For Love or Money

The Fee in Feminist Therapy

Marcia Hill, Ellyn Kaschak

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781317957294
• Edition: 1
• Topic: Psicología
• Subtopic: Psicoterapia

Realize how you can charge what your services are worth and still care about your clients! For Love or Money: The Fee in Feminist Therapy examines the rarely talked about topic of payment in therapy, taking a symbolic and psychological look at the meaning of fees to both the psychologist and client. This intelligent book offers firsthand advice and information concerning how gender can make a difference in your feelings about fees and how the managed care environment affects women clients. For Love or Money will help you handle your concerns about fees as it discusses payment for missed sessions, bartering, the meaning of fees with African-American women and with women in prison, and a model for pro bono work. Since most therapists don't discuss fees with colleagues, For Love or Money provides you with a way to gain information that might not otherwise be available to you. As a therapist, you will explore perspectives on what other therapists think about fees and what feelings other therapists have about the amounts they charge for their services. Some of the fee issues you will examine include:

• five typical therapist conflicts that are felt when it comes to fees
• the need to change managed behavioral health care to include equal payment for mental health care, length and type of treatment at the discretion of the client and provider, and appropriate training in women's mental health issues for all health care providers
• setting a frame of therapy that includes session time, session length, duration of treatment, fee, confidentiality, and the "rules" of client participation to allow for successful psychotherapy
• sound clinical reasons for enforcing payment for missed sessions and considering a situation where flexibility is recommended
• pro bono work that is satisfying With this insightful and well-written book, you will explore issues such as transference, the symbolic meaning of money, and feelings you may have that could interfere with your ability to follow through with your own payment policies. For Love or Money examines many of the issues that surround the taboo topic of fees and will assist you with tackling this seldom-addressed and often uncomfortable subject for the therapist who wants to help her clients, but may feel distressed at setting and sticking to established fees.

Payment for Missed Sessions: Policy, Countertransference and Other Challenges

Evelyn Sommers

SUMMARY. The policy of requiring payment for sessions canceled without adequate notice can result in dilemmas that many therapists wish to avoid. In this exploration, sound clinical reasons for enforcing payment under such circumstances, including the acquisition of therapeutic insight and modeled assertive behaviors, are discussed using case examples incorporating an examination of countertransference. One exception to this position, in which flexibility is recommended, is also described. The discussion removes the issue of paymentfrom the concrete domain of money for service by conceptualizing the scheduled appointment as a promise between therapist and client, late cancellations as unconscious challenges to the promise, and enforcement of payment as a means of protecting the promise. Therapists are encouraged to examine feelings that might interfere with their ability to follow through on their own payment policies. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678, E-mail address: [email protected] <Website: http://www.haworthpressinc.com>]

KEYWORDS. Payment policy, cancellations, feminist, modeling, countertransference

Like many practitioners in helping professions, I have a policy of charging the full fee for missed sessions unless I am given a specified notice of cancellation. Clients are informed of the policy during the first telephone contact and the first session. The only exceptions are for cancellations due to sudden illness, accident, or life and death situations. From time to time I have been confronted with challenges to the policy, leading me to reflect on the implications of creating and “enforcing” a policy of payment. In one instance, a client left a message on the morning of her weekly appointment to say that her daughter was arriving that day for a brief visit, so she would not be attending her session. The next week the client failed to mention her obligation to pay for the canceled session. I then had to choose a course of action taking into account boundary issues, clinical judgments, and my feelings about setting and standing firm on limits, all within the highly emotional domain of fee for service. Many therapists react to such dilemmas with a wish to avoid them, a feeling I have shared. Indeed, this writing was inspired by my struggles with payment issues, as well as by clients who have commented on the value of the difficult but rewarding “enforcement” sessions that have occurred as an outcome of their challenges to my policy.

