This paper discusses money-related-issues that may arise when working with fee-paying patients in psychotherapy.
I address the following:
• the idea that the monetary issues in therapy are sometimes used as means of communication from the patient as much as words are
• the approach of addressing monetary issues as a clinical material
• the nature of monetary issues
• various ways of addressing monetary issues
• monetary issues in relation to the duration of the therapy process
• monetary issues in relation to the patient’s level of mental health
• monetary issues and the method of fee-payment
• monetary issues in relation to the concept of counter-transference
• monetary issues in relation to psychotherapy as the “helping profession”
• discussion of case material
The paper does not address any specific issues the therapists themselves may have around money. However, the basic principles discussed are thought to be universal, i.e. applicable to any person and any situation. For the clarity of argument the topic is discussed from a standpoint where the patient contributes the therapeutic material and the therapist remains a neutral analyst of that material.
All patients’ names used in this paper are fictional.
Communication as Energy and the Psychotherapy Frame
The Psychotherapy frame
The psychotherapy “frame” is a set of conditions typically associated with the practice of therapy and agreed upon by the patient. E.g. patients are provided consultation under the following conditions:
• at the location of the therapist’s consultation room;
• at a previously-agreed time schedule;
• for a duration of 50 minutes;
• for which they pay a certain amount of money;
• payable at the time of the appointment;
Any variation exerted by the patient and not previously discussed with the therapist can be considered to be an influence on the frame. For example, the patient turns up at the therapist’s office at a time different to the agreed time, unannounced, and wants the therapist to take him in. As such, this action can be interpreted as a form of “communication” from the patient, but a form different to that used during the therapy session.
One of the major areas of the psychotherapy frame that can get influenced by the patients’ communication outside the therapy session is the area of the frame related to money.
• fee-amount (the $ amount the patient pays for the therapy session)
• time of payment (before the session, immediately after, beginning of the month, etc.)
• payment method (cash, cheque, internet bank payment, etc.)
• fee-subsidy (weather the patient pays the “market price”, only a part of it, or none at all)
• therapist’s cancellations policy and holidays policy (the details around the payment for these situations)
• specific requests from patients to deviate from the usual arrangement the therapist works by (in any of the above) or a rigid insistence from the patient on carrying forward a former arrangement despite the change in relevant circumstances
Other areas of the frame that can get influenced are for example issues around the time (time of the appointment, the duration, frequency of sessions, etc), policy around the phone-calls, etc. The issues related to these other areas of the frame are not discussed in this paper.
Communication as Energy
Science of physics suggests that all creation we perceive is essentially energy. All energy is fundamentally just one and the same. However, energy can be manifested in various ways. Some forms of energy are directly visible while others can only be seen indirectly through the manifestations they produce. Energy can be transmuted from one form to the other but its sum total stays the same – i.e. no portion of energy can disappear altogether.
If this definition is adopted and translated to the psychotherapy situation, it can be said that any communication in therapy is also an exchange of energy. The use of the verbal/paraverbal/nonverbal communication can be interpreted as a directly perceivable form of energy while the meaning of that communication can be gathered only indirectly through the manifestations (thoughts, feelings, sensations, etc.) that that communication evokes in the therapist (i.e. the counter-transference).
Communication in psychotherapy is largely about the verbal/paraverbal/nonverbal communication during the therapy hour but not entirely so. As the “sum total” of the communication is always the same it follows that whatever pressing psychic energy the patient presents can’t be communicated during the therapy hour in view of it being transmuted into a healthier way of being is going to have to be communicated elsewhere and through other means.
When thinking about psychotherapy, this “elsewhere” is the psychotherapy frame and these “other means” include any money-related issues.
While a portion of any monetary exchange can be directly perceived (and can also be called “objective”), there is also a portion of that communication that can be only indirectly perceived if the therapist investigates the meaning of that particular monetary situation. E.g. a patient usually pays for his sessions by cash but on occasion he uses cheques. While the objective difference is directly perceivable, the possible meaning for this patient doing so can be gathered only indirectly. One of the tools available for investigation of the monetary issues is the counter-transference.
