Warning & Disclaimer:
The ideas expressed in this chapter may be challenging and upsetting, as they may confront some of the dogmas of psychotherapy. It will also challenge the psychotherapeutic community who, like most attorneys, are focused on risk management rather than clients' care and integrity of treatment. The web page and the accompanying online course intend to introduce critical thinking to the field of psychology with regard to the issue of bartering. Dr. Zur believes that uncritically rejecting all or most bartering arrangements goes in the face of our professional and ethical commitment to serve clients of diverse economic class and cultures. This page is not a substitute for clinical, ethical or legal consultation. It only expresses Dr. Zur's opinions. Each case is unique and must be considered on its own merit.
Bartering, in general, is the exchange of goods and services. It has been part of humankind since the beginning, thousands of years before gold, silver or money was introduced. In psychotherapy or counseling bartering is the acceptance of services, goods or other non-monetary payments from clients or patients in return for psychological or counseling services. This web page focuses on bartering arrangements between psychotherapists and clients.
Bartering is more common with poor clients who seek or need therapy or counseling but do not have the money to pay for it. It is also part of the norm in cultures and communities where bartering is a generally accepted means of compensation and economic exchange (Canter et al., 1996; Cory, Cory and Callanan, 2003; Hill, 1999; Koocher & Keith-Spiegel, 1998; Zur, 2004a, 2006, 2007). It is also more common at times of economic depression, when either clients or therapists are in financial straights. The dominance of managed care in the last couple of decades has contributed to therapists' financial woes, which in turn are likely to increase their flexibility in terms of payment for services to include bartering and other alternatives to cash payment.
Bartering, as discussed in this paper, is the exchange of goods (chicken, cabinetry, painting, etc.) or of services (automobile repair, plumbing, house cleaning, etc.) for psychotherapy services. Common examples are: a poor artist barters his/her painting or an indigent client cleans the office in exchange for therapy. There are many ways to structure bartering arrangements. One common way is an exchange of the fair market value of the exchanged goods or services. For example if the therapists' fee is $120 per session, a client's sculpture with a fair market value of $1,200 buys the client-sculptor ten sessions. Some poor agriculture communities often have more flexible bartering schedules, where the arrangement is one chicken for one session. Other bartering of services arrangements are based on an hour-per-hour arrangement, where an hour of client's work is provided in exchange for one "therapy hour" (Zur, 2007).
Introducing bartering into the therapeutic relationship for reasons, other than financial, has been discussed thoroughly in Rappoport's unique text, Value for Value Psychotherapy: The economic and therapeutic barter (1983). In the only book that is devoted entirely to bartering in therapy, Rappoport discusses the therapeutic value in bartering even when the client can afford the full fee. He writes:
For its' framework, the Economic and Therapeutic barter (EBT), designed as both a financial option and a therapeutic adjunct, draws upon the practices of primitive trade and modern psychological theory. Taking from the social, economic, and interpersonal dynamics of each, ETB attempts to enrich the patient's therapy experience and increase the therapist's effectiveness, while fulfilling more intimately the personal needs of both. (p. 5)
Evolution Of Bartering
Bartering is as old as humankind. At the beginning of humankind, obviously, there was no money or gold coins, and people bartered or traded in almost all areas of their lives. They traded items, such as food, decorative apparel, tools or weapons and they traded services as well. Bartering arrangements can be traced via records to ancient Egypt 4,500 years ago. The earliest coins were found in Mesopotamia (now southern Iraq) around 2,000 B.C. The Roman Empire became the greatest trade center in the world around 100 B.C., which led to the global spread of coins minted in gold and silver. As transactions became too complex for straight bartering, coins were introduced. As it become too cumbersome to haul around a lot of heavy coins or large items for trade, money was introduced. While money has obviously been the dominant mode of modern commercial exchange, bartering has persisted through the history of humankind. At times of economic depression, understandably, many people, including psychotherapists and consumers of psychological services, seem to revert to bartering (Stein, 2002). During economic recessions people who are low on cash still possess their skills and talents (i.e., mechanical, graphic and web designing, programming, farming), still posses valuable or tradable assets (i.e., works of art, cars, computers, tools) and still own tradable commodities (i.e., corn, chickens, produce) (Zur, 2007).
