The Mentors’ Corner is a regularly featured column in the Independent Practitioner (IP) that highlights discussions from the MENTORS email group. In each issue of the IP, questions and answers pertinent to the Division 42 Student/Early Career Psychologist members will be addressed. If you are not signed on to the group, we encourage all members to participate and share in the stimulating discussions. The Division consists of members with a wealth of knowledge and expertise that should be shared with our new colleagues.

Note that the opinions expressed on the Mentors email group and within this column reflect individual perspectives and ideas only. As noted on the email group, there are more than one means to an end. This column is intended to highlight important topics and to generate additional areas of thought and insight for our members. - MG

Division 42 Mentor Program:
Division 42’s mentoring program, Colleague to Colleague, is up and running. Clearly, it is meeting a need present in the Division. We already have 12 pairs of mentors and mentees working together. If you are interested in being paired with a mentor to assist you with success in your practice or if you are willing to share your knowledge and expertise with a colleague please contact the coordinator of our mentoring program, Frank Froman, at frankf@adams.net.

Christine Szostak asked:

I had a student tonight send me a disturbing message and I am not sure how to deal with this. We were discussing sexual orientation, and many of my students were having difficulty with homosexuality. One particular student seems to have a lot of issues with it and I am really hoping to come up with a good way to deal with this. My hope is to correct this student’s misperceptions, biases, stereotyping, and discrimination. Any advice or information would be greatly appreciated.

Message follows:

I just wanted to share my opinion on the topic of sexual orientation. I am definitely against it and strongly believe there is no such a thing. However, I respect people that believe they have sexual orientations other than straight.

I believe that sexual orientation is a matter that you cannot decide on. If you are born a male or a female you have to be interested in the opposite sex. You cannot say, “I think I like the same sex better” because you do not have a choice.

If you have such an interest it might have some psychological reason, but it is a disorder and needs to be treated. Believing yourself to be attracted to same sex or being in a wrong body is as ridiculous as someone born in South Africa claiming that he is American or someone born in a middle class family claiming that he is a king or has come from Mars.

Today, in modern countries, homosexuality is becoming more popular. First, morality in societies is decreasing and people let themselves to do anything they want. Second, according to respecting rights of individuals, societies accept it (Which is an achievement for a culture that can tolerate such an odd thing, but it is still a misuse of freedom).

Also the fact that 10% of people believe that they are more attracted to the same sex doesn’t make it right. The only thing that it shows is that more people in modern countries have psychological problems and are not happy with their current situation. In the same way as your own statistic shows most of the suicidal cases are homosexuals.

Looking to these facts I wonder why you said (homosexuality) is not a disorder and it does not need therapy?

By the way these are only my beliefs. I don’t have enough education on this matter, so I would really appreciate if you could help me by sharing with me some references (mostly proving that homosexuality is not a disorder). I am willing to change my mind if I find something that makes more sense.

Alexander Imhaeuser responded:

Firstly, I would like to commend you for taking this issue seriously and bringing your concerns to the attention of the list.

The good news here is that the student is trusting enough [and I would let the student know that] to feed his understanding of homosexuality—no matter how distorted—back to you for a response. Also, the student appears inclined to discuss his/her opinions relatively openly, at least with you. I would certainly want to validate the student’s effort in formulating an opinion about this difficult subject.

To me, it would be important to point out that each of us holds morals and values regarding homosexuality, however this does not change the fact that sexual attraction/orientation to the same sex is not a matter of choice. The choice (or preference) is whether or not to come out of the closet. Moral judgments like your student’s weigh heavily on homosexuals—causing many to consider staying in the closet at a high emotional cost.

The likelihood of changing this student’s mind is slim, especially if he/she is fundamentally religiously oriented. If you can get a “moral” student to understand, however, that homosexuals don’t choose their orientation [like heterosexuals don’t choose theirs] but rather, are born with it/develop it as part of their sexual identity—like everyone else—than you have done your job.

Elizabeth Campbell commented:

I am struck by what a difficult but wonderful opportunity this is. The fact that this student has shared their opinion, yet also stated that they are open to evidence that challenges it and even asked for references supporting a different point of view, makes me wonder if they are really wanting some evidence that challenges their point of view. The request for evidence suggests openness to critical thinking, which is just what we want college students to do.

That being said, I completely agree with Alexander’s suggestion that this student’s willingness to be open and think critically should be commended. I also really like the idea of differentiating between choosing to be attracted to a certain sex vs. choosing to act upon that attraction behaviorally. The behavior is where many folks who have a problem with homosexuality are uncomfortable. Perhaps the place to start with this student is to make this distinction and then address the question not of whether acting on the attraction is okay (which might be too much for the student right now) but address the issue of whether the attraction is a choice.

I would strongly encourage you to identify some specific references for the student, especially since they requested this. Unfortunately, I don’t know of any off hand! I remember my husband sharing some really interesting research with me regarding the biological correlates of homosexuality—differences in finger length and things of that sort. On one listserv I am on (I can’t remember if it was this one) someone posted position statements from several different mental health/medical associations on treating homosexuality. Everyone said it was unethical, ineffective, and had a high potential to cause harm. Why? I assume it is based on research showing this.

