Training in psychiatry should explicitly and systematically address the issue of money and its impact in therapy. David Krueger observed that "[money] is one of the most emotionally meaningful objects in contemporary life; only food and sex compete with it as common carriers of strong and diverse feelings, fantasies, and striving" (1). Unexamined thoughts and feelings about money can have a profound effect on how treatment begins and progresses. Money cannot be prevented from intruding into therapy work. It is present whether or not its presence is acknowledged and comes into therapy through both the patient and the therapist. Meyers notes that residents in particular have significant difficulties in discussing the topic of fees and argues that the aversion to the topic demonstrates significant transference and countertransference conflicts regarding money (2). Avoidance of fee setting has been viewed as one of the most common mistakes in psychotherapy committed by residents (3). Residency training allows a unique opportunity for the exploration of financial issues in a supportive and nonjudgmental environment, providing a rich educational experience.

Informal ethical and social constraints limit the candid discussion of money and issues related to money (1). This could prevent discussion of the topic within therapy by either participant but should not dissuade therapists from examining the role that money plays. Money holds meaning for patients and therapists alike. Freud discusses fees in many of his works. He argues for frank and open discussion regarding fees, writing:

Freud’s comment can be a model for how therapists should conduct themselves within therapy. However, the topic of money is often overlooked even in personal analyses, as Krueger points out: "Even in these processes of profound personal understanding, issues involving the real and symbolic meanings of money are sometimes neglected." The difficulties of the therapist will be shared with the patient. It is the therapists’ comfort and resolution regarding financial issues that will determine how much patients will be able to address and resolve them (1).

Difficulty in recognizing and addressing money as a source of conflict has been especially problematic for residents. A study by Meyers showed that residents consistently overestimated the fees that they were charging to patients and preferred to have a receptionist collect those fees (2). Pasternack also found residents unwilling or unable to discuss matters regarding fees with patients or supervisors, to the detriment of the therapy they were conducting (5). The difficulties highlighted in these studies were overcome through clear policies regarding fees and discussion of the residents’ own attitudes toward money. This demonstrates how residents have considerable difficulties in addressing and discussing these issues within therapy. Dibella points out the necessity of dealing with such issues in education. He writes, "Good pedagogy requires many operations; these include the management of uncomfortable emotions caused by any subject matter, that interfere with learning" (6). Without being directly involved and responsible for both the negotiation and the collection of the fee, this deficiency will persist. There exists a need to make the subject of fees an explicit and fundamental part of resident training in psychodynamic therapy.

The frank and open discussion of financial issues has not yet been integrated into the training of residents in psychodynamic therapy. Pasternack highlights this, noting "Most residency programs do not include training in the financial aspects of their work as psychiatrists" (5). Avoidance of the topic within the scope of therapy therefore continues. The American Association of Directors of Psychiatric Residency Training (AADPRT) Psychodynamic Psychotherapy Competencies make reference to the topic of money and fees, but in general terms only. First, a resident is required to establish a stable frame, and one assumes this encompasses financial issues. Second, a resident is required to be sensitive to socioeconomic issues that arise in the therapeutic relationship. AADPRT expanded on this in their 1990 report regarding psychotherapy training, recommending the PGY-3 resident to "demonstrate competence and empathic functions in psychotherapy and deal with fee setting and collection in the outpatient clinic" (7). A more complete treatment of these complex aspects of doing psychodynamic psychotherapy could benefit the education of residents. A multitude of issues arise relating to money and fees, for both patients and therapists, and for residents in particular. The opportunity to discuss these issues in an environment of learning with experienced supervisors typically exists only in residency.

