Is your therapist biased by money?

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.

5 comments to Is your therapist biased by money?

  • anonymous

    To Cynthia, one thing I found very helpful in sussing out a therapist whom I found to be truly interested in helping me (and not just in it for the money) was to begin by seeing more than one therapist at a time. In my case, I started out by interviewing five therapists over the phone, eliminated two based on my phone conversations, then began seeing three in their offices on a weekly basis for the next four weeks. This gave me the opportunity to compare their approaches and styles, the rapport that I had with each of them and how I felt about working with them. It became very clear very quickly which would work for me and which would not, and it was mostly on the basis of their widely varying attitudes to their jobs. I think that the therapist’s countertransference around the money/economic issue is more evident to the patient than Dr. Reidbord might like to believe, especially when the patient has a chance to compare therapists side-by-side in this way. Good luck, Cynthia!

  • TK

    Multiple therapists at one time? A therapist would have field day with that. Did these therapists all know that they were involved in a therapist sweepstakes? I thought that only happened with Hollywood writers pitching their takes on a project! 🙂

    ***

    On a more serious note, I read Dr. Reidbord’s entry here just after reading Daphne Merkin’s piece that will appear in the upcoming Sunday NYT magazine, “Exploring a Life in Therapy.”

    http://well.blogs.nytimes.com/2010/08/04/exploring-a-life-in-therapy/?scp=1&sq=merkin&st=cse

    Permit me to quote from it fairly liberally, because parts of Merkin’s article go directly to what Dr. Reidbord wrote about so well and thoroughly.

    Merkin writes…

    “Therapy, as Freud himself made clear, is never about finding a cure for what ails you. Its aim, despite the lyrical moniker it is known by (“the talking cure” was not actually Freud’s phrase but rather that of Dr. Josef Breuer’s patient Bertha Pappenheim, whom Freud wrote about as Anna O.), was always more modest. Freud described it as an effort to convert “hysterical misery” into “common unhappiness,” which suggests a rather minimalist framework against which to judge progress. There is no absolute goal, no lifetime guarantee, no telling how much therapy is enough therapy, no foolproof way of knowing when you’ve gotten everything out of it that you can and would be better off spending your valuable time and hard-earned money on other pursuits.

    “All of which raises the question: What exactly is the point? How can you be expected to know when being in therapy is the right choice, to know which treatments are actually helpful and which serve merely to give the false sense of reassurance that comes with being proactive, with doing all that we can? Does anyone, for example, really know what “character change” looks like? That, after all, is what contemporary therapy that is more than chitchat for the so-called worried well aims to promote.

    “More pressing, who can be trusted to answer these questions? Looked at a certain way, the entire enterprise seems geared toward the needs of the therapist rather than the patient to a degree that can feel, after a certain amount of time, undemocratic, if not outright exploitative. With no endpoint in sight, it’s possible to stay in therapy forever without much real progress; at the same time, the weight of responsibility is borne almost entirely by the patient, whose “resistance” or lack of effort-making is often blamed for any stagnancy in treatment before the possibility of a therapist’s shortcomings is even acknowledged. As the psychiatrist Robert Michels observed in his aptly titled essay “Psychoanalysis and Its Discontents,” for patients, “it often seems as if psychoanalysis isn’t even designed to help them. Patients want answers, whereas psychoanalysts ask questions. Patients want advice, but psychoanalysts are trained not to give advice. Patients want support and love. Psychoanalysts offer interpretations and insight. Patients want to feel better; analysts talk about character change.””

    With all due respect to Dr. Reidbord, psychotherapists are not tax preparers, auto mechanics, or personal trainers. With all of these professionals — even with physicians! — the consumer has an objective measure of whether the professional is doing the job well, and whether s/he is getting what s/he pays for. Therapy, on the other hand, is inherently squishy. Patients do want to feel better. Therapists do offer interpretation and insight to try to get them there. Mostly.

    So I’m not so sure that Cynthia is way off base, trying to contain and control her concerns about whether she’s being held in therapy by the unconscious fiscal convenience of the therapist. Therapists might not want to comply with her request, but that doesn’t mean the request isn’t reasonable.

    One thing that might help here — I can already predict that Dr. Reidbord is going to smilingly accuse me of offering him another blog topic — is for the therapist to write an actual treatment plan for the patient, a la the kind of thing that Richard Zwolinski discusses at great length in a long series of posts over at psychcentral.com

    http://blogs.psychcentral.com/therapy-soup/2010/01/the-mental-health-treatment-plan-introduction-to-an-essential-ingredient/

    and also in his book THERAPY REVOLUTION.

    A written treatment plan by the end of, say, session #4, which Zwolinski notes must be and is subject to change and revision, would at least give Cynthia an actual benchmark by which to judge her progress and the work of the therapist. If definable progress is being made satisfactorily, which she could judge against her written treatment plan? I suspect she’d not worry so much.

