Most psychotherapists now have telepractices and conduct video and phone therapy sessions instead of face-to-face ones in an office because the majority of mental health providers switched to all, or primarily, Teletherapy sessions as a result of stay at home orders. While these types of online video or phone services are not for every client or practitioner, many therapists are reporting that, after moving their practices online and doing therapy with clients over several months, they find video or phone telesessions not only effective but convenient—and plan to keep offering some form of Teletherapy along with in-person sessions when they’re once again feasible.
However, clinicians are also reporting that when some new prospective clients find out in-person sessions are not an option they seem reluctant, resistant or unsure about beginning or making the switch to virtual therapy.
When this type of client reaction occurs, it causes psychotherapists to feel conflicted because client consent is needed in order to work virtually—and in-office sessions aren’t an option. Therapists also then wonder if it’s okay to influence a client towards Teletherapy when the client doesn’t seem to want it or is less than comfortable with it. Should therapists address the issue further when this happens or just refer? What's a therapist to do?
While there are many good reasons that people are reluctant to do teletherapy—no private place, no equipment but their phone, etc., it’s important to remember that when in-person services are not available some individuals may initially find it hard to switch to or commit to therapy that’s different from what they’ve thought about, imagined or come to expect. Teletherapy is that kind of different. No couch, just a screen.
While clinicians know that some reluctance or resistance to beginning therapy is usually present in any intake, and are used to addressing that, what counselors aren’t used to is handling intakes where the reluctance is around Teleservices--video or phone--when it's the only option available.
The truth is that many of the issues that are initially expressed as client reluctance about Teletherapy, they aren’t actually about the telesessions at all but are really just another manifestation of the client’s issues that are inherent to therapy—and these same types of objections or complaints would come up even if the therapy was face-to-face.
While it's important to keep in mind that online services are not right for every client or practitioner, a client’s reluctance, discomfort, and resistance is most often not about Teleservices, but about entering a new world where they are moving from a familiar way of operating to the therapy context where different rules apply. Our job as therapists begins with helping clients enter, become familiar with, and safely navigate the therapeutic context. We are, and need to be, their guide.
As you read the following information, be sure to remember:
What’s the best way to respond to a potential client who seems reluctant or resistant to engage in video or phone therapy when a therapist isn’t seeing clients in person in the office?
Teletherapy reticence, reluctance, discomfort, and resistance are clinical issues. The therapist needs to take charge of any conversations regarding teletherapy issues. Yes, it’s part of therapy and it’s the therapist’s job to aid-educate-facilitate pre-therapy (intake) or Teletherapy resistance conversations
New clients don’t really know what teletherapy is or what it’s like if they’ve never had therapy or online therapy before. They only have an idea of what it’s like or the description of what someone else told them.
Teletherapy with a clinician who is a good match can be a great option when in-person therapy is not available and many clients are great candidates for video or phone therapy.
Use your clinical skills to address and respond to a client or prospective client’s Teletherapy issues when they come up—just like you would address anything else. Treat the issues that come up about teletherapy sessions the same way you’d treat any other client issue.
Taking it personally = Countertransference!
Don’t take a client’s Teletherapy reluctance and resistance talk personally when clients demonstrate their issues and skill level in dealing with them—take or use a therapeutic stance just like you would about any other topic or issue. Under your guidance clients can then make an informed decision about beginning, continuing or ending Teletherapy.
Teletherapy is definitely here to stay. Its effectiveness is equivalent to face-to-face sessions and the flexible nature of video and phone sessions benefit both clients and clinicians. Add in the ease and convenience of scheduling a video or phone therapy session and talking with a mental health practitioner from the privacy of your home or another convenient location, and you find that these virtual services are a huge draw, especially for many people who are seeking therapy for the first time.
Telepsychiatry, teletherapy, telepsychology, and video therapy are more than just trends. In fact, a good number of mental health professionals are finding they prefer working with clients using teletherapy video and or phone sessions and will not be returning to in-office sessions. Yes, these therapists are reporting that they plan to keep their therapy practices solely virtual when in-office services become available again on a large scale.
Both in-person therapy and Teletherapy have advantages. Some view office sessions as a way to get some distance from problems at home and find it easier to see and deal with challenges objectively. Some clients prefer phone therapy, which works fine in many situations.
While Teletherapy and online services are not for every client or practitioner, online therapy is here to stay, like it or not. Consumers are changing, and so are therapists and their practices. Teletherapy has become another viable option for clients and mental health practitioners. It may not be the best option for everyone but the good news is that it is just as important and effective as the traditional therapist’s couch.
The biggest challenge therapists say they’re facing with telementalhealth, is how to talk with potential clients about doing teletherapy in place of in office sessions.
Since therapists now have telepractices doing video and phone sessions instead of face-to-face sessions in their office, they’ve discovered that having the initial contact--the intake or pre-therapy phone or email interaction—with a potential client is, and needs to be, a little bit different than the interaction a clinician is used to having when orienting a client to beginning in-office therapy sessions.
While clinicians are skilled and practiced in what to say and cover with potential clients during the first contact for in office therapy, now when potential clients call inquiring about therapy, therapists who aren’t doing in-office sessions find their biggest dilemma is what to say to introduce teletherapy video and phone sessions—and how to respond effectively to those potential clients who are resistant or reluctant to schedule an appointment or pay for these sessions.
When therapists aren’t seeing clients in their offices, what can they say to introduce potential clients to doing therapy through teletherapy sessions? What’s the best way to respond to a potential client who seems reluctant or resistant to engage in video or phone therapy when the therapist isn’t seeing clients in person in the office? What should a therapist say to a new client to orient and prepare them for video or phone therapy sessions?
As you know, when clients come to therapy they are entering a new world. They are moving from a familiar way of operating to the therapy context where different rules apply. Our job as therapists begins with helping clients enter, become familiar with, and safely navigate the therapeutic context. We are their guide.
For successful therapy, clients need to experience a safe enough environment where they can be free to examine things and share their feelings. For most clinicians and clients this previously occurred in a therapist’s office that had been specifically created to insure a safe, confidential, and supportive environment.
Now that the therapy office is a virtual one with therapist and client in a different location, no longer does the clinician arrange for privacy and provide the Kleenex, bottled water, tea, coffee or snack; decorative pillow to hug, comforting blanket and client chair or couch. Gone, too, is therapist greeting the client in the waiting room and the comfortable small talk on the way to the office. Clients, prospective clients and the general public are familiar with and know what to expect from in-office therapy; teletherapy not so much.
