Transference and Countertransference Issues Related to Fees

How fees are handled is an important part of therapy.

Posted May 15, 2019

Recently I got a referral from a low-fee referral center that is connected with my psychoanalytic training center. The patient’s fee was set at $100, which is considerably lower than my standard fee. During the first few sessions, David told me that he lived in a co-op apartment that he owned; he had a thriving business; and his father had created a stock portfolio for him that was worth over $1 million. I realized that the fact that he chose a low-fee referral center was a reflection of his feelings about himself, but I still felt cheated. That led me to thinking about transference and countertransference issues related to fees.

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Although many therapists and psychoanalysts have problems dealing with issues related to fees, there has been little theoretical attention paid to it. Nonetheless, I believe how the therapist handles this issue is central to treatment. I am not only speaking of setting and raising fees, but  collecting them and determining whether we are paid for sessions missed when the patient is working, sick, or on vacation.

The classical position is simple: You have a set fee and that is what you charge everyone. Patients pay at the end of each month. If the patient does not come, for whatever reason, they pay for the session unless you use it for another patient. If the patient is going to be gone for an extended period, they pay for the sessions if they wish you to reserve the hour.

However, in reality, therapists may not charge everyone the same fee because they are building their practice; offering treatment to low-income patients; or charging less based on frequency of sessions. Fees are also more complicated nowadays because many patients are covered by insurance. The patient may only pay a co-pay and/or the therapist may accept a lower than usual fee from the insurance company. In other words, the therapist may have good professional reasons for not following the classical rules or he/she may have countertransference. Most likely, both factors are in play. Regardless of whether or not the therapist has a professional reason for doing so, every time the fee is raised or lowered, you charge or don't charge for a missed session, you have feelings about it and so does the patient.

Feeling guilty about asking the patient for money is a common countertransference problem. What might that be about?       

  • You feel that you are above thinking about money and your work is more noble than that;
  • You feel you don't do this work for money but for love, to save your patients, to give them what you didn't get;
  • You feel talking and thinking about money is crass and maybe you associate it with certain class or ethnic identifications with which you want to disidentify;
  • You feel that the patient will not feel you are worth that much money and you don't want to be rejected;
  • You feel the patient will get angry and you want to be the "good" analyst; or,
  • You identify with the patient and never worked out your anger at paying your analyst.

On the other hand, although patients may want the therapist to charge a low fee or accept a low fee from their insurance company, they will have feelings about it that will affect the transference.

  • The patient may feel powerful and special because he/she can get the analyst to do what they want;
  • The patient may feel merged with the analyst rather than confront being separate people with boundaries and different needs;
  • The patient may feel guilty for paying less; or,
  • The patient may imagine the therapist resents being paid less.

How much of the patient's feeling about it is transference and how much is his/her reaction to our countertransference?

I am not suggesting that the policy be rigid and unbending, only that it be a general set of guiding principles. Of course, your set of principles may not be the same as mine. But, I don't think we can know when our behavior is due to countertransference unless we have a policy about these issues. Then, when we don't follow our policy, we can ask if we are having countertransference.