Psychiatric Annals

Fees in Beginning Private Practice

Jill S Adler; Thomas G Gutheil, MD

Abstract

Freud saw money as a sexual symbol, representative of anal and phallic preoccupations. In our culture money is also a symbol of worth, prestige, competence, masculinity, freedom, control, and security, focal conflicts in many people. The fact that the analytic community consists of a high proportion of upward mobile people with minority group backgrounds, as well as the fact that it occupies an ambiguous position in both medicine and psychology, may heighten any anxiety that attaches to money by way of any number of symbolic meanings money may have for the practitioner. This may account for the relative paucity of literature in this area.1

With the exception of a detailed article by Allen,2 a brief report by Randolph,3 and a chapter in Balsam and Balsam,4 little appears to have been written about beginning private practice after a training or clinic experience. We wish to discuss and report on the vicissitudes of this ubiquitous event, paying particular attention to phenomena in the therapist's experience and the countertransference as they relate to one of the most significant areas of novelty: the payment of the fee directly to the therapist. We anticipate exploring in this essay a variety of issues for consideration, rather than exhaustively covering the topic. Our discussion may be organized under three main rubrics: (1) manifestations of "beginner anxiety"; (2) "giving," "getting," and fees; and (3) fees and the transference-countertransference interface.

MANIFESTATIONS OF "BEGINNER ANXIETY"

The term "beginner anxiety" is in quotation marks because the therapist beginning private practice is rarely a true beginner in the field; only the new financial arrangement begins at that stage. With this in mind, let us consider two examples.

A resident, beginning to see private patients, commented that he had no difficulty deciding on afee, since he was quite convinced that his clinical sldlls were at least equal to those of his least competent senior instructors, who charged "full fee"; he therefore felt entitled to charge "full fee" despite being in the third year of residency.

1. Schonbar. R. A. The fee as a focus for transference and countertransference. Am. J. Psychother. 21 (1967), 275-285.

2. Alien, A. A note on the making of a psychiatrist: The transition from resident to private practitioner. Psychiatry 34 (1971), 410-418.

3. Randolph, G. Experiences in private practice. J. Psychiatr. Nurs.13 (1975), 16-19.

4. Balsam, R, M., and Balsam, A. Thinking about money. In Becoming a Psychotherapist: A Clinical Primer. Boston: Little, Brown & Company, 1974.

5. Burton, A. Therapist satisfaction. Am. J. Psychoanal. 35 (1975), 115-122

6. Levin, A. M. Private practice is alive and well. Social Work 21 (1976), 356-362.

7. Strean, H. S.. and Blatt. A. Some psychodynamics in referring a patient for psychotherapy. Psychoanal. Rev. 60 (1973), 101-110.

8. Green son, R. R. 7ne Technique and Practice of Psychoanalysis, Volume I. New York: International Universities Press, 1967.

9. Wolberg, L. R. The Technique of Psychotherapy. New York: Grune& Stratton, 1954.

10. Glover, E. The Technique of Psychoanatysis. New York: International Universities Press, 1955.

11. Alexander, F., and French, T. M. Psychoanalytic Therapy. New York: The Ronald Press, 1946.

12. Warson, S. R., and Denman, S. B. Needs for continuing education for psychiatrists: A preliminary report of a survey of Florida psychiatrists. Am. J. Psychiatry 126 (1969). 259-261.