The student raises the question of why so many homosexual persons commit suicide, suggesting this is evidence of psychological problems. I might point out to the student that the rate of depression and suicide is likely due to how people are treated because they are homosexual and the stigma around it, rather than because homosexuality is a psychological disorder.

Homosexuality was removed from the DSM many years ago and for a reason. Again, finding some specific research (maybe do a lit search on PsycInfo?) would be helpful.

Interestingly, this student has not provided any arguments as for WHY homosexuality is wrong, only that they have been told it is and that homosexuality and morality are linked.

I find that when people have their beliefs challenged they often search for exceptions that support their beliefs. In this case it might be an example of someone who dated the opposite sex in high school, then experimented with the same sex in college, and ends up married with 3 kids. Of course there are such examples, but if a student brings this up, I try to remind them that this doesn’t “disprove” the idea that homosexuality is biological. Research, which looks at the average across a group, suggests that in most (not ALL) cases it is not a choice.

Mitchell Hicks concludes:

I would only add one caution. It is not our job to change people’s morality. If this is what s/he believes on moral grounds, then that is what s/he believes. Certainly it is worthwhile to point out that the research suggests that both nature and nurture are involved in homosexuality, and regardless of the actual cause(s), those with sexual orientations other than heterosexual do not experience the attraction as a choice. Behavior, though, is always a choice.

That said, I would also suggest the “so what” question.  How do we then treat people?  Even if all s/he stated and believes were the complete truth, what implication does that have (if any) for how we treat people?

I think you can make a reasonable case that regardless of how sexual orientation develops most philosophical/religious/moral traditions can reasonably be interpreted as advocating being respectful, kind, and humane and otherwise not treating people who are different than you as monsters.  In this case, you are eliciting what his/her tradition says about it.

Dr. Shanyn Aysta asks:

I have a small, cash only private practice.  I want to offer a consistent sliding scale fee to clients.  I was wondering if anyone has a good sliding scale fee chart they use to determine what discount you will give clients. After going to an ethics seminar today, I learned that it is a good idea to have a chart you consistently follow (i.e., salary, # of dependents, debt and the amount of the discount).  Would anyone be willing to email me their chart or formula?

Henry Svec replies:

Why a sliding scale?  Why not charge full fee but do 10% probono?  I think that a sliding scale is a self esteem issue and nothing else.  I know of no other profession that promotes this type of idea.  Next time I take my car in for service I’ll ask them to adjust the bill based on my income last year.  Some agencies and private practices in our area charge .1% of income; if a client makes 60,000/year they would pay $60 per session.

Cynthia Arnold responds:

I completely and 100% concur. A sliding fee scale hurts all the other practitioners. If you can’t afford a doctor, you see a master’s level person, if you can’t afford that, you go to community mental health.

Steven Walfish adds:

I respectfully disagree. I have been in practice for 23 years and I can count on less than two hands when I have turned somebody away because of a fee (however, some are ruled out automatically because I don’t take Medicaid).

I see everybody (minus the 10 & Medicaid) that comes my way. If they can’t afford my full fee (and most can’t) I negotiate a reduced fee on an individual basis. I have always feared this would open the flood gates for all low fee clients. It never has. These lower fee clients often refer friends who do have insurance.  I make an excellent living (and have always made an excellent living minus build-up times when I moved and started a new practice) and I think my self-esteem is just fine.

The people that I have turned away typically want to pay a ridiculous amount given their income. I recall about 10-15 years ago a teacher who made 30k wanted to pay me $10-15.

I told her I would see her for $25. She said that was too much. I said, Sorry I won’t see you for less.

Dr. Clairessa Goad continues:

So Steve you see insurance patients too? I have had thoughts of re-initiating a private practice part-time, but fear the insurance hassles. I have thought instead of going that route, to work with clients individually to set a fee they can comfortable afford. I was not sure how realistic that was however. Please share your thoughts if you have more.

Steve Walfish replies:

I see clients who have insurance and those that do not. I am in full-time practice. I have considered at times dropping insurance. My last practice was in a working-class town, Everett, Washington. At least 98% of the clients in our practice needed/wanted to use insurance to pay for therapy. No way would I have gone without taking insurance. In my current practice in Atlanta I also do pre-surgical evaluations for gastric bypass surgery. The surgeons want me to make it possible for patients to use their insurance to pay for evaluations. There are hassles with authorization/collection but overall it is well worth it. However, I have a secretary that deals with the insurance companies and I don’t do this directly. That would be a MAJOR HASSLE.

