A Conversation About Therapists and Money is an overview of a workshop provided to counselors and therapists to address emotional and ethical issues they may have with the financial reality of private practice.

1. A Conversation About
Therapists and Money
Mary Crocker Cook, D.Min., LMFT, LPCC, LAADC
Connections CEU Institute
www.counselorceu.org
www.marycrockercookbooks.com

2. • https://www.youtube.com/watch?v=QF-X-BCSOaQ
Financial Behavior Types

3. Money Personality
• Alexis Avoider
• Oliver Over spender
• Ursula Under earner
• Hanna Hoarder

4. • Exercise: Get a piece of paper and draw a line down the middle, top
to bottom. Label the left column “Current Financial Behaviors” and
the right “New financial behavior’. Refer to your personality types and
list a few situations in which you exhibited those behaviors. Be
specific. When you have some examples, write down a different
response that you could have exhibited in the other column. What
stops you from doing THAT behavior?

5. Have you ever given a client a financial break on your fees,
only to watch them drive away from your office in a car valued
at $60, 000 or more?

6. Is this your car?

7. When Money is Our Issue?
Where’s the disconnect?
What we learned,
Experienced,
Messages we took in about who we are and what our place is in the
world.

8. • Financial upbringing exercise, pg 56, The Emotional Behind Money

9. The skill it takes to really hear the problems of
another individual and the gift of guidance,
feedback and the psychological tools we
provide is significant. Often because the skills
as a therapist come to us naturally, we feel
uneasy about really charging our clients at
least the going rate.

10. First, what exactly is our creed? We are supposed to be
helpful, but what is really helpful when it comes to setting and
maintaining fees, particularly in times of financial hardship?
Many therapists intuitively feel that we should be generous,
even at our own expense. So how do we unscramble all the
pieces to make good clinical decisions and take good care of
ourselves and our practices?

11. Ethical Responsibilities
California Association of Marriage and Family Therapists, CAMFT
http://www.camft.org/Content/NavigationMenu/AboutCAMFT/
WhatisCAMFT/EthicalStandardsPartI/EthicalStandardsPart1.pdf
NON-PAYMENT OF FEES:
Marriage and family therapists do not terminate patient relationships for
non-payment of fees except when the termination is handled in a clinically
appropriate manner.
9.3 DISCLOSURE OF FEES:
Marriage and family therapists disclose, in advance, their fees and the basis
upon which they are computed, including, but not limited to, charges for
canceled or missed appointments and any interest to be charged on unpaid
balances, at the beginning of treatment and give reasonable notice of any
changes in fees or other charges.

12. American Association for Marriage and Family Therapy Ethics Code,
2012
http://www.aamft.org/imis15/content/legal_ethics/code_of_ethics.aspx
Principle VII
Financial Arrangements
Marriage and family therapists make financial arrangements with
clients, third-party payors, and supervisees that are reasonably
understandable and conform to accepted professional practices.
7.1 Marriage and family therapists do not offer or accept kickbacks,
rebates, bonuses, or other remuneration for referrals; fee-for-service
arrangements are not prohibited.

13. 7.2 Prior to entering into the therapeutic or supervisory relationship,
marriage and family therapists clearly disclose and explain to clients
and supervisees: (a) all financial arrangements and fees related to
professional services, including charges for canceled or missed
appointments; (b) the use of collection agencies or legal measures for
nonpayment; and (c) the procedure for obtaining payment from the
client, to the extent allowed by law, if payment is denied by the third-
party payor. Once services have begun, therapists provide reasonable
notice of any changes in fees or other charges.

14. 7.3 Marriage and family therapists give reasonable notice to clients
with unpaid balances of their intent to seek collection by agency or
legal recourse. When such action is taken, therapists will not disclose
clinical information.
7.4 Marriage and family therapists represent facts truthfully to clients,
third-party payors, and supervisees regarding services rendered.
7.5 Marriage and family therapists ordinarily refrain from accepting
goods and services from clients in return for services rendered.
Bartering for professional services may be conducted only if: (a) the
supervisee or client requests it; (b) the relationship is not exploitative;
(c) the professional relationship is not distorted; and (d) a clear written
contract is established.
7.6 Marriage and family therapists may not withhold records under
their immediate control that are requested and needed for a client’s
treatment solely because payment has not been received for past
services, except as otherwise provided by law.

15. So, Where Do Our Issues Come Into Play?

16. Some therapists may even feel relieved by charging a lower
fee. They link their own self-worth, value and effectiveness to
appeasing and supporting the client in this moment of stress.
A lower fee feels like less pressure to push for change, and
more freedom to just be with the client, which is, in many
cases, the best intervention anyway.

17. Ironically, we tend not to recognize the legitimacy of empathic
listening alone as valuable and fee-worthy. Some of us operate
under the idea that we need to be masters of theory or savvy
interventionists in order to earn our keep. Do we
underestimate the value of providing a good ear and the
healing power of helping clients to talk openly and be
understood?

