Who Pays for Therapy?

    Does the value of psychotherapy http://shirahvollmermd.wordpress.com/2010/09/24/what-is-therapy-worth/ change depends on who pays for it? Oscar, fifty-five has seen me on and off over twenty years. He had a good job and he paid me without much fuss. He moved around the country, going to therapists in different cities, all with variable quality and variable costs, according to Oscar. More recently, Oscar is unemployed, partly by choice and partly by circumstance. He could get a job as a teacher, as he has taught with excellent reviews for decades, but he decided that he wants to find a job as a school administrator and that he does not seem to be able to find. He is couch surfing, going into “his dark hole” and doing less and less each day to help himself. His devoted friends got together and they offered to pay for psychotherapy; they have seen therapy work for themselves and they have seen it help Oscar in the past. Oscar calls me “I guess I need to make an appointment,” he says grudgingly. I call him back, “OK, let’s make an appointment,” I say flatly, to which he responds “I guess you are making me come in.” Confused, I say “making you?” He does not answer, but I see him the next day.”I know I confused you but my friends are making me come in. I don’t really want to be here,” he says, as tears roll down his face. “Now, I feel beholden to my friends because they are paying for it. I don’t want that!” He says firmly and decidedly. “It sounds like you are backed into a corner,” I say, feeling bad for Oscar and feeling curious about how he is going to manage his conflict. A third party paying for therapy-parents, insurance companies, friends-complicates the treatment. The payor is always in the room. Oscar knows that; I know that. The short answer is yes.