The Perilous Price of a Good Living

Recently I had the opportunity to talk with a group of young clinicians, and very bright young clinicians at that.  We were discussing the role of class in psychotherapy, and how to understand it psychodynamically.  I was demonstrating to them how difficult it was for therapists to talk about money, by asking each of them what they would set their fee at.  The majority of them were extremely reluctant to give a dollar amount, and it was striking to me that the dollar amount was almost to a penny what a leading insurance company set their allowed fee at.  But the most troubling response to me was “enough to make a good living.”

I imagine you’ve heard this phrase frequently–like me, maybe you’ve said it yourself from time to time.  It is a throwaway statement, which tells you nothing really about what kind of living a person wants or how much money they need in a capitalist society to make it.  Amongst professionals it is the “Whatever” of salary statements.

Pushing folks, I usually get a comment about “having a good home,” “enough to comfortably support my family,” etc.  These are similarly throwaway statements, but they indicate to me what continues to be considered socially acceptable when talking about money in mental health.  It is ok to want to make money if you only use it to support and shelter your family.  Maybe a vacation, but let’s not push it.  In her 1994 article “Money , Love, and Hate:  Contradiction and Paradox in Countertransference,” Muriel Dimen refers to “Puritanism’s conflict, in which hard work and thrift are valued, but their material rewards may not be enjoyed.”  In other words, what most psychotherapists consider a good living.

Often when working with consultees who are giving everyone a sliding scale fee and often acting out in their countertransference as a result of it, I work with this Puritanism, rather than combat it head on.  I’ll ask them to take a photo of their children, partner, any loved one who depends on them, and keep it visible to them in their office from where they usually set their fees.  These are the people, I tell them, who will go without because you have issues about your fee.  You may think you are being noble by sliding down all the time, but these people are bearing the burden of your nobility.

Am I saying you shouldn’t have a sliding scale fee?  Well yes and no, actually.  I certainly have 2 slots where I slide my fee.  Exactly two, because that is what I have determined in my business plan I can afford.  And if someone is going to be offered one, I always go over with them their financials.  So if you have a business plan, and if you can have a concrete conversation with your patients about how much money they make and expend in their life, you have my blessing, you can have a sliding scale.  But if you have not taken a good look at how much YOU need to make, what your plan is to earn money and have pro bono, and if you can’t bring yourself to talk about a patient’s finances, I don’t think you should have a sliding scale.  In fact, I’d suggest you should really only work in an agency and/or cap your fee at what Insurance Company A tells you are worth.

Because that in fact is how this got started in many ways.  We lament how exploitative insurance and public agencies are, but the reality is they provide us with a buffer from the conflict of having to talk with our patients about money.  Many of us make the third party the “bad guy,” because we don’t want to sully our therapeutic conversations with the topic of money.  Sex, sure.  Incestuous fantasies or homicidal impulses, no problem.  But cash? Forget it, that’s too tough to talk about.

Like many of you, I am very pleased that we have passed the Affordable Care Act this year, but I am equally happy that I don’t have to be limited to seeing patients via insurance.  This is the difficult paradox many of us try to keep secret:  We want everyone to have access to health care, but we don’t want our incomes capped by those rates.  Not everything our patients come to see us for is medically necessary treatment.  Some of it is quality of life and personal insight, and maybe our patients should pay for that themselves.  This may sound like a two-tiered system, and that’s because it is, and in my opinion you will see this two-tiered system get acted out as soon as we switch to a medical home, global payment model.

For me a good living is not having a home and enough to support my family.  I want an XBox, and an iPad, and someone to help me clean my house, and vacations and my Starbucks as well as some other things that even I am reluctant to admit.  I want things that exceed a comfortable lifestyle.  Maybe you want these things as well, or a yoga retreat, a summer home or a pony, I dunno.  Take a look at cable TV sometime, and ask yourself why there is such a proliferation of reality TV surrounding making/winning/wheeling/dealing so much money.  Our voyeurism betrays our fantasies.  But Priscilla or Myles, our inner Pilgrim, still trips us up, and we are afraid to admit exactly what we want as a good life.

In case you think that I have exorcised Myles from my psyche, let me assure you I still struggle with wanting, having and making money.  In a way, my evangelizing on this could be a reaction formation.  But it is a feeling, and I can’t let a feeling get in the way of understanding myself and being ethical.

You see, I’m with Plato and Socrates on this one. Socrates defined the good life.  The good life is the examined one, the life lived in pursuit of knowledge and consciousness.  Socrates doesn’t really talk about money when he talks about the good life, but he does make some interesting points about virtue and how knowledge leads our virtuous behavior.  Not what you feel, but what you know.

Sounds simple, but it isn’t.  In Meno Socrates describes how important perplexity is in the process of attaining knowledge, and hence ethics.  Perplexity is struggling with the contradictions to try to make sense of them, like “I want to help people,” and “I want the iPad 3.”

Periodically I re-evaluate what I want in my life, because my wants, my needs and my financials change.  My financial limits are clear to me, and not always in accordance with those of others.  For example, my billing company thinks that I shouldn’t allow balances higher than $200 to be carried.  I consider $400 to be my limit.  It is up to me to struggle with and get clarity on these things if I want to own and run a business.  And money runs through and beneath my business.  If I want to take a day off, my boss is pretty stingy.  I rarely take sick days.  I have a 48 hour cancellation policy that is much more rigid than many colleagues, but not as rigid as the week cancellation policy of some.  I can live with all of that, I’ve thought it through.  I don’t hide behind the vague salve of “making a good living,” I struggle with the perplexity of my needs and wants, the moral implications of them, and how to live ethically in the context of that struggle.

In many ways, that’s what I call a good life.

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