your comments I am going to re-think this. Thank you!
    Renee

    • Joseph Burgo, Ph.D. says:

      Renee, what I have done in the past is to offer a time-limited fee reduction in order to help someone get started in treatment. It will be clear from the outset that my fee will rise to its usual amount at the end of, say, six months. During that period, clients can decide whether or not the treatment they’re receiving is worth the fee I’m charging. This way, you don’t actually have to take anything on faith — you can see for yourself. I’d probably do the same thing again with new clients.

  11. vavavoom says:

    I am not a therapist but I am a financially challenged client.

    I think it is really important that fees are the fees especially in this sort of relationship. To bend the structure to me seems to bend the relationship.

    My financial situation is stretched because of my illness but I have cut out a lot of things with not much left over and kept my therapy in place because my health and happiness is that important to me.

    I also have been the beneficiary of pro-bono work via a well-known crisis line. It has made a huge difference in my life and I am deeply grateful for the professional support when I needed it the most. But that I think is a different situation where compassion takes over from commercial reality.

    That is just my experience for what it is worth.

    • Joseph Burgo, Ph.D. says:

      I agree that changing your fee for a client has a big impact on the relationship and distorts it in all sorts of ways.

  12. Penny says:

    Couple of thoughts. 1. As a licensed Marriage and Family Therapist I was not thrilled with your implication that a clinician with a Master’s degree should somehow be looked upon as “less” . A PhD does not necessarily make one a “better” therapist. I am actually enrolled in a PhD program myself , for my own personal growth , but it is not necessary for licensure and will not result in much of a change in my fees. 2. The current economic situation must be considered. I would rather have a solid client who is paying a reduced rate than no client . 3. There are many more clients who use their health care insurance now than ever before. Due to the ridiculously low reimbursement rates to therapists, and the paperwork jungle , many of us refuse to accept insurance and negotiate a lower fee instead. We still end up collecting more than the insurance would have paid in many cases, and get paid on the spot. 4. It is a complicated time in our culture for sure! In days gone by professionals would have never dreamed of some of the things that are happening in today’s world, such as marketing their services as doctors, lawyers or psychotherapists. That was considered “gauche” and we professionals were seen as somehow above that fray . Now the Internet and print publications are full of blogs, ads and photos of doctors, therapists , lawyers etc. People have become more educated about negotiating rates. I don’t necessarily LIKE all these sea changes, but have decided , as many lawyers have done, to have a certain percentage of clients in my practice who are probono, and a certain percentage who are paying a lower than normal fee. It does not interfere with the transference as it was a choice agreed upon by both parties. I have in fact had clients who voluntarily raised their payments when their income improved. Having said all this, I do truly appreciate your position . Most of my psychotherapist colleagues have always offered sliding scales , many do not take insurance, whether they have a Master’s or PhD. In order to stay competitive in the large city in which we work , especially in this difficult economic environment , this continues to be our solution.

    • Joseph Burgo, Ph.D. says:

      Penny, when I wrote that post I was concerned that some therapists with M.A.s might take offense. This has been my experience, and of course it doesn’t apply to anyone: the requirements for a Master’s Degree in California that will qualify you to sit for the MFT license specify so much coursework about family systems and communication theory that few candidates take coursework in psychopathology, depth psychology, psychodynamic therapy, etc. And yet, once they become licensed as “Marriage and Family Therapists”, the bulk of their practices does not consist of working with couples and families. They work with individuals and, in my view, are minimally qualified to do such work. Unlike you, many of them don’t get the additional training.

      Because I no longer accept insurance, my fee is about half of what it would otherwise be, and about half of what someone with my qualifications and experience would normally charge. The paperwork bureaucracy is intolerable to me, and that’s the price I am willing to pay in order to avoid it. Besides, insurance companies have become so restrictive, continually reducing the level of benefits, that it’s not such a big loss for the client anyway.

  13. M. says:

    I just read a article about getting what you want and they recommended tips for how to ask for discounts. One of the therapists I have seen allowed/offered sliding scale for a percentage of their clients and then if it filled up they wouldn’t take anymore.

    I guess the question isn’t about what others think about it, but more about what you think about it. I have to admit this, but I found it more pleasant to deal with te ones that weren’t bitter about returning your email or call. I preferred relating with them. Some people do it for money, and others have possibly a deeper passion for it that possibly they aren’t attached to the payment. Also they may not be suffering from finacial lack themselves but coming from a place of abundance. When we are abundant, we worry less about what we are recieving and want to reach out to help. Ive also worked with another therapist who comunicated to me that returning calls took up their time. (My thoughts were, thats part of the business, if you don’t like it, you can always higher a secretary.) I do know there are some clients that request more attention than others so, I can see things both ways. It also has to do with what space that the therapist is coming from, what they feel entitled to recieve… ect… Ive seen it all ways. Since each therapist is different and offers something unique, and each clients needs are unique, there is always the possibility that what you offer may be what they need but they might not be able to afford it. It’s really up to how YOU feel about it, no one else. I have someone that I work with that has a more abundant mindset and they are just glad to help. It’s not possible for everyone to come from that space, as we all are in different spaces in life.

    • Joseph Burgo, Ph.D. says:

      There are some assumptions in here that I disagree with. During my career, I’ve had many therapists as clients; I’ve also supervised them, and coming from a place of “abundance” was never the reason why they reduced their fee for their own clients. Some of the actual reasons were: guilt about charging fees, as if they owed it to their clients to give them what they needed (with some unconscious childhood determinants); a wish to have no needs themselves, where being a therapist was something like being a saint; projecting an unconscious desire to be taken care of into their clients, and then gratifying it, etc.

      There’s also a subtle moralistic note in your comment which implies that therapists who are willing to reduce their fees are “passionate” and coming from this place of “abundance” (good) while those who value their own work and feel they merit the fee are too “attached” to the payment” (bad).

      • M. says:

        It wasn’t coming from a moralistic standpoint on my end. Not everyone can afford it, but deeply needs it. I found it more healing when I released working with those types of people. It was as if I was finally able to focus on my healing. I was suffering from people pleasing syndrome so it makes sense that I was attracting that into my life. A big leap in healing happened for me, and it happened fast. I did learn something from everyone though, and appreciate everyone. My point is we all have different needs, including the therapists. I’m just sharing my experience, since we all have seperate perspectives and something to share and learn.

        Beacause of my finacial situations, I ask for discounts when I can, and I have received it from other professions. This comes from many years of paying full prices in spite of the fact that my illnesses and mental state affected my ability to function and or create a personal income for myself. I also will admit there were times that I spent money on things to treat myself from time to time, after going without it for so long it was a way of self-care. I even took a vacation, and it was good for me to do it after being sick and in pain for all of those years. My practitioners understood. It improved my mental state. Sometimes nuturing and being cared for is what a person needs to get back to that state of independence. There is a philosophy that says that we really don’t know what another person is experiencing until we step in their shoes. I had some people who told me I didnt loil sick or have any problems, but that was because they were looking from the outside, and not experiencing it first hand.

        My original point is that it really has to do with what you personally feel about it, what are your needs, what you think your service and time is worth… ect. When your needs are being met, it makes it easier to view the needs of others. If we are starving, then all we see is our hunger or poverty.

        I just hope that I helped you to see a seperate viewpoint, and thank you for sharing yours with me.

      • M. says:

        “Some of the actual reasons were: guilt about charging fees, as if they owed it to their clients to give them what they needed (with some unconscious childhood determinants); a wish to have no needs themselves, where being a therapist was something like being a saint; projecting an unconscious desire to be taken care of into their clients, and then gratifying it, etc.”

        These are all states of fear and poverty. You are still in the healing process. Also, this is just my opinion, but bringing your personal stuff into therapy is unprofessional and taking the focus off the client. 

        This is about you deciding what you are worth, what you want to charge, and sticking with it. 

        When you are fed and in a state of mental, emotional and physical abundance, you may even change your mind completely. It may feel safe or good for you to allow some to pay at a sliding scale.

        Also another way to view it is that everyone’s needs are being taken care of by the universe. If you have to reject someone due to inability to offer lower rates, know that they are being taken care of, that the channel that the teaching or information comes from is irrelevant. When we live in a abundant universe, everyone’s needs are always being met. The universe will open it up somewhere else for them. 

        • Joseph Burgo, Ph.D. says:

          These were my own clients (and sometimes supervisees), who happened to be therapists, and were discussing their feelings about charging fees during their own therapy with me. Entirely appropriate. And from my point of view, everyone is still in the healing process. You’re never finished.

          Once again, there is a subtle morality in your comments, although it’s cloaked in New Age language. According to this view, if you are “fed” and in this supposed state of emotional abundance, you may feel good enough to allow some people to pay on a sliding scale. You clearly view that as more enlightened and therefore better than someone who feels comfortable charging what he’s worth.

          • M. says:

            Im not enlightened I’m just sharing my perspectives. I’m not a New Ager, but I have had a variety of different therapies.

            We all have something to learn or share.

            You are just viewing it that way. I have compassion for your perspective, this is why I urge you to honor your needs. :)

  14. Shaun Fischler, LPC says:

    This is a great article. I am starting my private practice, and some in my group want to offer sliding scale and others don’t. I am in agreement with you on this. I think it applies to both short-term and long-term therapeutic modalities. The main issue to me is that we as therapists shouldn’t shortchange or treat ourselves differently than any other profession. We have worked hard and paid good money for our training and education, and I think we can easily become resentful of our clients if we charge them less than we know we are worth. We do help people hopefully live happier, more fulfilling lives, and that is worth quite a bit! I also think that when clients pay the full amount, they can be more invested in the process than if they pay a lot less. They value their money, and therefore they should value their time with their therapist and make the most of it. I also want to keep my practice simple as much as possible, and it seems to me that sliding scale just adds layers of complexity that I want to avoid.

    Thanks again for the great article!

    Shaun Fischler, LPC

    • Joseph Burgo, Ph.D. says:

      I agree, Shaun. I’m good at what I do and feel that my fee reflects the actual worth of the service I provide.

  15. Greg says:

    Yes, I’ve asked other professionals if they would do things for less than their published rates.

    Sometimes I’ve done it on the basis of hardship – can you give me a break and help me? And sometimes I’ve simply asked – it’s called haggling or negotiation.

    Sometimes the other professionals will do something for reduced fees, sometimes they won’t. If they do, it might be out of compassion … or it might be that business is slow right now … or it might simply be differential pricing that let’s them reach a bit more of the market (if you won’t buy Tide, will you buy Gain?).

    I wonder if the problem isn’t more with the boundaries of the professional, if they feel unfairly put upon by these requests?

    • Joseph Burgo, Ph.D. says:

      I’m not sure what you mean by “put upon”, but I can imagine that some therapists might resent being continually asked to reduce their fees when, for example, they’re in therapy themselves (the usual case) and their own therapist charges full fee. To me, my fee is simply my fee; it’s what I personally need in order to continue doing this very difficult and challenging work.

  16. GB says:

    With a dentist you get new teeth. With a mechanic, the car gets fixed. Are results tangible in psychotherapy? I think some have a problem with payment because they feel like they are doing all the work, and the process is endle$$.

    • Joseph Burgo, Ph.D. says:

      I always believe that, after several months in therapy, clients can decide for themselves whether it’s worth what they’re paying. I never ask a client to take anything on faith. If you don’t feel you’re getting your money’s worth, you should stop coming.

      • GB says:

        The question becomes several months of what? Money’s worth meaning talk? How does one stop coming after being led to believe that they are in much worse psychological condition, than when they walked in your door? Which would undoubtedly be the case. Then the client is shouldered with the guilt of dealing with these issues, and the financial commitment. And then there’s the omnipresent therapist asking “Well, what to YOU think is more important?”

        • Joseph Burgo, Ph.D. says:

          Are you saying that the therapist would try to persuade the client that he or she is in much worse psychological condition than when treatment began? You have a very cynical view of therapists, possibly justified from your own experience. I would never do such a thing. In my experience, most people don’t come for treatment until they’re in so much pain they feel compelled to seek help. I don’t have to convince them they need it and I would never try. Either they feel that the “talk” they’re getting is of great value or they move on.

          Your view on therapists manipulating clients to believe they’re sick is disturbing, but you’re not the first person to voice it. Lots of people view therapists as exploitative, fostering dependency so they can feed off of it financially, keeping clients in treatment when they don’t benefit from it. None of my colleagues is like that, though I suppose such professionals must exist.

          • GB says:

            I’m not saying that the therapist would try to persuade a client to stay, but the highly personal nature of the interchange, and the client’s lack of knowledge about therapy might lead them to believe that they have no options. Since the therapist is viewed as all knowing in most cases. I have an issue with the psychiatrists view of “pain” as well, but won’t get into that. My comments are not intended to be disrespectful, but I don’t think they flow with most of the other comments I read here. Thank you for your responses.

          • joe says:

            Persons are typically unconscious regarding the karma of emotions and their own desire for money. Spinoza defines emotion as a feeling of pleasure or pain accompanied by an idea about its cause. Money cast in this context is just an element of love or contempt, of paraphilia (efforts to cancel pain with distracting pleasure) or paranoia (failed efforts to cancel pain with distracting pleasure). Alice Miller says there is always a temptation for the therapist to seek a substitute parent among his or her patients. In terms of an adult who (A) brings money; and (B) reveals his or her inner world; the therapist is getting two things that may greatly satisfy a person’s need to experience a substitute parent or transparent husband or wife. Think about it …

            The label on a patient and context that he or she needs help getting “fixed” is a pure reenactment of the context where adults either find fault with a child to inflict pain or ingore the child who must regard him or her self as in some way defective and in need of fixing to “earn” love or restore pleasure. So paying an unconscious chump to diagnose a “disorder” is really a reenactment of an abusive social condition, and not really part of any healing process, it probably retards the effort to heal.

  17. Reiko Joseph says:

    Great topic. I’m currently an intern therapist working at a clinic that employs a very modest sliding scale. At the same time, I’m a therapy consumer, having just begun treatment with an established (read: full fee) psychoanalyst. I found your comparison to mechanics and accountants interesting because such professionals operate on an entirely different service model. For example, with accountants and mechanics:
    1.) You visit them as little as possible (once a year if you’re lucky)
    2.) Your dealings with them are strictly transactional, not personal
    3.) You may easily comparison shop via web or yellow pages to find a provider who fits your budget before meeting face to face
    4.) Both typically charge much lower hourly rates
    5.) Results are concrete, i.e. my brakes work or I am getting a tax refund
    6.) There is a clear, upfront termination point (your car will be ready at 4pm)

    All this is to say—what we do requires patients to make a much larger financial investment, takes far longer, is often messier and significantly more intimate. And if you’re providing psychodynamic therapy, there is no clear termination point, making it difficult for patients to work the expense into an annual budget. Given this, it’s not at all surprising that patients would entertain different expectations about paying their therapists than they would paying their mechanics. In short, long-term therapy is uncertain and financially costly. And it’s not concrete. For me, it’s a sound investment, but I can see how people outside the field would feel differently. It’s a hard thing to attach concrete value to internal change.

    • Joseph Burgo, Ph.D. says:

      Those are excellent points, and I think you’re right. Maybe the better comparison, as another comment on this post pointed out, is to physicians who typically don’t negotiate their fees. As for how to attach concrete value to internal change, the clients in my practice have either become clear on the value (even if it’s not quantifiable) or they move on. I don’t think going on faith is a viable option for something as expensive, difficult and time-consuming as therapy. Either you can “feel” its value or you should discontinue treatment.

  18. Reiko Joseph says:

    On a related note—When I first began working at my clinic, I had a patient who treated me as a standard service provider, like an attorney or a mechanic. In our very first session together, he laid out exactly what services he expected me to provide, e.g. a specific number of interpretations or insights per session, a step-by-step treatment plan, etc. I train at a psychoanalytically oriented clinic, so this in itself was great material to explore with him. But this also illustrates the “service consumer” mentality—you provide me with X and in exchange I will pay you X. What we do is not so neat, so I can understand why patients assume our fees are subject to negotiation.

