On Sliding Scale and Why Therapy Costs So Much
What's a sliding scale? Should I take advantage of a sliding scale? What are my sliding scale options? Why does therapy cost as much as it does? Are therapists greedy? Answers below...
The Sliding Scale
The sliding scale fee approach helps remove financial barriers that might otherwise prevent people from seeking therapy. It acknowledges that mental health care should be accessible to everyone, regardless of their financial situation. Many therapists offer a sliding scale rate to do a small part in making therapy accessible to more people. A therapist may offer a range of prices depending on income (for instance a therapist’s full fee is $200 but offers a price range between $80-$150 for people who cannot pay their full fee) or a therapist may offer a specific price and hold a few spots at that price (for example, 3 spots at $60 at any given time).
The sliding scale can help make therapy accessible for a few people. However, to make therapy accessible to all, serious systemic changes need to occur that individual therapists alone cannot correct for in their own fee structures.
Sliding-scale clinics and Therapists Offering Services in the East Bay and San Francisco
OpenPath Collective (You can choose your own therapist. Clinicians charge a max of $70 for individuals and $80 for couples)
Pacific Center (serving the LGBTQIA community)
Queer Life Space (serving the LGBTQIA community)
The Liberation Institute (fees starts at $1)
The Wright Institute Clinic
JFK Counseling Center
Church Street Integral Counseling Center
The Psychotherapy Institute
Alchemy Therapy
Cal State East Bay Clinic
Family Paths
Heart In Balance
Roots Community Clinic
Should I Take Advantage of a Sliding Scale?
When considering asking for a sliding scale fee, consider your income, your earning potential, and your access to wealth.
Consider paying the market rate or full fee of a provider if you:
Own your residence or can comfortably afford to rent at or above market rates.
Possess a higher earning potential due to factors like education level, gender and racial advantages, social class upbringing, etc. Even if you're not currently utilizing this potential, please acknowledge it as a choice.
Hold investments, retirement funds, or inherited wealth. Consider the difference between income and wealth.
Have a safety net of intergenerational wealth to rely on during difficult times.
Can indulge in recreational travel.
Have access to familial financial support during challenging periods.
Have the option to work part-time or not at all, thanks to a partner's income or family assistance.
View affording certain services as a discretionary choice rather than a genuine hardship. For instance, if you allocate similar funds to other valuable items or experiences like buying fancy shoes, classes, a special dining experience, or if using these services would simply involve trading off with these expenses, consider positioning yourself higher on the contribution scale.
Consider asking for a sliding scale spot if you:
Struggle with food or housing insecurity.
Support yourself or your family on a low income.
Health negatively impacts your earning potential.
Investing in a service would cause significant financial strain, potentially affecting your ability to afford essentials such as food, rent, or transportation to work.
Qualify for government assistance programs.
If this is the case, please advocate for sliding-scale!!! You deserve therapy!
Therapy Costs. Why does therapy cost so much?
Information you may not need, but have been curious about...
Let's get real and transparent about money! I am a therapist in Oakland, CA. It's expensive as heck to live here.
To rent a one-bedroom apartment for $2,500 (or $30,000 a year), one needs to earn $90,000 before taxes to qualify with the 3x rent income usually needed. When considering what income a private practice therapist needs to make, one needs to consider monthly and yearly expenses including professional organization memberships, organization events, licensing fees, office rent, consultation fees, individual therapy, marketing costs, electronic health record services costs, accounting fees, practice insurance, health insurance, educational materials, and continuing education. With a modest estimate of about $2,500 a month in expenses, 6 yearly client cancellations, and 4 weeks off for the therapist (for holidays, vacations, illness, and required continuing education courses this is very little), a therapist needs about 15 weekly sessions at a fee of $150/client or 22 weekly sessions at a fee of $100* to hit around $90,000. California Licensed Marriage and Family Therapists (LMFTs) in the private practice setting spend an average of 15.2 hours per week. Therapists also spend their working hours on legally-required note taking and documentation, documentation admin, email and other communication, business related admin, preparing for sessions, research, marketing, consultations groups and individual consultations, and membership organizational involvement.
Also, higher costs of living related to supporting children or partners, paying off student loans, having certain medical needs to limitations, or saving more for emergency funds (injury and illness of the therapist or therapist's loved ones), and retirement (should a therapist be working full-time at 85? should anyone?) may necessitate a higher income or charging higher fees. Having a supportive partner or generational wealth may necessitate a lower income.
Of course, a lot of people in Oakland make it work on much less the 80-90K. I strongly believe that everyone living and working in any given city should have access to income that qualifies them for a one-bedroom apartment, while being able to cover necessities, plus be able to take a vacation and have some fun. More on system changes in the section below.
*A note on insurance, insurance companies generally reimburse therapists much less than the market rates for therapy in Oakland (and generally). Some large insurance companies reimburse as low as $70 for a 50-minute session in California. This is one of the reasons many therapists do not accept insurance or very selective about insurance. One executive at Blue Cross Blue Shield made $11 million in 2021, by the way. 🙄🙄🙄
**If a therapist has $2,500 in expenses monthly and sees 15 clients a week, that's about $40 in expenses per session, so a $70 reimbursement fee nets a therapist $30 before taxes. 💸 And one clinical hour is more than an hour of labor with admin, consultation, preparation, etc. We're getting close to minimum wage with reimbursement rates like that! 🤬
Therapists Earning a Living and Thinking Beyond Individual Changes
Boy, does this bring up a lot of feelings! In my opinion, everyone deserve to live a life where they do not fear they will be evicted or be able to cover their bills and be able to relax, take vacations, and seek personal fulfillment. EVERYONE. People in helping professions deserve to be financially secure and enjoy their lives. I don't think this should be controversial. There is plenty of resources on the planet and the redistribution problem is not coming from individual therapists who are not sliding the fees enough.
And so, therapists have to take money for their services, because we live in capitalism where workers exchange labor for money, and therapists are workers.
Individual therapists, while playing a crucial role in providing mental health care, cannot alone make therapy affordable for all. The cost of therapy has become a significant barrier for many individuals seeking the help they need. This challenge underscores the necessity for systemic changes to the way mental health care is provided and funded. Individual therapists have limited control over the larger economic and societal factors that drive the high costs associated with mental health care. Offering a sliding scale is a tiny bandaid that may profoundly help individuals who secure sliding scale spots; however, offering more then allows an individual therapist to pay their bills, take time off, and enjoy their life is a disservice to clients. Therapists will burn out, loose empathy, and maybe quit.
Systemic changes should focus on increasing funding for public mental health services, community clinics, and government-funded initiatives that provide affordable or free therapy options. Or hey, universal income? Or hey, scrap capitalism altogether? Anyway, even the modest options of increased funding would reduce the burden on individual therapists to single-handedly provide affordable care and ensure that mental health services are widely accessible to those in need. While individual therapists can certainly strive to make their services as accessible as possible, the affordability of therapy is ultimately a systemic issue that demands systemic solutions. A bunch of burnt out, struggling therapists will never fix large scale injustice (like 11 million dolllar salaries paid to executives at Blue Cross Blue Shield). To make a more equitable and accessible mental health care landscape, we must advocate for policy changes, insurance reforms, increased funding for public services, and educational efforts to drive the necessary systemic changes.
