Pros, Cons, and Best Practices for Offering Sliding Scale if You Choose to

A common question many therapists struggle with, especially if their practice is private-pay only, is whether or not to offer sliding scale fees, and if yes, how much to charge. If you’re struggling with this yourself, know that there’s no single “right answer” for everyone, so whatever you choose to do is fine, as long as you’re comfortable with it. Having said that, here are the pros and cons to help you make an informed decision, and best practices if you choose to “slide.”

My Own Experience Fielding Requests for Discounts

In my consulting practice, I sometimes get requests from clients to discount my fees. This even though my clients are businesses! My answer depends on many factors, including my perception of how likely the specific client is to be asking out of a legitimate need (as opposed to their asking because they have nothing to lose by trying to get my support for less money). Other factors have to do with how much I want to work with that client on the project in question. That also helps me determine how deep a discount I’m willing to offer. In the past, I declined some requests, offered a 10% discount to others, and as much as 40% off once. However, in that last case I negotiated a bonus structure based on the value I bring the client.

The Financial Pros and Cons of Sliding Scales

Let’s start with the simplest arena – the financial one. The pro is that if you let yourself reduce fees selectively, you can charge high fees but still accept clients who can’t afford them. The con is equally simple. Anytime you slide your fees you’re giving away valuable commodities – your time, expertise, and experience – for less than they’re worth, losing money you could be earning.

The Emotional Pros and Cons of Sliding Scales

The emotional pro is that giving yourself the freedom to adjust fees downward lets you help people you want to help, even if they can’t afford your full fee. The con here is the flip side of the same coin – if you allow yourself that “out,” you’re more likely to struggle emotionally to avoid the slippery slope of simply giving everyone discounts.

The Ethical Pros and Cons of Sliding Scales

Ethically, as a therapist, your mission is to help those who need therapy. Anything that let’s you help more people, including flexible fees, can be seen as an ethical pro. However, there’s a con hiding on the other side of that coin. If you offer sliding scale discount to some but not to others, you’re charging different amounts for the same service. This seems especially unfair if you don’t verify that those clients who ask for a discount truly need it. So, unless you plan to ask for bank statements and tax returns (I certainly would never do that), you’ll be giving a discount to clients who ask, and not to others who may need it more but don’t ask.

The Therapeutic Pros and Cons of Sliding Scales

Especially if you make it clear on your website that you offer discounts, you give permission to clients who need them to bring that up with you. When you grant that request, you’re placing the first brick in the edifice of your therapeutic relationship, showing you care more about helping them than about money. However, the flip side here, as I mentioned in a previous post about reframing the sliding scale discussion, when someone gets something free or deeply discounted, they have less “skin in the game” and may not engage as fully in their therapy. Thus, offering a discount may “cheat” the client of the best possible outcome. In addition, if you come to resent clients who ask for and get a discount, you’re sabotaging your rapport with them, again robbing them of the best outcome you might have been able to provide.

Best Practices of Offering Sliding Scales

If after reading the above pros and cons, you choose to offer discounts from your full fee, here are some best practices to help you maximize the impact of the pros while minimizing that of the cons.

• Decide in advance how deep a discount you’re happy to give, so you don’t end up resenting clients who pay that lower fee
• Decide in advance how many discounted slots you’re willing to give
• Decide in advance to whom you’re willing to offer discounts, whether need-based, or population-based (e.g., seniors, students, first responders, active military, other therapists, etc.)
• Adjust upward your full fee so your full-fee clients offset the discount (e.g., if you give 50% discount to 10% of your clients, increase your full fee by 5%)
• Research low-fee and/or pro-bono therapy resources in your area, so you can refer to them clients who can’t afford even your discounted fee and/or those who come when your discounted slots are full
• Post on your website that you offer a limited number of discounted slots, and whether those are need-based or population-based (see above) so those who need it know they can ask
• Periodically revisit the discount with those clients who get it, so once they no longer need it you can release that slot to someone who needs it more (let them know in advance you’ll revisit it and use the honor system)
• Offer the discounted slots during your least-busy days and hours, so they’re less likely to prevent you from having a convenient slot available to your next full-fee client
• If you’re only offering discounts because your practice isn’t full, decide at what caseload you’ll stop giving discounts

Bottom Line on Sliding Scales

The debate on whether or not therapists should offer sliding scales isn't going away anytime soon, because both positions are valid. The above pros and cons should help you make an informed decision whether or not sliding scales are a fit for your practice, and what best practices to follow if you decide your personal answer is yes.