Tag Archives: fees

Limited

November 23, 2011 By in Countertransference, How therapy works, Learning Disability, psychotherapy, What to talk about in therapy Tags: , , , , , , , , 11 Comments

I am many things, I have some strengths that I can fairly claim as my own: I sing great lullabies, I am a voracious reader, an eager student. Although I probably think I am a little funnier and smarter than I actually am, I’m pretty sure I am generally amusing and informative to chat with in a social settings. I am very sensitive to color, and so my outfits match, and I’m good at decorating my living spaces in pleasing ways. I am interested in interesting people, and can curate pretty satisfying holiday parties with good food and good company.

On a professional level, I fancy that that I am, for the most-part, a good-enough therapist. Sometimes, I am even downright inspired at what I do. I have my small, brief flashes of brilliance.

And, there is a lot of stuff I really suck at.

Here is a sampling:

I wouldn’t say it is my regular practice, but it is not uncommon for me to be between 5 and 8 minutes late. Sometimes I also unintentionally start sessions early, or add additional time on the end of sessions.

(Unless you are my first patient of the day, and then it is actually uncommon for me to be on time. I give fair warning when people take these slots, and make up the time for all my latenesses at the end of sessions)

Of the all monthly statements I hand out, at least 2 or 3 of them each month are wrong – sometimes to your advantage and sometimes to mine. Sometimes they are glaringly, ridiculously wrong.

I regularly forget the dates, or mis-record when you have said that you are away on vacation, calling while you are in the middle of a massage on a beach somewhere, wondering why you missed the session.

It often takes several email attempts, with me offering alternate times, and then “oops!” taking them away again, for me to be able to reschedule appointments correctly.

I can only bear to sit down once a month to face-down my bookkeeping, and if you have a special request – such as a summary for past sessions, or reprinting a bill that has been misplaced – It can take me forever, and I may need multiple reminders.

For new cases, I often forget entirely or write down the wrong diagnosis code, or procedure code on your statement, which will annoy you only after it has first annoyed your insurance carrier, and delayed your reimbursement.

If you write me a check, and ask me to hold it until a specific date I have been known deposit it anyway causing you to bounce checks.

I think those are the highlights.

If you look at the list closely – you might quickly notice that it is all about time, money, numbers or dates.

But most clients don’t see or look for a pattern, they just feel the stinging effect that my error, my failure has on them.

They feel understandably forgotten, or angry, or disregarded, suspicious, neglected, ripped off, or exasperated. Some feel embarrassed for me, trying to find excruciatingly polite ways to show me my error with out shaming me, or revealing their disappointment or frustration.

People assume that it means that I am indifferent to their needs, that I am spacey or absent-minded, or flabbergastingly disorganized, lazy or dumb. Others forgive me instantaneously, too quickly, before they really take stock of the injury or irritation that has been inflicted.

Many expect that once they have mustered up the courage to say something to me about it, and I have heard them out, that I will never do it again.

But I will do it again,
and I make no promises that I won’t.

There are some things I simply cannot do no matter how much someone else wants or needs me to.

And there are some things I am not capable of no matter how I wish it were otherwise.

Its taken me my entire lived life to come to terms with that.
I still struggle with it now and then.

Here is what I can promise with absolute certainty: I will always, want to hear about the effect I have had on you. Even when it is hard for me. Even, and maybe especially when it makes me uncomfortable.

Better me than you. Its not rightfully your burden, its mine.

These are my limitations. I own them – I understand them. I have some appropriate compassion for myself, and even if I cannot do a damned thing to change reality, I can own the effect I have on others.

I would rather you never have to accommodate to my limits, but I have learned that I am not always able to protect others from the obstacles that I live with each day.

So, I will seek out, and actively withstand every feeling, frustration, anger, fantasy, sorrow, pity, fear, suspicion, and speculation about my “real” intention or unconscious motivation. I will reach for every association, every painful memory of past disappointments, every time someone has failed you in this way, left you waiting, made you feel forgotten, miscalculated your needs, or pressured to compensate for their failings.

