Although the meaning of money matters in psychotherapy has been addressed since the inception of this practice, these discussions have focused almost exclusively on the perspective of the client. It is only recently that the professional literature has begun to examine more extensively the perspective of the practitioner regarding money and the fee. The dramatic and at the same time subtle infiltration of managed care into various aspects of social work practice recently has required individual practitioners and consequently, the profession as a whole to actively attend to fee concerns. Within this current economic-practice climate, a range of recurring fee issues and related ethical dilemmas have surfaced.
This discussion delineates some of the fee-related issues and accompanying ethical dilemmas commonly experienced by social work practitioners. The discussion is an effort to enhance awareness and recognition of the issues that may in turn serve to inform practitioners as they struggle to intervene with clients in clinically and ethically sound ways.
Although the literature on ethical dilemmas in social work practice has addressed important concerns such as client confidentiality, practitioner values, sexual misconduct, and choice of treatment modality, scant attention has been paid to ethical dilemmas that are fee related. An ethical dilemma may be described as "any controversy that involves conflicting moral principles in which one experiences different moral pulls" (Purtilo & Cassell, 1981, p. 7). In attempting to resolve such dilemmas, consideration is given to personal values, attitudes, beliefs, duties, and obligations. Ethics plays a central role in clinical practice "not only as informing clinicians' goals and basic methodological assumptions but also as being an aspect of almost every judgement every clinician makes . . ." (Dean & Rhodes, 1992, p. 128).
A practitioner's ethical framework embodies universal values such as justice, respect, individual self-determination, and personal ethics. These values are part of every clinical intervention, which also is influenced by practice models and theoretical orientations, as well as the practitioner's view of cultural norms and beliefs. Finally, all of these variables are subject to the practitioner's interpretation in the process of practice implementation. Ethical-clinical tensions occur when a practitioner attempts to "maintain an ethical stance while understanding the client's sense of the importance of his or her different priorities" (Dean & Rhodes, 1992, p. 130). The NASW Code of Ethics (1996) acknowledges that ethics are subject to the "content and complexity of the human experience" (p. 1), while offering "a set of values, principles, and standards to guide decision making and conduct when ethical issues arise" (p. 2). The stated guiding principle of the code is to "enhance human well-being" within the framework of core social work principles and cautions that social workers "should be aware of any conflicts between personal and professional values and deal with them responsibly" (p. 3).
Simply put, the fee is likely to evoke a range of ethical-clinical tensions and dilemmas for practitioners in private and agency practice settings insofar as it represents the practitioner's or the agency's income. The implication of this, however, is quite complex because this reality is not always congruent with the client's priorities, potentially positioning the client and the practitioner in conflicting positions. Private practice carries an inherent tension insofar as the fee is the one aspect of the therapeutic relationship in which something is asked of the client from which the practitioner will benefit personally. In this context the social worker must effectively balance the primacy of the client's interests against his or her own income needs in any decision, whether it be in setting, adjusting, or collecting fees. …