Dilemma: What happens if two clients find out they pay different rates?
Therapy Today, October 2023

For mainly historic reasons, I have a few clients paying different rates. I have discovered that two of them now play Sunday football on the same local team. They don’t seem to know each other well and haven’t mentioned each other in sessions, but I am now worried that should a friendship develop and they find out they see the same therapist, they will share details of what they pay and realise they pay differing amounts. Should I address this now or wait until it comes up?

Karen Stainsby replies:

Practitioners routinely bear witness to some very intimate, embarrassing and perhaps shame-laden details of their clients’ lives. Usually, we work well enough with challenging material but when it comes to discussing fees, somehow it can feel different. Although fees often form part of the therapeutic frame, representing ‘a framework for dual affiliation’, it can be hard for many of us to discuss them with clients.¹

Much has been written about the place of money in therapy, described as the ‘last taboo’.² In her article ‘Payment matters’, Sally Brown considers that fee-setting involves ‘layers of interwoven dynamics’ uncommonly found in other small businesses. Some practitioners have difficulty reconciling the idea of providing ‘unconditional love’ while charging, and Brown raises the thorny question of whether it’s right to ‘make a living out of other people’s suffering’.³ In ‘Raising fees’, Stephen Hitchcock reminds us that while the ethical principle of ‘justice’ and the personal moral quality of ‘fairness’ might obviously apply to the therapeutic relationship, they can be ‘difficult to apply when money is involved’.⁴

Practitioners who charge for services have developed processes – sometimes by trial and error – with most reaching a ‘good enough’ position that works much of the time. Nevertheless, those who’ve ever had to decide whether to charge for a missed session will recognise difficult terrain. Money seems to have the power to make some practitioners feel uncertain, uneasy, perhaps guilty, causing them to behave rigidly or over-flexibly and with less ethical-mindedness than usual.

Even in contexts where clients don’t pay for therapy, money, by its very absence, is still present. What money means to us, how we symbolise it and the part it plays in our lives are all likely to impact our work. It may be useful to think about the place money plays in your life as you work out, in the first instance, what to do about these two clients, but then later, as you possibly consider more widely the financial management of your practice.

Having discovered these two clients meet each Sunday, you’re now worried. A question we sometimes ask clients is, ‘This situation’s gone on for a while. Why’s it now a problem?’ For you, the answer seems to rest on potential discovery and what that means to you and about you. I’m also curious whether something else has happened in either of the therapies or elsewhere to trigger concerns. Although you’re not acting in a ‘dual role’, you and these two clients are interconnected. While you, as a practitioner, are mainly bound to hold what each tells you as confidential, they can tell each other what they like about themselves, including what happens in their therapy, and this may have a bearing on things.

For ‘mainly historical reasons’ you’ve a few clients paying different fees. I’m working with limited information but wonder whether you’re clear in your mind who in your caseload pays what fee, what might account for differences and whether reasons underpinning individual fee-setting still apply? Do you have a universal starting fee or offer a sliding scale? Some practitioners have a sliding scale available to all clients who can self-select, although this can bring financial uncertainty, and relies on client honesty and being updated about any financial changes in their lives. Maybe you set a fee at the start of the contract that never changes or have agreed with clients when fees will be reviewed. The financial management of your practice might be efficiently managed but could rationales and other information have got lost among the day-to-day running of a busy practice and life’s responsibilities and pressures? Taking stock of fees might help you think through what to do about these two clients and perhaps others.  

Whether these clients already know about the discrepancy or find out later, how do you imagine each might feel? The one paying more may feel resentful, punished or that care comes ‘at a cost’, perhaps as elsewhere in their life. They may think they subsidise the therapy of others, that you don’t like them, or that they pay more because their problem is ‘complex’ or they’re ‘hard work’. Might they see it as unfair, discriminatory (Ethical Framework, Good Practice, point 22b), or accuse you of exploitation (Commitment 4d and Good Practice, point 35)? Heather Dale in the Good Practice in Action resource Charging for services within the counselling professions comments that exploiting clients may seem an obvious prohibition, but when money is involved, what counts as exploitation is ‘quite a complex area’. The client paying less might think they’ve got a bargain, feel ‘special’, worry their problem is unimportant to you, or that you are providing them with a ‘lesser’ or ‘second-rate’ service. They could imagine you don’t think they can afford it, feel patronised or fear that sooner or later ‘payback’ will be required.  

If clients have compared notes, one might ask you, ‘Why do we pay different amounts?’ It’s important not to get caught up in the conversation and launch into a justification, potentially breaching confidentiality (Good Practice, point 55). While we agree to be ‘as open and as communicative with our clients, colleagues and others as is consistent with the purpose, methods and confidentiality of the service’ (Good Practice, point 44) any response would best be, I feel, an ‘in principle’ one.

