Money is a powerful force in our society and deeply rooted in history and culture. I’ve heard many times over the course of training as a psychiatrist and psychoanalyst that money is the most complex and anxiety-provoking subject for patients and clinicians alike, more than sexuality or any other issue. In fact, while many therapists are comfortable with money matters, there’s a running conversation among therapists that not only is it hard to talk about money with patients, but that therapists themselves aren’t great at managing money, often with sloppy billing, difficulty setting fees, and feelings of anxiety and guilt around needing to be paid. It often feels like there is a love-hate relationship with money, requiring ongoing attention.

On one hand, clinicians seek financial security and the feeling of success and status which often accompanies financial health. On the other hand, being self-promotional, openly desiring financial success, or enjoying the spotlight may be frowned upon or viewed as incompatible with desiring to help others and serve the community.

Regardless of your personal or professional relationship with money, having financial conversations with patients is often necessary for treatment to progress. Any meaningful area which lies within transference-countertransference blind spots can lead to a breakdown of the therapeutic process unless deftly navigated; money’s deep and powerful roots in the psyche make it no exception.

According to anthropologist Jack Weatherford (The History of Money, 1997), token systems were used by primitive societies for both commerce and as a status marker. Consider, for example, the use of rare shells in oceanic groups and cacao beans in Aztec culture to even out differences in the value of bartered goods and in human sacrifice, respectively. Precious metals were used in trade, but it wasn’t until around 640 B.C. that the Lydian civilization started using regulated metal coins, fashioned out of “electrum,” a natural or human-made alloy of gold and silver.

The innovation of symbolic equivalence in the form of coinage, the brainchild of King Croesus, transformed business practices by creating standardized units for merchants to use, eliminating the time-consuming and unreliable practice of weighing gold and other precious metals. And that’s just the tip of the proverbial iceberg, leading into the modern system of banking established in the middle ages, and more recently the culture of debt, credit, and now cryptocurrency which fiscally defines the modern psyche and the frame of psychotherapeutic exchange.

Why Money Matters in Mental Health Care

The American Psychiatric Association’s Practice Guidelines for the Psychiatric Evaluation of Adults highlight that financial history is an important part of understanding a patient’s presentation. Money matters can be just as important as developmental history, professional background, psychosocial history, spirituality and religion, culture and family, and all the other elements which go into a comprehensive evaluation.

Specifically, the Practice Guidelines highlight how money problems can be a risk factor for suicide and aggression, not to mention depression, anxiety, and stress-related disorders. When a person is in need of treatment, finances can be a barrier to accessing proper care. Money also plays a role in clinical decision-making and in how patients receive care.

Constrained insurance coverage may deter clinicians from ordering quantitative tests and recommending treatments that are indicated, but more costly and not easily reimbursed. Patients with high deductibles or plans which don’t cover certain services or treatments, such as newer medications, may either not be able to adhere to recommendations or may decide not to. Frequently, patients do not communicate openly when financial issues interfere with care, adding fuel to the fire.

The good news is that financial stressors may be modifiable, leading to reduced risk and greater well-being. While is often too laborious and time-consuming, advocates may be able to get insurers to cover needed services. For all of these reasons, it’s advantageous for clinicians to become comfortable with this often complicated subject.

Financials as a Social Determinant of Mental Illness

It’s well understood that lower socioeconomic status is associated with a greatly increased risk of mental and physical illness. A 2020 Lancet Public Health study by Kivimaki et al of nearly 110,000 Finnish adults showed a five-fold increased risk for multiple diseases, with a path from early psychiatric disorders including mood and psychotic disorders, self-harming behavior, addictions, and a variety of later-life morbidity and mortality from liver, kidney, heart, metabolic and central nervous system disease, among others.

Financial stress as noted is an important factor. While socioeconomic issues are often insoluble in the short term, without understanding the nature of the problem, clinicians may assume the situation is hopeless. In many cases, however, help may be available from public services, through engagement with a case manager, through assistance from family members, or via personal efforts to change circumstances for the better. Debt and the specter of financial ruin can trigger depression, and even suicidality, by precipitating emotionally painful experiences of failure and inescapable crisis.

Clinicians have to be aware of how socioeconomic similarities and differences may play out in the treatment alliance. Research shows that structural racism results in disparities in care. When it comes to conversation about money, to best assist patients it’s crucial for clinicians to be culturally competent and aware of their own potential biases. Asking about financial security, including details regarding short-term emergency money, and longer-term planning, is a key component of basic security, including access to food, shelter, healthcare, and education, as well as overall well-being.