Mindfulness of the Psychotherapy Frame
In psychotherapy, patients bring their psychic energy in a particular psychodynamic form being played out in the patient-therapist field. It is in that field that the patient can more fully re-experience and re-evaluate the past events of their life as well as of their current situation. Any life situation or event can subjectively (emotionally) be experienced either as positive or negative for us, or we can have an emotionally non-charged (neutral) stance towards it. Patients seeking psychotherapy often have inner conflicts in that they perceive one and the same situation as both positive and negative. Through the process of therapy, such previously conflicting situations can eventually be perceived as neither negative nor positive for the patient but rather in an emotionally non-charged (i.e. neutral) way. In terms of energy, we can say that one form of energy has been transmuted into other, which we call healthier.
In an ideal psychotherapy situation the conflicting experiences would be brought forward by the patient within the therapy hour only and through using only words. However, as these conflicts are integral to the patients’ way of being and are a part of their everyday behaviour those conflicts are likely to have influence on the therapy process outside of the therapy session, i.e. on the therapy frame.
The more the psychic conflicts are being exhibited outside the consultation room (i.e. outside of the immediate reach of the appropriate clinical examination and interpretation by the therapist) the lower the chances for the patient to resolve their conflicting experiences. Conversely, a thorough attention to the psychotherapy frame ensures maximum benefits to the patient from the therapy. Monetary issues being a major area of the psychotherapy frame it follows that all such issues need be carefully and thoroughly explored.
Mindfulness of the existence and the importance of addressing any money-related-issues at the psychotherapy frame sets a necessary frame-work for a successful therapeutic outcome.
Instrumental and non-instrumental monetary issues
All monetary issues arising during the course of therapy can be categorized as either:
– being essentially an unconscious attempt on the patient’s part to achieve a sense of control over the therapy process through the manipulation of the monetary arrangements currently in place, or
– being a product only of the changed relevant circumstances
Even a simple, superficial, ordinary request may well be an attempt at (unconscious) communication from the patient and this can only be determined through an analysis of that communication.
In the course of any therapy and for any practitioner it is possible to come across a situation where the patient may feel a certain relevant issue hasn’t been paid enough attention. Depending on how important such an issue is to the patient it can be expected that the unprocessed situation might get exerted (acted out) through an unexpected issue arising in regards to monetary arrangements. This would be a case of a monetary issue in its instrumental form.
Clinical approach to monetary issues
Case by Case Approach
When exploring monetary issues the therapist can use the same “case by case” approach that would be used when treating other clinical material. All monetary issues can be looked at as being patient-specific and also situation-specific. If it is found than an issue can be classified as “instrumental” then that also means that that issue holds a specific subjective meaning for the patient and as such can be interpreted as a part of the patient’s problem that the treatment was sought for.
What follows below is a hypothetical example of a monetary issue arising in the course of therapy.
Case study – Danielle
Part of Danielle’s presenting issue is the resentment she feels over how much others seem to expect from her. She feels worn down by the demands of others but she never finds the courage to tell those “others” anything about it as she thinks her problem is only about her “not being clever enough” to deal with the demands in a better way.
When first enquiring about the therapist’s fee, Danielle says to the therapist: “Your fee is all right, that kind of money is not an issue”. She agrees to pay through the therapist’s office administrator immediately after each session. However, in the course of therapy, she is often late with her payments and has to be frequently reminded of missed payments. To these reminders from the therapist she replies: “Oh, sorry, I do always have the money with me, that’s not the problem, it’s only that I sometimes simply forget to pay. But I do pay you eventually.”
The therapist doesn’t explore the issue of late payments thinking the therapy is otherwise going well and the fact that Danielle sometimes forgets to pay for the session doesn’t matter that much. The therapist is also aware that Danielle often feels “pushed for performance” to a certain standard and can never relax because of it so the therapist doesn’t want to add to her burden by demanding that she follows the payment policy 100%.
As the time goes on and Danielle continues to forget her payments despite the therapist’s reminders, the therapist starts to feel annoyed about the situation. Danielle now sometimes misses a few payments in a row. However, the therapist doesn’t say anything, again not wanting to upset the course of therapy that is in his mind going quite well. He also feels it’s now too late to be bringing the issue up again as Danielle seems to have settled into eventually paying her debt and is never more that two to three sessions late in her payments. He decides he just needs to further tolerate the late payments.
