A few years ago I did a workshop on the role of the fee in private practice for a group of clinicians. Nearly all of the participants were uncomfortable with the topic and uneasy about dealing with their own issues about money and about collecting fees.
One problem that folks mentioned was feeling that clients took advantage of them, asking for fee reductions when they did not need them. This kind of feeling can poison the work with a client by creating resentment in the therapist.
Let me describe how I assess fees. First, I do not accept third party payment; this allows me to negotiate fees and to have a sliding fee scale. I do not put my self in the place of deciding what a person can pay. That seems like a prescription for problems to me. Following is roughly what I say to a patient during the first visit:
"The range for my fee is $X - $Y/hour. I have no idea where you fit best on this continuum. Only you know your financial circumstances and what you can and cannot pay. If you tell me you can only pay $X and then you come in every week talking about expensive purchases you have made or luxury vacations, I may begin to feel resentment. On the other hand, if you commit to $Y and you have problems paying your bills, you may begin to feel resentment. And resentment on either side will color our work together and can create problems. So it is important that you decide on what is neither too little nor too much and that will be your fee."
In my experience, patients strive to be fair and choose a fee which is neither too much nor too little. In the 15 or so years I have been using this system, I have never felt that I was being taken advantage of. Most people choose an amount between the middle and the upper limit.
What would I do if I believed that a patient was taking advantage of me? I would raise it as an issue. BUT first, I would spend some time reflecting on what the issue is and what I am feeling, because any resentment is a counter-transference reaction and something for me to deal with myself, either through self-reflection or in supervision. My goal in raising it with my patient would be to explore the meaning of what I was observing, not to gain an increase in fee or to punish the patient. The fee is always a negotiation, one we make and revisit as seems appropriate.
When a patient acts out with money -- and remember that time and money are the two main avenues for patients to act out in therapy -- it is an issue to be explored, whether it is forgetting the check, paying late, or any of the other issues around money that can arise. It is a clinical issue. Our job as therapists is to create a solid frame to support the work of the therapy.