I do not have any need to be protected from any of your feelings. And I absolutely do not want to leave you alone, to metabolize the effects of my incapacities.

Of course, I’ve been in the analytic community for more than 25 years as a patient, a supervisee, a student, a therapist, a supervisor, a group-member, and as a therapist to other therapists. I’ve withstood and earnestly explored every interpretation, blind guess, paranoid projection, thoughtful analysis, over/under reaction, judgement, assumption, and diagnostic formulation about these difficulties: hostility, anxiety, resistance, control issues, narcissistic indifference to others, separation difficulties, boundary diffusion, attention seeking, entitlement, self-sabotage, fear of success, an extension of my conflicts with my mathematically minded (and severely dyslexic father) affective flooding, masochism, on and on…

I am used to it. Through out my school years, everyone, including me, assumed that my difficulties with any numerical process, my complete inability to learn my multiplication, addition & subtraction tables, to remember my locker combination, to tell and estimate time and distance, to discern my left from my right, to know which way is North, to count change, operate a calculator or a cash register, to keep track of my belongings, or memorize a phone number were because I was a scatterbrain, or not paying attention or applying myself. I was clearly smart – it made no sense to me or to anyone else to assume that just I couldn’t do it.

Because I know what disruptions calculating time and money represent for others, I’ve devised some methods for coping with my disability: I use an analogue clock in the office because it is helpful to me in visualizing spatially how much time remains. Calculating time forward or backward from a digital clock was too difficult. I suspect I would function best with an hour glass.

(Actually, that is such a brilliant idea, that I just bought one for the office, just now)

I found a workable billing program which helps me prodce accurate bills about three-quarters of the time, but cannot completely protect me from myself: bad data in – bad data out.

There are times in the office, when it leaves me utterly helpless, lost, bewildered and vulnerable. I have to ask for help in figuring out a balled up account, a confusing insurance payment, a mysterious outstanding balance. I have had to accept clients protecting me (or not) when I have made billing errors, great and small, at my own expense. I’m sure that in my vulnerability I have also experienced losses and maybe even been taken advantage of, in ways that I will never, thankfully, be able to track or know about.

My cognitive limitations have forced me, over many years, to learn to be authentically, undefensively fallible, to recognize when I am beyond my capacities, to admit my need, to ask for assistance, and to accept help, while remaining intact.

I do not collapse in shame, doubt in my ultimate value or competence. I know what I have to offer. I know what I do well, what I do exceptionally well, what I do not do well, and what I cannot do at all. I have weaknesses and strengths. I am not afraid of either.

Most clients, over time, over several reworkings, begin to trust in the ways that I am solid, even if my numerical, mathematical, logistical functioning is not.

And I’ve come to understand that my inability to hide my weaknesses, and accept them, somehow gives others permission to accept their own real limitations with some self-compassion, and compassion for the people they effect.

If you, or especially if a child you know seems to have any of these difficulties in learning, calculating, mathematics, time-telling, counting change, etc. Please see http://www.dyscalculia.org or http://www.ncld.org for more information on learning disability diagnosis and support

copyright © 2011
All rights reserved Martha Crawford

What You Pay For

September 6, 2011 By in How therapy works, Psychotherapy Fees Tags: , , , 21 Comments

Talking Money Part 4 (of 4)

Every few years, I encounter a certain kind of wounded, fearful client who – in order to wiggle out of any vulnerability – attempts to hang onto their sense of power and privilege by insisting that the therapeutic fee makes therapy the equivalent of prostitution. Other clients are sure that the fee is hard, financial evidence that I do not and cannot care about them authentically – proof that it is “just my job” to “act” like I care. Some are sure that money changing hands means I am bound to agree with them, a paid endorsement of their behavior and fiscally insured admiration. Still others think that paying for therapy establishes the payer as a “loser” who has to buy friendship from me.

You are not paying me to pleasure you (therapy is rarely that pleasurable), like you, befriend you, cheerlead, or agree with you (I may or may not).

