Money talks: becoming more comfortable with understanding a family's finances.

Child and adolescent psychiatrists are taught to ask a broad range of questions during clinical evaluations. We routinely gather quite sensitive information about a family history of mental illness, secrets that could be influencing family members, reasons for divorce including affairs, use of substances, and concerns about physical or sexual abuse. During training, we learn how to build a trusting relationship, ensure confidentiality, and phrase questions in an empathic manner that facilitates discussing the intimate details of such varied conditions as eating disorders, obsessions and other anxieties, self-destructive behavior, and the like. However, questioning in one area of family life gives many child and adolescent psychiatrists great pauseVasking about money and the family`s financial status. There is similar ambivalence regarding setting and collecting fees. Fee setting may be considered in supervision or in transition to practice seminars, but, given the use of clinic settings to teach psychotherapy, few training programs have the opportunity to teach residents systematically how to determine fees, take responsibility for their collection, or explore the meaning of paying for treatment as part of their core curriculum. Why is there reluctance to deal with financial issues? The obstacles appear to be centered in training, cultural, and personal domains. Our culture seems to be open about many issues, including some intimate issues that would be taboo in other cultures, such as deeply held emotions, sexual indiscretions, substance use, or a family history of mental illness; however, it is clear that how much one earns, one`s financial values, or financial planning is private. Money in our culture is equated with self-esteem and success or failure, and is often used as the only concrete measure of self-Bworth.^ How much you make, like your college SAT score, becomes a broadly acknowledged yardstick for who you are, an easy measure of how you judge yourself, and how society values you (as a teacher, social worker, judge, public defender, nurse, radiologist, child and adolescent psychiatrist, venture capitalist, etc.) Disclosing financial status makes an individual feel exposed and vulnerable. Money is also used in remarkably powerful ways in our culture. It is a way of showing off, wielding power, and creating an imageVa persona for an individual. For people who are poor, their poverty may reflect the shame of failure: for people who are wealthy, their wealth may certify their success or elicit shame if they feel extravagant. Clothing, activities, cars, and vacations are means of communicating financial status and social class. It is noteworthy how many teenagers of the rich and famous choose to wear torn jeans, faded T-shirts, and clothing that looks like a hand-me-down from an older sibling, whether purchased from consignment stores or costly designer boutiques. At the same time, some from poor backgrounds attempt to compensate for their financial limitations or demonstrate their aspirations with selected items such as expensive sneakers or a car, even though such a commitment may put them under serious financial strain. How one feels or attempts to express financial status is a complex personal Clinical Perspectives aims to provide a venue for exploring topics of importance to child and adolescent psychiatry, fostering discussion about these issues, educating child and adolescent psychiatrists and the broader medical community, and bridging clinical practice and research. Where applicable, appropriate permissions for publication were obtained from the patient(s). Accepted October 5, 2007. Dr. Jellinek is with the Child Psychiatry Service, Massachusetts General Hospital, and Dr. Beresin is with the Child and Adolescent Psychiatry Residency Training Program, Massachusetts General Hospital. Correspondence to Dr. Michael S. Jellinek, Newton-Wellesley Hospital, 2014 Washington Street, Newton, MA 02462; e-mail: mjellinek@partners.org. 0890-8567/08/4703-0249 2008 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/CHI.0b013e3181619858 Assistant Editors