How are these issues currently addressed in residency training? The experience of the author is one wherein there is little attention to financial issues surrounding psychodynamic therapy with residents. At the University of Michigan, the theory and technique of psychodynamic therapy is taught through the Psychodynamic Psychotherapy Clinic. Residents undertake treatment of patients with psychodynamic therapy beginning in their second year of residency. Residents continue their psychodynamic therapy experience in the next 2 years with a larger caseload and case conference series. Each resident is also assigned a mentor, formally trained in analysis, to serve as a supervisor for ongoing therapy work by the resident. The resident and supervisor meet on a weekly basis. The resident evaluates patients for suitability for therapy, and the case is discussed between the resident and his or her psychodynamic supervisor. If they agree the patient is appropriate, the resident then refers the patient to the assistant director of the clinic for a financial evaluation. The resident is not present for this evaluation. The assistant director determines an appropriate fee from a sliding fee scale, based on the financial situation of the patient. The only information requested of the resident is the planned frequency of sessions. This fee is communicated to the business office to allow for appropriate billing. In many cases the fee arrangement is not communicated to the resident directly. When the patient attends therapy sessions, he or she is provided a billing sheet identical to other patients seen in the outpatient clinic. The patient gives this to the resident during the session, and the resident indicates the service provided and diagnosis code. The patient may pay at the reception window before or after a session, or may arrange to have a monthly bill mailed. At no time does the structure of the clinic rejoin the resident to address financial concerns unless the patient or resident raises them during therapy. The resident is otherwise outside the process of negotiation and collection of fees. The patient’s fee and balance may be obtained by the resident therapist at any time by contacting the business office, but the resident is not routinely provided the status of a patient’s account.

The symbolism of money was recognized early in the development of psychoanalysis. Geistwhite notes, "Money has been symbolically linked to feces, penises, and breast" (8). Money can symbolize self-esteem, esteem for others, power, potency, worldliness, or acceptance (1). For some patients, money can be understood as a means to prevent separation and individuation (1). They may have another assume responsibility for their finances, remaining financially dependent, or refuse to take financial responsibility. Some experience wealth and the associated independence it can provide as problematic for similar reasons and so will act to frustrate or avoid the accumulation of money. For others, the fear of doing "the wrong thing" with their money leads to complete inaction. Still others may use the accumulation of wealth as a means to meet narcissistic needs for validation and security. For some patients, self-esteem is based largely on external points of reference. Wealth may symbolize worth in an attempt to reverse the chronic envy they feel toward other people (9). Money can be seen to serve specific functions for patients, and exploration of financial issues has therapeutic utility. A patient’s relationship with money can be understood as indicative of his or her larger personality style and dynamic issues. This relationship is directly observed through financial interactions in therapy. These interactions can be interpreted to the patient to facilitate understanding of his or her own dynamics.

The therapist is not immune to reactions toward money. Chodoff warns that all therapists "will be handicapped in their dealings with their patients if they pay insufficient attention to the effects of fees on their own ideas and practices" (10). Many of those who practice medicine pursued the path through a genuine desire to help people in need. Many would like to believe they are beyond the desiring of monetary gain, "beneficent purveyors of good rather than as people involved in commerce" (11). Residents, who are early in their medical careers, may be particularly vulnerable. These beliefs can lead to blindness toward internal attitudes and expectations regarding money. When the income of a therapist suffers, it can breed anger and resentment toward patients who pay reduced fees or are difficult to work with. The requirement to become involved in financial matters can lead to uncomfortable feelings that will affect the way in which therapists interact with patients. For some therapists the exchange of fee for services may elicit an unconscious association to prostitution, the "selling" of a human relationship (12).

Psychotherapy is an exchange of fees for the provision of a useful service. For various reasons, residents struggle with the idea of therapy as a service for which payment can or should be expected. Schonbar observed of residents, "Left to his own devices, he characteristically undercharges and experiences much conflict about the issue of missed or cancelled sessions" (12). It cannot be escaped, however, that physicians benefit monetarily from helping those who are ill or in pain (6). The role of the resident in therapy goes beyond supplying expertise in the psychological sciences, though the resident often does not appreciate this. Pasternack highlights these additional contributions, writing "The therapist will be subjected to various strong emotional pressures which expose him to various internal tension states of his own" (13). Part of the work of the therapist, he points out, is "to maintain therapeutic attitude and have a positive approach toward the patient in spite of being exposed to all sorts of ‘toxic’ emotional states" (13). Uncertainty about the relative value of psychotherapy in the treatment process may contribute to acceptance of fees that are not commensurate with the work being done (13). Guilt may develop from being paid for providing psychotherapy, unlike providing invasive medical procedures, and may further inhibit the collection of appropriate fees (13). This ambivalence over the value of the therapy can undermine its efficacy (13). Anxiety may also come from the realization that in the work the resident does, there is no tangible product, no real "thing" to show for the effort invested (14). This can lead to a doubt of the value of any effort the therapist invests in patients. The desire to avoid collecting fees or reduce fees for patients may represent ways of repressing the guilt that develops from this doubt.