  19. J says:

    I think you’re right on in just saying “my fee is what it is”. That way it eliminates any of the emotional entanglement or other relationship difficulties that may arise (as they often do) when two people in a relationship are negotiating financial issues.

    Think of all the child support wars where ex-spouses bicker with each other over every little nickel and dime, and how in the end, everyone just loses, including the children because the ex-spouses got caught up in the battle of “nickel-and-diming” each other as a power struggle. If you just establish it as “it is what it is”, then it eliminates those potential power struggles, touchy negotiations, or feeling as if you are being devalued (based on what they will pay you) while at the same time they’re idealizing you.

    I also wonder if some countertransference issues can and do arise with clients for whom you have lowered (and lowered, and lowered) your fees to meet their “dire straits” and ultimately their therapy is compromised as a result?

    I should probably have an asterisk with my comment denoting the fact that I am one of the fortunate ones that has terrific health insurance with no visit limits, and only $5 per visit co-pays….so I am probably a bit jaded in arguing for your stance.

    Also, in regards to your comment response to another about emails and phone calls…being a borderline patient with some hefty attachment issues and loads of “acting out” through email, I can honestly say that I feel I have wronged my therapist in so many ways because she took the time for so long to read each of them, even if she wouldn’t respond (to try and stop the behavior, to no avail)….each of those emails took time, time for which I was never billed. I hope my rapid success in therapy and moving on to become a therapist myself provides her with some sense of reward for all that time spent (and unpaid) reading those emails.

    • Joseph Burgo, Ph.D. says:

      I always read emails and never charge for emergency phone calls, nor do I resent the time I spend. I do think that’s part of the job description, as another comment pointed out. If outside-of-session calls become a pattern, however, that’s a sign to me that the client can’t tolerate the length of time between sessions and needs to come more frequently.

  20. Anonymous says:

    I am very thankful that my therapist works on a “sliding” scale. I absolutely do bargin or coupon with every service I need. I network or barter wherever possible for services. If I did not, I could not afford any of the things that you’ve mentioned: the mechanic, the dentist… etc.

    At first, I felt very guilty for paying so little (I honestly couldn’t afford to pay more). I felt like “charity” work and I tried to bring food gifts and homemade foods to make up for what I couldn’t offer in cash.

    I will comment that he also told me that I was the first client to ever increase what I paid when my income increased. That shocked me. I thought that was how a “sliding” scale worked. Counseling at one of the Catholic centers in the city required proof of income and you paid the number that corresponded with your income level. Even now with my current therapist, when I have work through a second job I pay a higher fee than when I do not have the extra income.

    And there was a valid point made above about the therapist who goes above and beyond with phone and email support. I used to try to only contact my therapist by phone or email when I was prepared to pay for that attention. Do you know my therapist has asked me NOT to pay him for the extra attention? I figure that any time I am taking up his time for his JOB, that I should pay for that. That IS the relationship.

    Therapy is a highly-valuable and in some cases a life-saving service. But like any other service, if I can’t afford it, I simply don’t get it. If I can’t afford the mechanic, I drive a broken car or car pool or ask for a ride or take the bus. I am very thankful that I don’t have to forgo my therapy, because I believe with the added help and support that it provides, that I will one day be situated in a better financial place by making better life decisions and learning better coping skills.

    I am crazy thankful for my therapist and the support and understanding that he provides. He tells me that he trusts what I pay him. That statement has driven me to be even more trustworthy.

    By the same token, I get the idea of a fixed fee. If that is where YOU are comfortable, then that is what you should do. I honestly DID expect second-rate attention and I have even told my therapist to feel free to cancel or reschedule me if a full-fee-paying client called. I get the business aspect of it. When the day is done, the business owner has to earn his living in the way that is right for him. My dad is self-employed and we went without when a customer didn’t pay. I have seen my dad do too much “helping” for nothing in return. I really do “get it.”

    And I have a hard time believing the comment about a “limited” number of clients….REALLY? It seems like most of us are crazy these days. EVERYONE could use therapy. Maybe you should get with some of the drug company’s PR people…. Joke. Hope my perspective was useful somehow.

    • Joseph Burgo, Ph.D. says:

      Some of the feelings you experienced aren’t unusual — for instance, the feeling that, by paying less, you’ll get less, or guilt over imagined exploitation. If you work in the transference, you can see it come up in the material, especially in dreams. The client might report a dream where he or she went shopping and found a really good deal on sale, only to come home to discover the new purchase was shoddy and second rate.

      As for your observation that “most of us are crazy these days” and that everyone could benefit from therapy … that may be true, but only a small percentage of people seek treatment and are willing to pay for it. That’s one of the many reasons why psychoactive drugs are so popular: insurance usually picks up the full tab and it doesn’t involve the extensive time commitment and expense of psychotherapy.

  21. no one has brought up the issue of a client who has health insurance that covers psychotherapy. how do you deal with what their insurance will pay and would it be fair if the insurance covered a top level of payment per appointment? just curious if you take medicare or medicaid. they have set fees for what they will pay and if someone needs treatment with the stipulation that medicare etc would cover a certain cost and should the therapist accept that fee and not charge for what otherwise would not be the set fee the therapist had set for his other clients?

    • Joseph Burgo, Ph.D. says:

      If you become a provider with Medicare or Medicaid (I’m not), then I believe you have to accept their fee schedule and you can’t charge extra for one of their patients. As for the allowable fees covered by an insurance company, if you work with them, you have to accept what they’re willing to reimburse. It’s one of the reasons I no longer accept insurance, although in truth, what I charge is less than the allowable fee with any carrier that I know of. But at least I don’t have to deal with the burdensome paperwork that requires me to falsify the way I work, establish treatment goals I don’t actually believe in, and represent the work as if it were something more like CBT.

  22. marge says:

    what is your position on doing email between client and therapist whether there were a charge or not? i would like to hear you opinion further on alternative ways of doing therapy in this age of technology where everything is changing and congress has a bill on the floor where medicare with cover the costs of such things as online therapy. i know this is touch off topic but i would be very interested how you would eventually deal with this aspect of your treatment and fees.

    • Joseph Burgo, Ph.D. says:

      Sorry I didn’t reply to this earlier — I found your comment in my spam file.

      I have never charged anyone for responding to an email, nor would I. If I thought it was becoming excessive, I’d probably begin to wonder if the client needed to come more frequently, that the gap between sessions was too long. As for therapy in the age of technology, I do work by telephone with some clients who no longer live in the same city; I used to work with them face-to-face, however, so I have the “feel” of them in person even if we’re no longer in the same room. If I decide to start working by Skype with new clients, I’ll let you know how it works out. Especially for clients who live in remote places where therapy options are few, I think this could be a really great option.

  23. GT says:

    I stumbled upon your blog fairly recently and am grateful that I did. I have found it to be informative and I enjoy and appreciate being able to partake of your knowledge, experience & perspective.
    My profession is in the business world and as you point out in the second paragraph, the answer to all the questions you posed would be a resounding, NO!! Of course, I expect to pay, and pay the full competitive market price, for all the services that I acquire, as I expect most people do.
    As a client/patient who has been in therapy for about 3 years, my thoughts are that what I get out of this work is priceless. I actually feel that what I pay for my therapy is a bargain, not because money is abundant for me, but because I value what I get out of it. There is a saying in the insurance industry that you pay for insurance with your money, but you buy it with your health. That’s kind of how I see therapy, I pay for it with my hard earned money, but I buy it with an even harder earned work of going through the tough process. I also think this work is mutual, both I AND my therapist work hard at it. As such, I think my therapist also gets paid for it with money, but I hope derives from the process much more than just the money in return. I imagine knowing that I have made a difference in the lives of people, whether by providing healing, support, insight, tools and courage to live a more meaningful and manageable life would be priceless.
    That said, I think this is an issue in your profession because of the very nature of the profession. The work becomes a very personal & emotional matter, thus the necessity for all the boundaries. At least for me, if tomorrow I’m truly unable to afford to pay the standard rate of my therapist, I doubt that I would continue. Even if my t. graciously offers it, I think it would impact the work for me. It is hard enough for me to do it, knowing that I am “paying” for it, I can’t imagine it would be possible knowing that I’m not really “paying” for it. I don’t know, may be just pride but … However, if both the client and the therapist feel they can work through it, why not? Just because there are those who “abuse” the system, (those paying less than the standard rate, but venture in an European vacation :) ) it doesn’t mean that there are those who cannot truly afford it as they must put some food on the table instead.
    Check out the jung-at-heart.com blog. I believe she provides both analysis via phone as well as a sliding scale. At some point, I remember reading her thoughtful blog on this very topic.

    • Joseph Burgo, Ph.D. says:

      You are that rare person who feels that you ought to pay the fee, and that doing so helps clarify boundaries. In my experience, the transference often begins at day one with discussions of the fee. So many clients seek treatment and immediately establish an infantile transference, where they long to be “taken care of” by the therapist. The fee becomes emotional code for something else; for this additional reason, it’s important to be clear about it. This is not to deny the fact that many people are in financially difficult positions, of course. There are many low-fee and sliding scale clinics for people who truly can’t afford to pay full fee. But when they can, it’s important for the therapist to distinguish between “can’t” and “don’t want to.”

      • GT says:

        Really, am I that rare? I have a handful of friends/acquaintances who are or have at some point been in therapy and each one absolutely feels they ought to pay for it.
        Obviously, I don’t have your vast experience in the matter, but just as you find it disturbing that many have a cynical view of therapists as exploitative, fostering dependency, I as a client find it disturbing that many therapists feel that the client develops this infantile transference and wants to be “taken care of” for free. Not only is it disturbing to me, but quite patronizing! I am under no illusion that I’m “special” nor am I entitled to be “cared for” nor my therapist is my parent … I get that having someone that does care in that hour and is in it with me to help me is healing, inspiring …. Yes, naturally I would develop a strong liking to my therapist, who wouldn’t given a person that listens intently, refrains from putting any demands or judgment, encourages …. I may even fantasize that it would be great to have my therapist as a friend that I can call on any time. But I know it wouldn’t be the same out of that context. I’m not under any illusion that outside the frame of that room, my therapist is just another human being with whom I would have the same relational issues as I do with others in my everyday life. In fact, I imagine that my therapist’s wife and kids are probably doing their own therapy with loads of complaints & issues about him. I find it hard to believe that really most clients are as dependent & entitled as you say. I hope you give your clients the benefit of the doubt instead of assuming that most behave that way. I can’t imagine that as much as I hear such belief from therapists, that it does not affect them in their work with their clients.

        • Joseph Burgo, Ph.D. says:

          Developing an “infantile” transference is a normal part of psychoanalytic treatment (though not most other types of therapy). There’s nothing patronizing or judgmental about recognizing it. It is the development and interpretation of this transference that allows us to understand lifelong defenses and modes of coping with need and helplessness; it is a primary tool of psychoanalytic work. I would never assume that somebody felt that way but would interpret the evidence as it came up in session, as always. It is only the evidence that counts; you tell your clients what you think, based on what they’ve told you in session, and then they decide if it’s true and has any meaning for them.

          My experience may have been skewed by the fact that, on the whole, I’ve dealt with a more seriously disturbed population — people with personality disorders, for instance. In someone who is higher functioning such as you, this type of dependency issue may never come up.

          • Anonymous says:

            Thanks for clarifying the “infantile” transference development & interpretation actually being a tool – wow! I didn’t realize that and what am I, in my 3rd year. Anyhow, I’ll have to look for that now and oh my, this brings lots of questions to mind … Likewise, I’m sure my experience is skewed with my small circle of “high functioning” friends in therapy – what do you know, I won’t get so offended by those comments anymore – sorry, I know this is off subject on this post, but I learned something today!

  24. Rebecca says:

    Many people who are conflicted or resistant to therapy will cite finances as an obstacle or hardship. These may be the folks who could most benefit from therapy, unfortunately. But since client attitude is the single largest predictor of therapeutic success it may be best to weed out those that aren’t yet sure they want treatment.

    My concern is for members of socioeconomic groups who really do want and need therapy and who are additionally are in a situation where finding care is more difficult not just because of finances but because therapy is not the norm in their community and they don’t know how to seek it, and once they find it, how to pay for it.

    In any case I think stronger boundaries serves the alliance best. if you do provide sliding fees it’s not out of line to have a very clear, written procedure of reporting income and backing it up with tax or pay statements every 6 months. Presented as an impersonal, bureaucratic necessity this might help.

    • Joseph Burgo, Ph.D. says:

      Yes, well said. If a therapist decides to have a sliding scale, it’s crucial to be clear — impersonal and bureaucratic, as you say. It’s important to keep the issue as clear-cut and unemotional as possible, so that the client doesn’t interpret the therapist’s decision concerning the fee as a reflection of how he or she feels toward the client.

  25. Greg S. says:

    Actually, mechanics, dentists and the like are asked for discounts all the time. In the case of repairs or health care procedures that are not covered by insurance, or clients who do not have insurance at all, the old “Do you have a discount for cash” way of putting it can be face-saving, as it sounds a lot less beggarly on the part of the client, and the practitioner always has the option of replying, “No!” Sometimes, a discount is provided, sometimes not. It all depends on each individual’s, agency’s, or company’s policy on this subject, and in the area of mental health, there is nothing wrong with either approach, since if one doctor will not reduce his fees, plenty of others will, and there are community mental health centers that will even provide free or nearly free care. On the one hand, I’m sure that many therapists feel that they are being unfairly singled out to be expected to make more sacrifices than others, and I’m sure that they are even correct to some degree. On the other hand, Americans are among the cheapest schmucks on the planet — just look at how little we are willing to pay for something as potentially helpful or deadly as child care — and pretty much everybody is being shorted on the income side at the very same time he’s being nickeled and dimed to death on the expense side.

    • Joseph Burgo, Ph.D. says:

      Among the physicians I know, they have rarely if ever been asked to reduce a fee. “All the time” has not been my experience.

      There is no reason why someone shouldn’t try to negotiate a fee; if you can pay less, why not? One of the various reasons therapists do reduce their fees is because there are too many therapists competing for the client pool; as you say, if I don’t reduce my fee, another therapist will. But once you’re established, with a good reputation, a full practice and infrequent openings, you won’t have that motivation to reduce your fee. You may have *other* reasons for doing so, but you won’t feel driven by the competition.

      • LE says:

        I just stumbled on this. Yes, I’m two years late.

        Most people use health insurance to pay for their physician, so it’s a $20 (or so) copay, whereas they may not use insurance for therapy for any number of reasons (it’s not covered, they don’t want insurance to know, the therapist doesn’t take insurance, etc.). So I’d be less likely to ask my physician for a reduction, because my expenses for my physician are less.

        I actually have several points, so I’ll share them here. First, yes, people do barter and negotiate for services. I do private sports lessons, childcare, tutoring, and various other cash businesses, and all of my clients negotiate. A likely response may be “well, of course childcare is negotiated!” Well, why? I know what I’m worth, same as you do. My price reflects my experience, same as yours. Yet, from your entry, you may think that because I don’t have a PhD, my fee is negotiable. While you may not negotiate in the supermarket or in Macy’s, people do negotiate with other service providers, including plumbers, mechanics, dentists, and doctors. Therapy is largely a cash business, and a lot of cash businesses are negotiable. Second, I do think some therapists charge an absurd amount of money. My therapist charges $160 an hour. I go, and I pay, but when I put that in terms of my hourly wage and how much I have to work just to be able to afford that, it’s crazy. I actually started going to her because no one had an open spot and I was grateful just to be seen by ANYONE, so price wasn’t what I was thinking about at the time. Now, while I do like her, I maybe think I should have gone to someone else. Price DOES matter. And, like someone else said, there is something to market value. Maybe people who want to negotiate don’t necessarily think your services are worth your fee.

