Psychotherapy Relationship and Money: Strange Bedfellows?

by Chris Hancock, MSW

“Most things of exchange require money. The most worthy of exchange require the mind, heart, and time.” -Bobby Compton

When you pay for therapy, what are you paying for?

There are some themes that don’t always get the air time they need in therapy. At the top of the list is the long-considered “taboo” of money. The payment, the fee, the tab, the cost, the price, the dough, the green, the mullah, the donuts, the loot…the damage. That last one says a lot. I catch myself using it sometimes. I guess because unless you’re on a Bill Gates level it always stings a little to have to shell out.

The Yeast Has Awoken, mixed media, 2014

Currency is of course neutral. Neither intrinsically good nor bad, dirty nor clean, it’s our own personal and collective “shadow” with respect to money that consciously and unconsciously informs our financial exchanges. We project meaning onto money, “loading” it with everything we’ve internalized — from the monetary attitudes and class consciousness of our caregivers, to every calculated message mainstream advertising has injected into our subconscious since we were old enough to sit transfixed in front of a TV. The money “script” forms early; as such, our psychic relationship with money and our financial behavior is intensely conditioned, bound to our sense of self-worth, esteem, and other characteristics inherited and learned.

Maybe the term “loaded” to describe someone wealthy stems not so much from the actual weight of the money, but from our collectively unconscious knowledge of how much weight we add to money.

For many reasons, the psychotherapy relationship and the fee may always be strange bedfellows. The most obvious might be how easy it is to wonder if what is being paid for is empathy, for the actual caring. After all, if therapists really cared, wouldn’t they do it for free, charge less, or at least be more lenient with late cancellation or no-show fees? I’ve read this between the lines of many a client’s questions. I’ve heard it outright from more than a few. And I understand it. The disconnect that may seem obvious to the reader doesn’t always penetrate the complex and symbolic nature of the financial exchange between therapist and client. For many, these perceptions seem to result from ingrained familial and cultural programming, and the amount of conditionality attached to the demonstrations of caring received early in life.

As we know, money can either cut or cure. It can be gift and weapon, benefit and burden, source of security or wellspring of misery, and all things in between. Whether we’ve been groomed for financial enslavement via poverty consciousness or nourished on the bosom of limitless abundance, the imprint reveals itself through every thought, word, and deed involving the almighty dollar. For both therapist and client, what we’ve learned about money’s function and utility, its meaning, purpose, and role in our lives, and its connection to our self-concept invariably colors the entire therapeutic transaction.

What elephant?

I can remember feeling confused and anxious about the payment early on in my time on the couch as a young cash-strapped, insecurity-riddled musician, and later as a slowly-getting-my-act-together grad student on a Ramen budget. My first therapist, a Doctor of Psychology, was a tall, handsome, dapper dresser. His being a doctor with a prominent office locale made it easy to project all sorts of ungodly wealth and highbrow leanings onto him. Lacking in assertiveness, nursing a broken heart, and clinically depressed at the time, I never raised my feelings about the money. I guess I didn’t think I could. In fairness to my young neurotic self, neither did he that I recall, even in response to my consistent and rather bold no-show, no-call habit.

Most of that was my insidious fear and shame. I was probably also unconsciously testing him to see if he’d react like either of my parents to my overt non-compliance. But I believe I was also trying to communicate something about how odd it felt to pay him to…to what? I didn’t know. I only knew I couldn’t get through my predicament alone and desperately needed someone to walk through it with me, and affirm I would be okay. But was I paying him to care? Was he only “in it for the money”? What exactly was I paying for? All of this gnawed at me all the way through.

Maybe my Doc was as uncomfortable discussing the financial exchange as I was. He might have perceived no connection between my no-showing, my palpable shame, and my conflicts about the money. It’s just as likely that he was so aware of my insecurity and fragility that he chose to consciously ignore my acting out in favor of maintaining a safe “holding environment” — perhaps sensing that even a benignly inviting exploration of my behavior might overwhelm my fragile ego. He probably would have been right; I’ll never know, and maybe that’s for the best.

I quit my first therapy experience about six months in. It was, in part, because I started to feel better (and why keep up with what’s working, right?), but also because I sensed that to continue would require a serious unpacking of my past, which made me more anxious than I had been to begin with. I just wasn’t ready, so the choice was singular; I think Doc must have known this.

The take-away though was the absolutely genuine caring and concern I felt from him — my first taste of what really matters in therapy. It’s what I needed, and probably all I could have tolerated. I was far off still from getting better, but feeling better was a must. Interestingly, I’ve never been able to remember anything specific he ever said to me, but I’ll never forget his caring, his steadiness of presence, and his demonstrative empathy. There will, however, always be asterisks in my time with him, as one of the most symbolic, meaning-laden aspects of the therapy process went unacknowledged.

Light in the dark

The person who became my mentor is a therapist I began seeing years later during graduate school. A former Franciscan priest turned clinical social worker, he’d worked with a family member of mine a long while back. From the get-go there was an easy warmth, an accepting nature, and an unassuming confidence about him. I also quickly picked up an implied appreciation and deep wisdom about the complexity of the monetary aspect of therapy.

