香港六合彩精准资料

For mainly historic reasons, I have a few clients paying different rates. I have discovered that two of them now play Sunday football on the same local team. They don鈥檛 seem to know each other well and haven鈥檛 mentioned each other in sessions, but I am now worried that should a friendship develop and they find out they see the same therapist, they will share details of what they pay and realise they pay differing amounts. Should I address this now or wait until it comes up?

Karen Stainsby replies:

Practitioners routinely bear witness to some very intimate, embarrassing and perhaps shame-laden details of their clients鈥� lives. Usually, we work well enough with challenging material but when it comes to discussing fees, somehow it can feel different. Although fees often form part of the therapeutic frame, representing 鈥榓 framework for dual affiliation鈥�, it can be hard for many of us to discuss them with clients.¹

Much has been written about the place of money in therapy, described as the 鈥榣ast taboo鈥�.² In her article 鈥楶ayment matters鈥�, Sally Brown considers that fee-setting involves 鈥榣ayers of interwoven dynamics鈥� uncommonly found in other small businesses. Some practitioners have difficulty reconciling the idea of providing 鈥榰nconditional love鈥� while charging, and Brown raises the thorny question of whether it鈥檚 right to 鈥榤ake a living out of other people鈥檚 suffering鈥�.³ In 鈥楻aising fees鈥�, Stephen Hitchcock reminds us that while the ethical principle of 鈥榡ustice鈥� and the personal moral quality of 鈥榝airness鈥� might obviously apply to the therapeutic relationship, they can be 鈥榙ifficult to apply when money is involved鈥�.⁴

Practitioners who charge for services have developed processes 鈥� sometimes by trial and error 鈥� with most reaching a 鈥榞ood enough鈥� position that works much of the time. Nevertheless, those who鈥檝e ever had to decide whether to charge for a missed session will recognise difficult terrain. Money seems to have the power to make some practitioners feel uncertain, uneasy, perhaps guilty, causing them to behave rigidly or over-flexibly and with less ethical-mindedness than usual.

Even in contexts where clients don鈥檛 pay for therapy, money, by its very absence, is still present. What money means to us, how we symbolise it and the part it plays in our lives are all likely to impact our work. It may be useful to think about the place money plays in your life as you work out, in the first instance, what to do about these two clients, but then later, as you possibly consider more widely the financial management of your practice.

Having discovered these two clients meet each Sunday, you鈥檙e now worried. A question we sometimes ask clients is, 鈥楾his situation鈥檚 gone on for a while. Why鈥檚 it now a problem?鈥� For you, the answer seems to rest on potential discovery and what that means to you and about you. I鈥檓 also curious whether something else has happened in either of the therapies or elsewhere to trigger concerns. Although you鈥檙e not acting in a 鈥榙ual role鈥�, you and these two clients are interconnected. While you, as a practitioner, are mainly bound to hold what each tells you as confidential, they can tell each other what they like about themselves, including what happens in their therapy, and this may have a bearing on things.

For 鈥榤ainly historical reasons鈥� you鈥檝e a few clients paying different fees. I鈥檓 working with limited information but wonder whether you鈥檙e clear in your mind who in your caseload pays what fee, what might account for differences and whether reasons underpinning individual fee-setting still apply? Do you have a universal starting fee or offer a sliding scale? Some practitioners have a sliding scale available to all clients who can self-select, although this can bring financial uncertainty, and relies on client honesty and being updated about any financial changes in their lives. Maybe you set a fee at the start of the contract that never changes or have agreed with clients when fees will be reviewed. The financial management of your practice might be efficiently managed but could rationales and other information have got lost among the day-to-day running of a busy practice and life鈥檚 responsibilities and pressures? Taking stock of fees might help you think through what to do about these two clients and perhaps others. 听

Whether these clients already know about the discrepancy or find out later, how do you imagine each might feel? The one paying more may feel resentful, punished or that care comes 鈥榓t a cost鈥�, perhaps as elsewhere in their life. They may think they subsidise the therapy of others, that you don鈥檛 like them, or that they pay more because their problem is 鈥榗omplex鈥� or they鈥檙e 鈥榟ard work鈥�. Might they see it as unfair, discriminatory (Ethical Framework, Good Practice, point 22b), or accuse you of exploitation (Commitment 4d and Good Practice, point 35)? Heather Dale in the Good Practice in Action resource Charging for services within the counselling professions comments that exploiting clients may seem an obvious prohibition, but when money is involved, what counts as exploitation is 鈥榪uite a complex area鈥�. The client paying less might think they鈥檝e got a bargain, feel 鈥榮pecial鈥�, worry their problem is unimportant to you, or that you are providing them with a 鈥榣esser鈥� or 鈥榮econd-rate鈥� service. They could imagine you don鈥檛 think they can afford it, feel patronised or fear that sooner or later 鈥榩ayback鈥� will be required. 听

If clients have compared notes, one might ask you, 鈥榃hy do we pay different amounts?鈥� It鈥檚 important not to get caught up in the conversation and launch into a justification, potentially breaching confidentiality (Good Practice, point 55). While we agree to be 鈥榓s open and as communicative with our clients, colleagues and others as is consistent with the purpose, methods and confidentiality of the service鈥� (Good Practice, point 44) any response would best be, I feel, an 鈥榠n principle鈥� one.

