Pay What You Can: An Alternative to a Sliding Fee Scale

Many health and wellness professionals use sliding fee scales, formulas, and other methods to reduce fees for clients with limited resources. One model of fee-setting is simply called Pay What You Can (PWYC). In this structure, there may be a standard or common fee, but there is no set formula or scale for fee reductions. Instead, fees for each client are set on an individual basis. 

Kayte Heslet is a California psychotherapist who uses a PWYC process in her private practice. This interview was conducted in November 2021, and has been lightly edited for length and clarity.

Ben Caldwell: First, could you tell us about your practice? 

Kayte Heslet: I’m a licensed marriage and family therapist based in Los Angeles, in my 15th year of practicing therapy. I’ve been in solo private practice for the past four years. Before that, I worked in nonprofit community mental health and in a large public university counseling center. My specialization is in relational/developmental trauma, especially childhood emotional neglect.

My approach to therapy (and to life, the universe, everything) is deeply intentional. I work very relationally, and try my best to always engage a critical, anti-oppressive model of thinking with myself and the world around me. I try to identify different ways to collaboratively build the structure of the therapeutic relationship with an equitable distribution of power between the therapist and client. I also try to build those relationships without any decision-making power given to external entities, like insurance companies. 

You use a pay-what-you-can pricing model in your private practice. Can you say more about what that means?

The Pay-What-You-Can (PWYC) model that I’ve developed starts with a standard—or for the purposes of this conversation, a maximum—rate that’s comparable to average private pay rates in my area. Currently, I have set $160 as my standard rate, and any new clients who can afford that will pay that. I have a number of clients paying my standard rate, and beyond that, I offer wide flexibility according to what someone can reasonably afford by their own report.

The PWYC rate is set by a simple human-to-human conversation during the initial consultation after someone reaches out about therapy. Once I have more information about what a potential client is looking for in therapy, I generally have enough to know whether I want to offer services, or if I should assist them with referrals. I only take a new client when I feel that I can likely be a good fit for their needs. This helps me to eliminate situations where my internal emotional state might turn negative toward a client, which is a theme I hear often from other clinicians who are struggling with offering lower fees.

I don’t ask for any financial information or tax returns, and I don’t ask questions about household income or the number of people in the household. I don’t believe I, or a chart from a website, can be the best judge of another person’s financial situation. I’m comfortable with putting my trust in each person’s ability to determine what they can truly afford for themselves. 

Each time, I just ask the same question: “What would you reasonably be able to pay per session if we were to meet weekly?” Many people know this number already, because they’re often actively managing a precarious balance between their income and expenses. If they need time to think about it and get back to me, great. I already know and trust that I have put in the work in the background to allow for maximum flexibility. I don’t have to rely on each new potential client for any amount of money I “need” from them. I’ve already built a stable foundation where I know my income for any given period will clear the amount I need to bring in to cover my expenses.

This practical aspect is no different from what most therapists do when budgeting and tracking their income and expenses. I’m approaching it from a perspective of how to yield the most space for the client to make decisions about their access to and engagement with therapy. This allows them to make the decisions that are informed by their own needs and experiences, not mine. I see the value of the client and myself equally, see the value of our time equally, and I find my own value defined somewhere other than the dollar amounts I’m paid for my work.

This method is born from my personal values and ethics. My fee-setting process is an intentional example of how I see my opportunity to build the world I want to live in, via concrete and everyday practices. I say this to distinguish my own choices from the idea of prescribing anything for someone else. And because this is such a conscientious and intentional practice from my heart and brain, of course I also hope for it to light a spark in someone else.

I would imagine you encounter some skepticism from other clinicians when talking about your fee structure. What kinds of questions do you tend to get, and how do you usually respond?

I know that many people are skeptical when I explain allowing a client to set their own fee! Maybe they are imagining that people will lie about what they can afford, or that every client will hear that question and say “Great, then I choose to pay nothing!” But throughout years of these discussions, neither of these things have actually happened to me. 

I’m not asking what someone “feels like” paying, or what they “want to” pay for therapy. I use the specific wording of “can” or “able to” pay, because that’s truly the question I’m asking, and it reflects that they hold the power to make the choice. I’m looking at them as a human being, trusting them to see me as a human being. I truly believe that the reason why my model has worked so consistently well in my practice is that people feel they are being respected and treated with honesty, and they show me the same.

In so many discussions about how therapists deal with money, we hear about “scarcity mindset” vs. “abundance mindset.” In the bigger picture, scarcity mindset tells us that things that are harder to get are more valuable, and the more commonly available or easily accessible things are less valuable. Scarcity mindset leads us to focus on what we feel we don’t have enough of, and we can become so overfocused that we experience a sort of tunnel vision that increasingly emphasizes that lacking aspect. 