        One thing I haven’t seen on here is any mention of the “everyone should be able to afford healthcare!” movement. Granted, I’m not in favor of ACA, but I think that anyone who says they’re in favor of healthcare for all (not saying you are) should be in favor of a sliding scale or that therapists should accept insurance.

        Finally, my therapist would never call my savings “meager,” especially while going on about how I should be paying her more.

        • Joseph Burgo says:

          People do barter with one another, but they usually try to get as much as they can for what they have to trade. That’s only natural. It’s also about supply and demand — you chose your therapist because nobody else had any time open and she was able to command the fee she had set, given the lack of competition. In areas where there are many therapists, they often lower their fees to compete better. That’s the way a market economy works. Yes, price does matter — it goes up and down according to the market. If your therapist had charged $250, say, you probably wouldn’t have gone to her.

          I think it’s a mistake to try to assign some “objective” value to a therapist’s services. I’ve literally saved peoples lives or made an enormous difference in the quality of the lives they lead. What value do you place on someone’s life? I usually say to my clients that it’s up to them to decide whether I’m worth my fee — do they feel as if what I have to offer is of value, enough for them to pay what I charge?

          I prefer to set my fee at a reasonable level, based on what other professionals are charging and what I think I merit in the therapeutic community. (Personally, I think my fee is low for someone with my experience; my peers often charge twice as much as I do.) People who agree can come to me for help; if not enough of them do, I would need to reduce my fee.

  26. Penny says:

    Wow this is a hot topic! It seems clear that the “clients” come at this with their opinions based on their experiences in business negotiation , being in therapy themselves, and other perceptions. Joe and some of the other therapists come at it, not surprisingly , from an analytical point of view. Like many of you, I’ve been on both sides of the fence, although I never needed to ask my therapist for a reduced fee. But as a therapist myself I’ve given reduced fees. Joe has come up with a great plan: just charge a lower fee to begin with, and don’t take insurance. Boundaries are crystal clear and the topic of fees most likely never be an issue. I’ve chosen to be a little more flexible . I totally agree with those of you who have stated that the therapist should decide what works for his or her own business model and is in alignment with his or her belief system about why they chose to be a therapist in the first place, and what they believe serves the best interests of their patients . Really enjoyed this lively discussion!

    • Joseph Burgo, Ph.D. says:

      Me, too. I think I’ve got more comments on this post than any other — not what I would have expected.

  27. Josie says:

    As a client I was offered sliding scale (3 sessions a week for the cost of 1 and a bit) for approximately 2 years of my 7 years of therapy. It was early days and I believe it helped me to save my life. As a client, it said to me ‘this therapist isn’t just being ‘nice’ to me because I am paying her – she must genuinely care for me’. I am now a psychotherapist and I offer 2 slots a week to low income earners, usually students or single mothers. Part of my reasoning is indeed about my own stuff i.e where would I be if my therapist hadn’t offered that to me? When I offer sliding scale or low cost I usually negotiate a timeframe and then we renegotiate the fee. Having trained in social sciences after my psychotherapy training, I also consider socioeconomic inequalities and feel that it is important to offer affordable therapy to those who would otherwise not be able to afford it.

    • Joseph Burgo, Ph.D. says:

      There’s no right or wrong approach to this issue; we all have to decide what works for us as individuals and fits with our own values. Your policy seems sane and admirable.

  28. Marie says:

    After a year of therapy, my husband was laid off from his job and we had a bit of a financial crisis. I was just barely stable after being clinically depressed. I immediately told my therapist I’d need to drop out of therapy because of the financial situation, and he offered a reduced fee. In the end, I took it and was grateful. Six months later, our situation improved and I went back to the normal fee.

    I don’t resent paying at all. Honestly, I wouldn’t be able to do the work without paying. It’s too much to just put on someone — which is why I see a therapist.

    • Joseph Burgo, Ph.D. says:

      I’ve often done the same thing with clients going through a rough patch. With someone like you who values the work and has shown a commitment, I don’t mind reducing the fee for a time, until he or she can get “back on their feet.”

  29. TherapyGeek says:

    This topic is timely for me & good food for thought. It’s been 7 years since I began seeing my therapist (6 for group) and for the first few years I was fortunate to have a sliding fee spot (for individual). At some point along the way, my fee was raised but still not to the normal rate. After stopping group in April and having been only an intermittent client for individual, I was recently informed upon scheduling a session that my fee was now the normal rate. In the session I was informed of a new rule, that if I return to group I will also need to have 2 individuals per month.

    The logic of her decisions is solid, but I find myself having feelings about it. I find it interesting that while I consider myself as someone who values her tremendously, I do and have had anger & resentment over the fee. I’m not proud of this, yet still there it is.

    I think that if an arrangement had been made at some previous point that ok, after this much time the fee will change – I might feel better about it. Both times now when my therapist has made these changes, I’ve felt caught off guard.

    Thanks for a great post – I definitely need to reflect more on why it feels OK to harbor so much resentment about the fee for this service over others.

    • Joseph Burgo, Ph.D. says:

      You raise an important point, another complication in the entire issue. If someone is paying a lower fee, how, when and why do you change it? I have found that a response like yours is not unusual; it makes sense to me because the rise in fee can seem arbitrary, out of the blue. As you suggested, I’ve found it best to have a time-limited reduction when necessary, so that both client and therapist know what to expect. I hope you’re talking to your therapist about your anger and resentment — they have a place in your work together.

  30. Francheska says:

    As a professional I was determined: no sliding scale. My fee is due to my needs, it’s supported by hours of my work and learning, knowledges and results.
    Instead, I’m doing some free stuff if I think it’s necessary. I must say that most of this free services are paying off later – people can be thankful.
    About European tour – maybe there’s no sense to think what can another person afford himself, if I don’t know the way he did it.

  31. Deb Fuss says:

    I just came across this and totally agree with you. Most of my clients, however, are people with chronic, serious mental illness and they are often on Medicare from disability, or they have very few resources. I know they often don’t have money for a bus, let alone a trip to Europe, so I can’t, in good conscience, even charge them co-pays. To deny services to someone who really needs mental health treatment isn’t an option for me. It would be great to get the amount which I feel my services are worth, but I don’t see that happening unless I change the population I serve, but then I wouldn’t be as happy with my job.

  32. Montana says:

    Wow… A pool of water in the middle of this big dry therapeutic desert I find myself in! And I am really thirsty. Thank you for providing this searchable topic as I have been struggling with this for some time now. I would like take part in this opportunity to offer up my thoughts and experiences concerning this topic, although latent with meandering words and emotion, in hopes of changing my own direction and better serve my clients.

    I am currently a clinical counselor/art therapist and I started my private practice about 2.5 years ago. I use the word ‘currently’ to express my ambivalence about this endeavor and my feelings of being somewhat beat up by the consequences of accepting insurance and offering a sliding scale. I find myself more and more lately day dreaming about getting out of the business altogether… ‘maybe I’ll move out to some isolated cabin in the woods and become that strange old white haired lady with too many cats that everyone in town suspects has lost her mind.’

    In my experience, all that comes with accepting insurance somehow morphed into a full time job in and of itself leaving very little time to partake in the joys of digesting fresh therapeutic information and research. For instance, I began the billing process with a couple of insurance companies well over a year ago, and I am still trying to receive reimbursement. I am beginning to gather that they are well educated in the language of ‘keep them confused and misinformed until too much time has passed to reimburse.’ Then an appeals process is offered that begins a whole new chain of events not unlike an episode of the Twilight Zone. And just as worse, there are the issues of confidentiality and signing a contract to accept an insurance company as my co-therapist, or shall I say they accept me as theirs. I do not have a Master’s degree in this, nor do I have the energy to pursue one if I wanted to. I feel a rant brewing up, but I will contain myself.

    Do I or don’t I offer a sliding scale? I have been offering this service since I began my practice and it has also been a very difficult journey. I am working with someone now that I feel I am mistreating and enabling by allowing it to continue. I have joined in on allowing this client to pay nothing while lending my ear to some of the same financial inconsistencies. I believed my client’s inability to pay without evidence to prove such state. Now I am left with my own feelings of being taken advantage of, and even more unsettling, the knowledge that I gave permission.

    Something happened last week during a session with this particular client that really drove the nail in and caused such an unsettling reaction in my guts. I offered to share one of my art materials by suggesting she just break it in half to take with her only to later find that she took the majority of it leaving only a small piece behind. Something of this nature happened a few months ago with this same client leaving me more in a state of confusion rather than feeling a need to act. At that same time, I was experiencing the consequences of other clients promising to pay their balances next time and then never coming back. In addition, I was experiencing the consequences of not checking whether or not some of my other clients had met their deductibles before incurring a large counseling debt only to see their dust disappear forever into the sunset when informed. I did not want my experience about those issues to come in the middle of my response to this client. By experience, I include my own transference issues and questions concerning the ‘pay off” for me.

    So there it is…this issue has now spread over me like some infectious disease I affectionately call, DSM-007 -Disease of Boundaries. I thoughts are… okay, I accept that I am not completely altruistic, and just like my clients, I need to pay the bills, put gas in the car and eat. And, I surely hope I am not somehow unconsciously relying on positive reports from my clients as payment for services. The words, ‘thank you so much’ or ‘I feel so much better,’ do not sound like payment for services so why are they assumed to be? And no way can I walk out of Walmart with a vacuum cleaner in my arms, or even a pack of gum and say…I forgot my checkbook so I’ll pay you next week. So, if I am doing this as a job, why am I saying, ‘ Don’t worry, I don’t need to be paid? Am I angry at my clients for this or myself for this? Some of it is probably directed toward client behaviors but most of the anger falls heavy on my own shoulders. I created it, sold the tickets and allowed it to be a part of my definition as a therapist. At least there is some good news in middle of going through these experiences; if indeed it is my responsibility then the power lies with me and I can change it. I know it’s not over yet. There will be all kinds of tasty tidbits to own as this issue continues to unfold. Ugh…Thanks and no thanks for that awareness.

    Needless to say….YES, the insurance and sliding scale financial issues do and can affect the quality of service I provide to my clients. The effects spread far and wide, to consciousness and unconsciousness. At least for me they do.

    So, what does a seasoned therapist do when confronted with this type of conflict? I am treading water in sorting through what I do not want to do and what would cause the least harm to my client and myself. I do not want to blame the client for my feelings nor do I want to continue participating in creating and allowing this conflict. I know this issue is affecting how I respond to my client and I question whether or not the effects of exposing this to the client would cause more harm than good. There are so many factors to consider.
    I was hoping to read about how others resolved this conflict because I could really use some insight. As for self-care, I think a good dose of supervision combined with some good therapy is the best remedy for a diagnosis of diseased boundaries.

    Thanks for this opportunity to share on this topic; it was a humbling experience and it felt good to get some of that out of my body. I hope the words and my experiences help someone else out there. Your words really helped me.
    MT

    • Joseph Burgo, Ph.D. says:

      Thanks for sharing your experience and I completely understand. Sometimes it’s very hard to know what’s the best way to help your clients — as you’re saying, it’s not in their best interests if you collude with some unconscious wish they have to be taken care of financially, or given something for free. As for taking care of yourself, it sounds like you’re in midst of struggling with it and you’ll find your way out. One thing I sometimes say to my clients: “The therapy is all about you and YOUR needs. Unlike virtually any other relationship or friendship you’ll ever have, the work we do is for your emotional benefit exclusively. On the other hand, the fee is about MY need to earn a living and pay my own bills.” I don’t know if that helps, but it makes it clear for me where and how both of our needs are getting met.

  33. I like your post. It is very clear. Your reasons make sense.
    As for a new patient misrepresenting themselves to negotiate a lower fee, as in your story, the true financial situation eventually is revealed. It just doesn’t make sense to cheat on this.
    To potential therapy consumers: Your therapy is one place where you want to feel open and guileless. The more honest and straightforward you are in your therapy, the more you will get out of it. Don’t start off misrepresenting yourself; you really cheat yourself.

  34. Emily says:

    You can charge whatever you like as a therapist. The question is, who do you want as clients? Your fee, whether or not you take insurance (and Medicare or Medicaid), and sliding fee scale issues will all help to determine who you will have as clients. The people who are the sickest, and in most of need of services, will often have the least money (although sometimes they will have relatives who will help). In our society, therapy is for the rich. Poor people with mental illnesses get drugged, if they get anything at all. However, accepting less money or taking insurances is a financial sacrifice. It’s what you want out of life.

  35. Beth says:

    My therapist is priceless. I wish I could give him what he is worth to me. But I have three jobs and too much financial responsibility. I have worked hard all of my life, but I have had barriers that I have not been able to overcome to be more financially successful. I paid the full fee to my therapist who did not accept insurance or credit card payments. When I lost my insurance (meaning I had to start paying my other health care providers out of pocket) and lost my family, my therapist offered a sliding scale fee. I refused and chose to quit therapy, because I couldn’t pay the full amount and on top of other medical fees. Then I realized that my mental health was just as important as my physical health, and indeed affected my physical health. I humbled myself and went back to my therapist, accepting his offer for a reduced fee. He saved my life. There is no doubt that I would not have survived without his help. Could I have gotten the same help from a free or cheap public health clinic? I don’t know. But I am eternally grateful for his generosity. I think a therapist should NOT reduce fees is he or she is going to resent the client. If it causes hardship to the therapist of any kind, he or she should not do it. I would not stand it if I felt that my therapist resented me or that I became a burden.

    But I would never take my therapists’ generosity for granted. As soon as I pay off some other medical bills, I will redirect the money being spent there to my therapist. I will not go on any vacations. I will not quit any of my jobs, buy a car or a house. I wish I could do those things or have a little free time, some fun, but that is not my priviledge in life. I resent that some people have taken advantage of therapists and made them cynical towards the motives of clients who aren’t more financially able.

    • Joseph Burgo, Ph.D. says:

      I respect the way you’ve come to terms with your situation and how you approached your therapist. I’ve done the very same thing with other clients who gone through crisis periods. Sometimes people do need some extra help for a time. And I’m sure your therapist does it because he understands you need the help and value the work he does with you. It’s when people feel entitled to reductions in your fee that problems come up.

  36. Kate says:

    Ithink Iwould pefer to pay the full fee otherwise I would feel paranoid about discussing any purchases. I am guessing that when your client mentioned going to Europe your mind started contemplating the reduced fee instead of the real issues that the client is there to address.

    I have never been a therapist but grew up in a volatile enviroment, my recovery has become a top priority as I have gotten older. I have been a single mom for 15 years financially I can’t always afford the things that some married women can like expensive purses, clothes or jewelry. I can however eat healthy, exercise and take good care of myself physially, so my physical health is my accessory. Don’t quite understand women who will spend a fortune on female status symbols but won’t take care of themselves physically.

    If I feel that it is necessary for me to go to a psychoterapist to heal then I am willing to pay the usual fee, if I paid less a part of me would always woner if I was getting less than his other patients.

    • Joseph Burgo, Ph.D. says:

      You’re right — when the client mentioned the trip to Europe, at that moment I was more focused on the fee than on the emotional needs of the client. Although many clients would like therapists to be selfless, we actually do have needs; it’s important for ours to be met so that we can meet yours.

