There is a legend about Richard Cabot, later famed for both his knowledge of physical diagnosis and his instrumental position in fostering the development of sodai work as a practice. When he entered private practice, he assigned the task of fee setting to his secretary. After some months he noted his large bank account and inquired about his secretary's fee-setting practices. "Why, Dr. Cabot," she replied, "I charge them in proportion to the value of the carriages they arrive in." The legend stimulates in us thoughts about social origins, professional and social referral networks, private practice population, self-view, worth in the minds of others, financial attitudes and practices, and the further development of Cabot, his seaetary, and his patients.
The dynamic elements of addressing, understanding, and working through issues involving fees in psychiatry are important, complex, and tension-laden. Money issues stimulate survival, security, and pleasure aspects in all of us - as persons alone and as members of pairs, families, groups, classes, societies, and cultures. It is therefore a real, though not clinically surprising, paradox that fee considerations aimed at effective mutual mastery have received hardly any systematic clinical attention.
Our conjunction of personal, familial, and professional development during the past 20 years has led us to experiment in the sector that can be called "an optimal fee for the psychiatrist and the patient." This article describes in condensed fashion much of what we have worked out.
Initially this frame of reference, intention, and readiness to implement resides in the mature professional functions of the participants, ordinarily - because of the emotional problems, role expectations, and prior experiences of money (including fees) that the patient brings in - mostly in the psychiatrist. Our method consists of (1) handling initial concern about fees, (2) agreeing on a contract (3) setting the specific fee, (4) understanding the specifics of payment, and (5) implementing changes in the fee schedule. This style aims to (1) develop the psychiatrist-patient alliance, (2) bring to mutual consciousness the psychosocial dynamics related to money, (3) arrive at an optimal fee, (4) implement payment, and (5) change the fee and payment arrangements as may be indicated in the course of the relationship.
HANDLING INITIAL CONCERN ABOUT FEES
When initial question is expressed about the fee, it is handled with acknowledgment of the issue as a mutual interest and uncertainty, to be settled by discussion to arrive at a fee optimal to patient and psychiatrist. It may be enough at the moment to state with humor, "My fee is the most money consistent with consideration of you." If the monetary concern is overriding, the specific sector is explored as first-order business between patient and psychiatrist to lessen the tension to tolerable proportions and to introduce perspective about the professional relationship. At this time the fee agreed upon is specified as an evaluation fee, which may or may not be the same as a treatment fee depending on issues and decisions to be clarified later. In setting this fee, such parameters as short-term versus longer-term, definite versus indefinite duration, crisis management versus continuing involvement, and prejudices versus inquiring and inclusion all come into focus. These parameters are of value in psychosocial diagnosis as well as in interpersonal relationship and particularly require anticipatory attention lest the communication of other issues founder on the rock of the psychiatrist's narrow monetary focus or attitudinal rigidities as regards finances. In other respects, the tasks of initial acquaintance, role acceptance, formulation of problem areas, spelling out of goals, and agreement on treatment modes take their usual order and constitute the umbrella of contract.
AGREEMENT ON A GENERAL CONTRACT FOR THERAPY
We view the additional dimensions of contract as homeostatic issues and progress issues. The homeostatic (foundation, survival, equilibratory) issues include refraining from physical violence to self and others; restraint from property damage of self and others; setting a fee optimal and agreeable to each; paying one's bill; communicating about transitions, especially partings, and arranging an agreement about payment for unkept appointments. (In practice, we specify that there will be no financial charge for unkept appointments when 24 hours' advance notice is given. If less or no notice is given, the person not giving notice is responsible for any amount up to the agreed-upon fee, and the other shall decide how much to charge.) The progress (opportunity, affluence, desire) aspects include the agreement that each pursues the earlier agreed-upon goals in his or her own style, as a matter of choice, and with one's own riming.
SETTING THE SPECIRC FEE
Our method is (1) to inquire into the patient's opinion as to what fee is optimally agreeable to patient and psychiatrist for the experience (evaluation and/or treatment); (2) to seek understanding as to the basis for the opinion; (3) to set the fee in terms of healthy (autonomous ego) capacity, interest, and involvement on the part of each; and (4) to observe and influence the further vicissitudes as characteristic of the persons and process.
UNDERSTANDING THE SPECIRCS OF PAYMENT
Payment may be made in advance or never, in cash or by check, at the beginning or end of a meeting or when remembered because of some association, in person or by mail, or in an envelope or "bare." Each choice is a bit of data adding to the understanding of the person and relationship. Both primary and secondary processes and taken into account. Some patients ask, "When do you want to be paid?" We answer, "Preferably now, happily in accordance with our agreement, or, at worst, when we can get it." These alternatives describe a view of nature combined with professionalism.
IMPLEMENTATION OF FEE CHANGES
The contract spelled out above embodies a view of the life situation as well as the people as existing on an uncertain evolutionary continuum, where the optimal fee is also a variable of both real and symbolic significance amenable to both reality and transferential influences; these elements are important to understand together. This way of considering fee issues in psychotherapeutic evaluation and treatment facilitates communication and evaluation of third-party contributions as well. It clarifies perceptions, attitudes, and expectations with regard to private insurers, family, friends, and private or public social agencies. Decisions about contacting and using such resources are then made in ways that allow more solid assessment and more effective work on issues among patient, psychiatrist, and third parties. Personal and professional identity is spelled out and differentiated from other dynamics and structures and can thus be more consciously employed. The cost lies in added work tensions; the benefits, in integrity, self-realization, mutual respect, and psychosocial change.