He phoned me unexpectedly a few months after our initial appointment, which I’d scheduled ostensibly to “pick his brain” while applying to graduate schools and auditing courses to test the waters. What I really wanted from him, of course, was approval that I would be good at doing what he does, as if he could know based on one meeting. His later reaching out and gently reminding me that his door was always open really touched me. That thoughtfulness made it difficult to resist getting started for much longer, though I still managed to hold off for a few more months. But once I pulled the trigger, he was more than generous with the fee, which alleviated my anxiety and poked needed holes in my conflicts around money and the false dichotomy of “paying = caring.” I had to work through plenty of guilt for what was of course his choice to charge me what he offered, but I learned over time to accept his gesture, which helped me feel valued, respected, and quickly trusting.

Though I’ve offered him incremental “raises” ever since (he’s only ever raised his fees once that I can remember, and only five dollars at that), no amount of money could ever symbolize what I feel I’ve achieved and the gratitude I have for this therapist/supervisor/mentor who’s walked with me through darkness and light for the last decade and a half. What I’ve learned about myself with respect to money, underscored by his actions, as loud as words, is but one of the many reasons why I derive such fulfillment from my work life in particular. That’s been worth every dollar spent and more.

Many people, many therapists, are uncomfortable discussing money let alone the meaning of the exchange of currency in psychotherapy. Some therapists avoid openly exploring their client’s feelings about it. I know a few who set up their practices to compartmentalize the payment away from a face-to-face interaction, some employing third-party systems to isolate it entirely. Technology makes that easy, and perhaps easier still to justify. But whether conscious to the client or not, doing so makes a rather loud statement, and not a healthy one in my view.

Starting out in private practice after years in community-based mental health, I was ambivalent at best about navigating the financial terrain. Understanding that the exchange of currency as a self-employed clinician would bring me face to face with whatever vestiges of my money issues remained and carry waves of meaning and expectation on the part of clients was quite unsettling. I may never be completely at ease with it, but I’ve come a long way.

Touchy as it can be, these days when I initiate discussion about the money exchange with my clients, or when an interaction takes place that I intuit is enacting something about paying, I’ve trained myself to spot the significance and try to strike when the iron’s hot. (My running note to self: Aim to replace try with commit). In therapy, the meaning of any enactment is idiosyncratic to the person and often multi-layered. With respect to finances, it almost always has something to do with a client’s feelings toward me, some aspect of our work, and/or the relationship itself. And there’s gold in them there hills.

It still amazes me what just talking about it can do.

I’m still not sure how exactly how I’ve arrived at a monetary value for what I offer. It’s a strange thing to have to do — maybe not as much for the born or bred entrepreneurs of the world, but for me, strange indeed. Especially during those times when you don’t feel entirely on top of your game for whatever reason, it can feel like a hard line to hold. As a social worker, it’s part of the ethics and values of my profession to account for a person’s ability to pay, and this actually makes it somewhat easier (though my inclination would be to do so anyway). I find that by and large, if I stay tuned into what truly matters (the relationship), then arriving at a fee that feels fair to both tends to take care of itself. But the fee structuring and adjusting is an ongoing, fluid process — as much about both my and my client’s money scripts as a literal and metaphorical “happening” between self and other.

Heart-centered

My personal view, and I’m surely far from alone, is that what I’m being paid for is my time. Caring is of and from the heart. If I charged more, would it amount to more caring? Nope. Either I care or I don’t. And if I don’t, well “Houston, we have a problem.” Thankfully, I come to care pretty naturally once I get to know someone intimately.

Is there a limit on the amount of caring available to us? We can certainly fail to take care of ourselves, overwork and burn out to the point of compassion-fatigue. I’ve come close, at least twice now. But is there a caring ceiling? I think not unless we impose our own boundaries on it, or we’ve been seduced into a model of emotional scarcity, or finite-ness. In the therapy relationship there are ethical codes around how we may demonstrate that caring, as there should be, but not on caring itself. Caring can’t be regulated any more than it can be monetized.

This may be self-evident, but I feel what’s also being paid for (whether conscious to the therapy seeker or not) is the reasonable assurance that the therapist engages in a process of working through whatever of their own stuff could adversely distort their ability to see you and your issues clearly, and treat you effectively. That’s why, when seeking help, you want a licensed professional psychotherapist who understands their enormous psychic contribution to the relational equation.

Does paying even a hefty fee guarantee the therapist’s own issues won’t interfere? No way. A therapist who thinks otherwise is a danger to themselves and their clients. Whether pro-bono or at Beverly Hills rates, therapists are 50% of the psychodynamic, fallibly human, and subject to their own distorted perceptions of you, themselves, and what’s happening in your therapy sessions. The hitch is recognizing and working from the inside out of this inescapable reality. It’s arguably the cornerstone of our role. Here’s where our own therapy work matters most. That we’re continuously shining our own mirror through a process at least as depth-oriented and meaningful as what we’re guiding the client through is what can and should be expected, and indirectly, I’d say, part of what the fee symbolizes.

 [1] The client or the therapist?

 

 

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