Danielle is now doing quite well personally, she says, and it seems she resolved the presenting conflicts to a satisfying degree and is ready to leave her therapy. She plans to pay the four outstanding (“forgotten”) payments just after her last session. However, she forgets to do so and the therapist has to call her to remind her of the money she owes him. The situation continues for weeks with repeated phone calls from the therapist. Danielle eventually sends a cheque in but for three sessions only. The therapist can no longer be bothered chasing Danielle and decides to let go of the last payment she owes him. However, in the coming weeks and months he often remembers Danielle and the issue of the last payment.
The therapist replies to Danielle:”I appreciate that you’re not late with your payments on purpose, but I would like us to look into the issue nonetheless. My impression is that you might be having difficulties remunerating my work the way we agreed. I’m wondering if that might be because you’re not that happy with your therapy, maybe you expected more from it or maybe you think I am not providing a very good service, maybe I’m missing the point of the things you tell me, or something like that.”
Danielle: “No, nothing like that… that I can think of… But it can be a hard work sitting here for an hour.”
Therapist: “What do you mean?”
Danielle: “Well, I often leave here feeling like I’ve worked very hard, like I’ve been catching up with something. Maybe I’m not clever enough for this.”
Therapist: “It sounds like you might need more time in the sessions to think about things we discuss before you may be ready to move on to the next thing.”
Danielle: “Yeah, I don’t think I always get your comments but I just move on.”
Therapist: “So, maybe your late payments might be related to this in that the late payments might be representing your resentment over how fast things are happening in therapy.”
Danielle: “Hm, never thought of it that way… but I guess it’s possible.”
As a result of this conversation Danielle realizes how often in her life she doesn’t take enough time before making decisions but all too easily goes along with what she perceives is the expectation of her environment – just like she was perceiving that her therapist wanted her to move through the issues quickly, not take the time she needed to think about the issues to a more satisfying level. In return, she does however get the praise from that same environment, a praise that she craves as means of alleviating her feelings of “not being clever enough”.
In the above example the monetary issue is used by the patient (in an unconscious way) as means of communicating to the therapist that not everything is well with the therapy process.
When the therapist in the “Scenario A” doesn’t recognize Danielle’s need to have enough time in the sessions to work through the issues herself (without hastily moving on) and then further ignores addressing the issues of the late payments, Danielle is likely to leave therapy not fully addressing or understanding the underlying issues of her presenting conflict. This could happen despite the therapy sessions seemingly going fine.
In other words, in the “Scenario A”, the therapist is contributing to the re-enactment of the patient’s conflictual situation.
It may be worth stressing here that not all is lost if the presented psychic conflict gets partly re-enacted with the therapist through a monetary issue. Sensitive attendance to any monetary communication and the appropriate use of interpretation (as in the “Scenario B” above) even if addressed long after it has (first) occurred can get things back on track and promote development of trust from the patient.
Ways of addressing monetary issues
Generally speaking, issues around money are very sensitive for any patient. It is therefore important to address those issues in a way that is appropriate to the situation and the patient.
Monetary issues can be addressed in three different ways:
In certain situations it might be too destructive for the therapy process to explore the monetary dynamic with the patient. However, that dynamic can be analysed through reflection or supervision and the findings may be presented to the patient in a form of an appropriate request.
Such an intervention is warranted when an assessment is made that:
a) there is not enough emotional maturity in the patient to be able to take the interpretation as only a possibility, but that the patient would likely take the interpretation to be a fact and/or a judgement about herself
b) the patient’s Self-strength isn’t sufficient for any two-way exploration with the therapist
A contra-indication would be that the patient would experience an interpretation as an intrusion.
In the above case example, the therapist may simply say to Danielle that he is not completely comfortable not being sure if she is going to remember to pay after the session and would like her to start paying just before the session, and also that the session could start only once the fee has been paid. If Danielle still forgets to pay, she can do so by using the time out of the (beginning) of the session, so the issue is still contained within the session hour even though it is not discussed about. While possibly at first the patient may be at odds about such a request, eventually the patient is likely to appreciate the therapist’s openness about wanting the initial agreement to be honoured and likely to appreciate the therapist’s firmness around that policy.
In time, the patient may be in a position to talk about the money-issue with the therapist in terms of its meaning.
