Therapist gives sliding scale to one patient but not another

May 16, 2019 6:52 PM

My long-term therapist has told me repeatedly that they do not do sliding scale. I found out that they gave a considerably more affluent friend a sliding scale rate.

Obviously I'm not going to see this therapist anymore, but I have a few questions:

Is this, you know, done? Are therapists entitled to withhold information about sliding scale rates? Or are they generally obligated to disclose that they do offer some patients sliding scale rates but not others? I see why it's easier to just pretend that you don't offer sliding scale when you have no intention of offering it to a particular patient, and that it would make a patient leave if they heard "Yes, I do that sometimes, but I'm not going to with you." I'm just trying to figure out if this is merely a little icky or beyond the pale.

This is in California. The therapist is in private practice and does not take insurance.

posted by ziggly to Human Relations (33 answers total)

It’s funny—I don’t think this would bother me at all. I definitely wouldn’t leave a therapist I otherwise thought was good over it. One of the exercises I used to go through in therapy was coming up with benign explanations, and there are just so many options here:

Even if the therapist does not take insurance, your friend may have insurance that covers out of network therapists or may be getting reimbursed through a program like CalVCP or the Vet, and the therapist may have agreed to terms that allow your friend to submit. The therapist may also have a sliding scale for patients who have issues they find particularly interesting or are trying to gain experience with, or who are willing to participate in studies or group sessions. Or maybe this person is a friend of a family member, and your therapist is just doing a family member a solid. And finally, maybe you just don’t know your friend’s situation that well, and there are extenuating circumstances here.

In any event, it’s a little odd to me that you are “obviously” going to discard a long-term therapy relationship without at least asking the therapist what is going on. I guess the good news is that both your reaction and your question seem ripe for discussion with your therapist!
posted by suncages at 7:08 PM on May 16, 2019 [17 favorites]

I've seen two situations that aren't based on income where "sliding-scale for them but not you" can happen. One is when someone used to take sliding-scale, stops taking it, but grandfathers in old patients who were using it. The other is when someone sets aside a few slots in their schedule for sliding-scale patients, and won't offer a new patient sliding-scale unless a slot opens up.
posted by nebulawindphone at 7:09 PM on May 16, 2019 [28 favorites]

I’ve heard therapists refer to this as “I have room for 2 sliding scale clients on the low-end, 2 sliding scale clients at a midpoint range, and the rest of my sessions are full price.” The therapist may already have 4 clients using the sliding scale spots.
posted by samthemander at 7:09 PM on May 16, 2019 [13 favorites]

In other medical specialties sliding scale is not offered to folks as a general rule and when it is offered it is generally not publicized. There may be several considerations for what is politely referred to as ‘professional courtesy.’ It is possible that your friend or an associate of your friend has provided something of value to this practitioner (huge referral network, discounted printing services, internet work, some kind of consulting).

I would not leave a practitioner if I leaned that another client was receiving a discount. I would also not be seen by a mental health professional that was treating a friend or close-ish acquaintance because then issues like finding out what friend pays or that friend discusses you in therapy FEEL like things you want to discuss with therapist but therapist may struggle to remain neutral about.

It’s also reasonable to consider (without knowing this person) that your acquaintance may have some reason to not be honest with you about their fee.

So. I see you’re in a pickle. I’d be in a different pickle. If you mention to your therapist that you’ve gained information about their fee practices and they deny providing this discount, would you believe the therapist? Doesn’t matter because the therapist may not even be permitted to acknowledge that they treat your acquaintance. They almost certainly are not permitted to discuss payment.
posted by bilabial at 7:28 PM on May 16, 2019 [5 favorites]

Yet another possible explanation - some therapists will offer a sliding scale for specific, less popular time slots but not those that are in more demand. So someone coming in at 11 am might pay less than someone coming in after work hours at 6 pm.
posted by Miss Viola Swamp at 7:39 PM on May 16, 2019 [4 favorites]

You don’t know the reason your friend is getting a different rate to you (and neither should you.) Maybe they see the therapist more often than you and get a discount based on that. Maybe they’ve fallen on hard times that you’re not aware of. Maybe they refer people or are part of a business network.

