In therapy, anything and everything is up for discussion – whatever happens in and outside the therapy room, provides ‘grist to the mill’. But the material of therapy is not just about the experiences we bring; it can include how we experience therapy itself. The context in which it occurs, the practicalities that govern it, and the boundaries that contain it, can provide fertile ground for exploration and self-discovery. In the interactions that take place between two people in one room, even the practical and the mundane can become a vehicle for expression and a means of unconscious illustration of what is going on for the client, and what is going on in the therapeutic relationship.
Unless the therapist is using an online payment system such as that provided by welldoing.org, for many clients one of the first practicalities they have to contend with, is payment. Even those who are comfortable with the ‘great British taboo’ of talking about money, may find it awkward or jarring discussing payment in the same session as covering very personal or emotional issues.
In addition, the fact that they are paying for a ‘service’ can make it difficult for some clients to accept the very genuine nature of their therapist’s attention, interest, and caring. It is also a reminder of what many clients would rather forget – that despite the real closeness and intimacy that can be involved, the interaction is not a friendship, and it must retain some of the distance and imbalance of a professional relationship. Raising these issues and talking about them can feel embarrassing or painful, but they can be ‘therapeutic gold’, resulting in a rich exploration of clients’ doubts and fears around relationships, intimacy, and boundaries. They are also important to tackle because overcoming them and achieving a positive and secure attachment to their therapist, is what enables many clients to heal from past and present relational trauma or other difficulties.
The practicalities of payment can also function as the non-verbal equivalent of a Freudian slip and can be revealing of a client’s feelings and attitude at particular points in time. A few examples come to mind from my own therapy. Early on, my therapist wrote a note on one of her monthly invoices, asking me to pay by cheque or bank transfer (rather than by cash). Her simple request – made in that way, I am sure, to save me the potential embarrassment of discussing it face to face – triggered intense feelings of shame, anger and distrust. We spent a number of sessions talking about the childhood origin of those feelings, and my fear of ‘doing the wrong thing’ and not being communicated with directly. The same issues have come up again and again in the last four years, in a number of other guises.
I now pay by cheque, and I do so within a couple of days of receiving an invoice; however, my therapist recently remarked on how my payment wasn’t always this prompt. It used to take me several weeks to pay, though she kindly never mentioned it at the time. I felt too unwell to be organised; I kept losing my cheque book; I didn’t have time to look for it, or I kept forgetting. My therapist’s comment was not a complaint, but an observation on how things had changed. She interpreted the change as evidence of my commitment to and investment in the process of therapy and the therapeutic relationship, and the priority I now give to it. Though I never delayed payment deliberately, I think she is right in seeing the difference in the way I now approach it as a reflection of more than just an improvement in mental wellbeing, or greater organisation. It is a matter of the regard in which I hold her and her role in my life, and the importance of the task we are engaged in together. This has impacted me in several ways – including making sure I never misplace my cheque book!
I’ve also had a very recent realisation about the significance of a past payment habit of mine. I now feel comfortable handing over cheques in person, but for a while I used to send them in brightly coloured envelopes, imagining them dropping through her letterbox and onto the doormat and being instantly recognisable as having come from me. I was aware at the time of a desire to be seen as creative, and perhaps a little quirky. I shared a feeling that many clients experience – a desire to be ‘special’, their therapist’s ‘favourite’, and to stand out from the ‘crowd’ of other clients. It’s interesting to me now that it didn’t even occur to me that my personal qualities, our interactions, and the time we spend together in sessions, could be sufficient and special in their own right.
What I recently realised is that my behaviour was also driven by a powerful desire to be present to my therapist, when we were not together. The envelopes were a way of making contact, and of trying to ensure I was remembered, and kept in mind. This hunger for remembrance has become more obvious as I have become more adept at ‘keeping my therapist alive’ between sessions and holding onto a feeling of connection. It is as if my previous preoccupation with needing to keep her in mind was masking an underlying preoccupation with needing to keep me in hers. It’s a realisation I’ve come to after the fact, but it’s also another potent example of the way in which deep fears and desires can be communicated through the vehicle of the most ordinary and seemingly mundane things. I continue to realise that how and when you pay your therapist, can be so much more than a purely financial transaction!