In certain other situations it may be best to only make an interpretation of the situation, but without forcing a further conversation and also without making any requests for a behavioural change. E.g. the therapist may say to Danielle: “Being late with payments can sometimes indicate that the patient may be a bit resentful of the therapy or of the therapist. I’m not sure if that is the case with you, though.”
Such an intervention is warranted when an assessment is made that:
c) there is enough emotional maturity in the patient to be able to take the suggestion as only a possibility, not a fact and/or a judgement about herself
d) the patient’s Self-strength is not sufficient for further two-way exploration with the therapist
A contra-indication for this approach would be that the patient would have a negative response if she was presented only with a request for a different behaviour with no explanation given about the psychological meaning of that request, and that she would also have a negative response if challenged to make comments on the therapist’s interpretation.
In time the patient may be able to more comfortably contribute her thoughts about the given interpretation.
Finally, there are situations when it is absolutely necessary to “work in the relationship” and addressing monetary questions through exploration and interpretation with the patient of what they might mean for the patient-therapist relationship equals good therapeutic work. Such is the above “Scenario B” in case of Danielle.
Such an intervention is warranted when an assessment is made that:
e) there is enough emotional maturity in the patient to be able to take the suggestion as only a possibility, not a fact and/or a judgement about herself
f) the patient’s Self-strength is sufficient for a two-way exploration with the therapist
In this instance a contra-indication would be that making single-sided requests without the accompanying exploration/interpretation and without making room for the patient’s thoughts about it may promote feelings of mistrust and so be detrimental to the therapy process.
Financial arrangements and therapy process duration
With long-term therapy, a patient’s financial circumstances may change over time, for better or worse. The circumstances may change as a result of: loss of a job, new employment, marriage break-up, moving in with a new partner, pregnancy, etc. As a consequence a patient may start behaving differently in regards to his/her payment arrangements and change his/her views on the therapist’s monetary policies.
Because a change in external financial circumstances can be interpreted as an objective change, this may take the therapist’s mind away from the concept of the instrumentality of monetary issues. However, the instrumentality is intrinsically linked only to the perceived meaning of the changed financial circumstances, so it is only through the exploration of that meaning that these “objective” changes can be fully appreciated in terms of their possible influence on the therapy process.
In the view of pre-empting any possible influences on the therapeutic frame due to the changed financial circumstances, the meaning of any such change can be explored as soon as it is learnt about.
Three months into the therapy, Brenda is excited about the marriage proposal she got, especially as her presenting problem is a history of unsuccessful intimate relationships. She talks of a rather large “perfect” celebration she wants to throw to mark the occasion. The therapist is a little envious that Brenda wants to spend all her savings on the celebration but doesn’t think much of it. A few months later, after being married for a while, Brenda asks the therapist to change his cancellation policy as, as she explains, she has an unemployed husband now to take care of financially and she can no longer afford to pay for missed appointments (as per the previous arrangement). The appointments she misses only occasionally and only due to her busy and sometimes unpredictable work-schedule. The therapist sees this as a legitimate and understandable request due to Brenda’s changed financial circumstances and agrees to alter his cancellation policy without any discussion.
Not addressing the meaning of a change in patient’s financial circumstances and its implications for therapy carries a risk of the therapist being collusive with the patient’s unhealthy traits. In the case of Brenda the therapist may be colluding with her expectation that being married is going to be only an all-exciting experience. As he agrees to alter his cancellation policy it “helps” prolong Brenda’s unrealistic expectation. Her request may be seen as instrumental but the therapist doesn’t recognize it that way.
In another scenario, John is facing redundancy in three months’ time and says financially he may not be able to continue his weekly therapy before he can find a new job. The therapist experiences John as quite resourceful person who should not have problems eventually finding a new job and knows him as financially wealthy so rather than attributing his attitude only to the change in external circumstances the therapist interprets John’s intention to temporarily quit therapy as possibly an issue of shame of being unemployed. John replies that that may well be the case as he indeed thinks of himself as useless unless he’s very busy in a job. As they continue to talk about it in the coming weeks John becomes able to stay calmer with his feeling of shame rather than rushing into an activity attempting to mask that feeling, thus allowing more time to realistically explore his options for future employment. He recalls now how when changing jobs in the past he would jump to the first vacancy without thinking of its suitability and would often end up dissatisfied with his position. In the coming months John goes through a period of unemployment but then finds a job that suits him much better than any other he’s ever had before.
