The therapist's uneasiness in coping with fees reflects the special emotional loading of money in the United States as well as the therapist's own attitudes, guilts, and countertransferences. Fees in a group situation are especially meaningful barometers of the therapeutic relationship and the many problems they pose deserve careful scrutiny.1
Recent articles2"7 have focused on the resistances in both patients and their therapists to discussing freely their feelings about fees. The problem seems most evident in nonprivate clinic settings, frequent sites of residency training. This article seeks to examine the affective currents and dynamic issues set in motion by the initiation of a fee in a previously nonpaying group. It is suggested that inquiry into financial issues provides a powerful stimulus to thrust into awareness previously latent feeling states.
The subject group of six members had been in existence for two years and was viewed by the institution as an aftercare group for one of the inpatient services (as distinct from an outpatient group under the aegis of the outpatient clinic). Outpatient billing practices had not been established for this group, perhaps in part because of this administrative association with the inpatient service.
Consistent with the absence of a fee, the group culture was viewed as highly supportive, with few demands being made upon the members of the group. Working with the group had provided a richly rewarding experience for its two cotherapists - a resident, who was leaving, and Ms. O'Loughlin, a psychiatric nurse, who stayed on. As the resident had said, "The framework of the group is support, acceptance, and consistently positive responses to each other's needs; there is little pressure in explanation of absence."
Both therapists agreed that the group members, although "supportive," were highly capable of introspection, keen insight, and strong feelings. Now the members believed that a new doctor should be found to replace the departing resident, who had been with the group since its inception.
Dr. Vasile, the new resident, was introduced as cotherapist. During the first month after his arrival, the billing issue remained submerged at the group's weekly meetings as other affective currents swirled in the group process. Then the new resident received the monthly billing sheet (a computerized print-out); it immediately became clear that the group members, to the resident's surprise, had never been billed for group therapy. The new resident had firmly believed that some fee, however small, was integral to the process of psychotherapy and had assumed that some arrangement was already in force. The nurse cotherapist, when asked, acknowledged that she had never considered the issue.
BACKGROUND: BILLING POLICIES AND THE INSTITUTION
Recently, fiscal pressures (as much as therapeutic concerns) had contributed to an increasing awareness of the importance of fee collection on the part of the institution. Residents were alerted to this concern, billing practices were computerized, and more vigorous thirdparty collections were made, resulting in a 100 per cent increase in the clinic's revenue over two years. On one occasion, in fact, some months before his departure, the previous resident had received a notice concerning the new, more stringent outpatient billing practices; he had at that time assured the group that no fee would be required and that any bills sent in error were to be disregarded.
The institution expected that some fee would be charged commensurate with level of income as follows: 1. Persons with incomes greater than $12,000 per year were generally referred to a private therapist. 2. The maximum fee by state law was $11.83 for those with incomes greater than $10,000 per annum; third-party payers were billed this amount. 3. Physicians might bill patients with public third-party coverage a portion of the bill, welfare paying $8.83 and the patient $3 per visit. 4. Residents were permitted to charge no fee if indicated and if they so desired. The crucial feature of this arrangement was the high degree of discretion allowed the resident in setting a fee; he or she could charge any amount up to $11.83 or waive the fee entirely, with little explanation to the administration.
Consultation on the billing issue in weekly group supervision was obtained by the new therapist from a newly assigned staff supervisor, who strongly supported thé idea that some fee should be charged. The decision was made that the issue of billing would be discussed in the next group meeting. This event in the history of the group, coming at a time of transition - termination with one cotherapist and beginning with another - had profound ramifications. To examine this experience, we provide a brief outline of the group members (Table 1) and a chronology of their meetings before and after the date of fee setting.
GROUP MEMBERS (Altered Data)
During the first few sessions the new resident attended, the group struggled with the loss of the departed resident cotherapist, "Dr Williams." Jim missed the first group meeting and showed up at the second session in time to say good-bye. The overall mood of the group was one of depression and loss.