With teletherapy it’s extra important for us to remember that when clients begin therapy and enter the therapeutic milieu via telehealth their experience of changing contexts is much more complex than with in-office therapy sessions. This means that not only are new clients moving from a world where they behave in certain ways to a place where they are expected to think and act differently in the therapeutic setting, with telementalhealth this includes adding another layer to that—a video screen or a phone and the therapist and client being in two locations. That’s quite different from driving to, parking, sitting in the waiting room, and walking into a therapist’s consulting room where therapy occurs and the client is taken care of in person by the therapist.
How can a therapist re-create that experience with teletherapy and convey to clients and prospective clients that it works? For most new and continuing clients this shift to creating and utilizing a virtual space for therapy takes learning and practice under guidance and direction of a competent therapist—and that starts with the very first phone conversation when Teletherapy is presented.
As you read the following information, be sure to remember:
1. When therapists aren’t seeing clients in their offices, what can they say to introduce potential clients to doing therapy through teletherapy sessions?
When doing in-person therapy sessions, during the intake conversation, therapists usually disclose their credentials, review the address and location of the office, frequency of appointments, session length, cost, type of payment accepted, directions to the office, where to park, etc.—and discuss why the client is seeking therapy to make sure it’s within their scope of practice.
When teletherapy is involved, whether or not a client has requested video or phone sessions, it’s up to the therapist to introduce, disclose, and orient the client to not only the usual therapy information but also the video and phone delivery model, treatment methods, and limitations of the telemental health services the therapist provides (Section 2290.5 of the Code). How every therapist does this is different.
Regardless of whether a client requests telementalhealth services, or the therapist is informing the client that therapy will be conducted remotely by video or phone, the opening statement and disclosures are the same.
Most therapists begin with a simple general statement like, “During this time of social distancing and stay at home orders I provide therapy through telementalhealth video and phone sessions.” Some also include, “In-office sessions may be resumed at a future date and I will let you know when that becomes an option.”
2. What should a therapist say a new client to prepare new clients for video or phone therapy sessions?
After an opening statement saying why teletherapy sessions are the sole therapeutic format, stating your own version of the following information is helpful and covers required disclosures:
3. What are the things therapists need to address with potential telementalhealth clients during that first pre-therapy interaction/intake?
Aside from informing the client or prospective client about teletherapy by introducing, disclosing, and orienting the client to the usual therapy information, and the video and phone delivery model, treatment methods, and limitations of the telementalhealth services the therapist provides, the California BBS: Standards of Practice for Telehealth also state that before the delivery of teletherapy the therapist needs to obtain verbal or written consent from the client for those services.
In addition, the therapist needs to document in the client notes that informed consent was obtained from the client. This is more specifically stated by the BBS, in Section 5,b.
That’s enough on introducing and talking with clients about doing teletherapy instead of in-office sessions. Next time we’ll focus on how to respond to a potential client who seems reluctant or resistant to engage in video or phone therapy when the therapist isn’t seeing clients in person.
Teletherapy . . . Telehealth . . . Telemedicine . . . Telemental Health . . . Telepractice . . . Televideo . . . Internet Therapy . . . Online Therapy . . .
Teletherapy is everywhere. Like it or not, telehealth is here to stay during the current crisis—and is likely to stay in some form after it ends.
What’s a therapist to do? How can a therapist survive, and better yet, thrive, while doing so many live teletherapy sessions with clients?
Many therapists are now working from home for the first time doing therapy with clients using online video or telephone platforms in place of in person sessions. While working from home as a Teletherapy provider allows therapists to have a flexible work schedule and many other conveniences, the shift to virtual comes with many new challenges and stressors as we're adapting to what’s going on in the world and to this new setting and medium.
While Teletherapy is still therapy, it has idiosyncrasies. When doing a remote session it’s a much more exacting, labor intensive process for a skilled therapist to work effectively with the same things they do in person. Facilitating therapeutic communication and interaction is definitely different when you and your client aren’t in the same room—it requires another kind of focus, concentration, and energy. Add to that the fact that most therapists are now juggling a work-from-home therapy practice alongside home and family life while everyone's at home, too. The result? Therapists are reporting how exhausted they are after providing Teletherapy services to clients.
Teletherapy exhaustion, burnout, and fatigue are real.
Why is delivering Telehealth services so tiring? Conveying professionalism through a Teletherapy portal in your home requires that we develop and utilize a therapeutic telepresence and a “web-side” manner while conducting sessions through a screen—and that’s very fatiguing. Therapists are also finding that Telehealth delivery does not lend itself to the same type of marginless in-office scheduling where clients are seen back to back without any breaks.
Teletherapy is a much more strenuous delivery system than in-office therapy. That shouldn't be surprising since it’s well documented that sustained and prolonged use of digital devices—computers, tablets, smartwatches, smartphones—for video sessions and meetings leads to exhaustion, computer eye strain, dry eyes, focusing fatigue, and neck, shoulder, and back pain.
Here are tips for reducing the fatigue, stresses, and challenges of telehealth and conducting video therapy sessions, groups and meetings. Think of these tips as a menu of options. Try the ones that suit you, discard the ones that don’t.
Teletherapy Survival Tips for Clinicians
1. Teletherapy relies on a strong internet or phone connection.
Poor internet or phone quality is one thing that not only makes clients upset, it negatively impacts therapeutic communication, the therapist client connection, and the outcome of therapy. Anytime video gets glitchy and skips, sputters, gets pixelated or freezes the image—or the audio stops, develops, an echo or keeps cutting out—it becomes difficult to maintain therapeutic communication and the therapeutic connection diminishes.
Therapists need the best, most reliable internet connection—and Telehealth delivery platform—that they can get. Whether poor quality is on the client or therapist side, the experience of therapy deteriorates without solid audio and video. Poor internet or phone quality definitely interferes with progress, the outcome of the session, and the the therapeutic alliance.
Before scheduling a session, be sure to check whether the client has a good enough internet or phone connection, and the right type of equipment/device for video sessions, otherwise a different type of Teletherapy is needed.
