I know a lot of people think that sliding scale is a cool thing to offer. I am opposed to sliding scale. I’ll tell you why: Because in my first year of private practice, a college counselor convinced me to take on one of his students at half price. Then she came in every time with some new gold bracelet or cashmere sweater, and talked about the fancy restaurants and clubs she went to, that I couldn’t afford to go to. It didn’t work for me.
At the same time she was paying me $50/hr and I resented it, I was accepting other clients via Medicaid and getting $39/hr, and not resenting it. It wasn’t the money, it was the dynamic.
And on the other side, when I’m a client, I despise sliding scale – even in those years when it would have allowed me to pay on the low side. It makes me uncomfortable, because I like to know where I stand. I never know whether I’m paying the “right” amount. I don’t want to pay too much, or too little.
So I don’t think sliding scale works. For either the client or the business. Maybe it does work for some other people, but not for me.
Occasionally I have made exceptions. Someone showed up from another country, circumstances confidential, and I chose to invest a few days of therapy in her, no charge. I still feel good about that. Another client, back in my private practice days, ran up a large bill that took years to pay off. I feel fine about that, too. I found that I have been more successful in offering special arrangements based on special circumstances, and at my discretion, rather than as a standard practice.
I do support the values that sliding scale is supposed to represent: that professionals can help people in need by charging less sometimes; and that people who don’t have as much money can still get the help they need. I’ve just come up with other ways to achieve these, at least to the extent possible, for our nonprofit organization.
For example, if someone can’t pay our standard rate for a training, we often have trainers in training who work for a lower rate. And if they can’t pay that, well, we probably won’t help them. And similar for treatment. If someone can’t afford our typical therapy rate, we often have recent hires (that we have trained, and supervise) at a much lower rate. And if someone can’t afford even that lower rate, sorry, but we can’t give free service to the world.
I wish we could, and we try, but it only goes so far. We’re grant-funded to provide free therapy to victims of crime in our primary location, and we’re working towards doing this in other locations as well. We’re also pursuing other grants and contracts to provide free therapy. And we are conducting research that may establish intensive therapy as a standard therapy format so that ultimately insurance companies will cover it. But meanwhile if we give it away without somehow getting paid, we can’t afford to pay our staff.
We do disappoint people who don’t have the resources to access our services. They’re not happy about that, and I’m not either. But I’m playing the long game. So I have learned to live with disappointing some people every day, because we do not offer discounted or free training or therapy (unless the cost is getting covered in some other way). In fact we do a fair bit of unpaid work, but it’s primarily focused on our research. Thus our pro bono contribution is an investment in working towards a mental health care system in which the (currently) unique trauma-focused intensive therapy service we offer becomes widely available to all.
We all have to find our own balance and methods of making a living and taking care of others. Mine doesn’t skimp on taking care of others. And it doesn’t involve a sliding scale.
9 Responses
I agree- truly low income individuals may receive general mental health services at federally qualified health centers (FQHC’s) on a sliding fee scale. What is needed, to insure that not only those with either adequate income or insurance plans have access to highly trained specialty care such as is provided in trauma treatment, is for more clinicians to receive that training. As with education, significant disparities in quality of services exist, along economic lines.
We did a needs assessment of community mental health agencies in our region (Western MA) and found that only an estimated 6% of clients were receiving evidence-based trauma treatment. Despite the universal recognition (of our respondents, the clinical directors) that trauma was, for most of their clients, the most important thing to address. We feel we can help more people by developing and teaching effective treatment methods, than we can by only providing the treatment ourselves.
I am in disagreement. If a client has been raped or suffered severe trauma and is on sliding scale and has a piece of jewelry and or goes out to a place to dine you cannot afford, that is not her problem. She deserves to go out, do kind things fir herself and there are millions of dollars in the crime victim fund that pays for treatment. I was so fortunate to not pay 1 penny for the trauma therapy I received following a parent’s murder. I could go out to dinner, a means to overcome my PTSD. Thankfully federal and state and community empathy helped me heal. No one got wealthy off of being a therapist there. This thread sheds light on why so many people do not get the healing they need AnD deserve. Its like saying,” sorry about your abuse and trauma, don’t live, don’t do a kindness to yourself, just pay top dollar for me. No wonder why others turn to drugs, alcohol and sex, its cheaper.:(
Deni, I’m very glad to hear that you got treatment that was both helpful and free. We offer free helpful treatment to victims of crime, too; it’s a good thing.
Note that free therapy is not sliding scale; when it’s free, there’s no uncertainty about what is correct or expected re payment.
I have nothing against people going out to dinner or having nice things. I just didn’t like the feeling of having a client continuously blowing cash on luxuries while I had given her half-price because she had claimed not to be able to afford my fee. I find it much easier, personally, not to judge people’s choices re $ when they do not impact me directly (for example when I have given them a cut rate). In fact, I think I can be a better therapist by not putting myself in this position. If some other therapist can manage sliding scale to their satisfaction, that’s great; it doesn’t work for me.
