Clinicians new to private practice often have neither experience, nor comfort in, setting fees. To begin with those early in their careers may be uncertain about three things: (1) whether patients will actually call, (2) whether patients will pay and, most importantly, (3) whether what they have to offer is truly of value. These three concerns make the fee setting and/or fee negotiating very anxiety producing, indeed. Add to that the patient's anxiety and we have a recipe rife with the potential for enactments. Let's talk today about the clinician's contribution to this mix.
Anxiety about attracting patients
On first blush, an obvious solution to this predicament seems to be having more patients calling then you can possibly treat. That is, of course, more easily said then done. It is, however, an essential ingredient to having a successful, effective, private psychotherapy practice. And, that is one of the reasons why this blog focuses considerable attention on how to generate referral. Having more patients calling then one could possibly treat puts the clinician in the position of being able to focus on and think about (1)whether he is the best clinician for a particular patient (2) what fee is most appropriate for the patient; (3) what fee he feels comfortable accepting. Of course, being a sought after clinician does not alter the anxiety inherent in assuming the weighty responsibility for taking care of patients. And, more will be said about that in future posts.
(1) Will patients call?
The new private practitioner, even one with many years of clinical experience, is understandably apprehensive. Will patients call? If it hasn't dawned on him in the past as he signs his first lease or buys his first office, he becomes acutely aware that he is not only a clinician but the owner a small business. He has to pay rent, keep books, and, most importantly he must ensure that his care is reliable and of high quality. This places him in quite a precarious position so far as his patients are concerned: he needs them. And, I should note parenthetically that patients, already in a high state of alert, can sense that. There is much more to be said about that fact, but I shall reserve that for a subsequent post. For now, let us say that the practitioner is in that awkward, untenable position of needing patients. At this early juncture, it is perhaps naive and insensitive to say that this position of, "needing patients" gives the practitioner a whiff of what patients feel when they entrust themselves to our care. But, it's worthy of note that, in this regard, both patient and clinician are in the same, anxiety producing boat. This anxiety about referrals may make the clinician anxious when he is called upon to set fees.
(2) Will patients pay?
Patients have many feelings about the fee that they pay. With prospective patients it's important to be clear and straightforward about your fee. Ideally, one alerts them to the fee either during the initial phone call or in the first session. This is important because some, for example, those for whom therapy is a maiden voyage, may imagine that their insurance will cover your services. Unless you work for managed care this is unlikely so it's important to clarify that at the outset. At the end of the initial phone call, after setting the first appointment and providing the office address one might, say, "my fee is x", and that is payable at the time of the session (or at whatever time the clinician intends to collect the fee). Is that O.K. with you? This opens the door for the patient to assert that he plans to use his insurance or that he wishes to be seen on a sliding scale basis.
Another alternative, of course, is to wait until the first session and state your fee, 15 minutes before the end of the session. This allows you to explore the patient's feelings about it - and, to try to understand those feelings in light of the patient's financial realities as well as their unconscious fantasies. There is much more to be said about this, including: what sorts of fantasies do patient's have about the clinician's fee, should you have a sliding scale and if so, how should you set fee? These topics will be fodder for a subsequent post. For now, it seems important to point out that most new private practitioners are anxious about setting fees because they harbor the apprehension that they will lose patients. While this is true, at times, setting fees early on and clearly is an important aspect of the therapeutic frame. Clarity about them is reassuring to the patient.
(3) Is the clinician worth what he charges?
When the patient hears the clincian's fee, often, he wonders, is it worth it? Therapy requires a commitment of time and money but these are not the worst of the patient's anxieties. Rather, at both a conscious and unconscious level, he is aware that therapy can be painful. And, on top of all of this, he is expected to pay for it! While it is understandable that the patient would lament or question the cost of psychotherapy, it can be daunting to the new private practitioner who may have questions about his own skills.
An empathic tone coupled with an attempt to clarify both affective and reality based anxieties about the fee can prove most useful. Also, should the reality exigencies make the fee burdensome, the clinician ought to be respectful of those concerns either by reducing the fee or by referring to a low fee setting. Of course, it can be challenging to differentiate between neurotic anxieties and reality anxieties, especially when both clinician and patient are embarking on this new relationship. The best antidote to that is ongoing supervision or consultation with a clinician who is skilled both clinically and in the art of private practice. In this way, uncertainties can be expressed, clarified and addressed in the consultative setting. And, then the clinician can return to the clinical setting prepared to set his own anxieties aside and empathize with the patient.
There is much more to be said about these important topics and they will be addressed in more detail in future posts.
Best to all, Lynn Friedman, Ph.D.
(c) 2010 Lynn Friedman, Ph.D. All rights reserved
P.S. The waiting list to take this class has grown. Therefore, Johns Hopkins has added a second session to be taught April 30/May1. Already practicing professionals and graduate students from elsewhere are welcome to enroll as special students. The course will run from 9:00 am - 4:00 pm on Friday and Saturday. Information about registration may be obtained through the university. Some clinicians from out-of-town universities and practices have expressed an interest in attending and they are most welcome as it is only a 2 day course.
P.P.S. A list of all blog posts can be found at: http://www.drlynnfriedman.typepad.com
Confidentiality Policy: Please note for reasons of confidentiality and copyright all letters to the blogger will be summarized and edited. Also, I will not write about real patients. Instead, I will create fictionalized vignettes. When you pose a clinical question, please ask it in a general way. DO NOT write about real patients. Thank you.
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Lynn Friedman, Ph.D.
Psychologist, psychoanalyst, work-life consultant
Faculty Associate, Johns Hopkins University
5480 Wisconsin Avenue
Chevy Chase, MD 20815
301.656.9650
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Dr. Lynn Friedman welcomes referrals for supervision or consultation, feel free to call.
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