The topic of money and the doubts surrounding it can become a large unresolved area of countertransference for residents. Pasternack discusses the multitude of ways in which residents appear to avoid addressing the topic of fees in training (5). Residents often express concerns about not earning the fees being charged because they are also "learning from patients." Allen notes one of the most difficult problems residents encounter is overcoming the belief that therapy cannot be of benefit to both patient and therapist without one or the other being hurt or deprived proportionally (15). Meyers notes, "Psychiatric residents can easily rationalize that patients’ fees have little to do with their own incomes, material sustenance, or ‘professional concerns’ for patients" (2). Yet even for salaried employees, like residents, Koren and Joyce show that the fee remains relevant (16). The therapist’s evaluation of himself or herself, difficulty in setting and discussing fees, and hostilities all came into therapy despite the therapists not directly earning their income from the fees of their patients. Once they leave training, however, their livelihood may rest on negotiating these very issues. Financial needs of the therapist can also impact decisions in therapy. Chodoff warns therapists to be vigilant regarding how money can affect them, writing "the analyst’s financial needs play a role in his behavior with his patients which is disproportionate to the amount of attention it receives" (10). This may result in pressure to minimize unfavorable indications for therapy in order to recruit a financially desirable patient. There may be hesitancy toward treatment of patients who require a reduced fee at the lowest end of the fee scale. The continuation or termination of a patient also can be affected by the financial incentives the patient represents to the therapist.

Residents may also find financial disincentives to providing psychotherapy to a patient for whom it might be the treatment of choice. Residents, unlike their nonmedical colleagues, may also prescribe medications for patients. West highlighted the difference in earnings of psychiatrists who provide shorter medication management visits in comparison to fewer but longer visits including psychotherapy (17). Residents may find that economic pressures collude with personal biases to avoid the provision of any type of psychotherapy at all.

Important in this discussion is the difference between residents and formally trained analysts. No longer do the majority of psychiatric residents pursue their own psychoanalysis, though this remains a requirement for formal psychoanalytic training. Analysts are granted both the time and opportunity within their analyses to identify and address the feelings and fantasies they have regarding money. Residents do not enjoy this benefit, so an explicit and systematic approach to addressing these issues is necessary to facilitate this type exploration.

At the initiation of therapy, the establishment of a stable frame is essential. Discussion of the number of sessions per week, time of the sessions, and holiday breaks must be discussed to establish the frame. No less important is the discussion of the setting and collection of fees and the policy regarding missed appointments. These boundaries taken as a whole establish the frame. The frame provides for consistent interaction of the patient with transition objects, a necessity for the therapy to be meaningful. The therapist must maintain the consistency of this process, as this is the manner with which the frame will be preserved and utilized for the benefit of the patient. In this setting, when difficulty regarding the fee develops as therapy progresses, the significance of this reaction within the transference may be recognized. This can only be accomplished if a frame has been established in which the topic can be explored and the patient made aware of the change. Direct participation by the resident in financial negotiations is essential to the establishment of such a frame.