Appropriate exploration of a patient’s changed attitude due to the new financial situation promotes an understanding that a changed financial situation has an impact on person’s life only through that person’s perceived meaning of the new financial situation. In other words, the new financial situation only carries a potential for a change in the patient’s inner experience, but the direction or the extent of that change is not determined by the external event. Through addressing the change in financial circumstances in psychological terms, the patient is likely to feel empowered not to feel controlled by the external financial circumstances but to make the best possible use of the financial resources available to him/her.
Financial issues and the level of mental health
The more disturbed the patient the more destructive his/her inner conflicts (or, the stronger the identification with those conflicts). More disturbed patients are more likely to use not just words but also the issues around money as means of communicating their inner reality.
So, the more emotionally disturbed the patient the grater the chance a monetary issue may become a problem for the therapy, and also, the greater the chance that the patient may not be able to constructively talk about the issue with the therapist. This is however a matter only of a form of presentation the therapists uses for their communication (as discussed in “Ways of addressing monetary issues” chapter above).
Healthier patients have a greater level of separation from the inner conflicts and can think about them more easily without strong identifications. So, they can communicate their problems through words to a satisfactory level and therefore do not need as much to use the money-related-issues as an additional way of communicating their inner reality. These individuals are generally speaking more relaxed when it comes to discussing money.
However, any monetary dynamic to do with any patient at any time (regardless of their level of mental health) is worth addressing since the potential for unconscious communication through the money-related-issues is always there.
Again, as discussed above, sometimes the situation calls for only a management, sometimes for only an interpretation, and sometimes for an exploration of the issue.
Monetary issues and the method of fee-payment
There are different ways in which the patients may be paying for psychotherapy.
The most direct way to make payments is when the patient pays the therapist directly.
In some settings the payments are made through the therapist’s receptionist/administrator, and sometimes the therapy is paid for by the patient’s relative or a partner. In both instances, a third person is brought into the equation. The involvement of a third party complicates the situation and makes any instrumental use of money more difficult to detect and to address.
For the therapists working in an organisation the patients may be paying into the account of that organisation and the therapist is then paid wages for his/her work. Apart from that “organisation” becoming the “third party”, this situation also makes any monetary-issues that much more remote from the relationship between the patient and the therapist and therefore even more difficult to detect and address.
If an agency has a stringent policy around payments that does not necessarily mean that there would be no communication happening through means of money. In fact, that stringent policy may become a blind-spot for the communication between the therapist and the patient and the monetary issues may not be explored and discussed since they cannot be changed.
In case the payments are made directly to the therapist there can be different means of that payment. The most immediate way would be a payment by cash at the time of the appointment. Any other means of payment (such as using a cheque, eftpos, internet banking, etc.) again brings a “third party” into the equation to a degree.
Deferred payments or payments made in advance complicate things as well.
Initial discomfort of addressing financial arrangements
Psychotherapy is often, at least in the public’s eye, regarded as a service. As such, it is natural for any patient to think of money in its pragmatic form only. For a patient the question is often (at least initially) as simple as this: “The therapist provides the service, the market dictates the cost, and the patient exchanges money for the service received.” So, when exploring financial issues with the patients they may often at first be surprised at what that has to do with their therapy. They can sometimes get annoyed with the therapist for spending their valuable time discussing “irrelevant things”. The discomfort may particularly become visible when discussing cancellation and holidays policy i.e. when in a patient’s eye there is no “service provision”. However, in time the patients usually come to acknowledge their appreciation for the therapist’s thoroughness in addressing all presented issues, including any monetary issue.
This initial discomfort or surprise is not to be confused with a reaction from a patient who is at his/her present level of mental health unable to constructively discuss monetary issues (as discussed in the chapter about the level of mental health).
Monetary issues and Counter-transference
One way to address monetary issues is through the observation and use of counter-transference. Here, I refer to counter-transference in its broad definition – all perception, feelings, thoughts, etc, the therapist experiences with regards to a patient. More specifically of interest is any counter-transference the therapist experiences related to the monetary issue at hand.