Either way, their relationship to this other client is different to yours and they’re allowed to run their business as they see fit without justifying their pricing structure to you. You of course are allowed to decide that you’re not happy with what they charge but if they’re a good therapist and you thought they were worth $x before, what has changed, really?

If it turned out the other client was suicidal and needed to see the therapist four times a week just to hang on and that was why they were getting charged less, would that somehow make it better? (Not that this is something you’d ever find out) Because these could be the kind of things you’re asking to know. I’d let it go and move on.
posted by Jubey at 7:41 PM on May 16, 2019 [8 favorites]

Response by poster: This isn't an acquaintance; it's a close friend of many years who does not have to work a traditional job and has no other ties with the therapist, and made weekly appointments. The friend was actually very surprised to learn that I wasn't paying a sliding scale rate and urged me to negotiate one. I suppose one difference is that I have health insurance through my employer, but the reimbursement has been nearly negligible. The therapist works regular business hours and doesn't offer evening slots.

At the therapist's current rate, I can't afford to continue in any case. I'm just trying to figure out if there was some favoritism shown here.
posted by ziggly at 7:49 PM on May 16, 2019 [1 favorite]

Perhaps the therapist thought that since your friend doesn’t work that they were poor? Maybe your friend even indicated as such. So, maybe the therapist got snowed? I’ve had different rates for different people (I am not a therapist). Sometimes I gave lower rates to friends, important referrals, or people who seemed of limited means. But I’d never say that I have “sliding scale” rates. This year, due to extreme busyness, I’ve had to stick with a single (higher) rate than in the past even with folks who previously I had given a rate break. But in general, my rate breaks have not been due to favoritism (liking one person more)! I know exactly why I’m giving a rate break to each person when I give it. I’d be frustrated if a new client wanted someone else’s rate. Plus, some of my breaks were simply, in retrospect, not good business decisions.

I don’t know. If you can’t afford her rate, just tell her. Tell her what you could afford and let her decide. It’s really best not to dwell on it. You have no way of knowing and it’s not pertinent to your current issue.
posted by amanda at 8:08 PM on May 16, 2019 [4 favorites]

To deepen some of the previous answers: It's considered DEEPLY unethical for a therapist to reduce fees because a client makes referrals or to otherwise give "kickbacks," but bartering, grandfathering in old pay scales, or restricting the number of sliding-scale patients is well within the bounds of ethical practice. It's also well within the bounds of normal to offer sliding scale fees to clients without insurance but not to clients with insurance. Doing the documentation to submit claims to insurance takes a lot of work, and insurance companies often pay below-market reimbursement rates to therapists, so further discounting that doesn't generally make much sense; also some insurance companies stipulate in their contracts with therapists that if a client has insurance, the therapist can't have the client pay out of pocket (sliding scale or not) rather than use their insurance, so the therapist's hands are tied.
posted by lazuli at 8:11 PM on May 16, 2019 [15 favorites]

Your insurance really can stipulate they can't change the rate, and most therapists in private practice I know do have a limited number of sliding scale slots available. They need to make a specific amount a day to keep the buisness running, and if they fall below that no therapy for anyone.

It's surprisingly expensive to operate a private practice.
posted by AlexiaSky at 8:55 PM on May 16, 2019 [1 favorite]

"Sliding scale" for a self-employed therapist just means they aren't getting paid as much by certain clients. For some reason, I never really got that till my sister became a therapist.
posted by wryly at 9:36 PM on May 16, 2019 [2 favorites]

"Sliding scale" for a self-employed therapist just means they aren't getting paid as much by certain clients. For some reason, I never really got that till my sister became a therapist.

Right, it's not like some outside agency is making up the difference. Which is why it's normal for therapists to restrict the number of sliding-scale clients they're able to see, and why they may not want to get into debates about which clients deserve it more, which can lead to clients feeling like they have to "stay sick" in order to deserve treatment. (All of this being a great convoluted reminder of why universal healthcare coverage would be preferable to our current broken system.)
posted by lazuli at 9:43 PM on May 16, 2019 [9 favorites]

I don’t think you have enough hard “evidence” for any of us to say if your therapist has acted unethically. We don’t know either of you. But the therapist is in private practice, their time is their own and they set their own rates. Being a therapist is hard! Having variable rates to manage their complex business lives is fine.

