Timothy, a licensed psychotherapist in a major urban area, knew he needed to raise his fees. More than four years ago, he transitioned from a clinic setting to a private practice. He was now married with a young child. His colleagues, Timothy discovered, charged much more for sessions than he did. Although he was committed to offering a sliding scale fee for those who needed it, he wanted to raise his fee for his patients that could afford to pay more. The problem was he was afraid to raise his fees. Fearing the confrontation, he was anxious at the thought of someone getting mad at him or judging him. What if he lost all his patients?
Many therapists struggle with how to deal with their patient’s anger. And, when anger is directed at the therapist, it is even more challenging to work with. Yet with a few tips, therapists can gain the courage and confidence to negotiate anger. Furthermore, modeling for our patients that we can successfully navigate the murky waters of anger, tough interpersonal moments and temporary breaks in the connection, provides a therapeutic and growth-promoting experience.
Have you even had the experience of sharing your anger with the person you are angry with only to be responded to with compassion, interest to hear more and a willingness to work it through? If so, you know how great it feels. Most of us are used to our anger being met with defensiveness, abandonment of some kind or even retaliation. Conversely, when our anger is received by someone who responds with calm, curiosity and who stays connected to us in the face of our emotional reactions, especially anger, it is a transformational and potentially healing.
I gave Timothy a few tips to help bolster his confidence that he could raise his fees, deal with his patient’s reactions including anger and have it all turn out fine.
First, I recommended to Timothy that finalizing the payment was the very last step after the patient fully processed his/her feelings and thoughts. I assured him that if he felt there was a good reason not to raise a patient’s fee after they talked, that would be up to him. Perhaps they would settle on a smaller increase. Demanding anything or submitting to a patient’s demands would not help his patient feel safe, which was paramount. The main point was that he should not get bogged down with what would happen until he had given his patient the opportunity to share fully.
I explained, “This is about listening, giving your patient the opportunity to fully share his/her experience. Your stance should remain open, curious and calm. The goal is to provide an environment that enables a new, therapeutic and positive experience for your patient—even though it will be difficult. Your job is to stay present and connected. Above all else, do not retaliate by getting defensive, angry or invoking guilt. Try not to be pulled into figuring anything concrete out until the end of the session. Sometimes, it take several sessions to process anger.”
Tips To Help Your Patient Process Anger Safely and Therapeutically
Tip #1- State your intent directly, confidently and clearly. Body posture, tone and facial expressions should convey your confidence. “Timothy,” I explained, “You role is one of a wise and benevolent parent here. You are the wise elder guiding your patient. Your confidence that you’re all right will help your patient.”
Therapist: “I wanted to let you know that as of January 1st, I will be raising the session fee to $_________. I increase my fee every couple of years to cover my increased costs.”
Therapist: “It’s been three years since I raised your fee. I’m going to raise it $25 per session starting two months from now.
Tip #2- Invite your patient to share his/her emotions that come up in response to your statement.
Therapist: “I imagine this may bring up a variety of emotions and it’s important for our work and our relationship that we make lots of room here to talk about all the emotions that come up. Can we take a moment right now and just notice together what comes up for you now?”
You’ll want to encourage your client to really slow down and notice not only her thoughts but to notice her emotions, which arise in the body.
Step #3-Calm YOUR anxiety
As you read this now, I hope you will take a moment to notice what emotions arise in you as you imagine explicitly inviting the client to share his/her anger. If you notice anxiety, you are most likely not alone.
While you quietly await your patient’s response, work to calm your anxiety. I teach my patients and supervisees to calm their anxiety by planting their feet firmly on the floor, noticing the ground underneath them, and breathing deeply and evenly as they work to stay present in the here and now of the moment; connected to their calm and confident Self.
Tip #4- When your patient shares, sit back in your chair, relax and listen openly, use empathy but not so much empathy that you lose yourself and your needs, be it raising the fee or setting a boundary.
Here’s an example of what might come next:
Client: “Well I am not saying you don’t deserve the money but I am not sure I want to pay that.”
Therapist: “I hear you saying it’s not that you don’t think I deserve an increase but you are not sure you want to pay that. Did I hear that right?”
Client: “Yes, that’s right.”
Therapist: “Thanks for sharing that. And, what emotions come up for you as you share that?”
Client: “Well I guess I am annoyed and surprised.”
Therapist: “Great noticing of your emotions—that’s not always so easy to do! And…I so appreciate that you are being open and honest with me. It means a lot. What’s it like for you to let me know that you are surprised and annoyed?”
Client: “I am glad I could tell you.”
No matter how your patient responds, affirm them and ask if they would be willing to say more.
Here’s an example of what most therapists fear (but such hostility is rare in my experience).
Client: “Who do you think you are charging so much!”
Therapist: “I am so glad you are letting me know how you really feel. Will you tell me more? What else does it bring up for you that I want to raise my fee?”
Tip #5- Help the patient deepen his emotional experience. You can do this in various ways. Here are a few questions you could ask:
Therapist: “It makes sense to me that anger would come up. Can we take this opportunity to get to know your anger a bit more? What happens inside your body that let’s you know you feel anger?”
Since all emotions are really just a host of physical sensations, this question helps the patient get to know how he/she experiences anger. It might activate old memory networks and help the patient make connections with how the present and the past connect.
Therapist: “I know we have a strong connection and you have good feelings towards me as well. But right now, let’s just honor your anger because it’s a very important emotion for protection and safety. If just the angry part of you could speak freely, what would it say?”
This intervention lets your patient know that they are more than just their anger, which is reassuring. People do not want to be seen as “angry people.” By letting your patients know that you can hold all aspects of them, they will be more open to sharing their anger.
Notice that this is now an exploration and not a confrontation. We are helping our patients get to know themselves in deeper ways. Patients truly appreciate the freedom and safety to explore parts of themselves that typically are avoided or feel unacceptable.
Tip #6-Keep encouraging and asking them if there are any other feelings and invite them to tell you more.
Therapist: “What else does my raising the fee bring up?”
If you keep asking, “what else do you notice” or “what else does this bring up” you and your patient will keep learning more about him or her. Eventually they will say, “That’s all.” Then you affirm, affirm, and affirm the patient for their openness. Which brings us to the next tip.
Tip #7-Thank the patient for being open and honest. Share how much that means to you. Affirm your patient’s courage in sharing angry feelings and let you know you know it is not an easy thing to do.
Therapist: “I so appreciate you sharing everything you did and contending with this. I know it is not any easy thing to do. You are very courageous.”
Tip #8- Ask the patient what it is like to be able to openly share feelings?
Therapist: “What’s it like to talk about this together?
The purpose of this question is to help the patient realize he had this new and good experience with you where he could share his true feelings. By asking this question, you are helping your patient put left-brain language on the right-brain experience he just had. Putting language on an experience helps integrate the brain. Knowing we have had an experience is very important or it can be forgotten or dissociated.
Tip #9- Use the information you learned to access if the fee raise is right for your patient. Only if patients says they will not be able to pay their rent, buy food or that it cuts into other non-discretionary income, would I not raise a fee. If they can afford it, even though they are not happy about it, processing the emotions that come up typically is all that is warranted.
Timothy was very courageous. He informed five of his patients that he was increasing their fee $25 per session. One patient asked for $15, which felt reasonable to Timothy. The others accepted it. None of them left his practice.