Psychotherapy for those who do not pay -understanding money in the therapeutic relationship

Confer Clinical Enquiry Series II Tavistock Centre: 12th May 2000

From its beginnings is the early 90s, Respond has existed to provide psychotherapy to people with learning disabilities. We also provide training, supervision, helpline and website support to professionals and carers on issues of disability and abuse. Our original referral criteria was that all those we worked with had been victims of sexual abuse. In 1994 this was broadened to incorporate those who had also gone on to abuse others. We currently work with around 30 individual clients per week and, despite some core funding from the Department of Health and other charitable trusts, have to charge for our work. We charge £46 per session, a sum that immediately places therapy outside the direct financial reach of our clients, whose average weekly net income is around £14, once items such as rent and contribution towards food have been deducted from their benefits.

The majority of our clients occupy a lowly place in society. Many live in settings in which many of us who do not have learning disabilities would not choose to live - group homes or hostels, hospitals and semi-independent flats. Few work, and of whose who do, the number receiving normal recompense instead of token payments form another marked minority. It is an unfortunate given that there will be few in tonight's audience who provide psychotherapy to people with learning disabilities (which could be the subject of a whole other Confer evening in itself). The implications of how psychotherapy is provided to people who do not pay for their own treatment are, however, far reaching and extend across a broad range of client groups.

Freud's view of the unconscious meaning of money as something sexual and as something faecal alerts us to the need to be bringing both associations into the room itself. The fact that it is not the client him or herself who is paying for their therapy themselves might indicate that money and its meaning would be absent from our therapeutic work. And yet it seeps into the work in all kinds of ways. The patient who, when seemingly stuck in his associations, would stare at me hungrily, asking me if I could lend him some money. And who, in other sessions, seems unable to stop his memories of early deprivation and starvation from flooding out, stands up at the end of the session, letting the contents of his track suit bottoms spill out onto the floor - his tobacco, grubby handkerchief and his coins. All faecal brown, all sadly stared at by him as he decides whether it is worth retrieving them. We would hope for attitudes, fears and fantasies evoked by money to be communicated by our patients if it is them paying for their treatment. Thus we would hope to explore such issues as the money paid being symbolic of the patient's worth, the fee arrangement being a statement that a commitment is expected from both parties, and that a solid system of payment can also symbolise the analyst as a person who accepts the aggression of the patient without fear. As James Raney puts it: "The frustration of dealing with a therapist who knows what he wants and will not be compromised, directed, or frightened addresses passive and masochistic tendencies in the patient…..The patient is unable to injure the analyst or exhaust his patience via the fee. An adequate fee is sufficient compensation in reality for the inevitable aggressions that are part of successful treatment. The patient has no further realistic debt of gratitude, or gratitude's darker companion, guilt."

In looking at information on other organisations providing psychotherapy where the patient themselves do not pay, the most common comparison that came up was with treatment funded by insurance companies. A study in West Germany looked at relapse rates, hospitalisations and self descriptions of patient satisfaction to conclude that psychoanalytic therapy paid for by insurance companies improved the pre-treatment states of the patients. Unfortunately non insured therapy was not compared in this study. These and similar studies indicate that psychotherapy reduces symptoms, but says nothing about the influence of insurance on the therapeutic process. Our experience of dealing exclusively with third party payers indicates that psychotherapy paid for by someone who is not in the consulting room cannot fail to be affected by this arrangement, as must the frame that surrounds the work.

The process by which Respond works involves referrals being made on behalf of our patients by social workers, community nurses, psychologists, probation officers, amongst others, who locate funding for an initial psychotherapy assessment and then, in most cases, on going work. This introduces the dilemma of who the therapeutic contract is with - the client or the purse holder? When we are in therapy ourselves, therapy that we pay for, we are the ones making decisions about whether we attend or not, and how long our treatment continues for. The contract is clear - it is between us and our analyst. I suggest that, in work where the fees are paid by a third party, there exist two contracts. The analytic contract between the patient and therapist, and the other contract between the two organisations - in our case, Respond and the Social Service Department, Probation Office or Health Authority. There is already in this arrangement something Oedipal about this parental coupling occurring just out of sight of the patient. It is impossible to neatly separate both contracts, and one of the struggles of this work is to prevent a cross contamination of contracts, a contamination that can leave patient, analyst and organisations unclear about which contract they themselves have signed up for, and result in feelings of chaos in the patient and, in some cases, in the referrer too.

Fees, whoever they are paid by, are part of the therapeutic frame but, unless carefully managed, the fact of a third party payer may threaten the ability of the frame to safely contain. The meaning of money is partly rooted in power and authority, and we have had to be circumspect about where that power lies in the determining of clinical goals.