How to Talk to Patients About Money

To start, taking a financial history can provide important diagnostic clues.

Many psychiatric problems manifest around behavior with money and spending. Clinicians can ask about these issues directly during evaluation, for example, as part of screening for bipolar disorder, ADHD, or gambling. Difficulty with finances may be reflective of executive function impairment, learning differences, or problems with self-organization.

Given that impulsivity and impaired decision-making exists in many psychiatric conditions, these questions unearth core issues surprisingly well, often more effectively than asking about symptoms.

Here’s a sample starter conversation between a clinician and a patient that gets at financial history:

PSYCOM PRO SCRIPTED MONEY Part1

View the PDF (Part 1)

Encouraging patients to talk about money matters not only reveals important information about their personality, coping style, and resources but may also provide clues to assist in the diagnosis of psychiatric illness which may otherwise be missed. Financial history may also reveal underlying relationship problems, even providing clues that the patient may be in an abusive relationship. They might be hiding these concerns out of fear, often unaware that certain behaviors, such as being controlling with money, suggest abusive dynamics.

Psychological Dimensions of Money: Family History & Beliefs

In some ways, the psychological dimensions of financial affairs are the richest. It’s crucial to explore the role of money in the family system as well, both developmentally and as part of active family dynamics. Patients internalize attitudes and beliefs about money early on in life, and authority relations shaped by parent-child relations can be a source of adult dysfunction which money questions tap. The above infographic also provides an example of talking to clients about their beliefs regarding money.

Patients may have maladaptive beliefs about money which affect interpersonal relations, professional performance, and personal development, often overlapping complexly. Asking patients about the meaning of money can reveal much about their personality, how they value themselves and get their needs met, how they go about seeking security in the world, how they deal with other people when the stakes are high, and so on. Understanding patients’ relationship with money is revealing of their personality, unconscious fantasies and cognitive schemas, often leading to therapeutically fruitful conversations.

The Impact of Finances on Intimate Relationships

Financial issues commonly play a role in relationship conflict. Couples who share avoidant coping around money frequently neglect financial issues, leading to real-world consequences as well as poor relationship satisfaction, often accompanied by conflict avoidance. When there is a mismatch – as when one partner is keen to address budgeting issues and the other tends to procrastinate – dynamics can become explosive.

For couples where trust is an issue, keeping secrets about money, inequitable payment arrangements, and related disparities can be both a symptom of underlying issues and a precipitant of conflict. In couples with maladaptive, even abusive dynamics, money is often used by one person to control the other.

Here, a sample dialogue with a patient about money problems in a relationship:

PSYCOM PRO SCRIPTED MONEY Part 2

View the PDF (Part 2)

Chronic resentment is poisonous to relationships, and money problems are right there alongside intimacy among major problems that people often don’t readily address – though a little help often goes a long way. Clinicians can help couples work through conflict by collecting history and encouraging financial literacy. Often, when couples get on the same page regarding household finances, other areas follow suit – dealing with money is a learning process that helps couples mature while also alleviating stressors that interfere with healthy relatedness.

Managing Money in the Therapeutic Relationship

Talking about money openly in the treatment frame is often therapeutic, especially for those who avoid talking about money, because of shame or other forms of discomfort. Being able to deal with money in a healthy way, however, is generally required to being a satisfied and successful adult. Quite often, money issues come up in the context of treatment, in relation to payment timeliness or tardiness, and in the discussion of fees. It’s preferable for the clinician to be comfortable speaking about these sorts of financial matters.

Consider the scenario described at the bottom of the above infographic (Part 2) on money in the therapeutic relationship.

When clinicians don’t handle money and billing well, it can undermine the treatment relationship as well as cause practical business problems, such as making it hard to get reimbursement for insurance claims or be up to date on fee-for-service collections. Addressing money issues in the here-and-now, as with other areas of focus on the therapeutic relationship or transference, is a powerful therapeutic tool when managed well, allowing patients to work through thorny problems within the therapeutic relationship.

Overall, finances can be an important stressor for clients and clinicians alike. By working to understand the nature of any money issues and talking about them openly, clinicians can guide patients to means of assistance and/or personal improvement. If financial matters extend beyond the scope of treatment, clinicians may concern referring patients to a financial advisor or coach for focused assistance.

 

See also, Dr. Brenner’s clinical guide to trauma-informed care.

 

Last Updated: Apr 20, 2021