2. Create the right environment for you.
Just as your office set-up is a key part of your in-person practice, how you arrange your remote office can make a big difference in your sessions.
3. Create the right environment for the client.
4. Ways to reduce exhaustion and minimize fatigue, dry eyes, computer eye strain, focusing fatigue, and back, neck, and shoulder pain.
5. Consider using phone sessions.
Today, during the COVID-19 public health emergency, the majority of licensed and registered mental health professionals in California have shifted to providing psychotherapy services using telehealth. Most are new to telemedicine and what’s required by the California Board of Behavioral Sciences (BBS). Questions abound . . .
What telehealth platforms can I use during the COVID-19 public health emergency? What communication technologies are still prohibited? What communication products or technologies can I use if I want a HIPAA compliant telehealth platform for my practice? What things am I required to do with each client when I begin telehealth services? What am I required to do with clients at the beginning of each telehealth session?
The answers to these questions and more are in the three following BBS telehealth documents presented here in full for easy use and reference—with links to the original documents.
Read them. Comply with them. Keep your license, and yourself, free from unprofessional conduct and disciplinary action.
1. BBS: Standards of Practice for Telehealth California Business and Professions Code
All persons engaging in the practice of marriage and family therapy, educational psychology, clinical social work, or professional clinical counseling via telehealth, as defined in Section 2290.5 of the Code, with a client who is physically located in this State must have a valid and current license or registration issued by the Board.
All psychotherapy services offered by board licensees and registrants via telehealth fall within the jurisdiction of the board just as traditional face-to-face services do. Therefore, all psychotherapy services offered via telehealth are subject to the board's statutes and regulations.
Upon initiation of telehealth services, a licensee or registrant shall do the following:
A licensee or registrant of this state may provide telehealth services to clients located in another jurisdiction only if the California licensee or registrant meets the requirements to lawfully provide services in that jurisdiction, and delivery of services via telehealth is allowed by that jurisdiction.
Failure to comply with these provisions shall be considered unprofessional conduct.
2. BBS statement on HHS Telehealth Announcement of Enforcement Discretion
U.S. Department of Health and Human Services (HHS) Announcement
of Enforcement Discretion for Telehealth Remote Communications
The Office for Civil Rights at the U.S. Department of Health and Human Services (HHS) has announced that it will exercise its enforcement discretion and will waive potential penalties for HIPAA violations against health care providers that serve patients through everyday communication technologies during the COVID-19 public health emergency.
During this time, covered health care providers subject to HIPAA may provide telehealth services, in good faith, through remote communications technologies that may not fully comply with HIPAA requirements. This applies to telehealth provided for any reason, whether related to health conditions related to COVID-19 or not.
What Telehealth Platforms Can I Use?
HHS states that covered health care providers can use any non-public facing remote communication product that is available to communicate with patients. This includes popular applications that allow for video chats, such as the following:
What Platforms Are Still Prohibited?
HHS still prohibits using communication products that are public-facing. Therefore, do not use these types of platforms. Examples of public-facing communication products include, but are not limited to, the following:
I Still Want to Use a HIPAA Compliant Telehealth Platform For My Practice. What Are Some Examples Of These?
HHS provides some examples of products that are HIPAA compliant and will enter into HIPAA business associate agreements (BAAs) in connection with the provision of their video communication products. (They stress that they have not reviewed the BAAs for the below entities, and that this is not an endorsement, certification, or recommendation):
HHS Notes That HIPAA Applies Only to Covered Entitles and Business Associates. How do I Know If It Applies To Me?
HHS provides the following bulletin HIPAA Privacy and Novel Coronavirus. This topic, HIPAA Applies Only to Covered Entities and Business Associates, is covered toward the end of Page 5.
Where Can I Find More Information?
You can use the following links for more information from HHS:
Detailed explanations regarding telehealth requirements, for licensees and registrants, are contained in the following statutes and regulations:
This section applies to clients who are physically located in California.
This section applies to clients who are physically located out-of-state.
Prior to the delivery of health care via telehealth, the provider initiating the use of telehealth shall:
Additional information regarding telehealth is contained in the following statutes and regulations:
Getting the word out about your therapy practice is important. To be successful in private practice, you need a steady stream of clients—QUALITY referrals that are a good match for you and your practice. Letting people know what you do therapeutically and how you can help them, not only helps fill your practice, it helps you help more people.
The more people who know about your therapy services and expertise, the easier it will be for those who need your services to find you and get the help they need. Consider the ways you can let colleagues, prospective clients, and referral sources know about you and your services.
1. Getting the word out about your practice is a community service.
Getting the word out about your therapy services and expertise is really about letting people in the community know about you, your practice and your services. It’s educating those in your community—your peers, prospective clients and referral sources—about what therapy is, who you serve in your practice and how you help them.
Tip: When clients go to your website, directory listing, and social media pages, what they are really looking for is: Who are you? What can you do for me? How can I contact you? Make sure your content on your website, directory listings, and social media pages gives them that information clearly and easily.
Tip: It doesn’t matter what you do to get the word out about your practice and services but you have to do something. Since you have to do something, ONLY do the things you like.
Tip: Remember, only do what fits or makes sense to you to get the word out—and always within legal and ethical guidelines! It’s okay to make things up to do that you like. However, you will have to try things out to see what you like.
Tip: Be sure to make the act of promoting yourself and your skills and services energy producing instead of energy draining.
2. Getting to know people in your community and letting them get to know you, the services you offer, and the type of work you do, brings in quality referrals.
People who already know about, like, or trust you are more likely to refer to you than anyone else. People trust their friends and people they know so that’s why word of mouth,whether in person or online, is the most valuable source of referrals for your practice.
Tip: Connect with local businesses. Introduce yourself to other local business owners who are your neighbors. One therapist I know who moved into a new office went to each one of the businesses around her—introduced herself, met and got to know the business owners and or those who worked there, found out about their businesses and gave them her business cards and brochures.
Tip: Join a professional organization or association. Attend meetings of professional groups, associations or organizations to get known in your community. Become a member. Volunteer. Register and attend a conference.
Tip: Post your professional and or practice information to a directory. GoodTherapy, Psychology Today, LinkedIn, etc. Remember that Linked In is social media for professionals, and is a trusted source for professional services and referrals.
Tip: Either donate products or volunteer your services to a worthy cause and get your name and the name of your practice out there to new people while doing a good deed.