None of the group members spontaneously acknowledged the loss of Dr. Williams, but each spoke of his or her longing for a previous individual therapist. Scattered absences occurred during these first meetings as feelings of loss proved difficult to bear.
Jim denied missing Dr. Williams; the doctor, he said, had "taken from the group but given nothing." Martha told Dr. Vasile: "I miss Dr. McGraw [her previous individual therapist, who had departed a month earlier], and I can't get along with you." George said that the group, since Jim's departure, was "a car without a motor." Bill deflected an inquiry about missing Dr. Williams and praised the new. doctor, commenting on how he had worked as a first-year resident, "running around like a fire truck on the ward." Group members looked to the nurse cotherapist as a "familiar face" and joked about her appearance and charms. Bill noting that she was "a nice girl."
The topic of billing was broached in the first few minutes of the sixth group meeting. The new cotherapist stated matter-of-factiy that the monthly billing slip had arrived and that he had discovered that no group members had been billed. A stunned silence greeted this statement. Pronouncements were made by the patients, in turn, that billing was "not a part of the group." Bill noted that he was "doing the people here a favor by coming to the groups." After the new cotherapist asserted that some payment should be made, Martha angrily denounced the resident as a "bad person." "I hate you!" she said, storming out of the room. Joyce placed a dollar bill on her lap. "I'll give you this now and then I'm through," she said. "This will cover the prescription I want you to write." She continued to insist that she would leave the group if any payment were required. Pam asserted that the doctor had raised the issue for discussion. The group had decided not to pay, she reasoned; the decision was thus made, and no one would pay.
The resident reiterated his position that some payment would be required - whatever people felt they could afford. He was supported by his cotherapist, who attempted to explore why group members were willing to spend money to bring doughnuts to meetings (in fact, one member, Joyce, had brought $1.50 worth to that particular meeting) but did not want to pay the clinic.
Bill apologized for Martha's leaving the meeting. But he noted that the group was "voluntary" and that he would never have come if he had known he would be charged. The group agreed to discuss the issue further at the next meeting. George announced in parting that he would not pay, but he refused to say why.
A tense atmosphere marked the next group meeting. Joyce did not return. Martha was present and apologized for leaving the meeting of the previous week. She expressed a willingness to pay $1.50 per meeting. The resident noted that the standard group fee was $3 per visit. Individuals discussed what they could afford. Pam described her experience paying other doctors. George commented that he had paid his inpatient bill - not required by the institution - and that it had amounted to close to $3,000. Bill mentioned paying his individual doctors "for the medicine and a blood pressure check." He noted that he would be willing "to slip you a dollar under the table each week - I just don't want to see the bill in the mail."
George also spoke angrily of too many bills in the mail. Martha and Bill nostalgically reminisced about their inpatient experience, recalling the many things they were forced to do, such as taking psychologic tests. Bill and George described young new attendants who pushed people around, abusing their power. Bill, Pam, and George all asked why it was that the members of their group had not been billed as all the other groups were. Bill suggested that the group call up the departed resident and ask him directly.
The therapists' efforts to encourage expression of feelings at not being billed were deflected. The question was raised: Why did the cotherapists think that making some payment was so important? Pam said she understood how a professional would wish to be paid for services rendered. Martha insisted that a decision be made about her having a new individual therapist; moreover, she had never been asked for payment. George observed that he was considering seeing his previous therapist privately and noted, "Psychiatrists are poor psychologists when it comes to paying money." Pam commented near the end of the meeting that Martha had told her over the phone that she could not go on without an individual therapist. Martha sat quietly and then told Pam, "You shouldn't have told them."