In the course of such communication, discussion, and action, characteristic response patterns emerge; evident in these patterns are significant work tension and readiness for clinical intervention. When the matter is first broached, a sequence of responses is discernible in phases of varying intensity. The intensity of each phase reflects integration of personality structure, older and established attitudes and experiences involving money, recent experiences, current adjustment, and plans for the future. The phases are (1) surprise, ranging to shock or disbelief; (2) repression and distortion; (3) recurrent distortion despite clarification by the psychiatrist; (4) allusions to prior experiences with money; (5) offerings of amounts usually in accord with psychosocial dimensions different from one's own consideration of self and others in the here-and-now; (6) understanding of the meaning of such amounts in the current life situation; (7) resolution, openly taking into account the life circumstances, values, and goals of patient and psychiatrist; (8) setting a fee, the payment of which can be more effectively understood and dealt with; and (9) openness as to potential review and revision.
In the course of such negotiations during evaluation and treatment, considerable sharing of perceptions, expression of affect, and resistance or progress in relationship take place. This is a particularly educational, delicate, and complex process for late adolescents and young adults whose autonomy and interdependence facets are shaky, poorly defined, or at times opposed (healthily or unhealthily) to the tenets of family or other social forces and resources. Likewise, with the poor or wealthy the issues often require extrasensitive handling to establish mutual respect and cooperation. The twin dangers of overidentification and underempathy are frequently lurking in the innards of the two parties. The task at hand is to channel to consciousness and to promote mature management.
Group experiences (conferences, seminars, consultation, or psychotherapy) stimulate anxiety and foster opportunity with regard to fee management. That group therapy fees are to be arrived at optimally within the group is an idea (and practice) that meets much resistance. Patients and psychiatrists usually settle this matter outside the group boundaries, before or after the meetings. As we have utilized fee setting and management within the boundary of the group therapy content, further observations emerge of relevance to the psychic and social processes.
The fee negotiation process may be viewed and undertaken as a hiring of the therapist by the group as a whole. Here the contract is between the therapist and the group as a whole. There is some de-emphasizing and distancing of the individual patient-therapist relational intensity. Feelings and thoughts about individual differences then remain among the group patients. These are expressed in a way that facilitates the therapist's position as a less involved consultant interacting with, and dependent on, the decisions of the group as a whole. These are dynamic complexities reminiscent of employer-employee-union types of contract negotiations.
For the most part, our experience has been with patients evaluated and related to initially and contractually on a one-to-one basis, where the prescription of group psychotherapy is mutually implemented in accordance with communicated roles, problems, goals, and program agreement. In this arrangement, the fees remain individually negotiated and the group participates in various ways. In psychosocial respects, the fee negotiation process assumes the character of ritual, serving as part of the rite of passage for the initiate. The group members lend orientation, encouragement, criticism, humor, tolerance, faith, skepticism, and cynicism en route to settling upon a fee. From the psychiatric viewpoint, the area is very often approached via a displaced, generalized, or inquiring kind of discussion of money, at times stimulated by the handing out of monthly bills in the group as part of the process. From the sociologie viewpoint, the patient usually initiates the discussion of money. Group responses - such as "This is a matter for you and the doctor to settle together," "We've each been through this, ha ha," or "What's optimal for you?" - counter the ordinary response of "I've never heard of such a thing." The group intently observes both the new member and the therapist, especially the latter, as a way of examining the experience of each in a recurrently confirmed manner. Indeed, the fee setting provides stimulus and opportunity to review the current fee of each internally or together. Changes in fee during the course of therapy are a matrix for corrective ego experience when initiated by the patient or - especially - when volunteered by the therapist.
We have described a method of setting fees on a mutual basis and spelled out professional goals of this approach. We have mentioned issues that arise - personal, professional, institutional, strategic, and technical - and a style for integrating them. We have discerned phases of varying intensity in an overall sequence of patterned response to this negotiation. We have reported on both complications and benefits of such interaction for adolescents and young adults, the poor and the rich, the individual and the group. We note that there is increased work tension to be borne by the psychiatrist relative to (1) increased awareness of his own life aims, (2) taking time and effort in the mutual endeavor, and (3) increased complexity of bookkeeping. We view the full implementation of fee negotiation as a psychosocial variable that helps to define more broadly, more deeply, and more efficaciously the patient, the psychiatrist, and their functional groupings.
Such fee negotiation has specific clinical benefits. It clarifies and optimizes the role and task alliance. It faces the psychic conflict between "optimal" treatment and "affordable" treatment. It deepens the joint awareness of social and psychologic attitudes of patient, psychiatrist, and others. It confronts cultural materialism and conditioned stereotypes by acknowledging human needs and interests as differentiated from economic class rigidities. It sets an economic basis on which later changes can be viewed and handled, and it promotes fee setting "with" as contrasted to "for" or "to."