Apart from the impact on the therapeutic relationship and process, there’s a risk these two clients might fall out over it, accusing you of harming their friendship (and if they can’t face each other on the football pitch, possibly their hobby and wellbeing).  

You’ve always the option of doing nothing, apart from to be prepared if challenged. However, this situation does seem to be preying on your mind. Waiting to see if it’s raised might leave you waiting nervously. One mention of ‘Sunday football’ might see your pulse rate rise as you think ‘Here we go!’

So, let’s say you decide to pre-empt the situation and raise the issue. Before doing anything, think through any potential impact on the therapeutic relationship and process. Would you raise it with one client – or both – and how might you introduce this tricky subject? When might be a ‘good/bad time’? Is this conversation even possible without subtly confirming you know the other client? 

I’d suggest you have prior discussions with your supervisor having first dug out the I’d suggest you have prior discussions with your supervisor having first dug out the contract(s) agreed, which hopefully include a ‘record of what has been agreed and of any changes or clarifications when they occur’ (Good Practice, point 31e).

If contract(s) allow and the ‘monetary gap’ is not too great, some might consider ‘balancing’ fees by raising one client’s fee or lowering the other’s, which might produce puzzlement in the latter who resents having previously paid ‘the extra’. Other practitioners may consider ‘balancing’ unfair or an attempt to make yourself ‘feel better’. Of course, raising fees sometimes bring its own issues. Whatever happens, there may be useful material to explore in the service of the client.

Most practitioners act in genuine and honest ways, but you might worry you’ve made a mistake with fees. Supervision would be a good place to explore this, find out how it happened and decide what to do next. All personal moral qualities, in particular candour, apply, as do ‘Our commitment to clients’ number 6 and Good Practice, point 52. The Good Practice in Action resources GPiA 073 and GPiA 113 provide supportive information on accountability and candour. Realistically, no one expects practitioners to work ‘mistake free’ but the sooner mistakes are recognised  and addressed the better. Ani de la Prida comments, ‘There can be therapeutic value to therapist vulnerabilities and “mistakes” that are transparently acknowledged with immediacy’ (GPaCP 004).

This dilemma’s been a worry to you, so it’s important you find some sort of resolution. The ethical principle of self-respect means we’re entitled to apply all other principles to ourselves as well as our clients. As we commit to ‘promoting the client’s wellbeing’ (beneficence) so we commit to look after ourselves. To work effectively and to professional standards we need to attend to ‘care of self as a practitioner’ (Good Practice, point 91). We should periodically ask ourselves whether the money we earn enables us to take good enough care of ourselves and ‘maintain our own physical and psychological health’ (Good Practice, point 18; Good Practice in Action 088).

Coming back to supervision, as fee management is a boundary issue, it might be a good time to review other practice and therapeutic boundaries (Good Practice, point 33a; Good Practice in Action 110 and 111). Also, I hope your supervisor provides support with how you feel about this situation and its impact on you.

Money can be a complex and awkward subject, and I don’t imagine you’ll be alone in having concerns about fee discrepancies. Often, like other situations, it’s not what we’ve done as what we do next that matters. So, for the success of the therapeutic relationship and process, it’s important you can explain the reasons behind decisions but also that you and your clients feel content enough to move forward together on the right footing.

Reader responses

We can only work with what is brought to us – and work with openness

As a therapist working with musicians and music industry professionals, I am aware that sometimes clients may know each other and a scenario like this can easily occur, even though it hasn’t happened to me yet. For example, the clients that I see separately could easily be at networking events together, backstage at a gig, or potentially collaborate with one another on future projects. Through conversation, they might well discover that they are both working with me. First, I accept this possibility – if a client chooses of their own accord to bring this to me, I am happy to have that conversation with them. If unexpected issues arise as a result of two clients working with me at the same time, I will be ready to embrace it as part of the therapeutic work taking place. However, should it ever be me who makes the discovery that my clients know one another, I would not mention this to either of them. We can only work with what is brought to us – and work with openness – while always protecting the confidentiality of each client.

In terms of issues around rates, I find that discussing finances at the assessment stage is essential to managing this potential scenario. Financial issues can undoubtedly bring up challenges for both client and therapist, so to ensure I am containing myself and the client, I am clear about finances from the onset, with full transparency about how I work across my practice. At assessment stage, I always let the client know my fee and my requirements for payment. My clients in private practice are all charged the same fee; however, some of my clients are referred to me via a charity called the British Association for Performing Arts Medicine, which funds the client’s sessions. This means that one client might be paying a fee, while the other is receiving free therapy. I let my clients know this, and that if they are struggling financially, they can contact the charity I work for and that this would involve a clinical assessment to see if they would be eligible for up to six paid-for sessions, and that the charity pays me. I let them know that if they wanted to continue beyond the six sessions, they would need to be able to pay my normal rate.

