This is the 4th post in the series
Reduced Fees, Sliding Scales, and Lessons Learned.
The series actually begins here.
How Does Your Reduced Fee Reflect on Your Overall Reputation?
Are you thinking about advertising the fact that you offer a sliding scale fee? I strongly discourage mental health professionals from doing this and here’s the reason why . . . .
Once referral sources discover that you routinely provide services for a reduced fee, that is the idea that 
becomes attached to your name i.e. you provide the cheap stuff.
That’s NOT what you want to be known for even if you run a non-profit and routinely charge less than the Usual and Customary Fee for your services.
Your reputation should be based on the services that you provide and what differentiates you from your peers . . . not on having the lowest rates in town.
You make a good point. As a balancing (not refuting) view lower fees don’t necessarily mean lower quality. Quality services (quick responses to referral sources, being on time for appointment, getting referrals in within a week, progress updates when appropriate and with releases, focusing on real life measurable outcomes, professional and collaborative participation with teams, frequent check in on the therapeutic alliance, and discharge planning from the outset) are recognized by both the client and the referral sources. The fee in therapy isn’t tied 1:1 to quality… you can do both and be known for both.
Thanks for a great thought provoking blog!
J. Kipp! Welcome back! You are absolutely right. Low fees do not equate to poor services and higher fees do not equate to higher quality services. What I meant to say is that once a therapist becomes known as the one who offers services at a reduced fee, colleagues often begin to refer all their low-fee clients to that therapist while keeping their full-fee clients for themselves.
It’s important for therapists to know what they can and can’t afford to give away – time, talents, and resources – and to recognize the implications for doing so. Those boundaries will enable you to donate the right amount to the right clients in the right way . . . so that your clients and your own needs are met while growing your private practice.
Tamara, I’m not sure whether to question your choice of colleagues or the ethics of those colleagues first; that is assuming you actually experienced what you talk about here. You raise some solid points for consideration. They aren’t points that support some of the conclusions you draw, however. You sum it up best in the second paragraph of your response to J Kipp. And none of what you say there implies that any of the ‘bad things’ you mention will happen.
Hi, Rob. It’s good to have your voice here.
“Colleagues” in this post is defined as the members of one’s profession so I’m sure that we can agree that I didn’t “choose” my colleagues. And, overall, I am very proud to be associated with the licensed counselors that I work with.
And, yes, I actually have experienced other professionals acting on their clients’ best interests and referring them to services with sliding scale fees. As a Licensed Professional Counselor, it is expected that we will gather and have available resources for our clients. As such, it is logical to conclude that if you advertise that you provide your services on a sliding scale fee, others will likely retain that information as a resource for future clients in need.
It has also been my experience on more than one ocassion to have been present in conversations with other professionals who questioned the quality of a therapist’s skills based solely on the fees charged for services. As I’ve already stated, it is not logical to draw conclusions about quality of services based on fees charged or the population being served. Nevertheless, my point is that it happens.
The truth is your published fees say a lot more about your perception of the value of working with you; and, those same published fees say a lot less about the actual quality of the service being provided. I’m simply advocating that counselors be conscious about when / where / how they choose to adjust (and advertise their adjustments of) fees to accommodate clients in need.
Rob, do you offer a sliding scale fee and, if so, do you publish it?
Tamara,
I never thought about the points you make outlined in the blog post above in terms of becoming known for offering sliding/reduced fees. I have been questioning taking this wording off of my website for a while now and your points really got me thinking that I don’t want to continue to advertise a reduced fee option. In talking with colleagues and supervisors, there were other reasons I was considering taking that wording down and I hadn’t even thought about it from the perspective of how colleagues perceive our services. Thank you for opening my eyes to this additional perspective! It definitely has given me more to think about and just in time because I’m working on a website redesign!
Catherine, you’re so welcome! Each of the mental health disciplines addresses in their codes of ethics the need to make our services available to those who need them so my assumption is that all responsible and ethical mental health professionals do so. However, I do not advertise that I do so or how I choose to do so and I recommend that other professionals follow suit.
I want referral sources to refer to me because they recognize my clinical skills. I want clients to choose to work with me because we are a good fit. And, I want to make those financial accommodations to highly motivated clients who are going to do really well with me – and not to brand new clients who are choosing me simply based on my fee. I know that from a clinical standpoint and also from a business standpoint that my best work gets done with clients who are highly motivated to work with me.
(Don’t forget to let us know when your website re-design is done!)
Tamara,
Yes, I completely agree with you! Since graduate school, I have known that making my services accessible to those who may not be able to afford my full fee is a value of mine and it would feel incongruent to not offer reduced fees to a highly motivated client who is a good fit. I have had the experience where clients chose me based solely on my lower fee and I have found that therapeutically, they were not highly motivated and I found myself working harder than they did. From a business standpoint, those are not the types of clients I want my practice to be built on for a plethora of reasons. I am curious how you handle this on professional profiles (i.e. Psychology Today) that ask you if you offer reduced fees and in person at professional networking events when you’re asked if you offer reduced fees/sliding scale?
