You sit down for your session and your client instantly dives into the following:
“Oh! I need to skip next week. Ben and I are going to Calistoga for a wedding. Ugh. It’s his friend from college. I barely know them. But hey! Calistoga will be cool, I guess.”
While there’s all kinds of interesting clinical information here, your mind short-circuited at the, “I gotta skip next week because Calistoga!”
Why?!
- You’re about to miss out on income next week and that majorly sucks because your student loans just went up and you don’t know if you can cover them.
- YOU would die to go to Calistoga for any reason, but you can’t afford it, especially now that you’ll be missing a client hour.
- This client is on a sliding scale! How the fuck is she going to Calistoga for a week?!
Am I right?
Can I get an amen?
NO! NO.
We don’t need to “Amen” this shit. We need to fix it.
I mean, yeah. This is an extremely familiar scenario for therapists in private practice but it doesn’t have to be. There are systems you can implement to make sure you’re taken care of so when your clients have a sudden vacation announcement, you can be present to think about about what’s going on and tie it into the clinical work, rather than falling into that oh-so-common spiral of fear and resentment.
I recently finished another round of Lean In. MAKE BANK. and, I gotta stop for a moment to acknowledge my students. They are fucking phenomenal and inspiring and BOLD. (Hi guys! You’re great!)
In this course, I encourage students to lean into the clinical piece, to utilize their client’s material to understand the larger patterns in the client’s lives (aka. I encourage my therapist students to do therapy).
But let’s be real! “Doing Therapy” is hard if clients are taking great vacations or buying amazing new shoes when they’re on a sliding scale. There are a ton of ways to address this.
A. Continue to spiral into resentment and envy.
B. Remind yourself that you’re a nice therapist and look within to find all the positive feelings you have for them (#avoidancemuch)
C. BRING IT UP!
When I introduce this idea, many therapists go straight to the question, “If I bring it up, aren’t I shaming my client?!”
It’s a great question.
Let’s say we utilize a clinical intervention like,
“Hannah, I notice you just bought a Gucci purse last week and now you’re leaving for a week to go to Calistoga, yet you’re on a sliding scale here. What do you make of that?”
[Are you freaking out right now at the thought of that? Take a deep breath. Roll with me here.]
If we were to do that, it might suddenly dawn on Hannah that she’s been spending all this money, yet not paying your full fee and this realization most definitely could bring up shame.
Henceforth, many therapists do the math and conclude, “I have shamed my client.”
It’s a common misconception and therapists do it a lot!
We conclude that if a client feels something uncomfortable when we make an observation, then we have done something wrong.
No. Stop. FALSE.
I want to reframe this for you once and for all.
Think about it. The REALITY is that Hannah has been on your sliding scale and she has also been spending a ton of money. This is reality. There is something going on here, a contradiction is at play. It is our role as therapists to notice and observe exactly these kinds of contradictions.
It isn’t about blame or shame. It’s not your “fault.” It’s not her “fault.” Something has been happening between the two of you and it warrants being addressed.
Why?
A. So the client can recognize she’s been scamming you all along and needs to make amends.
B. So you can raise her fee starting now and even demand a little back pay.
C. Because this phenomenon likely plays out in other areas of the client’s life and by examining it together, she will gain a greater understanding of herself and her interpersonal relationships.
Did you guess “A”? If yes, bring it to your own therapy.
But if you guessed “C” – you win!
Look, it is your job to observe and go into the uncomfortable material that ALMOST EVERYONE in the client’s life avoids. Or, if people in the client’s life are pointing it out, they are likely doing it in a problematic way that the client can’t hear. Your job is to gently take your client’s hand (METAPHORICALLY) and walk with them into areas that are too uncomfortable to traverse alone.
SO – if Client Hannah feels ashamed in response to this realization, take that up!
There are a variety of ways this can happen:
“Hannah, I notice you and I have been colluding together to avoid looking at this.” ⇒ Shares responsibility and brings you in as a teammate.
“Hannah, I’ve been thinking about my role in not addressing this.” ⇒ You’re going first and modeling a gentle curiosity about your feelings and thoughts.
“Oh, man. It seems like neither of us have really thought about this together before. What’s it bring up for you?” ⇒ Shares responsibility AND invites her to talk about feeling bad or ashamed, to which you can express curiosity and inquiry.
“Huh, shame? Like you’ve been hurting me rather than us participating in something together?” ⇒ You’re helping Hannah begin to think about the interpersonal interaction, which removes the doer/done-to aspect of relating.
When there is ‘acting out’ or ‘strange phenomena’ occurring around how money is being dealt with in the therapeutic relationship, 100% of the time, hands down, it is pointing to something else. Something MAJOR.
Money is a symbol of reality (she’s getting deep here, folks) and by not addressing this discrepancy, you are facilitating the avoidance of reality, which does your client a disservice.
Got it?!
Re-frame of the day:
“I cannot shame my clients.”
A client may feel shame in response to something I say, but unless my intention is to shame them, it isn’t my job to make it go away, but rather to come in closer and be with them in and curious about their shame.