Tip: Consider getting some promotional products with your name, website, phone number, email, and or practice specialties on them to hand out. Pens, notebooks, notepads, post-it notes, shopping bags, led flashlights, etc., are all favorite types of promotional swag that people appreciate.
3. Tapping into existing relationships is the fastest way to fill and grow your practice.
People trust other people and the experiences they have so that’s why when people hear from a friend, someone they know or a professional they trust, about a service or product they choose that one over others. For therapists, the first few referrals after you open your private practice will usually come through in person connections and relationships you’ve already built.
Tip: Build an email list. Who should you put on it? Include those you meet while networking but don’t stop there, add close friends, acquaintances, family members, extended family; neighbors, acquaintances. Professionals you have personally used—medical professionals such as doctors, physical therapists, psychiatrists, dentists, dental hygienists—as well as business professionals who are lawyers, estate planners, financial planners, as well as nutritionists, doulas, Lamaze instructors. Personal trainers, Pilates instructors, meditation instructors, massage therapists, aestheticians, hair stylists. Those who attend your church or who worked with you in the past as well as elementary, middle and high school teachers and coaches. Mentors, past clinical supervisors and professors, classmates and supervision group members. teachers, guidance counselors.
Tip: Send regular emails to your list to keep them informed of what you are doing in your practice—do this at least three times a year. Or start a free monthly email newsletter and send it to your email list.
Tip: Utilize Your Email Signature. Make sure your email signatures contain contact information for your business—links to your website, upcoming workshop, new book or audiobook, podcast, video, YouTube channel, etc. This makes it easy for people to know more about you and what you offer.
4. Consider using some type of social media to get the word out.
Today there are a lot of people who are looking for help—and most of them aren't asking their friends or family for referrals. They are looking on the internet at websites, social media platforms (Facebook, YouTube, Instagram, Messenger, Snapchat, Twitter, WhatsApp,LinkedIn, Tumblr, Tik Tok, Viber, Pinterest, etc.) and closed groups, discussion groups or forums (Quora, Reddit, etc.).
Because social media helps you build relationships, using social media to get the word out about your services allows you to showcase skills and expertise and to build relationships with existing and potential clients and referral sources.
When you post a variety of content on social media (blogs, articles, videos, quotes, podcasts—your content as well as other’s), you can build recognition, connect with your peers, referral sources, and potential clients to show them that you are trustworthy. You’ll definitely get some interest in your work from this—people will love your content and want more.
Tip: Not all social media platforms may be suitable for your business. Different customer segments frequent different social media. There's no point in spending time and money on promoting your business on a social network that your customers don't use.
Tip: When you blog or write articles regularly, social media is a great place for you to share that content. You can also share articles that you find interesting, inspirational quotes, podcasts, and videos that you think those following you would enjoy. All these are great relationship builders.
Tip: Record a video blog post and put it on your website or upload the video to YouTube. Record a Facebook Live or Instagram Stories short video. People love this content and enjoy getting to know you through what they see and hear on the videos.
5. Track what’s working and then do more of it.
Know the results you get from each thing you do to get the word out and repeat what works. Quit what doesn’t work.
These are all fairly low cost and not too time consuming tips for getting the word out. See which ones you enjoy doing and that work best to fill your practice.
Getting Paid: Fast, Easy, Convenient, & Cost-Effective Ways to Get Paid & Increase the Cash Flow in Your Practice
When clients pay for therapy in your practice, what type of payment do you accept?
Check? Cash? Credit Card? Debit Card? HSA or FSA Card? Money Order? Yes, they still issue money orders.
Today there are so many options to choose from for client payment. How do we decide which one is best for us and our practice? What are legal and ethical options available to therapists to get paid fast and not have to pay too much in bank or credit card charges?
This is the sixth article in a series on Getting Paid: Talking with Clients About Money Matters:
Not too long ago clients handed their therapist cash or a check before or after the session; were sent an invoice/billed at the end of the month; and then mailed or brought in their check or gave the therapist cash at the next therapy session.
Should you consider adding or changing the type of payment you accept for therapy charges?
How can a therapist decide which forms of payment are best for their therapy practice?
With whatever types of payment you decide to accept in your therapy practice, it’s important to look at how much it costs you or saves you—in time, energy, wait time for funds, as well as charges/money—to process those funds and get them into your practice bank account.
Therapists, like most small business owners, are always wanting to know what the best way is to get paid and increase their available cash. They want to know how to get their funds into the bank as quickly and easily as possible and how to pay the lowest possible amount to do that. Having earned this money, therapists want to take home as much of it as possible, save time, and have more clients.
In fact, the most common reason therapists give for accepting only check or cash is that it costs money (just under 3% of each transaction) to take credit cards. And, as you have probably heard, most therapists do not like to--or want to—pay any credit or debit card, or other type, of processing charges since this amount is subtracted from what the therapist is paid.
However, contrary to popular lore, whatever type of payment a therapist accepts for therapy sessions, it costs the therapist something. At the very least it costs time, energy, effort, and time before the funds can be accessed, and it can also cost money per transaction. How is it worth it for a therapist to take card and electronic payments and pay those transaction fees?
Giving your clients more ways to pay can increase the number of clients in your practice and improve your cash flow.
It's a fact that most clients expect to be able to use credit or debit cards when paying for things. Today’s clients, whether no matter what their age, find it convenient to pay via credit or debit card, or directly from their HSA or FSA. If you do phone, video or other types of virtual or remote sessions, credit card and electronic payments are essential because they enable the client to pay you before or after the session.
More payment options that are convenient means more access to care for a larger number of people—and result in more clients in your practice.
Whether a therapist accepts payment by electronic means--credit card, debit card, e-check, wire transfer, Zelle, Venmo, etc.—depends on both the therapist and clients’ preferences and needs. Many therapists find that their number of paid weekly client hours increase when they accept credit cards. Clients often like to get rewards--points or miles or cash back—when they pay for therapy.
If you don’t accept credit cards but accept checks or a bank transfer of funds, clients who want the rewards can use Plastiq. With Plastiq a client can pay with a credit card—and even split the charge between two different cards—and the therapist is sent a paper check or receives a bank transfer right away, just as if the client had paid with a credit card. Another benefit to the therapist with Plastiq is that the client pays the credit card processing fee, the therapist doesn’t. Many therapists love that because it means they receive all the money paid for the session.
