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Understanding Fees in Mental Health Practice.

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 Practice Innovations © 2017 American Psychological Association
2017, Vol. 2, No. 3, 123–135 2377-889X/17/$12.00 http://dx.doi.org/10.1037/pri0000048

Understanding Fees in Mental Health Practice

Gerald P. Koocher and Christina Soibatian

DePaul University

The theoretical and practical underpinnings of fees charged by mental health service
providers are discussed in terms of historical and ethical contexts along with a selective
review of published research. Key concepts are explained in the context of how they
influence fee setting, discussion of fees with clients, fee disputes, and the influence of
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

third-party payers. Practical considerations for dealing with these issues in the evolving
This document is copyrighted by the American Psychological Association or one of its allied publishers.

health care system are discussed and recommendations for practice are presented.

Clinical Impact Statement

The issues and discussion contained in the manuscript will assist clinicians in
considering their fee practices from both practical and ethical perspectives. Mem-
bers of the public reading the manuscript will understand what they should expect
from mental health clinicians with respect to fee practices.

Keywords: billing, fees, independent practice, psychotherapy, third-parties

Practice finances and fees rarely come up for
discussion in the course of a mental health profes-
sional’s academic training. More typically, curri-
cula and faculty avoid or ignore specific discus-
sion of actual practices involving billing,
collection, and third-party reimbursement (Barnett
& Walfish, 2012; Lovinger, 1978; Totton, 2006;
Waska, 1999). With a natural focus on assess-
ment, psychotherapy, and evidence-based practice
one can understand how matters seemingly related
to the business aspects of professional practice fall
to the wayside in increasingly crowded graduate
curricula. Unfortunately, such omissions may
leave newly trained clinicians unprepared for
many types of independent or institutional prac-
tice and put some at risk for ethical infractions or
Editor’s Note. Jeff Zimmerman served as the action editor
for this article.—JZ
This article was published Online First August 14, 2017.
Gerald P. Koocher and Christina Soibatian, Department
of Psychology, College of Science and Health, DePaul
University.
Correspondence concerning this article should be ad-
dressed to Gerald P. Koocher, College of Science and
Health, Department of Psychology, DePaul University,
1110 West Belden Avenue, Suite 403, Chicago, IL 60614.
E-mail: koocher@gmail.com
123
inability to compete financially in an increasingly
crowded marketplace of providers. This article
focuses chiefly on psychotherapy practice, as op-
posed to assessment and consultation, although
we will address some specific challenges in that
arena. When one’s practice focuses chiefly on
assessment, contracting often becomes more
clear-cut than when one develops extended thera-
peutic relationships. Even experienced clinicians
find discussing fee practices openly a challenging
task, given the reluctance of professional organi-
zations to allow potentially anticompetitive busi-
ness discussions in their public meetings or sup-
ported communication media such as publications
and online discussions. We will review mental
health service fees in historical context, the extant
literature related to such fees, and the challenges
that evolving changes in the mental health service
marketplace may trigger.
How Do Clients and Clinicians View Fees?
Examining the individual-level relationships
between clients and clinicians, both parties may
experience feelings of anger, shame, jealousy,
and greed when discussing payment for therapy
(Fehr, 2012). All people attach meanings to
money as a function of many variables in their
lives including culture, class, family patterns,
 124 KOOCHER AND SOIBATIAN
gender, and personality (Estrella, 2010). Most
of the research published on fees has relied on
data from clinicians of White European ancestry
who work chiefly from a psychodynamic per-
spective (Lecker, 2016). As more individuals
become insured and those who may not previ-
ously have had coverage find their way into
clinicians’ offices the range of interactions
around fees will become more complex. Money
can represent power, love, freedom, or security,
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evoking strong feelings in clients and clinicians
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alike. Psychotherapists may describe such feel-
ings in terms of transference or countertransfer-
ence, but clinicians should strive to remain
mindful of the power and emotions attached to
fees. Discussions of money in the context of
therapy can become a kind of message that
clients use to convey to their feelings to clini-
cians including: resistance to therapeutic work,
passive aggressiveness, or testing the therapist;
feelings of unresolved debt, excessive submis-
sion; acknowledgment, and gratitude. Amid
these complexities, clinicians must strive for
awareness of clients’ perceptions, their own re-
actions, and initiate a dialogue when needed.
Historical Perspectives: Classic
Psychoanalytic Viewpoint
Arguably, the creation of psychoanalysis rep-
resented the birth of psychotherapy as a means
of earning a living in independent practice and
in the most simplistic sense we probably owe it
all to Martha Bernays. When 26-year-old Sig-
mund Freud met 21-year-old Martha in 1877 he
was an ambitious budding neuroscientist who
spent much of his time studying brain tissue in
the lab. In an apocryphal account of their first
meeting harkening back to the story of Adam
and Eve, Sigmund first spotted Martha peeling
an apple. Instantly smitten, he desperately
wanted to marry but understood that would
prove a financial impossibility, if he pursued a
research career. Sigmund Freud sacrificed his
scientific ambitions to become a practicing phy-
sician, and ultimately stumbled into discovery
of the “talking cure” while seeing enough pa-
tients to afford marrying his true love, Martha,
and supporting the six children they had to-
gether over the next 9 years (Stone, 1971). So,
began fee-for-service psychotherapy.
