The Therapist and the Fee: Why Everything Works out and Also Doesn By Simon Yisrael Feuerman, PsyD, LCSW on 4/9/13 - 1:39 PM

A close friend of mine is a wonderful therapist, a child of the 60s, a gifted man, large-souled, big-hearted and wise. His practice nourishes him and is saturated with life. He is committed to a worldview that eschews anything close to greed. “I won’t ask my patients for more, at least not if I can avoid it,” he says. “Often I will wait years to do it.”

My friend’s position makes perfect sense to me. He is a thoughtful and principled man. His role as a professional is anchored in a deep caring for the poor and those who have less. People trust him and his love for them. Anyone can see why he is successful.

And yet what fascinates me is that there are practitioners equally effective who take the opposite point of view. They are practically bullet-proof around money. They regularly raise fees with no compunctions. One colleague, a psychoanalyst and social worker, charges $200 per session and raises the price every two years in $25 increments.

Both of these therapists have large practices and enjoy their work. Both of them claim that they work in the best interests of clients. In fact, my high-flying colleague insists that she raises her fees in order “to help” her clients. “It is selfish not to raise fees,” she insisted to me.

“Clients form an unrealistic dependency and attachment to me,” she explained. “When I raise them, it allows them to separate from me by getting angry at me. It helps me too to be sure, but it is also a gift to them.”

Who is “right”?

Of course, it would be difficult to establish what is right and wrong in a field where so many different, seemingly counter-intuitive actions can be therapeutic. Where else do you have a field in which the “giving” or “self-sacrificing” therapist who is easy on the rules, winks at missed sessions, lowers the fee at the drop of a hat, can often be counter-therapeutic?

And yet it is possible that both therapists are “right.” Each, by being whole-hearted in their approach, may have a struck a deal with their patients’ unconscious. In the case of my friend who almost never raises fees, he has communicated successfully to his patients a simple message: “I won’t easily leave you. I will be with you and be kind to you.” If you knew this man, you would know how genuinely he feels this and believes this and whole-hearted he is. This communication may be helpful to some people who have experienced the traumas of life. They trust his love for them and their love for him until they gradually integrate reality into their lives and mature.

The other therapist seems to have communicated the exact opposite message—that may be equally helpful: “I will always leave you. I will always raise fees and I will always take care of myself in this relationship as well as you.” Paradoxically, for some people, that may be a building block of psychological maturation. Patients may need to trust the therapist’s narcissism in order to accept their love. Bertolt Brecht once famously quipped, “I desperately need someone upon whom I can firmly not rely.”

The late Hyman Spotnitz, father of modern psychoanalysis asked: How do you know if someone needs treatment? He likened a person to a car. “If the driver turns the wheel to the right and the car goes right, or if he steps on the brakes and the car stops, he won’t need to bring the car to a mechanic. But if you turn right and the car goes left, or you brake and the car doesn’t stop, then you need a mechanic.”

People try to lose weight, to be better spouses, to not yell at their kids. We give ourselves all kinds of commands and yet some of us find ourselves moving to the right when we ordered ourselves left. Instead of saying no we said yes or the other way around. And we are astonished.

Many therapists are confused about what to charge in the first place and when to raise fees. One therapist in a supervision group I ran was skittish about her fees, but wanted very much to raise them. She drilled with the group over and over again: “I am going to tell that patient my fee is $150!” I am going to wash that man right out of my hair. And the group cheered her on: “You go girl!” But when it came to saying it to the patient, the actual number got stuck in her throat. “How much do I owe you?” her cooperative new patient asked her. “$110,” the therapist blurted out uncontrollably. “I hate myself,” the therapist later told the group. “I am a loser.” The group would have none of this self-attack. They warmly helped her to talk about her conflicts around money, which were deep, and within a short time she proudly set her fee with a full heart.

If you’re whole-hearted about what you do, as in the cases above, it usually works out just fine no matter what you do. If you are conflicted, it won’t and you, your practice and your patients will suffer.
We therapists may resist this as intensely as our patients, but most often, the way to find out more about what is right for you and what is in your heart, is to talk about it in treatment and supervision.

File under: The Art of Psychotherapy