The role of the resident as the negotiator and collector of fees serves to reinforce the stability of the frame. When the resident negotiates and collects fees, this also conveys the sense of comfort on the part of the resident which allows for discussion of financial concerns. Geistwhite argues the setting of the fee can potentially be the most awkward parameter negotiated in therapy (8). He notes "The nature of the fee setting in many ways foreshadows how future sensitive topics will be handled" (8). Comfort with this difficult topic may also allow for discussion of other difficult material later in the therapy. Paying the fee also creates a boundary of the patient-therapist relationship. This boundary reinforces the primary aim of the therapy for the patient, paraphrased by Guthiel and Gabbard as "This is not love, it’s work" (18). A patient may construe receiving a bill in the mail as indicative of the absence of financial considerations within the office. Instead, when the resident hands the patient a bill and takes from the patient a check, it again reinforces the frame. It allows the patient to experience this in concrete terms, of paying for therapy. The payment or lack thereof, when experienced entirely within the therapeutic relationship, allows both the patient and resident to recognize and address these behaviors. When the billing process includes office staff, the patient may express concerns regarding breaches in confidentiality. This may impact the therapy, as the patient no longer feels as though material is confined to the office.

Within the context of therapy, the process of paying, or not paying, a fee by a patient can represent feelings of hostility, guilt, contempt, seduction, anxiety, or a perception of fragility (15). The practices surrounding the payment of fees are open to many dynamic considerations. Patients may pay fees in advance in an effort to placate or bribe the therapist, in an attempt to fend off fantasized hostility (16). Freud noted that that the presence of the fee served to reduce the resistances of the patient in therapy, and he discouraged treatment of patients for free (4). Menninger advanced a rigid view of fees in the spirit of Freud, indicating, "analysis will not go well" unless the patient makes a sacrifice to be able to afford the therapy (19). Menninger characterizes this as "an optimal frustration" (19). Haak also advises a rigid fee system to prevent therapy from becoming a matter of indifference to the patient (20). Glover advocates for consideration of several factors in setting fees, stating, "One guiding rule should invariably be followed, namely, never to insist on a fee that is likely to be burdensome to the patient" (21). Marmor cautions us, however, to not mistake the fee paid as motivation to get well. He notes "While the amount of money he is willing to pay to get rid of his illness may indeed reflect the degree of his motivation, it is not the source of it" (22). Through direct participation in the establishment of a sliding scale for patients, the resident will confront the degree to which patients "sacrifice" for therapy. This will also cause the resident to confront his or her own beliefs about what constitutes a "fair" fee for the patient, and how that might be determined.

In the experience of the author, the resident is removed from the negotiation of fees entirely. This allows the false perception that fees will not play a part in the ongoing therapy. Yet Dimen reveals this as false, writing, "I insist that the anxiety money generates cannot be banished from the consulting room. On the contrary, it is endemic to the particular sort of work analysts do" (14). The unconscious feelings of the resident may be disclosed through inappropriate application or avoidance of the establishment or modification of the fee. Negotiating the fee may also allow the resident to demonstrate some level of competence, making it easier to accept his or her limitations and further build competence as therapy progresses. Building competence will also enable the resident to adjust fees for patients as conditions warrant. This can be utilized in a therapeutic manner if discussed with the patient beforehand. In this way, the resident shows confidence in the treatment and the ability of the patient to achieve more as treatment progresses.

A reduced fee may represent a test of the residents’ willingness to collude with the patient in efforts to foster dependency (5). The patient may desire to foster some indebtedness within the resident. For the patient, the connotation of a reduced fee may create a sense of being "special" to the resident in some way (23). Conversely, the reduced fee may serve to reinforce attitudes of inadequacy within the patient, and create a sense of indebtedness to the therapist. This may allow the patient to unconsciously justify a lack of progress within therapy, to become submissive or overly nice or to feel a need to remain "interesting" to the resident, which might be difficult to detect. Feelings of indebtedness can lead to fantasies of the resident collecting payment in other ways. The patient can experience this as a form of seduction. This will lead to significant tension within the therapeutic relationship and hinder treatment until this is uncovered and addressed. The resident may wish to appear above monetary concerns, as Dibella notes "Raising fees clashes with the physician’s image of benevolence" (6).