Your next Step:
Leave a comment, Sweets! Does anxiety about “shaming your client” ever keep you from speaking up even when you KNOW it’s important? Got a cool reframe that has allowed you to overcome this fear? No idea?! Let us know below.
I loved the ‘we’ve been colluding together’. Thank you for that!!
And btw, you’re amazing!
Marne! Welcome! I’m so glad to have you and excited to find out what you take away and IMP.LE.MENT.
BOOYAHM.
… aaaand the Thompson Girls are unanimous in thumbs-down on the sliding scale! (No, Abby and I don’t know each other). What she said … everything about verifying economic need … privilege in asking for a discount … she said it better than me :).
BWAH HA HA! High five for the Thompsons!
fuck yeah Thompson ladies!
I love this article. In my opinion, there’s so much that’s fraught about sliding scale. I want to increase access to therapy as much as anyone else, but I have found that the clients for whom a break would make a huge difference rarely actually ask for it– that there is a huge amount of privilege in expecting (or at least being able to ask for) a discount on a service.
I don’t think we therapists should be implementing sliding scale without a clear idea of not just what income level qualifies someone, but how we plan to assess and re-assess the overall financial picture. And to be honest, I’m not a CPA, and probably not qualified to make that kind of assessment. One thing that I find myself repeating over and over in my head and to colleagues is that “one woman in private practice is not going to make a change in income disparity and class by discounting their own work”- that these issues that we often want to apologize for with our sliding scale need to be addressed on a systemic, and not individual level.
Tl;dr- I really appreciate
BOO-FUCKING-OOM, ABBY! I LOVE this part: “One women in private practice is not going to make change in income disparity and class by discounting her own work.”
*Abby drops the mic*
You have clearly thought a TON about this and I couldn’t agree more. If one DOES offer a sliding scale, it ought to be *after* she has understood what her full fee needs to be, learns how to charge that consistently, has a quality of life that allows her to truly show up and THEN if she wants to make the choice to slide or give back in some OTHER way, by all means.
Tl;dr- I really appreciate YOUR words!
Haha, true story, once ran into a client on a holiday day in Calistoga. Brief chat. They were spending $ on local merchants. Me? Only window shopping and seeing the sights. Yep. That’s how this psychologist goes to Calistoga, etc. BYOStringcheese.
It’s true that clients mention vacations, recent purchases and possessions, oftentimes indicating the monetary value (ex. my $X value electronic whatever that I just got). And then there’s this SICK feeling, you nailed it (!), reverting back to sliding fee and being a sucker, because you know they know you know that they’re … what? Not playing fair? Assuming we are some kind of a one-person welfare agency? Or that we can absorb the loss because the disparity is just for this one special client (them) (and so they may think, that it’s only them)? Or maybe because we must overall be rich, so it doesn’t matter? There must be some assumption going on that justifies / rectifies the disparity, for most sliding scale clients, and you’re asking to turn this into a clinical issue. BUT THEN WHAT? When the thinking pattern is uncovered, what comes next? Thanks.
AMAAAAAZING question, Carol! SO juicy. We talk about this A.TON in Lean In. MAKE BANK. which my students will certainly tell you about. HA!
I’m going to go to the anxiety underneath the question – So, we talk about the pattern and then what?! The answer: I have no CLUE.
Okay, that’s not true. I definitely have ideas, but the reality is, the only way to know what happens next is by diving in. So often therapists want all the answer *before* they make a move and they avoid anything that is unknown when, in fact, the BEST therapists take the risk to go to the heart of the issue WITHOUT knowing what’s on the other side. I can tell you from my own experience, from talking to hundreds of therapists and from taking over 40 clinicians specifically through this process around money, diving in and discovering – along with your client, what’s on the other side: Life Changing. For everyone involved.
Here’s to exciting – and meaningful – discoveries!
This is a great article, Tiffany. I think that often we do not want to bring up such issues because we are afraid of CONFLICT and because we want to always be the nurturing, nice therapist who only helps our clients feel better about themselves. But the truth is, that is not what real therapy is all about. Thanks, TIffany!
Absolutely, Carolyn! There is certainly a place and a stage for nurturing, but if that’s all one is doing as a therapist, they are missing out on so much depth. Alas and alack!
This was great Tiffany. I’m pretty on top of this stuff with most of my clients but definitely need to work through my stuff with a long-term low fee client. I love the suggestions you give that acknowledge the shared responsibility.
Man, I hear you, Karen. There is SO much to consider with long-term clients who started early on in the process. I would love to dive into this and hear from therapists who have thought and engaged with this topic from all kinds of angles! Thank you for bringing this up, K-Dawg!
Tiffany, I love this article. What comes up for me in doing what this article suggests, is somehow interfering with client’s full trust of the ability to share everything with me without it being used by me in some way. What I feel is that when a client shares with me about her husband’s huge new bonus, and then I say, “well what about my fee” it would inhibit her from sharing her joys with me in the future. Because I took her disclosure and it ended up financially impacting her. Does that make sense? Thanks for your help!
Ha! It definitely makes sense, L!