  37. Dr bob dick says:

    I’m a 4 decades in private practice psychologist. I’ve worked mostly successfully with a sliding scale for 25 years. Most folks don’t take advantage, & since my focus is the work of healing, it’s been decades since I felt bad about folks asking a fee that I felt too low or turned out to be so. Some folks bargain for the lowest fee possible from me, & most of ‘em would not receive
    excellent treatment if I insisted on what I imagine they can pay. I prefer not to get tangled in their finances, usually accept their sliding the fee down from my standard amount if we fit right otherwise. Sometimes I refer to other healers who charge less or who take insurance.
    My fee also slides up, which my colleagues still don’t understand or feel comfortable with. It all balances out well enough on the whole, & folks w/ more money help pay for those with less money. I also barter very carefully r art or services [ I find this program's erasing words when I want to edit maddening #*!% !!]
    for art or services – that’s much trickier than sliding scale, & I suggest therapists with less than 15 years or so experience not do it. Healers better
    not do barter unless they’re prepared to put all their thoughts & feelings about all aspects of
    the exchange
    honestly into words & expect the same of the client. Otherwise the transactions
    can’t be used as up time example & demonstration of behavioral or emotional patterns needing attention. A very complex issue & worth mich more than the energy i’m willing to type-out. bd

    • Miryum says:

      I find it refreshing that you feel comfortable about bartering and are committed to having all your thoughts and feelings re the bartering, and putting them into words, and having your clients do the same. I find it productive work!

  38. victoria says:

    i just found your excellent site doing further research on bpd … (my ex fiance was diagnosed just before we broke up)…

    your present a thoughtful argument to the fee question i had never fully considered ,,, and i only read the thread of S’s response (who also makes some very good points.) my only remark is a bit tongue in cheek, in saying i can’t believe her opinion of your work is “not a hard day’s work” …. i firmly disagree when the “energy” required mentally and emotionally to be any good at doing what you do can be exhausting i’m sure.

  39. Hermes says:

    Absolutely right, Joseph!

    “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.”

    I think a good psychologist is worth his/her weight in gold.

    Speaking of the U.K. I thought I might add these two links.
    http://www.bps.org.uk/news

    http://www.psychminded.co.uk/news/news2011/aug11/Mental-health-stigma001.html

    Referring to Steph’s posts, there is a huge demand for therapy and psychological services in the U.K. and in my own country, Ireland. Not enough psychs to go round! And those in practice are innundated with work. There are therapists who are paid by the Health Services, and a very large number of psychologists in private practice. However, attitudes are I believe somewhat different from those in the U.S. Very very few people here would admit that they are seeing a therapist, in fact they would roundly deny it. Yet a huge number of people are going to psychologists. There is a stigma still attached to mental illness or mental distress. So it SEEMS as if no one is going to therapy.
    A friend of mine who works in the disability sector was telling me that people will never disclose even that they have something as common as depression, given that if an employer found out a) they wouldn’t get a job they are seeking, and b) they might well find themselves out of the job they have.
    I don’t know what happens. Do people here creep in the back door of the psychologist’s office, heavily disguised?

    Hermes

    • Joseph Burgo, Ph.D. says:

      I’m beginning to think that the option of distance therapy via Skype, where the person can feel entirely safe and private, while working with a qualified professional who may be ANYWHERE, is the coming thing. In addition to working with clients in other states, I now do online counseling with people in other countries, too. What an interesting time we live in!

  40. Jonty says:

    This is a great blog conversation! I am a client not a therapist and I am just going through a difficult scenario with my therapist because of fee issues. Initially my therapist decided to charge me less because I was a student which was really helpful. When I graduated and got a job she upped the fees to what I thought was the standard rate – completely fine and appropriate. Three weeks ago she told me that I still wasn’t paying the appropriate fee, educated me on the fee structure, strongly emphasised the importance of boundaries with fees and treatment, and challenged me to as what value I put on therapy. I got really upset as I thought I had been paying appropriately and had valued the sessions properly and with respect (not cancelling, minimal rescheduling and within appropriate time frames, not being a ” no show” and being on time). I left that session feeling that I had been cheating my therapist out of fees. I now feel like it’s impossible to go back. As a client I was unaware of the therapists fee structure or how they negotiate fees with their clients. I just paid what I was asked at the front desk. I think there are significant boundary issues with reducing fees and creating special arrangements with clients. Paying the appropriate fee at least gives you a feeling that you have some control in a relationship in which there is a power imbalance and one in which you are already vulnerable. From someone who has been burned by this experience – charge the going rate and make it obvious initially and at the front desk. I would have paid whatever the rate was as I thought it was worth it – now I just feel I have lost what was a good therapeutic relationship.

    • Joseph Burgo, Ph.D. says:

      It sounds like your therapist means well but didn’t handle this issue particularly well. She may have thought she was giving you the relevant information at the “right time,” when you’d be able to absorb it and respond appropriately, but I agree with you — it’s much better to be up front and clear about fees all along, in order to avoid such issues. One way I’ve dealt with it in the past, when I had a client going through a financially difficult period, is to reduce the fee for a specific period of time, with the understanding that it would go back to full fee on a certain date. I’ve also taken on people at reduced rates, but never indefinitely. I always specify a date when the fee will rise to my usual fee. I’ve found (as you have found) that being clear and straight-forward is essential. But you should talk to your therapist about it; maybe she made a mistake and will learn from it. Especially if you feel the work has been valuable to you, it would be shame to give it up now.

    • Dr bob dick says:

      I’m really sorry the discussion of fees was so problematic for you & your therapist. a
      I hope this issue offer you an opportunity to face your discomfort and return to discuss & clarify your thoughts and feelings, if only to drop the bad feelings, freeing you to decide whats best for you, rather running from the darker side of intimacy.
      I agree that the therapist erred, & since we all make mistakes, I do hope you would consider the experiential learning involved in talking a difference thru’ while staying emotionally connected to each other — no need to throw the baby out with the … It’ll be real useful for Both of you to address, rather than avoid this conflict — how else can one learn to deal openlyy & directly with the inevitable pains & disappointments in any close relationship unless one practises ? Practice
      makes progress.
      A good Interpersonally focused weekly group therapy might also offer further opportunity for dealing with the scary & challenging aspects of deepening emotional intimacy. This is especially crucial in pair-bonding.
      I wish you clear thinking and excellent self-care. Warmly, bd

  41. Miryum says:

    I’m currently in therapy/analysis and I did ask for a reduced fee because my income is pathetically low. My every last dollar goes toward therapy. I don’t take vacations, don’t do manicures/pedicures/massage/spa services, don’t shop for clothes, save for an occasional necessary article of clothing such as a new pair of shoes when the current one is full of holes. Don’t buy takeout. Don’t subscribe to cable. My purchases are minimal, and then only for necessities. I do indulge in penny books on Amazon. Books is my one indulgence, but then again, they’re only one penny (plus 3.99 shipping), and the books are generally related to furthering my therapy work.
    And though I have asked for a discount, I certainly intend to increase the payment as soon as I have the means to do so. I view this reduced fee as a temporary state. In the meantime I feel extraordinarily blessed to have this opportunity and privilege to work with this analyst, and to benefit from our work.
    Still, if I were doing this work, I’m not sure I would offer a sliding scale. I would probably decide ahead of time, what might be the lowest fee I’d feel comfortable accepting. And if someone could not pay it, I’d refer them to a low-cost treatment facility. On the other hand, if I were just starting out, and it were a matter of not being able to fill my slots, vs. filling them with reduced-paying clients, I wonder what I’d choose.
    I don’t intend to work in this field, so I guess it’s a moot point.
    Still, I enjoy picking my brain.
    I really appreciate everyone’s sharing here.

  42. EastCoaster says:

    I’ve seen my psychiatrist since he was in the second year of his residency and am now in full-blown analysis with him. When he was house staff, I paid nothing, because Massachusetts law did not allow hospitals to send bills to patients who made less than 200% of the poverty level. He reduced the fee when we went from 2 to 3 times a week, and when I got a job, I raised it on my own. He said he knew that I would raise it. I’ve even hired a coach to help me get a better job, and he seems okay with that.

    At the same time, I know that he probably does some ER shifts. He initially offered to take my insurance and then decided not to, and he’s getting necessary hours to train as a psychoanalyst. So, he’s getting something too. Further, I know that he does not rely on his private practice for all of his income, since he is preparing for a research career as well and has NIH grants.

    I did go on a vacation to meet my boyfriend’s parents. We drove. We’ve since flown at Christmas, but they help pay for the tickets. His first response was, “Good, you need a vacation.” I’ve since gone to see relatives in Colorado where I did do some skiiing (paid for by my boyfriend.) I hadn’t seen them in years, so I think it was important. I do feel guilty about the iphone I got, (and I bargained with Verizon) but ultimately went with AT&T because we were able to get a discount through my boyfriend’s company, making the monthly payments less than what I was paying before.

  43. Dr bob dick says:

    I think a therapist’s attitude & practices around fees & sliding scales changes as we gather experience. There are many ethical & ligitimate ways to deal with the issues, & as in most complex human affairs, there are likely many right-enough paths. bd

  44. Adam says:

    New to the blog; I enjoy it a lot. An issue about sliding scales: I’m wondering what those therapists who use them use as criteria to set their sliding scale fee for particular individuals. I will pay my therapist 11.3 % of my gross income–the fee I pay is still way below her standard fee. She’ll get an additional modest amount from my ins. co. –total still doesn’t begin to approach her standard fee. She suggested this low fee and I readily agreed. In some sense then she had to consider what a reasonable amount of disposable income is for me, what kind of lifestyle is reasonable etc. I feel like I got a good deal, so am OK with this, but it’s really strange to look of it in terms of how much $$$ she thought she should or shouldn’t “take” from me. Made me, a beneficiary of the sliding scale, have to agree with a whole lot of what you said.
    .

    • Joseph Burgo, Ph.D. says:

      Thanks, Adam. It’s hard to say what your therapist took into account when she made that calculation. To me, it seems impossible to understand what is “fair” to “take” from another person. Seems much simpler to have the same fee for everyone.

  45. Anonymous says:

    I think part of the problem is that the profession is less regulated than other professions. Many people do not understand the differences in therapist’s degrees and certainly training. Therefore they have no way to place value on the expertise and benefit of such expertise. After all a Master’s level therapist can practice well outside of his/her training without consequence, even if that might be termed “unethical” it would be difficult to prove. And there are even those who practice “therapy” without a license and charge a fee without any regulation. I understand that a Ph.D therapist has years of graduate training and gets less respect it seems for their expertise than other professions with similar years of training. I just think it’s because the profession is so “watered down” and the benefits are confusing, whereas the harm from those with insuffient training is well known.

    • Joseph Burgo, Ph.D. says:

      It’s an interesting point, and one I wouldn’t argue with, but I don’t think the answer is more regulation. Psychotherapy isn’t like other professions, in my view … at least not like being a physician or an accountant, where you have to demonstrate concrete skills and knowledge. How do you demonstrate empathy? How do test for the capacity to develop a relationship with another person, over time, and help that person to grow?

  46. TPG says:

    What do you do with patients in long term therapy with you who have a major, documented, financial setback? Or a series of setbacks that occur all at once — a firing from a job, a house that goes underwater, etc. Do you “fire” them from your practice if they can’t pay your full fee, and refer them to other therapists? Or do you adjust your fee for them, with proviso that it will be adjusted back upward when patient finances stabilize.

    I can tell you this. I’ve been with the same dentist for 10 years. I recently have a massive financial setback, and needed bridgework done. He reduced his fee massively — gigantically! — out of respect for our relationship. BTW, this was a completely professional relationship. We were not social friends outside his office.

    • Joseph Burgo, Ph.D. says:

      As I said in a response to another comment (different post), I’ve never “fired” anyone who’d been working with me for a while. Your dentist had known you for 10 years — you had a relationship. That’s the difference. I’ve always reduced my fees for ongoing clients in need, but I don’t reduce my fees at the outset for someone I don’t know.

  47. Lola Jacobi says:

    This is a fascinating thread of thoughts. I am a psychoanalytic psychotherapist currently working within the NHS ( in the UK ) and privately. I am paid a salary for my 5 days a week. I have a full diary with two long running groups and also patients whom I see weekly. They of course pay nothing, directly ( though our taxes here in England eventually pay my salary ) and I am amazed how often my patients cancel or simply do not attend. However in my private practice, where I charge the exact same fee regardless, I rarely have anyone cancel. So I wonder about perceived value when something is ‘free’ or reduced.

    I decided to have one set fee and stick to it. However I have made it easier for those who have had unexpected hard times, in various ways by extending payment beyond their ending with me for instance.
    There is so much revealed by the ways in which people prioritise or make choices. I decided to charge one set fee so that I avoided taking on someone who I ‘ found fascinating’ at assessment and might inadvertently act into their narcissistic needs or indeed mine. I give my fee clearly on the phone and if they cannot afford it, they do not even attend an assessment/consultation. If someone arrives and has a consultation ( which is free) and at that point decides to barter then I pass the decision back to them. I re state the fee, and tell them that they can phone me back to let me know if they want to begin the process of therapy with me at this time. If I have grave concerns about them, I ensure that they have the names of colleagues who do have reduced fees and I urge them to invest in their emotional health.

    • Joseph Burgo, Ph.D. says:

      It’s interesting what you say about the way that people who don’t (directly) have to pay for their sessions treat them more casually. I believe it was Freud who originally said it’s important for clients to pay a fee in order to value the work appropriately but I’ve never entirely believed that. Your experience suggests that it may actually be true. It sounds to me as if you have come to conclusions/policies similar to mine. You really made me stop and think when you wrote about feeling the urge to reduce your fee for someone who you “found fascinating.” I often have to fight that same urge. I think this urge sometimes reflects my own narcissism, where I can easily feel that I must be the savior because what I have to offer is so special! It’s embarrassing to admit that, but there it is.

      • lola jacobi says:

        That is exactly why I stick to my fee. If someone attends and ‘hooks’ me into a powerful feeling from the off, that I am special, their saviour, or the only therapist that is going to ‘sort them out’ and therefore I must see them for less, as they really cannot afford my fee….then I can slow down take a deep breathe, consider what is going on in the transference and the countertransference, stick to my fee and if they choose to continue then we can explore what is getting set up
        between us. The frame is held by me. I am responsible for that boundary so that we can then explore the narcissistic need or the sense of entitlement, or their impoverished sense of self, or whatever else comes up. They can be furious and resentful and then we can explore all of that together. It’s never dull.

  48. Hermes says:

    Mmmmm, Joseph. I think Freud had a point. I work in an entirely different field, and yet at times I have had to be “therapeutic” and “hand-holding”. L.
    And only the other day I was talking to someone who works in the area of physical therapy on this very same topic, and he said too that clients don’t place appropriate value on the work (and cancel!) if for some reason they are not charged.

    You and Lola mention “fascinating clients”. Humour me and tell me what that means.

    Best wishes to everyone
    Hermes

    • Joseph Burgo, Ph.D. says:

      A fascinating client means different things to different people. For me, I’m often intrigued by artists as I admire them so much.

  49. Hermes says:

    Joseph, I think what good therapists have to offer IS special, very special. If those skills were not so special then anyone could do the job.
    You say it yourself:

    “Psychotherapy isn’t like other professions, in my view … at least not like being a physician or an accountant, where you have to demonstrate concrete skills and knowledge. How do you demonstrate empathy? How do test for the capacity to develop a relationship with another person, over time, and help that person to grow?”

    Certainly no layperson could do what you do, and by that I mean the family, relatives and loved ones of your patients. Friends and loved ones may be empathetic and insightful, but no one has the skill and patience to interact with and help patients like yours.

    On the matter of remuneration I read earlier in one of your posts what you charge in professional fees, and how you and other therapists pondered the question of slidin scales, patients in financial difficulty, and so forth.
    I read a few days ago, to my complete amazement, about a “medium” in the U.S.A. who charges US$1200 for a one-to-one session (and more depending on the number of people). Yes, you have read the figure correctly! It would appear he is booked up ages in advance. And these are recessionary times. I would bet good money that there is no negotiating HIS fee.
    And people do go back again for more…..