13. Koren, L., and Joyce, J. The treatment implications of payment of fees in a clinic setting. Am. J. Orthopsychiatry 23 (1953), 350-357.…

Freud saw money as a sexual symbol, representative of anal and phallic preoccupations. In our culture money is also a symbol of worth, prestige, competence, masculinity, freedom, control, and security, focal conflicts in many people. The fact that the analytic community consists of a high proportion of upward mobile people with minority group backgrounds, as well as the fact that it occupies an ambiguous position in both medicine and psychology, may heighten any anxiety that attaches to money by way of any number of symbolic meanings money may have for the practitioner. This may account for the relative paucity of literature in this area.1

With the exception of a detailed article by Allen,2 a brief report by Randolph,3 and a chapter in Balsam and Balsam,4 little appears to have been written about beginning private practice after a training or clinic experience. We wish to discuss and report on the vicissitudes of this ubiquitous event, paying particular attention to phenomena in the therapist's experience and the countertransference as they relate to one of the most significant areas of novelty: the payment of the fee directly to the therapist. We anticipate exploring in this essay a variety of issues for consideration, rather than exhaustively covering the topic. Our discussion may be organized under three main rubrics: (1) manifestations of "beginner anxiety"; (2) "giving," "getting," and fees; and (3) fees and the transference-countertransference interface.

MANIFESTATIONS OF "BEGINNER ANXIETY"

The term "beginner anxiety" is in quotation marks because the therapist beginning private practice is rarely a true beginner in the field; only the new financial arrangement begins at that stage. With this in mind, let us consider two examples.

A resident, beginning to see private patients, commented that he had no difficulty deciding on afee, since he was quite convinced that his clinical sldlls were at least equal to those of his least competent senior instructors, who charged "full fee"; he therefore felt entitled to charge "full fee" despite being in the third year of residency.

A therapist seeing his first private patients after postresidency military service began charging a fee substantially less than the current rate in his geographic area, feeling that he was "a beginner"; as his private practice and experience increased, he charged new patients inaeasing amounts until his fees were standard for his area. He discovered, at the outset, that when he mentioned his early low fees to his peers he was energetically rebuked, sometimes with considerable heat, for charging so little.

These contrasting examples appear to suggest some of the ways in which the amount of the fee, in and of itself, may interact with selfesteem, narcissism, entitlement, and competitive elements around the issue of beginning to collect one's own fee. The first example suggests to us the way in which a counterphobic stance, in response to the anxiety of fee setting, may subserve competitive strivings in the graduating trainee. The second example highlights the new practitioner's sensitivity to his "beginner" status, perhaps to the extent of undervaluing his work. Peer competitive phenomena, moreover, find ready expression, as indicated, around the issue of fees.

Obsessional defenses of various kinds are a familiar mode of dealing with the anxiety of starting out. Concern with the billing form - its typography, language, whether the month's total is presented as a whole or itemized by sessions - serves as a common focus for such anxieties. In supervisory settings we have been impressed with the significance of the name given to the doctor-patient encounter; "appointments," "sessions," "meetings," and "hours" (or the omission of any such term) connote highly idiosyncratic meanings for the individual therapist.

A beginning private practitioner used the term "hours" on his billing form. An obsessional patient raised the objection that, since the sessions lasted 50 minutes, they could not be so called. The therapist was acutely embarrassed beyond the degree appropriate to so clearly symptomatic a confrontation. He was later able to identify the way in which the patient's remark touched upon his (the therapist's) guilt about exploiting this particular patient, who tended to employ a "victimized" attitude towards the world.

Anxiety may express itself as overemphasis on the fee as issue, as well as underemphasis or avoidance.

A psychiatrist beginning private practice was mentally primed to discuss the fee as a clinical issue. He said to one patient, "Perhaps we should explore the meaning of your unpaid bill as a resistance to treatment." The startled patient replied, "But, Doctor, you just gave me the bill two days ago!"

In a comparable number of situations, of course, the beginning practitioner may be tempted to err in the other direction, allowing the back bill to accumulate to excess because of paralysis about exploring the issue or confronting the patient.

"GIVING," "GETTING," AND FEES

A beginning private practitioner, handing a bill to her first private patient, felt compelled to ask how the patient felt about receiving the bill. The patient gave the matter-of-fact response, "I was expecting to get one." The therapist felt compelled to persist, 'Yes, yes, but how do you feel about it?" In later supervision, the therapist discovered that this persistence derived from the fact that, for her, to charge a fee had unconsciously become an aggressive act, for which she felt guilty and, consequently, felt compelled to check whether the patient was all right after this "aggression" and whether the patient was forgiving of her.

