This content is provided by zynnyme, an affinity partner of AAMFT. This information is not necessarily the view of AAMFT and should not be interpreted as official policy.
Therapists are helpers at heart. We got into this work because we genuinely care about people and want to make a difference. We all believe in the power of therapy and its impact on not just the individual but also the family and the legacy left by each person we work with. Therapy is something that we want everyone to have access to, but how do we do that within the current context of our healthcare system?
The Truth No One Wants to Admit: Being Underpaid Can Impact Clinical Outcomes
Fees that don’t lead to a livable wage, inconsistent income, and the creeping dread of burnout don’t exactly make for a thriving private practice—or a happy, healthy therapist. And a burnt-out therapist does NOT lead to great clinical outcomes. Therapists who are struggling to live on an unlivable wage also often do not have access to consultation, training, rest, or sustainable caseloads. And yes, all of these impact clinical outcomes.
Bridging the Gap in the Healthcare System
The current landscape of mental health care in the United States is a challenging one for therapists and clients alike. Insurance companies, which are supposed to bridge the gap between care and affordability, often make it harder for both parties. Therapists are grappling with clawbacks—where insurers retroactively recoup payments for services already provided—and steadily declining reimbursement rates. These practices not only undervalue the work of mental health professionals but also discourage many from accepting insurance altogether. As a result, clients seeking affordable care are left navigating a shrinking pool of in-network providers, while therapists face increased pressure to balance accessibility with their financial and professional sustainability. This cycle perpetuates a broken system where both clients and clinicians pay the price.
For years, mental health has been underfunded and overlooked, leaving therapists to play the role of superhero—minus the cape, plus the student loans. The truth is individual therapists can’t fix systemic problems like inadequate funding or insurance barriers. Yet we’re often left holding the bag.
What’s the takeaway? We shouldn’t be the only ones patching the holes in a broken system. Advocacy and systemic change are where the real magic happens.
But what do we do at an individual level? How do we keep helping without helping ourselves into exhaustion? Let’s dig in.
Sliding Scale Fees in Private Practice
Ah, the sliding scale: the DIY solution therapists often turn to when we want to make therapy more affordable. Essentially, it’s a fee structure where clients pay based on what they can afford. Seems simple, right?
Sliding scale fees might seem like the hero we need, but they can come with some sneaky ethical dilemmas. For starters, charging different client's different rates for the same service can make things feel a little… wobbly. Imagine a client paying full price finding out someone else gets the same care for less—awkward, right? It could create feelings of unfairness or even erode trust in the therapeutic relationship.
Plus, therapists are human, and let’s be real—there’s a chance you might subconsciously invest differently in someone paying less versus someone paying your full rate (even if you don’t mean to!). Could resentment arise in the therapeutic relationship if you hear about something that infers to you that the client could pay the fee for therapy? We think it could.
This variability can conflict with the ethical principles of fairness, transparency, and maintaining the value of therapy. The result? Sliding scales can unintentionally slide right into murky territory, making it essential for therapists to tread carefully and consider alternatives that feel fair and aligned with their values. Sliding scales are not always the knight in shining armor they appear to be.
The Ethics of Using a Sliding Scale
AAMFT emphasizes fairness and transparency. If you’re using a sliding scale, it better be clear, consistent, and above all, ethical. This means that if you choose to use a sliding scale you need to remove bias from your process, so that every person that comes through your door gets the same access based on the same factors.
In a CPH Insurance Avoiding Liability Bulletin it was mentioned by Richard Leslie, “My view is that a "sliding fee scale” is unnecessary, unwise and problematic." Most sliding fee scales used by nonprofits and other entities base the fee on the financial condition of the patient. In order to properly implement such a policy, entities must ask for certain information and perhaps supporting documentation, like tax returns. Most private practitioners do not want to get into that kind of detail in their practices. Psychotherapists usually establish fees that they are comfortable charging and stay with those fees until they decide to raise their fees. Physicians and other practitioners likewise establish a “usual and customary fee” and typically do not change their fee for different patients. If the patient can’t afford the fee, he or she can be referred elsewhere."
Sliding scales aren’t a no-no, but they’re not exactly a “yes-yes” either.
Let’s think outside the sliding-scale box and explore some fresh alternatives that keep therapy accessible without leaving therapists feeling like overworked superheroes.
First up, there’s the Privilege-Based Sliding Scale. An example of this would be the Green Bottle Method created by Alex J. Cunningfolk. This spin on the traditional sliding scale puts the power in your clients’ hands. Instead of awkward financial disclosures, clients self-select their fee based on their resources, privilege, and ability to pay. It’s judgment-free, transparent, and as a bonus—way less paperwork for you! This approach empowers clients while taking the emotional and administrative weight off your shoulders. Yet, what will you do if you find that this process doesn’t lead to a sustainable wage? Or, if clients that appear to have more financial privilege are consistently self-selecting for a sliding scale, while clients who are struggling do not?
Then there’s Group Therapy, the ultimate win-win solution. Group therapy gives clients a built-in support system, reducing feelings of isolation while being budget friendly. For therapists, it’s a great way to maximize impact without burning out. Pro tip? Market it as a unique, collaborative feature of your practice—because group therapy is seriously underrated and underutilized.
Another option is Tiered Service Models, which are like a buffet of therapy offerings. You can create a range of options: lower-cost services such as workshops, self-guided programs, or one-off consultations for budget-conscious clients, while reserving your one-on-one sessions for full-fee clients. This approach not only protects your time and energy but also gives clients more ways to access your expertise.
You can also choose to Give Back, as our AAMFT ethics mention, and improve accessibility, changing the system from within through lobbying, advocacy and volunteering at a government level to affect change.
And sometimes, you just have to pass the baton. Build Advocacy and Referral Networks by connecting with nonprofits or other clinicians who offer sliding scale or low-cost options. It’s okay to acknowledge when a client’s needs fall outside your financial or professional capacity. Bonus points for getting involved in advocacy efforts to push for systemic changes like better insurance reimbursements and increased mental health funding—because real change happens when we shift the system, not just our individual practices.
Finally, there’s the all-in strategy of Lower Fees Across the Board. While it might sound like an easy fix, it comes with a big red flag: burnout. If you decide to reduce rates for all clients, make sure you’ve got a rock-solid self-care plan and a realistic client load. Remember, being a therapist isn’t about self-sacrifice—it’s about sustainable care for both you and your clients.
Redefining Accessibility and Sustainability
Sliding scales aren’t inherently bad, but they’re not the only (or always the best) solution. Whether it’s privilege-based models, group therapy, or tiered services, there are plenty of creative ways to balance accessibility with sustainability.
And let’s not forget the bigger picture: systemic change is the real game-changer. So, while you’re doing the amazing work of supporting your clients, don’t forget to advocate for a system that supports you, too.
because at the end of the day, the best therapy happens when both client and therapist are thriving.