    Do this not seem disturbing? I hesitate to use the word “insane”.

    Hermes

  50. Zoe says:

    I found my therapist via an autism website as she works often with Asperger’s kids, and my daughter has Asperger’s. So I had originally contacted her in hopes of her working with my child. She uses a family-based approach, so wanted to meet with different members of our family, to get a sense of the whole family dynamic. I appreciated that. She charged me $45 (low end of scale…high end $70) for a 50 min session, and told me on the phone that in this economy, she felt it was important to keep the low end of the scale pretty low. I found out afterwards that she had only been a therapist for a year (she is older and this is a career change), so very likely that was her real reason for the low end.

    This suited me fine, since we had our daughter involved in so many other things like private school and social skills groups that were hard on us financially, not to mention the fact that I am in school full-time not working, and I felt like the therapist was good. But after I met with her privately a few times, it became obvious to both of us that I really need to be in therapy for a number of reasons, and I alone have seen her (my daughter now sees someone else) for about 4 months. In the span of this 4 months, she raised her rate so much that I had to stop seeing her weekly and made it every other week. Her low end went from $45 to $60 to $70 to $80 to $90 to $100. No less than 5 rate changes in 4 months. Now her sliding scale is $100 – $150, and I feel stuck and pissed.

    Isn’t this kind of rate hike a little drastic over such a short span? When I mentioned it, she said something about her prior rate being equal to what, say, “a dog groomer would make”. Oookkkaaayyy….then why make mention of the fact that you offered such a low rate because of the poor economy a few months ago!?!?! I feel pissed because I feel she was not entirely honest with her intentions. That said, she seems like she is good at what she does, and I am now attached and I think she knows it. In session I am up to my eyeballs in all the “stuff” from my past and I think she knows it would be too hard to start over with someone else. I could go through insurance, pay $45 a session and be able to go weekly, but I can’t bear to leave her now (transference, yadayada…I honestly go back and forth between adoring her and hating her) I understand that a therapist needs to charge what they feel they are worth, but for crying out loud don’t make it seem like you are some kind of philanthropist with low fees then hike the fee once your client is hooked!! Sorry, I am not yelling at you, I am just venting about my own situation… If anyone has any insight that will help me view this situation with less resentment, by all means let me know…

    • Joseph Burgo, Ph.D. says:

      I think your reactions are entirely justified. If she has a sliding scale, based on your financial ability to pay, that ability didn’t change within 4-5 months. When I started off many years ago and had clients paying low fees, I never raised their fee more than $10 per year, and they usually knew well in advance (6 months) that the fee would be going up as of the first of the year. I think your assessment is accurate — that she reduced your fee because she was “needy” herself and wanted more clients; once she had enough, she raised her rates.

  51. beth mft says:

    I am a masters level therapist. I believe we should have a certain percentage of our clients as sliding scale, but not all. When I had less money, I DID ask my dentist and mechanic if they had lower fees, and often times they did or could help out in some way or another. Now that I can afford life, I don’t do that.
    In some ways we are like other professions, but in some ways we are not. I do believe we have more of a relationship with our clients than, say a dentist. I see him once every six months or so, and strongly dislike going to see him. My clients come to see me as a safe place, where they can share a part of themselves they feel too scared/embarressed or for whatever reason it is too difficult to share with others; even themselves. If the fall into a hardship while we are seeing them, I think we can possibly work with them for a while ( don’t mean charging zero, but going down a bit possibly),… I think that is our duty. Yes, we need to take care of our own needs. But we also need to be there for our client…

    • Herbert Peress says:

      I think beth mft’s answer is balanced and fair and reasonable. It doesn’t take care of the resentment for Joe’s Euro traveler but that aside I like it.

  52. CeeCee says:

    It’s like MDs. In residency, they are pretty much “salaried’ slaves. And PCPs…oh my goodness. They are undervalued and get reimbursed like crap, and yet everyone thinks they should work 80+ hour weeks because they “aren’t in it for the money”. If my therapist was living in poverty, I would have an issue. Someone who allows you to be in a safe place and helps you so much, physically or mentally, deserves to be payed right, especially when they own their own practice! Unfortunately, there are those people out there who can’t afford it at all. I mean they pay for nothing extra, but can’t get insurance at all. I am grateful to those therapists and doctors, along with many other service providers, who have a sliding scale for some of their patients. If it came down to me needing therapy that bad, I would just have to get onto a program because I can’t even hold a job half of the time due to extreme anxiety. But if I had a full time job, I would probably pay someone 150 per session.

    • Joseph Burgo, Ph.D. says:

      Or you could say that patients who can’t afford specialists go to health clinics, often staffed by interns and residents; you may pay less but you won’t get the top, most-experienced person in the field. That seems fair to me. As I’ve said before, I’ve seen many many people for very little money over the years. I’ve “paid my dues,” so to speak, as younger professionals will continue to do, but I no longer adjust my fee.

      • Penny says:

        All I can say is being someone who has zero income, no health insurance and needs therapy, I am very grateful for those therapist who see their jobs as serving their community and the needs of others and therefore will do all they can to help those in need and who can not afford therapy. Now, I do not think that therapist should work for free but I think that the answer Beth above gave was the perfect one. I think someone serving a community should make an allowance to have a percentage of patients that they offer reduced fees too. Once they reach that percentage, all others go on a waiting list til someone completes treatment from that group. I hate to say this but as the govt does, the loss of the reduced fees are passed along to the paying customers. Is this fair? No but it is what it is. We pay extra or more taxes to help the needy with the welfare etc. or at least a percentage of the loss could be passed along to the payin customers. That away we all are helping those in need Jim can’t afford therapy. The question is HOW to affectively determine WHO really is in need an what the guidelines will be. And HOW to weed out those who want YOU to help them afford their trips to Europe.

        Just my thoughts :)

      • Jethro says:

        Most people have to budget. Most people have to juggle. Most people do not pay full price if they do not have to. I found an independent mechanic who works on my cars. He has his own shop, charges less than a dealership shop, and arguably does better work. Moreover, I like him, trust him, and I’m loyal. I also send a lot of work his way whenever I can. He’s a rare breed. You are not. Even if you’re good at what you do, good psychologists are easy to find. Supply and demand. I would argue that a vacation to Europe or an extravagant purchase could provide the same psychological value you offer—perhaps more. I don’t think your client is screwing you at all. I doubt if it’s even personal. They probably love you and value you a lot. However, they are just making a budgetary decision—and you’re a line item in it. Just raise your rates, with notice, and flush out some truth about where you stand. You may be worth the commitment—or not.

  53. Zadie says:

    I accept all that you’ve written. Therapists need to earn an income, they do the training and acquire the skills and have a right to be paid for this just as in any other profession. I’ve never asked my dentist to change his fees (although I wish I could); or expected discounted services from my hairdresser or mechanic. My problem now is, knowing all this and yet finding that I either need to end therapy with my therapist or get further and futher into a debt I can’t repay. I should never have started with him, and should have chosen someone who charged a fraction of his high costs (as you mentioned in your response to Ceecee); yet he had the skills and background I sought, and gave me hope of things changing and that hope carried past logic and sense. Now I’m in a terrible mess financially and I find myself in the grips of having massive attachment issues going on; intense fear of abandonment and yet I’m the one who needs to leave. I can hardly handle that thought yet alone the reality of living it. I will be left dealing with fighting so much alone, including losing him and while logically I know it’s my fault; it is also heartbreaking and ever so terrifying. I know he needs to make a living and that for him he will just find another client who actually can afford his services; I just hate that money always ruins everything.

    • Joseph Burgo, Ph.D. says:

      If you were my client, I’d discuss with you the need for you to increase your income; until you could do so, I’d reduce my fee for a specified time period. Reducing your fee for a new client who wants to pay less from the beginning is different from a client like you with whom you have an established relationship.

      • LuLu says:

        I’m in a similar situation as Zadie. My therapist has agreed to lower her fee by $50 to $150 on several occasions but then I get the bill and it’s $200 per session. I’ve confronted her several times about my bill and my inability to incur more debt while paying off what I already owe her, and while we seem to get it sorted in the moment it’s always an issues come bill time. She insists I am “crisis-ing” at the moment (as she often does) and says the answer is more sessions, often encouraging me to come for multiple sessions a week. At $200 a pop I cannot afford this, and I have been explicit about that. Her admin assistant is not helpful at all and I have chased her down to pay my bill partially with a flex card she seems unable to run. I just got off the phone with my psychotherapist *again,* and I begged her to run the card before it’s the new year and we lose the benefits.

        Also, I would like to say that she has been texting behind my head while I lay down for sessions. She even told me “hang on a minute while I send this text.” When I confronted her about this, she got very defensive. I don’t feel I should be paying *anything* for the sessions she wasn’t present. In those sessions, my needs weren’t met at all, regardless of fee. If I went to a doctor and he just texted the entire time he saw me, I’d walk out of the appointment. And by the way, I am a medical health professional and I would never ever do this to my own patients and then demand they take me seriously as a professional and bill them as if I’d given them my best care.

        • Joseph Burgo, Ph.D. says:

          Find yourself a new therapist. Texting during session is unacceptable.

          • LuLu says:

            Thanks for confirming what my intuition was telling me. Regarding payment, I have been chasing this therapist and her admin assistant down for two months to pay for several marital therapy sessions with a flex spending card. Not only did she let the clock run out on the card (there was a problem with her vendor she asked US to investigate…?!), but she called me and blamed my fiance and told me he needs “a lesson in responsibility.” We will not be seeing her anymore as a couple, either. She just sent me a bill for my solo sessions that had fees we hadn’t agreed on and extra sessions on the bill. When I asked her about it, she said she wouldn’t look at the bill until she’s back in town two weeks from now although she had no problem calling me last night to blame her lack of organization on my fiance. I’m so frustrated and I feel betrayed, which I’m ashamed about, and now I have such a giant bill I have to pay off I can’t afford to see anyone else right now.

  54. Joseph I found this post refreshing and it does resonate with me. At our practice, we do not operate a sliding scale, and I prefer not to work with clients on a discount. However, in our publicity material we do say something generic along the lines of ‘for those on a low income, a discount rate may be negotiable’. Truth is, for those on a low income, they probably wouldn’t even be able to afford our discount rate for more than a very few weeks.

    Like many others, I have done my time of providing counselling for no pay, in training placements and in voluntary settings when I was first qualified and struggling to find paid work. I’m glad that agencies providing free counselling for those with little money do exist. I also value greatly the commitment to change that is made by my clients who pay for our services.

    • Joseph Burgo, Ph.D. says:

      Yes, most of us put in years of unpaid work or for low wages as part of our education. There are many resources available for people who can’t afford to pay full fee but that usually means a therapist in training.

  55. Nicky says:

    I’m a little lost for words here. I’m a long term ‘faithful’ client who has never had the courage to negotiate a fee with her counsellor! I always pay the maximum even though in the early days I resented such an exhorbitant cost! I suspect that I, like many other clients out there, do secretly harbour a desire for their therapists to actually follow through on their words in a practical sense. I know that my therapist enjoys working with me and having briefly touched on termination once or twice, I also know that he will miss me. All that said, I have had to cut down to fortnightly appointments now because of financial commitments which he knows about and found myself feeling rejected and angry because he made no effort to offer me a reduced price. And yes, I do realise that’s a defence mechanism cutting in!

    However it is comforting to know that, given the right circumstances, you professionals are prepared to lower your fees to ensure that we clients continue to receive the benefits of your care.

    All that said, I wouldn’t want to change him or our work together. And I do get an awful lot of backup from him in the form of email throughout the weeks inbetween so really I can’t grumble.

    Perhaps you therapists should be looking at a set fee rather than a sliding scale. Maybe that would make your clients feel a little more equal to each other in respect of each one being of the same ‘value’ and it would set a very important boundary right from the start. It would certainly take another worry away from us, your clients!

    • Joseph Burgo, Ph.D. says:

      I suppose his willingness to reduce the fee would depend upon the nature of those “financial commitments”. If someone loses a job or has a financial disaster, I always work with my clients, and I suspect most therapists would do the same.

  56. Samantha says:

    I am an MFT registered intern working in a private practice. I have to bring in my own clients. I am in the process of working on a sliding scale. The scale I am considering goes from $10 to $50. Yes, I do realize this is extremely low. However, the cost per hour (or session) is relative to the therapist. What I mean is, the median is $30, that wage provides me and my family what we need and a bit extra. I do not have a need to make $130 an hour. That is just me. Also, I have been looking for jobs that allow me to earn hours towards my license and the average pay for those jobs (if I can get one) is $15.00 per hour. Why would I work for that when I can work in the private practice, make my own schedule, and work the hours I want to work? Working with a sliding scale hopefully will give me clients but also allow me to be with my family instead of working 40 per week plus travel and gas. The trade is worth it to me. Later, as I gain more experience, or if I feel the low end of the sliding scale is being used too much for my comfort, I will change it. That is my right. If a therapist does not wish to lower their fee, then do not lower the fee. That is your right, there is no need to justify it, intern or not.
    I do not know about other states but in CA therapist cannot charge cash clients less than clients who use insurance. This may be a factor in what a therapist charges.
    It is not for me to judge where a client gets the money to do the things they do. How do I know someone else did not pay for their trip to Europe? Or that the person or family did not save for 10 years to go on this trip. If you cannot offer the sliding scale free of judgment, then maybe offering it is not a good idea.

  57. Paul says:

    If I go to a dentist for a crown and pay his full fee, I expect that dentist to revisit my crown for free if there are any problems with it. If I pay a mechanic his full fee for a car repair, I expect the car to be repaired. In therapy there is no way to decide if the service paid for has been discharged as distinctly. Therapists are not like dentists or mechanics where the customer knows, per visit, if the paid-for service has been performed. If you insist that your fee should be immutable, you should be able to warranty the results of your sessions. I understand you have to make a living. So does the mechanic. But a mechanic who fails to actually repair cars per customers expectations will not make a living as a mechanic for long, regardless of his needs.
    Therapy is a fundamentally different kind of service. If a patient attended and adhered to a therapy schedule that you specifiy for say 3 years and is not improved, would you refund your fees?

    • Joseph Burgo, Ph.D. says:

      If a client came for six months and felt there was no value in the work we were doing, I would suggest we discontinue. While I agree with what you say up to appoint, clients need to feel the ongoing value of the work and shouldn’t simply take it on faith.

      • Anonymous says:

        As a psychologist, and former master level licensed professional, it was only after I changed my practice paradigm about fees that I matured and my clients matured. There is a huge lesson in paying for missed sessions and full fee, as well as all slots you rent from the therapists schedule….you go on vacation = she should have less income? Would you want your employer lowering your income when she goes on vacation? The degree of maturity the experience takes (yes, I’ve been on both sides of this policy) is empowering like nothing else…and repeatedly I see clients generalize the experience with maturity in other areas of their lives, worth every cent.

        • Joseph Burgo, Ph.D. says:

          As you might imagine, I’ve had the very same experience. It is empowering, for both therapist and client.

      • Nathan says:

        I am very interested in ways of making payment for mental health services more outcome dependent, precisely because of the uncertainty inherent to the field, and the time/energy/financial commitment/risk clients need to put in. In this regards, it would be shifting therapists to a model being asked of teachers, with better educational outcomes of students being rewarded with higher pay and poorer outcomes leading to a loss of job security. Therapists who help patients the most and most quickly should be paid more (and have full practices) while those who don’t should get paid less. This will also deal with overcrowding in the field, as the most helpful therapists’ practices will grow while those who can’t cut it will not be able to stay in business.

  58. Maria says:

    This topic hits home for me at the moment. I have been seeing my therapist weekly for the last 3-1/2 years. I am a reliable client (no payment issues, doesn’t cancel, sticks to the schedule).

