Professional Psychology: Research and Practice
2017, Vol. 48, No. 5, 327–334
© 2017 American Psychological Association
0735-7028/17/$12.00 http://dx.doi.org/10.1037/pro0000140
Advancing Training in Session Fees Through Psychology Training Clinics
Mindi N. Thompson, Stephanie R. Graham, Dustin Brockberg, Mun Yuk Chin, and Tiffany M. Jones
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
University of Wisconsin-Madison
Psychology training clinics can meet the needs of communities who have limited access to quality and
affordable mental health services by offering sliding scale or reduced fee structures. The use of sliding
scale fee structures in psychology training clinics also provides a rich training experience for graduate
student trainees. Yet, limited attention has been directed toward understanding how to effectively train
graduate students and clinicians to discuss session fees and other social class-related issues within
psychotherapy. The purpose of this article is to address this gap by describing a conceptual model used
in 1 psychology training clinic that integrates session fee considerations into training, service delivery,
and supervision. Suggestions and exemplars related to each model component (i.e., training clinic
mission, client paperwork and marketing, training, service delivery, supervision, and consultation) are
described. The model components mutually inform 1 another in order to contribute to the provision of
mental health treatment to clients and to enhance trainee skill development related to money and social
class considerations. Implications for training and limitations of the model are discussed.
Keywords: session fees, social class, sliding scale, training, training clinics
Research has demonstrated that social class-related factors such
as low levels of family income, high levels of family stress, and
unemployment are related to mental health outcomes, including:
increased anxiety, depression, and stress (e.g., Sleskova et al.,
2006). Individuals with social class-related concerns and stressors,
however, are less likely to access mental health treatment (e.g.,
Nadeem, Lange, & Miranda, 2008). Despite documented (e.g.,
Falconnier, 2009; Miranda et al., 2003) disparities in psychotherapy treatment attendance and outcomes for patients from low
social class backgrounds (i.e., an individual’s perception of oneself
as on the lower end of the stratification hierarchy; American
Psychological Association [APA], 2007), social class often has
been a neglected contextual variable within psychotherapy literature (e.g., Goodman, Pugach, Skolnik, & Smith, 2013; Smith,
2009; Thompson & Dvorscek, 2013). One consistent theme that
has emerged from the literature is that clinicians lack specific
training and skills in the incorporation of social class-related issues
into treatment (e.g., Appio, Chambers, & Mao, 2013; Ballinger &
Wright, 2007; Balmforth, 2009; Kim & Cardemil, 2012; Liu,
Pickett, & Ivey, 2007; Pope & Arthur, 2009; Stabb & Reimers,
2013; Thompson et al., 2015). Low cost and sliding scale fee
clinics offer one outlet for individuals who have limited access to
resources (e.g., money, health insurance coverage) to seek mental
health treatment (e.g., Aubry, Hunsley, Josephson, & Vito, 2000).
This article was published Online First June 1, 2017.
MINDI N. THOMPSON earned her doctoral degree in psychology (concentration: counseling psychology) in 2008 from the University of Akron. She
currently works as an Associate Professor and Director of Clinical Training
in the Department of Counseling Psychology at the University of
Wisconsin-Madison. Her areas of professional interest include social class,
vocational psychology, psychotherapy, and consultation.
STEPHANIE R. GRAHAM earned her doctoral degree in counseling psychology
from Auburn University. She is currently a clinical associate faculty member
in the Department of Counseling Psychology at the University of WisconsinMadison where she serves as the director of the Counseling Psychology
Training Clinic. Her areas of professional interest include supervision, competency development, and counseling with LGBTQ individuals and couples.
DUSTIN BROCKBERG received his MS in counseling psychology from the
University of Minnesota–Twin Cities. He is a current doctoral student in
the Department of Counseling Psychology at the University of Wisconsin–
Madison. His areas of professional interest include PTSD treatment modalities, reintegration issues for student service members/veterans, veteran
culture, and veteran help-seeking decision-making.
MUN YUK CHIN received her masters degree in counseling psychology
from Northwestern University. She is currently a doctoral student in counseling psychology at the University of Wisconsin-Madison. Her areas of professional interest include social class identity, LGBTQ health, and psychotherapy.
TIFFANY M. JONES received her bachelor degree in psychology from
Cornell University. She is currently a doctoral student in the Department of
Counseling Psychology at the University of Wisconsin-Madison. Her areas
of professional interest include mentorship, academic persistence, and
multicultural counseling.