For therapists, card and electronic payments can mean freeing up more time, energy, and effort—and quicker access to funds because of the following:
One way to increase income from your practice and not have to pay any transaction fees is to have your clients pay you using Zelle or Venmo.
One therapist I coached added Zelle to his practice in addition to credit cards as a payment option and increased his take home earnings $100 per month because he didn’t have to pay that amount in credit card fees. That was a very easy way to bring in $1200 more that year. Another therapist in one of my practice development groups added Venmo as a payment option when a client suggested it. When using Venmo, the client pays through the app at the end of the session—just a couple of clicks—then there's a ding on the smartphone, the therapist receives it, opens the app, clicks on the amount of the balance. then clicks on the deposit button. Voila! Two days later it’s in her account. If she wants it instantly then she clicks on the instant deposit button and pays a small fee, then it’s deposited in her account shortly after that.
Here are some descriptions of options for getting paid spelled out:
Credit Card processing companies that therapists report using are: Square, PayPal, Stripe, Ivy Pay or their bank. These companies also process debit cards and bank funds. These processors charge/keep a small percentage of the dollar amount of the transaction, usually just under 3%. Some therapists use a credit card terminal to swipe or insert cards—this is purchased from the card processor by the therapist—others use an app on their phone or tablet. I use the Square Terminal in my office and have it on my desk; it’s easy to read, insert cards in, and processes very rapidly. Very professional, convenient, and easy to use.
Venmo and Zelle transfer funds from the client’s bank account and deposits into the therapist’s bank account. They do not charge/keep any amount from the transaction. However, for instant transfers, Venmo does charge a small amount, equivalent to a credit card processing fee.
Plastiq, as described, charges the client’s credit card and deposits the full amount, no charge to the therapist, into the therapist’s bank account. The credit card processing charge is paid by the client in addition to the amount the therapist is paid.
HSA (Health Savings Account) and FSA (Flexible Savings Account) Cards are debit cards and are processed the same way. Clients who have HSA and FSA cards like to use those because they aren’t taxed on that income since it can only be used for qualified healthcare expenses—therapy is one. HSA and FSA cards help clients with high-deductible health insurance plans cover their out-of-pocket costs. Another thing to note about HSA cards is that contributions, up to the yearly IRS limit, can come from the client, the employer, a relative or anyone else who wants to add to the HSA.
So now you’ve had a presentation of a number of the options available to therapists for getting paid fast, and in easy, convenient, and cost-effective ways. By no means does this article include every option available to therapists as there are many more not mentioned here. Should you decide to add some new payment options to your practice it will, I’m sure, give you added time, money, and clients. See what differences these new options bring to your practice.
Getting Paid: Introducing & Talking About Sliding Scale, Adjusted Pricing & Specialized Alternatives—The Words You Use Make a Difference
Getting Paid: Talking About Sliding Scale Pricing—The Words You Use Do Make a Difference is the fourth article of the Getting Paid: Talking with Clients About Money Matters Series.
How much do you charge? What’s your sliding scale? Is that the lowest you charge?
How much can you slide? How low can you go?
If you dread hearing these questions you are not alone.
While questions about a lower price or a sliding scale used to be asked from time to time, therapists are reporting that now they are asked these questions all the time—from just about everyone who calls.
What’s problematic about this?
Well, before this recent phenomenon started, sliding scale requests came from just a few—usually those with a low income or reduced ability to pay, a financial hardship or significant unexpected expense. Now a majority of those asking for lower or sliding scale pricing more often have adequate resources, income, and an ability to pay. What’s a therapist to do?
Offering lower pricing to clients truly in financial need who require mental health services, is a time-honored tradition in the practice of therapy. Sliding scale and other types of price adjustments were instituted to make therapy services available to those whose economic circumstances didn’t allow payment for the full cost of services.
Having these accommodations available allows therapists, at their own discretion, to adjust the amount a client pays and can manage on a regular basis
Like most therapists in the mental health profession, I believe in, and support, making affordable therapy available to people who don’t have much money and those experiencing a financial hardship.
Clinicians, who are committed to this, routinely offer those in need a variety of options that allow them to afford and pay for needed mental health treatment. Many therapists also work with certain clients on a case-by-case basis to offer specialized arrangements based on their particular needs and circumstances.
Some of the options private practitioners use to make therapy affordable to clients in financial need are: pricing based on income; lower pricing; a percentage or number of lower priced client spaces; an allotted length of time or number of sessions of lowered pricing for a certain number of clients; flexible scheduling (three sessions per month, every other week, etc.); charging less for shorter sessions; payment plans; pro bono sessions for a client or two; charging less for sessions during slow periods of the day; special arrangements based on special circumstances; a limited number of reduced-price scholarships; sliding scale; etc.
With so many callers asking about the lowest prices they have, now therapists feel even more to reduce prices because
While clinicians believe it’s important to offer sliding scale pricing only when a client is genuinely in financial need, unfortunately, when repeatedly asked about sliding scale or lower pricing, many end up undercharging, letting clients determine the fee, maxing out the number of low-cost clients their practices can accommodate, cutting prices below the minimum amount needed to keep their practice open, and feeling resentful or taken advantage of by clients they gave a lower price to and then discovered were spending large amounts on luxuries (new, high priced cars, jewelry, vacations, designer clothing; dining at pricey restaurants, etc.) after they’d claimed they couldn’t afford to pay for therapy and needed a lower session price.
Sliding scale, special arrangements, and lower prices upon request were never meant to be offered as options to those who had resources, could afford to pay the full price, and who, for other reasons, don’t want to or think they should.
It’s also not financially feasible for any private practitioner who wants to remain in business, to give a discount to every single client who wants to pay the lowest possible price for therapy—after all we need to keep our practices up and running, be able to cover practice and professional expenses, and support ourselves and our household.
Responding to callers and clients who are asking, but don’t really need or qualify for a lower therapy rate, is a very different type of conversation than the one clinicians trained for and are familiar with—people who genuinely have, a financial need.
As therapists, our task is to find the right balance of how, and how much, we can adjust session prices, for which clients, and how many—and not go out of business. In the current climate, navigating talking about prices with these clients takes more specialized skills and requires a totally different mindset, approach, and vocabulary.