    Unfortunately, I’ve hit upon some distressing times financially…getting divorced, going on short term disability – then ultimately losing my job. Now, my insurance – which I pay a considerable amount for, privately, with only unemployment income, struggling to keep the roof over our heads – is capping my sessions. My therapist said he would work with me and even suggested bartering. I am the one who is uncomfortable with it. It creates an imbalance that I cannot tolerate.

    I know that each insurance company’s negotiated rate is different. My therapist charges $130/hour – but I know that my old insurance company capped it at $80/hour. My latest insurance company’s cap is $72/hour.

    So, as I am quickly approaching the end of my insurance covering my sessions for this year, I’d like your feedback on how you would feel if I requested to pay the lowest insurance negotiated rate.

    I don’t want there to be an imbalance. And I’m fearful of the impact that any other kind of arrangement would have on our relationship. So, my thought is that if this is a rate that he’s accepted through a particular insurance provider, then it would be something that we both could live with – and there wouldn’t be such an imbalance.

    Would that sound reasonable to you?

    • Joseph Burgo, Ph.D. says:

      That sounds entirely reasonable to me. And from what you describe of your therapist, I bet he’ll be amenable.

      You might want to explore this issue of bartering and a perceived “imbalance” in more detail with your therapist — sounds like it may be a transference issue.

  59. Verity says:

    Hi, I have a question about fees in general and what people would consider to be reasonable. My therapist takes about 10 or 11 weeks off a year around holiday periods. Great- no problem with that! However, she often tells me about 3 weeks beforehand- I personally don’t have an issue with that either.

    The problem arises when I go away on vacation- my line of work often means that I have to take my vacations outside of “regular” holidays. For example, this year we are going away in September instead of June/ July / August. She is away during August and we start sessions again in September. I gave her 3 months notice that this is when we would be away. She says that these sessions will need to paid for ($76 each) if no one can fill those slots while I’m away.

    I have tried to ask what she feels would be a “reasonable notice period” to tell her I’m away. The reply I got was “there is no notice period- are you saying you want me out of pocket just because YOU go on holiday?”. I have tried to tell her that there will inevitably be times that I may not be able to make my sessions- we are not always going to be on vacation at the same time. She has even made a big deal about not charging me for my session the day before my wedding because she was unable to fill the slot ( I gave her 13 months notice about that!)

    I would never dream of offering any professional less than “their fees”, but I am beginning to feel annoyed about this. More so about the fact she expects a courtesy that she does not extend herself. Her attitude to me whilst we discussed this at my last appointment makes me feel I can’t work with her anymore. The problem is I have spent about 3 years with her, I do feel like I have reached a ” plateau” progress-wise with her, but I feel it would be a shame to start over again with a new therapist.

    • Joseph Burgo, Ph.D. says:

      Therapists have different cancellation policies and hers is not at all unusual. I try to explain it this way. She sets aside this time and guarantees it for you; you agree to employ her for that service. Now, if your employer told you that he or she didn’t need you on Thursday and wouldn’t pay you for that day, would you feel that was fair treatment? Just because you’re not going to use the hour she sets aside for you, does that mean she shouldn’t be paid?

      You have to look at it from her point of view: if clients can simply cancel sessions and not pay, then she would never know how much money she would be earning each month. She has to be certain of her income so she can pay her bills, just as other workers need to know how much money they will bring home in their paycheck.

      • Mary says:

        It is the therapist’s job, in this case, to generate the business to pay for the time the client will be absent. The therapist is an entrepreneur, and should adapt to the reality that demand for their services is not always consistent.

        The client’s notice of 13 months in one instance and 3 months in another case is more than adequate. Two weeks’ notice would have been sufficient.

        The therapist’s having “made a big deal” about not charging for Verity’s wedding day, which she gave 13 months notice about, is unprofessional, as is the remark, ““there is no notice period- are you saying you want me out of pocket just because YOU go on holiday?”

        If my physician, dentist, landscaper, cleaning lady or pet-sitter made the above statement, I would tell them I valued them and their services, but that our business relationship is a two-way street.

        I would request a two-week notice period to be given if either party needs to be absent. If any service provider wouldn’t agree to that, I would find services with someone else instead.

        In therapy, I would not only request a similar arrangement, but also share any feelings, thoughts, bodily sensations, dreams, fantasies or other reactions pertaining to this issue.

        Verity’s therapist seems to be asking for a free ride and doing so with an attitude of entitlement. I would tell her I thought that.

        I respect that Verity and the therapist have a relationship that encompasses much more than this issue, and therefore it might be difficult for Verity to end the relationship.

        Solely on the basis of the information Verity shared about her therapist, my own personal response would be to leave. Someone in business for themselves needs to work out a more equitable agreement regarding clients’ cancellations, and present it in a business-like way.

        A first-come, first served policy would enable the business person/therapist to serve anyone on their schedule; a client would realize they risk losing the appointment if the provider is scheduled with someone else.

        It’s also telling that the therapist here apparently can’t find other work 13 months in advance.

        I would reread my post, if I were Verity, and be aware of how reasonable it is, of how much common sense and strength it reflects. I would trust my perceptions — see what I see and know what I know both about myself and my therapist.

      • Dian says:

        I pay my therapist weekly even if I cancel within a few days time, and that is to ensure that no monetary issue interjects into the work. Still, a thirteen month advance notice…? That is beyond annual expectations. That amount of notice should not be revisted as a reminder to anything other than absolutely normal human behavior.

    • Ashton says:

      Hi Verity,
      I’ve had one therapist for a number of years, then had to re-locate to an area where I now do occassional follow-up counselling with another. Neither of the therapists I’ve had were ever as inflexible as what you describe above. I find your counsellor’s remarks really surprising–giving as much notice as you’ve given! Therapists have great power over those clients who’ve stayed with them for a time. I for one would not want this sort of distraction, having to wonder what’s a reasonable amount of time to give notice, feeling uneasy about having to pay for sessions that won’t take place, and so on. You ARE giving her due consideration by offering such advanced notice and are hardly “simply cancel[ing] sessions and not pay[ing]” for them, to cite JB’s remark below.

      All best finding a resolution,

      Ashton

    • Michele says:

      My first instinct is to say, this feels horrible to me. I’m a trainee counsellor and I can’t ever imagine treating a client like this. I guess it’s down to different inherent natures. Some people are more business orientated about their work than others. Some people will see it more of a spiritual path for them. I think if I get to that stage I will just have to find better paid work.

  60. Unknown says:

    As a client I took offense to the response relating to payment for vacation. While I respect the work of my therapist and the help and growth sh has provided me, I would never have agreed to see her if my vacation had to be scheduled around hers. It is important that we as client adhere to policy guidelines and pay for services rendered. I have no problem with not having a sliding scale because I am paying my therapist for her expertise and training not to be my friend. Part of the therapy process for a lot of clients is learning to live life and not just existing. Learning that you are able to take a vacation from it all on your terms is greatly beneficial. I believe that you contradict yourself by saying the services are akin to those of a dentist or a mechanic and then turn around and say they need to be sure of their income. Being in private practice as a therapist is scary, never knowing how many clients and if all will show. But therapist know this going into private practice. My job as a client is to listen learn, talk interact and pay my dues, it is not to keep my therapist in business. A therapist forcing me to pay or take vacation when they wish is detrimental to the client/therapist relationship and in most cases can trigger a client because we are once again being forced to abide by our “authority” figures demands. I expect to take vacation when I can and to provide a reasonable time frame to my therapist so that she may fill the therapy hour and if I miss or don’t cancel within 24hrs then it is my responsibility to pay. I understand when returning from vacation I may not have my regularly scheduled time because it has been filled but that is a reasonable expectation.
    Just my thoughts….. We as clients do not need anymore of a power trip to let us know the power imbalance that exists. We need the imbalance because you are the expert and we seek you out for help. But remember just as you expect us to be reasonable and respectful, we also are worthy of the same.

    • Joseph Burgo, Ph.D. says:

      I understand your perspective and believe all these issues should be discussed up front. That way, the client can decide whether he or she wants to enter into a therapeutic relationship based on the terms you describe, or look elsewhere. There are plenty of therapists who don’t charge for missed sessions, even ones canceled at the last moment. Clients are free to work with therapists who have policies of which they approve, and therapists don’t have to work with clients unwilling to accept their cancellation policies.

  61. Ashton says:

    Hi.

    If my therapist had not allowed a sliding-scale mode of payment I’d not have been able to undertake the first 2-3 years of counselling. I was a graduate student living on next to nothing. One cannot simply stop counselling that involves EMDR techniques because of lack of funds. Changes for me soon ensued, my new salary allowed me to jump to full fee, and here I am post-therapy, intensely grateful for that wonderful counsellor of mine.

  62. Gwen says:

    I respect the need for your own boundaries. I only regret that poor health insurance and a low-paying area (and massive student debt) keep me from using online counselors (we have a nice low-fee service place nearby but anxiety keeps me away! My own fault, really). But regardless of how much you charge, you are making a positive impact on the world, and there are plenty of less expensive options for the poorest of the poor.

    • Joseph Burgo, Ph.D. says:

      Thanks, Gwen. I agree that there are other options, and as I’ve said before, I did years of low fee work at the beginning of my practice. We all do — it’s how we gain experience.

  63. Julie says:

    Interesting topic, or “in-stressing” as one of my kids used to say as a toddler. Good to address because everyone thinks of it.

    I’ve been using an experienced therapist with no sliding scale. My insurance situation changed. My benefits ran out. With additional changes in marital status and job status– none being an improvement to my financial situation–things spiraled downward financially.

    I DID ask my dentist for a discount on work on my kids. He said yes! I DID ask for a discount for repairs to my car. The mechanic said yes! (I had to wait awhile, I was no longer first on the list, and he was searching for discounted parts). I DID ask the hairdresser for a discount on haircuts. She said yes! (She gives me the children’s rate… she cuts my kids hair, I have easy hair to cut). When moving, I DID ask the realtor to cut her commission if necessary and she agreed. I think people are very willing to help if you have a long standing relationship and mutual respect.

    My therapist OFFERED to reduce his fee because I was an established client in crises with PTSD symptoms, sleeping little more that 3-5 hours a night for a few months. He knew about the financial stress and exhaustion of benefits and said he would never do it for a new client but would for me. Yet, I had trouble accepting this offer for many of the reasons, some you state above. Would I then become less important to him then a full paying client? Is he, a very good therapist, less important that Citibank, with whom I’m debt? Isn’t work on my psyche more important than my car, teeth and hair? Aren’t I paying for an education? (I’ve had several previous less helpful therapists– and less expensive– so I appreciate a good one)

    Finally I agreed to pay the reduced fee (60% of the regular) and then when therapy is over pay the balance in the future whenever I can. He says he has received payment from clients years after working with them. But I got the strong impression this offer doesn’t go out to just anyone so I appreciated the trust. Afterall I have had to put trust in him.

    • Joseph Burgo, Ph.D. says:

      That’s pretty much the distinction I make. I wouldn’t take on a new client at a reduced rate, but I’d reduce my fee for someone in extremis with whom I’d been working and who’d placed his or her trust in me and our work together.

  64. Jovana says:

    Frankly, it never occurred to me that my doctors/clinicians would NOT work on a sliding scale. Perhaps it is because my father is a doctor and has always treated those less fortunate with respect and dignity, and has never turned them away when they were suffering. And my health care providers and professionals (including my mechanic) will work with me.

    So back to Dad, yes, I suspect if he DID turn people away and only treated those that could afford his “fees”, he would be driving a Porsche instead of a Corvette, we would have been raised in a 10,000 sq ft house vs a 5K one and he would be taking more vacay with Mom… but I suppose his values are just different than yours.

    And he is not resentful of his clients that can not afford to pay him the full fee. He moved to a different hospital 30 miles away and those same patients followed him. They are willing to do the drive. So from your point of view, then, I guess he should be a little pissed off that they could AFFORD the gas to come see him but not AFFORD his full fee (confused).

    Also, if my father would actually embrace technology (a miracle) and decided (let’s just pretend) to see patients through Skype or some incredible time travel machine, and then started kvetching about his sliding scale fee and not being able to meet his overhead, it would lead me to think he was suffering a tad bit from dementia.

    My thinking: “Dad, all you need now is a cell phone, a computer, Skype account” so what kind of overhead are you thinking? (not to mention the fact that my parents house would be considered a deduction because he practices at home).

    It seems this particular topic, you are seeking some sort of input (negative so you can fight and positive so you can feel validated) to justify your actions. However, perhaps all that is important is what you think and your “following” will follow.

    Best wishes to you

  65. Katie says:

    No sliding fees? I worked for twelve thousand dollars a year as a counselor for two years after I had my Masters. You want money, then go get it. Go0d for you. We all make choices.

  66. Josh says:

    I just think you are being a little bit selfish. That’s just MHO.

    • Joseph Burgo, Ph.D. says:

      If by “selfish” you mean I’m thinking about my own needs, I agree. Being a therapist, confronted on a daily basis with people’s pain and emotional needs, is a very challenging job. If you don’t make sure your own needs are being met, you can’t do the work. Instead you become burned out or depressed. Many therapists quit the profession for that reason. After 30 years, I still love my work.

  67. TPG says:

    I have no problem with an inflexible fee, so long as you devote a decent amount of time to pro bono work. That is, always have a couple of patients in your practice whom you do not charge at all, because they cannot afford your fee at all. These people would likely come from very different walks of life than most who can afford to pay. They may well be poor — custodians, taxi drivers, cafeteria ladies, laborers, hard-core unemployed, etc. It is good for them and good for the world view of the therapist, too.

    Doctors do pro bono work all the time. Lawyers are practically mandated to do it by bar associations. It’s good for therapists, too.

    BTW, I don’t consider pro bono work giving free seminars or talks that could result in practice building. Pro bono work means doing what you normally do for the good of the public.

    • Joseph Burgo, Ph.D. says:

      How about the many hours I spend on this website, sharing my insights and answering comments, not to mention the many private emails I receive. Does that count as pro bono work?

      • TPG says:

        No, not in my opinion. While those are obviously valuable things, they are also sideways practice building. It is particularly true because you personally are willing to work long distance by Skype, so the usual state licensure boundaries don’t necessarily apply.

        In pro bono, I’m talking about the same kind of pro bono as a private-practice lawyer who takes on an indigent criminal client who can’t pay, or a doctor who takes on some patients who have no resources or insurance.

        It’s a bit of a strict definition, I know. But it makes, at least for me, the no-sliding-scale thing easier to swallow.

      • Jane says:

        I think you are doing a wonderful job here, offering this forum, your insights and comments. It is pro bono work in my opinion and I appreciate it. Thank you!

  68. Annie says:

    I’ve only just come across this website (via a google question) and I have been following the discussion on fees. I think Dr. Burgo’s question about whether this website is a pro bono service is a valid one. Because even before this question I had been thinking what a wonderful resource this site is and free, there is no subscription or sign up fee.

    • Joseph Burgo, Ph.D. says:

      Thanks for saying so. The prior comment seems to hold the view that if I get ANYTHING out of it, then the website can’t be considered pro bono. It has to be selfless to qualify. I don’t believe in the existence of selflessness because I think feelings of self-esteem are tied into the supposed selfless acts of most people.

  69. Joseph Burgo, Ph.D. says:

    Very well said and a welcome contribution to this discussion. Thanks for taking the time to offer such an intelligent, well-thought-out comment. I completely agree about the importance of boundaries and up-front discussion about the “terms” of the relationship.

  70. E says:

    Hi,
    I think what you say makes alot of sense.

    I also think there exists a problem that is probably nobody’s fault and may have no solution as well. I think that trainees may be appropriate for people with more mild to moderate mental problems, but may have a higher chance of actually being harmful or accidentally traumatizing someone who is severely and deeply troubled or disabled. My experiences may not be representative or I may be wrong for other reasons.

