Tuesday, January 28, 2014

Money Matters

I’m not good about money. I never have been. Managing my own finances has never been a problem, but setting patients’ fees is an entirely different matter.  

Early in my career I was treating Sharon, an artist, who told me how much she made yearly from her art. It wasn’t much. My regular fee wasn’t much in those days either. Still, I reduced my fee. Several months passed. In the course of one session she began to talk about the apartment buildings she owned that had been left to her by her now deceased parents. I was shocked, and angry, too angry to say anything at the time. The next session I was ready. 

“Sharon,” I said, “Last session you talked about being a landlord. Can you say why you didn’t tell me you owned apartment buildings when we first discussed your income and your fee?” 

“It never came up,” she replied. “We were talking about the money I made from my art.”

“That’s true. But don’t you think not mentioning your other income was dishonest?” I asked. 

“No,” Sharon replied blithely. 

“Really? You don’t feel you were hiding your rental income so that I’d reduce your fee?”

“My father used to say never offer any information you’re not asked for,” she said.

“You experienced your father as a ruthless, indifferent, uncaring man. And now you’re modeling yourself after him?”

“I never thought of it that way. It’s not something I decided to do. I guess I just do it automatically when I deal with something business related. I’m sorry. You’re right. It wasn’t fair of me.”

So that situation had a satisfactory ending both financially and therapeutically in that we were now able to explore Sharon’s identification with her father.  

More recently, the result wasn’t as positive.

I receive a call from Jackie, referred to me by a former supervisee. We set up an appointment and as we are about to get off the phone she asks my fee. Although I prefer to discuss fees in person, I answer her question and tell her my regular fee is $250 a session. She gasps. Without a moment’s hesitation, not knowing anything about her finances, I offer to see her for $150. She agrees and comes in at the designated time. 

Jackie sought treatment because she and her husband just learned that he is sterile and are now wrestling with whether or not to adopt. Jackie is also trying – not very successfully - to not be angry with her husband for a medical condition beyond his control. Being a mother has always been Jackie’s dream. Her mother died when she was only a year old, leaving her to be raised by rigid, rejecting grandparents. We discuss her desire to give her own child an experience she herself cannot remember ever having. She understands, but remains focused on her anger at her husband and his failure to give her what she has always wanted.

As the therapy progresses, I learn that their marriage has never been fulfilling for her. She describes her husband as both withholding and an inadequate lover. She stays in the marriage because she’s dependent on him. And for financial reasons. She has a seven-bedroom home on three acres of land, horses, a cook, and a housekeeper.

I am not happy. I reduced my fee for a woman with huge financial resources! And it’s my own doing. She hadn’t lied to me. She hadn’t withheld information about her wealth. All she had done was gasp and I lowered my fee! 

As we approach the new year, I tell Jackie that come January I will be raising her fee to $250. I understand that a $100 increase is a lot, but given her financial circumstances, it doesn’t seem unreasonable.

“Well,” she says, “I was planning on stopping anyway. All this talking isn’t getting me anywhere. My husband is still sterile and I just have to stop being angry at him and decide whether or not adoption will work for me.”

“Do you think your decision to stop is related to my talking about increasing your fee?” I ask.

“No, not at all. You’re right. I can afford it. But I don’t think this is helping. So why should I bother continuing?”

“Can you say, Jackie, how you felt about my raising your fee or, for that matter, how you felt when I lowered it when we talked on the phone.”

“I don’t know. I didn’t think about it.”

“Can you think about it now?”

She shrugs.

“Do you think you felt given to when I lowered your fee, given to in a way you haven’t experienced much in your life and that now you feel I’ve deprived you yet again?”

“You’re making too much of this. You always do. You over analyze. It’s just time for me to leave.”

And so I lost Jackie. As a result of my difficulty dealing with money.   


Unknown said...

Your blog this week struck a chord with me as usual, Linda. I wonder if there are many therapists who don't struggle with setting fees? I've often thought it would be nice to practice in an office that had a receptionist dealing with the fees, but it seems like it would take away from an opportunity to look at an important issue with patients. I wonder what it would be like if our medical doctors set and collected fees from us when we visited them?

Linda Sherby PH.D., ABPP said...

Thanks for your comment, John. I'm sure many therapists struggle with setting fees. Perhaps that's almost a necessary condition for who we are - caregivers who are concerned about others. We're care about others' feelings and their past and present life circumstances, including their financial circumstances. So we're always weighing if a patient can afford what we're charging against our own needs and what seems "fair. It's part of the freedom and the burden of being a therapist in practice for ourselves.

I've never wished for a secretary who could take care of the money because, as you said, it would remove important information about the patient, as well as the interactional component that needs to occur when setting the fee.

And I never thought about physicians having to talk about fees with their patients. It's certainly an interesting thought, and something that I'm sure will remain only a fantasy.