Once attuned to this countertransference difficulty - a common one in early private practice - the therapist could note other indications of this conflict. Mental health professionals, however, are particularly vulnerable to such conflicts about being paid professionals because of their fundamental orientation to being "giving," an important element in the choice of the helping professions. All novices experience the temptation, even the pressure, to "make up" for the deprived patient's bad mothering by becoming the "good mother." Health professionals are, moreover, dealing with basic dependency issues by "giving what they would like to get" - i.e., becoming caretakers as a way of adaptively using the universal and human wish to be cared for. As Burton has said: "An intrapsychic hunger is set up in certain personalities which finally results in becoming a healer and quiets these needs."5 Fees bring out conflicts at the heart of these basic drives.

A beginning practitioner made certain to give the bill to his patients at the beginning of the sessions; if the session began without this happening, the therapist would wait until the start of the next session to present it. He became aware that this custom was based on the assumption that if the patient received the bill after a particularly intense or difficult session, the therapist might be experienced as conveying the impression that charging the fee was directly related to how burdensome the patient was to listen to.

In this somewhat retaliatory fantasy about the meaning of the fee, we again note the conflicts around imagined sadism in charging fees for services rendered, perhaps especially as the conflict touches the therapist's self-image as selfless giver.

Allen accurately captured one element of the "giving" conflict when he noted:

. . . there was some feeling that collecting a fee, learning from a patient, or benefiting in any way from the practice of psychotherapy must of necessity be to the patient's disadvantage. As is evident from this material there was a strong tendency for many of the residents in the group to dichotomize issues, viewing benefits as flowing to only one of the parties in any given relationship.2

On the same topic, Schonbar has observed:

. . . some therapists feel guilty about "selling" a human relationship, seeing it as a kind of prostitution. Similarly, there are those who, despite Freud's admonition [in his 1913 paper "On Beginning the Treatment"! cannot admit of the crass businesslike aspects of the treatment situation in terms of satisfying their own needs for status and security. The professional role this type of therapist needs to assume is somehow denigrated by the symbols of being "in trade."1

In this connection, a recent article by Levin discusses the problems faced by clinical social workers as a result of membership in a profession that has its roots in a philanthropic orientation. He notes the reasons, among others, for conflict about private social work practice:

1. Private practitioners deviated from the traditional social work mode.

2. Social work ideology viewed the profit motive as exploitative to people in need.

3. Social work ideology was challenged by the idea of clients voluntarily paying for service rather than being the "needy," relatively passive recipients of "help."8

These philanthropic origins (shared by medicine and social work) may serve to reinforce the countertransference difficulties about being "giving" - conflicts to which mental health professionals, as we have earlier indicated, are especially vulnerable.

FEES AND THE TRANSFERENCECOUNTERTRANSFERENCE INTERFACE

Anger. The following example illustrates how the fee can become the focus of the patient's transference rage and the therapist's difficulty bearing that rage.

Beginning private practice, a therapist agreed to continue with a patient from the state-funded clinic where both had begun their work together. They agreed that the patient would pay a reduced private fee until a jointly set date, after which the full private fee would be paid, with the understanding that the patient would arrange her finances income, budgeting, etc.) so as to be able to afford the full fee. It rapidly emerged that the patient viewed the reduced fee as "not really paying"; around the idea of "full fee" there crystallized all the resistance to assuming adult responsibilities in her life. It was highly significant that the patient felt she had received attention from her physician-father only when she was "sick" and, consequently, a "nonpaying patient" of father! Clearly, "really paying" meant giving up intense but conflicted childhood specialness to an important object. Despite deep and repeated exploration of this and related issues, the patient remained unable to set the date or make plans. It became clear as time went on that continued discussion was serving two purposes: (1) the patient was postponing coming to grips with adult responsibility; (2) the therapist was postponing the confrontation and the attendant anger that would predictably erupt. Without a confrontational stance, the discussion of the patient's feelings could be no more than an intellectualized process, lacking the necessary affective component.