DUSTIN BROCKBERG, Mun Yuk Chin, and Tiffany M. Jones contributed
equally.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to
Mindi N. Thompson, 335 Education, 1000 Bascom Mall, Madison, WI
53706. E-mail: mindi.thompson@wisc.edu
Low Cost Therapy and Psychology Training Clinics
Since the late 1800’s, psychology training clinics have had an
important role in the development and training of future psychologists (Association of Psychology Training Clinic [APTC], 2015).
A 2011 survey of APA accredited clinical, counseling, school,
combined, and integrated programs demonstrated that 65% of the
195 participating programs had training clinics housed within their
department’s administrative control (Hatcher, Grus, & Wise,
2011). Most training clinics utilize a tripartite model that includes
emphasis on training, research, and service delivery within the
context of meeting community needs (APTC, 2015). Many psychology graduate programs view training clinics as a primary
source of supervised practical learning experiences for graduate
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THOMPSON, GRAHAM, BROCKBERG, CHIN, AND JONES
student trainees that have been demonstrated to contribute to
positive outcomes for development of trainee competence (e.g.,
DePue & Lambie, 2014; Hannum, 1988).
In the United States, many psychology training clinics housed
within institutions of higher education use a sliding scale or
reduced fee structure and rely upon trainees and clinic staff to
negotiate fees with clients (e.g., Aubry et al., 2000). As such,
training clinics offer an opportunity to serve clients with constrained finances while simultaneously providing critical training
to graduate students (e.g., Aubry et al., 2000). Data from the APTC
(2015) indicated that of 133 member clinics, 116 (87%) used a
sliding-scale fee structure that allowed reduced session fees according to client social class information (e.g., income, education,
dependents, employment or unemployment status, health insurance). Training clinics, therefore, offer graduate training programs
a mechanism to actualize a mission of social justice by meeting the
needs of community members who may otherwise be unable to
access mental health treatment. As such, training clinics are in a
unique position to contribute to addressing documented (e.g., Chu
et al., 2012; Falconnier, 2009) mental health treatment disparities.
In addition, scholars and practitioners (e.g., Clark & Sims, 2014)
have suggested that the utilization of a sliding-scale fee structure in
psychology training clinics creates a rich training paradigm. Specifically, Clark and Sims (2014) described some of the ways in
which trainees working within a sliding scale treatment model are
forced to grapple with a variety of clinical and professional development issues. For example, this model forces trainees to carefully
consider potential benefits and drawbacks to pay structures, cultural and contextual factors that impact client’s ability to access
care and experiences within psychotherapy, and ethical considerations associated with the provision of mental health treatment as
reflected in the APA code of Ethics (APA, 2010) such as boundary
management (Standard 10.1) and informed consent (which includes informing patient of fees). Deliberate attention to training
therapists in conversations regarding session fees also is aligned
with the recent competency movement in health service psychology that includes the expectation that clinicians are competent in
reflective practice and professional judgment (e.g., emotional competence, professional self-awareness) as well as cultural and individual differences and diversity (American Psychological Association Council of Representatives, 2017).
Money and Session Fees in Psychotherapy
Although many psychology training clinics utilize a sliding
scale fee structure, relatively little is known about the process by
which beginning therapists are trained in this model and no empirical data exist examining the effectiveness of such models. Not
surprisingly, scholars (e.g., Clark & Sims, 2014; Herron & Sitkowski, 1986; Koocher & Keith-Spiegel, 2008) have begun to
question the extent to which the topic of fee collection is addressed
in a systematic or consistent manner in psychotherapy training and
supervision and have called for further attention to this issue. This
echoes the calls from a growing group of scholars and practitioners
(e.g., Appio et al., 2013; Balmforth, 2009; Goodman et al., 2013;
Kim & Cardemil, 2012; Liu et al., 2007; Smith, 2005; Thompson
et al., 2012, 2015) who have noted the dearth of attention to how
social class and money are addressed within psychotherapy and
how clinicians are trained to competently address such issues.
Although empirical data are limited, some authors (e.g., Cerney,
1990; Clark & Sims, 2014) have begun to identify factors that may
act as barriers to therapists and trainees engaging in explicit
conversations with clients about money. The first set of explanations relates to personal discomfort and concerns that therapists
may have regarding their ability to effectively engage in such
conversations because of their own social class-related experiences
and financial status relative to their clients. For example, lapses in
fee conversation and collection may be related to unresolved
therapist issues about the meaning of money (DiBella, 1980),
therapist family of origin social class experiences (Clark & Sims,
2014), and therapist personal social class (Thompson et al., 2015).
