Why We Don't Offer a Sliding Scale

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September 28, 2016 at 2:54 PM

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.

Tags: sliding scale social justice psychotherapy

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Posted by Virginia Pond, LCSW on
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.
Posted by Ricky Greenwald on
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.
Posted by Deni on
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.:(
Posted by Ricky Greenwald on
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.
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