Freud argued that discussing money, like sex,
represents taboo in society. His views on the
nature of money are captured by his remark,
“money matters are treated by civilized people
in the same way as sexual matters-with the same
inconsistency, prudishness and hypocrisy”
(Freud, 1913/1958, p. 131). He suggested clini-
cians should directly address the topic of money
and fees with their clients, recognizing that the
conversation may create feelings of envy, greed,
benevolence, guilt, and shame between the psy-
choanalyst and the client. Lovinger (1978), like
Freud suggested that a direct and candid ap-
proach about money was the best means to
begin a client–psychotherapist relationship.
Psychoanalysts continue to report curiosity
about discussing the meaning of money with
their clients even if doing so brings up anxiety
(Whitson, 1989).
Over a century later, psychoanalysts continue
to explore their understanding of setting fees
with clients. Brenner (2011) described Freud’s
conceptualization, as one in which the client
leases the analyst’s time. This qualifies as the
earliest rationale for charging even when the
client misses sessions. In true psychoanalytic
form, every financial transaction may warrant
interpretation. For example, a client who does
not pay their bill may be showing resistance.
The client who pays in full on time may simply
be following the agreed-upon contract or be
unconsciously seeking to please the therapist
parent figure. Suppose a client seeks to pay for
some analytic sessions in advance for the stated
reason of securing an end of year tax benefit.
The analyst might offer an interpretation that
the underlying reason for paying in advance
actually represented a fantasy of holding on to
the analyst because the client feared death or
abandonment. Any behaviors involving money
may warrant interpretation.
Akhtar (2011) also expressed a belief that
analysts who depend solely on clients’ mental
suffering for their income would become needy
and potentially exploitative. He suggests miti-
gating such countertransference issues with cli-
ents by having collateral sources of income to
free the analyst from the emotional and eco-
nomic pressure of having to earn their living
solely from revenues derived from one’s prac-
tice. He advises developing collateral sources of
income such as a “guaranteed salary in an in-
stitutional setting, inheriting wealth, marrying
well, or winning the lottery (p. 4),” although he
does not provide specific implementation strat-
 UNDERSTANDING FEES IN MENTAL HEALTH PRACTICE
egies for those guidelines. In addition to under-
standing fees in the context of psychoanalytic
practice, we will also discuss the role of fees
used in transactional analysis, an approach
which has supplemented many Freudian con-
structs.
A 20th-Century Perspective: Cognitive and
Person-Centered Approaches
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Transactional analysis, pioneered by Eric
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Berne provides a more contemporary model of
interpersonal transactions, specifying the per-
spective of the parent, adult, and child aspects
of the self. He advocated calling out the specific
wishes, needs, and agreements tied to these
aspects of selfhood transparently in therapeutic
relationships. That approach offers considerable
insight into how we frame and view contracts in
therapy today (Sills, 2006). Berne’s suggestions
for business-like contracting (the adult self) be-
tween therapist and client presaged current eth-
ical practice across many theoretical psycho-
therapy systems. Such contracting can trigger
emotional reactions (of the parent or child-self)
early and provide an opportunity to explore
each perspective in emotional depth.
Other contemporary theoretical systems such
as cognitive and person-centered approaches
use analogous frameworks, seeking to meet the
ethical requirement for full information and
consent at the outset of the professional rela-
tionship. This ethical stance cuts across all of
the major associations of mental health profes-
sionals (e.g., see American Psychological Asso-
ciation [APA] Code of Conduct, Section 6.04,
American Psychological Association, 2010;
American Association for Marriage and Family
Therapy [AAMFT], ethical standard 8.1– 8.6,
American Association for Marriage and Family
Therapy, 2015; American Counseling Associa-
tion [ACA], ethical standard A.10, American
Counseling Association, 2014; American Psy-
chiatric Association [ApA], annotation section
2.5–7, American Psychiatric Association, 2013;
and National Association of Social Workers
[NASW], ethical standard 1.13, National Asso-
ciation of Social Workers, 2008).
More recently, Lapworth and Sills (2011)
collaboratively described the importance of set-
ting up a business contract as a means to address
all the practical arrangements in a therapeutic
relationship, including how fees would be paid,
125
setting the time and duration of sessions, where
sessions take place, and confidentiality. Further,
they highlight the purpose of a business contract
as different from a treatment contract, where
clients may discuss the specific changes they
want to make in treatment with their therapist.
Others have addressed contracting from the
approach of cognitive therapy (Wills, 2006)
and person-centered approaches (Worrall,
2006).
As in any human relationship, a transaction
that seems agreeable at the outset of a profes-
sional relationship may seem less so as matters
progress. From an ethical perspective, we must
approach offering professional services as a
business contract representing mutual agree-
ment and honor such agreements unless or until
the parties mutually come to an understanding
on a modification. Proposed changes will often
trigger emotional responses that the client and
clinician will both filter through the context of
their own life experiences. Dealing with such
emotionally driven responses becomes the ob-
ligation of the clinician. Because clinicians usu-
ally have a dominant power position by virtue
of knowing points of sensitivity and intimate
secrets of the client, they have a responsibility
to recognize and initiate discussion when re-
lated difficulties occur.
