The Battle of Sustainability for Therapists vs. Accessibility for Clients

Do you remember the last time you had to turn a client away?  It was probably one of these scenarios: 

• you didn’t take their insurance

• they couldn’t afford your private pay rate

• your schedules didn’t line up

• you had no availability

• it just didn’t seem to be a good fit

Maybe you didn’t refer out but instead decided to lower your fee or agreed to see them outside your normal “office hours”. 

You might also find it difficult to say no to requests from current clients to reschedule or waive cancellation fees.  Then there’s the guilt for taking time off, even when you’re exhausted or getting sick. 

No matter what the reason, it can be extremely hard to turn a client away or potentially disappoint them in some way.  Sensitive Therapists have a lot of empathy and feel deeply for others which leaves us to struggle often with the conflict of sustainability and accessibility:

• Therapist Sustainability - a manageable weekly caseload that earns enough to cover expenses and leaves room for a vibrant personal life

• Client Accessibility - access to services consistently and within budget

When looked at as a duality, clinician sustainability versus client accessibility is a lose-lose situation.  Either the therapist prioritizes themself but feels guilty or the therapist prioritizes the client but feels resentful.  Then there’s the worst-case scenario where the therapist becomes burned out and unable to help ANY clients. 

What gets in the way of the therapist and the client both feeling supported?  Sometimes it’s a simple matter of the therapist expanding their referral network and doing some inner work to hold business boundaries around fees, scheduling, and clinical specialty.  This helps the potential client get referred to a great fit therapist or the existing client having boundaries modeled for them. 

Unfortunately, we’re also faced with a systemic problem due to lack of funding for mental health services plus low reimbursement rates and limitations by insurance companies.  Therefore this burden falls on the shoulders of the individual therapist.  Either the therapist in Community Mental Health who has weekly quotas to meet or the therapist in private practice trying to maintain a viable business.  In some communities, there may also be a lack of clinicians or few low-fee services.  

With the pandemic increasing need for care and potentially decreasing ability to afford services, the pressure on therapists to reduce fees and increase availability is greater than ever before.  

Client Demand is High, but Guilt is Higher 

While demand is high, the guilt of turning clients away is even higher for Sensitive Therapists.

Your empathy can become an Achilles heel when it comes to prioritizing long-term sustainability over short-term accessibility.  

In an effort to increase accessibility to care, you may end up taking on too many clients or working with clients who aren’t the right fit for your specialty/therapeutic style.  I completely understand this because it’s heartbreaking to say no to a client who either really wants to work with you or is struggling to find/afford services elsewhere.  

So what should you do when you need to see fewer clients or set boundaries around your availability in order to have a sustainable practice for the long term? 

Check-In with Yourself

Start by exploring WHY you’re feeling the pull to take on a client who may not be a good fit or stretch outside your frame for current clients.  Are there other therapists in your area that would be a good match? If yes, what’s getting in the way of referring this client along?  Do you have an internal narrative that you need to help everyone? Is there financial scarcity at play? Are you struggling to make referral connections? 

Build Your Referral Network

Having other therapists to refer to can take a significant amount of pressure off your shoulders plus you may make some new therapist friends.  With the rise of telehealth, you may be able to expand your referral network more than previously possible.  

• Find out who in your area (or state) has availability, offers a sliding scale, and sees clients within a similar niche. 

• Join local therapist Facebook groups, Meetups, or other professional communities. 

• Create a list of all the low-fee counseling centers in your area. 

Calculate Your Sliding Scale Range 

Instead of offering an unlimited number of sliding scale spots or none at all, identify how many appointments you can afford to reduce.

• For example, if you need to bring in $6,000 per month before taxes and you have 15 client appointments per week (60 per month), then you need to make $100 per appointment on average.  

• You can increase your full fee for those who can pay while being able to offer more sliding scale options, such as:  

  • 10 sessions at $120 each = $1200

  • 5 sessions at $60+ each= $300

  • 15 weekly sessions = $1500 per week ($6,000 per month)

Make Time Off a Consistent Part of Your Practice

The longer you go without a vacation, the higher the risk for burnout and the more difficult it can be for your clients to adjust to you being away.  It doesn’t have to be anything elaborate to be effective - a long weekend, a simple staycation, or a brief getaway can help you recharge.  However you spend the time away from your practice, just be sure to find a backup therapist and turn the out-of-office alert on in your email so you can truly relax! 

When it comes to balancing your needs with those of your current or potential clients, you’ll be faced with important questions: 

• Do I charge more per session and/or go off insurance panels to see fewer clients and prevent burnout? 

• Should I offer sliding scale rates?  How much can I afford to reduce my fees? 

• Is it okay to maintain boundaries around my schedule and refer clients out when our availability doesn't match? 

• Am I the right fit for this client or should I refer out to a therapist with a different specialty? 

• What’s the right amount of time to take away from my practice to recharge? 

• How can I honor my value of accessibility to help more people get access to my services? 

There are no right answers to any of these questions because only you know what’s right for your practice, energy levels, and financial needs.  Although you alone cannot solve the problem of mental health accessibility, you can make sure you maintain a sustainable practice so you can offer care for years to come while honoring your own needs.