These three concerns make the fee setting very anxiety producing, indeed. Add to that the patient’s anxiety and we have a recipe rife with potential for enactments. Let’s talk today about the clinician’s contribution to this mix.
On first blush, an obvious solution to this predicament seems to be having more patients calling then you can possibly treat. That is, of course, more easily said than done. It is, however, an essential ingredient to having a successful, effective, private psychotherapy practice. And that is one of the reasons why this blog focuses considerable attention on how to generate referrals. Having more patients calling then one could possibly treat puts the clinician in the position of being able to focus on and think about (1) whether he is the best clinician for a particular patient (2) what fee is most appropriate for the patient; (3) what fee he feels comfortable accepting. Of course, being a sought after clinician does not alter the anxiety inherent in assuming the weighty responsibility for taking care of psychotherapy patients. And more will be said about that in future posts.
The new private practitioner, even one with many years of clinical experience, is understandably apprehensive. Will psychotherapy patients call? If it hasn’t dawned on him in the past as he signs his first lease or buys his first office, he becomes acutely aware that he is not only a clinician but the owner a small business. He has to pay rent, keep books, and, most importantly he must ensure that his care is reliable and of high quality. This places him in quite a precarious position so far as his patients are concerned: he needs them. And I should note parenthetically that patients, already in a high state of alert, can sense that. There is much more to be said about that fact, but I will reserve that for a subsequent post. For now, let us say that the practitioner is in that awkward, untenable position of needing patients. At this early juncture, it is perhaps naive and insensitive to say that this position of, “needing patients” gives the practitioner a whiff of what patients feel when they entrust themselves to our care. But it’s worthy of note that, in this regard, both patient and clinician are in the same anxiety producing boat. This anxiety about referrals may make the clinician anxious when he is called upon to set fees.
Patients have many feelings about the fee that they pay. For this reason, it’s important to be clear and straightforward about how you will handle fees. Ideally, it’s helpful to discuss the fee during the initial phone call or in the first session. Some patients, for example, those for whom therapy is a maiden voyage, may imagine that their health insurance will cover your services. Unless you work for managed care this is unlikely to be the case.
Therefore, it’s important to clarify that at the outset. At the end of the initial phone call, after setting the first appointment and providing the office address one might, say, “my fee is x”, and that is payable at the time of the session (or at whatever time the clinician intends to collect the fee). Is that O.K. with you? This opens the door for the patient to assert that he plans to use his insurance or that he wishes to be seen on a sliding scale basis.
Another alternative, of course, is to wait until the first session before setting fees in psychotherapy. For example, 20 minutes before the end of the session you might state your fee. This allows you to begin to explore the patient’s feelings about it – and, to try to understand those feelings in light of the patient’s financial realities as well as their unconscious fantasies. There is much more to be said about this, including: what sorts of fantasies do patients have about the clinician’s fee? Should you offer a sliding scale and if so, how should you set fee? These topics will be fodder for a subsequent post. For now, it seems important to point out that most new private practitioners are anxious about setting fees because they harbor the apprehension that they will lose patients. While this is true, at times, setting fees early and being very clear about them is an important aspect of the psychotherapeutic frame. Clarity about them is reassuring to the patien
When the patient hears the clincian’s fee, often, he wonders, is it worth it? Psychotherapy requires a commitment of time and money but these are not the worst of the patient’s anxieties. Rather, at both a conscious and unconscious level, he is aware that psychotherapy can be painful. And on top of all of this, he is expected to pay for it! While it is understandable that the patient would lament or question the cost of psychotherapy, it can be intimidating to the new private practitioner who may have questions about his own skills.
An empathic tone coupled with an attempt to clarify both affective and reality based anxieties about the fee can prove most useful. Also, should the reality exigencies make the fee burdensome the clinician ought to be respectful of those concerns either by reducing the fee or by referring to a sliding scale setting. Of course, it can be challenging to differentiate between neurotic anxieties and reality anxieties, especially when both clinician and patient are embarking on this new relationship.
The best antidote to that is ongoing clinical supervision or consultation with a clinician who is skilled both clinically and in the art of private practice. In this way, uncertainties can be expressed, clarified and addressed in the supervisory setting. And then the clinician can return to the clinical setting prepared to set his own anxieties aside and empathize with the patient.
Setting fees in psychotherapy can be uncomfortable. Yet, doing so provides a template for talking together, and understanding, the array of different challenges that occur in psychotherapy.
I provide supervision for psychotherapy and for psychoanalysis. Also, I provide psychotherapy and psychoanalysis. If you are interested in working with me, feel free to call: 301.656.9650.