In their 2015 qualitative investigation with mental health providers, Thompson et al. (2015) showed that therapists commonly cited
emotional reactions and countertransference (including experiences of guilt, fear, and judgment) in response to working with
clients from differing income backgrounds in psychotherapy.
In addition, therapists (and particularly new therapists) may
avoid conversations in order to compensate for the inadequacy that
they feel related to their ability to provide effective treatment.
Some older empirical evidence (e.g., Meyers, 1976; Pasternack &
Treiger, 1976) demonstrated that trainees’ internalized beliefs
about the inadequacy of one’s services contributed to their tendency to ignore established fees, neglect to assess whether clients
are paying agreed-upon fees, and fail to require clients to pay
outstanding bills. More recently, in a qualitative study examining
psychotherapist’s experiences about fee discussions with clients,
Lasky (2000) indicated that even advanced therapists reported
feeling ambivalent about collecting fees and experienced discomfort related to managing the financial aspects of psychotherapy.
Because trainees may feel particularly insecure about their ability
to deliver effective treatment, they also may be likely to believe
that their services are of limited monetary value (Clark & Sims,
2014). Such beliefs, if left unaddressed, may reinforce trainees’
desire to escape feeling pressure to perform and lead to the
avoidance of conversations about money. Clinical supervisors who
are uncomfortable or feel ambivalent about discussing money
explicitly with clients or trainees also may be likely to avoid such
conversations.
Because most training programs prioritize the development of
trainees’ psychotherapeutic skills rather than their financial or
business proficiency, faculty and supervisors may be less likely to
incorporate explicit training related to money matters. Accrediting
bodies generally have not required trainees to demonstrate competence in the financial aspects of operating a clinical practice
(Clark & Sims, 2014) and prior data (i.e., Gerstein & Shullman,
1992) showed that the majority of psychology training programs
do not require or provide the option for students to take courses in
business management or organizational psychology. Clark and
Sims (2014) also noted that the number of psychology academic
faculty directly involved in independent practice or other fee-forservice endeavors is limited, which may hamper the dissemination
of social class and business-related knowledge to trainees. This
gap in training is particularly problematic when considering that
trainees who enter independent practice and other fee-for-service
settings will do so without adequate knowledge of financial aspects of psychotherapy or comfort in discussing basic money and
fee issues with clients.
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SESSION FEES IN PSYCHOLOGY TRAINING CLINICS
Taken together, literature suggests that a variety of factors may
contribute to the lack of specific attention to social class and
money-related issues in psychotherapy practice. Clark and Sims
(2014) suggested that although trainees may gain applied experience in fee negotiation and collection at some point in their
training, the consistency and quality of this skill set varies across
programs, practicum placements, and trainees. Given the role of
psychology training clinics in training the next generation of
psychotherapists, it seems important to more closely consider how
session fees and social class-related issues can be better integrated
into training. The purpose of this article is to describe how one
training clinic explicitly integrates money and fee-related issues
into the clinic structure and clinical training so as to spark avenues
for future training, practice, and research. This seems particularly
important given the recent competency movement that is central to
health service psychology training programs that now requires that
trainees be competence in areas related to management and individual and cultural differences within psychotherapy treatment
(American Psychological Association Council of Representatives,
2017). Although a full review of the relevance of session fees and
social class-related conversation across all treatment settings is
outside the scope of this article, we hope that some elements
incorporated into our discussion of the model components may
have some applicability across settings.
A Psychology Training Clinic Model
In the sections that follow we describe our model. We integrate
exemplars based loosely on clinical and supervision case material,
training practices, and relevant literature to illustrate each component. The first three model components (mission; policies and
procedures; and marketing and client paperwork) are the structural
elements that form the backbone upon which training is delivered.
In other words, the clinic mission drives the development of
policies, procedures, and paperwork that guide the clinic’s day-today functioning, fee structure, and the way that individuals (e.g.,
prospective clients, community members) learn about the clinic as
a prospective treatment setting. These foundational components
inform our developmental training sequence designed to review
relevant literature and provide trainees experiential practice in
addressing social class and fee-related issues with clients. This
sequential training offers trainees and clinic staff foundational
knowledge on which service delivery, supervision, and consultation (which mutually influence one another) are based.
