A century of fees

By John Soderlund


Question 1:

"How can you pretend to care about my problems if you're so concerned about money. Surely this payment can wait until next week. You're just in this for the money."

Rate the source from which you have most often heard this accusation.

1. A client;
2. A critic;
3. Another professional;
4. Yourself.

Question 2:

In your professional life, you feel most guilty, most often, about:

1. Inaccurate, inappropriate or badly timed interventions;
2. Not caring sufficiently about your clients;
3. Thinking about your next meal during a session;
4. Asking for the money owed you by a client.

 If you answered 4 to one or both of these questions, you're in good company. Therapists have a long and tortured history with relating to money. Being a helping professional, we tend to think, is about helping before it is about making a living.

So, it's rather fortuitous that the pioneers of psychotherapy discovered the convenient route out of our guilt about making money from the misery of others, namely the idea that our clients may benefit as much as we do from paying their fee in full and on time.

Notwithstanding Freud's early assurance that the fee was a catalytic imperative to health, the most distressing fact about the fee in psychotherapy is that it has hardly been explored in the research or theoretical literature. Such is the ambivalence therapists feel about having their source of income scrutinised that it has been hardly glanced at by the bulk of the profession.

Freud, writing in 1913 (Freud, 1958), strongly endorsed the importance of fees as an indispensable part of the curative motivation in therapy. But he conceded that there may be occasions when therapy can be effective without the payment of a fee.

Since Freud, much of the most ardent support for the idea that fees are an integral part of the service process in therapy has come from the psychodynamic camp. The fee represents a necessary part of the patient's effort in psychotherapy and not just any sacrifice will do.

Robert Langs, in his landmark Psychotherapy: A Basic Text (1982) argues for a fixed fee to be maintained throughout the therapeutic treatment process, suggesting it is one of the constants which constitute the frame and provide the predictability and consistency necessary for the therapeutic work to be effective. He is not at odds with the idea of a narrow fee range and the provision of low cost therapeutic services, where appropriate, however.

The defense by other psychodynamic therapists of the fee has often been rather prosaic. Jean Frecourt (1992) writes that the analysand's payment of the fee is a transferential gesture that transcends the "purchase of a service". This, he says, has been insidiously ignored by the majority of psychoanalytic writers, despite Freud's rejection of low analytic fees as diminishing the value and effectiveness of a cure. By contrast, Frecourt argues, free analysis is counterproductive , especially in cases of "young female patients whose enthusiastically transferential gratitude might be expressed through offers of payment by sex".

Some psychoanalysts have gone as far as to refuse payments by third parties - most commonly insurance companies paying on behalf of clients - which they assert removes the fee from the control of the patient, potentially contaminating the therapeutic relationship (Wortman, 1984).

However, an earlier study (Power and Pilgrim, 1990) found a further, dare we say it, countertransferential, twist to the vociferous support by therapists of the payment of a fee. This survey of 11 British psychotherapists found that those practitioners who felt most strongly that the fee was essential for effective psychotherapy, and that the fee was symbolically important for clients, were also most heavily dependent on fee paying for their livelihood. They were also less ambivalent about receiving money from clients.

A number of prominent cognitive theorists also propped up the fee's desirability rating. Festinger's (1957) classic cognitive dissonance theory, as applied to therapy, meant the fee would constitute part of the dissonance created in the therapy encounter. The dissonance would serve as a motivating factor for the client to change in the direction of greater health.

The fee-free camp

Despite the legacy of long-standing support for the curative nature of the fee, though, a number of writers have challenged and offered evidence for the idea that therapy can be effective in the absence of a fee paid by the client. Some even argued that the fee may be countertherapeutic in some circumstances.

The most crushing challenge to the necessity of the fee has been the increasing prevalence of third party payers in the past two decades. Reimbursement of psychotherapy fees by medical insurance schemes has taken the fee and its implications out of the hands of the majority of users of psychotherapeutic services. As early as 1984, Inman and Bascue (1984) found that 60 percent of psychotherapy income of a sample of therapists came from insurance reimbursements. That figure began to drop when the managed care revolution took a real bite out of the benefits payable to psychotherapists.

And administrative and therapeutically complicating scuffles with managed care companies are pushing a growing number of therapists into the fee-for-service approach to making a living.

Despite this pressure, though, the belief in the therapeutic indispensability of the fee was on a hiding to nothing some time back. Herrron and Sitkowski (1986), in a comprehensive review of the literature, conclude that the time-honoured clinical folklore that patients who pay do better than those who don't is not supported by the weight of research in the field.

But they caution that the bulk of these studies have not been conducted with private practitioners, where money is probably of more significance for therapist and client than it is in settings where a third-party payer is present and other motivational factors may be at work for both therapist and client.

They note also that fees have a barrier effect for certain clients, making therapy a financial impossibility for some and only a short-term possibility for many.



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