Deontec

Money and therapy

psychology

One of the biggest factors determining the efficacy of therapy is the quality of the therapeutic relationship. It seems that how you feel about your therapist is just as important, if not more important, than the particular type of therapy you receive.

This makes some intuitive sense. In order to get value from therapy, you typically have to attend sessions over an extended period of time, share your innermost thoughts and feelings with your therapist, and follow any exercises or advice they might give you. All of these things are unlikely to happen if you don't actually like or trust your therapist.

But one thing that might undermine your positive feelings towards your therapist is the fact that you're paying them for their services. Money inevitably affects the nature of relationships, and it may spark thoughts like:

Unfortunately, once you've entertained these kind of thoughts, it's hard to dismiss them wholeheartedly.

And it's not just patients' feelings that are affected by money. Many therapists experience anxiety, or even guilt, over charging a fee. The idea of refusing to help people in need because they're too poor to afford a fee makes many therapists deeply uncomfortable.

All of this raises 2 questions: if a therapist is paid by someone other than the patient, does this allow for a better therapeutic relationship? And if so, does this mean that therapy is more likely to be effective when the patient is not directly paying the therapist for their services?

It might seem unlikely that the structural issue of how therapists are paid would have much bearing on therapeutic outcomes. But given the importance of the therapeutic relationship, I would have thought it's worth exploring whether eliminating tensions relating to money could improve outcomes.

My instinct is that to see any effect, there would need to be a total disconnect between the therapist getting paid and the patient receiving therapy. If a person's therapist were being paid by a friend or family member, for instance, the tensions around money would likely remain. Therefore, to see any benefits, I imagine you would need to eliminate the transactional element of therapy. In other words, the therapist's payment should not be directly tied to seeing any particular patient. The obvious way to achieve this would be to have therapists paid a salary by the state or a charity (the other benefits of which would clearly far outweigh anything being discussed here).

We might be tempted to look for answers to these questions by comparing therapeutic outcomes between patients receiving therapy on the NHS and those paying privately. Unfortunately this isn't a good comparison because the NHS has such long waiting times (6-12 months) and offers such short treatment courses (typically one block of 6 or 12 sessions) compared to the private sector. But if we could control for these factors and just vary the party paying the therapist, I would be interested to see if this had any bearing on therapeutic outcomes.