A Note on Non-Payment of Psychiatric Fees

When a patient in psychotherapy fails to pay his bill, he has violated an explicit and agreed responsibility. In an effort to gain some understanding of the dynamics of this problem I have reviewed all instances in my private practice in which it has arisen. I have found that the proportion of debt-beaters (or 'deadbeats') has remained stable over the years at about one patient in seven (36 out of 242 consecutive cases seen in the last six years). Since other difficulties in the conduct of psychotherapy, such as patients quitting treatment, have gradually diminished in frequency as I have gained experience (Gedo, 1959), the continued occurrence of the non-payment problem suggests that some particular characteristic of these patients is the principal independent variable involved.

Closer study of my cases reveals that non-payment was frequent when someone other than the patient was responsible for the bill. Since I have no information about the motives of these individuals, this report will exclude such cases. When this is done, the remaining patients display a remarkable consistency in their psycho-pathology; none was schizophrenic, none was overtly depressed; all these patients had come for help because they had been depressed or presented various complex defences against experiencing affective disturbances.

One prototypical case report follows:

A 48-year-old commercial artist sought psychotherapy because he could not moderate his hostility towards men. He gave a history of severe competitive conflicts with a cold, authoritarian father and an older brother; he had great difficulty in discussing his mother in any way, but conveyed that he had had little contact with her. Once-a-week therapy was begun, and the patient's initial difficulty in talking gradually subsided. He showed some reluctance to pay my bill after the second month of therapy, but this was well rationalized behind 'realistic' considerations. He decided to pay for each hour at its conclusion, an