Shirah Vollmer MD

The Musings of Dr. Vollmer

Who Pays for Therapy?

Posted by Dr. Vollmer on November 6, 2010

    Does the value of psychotherapy 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.

6 Responses to “Who Pays for Therapy?”

  1. Suzi said

    I don’t understand then. Why is he there if he doesn’t want to be?

    I mean, if it were tickets to the footy or a day out with his friend then, I would assume, he could either accept or decline the offer?

    I think I feel more for you in this case.

  2. Shelly said

    A third party paying for therapy might mean that he needs therapy, i.e. the message meaning “he is crazy.” However, a person paying for himself might mean he is there because he wants a tune-up or he wants to better himself. The implications in the first are shame and in the second are simply self-time.

    Did Oscar ever come back?

  3. Kristin said

    Interesting issue. Can therapy ever be effective is the person doesn’t want to be there? A basic level of motivation seems to be a minimum requirement.

    Even if the patient were motivated, I can see lots of potential problems with this arrangement, especially if you agreed to accept payment directly from the friends. What if the friends decide to cut off payment at a particularly sensitive time in the therapy, when the patient desperately needs your help? Would you be ethically required to continue treatment without payment? Maybe doctors should require a retainer from third party payors that would cover a bare minimum of “winding down” sessions.

    I wonder what Oscar’s friends mean when they say they are willing to pay for his psychotherapy. They probably mean they are willing to pay for a couple of sessions (as opposed to long term therapy stretching over years), right? Do you conduct therapy differently when you know there are sufficient resources for a patient to continue for as long as she wants, as compared to a situation where the ability to continue is highly uncertain?

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