    I am not sure if there is a solution for people who can not hold down a job, who are holding onto life by a fingernail or two, and who have struggled to survive years of medications making things worse.

    I know this is just a few vague poorly expressed words from a nutcase. It’s just a question I wonder about and believe has no good answer, and no one to blame.

    • Joseph Burgo, Ph.D. says:

      No, I think it’s a very good point. It is unfortunately the people who need help the most (and who are often indigent or barely scraping by) who end up with the most inexperienced professionals — trainees. Someone who has spent ten years in college and has student loans to repay, who already has a license and an office to support, can no longer afford to see many people for $5 a session.

  71. kathy says:

    Interesting topic. About paying for vacation time, employers do tell employees they need to take off without pay. I experienced this recently with hurricane Sandy.
    Ive struggled with this issue in my therapy. My therapist doesn’t take insurance so I pay out of pocket and try to get reimbursed by my insurance co. That is difficult to do since I am not experienced in dealing with them like a health care provider would be, and because I am emotionally overwhelmed, which is why I’m in therapy. Dealing with insurance companies is not easy. Frankly, I have developed an addiction to therapy in part caused by the financial debt it has resulted in, leading to more emotional overwhelm and more need of therapy.
    In addition, financial issues and how we deal with them are common emotional stressors. Dealing with them are as important in therapy as dealing with other relationships.
    But them main point Id like to make is that this is an issue because our healthcare system is problematic and capitalistic. Fee for service doesn’t serve well. Not only does it encourage a therapist to prefer a higher paying client: it encourages extra sessions.

  72. C. OFee says:

    I found this fascinating! Its not often I have had the benefit of an opinion from ‘the other side’ of the therapy fence.

    First & foremost, I feel all of us have a responsibility to do what is needed to keep ourselves healthy & whole. Managing the business/monetary side of providing such a unique service like long term psychoanalysis is fraught with many ethical pitfalls, at least it seems that way from MY side of the fence. If charging the same fee to everyone is how you balance things, then so be it! Your policies and expectations within your practice seem to be well thought thru, clearly stated & comfortable for you. I feel that choosing a therapist is WAY more involved than choosing ANY other professional. Understanding a therapist’s policies are a vital part in choosing someone with whom you will share so much & work so intimately with. It should be a clear understanding on both sides how things work, financially & otherwise. It is up to the patient seeking therapy to find someone whose policies they understand & can work within. It is up to the therapist to clarify policies & screen patients who aren’t able to work within their guidelines. What if questions should be addressed BEFORE the issue arises; I always ask lots of them. Personally, I need the reassurance of knowing the answer to them, so I ask. Perhaps its the experience of having pursued therapy for most of my adult life.

    My question is slightly off topic…HOW does someone find a new therapist? I don’t mean call the insurance company for referrals! I have a unique situation – I am totally at a loss at how to solve it!

    My mother is a counselor, and worked at the local domestic violence shelter for 25 years. In that time, she regularly conducted trainings across our half of the state. I have recently relocated to my parents home (recovering from cancer AND a breakup). Finding a therapist interested in lon gterm therapy is difficult – add in the “Mom” factor…NOW add in that my diagnosis is DID/MPD/BPD. I have been searxhing, calling & interviewing for 18 mo & I am almost to the end of my rope. The other factor is that finding a psychiatrist here is also difficult…the first one I saw said “DID and BPD aren’t REAL. I learned that in MEDICAL SCHOOL. You have had bad therapists who lied & confused you.” I was shocked. I had been trying to explain my anxiety, panic attacks & regular, reoccuring nightmares when HE asked if I had been given that diagnosis…I hesitantly answered honestly (lomg ago learned that there is discrimination & disagreement about DSMV codes & names…I just want help, codes are a clerical issue not a definition!) He also prejudged me about my cancer treatments…he asked if I had used Marinol & when I answered Yes he instantly wanted to drug test me, even though that was years ago! I persisted trying to explain that I needed help, that returning to my antidepressants was warranted given that in the last year I lost my fiancee, had to move cross country AND back in w my parents, plus 2 deaths – one a family member, one a close friend. He argued w everything, then ended the appointment with “I am refusing you treatment. You are a confused liar who needs self discipline.” When I answered “Excuse me?” I was stunned into speechlessness & didn’t know what else to say…hoping I had imagined it. He repeated it & added “please leave my office”.

    I left, feeling like I was dreaming. I cried, yelled at him inside the safety of the car on th eway home… it took several weeks to get up enough nerve to return to my regular doctor & confess it all. I cried telling her the story. She had wanted me to see the OTHER guy in that office…she said to make an appt w him. When I tried, I was informed it was impossible since they covered for each other. I then found a LOVELY psych who started me on a new combo of meds I had never tried, or even heard of before. I began to improve, managed to find a therapist 45 miles away & went to my 1st appt w him only to discover he LIVES in my hometown. I went a second time, but was far too uncomfortable…his office was very tiny, he knows my Mom & he informed ME of our treatment goal that second visit. Then, last month the psych retired & my regular doc refused to refill while I searched another psych.

    All this in 3 months has left me wondering WHAT THE F$#*???? When I lived on the West Coast it took footwork to find a therapist that I ‘clicked’ with…but this is INSANE! I live in the Midwest now, outside St Louis. Near enough to see a specialist there, but I worked HARD finding a primary doc on the Illinois side of the river, since my transportation is my Moms car. When I lived in New Mexico the last 2 years, I had no issues finding a psych…but EVERY therapist I interviewed said “Sorry, I don’t have the expertise to handle your case.” when I explained my history. My therapist who diagnosed me, worked w me for 2 years and completely changed my life forever was a PhD who did what you do – long term psychoanalysis. I LUCKED into him, he was a referral from the insurance! I lost him when I had to relocate to Seattle for family reasons, but found someone new thru interviewing. We stopped work when she tried to begin play therapy & sand table work

    • Joseph Burgo, Ph.D. says:

      I wish I had a good answer for you. It sounds like the problem is geographic — not enough qualified professionals in your area. What I often tell people is to search the Internet for local professionals using the terms “psychodynamic” and “psychoanalytic.” Best of luck.

  73. Denise says:

    I think there are some distinctions to make about a sliding scale. First I think if someone is an established patient of the therapist, its important for them to have continued treatment, especially if there are issues such as the patient just suffered a major loss, or any vulnerable time like this, and to suddenly discontinue therapy would be ethically wrong in my opinion because of the financial. In that case, the therapist should make some type of arrangement so as to allow the patient continued treatment. This is different than a brand new patient requesting long term lower fees. In summary I think its fair to say that a therapist is akin to a medical doctor or other healthcare professional. This is different than some other lines of work such as a mechanic, although I did have a mechanic who allowed me to pay in several installments so I could have a working car. The work therapists do when it is done well and ethically is extremely valuable. Therapists know some clients even from the very nature of their issues, such as if a patient has schizophrenia and can’t work much, that a certain percent of patients will have trouble affording therapy, so maybe one solution is to be selective in what patients need the therapy the most (such as someone who’s family member just died) and would be harmed the most if they had to abruptly stop therapy. The bottom line is that an established patient shouldn’t be abruptly dropped from therapy for monetary reasons,and a new patient if they are in a particularly hard situation should be given some type of sliding scale maybe for three to six sessions, just to help them over the hump type of thing. Most lawyers do have pro bono clients and many doctors also reserve a small percent of clarinets to see pro bono, I think its a good idea for therapists to whenever possible set aside a small allowance for pro bono patients.

  74. Here is my experience from both sides of the fence. When I first started seeing a psychologist, I was just finishing my short term disability period from a well paying job and still covered by my company’s health insurance with a $40 copay per mental health outpatient appointment. My first provider was a PhD. psychologist who was in network. My physical and mental health continued to deteriorate resulting in the transition period to permanent disability status. During this time my emergency savings were drained, my 401k emptied, my home sold to avoid foreclosure, my disability income from my employer reached its limit, and finally bankruptcy filed along with application for welfare until social security disability was granted. During this five year period, I lost the ability to have insurance coverage for my first psychologist and became his cash client. I was unable to sustain payment of $120 per session and found as many creative solutions as I could until it became clear to both of us that my options and resources were gone. He helped me find a community clinic that provided me with free group sessions and $25 individual sessions. Tragically, my therapist at this clinic actually did more harm than good leading me to a series of inpatient psychiatric hospitalizations both voluntary and involuntary. My covered access allowance was very quickly used up, leaving me with a hefty collection agency account and often the gut wrenching choice of buying food vs. getting treatment. Finally I was granted Social Security Disability and Medicare benefits, which allowed me to find a life saving PhD psychologist who accepts the medicare reimbursement as payment in full. This amazing man took quite some time for me to find and thank heavens through my work with him I was able to actually start recovery, leading me to my current status as a PhD candidate in Natural Medicine and a clinical internship at a neuro therapy foundation. At my foundation we offer treatment to clients through insurance or cash; but for those without financial means we offer treatment if they or a family member on their behalf donate to the foundation by way of cash, goods needed, and/or services rendered. Each of these donation arrangements are discussed upfront on an individual basis and are more than fair in my opinion.
    I feel the real problem here lies with the inequities of reimbursements from the insurance companies. Mental health treatment is just as vital as primary medical care, yet received on a weekly basis if not more. Unlike physical medicine, mental health care typically does not involve a few comprehensive appointments with five or six follow up visits leading to ” full recovery”. The intensity, frequency, and duration of mental health care far exceeds the physical model that insurance companies seem to ascribe to. This leads directly to the dilemma of the provider not being compensated enough, the patient not being treated enough, or in most cases both. I feel we are all better served by focusing our efforts on the insurance reimbursement end of things, rather than making the client or provider the “bad guy”.

  75. Vince Adkins says:

    Little else can be a corrective to an unhealthy fantasy (i.e., transference and/ or countertransference) than the patient writing a check for two-hundred-and-forty dollars after each session.

  76. sc says:

    Dr. Burgo,
    It’s been interesting to read your fee policy and the comments as I consider how to restructure fees for my private practice, which I plan to introduce to clients next week. As you note, those of us who depend on the income generated by our practices started out offering sliding scale fees (my early work was in an agency) and after 15 – 20 years I find myself increasingly questioning why the sliding scale fee structure is regarded as almost an entitlement in the field of psychotherapy, and seems to be connected with the quality of empathy. A therapist who does not offer a sliding scale fee seems to be regarded as less empathic than one who does, yet an ENT or a dentist would not be expected to offer a sliding scale. As part of this discussion, I think it may be worthwhile to note that many physicians schedule 2 – 3 patients per 15 minute period while therapists generally see 1 client per 50 minute period. The therapist’s business is affected to a proportionately larger degree by the fee amount, late cancellations, late payment, etc. I love my work, feel privileged to do it and also beleive that the empathy I feel for my clients can comfortably and logically coexist with my policy of setting a non-sliding fee based on years of study, experience and training.

    • Joseph Burgo, Ph.D. says:

      Of course I’m on the same page as you, and you’re right, it does seem as if many people believe that therapists who don’t offer a sliding scale are less empathic. As you know from your own experience, it’s simply not true but you won’t convince the naysayers.

  77. susan says:

    Hi Dr J.. Firstly i wanted to thank you for your website and always look forward to what you and other visitors choose to discuss.
    Its always insightful and helpful.
    I see a clinical Pyschologist fortnightly and in Australia we only get a small number of rebatable visits per 12 month period. I knew that i would run out before the end of the year so i asked my therapist if i could pay myself for every second session. He understands that i am unemployed at this time and we settled on a fee that met his needs and was sustainable for mine. It wasnt a huge reduction of his fee but has allowed me to continue with him.
    I agree that it takes many years of hard work and study to gain your qualifications and you should be paid accordingly .. however i do think that that decision to lower a fee for an individual client should be something that happens based on many factors taken into account by the therapist and the client with no pressure on either party.

  78. Julia Biales says:

    What about a “pay it forward” program? I run a CSA and not everyone can afford organic food. However, I put out the option for anyone to buy open shares so that I can provide food baskets for people who need to eat but don’t earn enough to pay their own.

    People like “pay it forward” baskets and people who have gotten them over the years often in turn purchase extra shares so that I can share the gift of healthy food.

    It’s a good way to keep in touch with clients who may have moved, to find out how their stories are going, and to support the common vision we hold.

    JulieB

    • Joseph Burgo, Ph.D. says:

      Interesting idea. I’m not sure how I would implement that.

      • Julia Biales says:

        What people I know do who offer services is have a paypal button for contributions to a deserving cause fund; also, some people include the possibility in greeting cards. If you have helped someone they will often want to provide gifts to others of the same help.

        The onsite button gives the possibility of doing so while maintaining privacy.

  79. Rob says:

    I started a private practice a year ago. I think you are right on the money in saying that you are worth your fee. I have also set a limit of my base minimum and only allow a couple of spots. An early potential client called and asked if I had a sliding scale, I said yes and the base minimum. She stated that my base minimum was still too high, and she pleaded with me to reduce it lower. Being the naive, green psychotherapist, I said yes to a lower fee. During the initial interview the client walked in with a Whole Foods bag, which I thought was weird. When I asked about financial stressors, she said none. I was flabbergasted. I did not address the obvious inconsistency right then and there, which I wish I would have. I became very resentful and when I did address her, I believe it resonated in my voice. Needless to say we ended our therapeutic relationship shortly. I don’t think a sliding scale is necessarily bad. Now my initial evaluation is the same fixed price for everybody, but I have a couple of spots for sliding scale that are only discussed after initial evaluation- if asked and if I feel it is warranted. I believe the fee issue is what a therapist feels comfortable with, and it takes some trial and error to find that comfort zone. Furthermore, it is alright to raise/change one’s financial policy as one grows in the field. I think that should also be part of the discussion. I think I have prattled on enough.

    • Joseph Burgo, Ph.D. says:

      Hardly prattling! I think that there is no right or wrong answer here, and as you say, “the fee issue is what a therapist feels comfortable with.”

  80. Joel Bell says:

    I appreciate the tenor of the voices in this discussion–which also probably reflects the graciousness of the host…
    I am a PhD depth psychologist who also struggles with this issue. I adopted my fee structure from my own shrink which reads:
    “Psychotherapy, consultation and supervision work on a sliding scale, between $100.00 to $150.00 a session and your perceived ability to pay. Sessions generally run 60 minutes. I do not accept insurance.”
    If I have a “niche,” it would be that I am express that I don’t diagnose and that such a system has become its own pathology. The more recent clients tend to pay within the range quoted. However, more and more the issue of co-pays and insurance reimbursements seems to be preventing people from the negotiation of their particular circumstance and what fee would permit them to receive therapy even when they cannot pay within my range.

    I admire very much the position you describe Joseph, as well as its nuances and am close to removing any initial negotiating as implied by my statement (“And your perceived ability to pay.”) As well, and probably the same sort of boundary issue, I am looking to confine my practice to working hours 8ish to 5ish rather the customer service/closet hysteric model where I must fit into their schedule. Desperation will do that to you and evoke the mess of boundaries as well.

    Thanks for this discussion.

    Joel

    • Joseph Burgo, Ph.D. says:

      Thanks, Joel — and my apologies for taking so long to approve your comment. I’ve been on vacation and only returned to the office today.