The resident may also use the reduced fee as an unconscious (or perhaps conscious) justification for exploitation of the patient in other ways. The resident may be providing a reduced fee or free therapy to enhance his or her self-image or repress guilt from feelings of inadequacy. As Dibella cautions, "Ignored transferences and countertransferences can easily collude" (6). By negotiating the fee, the resident demonstrates the ability to tolerate the questions regarding his or her inadequacy that the patient might bring up. Further, the attention to the fee arrangement also implies to the patient the attention that the resident pays to the impact of such topics on the self. As Geistwhite writes, "an attitude of disregard for the fee represents some degree of disregard of the self on the part of the therapist …" (Italics in original) (8). Residents will be able to understand the devaluation of the patient as a projective defense and work with this in the therapy. By requesting or insisting on a lower fee, the patient may be attempting to make the resident inferior, either to boost the patient’s own self-image or as a means of defending against wounding insights the resident might later offer. Reductions in fee may be the first indication of a powerful countertransference reaction for the resident and will allow this to be resolved before therapy is further compromised. With this understanding, the resident may choose to start with a lower fee to make the work more comfortable and then increase fees as therapy continues, using increasing clinical competence as the justification.

Free treatment can arouse the same feelings that a reduced fee creates. The lack of an exchange can create problems within therapy because the removal of payment from the therapeutic encounter does not remove the impact money has on the therapeutic relationship. The patient may experience the resident as having a saintly or rescuing quality because of the absence of payment for the services. This may serve to satisfy fantasies the resident has of being a "helpful doctor" or of being above monetary concerns. Again, a resident still doubtful of his or her clinical competency may be more vulnerable to accepting these attributions without examining the underlying meanings. Geistwhite discusses how in this therapy arrangement the patient may withhold his or her attendance instead of payment in an effort to punish the therapist (8).

The non-payment of fees or carrying a balance can be efforts of the patient to maintain the relationship with the therapist and ward off fears regarding either resolution of therapy or termination. The money owed may be viewed as something that belongs to the therapist and may become a transition object. The patient may be trying to determine what importance the therapist places on money by how long nonpayment will go unnoticed. Nonpayment could be a way of inciting anger from the resident, or a manifestation of hostility enacted through withholding (16). Gifts may be used as a way of paying for therapy in an oblique fashion, in an attempt to reduce a sense of indebtedness felt by the patient. Therapists may tolerate the nonpayment of fees due to countertransference issues, through an unconscious desire to abet indebtedness, or to avoid confrontation within therapy. On the other hand, the absence of a fee may allow the therapist to gain some level of mastery of their beginning status, by allowing them to feel as though they are not engaged in an exploitative arrangement with the patient (8).

Advanced payment may represent a "security blanket" against whatever else the patient might say or do in therapy. Gedo describes a colleague’s patient in her 80s who paid for a year of therapy in advance (24). This was clearly a magical reassurance against loss of the therapy relationship, and in this a reassurance against death itself. The offer to pay large fees out of proportion to the income of the patient can be a method of controlling the relationship, of doing therapy "on their own terms." For some patients, the large fee may serve as a way of ameliorating guilt from another source through the therapist (16).

The source of payment for fees is also of significant concern for therapists. In the current environment of managed care, third-party payer systems are increasingly common. These third-party systems may represent the method by which many patients are able to come into therapy. The decision by the therapist to participate in one of these programs can significantly impact the number and type of patients seen. The presence of the third party will be experienced by both the patient and the therapist within the treatment relationship. The third party becomes another transference figure in therapy. This remains true whether an insurance company or a family member is providing payment for the treatment. The patient may have concerns regarding the confidentiality of the therapy when a third-party payer is involved, and this may hinder progress unless it is recognized and discussed.

Eissler, in an addendum to his article on payment of fees, brings up another situation that bears mention (25). In this addendum, he discusses the issues that arise with treating a prostitute or one who engages in illegal activities to generate an income. The way in which this individual earns the money to pay for therapy will likely have a negative impact on the treatment that will follow. By accepting this payment, is the therapist unconsciously or unwittingly providing an endorsement of the behavior of the patient? Eissler recommends postponing therapy until the patient can find a legitimate means of earning an income.