In fact, I will care about you for free. If I’ve taken your case, I’ve already determined that you are someone that I can care about. Forming a healthy, authentic alliance is a prerequisite to effective treatment. I simply don’t take cases if I can’t find solid empathic ground to stand on. If, after the first or second session, I don’t think that I can sustain my commitment to behave in a caring way toward you through dark and prickly times, I will make a referral to better-matched services.

This is what you are really paying for:
To keep my needs out of your way.

People often have a fantasy that my children, my husband, my parents, my friends are the real recipients of the selfless, apparently needless, one-sided nurturing that, in the office, I appear to be capable of providing. They aren’t. My husband suffers through my impossible, demanding, hungry-boring-selfish bits as steadfastly as I suffer through his. My children have to clean their rooms, help with chores, and deal with my impatience, irritability, and blind-spots. No one is getting for free what I try to provide in the office.

If we were friends, meeting once a week for a glass of wine during a rough patch, I would listen supportively about half the time and eventually, the next week – if not the very same night over the same drink – you’d have to give me equal air-time to blather on about the crap in my life.

When an acquaintance tries to tell me a long, detailed dream at a social function, I’m bored, burdened, looking for some way to extricate myself from the conversation as it is slips into a non-mutual place. Or perhaps, for a friend, I will patiently listen because I trust that they have been there for me, or will be in the future, through some equally self-absorbing struggle of my own. When clients tell me long, detailed dreams in my office, I’m fascinated. I’m absorbed, I’m going in deep – and amazed by the treasures I find there. I can offer up my intuition, suspending most of my interpersonal needs because, instead, my financial needs are being considered and that is how our relational equilibrium is maintained.

You are paying for therapy so that the discussion can continuously be all about you. So that I can, regularly and to the best of my ability, set aside my own shit to meet you on your terms. So that you don’t have to take care of me and immerse yourself in my life half the time. The fee is how you take care of me back. You owe me nothing beyond it. The fee is why our relationship is mutual. The fee compensates me for the inherent imbalance in the relationship. My needs are explicitly met there.

Obviously, I have the usual fixed business expenses of the self-employed that need to be covered so I do not accrue debt in the process of caring for others. My office rent, office liability and malpractice insurance, phone lines, office supplies, computing expenses, ongoing professional training and development, sick days, personal days, health insurance are factored out of the fee before I can begin to meet my family’s and my own needs for food, clothing, shelter, education and recreation.

Without the fee, I will come up against my own healthy boundaries, which will stop me from crossing the borders of my own needs for anything but short bursts of altruism. Explicit charity in all forms, emotional charity included, is tricky. All sacred texts talk about the importance of giving with anonymity – in a manner that can’t inflate the giver or disempower the receiver. Complicated, binding resentment emerges easily between known benefactors and their beneficiaries who are continuously involved with each other. Vast power differentials will emerge in any ongoing personal relationship that rests merely upon charitable impulses. Balance and mutuality are absolutely necessary in order for healthy intimacy to survive.

If the treatment is sometimes satisfying, gratifying, inspiring, warm, or pleasant for me, that is a nice perk, a tip perhaps – like the spare change that I sometimes find in the cracks between the cushions of my office couch.

But it’s not your job to keep me happy. It’s my job to invest my energies toward you, traveling all the way over to your universe of needs and wounds – and leave mine as far behind as I can. You are paying me to cross my boundaries consistently in ways that would be dangerously unstable, detrimental, masochistic, narcissistic, or avoidant if this relationship were taking place in my personal life. The fee protects me from pretending I am needless and perfected and generous. The fee protects you from primal indebtedness. The fee allows us both to explore symbolic and emotional dependencies over the long term, with safety and mutual self-respect.

The fee is the anchor that keeps us tethered to solid ground. Or perhaps it is better conceived of as ballast to keep the very real, but potentially lopsided intimacy of the therapeutic relationship balanced and afloat.

Revenue Realization

August 11, 2011 By in Psychotherapy Fees Tags: , , , 3 Comments

Talking Money Part 2 (of 4)

My friend Abdi said, as I lay on his acupuncture table with a needle in my eye socket to release my then chronic migraine headaches: “It can be a cruel thing to let people get better at your own expense. It teaches them that they can only grow stronger by depleting you, and they will either learn to feel ‘better’ ruthlessly or, they just won’t get better at all.”

