Thank you to everyone who responded to the November Clinician's Quandary. Here are some of the top responses! (Submit to next month's Clinician's Quandary here.)
November Quandary: I’ve been working with my client Carla for about six months. In the past, she’s been good about paying for sessions on time, but she recently lost her job, is short on cash, and has missed her last five payments. She still wants us to meet weekly, but says she’s unsure when she’ll be able to pay me in full. Although this isn’t sustainable for me, I’m trying to be sensitive to her situation. How should I proceed?
1) Suspend Therapy, but Keep Communication Open
How I handle clients who couldn’t afford to continue therapy always depends on their financial situation and where we currently are in therapy.
In one instance, a client I’d worked with for several years had long been struggling with debt related to her partner’s disability. She was quite embarrassed about it, so much so that she even viewed her credit score as a measure of her self-worth! In therapy, we talked about how incurring debt with me might affect our therapeutic relationship. Knowing that she’d been conscientious about paying off her other debts, I trusted that she’d pay off her debts to me eventually, and she did. Later, her insurance changed to a plan I don’t accept. This posed an even greater challenge. We continued therapy for several months, but eventually I referred her to another therapist who accepted her plan—a decision that was ultimately in her best financial interest.
In another instance, a young client of mine had aged out of her parents’ insurance plan, and her employer didn’t offer health insurance. We were in a difficult position since we’d spent months building a therapeutic relationship. She’d had trouble trusting other therapists in the past and suffered from complex PTSD, so I knew that referring her out would be tricky. Together, we worked out an arrangement where she’d come to therapy whenever she saved up enough money to do so. Between sessions, we decided to stay in touch through email and text, so as not to lose momentum in our work.
Although a solution like the latter may be a bit unorthodox, it’s worked for me. In this therapist’s situation, I’d find an approach that works for both me and Carla—without dropping therapy entirely, if possible. But as a general rule, I do my best to educate myself and my clients early on about how their insurance works and how much they’ll have to pay out-of-pocket, so this doesn’t disrupt therapy down the road.
Lisa Jaynes Johnson, LMFT
2) Don’t Be Afraid to Be Unconventional
It seems to me there are several choices for what to do with Carla. The first would be to continue seeing her for therapy and hope that, eventually, you’ll get paid. This probably wouldn’t be a good business decision, although it’s may be the simplest. The second option would be to stop seeing Carla until she catches up on her bill, but depending on Carla's issues, this may cause you to lose ground gained in your work with her. Another option is to refer her to someone who has a sliding-scale fee or is used to treating clients who have trouble affording therapy and has procedures in place to deal with this.
If I was this therapist, I’d ask Carla to bring in a list of her monthly expenses and we’d compare it against her monthly income. It’s possible that she isn’t budgeting properly, in which case I’d use this as an occasion to teach her how to create a budget and stick to it. In the process, we’d determine how she might adjust her budget to pay for therapy on a regular basis, even if she can’t afford to pay 100 percent of her bill every time. I’d make reviewing her budget part of weekly homework assignments and make a point of covering in each session how she’s handling the adjustment. We might even draw up a contract that outlines the plan and lists consequences for us working together should she fail to stick to the budget. This exercise might seem unconventional to some, but I think it could be very therapeutic for Carla.
Mitchell Davenport, LPC
3) Look for Therapeutic Relevance
I always keep my clients’ credit cards on file as part of the intake process. This increases my leverage and comfort in the therapeutic relationship, so I can focus on quality therapy without spending my energy thinking about when or how I’ll get paid. Still, even with this cautionary step, financial issues inevitably arise, especially when clients like Carla lose their job.
I see therapy as an equal partnership; my feelings not only matter, but have therapeutic relevance. Thus, in this situation, I might ask Carla how she believes I feel about not being paid for my services. It’s vital to have a soft, curious, yet serious tone when doing this. It’s an opportunity to show self-respect in the therapeutic relationship and it could be an important therapeutic moment for Carla. After all, if you’ve felt taken advantage of as her therapist, then other people in her life may have too.
