By Norman Cerny, LISW-S | Small Works Counseling
Someone can work full time, have health insurance, and still spend weeks trying to find a therapist they can afford. Maybe their deductible is high. Maybe the therapists on their plan’s list aren’t taking new clients. Maybe the only person with an opening has little experience working with queer or trans clients, and they’ve already had enough appointments where they spent half the time explaining themselves.
When I set fees at Small Works Counseling, I think about that person. I also think about the person who earns just enough to fall outside a public program’s eligibility rules, or whose hours change from week to week. What would make it possible for them to start therapy and keep coming?
Why would a therapist choose private pay?
Private pay means you pay the therapist directly for a session. At Small Works Counseling, I offer direct-pay options and also accept Traditional Medicare. I chose to make private pay part of the practice because it gives me room to set fees up front and offer different rates based on what people can afford.
There’s a practical reason, too. In a small practice, the therapist often doubles as the person who checks benefits, submits claims, and follows up on denials. Direct payment takes some of that work out of the process. The U.S. Government Accountability Office found that even people with insurance faced barriers to getting mental health care, including inaccurate provider directories and limited in-network availability. Stakeholders identified low reimbursement as one factor that can discourage clinicians from joining insurance networks (U.S. Government Accountability Office, 2022).
Privacy can also matter. For a queer or trans person on a family member’s health plan, it’s reasonable to ask what information a claim might generate and who could see it. Paying directly without submitting a claim keeps that visit out of the insurance claims process. The therapist still keeps a clinical record, and confidentiality rules still apply. Under HIPAA, when a service is paid in full out of pocket, a covered provider generally must honor a request to restrict disclosure about that service to a health plan for payment or health care operations, provided the disclosure isn’t otherwise required by law (U.S. Department of Health and Human Services, 2022).
What equity pricing looks like at Small Works
Equity pricing is our sliding scale. It starts with the idea that the same fee can mean very different things in two households. Two people might earn the same salary, while one has savings and paid leave and the other is supporting family, paying down medical debt, or losing wages every time they take an hour off.
Our scale draws on Alexis J. Cunningfolk’s Green Bottle Method, which asks people to consider their overall access to resources. Income is one piece of that picture, alongside savings, debt, financial support, and the ability to cover basic needs (Cunningfolk, 2015).
Small Works Counseling Equity Pricing Equity pricing tier Per session When it might fit
Abundant resources $100 Your basic needs are comfortably covered, and you have savings or other financial support to fall back on. Paying this rate helps make lower rates possible.
Steady resources $75 You generally cover your essentials, but a recurring therapy bill takes some planning.
Limited resources $50 Income is unpredictable, essentials are already hard to cover, or expenses such as debt, caregiving, or medical bills leave little room for therapy.
Equity pricing spots are limited. When you’re considering a tier, think about what it would cost to keep coming over a month, especially in a month when the car needs work or your hours get cut.
What this has to do with solidarity
My politics shape how I think about the cost of care. From a progressive, leftist perspective, the conditions people live under are part of the mental health conversation. A person can learn ways to cope with stress and still need affordable housing, paid leave, or a job that gives them enough hours. When people struggle to afford therapy, I think the practice has a responsibility to look at what it can change about its own fees.
I draw on mutual aid as an ethic of solidarity. In Social Text, Dean Spade (2020) describes mutual aid as people meeting immediate needs together while organizing to change the conditions that created those needs. A sliding scale puts one part of that ethic into practice. People with more room in their budgets help make lower fees possible, and people who use those lower rates receive the same care. The scale also needs to pay for the labor that goes into providing therapy, including the work between sessions.
If you’re considering therapy with Small Works Counseling, you can check our Rates and Sliding Scale page and ask about current openings at the rate that fits your budget.
References
Cunningfolk, A. J. (2015, August 11). The sliding scale: A tool of economic justice (aka the Green Bottle Method). Worts & Cunning Apothecary. https://www.wortsandcunning.com/blog/sliding-scale
Spade, D. (2020). Solidarity not charity: Mutual aid for mobilization and survival. Social Text, 38(1), 131–151. https://doi.org/10.1215/01642472-7971139
U.S. Department of Health and Human Services. (2022, December 28). Under HIPAA, may an individual request that a covered entity restrict how it uses or discloses that individual’s protected health information (PHI)? HHS HIPAA FAQ
U.S. Government Accountability Office. (2022, March 29). Mental health care: Access challenges for covered consumers and relevant federal efforts (GAO-22-104597). https://www.gao.gov/products/gao-22-104597