The eighth meeting with the new resident began with Pam lamenting about the "breakup of the group" over the money issue. Martha was no longer talking to Pam and was absent at this group meeting; she had been assigned an individual therapist, though she was expected to continue with the group. Joyce had not returned. Bill regaled the group with his navy experiences - he said he had been manic on the deck of his aircraft carrier, waving in the planes while psychotic. He spoke briefly of missing Joyce. At the end of this meeting, group members were told they would be receiving a bill in the mail for $1; they were assured that the issue of how much to pay remained open for discussion until the group resolved how much each member would pay, be it 10¿ or the maximum fee of $3. The $1 fee was an artifact of the computer billing format, required for the billing lists. Both Bill and George spoke of wishing that they could pay the cotherapists personally; they were assured that this would be considered. The group was given four weeks to reach a decision.
One morning before the next group meeting, George presented himself to the outpatient clinic, angrily waving a bill he had received for the group. The new cotherapist was paged to discuss the matter with the irate patient. George threw the bill at the resident's feet, insisting that he had been deceived; he would not pay $1. "I can't stand these computers. You said we could pay anything!" Efforts to reassure George were to no avail. He strode off enraged, asserting, "I'm finished with the group."
The following group meeting was unattended; the cotherapists sat alone. They speculated that the mailing of the monthly bill might be a major cause of the absences. The next day Bill was waiting in the lobby of the hospital for his appointment with his new individual physician. When the resident cotherapist inquired about his absence from group, Bill blushingly smiled and stated, "I'm through with the group - I've gotten all I can out of it." He was assured that the door was open for his return.
At this point the group was in disarray. The cotherapists decided to continue meeting during the same hour, awaiting the return of the group members. The next meeting was marked by the return of George and Pam. A mood of sadness and anger was apparent. Pam noted that it was reasonable to pay a fee, but she did not like the way it was handled. She observed that it was difficult for others to deal with the change from the previous resident, who had required no fee. George said he would pay $1 but expressed resentment that he had received another bill. He then expressed bitterness towards the women in his life - two chronic schizophrenics - who repeatedly took money from him, often in sums of $50 or $100, to buy gifts for themselves. He lamented about having recently been deserted by one of these women, who had left for New York, paying the fare with money he had given her! He reviewed the experience of paying his inpatient bill: "I just did it, that's all" - a distinctly atypical behavior in a state hospital where in patient billing usually yields very low return. He noted, "I've given them enough - I'll pay you, but not the hospital." The absent members were discussed. Pam felt that Joyce could not afford anything. Pam then noted that she was "high," with racing thoughts and insomnia despite having taken chlorpromazine; precipitants of this state were not clear to her. Discussion focused on her regulating her lithium and chlorpromazine. She denied being upset over the threatened dissolution of the group but noted that "it's a real shame."
The next group meeting was marked by the return of Joyce: "I figured I'd come back." George had visited her on her job and had appealed to her to return, insisting that the money issue was still not settled and that she did not have to pay $1. Joyce remained silent. She was encouraged by the other two group members to pay something, perhaps only 10¢ per visit. George again spoke of the woman he had financially supported, who had left him to live in New York. While discussing this, he stood up to leave but was persuaded to stay in the room and share his feelings of bitterness. Pam mentioned paying the full $3 fee, then noted that she would prefer to pay $2.50 "because I think all medical care should be free." Bill was called by George during this meeting and was asked to return - an invitation he declined.
The ensuing meeting was noteworthy for its depressed mood. George spoke sadly of his lost girlfriends. Joyce commented on her vegetable garden and then noted that she was supporting a brother with chronic back pain, giving him close to half of her weekly check; she felt unable, however, to give much to the group. Joyce and Pam spoke of a resident who had cared for them years ago before becoming ill and being forced to leave the program suddenly. Pam spoke of her frustration at not being given a chance to terminate and regretted that this resident had known her only when she was an inpatient. She fondly recalled the previous group cotherapist, who had cared for her medically as well and had initiated a trial of lithium that had substantially improved her life. "He told me I deserved a trial of lithium a long time ago. I owe him a lot." She then disclosed that she had been feeling much better, sleeping well with the aid of chlorpromazine and no longer "high."
