"When we were negotiating the fee from the fee scale when I was an outpatient, 1 had saved up about $100 and I was sure you knew this from reading my mind, so when you figured out my fee from what I told you I had, I thought you were secretly going along with my deception because you wanted me sexually, so I broke treatment because I thought that was unfair. I thought I didn't have to tell you this because, since we were both FBI agents, you knew all about it already."*
This vignette from the therapy of a manicdepressive woman, discussing in retrospect her reactions to the setting of her clinic fee, illustrates the range oí possible confusions and misunderstandings that can arise around so apparently clear-cut an issue as money. The fact that this patient, when well, worked with money in a bank olid not prevent her from interweaving the concrete clinic fee with the agressive, libidinal, judgmental, and paranoid elements that characterized her illness.
The clinician is quite familiar with such interweaving of the "objective" and the personal; but it has been said that "often, money is harder to talk about than sex."1 Supervisory experience confirms that money as an issue is frequently omitted from consideration in planning treatment, medication, rehabilitation, and other aspects of patient care. As Havens has remarked, for example,
The problem [of the cost of medication] is heightened by the tendency of doctors to ignore money matters or to be appallingly ignorant of critical details concerning them. Psychiatrists often overlook even the relevant psychology of money: For example, many people would rather be sick than poor, or at least they would be willing to be less than healthy if they could remain relatively wealthy - something doctors seldom understand. . . .2
It is not our purpose in this series to swell the already-swollen files of reports in economic terms on mental health funding, or the lack thereof, on the national scene;* nor do we plan to speculate about the forces of capitalism, class status, anality, or the upsurge of mercenary concerns as they might account for the problem of insufficient attention to the role of money. Rather, we intend to review a spectrum of situations in psychiatric practice where money as a clinical issue enters into the therapeutic or administrative process and to highlight the significance of money in the clinical experience of patient and therapist as individuals. This series of reports is intentionally rich in case vignettes, in an effort to heighten the focus on specific, clinical issues.
We focus first on the patient examined in the detail made possible through the one-to-one: the interaction between fee for therapy and the therapeutic process reveals the complex dynamic reverberations evoked. The general topic of fee setting is given a unique and thought-provoking treatment as regards its therapeutic potential. We then consider money as it enters into the experience of beginning private practice. The interface between patient and hospital ward is next studied through the symptom of window breaking as a milieu event, with the administrative, therapeutic, and ethical questions arising from the act of charging patients for this form of damage.
We subsequently describe the explosion in a supportive therapy group when the question of fees is raised. The next article illuminates how the abuse of Sodai Security Insurance - ostensibly a minor criminal offense against public funding - can represent a central aspect of the patient's psychopathology while stirring the therapist's countertransference responses. Another public funding issue - disability - is investigated for the lessons it contains concerning the clinical meaning to patient and therapist.
Finally, in our last article, we consider the impact of patients' being transferred from private sector to public sector because, for a variety of reasons, the money runs out. A selected bibliography on money as a clinical issue is appended. Through these articles runs the theme of the difficulty - and the importance - of talking about money as a therapeutic issue.
In a survey so broad, we cannot avoid raising many more questions than we can possibly answer; fortunately, this is our hope. In the "gold rush" to ensure funding, there is a danger that the individual patient will be trampled underfoot unless attention is called, repeatedly, to his personal experience. His experiences related to money have been undeservedly neglected in the literature. As clinicians it befits us to study ourselves and our attitudes as we confront the ever more urgent and complex question: Who will pay for a patient's care? Our thesis is simply that far more attention needs to be paid to money as a clinical issue; this series of articles is an attempt at a beginning.**
To protect the confidentiality of the patients described, we have fabricated composite and fictitious histories in regard to all but the essential monetary details.
1. Balsam, R. M., and Balsam, A. Becoming a Psychotherapist: A Clinical Primer. Boston: Utile, Brown & Company, 1974.
2. Havens, L. L Some difficulties in giving schizophrenic and borderline patients medication. Psychiatry 31 (1968), 44-50.