Payment Schemes
More than a quarter of Americans report dif-
ficulty paying medical bills, and in one large
study focused on outpatient general medical
care, 24% reported major depressive symptoms.
(Hunter et al., 2016). Regardless of whether the
client is uninsured, has some coverage, or will
plan to pay totally out-of-pocket we should
anticipate that costs will concern many cli-
ents. We should also expect that clients strug-
gling with symptoms of anxiety and depres-
sion, the two most common symptoms that
lead people to seek mental health services,
will feel financial stress as additive to their
emotional issues.
Using the same data set as Hunter’s group,
Brown et al. (2017) reported on a psychiatric
subset of the 422 depressed patients and found
that 38% included a conversation about costs.
The data source was a commercial database
(Verilogue Point-of-Practice audio-recorded
and transcribed clinical encounters). There may
 126 KOOCHER AND SOIBATIAN
be some sampling bias in the sense that the
parties knew they were being recorded. Of these
conversations, 51% involved the costs of med-
ications and were brought up more often by
providers than clients (62 vs. 38%). Patients
were more likely to bring up the cost of the
provider visits (27 vs. 10%). An interesting find
was that 45% of cost conversations yielded cost
saving strategy such as providing free drug sam-
ples or changing to a lower cost option.
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Alexander and his colleagues (2003, 2004)
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conducted surveys of physicians’ and their pa-
tients’ beliefs about discussing medical costs in
academic and community medical settings in
and around Chicago. The results clearly dem-
onstrated that 63% of patients wanted to talk
with their physician about out of pocket costs,
and 79% of physicians believed that patients
wanted to have such discussions. In contrast
only 35% of physicians and 15% of patients
reported having such conversations. Among pa-
tients, barriers to such conversations included
their own discomfort (19%), insufficient time
(13%), a belief that their physician did not have
a viable solution (11%), and concerns about the
impact of discussions on quality of care (9%).
Among the physicians surveyed, the most com-
mon barriers reported included insufficient time
(67%) and a belief that they did not have a
solution to offer (19%).
Whether clinicians embrace psychodynamic
or more transactional or cognitive contracting
approaches (sans interpretations) with respect to
fees, decision making becomes more compli-
cated when a third party payer influences or
frames how the fees are set and paid. When the
clinician and client do not have full control over
fees, an integral part of relationship is lost and
along with it some options for developing and
modeling problem-solving (Solomon, 2010).
Similar problems can occur when services or
products are swapped through bartering as a
payment scheme. Nonetheless, a lack of full
control should not inhibit a complete discussion
of the client’s responsibility, the consequences
of choices made in selecting coverage or pro-
viders, any restrictions that the clinician must
attend to, based on legal or contractual obliga-
tions (e.g., collecting copayments, providing ac-
curate diagnoses, and accurately reporting fees
charged and services rendered).
Dealing With Third-Parties
Beginning in the 1960s, Federal health care
policy in the United States focused on enticing
physicians to become providers for Medicare by
using a fee-for-service system. This model in-
centivizes the delivery of volume-focused ser-
vices by independent clinicians who have no
particular incentive to communicate or coordi-
nate services with each other. Providers are paid
to deliver services with no attention to compre-
hensive outcome quality. Thus, a depressed client
with obesity, heart disease, and Type-2 diabetes
may receive treatment from a psychotherapist, a
cardiologist, an endocrinologist, and a primary
care physician who seldom (if ever) interact re-
garding patient care. This context often yields
suboptimal outcomes when the client’s depression
impedes adherence to treatment recommendations
for their other chronic conditions (Koocher &
Keith-Spiegel, 2016).
The entry of nonclients into the role of payer
or intermediary contractor with the clinician at
once made mental health services more afford-
able and more complicated. In historical con-
text, the concept of offering third-party or in-
surance coverage for mental health services has
attracted a range of interesting critiques. Some
early critics asserted that including psychother-
apy benefits as part of health insurance coverage
represented inequitable service to different in-
come groups (Albee, 1977a, 1977b). Others
raised threats to clients’ confidentiality implicit
in reporting their status as therapy clients and
diagnoses to others (Alleman, 2001; Austad,
Hunter, & Morgan, 1998). Concern about ac-
countability and review criteria grew (Acuff et
al., 1999; Alleman, 2001; Austad et al., 1998;
Bersoff, 2008), and some professional leaders
even cited expensive litigation between clini-
cians and insurers as a disincentive to coverage
(Kiesler & Pallak, 1980). The quest for vendor
status has also led to many intra- and interpro-
fessional squabbles about who ought to qualify
to bill third parties for which mental health
services.
Clinician struggles during the 1970s and
early 1980s involved gaining access to physi-
cian dominated third-party provider rosters.
