How To

Since September, psychologist Nancy Molitor, PhD, of Wilmette, Ill., has seen an increase in the number of patients who are anxious about their ability to pay for her services.

"People want to cut deals," she says. "More are paying for sessions with their credit cards, and some can't even do that. Some clients have asked if they can pay 10 or 20 percent less." She fears that many who need treatment aren't able to get it, or continue getting it, because they can't afford it.

Molitor has found ways to help, usually by reducing her fees slightly. "I wasn't going to abandon them," she says.

But, she admits, if she has to cut her prices for all of her clients, she's a bit worried about the long-term implications for her own finances. Her dilemma isn't new or exclusive to today's economy. Most psychologists have clients who can't afford therapy fees from the beginning or hit hard times mid-therapy due to the death of a spouse, a job loss or other unexpected event.

When that happens, it's important for psychologists to have a reduced-fee policy or other strategies in place to help, and to avoid feeling tongue-tied when a patient requests a financial break, says Jeffrey Barnett, PhD, a practitioner in Arnold, Md., and incoming chair of APA's Ethics Committee. "You want to address it in a thoughtful way that is sensitive to their financial need, but doesn't take advantage of the professional either," he says.

Helping with fees is trickier for clients that are covered by insurance since most insurance companies don't allow waiving co-payments or deductibles, says Maureen Testoni, JD, director of legal and regulatory affairs for APA's Practice Directorate. Psychologists may want to ask the insurer to waive the co-payment or deductible for specific clients, she adds.

Nonetheless, there are a variety of ways psychologists can help people who must pay for treatment out of pocket to weather a financial downturn. They can:

1. Propose flexible scheduling. Barnett has several clients he sees every other week, rather than once a week, to lower costs. He also will see them for half-hour rather than hour sessions. "Perhaps they're in a place where they should be doing that anyway," adds Holly Hunt, PhD, a psychologist in Long Beach, Calif. Some patients, she notes, are ready to add time between visits to do take-home therapy assignments or join therapy groups that meet during the off weeks. Practitioner Rachel Barbanel-Fried, PsyD, charges students and others with flexible schedules less because they can come in during slow periods, such as mid-afternoon.

2. Suggest a payment plan. Another option is to allow patients to pay a portion of their fees now and add the balance to a tab they can pay down over time when their financial situation changes. "Frame it like you are going to help them weather the storm and that when the problem is solved, we'll go back to what you had," advises Chicago practitioner Chris Stout, PsyD. "Some people feel more comfortable when it doesn't sound like charity."

3. Offer a sliding fee scale. Hunt lowers fees for self-paying clients based on their incomes and number of dependents. Psychologists need to work with patients to find a comfortable balance; resentment over fees can "feed into the therapeutic relationship and create harm," she says. Offering a sliding scale for self-pay clients that is lower than what the psychologist is paid by Medicare or private insurers can be risky, however, because the payer may say the psychologist has been charging them "artificially high fees" and ask for a refund, adds Testoni. This is a risk primarily in situations where a significant percentage of a psychologist's clients are charged less than what the psychologist receives from Medicare or other insurers, she says. For more information on sliding fee scale do's and don'ts, visit

4. Accept what they can offer. Atlanta psychologist Steven Walfish, PhD, asks clients what they can afford to pay before therapy begins. "There have been only a handful of times when a person could afford more than they pay," says Walfish, a practitioner for 27 years. "I have always been afraid of people finding out I am willing to see people for less money and that it would open the floodgates for low-paying clients, [but] it's never happened."

5. See them pro bono. Many psychologists see a percentage of clients at no cost, a strategy that's encouraged by the Ethics Code but not embraced by everyone, says Barnett. "If every psychologist did that, it would meet a big need," he says.

6. Refer them. If you and your client can't agree on a fee—or you have already maxed the number of low-cost clients you can afford—send them to a local community mental health agency or a university training clinic. "Some [psychologists] are also willing to slide lower than I am, so I make referrals to them," says Barbanel-Fried.

Some clients may also benefit from paying in services rather than cash. Bartering is allowed under the Ethics Code if it's not exploiting the client or clinically contradictive (such as negotiating help on your Web site from a client with an Internet addiction). Still, it is important to understand the value of the services being put forth, practitioners say. Patients and psychologists should agree on the value in advance and psychologists will need to be sure to declare the services as income at tax time, says Barnett.