I also get them to weigh up if they want to work long term or short term, and to consider the financial implications of this. I find that ensuring each person has this information from the start creates transparency and gives them the opportunity to make a choice about how they wish to continue. The assessment and contracting stage, therefore, is crucial to this scenario as it is then that the therapist establishes the boundaries in which they work, and can hold the client in the safety of that professional framework. Historically, I have changed my fee over the years and I would be happy to discuss this with a client if asked.

Denise Devenish MBACP is a music industry specialist counsellor. www.denisedevenishcounselling.co.uk

My previous experiences have taught me the importance of simplicity in managing therapeutic relationships

I work with ethnic minority groups and the neurodivergent community, and I encounter dilemmas that require careful consideration and sensitivity. I work on the premise that it is better to be upfront from the beginning in private practice. One such scenario arose when I started working closely with a community centre, and to make my services more accessible I offered a sliding-scale fee structure. I was transparent about this with all my clients from the beginning as the clients from the community centre had close relationships due to a shared faith. However, an awkward situation arose when a client confronted me about this differential pricing. This not only caused a rupture in our therapeutic relationship but also led to another client, who was on the sliding scale, frequently missing sessions without sufficient notice, contrary to the terms in our contract. This experience led to feelings of resentment seeping into the relationship. It seemed that despite having endeavoured to do the right thing by being upfront about my sliding scale, this consideration wasn’t taken into account.

The incident prompted me, therefore, to reconsider my pricing approach. I now no longer offer a sliding scale. My previous experiences have taught me the importance of simplicity in managing therapeutic relationships – while it’s crucial to strive for accessibility and inclusivity in therapy, it’s equally important to maintain clear boundaries and consistent policies to prevent misunderstandings and preserve the therapeutic alliance. And sometimes, even though you try to maintain clear boundaries, it’s still not always quite smooth sailing.

Yasmin Shaheen-Zaffar MBACP (Accred) is a counsellor in private practice working with ethnic minority groups, interfaith relationships and the neurodivergent community, and is the founder of Polyvagal Teen. www.polyvagalteen.com

Clients do talk about their therapy but not always in great detail

Even though your clients share part of their life outside the therapy room, their relationship with you is completely separate. They’re on different fees because of differing circumstances, relevant to each of them individually. How you charge your patients is up to you, and not standardising your fee is your prerogative; if they were to talk about their fees, it might reveal more about their individual circumstances rather than becoming a critique of your practice.

In my experience, where there is a shared life outside of the therapy room, clients do talk but not always in great detail. Where it becomes difficult is the acknowledgment that someone else knows about the space they visit where they can be vulnerable and talk about all the things in life that are difficult for them – it’s this that you might have to acknowledge in your sessions. A lot of the time clients want to keep their relationship with you as their therapist safe. It’s less about comparing detailed practical notes; if anything, it’s about comparing the quality of each other’s relationship with their therapist.

I have worked in schools where children from the same class are coming to therapy and I’ve also supervised that work. Children in the same class that end up with the same therapist experience a very overt sense of having to share a parental figure in their therapist with a representation of a sibling in their classmate. It’s not surprising that they might want to know about how their classmate came to therapy, and with their same therapist, for how long and any other unique or special arrangements that might be in place. As the therapist, it’s within your role to carefully manage that boundary. When supervising this work previously, this is the key point I have emphasised to my supervisee. There’s the potential for boundaries to get very messy, but your responsibility is to each client, individually, and what they want to bring as part of their work, not what you think they need to hear.

By acknowledging other clients unprompted, even if you don’t say who they are but perhaps reveal a common thread, there’s a big risk of revealing confidential information about your clients. If you leave it unprompted then you have the opportunity to deal with a situation as and when it arises. It’s worth thinking about whether, if this situation hadn’t arisen, you would have mentioned other clients to the person you’re in the room with at all.

This has happened to me a couple of times as a client. I was grateful that my therapist did not mention it until I did – by them not telling me they already knew some of their clients knew each other, it made me feel like my information had also not been divulged to anyone else, as I should be able to expect as a client in a trusting therapeutic relationship.

Marianne Rizkallah is Head Music Therapist of North London Music Therapy, a registered supervisor with the British Association for Music Therapy (BAMT) and a former BAMT Vice Chair of Trustees. www.northlondonmusictherapy.com