So, what’s the best way to respond to a caller or current client who wants a price accommodation but doesn’t need one?
Money Talk: Words & Phrases to Consider
Let’s look at some of the words that can make a difference when a clinician talks, writes, or communicates about money matters involving sliding scale and adjusted pricing for those with limited income—and how and why these words can affect the amount a person is willing to consider or pay for therapy services.
This information applies equally to phone calls, face-to-face conversations in real time or virtually, emails, texts, social media postings, and what’s printed in marketing materials or written on a website. Yes, each of these words and phrases can have a direct effect on the perceived value of the services a therapist provides and the amount clients are willing to pay for the clinical services you provide.
As you read the following information, be sure to remember:
Now about that vocabulary . . .
As noted in Getting Paid: Talking Fees, Pricing, Prices The Words You Use to Talk to Clients About Money Matters in Therapy Do Make a Difference using fee, full fee, my, my fee, etc., currently seem to signal to those seeking therapy that any stated rate for clinical services is just a starting point. It’s automatically assumed therapists are open to requests and negotiating lower prices.
You’ll notice that the words listed aren’t used in this article—that’s why. To review alternate wording, click the link. Using some of these suggested words may eliminate a client who doesn’t need a sliding scale asking you about one.
1. Low, lowest, lower . . . Reduce, reduced . . . Discount, discounted . . .
Lowest price/prices/rates/amounts . . . reduced price/prices/pricing/rates/amounts . . . discounted price/prices/pricing/rates/amounts
Are the people who call us about our services seeking therapy or shopping for therapy?
In today’s world using any of the words listed seems to put people on the “I’m shopping” channel. Not exactly the best channel to be on to seek professional help for mental health issues or work, family and relationship problems, self-regulation skills, healing past traumas, addiction, recovery, anger management, parenting skills, growth, etc. It’s sometimes very easy for people to get mixed up about what type of professional help they need and what that costs.
Are people looking for a professional who’s trained and skilled in helping clients like them with their presenting issues? Or are they looking for the lowest possible price for counseling? How much is it necessary to pay? What difference does the price make?
These are all important questions for therapists to address when clients call about therapy and cost is discussed.
As mental health professionals who are highly skilled and experienced, we don’t want to add to any confusion, so it’s important we’re aware of the words we use when we talk or write about the price for therapy services so we don’t inadvertently encourage clients to shift into a shopping for the lowest price mindset or turn into a “therapy price shopper.”
Clinical services are valuable and worth paying for since stopping unhealthy behaviors, learning new skills, and how to take better care of yourself can save both money and time as well as help you take advantage of opportunities that make your life better.
How much does therapy save when you don’t get divorced, lose your job, get a DUI or???? When you compare the cost and benefit from what you receive then the price may seem worth paying—even if you must rearrange your budget, put it on a credit card, arrange a family loan or payment plan, etc.
Unless therapists are specializing in clients who only want to pay low, reduced or discounted prices for therapy services, in general, it’s best for those in private practice to use other words and not any variation of “low, reduce, discount” when referring to or stating pricing for therapy services.
2. Sliding Scale
When in conversation or writing, substituting one of the following words in place of “sliding scale,” price . . . rate . . . amount . . . pricing . . . cost . . . charge . . . along with adjust, adjusted, alternate, alternative, affordable, special, economy, helps clients understand, and cognitively register, that this isn’t the type of pricing range where a therapist will, upon request, “slide” all the way to zero, or some other very low price.
Adjusted price . . . economy rate . . . special pricing . . . cost adjustment . . . more affordable amount
Using this wording usually results in fewer requests and conversations from those not truly in financial need. With these words people, usually don’t just automatically try to negotiate to make a stated price lower.
Let’s look at this from another perspective . . . When you go to a doctor, attorney, dentist or other professional, do they use the term, sliding scale? Most likely these professionals use words like adjustment, introductory, limited time or another pricing term.
Clients are familiar with this wording. and when it’s used, don’t automatically assume that the price stated is open for negotiation to a lower one. Nor do they experience these definitive words as an invitation to ask for a discount or adjustment to a much lower number.
Now’s a good time to take a moment to think about and consider the words you are using with the people who call or clients who want to change the amount they pay, what you’ve read about this, and what your colleagues are saying about handling these things and if, and how, it’s working for them, and for you.
That’s enough for today on talking sliding scale pricing and getting paid. I hope you’ve found it useful to understand how the wording you use to talk about sliding scale pricing can increase or decrease the money you earn in your practice. See for yourself how the words you use can make a difference.
The next article, the fifth in the Getting Paid Series, covers sliding scale, part 2—specific suggestions about how to introduce and talk about your sliding scale, adjusted pricing and specialized alternatives.
Getting Paid: Talking About Sliding Scale Pricing—The Words You Use Do Make a Difference is the fourth article of the Getting Paid: Talking with Clients About Money Matters Series:
1. Talking with Clients About the Price & Value of Therapy
2. Talking Fees, Pricing, Prices—The Words You Use to Talk to Clients About Money Matters Do Make a Difference
3. Talking Pricing, Services, Rates—The Words You Use to Talk with Clients About Your Services and Rates Make a Difference
Getting Paid: Talking Pricing, Services, Rates—The Words You Use to Talk with Clients About Your Services and Rates Make a Difference
Talking with clients about therapy services, cost and payment, and the importance of making and keeping regular appointments is a vital part of therapy—and finding the right words to use professionally and clinically to convey the value of these services and the appropriate cost, time-frame, and involvement—is key to the success of every therapist’s private practice.
However, today many therapists are finding that they must spend significant time and energy to reset a client’s, or prospective client’s, expectations for therapy with regard to cost, frequency, duration, participation, and involvement in the therapy process.
As a result of these challenging money-driven clinical conversations, many therapists have reduced their rates significantly and are undercharging--and frequently being paid too little—for their therapeutic services. Yes, and, sadly, all too often, therapists are being persuaded to give their services away free.
This is the third article in a series on Getting Paid: Talking with Clients About Money Matters:
Unfortunately, it is a common misperception that charging as little as possible is the best strategy for attracting new clients and filling a practice.
However, undercharging and underearning seriously harm your business if you are mainly providing low cost offerings to clients—you and the work you do aren’t valued by these low-paying clients, you still need a lot of clients, and any new client makes very little difference to your income.