Considerable effort went into so-called freedom
of choice (FOC) legislation and lawsuits
(Resnick, 1985) seeking to allow clients with
insurance coverage to choose their own mental
 UNDERSTANDING FEES IN MENTAL HEALTH PRACTICE
health care clinicians. FOC generally refers to
whether the mental health clinician is autho-
rized to directly bill a third party for services
rendered to a client, as opposed first having to
obtain the approval or referral of a physician or
other gate keeper. At least that was the histori-
cal battle. More recently, access to mental
health benefits and other specialty health care
services have become heavily managed under
contracts in which the insurers offer lower cost
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premiums for some policies that limit access of
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their policy holders to preferred networks. The
insurer negotiates for discounted fees from cer-
tain individuals or group practices and may
limit their policy holders to obtaining treatment
only by in network providers. Those who
choose to seek care outside of prescribed net-
works will likely have reduced coverage for the
costs incurred.
Clinicians pressed the FOC concept as a right
of the consumer throughout the 1960s and
1970s, in an era when psychiatrists seemed in
control of such matters. Psychologists argued
that they had excellent qualifications to function
as independent health service providers. For
example the typical doctoral-level psychologist
has far more hours of relevant classroom and
supervised experience in mental health treat-
ment than most psychiatry residents. Other ar-
guments included the claim that the broader
availability of psychologists improves con-
sumer access to qualified care and increases
competition among professional provider
groups, with resulting cost benefits to consum-
ers. Some asserted that failure to recognize li-
censed psychologists as independent providers
constituted an unreasonable restraint of trade.
As states increasingly granted independent li-
censure status to clinicians with master’s de-
grees (i.e., social workers, mental health coun-
selors, marriage and family counselors, and
rehabilitation counselors) these professions be-
gan to clamor for so-called direct recognition
laws. This led to interesting turn-about situa-
tions in which some psychologists argued
against allowing direct access to insurance pay-
ments by master’s degree holders, much as psy-
chiatrists had sought to limit psychologists
some years earlier.
There will always be a market for clinicians
outside of health care systems or insurance pan-
els, but the robustness of that market will de-
pend on the disposable income of clients and
127
their willingness to seek care outside of their
insurance coverage system. Insured people be-
have differently from the uninsured. Many po-
tential buyers will not purchase health insurance
unless they expect to use it, and people who
have health insurance coverage will seek more
care than those without. These principles are
known as the moral hazards of insurance. Third-
party management of mental health fees along
with required copayments and deductibles help
lessen the so-called moral hazards of insurance
and put pressure on clinicians to think carefully
regarding all aspects of their treatment plan-
ning. At the same time, there are great risks
inherent in a system of health care delivery that
potentially provides for-profit insurance provid-
ers with systematic incentives to withhold care
or raises unreasonable barriers to receiving
needed services. Ironically, managed care and
capitation models introduce a new kind of moral
hazard by creating an incentive among those
holding capitated contracts seeking to reduce
insurer costs to provide less service (Koocher &
Keith-Spiegel, 2016).
The ethical challenge for the clinician in-
volves negotiating an appropriate role within
these complex systems. We should hold the best
interests of our clients paramount, but cannot
ignore the fact that we will need to address the
requirements or restrictions of some third par-
ties to serve the largest number of potential
clients. Some sought-after clinicians in specific
market places have the ability to opt-out of
engaging with third parties completely by tak-
ing on only self-paying clients. Such strategies
will not prove viable options for most clinicians
or clients, leaving the clinician with a number of
challenges: helping each client understand the
limits of their coverage at the start of the pro-
fessional relationship, having clarity about each
party’s role in advocating for correct and timely
payments, and balancing the need to advocate
on behalf of clients while attempting to main-
tain a provider relationship with powerful third
parties.
Bartering and Other Nonstandard Exchanges
At one time, ethics codes discouraged ex-
changing anything other than money for thera-
peutic services, because of the potential for tak-
ing advantage of clients and complicating the
professional relationship. Except for the NASW
 128 KOOCHER AND SOIBATIAN
code (Section 1.13) that provides a list of con-
siderations, the ethics codes of other mental
health professions have dropped strong caution-
ary statements, admonishing only that one con-
sider clinical contraindications and potential for
exploitation (APA: 6.05; AAMFT: 7.5; ACA:
A.6, A.10.e, C.6).
How and why did this transformation occur?
Perhaps because of third party coverage issues
or because more people seeking psychotherapy
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may be unable to afford it. On the surface
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allowing bartering in hard economic times
seems like a win–win situation for clients who
want therapy and therapists who want clients.
However, bartering creates many risks, and all
of the potential liability falls on the clinician
(Koocher & Keith-Spiegel, 2016). Charges of
exploitation by clinicians increase when the
value assigned to the therapist’s time or skills is
set at a higher rate than those of the clients.
Because the therapist’s hourly rate will more
likely exceed what one would pay a client, this
risk probably exists in most service-for-service
exchange agreements.
Exchanging professional services for tangible
objects may pose fewer risks of exploitation,
because fair market prices can usually be estab-
lished by an objective source. However, the
value of goods often depends almost entirely on
what buyers are willing to pay for them. Deter-
mining the true value of some items will prove
challenging, and charges of exploitation could
easily arise. Therefore, we urge considerable
caution when professional services are traded
for tangible items.
