A Sideways View

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Paying for Psychotherapy

How and how much do you pay your therapist? Does the fee effect the outcome?

Dissonance theory would predict, with some caveats, that the more we pay for something the more we value it.

We happily pay for many services we require. We pay doctors and dentists, hairdressers and physiotherapists, car mechanics and consultants. But what about those who offer “the talking cure”. How much should you pay your therapist and why may one more than another?

It has been observed that, since Freud, many psychoanalysts have argued that patients do not get well unless they pay for their treatment.

Therapists have written about money in analysis: how they “charge” their patients. Unlike sex and death, money does seem to remain a taboo subject. The analyst's complexes and practices about money can clash badly with those of the client, causing particular problems.

The agreement about fees, the presentation of bills, the charging for cancellation, the increases of fees, can all present problems as well as opportunities to understand how the relationship is progressing.

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So higher fees mean better work? Yet payment is received for work in progress which cannot guarantee results. Therapists' fees also confirms their self-esteem, professional status and belief in efficacy. Thus when this is challenged by patients, the therapists have to confront their own attitudes to money and then negotiate that meaning with the patient.

Some Freudians see money as a vehicle for favourite concepts like transference and counter-transference. Other issues include therapist, unhealthy, pathological greed where they use the defence mechanism of reaction formation to deny their entitlement to an adequate fee and ‘healthy’ greed where the fee is a normal entitlement to the position, role and task performed. Money it is argued can help therapist and patient understand the therapeutic boundaries of treatment.

Inevitably a patient’s fee restricts both the entrance and continuance of therapy. There are emotional and financial issues regarding the fees that both client and therapist need to confront honestly. Issues need to be discusses early and frankly so that expectations are made clear. There is conflict but it needs to be discussed.

The psychoanalysts have also looked at the heads and tails of money: its good and bright side vs. its bad and dark side. Hence the interest in how the words gold (in German) is related to guilt in English and how gift and poison are related. The psychoanalysts are interested in how people manipulate their bad feelings by ‘injecting’ (projective identification) into objects.

Feelings of despair, rage, guilt, need for love, are too dangerous to experience consciously and are “injected” into money which becomes a poison container.

Therapists “lease their time”. It is interesting to note that Freud wrote about and worried about the adequacy and unevenness of his income from therapy. He seriously focused on money. He felt greed and cynicism toward some rich patients and benevolent and paternalistic condescension to poorer patients. Yet he argued therapy was a bargain because it restored health and economic efficiency.

Many professionals charge for their time (doctors, lawyers). Their mental labour fee is a sign of their professional status and an index of authority, privilege and power. It is important that psychotherapy is bought and sold under conditions that heal and not ‘dis-ease’.

Analysts usually want to see themselves as beneficent purveyors of good rather than involved in commerce. They sell their services to make a living.

Therapists have written about money issues with interesting case studies. Barth (2001) discussed four case studies where she used “money-talk” to discuss and negotiate separateness and connectedness in therapeutic relationships: “In matters of money, questions about fees, insurance arrangements and payment style, for example, can lead to significant information about issues of dependency, deprivation, envy, longing, connecting, and other aspects of relationship – both within and outside of the therapeutic interaction.” (p. 84).

Three positions on paying for therapy:

(a) It is beneficial to therapeutic outcomes

Seeing a therapist involves an explicit or implicit contract. You ‘buy’ expertise, help, advice. But are therapy patients buying love or friendship and how does that influence the relationship?

Many people argue that psychotherapy should be available for those in need of treatment for their mental disorder, funded by the state. Yet you could argue that some fee is necessary in order for psychotherapy to be effective. Paying increases a sense of worth and commitment. Things given free are often seen as worthless

The two interesting questions in this area are how, when and why does the fee affect the outcome (if at all); how can or should we interpret patients’ payment style and methods (timing, cash vs. cheque). Some suggest there is a connection between successful psychotherapy and a client making a sacrifice (being the fee paid to the therapist).

Indeed a fee providing a stable boundary for the patient and therapist, as opposed to it being beneficial due to money’s sacrificial effect.

Paying a fee for therapy adds to the dissonance created by the effort required to engage in psychotherapy. This leads to increased motivation for the patient to achieve the goals set in therapy in order to remove the dissonance.

(b) It is detrimental to therapeutic outcomes

Thirty years ago researchers conducted a study confirming this view, with volunteers being randomly assigned to either a fee or no-fee counselling session. After the treatment session all participants reported reduced levels of symptoms and distress. Yet interestingly, the no-fee treatment group were found to benefit from greater symptom reduction than the fee-paying individuals, completely contradicting research suggesting paying for therapy enhances the outcomes. Interestingly, those paying for treatment had greater expectations of its results, but these did not materialise.

Another study supported this finding in a study of 434 patients assigned to one of five fee-assessment categories (no payment, welfare, insurance, scaled payments, full fee) based on the individual’s ability to pay. The study concluded that fees had no significant effects on outcome, appointments or attendance.

Reasonings behind the beneficial effects recorded as a result of free treatment have been offered by numerous authors. Some suggest that in a no-fee environment a patient’s therapist is regarded as more caring, which is received positively by clients and facilitates positive changes. Alternatively, it may be that those paying fees have higher expectations of treatment which results in them underestimating the beneficial effects of therapy in self-reports following treatment.

Perhaps therapists involved in billing and collecting fees improve clinical practice. Such findings suggest that fees have an impact on the clinical relationship through impacting the therapist as opposed to the patient.

(c) It does not impact the outcome of therapy

Neither therapists nor patients often talk about their personal income or financial resources. On the other hand therapists often report how many patients dream and fantasise involving money. Some, like Freud, note associations with dirt and faeces, others with semen and love. Inevitably some therapists think that some therapists say patients lie about their money (underestimate their income) in the hope of having their fee reduced.

Clearly therapists who work in institutions as opposed to those who work privately have different attitudes and behaviours with respect to fees. It has been noted that some corporate therapists do not report sessions and invoice clients or departments, expressing their rebellion against and resentment toward authority.

One issue is the sensitivity and compassion of therapists and their identification with the economic plight of patients. Somehow fees seem to go against the whole humanitarian ideals of therapists and enterprise of healing.

There are all sorts of issues for the therapist. First they know that there is a strong subjective belief that worth and price are linked. If you charge little you are seen to be of less skill, efficacy, and helpfulness. Next, there is the issue of charging patients not according to their needs but their income. Some ponder on the fact that if they know some patients are paying much less than others that they treat them differently. Then there is the issue of whether the fee should be related to some outcome. Also, how the fee is paid and to whom.

So is payment a minefield with all sorts of dangerous hidden devices or a field in which to mine important beliefs and feelings of both patient and therapist?

Furnham, Adrian, (2014). THE NEW PSYCHOLOGY OF MONEY. London: Routledge,

 

 

 

Adrian Furnham, Ph.D., is a professor of psychology at University College London and the Norwegian Business School.

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