Before I answer your question, Catherine, I want to touch on a different point. Sometimes I hear therapists blaming the client for the “poor fit” and “lack of motivation.” That’s not what I’m hearing from you but still . . . I hear it way too often. And, truthfully, I’ve been that whining therapist on occasion and know how easy it is to go there if we aren’t vigilant about our own boundaries i.e. knowing what belongs to me . . . and what belongs to my client. So . . . as a heads up for any of you who may find yourself feeling like your client isn’t “motivated enough” or isn’t “trying hard enough” or some other seemingly logical version of blame-the-client . . . . Any time this shows up in your thinking, I would urge you to rearrange your brain to acknowledge and embrace this mindset as being much more about a glitch in your own boundaries than it has anything to do with your client.
I do not state that I offer reduced fees. At networking events or whenever I am asked by a potential referral source if I offer reduced fees or a sliding scale, I respond by saying “I am happy to talk to this client to see if we are a good fit. If I’m not, I will be happy to refer her to other colleagues that I trust to do good work. I will work with him / her on the finances if that’s what we need to do. And, I have never refused to see a client because of money.” I tell the truth.
Hi Tamara,
Thanks for touching on this different point. I think it is an important reminder for all of us to not fall into blaming the client and I appreciate you bringing it up in this conversation. I think that being vigilant of our own boundaries, self-reflection, and professional consultation/supervision are critical imperatives for each of us as therapists. Also, thank you for answering my question regarding how you answer questions about sliding fee at networking events or when speaking with potential clients. It is helpful to hear how you would respond and to think about what is my truth and how do I want to respond to these inquiries? Thanks!
You’re so welcome!
Hi Tamara,
I appreciate your posts, because frankly I think we often do not know our worth and there is a general mind set that mental health should be free or low cost. This obviously does not negate the truth that the general public needs increased access to services, but not to the tune of the provider ending up in great need because of it! Nevertheless, I wonder about your thoughts on the new site: Open Path that is a place to directly advertise your willingness to take on lower fee clients at Open Path’s determined range (30-50). The site is: openpathcollective.org. Thanks in advance for your thoughts!
Hi, Rachel! Thanks for dropping into chat!
I think each of the major professional associations for mental health professionals mandates that we not make our services available just to those who have resources and it’s up to each of us to decide how to do that.
While many of my colleagues and friends choose to offer a “sliding scale,” I rarely find that they are offered in a fair and equitable way.
Open Path seems like a great alternative for those who choose to offer reduced-fee services and I love the idea of making our services available to those who cannot otherwise afford them.
Hi Tamara!
I know this is an older post, but hoping to get some ideas. Im actually starting my own speech therapy private practice and figuring out the best way to get paid.
I have a few clients right now that pay a reduced rate–and I want to try to become an insurance provider for them. Can I raise their rates once I am a provider? Is that legal?
Can I provide private pay clients with a reduced rate if they pay for a certain number of sessions ahead of time? like a package deal? or do I need to provide those same packages to clients that are in network?
I live in an area that slideing fee scales occur regularly and there is a mix of individuals that are really well off and those who are really poor. Im trying to figure out how to set my rate to appease both groups… but its tricky.
thanks,
Amber
I have a peculiar problem as an Indian therapist practicing in India. There are many Indians working abroad (US, UK, Europe, etc) who choose to be in therapy with Indian therapists based in India and not in the country they’re living, so they can pay far less fees for the same services, which can sometimes feel prohibitive abroad. Mostly, they share this reason openly. Sometimes, they say they’re (also) doing so because an Indian therapist will better understand their cultural nuances – which is true – though, they don’t consider that an Indian therapist in their (adoptive) country may understand the nuances of straddling two identities even more.
I’m confused as to what fees to charge such clients. One, irrespective of geography, I’ve experienced in my years of private practice that if the fees is far below the client’s means, for the most part, they take therapy for granted. Two, I wonder about economic equity (over equality) — my clients in India invest a certain percentage of their earnings/spending capacity on therapy, while clients abroad have double or triple the earnings (and often, also spending capacity) based not necessarily on working more but on earning in a currency far stronger than the Indian rupee and thus spend a smaller percentage of their spending capacity on therapy, because they live/work abroad while also having access to therapists back home.
Would it be reasonable to offer such clients a sliding scale that starts at a higher amount? E.g. if my fees is about 20-25 USD (for 60 min) for my clients in India, with a sliding scale/reduced fees option based on their financial circumstances, that I ask Indians working abroad for 35-40 USD with a sliding scale/reduced fees option? This is still significantly less than they’d pay a therapist in their adoptive country, so that therapy is still comfortably accessible to them, while being more equitable with what Indian residents/citizens pay.
I appreciate you reading this; thank you so!