When a client suggests a bartering arrange-
ment, a therapist without a clearly understood
“no-barter policy” can be placed in any of three
uncomfortable positions. First, if a therapist is
known to barter, which is probable in small
communities, turning down an unwanted pro-
posal could be experienced as a rejection. Sec-
ond, must a therapist accept something un-
needed or unwanted? Can you offer a
meaningful excuse for declining a client’s re-
quest; for example, “I sometimes accept goods
for services, but I’m allergic to potatoes don’t
need a llama rug.” Third, how does a therapist
react when one bartering client refers someone
who also wants to barter, but the referral clearly
is not clinically suited to it? Some of these
predicaments may not end up on ethics commit-
tee tables but remain sticky nonetheless, with
the potential to cause the kinds of hassles ther-
apists would certainly prefer to avoid.
Clinicians should remain mindful that most
professional liability insurance policies specifi-
cally exclude coverage of disputes that involve
business relationships with clients (Knapp,
Younggren, VandeCreek, Harris, & Martin,
2013). Such insurance carriers may interpret
bartering arrangements as business relation-
ships and decline to defend policy holders if
bartering schemes lead to complaints or law-
suits. In addition, failure to report the monetary
value of bartered services of goods to the gov-
ernment constitutes tax evasion. To fully meet
legal and ethical obligations clinicians must
maintain detailed documentation.
What We Teach About Fees
Most training programs in the mental health
professions avoid discussing the business of
practice, including fees. Depending on the na-
ture of the professional training program, such
discussions (when they do occur) may range
from viewing payment for services as a simple
business transaction to ascribing profound rela-
tional or psychodynamic meanings (Erle, 1993;
Holmes, 1998; Monger, 1998; Shapiro & Gin-
zberg, 2006; Tudor, 1998; Valentine, 1999;
Waska, 1999). Fees certainly do have substan-
tial psychological impact on a number of levels
and may often become a therapeutic issue (Hix-
son, 2004; Newman, 2005; Sommers, 2000;
Valentine, 1999).
We typically teach students to deal with the
emotions that come up in the course of treat-
ment from the client and within the therapist,
but we do not often address such feelings in the
context of fees. The client does not owe the
clinician gratitude, respect, consensus, or any-
thing other than a fee for services rendered. In
that sense the fee can trigger special meaning in
terms of transference issues (Rogoff, 2006; Sha-
piro, & Ginzberg, 2006; Totton, 2006; Waska,
1999). As a result, the client may react to a
change in fee in the same manner as some duty
owed in relationship with another significant
person in his or her life. It may become a means
of addressing the anger held in relation to a
demanding parent or represent a penance to
atone for some imagined wrong to a spouse.
We should prepare to deal with fees as both a
business transaction and a potential emotional
 UNDERSTANDING FEES IN MENTAL HEALTH PRACTICE
issue in the course of treatment, but it rarely
comes up until trainees encounter the issues in
clinical settings. Often such issues are ad-
dressed by business office personnel of the prac-
tice or agency, insulating trainees and prevent-
ing them from fully understanding the processes
involved. Additionally, trainees are not typi-
cally expected to interact with third parties after
rendering services to their clients or work with
clients who are paying out of pocket, which
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further prohibits their understanding of setting
This document is copyrighted by the American Psychological Association or one of its allied publishers.
fees for their services. The early career profes-
sional may not recognize their lack of formal
education and training experience in this arena
until they begin to set up their own practice or
join one that requires them to take on such roles.
Factors Influencing What to Charge
Once students become licensed clinicians, the
amount they charge in fees will vary based on a
number of factors including local market rates;
the clinician’s level of experience; the clini-
cian’s social, political and philosophical beliefs;
and their sense of entitlement or self-worth
(Tinter, 2009). The client’s ability to pay, em-
ployment status, and whether the client is pay-
ing the fee out of pocket or through a third party
will also affect the charges for service (Field &
Hemmings, 2007). The gender of a clinician
also influences clinicians and clients’ experi-
ences, expectations, and choices around money,
as do the cultural influences of how money was
managed in their families of origin (Shanok,
2012). Thinking through these complexities will
help guide a clinician’s decisions, although so-
cial comparison can also play a powerful role
(i.e., What are my peers charging? Are my
services worth as much or more than theirs?).
While the preceding comments clearly apply
in work with self-pay clients, insurers represent
a major market force by setting so-called “usual
and customary” fees. Insurers rarely publicize
these rates, but the bench marks are not difficult
to discover and soon become the norm. There is
no incentive for a clinician to charge a lower
rate than they know the insurer will willingly
pay, and there are some incentives for claiming
a higher “usual and customary” fee even when
one’s contract with the insured mandates ac-
cepting a lower rate in full satisfaction of one’s
fee. Claiming a higher “usual and customary”
fee may contribute to elevating one’s profile in
129
the context of future contracts. Some group
practices or individuals with special skills (e.g.,
fluency in American Sign Language, work spe-
cialized populations, or working in areas not
well served by the insurer’s pool of covered
providers) may gain access to closed panels or
negotiate higher fees as the companies seek to
demonstrate full compliance with the Ameri-
cans with Disabilities Act or other regulatory
standards.