In this case, the decision to increase the fee as planned communicated to the patient, among other things, that her anger could be tolerated. As with almost any aspect of therapy, both to discuss and not to discuss fees can function as resistance. In general, the avoidance of discussion of matters of fee frequently serves to keep anger and other "negative" affects out of the therapeutic field. Patients may intuitively sense this avoidance and respond to it in characteristic ways.

Comparative/competitive elements. A senior social worker beginning private practice agreed to treat a patient for a reduced amount. As treatment advanced, the patient began to devalue the therapist around the reiterated theme: "You're no good; you're not qualified enough; you can't help me." At a critical point in therapy, the patient obtained a secret consultation from a psychiatrist without discussion with the therapist - a form of acting out that intensified the therapist's already-aroused feelings of helplessness and inadequacy. The consultant - in addition to urging the patient to return and continue with the therapist - stressed how the low fee contributed to the patient's self-devaluation, expressed as devaluation of the therapist and the treatment, in partial illustration of this, the patient paid the consultation fee on the spot (yet remained zveeks behind in her regular, far lower therapy bill); the patient had remarked to the consultant, "You must be good to charge so high."

The therapist was able to identify a previously undetected element pervading this transaction: the therapist had herself been in private treatment some time earlier and "automatically" compared herself unfavorably with her own therapist - a view that contained reality elements (her own therapist had been more experienced than she now was) and elements of unresolved transference familiar to all clinicians. These elements played important though largely unconscious roles in both the setting of the lower fee and the conflicts aroused by the patient in the fledgling private therapist. This clinical vignette suggests that an important area for future investigation might be the influence, on negotiations concerning the fee, of the therapist's having been in private treatment. The events of the case make clear how the fee, the patient's interpersonal style, and issues of self-esteem interwove themselves with the countertransference, leading to an impasse in therapy (fortunately later resolved).

Inhibition. Conflicts about iees may express themselves as specific inhibitions felt by the therapist.

A couple was referred to a beginning practitioner around the question of possible divorce. It rapidly became clear that the husband's wish for guaranteed results would lead him to break treatment or refuse payment if either the outcome were not what he wished or the therapist took any stand about the relationship. The therapist found himself severely inhibited in exploring the material by the implicit threat of nonpayment.

Inhibitions may extend beyond the actual patient to the context, as the following example suggests.

A psychiatrist beginning private practice was referred a patient by a psychiatrist-friend. After a time the patient became derelict in paying his bill. The psychiatrist experienced inhibition in making this an issue, out of anxiety (only later identified) that the patient would complain to the psychiatrist's friend (i.e., the referral source) with the feared result that the friend might come to view the therapist as "interested only in money. "

In this example the issue of fee interdigitates with that of referral, a vast and underexplored topic in itself (an exception to the rule of silence on the topic is an excellent article by Strean and Blatt7).

A psychiatrist beginning private practice was referred an extremely wealthy patient by a fellow physician who urged, "Charge this patient $45 [a higherthan-average fee for the area] - she can afford it." The treating psychiatrist felt great pressure to charge this elevated fee and, in effect, felt she could not deviate from the referrer' s recommendation. One source of the conflict about this issue was the fact that the psychiatrist was currently paying less than that amount to her own training analyst.

Here again the referral source enters into the negotiation in complex ways, almost as a third party to the transactions.

Symptomatic acts expressive of transference and countertransference. Third-party payment systems are not immune from symptomatic acts that, properly investigated as part of the legitimate fabric of the therapy, yield information both relevant and useful.

A male therapist, filling out his first insurance forms for a female patient being treated for depression, noted with the passage of time that he persisted in checking off a box on the form that indicated that the problem was not related to pregnancy (usually this section of the form would be ignored unless specifically related to the complaint). He was able to determine through introspection that this minor, routine activity represented a resistance to unconsdous eroticized fantasies about the patient, magically warded off by the repeated "denial": "No connection with pregnancy."

