Fee setting is often framed as a business decision. For therapists, however, it is also an ethical, relational, and systemic one. How we set, communicate, and work with fees touches into questions of access, value, power, and fairness, not only within the therapy room but also across the broader economic and cultural conditions we work within.

These questions are especially alive today as therapy becomes more visible online, more expensive to train in, and more entangled with global markets of care.

This post explores some of the tensions therapists face when navigating fees, particularly in relation to structural inequality and practitioner sustainability. It invites reflection on how we understand worth, care, and responsibility in a world shaped by economic disparity and the rising cost of professional practice.

Between Ethics and Sustainability

Most therapists are familiar with the ethical obligation to avoid financial exploitation. Professional codes require transparency, fairness, and respect for a client’s capacity to pay. Yet these principles are shaped by context.

Is it fair to charge £80 an hour in a country where the minimum wage is £10? What about charging the same amount to someone based in a lower-income region, where that fee might exceed the average weekly income?

Therapists are also asked to consider the sustainability of their work. Fees must support more than the hour spent in session. They must also cover the unpaid labour of preparation, notes, supervision, training, and administration. For those without financial security or external support, offering lower fees to everyone may not be viable.

These questions of fairness quickly meet the realities of unequal systems. What looks reasonable in one context may be exclusionary in another.

Access and Structural Inequality

The private therapy model assumes that those who need support can afford to pay for it. In reality, this excludes many. Public services are often overstretched. Community organisations face frequent cuts and instability. This creates a tiered system of mental health care, where access is shaped by income, location, and cultural fit.

Sliding scales are one attempt to meet this reality, but they carry limitations, particularly for practitioners who are themselves navigating precarity. Some offer reduced-fee or pro bono spaces, but the financial strain and emotional toll of offering reduced-fee work are often carried privately, without structural support.

Therapists in low-income economies face a different set of challenges. In countries where therapy is still emerging as a profession, fees may need to be very low to be accessible, while training, supervision, and resources are often priced internationally. This creates a significant imbalance.

The result is uneven terrain, where the ethics of care meet the economics of survival.

The Uneven Terrain of Cross-Border Work

Online therapy has expanded access and blurred geographical boundaries, while also raising complex questions about fairness, regulation, and economic disparity. A therapist in the UK might charge £80 an hour to a client living in a country where that sum equals a week’s wage. Licensing, taxation, and differing living costs make fairness difficult to define.

A therapist might also find themselves licensed in one country but working online with clients in another where legal frameworks differ or professional recognition is absent. The relational field extends beyond borders, but regulation has not caught up.

These cross-border dilemmas deserve closer attention and thoughtful discussion within the profession.

Beyond Individual Decisions

While much of the fee conversation focuses on personal choices, it is important to name the systems in which those choices are made. Personal decisions always sit within collective conditions of economy, culture, and professional structure. Without naming those, individual ethics risk becoming a form of quiet self-blame.

Therapists work within late capitalist economies where mental health is increasingly marketised and where care is shaped by consumer logic. These tensions show up in daily decisions about who can access support and how therapists sustain their work. Many therapists want to be generous and accessible and also need to earn a living. They want to offer continuity and depth while facing rising training costs, insurance premiums, and practice overheads.

These are not issues that can be resolved through individual conscience alone. Training institutions, professional bodies, and policymakers also carry responsibility. Training pathways could include discussions of economic access or offer subsidised supervision for early career practitioners. There is a role here for structural supports such as subsidised supervision, low-fee directories, collective sliding scales, and more equitable pricing models within the profession.

A Practice of Transparency and Care

Rather than avoid the discomfort, we may benefit from naming it. Fee setting is not just about numbers. It is about values, limits, and care. Being explicit about what informs our decisions, where we feel stretched, and how we are attempting to respond can build trust and reduce assumptions.

I have sat with clients who hesitated to continue because of cost, and I have felt that same hesitation inside myself when setting fees. It is a discomfort worth staying with.

In my own practice, I use a mixed approach. Each session includes a fixed base contribution to cover costs, with an invitation to add more if possible. It is not a requirement but a shared reflection on means and value. The approach is influenced by practices of mutual care and generosity found in various traditions.

It often becomes part of our first conversation, opening questions about value, agency, and what we expect from therapy and from one another. Some clients, especially those from corporate or coaching contexts, ask if this model is sustainable. My answer is yes. Over time, I have found that models grounded in trust and reciprocity often support continuity and sustainability.

This reflects a wider thread in my work, exploring how therapy can stay relational and grounded in context, even in its practical structures.

Questions to Sit With

These questions can support thoughtful reflection on the practical, ethical, and relational aspects of fee setting. They offer a way to stay focused on core considerations in the face of competing demands.

• • How do I define fairness when it comes to fees?
  • What role do I believe therapy should play in a wider system of care?
  • How do I hold my own needs alongside the needs of others?
  • What would collective or community-based responses to these dilemmas look like?

Returning to these questions over time supports clarity and consistency. They help us stay oriented when conditions shift and the balance between care and sustainability must be reconsidered. How we navigate these questions will shape not only who can access therapy, but what kind of care remains possible in a changing world.

Further Reading

• • The Market and the Mind: Mental Health in Neoliberal Times – Tehseen Noorani
  • The New Structural Social Work: Ideology, Theory, Practice – Bob Mullaly
  • Bringing Context into Therapy: How Social Class and Race Matter in Psychotherapy – Lisa A. Goodman et al