Structural Elements
Mission. Mission statements offer one way for training clinics
to define their purpose and to articulate a connection to the home
academic department and the community served by the clinic (e.g.,
APA, 2006; APTC, 2015). As such, mission statements are a
mechanism by which training clinics can explicitly integrate the
community context and explicate a social justice focus by articulating the goal to serve those who may otherwise be unable to
afford mental health treatment. Because many training clinics are
funded via internal sources that augment revenue that is generated
from service delivery, training clinics often have flexibility to offer
sliding scale services. In this way, psychology training clinics can
meet a community’s need for quality and affordable mental health
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services that may otherwise be absent, thereby reducing barriers to
treatment for underserved populations. Treatment settings that
strive to serve the community may want to consider how to phrase
their mission statement in such a way that (a) speaks to this
commitment and (b) explicitly describes the ways in which this
commitment is actualized (e.g., via sliding scale, pro bono services
for particular groups, diversity among therapists, variety of presenting concerns served). For example:
The University of Wisconsin-Madison Counseling Psychology Training Clinic (CPTC) is a training facility for the Department of Counseling Psychology’s graduate training programs (Ph.D. and M.S.). The
fundamental mission of the clinic is twofold: First, we aim to provide
the highest quality training in Psychology. Second, we strive to offer
affordable, quality mental health services for the larger Madison
community. The clinic supports the research of department faculty
and students and seeks to advance understanding of psychological
health conditions and effective clinical services. The clinic is fully
committed to the upholding ethical standards of the American Psychological Association (APA) and the American Counseling Association (ACA), and all applicable legal standards. The clinic is philosophically guided by a fundamental commitment to financially
accessible psychological practice that is grounded in science, and is
concerned with the cultural, dynamic, behavioral, and humanistic
processes of counseling practice. (Counseling Psychology Training
Clinic Handbook of Policies & Procedures, 2016, p. 2)
This mission statement is succinct, which allows us to include it
in our promotional materials when we connect with campus leaders and community organizations. It affirms our commitment to
providing “affordable” and “financially accessible” services. The
mission statement directly informs our clinic’s policies and procedures, clinic marketing materials, and client paperwork.
Policies and procedures. Psychology training clinics, as with
any mental health service agency, need clear policies and procedures that guide operations (e.g., treatment provision, ethics, supervision, training, paperwork). A full review of our policies and
procedures is outside the scope of this article; instead, we focus on
those that relate directly to social class and fee collection. Setting
up an administrative structure regarding fee collection provides a
framework from which trainees are expected to operate, upon
which money-related decisions are made, and from which client
paperwork and marketing materials are derived.
Mental health treatment settings are expected to adhere to ethical guidelines when developing policies and procedures. The APA
(2010) outlines specific areas of competence and awareness regarding financially related concepts, including: advertising (5.01),
fees and financial arrangements (6.04), barter with clients/patients
(6.05), and referrals and fees (6.07). In addition, scholars (e.g.,
Knapp & VandeCreek, 2008) have discussed ways in which psychologists might set fees and create financial arrangements with
clients (e.g., cancellations, bartering, collection agencies, insurance) within professional ethical standards. The ethics code stipulates the need for psychotherapists to be aware of social class and
clients’ ability to access psychotherapy when structuring policies
and procedures.
In the U.S., the Federal Poverty Guidelines (FPG; U.S. Department of Health & Human Services, 2017) offers a mechanism for
developing a sliding scale fee structure. When establishing fees,
mental health providers seeking to utilize a sliding scale fee
structure may benefit from using the FPG as a point of reference
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THOMPSON, GRAHAM, BROCKBERG, CHIN, AND JONES
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while also considering the FPG in the context of the specific
community context. In other words, because macroeconomic factors (e.g., regional unemployment rates, local poverty rates, neighborhood context) vary widely, session fees within a specific community context may need to be adjusted. Further, treatment
providers may benefit from assessing whether and how to adjust
fees based upon existing clientele and clinic mission on an annual
basis given the relative instability in local and global economies
over time. We include an excerpt from our policies and procedures
manual that speaks explicitly to session fees as an exemplar.
Many counselors struggle with a discussion of fees for services. At the
CPTC, we value that we can offer truly low cost services. In addition,
these services are worthwhile and the payment should reflect the value
of the services while also being fair to the client. Further, we see it as
valuable to your training to gain experience in discussing such topics
with clients. Carefully consider how your own discomfort with such
topics could influence this process. Counselors work with each client
to determine session fees. Fees are based on information provided by
the client on the Services Payment Form and the Fee Schedule. The
fee schedule takes into account a client’s total yearly income and
number of persons living in the household based on living in the area.
Session fees should be determined during the intake session.