In a comparable way the check issuing from the patient may symptomatically express conflicts about the transaction.

A beginning private practitioner noted that one patient's characteristic way of writing the amount of the check was to say: "Only $ [amount]." A supervisor urged her to bring this to the patient's attention atan appropriate moment. When she did so, the patient replied that this was a common way of indicating the amount. The therapist, feeling somewhat embarrassed and betrayed, confronted the supervisor on leading her into this "trap. " The ensuing discussion clarified the manner in which the patient was employing reality as a resistance to examining in therapy the personal associations to this habitual mode of writing checks, significant in a patient who felt cheated by life and experienced low self-esteem.

DISCUSSION

Because the inception of private practice occurs with extremely high frequency in the careers of mental health professionals, it is all the more astonishing that so little has been written about it. None of the basic works in psychotherapy and psychoanalysis since Freud (e.g., Greenson,8 Wolberg,9 Glover,10 and Alexander and French11) address the individual experience of the beginner.

As noted earlier, Allen2 perceived the need for a seminar, aimed at residents, on issues related to beginning private practice, part of whose "curriculum" included discussing fees. His far-ranging report on the seminar experience leaves the reader feeling that such a seminar should be obligatory for every training program, especially since one survey of practitioners found that approximately 28 per cent "felt that their formal residency programs were less than adequate in training them for the actual problems commonly encountered in psychiatric practice."12

Allen reports:

The prospect of assuming responsibility for setting a substantial fee and collecting it was a source of considerable anxiety to many in the resident group. There was also considerable guilt about the prospect of asking fees approaching what their teachers asked of patients.2

Randolph3 describes her experience in beginning private practice in psychiatric nursing. The article is almost unique in its detailed description of the subjective aspects of carving a niche for oneself in the community as a practitioner. While not addressing the dynamics of payment, Randolph does describe some of the problems associated with fee charging.

Balsam and Balsam4 wisely devote an entire chapter of their "primer" to the topic 'Thinking about Money"; this thoughtful chapter is titled with supreme aptness, since - as the dearth of literature strongly suggests - the problem is not the money, it is the thinking about it!

It may often be difficult to distinguish problems related in a general way to the relative inexperience of the beginning private therapist from those specifically related to the experience of "hanging out one's own shingle," as the latter are reflected in phenomena around billing and fees. In any case, few aspects of the practice of private psychotherapy as regularly compel the practitioner to examine his experience of himself as a therapist as do the transactions related to the fee. Though fee setting and fee charging are all too often perfunctorily performed transactions, the issues that emerge around the meanings of money for both therapist and patient are of far more central significance than is usually acknowledged, as regards both the process of therapy and the identity of the therapist.

Discipline identity. Determining the amount of fee to be charged involves a beginning psychotherapist in much-debated questions about both his individual professional identity and his discipline's professional "status." For example, different disciplines within the field of mental health are identified with particular skills that each brings to the task of psychotherapy: psychologists have the benefit of specialized training in the diagnostic assessment of patients; psychiatrists, in understanding the physiologic components of illness; and social workers, in a supportive, empathie orientation to patients. Regardless of individual training, abilities, or experience, the beginning private therapist is, to some degree, bound by the fee scales imposed by the regional norms of his discipline. For example, it is common for nonphysician therapists as a group to charge lower fees than their physician counterparts. This can clearly affect the self-esteem of the fledgling practitioner. The issue is further complicated by the meaning for patients of paying a lower fee. This may be illustrated by patients whose selfesteem is compromised; their choice of a "low cost" therapist may reflect devaluation of both self and therapist; thus the treatment setting is in danger of perpetuating the pathologic attitude that brought the patient into treatment in the first place.

