Even Freud Worried About Money

Wein International

I was reading Everyone Needs Therapy the other day and found her post on therapists getting paid that contained this insight:

" . . . patients want to think that their medical providers are very rich, as money is the generic symbol of success, and they don't want to be seeing an unsuccessful professional. So you thinking that I'm actually worried about getting paid probably worries you.

Yet this is how it is."

It's a maddening idea. Clients tend to think that therapists don't need money.

What a catch-22. This makes it difficult to insist that clients pay promptly and in full. It makes it just as tough to be accommodating if the client misses a payment. Calling to check up on payment implies you need money - which alienates the client.

No wonder you're worried.

Even Sigmund Freud fretted about how money affected his practice and how his need to be paid dictated the relationship he had with his clients. This article by David Smail discloses that Freud habitually referred to wealthy female patients as "goldfish."

In his letter to Fliess on September 21, 1899, Freud writes:

"A patient with whom I have been negotiating, a 'goldfish', has just announced herself - I do not know whether to decline or accept. My mood depends very strongly on my earnings. Money is laughing gas for me. I know from my youth that once the wild horses of the pampas have been lassoed, they retain a certain anxiousness for life. Thus I have come to know the helplessness of poverty and continually fear it. You will see that my style will improve and my ideas will be more correct if this city provides me with an ample livelihood."

Freud believed if he earned a solid income, he would perform better as a therapist. And it makes sense - anxiety over payment can affect the quality of your work and the quality of your life.

I don't intend to hold Freud up as some sort of therapy god -- perish the thought! I mention him here because he is considered the "father of psychiatry" in popular imagination and as such, he recieved a great deal of status and acclaim during his life time... and yet, he still worried about money.

Why did I write this? What can you get out of reading this?

I'm not sure. Maybe I just want to say -- I understand.

It is not wealth one asks for, but just enough to preserve one's dignity, to work unhampered, to be generous, frank and independent.
           - W. Somerset Maugham 


It never occurred to me to NOT pay the various professionals I deal with at time of service.

That being said-wondering if/when I am going to get paid for services does affect the quality of my work and my attitude...and I'm not a therapist.
Everyone forgets once in a while but those who make it a habit quickly find themselves cut off from my services.

leigh's picture

Welchva - good point, thanks for starting the discussion! I think the issue comes mostly for talk therapists or therapists who deal with insurance companies. What usually happens is:
1. the client pays their co-pay, and the insurance info looks ok
2. a few sessions pass after the therapist files for the insurance claims
3. the clients insurance company refuses to pay.
4. So the therapist has to call the client and request full payment for past services :(

This is the main reason so many therapists are seeking self-pay clients who prefer not use their insurance.

As the blog-master here knows; I have a great deal of history over the past 25+ years with paying for ALL types of therapy - through many avenues. Yet today; in my experience, there is really only one way. Cash is King. The only therapists (be they psychiatrist (MDs), psychologist, LCSW, certified counselor, or physical - like PT, OT, Speech, Rehab, massage, other bodywork - or energy work - the ONLY ones who take insurance (if you are lucky enough to have insurance that covers your needed type of therapy) are those affiliated with very large institutions who can afford to wait for the cash-flow trickle of the insurance industry, and absorb the "loss" if insurance does not pay and the client can not or will not pay for services already rendered. Almost every provider has the "Payment is Expected at Time of Service" sign at the front desk or by the sign-in sheet. It's there for a reason. Everybody needs to get paid - it's just a dirty subject we don't talk about like the need everyone has to use the toilet. It is that way because we, as a society, have let it become that way. Therapy is a healing art; yes. It is also a business. Much like medicine. Therapists need not obsess out loud to their clients while working with them about monetary concerns; neither though should they be ashamed or embarrassed to expect to be paid for the service they provide. I have a friend who is a Physical Therapist - I met her through an insurance-covered program at my local outpatient facility. We developed a personal rapport over the years (on and off) that I saw her for PT sessions. When my insurance changed, and I could no longer see her for PT at the hospital outpatient center, we took our friendship outside her workplace. When we go to lunch - we are friends who split the check and talk freely about any and all things. When I see her in her home for a private PT session; I put the money on the table first - and if we talk at all; it's only about my body structures and what I can do to help them feel and perform better. We don't mix the two. It would never occur to me not to pay her full fee; or to come to a scheduled session not prepared to do so. If I was in agony and had no money, I would call her to make alternate payment arrangements, if possible, BEFORE scheduling a session. To do otherwise would lessen her respect for me, and cheapen both the professional and personal relationship we have. I suggest that the therapy community as a whole take a deep breath, and all start getting just a little more assertive in the "collections" department. Clients won't get the message if they don't hear it, see it - and sometimes; feel it. "No, I"m sorry, I can't see you again until you have paid the balance on your bill with me. Would you like to make arrangements to do that now?". Money - or lack thereof - is button issue for many people; from all walks of life. Why should therapist be expected to settle for less?