October 4, 2017 at 9:36 pm
I have paid in the past in cash and via internet banking. for me the payment caused some degree of anxiety, had I remembered it? (I had forgotten maybe twice in 4 years), should I do it at the beginning or end, do I hand it over to her hand or leave it lurking somewhere in view? do I draw reference to it… if I do BACS do I do it up front or retrospectively, one session or more at a time, do I email to say its done or hope it gets found in her bank account at some point? It wasn’t something I ever brought up in therapy but your blog post reminded me that actually money is a big thing in therapy and part of my own anxiety also revolved around the paying for relationship, which seems odd to do, but that relationship is also a service, one that I am eternally grateful to have been able to afford. somehow, for me, the payment reminded me I was in therapy and sometimes that could leave me feeling shame that I was there, that i needed to be there, and sometimes the payment acknowledged the fear that I was somehow a botheration to her (not something ever expressed by her or even evident in other ways, just my own fear), by paying her maybe I could justify the botheration factor that I imagined was there.
with the shoe on the other foot though I did occasionally get the sense that actually for her too money was a cause of embarrassment, on the couple of occasions I (genuinely) forgot to bring the fee there was an awkward embarrassment almost in her for asking. its a difficult one. but one definitely worth the discussion, though we never did, and now don’t have to!
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October 14, 2017 at 10:03 pm
Thank you for the really interesting comment, it raises a lot of interesting points and possibilities – and I’m sure there was no ‘botheration’ involved 🙂 Like you, I sometimes get the sense my therapist may also be a little hesitant to bring up money, though it’s also possible she does it entirely on my own account. Very early on, I remember there was a change in her rate between my two ‘trial’ sessions and me starting therapy properly. I paid her for the second trial session (the first was free), but at the old rate, and she never corrected me, instead my first monthly invoice was at the new rate. I included what she hadn’t charged in my next payment, without her asking, but I did wonder why she hadn’t mentioned it! I assumed it was more for my benefit, I think, than her own feelings about it, and I think the same goes for why she asked me to pay by cheque or bank transfer rather than cash, in writing, rather than in person….thank you again for your comment! how are you doing and how are things going, a few months on? I think of you often, and wonder what life post-therapy is like for you…..
October 4, 2017 at 10:20 pm
This is one area where I’ve never struggled but I can understand why others do. I pay in advance, always in cash. If I’m feeling delicate I ask if I can pay at the start of the session because I know by the end I will be in such a ‘little’ place it will jarr me to have to pay and ruin any closeness. I’d rather get it out of the way, pay a month in advance so I don’t have to worry.
Why doesn’t this bother me? Mainly because I am a business woman myself. I understand that I am paying for her skills, her training, her time. I’m not paying for her care because if she didn’t care about me, she wouldn’t work with me even if I paid her double what she asks. I know that. How do I know that? Because as a wedding photographer, I don’t work with clients whose wedding I don’t care about. Why? I don’t do my best work for them. I work with emotion and relationships and people. I capture memory. If I don’t care, I don’t sense their emotion and miss crucial parts of the emotional journey from engagement to the last moments of their special day. I don’t do my best work which ultimately affects my confidence, my skills and my reputation. I have 1 shot. I have to care or I am terrible at what I do. I pride myself on making clients cry from happiness and loving memories when I deliver their finished albums!!! They nearly always comment on how well I have captured their relationship, their personalities, the little often over looked details and the emotions. I can’t do that if I don’t care… REGARDLESS of money. I’ve turned down £2k weddings because I just didn’t gel with the bride (bridezilla). I’ve accepted £250 jobs because I was emotionally connected to their story (the father of the bride was terminally ill so it was a rushed, cheap affair so he could walk her down the isle) but I worked my ass off for them. This isn’t an advert in case it sounds like it because I’m not taking on new clients at the moment.