Scholarly articles on factors that influence fee
setting in psychotherapy are rare. In part this stems
from a general reluctance by scholarly journals to
publish papers that might be deemed as straying
into the business of practice as opposed to more
traditional realms of behavioral science scholar-
ship. Actual fees can differ as a function of edu-
cation and training, business experience, local
competition, and even the psychotherapist’s gen-
der (Buck, 2000; Field & Hemmings, 2007; Hill
& Kaschak, 1999; Zur, 2014). In one study the
genders valued their services equally, but women
in the sample weighed local competition as having
a greater influence than men. The authors opined
that this finding might result from greater numbers
of subdoctoral female therapists in the community
(Newlin, Adolph, & Kreber, 2004). Men have
generally reported higher rates and higher median
full-time salaries than women clinicians (Stetell,
Pingitore, Scheffler, Schwalm, & Haley, 2001).
The types of institutions or practices where
clinicians work can also influence the ways fees
are set for clients. One study analyzed fees and
clinical practice data for 872 members of the
APA’s Division of Clinical Neuropsychology
(APA Division 40) by area of clinical practice,
employment setting, assessment methodology,
and U.S. geographic region (Putnam & Deluca,
1991). The distinction between institutional-based
and independent practice fees reflected the most
prominent differences, with institutions generally
charging lower hourly rates, having higher fixed
rates per client, performing lengthier examina-
tions, and paying higher hourly wages to techni-
cians. Neuropsychologists charged higher hourly
rates than clinical psychologists for specialized
neuropsychological services and, not surprisingly
for specialty practices, averaged more examina-
tions per month. Clinicians based in teaching hos-
pitals reported higher fees for assessment than
those in other employment settings (Putnam &
DeLuca, 1991).
 130 KOOCHER AND SOIBATIAN
What Factors Drive Rate Changes and
Sliding Scales?
When a client has participated in psychother-
apy for an extended period of time and inflation
or other costs of conducting a professional prac-
tice (e.g., rent, utilities, insurance, and staff
salaries) have risen, adjusting fees upward is not
unreasonable. Any fee increases must be framed
thoughtfully with advance notice and with due
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
consideration for each client’s economic status
This document is copyrighted by the American Psychological Association or one of its allied publishers.
and treatment needs (Barnett & Walfish, 2012;
Pepper, 2004). Some clinicians, for example,
will raise fees for new clients while maintaining
ongoing clients at their preexisting rate. The
ethical point to consider is that mental health
clinicians incur added responsibility because of
the influential roles they occupy relative to cli-
ents (Koocher & Keith-Spiegel, 2016). At the
same time, clinicians should remain mindful of
self-care. Failing to raise one’s rates as costs
increase causes a disservice to oneself and can
lead to resentful feelings toward those paying
lower fees. From a marketing perspective, once
one becomes established in the community,
concerns about losing patients by increasing
fees to keep pace with cost of living diminishes.
Professional associations in the mental health
fields generally encourage their members to
provide some pro bono services or offer sliding
fee scales to assist low-income or uninsured
clients. Such encouragement represents ethical
aspiration, rather than enforced rules. Such dis-
counting can also pose some complex issues
when clinicians are asked to report their usual
and customary fees. How does one go about
making decisions about who gets a reduced fee
option and what (if anything) does the clinician
mention about this when asked directly about
usual rates by clients, third party payers, or
regulatory agencies?
Offering sliding scale fees to clients poses
many challenges. One advantage of this process
involves a chance to open a discussion and
explore the client’s relationship with money, as
well as where they would place themselves on
the sliding scale. A particular disadvantage of
this approach involves the client’s potential to
misrepresent their circumstances at their own or
their therapist’s expense by paying too much or
too little because they do not want to explore the
issue of money further. In addition, clinicians
have to be careful not to make assumptions
about clients that may not prove accurate (Field
& Hemmings, 2007).
Offering sliding fee scales can create some
moral hazards, depending on how they are ap-
plied. Clinicians may feel cast in the role of
social engineers as they try to determine who is
worthy of special treatment, and who is not.
When clinicians have no objective or consistent
basis or criteria to determine “worthiness,” the
decision can fall to personal biases or emotional
impulses. Sliding scales can also punish those
who willing and able to pay for the clinician’s
expertise and time while rewarding those who
are not. Although sliding fee scales do not di-
rectly apply to insured, unless or until their
benefits are exhausted, the issue is sometimes
addressed in contracts.
One approach would involve trying to iden-
tify the normative fees for mental health ser-
vices in your geographic area. Understanding
the current mental health CPT codes (American
Medical Association’s Current Procedural Ter-
minology) that define procedures and allowed
minutes that link to insurance reimbursement
rates will also prove useful. Using this data as a
starting point, consider the lowest fee that you
would accept without risking feelings of resent-
ment toward the clients you seek to help, and
plot some steps in between. Consider the num-
ber of clients to whom you could offer a sliding
scale in terms of revenue you would forgo and
the expenses associated with your practice.
Consider a breakdown of income levels and fees
based on your usual and customary rate and low
fee points you are willing to consider. You may
want to apply an objective measure such as the
current U.S. Federal Poverty Guidelines1 and
samples of sliding fee scales. Consider how you
would gather and document fairness in admin-
istering a sliding scale. One way to do this
would require creating a form to collect relevant
information from each client (e.g., proof of an-
nual household income, number of dependents,
chronic illnesses, etc.). Another strategy might
involve accepting a limited number of reduced
fee clients referred by a community agency that
does the screening for you.