You are put off by this one and will stop seeing them. It sucks but all is as it should be.
posted by pazazygeek at 11:54 PM on May 16, 2019 [1 favorite]

It is possible that your therapist has had problems with boundary pushing clients, and does not offer a sliding scale until they are sure/certain/convinced/absolutely proven that the patient in question is not one who will overwhelm them with wanting more special support. It doesn't matter that you are not someone who would do this. They may have a policy where they will not reduce fees unless they themself propose it. Therapists work with a lot of people who are boundary pushers and they have all been badly burned and have permanent scars from clients who use suicide attempts etc. to manipulate them. Asking for free or reduce rate therapy is one of the ways that boundary pushing clients try to manipulate the therapist-client relationship so that they become a 'special patient' or 'favourite patient' ; a patient who does this is also the one who may get into the habit of phone calls on every holiday, getting upset if the therapist doesn't remember things etc. Therapists have to work like hell to avoid dependent clients, as frequently a dependent relationship with a therapist means the therapist is not facilitating progress, but has gotten a role in the client's dysfunctional patterns. Dependency and special patient status normally means being stuck in transference stage.
posted by Jane the Brown at 5:02 AM on May 17, 2019 [1 favorite]

If you would otherwise continue with this therapist, you might want to consider discussing the situation with them (both feelings and logistics).
posted by chesty_a_arthur at 5:16 AM on May 17, 2019

Your therapist lied to you. You are right to find another one.
posted by thatwhichfalls at 5:58 AM on May 17, 2019 [11 favorites]

It would make me not want to see the therapist. There are any number of reasons why some clients may be charged different amounts than others (as people have described above), and that wouldn't be a huge problem for me because them's the breaks, but it sounds like you explicitly asked and were told that everyone pays the same amount. My personal tolerance for "little white lies" is a lot lower than other people's, so it would bother me enough to feel uncomfortable with therapist and destroy our therapeutic relationship.
posted by metasarah at 6:05 AM on May 17, 2019 [2 favorites]

I'm another person who doesn't tolerate lying, but if I really liked the therapist, I'd ask and see if the relationship could be repaired. Therapists have every right to decide how much they want to charge, but this therapist was not honest about it.

That said, the fact that this therapist told you this multiple times makes me wonder a bit, as that makes it sound like you were unwilling to take no for an answer. A therapist who offers a sliding scale is volunteering to take a pay cut. That's really a huge thing - imagine any other employer (which is what a client is) continually asking to pay a person less. Sorry if I'm overstepping here, but this seems something worth thinking about. If you continued to ask after being told no, you may not be this therapist's favorite client.
posted by FencingGal at 7:05 AM on May 17, 2019 [1 favorite]

It's clear that others here are not particularly sensitive to lying, but in this kind of relationship, being lied to would be an absolute deal breaker for me. If they only had certain sliding-scale slots, they easily could have explained that. At the same time, I wouldn't have pushed the issue with her multiple times. But that feels like another topic altogether. Taking the question at face value, being lied to would mean it's time to end the relationship and find someone you can trust with this sensitive relationship.
posted by thegreatfleecircus at 7:06 AM on May 17, 2019 [6 favorites]

Whether this would feel like a lie to me would depend a lot on the specific circumstances. If I were a therapist who no longer takes sliding-scale patients but has some grandfathered in, or who has a small handful of sliding-scale patients taken on for special reasons but does not anticipate taking any more in the future, "I don't do sliding scale" would seem functionally equivalent to "I have done it in the past but will not be doing it for anyone new moving forward" and I can imagine it seeming perfectly ethical to just say the first, shorter version. You therapist does not owe you an explanation of business choices she has made in the past that have no possible bearing on your situation.

"I sometimes do sliding scale but for whatever reason ("the slots are all booked up and I've already got a waitlist a mile long," "something specific about your case makes it unsuitable for that," "I only do it for uninsured patients") I won't do it for you specifically" feels different and as if it should probably be disclosed, if you've asked specifically about it. Maybe you're willing to be on that mile-long wait list, and you should be given the opportunity if that's so.

