Making my sliding scale more...slide-y

Therapy, access, and seeking economic justice

As I’ve discussed here a little in the past, mental health care access is a massive social justice issue. As a middle-class white cis woman who does therapy outside of the traditional mental health care system, I’m frequently aware of the ways that many people who could really use my help, can’t get it. I don’t accept health insurance, so it’s not possible for my clients to use co-pays or receive care for free.

Since I started as a Certified Rubenfeld Synergist / Somatic Therapist, though, I’ve had a sliding scale. From the beginning, I’ve offered it to all clients, allowing them each to choose where along the scale feels good to them. I remember someone asking me once, “Doesn’t that make everybody just pay as little as they can?” The answer to that, interestingly, is no, absolutely not. Often, people who feel strapped will still pay, say, $5 more than the lowest number, though several simply pay the low number, even when that’s a struggle. Many will pay the top number without hesitation. Lots of folks put themselves in-between.

Because it turns out that people have complex relationships with money, with care, with paying what they think a service is worth, with keeping up their side of an agreement, with being someone who can take care of themselves…there is a lot, a lot, that goes on in people’s heads and bodies about money. I am by no means an exception to this rule. I grew up relatively poor, and the deep message in my body about money is that there is never enough of it, and I should never expect there to be—certainly not for me.

I had help from mentors on setting my rates high enough, and there’s been a fair share of motivational talk about what my work is worth. But I’m also aware that as it stands, even my lowest available fee is not accessible to many people who could really use my help. And I feel that part of my own relationship—to money, to work, to my own value, to my clients—needs to shift if I’m going to feel good about what I offer to the world. After all, “the world” is a pretty limited concept if you’re only talking about people who can afford $65-100 an hour.

A friend pointed me to this wonderful article about the sliding scale as “a tool of economic justice.” For a long time I felt as though I was doing enough by keeping my rates relatively low compared to the market. But as I think more and more about that market, I’m less and less easy with it. Why should folks who can’t afford the $150-250 an hour that many good therapists charge—which is to say, most folks, but especially folks who aren’t middle class, white, cis people like myself, i.e., the folks who likely need it the most—have to either be at the mercy of our extremely broken health insurance system, or not get help at all?

Many therapists, even ones who could accept insurance, have opted out of the health insurance system, which requires diagnosis from the DSM in order to pay for treatment, and which mires private practice therapists in mountains of paperwork in order to get paid. I’m sure I’d find the paperwork annoying, but the larger reason I don’t want to be a part of that system is its contrary and pathologizing nature. Many of the best therapists I know have decided the same.

The sliding scale is a handy tool for this problem, and some of those therapists also offer it. But I recognize that I’ve been narrow in my possibilities for using it, and possibly even confusing potential clients. A true sliding scale offers a choice of ranges, which are based on what the client can afford. More punitive forms of it require income verification, or some other means of determining whether the person “really needs” it, which is ableist and humiliating, and not a racket I want to get into. But the article I linked above discusses the sliding scale as not just a tool of economic access, but of accountability to self and community:

“For a sliding scale to work it relies on the principles of truthfulness, respect for complexity, and accountability. I do not ask for income verification. I trust my students and clients to be honest. Community thrives when accountability is a central value, because that is where trust grows and depth work can be done. Teachers deserve to get paid and students deserve classes which recognize the multiple realities of economic access and privilege that exist.”

With all of this in mind, I’m currently working on crafting a new sliding scale for my services. The low end will be lower; the high end, higher. I plan to offer three ranges. I want to be able to help more people. And I want folks to whom it is an important value to pay me “what I’m worth” (yes, they exist!) to help make up the difference and allow access to those with fewer resources.

In the course of determining this new scale, the other really important principle I’m taking from this article is the idea of sacrifice versus hardship, when determining where along a sliding scale you place yourself. As the author explains it,

“If paying for a class, product, or service would be difficult, but not detrimental, it qualifies as a sacrifice. You might have to cut back on other spending in your life (such as going out to dinner, buying coffee, or a new outfit), but this will not have a long term harmful impact on your life. It is a sacred sacrifice in order to pursue something you are called to do. If, however, paying for a class, product, or service would lead to a harmful impact on your life, such as not being able to put food on the table, pay rent, or pay for your transportation to get to work, then you are dealing with hardship. Folks coming from a space of hardship typically qualify for the lower end of the sliding scale.”

There’s a great graphic, which I’ll share here, that breaks down some of the criteria you might use when figuring out what part of a sliding scale to use. It asks each person to take an honest look at what paying for this service means for them, and takes into account some of the intersecting issues that go into financial privilege. I’m aware that the stuff about cars doesn’t apply everywhere, and of course the issues put into the “bottles” in the graphic are by necessity incomplete. But it feels like a really good start to me.

I’ve set the image at the large size, because the type is quite small, and I’ve included an image description below (it’s too long to go into alt text, so it’s kludgey, but I wanted to make sure this image especially was accessible).

I’d love to hear your thoughts about this model in the comments. Have you engaged with a sliding scale as a purchaser, or offered one as a business? How did it feel to engage with? What do you think it takes to make a sliding scale a truly equitable tool?

Image description:

Title text: The Green Bottle: Where You Fall on the Sliding Scale

[Three bottles are pictured in a box, each with a different amount of green filled in. Down the left side of the box it says “Financial Privilege.” Along the bottom of the box it says “Personal Financial Experience.” 

The left bottle is fully green, and the text inside reads:]

I am comfortably able to meet all of my basic* needs
I may have some debt but it does not prohibit attainment of basic needs
I own my home or property OR I rent a higher-end property
I own or lease a car
I am employed or do not need to work to meet my needs
I have regular access to health care
I have access to financial savings
I have an expendable** income
I can always buy new items
I can afford an annual vacation or take time off

[The middle bottle is half-full of green, and the text inside reads:]

I may stress about meeting my basic needs but still regularly achieve them
I may have some debt but it does not prohibit attainment of basic needs
I own or lease a car
I am employed
I have access to health care
I might have access to financial savings
I have some expandable income
I am able to buy some new items and I thrift others
I can take a vacation annually or every few years without financial burden

[The right bottle is only about a quarter filled with green, and the text inside reads:]

I frequently stress about meeting basic needs and don’t always achieve them
I have debt and it sometimes prohibits me from meeting my basic needs
I rent lower-end properties or have unstable housing
I do not have a car and/or have limited access to a car but I am not always able to afford gas
I am unemployed or underemployed
I qualify for government assistance including food stamps and health care
I have no access to savings
I have no or very limited expendable income
I rarely buy new items because I am unable to afford them
I cannot afford a vacation or have the ability to take time off without financial burden

[At the bottom of the graphic are two footnotes:]

*Basic needs include food, housing, and transportation.
**Expendable income might mean you are able to buy coffee or tea at a shop, go to the movies or a concert, buy new clothes, books, and similar items each month, etc.

[Credit: designed by Alexis J. Cunningfolk, www.wortsandcunning.com]