Should You Offer a Sliding Scale in Your Therapy Practice?

The National Institute of Mental Health  estimates that approximately 25% of individuals living in the United States are living with a mental health concern. This includes a range of mental health concerns such as anxiety disorders, depressive disorders, substance abuse disorders, mood disorders, and personality disorders. Mental health concerns impact everyone differently which means that some will struggle more than others. In this post, I discuss everything you need to know about offering a sliding scale in your therapy practice.

The National Institute of Mental Health reported that approximately 64.5% of U.S. adults living with a serious mental illness in 2020 received treatment for their concerns. This does not account for the millions of individuals who are living with mild to moderate mental health concerns, and those who are struggling without meeting criteria for a mental health concern.  If only 64.5% of these individuals are receiving the care they need, it means that there is another 35.5% of individuals not getting the care they need. This is millions of adults living in the United States struggling more than they would be if they were engaging in the appropriate treatment.

There are a variety of barriers that Americans face when it comes to mental health care. The first of which would be access to the proper care. In rural areas, there can be limited access to mental health professionals and other treatment options. Some individuals may not have the means to travel to health care providers. Recent years have had a significant impact on Telehealth medicine, and the use of virtual appointments. While this has undoubtedly had a positive impact for many individuals, not everyone has access to the internet or a device to access virtual health care appointments.

Another factor that many potential clients have to worry about is the cost for treatment. Mental Health treatment can be costly, especially for individuals who do not have medical insurance, and those with high co-pays. Therapy sessions can range from $75- $200 per session depending on the provider. Even for those who have insurance coverage, having a copay each week may be an expense that they cannot spare, despite how much they are struggling with their mental health. Having a sliding scale therapy practice can benefit individuals who are struggling and are not able to afford the mental health treatment that they need. 

What is a Sliding Scale in Therapy?

Sliding scale practice typically occurs on an outpatient treatment basis. Sliding scales are typically available in a private setting that is not run by a larger company or corporation.  The main difference between sliding scale therapy and other mental health therapy is that the fee for service is based on the client’s income or another predetermined factor, not a flat rate.

When it comes to the therapy sessions, there is no difference between sliding scale practice and other mental health practices. The overall goal of sliding scale therapy is to open a door for the almost 40% of individuals in the United States who have a severe mental illness, and those who are living with mild mental health concerns. As therapists, we would provide the same level of care we would to any other client, and use similar therapeutic approaches. Deciding to offer a sliding scale requires significant planning, thought and consideration for the benefits and negative aspects of it. 

Benefits of Offering a Sliding Scale

Let’s explore some benefits of offering a sliding scale in your therapy practice:

1. Helping Individuals Who Can’t Afford Mental Health Care

The main benefit to a sliding scale practice is that you would be able to help individuals who may not be able to afford the mental health care they need. This allows you to maximize the positive impact you can have on your local community.  If you are wondering about how this would impact your overall income from the practice, a sliding scale tends to balance out when you are charging based on the individual’s income. 

2. Increase in Therapeutic Gains

If we look at this from a client standpoint, there are a variety of gains that they can get from a sliding scale therapy practice. They may find that they are less stressed about being able to afford the care they need, which can have a positive impact on their therapeutic gains. Having access to weekly sessions can have a significant impact for someone who is struggling with a severe mental health concern.

3. You’re in Control of Your Cost Structure

Another benefit to a sliding scale in therapy practice is that the therapist is in control of the scale, and how to calculate the sliding scale fees. Typically, sliding scale fees are based on the client’s income. There are a few ways that a therapist could go about establishing their sliding scale. One of which would be to assign a session fee to specific income levels. For example, someone who makes between 30,000-40,000 annually may be charged $50 per session, whereas someone who makes 100,000-115,000 annually may be charged $150 per session. A second option available to Counselors and Therapists is to use a formula that determines the client’s fees. Formulas can take the individual’s income into consideration. 