Poverty is one very real driver of this cycle, but many people who aren’t actually living in poverty find that we also can become stuck in the brutal spiral of scarcity-driven thinking. It’s certainly valid to apply these concepts to how we think about money in private practice, but I feel it’s even more important to apply to our thinking about potential clients.

We could say that a scarcity mindset toward a new client fears and expects that the client will have a scarcity of honesty, respect, or care toward us. We might fear that they’ll be calculating, negotiating, argumentative, or will want whatever they can get for free. It might sound like, “I have to guard myself so that I won’t be lied to and taken advantage of.”

Conversely, a version of abundance mindset toward a new client might acknowledge that they’re seeking help and going to the difficult effort to contact a therapist. They’re in a vulnerable position, and of course they have the expectation that they’ll exchange money for services. There’s no competing interest between a client’s needs and my own, especially when I’m aware of my personal boundaries and needs alongside my client’s.

One rebuttal I’ve heard many times from other therapists is “But why offer a discount on your expert services, when you are worth so much more than that?” And, truly, this isn’t to say it’s somehow wrong to assign value to your time and services. I just use a different lens because of the awareness I have of my own privilege, and because I have strong feelings about being forced by prevailing norms to engage my business in what I see as exploitative and inhumane ways, just to be able to survive. I can’t accept that as my only choice. I wasn’t “worth less” earlier in my life when I was paid less money, and I’m not “worth more” now just because I had the privilege to access education via scholarships and Sallie Mae.

None of my clients have ever insisted to me that they can’t pay anything at all. If that did happen, and it wasn’t okay with me for some reason, therapy involves a mutually consensual relationship. I would be free to say, “I’m sorry that I’m unable to accommodate that,” and provide referrals if that’s what I needed to do. It may even be tough to believe, but longer-term clients often approach me to raise their fees upon an increase in their income or decrease in their expenses. This has happened not just a couple of times, but dozens of times. I believe this is because of the authenticity of the trust and relationship built between us. They feel valued by me, and genuinely value what I offer.

Of course this model isn’t going to align with everyone’s ideas or needs. I don’t advocate that therapists whose financial lives are already affected by multiple intersections of oppression should be doing what I’m doing. But I would like to reflect on the idea that something is fundamentally broken in a world where it’s been normalized that trillions of dollars can sit hoarded and tax-sheltered, while very real living people are dying simply for the lack of basic resources at the same time. 

I believe wealth inequality is among the most dangerous problems this world faces, second only to climate change. I see my individual self as a part of, and connected to, many larger circles of collective self. Whether it’s my family, my local community, our professional community, our planet—if something benefits only me, and in doing so causes significant harm to another, it’s not a balance I can accept. 

When something benefits multiple people or groups of people, then it’s mutually agreeable that it has an inherent larger-scale value. And when something especially benefits and empowers more oppressed and marginalized people, that’s the ideal outcome. By this measure, the current system of for-profit healthcare doesn’t meet the definition of beneficial.

I think I know the answer to this, but it’s worth asking anyway: Do you still meet your own income goals with this model? I’m sure some colleagues have a knee-jerk reaction of “I could never do that, I wouldn’t be able to make a living.”

I’ll be transparent here: My household is two-income, for three family members including a child. So I’m not the sole earner in my family. I’m a cisgender white woman, with a master’s degree that I had the choice to pursue after becoming the first college grad in my family. Having another predictable income in our home allows for my own income to be flexible without putting us in immediate danger. All of these facts are some of the various kinds of privilege that all benefit me, and acknowledging this privilege means I can decide what I do given those conditions.

I’m still able to make enough money if anything were to change about my family’s situation, and I continued to work as hard to bring in new clients as I have in the past, it would be fine. But currently, I’m allowing my caseload to slow down naturally to allow time for the other things I enjoy doing, like writing about this topic.

The reality today is that, through my private practice, I receive more financial resources than what my family needs for me to provide, and this is another opportunity to align my values and my practices. Any amount of money I make beyond my own needs is redistributed directly through mutual aid practices that I’ve built through relationships and organizations in my communities. I’m regularly redirecting a large amount of money (what would be considered profit beyond my costs) each month directly to people living within some of the most violent intersections of oppression.

June Jordan’s “Poem for South African Women,” which memorializes the tens of thousands of women who marched on Pretoria in protest of apartheid  in 1956, closes with the line “We are the ones who we have been waiting for.” This is why I’ve worked so hard to create and protect my vision of the more equitable and compassionate world I want to be living in and leaving to the next generation. I find my solution in developing simple everyday pieces of radical practices to build that world into reality.

This isn’t a self-sacrificing act of charity or philanthropy, and I don’t see anyone else as being in need of my saving. But this is a choice I’m making to see the value in all of us, to see that we all need each other. This is my act of resistance against exploitation and being forcibly assigned a dollar value, and the refusal to accept that for anyone else, just the same.