The clinic strives to provide high quality services at a low cost. The
minimum fee is $10 per session; however, a lower fee can be negotiated if circumstances warrant. Know that we will still slide below
this or temporarily remove the fee if needed for clients and you are
encouraged to discuss with your supervisor about how to have these
conversations with clients. After the first session, clients may pay
their session fees when they check in at the front desk. Please talk with
your supervisor about how to discuss this directly, but therapeutically
with clients. If your client is having difficulty with making on-time
payments or regularly misses session payments, please let you supervisor know immediately so that you can develop a plan to assist your
client with payment (e.g., either by reducing fee/removing fee or
creating an alternative payment plan). (Counseling Psychology Training Clinic Handbook of Policies & Procedures, 2016, p. 20)
This excerpt speaks to our mission to deliver low cost services
and attempts to normalize the challenges associated with these
conversations in order to encourage trainees to seek supervision
and consultation. It describes some of the particular policies and
procedures that trainees and clinic staff are expected to follow
related to setting session fees and collecting payment.
Client paperwork and marketing materials. Information
related to fees for treatment also is communicated via client
paperwork and clinic marketing materials that are presented to
prospective clients and community members. Prospective clients
who are deciding whether or not to seek services may be interested
in learning about details related to typical session fees (and how
they are determined) and payment policies. We have found that
some clients feel comfortable asking such questions during an
initial phone conversation with a clinic staff member whereas
others have indicated feeling grateful that the information was
clearly described on clinic marketing materials (i.e., web site and
brochures) because it allowed them to proceed with scheduling an
appointment without fear or shame related to their inability to pay
for treatment. As such, maintaining up-to-date web sites and clinic
brochures that provide information regarding clinic policies and
procedures about fees to prospective clients and referral agencies
is important.
Clear and flexible language specific to the fee structure and
related policies included in client paperwork serves as a useful
point of reference for clients and trainees. We have found that
visual aids or graphics (e.g., a chart related to family income and
suggested session fee) serve as beneficial prompts from which
clients and trainees can engage in fee-related discussions. Because
economic factors can change rapidly, particularly for individuals
whose income is less secure (e.g., Appio et al., 2013), we believe
that it is important for client paperwork to communicate flexibility
in fee arrangements. We have found that communicating flexibility
in the fee structure lessens clients’ worry about their ability to
engage in treatment and normalizes the integration of social classrelated conversations throughout treatment.
Training Therapists to Integrate Social Class- and
Session Fee-Related Issues
We believe that training is at its best when it occurs at multiple
points in time and is developmental in nature so as to build upon
trainees’ growing skills and competence in understanding and
addressing social class-related issues in treatment. In the paragraphs below, we overview the phases of training that we use to
guide service delivery, consultation, and supervision. In the first
training module, we host a group orientation and training when
new staff and trainees start at the site. This training consists of an
overview of the clinic mission, services offered, and expectations
regarding fees for services. Initial team-building activities are used
to increase familiarity and begin to establish trust. Next, the clinic
administrative team facilitates discussion of relevant information
from the Clinic Handbook, Policies and Procedures Manual, and
client paperwork.
In the next training module, we review the rationale for the
sliding scale fee structure. This decision was informed by prior
research that has noted that discomfort or ambivalence about
money-related conversations in psychotherapy supervision and
training is a contributor to psychotherapists’ tendency to undervalue or avoid conversations about social class and fees with
clients (e.g., Clark & Sims, 2014; Thompson et al., 2015). In this
training module we also review data that has demonstrated that
session fees do not negatively impact client outcomes. For example, Clark and Sims (2014) demonstrated no relationship between
the fee that a client paid for treatment and client progress, attendance, and number of sessions completed. Finally, we highlight
findings regarding the importance of considering social class and
money within the context of psychotherapy (e.g., Kim & Cardemil,
2012; Smith, 2009; Stabb & Reimers, 2013) and describe the ways
that adopting a sliding fee scale structure allow us to realize our
clinic mission to increase accessibility for individuals who may
otherwise be unable to access psychotherapy (e.g., Pope & Arthur,
2009).
In the next training module, we use role plays conducted in
dyads or triads to allow clinic personnel to practice explicitly
integrating conversations about money and social class-related
issues within various stages of work with clients (i.e., discussing
fee for services during initial phone screenings for clinic administrative staff; discussing and determining fees during intake for
trainees). Given that trainees’ comfort in delivering services is an
important factor in effectively navigating the delicate topic of
financial and session fee information with clients (e.g., Clark &
SESSION FEES IN PSYCHOLOGY TRAINING CLINICS
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Sims, 2014), we believe that it is important for trainees to have
opportunities to practice these conversations in a relatively lowrisk situation with opportunity for feedback. We include an exemplar from a role-play based loosely on case material in which one
trainee assumed the role of psychotherapist and the other of client
during a face-to-face intake session. Prior to the start of the
role-play, the “client” is provided with context regarding the
client’s current social class, concerns about committing to a fee
because of his precarious job situation, and feelings of shame
about not paying what the chart suggests to be his “full amount.”