To illustrate this point I will provide a composite of several cases in which money has played a important part. An Asian woman with Down's Syndrome who has lived much of her life in a large hospital, although she is not ill, or, more accurately, was not ill when she first entered the hospital. For twenty years she lived in a room which did not have a lock, and found herself the victim of sexually aggressive men - mostly other patients although it is suspected that she was also sexually abused by a member of staff. Because she lacks words, she never told anyone of what had happened to her, or, if she did, it was dismissed as manifestations of challenging behaviour. She now lives in a small group home with a caring staff team who, some months after she first moved in, began to realise that her frozen state, her depression and her attempts to harm her body were not in place simply because she had a learning disability or because she had lived for a long time in a hospital. Through drawings and some limited sounds she managed to communicate to her keyworker that terrible sexual things had happened to her in hospital. As is true of many of our cases, legal action was not made available to her, although a referral to Respond eventually was, after much battling for it by the staff team. A year into the work the care manager responsible for the funding of treatment decided that there was no evidence the therapy was making the woman better, and gave us six weeks to finish the work. The inequity of this felt very stark. We looked at the work and how it was benefiting the patient. We noticed her growing sense of self esteem, illustrated by the eye contact she was now able to sustain with her therapist, something that was impossible in her first stages of treatment when she would stare blankly at the floor. The fact that she was able to stay in the room for forty five minutes instead of two. The fact that, instead of pulling distractedly at her fingers she now drew pictures for her therapist, pictures of terrible dreams she had had, and faces of people who had hurt her. She also drew pictures of herself as a little girl, but struggled more with pictures of her mother, who always seemed to be more of a scribble than a shape. In the sessions themselves there were periods of silence which felt electric and full of life. There were other sessions in which she slept, sometimes lightly, always aware of her therapist's presence in the room, at other times heavily, like an exhausted child able to feel safe and secure in the presence of another. A new experience for this woman. We also heard from the staff team that the woman was improving outside of her sessions. She was less depressed, harmed herself less often, and responded more readily when staff attempted to talk with her about her feelings. It struck us as a work in progress, and, based on Respond's clinical experience, work that may need to continue for some years.

Analytic psychotherapy with people with learning disabilities will not, by definition, just analyse the effects of sexual trauma. It will also seek to analyse the effects of an earlier trauma - that of being born with a disability itself. Particularly, though not exclusively, for those patients whose disabilities and verbal communication difficulties are severe, this form of treatment may well last beyond the average of three years which seems to be the most that funders are bear to contemplate at the point of referral. How then to translate this knowledge to the person with the money? We have a wide range of experience of these kind of struggles and they vary enormously. Some funders are happy to defer to clinical opinion while others are not. The experience of being a patient for whom therapy is ending because of financial considerations is a difficult one.

A man I worked with was originally given just a month to finish therapy by his new social worker. Fortunately she listened to reason and we eventually had another year in which to finish on top of the two and a half years we had previously worked together. Because of the level of his learning disability, it was assumed that he had little understanding of the complexities of the funding situation, and so he was told by his social worker that she had decided he was much better than he was when he first came to respond and so his treatment could come to an end. "Treatment" was not the word that was used, interestingly. The work was referred to as "your visits to London", or "your chats with Alan". The news was initially greeted by denial, just as news of an imminent break tended to be blotted out before it could begin to be processed. Eventually he was better able to link the cessation of funding with the loss of his mother, who had left him on the steps of a public building when he was a few weeks old. I became aware of my countertransference reaction of guilt and fear the nearer we came to our final session. Guilt for not doing enough to continue his treatment. Fear that the loss of his therapy would heighten his risk to others (he had originally been referred after sexually abusing teenage boys, and had a propensity to sexualise loss). He was a man who had always evoked powerful feelings in those around him (as evidenced by his social worker's original manic need to kill off his therapy). He talked very appropriately of the pain he felt in ending his work with me, and the loss that had penetrated him, a loss he was more and more able to tie in with earlier deprivation. And yet the more he talked the more uncomfortable I found myself becoming. I questioned how assertive I had been about the withdrawal of funding, and berated myself for too readily complying with "just another" year's worth of funding. This was, I knew, a man who needed years more work if his sexual acting out was to be truly analysed.

There is a need to assert on behalf of the patient co-existing with the danger of the therapist feeling the victim as well. It was important to discuss with him the fact that someone else had decided the work was coming to an end. This was, of course, symptomatic of much of his life - a life in which the only decisions he had been allowed to make for himself turned out to be mistakes, often powerfully sexual mistakes. This allowed him knowledge of a concrete reality - the attack had come from outside, while also allowing his fantasies to be explored - that I was the one who sought to kill him off, who could no longer bear him. He became again the unholdable infant whose screams serve only to push those he needs away from him. We carved out an ending which could be discussed but the fact remained that it was an ending neither of us had chosen, marking the treatment out as differing from therapy you or I would choose for ourselves. The frame surrounding the work was also different. And not simply because of his sexual risk, although that undoubtedly had a bearing on the liaison between Respond and his referrers.