Not liking sliding scale is not the same as being greedy and heartless. There are other ways to be caring and helpful, as noted in the post.
While it is a personal choice to offer a sliding scale or not, the more important ethical consideration is to ensure you are applying your exceptions fairly. A truly skilled trauma therapist can look objectively at these dynamics and the ways they reflect the patterns that the traumatized person has developed to cope. Sliding scales are often set up to ensure that therapists are charging everyone fairly based on an objective metric rather than a therapist’s opinion about a client’s wealth. Usually a client has to provide a pay stub or benefit check to show income, and while it is of course not perfect it at least shows an attempt to be equitable. I hope that other clinicians do not see this post as acceptable modeling of attitudes toward clients. You may have missed something important through your biases…for example, someone who is being actively sexually exploited may very well show up with a new phone and fancy nails each week. Having “things” does not necessarily signal that someone has money.
I agree with the fairness/equitable point if one is running a large group practice or clinic with a generic mission to serve all fairly and equitably. I do not agree that this should apply to therapists in independent practice. When acting solely on their own behalf, therapists are entitled to determine the direction of their charity. There is no rule saying that I must give every charitable cause equal or fair consideration. To the contrary, I may be particularly interested in supporting environmental causes and have no interest in supporting the arts. Similarly, just because I treated one person at no charge does not mean I should treat everyone at no charge. I get to choose to whom or what I give.
I strongly agree with another of your points: that therapists should make an effort to maintain a positive and non-judgmental attitude towards their clients, even when their clients may (for example) claim poverty and then show up with a new phone and fancy nails.
The way I maintain the positive and non-judgmental attitude is by not offering a sliding scale! Then I do not feel taken advantage of, and am able to be more objective. This is one way to operationalize maintaining the therapeutic frame and focusing on the client’s needs: by not entwining the therapist’s own needs with the client’s behaviors.
Hi… I’m not here to agree or disagree agree with any of the prior posts on this issue. I believe each individual has valid points on a whether a “sliding scale” approach to payment for services. I’m only here to ask for opinions on a hypothetical basis. If a client is in need of financial assistance or “free” services or if they still cannot afford to pay for services because they were unable to obtain treatment at no cost and it will take them years to pay for the treatment, how is a decision made to either offer them the government funded treatment at no cost, allow them to pay for the treatment in a timely manner in which their income allows or to make the unfortunate decision to be unable to treat them at all?? I do agree that someone who is receiving “free” treatment should not be coming in with expensive new things every day or week of treatment, but, I also think that other situations could be taken into consideration such as if these items were a gift or gifts from a friend or loved one who is “wealthy” or has the means to do so and is doing so out of love and support for the person receiving treatment. Or, another situation that comes to mind is what if the expensive things are a coping mechanism for the person receiving treatment?? I ask this as it used to be one of my many coping mechanisms to deal with my own “issues”, for lack of a better term. Also, if the person receiving treatment is disabled and receiving SSDI as their only source of income and is an adult who is considered single and therefore, if working and filing taxes would claim themselves as head of household, with or without any claimed dependents such as a child/children or spouse, but is living with or without parents who are in societies opinion, “well off” or “wealthy”, would their case be considered on a basis of their personal income from the Social Security Department or would their parents income or if retired, their savings, assets, ability to take out a loan, etc., be taken into consideration of payment vs. no cost treatment?? I can think of many scenarios in which a person who claims poverty could obtain expensive things. Besides being gifts, they could be stealing or borrowing these things, in either case to make themselves feel better about themselves for whatever reason. I personally feel dressing well while in treatment or any other setting helps increase self-esteem which in turn helps with focusing more on the task at hand rather than comparing myself to others because I’m either jealous of what other people look like or have that I don’t and/or feeling like a lazy, unmotivated slob. But that solely based is my own “issues” with body image and how others perceive me. One more point I’d like to make is that a person seeking treatment could be very wealthy but dress like a person in poverty in order to convince others of his/her need for a sliding scale. I realize there are SO many factors which could persuade or dissuade a person from receiving treatment on either a paid or “free” basis. Does multiple referrals from different outside therapist’s/psychiatrist’s/physicians come into the decision making process?? Thank you for taking the time to listen to my thoughts on this issue!! Be well and to Dr. Greenwald, thank you for offering these treatment programs to the community… I’ve been told that these therapeutic treatments can be life changing from a number of different individuals!!
I can only respond as pertaining to our own program, in which we offer intensive trauma-focused therapy at no cost to Western Massachusetts victims of crime. We don’t do any type of evaluation of the client’s ability to pay. We just offer the service at no charge, to anyone who is eligible. Eligibility is determined by where the person lives, whether or not they have been a victim of a crime, and whether we determine that they can safely and productively engage in intensive therapy at that time.
One advantage to providing free therapy — similar to providing therapy at one’s standard rate, without using a sliding scale — is that we are not required to judge a prospective client’s financial means.
The narcissism and outright lack of empathy coming off of this blog post is downright sickening! I hope your clients don’t experience this disgusting attitude during their visits! This is almost Jordan Peterson levels of greed and narcissism!