Trainee: At this clinic, we offer services at a sliding scale
rate which means that you and I will select your fee
based upon your financial situation. We use this
guide as a starting point to determine fees (refers to
fee schedule). As you look at this sheet, what
thoughts do you have?
Client:
It suggests that I pay $20 a session . . . (silence)
Trainee: Ok. And how does that feel for you?
Client:
Well, that seems like more than I can pay.
Trainee: What seems more reasonable for you at this time?
Client:
I am not sure.
Trainee: Our suggested minimum fee is $10 per session;
however, we do not want payment to be a barrier to
your ability to pursue therapy. So, I am happy to
discuss what feels like a fair and doable session fee
for you.
Client:
Ok. I suppose I could pay $10. But I feel badly
because according to this sheet, I should be paying $20.
Trainee: I think that it is important that we find a payment
that feels like a good fit for you. In other words, we
want you to feel able to come to therapy and to pay
what you believe is a fair rate. We know that it is
important to find that balance.
Client:
. . . The thing is that I have a job now and so this
says I should pay $20, but I’m not sure if I will be
able to keep my job. So, I can pay $20 for now but
that may change.
Trainee: I hear your concern and want you to know that we
can adjust your fee accordingly should your job
circumstances change. Perhaps we can start with a
$20 fee and continue to discuss how that fits with
your needs. How does that sound?
Client:
That sounds fine to me.
Trainee: Ok, I will do my best to check in with you periodically about the fee. I also encourage you to share
any questions or concerns that you have about your
fee or your finances more generally throughout our
work together.
Following the role-plays, other trainees and clinical observers
(e.g., front desk staff, clinic TAs) provide feedback and support in
331
small group settings. Next, the clinic director facilitates a large
group conversation to highlight themes, discuss best practices, and
share strategies for managing conflict or awkward exchanges.
Such experiences, in combination, help to normalize the discomfort that trainees may experience in these initial conversations and
provide foundational skills and strategies for effectively managing
these conversations.
A final module in this initial training sequence focuses on
trainee self-reflection of values, assumptions, and biases regarding
money and social class. Given the relative lack of explicit attention
to social class-related issues in psychotherapy training (e.g., Clark
& Sims, 2014; Thompson et al., 2015), we believe that it is
important for trainees to gain competence in their ability to discuss
topics that may otherwise be “taboo” in psychotherapy. Toward
this goal, we ask trainees to engage in explicit conversation and
self-reflection regarding their own class-related socialization experiences (and present experiences as a graduate student who may
be accruing debt) and to complete social class-related assessments.
Trainees engage in small group conversations with peers and
larger group conversations facilitated by clinic staff, department
faculty, or others with expertise.
Training continues throughout the year with case conferences,
didactic presentations, and experiential workshops. Some activities
include specific attention to social class-related issues in mental
health treatment. Given our developmental training focus, we
believe that it is important to revisit topics in future formal training
modules (i.e., clinical training workshops) as well as via supervision and consultation after trainees and staff have had actual
money-related conversations with clients that deepen their understanding of the complexity of the conversations.
The Use of Supervision and Consultation to Augment
Service Delivery
Consistent with recommendations from others (e.g., Cerney,
1990), it is important to integrate considerations related to session
fees throughout all aspects of service delivery. We use a developmental approach to training students by walking them through the
various points at which such conversations occur and provide
exemplars regarding how to respond to client and trainee needs.
Because delivery of competent and effective mental health treatment to all clients regardless of their ability to pay for treatment is
fundamental to our clinic mission, we train students to appreciate
that fee-related conversations with clients are ongoing and that
clients can benefit from psychotherapy regardless of the fee that
they pay for treatment.
Initial fee conversations often occur during telephone triage/
screening conversations with prospective clients. The clinic staff
person conducting the telephone triage describes the sliding scale
fee-for-services, the range of fees paid per session, and the process
by which the fee will be determined in the first face-to-face
meeting. Prospective clients are asked to consider a feasible session fee. This initial informational conversation about fees is
generally brief and allows the prospective client to ask any feerelated questions in a low risk interaction. Here is an example
excerpt from an initial conversation with a prospective client.