  • @ Anon: As TK writes, most therapists take a dim view of comparison shopping for a therapist. Yet it is certainly an option, and in this consumer oriented culture, hardly surprising. It probably goes without saying that first impressions can be misleading, and that initial rapport — or a therapist’s apparent attitude about his or her job — may not correlate well with helpfulness or efficacy in the longer run. But these are pragmatic (and obvious) truths about a very non-pragmatic issue. Ultimately a therapy has to “feel right,” or at least right enough. Every would-be patient has a different way of gauging this, and for some it may help to stack therapists against one another to feel more confident about the one ultimately chosen.

    @TK: Psychotherapists are not tax preparers or auto mechanics. However, this doesn’t mean the “consumer” has no sense at all of whether a therapy is real or helpful. If this concern comes up early, I usually suggest to patients to give it some time, a few months say, and then decide for themselves if it’s worth their time, money, and emotional discomfort. In another post I wrote that my ultimate goal as a therapist is to make myself obsolete. One example of this is that I encourage patients to make their own decisions (rather than me making them), and to live with, and learn from, the consequences. This includes the decision to be in therapy. I’m apt to argue in favor of sticking with it, or point out that change can be slow, or even posit that doubts and an urge to flee can be a resistance worth exploring. But in the same breath I’ll note that we have to decide such things for ourselves.

    I just read Daphne Merkin’s article on your recommendation. It’s an odd piece. At the risk of analyzing someone I’ve never met, it seems that her considerable intellect and facility with psychological lingo interferes with therapy. She reminds me about a fine paper I read some years ago called “Psychological-Mindedness as a Defense” by Gerald I. Fogel, and about a number of patients I’ve seen over the years who make a lifestyle out of therapy without ever letting anything change. Her search for the “perfect” therapist is misguided of course — none of us are perfect. Her rather exhibitionistic article almost seems to be another attempt to throw herself upon a hoped-for caretaker, her readers in this case, to see if we’ll love her, warts and all. Ultimately it’s sad that in focusing on analytic technique and the quirks of her therapists, she’s missed the forest for the trees.

    Re treatment plans: I teach psychiatry residents about case formulation, which carries with it implications for the strategies and tactics of treatment itself. Nonetheless, I agree with Freud that dynamic therapy is like a chess game: There are standard openings and endgames, but the middle must be improvised; there is no plan. Treatment plans apply best to manualized therapies like Beck’s cognitive therapy, DBT, and some time-limited dynamic psychotherapies. Do you prefer a carefully crafted orchestra score, or a jazz improvisation? Neither is inherently better music, although the former may be more comfortable in its predictability.

    I’ll be unable to blog or respond for about the next week, so it’s nothing personal if you comment further and I don’t reply (or moderate your submission to make it visible).

  • anonymous

    To TK: My method of selecting a therapist was not a sweepstakes– it was not a game of chance. It was an honest, thoughtful interview/decision-making process aimed at selecting the professional who I ultimately determined was the most qualified for the position for which I was hiring. We conduct this type of competitive process all the time in connection with engaging other types of service providers. There is no reason that we should not conduct it with therapists– particularly since it is likely that we will be investing quite a bit of time and money in that professional’s services. Does it make you, as a therapist, uncomfortable to think that your patients might be comparing you to your competitors in determining whether to engage your services?

  • TK

    Anonymous, you make a good argument. I can see how some therapists would object on the same theory that they’d like an affair partner to terminate the affair before entering couples therapy, so there could be no issue of split loyalty in the process, but that doesn’t make your argument any less strong.

    As for Dr. Reidbord’s thoughts re treatment plans, he wrote…

    “Do you prefer a carefully crafted orchestra score, or a jazz improvisation? Neither is inherently better music, although the former may be more comfortable in its predictability.”

    I think both can work. But I don’t know that both are equally effective for the patient where there is real concern about the financial impact of the therapy, and worry that unconscious fiscal convenience on the part of the therapist is at least partially driving the therapy.

    Too often in my experience, jazz improvisation can too often sound like the Spinal Tap “free jazz” sequence from that seminal movie! That is, aimless. That is, pointless. That is, you listen to it, and get nothing from it. On the other hand, outside of some of the most rigid CBT’ers, there’s not so much psychotherapy that’s scripted like the countdown to the launch of a space shuttle, or a performance of a Beethoven piano concerto. Flexibility is inherent. New things emerge.

    However…

    That said, even knowing that flexibility is crucial and that new things may emerge, when one goes to a doctor, one can reasonably expect a diagnosis and a plan for treatment. When one sees a lawyer, one can reasonably expect an assessment of the situation and a plan of attack. Plus a rough assessment of how long it will take and what it will cost. When one sees a career counselor, ditto. Accountant, ditto. Personal trainer, ditto. Why in the world would or should psychotherapy be immune or an exception? I didn’t love the Merkin piece either. I found it exhibitionistic. But if she’d gotten treatment plans from all the therapists she’d seen, and was able to measure progress/no progress against those plans, I don’t think she would have reached the determination that the psychotherapist too often reminded her of the Great Oz behind the curtain. She could saved herself a great deal of time and money, if her actual intent in entering therapy was to get better.

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