"The pnce we have to pay for money is sometimes paid in liberty. "
- Robert Louis Stevenson
In many state hospitals, including our own, it has been the widespread assumption that those who "cannot earn" should not be considered responsible in financial matters. This assumption runs counter to more recent opinions that the independence and responsibility of the mental patient are themselves qualities that should be nurtured. Three cases will be presented as examples of the way in which unemployed, hospitalized patients can constructively be held accountable for the disability income they receive - funds that are intended by society (and therapy) to encourage independence. These cases constitute a "syndrome" posing a significant challenge to therapists; the "syndrome" consists of the situation in which patients - and their families - have illegally received Social Security Disability Income (SSI), intended for the financial support of the nonworking mental patient outside the hospital, when the patient was actually on inpatient status and thus ineligible to receive the funds.
In each of the three cases presented, this state of affairs occurred, at first, with the tacit consent (expressed by ignoring the issue) of mental health personnel working with these patients and their families. Subsequently, the patients were confronted by the therapists with the facts regarding eligibility for SSI after it had been discovered that the patient (by being in hospital) was probably* receiving SSI against regulations. The impact and clinical meaning of this event represent the core of this article.
The regulations regarding eligibility indicate that the patient cannot be an inmate of a public institution for more than 14 consecutive days per month while receiving SSI under the following definitions:
. . . absent evidence to the contrary, presume that an individual on conditional release or convalescent leave for more than 14 consecutive days is no longer an inmate or patient "throughout the month." An individual who is discharged or released, but remains at an institution for want of another place to live and is not an employee (see SSIH 5720D), is an inmate. . . . For SSI purposes, consider the individual discharged or released if there is no evidence of a specific requirement to return to the facility within 14 days. Determine the intent of a public institution from conditions, if any, imposed at the beginning of the absence.1
CASE MATERIAL (COMPOSITE DATA)
Case 1. The patient is a middle-aged woman with a long history of chronic hospitalization after severe family deprivation in childhood.
After transfer to our hospital she remained an inpatient, resisted all plans for outpatient planning, but continued to receive SSI and kept her apartment, visiting it by day. At the urging of the ward team, her therapist reluctantly confronted her with the possible illegality of continuing to receive SSI during this period. She at first exploded with anger, stating that members of her family were "taxpayers and owe it to me." She also felt that the state "owed it" to her for having mistreated her for many years.
Following this confrontation, however, she called the local Social Security office and also asked her social worker to help research the regulations for her. After clarifying the regulations to herself, she told her therapist that she was afraid that "I'll lose all my shit." She then began to plan for long weekend passes and extended passes in order to receive SSI legally. In four months - for the first time in her life without running away from the hospital and without unilateral administrative discharge - she negotiated successful discharge from the hospital at her own request.
Since then she has been notably less selfdestructive and appears to be making better use of her finances. In therapy she has, for the first time, been able to ventilate anger verbally at her mother and family for her early abandonment. Case 2. A middle-aged man was hospitalized for schizophrenia for the first time three years ago. Since then he had been steadily hospitalized with only brief discharges home. At home he rapidly decompensates. On the ward, despite a bland and helpless appearance, he has remained a severe suicide risk.
After two and a half years of almost constant hospitalization, he made a brief but abortive attempt to move to a halfway house. At that time SSI was arranged. The placement fell through when the patient began to have paranoid fears about traveling to and residing at the halfway house. His family also resisted and undermined this attempt to move away from home. He then became catatonic and was rehospitalized.
Five months after this move, his therapist inquired into his financial situation when it became apparent that the patient was receiving many new articles of clothing, apparently gifts from home. The patient said that he had been able to save money. When asked the source, he stated with visible and uncharacteristic anger that this was "a secret" and that it was none of the therapist's business. This stance was further unusual because the patient had always appeared forthright, affectless, and concrete and was apparently suffering from apparent "loss of memory and feeling" about certain painful events that had occurred before his first hospitalization. After further inquiry and much angry resistance (the first such encountered in nine months of work with the therapist), he admitted that he and his mother had made a pact "not to tell" of the continuing SSI that had been arranged for his (now fictitious) living outside of the hospital. The checks, which his family continued to receive at their address, were brought in by the father to be signed by the patient and then deposited in a family account. The patient did not know how much money had been collected or how much was set aside for his use. He knew only that his mother bought him new clothes "for the hospital" with this money.
The patient was then advised oí the possible illegality of his continuing to receive the SSI under Social Security regulations. After three weeks of agonizing rumination and role play with his therapist in which he rehearsed confrontation with his parents, he informed his family of the situation and induced his father to make the call to cancel the SSI payments.
After initial anger at his therapist for "touching on secrets," he began to ventilate anger at his family for "taking my money without telling me how much" and to delve into the areas of former memory lapse and share heretofore undiscussable secrets concerning a love and sexual disappointment experienced before his first breakdown.