In case of Danielle, in the “Scenario A” the therapist starts to feel annoyed at her repeated forgetfulness to pay for her sessions but chooses to ignore that response as being outside the therapy process. I.e. he ignores counter-transference related to the presented monetary issue as within the therapy hour everything seems to be going well. This eventually leads to somewhat negative outcome for both the patient and the therapist.
In the “Scenario B” the therapist however takes his annoyance to mean that possibly not everything is going well in therapy and initiates the exploration of the monetary issue with Danielle. This leads to a more positive outcome for both of them.
Counter-transference can be particularly useful in situations where there may be a societal expectation on the reaction to a given situation. In case of Brenda, it may be considered quite appropriate for her to feel nothing but excitement over getting married and wanting to celebrate as much as possible. However, the therapist also felt some envy of her patient spending her savings on the celebration but did not address that counter-transference. Had he done so he may have initiated a conversation that could have helped Brenda be more mindful of her expectations on what a married life might be like thus helping her reach a more realistic position on spending her savings.
In case of John the therapist has used his knowledge of the patient (and this “knowledge” can be viewed as the counter-transference) to assess weather John’s idea of quitting therapy due to redundancy would or would not be instrumental act.
The existence of counter-transference related to monetary issues is in essence a message to the therapist that he/she is missing something in the patient’s communication, i.e. that the therapy itself is not going as well as it could.
As shown above, that very counter-transference can be the right starting point in addressing the presented money issue. The “objective” particulars around any monetary issue can be left aside for the time being, while the underlying dynamic is being explored. Once all of the patient’s relevant inner reality is addressed, the particulars of the financial arrangements can be brought back into the picture. With more clarity about the meaning of the presented monetary issue, it is now possible to make the appropriate new financial arrangements (if they need to be changed at all).
Psychotherapy – the “helping profession”
One specific question around money and psychotherapy is related to the issue of psychotherapy being publicly perceived as the “helping profession”. There is a particular potential problem here and it refers to the situation where a patient may take the word “help” to mean that psychotherapy has to be easily affordable. Candidate-patients may sometimes place requests on the therapist to lower the fee to a level that’s acceptable to the patient.
Such requests can also happen later in therapy. E.g. a patient who had received inheritance and put aside the money for 6 months therapy as he had never thought he might need more time than that is at the expiry of that period in a situation where the therapy is no longer as easily affordable and so he wants the therapist to lower the fee so he (the patient) can continue the therapy.
While it is not suggested that there should be no room for negotiation over the fees or that the adjustments may not be needed in particular situations, in general it may be better to exercise caution whenever such a request is encountered. What has to be taken care of here, again, is the question weather the request from the patient may be an instrument of (unconscious) manipulation, the patient “fishing” to see how “soft” or “hard” the therapist may be.
It is difficult to imagine one could always immediately know what may be at stake with a particular request and have an immediate appropriate response, so it may be necessary to take some time to explore the request first and respond to it later. The exception is a situation where the therapeutic work is at a stage where the issue can be addressed “then and there” with the patient.
A particular new financial arrangement may or may not need to follow. Sometimes, a significant part of the therapeutic work can actually be done while negotiating fees. If the negotiation of the fee is stretched over a few sessions (along side other work) and the patient then decides that the terms are not acceptable to him or her and leaves the therapy, that time spent may be of higher quality than if the therapist would immediately agree to a lower fee without any discussion – in the view that the patient is going to stay in therapy for a longer time and therefore benefit more from it. Number of sessions alone does not determine the extent of help provided to the patient.
It is possible that a patient may find the therapist’s financial policy unacceptable from the very first session and may not be willing or able to talk about it in terms of its meaning at all. This would be a rare case, though, as patients usually show signs of appreciation for the therapist taking care and time to analyse the issue before agreeing to anything. Such attitude of care from the therapist models to the patient that it is both possible and all right to value oneself and plainly communicate that position to the other person even in the face of the fact that the situation may not work out for either party (if they are not able to reach a working-agreement).
Case study – Joanna
I was seeing Joanna in an environment where the patients pay for their sessions through the office reception and the therapist does not have an immediate involvement with the payments. The general payment policy was to “pay at the time of the appointment” but the therapists had some discretion over this policy. As a rule, the receptionist doesn’t question patients’ payments under the assumption that they are negotiated with the therapist and ultimately the therapist’s and not the receptionist’s responsibility. This is also supposed to reduce the involvement of a “third party” to a minimum.