The introduction of the Internet revitalized the usage of bartering in our culture. A new frontier opened for people to trade services and goods. Hundreds or even thousands of websites, such as www.craigslist.org, www.barterco.com or www.barterforless.com, offer all kinds of online bartering arrangements. The burst of the high tech bubble in the late 90s exponentially increased those who suddenly became poor, were ready to barter and were skilled and trusted to do it online. Barter postings on Craigslist have skyrocketed to thousands of postings each month. Online bartering seems to know no limits. People simply list online the skills, talents and services they are ready to trade and then make an additional list of what they need or desire (Stein, 2002). When cash is sparse, many people trade their graphic skills for car repair, massage for a bicycle, foreign language tutoring for a German shepherd puppy, web design for a timeshare or painting (viewed online) for a home sound system. While some websites focus the bartering in small geographic areas where services, such as car repair, can be easily traded, others are keeping it open for the global village. Barter has become a major force in the economic system of the United States. Organized barter represents a $16 billion dollar industry (www.barterco.com).
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Opposition to Bartering
Bartering has been an especially controversial issue among psychotherapists. Consumer protection agencies, licensing boards, ethics committees and risk management experts often frown upon all forms of bartering. The reason they place bartering high on their avoidance list is because they consider the "power disparity" between therapist and client as likely to lead to exploitation of the client by the therapist in the bartering arrangement. Another opposing view is given by Faulkner and Faulkner (1997) who, mistakenly, assume that the analytic approach is universal and presumptuously claim that bartering should be avoided because it results in the therapist's harmful self-disclosure. Many of those opposed to bartering view it as the first step on the slippery slope towards harm or sexual relationships between clients and therapists (ASPPB, 2003; Doverspike, 1999; Grosso, 1997; NASW, 1999; Woody, 1998). The California Department of Consumer Affairs (1990) and the California Board of Psychology, along with the Association of State and Provincial Psychology Boards (ASPPB), (2003) even include the mandate to avoid bartering in their official brochure, "Professional Therapy Never Includes Sex". In the section in include bartering as one of the "Signs of inappropriate behavior and misuse of power"(p. 8). Traditional analysts view all forms of bartering as interfering in transference analysis and, therefore, are harming to the therapeutic process and damaging to the client.
The literature on bartering seems to focus primarily on the potential hazards of bartering and the ensuing mandate to avoid it as much as possible. While bartering for services seems to be frowned upon by most experts and ethics codes, the bartering of goods seems more acceptable (Canter et al., 1996; Koocher & Keith-Spiegel, 1998). The support for bartering comes from the acknowledgment that bartering may be the only way for indigent people to get therapy, when it is done as a normal aspect of agricultural, rural and other communities (Canter et al., 1996; Cory, Cory and Callanan, 2003; Hill, 1999; Koocher & Keith-Spiegel, 1998; Zur, 2006, 2007). Some of those who oppose bartering reluctantly acknowledge that bartering cannot always be avoided. What seems to be missing in the literature is a discussion of bartering that is done intentionally and deliberately in order to enhance the client's mental health or as part of a well thought out treatment planning. Interventions that include bartering, like any other intervention, must be matched with the client's needs, wishes, style, situation, culture, etc. The focus in this paper is not on the traditional "do no harm" approach but on "do good" or do what is most likely to benefit the client and improve his or her mental health.