Apart from the impact on the therapeutic relationship and process, there鈥檚 a risk these two clients might fall out over it, accusing you of harming their friendship (and if they can鈥檛 face each other on the football pitch, possibly their hobby and wellbeing). 听

You鈥檝e always the option of doing nothing, apart from to be prepared if challenged. However, this situation does seem to be preying on your mind. Waiting to see if it鈥檚 raised might leave you waiting nervously. One mention of 鈥楽unday football鈥� might see your pulse rate rise as you think 鈥楬ere we go!鈥�

So, let鈥檚 say you decide to pre-empt the situation and raise the issue. Before doing anything, think through any potential impact on the therapeutic relationship and process. Would you raise it with one client 鈥� or both 鈥� and how might you introduce this tricky subject? When might be a 鈥榞ood/bad time鈥�? Is this conversation even possible without subtly confirming you know the other client?听

I鈥檇 suggest you have prior discussions with your supervisor having first dug out the I鈥檇 suggest you have prior discussions with your supervisor having first dug out the contract(s) agreed, which hopefully include a 鈥榬ecord of what has been agreed and of any changes or clarifications when they occur鈥� (Good Practice, point 31e).

If contract(s) allow and the 鈥榤onetary gap鈥� is not too great, some might consider 鈥榖alancing鈥� fees by raising one client鈥檚 fee or lowering the other鈥檚, which might produce puzzlement in the latter who resents having previously paid 鈥榯he extra鈥�. Other practitioners may consider 鈥榖alancing鈥� unfair or an attempt to make yourself 鈥榝eel better鈥�. Of course, raising fees sometimes bring its own issues. Whatever happens, there may be useful material to explore in the service of the client.

Most practitioners act in genuine and honest ways, but you might worry you鈥檝e made a mistake with fees. Supervision would be a good place to explore this, find out how it happened and decide what to do next. All personal moral qualities, in particular candour, apply, as do 鈥極ur commitment to clients鈥� number 6 and Good Practice, point 52. The Good Practice in Action resources GPiA 073 and GPiA 113 provide supportive information on accountability and candour. Realistically, no one expects practitioners to work 鈥榤istake free鈥� but the sooner mistakes are recognised 听and addressed the better. Ani de la Prida comments, 鈥楾here can be therapeutic value to therapist vulnerabilities and 鈥渕istakes鈥� that are transparently acknowledged with immediacy鈥� (GPaCP 004).

This dilemma鈥檚 been a worry to you, so it鈥檚 important you find some sort of resolution. The ethical principle of self-respect means we鈥檙e entitled to apply all other principles to ourselves as well as our clients. As we commit to 鈥榩romoting the client鈥檚 wellbeing鈥� (beneficence) so we commit to look after ourselves. To work effectively and to professional standards we need to attend to 鈥榗are of self as a practitioner鈥� (Good Practice, point 91). We should periodically ask ourselves whether the money we earn enables us to take good enough care of ourselves and 鈥榤aintain our own physical and psychological health鈥� (Good Practice, point 18; Good Practice in Action 088).

Coming back to supervision, as fee management is a boundary issue, it might be a good time to review other practice and therapeutic boundaries (Good Practice, point 33a; Good Practice in Action 110 and 111). Also, I hope your supervisor provides support with how you feel about this situation and its impact on you.

Money can be a complex and awkward subject, and I don鈥檛 imagine you鈥檒l be alone in having concerns about fee discrepancies. Often, like other situations, it鈥檚 not what we鈥檝e done as what we do next that matters. So, for the success of the therapeutic relationship and process, it鈥檚 important you can explain the reasons behind decisions but also that you and your clients feel content enough to move forward together on the right footing.

Reader responses

We can only work with what is brought to us 鈥� and work with openness

As a therapist working with musicians and music industry professionals, I am aware that sometimes clients may know each other and a scenario like this can easily occur, even though it hasn鈥檛 happened to me yet. For example, the clients that I see separately could easily be at networking events together, backstage at a gig, or potentially collaborate with one another on future projects. Through conversation, they might well discover that they are both working with me. First, I accept this possibility 鈥� if a client chooses of their own accord to bring this to me, I am happy to have that conversation with them. If unexpected issues arise as a result of two clients working with me at the same time, I will be ready to embrace it as part of the therapeutic work taking place. However, should it ever be me who makes the discovery that my clients know one another, I would not mention this to either of them. We can only work with what is brought to us 鈥� and work with openness 鈥� while always protecting the confidentiality of each client.