While I know you wouldn’t whip out that, “What about my fee?!” right when a client talks about the bonus, even if you’re delicate and thoughtfully tie in the discrepancy, our clients may still feel like, “What the heck, you’re trying to use me for my money!”
The *truth* is that we are providing a service and we need to get paid for that service. BUSINESS. The truth ALSO is, that we care deeply about our clients in complex ways. We often know them in ways we don’t know anyone else in our lives! Both love and hate coexist. If we can talk openly with our clients about this dilemma, this conflict, this confusing oxymoron, then there is so much to be understood, to unpack.
“Martha, I bet it feels like any time you tell me about a bonus or a great vacation, I’m going to get right up in there and try to scam you for a higher fee.”
Then stand the fuck back and see how Martha reacts. Can you imagine how freeing it would feel for her to be able to talk – right out in the open – about her fears of being taken advantage of, WITH THE PERSON SHE FEARS IS TAKING ADVANTAGE OF HER?! Most people never get this opportunity, to really dive into what it means to be in a relationship with someone who also has needs and then to figure out how to negotiate the complex feelings that come with this.
Boy, howdy, L! I’m getting all hot and bothered as you can see. There is so much depth just waiting to be explored.
Thank you for asking this, L! It was another thought I had. Glad to hear Tiffany’s answer and glad you brought it up!
I’ve just started following you Tiffany and man, you are a breath of fresh air! It made me stop and take a look more closely at the fact that I have clients say they will drive and come see me no matter where I am. ( lease is ending and I have to relocate)……So that MEANS something…it means I can take this thing out and see what she can do, amiright? With a new location will be coming new policies that start providing some self care!
BOOM. YES! You are adding value to your clients lives, Teresa and they *feeeel* it. High five!
So, yes, be bold. Show up! And keep doing your good work.
This all comes up for me! It can be so uncomfortable talking about these dynamics in session because I feel vulnerable not knowing how the client will respond and react to my bringing up these discrepancies. I think it is challenging because it brings me as a human even more into the room in areas where there is still personal discomfort ie money and rates and worth and remembering I am providing a service in addition to being a compassionate human. Your article makes me want to address these issues with more boldness, inner strength, and calm. They are such rich opportunities for growth all around!
Thanks again for talking, writing, and normalizing these experiences!
YES!! Love it.
The fact is, you ARE a human. Dirty ole humanity, sheesh. I try to shuck it off myself all the time, but there it is, creeping up on me. 😉
I’m very glad you are feeling emboldened to start showing up more fully with your clients in service of serving them. Good on you!
Hi Tiffany- this is great. It’s something I’ve been grappling with for a while now. I’d like to ask your opinion, though, on how we deal with the fear that if you bring up money and possibly shame the client, that they’ll quit therapy altogether? I’d love to say that it only has to do with me wanting them to be in therapy for their own welfare, but it’s not. It’s also me wanting to eat…and I definitely never go to Calistoga!
HA! We gotta get you to Calistoga, Wendy!
And this is an awesome question. I think a lot of therapists keep their mouth shut with interventions that would be SO helpful to their clients because they are afraid of the client leaving. Shoot! I was once guilty of this myself. But I found that once I got clear about my mission to do or say what I SAW was going on in the client’s life without fear of them leaving, became more B.O.L.D in an effort to have honest discourse, it has made a huge difference in the work and clients not only appreciate it, but they STAY.
Look, there are very few people who are really honest about topics that are uncomfortable or taboo and our client’s lives (shoot, OUR lives) suffer because people are afraid to be truthful about the things they see happening in our lives. If you can be that person, that *therapist*, you’ll be doing the world a service.
About the fear of client’s leaving because we gotta have sustainable businesses, I. Get. It. That’s were investing in very good marketing services comes in and getting clear about what you need in order to show up 100% for your clients, fear free. If you didn’t have to worry about money anymore, what kind of therapist would you be?
I have made a decision not to offer any sliding scale slots. First of all, I’m still on a couple of insurance panels and technically that’s a violation of our contracts with insurers (although I think insurers have a lot of nerve saying what we can or cannot charge private pay clients – taking insurance involves A LOT of expenses that private pay does not and their maximum allowable is never your full fee). Secondly, too often therapists get into situations where the client seems to be gaming you. In order to get the required number of hours during my postdoc year (I was in a rural area and it was haaard to get those hours), I charged $20 a session (!). There were clients who even tried to game me over that! Lesson learned.
I am a psychologist with a maternal mental health practice. I have signed up with My Red Tent, who asks you to provide one pro bono session to a needy mom (haven’t gotten any requests in a year, though). Pro bono is preferable to me – and when they come in, we will specify how many sessions they are being offered (not indefinitely for years).
I also have an opportunity to get in on the ground floor of a Mothers of Preschoolers program through my church. It’s my area of expertise and so I’m going to volunteer there. It fulfills my ethical obligation to give back to the community in a way that a sliding scale can never do.
Thank you so much for sharing how you do things in such detail! It is helpful for us all to see how many different models can be used when thinking about how to give back while also staying in integrity with our business goals!
i love this! thank you for all the direct language at the end too— that’s super helpful. 🙂
Mariam! I’m so glad it was useful!! 🙂