As a clinic, we offer a sliding scale rate, which means that we are
flexible in determining your session fees depending on your financial
capacity including such things as your employment status, annual
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THOMPSON, GRAHAM, BROCKBERG, CHIN, AND JONES
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income, and number of dependents. Most of our clients pay between
$5 and $40 per session. During your first session, your therapist will
discuss this in greater detail and the two of you will decide on a
suitable fee. In the meantime, please think about a fee that seems
reasonable for you. Do you have any questions at this time?
In a client’s first face-to-face intake session, the session fee is
determined via conversation between the therapist (trainee) and
client. The therapist is responsible for sharing the fee structure
information and policies. This involves direct reference to the
clinic’s mission and fee structure paperwork, includes exploration
of the client’s ideas about the suggested fee based upon the fee
structure, negotiation of a feasible fee (as needed), and a stated
commitment to revisit the agreed upon session fee at any point
during treatment.
Throughout treatment, trainees are encouraged to initiate direct
conversations about the fee arrangement rather than waiting for a
direct request from the client to change the previously agreed-upon
fee. Trainees are trained to pay attention to client language related
to social class and to explore these topics as they arise. For
example, indicators of financial stress, potential or actual job
change, unemployment, family changes (e.g., loss of family member, birth of a child), health issues, and frequent session cancellations or no shows may suggest times at which it would be clinically indicated to readdress the fee arrangement. Chronic late
payments or missed payments also may represent an indirect way
by which clients indicate that they are struggling financially. We
view missed or late payments as an opportunity for trainees to
readdress fees with care and flexibility. While this is oft an
anxiety-provoking clinical situation for novice clinicians, it can
provide a valuable training opportunity for directly addressing
issues related to social class in psychotherapy. The front desk staff
notifies the therapist prior to a session if a client has an unpaid
balance, indicated an inability to pay for their session, or requested
to pay at a later date. Therapist trainees address this directly during
the subsequent session, and if appropriate, set a new session fee
that better fits the client’s current situation (i.e., decreasing the
agreed-upon fee, temporarily removing the fee, or setting up a
payment plan should the client be struggling financially but express discomfort with temporarily reducing or eliminating the fee).
Ongoing supervision and consultation with clinic staff and supervisors is important to ensure that conversations about fees with
clients are initiated as indicated.
Following these conversations related to fee setting, we encourage trainees to use ongoing supervision and consultation to further
cultivate their skills. Supervision and consultation are designed to
inform and enhance skill development and service delivery (Bernard & Goodyear, 2014; Watkins, 2011) as well as to offer a
supportive space from which trainees can increase their competence in discussing money-related issues with clients. Because
some data indicates that trainees may be unaware of ways in which
their own discomfort related to money impacts delivery of services
(e.g., Smith, 2009), we expect supervisors to attend to clients’
social class and to initiate these conversations with supervisees.
Based upon research that has highlighted the prevalence of countertransferential reactions among mental health providers who
work with clients from low-income backgrounds (e.g., Thompson
et al., 2015), supervisors are advised (and, if needed, trained) to
encourage trainees to explore their personal reactions (e.g., em-
barrassment, jealousy, guilt) when discussing or social classrelated issues with clients.
Group debriefing and case consultation provide added opportunities for therapists to engage in conversation related to
session fees and client social class-related concerns. For example, our training clinic utilizes group debriefing at the end of a
clinic shift to offer a space for therapist trainees to consult
about their cases and to receive supervision and support from
clinic staff and peers. Clinic staff and supervisors are expected
to integrate social class-related conversations into these group
conversations in order to normalize trainees’ feelings of insecurity and anxiety regarding social class-related issues and to
share strategies that will assist them in integrating social class
into client conceptualization, treatment planning, and intervention. The following excerpt depicts how session fee concerns
that came up in a session were integrated into group debriefing
and individual supervision.
A beginning trainee appeared unsure in session when her client
indicated his need to have his session fee reduced as a result of his
recent unemployment. During the group debriefing, the trainee shared
her reactions (e.g., guilt, sympathy) in the context of her own upbringing in a working class family. Her peers validated her feelings
and acknowledged her struggle to respond to the client in session. Her
peers and clinic staff offered perspectives from which she may support the client’s expressed negative feelings about accepting “charity”
if he agreed to reduce his session fee while highlighting the flexibility
in the fee structure and its alignment with the social justice mission of
the clinic. The clinic supervisor offered support and provided resources for her to explore social class as an aspect of identity. They
agreed to follow-up individually the next day.