I also pay for everything I can in cash because a) it has more value… handing over a card gets the job done but if you hold a £50 note in your hand just see how much harder it is to hand over than your debit card… try it. You’ll see. As a result, I like to pay her in cash because I am placing more value on our time b) you never know when someone will cash your cheque. If they do it later than you anticipate and you forget, it may bounce and that will destroy the relationship far more than handing over cash does c) from my previous marriage I was left in sh** loads of debt that I had to get a debt relief order for. I went on a money management system that advocated paying for everything possible in cash. I now run an envelope system and each one is filled with different budgets; food budget, pocket money, fuel money etc. In this way… I don’t have need for or want a credit card. We do have one for larger purchases (0% interest which we then switch around like mad… we’re called ‘card tarts’ for this but it works!) but that’s it. I have learnt the value of money and how to live within our means. Paying her upfront at the start of the month instead of week by week means that there is NEVER any temptation to dip into her ‘envelope’ to buy something frivolous. I prioritise my time with her above everything else.
I actually feel that in this way I am strengthening our relationship because she knows me to be reliable in this regard. She never has to worry that I’ll forget. I once had a dream that I did and it panicked me badly but literally across the street from her office is my bank so all I’d do is run straight over, grab the money and run back. I feel that she trusts me enough to know I would do that if I ever DID forget and wouldn’t just run away.
I know it’s rough to pay therapists but actually at the end of the day like I said you’re paying for their time and expertise NOT their care. Secondly it’s actually more detrimental to your relationship NOT to pay, to continually forget, to be late etc. You want to stand out and be a good client? Be the one who pays on time, every time and your therapist will trust you.
I hope that my experience as a service provider (though not a therapist) shows that those of us who love our jobs love them because of the people we work with, not the money. I hope that my word is taken as being trustworthy because I am not a therapist therefore not obliged to say this for any other reason than it may help others understand that just because you pay someone doesn’t make the care you receive LESS genuine, it is just what needs to be done.
And yes before you ask I am very connected to my therapist, I think the world of her and I too hate the professional boundaries. No, I definitely do not see her in the same way as the guy who washes my windows… I am not emotionally detached from her. I can just see payment in a totally separate way to the rest of our relationship, that’s all.
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October 6, 2017 at 2:01 am
The integrity of your photography practice is remarkable. Brava!
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October 14, 2017 at 9:57 pm
Thank you so much for the detailed comment! 🙂 I completely agree with your comments about payment not making the caring any less genuine, and like you, I also see payment as separate to the rest of our relationship, while at the same time appreciating why some clients find it so difficult. It’s odd, because while I placed so much emphasis on my ‘integrity’ in being completely straightforward with my therapist about everything (all my ‘googling’ instances’ for example), I didn’t see the contradiction with what I was doing with payment – I guess because I was ‘doing it’ subconsciously and not at all with intent. I felt bad for being late, but I guess even though it was ‘unconscious’, I still somehow managed to make sure I never ever paid later than the end of the month in which I received the invoice. Which I guess probably says something in itself…..thank you for your really thought provoking comments which have helped me to see a little more about what was going on!
October 4, 2017 at 10:49 pm
Interesting. I never gave this much thought. With my current therapist Dr L, I pay at the end of each session by debit card – he has a little EFTPOS terminal on his desk. While that may seem very cold, the process of paying is actually quite grounding and provides a transition even after an extremely distressing session.
He sets his fee quite low in comparison to most other psychiatrist therapists and I can claim about 2/3 of it back through our publicly funded medical scheme. I am not sure if he ever bills third parties instead of having the patient pay and then claim back. He’s never said so explicitly but from comments he’s made when I’ve discussed my own billing dramas as a surgical assistant I think he doesn’t – and given my own experience of delayed payments and rejected claims as a provider I fully support that position.