1
Federal poverty levels per HealthCare.gov may be
found at https://www.healthcare.gov/glossary/federal-
poverty-level-FPL/
 UNDERSTANDING FEES IN MENTAL HEALTH PRACTICE
From an ethical standpoint, the actual fee
charged for services rendered is not as impor-
tant as the manner in which it is set, communi-
cated, managed, and collected. Full discussion,
transparency, and fair treatment are the key
principles. By definition, however, many clients
may be regarded as somewhat vulnerable to
potential abuse because of emotional depen-
dency, social naiveté, psychosis, or other psy-
chopathological conditions. We must remain
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
mindful that the therapist has a fiduciary obli-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
gation to consider the best interests of the client.
When considering fee comparisons, matters
quickly become complicated by the issue of
what constitutes a “therapy hour.” A clinical
appointment session could range from an 8- to
10-min medication check by a psychiatrist or an
advanced practice registered nurse (APRN) to
120-min or longer for a family or marathon
group session. Some clinicians offer their cli-
ents 60-min hours, while for most others a treat-
ment session will more often occupy 50, 45, or
even fewer minutes. Likewise, group or family
therapy sessions might extend 90 min or more,
making clear direct fee comparisons across mo-
dalities and clinicians difficult (Koocher &
Keith-Spiegel, 2016).
Shortening the session may seem a way to
increase cash flow by degrees, much as some
food packagers keep the box size the same,
while decreasing the contents. However, the
practice more often results from an effort to
catch up on the hidden demands on the thera-
pist’s time. Record keeping, filing health insur-
ance reimbursement claims, detailing treatment
plans, and making telephone contacts related to
cases have increased significantly beginning
with the advent of managed care. In many cir-
cumstances, therapists may spend 50 min meet-
ing with the client, only to spend substantial
additional time completing therapy notes or
other documentation necessary to seek third-
party approval for additional sessions. Of
course, if the requirements of some insurers
prove too onerous a practitioner need not con-
tinue to contract with that carrier.
One creative approach to reward and incen-
tivize treatment engagement tested financial
discounts as a means of promoting psychother-
apy attendance and adherence. A sample of 110
outpatients at a university affiliated mental
health training clinic participated with 51% en-
rolled in a financial incentives condition that
131
offered a 5% fee discount applied iteratively
sessions if they followed defined criteria (e.g.,
completed homework). The groups did not dif-
fer significantly in the number of sessions at-
tended, therapy duration, and number of no-
shows and cancellations. However, after
adjusting for Global Assessment of Functioning
(GAF) scores at intake, patients who received
the financial incentives had significantly higher
GAF rating at termination compared with those
who did not. The authors concluded that finan-
cial incentives rewarding therapy attendance
and adherence with discounted fees can yield
improved clinical functioning (Stanley, Chu,
Brown, Sawyer, & Joiner, 2016). No objective
outcome measures were deployed and reliance
on the now obsolete GAF with scores generated
by the same clinicians who provided the cash
discounts does raise questions of potential for
inherent bias. While interesting, this model
would likely not prove feasible for a privately
practicing therapist.
Addressing Fee Disputes
Fee disputes create a frequent trigger for li-
censing board complaints against mental health
clinicians (Knapp & VandeCreek, 2012; Knapp,
Younggren, VandeCreek, Harris, & Martin,
2013; Woody, 1988, 2000). Typically, such dis-
putes arise in connection with billing and flow
from miscommunications, procedural igno-
rance, or naiveté rather than greed or malice
(Barnett, Zimmerman, & Walfish, 2014; Barnett
& Walfish, 2012; Zuckerman, 2003). The thera-
pist– client relationship creates creditor and
debtor relationships just as in most other pur-
chases of service. Inevitably, some clients will
fall behind in paying for services or fail to pay
for them at all. When a client remains in active
treatment while incurring a debt, the matter
should be dealt with frankly, including a discus-
sion of the impact of the debt on treatment. In
most cases, however, the more challenging pay-
ment problems arise after formal service deliv-
ery has terminated. Because of the nature of
clients’ reasons for consulting mental health
professionals and the nature of the relationships
we establish, however, we have some special
obligations to consider in formulating debt col-
lection strategies (Koocher & Keith-Spiegel,
2016).
 132 KOOCHER AND SOIBATIAN
Careful billing practices can avoid creating a
client debt problem in several ways. First, work
with clients from the outset to help them under-
stand fees and what their insurance (if they have
insurance) will cover. Next, consider having
clients pay any fees or copayments at the time
services are rendered. If your practice prefers to
invoice clients, do it in a timely manner and
address any payment problems or delays as
matter-of-fact issues promptly. When extensive
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
time commitments are likely and the particular
This document is copyrighted by the American Psychological Association or one of its allied publishers.
services may not be covered by insurance con-
sider seeking a retainer, as discussed below in
the context of educational, neuropsychological,
or forensic assessments. The key is understand-
ing that one can act as a caring professional and
as an ethical responsible operator of a business
simultaneously.