The next meeting focused on attempted reintegration of the group. Joyce did not appear. Pam commented that Joyce had given $2,000 to each of her sons (her life savings) in recent months. She had a marginal relationship with them, however, in that they saw her only twice a year "to install and remove the air conditioner." George noted that he was receiving an 18-year pension as opposed to the 22-year pension that was due him from his employer. "They made a clerical mistake. I never asked them to correct it." Pam observed that Martha was no longer talking to her since leaving the group. George and Pam spoke sadly of being abandoned.
Follow-up. Jim was lost to follow-up. Martha was meeting with her individual therapist and had agreed to pay $3 per visit, with the balance being paid by health insurance. She spoke of her rage at the new cotherapist for "not giving enough and being too strong." She had met the group's previous cotherapist on the street and asked him to see her individually, saying that she was willing to pay; this offer was declined, the former resident citing institutional constraints on his assuming more patients. Martha once called the nurse cotherapist, seeking a favor: the purchase of hospital meal tickets - this had been a custom in the pre-fee group. Bill continued to see his individual physician, paying him $3 per visit through SSI.
This article describes the experience of initiating a fee in a group that had previously functioned free of charge. The feelings mobilized by this alteration in policy, coming as it did at a time of termination from the previous (non-fee-demanding) cotherapist, included shock, rage, and mourning. Those who returned to the group exhibited a capacity to grieve and bear depression. The initiation of a fee seemed to crystallize the feelings of anger at being abandoned by the previous resident; it also mobilized feelings of entitlement (patients felt the hospital owed them something, not the other way around) and revived latent conflicts over dependency; these conflicts may have involved guilt and shame over being hospitalized for long periods without paying. These issues were largely camouflaged by the mechanisms of denial, projection, distortion, and displacement.
Strikingly, the fee engendered discussion of concrete financial issues of great significance. Patients' descriptions of their "money behavior" with others revealed much of their own psychic economy. The undifferentiated potential of the issue of money renders the examination of a given patient's "cash flow" a remarkably sensitive barometer of their most urgently felt needs, both material and psychic.
From the point of view of group behavior, the initiation of a fee bore rich "dividends." It allowed the group to experience the cotherapists' capacity to bear group rage and depression. The fee became a focus of dynamic issues about giving and receiving, dependence and independence, altruism and exploitation, infantilization and maturation; without the institution of a fee, these feelings might well have remained unexpressed, given the group tradition of "support" without exploration.
The importance of attention to money matters in psychotherapy has been stressed in the sparse literature on the subject. Balsam and Balsam8 have reviewed the intensely conflict-laden issues concerning finances; for the resident early in training, issues of self-worth may be paramount; the tempting narcissistic gratification of being an all-giving savior may prove more alluring than asking for a fee, especially when the patient denounces the therapist as uncaring and concerned only with money. These pitfalls seem most apparent in a setting such as a clinic, in which an atmosphere of unreality about fees is engendered by a maze of welfare, disability, and other third-party regulations. The importance of working through "agency" interferences to the psychotherapeutic relationship has been discussed elsewhere.9 In the group process described. Bill and George bitterly objected to paying the Department of Mental Health, stating "We pay our taxes!" It should be noted that the previous resident agreed with the group that George's voluntarily liquidating his inpatient bill was uncalled for, thus establishing a precedent for later nonpayment.
