Money is an underdiscussed topic in graduate programs, supervision and peer groups, yet every therapist I know has felt the awkwardness of seeming mercenary when insisting to a client who has fallen behind that he or she needs to pay. Unfortunately, most therapists were never coached about how to reconcile the closeness of the therapeutic encounter with the fact that therapy is also a business. When I first started out, I made the mistake of letting my caretaker impulse overcome me and charging a certain client who was in crisis a lower fee for several sessions. When she didn't pay even that fee and later let it drop that she had gone on an extravagant vacation, I felt like a fool. It has taken me years to understand that therapy is not separate from the exchange of money. I am in this profession because I care and have skills and knowledge that can help, and I also need to make a living.
These days, I run into the problem of clients who don't pay far less frequently than I used to. I attribute this to two changes I've made. The first was convening a peer group to discuss money issues. We examined our family values and messages about both the importance of money and the secrecy that often surrounds money matters, while also looking at the impact of social messages about gender and earning potential. When I heard everyone's war stories about clients who owed hundreds of dollars or terminated therapy without paying, I realized that my discomfort with money wasn't a character flaw, but a deficit in my training. More than anything, doing this personal exploration is what prepared me to explore the topic with my clients. The second change I made was developing a few practical steps to make it more likely that my clients will pay on time: prevention, intervention and having a bottom line. Prevention involves setting clear boundaries up front about my expectations regarding payment. I give written guidelines to clients during the first session that explain how I run my business: I prefer to be paid weekly, but will accept payment monthly; I charge for missed sessions unless clients give me 24 hours' notice. My guidelines also extend to questions about sliding fee scales and how much notice I give before I raise my fee. I ask my clients to read and sign die guidelines while they are in my office. The next week, I follow up and ask them if they have any questions or thoughts about them. Even though it's not legally binding, the document signals a commitment to take the business side of therapy seriously. Later, if money issues come up, I show them the signed copy I keep on file.
Of course, having a signed piece of paper doesn't eliminate conflicts over money. When the client's checks keep bouncing or are never sent, I have to intervene. One client, Sherry, was four weeks behind in her payments, for which she offered a series of reasonable excuses. The next week, Sherry's session focused on a very intense description of an episode of childhood abuse. But when she got up to leave at the end of the session without paying me, I cleared my throat and said, "So, today is the day you need to settle up for the last few sessions, as we agreed." She was upset that I could care about money after she had just revealed her deepest pain. At that moment, thinking about money as a boundary made it easier to stick to my guns. Sherry's not paying was not only a violation of our contract, but a replication of old family patterns in which uncomfortable issues were not discussed and boundaries were regularly violated. My kind but insistent tone let Sherry know that I was not her mother or her best friend, and that money was a fact in our relationship as surely as the clock that told us when it was time to end the session. Although she was angry, she wrote me a check before she left.
At the beginning of the next session, Sherry talked about feeling humiliated that she had to pay someone to care about her. It gave us an excellent opportunity to talk about the therapeutic relationship, what she could expect from me and how I was different from a friend or parent. I saw this conversation as a deepening of the bond of trust between us. She admitted that my treating her like an adult by expecting her to pay had given her a positive sense of herself as being capable and mature even while she was exploring her childhood wounds.
Having a bottom line about our fees is hard for all of us in the helping professions. It doesn't mean cutting off anyone who doesn't pay like clockwork, but it does mean not being a doormat. I try to catch potentially disruptive money issues by dealing with clients' accrued balances in a timely way. I also address clients' resentment at being charged for a missed session that they forgot to cancel and explore their expectations of how "understanding" I will be when they tell me about financial hard times. With some clients, there has come a point at which I have had to recommend that they take a break for a few months until they can catch up on payments, or I've discussed options such as coming in less often to make therapy more affordable. There are very few cases in which I have had to say to clients, "No more therapy until you pay me for the sessions you owe." Sometimes, hearing that I am going to be that firm about payment jolts clients into action and a check appears in my mailbox. Other times, the client hears it as a rejection and leaves in anger. I try to leave the door open as much as I can, while at the same time holding to my bottom line. I am always on the lookout for creative options. One colleague who had past experience of clients who ended therapy without paying their balances now asks clients ending therapy to write postdated checks that she can cash throughout the year. It has cut I down on the amount of collections she has to do, and makes it easy for clients, who don't have to remember to send money every month.
The only way I can make sure that money issues don't harm the therapeutic relationship is to be self-aware enough about my own issues around money, and then be willing to raise the subject with my clients when it comes up between us. There is an old truism: that therapists are more comfortable discussing clients' most intimate sexual details than talking about money. This is no longer true in my practice. I now welcome the opportunity to examine the meaning of money with my clients. Our clients are not going to lead the way. When money issues come up in therapy, it's up to the therapist to blaze a trail of openness, honesty and healthy limit setting.
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Photo © Valentin Armianu
Topic: Business of Therapy
Tags: boundaries | boundary issues | building a private practice | business | Business of Therapy | ethical issues | healthy boundaries | money | peer | private practice | professional boundaries | psychotherapy business | supervision | therapy business