Working on the low-salaried front lines at what I called “the Big Box Store of Mental Health Services,” a heavily endowed “non-profit” agency for the formerly incarcerated severely mentally ill, I was sandwiched between the institutional violence that my clients withstood every day from the mental health/legal system, and my commitment to help them avoid committing personal acts of violence- a likely possibility if they weren’t extremely well cared for. I felt trapped in a masochistic position to my work and my profession.

The only way out seemed counter-intuitive: to take on more work. Since I had never negotiated or collected fees from clients, I decided to take a night job at a for-profit outpatient drug and alcohol rehabilitation center leading a 3-hour-long evening group (dear god, three hours) for sleepy-eyed drug-sick clients fresh out of detox. I confronted their resistances, manipulations, and evasions – and I eventually learned to successfully collect their urine and their $35 co-pays at the end of each night.

Next, I found a rent-by-the-hour therapy office, printed up business cards, and decided upon a moderate but self-respecting fee for a new therapist in private practice – which I planned on sticking to.

Almost all of the clients that first contacted me as a private practitioner were uninsured. Many of my first clients were sex workers, “exclusive” escorts, whose services were offered at very high prices. They referred many friends. And they paid my “full fee”, in freshly collected cash, which I accepted…squeamishly.

Another full fee referral stream came from a citywide foster care/group home agency: providing therapy for their at risk youth. I was amazed by the strength that these women and children could marshal in the face of horrible traumatic histories, and their ability to create change in their lives in light of the ongoing re-traumatization that they all faced.

It also became clear, on my end, that this was a terrible business model:

The kids aged-out of foster/group home care with no supports or any other reliable adults of any kind, and I suddenly had several totally overwhelmed traumatized young adults, with minimal burger joint incomes, doing their best to pay me a token $5 per session. Meanwhile, as the sex workers got healthier and stronger, they earned less in the “oldest profession” – as did I – as their fees shrunk to accommodate healthier and more self-regarding (and much lower-paying) work.

I was impressed and proud of the dramatic changes and the commitment to growth everyone had shown, proud of my own work – and I was just barely covering my expenses.

I hopped on an HMO insurance panel in an attempt to reach a new client base. I spent a very long 6-months, foisting the company’s financially mandated treatment “recommendations” onto our mutual clients: a business relationship which ended abruptly and forever one evening. A “care manager” determined, that from a cost perspective, Overeaters Anonymous would offer better support to a new client of mine: a 90-pound woman in recent anorexic relapse, following the diagnosis of a cancerous breast lump. She had, in previous years, a “high utilization” of her mental health benefits, which they were now deciding to cut off. After asking if they actually thought that a 90 pound woman sounded as if she had been over-eating, I resigned from the panel. I then negotiated a fee with my client that she and I could both, albeit barely, afford. I never signed a contract with any insurance company, ever again.

Money, money, money.

From this point forward, the only contract in the room, would be the one my clients and I negotiated together. I was worried, at first, that the gap between what I needed and what my clients needed would be irreconcilable. But – like a Quaker building consensus at business meetings – if you wait long enough, listen deeply enough to yourself and others, seemingly irreconcilable stances can find unity.

Here is what I knew:

When I let the client or the setting alone determine my value, I would be insufficiently reimbursed, injure myself, and set a destructive model for my clients.

I had also determined that setting fees based solely, rigidly on my own needs and desires was not realistic or sustainable for me. Abandoning clients in times of real financial crisis felt profoundly, spiritually and ethically, intolerable. It still does.

I needed to find a third way – not my perceived need alone or my clients’ perceived need alone. A way for money to become an extension, a true negotiation, of our mutual needs in the relationship. It struck me that there was a sacred fee, an optimum fee, that would need to emerge in the space between the client and myself, and perhaps this would be a different amount for each relationship. As relationships evolved and shifted back and forth, perhaps the fee had to as well. We needed to discover the healthiest amount for them to invest. The healthiest amount for me to receive, offering compensation for the inherent imbalances in the relationship, honoring and respecting all the needs of both people in the room.