18. Is therapy a luxury? Is it a necessity? Who
decides this and how? Some therapists tell
me that they feel guilty charging any fee
when clients are having a difficult time
financially. Others have shared with me
that they are having difficulty paying the
fee for their own therapy and supervision.

19. And what about our fear of losing clients, of financial
insecurity, or of ineffectiveness? It's difficult enough to have
your own business and have your paycheck change from week
to week. To have to bring in business concerns on top of doing
therapeutic work adds to the pressure. How much do we
know about our own worries and the effect they have on our
decision making when it comes to fees? Some clinicians think
they must slide to keep business.

20. People don't negotiate fees with the grocery store, cable
company or the gas station.

21. Lawyers do pro bono work, or barter. We can make this part of
our work too, but should it really be our only way of thinking
about our work? Why is it that many therapists' default
thinking goes to the value being less rather than more? Or
maybe it should be as one therapist I know says, like taxes.
The more you make, the more you pay.
https://www.youtube.com/watch?v=05_l0CHTJ0g
(13 minutes)

22. How involved ought we be in a client's decision to begin or
continue treatment?
Should we encourage clients to stay?
Is that too "sales-y"?
Do we slide our fee? (Does the massage therapist or
physician?)
Do we really believe in what we do?
Is it possible that coming to therapy actually helps people
prosper?
Why are we hesitant to conduct business as usual when a
client is stressed?

23. The Question of Sliding Scale Payment in Psychodynamic Therapy
Posted on July 19, 2011 by Joseph Burgo
http://www.afterpsychotherapy.com/sliding-scale-payment/
After struggling with this issue, I finally came to the conclusion
that my fee should be my fee and remain the same for all
clients. My reasons are two-fold:
First, if you maintain your professional boundaries as a
therapist, then your own emotional needs and issues don’t
enter into the treatment.
While you derive meaning and satisfaction from your work,
therapy is entirely about the client’s emotional needs, not
your own.

24. You do have personal financial needs, however, and those are
met by the client paying your fee. In other words, the actual
therapy is about the client’s needs, the fee is about your
own.
If you’re working for less than your usual fee, do you give less
to your client?

25. Second, while clients often become emotionally dependent in
therapy and develop a parent-child transference, you are not,
in fact, their parent and it is not your job to look after their
financial needs. Your job is to give them the best treatment
you can.
Quite a few of us entered the profession because of an
unconscious wish to cure a parent or in order to feel needed
(rather than being needy ourselves); these factors might
distort how we set our fees so they need to be understood
and sorted out.

26. The truth is, I need to earn money to support myself and my
family; being appreciated for the work I do and feeling good
about myself as a therapist are all well and good but they
don’t pay the mortgage. My expenses won’t go down just
because half the clients in my practice are paying reduced
fees.

27. Possible Answers When Money is an Issue for
the Client
Sometimes, of course, a duck is a duck.
Someone loses a job, or does not have the
means to afford a higher fee. But I have
seen many different solutions to these
would-be obstacles to treatment. Some
people come less often; some have to take
a break for a while. Some do shorter
sessions.

28. Some therapists do online counseling, and since it's more
convenient for them, they feel they can charge less.
Some therapists do reduce fees when the need is clear, and
with the understanding that when things get better the fee
will be returned to its regular status.
Others save a few sliding-scale slots as part of their overall
caseload and reserve them for a population they feel most
needs it, such as young adults or single parents.

29. In some cases, suggesting or agreeing to lowering the fee may
be communicating the idea that we agree that things are
indeed pretty bad for the client, and they won't get better—
that they are poor and perhaps helpless to figure out how to
figure out their money situation.
We may be sending a message of despair, not of
understanding and support. Other clients may feel loved or
cared for, but for some it may signal that we don't value the
work, or value the client.

30. One therapist said that after she lowered the fee, the client
stopped coming. After several attempts to reach her, the client
finally called back and said that she felt guilty and
embarrassed paying so little and so decided not to come. It
can work the other way as well. A lower fee may leave us
resenting the client, particularly if it has not been thought
through enough.

31. Some therapists like the feeling that they are being supportive
or practical, loving even, when they are negotiating a fee. And
it may be true, since being so is the heart of much of what we
do as psychotherapists. Many of us, particularly from social
work or social welfare backgrounds, have the idea that we
must offer up at least some of our services as charity.

32. This is a worthy ethic of the helping professions and our
practices. However, should it be done habitually to the point
where we have difficulty meeting our own obligations or
goals? Our relationships with clients are important. Our time
with them is sacrosanct. We work hard with concentrated
effort and dedicated time. We are not (well, I don't think so)
merely the mani or the pedi that could be done at home.

33. Can we suggest that clients look at things this way, too?
Dare we question the priority that therapy holds in their
budgets?
Or suggest giving up something in order to pay our fee?
Should we question their leisure plans, hobbies or choices?
Should we help them to view therapy as an investment in
their marriage, financial recovery or success in life?
Do we really believe this is a luxury item or a vital part of our
clients' well being?

34. Shifting to Financial Success Thoughts
A shift has to first begin in our minds
and in our thinking, in order to
experience financial success. Being
aware of the limitations that come
from conscious mind and moving our
unconscious beliefs into a state of
consciousness is paramount.