If you’re in private practice you have a responsibility to find clients who can pay your rates and keep you and your practice solvent so you can do the work you were meant to do instead of spending all your time and energy trying to keep you practice full.
The therapists I talk to are tired of undercharging and underearning.
Therapists want to work less, earn more, and make a bigger difference. More and more therapists are seeking out clinical and practice coaching so they can take charge of clinical money conversations and refocus them on the value, relief, and life/relationship/health changing/enhancing, conflict/anxiety/depression reducing benefits that clients are seeking from in person, face-to-face therapy work with a trained professional—and they charge more and are paid accordingly. Their income increases, they attract more clients, they fill their practice. Therapists deserve to earn a good living for the work they do.
The Wording You Use Can Make Difference in Your Income
As in any clinical endeavor, the words you use to describe your services do make a difference. In this case, the amount a client is willing to pay for therapy with a trained professional—and in order to receive the desired result/relief/outcome.
Yes, the meaning our words convey can either increase or decrease the amount of money we earn and are paid for therapy. You’ll find that people will pay in full and out of their own pocket for your services, when they believe you are the professional who can give them what they want—and the wording you use to describe your services conveys that.
Money Talk: Words & Phrases to Consider
Here are some examples of words that can make a difference in income when a clinician talks, writes, or communicates about therapy or money matters—and how and why these words can affect the perceived value, and subsequently, the amount a person is willing to pay for the therapy services provided as a clinician.
This information applies equally to face-to-face conversations in real time or virtually, to emails, texts, social media postings, and what’s printed in marketing materials or is on your website. Each one of these words and phrases can have a direct effect on the amount a client pays you for your clinical services.
As you read the following information, be sure to remember:
1. Help, Support, Advice, Listening, Guidance
Many therapists, clients, and lay people refer to therapy as: help, support, advice, listening, guidance, appointment, etc. When it comes to the amount of money a client is willing to pay for each of those ‘services,’ the perceived value and worth is low since these are things that non-professionals—friends, colleagues, neighbors, parents, siblings, support groups, online forums, etc.—can, and do, provide.
Exceptions to these would be: professional help/support/advice/guidance. These combinations have a higher perceived value of worth and price to clients.
Contrast the words: help, support, advice, etc., with the following ones that have a higher perceived value and worth: session, service, psychotherapy, counseling, treatment, recovery, consultation. Now combine them: psychotherapy session . . . therapy session . . . counseling session . . . psychotherapy services . . . therapy services . . . therapeutic services . . . professional services . . . depression treatment . . . anxiety treatment . . . bipolar treatment . . . trauma recovery . . . professional consultation . . . etc. These terms mean business. They are definite and professional. To clients they position you as a worthy professional who is both trained and capable of giving them what they want.
Other terms of higher perceived value that can be added when appropriate: licensed, certified, approved, supervised by, etc. Yes, clients will pay you more for your service when these words are added.
Here are two examples of lower perceived value wording: my services, services I provide. However, when you add other words to those two phrases you come out with higher perceived value: psychotherapeutic /psychotherapy services I provide. Add another certifier to that and you then have the highest perceived value: psychotherapy conducted by a licensed psychotherapist/clinician.
What word or terms do you, and your clients, prefer—or use—to talk about or describe the services you provide? Which would you or your clients pay a higher price for?
2. Ask, Get, Take, Accept, Charge
I ask $ . . . What I ask is $ . . . How much do you get for a session? I can take $ . . . The fee I accept is . . . I charge $ . . . What I charge is . . . What do you charge?
Are you asking or is it the cost? Are you asking or is it the price?
Be professional and definite: “The cost is . . ." not “What I ask is . . .”
State what the cost is for. “The charge/price/cost for/of the 60-minute session is . . .”
Here it’s important to remember that a client doesn’t “give you money,” a client pays for services rendered.
You have earned the money the client pays you. You’ve provided services to the client. In this case, services provided by a highly-trained professional—as therapists we have quite a bit of education, training, skills, and experience, not to mention licensure or supervision by a licensed person. Therapists deserve a fair rate of professional compensation.
Here are some alternative words and phrases to consider when stating the prices for the services you provide in your practice. Using these terms positions you and the services you offer as confident and of high value and worth:
The PRICE is . . . The COST is. . . The RATE is . . . The AMOUNT for that is . . .The session price is . . . the session cost is . . . the session rate is . . .The Price/Cost/Rate/Amount/Charge for that service is
Decide for yourself what fits you, your clients, and your practice best. Try a few of the phrases out. See what fits you best.
3. Free, discounted, reduced, lower
“No charge,” “no cost,” and “complimentary” are better wording for practice success than the word “free” which seems to mean to people that your services aren’t worth much and they should expect to receive all your services “for free,” all the time.
Discounted, discount, and reduced rate are popular words. Again, they are not the best for practice success as they train people to always ask for “a discount” or reduction.
A better choice in wording is “special” price/pricing or “introductory’ pricing, “a special offer” or even, “a limited time offer.” With these words and phrases, people associate your services as something of worth that are available at this pricing for a limited amount time.
Sometimes people ask if you have a “lower” fee or if you will “lower” the fee or even, “What’s your lowest fee?” Some better alternative words and phrases are an “adjusted” fee or “special pricing” or “professional courtesy” pricing or even “college student” pricing.
It’s important for mental health professionals as a profession to not train people to expect therapists to always reduce, discount, lower or charge the lowest fees just because a client wants but doesn’t need an adjusted fee.
It’s important that therapists, as a profession, maintain a reputation for being paid well for the good work they do—work that’s worth every dollar they’re paid. It’s not a good thing for therapists to be known for charging the lowest rates in town to anyone who asks even when they don’t need a price adjustment.
4. Fee Scale—Prices, Pricing, Rates, Fee Range
When talking numbers around the amounts you charge for your services, most therapists find it’s better received to refer to pricing, prices, and rates, as a “fee range” instead of a “fee scale.” Using the term “fee range” is associated with “a range of services and fees.” People seem to understand that concept easily. A fee range connotes choices and options whereas “fee scale” suggests some type of ranking or judgement.
That’s enough for today about money matters and getting paid. Next time we’ll address wording around sliding scale which is a whole topic in itself!
