Money in Psychotherapy

by Diane A. Suffridge, Ph.D.

I publish a blog every two weeks for therapists who are in training or newly licensed.  The question poses a dilemma that is common to new practitioners, and the answer provides some suggestions on resolving the dilemma.  This post may also provide some insight to readers who find themselves with mixed feelings about paying for psychotherapy.  

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QUESTION:

My internship is in an agency that charges sliding scale fees.  One of my clients hasn’t paid for the last two sessions, saying he forgot his check both times.  I know he can afford it because he just came back from a big vacation to Hawaii.  How can I bring this up with him and get him to pay on time?

RESPONSE:

This is a difficult clinical issue, and it’s a good experience to have during your training.  If you plan to work in a private practice after licensure, you will find that the meaning and emotions associated with client payment and fees become more complicated when it represents your income and livelihood.  Having this experience while you are in training and not dependent on the fees for income allows you to come to a better understanding of the issues involved for you as well as your clients.

I recommend that you approach the exploration of money and fees by reflecting first on the meaning and emotions that are present for you both personally and professionally.  Often money is a way of expressing and experiencing value or validation, and it may be used as a tool to exert interpersonal power.  Feelings related to self-worth are often associated with the exchange of money in a relationship.  These may include entitlement, comfort, envy, shame, deprivation, and pride.  Think about the role that money plays in your family relationships and the meaning of money in your cultural community.  You may become aware of implicit messages like “it’s not polite to talk about money,” “you have to fight for everything you get,” “you’re only worth what people give you,” or “if you work hard enough you’ll get what you deserve.”

In addition to your personal and cultural history with money, your current status as a therapist in training includes complex relationships with money.  You may have taken on significant student loan debt or received support from a partner or family member.  You are probably working as a volunteer or receiving a small salary while you are accumulating hours toward licensure, and you may be working another job in or outside the mental health field to pay your expenses.  All of these factors will contribute to the feelings that arise in you when your clients pay or don’t pay their assigned fees.  These will become heightened when you are in a private practice and your client fees are a source of income.

Once you have become more clear about how money impacts you in your clinical work, you can move to reflecting on the meaning of money for your client.  Some of the things to consider are his early family experiences related to money, value, and power; cultural messages related to money and gender, since there may be different expectations for men and women; the meaning it has for him to seek services at an agency that offers a sliding scale; and the emotions associated with his financial choices.  Think about conversations and interactions you have had in setting his fee, in sessions when he brings payment and when he doesn’t, and when he tells you about purchases or expenses like his recent vacation.

Your understanding of how you and your client think and feel about money will help you begin to identify the relational and cross-cultural dynamics in this therapy relationship and specifically in his recent lack of payment.  A few possibilities to consider are: your client feels shamed by requesting a sliding scale fee and manages his shame by withholding payment; you are reluctant to discuss money openly and have had difficulty setting an appropriate fee and clear expectations about payment; your client devalues his emotions and needs for nurturing leading him to forget payment for a service that involves both emotions and needs for nurturing; your client associates masculinity with interpersonal power and is attempting to balance the power differential.

What is important in your examination is to consider the contribution that you and the client are each making to this current conflict which will help you identify what you need to do internally and interpersonally to address your client’s lack of payment.

For more about Diane Suffridge, visit: www.dianesuffridgephd.com

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Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

Why “Just Get Over It” Doesn’t Work with Anxiety and Depression 

By Melanie Greenberg, Ph.D.

We are continually bombarded with messages from the media and self-help gurus that we are in charge of our own happiness. All we need to do is buy this product ot follow that secret formula and we can get rid of anxiety and negative emotion for good.  If getting rid of negative emotions is so easy, why is it that more than 21 million children and adults get diagnosed with depression each year and that depression is the leading cause of disability for adults age 15-44? Why is it that 40 million adults in the United States suffer from an anxiety disorder?.

The truth is that we can’t just get rid of negative emotions when we feel like it.

Below are six reasons why negative emotions l(like fear or  distress) are such a struggle for us:

(1) Our brains are wired for survival, not happiness. That is why they keep bringing up negative emotions, past mistakes, and worries about the future. We can get stuck in repetitive cycles of self-criticism, worry, and fear that interfere with our ability to be fully experience and react adaptively to what is happening in the present.

(2) It doesn’t work to just shove negative emotions down or pretend they don’t exist. Because of the survival wiring of our brains, they will be given high priority and keep popping up again in conscious experience. In fact, some research by Daniel Wegner and colleagues suggests that suppressing thoughts while in a negative mood makes it more likely both the thoughts and the negative mood will reoccur.

(3)  Our physiological systems can react to mental images and events as if they are happening in the real world. Try thinking about smelling and then biting into a lemon.  You will likely feel a change in saliva in your mouth. Now think about putting your hand on a hot stove. Do you feel your heart pounding a bit faster?  Thus, when fearful thoughts and images come into your mind, your heart starts to race or your breathing get short.

(4) Negative thoughts feed on each other. We may begin by worrying about not having enough money. Then we may think, “What if I lose my job?”  and then about all the people who won’t help us and the past mistakes we made getting into this financial situation in the first place. Before we know it, allowing ourselves to dwell on a small negative thought has led to a mental mountain of difficulties.

(5) The things we do to avoid or try to cope with feeling negative emotions may be more counterproductive than the emotions themselves. People frequently turn to alcohol, marijuana, or prescription drugs, such as Xanax, to escape anxiety. These substances have negative effects on mood and motivation and addictive properties. Turning to food excessively can lead to overweight or obesity and low self-esteem associated with weight gain.  Getting angry and blaming others for our negative emotions can ruin our relationships. Shopping or avoiding opening the bills can lead to mountains of debt.

So what do we do with those distressing and uncomfortable feelings? The answer is surprisingly simple – We learn to make peace with our own feelings and, by doing so, take away their power. As we begin to untangle the feelings themselves from our negative judgments about them (e.g., crying is a sign of weakness), we begin to allow them in. We learn when to listen to our feelings and when to calm them down. Once we understand the connection between events in our lives, our thoughts, and our feelings, we can better anticipate our own reactions, make better choices about how we spend our time, and prepare for emotionally “high risk” situations.  We can also use mindfulness techniques or cognitive reframing strategies to take a step back and see the issue from a broader, wiser perspective.

Psychotherapy can provide you with expert guidance, coping strategies, and emotional support to experience and express your own feelings, while staying grounded and present.  The effects of allowing in your natural, healthy emotional emotions can be transformative and empowering. You need to face your own feelings to get back in the driver’s seat of your life.

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To contact Dr. Greenberg or to find out about her services, e-mail her at melaniegreenberg@comcast.net , visit her website http://melaniegreenbergphd.com/marin-psychologist/ or read her blog – The Mindful Self-Express  http://www.psychologytoday.com/blog/the-mindful-self-express.

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Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.