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Bartering, Boundary Crossing & Dual Relationships
Bartering has often been confused and equated with dual relationships and boundary violations and, consequently, with risk and harm (Doverspike, 1999; Faulkner & Faulkner, 1997; Grosso, 1997; NASW, 1999; Woody, 1998). Those who take this rigid and dogmatic approach to dual relationships usually also judge bartering as inherently unethical and harmful. The fact is that only bartering of services constitutes dual relationships; bartering of goods does not necessarily translate to dual relationships. Dual relationships occur when a therapist has a secondary relationship with a client in addition to the therapeutic one. Many types of bartering of services-dual relationships can be clinically beneficial and ethically sound (Lazarus & Zur, 2002; Zur, 2004a, b, 2006, 2007). All bartering arrangements between therapists and clients are boundary crossings. Boundary crossings are defined as a deviation from a strict analytic or risk management practice. Examples of boundary crossings are any self-disclosure, appropriate gift exchange, flying with a client with fear of flying or a home visit. While all bartering is boundary crossing it is not necessarily boundary violation (which is defined as a harmful and exploitative violation).
When a client barters a sculpture in exchange for therapy, most experts agree that this does not create another relationship besides the therapeutic one. The sculpture just replaces the cash payment, and the bartering arrangement constitutes boundary crossing but not boundary violation. However when a client pays for therapy by cleaning the therapist's house, this arrangement definitely constitutes dual relationships because in addition to the therapist-client relationship now there is also an employer-employee relationship. (Some therapists consider even bartering of goods as dual relationships, not only boundary crossing. This is because it involves a seller (client) - buyer (therapist) relationship in addition to the client-therapist relationship.) For online web page that details definitions of boundary crossings, boundary violations and dual relationships and online clinical and ethical guidelines for boundary crossings and dual relationships, go to Zur, 2003.
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Types & Arrangements Of Bartering
There are a couple of major types of bartering such as goods, services or their combination. There are also other more unusual types of bartering described below. Following are descriptions of some of these bartering practices.
Bartering of Goods
Bartering of goods involves the exchange of tangible goods or objects for psychotherapy. Examples are when a client pays for psychotherapy with a chicken, rice, fresh produce, a painting, a sculpture or a chair. As was noted above, bartering of goods seems to be more acceptable and less problematic that bartering of services (Canter et al., 1996; Koocher & Keith-Spiegel, 1998). The reason given is that a fair market price or value can be established more easily and more objectively for goods in comparison with services, and therefore clients are less vulnerable to therapists' exploitation. However, even bartering of goods must be handled with care, as some objects such as a "family heirloom" may have a strong sentimental value acceding its monitory value (Grosso, 1997).
Bartering of Services
Bartering of services involves the exchange of a client's work or services for psychotherapy services. Examples are when a client paints the therapist's house, fixes his/her car, provides the therapist with billing or landscaping services or cleans the therapist's office or home. Bartering of services is considered dual relationship and is often seen as much more complex, problematic and much less acceptable than bartering of goods (Canter et al., 1996; Koocher & Keith-Spiegel, 1998). The much given reason is that the discrepancy between the therapist's hourly fee and the poor-client's is often large and therefore problematic. Another often cited reason is when the therapist is dissatisfied with the client's services, but voicing it is likely to interfere with therapy. Along the same line of thought, disengaging from or stopping a bartering of services arrangement can be much more complicated than disengaging from a bartering of goods arrangement, whereby the therapist simply returns the goods to the client. Additionally, in bartering of services it may be more complex to determine the fair market value of the client's hourly fee. Generally there are two ways to arrange bartering of services. One way is to barter according to each person hourly rate. An example of this is a client, whose hourly rate is $10, would clean the therapist's office and work for 12 hours for each $120 session. Another potential arrangement is where the exchange is an-hour-for-an-hour where the client works one hour for each session (Zur, 2007). Like dual relationship, bartering of services, if conducted with thoughtfulness, integrity and clinical sensitivity, may be an acceptable and helpful arrangement. A much more complex and difficult bartering arrangement is when a client acts as a financial, investment or business adviser, marketing consultant or defense attorney for the therapist. One must be very careful when entering into such a complex bartering or dual relationship arrangement. Another complication, which can arise in a bartering of services arrangement, is when the patient-employee is injured while providing the service to the therapist-employer.
