Tit For Tat
by Dr. John Riolo
Well, Garry, wouldn’t be great to be able to swap therapy for, say, gardening or home repairs or whatever? No muss or fuss, no billing, no managed care, and everyone wins. No? In theory I am all for it. In theory that is. In practice you see that sometimes things are not always as simple as they sound.
Ofer Zur says, “There seems to be a consistent tension within all of the Codes [of professional ethics] between the cultural diversity and sensitivity and the bartering mandates.” He’s absolutely right. Codes of ethics do have such tension. It’s often frustrating reading such codes since like the Bible you can often find a passage that will fit almost any interpretation you choose until you come upon another that seems to say something different. With the exceptions of sexual contact with patients and fraud, codes of ethics offer few absolutes. It reminds me of that great line in the movie Pirates of the Caribbean about the pirate code, rather than rules, are guidelines which can be followed or not.
But where does that leave us as therapists--or the consumers for that matter. We have to choose from among different sections of our codes of ethics in terms of which ethical principle should take precedence over another under a given set of circumstances. If we do not choose wisely, it is our patients who suffer. Let’s clarify some points. Zur is right again when he says that bartering is not always a dual relationship if the patient is offering us goods rather than services. Exchanging a piece of sculpture for therapy is no more a dual relationship than exchanging dollar bills. So to say that bartering is always a dual relationship is grossly oversimplifying the matter. And of course not every dual relationship is unethical. However, should the burden of proof fall on our patients to show that they were harmed beyond reasonable doubt or should we hold ourselves to a higher standard?
There are a host of problems that must be considered with bartering--not the least of which is deciding how we set a fair value on our services as well as on the patient’s, who will offer goods or perform services for us in return. In bartering, whether it’s a piece of art in exchange, a chicken or services, we need to determine a fair price for all the goods or services that are exchanged. That’s where it can get dicey.
First, what value do we set for our services? Well, we can use our usual and customary fee, which can be $100 or more. Why not? Garry, I think it was you who said in one of our previous discussions, “I frankly don’t know of any professional whose time is worth over a hundred bucks an hour, unless their operation requires considerable logistical backup and equipment, and other overhead etc. “However there are a lot of therapists who charge $100 an hour and more when they can get it. But, how often do they actually get that fee? Look, we know that often when you ask therapists what their “usual and customary” fee is, they respond back with a number that represents something that may not be either usual or customary for them at all but what they wish they can get in the best of cases. We might as call it a wish or dream fee. Often however what they really charge and get is far less. We know that if they take managed care insurance that fee is quite a bit less. We bemoan that a lot, don’t we? Sometimes, we offer some people what we call a sliding fee if they can’t afford what we would like to charge, and in those cases, we charge less. And sometimes it’s not a matter of patient not being able to afford the therapy, but we simply can’t get any takers at our “usual and customary” or wish fee, so we actually take people at discounted fees to fill hours that would otherwise go empty. And some of us actually offer pro bono services on occasion.
But what monetary value will we set on our services when we barter? Should it be the high-end wish fee we rarely actually get or some number closer to the average fee we actually get? If it the high end, it’s like the guy who donates his moth-eaten old clothes to Goodwill and then claims tax deductions as if they were practically new designer outfits.
How to set a fair value on the patient’s goods or services? Goods are usually less complicated to assess if we have some idea of the fair market value of the goods or use some objective third party appraisal for an artwork for example. The patient’s services may be more complicated but if they are professional services, there may be established rates. For example, plumbers’ hourly rates are comparable to therapists so it might be a 1:1 exchange and that can make it easy.
Zur gives some great examples of bartering handled well. I could easily see myself contemplating a bartering relationship if I were in the same circumstances. I particularly appreciate the example of his returning a piece of sculpture when the client was not satisfied with the therapy. I think we should consider giving refunds to unsatisfied clients whether it is cash or goods. It’s good business, and it’s ethical business as well.
However while there may be an occasional cash poor attorney wishing to barter their legal services valued at $350 an hour in exchange for therapy, I think it’s more likely we will be dealing with unskilled or semi-skilled laborers of the working class and the poor who are most interested in barter. So what’s an hour of their time worth? Minimum wage? $10 an hour? What?
Let’s suppose we have a situation where a therapist sees a patient who will agree to barter therapy for doing household chores which could include everything from doing laundry and cleaning toilets, to odd jobs such as running errands. Setting a value of $10 an hour for unskilled labor is not unreasonable. The patient of course, needing the therapy, agrees. Now if the therapist used $100 an hour as the value of their services we have a 10:1 ratio. So for every hour of therapy the patient gets they will need to work off 10 hours doing laundry, cleaning toilets etc. No real problem if treatment lasts only a few sessions, but if treatment gets protracted, this bartering arrangement can approach the absurd. What if the patient requires 20 or 50 hours of therapy or more? It’s not unheard of. But at a 10:1 ratio after 50 hours of therapy the client could conceivably find themselves in a situation there is no way they can pay off such a debt.
Even without things getting that drastic or to the point of absurdity, my point is that as the number of hours the patient is employed mounts, we can have a version of nannygate. As your patient owes you more and more hours, it becomes increasingly difficult to claim that your patient/laborer would be an independent contractor. They would be your employees. So as an employee you would be required to pay Social Security and Medicare taxes on “employees." By the way, in a bartering situation should not both parties report something as income on their taxes? The IRS thinks so. It may vary from state to state, but how many hours must an employee work before they are entitled to health benefits?
Oh, and if you’re successful at convincing the patient and the IRS that the patient is really an independent contractor, the patient not only has to pay income tax on every $10 they supposedly earned but 100% of FICA as well. That $10 an hour suddenly is reduced in practical terms to minimum wage or less in no time. One more thing: since no money exchanged hands, can the client deduct the cost of therapy on their taxes as a medical expense or are they out of luck there as well? Once the patient realized what hit them they probably might wish they took a minimum job at WalMart and paid cash for therapy or did without.
Look, Garry, my caution about bartering is not because I think it always involves dual relationships. It may or may not. And dual relationships are not necessarily unethical. Some may be and some not. My concerns have to do with the fact that the bartering relationship may start out simple but can get complicated real fast. If therapists are going to engage in bartering relationships with patients, they must have an inordinate amount of common sense, which as I've said, is not all that common among psychotherapists. They also will need a fair amount of business sense and knowledge of business law and taxes etc. Again as a group, psychotherapists seem to be behind when it comes to business sense. But perhaps most important they will need an ability to anticipate and prepare for unintended consequences.
If they can’t bring common sense, business sense and the ability to deal with the unexpected to their work, no matter their clinical skills or good intentions they may find that no good deed goes unpunished.
John Riolo is a psychotherapist, Vice-President of Psychjourney and consumer advocate. He is known as the Insider and sometimes known as the therapist other therapists love to hate. His website Your Advocate Online includes many articles addressing the inner trade secrets of psychotherapy. Listen to his new Internet radio show, The Insider. Contact him at johnr@psychjourney.com
