Setting fees: the conscious and unconscious meanings of money.

Career Perspectives discusses alternative careers for psychiatric nurses in a variety of settings such as managed care, forensic nursing, and critical debriefing. This column explores concepts and topics that will assist advanced practice psychiatric nurses build their practice with ease and confidence. In this issue, Dr. Lanza discusses the conscious and unconscious psychodynamic issues surrounding money and setting fees for clients that reflect an understanding of the emotional meaning of money for both the therapist and the client. Money is a taboo subject for many people and is a complex of paradoxes. Ambivalence about discussing personal thoughts and feelings regarding money contributes to misunderstandings in the therapeutic process. Many of us were taught it is impolite to discuss how much something costs or how much money someone earns. In fact, social class can be invoked: If you have "class" you don't discuss money, or "if you have to ask how much something costs, you can't afford it." Money is related to the Protestant ethic that reflects hard work as being praiseworthy, but coveting the pay is wrong. These ingrained attitudes about money make it difficult for therapist and client to have necessary and comfortable discussions about fee for service. The therapist and client need to evaluate both their financial status and value for the therapeutic process in order to come to an agreement about payment that meets the emotional and physical needs of each person. Identifying one's relationship to money helps articulate what values are being expressed and the role of money in the person's life. Understanding money issues and what sabotaging beliefs exist about earning and having money clarifies areas that need to be addressed in setting fees. Many theorists have written about the impact of the personality on attitudes toward money and treatment implications of payment of fees. A historical survey of psychoanalytic thinking regarding money is useful as a prelude to discussing how to set a fee commensurate with one's training and service offered. Psychodynamic Issues About Money Money is an immensely powerful symbol containing a plasticity that allows for an unlimited range of emotional and material fantasy (Lockhart, 1982). Money, therefore, can symbolize not only the comfort of being taken care of and loved but also issues of dependence and survival (Balsam & Balsam, 1974). Combined with its capacity as a means of exchange in a society dominated by materialism, it is not hard to understand the centrality of money issues in shaping the course of personal relationships. In a survey of 2,000 men and women, money--more than sex, children, or in-laws--was the most common source of conflict for America's married couples (Cohen, 1995). Freud (1913/1961) sensed that people were vulnerable to conflicts about money when he wrote that "money matters will be treated by cultured people in the same manner as sexual matters, with the same inconsistency, prudishness and hypocracy" (p. x). Classical psychoanalytic views relate money to early psychosexual stage conflicts (Fenchel, 1981; Reider, 1986; Schonbar, 1986). The quest for money may be equated to Klein's (1957) longing for the "inexhaustible breast." Abraham (1917) contended that money may be used as an attempt to deal with anxiety related to separation issues. He believed lack of money may be perceived as a threat to safety and gives rise to depression and emptiness. Freud maintained that the range of people's reactions to money, from vulgarity and repulsion to desire and admiration, was similar to reactions of a child during toilet training. He surmised that the repulsive response was actually a reaction formation to the stimulus, while the attraction was related to the direct acceptance or sublimation of instinctual wishes. Later, money is frequently used as a reward system, to punish, praise, and insure that obligations are met. …