I always just assumed I would pay my bill right away. Grant, I rarely see any form of medical or therapy professional but I just operate under the mindset that if you get a bill you pay it right away.

I do agree that money is laughing gas, not just for therapists. Even though Freud may not be held in as high regard as he used to be, there is still wisdom found in his words.

Still, I'm dismayed that people would be so stingy with their money. Service has been rendered. Pay up!

leigh's picture

Yeah - it's really only an issue for therapists who deal with co-pays and insurance providers. Most people really do want to pay - they pay their insurance premiums and co-pays and expect that the insurance company will pay on time -- which they hardly ever do on time and sometimes not at all.

I think the reluctance of insurance companies to deal fairly with therapy providers points some linger ideas that therapy as a whole is a luxury - mollycoddling - just to humor the 'goldfish' who can afford to be treated well... Everyone else gets a revolutionary, patented, new pill for their problems.

One thing I neglected to mention in my earlier comment on Big Pharma, but which is relevant here as well - those pills you talk about? The insurance companies don't have half the problem paying for them - and the "new" ones are often hundreds of dollars for a 30-day supply. The ones that are generic - that's why people swallow a pill. Let's see - I have a choice; I spend $8 for a 30-day supply of generic zoloft; or I spend $95 for a 55-minute hour of "talk therapy". Which do you think most people are going to go with - if they have to choose? Like I said, it's the system that says bodywork is not a necessity that is messed up - it most certainly IS a necessity!

In terms of the co-pay thing, I know quite a few folks who require payment in full at the appointment, and then provide receipts that can be submitted to insurance companies afterwards for reimbursement. This of course doesn't address the larger problem......
I once saw a therapist who told me at our first session that I could pay her later, which really surprised me, at the time; it seemed like she was trying to appear relaxed and easygoing, but I actually felt worried for her- she didn't know me at all, and really had no garauntee that I would ever come back! (I did, and paid her). I think part of the problem is that a lot of us have somehow been programmed into feeling that being clear about payment is in some way 'mean' or 'harsh'- that if we care for our clients we understand and accomodate, and 'pushing' them for payment wouldn't fit into that schema. Personally, I think it all comes back to boundaries, a big part of which is tranparency from the outset: here is how I work, what I expect to be paid, what I provide in exchange and in what timeframe all of this should occur. We make counselling contracts around all sorts of other things: treatment goals, therapeutic approach, session length, etc- I think money should just be a routine part of those conversations, and like Denise was saying, we have to be able to back up what we say- again, boundaries. What makes it so difficult, I think, is setting limits when people are vulnerable and exposed, which they/we inevitably are in therapy- it's really hard to say no to someone who is suffering.

Heather - you're right of course, that's it's extremely difficult to stick to our boundaries when someone is obviously vulnerable and suffering. From the other side, though, think of it this way: if my therapist has part of her/his mind on financial problems while counseling me (or working on my body) - I am not getting my money's worth, because the therapist is not fully present with me at the time - which only increases my anxiety/agitation because most clients will sense that you, as the therapist, aren't really "there" for them - and that's what they need for that hour for which they are paying. Therefore, I want and NEED for my therapist to get paid - by me, and by all her/his other clients, so that my therapists can be "all there" for me when it's "my turn". Medical collections is a very sensitive business - yes, I've done a little of that, too in my "jack of all trades" work experience - and yet it still needs to be done. Just with a lighter, more compassionate touch than say - collections for a credit card company or large chain store.

I just read that post on 'Everyone Needs Therapy': she certainly made the waiting for money issue sound really stressful. I can see how that kind of stress would make it difficult to focus, or, maybe more so, to feel resentful with clients, which as Denise was mentioning, would not be good. It certainly seems to complicate things....

