“I want to help people!”

Having sat on many an admission and training selection committee for students in psychology, I can attest that this statement is undoubtedly one of the most common—and  boringly unoriginal—responses to a query regarding motivation for aspiring to a career in my profession.  (Dear Future Graduate School Applicants,  Find a new “right answer.”)

Every client wants a therapist who at his or her core has a deep, genuine desire to aid and assist them in time of turmoil, distress, and pain.  Clients need help.  They need someone who wants to help.

A problem exists when things occur during the course of the therapeutic relationship that, while on the surface may appear to be charitable or compassionate, actually yield the opposite result.  Enter:  iatrogenic effects of medicine.  Students of psychology are introduced to the vocabulary of iatrogenics—an adverse effect or harm that occurs as a result of clinical intervention—on their well-intentioned path of providing care.   Following degree conferral and the addition of a fancy suffix to their name, clinicians suddenly hold a great deal of responsibility to protect the welfare of those who elect to entrust them with their care.   This applies to multiple facets of a client’s treatment experience but is readily apparent in regard to fiduciary responsibility.

A professor described to me during my training that as a clinician, part of my job and an important part of the clinical process, is to create and maintain consistent boundaries.  It was part of my client’s job, consciously and unconsciously, to test these various limits and lines.  This is the nature of human relationships and interactions. 

Boundaries in therapy related to billing, fee setting, payment, and cancellations can be challenging for clinicians to uphold with confidence and consistency.  Money conversations and the core issues underlying them are rarely comfortable for most people, but if you can’t have have them in the safety of the confines of a therapy office a therapeutic relationship, where are they happening?  More likely than not, nowhere.

Herein lies part of the problem. In over a decade of clinical work, I have come to learn that financial issues – directly or indirectly – are often a part of the storm of psychosocial and relational stressors that bring individuals or couples into my therapy office. The positive potential for modeling and skill building surrounding financial discourse when a client enters therapy is significant.  Clients should not be missing out on opportunities to grow because their therapist would prefer to take the path of least resistance.  Growth happens in therapy, and in life, when we turn into discomfort and have the hard conversations.   This requires courage both from client and clinician.

Talking with others about money, helping them figure out how they are currently limited, and aiding them in articulating a vision and building a bridge to where they want to go requires that first we talk about it.  I view it as my responsibility as a clinican both to take the lead on facilitating courageous money communication and modeling healthy financial boundaries.  Clients’ worlds are filled with models of what not to do with money, which may have contributed to why they are sitting across from me.  I need to show up differently. 

My policies, communication, and actions surrounding the business of psychotherapy present rich opportunities to model behavior that, overtime, I hope my clients can internalize and channel when pushed in their own lives and relationships.   They will observe whether or not I am able to value myself and hold my ground when challenged.  They may not appreciate a limit set in the moment, but I hope that farther down the road they can reflect on our co-created interaction and think, “if she can do that, maybe I can do that.”

Consistency provides containment, in clinical work and in all relationships.  We may not always be enthusiastic about a boundary, but on a deeper level not knowing what to expect can unmoor us.  If you’re entrusting deeper more vulnerable aspects of yourself and your story to someone, it should be someone who has their stuff together.  A clinician will show you whether his or her own house is in order.  You may want to question whether they can help you put the pieces of your life in place if they are flaking when you desperately need a foundation.

I am not helping my clients by shirking away from uncomfortable conversations.  Avoidance of discomfort or conflict masquerading as attempts to be “nice” or “understanding” are anything but.  If I will internally resent a choice I make in my work, it will come out sideways at some point.  This isn’t healthy for me. What is not healthy for me is definitely not in service of my clients.

Clinicians:  Money.  Talk about it early and often.  It will help your client start to do the same outside of your office.  Model it well.  You may be one of the only healthy pictures and teachers he/she has of strong financial literacy your client has.   If he or she waltzed into your office, collapsed on your couch, and reported to you that an employer repeatedly stopped depositing their paycheck on the 15^th of month, would you advise the person not to question what was going on?  Of course not.  Practice what you preach.

Clients: Find a therapist who is willing to have uncomfortable conversations.  You are paying far too much for your 50-minute hour for it to mimic the kind of exchange you could have with a friend over a $6 latte down the street at Starbucks.  You deserve someone who is consistent and reliable.  This person should be able to serve a strong role model for you financially and relationally.  Your therapist should be a picture of self-respect and someone who can own his or her worth in a way that you can channel and aspire to in your own life. You have enough people in your world who are showing you what happens when you undervalue yourself, don’t say no, and bend until you break.

While you may have experienced a sense of relief if you weren’t confronted about the therapy bill you paid late last month, perhaps you should think again.  It may be time to find a new couch to sit on.