Case 3. A middle-aged man was admitted to our hospital, for the second time, several years after his first schizophrenic episode. Since then he had been almost continuously hospitalized, spending time at two other state hospitals. During his first hospitalization, SSI was arranged to support his living outside upon discharge. It had never been discontinued.
In a conference interview after six months of hospitalization, he related that his mother had bought him a $300 gift, which he kept at her house for use when he visited home. When questioned on the source of such finances, he exploded with anger at the interviewer and said that this "was none of your business." After the anger had subsided, he admitted that the gift had been bought with SSI money and that he believed that his mother was "cheating and blackmailing" him.
It became clear in further interviews with his therapist (who had been reluctant to discuss financial matters with him before) that his mother had been collecting his SSI checks, signing them herself, and depositing them in her own account. He had no knowledge of how much had been collected over the almost-fouryear period, nor did he know how much had been spent on his behalf during that time.
After this revelation he was able in therapy to ventilate anger at his mother "for cheating me out of what's mine." At the same time, he rationalized that his mother "needed the money." When the possible illegality of the situation was pointed out to him, he was able to acknowledge that the money was possibly neither his nor his mother's. One month thereafter he moved into a group home, paying for it with SSI that he began depositing in an account of his own. He recently told his therapist that he felt the money was "important to me - after all, it's to help me get out, isn't it?"
The forces not to talk about money are powerful. They include our resistance as therapists to be seen as, and to feel, mercenary and our reluctance to ask patients to examine their own finances and, by implication, to consider what our treatment is really worth to them. The sicker or poorer the patient, the less we are likely to ask or talk about money. In institutions (private as well as public), accounting and billing offices, third -party payers, treasurers' offices, and state and governmental financial arrangements all provide distance from dyadic financial transactions with a patient. In hospital settings, therapists and patients alike are sometimes glad to abdicate the responsibility for talking about the money (or the lack of it) in a patient's life; often this abdication reflects the shared antipathy towards the authoritarian aspects of institutional financing, as well as a perhaps shared wish to be "cared for" unconditionally while having financial responsibilities taken care of by someone else.
Whatever feelings are aroused concerning talk about money, estimates suggest that well over 90 per cent of crimes committed in the United States have an economic basis,2 and Knight has observed that "inappropriate uses of money may create, as well as grow out of, deep emotional conflicts. Money -sickness is one of our most common illnesses but often not recognized as such, by the individual or others."3 Aside from a small body of literature dealing with the importance of fees in psychoanalysis,4*5 and discussions of third-party payments and psychiatry,6 there are relatively few reports dealing with specific clinical issues related to money in the patient's life - particularly the patient who is poor. However, a number of recent reports urge therapists to consider financial issues as a focus of conflicted action and thought accessible to re-examination and work in therapy.710 This point of view carries particular urgency when all medicine is under pressure (with the coming of national health insurance) to examine its costs and controls. Certainly, psychiatrists should not be the last to study the importance and meaning of economic issues in therapy and in the life of the patient.
MONEY MATTERS, THE PATIENT, AND THERAPY
It would be inappropriate to assume that every patient abusing SSI would respond in a manner similar to those described in this study. For the patients presented, however, it is obvious how important were the financial arrangements concerning SSI to their predicament and pathology. In each case the therapist was initially reluctant to approach these issues and did so only with trepidation; yet this inquiry was an important step in treatment.
In Case 1, SSI represented the core of the patient's entitlement - namely, that SSI, in spite of its misuse and misappropriation, was a reparation owed her for injustice. The therapist's challenge of this notion by informing the patient of the legal constraints on the use of the income was an appeal to her sense of adult responsibility, which encouraged her to refocus her position of entitlement toward helping herself, instead of demanding reparation. In order to protect "her own," she has taken productive steps toward moving out of the hospital and using her money more appropriately. She also demonstrated that she could no longer "afford" to regress and remain chronically hospitalized. When the therapist raised this as an issue, the patient, for the first time, was able to ventilate in words her long-felt hostility toward her mother; this therapeutic event may have been a first step in closing the gap between reality and a sense of entitlement stemming from real deprivation and abandonment.
Cases 2 and 3 demonstrate that a sense of entitlement can be shared by a family, who may unconsciously turn to a financial agency to make reparation for the burden of a sick family member. These cases also can be seen as examples of a "double bind"9 or "transmission of family irrationality."10 The families expropriated SSI money for their own use, telling the patient, "It's for you." Deception and dependence were furthered by "gifts" bought with the money for the patient. A duplicity was maintained between the purpose of the money (i.e., the patient's support outside the hospital) and the actual use of the money (i.e., the family's support, at the expense of the patient's remaining in the hospital while being "bought off" with gifts). In both cases there were pacts of sworn family secrecy that bound the patient to a family deception as well as to an enforced dependent position.
In all three cases the misuse of SSI money represented significant intrapersonal and intrafamilial conflicts for the patient. Money and its misuse in this context appeared symbolic of defiance of an ostensibly abusive system. On confrontation, the issue was rapidly verbalized as anger, previously unexpressed, at parents who had abused the patient, through manipulation or abandonment. It is interesting that in each case the patient conveyed a sense of relief at being "found out," at being finally allowed to be angry at his family, and at being asked to be responsible for his own finances.
