How Does The Sliding Scale Work In Therapy?

In our initial consultation call about therapy, I often tell clients who want to consider a sliding scale space that we’ll take a week to think about what makes sense. This post can hopefully help us decide collaboratively and give you some good ideas for when we talk about money in therapy. The questions in this post were inspired by Chynna Haas.

The reasons I offer a sliding scale in my therapy practice are:

1) People’s financial lives can change quickly. It want to do my best to ensure that no one I work with and build a relationship with looses access to therapy once because of their inability to pay. That means that if you go through a divorce, loose a job or experience a financial hardship, you shouldn’t have to worry about finding a new therapist because of money.

2) Good therapy should be accessible to people who need it most. It’s part of my commitment to offer EMDR and therapy to clients based on fit, even when they can’t afford to pay the full fee.

3) Talking about money can be therapeutic, I believe we can have conversations that are transparent and help us heal our relationships to money if we don’t avoid them. It’s important that the price of therapy is something that people are conscious and intentional about. I want the number we decide on to feel like an investment, something you think about and budget for. It should be an amount that will motivate you to bring your best self. But the cost of therapy should never put you at risk of loosing access to housing or food. A healthy investment will be different for EVERYONE. A sliding scale spot can be $20 or $200.

Here are some things to consider if you’re wondering whether or not it could be equitable for you to have a sliding scale space in therapy. It’s great to take some time to reflect and journal about these questions before we talk.

Income and Earning Potetial:

If you have a high earning potential, you’re probably not a good candidate for a low fee sliding scale space. Here are some questions to help you figure out if you have a high earning potential or income.

Is your salary higher or lower than the average person where you live?
Do you have more than one stream of income?
Do you experience discrimination in hiring due to your background?
Are you sick or disabled in a way that impacts your ability to work?
Is your career stable? Have you ever been denied work due to incarceration history?

Housing and Assets

Housing and assets impact your financial freedom and stability in important ways. It’s important to recognize whether or not any of these things impact your ability to pay for therapy.

Do you own the home you live in or get help with paying your rent or mortgage? Do you have stable housing?
Do you own or lease a car? Or do you rely on public transportation?
Are you able to figure it out when your bills are due?
Does your housing meet your needs?
Do you have enough space for yourself at home? Or live far away from where you need to be for work our school?
Do you have significant debts? Medical or student loan debts?
Do you have assets or money saved and invested for retirement?

Family Support and Intergenerational Wealth

Even if you personally don’t earn a lot, many people have access to resources because family members have enough wealth to help support them.

Do you have access to family resources and financial help making payments if you need them?
Do you live at least partially off of unearned income?
Are you supporting other people in your family with you income?

Expenses

Your expenses can have a big impact on your financial life.

Is your health insurance covering a significant part of your therapy?
Is someone else paying for therapy? Or are you paying for therapy or are you paying for therapy using a flexible spending or health savings account?
How easily can you easily meet all of your basic needs and still buy new items, or go on retreats and vacations?
Do you have medical expenses not covered by insurance? Or immigration expenses?

It’s okay (and NORMAL) if these questions bring up some emotions for you, I’m looking forward to connecting and talking more about them in our next meeting.

Sydney

Why I'm a Health At Every Size Therapist

“Weight is not an effective measure of attractiveness, moral character, or health. The real enemy is weight stigma, for it is the stigmatization and fear of fat that causes the damage and deflects attention from true threats to our health and well-being.”
- Linda Bacon

 I work to listen and acknowledge the realities of living in a larger body in a weight obsessed world and no way will I expect you to loose weight as the result of our work. My goal will be to make sure that you feel unconditionally respected and heard. 

What that means is in therapy, I strive to care for you in your body at any size. We’ll always find opportunities to adjust a yoga asana so that it fits your needs, you’ll always have a comfortable place to sit in my office for trauma therapy. When we talk about food or wellness behaviors, I won’t assume that I know anything about your life based on the body that you’re in.

The Research & Ethics of Centering Weight in Wellness

A comprehensive review of research called "The Weight-Inclusive versus Weight-Normative Approach to Health" found that not a single weight loss program in history has generated the results they promised for the majority of participants.  It's clear that the majority of health and wellness professionals are not educated on the literature surrounding the weight-based approaches to health, and many don’t know any alternatives to their current model. 

Researchers are as sure that people who pursue intention weight loss regain weight in the majority of cases as we are that smoking causes cancer. Any other medical or wellness based intervention with this kind of data would be thrown out and considered unethical for providers to recommend to clients.

Some negative impacts of weight focused approaches to health can include:

Weight Bias and Stigma: A cultural focus on weight and weight loss is connected to a deep seeded belief that people can be determined to be more valuable, intelligent, attractive self aware, or more lazy, stupid or untrustworthy based on body size. Centering thinness and associating it with health supports negative attitudes and beliefs about people who live in larger bodies. Weight stigma is associated with diminished health and well-being, and also workplace and social discrimination. Weight bias can be a major reason that people who live in larger bodies avoid doctors and receive worse care in the doctors office.

Weight Cycling: The most common result of attempted intentional weight-loss is weight cycling, not long term weight loss. The repeated loss and regain of weight is linked with negative physical health outcomes including: muscle loss, hypertension, inflammation, less physical activity, forms of cancer and higher mortality. Weight cycling is also connect to harms to emotional and mental well-being, like lower self-esteem and increased stress. 

Disordered Eating: Pursuing weight loss often leads to disordered eating behaviors. One out of four eating disorders starts with a diet and the evidence is growing everyday that trying to maintain a lower body weight can put people at risk for binge eating disorder and bulimia nervosa.

Benefits of Weight Neutral Health Care

Repeatedly, when weight neutral approaches to supporting wellness behaviors have been tested against intentional weight loss, the weight-neutral approaches result in better emotional, physical and mental wellbeing. 

From blood pressure to increasing physical activity, weight inclusivity benefits peoples physical health. 

What is a weight inclusive approach to wellness and what does it mean for you?

A weight-neutral approach to wellness includes the evidence based beliefs that:

1) a person's health and quality of life can’t be assessed based solely on their body size or weight. 

2) Body size and weight aren’t as directly and linearly related to wellness as is commonly thought. 

3) Body weight and shape are determined by a complex set of genetic, metabolic, physiological, cultural, social, and behavioral conditions. 

4) Throughout history bodies have come in a variety of shapes and sizes, we shouldn’t expect the majority of people to live in a small range of body sizes. 

5) People of all sizes can benefit from emotional, mental and physical support in health decision making that can lead to improved well being. 

If you want to improve wellbeing for yourself, your family or your organization, the ethical way to do it is with a weight neutral approach. 

Compared to dieting, weight inclusive approaches also support self-esteem and help people avoid the pitfalls of disordered eating.  Weight neutral health care avoids almost all of the harmful impacts of dieting interventions when done right and people don’t drop out of programs that actually help them to feel better! 

If you’re wanting an approach to health that’s truly about wellbeing and that welcomes and cares for your body as it is, weight inclusivity is really the only way to go.