Private practice vs. clinic experiences. A resident, discussing in supervision his first private patient, remarked, "When I gave him the first bill, I suddenly felt like a charlatan!" This comment captures the peculiar feelings about billing for services that are specifically one's own. In the clinic (training) setting, the therapist's identification with the institution diffuses the focus on the self; one rationalizes: "It is not I who charge this fee but the clinic, charging for its total services delivered in part through me." Even though the average clinic therapist is likely to feel some personal association with the clinic bill for his patients, this diffusion renders it more difficult to obtain experience in what it feels like to set one's own fee.

Koren and Joyce13 have capably reviewed the dynamic matrix around clinic practice and fees, stressing the value of studying money behavior. But beginning private practitioners are frequently inadequately prepared by their training programs or work settings to manage thoughtfully the fee-related aspects of private practice; the much-debated questions of individual and professional identity mentioned earlier are, in fact, not even addressed by the "curricula" of most training programs. At worst, training or working in the public sector may actually implicitly discourage thoughtful analysis of this aspect of psychotherapy. A psychiatric resident, for example, may infer that the failure of his program to discuss the dynamics of fees is based on the inherently distasteful nature of the transactions and of those participating in them.

The absence of literature on this subject merits some speculation, especially in the light of Schonbar's comments that serve as the epigraph for this article. Two main hypotheses might be proposed for further exploration.* One is that (as a colleague has suggested) money is to our culture what sex was to the Victorian Viennese; that is, despite Freud's admonition against hypocrisy on this topic, a taboo exists even in the professional community against free exploration of money matters. A second possibility is that beginning private practice is charged with such conflictual anxieties that the experience is rapidly forgotten and put aside, unavailable for reflection and description in the literature. This silence, of whatever origin, is undeserved. We strongly recommend that greater attention be paid to fee setting within the training setting as a clinical event deserving careful supervision; one useful approach would be the creation of a seminar on private practice for trainees along the model of AUen.2

As a final note, we might observe that symptomatic behavior around fees is by no means confined to the beginning private practitioner, as the following vignette illustrates.

A candidate in training had been berating her very senior training analyst for weeks concerning his not saying anything at all. At the end of a session, he handed her the bill, folded. Seated in her car, about to drive off, she opened the bill; it was blank.

BIBLIOGRAPHY

1. Schonbar. R. A. The fee as a focus for transference and countertransference. Am. J. Psychother. 21 (1967), 275-285.

2. Alien, A. A note on the making of a psychiatrist: The transition from resident to private practitioner. Psychiatry 34 (1971), 410-418.

3. Randolph, G. Experiences in private practice. J. Psychiatr. Nurs.13 (1975), 16-19.

4. Balsam, R, M., and Balsam, A. Thinking about money. In Becoming a Psychotherapist: A Clinical Primer. Boston: Little, Brown & Company, 1974.

5. Burton, A. Therapist satisfaction. Am. J. Psychoanal. 35 (1975), 115-122

6. Levin, A. M. Private practice is alive and well. Social Work 21 (1976), 356-362.

7. Strean, H. S.. and Blatt. A. Some psychodynamics in referring a patient for psychotherapy. Psychoanal. Rev. 60 (1973), 101-110.

8. Green son, R. R. 7ne Technique and Practice of Psychoanalysis, Volume I. New York: International Universities Press, 1967.

9. Wolberg, L. R. The Technique of Psychotherapy. New York: Grune& Stratton, 1954.

10. Glover, E. The Technique of Psychoanatysis. New York: International Universities Press, 1955.

11. Alexander, F., and French, T. M. Psychoanalytic Therapy. New York: The Ronald Press, 1946.

12. Warson, S. R., and Denman, S. B. Needs for continuing education for psychiatrists: A preliminary report of a survey of Florida psychiatrists. Am. J. Psychiatry 126 (1969). 259-261.

13. Koren, L., and Joyce, J. The treatment implications of payment of fees in a clinic setting. Am. J. Orthopsychiatry 23 (1953), 350-357.

10.3928/0048-5713-19770201-06

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