Getting Paid: Talking Fees, Pricing, Prices—The Words You Use to Talk to Clients About Money Matters in Therapy Do Make a Difference
Getting Paid: Talking Fees, Pricing, Prices—The Words You Use to Talk to Clients About Money Matter in Therapy, Do Make a Difference is the second article in the series on Getting Paid—Talking with Clients About Money. If you’d like to read more, here’s the first article: Getting Paid: Talking with Clients About the Price & Value of Therapy.
As a mental health professional, the words you use in money conversations matter to you, your clients, your colleagues, your employers, and to your therapy practice.
When communicating about money and therapy services it pays to pay attention to the language we use in our clinical role because the meaning our words convey can either increase or decrease the amount of money you are paid as a therapist.
Yes, the words and phrases you use truly contribute to the bottom line of your therapy practice.
Money Talk: Words & Phrases to Consider
Let’s look at some of the words that can make a difference when a clinician talks, writes, or communicates about therapy money matters—and how and why these words can affect the amount a person is willing to pay for the therapy services you provide as a clinician.
This information applies equally to face-to-face conversations in real time or virtually, to emails, texts, phone calls, social media postings, and what’s printed in marketing materials or is on your website.
Yes, each one of these words and phrases can have a direct effect on the perceived value of the services a therapist provides and the amount a client is willing to pay you for the clinical services you provide.
As you read the following information, be sure to remember:
1. My, Me, I, You, Your
My fee . . . I charge . . . What I ask is . . . What is your fee? How much do you charge? What do you charge?
Do clients pay you or do they pay for therapy services or the sessions you provide?
The fact is that most clients don’t really want to pay you. Clients want to pay for therapy or services or for the help and expertise that a therapist provides.
When therapists pair the words, “I, me, mine, you, your,” with fees and pricing it can make paying for therapy seem like a personal interaction instead of a professional one. Many clients will pay less or feel reluctant to pay for what seems like a personal transaction of caring and help.
When a therapist uses the words, “I charge,” people unconsciously think, “Ok, you charge that; how much do others charge?” Saying what you charge sounds like it’s arbitrary and negotiable. When clinicians use the term, “my fee,” the same principle applies.
Making one small change—using the word “the” in place of “my, me, mine, and I”—works surprisingly well to communicate a professional charge for services rendered.
The very personal and idiosyncratic “my fee” becomes “the fee.” “I charge,” becomes “the charge.” “Pay me” becomes “Paying for therapy or the session.” Which sounds more professional to you? Does “the fee” seem like it’s automatically open to adjustment?
Here are some alternatives:
The cost of the session is ___
The price of your session is ___
The charge for your session is ___
Using this type of focused clinical language activates the cognitive/thinking parts of the brain and helps a person operate from an integrated thinking, analyzing, and decision making mode instead of an “emotional” mode which is more feeling driven and can make these types of money matters conversations more personal, intense, and stressful for both therapist and client.
Therapists often use the word fee to address the amount of money that is charged for therapy services provided/delivered/rendered. However, the word "fee" seems to come with quite a bit of baggage for both clients and clinicians.
To most clients encountering the word “fee” in the context of therapy is synonymous with “fees are always negotiable” or that the number is meant to be adjusted to a lower amount.
Substituting one of the following words in place of “fee”—price, charge, cost, amount, or rate—helps clients cognitively understand and process that this number is the actual amount it costs and that they’re expected to pay for services. With these words people don’t usually react so reflexively to negotiating to make the amount lower.
Think about this . . . when you go to the doctor or dentist or other professional, do they usually use the word fee? Most likely they use words like charge, price or cost. Consumers are used to this type of pricing language and understand this is the number they must pay. People do not automatically associate these definitive words with the possibility of negotiation and adjustment to a lower number.
By using this type of consumer wording, therapists can bypass the client’s automatic reflexive perception and response to the therapist’s “fee” as a starting point for negotiating payment even when no fee adjustment is realistically needed.
As a result, of making this change in wording the clinician’s money conversations are usually shorter and the amount a client pays for therapy is usually higher but is still what the client can afford.
3. Full Fee
My full fee is . . . My regular fee is . . . The full fee is . . .
What actually does “full fee” mean? Is there a “partial fee?” Why do we as therapists say, “full fee?” Why don’t we as therapists just use fee or price or charge without the adjective?
Attaching the word “full” to the word “fee” with regard to therapy causes the client to wonder, think, entertain, ask or explore what the fee that isn’t "full" is—and then clients ask you about that other fee!
What a pickle for the therapist. As professionals, we don’t realize when we are inadvertently inviting discussion and negotiation about the amount of therapy payment when it’s not needed.
An alternative to using “my full fee” is to use more definite and clear language, such as “The price for a 50-minute session of therapy is . . . ” or “The charge for your therapy session is . . . ”
Decide for Yourself What Fits You, Your Clients, and Your Therapy Services Best
Confidently take charge of money conversations by using the aforementioned professional and clinical language suggestions and recommendations tailored to your client population and clinical practice. Focus on the value, cost, worth of the therapy service to the client and their life.
Remember to keep the language, wording, and focus of the clinical and professional money matters conversations on the client responsibility for payment for services needed, received and provided—not on what or how much the therapist gets or charges.
Allow the client to pay a fair price for the therapy benefits they receive from you.
That’s all for this article on getting paid and how the wording you use as a clinician to talk about money matters can increase or decrease the money you earn from your client work.
I hope you have found it to be useful, thought stimulating, supportive, and encouraging to your efforts to get paid what the therapy you provide is worth. See for yourself how the words you use can increase the amount of money you earn from your practice.
The next article, the third in the Getting Paid Series on money matters conversations, will address words to use to refer to the services you provide, to describe your prices and fee scale, and how to introduce and talk about your sliding scale.
Talking Fees, Pricing, Prices—The Words You Use to Talk to Clients About Money Matters Do Make a Difference is the second article of the Getting Paid: Talking with Clients About Money Matters Series:
1. Talking with Clients About the Price & Value of Therapy
2. Talking Fees, Pricing, Prices—The Words You Use to Talk to Clients About Money Matters Do Make a Difference
Lynne Azpeitia, LMFT
For 10+ years Lynne Azpeitia has helped therapists to live richer and happier lives through her workshops, private practice and career coaching, and her practice consultation groups which train, support, and coach licensed therapists, interns & students how to create and maintain a successful, thriving clinical practice and a profitable career