In working with people who cannot pay themselves the frame changes - the provider of therapy has to think carefully about whether the provider of money has a right to information about the therapy. Since they are paying, do they deserve to know if the patient is attending sessions? More controversially, do they need to know if the patient is engaging in the sessions, and what kind of issues are being explored? We have learnt that it is possible to construct a frame that includes the referrer (it is important to remember that sometimes the referrer is not necessarily the funder). As long as the therapist is not having to have direct contact with the referrer (in Respond a colleague would be having conversations with the referrers) it is possible to maintain a boundary around the analytic work itself. There will always be tension here between what transpires between patient and therapist and what transpires between case manager and referrer, and, like most things, this tension can be better managed the more it is talked about. It may go without saying that the support for therapy, both financial and practical, is affected by the circumstances of the abuse. In those cases where abuse has taken place in the setting for which the referrer has responsibility, guilt, fear and an appreciation of legal accountability tend to be more effective arguments for long term psychotherapy than discussions about the need for the unconscious aspects of the trauma to be made conscious.

For some time Respond was able to offer free psychotherapy to those whose referrers could not afford to pay for them. In one twelve month period we began with five patients attending on an unpaid basis. By the end of the twelve month period just one was left. To get a patient to Respond usually involves the referrer in a series of struggles. By the time funding for an assessment or for on going treatment has been achieved the referrer's level of investment will have been sorely tested. There is often a sense that so much has been gone through to achieve the funding in the first place, the referrer will endeavour to keep the support of the therapy alive for as long as possible. One question arising from this is when it is just us and the patient, is there enough there to allow the therapy to live?

We have had to conclude that offering free places to patients may not ultimately be helpful. We do have a responsibility to ensure our services are accessible to people on low or no income, but the sense of gratification we felt when setting up free places is all too easily replaced by feelings of guilt when it became clear that lack of money also represented a lack of a concerned parental figure or caring network in place to ensure treatment is properly supported. Interestingly this extends to services directly for workers. When we offered a free support group for workers to help process the difficulties in working with people with learning disabilities who have been sexually traumatised, the response was patchy, and the group difficult to sustain. Now that we charge workers to come along, and also call it a Professional's Forum rather than a support group, commitment is higher and the group seems to have a higher chance of survival.

There are dilemmas in providing psychotherapy that is not paid for by the patient. Although I would not concur with the often stated view that the situation removes the potential for issues of money to be worked with and analysed (our practice is full of examples of money and its multiple meanings occupying a central place in the work), I do think there exists a danger that the third party payer arrangement can induce misplaced views of the therapeutic provider as a charity rather than a clinician. Alan Tulipan makes the points that "Charging high fees means something. Charging low fees also may carry its burdens, not the least of which is a self-inflated sense of beneficence toward the less well endowed - a potentially condescending intrusion at best." This is always a danger when working with patients on the margins of society, and one that can infiltrate many layers of contact with the patient. The dual set of contracts I mentioned earlier bring with them a set of challenges for organisations or private practitioners. The contract between therapy provider and the purseholder has its parallels with the contract between therapist and patient. It is not unusual for those paying the bills to exhibit symptoms which we would expect to remain the territory of the patient: To act out their ambivalence about psychotherapy through letting bills go unpaid for many months, ensuring that hours are wasted in fruitless and frustrating telephone calls, to be overly seductive (the promise of even longer term funding being a particularly powerful tool of seduction) and to exhibit murderous rage - a desire to kill off the therapy often, paradoxically, at the point at which the patient herself is entering a deeper stage of engagement and voicing a hunger for more treatment and not less. We have learnt that there is a balance to be struck between feeding into this acting out, and maintaining the boundaries of the work. We strive to keep the boundaries in place, and to recognise the acting out of the funder for what it is, while also, on occasions, having to pragmatically feed their hunger. Much of the acting out from the funder may be rooted not just in ambivalence about psychotherapy, but also in envy of the provider of the therapy, a rage that their own system has, on some level, failed the patient. They have had to acknowledge their own deficiencies and accommodate the skills and abilities of another. Envy of expensive resources being provided for the patient and envy of the patient herself may seem to be a paradox when we consider the concrete reality of the deprived lives the majority of our patients live, but it seems to be manifest from funders, escorts, family member and, perhaps, therapists as well. Small wonder, then, that discussions about money never seem to be just discussions about money, whether they are discussions with the patient in the room, or the patient outside of the room.

Copyright Alan Corbett 2000