Other authors have directed attention at the phenomenon of a "covert conspiracy" between therapist and patient to avoid discussion of fees, reflecting a refusal by both to examine unfulfilled dependency yearnings and to assume personal responsibility.2 Examining the experience of a resident clinic at a teaching hospital, Pasternack and Treiger3 reported a fourfold increase in clinic revenues after residents' feesetting behavior was scrutinized. The residents themselves reported an increased sense of realism and self-esteem about the quality of their work, once conflicts about charging a fee were elucidated.*
Threats to effective psychotherapeutic relationships engendered by free psychotherapy have been described;2 patients may experience guilt over paying nothing and may feel a sense of obligation to the therapist. The absence of a fee may be viewed as a seduction. The destructive potential of this unexamined sexual fantasy is self-evident; in fact, Martha developed highly eroticized transferences to her non-feedemanding male therapists. (Her new female individual therapist noted that Martha felt "punished" by being assigned a woman therapist and spoke excitedly of her longings for her departed male therapists.) Finally, covert acquiescence to the patient's wish for oral gratification by charging no fee eliminates the opportunity to examine resistance related to giving in more general terms and hinders the patient's commitment to self-exploration.
Yet money need not be viewed only as a patient's "Rorschach test" upon which fantasies and wishes are projected; it also represents the "royal road" to understanding the activities of daily living. Examination of a schizophrenic's wallet10 has been viewed as a valuable source of information for the therapist; scrutiny of the expenditure of what was in it may prove equally intriguing. Two patients, Joyce and George, revealed striking facts about their personal lives - the former spending thousands of dollars on relatives with whom she had sparse contact and the latter giving substantial sums to rejecting, manipulative women in a vain effort to gain their favor. These revelations about their psychic economy were facilitated by discussion of their money behavior.
Transference and countertransference issues, in settings where fees are not paid by the individual (or are prepaid), may create in the therapist a special sense of liberation from being "sullied by base financial matters"; this attitude may lead to loss of the opportunity to examine conflicts concerning money.11 It has been suggested that a tendency to view patients in more impersonal terms may be evoked in the therapist when direct fee for service is not required.4 The critical point is that denial of the importance of the payment arrangement and the patient's feelings about it gravely threatens serious psychotherapy. Further, there need be no "deification" of a private fee; a $1 payment may create a professional climate and represent a real sacrifice to an indigent mother; a $5 fee may be meaningful to a debt-ridden college student.
Review of the literature reveals conflicting estimates of the importance of the fee arrangement to the psychotherapeutic outcome. Kadis and Winick/ focusing on fee payments in group psychotherapy, noted that the therapist may feel more threatened by confronting several patients from whom he is asking for money; they viewed money behavior of patients in groups as a critical barometer of group process. Schonbar5 contrasted the transference and countertransference impact of fixed (clinicestablished fee) versus flexible (therapistestablished fee) billing practices and observed that a flexible system "may in the long run put more pressure on the therapist to face his neurotic conflicts." Koren and Joyce6 examined the fashion in which the fee is utilized "to act out feelings and to manipulate the treatment relationship." They found that when fees are not charged, "infantile dependency reactions are perpetuated."
Efforts to "objectify" the effects of fee payment have been reported. Pope et al.7 retrospectively examined records of 434 clients at a mental health center and found no significant effect of fee assessment on "treatment outcome," once diagnosis and socioeconomic status had been ruled out; effects of therapy in this study were very broadly defined by gross ratings. Conversely, Stanton12 compared two weight-reduction groups and found significant weight loss only in the group that was charged a fee. Davids13 presents a theoretical justification for his belief that fees do influence therapeutic outcome, postulating that they produce a pressure to achieve results if they represent a significant sacrifice to the patient. Thompson and Handy,14 examining the effect of charging college students $5 for utilizing a testingcounseling process, found no influence on students' evaluation of services in institution of a fee, but neither the counselors' nor the clients' attitudes towards the value of the tests were controlled in the fee and the no-fee groups.
SUMMARY AND CONCLUSION
The impact of initiating a fee for group psychotherapy in a previously nonpaying group has been described.* Our experience supports the notion that attention to feelings related to money matters provides a rich source of dynamically significant material and creates a climate conducive to serious psychotherapy; it fosters the examination of resistances that remain undisturbed in a nonpaying setting. Group members in the non-fee-paying period felt that "showing up for group" was a favor, giving enough to the psychotherapy. This article does not purport to "disprove" the usefulness of "free" psychotherapy if the objective is "supportive," by which we assume is meant treatment designed to "seal over" areas of conflict and resistance without effecting significant behavioral change; but even this process, as noted above, may not be without adverse effects.
