Learning to ride, falling down, getting back on
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Keith Russell Ablow
It was heartening to see a discussion of therapist fees [“Delicate Business,” Issue 200], since paying for therapy is like mixing oil and water.
When I was first in therapy, I began dealing with issues that made me feel desperate and scared. Or maybe I had developed an inappropriate dependence on my therapist. In any event, I needed more therapy — more than I could afford. That’s when the reality of my relationship with my therapist hit me.
I still do therapy occasionally, but I am aware of its contractual nature. I make sure I have a well-focused issue. And I make sure I get my money’s worth.
I don’t think therapists are entitled to the same fees doctors charge. It’s unclear exactly what they’re offering. Certainly, they deserve remuneration for their time and skilled listening, but there’s a lot of pretense involved in therapy.
Clients pretend therapists care about them personally. It makes the therapy more powerful but it isn’t (and can’t be) true. Therapists pretend their work is based on reliable science, that they know what they are doing. Most of the time, they don’t.
One of the most poignant aspects of the essay was the therapist’s ambivalence about charging for his work, and his difficulty in dealing with his own feelings.
I’ve spent the last eighteen years working in a community mental health center. Such centers usually charge according to the patient’s ability to pay, and many patients pay nothing for their treatment. As Keith Russell Ablow suggests, there is no convincing evidence that such treatment is any less effective than that offered in private practice.
Over the years I have heard many psychiatrists express their liberal anguish about extracting fees from their patients. Very few of them, however, are willing to abandon their lucrative practices in order to do something about the problem.
Keith Russell Ablow’s “Delicate Business” [Issue 200] was poignant reading for me. As a psychotherapist, I too have often felt like a “prostitute feigning romance.”
Practicing psychotherapy reminds me of when, as a teenager, I’d sit with friends at our local diner, shoving quarters into the jukebox, selecting our favorite ballads of unrequited love. Only now, I am the one inside the plastic bubble that harbors the (oldies but) goodies. I am the one spinning the tunes, engaging the pain of my clients’ unfulfilled relationships. I am the one the quarters disappear into.
I marvel at how I and other psychotherapists deny the inherent, obvious conflict of interest in our role: on one hand, the integrity of our work demands that we be as effective as we can, that we finish with our clients as quickly as possible; on the other hand, our livelihoods may depend on our being relatively ineffective, so that we can have repeat customers over an extended time.
If we’re willing to play the game with the insurance companies — give them the diagnostic codes they recognize as a legitimate basis for treatment, and stay within the time and dollar limits that they dictate — we can make handsome salaries as prostitutes for the examined life.
It is refreshing to hear from a member of the psychiatric profession who continues to examine his own life.