Ultimately, if Carla’s inability to pay isn’t sustainable for you, it’s essential to set a firm yet compassionate limit on when you need fees paid, and be willing to provide lower fee referrals if she simply can’t pay. As an alternative, some therapists reserve spots in their practice for financially challenged clients. I recommend having a sliding-scale fee chart handy as part of your professional disclosure statement if you’re one of them. A last option is a payment plan: can Carla credibly pay what’s owed when she gets a job by a certain date?
Jason Linder, MA, LMFT
San Diego, CA
4) Put Your Foot Down, Compassionately
The critical issue here is that what Carla is asking for isn’t sustainable for the therapist. Still, that doesn’t mean you can’t model self-care and compassion at the same time. There’s an old rabbinical saying: If I am not for myself who will be, but if I am only for myself what am I, and if not now, when?
So how can you be sensitive to your client under these circumstances? In this therapist’s position, I’d work on winding down therapy, helping Carla create an exit plan that focuses on strengthening her sense of personal autonomy and competency.
Perhaps a good place to begin is with Carla’s request to continue in therapy even though she has no idea when she might be able to pay. This could indicate feelings of vulnerability and dependency that would be worthwhile to explore with her. I might also explore the other challenges she’ll undoubtedly face as she cuts back on expenses she’s become accustomed to, including the emotional discomfort she’ll probably experience. Finally, in terms of getting treatment during this rough spot, I’d suggest Carla start looking for more affordable therapy, perhaps in the form of online or group therapy, or community mental health services aimed at low-income residents.
This therapist will need to decide how much more time he or she is willing to devote to Carla before they terminate therapy. I’d want to come up with a date for a final appointment where these next steps are discussed. The more detailed your exit strategy, the more likely it is to succeed. Depending on how you feel about it, you might offer brief, occasional check-ins via phone for a specific period of time while Carla negotiates the new transition. But however you proceed, you can’t put off dealing with this issue for too long. Doing so will only send ambiguous messages that increase the potential for distress on both your end and hers.
5) Look for Therapy in Other Forms
How I’d react to this situation depends in part on where Carla lives. In some countries like Australia, for instance, people are reimbursed by Medicare for up to 10 therapy sessions annually, although this might not help too much if Carla wants to meet weekly. The bottom line: I’d start doing some research to find out what kinds of services are available to Carla, either less expensive therapy—at community health centers, for instance, or rebates that will help out with costs.
If I was working with Carla, my decision would ultimately depend on our relationship, where we are in the therapy process, and my own financial needs. Offering weekly pro-bono sessions means taking a big pay cut, so I’d want to talk with Carla about her situation in more depth to make the best decision possible. I’d ask her questions like “What’s the likelihood of you getting a job soon?” or “How do you feel you can be best supported by others during this time of financial strain?” The focus should be on helping Carla meet her basic needs, and her community and family could play a large role in helping her bounce back.
If we ultimately decided to terminate therapy, I’d let Carla know that I’d hold a place for her in my schedule if she was ever able to return, and tell her she can resume where we’ve left off at any time. I’d explain why it would be irresponsible for me to let her debt accumulate if it doesn’t look like she’ll be able to pay off her sessions any time soon.
We have to do what’s best for our clients and ourselves. We therapists are providing a service. Our clients have to be aware of this and can’t always expect us to accommodate them, especially when there are other therapeutic avenues, like community and family, available.
Fiona Tischmann, LCSW
We'll post a new response to each Clinician's Quandary on the first Tuesday of every month! See how to submit to next month's Quandary here.
December Quandary: I know that accepting gifts from clients is an ethical no-no, but when my client Asha recently gave me a homemade necklace (a shell she’d found on the beach and strung on a piece of leather), it seemed innocuous enough to thank her and keep it. Now she asks about it at almost every session, wondering why I’m not wearing it and if I still like it. Asha and I have been working on her attachment issues, a likely result of childhood neglect. I think I can turn my error into a therapeutic teaching moment, but I also worry that by offending her, I may lose her as a client. What are some ways I can best handle this?
Photo © iStock/SIphotography
Tags: Alliances | business | Business of Therapy | Challenging Cases & Treatment Populations | challenging clients | Challenging Clients & Treatment Populations | Community health care | community mental health | money | psychotherapy business | rapport | self-care | therapeutic alliance | therapy business | Unemployment | Clinician's Quandary