At one point in therapy, without my knowledge, Joanna started paying for her three-times-a-week sessions a week in advance. When I learnt about it (through the receptionist) I asked the patient about it and she explained that it was for the “reasons of convenience ” only. I didn’t explore the issue any further.
At a later day, again at first unknown to me, she decided that now she would be paying for all three sessions only at the end of the week.
As I learnt about it (again through the receptionist), this sudden change in the payment habit intrigued me and I decided to talk to my patient about it. It turned out that there was a particular meaning to Joanna’s actions that was a lot deeper than just the “convenience” as it seemed at a first glance.
In the first instance – while she was paying a week in advance – she did so because she was at the time feeling quite vulnerable and needed the sessions to help her through the week. She also worried I could become unavailable to her and by paying in advance she in her mind attempted to secure my presence and availability.
However, later on in therapy, and at a point when Joanna felt I kept missing the meaning of something important that she had been telling me about, she decided my work wasn’t any longer worth as much as it used to be and paying at the end of the week was a sign of her being disgruntled with my performance. Paying late was means of devaluing therapy. Paying at the end of the week also gave Joanna an option of leaving the therapy at the end of a week without paying at all for the last three sessions and this was giving her a sense of control / power over the therapy.
So, after having worked through this seemingly superficial issue of paying for Joanna’s three-a-week sessions in advance or afterwards, and in conjunction with our previous work, she was able to better understand her need to control her environment in an attempt to have her needs met.
The issues of trust became more transparent and could be talked about in therapy and since that time Joanna became more able to stay in touch with previously avoided feelings of abandonment and hurt. She again started paying her sessions one-at-a-time.
However, for some time on, she at times felt she wanted to pay the session in advance and sometimes only afterwards. She was however open about this and initialised the talk about it herself. She wasn’t any longer hiding her payment behaviour. To both of us this clearly indicated whether she was feeling more optimistic or pessimistic about her sessions and the process of therapy.
At this point I thought there was enough clarity about what was happening in terms of her payments and that her behaviour at the time was congruent to how she was feeling about therapy – and that telling me about her payment-time for any particular session was a way of saying how she felt about therapy on that particular day.
The whole question eventually became irrelevant, as Joanna became able to speak about her feelings about the therapy a bit more and needed to act on those feelings a little less.
In psychotherapy, patients may use monetary issues as a way of communication in the same way the words would be used. For a particular therapy situation any monetary issue is always a unique contribution to that therapy process. Monetary issues hold meaning for the patient that may be just as important as any other issue brought to therapy.
When a monetary issue arises it can be approached as any other clinical material. Unless explored and addressed, some of the psychic energy from the therapist-patient field may end up being dissipated outside the conscious relationship. Patients may use monetary issues as means of acting out their inner conflicts. If a monetary issue remains analytically uncontained, the potential benefit of therapy is reduced.
One way of addressing monetary issues is the exploration of the counter-transference. As appropriate, this exploration can be done with the patient or only through the reflection and/or supervision. If explored outside the immediate relationship with the patient, the findings may be brought back to the patient in a form of an interpretation and/or a request on how to proceed with the situation.
With the view of gaining more clarity in what meaning the particular monetary arrangements may hold for the course of a particular therapy, those monetary arrangements can be reflected upon even when no immediate issue is present.
Finally, it is not suggested that the exploration of monetary issues always leads to only an insight of the underlying dynamic and its meaning while practical financial arrangements remain unchanged. Circumstances in life and in therapy do change and so the financial re-arrangements may need to be made, but it is only when the situation is emotionally non-charged that the appropriate arrangements can be made. This is referred to in the text above as a “non-instrumental” situation. Appropriate arrangements are eventually usually seen as neutral (non-instrumental and non-emotional) by the patient, as well as by the therapist. Reaching the objective of non-instrumentality of any arrangement may take several sessions or several attempts.
Published: November 2008
Ivor Tomasevich was born in Croatia where he trained as a psychologist and Integrative Gestalt psychotherapist. In 2000 he moved to Auckland, New Zealand where he practices as a psychotherapist with a particular interest in Psychoanalytic Psychotherapy.