Either way, though, this doesn't strike me as a grave ethical lapse on her part, and as if it could hinge hard on the exact wording of the conversation. Since you're moving on anyway, I'd try to just assume the most charitable explanation and put it out of mind. If it's still bothering you after some time has passed, that might be something to discuss with your new therapist.
posted by Stacey at 7:31 AM on May 17, 2019 [3 favorites]

I think you are completely justified to stop seeing this therapist based on the fact that you were lied to. I would be super pissed off too.
posted by a strong female character at 7:45 AM on May 17, 2019 [7 favorites]

It may be worth considering that there is a qualitative difference between statements that may be interpreted as lies in the following scenarios:

I have x qualification - that’s a binary question

I have specific experience in y - that’s also binary but only to the extent that somebody has to have done something once to have that specific experience. In most cases you‘d want a medical provider to have done something more than once before they do it with you

I am not taking on new patients - yes, that may be binary. Even in that case the answer may change tomorrow because a patient leaves the practice. It could also be shorthand for I only have timeslots left for somebody who would need to see me every two weeks or less or I prefer not to fill any vacant timeslots because I need to free up time for teaching or research or whatever. But I‘d never expect anybody to explain that because their time is valuable and anything that leaves perceived exceptions may result in lengthy discussions with some people, which would waste both our time.

My rate structure is abc - unless the service offered is extremely standardised like a hair cut, that kind of statement is largely meaningless and even there the official price list is at best an indicator. People can charge what they want as long as they don’t break any specific laws or guidelines if such guidelines exist for a specific jurisdiction or professional body. These are business decisions and therapists are businesses. And again, it may be shorthand for more complex reasoning which is however none of the other person’s concern and is not up for discussion.

Clearly, it is up to the individual how they feel about such ‘shorthand’ responses, if indeed that is what it is as opposed to a misunderstanding. But I’d be troubled about lies regarding qualifications and experience, not about somebody refusing a discount they aren’t obliged to give.
posted by koahiatamadl at 10:08 AM on May 17, 2019 [1 favorite]

... why don’t you just ask?
posted by stoneandstar at 10:19 AM on May 17, 2019 [2 favorites]

I'm just trying to figure out if there was some favoritism shown here.

We can't possibly know the answer, and speaking for myself, it would hurt my mental health if I were to dwell on a thing like this in my personal life. I would try not to focus on what other people are getting more/less than you are because someone else will always be getting more and the gnawing worry will consume many things such as a productive therapist relationship and friendship.

Also, one other thing. "Obviously I'm not going to see this therapist anymore," it isn't obvious to me, but any loss of trust in your therapist does probably end the relationship or significantly weaken it's effectiveness. I'm sorry this happened and brought up these feelings. I have struggled with jealousy in similar terms before so I think I have some understanding of how it feels.
posted by OnTheLastCastle at 11:14 AM on May 17, 2019

Just to say, yeah, it's completely OK to be sensitive to lying. Not everyone is sensitive to it, and that's also OK. Not tolerating lies opens some doors in life and closes others. Which is fine. We don't have to all share the same values, and values can be useful factors in selecting a good fit in any working relationship. As a data point, your "obviously" was appropriate and unremarkable to me. In our alienated societies, lies are often useful, valuable and necessary. But it's fine to want your therapist to have the communication skills to offer the nuanced answer, eg grandfathering, or even personal discretion. It's a bit thorny and requires a bit of courage to do so, and that's completely OK.
posted by Mistress at 2:10 PM on May 17, 2019 [2 favorites]

I mean, I’m sensitive to lying, but in multiple hypotheticals listed above, the therapist would not have been lying to you. Adjusting rates in order to allow a crime victim or vet to have the session covered is not a sliding scale. Having cheaper sessions at 1 pm than at 8 am is not a sliding scale. Giving a temporary discount to a suicidal patient so they do not off themselves is not a sliding scale.

By asking for a sliding scale, you effectively asked whether financial situations are a reason for your therapist to make less money. He told you they aren’t. It is entirely possible that he chose to make less money during your friend’s sessions for reasons other than your friend’s financial circumstances. Concluding that he lied to you would require you to discard that possibility, and I see no basis in your posts to do so.

But in any event—if you feel lied to, that’s what matters.
posted by suncages at 3:22 PM on May 17, 2019 [2 favorites]

I am very sensitive to lying. I don't consider it a lie if you're not entitled to an answer.