Negatives of Offering a Sliding Scale

Now that we’ve reviewed some positives, let’s highlight some of the negatives of offering a sliding scale in your therapy practice.

The idea of a sliding scale therapy session sounds idyllic. After all, we become therapists because we have a desire to help others. There are, however, some things to consider when you are trying to decide if a sliding scale is the right thing for you and your practice.

1. Potential Problems with In-Network Insurance

Something you will want to take into consideration is if you are working with managed health care companies. Many managed care companies have contracts with the health care providers that are in-network for their members. These contracts tend to be specific about the cost of your service, and the percentage that they will cover.  If you offer a sliding scale fee that is less than what the managed care company had agreed to pay, they can then opt to pay for their percentage of the sliding scale fee, not your previously stated fee for service.

If you do not work with a managed care company, you do not have that concern to consider. However, you may run into a client with a similar thought process if they learn that you are charging a lower fee to someone else based on income. While this may be easier to navigate than a managed health care company, it can still be a difficult situation. This would also be dependent on clients talking about the cost of their sessions.

2. Ethical Concerns

There are ethical concerns that can come into play when we talk about sliding scale fees as well. Keep in mind that fees, including sliding fees, are typically negotiated and agreed upon in the first session.  Charging someone less for a therapy session based on their income can be seen as discriminatory. As an example, you can have a client who has a higher income than others, however this individual may have more expenses each month. Not luxury expenses, but maybe this individual has medical expenses, has children, or cares for a loved one. We do not know enough about our client’s financial situation to fully understand their abilities in their initial session.

3. Advertising Your Sliding Scale

A tricky part of offering a sliding scale is how to let people know that you have one. If someone is worried about being able to afford therapy, chances are that they will look up a number of different providers to compare prices. Which brings us to our next discussion point of advertising your sliding scale.

There are pros and cons to advertising your sliding scale. A pro is that it can be seen by individuals who may not reach out to you after seeing your typical fee for service. The down side to this, is that you could have individuals ask for a reduced fee with other motivations. As an example, someone may not want to pay the full fee if they have hesitations about going to counseling in the first place. You would then have to tease out the factors that contribute to your sliding scale.  A sliding scale is meant to help individuals who are struggling with their mental health and truly cannot afford the mental health care treatment they need.  

Final Thoughts on Offering Sliding Scales in Your Therapy Practice

If you are on the fence about offering a sliding scale fee in your therapy practice, take time to consider your motivations. Was there an event or a trigger that set this idea in motion for you? And if so, spend time with that event or trigger to understand why it led to you wanting to make a change. There are alternative options that a Counselor or Therapist can do to offer services to those who may not be able to afford sessions, such as offering pro bono sessions in your schedule.

If you are currently working with a contract with any managed health care companies, you will want to decide if you would be comfortable with the companies paying your sliding scale fee if they learn of your lower fees. Chances are, you would want to use an alternative option to help individuals who are unable to afford your services.

If you still find yourself on the fence still, another option would be to speak with colleagues who offer sliding scales. There are a lot of variables to consider if you are thinking about having a sliding scale, and then even more to think about if you decide to implement one. For example, what criteria would you have for individuals who are able to use your sliding scale?  It may also be useful to talk through negotiating your fee with clients as well. Money is often viewed as a taboo topic to discuss, and can be uncomfortable for us as professionals and for our clients.  If you have a colleague who offers a sliding scale fee, you can also speak with them about how they approach the topic with new clients. Is this something they have in their intake forms, or is it something they mention to clients based off of what is being discussed in session?

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Author: Kayla VanGuilder, MA, LCMHC

Kayla is a Mental Health Counselor who earned her degree from Niagara University in Lewiston, New York. She has provided psychotherapy in a residential treatment program and an outpatient addiction treatment facility in New York as well as an inpatient addiction rehab in Ontario, Canada. She has experience working with individuals living with a variety of mental health concerns including depression, anxiety, bipolar disorder, borderline personality disorder, and trauma.