If a clinician decides to use a debt collector or
small-claims court action to obtain payment,
several risks come into play. State and federal
laws place significant regulations on debt col-
lection practices. Clinicians retain responsibility
for any actions taken by debt collectors on their
behalf. Filing a small claims case requires pub-
lic disclosure that the client owes the clinician
for their services, but one must take care not to
breach confidentiality apart from the dates of
service and fees incurred. Initiating any formal
debt collection practice may trigger a valid or
simply retaliatory complaint to a licensing
board. Even if such complaints are not upheld,
the effort and other costs in defending them may
outweigh the value of the amount owed.
Preventive strategies would include clear di-
rect conversations with clients regarding
charges and payment expectations. Ideally,
these would include written and oral explana-
tions, prompt discussion as problems arise, and
avoiding the accumulation of substantial client
debt to the clinician. When in doubt, consulting
with experienced colleagues or one’s profes-
sional association will often prove useful.
Special Considerations in Assessment
and Consultation
Clinicians conducting an evaluation or consul-
tation engagement have a cross- sectional arrange-
ment with their clients that differs significantly
from the longitudinal relationship between psy-
chotherapist and client. In such contexts, some
clinicians require clients to pay certain fees in
advance of rendering services as a kind of retainer.
This would qualify as an unusual policy in a
general psychotherapy practice, but is not unethi-
cal as long as the contingencies are set by mutual
agreement and well documented. The most com-
mon uses of such advance payments or retainers
involve relationships in which the clinician is
asked to hold time available on short notice for
some reasons (as in certain types of corporate
consulting), when certain types of time-consum-
ing assessments or litigation are involved, or when
final payment for all services may not seem as-
sured.
Specific examples might include forensic and
neuropsychological assessment. When a therapist
agrees to undertake a child custody evaluation,
and the two hostile contesting parties each agree to
pay half of the fee in advance, at least one of the
parties will potentially become unhappy with the
outcome. In such circumstances the unhappy party
may refuse to pay for the services rendered be-
cause of displeasure with the findings. Another
example might involve a family requesting a pri-
vate neuropsychological assessment of their child
in the hope of securing changes in the child’s
special education IEP (Individualized Educational
Plan). Such an evaluation may well require the
neuropsychologist to invest 5 to 10 hr or more of
data collection, plus similar amounts of time in
preparing a report. In addition, the parents may
hope that they will be reimbursed for the cost of
the evaluation by insurance or the school system
with no assurance that this will happen. Federal
law (HIPAA) and professional association ethics
codes preclude withholding medical records nec-
essary for patient care, and in some cases the
assessment report (a record) is the final product. In
such situations, it is not unusual for the clinician to
request a retainer or escrow payment before com-
mencing work or at stages in the evaluation, be-
fore completing the final report (Koocher &
Keith-Spiegel, 2016).
Implications for Training and Practice
The message inherent in this review and dis-
cussion has several lessons for current practice in
the mental health professions. From a historical
perspective, psychotherapists have long recog-
nized the importance of having clear direct dis-
cussions about fees with clients. We have also
recognized the social taboos associated with doing
so that we must overcome to have such discus-
 UNDERSTANDING FEES IN MENTAL HEALTH PRACTICE
sions. We understand the emotional complexities
that flow around people’s attitudes toward money
and the exchange of wealth in the context of
sharing emotional intimacy (whether with one’s
family members or psychotherapist). In overcom-
ing these taboos we must do a better job of pre-
paring our students to understand the economic
forces that will bear on professional practice and
coach them on ways to succeed in the profession
and to serve clients of all economic strata fairly
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
and effectively.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Recommendations
Before offering services, clinicians should
talk with peers in the same marketplace and
reach a personal decision about what they will
charge for their services. The peer consultation
will help inform market factors, but the personal
decisions how to value one’s time should in-
clude reflection on the meaning of money and
service to the clinician in addition to client
considerations. This will help to sort through
questions about participating as a provider to
third parties and your willingness or ability to
offer a sliding fee scale.
If you plan to accept third-party payment,
read any contracts offered to you carefully and
understand all provisions before signing. Con-
sultation with an attorney or your state profes-
sional association may assist in this process. If
you do not feel able to honor the terms of the
contact, do not agree to it.
Clinicians should incorporate a discussion of
fees at the start of any professional engagement.
The discussion should ideally include a schedule
of fees that addresses what services are offered
and the charge associated with each service; the
limits that apply to any third party coverage (if
accepted); and any special conditions (e.g., requir-
ing payment for missed appointments or a re-
tainer). If you plan to offer a sliding fee scale, give
careful thought to how you will offer and apply it,
and put those policies in a written form that you
will review and update regularly.
Formulate a policy on whether or not you will
entertain nonstandard compensation models,
such as bartering. While ethically acceptable
under some circumstances, the complexities and
potential problems suggest that avoiding such
practices would be wise.
Establish billing and collection policies and
review these with clients and any employees or
133
business associates employed for these pur-
poses. Remain mindful that the clinician will be
held accountable for actions of their employees
or agents. Give particular thought to how you
can avoid and manage fee disputes by clarifying
fees in writing, not allowing large bills to accu-
mulate, and discussing any fee issues in a direct
and timely manner with clients. In teaching and
training settings, regularly discuss fees and re-
lated policies with students well in advance of
their entering clinical settings and on a continu-
ing basis as they become more experienced.
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Received July 30, 2015
Revision received June 19, 2017
Accepted June 21, 2017 䡲