Discussions with colleagues and articles by authors such as Michele Bograd (1991) have underscored the struggles with payment issues that are common to many practitioners, especially those who attempt to work collaboratively with their clients or are concerned about issues of fee setting related to the ability of clients to pay, along with consideration of their own needs. Dealing with the exchange of money for counseling and psychotherapy is often considered an annoying and distasteful task, and asking for payment when a session has not occurred presents special difficulties for those who think of themselves as helpers. Yet psychologists and counselors providing services in private practice must address, directly or indirectly, the issue of payment with each client who engages their services. Fees must be named; invoices must be presented and paid; insurance forms must be signed for payment; availability and limits of benefits, billing practices and other related matters must be discussed. Frequently these discussions of payment are viewed as an imposition on the therapy relationship, stealing time away from the “real” stuff of psychotherapy and engendering a possible threat to the process. However, money is a fundamental, practical, and emotional factor in our lives and it is important for the upkeep and well-being of us all. Therefore, money in some ways levels the intersubjective field between client and therapist as well as introducing an additional level of complexity. Thus, the process of exchanging money for service presents a rich source of psychological material and challenges for the therapist and client to address in the here-and-now of the therapeutic relationship. Many concerns related to this topic are discussed elsewhere (e.g., Krueger, 1986) such as determinants of policy and the fact that a policy which allows for exceptions to payment places the therapist in the uncomfortable position of having to judge the merit of absences. My focus in this discussion is on the issues and effects arising when a policy requiring payment for missed sessions after the requested notice is not given was enforced. I also describe a situation in which it was therapeutically helpful to be flexible when a client protested paying for missed sessions. Underlying the different decisions was my wish to establish and maintain trust by creating a secure, though not rigid, structure for therapy and upholding it, and by demonstrating that I value my own time and word. To illustrate the kinds of issues that can emerge I have constructed composite case examples of five types of client reactions to the requirement that they pay for missed sessions-angry, passive, compliant, responsible, and distressed-into which I have incorporated discussion of related countertransference issues.

In therapy, I work from the feminist principle of illuminating-not reinforcing-power differences, so the policing tone of the word “enforce” creates discomfort for me. At the same time, the term most accurately reflects my feeling about performing this difficult task. The tension resulting when power is both held and exposed is perhaps one of the most difficult aspects to manage in the therapeutic dynamic. Thus, policy is enforced by authority of the therapist’s position and the vulnerability of the client in the therapy, while the therapist knows and the client may understand that the client is able to disempower the therapist by withdrawing from therapy.

PSYCHOLOGICAL APPROACH TO UNDERSTANDING

In developing my understanding of the complexities of this issue, I have drawn from various approaches to psychoanalytic thought, relying on the work of Robert Stolorow and his colleagues (Stolorow, Brandchaft & Atwood, 1987) for some basic principles. Their reformulation of fundamental psychoanalytic principles is compatible with my own thinking and my feminist perspective, although theirs is not a feminist analysis. The fundamental position of these theorists differs from other psychoanalytic approaches in that it emphasizes the inter-subjective field created when two “subjectivities” intersect. They believe neither that a therapist is able to achieve and maintain a position of neutrality nor that particular concepts are true in all cases (and thus “concretized”). Their position has implications for basic psychoanalytic principles including transference and countertransference. The authors caution against concretizing the notion of transference as regression to a reenactment of an earlier experience, displacement to the therapist of emotions that have been repressed, projection, or distortion of reality. Rather, they understand transference as “a microcosm of the patient’s total psychological life … an expression of the continuing influence of organizing principles and imagery that crystallized out of the patient’s early formative experiences” (Stolorow et al., 1987, p. 36). According to these authors, it is essential that the client’s subjective perspective is always the starting point for understanding. From this perspective, “the analysis of transference provides a focal point around which the patterns dominating his [sic] existence as a whole can be clarified, understood, and thereby transformed” (p. 36). Countertransference is understood not as something generated by the client’s pathology but a manifestation of the therapist’s organizing principles and psychological structures. Countertransference and transference are viewed as “an intersubjective system of reciprocal mutual influence” (p. 42) which means the organizing principles of the therapist and client interact and influence each other, forming a unique intersubjective field.

My thinking has also been guided by behavioral principles, drawing from the work of Wachtel (1997) who integrated psychoanalytic and behavioral principles. Wachtel believes that behaviorism provides the means to “actively intervene in the human dilemmas that psychoanalysis has enabled us to understand …” (p. 5). In my discussion of case examples the power of modeled behavior is fully in evidence and gives pause to reflect on the importance of therapists continuing to develop their self-knowledge.