It is important to note that comfort levels can change over
time as a trainee gains competence navigating social classrelated conversations. For example, a more experienced trainee
who no longer feels anxious about initial fee-for-service discussions may struggle when a client asks to reduce the previously agreed upon fee later in treatment. Similarly, a trainee
who had gained comfort discussing social class as an individual
who was struggling financially may have difficulty engaging in
these same conversations if that trainee’s own social class
changes based upon life circumstances (e.g., partnership/marriage, student loan debt, graduation).
Summary
Prior literature (e.g., Clark & Sims, 2014; Thompson et al.,
2015; Wise & Cellucci, 2014) has highlighted the importance of
training psychotherapists to competently address issues related to
social class and session fees with clients and prospective clients.
Psychology training clinics are in a unique position from which to
serve the needs of clients who may otherwise be unable to access
treatment by providing affordable mental health services. Our
purpose in this article was to describe how one training clinic
explicitly integrates money-related issues into decisions related to
service to the community, graduate student training, and the provision of mental health treatment to individuals who may need
access to reduced fee services.
SESSION FEES IN PSYCHOLOGY TRAINING CLINICS
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Implications for Training and Application of Model
Components to Other Settings
Our decision to explicitly emphasize social class in all components of our clinic training model was based on findings from prior
literature (e.g., Thompson et al., 2012) that suggested that acknowledgment of social class-related issues among clients who are
low-income has been found to enhance the therapeutic experience
for some clients. While training clinics offer a clear mechanism for
this to occur, they represent only one possible outlet for this
training. Self-reflective exercises and didactic content related to
social class and fee-for-service issues also can be integrated into
coursework (e.g., theories, practicum, ethics) and professional
training seminars, particularly given findings from prior research
(e.g., Thompson et al., 2015) that have demonstrated that most
psychotherapists have never received formalized training in these
topics. A focus on self-awareness over time also is needed among
mental health professionals as personal income, status, and other
social class-related factors fluctuate.
Consistent with much of the limited research in this area regarding social class and mental health treatment disparities (e.g., Ballinger & Wright, 2007; Balmforth, 2009; Pope & Arthur, 2009), we
focused our conversation and discussion of examples in this article
on clients who are on the lower end of the social class spectrum.
It is important to note that some challenges related to conversations about money and session fees also are relevant to clients with
considerable economic resources. For example, training clinics
and other sliding scale treatment settings also serve clients who
have considerable financial means and are making a choice to
engage in therapy in a particular low-cost setting. These clients
may request a minimum fee even though they note later in treatment that they have considerable access to resources. This challenge also provides opportunity for rich conversations regarding
client case conceptualization and represents an important direction
for future research.
It is important to note some of the assumptions and characteristics of this training model that may limit its applicability to other
mental health treatment settings. As previously noted, the ultimate
goal as indicated in our clinic mission statement is to utilize a pay
structure that ensures access to services for financially constrained
clients. If, on the other hand, clinics or private practices need to
generate revenue such a mission and its associated policies for
sliding scale fees would require further negotiation and deliberation. In these cases, the clinic or practice will need to determine
how to best align fees and desired mission with constraints imposed by the need to generate a certain amount of revenue. One
possibility could be to determine a certain percentage of the
caseload that can be served on a sliding scale or pro bono basis. In
addition, our training clinic is based in the U.S. and assumes that
not all individuals have access to psychotherapy. Further attention
is warranted when attempting to apply model components to a
different national context in which individuals may have universal
access to mental health care.
Recommendations for Future Research
Future empirical research is needed in order to understand the
usefulness of sliding scale fee structures and its relationship to
training and experiences in psychotherapy. Given the dearth of
333
literature in this area, several directions are warranted. These
include, but are not limited to: (a) examining how clients experience the use of sliding scale fees and conversations about fee
structures (Lejeune & Luoma, 2015); (b) developing and evaluating standardized mechanisms that can be implemented to augment
training psychotherapists to address and integrate session fee and
social class-related conversations in psychotherapy; (c) training
students to understand mental health policy and insurance funding;
(d) exploring psychotherapist factors that may contribute to clients’ willingness to engage in social class-related conversations
within psychotherapy (Sackett & Lawson, 2016); and (e) understanding best practices for supervisors to integrate client social
class factors in treatment planning and case conceptualization.
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Received November 14, 2016
Revision received February 15, 2017
Accepted March 13, 2017 䡲