Patients miss appointments for a wide variety of reasons. In some instances it may be related to the material being discussed in therapy. In others, considerations such as transportation or childcare might be involved. Absences can be common, and how the resident addresses these reasons, and whether distinctions regarding reasons are made, is a fundamental part of the therapy process. Important for residents is the idea that the actions of the patient have meanings, and these are the substance of therapy. Pasternack points out, "during the course of therapy, childhood patterns of behavior warded off mental conflicts, and other painful issues come to the surface. Patients may miss appointments or come late in an attempt to avoid facing painful material at critical junctures in their therapy (13). The need to address missed appointments comes from the therapeutic utility of exploring this behavior.

The policy of charging or not charging a patient for a missed session cannot be rationally divorced from the issue of fees in therapy. Blackmon argues that the billing of a missed session is actually part of the treatment process (26). In some clinics, missed appointments are addressed by a rigid "policy" without thought regarding how or why such a policy is developed. This may serve to further divorce the issues of fees from the therapy work, however, instead of connecting the two. The resident developing a policy on missed sessions, and on whether to bill for these, could also serve to illuminate countertransference issues of which the resident was previously unaware.

The literature on this topic is deeply divided, and multiple recommendations have been made. Freud wrote regarding his policy on missed appointments: "I adhere rigidly to the principle of leasing a definite hour. A certain hour of my available working day is appointed to each patient; it is his, and he is liable for it, even if he does not make use of it" (4). Fromm-Reichmann advocates more flexibility in addressing fees (27). She writes, "a patient who breaks an appointment for valid reasons should not be charged… The old psychoanalytic concept that psychotherapy will not be successful with patients who do not make a financial sacrifice to obtain it…is an unfortunate misconception engendered by misleading teachings of our modern culture" (27).

Fromm-Reichmann believed that therapists were part of the cultural standard of not being paid if services were not rendered (27). Implicit in this assertion is the need for the resident to become an arbiter of valid reasons for missing a session. No therapist can determine with certainty when a patient is providing a valid excuse, presenting an excuse that represents unconscious resistances, or simply lying (11). In this arbitration process, the resident’s biases, including attitudes toward the loss of income due to absence, will inevitably affect the decision.

The issues highlighted by working with fees and the learning that could occur through discussion of these issues apply to a range of situations beyond psychodynamic therapy. The negotiation of fees for services is ubiquitous to all forms of psychotherapy. Yet, even the physician who steps away from psychotherapy will find these issues continue to be relevant. Most patients obtain care through a combination of insurance payment and self-payment. In this environment, questions and disputes regarding fees and charges will remain. The symbolism of the treatments prescribed by physicians could be better understood and utilized in building trust with a patient, leading to better outcomes (28). Even the general skill of identifying, analyzing and addressing conflict within the therapeutic relationship is sharpened through this type of work.

Residency programs are in unique positions to establish curricula through which residents obtain proficiency in negotiation and collection of fees for psychodynamic therapy. The topic of money is present in the therapy relationship for both the patient and therapist. Residents, in particular, experience significant difficulty with financial issues and would greatly benefit from specific consideration of this topic. The subject of money and fees within therapy must be approached through open and frank discussions to foster comfort with the topic. Didactic sessions addressing the policies of the clinic for establishing fees, management of sliding fee scales, financial assessment of patients, development of policies for missed sessions, and procedures for collection of fees and addressing delinquencies should be developed. Supervisors of residents can reinforce this process through regular discussion of financial issues in supervisory sessions. Pasternack notes that the increased attention given to financial topics by supervisors was of special importance in reversing the attitudes of residents (5). The greatest impact will be achieved by making the resident central to the process of billing and collecting fees for therapy.

This article is one winner of this year’s Frieda Fromm-Reichmann Fellowship Award for Residents, cosponsored by the Endowment for the Advancement of Psychotherapy and the American Association of Directors of Psychiatric Residency Training.