What You Pay For (by Martha Crawford)

what you pay for

Therapy: What Are You Paying For?

(Guest Blog from Martha Crawford)

Every few years, I encounter a certain kind of wounded, fearful client who – in order to wiggle out of any vulnerability – attempts to hang onto a false sense of power or privilege by insisting that the therapeutic fee makes therapy the equivalent of prostitution. Other clients are sure that the fee is hard, financial evidence that I do not and cannot care about them authentically – proof that it is “just my job” to “act” like I care. Some are sure that money changing hands means I am bound to agree with them, a paid endorsement of their behavior and fiscally insured admiration. Still others think that paying for therapy establishes the payer as a “loser” who has to buy friendship from me.

You are not paying me to pleasure you (therapy is rarely that pleasurable), like you, befriend you, cheerlead, or agree with you: I may or may not.

In fact, I will care about you for free. If I’ve taken your case, I’ve already determined that you are someone I can care about. Forming a healthy, authentic alliance is a prerequisite to effective treatment. I simply don’t take cases if I can’t find solid empathic ground to stand on. If, after the first or second session, I don’t think that I can sustain my commitment to behave in a caring way toward you through dark and prickly times, I will make a referral to better-matched services.

This is what you are really paying for: To keep my needs out of your way.

People often have a fantasy that my children, my husband, my parents, my friends are the real recipients of the selfless, apparently needless, one-sided nurturing that, in the office, I appear to be capable of providing. They aren’t. My husband suffers through my impossible, demanding, hungry-boring-selfish bits as steadfastly as I suffer through his. My children have to clean their rooms, help with chores, and deal with my impatience, irritability, and blind-spots. No one is getting for free what I try to provide in the office.

If we were friends, meeting once a week for a glass of wine during a rough patch, I would listen supportively about half the time and eventually, the next week – if not the very same night over the same drink – you’d have to give me equal air-time to blather on about the crap in my life.

When an acquaintance tries to tell me a long, detailed dream at a social function, I’m bored, burdened, looking for some way to extricate myself from the conversation as it is slips into a non-mutual place. Or perhaps, for a friend, I will patiently listen because I trust that they have been there for me, or will be in the future, through some equally self-absorbing struggle of my own. When clients tell me long, detailed dreams in my office, I’m fascinated. I’m absorbed, I’m going in deep – and amazed by the treasures I find there. I can offer up my intuition, suspending most of my interpersonal needs because, instead, my financial needs are being considered and that is how our relational equilibrium is maintained.

You are paying for therapy so that the discussion can continuously be all about you. So that I can, regularly and to the best of my ability, set aside my own shit to meet you on your terms. So that you don’t have to take care of me and immerse yourself in my life half the time. The fee is how you take care of me back. You owe me nothing beyond it. The fee is why our relationship is mutual. The fee compensates me for the inherent imbalance in the relationship. My needs are explicitly met there.

Obviously, I have the usual fixed business expenses of the self-employed that need to be covered so I do not accrue debt in the process of caring for others. My office rent, office liability and malpractice insurance, phone lines, office supplies, computing expenses, ongoing professional training and development, sick days, personal days, health insurance are factored out of the fee before I can begin to meet my family’s and my own needs for food, clothing, shelter, education and recreation.

Without the fee, I will come up against my own healthy boundaries, which will stop me from crossing the borders of my own needs for anything but short bursts of altruism. Explicit charity in all forms, emotional charity included, is tricky. All sacred texts talk about the importance of giving with anonymity – in a manner that can’t inflate the giver or disempower the receiver. Complicated, binding resentment emerges easily between known benefactors and their beneficiaries who are continuously involved with each other. Vast power differentials will emerge in any ongoing personal relationship that rests merely upon charitable impulses. Balance and mutuality are absolutely necessary in order for healthy intimacy to survive.

If the treatment is sometimes satisfying, gratifying, inspiring, warm, or pleasant for me, that is a nice perk, a tip perhaps – like the spare change that I sometimes find in the cracks between the cushions of my office couch.

But it’s not your job to keep me happy. It’s my job to invest my energies toward you, traveling all the way over to your universe of needs and wounds – and leave mine as far behind as I can. You are paying me to cross my boundaries consistently in ways that would be dangerously unstable, detrimental, masochistic, narcissistic, or avoidant if this relationship were taking place in my personal life. The fee protects me from pretending I am needless and perfected and generous. The fee protects you from primal indebtedness. The fee allows us both to explore symbolic and emotional dependencies over the long term, with safety and mutual self-respect.

The fee is the anchor that keeps us tethered to solid ground. Or perhaps it is better conceived of as ballast to keep the very real, but potentially lopsided intimacy of the therapeutic relationship balanced and afloat.