Laurie Ferguson adds:

My 2 cents on the matter -- when my sliding scale fee for a given client was zero in a community mental health clinic, I had many patients simply not show up, perhaps because they felt that they didn’t “own” the therapy or it wasn’t “valuable” (we’ll leave my assuredly fabulous therapeutic skills out of this for the moment!). When paying even one dollar, the no-show rate improved. I agree with the writers who noted that most other professions don’t use a sliding scale and that it can hurt all mental health professionals. As much as I’d personally like to avoid it, a sliding scale might be necessary to have clients at all in some smaller, economically depressed areas. But, I would avoid pro bono work for psychotherapy, instead charging the client something, however small, in order to communicate that this is important work. Pro bono work would be less psychodynamically loaded if used when consulting to community groups, psychoeducational groups in the community, outreach work, etc.

Cynthia Arnold replies:

Again, I have to ask... how is it FAIR to decide what patients will pay. Does this mean that someone who works very, very hard and has $3-5 million (as a good number of our clients have) have to PAY FULL PRICE while our single parent teens DO NOT? It really seems like ‘sticking it” to the rich person. It seems like reverse...’moneyism”. I mean, if I went into a department store and they said, well, for you this shirt is $130, but for the lady who dropped out of grad school... it is $80....

This really baffles me.

Steven Walfish responds:

Fairness has nothing to do with it. This is capitalism. I own my own small business. I can decide what to charge or not to charge. If somebody doesn’t want to pay a certain fee they can go elsewhere. I have a client that is a defense attorney. He negotiates fees on every case. No standard fee. He says there is no BC/BS or Cigna that sets fees. Some people pay thousands for the same service that others pay hundreds for.

Chris Loftis adds:

Maybe it’s just more humane - Patients with serious and persistent mental illness are often poor and unable to maintain adequate employment and housing. I don’t think it’s humane, or fair, to tell them “go find a lower level provider” or “tough luck if you can’t afford me.” 

Carol Perlman responds:

One more thought to add to this interesting thread...

At a recent conference I attended, a speaker made the point that even in this economy, people DO have disposable income, and each person makes decisions about how to spend it. So, for example, you have the woman who makes 25K and says she can only pay $10 for her therapy session, but pays $200 every 6 weeks to get her hair cut and colored. So, using a simple formula of income and # of dependents may not be so helpful.

Ben Tilton replies:

Based on my own observations and behaviors, I would have to say that most psychologists I know error on the side of generosity with their clients, as opposed to greediness.  We have many ethical guidelines about how we should practice without exploiting clients.  For example, we cannot pay or compensate others for referrals, nor can we refer others with an expectation of “kick-backs”.  We cannot treat co-workers, our significant others’ co-workers, or most people we interact with on a daily basis.  So, our business is very different from other ones.  It’s amazing that psychologists manage to stay in business with all of the necessary and important guidelines to which we adhere! 

If anything, I believe that we do not place enough emphasis on how valuable our services are to others.  How much is it worth to get out of a depression?  How much is it worth to feel free for the first time of your life?  How much is your self-esteem worth?  Your general sense of happiness or well-being?  How much would you be willing to pay to have noticeable and lasting positive changes in your life?

Bob Resnick adds:

Some thoughts from a long time practitioner:

Sliding scale fees may not just benefit the client - they may also benefit the therapist, the profession and the community. 

Two personal motivations for my having a sliding scale:

1. It’s a way of giving back – not to those that gave to you, but to the next generation of therapists and clients.
2. It’s a way of staying in touch with the real world, with the issues real people from all walks of life deal with.  By restricting a practice to only those who can afford to pay full fee, you soon (after some years) lose touch with the lives of students, blue collar workers, single moms, older people, young professionals in debt (know any of those?), etc.  It is crucial, as a therapist to stay in touch with the world to remain relevant.

Joan Huebl replies:

This is an interesting discussion, if someone spends $200 every six weeks on his/her appearance but can’t afford $30+/week for therapy; I think we have a good idea about what is valued.  In the US, at least here in CO, one doesn’t go into a Safeway store and bargain about the price of milk or Ben and Jerry’s, and we certainly don’t go to the local hospital and bargain over the price of angioplasty.  We find money for the things we want, need, and/or value.

So isn’t the discussion we have with our potential patients’ one about the value of psychological services?  If we can engage people in this discussion, explicitly selling the value of our services, I think we can arrive at a price that both parties will agree is fair.  We can always make adjustments when someone falls on hard times, but all of that has to be a negotiation with our focus on helping the patient see the value of his/her therapy and asking the question then, what is your mental health worth to you?  As that credit card commercial says, “price of 1 session $100, price of mental health priceless.”  We, of course, have to believe that!

Guerda Nicolas concludes:

I used to have a part-time practice until recently and have appreciated the conversation about sliding fee scale.  Here are my own reflections on our conversation on the subject thus far.  Although I agree that we need to think about the therapeutic aspect of having a sliding fee scale and the ways that this is communicated with clients, I am concerned that we are making certain assumptions about the “type of clients” that such a service should be offered to, as well as the facilities where “doctors” and expert and effective service providers are found.  Although, I am aware of the business aspect of the work, I want to caution that we do not loose sight of the humanity aspect of our field and the need for us to develop effective therapeutic relationships that will lead to healing for all clients!

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