It dawned suddenly, that talking money and negotiating fees was nothing more and nothing less than the exploration of the entire process of human relationship.

Talking Money, Part 1

August 7, 2011 By in Countertransference, Psychotherapy Fees, Self Care Tags: , , , , ,

The Road to Burn Out

I graduated from social work school a few months after Newt Gingrich released his “Contract On America” – slashing social service funding. My graduating class was riddled with anxiety about their ability to get hired at all for the significantly diminishing, shockingly low-paying, and exhausting non-profit agency and state jobs that clinical social workers take out tens of thousands of dollars in student loans to be trained for.

After spending most of my twenties waiting tables in NYC, the $28,000 starting salary for my first agency job (with insurance and sick days!!!) seemed like a fortune. I was hired to work with severely and persistently mentally ill ex-offenders and found the work moving and intellectually challenging. Burnout seemed impossible! An abstraction, a professional hazard – but nothing to worry about personally! I had all my needs met, more security than I’d had ever before. Sick days!! Four weeks paid vacation and did I mention 30 sick days!!!!

It hadn’t occurred to me that those benefits were offered for a reason. And that I wasn’t earning enough to actually afford to go anywhere on those glorious paid vacation days…

The new schedule meant arriving at 8:30 am and clocking out at 4:00 pm – but staying until 8:00 or 9:00 pm to complete the ungodly stacks of paperwork, progress notes, treatment plans, assessment tools, documenting all contact with collateral service providers, phone calls, immigration applications, food stamps, Medicare, Medicaid, SSI forms, urine sample lab forms, parole officer reports, police reports, hospitalization and discharge forms, incident reports, alternative to incarceration assessments etc. I stayed late so that I could at least preserve the hours when my clients were on the unit, to provide some treatment, for god’s sake.

Around the second year, I realized that stress-induced migraine headaches and every imaginable cold and flu virus from a weakened immune system, were going to use up more of those sick days than I could have ever imagined.

And that a week or two of those vacation days were going to be used pinned to my mattress with dread, guilt, and paralyzing despair, unable to face again the multiple tragedies of the average work day. Supporting clients in taking, or not taking, horribly toxic but necessarily effective medication. Clients dying. De-compensating. Disappearing. Clients absorbing institutionalized abuse and perpetrating it on the street. Having men and women that I trusted, and who trusted me, their eyes terrifed, taken forcibly to the hospital in restraints because I had noticed some tell-tale but certain signs that the voices had returned, and were likely commanding them to act, as they had in the past, to harm others, maybe even me.

And the salary just didn’t seem like so much somehow.

This is the formula for burnout. The work itself requires that you take deep, vigilant care of yourself, just to come back to baseline. In order to do that, you need trips away from the city, some contact with the larger world and nature. Perhaps acupuncture or massage, at the very least, a new pair of running shoes or a gym membership: something to work the adrenaline out of your body. You need one or several blessedly peaceful hobbies or activities that have nothing to do with your work, and hours or days to socialize with healthy friends. You need to feed yourself clean, healthy food, have excellent sleep hygiene. You need a home that feels like a haven, and some faith in your ability to pay the rent. You certainly need plenty of your own therapy, private supervision, maybe group supervision too, and probably advanced training. And, especially in New York City, all this costs money, and time.

And you don’t have any, and you have to pay-off those humongous student loans too.

Although in social work school we talked about the possibility of burnout, the realities of poverty, the importance of entitlement programs and social policy, no one had ever talked about the necessity of money FOR the clinician, as an essential tool to buy time, purchase self-care, and to save themselves from sinking into the matrix of trauma that surrounds them everywhere, everyday.

My idealized, youthful, privileged fantasies about money “not being important” were gone with the wind. It would be quite some time before I would have my own Scarlet O’Hara moment and cry out, “I will never be hungry again!!!!” But the journey toward finding some kind of balanced, Self- and Other-respectful relationship with money would soon reach a new turn on the road.

To be continued….

copyright © 2011 Martha Crawford

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