35. Take a look at what making a
great deal of money creates in
your body and mind. Does your
stomach feel stressed or excited
about the possibilities?
Can you feel a sense of gratitude
for the potential of having large
sums of money or for some
reason is your feeling one of
guilt and unworthiness?

36. Sometimes religious teachings interfere with financial success.
Many religions equate financial success with close to sin. This
can make it difficult to expect and ask for money in return for
counseling and the services we provide.
Many religious leaders are very wealthy and
do not feel that making or having money is a
sin. Some of the wealthiest institutions are
church affiliated corporations. Maybe it’s not
the money, it’s what we do with the money
that is important.

37. There is a great exercise that can assist you to get a sense of
what you would do with large amounts of money. Imagine
that tomorrow you get a check for $100, decide what you
would do with it. The next day you get $200, decide how you
would spend it. The 3rd day you get $400 and on the 4th day
$800, by the 5th day you get $1600 and the 6th day $3200. Do
this exercise for 2 weeks, doubling your money each day. Soon
your check is over $100, 000. Extend the gift of money for a
month.

38. Now we are talking about the kind of money that can change
the world. Are you a good person to be given this large sum of
money? Will you do things to help others?
I know the answer is yes and it is important that you realize
that you are the right person to be trusted with a lot of money.
Getting used to the concept of having an abundance of money
is a skill. It takes commitment and belief in yourself, to make it
happen.

39. This brings us to the idea of solutions to the lack of money
issue. There are two avenues to pursue.
One is to work harder which can be fulfilling in it’s own right,
but it can lead to a life that is out of balance.
The other answer is to work smarter. Psychotherapists usually
have more then one gift to share with the world. The career as
a psychotherapist offers many avenues to pursue along with
the hourly counseling of clients. Many psychotherapists are
great speakers, great writers, great artists or dancers, or many
are entertainers and teachers.

40. Expanding a private practice to incorporate
more then one talent can offer more ways to
touch the lives of others and also bring in
additional income. Interestingly enough,
while pursuing these other avenues, most
likely new clients will call for hourly
appointments. The variety of sources of
income can be stimulating and more fulfilling
for the therapist.

41. The comfort and success a psychotherapist experiences
directly reflects the state of mind of the psychotherapist in
reference to money. Money is a symbol. It symbolizes
freedom, power, abundance, security, and a welcome state of
generosity.

42. If the psychotherapist lives in fear of “ not enough” this will
result in limited income and monetary problems.
If the therapist believes in abundance, believes in herself or
himself, believes in their life’s purpose and all that their talents
can do to help the world, the therapist will experience financial
success.
Focusing on dreams and goals while absolutely knowing that
accomplishing these dreams and goals is possible establishes an
air of confidence and reliability for clients seeking help from a
therapist.

43. The energy emitted from this type of confidence and
enthusiasm is infectious. Clients can feel it and want that kind
of feeling for themselves. The way to create this kind of
energy involves actually taking the time to visualize money as
a friend, as a means to create whatever you wish to create.

44. Each morning or evening, spend a few
minutes imaging that you actually have and
feel comfortable with large sums of money in
your bank account. Feel the gift of being able
to not only provide for yourself and for your
family but also how it feels to use that money
for the benefit of mankind. This exercise is a
bit like working out. It takes practice and
determination to expand our muscles, just as
it takes those same behaviors to expand our
thinking.

45. Secondly, you will need to refute whatever beliefs or feelings
that come up to sabotage financial success. Each negative
belief needs to be paired with an affirmation that includes a
positive belief about yourself. An example might be: “If I am
financially successful, I will feel guilty about having money
when others are suffering financially. Someone else may
deserve or need the money more than me.”

46. The rebuttal is “ I promise to use the money in a way that
benefits others, either by providing employment, giving to
charities or directly helping others and it feels good to be able
to do this.” Saying the affirmations out loud intensifies the
positive effect because it will hit more then one of your
senses. The repetition of these affirmations increases ones
belief and commitment to oneself. It gets easier and more
believable with time.

47. The great part about role modeling an adult view of money is
that you will become a better role model for your clients and
it will become more second nature to assist them with their
money issues. Money is presently important in our world and
as long as money is the ticket to some of the things we desire,
we need to be a better “mother to our money”. Just believe in
yourself, which is such a strong message we teach to our
clients.

48. References
• ‘And How Does That Make You Feel?’ The Cost of Therapy
http://thebillfold.com/2013/05/and-how-does-that-make-you-feel-the-cost-of-
therapy/
• Lowering the Fees in Hard Times: Meaning Behind the Money
by Melissa Groman http://www.psychotherapy.net/article/psychotherapy-fees
• Fees In Therapy: Summary and Guidelines
By Ofer Zur, Ph.D.
This article is part of an online course on Fees in Psychotherapy.
http://www.zurinstitute.com/ethicsoffee.html
• Janet Whitney, MA, MFT
http://www.theravive.com/research/Psychotherapists-and-Money
• Joseph Burgo, Ph.D http://www.afterpsychotherapy.com/