Clearly no therapist should feel that he or she is the watchdog over financial abuses by the patient, whether it be of SSI, income tax, or unpaid bills (unless, of course, they are the therapist's own). In the case of SSI, the primary responsibility is clearly that of the Social Security Administration. It is the therapist's responsibility, however, to explore the uses and abuses of money in the patient's life; no matter how hard this may be for the hospital doctor, it is his or her responsibility to examine the finances that may bear on a patient's independent existence outside the hospital and to study the patient's "money behavior."
In all three cases the therapists were aware of initial reluctance to approach these issues and confront the patient. Much supervisory, team, and staff support was required for the first patient to be so confronted; the other two were, predictably, easier to confront, once the precedent had been set. This reluctance owes its origin to several factors, subsumed under the rubric of countertransference.
The first factor was a reluctance to "rock the boat." While all the cases were difficult ones, the therapist and social worker were just getting into a working relationship with the respective patients and their families and feared that this frail alliance might be ruptured. All the therapists had sensed intuitively the anger that might - and did, in fact - arise from such a confrontation.
The second factor was an identification with the patients' entitlement by the underpaid therapists and social workers themselves chafing at the deprivations imposed by low state salaries. The patient able to "beat the system" readily tapped into springs of vicarious gratification for the therapists.
Finally, the patients' rebellion against "the system" may have appealed to rebellious feelings directed at parental figures still latent in the therapists' unconscious. In addition, conflicts over sadism contributed to hesitancy about confrontation - the therapists fearing to cast themselves in the role of oppressor of those already quite sufficiently oppressed.
As our cases have shown, reluctance to talk of money and its meaning in therapy may not only delay therapeutic progress but even foster deceptions interwoven with individual and family pathology. Therapists have a continuing need to examine what perpetuates individual or family deceptions that further our patients' "obligation to remain sick."11,12 Finally, with health funds in ever shorter supply, we need to face squarely accountability regarding our own financial and therapeutic oversights.
Every therapist or mental health worker assisting the patient in applying for Social Security Disability Income should know the regulations governing its use and inform patients and their families of the facts. Although it is primarily the responsibility of the Social Security Administration to detect and correct misuses of these funds, it is, as we have shown, crucial for the therapist to feel free to discuss the uses and possible abuses of this money with patients and families as a legitimate part of the therapy. Since abuses are most likely to be connected with rehospitalization, it is precisely then that continuing SSI (illegally) can be a factor in perpetuating the patient's "sick role." Therapists who are uninformed, or deny themselves knowledge of their patients' finances or the regulations, may be contributing unwittingly to sick-role maintenance as well as forfeiting an opportunity to explore the affects behind a symptomatic act that - as our cases show - may embody central themes of entitlement and family pathology.
1. Claims Manual. Social Security Administration. Washington, D.C.: U.S. Government Printing Office. 1975 (March), p. 5725.
2. Sutherland, E. H., and Cressey. D. R. Principles of Criminology. Philadelphia: J. B. Lippincott Company, 1966.
3. Knight, J. A. For the Love of Money. (In press.)
4. Fingert. H. H. Comments on the psychoanalytic significance of the fee. Bull. Menninger Clin. 16 (1952). 98-104.
5. Chodoff, P. Psychoanalysis and fees. Compr. Psychiatry 5 (1964), 137-145.
6. Reed, L. S., and Meyers, E. S. Health insurance and psychiatric care. In Freedman, A. M., Kaplan. H. J., and Sadock, B. J. (eds.). Comprehensive Textbook of Psychiatry, Volume 2. Baltimore: The Williams & Wilkins Company, 1975.
7. Frank, J. Persuasion and Healing. Baltimore: Johns Hopkins University Press, 1973.
8. Balsam. R. M., and Balsam, A. Becoming a Psychotherapist: A Clinical Primer. Boston: Little, Brown & Company, 1974.
9. Nash, J. L., and Cavenar, J. O. Free psychotherapy: An inquiry into resistance. Am. J. Psychiatry 133 (1976), 1066-1069.
10. Pasternack, S. A., and Treiger, P. Psychotherapy fees and residency training. Am. J. Psychiatry 133 (1976), 1064-1066.
11. Bateson, G., et al. Toward a theory of schizophrenia. Behav. Sci. 1 (1956). 251.
12. Lidz. T.. et al. Intrafamilial environment of the schizophrenic patient. Vl: The transmission of irrationality. Arch. Neurol. Psychiatry 79 (1958). 305-316.
13. Bursten, B., and D'Esopo, R. The obligation to remain sick. Arch. Gen. Psychiatry 12 (1965), 402-407.
14. Sobel, R.. and lngalls, A. Resistance to treatment: Explorations of the patient's sick role. Am. J. Psychother. 18 (1964), 562-573.