Therapy requires just 3 things: a time and place to meet, payment and the honesty of the client.
Without those, therapy cannot happen. Payment is required because without it, it is not a professional relationship. Not only is it not professional, it also tends to encourage feelings of entitlement and stimulates rescue fantasies within clients. One of the primary purposes of therapy, after all, is to develop the initiative and courage of the client – and those qualities are the exact opposite of those involved in a rescue fantasy. Demanding payment also goes along with treating the client as a capable adult.
Beyond that, conducting therapy without payment sets an awful example for the client, in that much psychological distress is the result of systemic inequality in the amount of effort expended and the return at work and love (Fitch, Hamilton, Basset & Davey; Phongsavan et al., 2006; Taylor, Budescu & McGill, 2011 – this is particularly notable in studies on caretakers; see Adelman et al., 2014). In other words, much distress and disturbance can be traced back to fundamental and systemic inequalities in our exchanges with the world and other people.
Thus on the one hand encouraging clients to be more assertive about getting their needs met and a more equal exchange in their life while at the same time capitulating and doing the exact opposite in one’s relationship with a client is the height of hypocrisy. Further, workers in the mental health field are particularly susceptible to this distress (and subsequent burnout) (Rossler 2012; Volpe et al., 2014) and therefore need to be particularly alert to sharp inequalities between what they are giving out and what they are getting in return. Consistent good work can only come in the context of consistent payment (i.e. consistent income for the therapist).
Finally, not speaking up and demanding payment suggests weakness on the part of the therapist, and may suggest to the client that the therapist is simply not strong enough to deal with the clients problems. It is the responsibility of the therapist to bring things out in the open, maintain strong boundaries and address problematic behaviors in the clients life. Not talking about money also encourages the use of non-payment (or late or incomplete payment) as a way to express anger.
So although nonpayment is not an option, if I was in a position to offer a lower fee that was feasible for him/her (if he/she was in financial distress), then I would readily agree to it – but again it would depend on my context and the clients. If therapy had already begun when a financial difficulty arose, I would be willing to go especially low. But if the client was really unable to pay anything, then I would refer him out after a few concluding sessions – because I would be doing neither of us a favor by continuing it.
Adelman, R. D., Tmanova, L. L., Delgado, D., Dion, S., & Lachs, M. S. (2014). Caregiver burden: a clinical review. Jama, 311(10), 1052-1060.
Fitch, C., Hamilton, S., Bassett, P., & Davey, R. (2011). The relationship between personal debt and mental health: a systematic review. Mental Health Review Journal, 16(4), 153-166.
Phongsavan, P., Chey, T., Bauman, A., Brooks, R., & Silove, D. (2006). Social capital, socio-economic status and psychological distress among Australian adults. Social science & medicine, 63(10), 2546-2561.
Rössler, W. (2012). Stress, burnout, and job dissatisfaction in mental health workers. European archives of psychiatry and clinical neuroscience, 262(2), 65-69.
Taylor, R. D., Budescu, M., & McGill, R. K. (2011). Demanding kin relations and depressive symptoms among low-income African American women: Mediating effects of self-esteem and optimism. Cultural Diversity and Ethnic Minority Psychology, 17(3), 303.
Volpe, U., Luciano, M., Palumbo, C., Sampogna, G., Del Vecchio, V., & Fiorillo, A. (2014). Risk of burnout among early career mental health professionals. Journal of psychiatric and mental health nursing, 21(9), 774-781.