Breaking the cycle of either positive or negative prostitution fantasies requires a return to reality. The provision of psychiatric services by a female psychiatrist to a paying male patient in no way represents prostitution. Her relationships, sexual and otherwise, occur outside of work, and she never engages in a sexual relationship with a patient. He, as the patient, can only buy psychiatric services. He may have problems in his relationships with women, but those will be treated through the psychotherapy process, not by engaging in sex with the therapist.
Prostitution transferences are occasionally triggered when male psychiatrists give female patients fee reductions. The woman may react negatively, feeling he is trying to buy her cooperation. She may wonder what else he wants from her or fear she owes him some kind of service. Conversely, if she is comfortable using her seductive abilities (positive transference), she may take a colluding stance in reaction to this "payment," thinking he finds her attractive and wondering what else she can do to keep the relationship going. On the countertransference side, the male psychiatrist may find himself having positive feelings about the fee reduction (the payment), hoping she'll do more work or put in more effort. Or he may have negative feelings about the fee reduction: that he had to "buy" her cooperation or that he's been tricked.
Early recognition of prostitution or seduction fantasies at the time of payment can provide an easy and often humorous segue into this minefield. Talking about it aloud quickly brings reality and consciousness to the fore, allowing discovery, insight, and learning to occur without the dangers of acting out unconscious sexual drives.Nonpayment
Nonpayment can be addressed on 2 levels: first, on a concrete level as a breach of the patient-provider contract,13 and second, on a psychological level as resistance to treatment or the manifestation of a transference phenomenon. Payment is part of the treatment agreement, and because nonpayment breaches the contract, there is no legal duty to treat or continue to see patients who do not pay for services. On the other hand, fiduciary duties to patients are not contingent on payment.4,8 Nonpayment does not give the psychiatrist permission to act unprofessionally, withhold records, or act in a way that might cause the patient harm.
It has been noted that the fee is an area in which a patient can really hurt or frustrate the psychiatrist.14-16 Analyzing this expression of aggression can move the patient forward therapeutically. The psychiatrist must persuade the patient that understanding the psychology behind the nonpayment may forward his or her personal growth. The patient needs to see parallels to other behaviors or relationships17 and is guided to understanding nonpayment as a repetition of this pattern within the treatment relationship.
Sometimes nonpayment is a form of resistance to treatment. Nonpayment allows, and even compels, the patient to end treatment. When the psychiatrist suspects this motive, it should be interpreted quickly and directly by asking the patient if they desire, on some level, to leave or end treatment. If the patient drops out or is terminated without this interpretation, nonpayment may cause successive treatment failures, leaving the patient to believe, erroneously, that he or she is untreatable.
The most critical aspect of managing nonpayment is to confront it early, when only a small debt has accrued. If a patient's account is just overdue and the next visit is soon, bring it up at the beginning of the session and address any issues that come up, documenting both the problems and the plan in the progress note. Stick to your policies regarding fee reductions and discuss all the available options, including taking a break, decreasing the frequency of appointments, transfer to a less expensive provider, or treatment termination. If the patient's visit is a long time off, continue to send the overdue bill monthly, noting the aging of the account (eg, second notice, third notice, and so forth). Many patients will pay during this interim and problems with timeliness or affordability can be discussed during the next visit.
For patients who discontinue treatment leaving an unpaid bill, simply send a bill each month, again indicating the aging of the bill. In addition, it can be useful to include a request to call the office for a payment plan or if they are having problems paying. Determine the maximum number of billing cycles. This limit avoids undue harassment of the patient who can't or won't pay18 and facilitates moving on to the acceptance phase when no money is forthcoming. Remember that not all patients will pay their bill.
After attempts to resolve the payment issue have reached the limit on billing, the psychiatrist should end the treatment. There are 2 important requirements for terminating a patient for nonpayment. First, the patient cannot be in crisis or simply abandoned without notice.8,19 Second, the termination must be done with care4 and communicated clearly to the patient. This can be done during a visit for active patients. For patients who have dropped out of treatment or remain incommunicado, a letter will suffice. Termination letters should mention the outstanding bill, lack of communication or action on the patient's part, and clearly state that the termination is occurring because of nonpayment. Include a copy of the termination letter in the patient's chart.Concluding thoughts
Money and financial issues are an integral part of psychiatric treatment and should be addressed during clinical care. A few simple, preventive steps, open dialogue, and documentation can help minimize risk.