  81. Elizabeth says:

    I have read this thread with great interest. I am a clinical social worker in private practice and do not offer a sliding scale. My rates are competitive with my colleagues’. When I decide to take on new clients I ask them up front about how they feel about the financial commitment that is involved in therapy. If it is a problem for them, I give referrals to other clinicians and clinics who may meet their financial needs better. This might sound like I’m giving my business away, but I have had a waiting list of clients for the past three years. When an existing client encounters financial hardship, we create a payment plan that will work for them. I work with a small percentage of “pro bono” cases in that I will accept crime victims compensation and other contracts at a fraction of my hourly fee and do not ask clients to pay the difference. I rarely charge for phone calls to other providers to coordinate care or for short phone consults and e-mails. I accept credit cards, but discourage their use for therapy if my clients are in debt or might risk doing so. If I know a client has a certain budget, we create a treatment plan that might use more homework. If a potential client needs intensive therapy, but cannot afford me, I refer them on. After all, it’s not about me.
    I feel it is my responsibility to give my clients the support and skills they need to “live their lives”. I personally don’t take on clients who may need regular therapy for years. Of course there is not way of knowing this with all clients when they first present themselves. And there are always the clients who come back for “tune ups”.
    I guess my point in writing is that I see a lot of mental health professionals skip over the necessary discussion with their clients about finances way too often. If it’s hard for clinicians to speak to their clients about money, imagine how our clients feel.

  82. Alex S. says:

    I have no issue with your policy on a sliding scale. However, it’s extremely disconcerting to see you defending the therapist who made her client responsible for payment 3 months and 13 months in advance. Saying that everyone’s cancellation policy is different is ABSURD. That is highway robbery and I would run away fast from any professional who tried to pull that with me.

    That’s essentially putting a client on an ‘automatic payment’ system – no different than ordering something off the internet and finding out your credit card has been enrolled for a year without your authorization. No client should be responsible to pay for sessions not rendered – it’s one thing if it’s a last minute cancellation, but 3 months??? Are you joking? No professional with real credentials would do something like this. NO ONE.

    And you should probably stop comparing all therapists to doctors as many just have their masters degrees – 2 years in school, with another year of training…medical doctors spend years more in school with fellowships, internships, etc. Their services are also paid for on a larger percentage by health insurance.

    You need to take into consideration that patients are not shelling out $150 to their medical doctors – they pay office co-pays. While it’s not your fault – insurance doesn’t cover much anymore with therapy. This means that only the wealthy can afford your services – you leave a LOT of people out. If you are booking enough clients to fill your schedule at top price – good for you. but I suspect many are not – and it’s time they get with the program and lower their fees to something that won’t keep people in debt.

  83. anonymous says:

    I have been with a therapist for over 15 years. Prior to her I had many therapists other — some short term, others 5+ years. It took a long time for me to develop trust with my current therapist. (complex PTSD and DDNOS). I started private pay, insurance covered for many years and then policy changes happened three or so years ago and I have been paying predominately out of pocket. Not really within my budget, but I was (and am) very committed to becoming whole and healthy so that I can truly live my one life. In the recent past my employment changed and my income was substantially reduced. Tried to get insurance to cover — but no go. I have asked my therapist if she would consider a reduction (already reduced 30% — but intensive at the moment and go weekly.) For the past year we finally got to where my defenses have been worn down — which I know intellectually is a very good sign, but experience wise is quite debilitating, incredibly painful, and very disorientating. I am at the point where I have not yet developed new inner resources to cope and probably have become too dependent on my therapist. The past year has been beyond intense, crisis ridden and exhausting. I have tried to look into other therapists (many phone interviews) — but can’t get myself to try one. It was so incredibly difficult and painful to get to the place I am now with my current therapist and I can’t imagine beginning again and ever letting anyone in that close — especially in my current state of mind. I truly understand her not wanting to reduce fees (although very disappointed) further since I do have a tendency to play around with the idea of suicide (have been hospitalized several times, treatment for chemical abuse and trauma) and understand the stress and demands a client like myself is . My question is this…I am currently trying to see if I am able to help myself, without therapy — but if I become suicidal or it just gets beyond crazy again — would it make more sense to try to borrow money to continue with my current therapist (who thinks it may take another year to get to the point where I am able to manage my emotions and truly want to exist and be in the world) or try to find another therapist. Your thoughts would be much appreciated.

    I will say I do believe my therapist is qualified, and I do think I have made strides — just I started from Mars and am just entering earth. So… not yet even at square one in terms of beig in the world and relating to others on the same plane.

    • Joseph Burgo, Ph.D. says:

      If you have a therapist you trust and believe is helping you, I’d move heaven and earth to find the extra money to pay the fee. It’s what I did in my 20s, living in a state of deprivation in order to pay for my own therapy.

  84. Jorge says:

    Great subject, thanks for addressing it. Highly subjective though and your positions do reflect the dominant culture of “selling time”. There is actually not much to be said to your well reasoned and grounded piece. In the end, it is a choice. There are consequences to the choices. Your choices fit your particular sense of self.
    About the Europe traveler: once you agree on a fee, based on whatever information the client provided, truthful or not, it is actually none of your business how the client chooses to use the savings. Why the client feels compelled to tell you is a good question. He probably wouldn’t tell his mechanic, or his dentist. You see, you don’t discuss your finances in detail with the client when you set the fee.
    Now, the truth is: there is something off in a culture where the median salary is 35,ooo/year, that a psychotherapist expects an income of 150,000.

  85. Katie says:

    “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?”

    I just wanted to comment on this. I think it is possible the reason feelings of having to pay a lot of money for therapy can seem expensive and is expensive for some people is it is dealing with things that should have been given freely by loving parents in an ideal world to create a loving foundation to live in the world. They were not given and now have to have to pay for it can feel unfair, at least the amount that is required to pay. It also deals with personal, intimate things about a person’s life and who they are as a person but is actually a business transaction that can lack unconditional love needed or to show a person how to give that love to themselves. It should have been free at birth from parents but was not and now have to pay large amounts of money seems not right in some way. The problem is, it IS business. That’s my short comment with much more I could add.

  86. Deborah says:

    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’.

    If my car broke down & I couldn’t afford to repair it……or even when I run out of gas by the end of the month…..I sit at home & I don’t go to the places I want to go to or I find someone who can pick me up until I can finally afford the money to fix the problem. I have no way of spending money that I don’t have & I will NOT use credit in order to spend money I don’t have either.

    As for the dentist….I have a whole mouth full of broken off teeth that I can’t afford to have fixed……even going to the University Dental school which is the lowest possible fee available….I still don’t have the money to pay their no interest monthly payments….so I do without until I get to the point where I have the money…..& that’s just the fact of my life that I have to live with because I refuse to pay money that I don’t have.

    So if my only option was to have a therapist who charged more than I could afford…I would do without no matter how bad I needed the help….or I would try to find one who worked within my financial limitations……I have been lucky because I have found the most wonderful psychologist & DBT group that does work within my limitations & I have received more help from them than all the full payment high cost psychologists I ever found in California now that I have moved to KY.

    With your policy, you either get only those rich people who can afford your price or poor people who pathetically will go into debt no matter what just to have you for a psychologist…….hmmmm, interesting limitations to be placed on a practice.

  87. Rich says:

    Dear Dr. Burgo:

    I understand exactly how you feel about your fees. Your outlook is not unreasonable. I would NEVER be so rude as to ask a man to work for less. If I can’t afford it, I’ll just go somewhere else and look for alternatives. I hate to be negative, but the fact is some people are just darn “cheap-skates” even though they have lots of money. I think THAT is a form of mental imbalance – in my unqualified and unprofessional opinion.

    I once had to find an alternative, and did. I got help from a counseling center that had post-doctorate students doing counseling. It was free if you had no money, and the most they charged was $65.00 dollars per week for up to three sessions per week. Sure, the guys were not that experienced but they had the education.

    I paid the $65.00 and came in twice per week. I consider that a very reasonable! It did help a bit while I was going there. The only thing I did not like was these guys constantly urging me to go on anti-depressants. No benzos for me, thank you very much!

    All that being said, this article brings up a problem with a very straight-forward answer. Healthcare, including mental health, needs to be nationalized. Patients would not have to pay to see ANY doctor for ANY reason. The doctors would become employees of the State. In a system like that, however, education for those with the ability to be doctors should also be free and provided by the State. These doctors should also be EXEMPT from any income taxes because they are serving the public.

    Health care for profit is just immoral. I am not saying you are immoral, but the entire system is. We need Socialism… relegate all the corrupt health insurance companies to the history books as a lesson on how NOT to take care of society!

    • Joseph Burgo says:

      Ah, we could have a long conversation about how to manage health care in this country. I lived in France for a year and was thoroughly unimpressed by the free medical care. Plus if everything is free then everyone would want to go a therapist and there would be a shortage with the familiar waiting list.

      But let’s not argue!

  88. Lee M. says:

    What if instead of a sliding scale, a different kind of format was set up. Two comes to mind:

    1) A set fee for a disorder or problem ($500 to overcome social anxiety) with some well defined boundaries. This way, the person will feel free to get the goal met with out feeling like there is an attempt to drag out the number of sessions.

    2) Auction off the hours according to demand. The low price will represent low demand time slots and levels of experience. The high price will represent high demand times and more experience.

    • Joseph Burgo says:

      I think those are both interesting ideas. I have two questions.

      What if the client doesn’t “overcome” the problem within that “well defined boundary”?

      In number 2, are you talking about different therapists with differing levels of experience?

      • Lee M. says:

        Idea #1, My brainstorm in relation to a set price per set therapeutic intervention would be based upon some well established reference point. For example, mechanics often charge by the ‘hour’ for a particular service because there is a industry average expectation of being able to do that particular task in a particular amount of time.
        Now, I know that doing an intervention is much different and more variable than doing an intervention with a human being with emotions and baggage, but I ponder if the “set price/goal set” would increase motivation and lower resistance. Thus, the supposed amount of time would be less. Perhaps?

        • Joseph Burgo says:

          Hmmm. I doubt it, but I’m curious to hear what others think. I’ve known therapists who have set termination dates with highly resistant clients, in order to lower their resistance and get the work done. It didn’t seem to work.

      • Lee M. says:

        Idea #2, regarding the auctioning off of the hours, yes, there would different levels of experience and different levels of uniquness that would be reflected in the price. The inexperienced counselor would 1) have less skills 2) have more time 3) have to start somewhere. Thus, the demand would be low and they would have lower prices. Also, they may be able to start building up their volume but those that are looking for the low cost option.
        The more experienced would have more demand of their limited supply of hours, and then be able to charge more as time goes on because of their reputation.
        In a way, this is already happening now because therapists do charge different based upon experience. The only difference is that there would be more variability in the prices as the individual hour would be bid on. Evenings may be in higher demand, so the price would be higher. The unemployeed worker that may not have as much money but have more time on his/her hand could have therapy during a time of less demand.

        • Joseph Burgo says:

          Lee, I think you’re right, that in many ways, this is exactly how it functions. My fee was much lower when I was less experienced and had fewer clients. That’s how you build your practice. I’m not sure about how the evening/day thing would actually work, but I do know that when I was younger and would still reduce my fee on occasion, I was much less willing to do so for my evening hours.

  89. Laura says:

    Firstly, thank you the work that you do on this site. It has been very informative and helpful to read not only your words, but the comments of others. I often look for some form of mini-therapist-replacement during August, so it was handy to come across this resource.

    The issue of fees and boundaries, for me, is an emotive one. It never occurred to me to think of paying anything less than the full fee, and, if I could not afford to pay, I could not undertake the therapy.

    However, I am self-employed and, over the past 6 years, I have been periodically without work. I have been honest about my position and have suggested either a reduction in the number of sessions (currently 4 per week) or ending the therapy.

    My therapist has twice offered different ways of managing the fees which have involved me paying at a discounted rate and then paying the balance when I have got work again. Whilst I found these conversations uncomfortable (shame derived from thinking I “should” be able to pay), we did work things out and manage to discuss my view that the fee is a major boundary for me. I am also aware of, and grateful for, the trust that he placed in my ability to generate work.

    Where it became unmanageable for me was the third time when it was taking a very long time to get more work and I was increasingly anxious about my ability to continue paying for the therapy; I had worked out when my money would ‘run out’ and the deadline by which the decision needed to be made and was fretting as it became closer. My therapist attempted to reassure me and mentioned that, if necessary, he would work for free. My logical self recognised this as an amazing display of support and kindness. I proceeded not to be able to speak to him for three weeks (muteness being my primary fear response).

    I managed to get more work within days of my self-imposed deadline. I felt an immense level of relief that the issue of “free” therapy did not, in my mind, require any further discussion (or muteness). It struck me how important it was to me that the professional boundary created by fee-payment was kept, rigidly. That there was NO WAY that it was safe for me not to pay for my therapy. Even though I live in London, and had previously received NHS delivered psychotherapy.

    This issue has opened up a massive conflict for me as I can see through my behaviour that my defense mechanisms had been triggered, so it is important to work this through with my therapist, however, they have been triggered to such an extent that talking is nigh but impossible. I will do one day though. It’s on my “to-do” list – not that I am trying to control everything, just most of it.

    So, whilst I am immensely grateful to my therapist for his flexibility; I am also incredibly challenged by what it represents to me. I probably would never approach a therapist who worked on a sliding scale of fees. I couldn’t tolerate the uncertainty and would probably insist on paying the highest price, even if it were beyond my means.

    • Joseph Burgo says:

      I suspect that there are some important issues around emotional dependency here, and that it feels much safer to believe it’s a purely financial transaction rather than a deeply emotional one.

  90. Bee says:

    Hello Joe
    “…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. ”
    Wow. We seem to inhabit very different worlds. I completed a year-long MSW internship in a pre-doctoral training program for PhD Psychology candidates (university clinic setting). For that clinical year, I was also the official supervisee upon whom the pre-docs trained, for supervision skills. I was asked “What do social workers do, anyway?” I heard many conversations, passionate, about what fields the pre-docs decided they would never enter, how much they would be charging, their expectation that they might be able to prescribe medications, which would increase their income. Eager, sure of their future. At the time, I was a divorced, single, custodial mother with two children in college and a teen with a classified disability. I was responsible not only for my own education (I have always paid my own way), but half of my kids’ (and the child w/disability is now in college). I do not need to tell anyone how difficult this has been, we all find out eventually.
    In my graduate program, only one person (a young spouse of a medical doctor) was even close to your description. In my work, usually with non-profits or other similar agencies, there are no PhDs willing to take on these jobs. I saw mandated clients, testified in court, coordinated services in homes, with foster-care agencies, adoptive agencies, worked with victims and perpetrators of all ages, individually and in families. Some of my clients are dying. Some are trying to kill themselves. Many are substance abusing, self-mutilating/self-harming. They hustle in various ways. Many have committed the worst of horrible crimes, and yes, they tell me. I have exercised “duty to warn”, engaged child protective services, been threatened and stalked. I was hit, once, by a young woman. I’ve worked and been on-call weekends for psychiatric emergency, suicide, rape and assaults, meeting people in hospitals and specialized clinics, arranging for safe housing, carrying extra clothing with me at all times, coordinating with police and extended family. My cohorts made home visits in all sorts of situations and scooped up all manner of people who fall through ever widening cracks. In these clinics, in prisons and jails, there were no PhDs except in an occasional administrative position. Often, my work would be restricted or end due to budget cutting. Women’s and children’s programs usually get cut first. So I write letters to senators, and I advocate. I provide my own health insurance, as a contract worker. My jobs have paid between $15-25 an hour. I buy my own supervision, my own therapy, buy my own malpractice ins, try not to screw-up, and am not unusual. Social Workers, Psychologists, Psychiatrists, Doctors, Nurses, Mental Health support personnel and Administrators work best in the interest of humanity as an integrated effort. I do not consider my cohorts to be hobbyists, Joe.

  91. HJ says:

    While, I totally understand where you are coming from, you are not the type of therapist I want to work with. I think you forget or don’t want to think about the fact that some clients are adult children who want to be taken care of. It’s like “I am a child and I want to do whatever I want and why can’t you just support me a little here?” By saying your needs must be met, you’re saying adult childrens’ needs are not the most important. Adult children must be felt their needs are the most important.

Leave a Reply

Your email address will not be published.

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>

This post is password protected. Enter the password to view any comments.