It's only a stressor if you allow it to be, or think of it as one... when someone signs up at the local health club, or spa, or swim club even, they expect/demand payment from the get go. Plus a subscription fee, no less!
They have no qualms asking for money upfront for their supposed 'therapeutic benefits', like swimming, using gym equipment, etc. So neither should any therapist worth her diploma! Even people who go to jazzersize who just shake their booty to pre-recorded music, or go chant a mantra in their yoga class, expect to pay up front. Body therapists who do massage, energy work, rolfing, swedish, whatever, need to get over the fact that they are the same or better than all these other so-called 'body beneficial' places. Why? Because their work is custom-tailored to the aches and pains of each individual, and they have devoted considerable time, money and energy to get their certification. Which is more than you can say for your local jazzercise instructor!
Maybe a 'help' would be to put a couple of gently used gym equipment in the waiting room, like a treadmill, and that specialty arc-walkers, for the patients to use while waiting. This would give the illusion, sort of, of being at the gym, or using gym equipment, and then neither party would feel so anxious about the payment issue.
My health food store offers an area where their books can be perused while sitting on nice love seats, and drinking whatever herbal tea is being served.
Then people don't mind the slightly higher prices that might be had for some of the products at local grocery stores. Why? Because there was the added feature of info from health books on many subjects, a comfy sitting area, some nice hot tea, and Laura's above-average knowledge about health issues, or at least where to go for the latest cure for cancer, like Dr. Simoncini's books and videos. So I don't mind paying that premium when I visit Cappabianca's health food store.
And then don't forget that desk drawer where the patients are to drop off their payment of the day, either before or after their therapeutic massage.
Make sure this is visibly noted several places, so it's not conveniently forgotten. Or, alternately, offer a 10% off if the patient gives you "billing information", which means their credit card will be charged for service, and they don't have to worry about it.

Dr. Drea - while I agree with you that "value-added-service" (which is what you are talking about is called in the business industries as opposed to the service industries) can indeed, attract and retain more clients - there is still one issue left unaddressed in the whole payment discussion. That is that while the client may not disagree with the fact that the service you are providing is WORTH what you charge, or that you DESERVE to paid up front without argument once the client understands your "policy" - what if said client just doesn't have the money? To me, that means I just don't get the service. Now ask me if I could be that way if it was, say, my child who needed the service, or my elderly and dependent parents - would most clients then not look for a way to get what was needed, even if they didn't have the resources to pay for it? That is one advantage that Leigh's idea of "pre-pay" DOES have over all the others - if it's already been paid for before it's needed, then I (as client or therapist) don't have that additional worry. But again, the gym, the spa, and even the jazzercise teacher - most probably are not individual sole proprietors with no employees/subcontractors - who count on every dime they bill out in order to meet the bills coming in. So it gets sticky - you want to accept barter, or discounts, etc. - but the vendors/people you as the therapist have to pay may not be willing to do that - and so you need "real" money. And we all know you can't get blood from a stone. But what compassionate therapist wants to turn away someone who is really in need? So, it's back to that catch-22 situation (or as you may prefer; which comes first - the chicken or the egg!?). I agree that it SHOULD not be an issue, but it is - because we are not all socialized with the same values and the same flexibility in willingness to work something out when it doesn't fit in the established "system". I appreciate what I think is your point, that the therapist should not let herself/himself feel out of control of the situation - due to payment issues - because on some level we all know that everyone needs to get paid. I do think it is harder for those whose work is even a little bit outside the mainstream, though, to truly stick to a firm and fast policy, and therefore - they do sometimes get into financial trouble. Perhaps - as I believe Leigh mentioned in an earlier comment - therapists should consider going "back" to school for a class on "how to manage your business" to gain the tools - and the confidence needed to employ them - for collecting their receivables.

Reading this conversation just reminded me of some vicarious trauma research I was involved in a few years ago, and one interesting point that arose was that folks identified having the most trouble setting boundaries with clients who were the most vulnerable and needed the most help. Not rocket science, I know, but I think it speaks to the difficulty of ultimately refusing service to someone who can't pay. Dr. Drea I hear your point about us all being entitled to payment like any other profession; I absolutely agree. I think where it becomes complicated is when the question arises of whether people should be entitled to help regardless of their economic situation, which I realize is sort of a philosophical question, but becomes much more concrete when you've got someone sitting in your office. Don't get me wrong; I'm not planning to work for free and I don't think anyone else should have to either, but I can see where the struggle arises.