The psychologist I was seeing last year was rather dodgy as far as payment. I am eligible for Department of Veteran’s Affairs funding for my mental health treatment, but the DVA fee scale pays a lot less for a psychologist than a psychiatrist. Under the scheme providers who claim direct payment from DVA are not permitted to charge a gap fee (I think the idea is that they’re supposed to just suck up a lower fee as part of their goodwill towards veterans, which seems pretty unfair on them), but this practice was open about making me pay the fee difference. I can fully understand it as a business decision, but I’m not sure how they reconcile it ethically. In theory DVA would cover the full amount of Dr L’s current fee, but I would not even consider asking this of him unless I was financially desperate, partly because of the uncertainties and inconvenience for him but also because I think that paying something rather than getting it entirely free means that you value the service more.
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October 14, 2017 at 9:51 pm
Thank you so much for reading and commenting, and I’m glad it was thought provoking! 🙂 it is definitely such a complex area, and people (both therapists and clients) handle it so differently, and what works for some, is difficult for others!
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October 5, 2017 at 10:13 am
I’m currently – unexpectedly- in such a crap financial position, I am running a tab with the therapist I usually pay every week, usually in advance. He’s also the one I am in the midst of a very difficult rupture, and it’s feeling very uncomfortable to be challenging him and not paying him, all at the same time. I am thinking of leaving, anyway. But I am going to need to either find a way to get back to paying him weekly or stop. Somehow it just doesn’t feel right to be giving him such a hard time and not paying him on time, all at the same time..
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October 14, 2017 at 9:49 pm
I’m so sorry things are so difficult in therapy at the moment, and you are thinking of leaving. And I can imagine that it must make it that much harder to work on healing the rupture when there’s all the feelings surrounding finance, going on as well. Hold on, if you can, despite the difficult current situation – he knows you were always a reliable client and given your situation I think he must be genuinely understanding and does not link the rupture with the non-payment, although it seems the connection feels really difficult for you (as it would for me too!). Ruptures are so very painful, thinking of you…..I don’t know if it helps, but in my own therapy, the worst and most painful ruptures have also ended up being the most significant in the long-run…..courage, and wishing you all the very best both in your therapy, and in the financial position…..
October 15, 2017 at 2:28 am
Thank you so much for your kind words.
The payment thing…
I have sorted it out in other ways. I just can’t do the kind of work we are doing and have that be messy, too. It’s made things hard in other parts of my life, but I don’t need any more complexity with him right now. It just didn’t feel right.
I very much want to be able to hang in there, because as painful as it is, I am learning so much from this. It’s a hugely familiar dynamic and this is a gift, in a way, because I have no choice but to resolve it or shove it all out of sight again by making him the bad guy. My bad exT literally was the bad guy (gal), if we’re talking in simplistic terms. It was almost impossible to look at my role in things, both for me or subsequent therapists.
Thanks again, and I will continue to read your blog for all the wisdom and understanding it gives. It’s so reassuring to hear from others who have been there and come out the other side intact.
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October 6, 2017 at 1:42 pm
The question of money and therapy is fraught with an overlay of multiple potential meanings. Money is an odd thing, kind of like a projective psychological test. We put something of ourselves, our psyche, into these metal pieces and rectangular papers. They tell us about ourselves, both the patient and the therapist. As a result, what appears on the surface to be about dollars or pounds might be about so many other things, past and present. Thanks for this post. It makes me think I should write more about it myself.
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October 14, 2017 at 9:42 pm
Please please do, I would love to read it! 🙂
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March 29, 2018 at 10:51 pm
So interesting to read this post!! I just sent a payment through the mail a couple weeks ago and I put kitty stickers all over the envelope!!!!! Then I was kinda embarrassed I did that. Oh well….
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May 12, 2018 at 9:54 am
Don’t worry, I’m sure there’s no need to be embarassed, it sounds cute 🙂
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