Interventions

There are two prerequisites to using fee as a clinical tool in group therapy: First, the leader needs to feel "entitled" to his or her earnings and free to lift the money taboo in the group. Second, a fee and billing policy has to be presented to and accepted by prospective members in the pregroup interviews: members are responsible for paying the bill. Those using third-party payments should pay the therapist directly, if possible, and get reimbursed by the insurance company.

Bills will be handed out in the first session of the month and members are expected to pay in full prior to the end of the month (or any other consistent agreement).All financial matters will be discussed in the group, including overdue payments.

Members missing sessions will be charged. Some therapists agree to a number of missed sessions per year (it has to be clarified that third-party payers do not reimburse for missed sessions).

The policy needs to be revisited in the initial sessions or when a new member joins the group. Contract violations, however, are inevitable.

Clinical interventions when the contract is violated: Mike stayed in the group room until all the other members left. He seemed nervous as he told me he could not pay the bill that month because he lost his job. I responded: "it is important we discuss it next week in the group." The following session, I announced in the beginning of the session that some members were late with their payments. Mike was quiet until Joe said to him: "You look distracted." He then shared: "I lost my job two months ago. I can't pay my bills." Joe turned to me and asked if I can postpone Mike's payment this month. Mike's voice broke as he said: "1 was ashamed to share it with the group, 1 feel like a failure. My brothers have high-powered positions. I couldn't tell them I lost my job." I asked the group how I should handle Mike's fee for that month. Several members asked me to postpone the payment and I agreed.

Following this session, Mike reported feeling more confident in his job search and told his brothers he lost his job. To his surprise, they offered him a loan. By initially not sharing his job loss with the group, he enacted his fear of being humiliated by his brothers (this was later discussed in the group). My adhering to the policy that financial matters will be discussed in the group, and the group's supportive and nonjudgemental responses, empowered Mike to discuss the job loss with his brothers and pursue the job search assertively.

David announces in one of the group meetings he will miss one of the group sessions the following month since he will be on his honeymoon. He then turned to me and said: "I am giving you five weeks' notice so you won't charge me for the session." The whole group was looking at me. I had mixed feelings. On one hand, I felt happy for David who was getting married after searching for a mate for a long time and wanted to do something special for him. On the other, I wanted to enforce the agreement that I charge for missed sessions. I kept quiet. David then asked me: "Is this okay with you?" I then responded: "Our contract is that all members pay for missed sessions." David and two other members were enraged with me. Mark said: "That's his honeymoon, how can you do it?" Sara then said: "So since I am not married I can't get special privileges?" David then shouted: "My brother was always special. He got the awards at school, he played the violin, the girls loved him, my mother loved him. I always thought I was adopted. I never did anything right!" Sara responded: "I love you. I am happy for you that you are getting married, but I think you need to pay for the session."

This was the first time David expressed the transferential wish to be special and the intense anger toward his mother. In following sessions he expressed warm feelings toward Sara, apologized for shouting at me, and paid for the missed session.

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