Ivor practices from the Apollo Centre and teaches at the Auckland University of Technology, School of Psychology.
The issue of fees is a fascinating one. As one therapist I know says, “Money is never just money’!
Readers may be interested in this from the analyst John Gedo:
When a patient in psychotherapy fails to pay his bill, he has violated an explicit and agreed responsibility. In an effort to gain some understanding of the dynamics of this problem I have reviewed all instances in my private practice in which it has arisen. I have found that the proportion of debt-beaters (or ‘deadbeats’) has remained stable over the years at about one patient in seven (36 out of 242 consecutive cases seen in the last six years). Since other difficulties in the conduct of psychotherapy, such as patients quitting treatment, have gradually diminished in frequency as I have gained experience (Gedo, 1959), the continued occurrence of the non-payment problem suggests that some particular characteristic of these patients is the principal independent variable involved.
Closer study of my cases reveals that non-payment was frequent when someone other than the patient was responsible for the bill. Since I have no information about the motives of these individuals, this report will exclude such cases. When this is done, the remaining patients display a remarkable consistency in their psycho-pathology; none was schizophrenic, none was overtly depressed; all these patients had come for help because they had been depressed or presented various complex defences against experiencing affective disturbances.
(1963). A note on non-payment of psychiatric fees. International Journal of Psycho-Analysis, 44:368-371.
What else does Gedo say about non-payment?
I have had clients (two) who have, unbeknownst to me, remembered that they owe me for a session and have paid me years later. Has anyone come across other variations?
Could it be that charging too low a fee is actually detrimental to the therapy?
A couple of more quotes from Gedo:
“I am indebted to Dr Leroy Levitt [for this example]: an octogenarian who was afraid of imminent death offered to pay a psychiatrist for a year’s treatment in advance, clearly as a magical reassurance against object loss.”
“In those cases whose delinquency about the fee is a new symptom, brought forth by the therapeutic regression in the transference, it is the therapist’s responsibility to conduct himself in such a way that the patient can become aware of his impulse (if possible without acting it out, of course).”
Too low a fee detrimental to the therapy?
I have tried to address this issue in the “psychotherapy – the helping profession” chapter im my article. (see above)
In short, what i believe has to be taken into account is both the patient’s and the therapist’s motivation behind such a “low fee” arrangement.
If the motivation is not explored and if the fee is set below the therapists usual fee, then i believe, yes – it can be detrimental to the therapy – as a part of the psychic conflict can get acted out through the financial arangement.
In response to: “Mensch”
I would think that any deviation in payments from the initial arrangemet (including forgetting and then remembering to pay) would indicate that some of the psychic material is being played out outside the agreed therapy frame – and as such is worth exploration when it arises (becomes consciously available to either of the parties in the therapy).
How does one work out what one’s fee is? What factors? Does anyone have advice, articles, etc. on this?
I would think there would be two major factors in determining one’s fee: the objective factor and the emotional factor.
The objective factors would include the range of fees the other practitioners in your area charge – including any variations due to the level or type of the practitioner’s training, seniority, area of work, etc. (if applicable).
The emotional factor is how one feels about actually charging patients that objectively set fee (or charging them at all!).
For maximizing the benefits of the therapy it would be good if the therpist would feel at ease with the fee he/she charges. Any issues could be explored either with the patient(s) or in supervision, as apropriate – you can see my article above for some ideas on this.
Money is a big issue not just for psychotherapy but for most of modern existence, as the current credit crunch demonstrates so well. Money and more, ‘value’, as our current circumstances show, is subject to inflation and deflation, confidence and fear.
To take a slightly different tack here, I wonder how much a therapist’s investment in making a living (and need to say build and maintain a client base) affects a populations perceptions of psychotherapy and mental illness?
I wonder for instance if this pragmatic dimension of working as a psychotherapist contributes to a common perception that therapists want to lock patients down into long term contracts much like how companies like Vodafone and Telecom insist on 12 or 24 month contract terms with penalties for defaulting? I think this is often a factor that keeps potential patients away from consulting rooms.
I very much like the idea of communication as energy… money is a kind of energy transfer or exchange as much as communication is. The therapeutic dyad (therapist – patient) is however not an isolated unit of exchange but itself part of a larger flows of energy. How difficult is the field of energy accounting!