Earlier this year, blog commenter TK wrote:
“Isn’t this the greatest countertransference, in this age of fee-for-service psychotherapy as opposed to psychotherapist-on-salary: How do I work around my own economic motivation in deciding whether to continue with a patient or terminate?
“In other words, how does one reconcile the consistent economic incentive to keep a client coming back to your office, particularly when one is being paid by the therapy hour instead of by salary? After all, there’s always something to work on, to improve, to understand better…
“In other, other words — and this is only partially tongue-in-cheek….Is there truth to the adage that you don’t ever want to see any psychotherapist who has openings in their practice?”
In a similar vein, a reader named Cynthia more recently posed a challenge:
What would you think about a patient asking a therapist at the outset of therapy to report to her at the start of each session how many client/patient hours you have scheduled for that week? That would give her real insight into what’s going on in the therapist’s practice, and would help determine how important it is for the therapist for her to keep coming back. Would you personally be willing to provide that kind of information?
To me, this seems far more important to know than any therapist personal life information that would arouse normal patient curiosity.
I replied to Cynthia’s comment, noting that such disclosure might appear to be a useful consumer tool not only for therapy clients, but also for anyone hiring an electrician or plumber, a lawyer, a music teacher, or a medical doctor. For each of these, financial incentive may be a factor in determining how “important” it is for the customer, client, or patient to return. However, none of these service providers offer this information, and presumably all would consider the question intrusive and overly suspicious.
Of course, even having this concrete information may lead to different conclusions. An underemployed service provider may be relatively unskilled, and/or more desperate for income. As TK offers: “you don’t ever want to see any psychotherapist who has openings in their practice.” On the other hand, overly busy providers may not be available at all, may be hard to schedule, or may not give you their full attention. Nor is busy-ness always a sign of quality. Some providers market themselves better, or offer faddish services that are popular at the moment. All of this applies equally well to hiring a house painter or a psychotherapist.
Seeing a therapist is different than hiring a plumber or painter, though. Popularity (e.g., high ratings on Yelp, or on one of the dedicated rating sites for doctors or therapists) is no guarantee of a good personal connection with you as an individual. Rapport with a therapist is more idiosyncratic and subtle than that, a matter of chemistry. Also, since therapy quality is more subjective than the quality of a plumbing or paint job, the impressions of others may not be as reliable.
However, even if we agree that a busy therapist is apt to be a good therapist, TK and Cynthia share a somewhat different concern. They worry that therapist economic incentive may lead to unnecessarily prolonged therapy. “Isn’t this the greatest countertransference…?”
In a sense, yes, the wish to be paid for providing psychotherapy is the greatest countertransference. There are important ancillary gratifications of the work — the satisfaction of helping troubled people, the intellectual challenge — but being a therapist is, first and foremost, a livelihood. A therapist who lacks the money to buy food, or who faces eviction or mortgage foreclosure, is not in a position to “bracket” his or her own needs and put the patient’s first. I confess that when I first opened a private office in 1995, retaining my first few patients mattered more to me than it should have. While I don’t believe I harmed anyone, or kept anyone in treatment longer than needed, the economics loomed large in my mind.
However, this situation passed quickly. I cannot speak for all therapists or all psychiatrists, but on the whole we make a decent living whether our practices are full or not. Patients come and patients go; the economics surrounding any one patient is not a major consideration. As in many features of the therapy relationship, the dynamics feel weightier to the patient than to the therapist. This makes good sense, as the patient only has one therapist, but the therapist has a number of patients. (And transference magnifies these issues for the patient more than countertransference does for the therapist.) Thus, a vacation of either party usually matters more to the patient. Fees and money issues usually matter more to the patient, and so forth.
As I read the comments of TK and Cynthia, I recognize a core of realistic concern that the therapist may be biased by economic incentive. But barring specific evidence of desperation or money grubbing on the part of the therapist, I can’t help but think of this as a concern magnified by transference. Economic incentive is the default situation when hiring anyone for anything. Do you worry that your car mechanic, tax preparer, or personal trainer is just stringing you along for the money? We all need to keep our eyes open, but there’s a point at which one’s natural suspicion can give way to trust and a sense of security. Healthy relationships reside in the sweet spot between gullibility on the one hand, and paranoia on the other. If suspicion persists, whether in therapy or elsewhere, there is a problem. Maybe the other person gives subtle signs of untrustworthiness. Maybe one’s own “trust meter” (transference) is a bit askew. Figuring this out is itself the stuff of dynamic therapy; it can shed light on one’s relationships inside and outside the therapy office.