But unfortunately the therapist gave an answer instead of just saying it was none of OP’s business, and the answer was a lie. I could not keep seeing a therapist that told me lies to direct questions.
posted by fireandthud at 3:29 PM on May 17, 2019 [7 favorites]

i see clients (i'm not a talk therapist). i don't do sliding scale, which TO ME means that everyone gets to choose how much they pay based on whether they feel like they can afford it. However, sometimes i give my friends a cheaper price, and sometimes i give new mothers who bring their babies a gift of a free session, and sometimes i trade a session for a whole lot of beef from a farmer who has a lot of beef but no money. but if someone asked me "do you do sliding scale" i would say "no" and not mention the beef etc and also not feel like i was lying.

if someone found out that i had charged someone else less and also felt like i had lied to them, i would be bummed out because i consider myself an honest person who is trying to do the best thing and who is not a machine but also eventually has to pay my own rent. but i would definitely not then turn around and offer them a cheaper rate and i would be relieved when they did not come back. that might not be the most mature or correct approach but it is pretty human.

if i was someone who found out that someone had charged me more than someone i felt was wealthier than me, i would wonder if they liked them better and might not want to go back. i think that's a pretty normal and human response.

i think you can make this decision though without needing to know if there was favoritism and also not deciding that you were lied to. i think it can be simpler, and that will feel better for you. i hope this is ultimately what you do.
posted by andreapandrea at 12:39 AM on May 18, 2019 [1 favorite]

After reading your follow-up to the question, my guess is that the sliding scale is due to lack of insurance/cash pay vs. insurance. As lazuli mentioned, it costs extra money and time and paperwork to accept insurance. If your friend is paying at the time of the visit with a check, that is better cash flow for the practice and less in administrative costs.
posted by jeanmari at 4:28 AM on May 18, 2019

A lot of people are shaming you for your emotional response here so I just want to offer that I too would be baffled and upset that a rich friend got to pay less for a service I needed but could not afford, and would also discontinue my relationship with that therapist. I wouldn’t say she outright lied to you, or if she did, the lie was small, but I would also assume favoritism of my friend (whether right or wrong), and you cannot get clarification from your therapist because she cannot discuss someone else’s financials with you. My paranoia over this would absolutely muddy my relationship with my therapist, so I would move on to someone else.
posted by Yoko Ono's Advice Column at 5:01 AM on May 18, 2019 [4 favorites]

Best answer: Yes, your therapist lied to you in response to a direct question, yes, that is reason to completely lose trust in them, yes, you need a new therapist. I’m completely baffled by people upthread saying that they will flat out lie to clients about their business practices but don’t consider saying “I don’t do [X business practice that they engage in constantly]” to someone’s face to not count as lying. I also have a number of difficult clients who need to be told various white lies for various reasons. The validity of those reasons — enforcing personal and often physical boundaries with unsafe people and avoiding violence— doesn’t make those necessary lies NOT lies. You can’t trust this therapist, for whatever reason they don’t feel they can trust you enough to be straight with you, that’s an impossible and toxic foundation for a therapeutic relationship and you need to terminate ASAP. I’m sorry you’re getting so many shaming or flat out insulting responses here, this thread is bizarre.
posted by moonlight on vermont at 7:58 AM on May 18, 2019 [8 favorites]

Charging one client less than another for unspecified reasons is not "sliding scale". Sliding scale indicates that fees are charged based on variation of a particular standard. One can give cash discounts, grandfathered prices, quantity discounts, or any number of other discounts and it does not count as "sliding scale". It's not clear that your friend (or several commenters here) understand the difference.
posted by oneirodynia at 12:47 PM on May 18, 2019 [4 favorites]

Response by poster: The therapist does not accept or handle insurance in any way from anyone (or at least, that's what they tell me). They do not bill; they take a check at the beginning of the session and do not accept any other form of payment. The therapist sees patients during normal business hours four days a week and there are no premium or discounted time slots (again, that I know of). There really hasn't been any discussion of costs aside from "This is my rate."

I'll just leave this here for anyone who might need it: How much can I expect to pay for therapy?
posted by ziggly at 3:05 PM on May 18, 2019 [2 favorites]