POLICY AS PROMISE

A promise is assurance given from one person to another that the other has a right to expect a particular action will take place. This is the underlying assumption of a scheduled appointment for therapy, that the therapist will reserve the period of time agreed upon exclusively for the client and will schedule no other appointments for that time. In accepting the promise, the client agrees to attend during the designated time so the two can consult for her or his benefit. The therapist is entrusted to keep the promise but has the additional responsibility to protect the promise from unconscious challenges made by the client, which sometimes come in the form of canceled or forgotten appointments. These unconscious challenges are usually signals that the client is experiencing a difficulty which she or he is unable to articulate. It is the responsibility of the client, in accepting the promise, to give appropriate notice, to turn up for the appointment, or to pay the fee. The failure of the woman in the opening paragraph to mention her obligation to pay shifted the responsibility back to me to remind her. Part of my work in keeping my promise was to help this client honor her acceptance of the promise, which she was unable to do at the time, for reasons we did not yet understand.

Promises are often problematic for clients who may have experienced countless unkept promises as children and adults. Past experiences of broken promises may have led the client to undervalue the promise of a scheduled appointment and to expect it to be undervalued. As the therapy progresses, an increasing and possibly conflicted dependency on the therapist and her promise to be present at the sessions may develop. Therefore, it is important in making policy that the practitioner determines exactly what the agreement will be, taking into consideration her own needs along with those of the client. However compassionate it may seem to allow client self-determination in matters of keeping appointments, or, on the other hand, how punitive it may seem to set and enforce a policy, caring for clients includes providing them with a clear statement of the promise made to them along with the implications of their acceptance of it. Conceptualizing appointment-setting and policy as a promise removes them from the realm of punitive interactions and places them in the realm of assisting the therapy process.

COUNTERTRANSFERENCE AND THE ANGRY CLIENT

Therapists think of themselves as helpers, not enforcers, so strong feelings can arise when it becomes necessary to stand firm on policy requiring payment for missed sessions. The nature of those feelings and the ways they are understood and managed can profoundly affect the course of therapy. One of the most difficult hurdles can occur if the therapist anticipates a client’s anger. If she struggles with anger-related issues in her own life, the anticipation of a client’s anger may bring her fears to the surface and possibly interfere with her ability to stand firm on policy. A client I shall call “Darleen” touched off such a dilemma.

Darleen was a woman in her mid-30s who spent her life, outside her workplace, in near-isolation because she was afraid of her own anger. In her sessions, we had discovered that her anger had developed much earlier in life as protection after she was sexually abused and its force had intensified as she became increasingly aware of the sexism that existed in her work world. However, it had come to dominate her emotional life and feel unmanageable. Clinicians have often observed that victim/survivors internalize or identify with their aggressors and begin to act towards others in highly aggressive ways (Davies & Frawley, 1994; McCann & Pearlman, 1990), something Darleen had done throughout her life in reality and imagination. The two intimate relationships in her past ended when she came close to violence, though she had always stopped herself before actually becoming physically violent. In apparent contradiction to her aggressive outbursts, Darleen was unable to say “no” to requests made of her which resulted in her adoption of an attitude of resentment towards most people in her life and a feeling of being victimized.

Darleen had canceled her appointment the morning of her session because she had scheduled a dental appointment at the same time. When she arrived at my office the following week she did not mention the incident. Her omission left the choice and responsibility with me to remind her or to make an exception. Considering Darleen’s emotional history, my anticipation of an angry response to the news that I would be holding to my policy was not surprising. More unexpected and worrisome was my own feeling about confronting her with this news. As the moment drew near, I felt the rush of energy that signals fear and knew that my countertransference was active, dredging up the angry and unpredictable figures from my past that could still unnerve me at times. I wondered if Darleen would glare at me, become angry, or walk out. I was being confronted by my own feelings but also recognized that my concerns were rooted in the reality of this client’s potential for violence. Aside from apprehension about Darleen’s anger I worried that a confrontation could truncate her therapy. I vacillated between roles: I was simultaneously the enforcer, the victim, protector, and therapist. The challenge I faced-to manage my feelings while carrying out the intervention I believed to be in her best interests-was hardly unique, but I felt like a pioneer in uncharted territory. Intuitively, I sensed it was important to be firm with my policy, to bring structure to the intersubjective field, rather than manage the issue in a more collaborative manner, as I might do under other circumstances.

