We psychologists and therapists do not like to discuss payment with our clients. Why? According to a study dating all the way back to 1996, psychologists avoid the topic of payment because we tie it into our own insecurities. We worry about creating potential conflict with clients, we question our worth, and we are sometimes uncertain about the definition of the service we provide (Keuffel, 1996).
We don't even like to discuss money in our own professional literature, which is why I had to scrounge up a 15-year-old study. It was one of the most recent I could find on the subject of therapists' attitudes about payment. As I've pointed out elsewhere, we shrinks avoid turning the public spotlight on ourselves.
Though we are loathe to discuss payment, we have complex policies concerning money. Psychologists are much likelier than other professionals to adopt sliding-scale fee structures, which are variable rates based on a person's ability to pay for our service.
That sort of arrangement should necessitate pragmatic discussions about money between therapist and client. But for the most part it works like this: client asks therapist for a discount; therapist says "OK."
Often, the therapist ends up working extra to make up the lost income.
Still, despite the consequences, we avoid the topic of payment like a politician avoids the confession booth. But even though we don't discuss money within our professional literature, and we avoid discussing it with our clients, you can be sure that we discuss it amongst ourselves.
Sliding scales are a frequent water cooler topic. We often interrogate each other: do you offer sliding scales? What's your lowest fee? How do you decide whose fee to reduce? Don't you get tired of working for free? At some point in our careers, I think all psychologists search for guidance on these questions. There are no objective criteria, which is how I came to write about this.
Over at ironshrink.com, my Q & A blog, a fellow psychologist asked how I handle sliding scales within my own private practice. I agonized over the answer, but it forced me to put words to my own long-held beliefs. Something about it still feels dirty - not my answer, but the fact that I discussed compensation in public. It's taboo, and that's silly. It shouldn't be.
As I ground out my answer, I noticed something about sliding scales that seems particularly sacrilegious: they can have unintended consequences, such as forcing full-fee clients to unknowingly subsidize reduced-fee clients. There are other potential hazard that therapists should contemplate before adopting a sliding-scale fee structure.
The larger point is that we psychologists are helping no one by avoiding the topic of payment. If anything, we're complicating matters and being needlessly clumsy. Money should be treated as nothing more than it is: fair compensation for service rendered. By discussing it in public, I'm taking a dose of my own medicine and facing an insecurity.
Funny how we always come out stronger for that.
References
Keuffel, C.R. (1996). The money metaphor: Therapists' experience with fee transactions with their clients. Dissertation Abstracts International: Section B: The Sciences and Engineering, 57(5-B), 3413.
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Dr. Smith is a psychologist in Denver, Colorado and the author of The User's Guide to the Human Mind: Why Our Brains Make Us Unhappy, Anxious, and Neurotic and What We Can Do about It. You can read the introduction and find other goodies at guidetothemind.com.