A second conclusion drawn from our experience is that examination of fee practices serves to stimulate profound countertransference feelings, which not infrequently inhibit consideration of financial matters. For the resident cotherapist in the group described, the wish to avoid raising the fee issue reflected feelings of uncertainty of self-worth in the group setting, a new arena for him; he experienced feelings of anxiety and dismay in realizing the enormity of the task of dealing with the rage evoked by his insistence on a fee.
For the nurse cotherapist, fee initiation at first resulted in anger at the new resident for "messing up" the group she had bravely held together for three weeks as she sought a new physician cotherapist. As the fee issue emerged she found herself feeling "worth something" to the group; there followed a transmutation from a nurturing nursing model supporting the "doctor-teacher" to an equal role in the treatment of the group. This role transition was keenly felt by the group members, who had grown accustomed to a less assertive nurse cotherapist.
In sum, the issue of fee payment resonated throughout the transference and countertransference in the group. It served to focus the sources of resistance against objectifying the relationship: resistances based on the wish that therapist be friend, mother, etc. It embodied reality issues - a jarring note for those who wished to use the group to gratify unconscious wishes - and it provided an idiom linking therapy to the concrete world of money behavior in the patient's past and present life. Ours is a money culture. Inattention to this reality in psychotherapy deprives patients of the opportunity to explore latent wishes and fantasies; it also deprives the therapists of the opportunity to re-examine their own sources of psychic gratification.
1. Kadis, A. L1 and Winick. C. Fees in group therapy. Am. J. Psychother. 22 (1968), 60-67.
2. Nash, J. L,, and Cavenar. J. O. Free psychotherapy: An inquiry into resistance. Am. J. Psychiatry 133 (1976), 1066-1069.
3. Pastemack, S. A., and Treiger, P, Psychotherapy fees and residency training. Am. J. Psychiatry 133 (1976), 1064-1066.
4. Goldensorin, S. S., and Haar, E. Transference and countertransference in a third-party payment system (HMO). Am. J. Psychiatry 131 (1974). 256-260.
5. Schonbar. R. A. The fee as a focus for transference and countertransference. Am. J. Psychother. 21 (1967), 27S-285.
6. Koren, L1 and Joyce. J. The treatment implications of payment of fees in a clinic setting. Am. J. Orthopsychiatry 23 (1953), 350357.
7. Pope. K. S., et al. .Fee assessment and outpatient psychotherapy. J. Consult. Clin. Psychol. 43 (1975). 835-841.
8. Balsam, R. M.. and Balsam. A. Thinking about money. In Secoming a Psychotherapist: A Clinical Primer. Boston: Littie, Brown & Company, 1974.
9. Wohl. J. Third parties and individual psychotherapy. Am. J. Psychother. 28 (1974). 527-542.
10. Roth. S. The schizophrenic wallet. Psychiatr. Opin. 5 (1968). 38-42.
11 . Safer. J., et al. Demographic and psychological characteristics of psychotherapy outpatients receiving Medicaid. Int. Ment. Health Res. News!. 17 (1975). 14-16.
12. Stanton. H. E. Fee-paying and weight loss: Evidence for an interesting interaction, Am. J. Clin. Hypn. 19 (1976). 47-49.
13. Davids, A. The relation of cognitive-dissonance theory to an aspect of psychotherapeutic practice. Am. Psychol. 19 (1 964). 329-332.
14. Thompson. A. . and Handy, L. C . To charge or not: An empirical question, J. Counse J. Psychol. U (1967). 358-360.
GROUP MEMBERS (Altered Data)