In those moments I also understood the importance of this event to my development as a therapist. The gnawing archaic question of the value of my services floated into consciousness and hovered. I entertained the possibility of suggesting a reduced rate for the missed session, questioned the wisdom of my decision to enforce my policy, and probed my memory for supervisors’ teachings, or for readings or discussions that would either endorse my position or support an amendment to my policy, this one time. Knowing that Darleen longed to feel loved I considered the possible benefit of enacting the role of nurturing parent by waiving my fee, an option that reflects the struggle of many women therapists who feel obliged to take on the role of nurturer, sometimes at great personal sacrifice. Such selflessness is consistent with personal relationships in which women’s caring is expected, no matter what the cost to them (Bograd, 1991; Philipson, 1993). The expectation is that because women are “naturally caring” they should provide services without payment or they should accept less payment than would a man in similar circumstances. My profession makes a worthwhile recommendation that members provide a portion of their services pro bono, but it is important to be clear, in each case, about the reasons for doing so, otherwise women risk colluding in their own subordination, and the implicit message to other women will be that they should do the same.

Ultimately, I recognized my fears and attempts to divert from the path I needed to take, and agreed with Furlong (1992) from whose work I inferred that failing to charge for this session would have constituted acting out my wish to avoid Darleen’s anger. Still, I was tempted to flee from this responsibility and felt concerned about my capacity to hold her anger and remain fully present for her. I knew that I needed to ride the waves of her anger without fleeing emotionally, without compromising my integrity or becoming resentful. If I failed to act on my cancellation policy I might have sustained an unconscious resentment of my client and disappointment in myself, an unhealthy mixture the best antidote for which is to act from an ethic of self-care. In this instance, self-care meant staying with the policy I had established for occasions such as this.

Imagining myself in Darleen’s position, I knew that she, too, needed this opportunity. For her, the challenge would be to work through her anger safely and non-aggressively with the very person whom, in that moment, she would view as another soft-voiced oppressor asking for her compliance. In this, I am not implying that provoking anger in a client is justifiable. Rather, I knew intuitively that Darleen would be angry and that she often felt anger she did not express and could not resolve, leaving it to fester and foment inside. If I had taken another approach such as exploring with her at length the issue of payment, we may have been spared the expression of her anger in the session and she may have taken responsibility for payment. It seemed likely, however, that she would have felt shamed or manipulated and resentful, a conclusion I reached thinking about her frequent references to the lengthy, seductive conversations used by the woman who had sexually abused her to manipulate her into complying. Moreover, if I had let my fears prevent me from standing firm on my policy, I would have inadvertently reinforced her sense of being the aggressor, a part of herself that she feared and disliked, and she would have been left with a model of fear rather than strength. Keeping these things in mind, I decided to enforce my policy, carefully and straightforwardly, treating her simply as an adult involved in a transaction with another adult. I both feared and hoped that in response she would express her anger, and hoped that I would be strong enough to contain it while helping her to explore all its components both present and past. If, instead, I became preoccupied with concerns about myself in this session, I would be unable to tend to her needs or to maintain “sustained empathic inquiry” (Stolorow et al., 1987) in order to explore the meaning of this event for her.

When I reminded Darleen of the policy she became angry and emphasized that she needed the dental work and had been able to take advantage of a cancellation rather than waiting months for an appointment. I explained that I supported her care of her health as well as her freedom to make choices, but in assuming I would overlook my fee for the missed session she was asking me to bear responsibility for her decision. Darleen’s expression softened and her mood shifted as she began to understand the reasons for my position, and we were able to begin the emotional process of exploring the meaning of these events. During the months that followed I noticed that Darleen was interacting with increasing self-assurance, vacillating less betwee...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Series Page
• Table of Contents
• About the Editors
• For Love and Money
• Psychotherapists’ Ambivalence About Fees: Male-Female Differences
• What Are We Worth? Fee Decisions of Psychologists in Private Practice
• Women, Mental Health, and Managed Care: A Disparate System
• The Function of the Frame and the Role of Fee in the Therapeutic Situation
• Payment for Missed Sessions: Policy, Countertransference and Other Challenges
• Reflections on the Symbolic and Real Meaning of Money in the Relationship Between the Female African American Client and Her Therapist
• Barter: Ethical Considerations in Psychotherapy
• The Price of Talk in Jail: Letters Across the Walls
• Private Practice with a Social Conscience