Well Heather... it shows you have a kind heart, to believe all who really need the therapy should be entitled to receive it. I'm not talking state-mandated socialism here though, since I'm basically a fiscal conservative. But I do believe in alms-giving of any kind, be it to your local place of worship, a neighbor in need, or a client in need. Those people who at one time or another need help (and who hasn't been short on funds at the end of the month?) will also enjoy times of 'feast' rather than the occasional 'famine'. These would comprise about 10% of the population at any one time, even in our abundant land. The good word says 'the poor shall always be among us'. Therefore, only 10% of your patients would typically not be able to pay. You could do one of two things, or a combination of both: either donate the the time to treat those in need for free, as a sort of volunteer/alms-giving deal, or raise your rates for your paying clientele by 3% to cover the shortfall (they will hardly notice the raise).
Either way, you're covered. What goes around comes around, and if you give away your services for free, you're bound to recoup it some way or another, in this life or the next. And your business will expand, because you'll no longer be worried about collecting from the poor. They will tell their friends, not all who share their current misery, and they will be inclined to pay a visit to the 'good Samaritan'. You could limit this "love treatment time" to Friday afternoons, on a first come-first served basis on a sign-up sheet. Having healthier people in a community is only going to accelerate economic recovery, a feeling of sharing, an experience of bonhomie. And you can believe that when those patients get a job, they will continue coming to you, for their body work!
You can even have a 'share list' where people write down what they really need, such as a job, a piece of furniture or an appliance, tutoring for their child, clothing, etc. Then those 'do gooders' as they are wont to be called, can bring their surplus in. All will benefit, and you'll enjoy the surplus business. Those who sign up for 'free Friday' afternoons could be required to bring in something small, like a package of cookies, to share with others who are currently down with their luck. It's an awful feeling being a beggar, but if you come with something in your hand to share with others, it removes that stigma. Others in your community who hear about your generosity and success will decide to make a for-fee appointment to see you and become part of your following! And best of all, you won't have to worry about that sticky part of the business anymore, trying to get blood from a turnip, or as they are sometimes called, the dead-beats. Well, that's my prayer for you anyway!


Heather - this is especially true for therapists (and anyone else) who work with the "underserved" population. I want to offer a hand up; not a hand out. So, how do I go about doing that? If I refuse service - that doesn't help anybody up and out of their present circumstances. If I let myself be "taken advantage of", that does not serve me, or ultimately the client, either. This is really hard for me; my work involves sharing information - so how much do I share for free? And when and how do I say, "Sorry, but if we continue this conversation, I'm going to have to charge you $X per hour"? It's a little more subjective with me (advocacy/research/and other services) than with someone who has "set" fees - and since the population I aim to serve are the very same people who are in the least favorable position to pay for those services - I struggle with this as an ethical dilemma. I know I can't be the only one with these concerns, though, so I am glad we are having a conversation about it. I need to hear the perspective of others. Thanks for sharing your thoughts here.

I get such good ideas from this website! Reading this thread had actually gotten me thinking about folks I know who work on a sliding scale for exactly this reason, though the 'free-Friday' idea is interesting as well. Thanks everyone for your thoughts.

DD - Along with "what goes around, comes around" (which I absolutely believe - even if it doesn't always seem so at the time) - I also believe in the "hand up" not "hand out" - theory. One of the reasons I have such respect for some of the missionaries that I know - the ones who really get their hands dirty digging clean water wells, ministering to the very sick - no matter how they got that way, helping third-world (and domestic) farms become sustainable through educated and rotational agriculture practices, etc.... "Give a man a fish, .... Teach a man to fish....." I know you know what I'm referring to there. And yet. I grew up believing in that "circle" where we all take care of one another - and that works wonderfully - until someone gets up and leaves the circle and then the circle is broken. Sometimes, someone else comes along to take the place of the one who left - but in this imperfect world of ours here on earth - sometimes no one does. And all the "givers" are left with more work, split between less participants. Until, one day, there just isn't enough time, energy, fiscal resources, whatever - to go around. And then the circle dissolves. This is what happens when compassionate people go TOO far the other way in an effort to protect themselves. As a good therapist friend recently reminded me - it's really all about balance. And boundaries are part of keeping one's balance. So the establishment of clear boundaries is in everyone's best interest - and most people agree with that on principle. It's in the manifestations of our principles that we (and certainly I count myself in the lead here!) often get "stuck" - even if we generally know right from wrong. I like your idea of the Community Share (re: Free Friday Afternoons) and if more therapists (and other service providers) offer it - I am most interested to see how we, as a society now in 2011 here in this place, truly respond in the long-term. I hope (and pray) your optimism is warranted. I have some small concern that it may not be. In the meantime, each provider will have to do the best he/she can - and that will depend on many individual factors - location, resources, client-base, philosophy, etc. I am always pleased, though, to see your ideas flowing. Thanks.