In terms of issues around rates, I find that discussing finances at the assessment stage is essential to managing this potential scenario. Financial issues can undoubtedly bring up challenges for both client and therapist, so to ensure I am containing myself and the client, I am clear about finances from the onset, with full transparency about how I work across my practice. At assessment stage, I always let the client know my fee and my requirements for payment. My clients in private practice are all charged the same fee; however, some of my clients are referred to me via a charity called the British Association for Performing Arts Medicine, which funds the client鈥檚 sessions. This means that one client might be paying a fee, while the other is receiving free therapy. I let my clients know this, and that if they are struggling financially, they can contact the charity I work for and that this would involve a clinical assessment to see if they would be eligible for up to six paid-for sessions, and that the charity pays me. I let them know that if they wanted to continue beyond the six sessions, they would need to be able to pay my normal rate.

I also get them to weigh up if they want to work long term or short term, and to consider the financial implications of this. I find that ensuring each person has this information from the start creates transparency and gives them the opportunity to make a choice about how they wish to continue. The assessment and contracting stage, therefore, is crucial to this scenario as it is then that the therapist establishes the boundaries in which they work, and can hold the client in the safety of that professional framework. Historically, I have changed my fee over the years and I would be happy to discuss this with a client if asked.

Denise Devenish M香港六合彩精准资料 is a music industry specialist counsellor.

My previous experiences have taught me the importance of simplicity in managing therapeutic relationships

I work with ethnic minority groups and the neurodivergent community, and I encounter dilemmas that require careful consideration and sensitivity. I work on the premise that it is better to be upfront from the beginning in private practice. One such scenario arose when I started working closely with a community centre, and to make my services more accessible I offered a sliding-scale fee structure. I was transparent about this with all my clients from the beginning as the clients from the community centre had close relationships due to a shared faith. However, an awkward situation arose when a client confronted me about this differential pricing. This not only caused a rupture in our therapeutic relationship but also led to another client, who was on the sliding scale, frequently missing sessions without sufficient notice, contrary to the terms in our contract. This experience led to feelings of resentment seeping into the relationship. It seemed that despite having endeavoured to do the right thing by being upfront about my sliding scale, this consideration wasn鈥檛 taken into account.

The incident prompted me, therefore, to reconsider my pricing approach. I now no longer offer a sliding scale. My previous experiences have taught me the importance of simplicity in managing therapeutic relationships 鈥� while it鈥檚 crucial to strive for accessibility and inclusivity in therapy, it鈥檚 equally important to maintain clear boundaries and consistent policies to prevent misunderstandings and preserve the therapeutic alliance. And sometimes, even though you try to maintain clear boundaries, it鈥檚 still not always quite smooth sailing.

Yasmin Shaheen-Zaffar M香港六合彩精准资料 (Accred) is a counsellor in private practice working with ethnic minority groups, interfaith relationships and the neurodivergent community, and is the founder of Polyvagal Teen.

Clients do talk about their therapy but not always in great detail

Even though your clients share part of their life outside the therapy room, their relationship with you is completely separate. They鈥檙e on different fees because of differing circumstances, relevant to each of them individually. How you charge your patients is up to you, and not standardising your fee is your prerogative; if they were to talk about their fees, it might reveal more about their individual circumstances rather than becoming a critique of your practice.

In my experience, where there is a shared life outside of the therapy room, clients do talk but not always in great detail. Where it becomes difficult is the acknowledgment that someone else knows about the space they visit where they can be vulnerable and talk about all the things in life that are difficult for them 鈥� it鈥檚 this that you might have to acknowledge in your sessions. A lot of the time clients want to keep their relationship with you as their therapist safe. It鈥檚 less about comparing detailed practical notes; if anything, it鈥檚 about comparing the quality of each other鈥檚 relationship with their therapist.

I have worked in schools where children from the same class are coming to therapy and I鈥檝e also supervised that work. Children in the same class that end up with the same therapist experience a very overt sense of having to share a parental figure in their therapist with a representation of a sibling in their classmate. It鈥檚 not surprising that they might want to know about how their classmate came to therapy, and with their same therapist, for how long and any other unique or special arrangements that might be in place. As the therapist, it鈥檚 within your role to carefully manage that boundary. When supervising this work previously, this is the key point I have emphasised to my supervisee. There鈥檚 the potential for boundaries to get very messy, but your responsibility is to each client, individually, and what they want to bring as part of their work, not what you think they need to hear.

By acknowledging other clients unprompted, even if you don鈥檛 say who they are but perhaps reveal a common thread, there鈥檚 a big risk of revealing confidential information about your clients. If you leave it unprompted then you have the opportunity to deal with a situation as and when it arises. It鈥檚 worth thinking about whether, if this situation hadn鈥檛 arisen, you would have mentioned other clients to the person you鈥檙e in the room with at all.

This has happened to me a couple of times as a client. I was grateful that my therapist did not mention it until I did 鈥� by them not telling me they already knew some of their clients knew each other, it made me feel like my information had also not been divulged to anyone else, as I should be able to expect as a client in a trusting therapeutic relationship.

Marianne Rizkallah is Head Music Therapist of North London Music Therapy, a registered supervisor with the British Association for Music Therapy (BAMT) and a former BAMT Vice Chair of Trustees.