Bartering as Part of a Pro Bono or Low Fee Arrangement
Very often a bartering arrangement is in lieu of or part of a low fee or pro bono arrangement. In this case the chicken, fresh produce or services provided by the client are part of the pro bono or low fee arrangement (Zur, 2004a). Canter et al. (1996) states well: "Pro bono services, although certainly at times an option, may not always be possible, either because of therapeutic issues, the discomfort or unwillingness of the client or patient to accept free service, or financial pressure on the part of the psychologist, particularly in economically depressed areas where many indigent clients may need psychological services" (p. 51-52). Many clients feel that they owe the therapist some compensation and many others are too proud or dignified to accept the services for free. In these situations in order to avoid humiliation, a bartering arrangement in lieu of low fee or no fee arrangement may be the appropriate and clinically preferred solution.
Additional Types of Bartering
Combination of Goods and Services: Some bartering arrangements include a combination of goods and services as in the case of a client who builds a custom made cabinet for the therapist's office. In this case the patient is an employee-designer for the therapist as well as the producer of goods, the cabinet. Another form of bartering is when the arrangement is that the client conducts community service or a volunteer job for a local cause in lieu of a low fee or pro bono agreement with the therapist.
Bartering with the Wealthy: Another form of bartering is when the arrangement is that the client, who is not in financial distress or may be even quite wealthy, conducts community service or a volunteer job for a local cause in lieu of a low fee or pro bono agreement with the therapist. Rappoport (1983) describes a combination of cash and barter with clients who can afford the full fee. Bartering, in this approach, is a form of a clinical intervention, where clients get to observe and analyze their actions and reactions to the bartering arrangements.
Swapping Guns for Therapy:
American Psychological Association's newsletter Monitor on Psychology reported in 1995 on an unusual program in California, in which psychologists were urging Californians to trade guns for therapy. Members of a couple of county psychological associations (i.e., San Diego, Contra Costa) were involved in gun-exchange and public-education programs that they hoped would reduce the number of guns and raise public awareness about gun violence. Psychologists, in some cases, offered three free hours of therapy per person, with the stipulation they would help the person continue to go to therapy by providing sliding scale fees or other incentives.
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Ways Of Arranging Bartering
Regardless of the type of bartering arrangement between therapist and client (i.e., service, goods), there are several ways that therapists and/or clients can meet, negotiate and arrive at their bartering agreement.
Obviously, the simplest and most common is where therapist or counselor negotiates the bartering agreement directly and in person with their client. This can take place before or during the first session or later on in therapy. The dialogue can take place in person or by other means of communication, such as phone or email.
Some areas in the country have local trade associations that facilitate bartering arrangements between therapists and clients. These associations are composed of local merchants who agree to conduct business with each other via bartering and without the exchange of money. The association standardizes the criteria and value of services and products, and its computer keeps track of the points or credit that each member accrues or dispenses. Therapists and clients do not negotiate the bartering agreement directly with each other. The only requirement is that both are members of the trade association (Canter et al., 1996).
Online Bartering for Online Therapy
The boom in online bartering has been interdependently parallel with a boom in online therapy also known as tele-health or tele-therapy. These two developments form a new type of bartering for a new form of therapy, online bartering for online therapy, as online therapy is becoming more utilized and accepted (Maheu, Whitten & Allen, 2001). The ethics and laws of online therapy have been the focus of lawmakers, consumer protection agencies and ethicists. Virtually all states, including California, require people who deliver psychological services to be licensed in the state where the patient resides (APA, 1997; BOP, 2001a; BBS, 2003). An Internet search so far reveals very few references to therapists who barter online for goods or services. I suspect that the continued boom in online bartering and online therapy will bring an inevitable parallel increase in a new frontier of online bartering of online therapy.
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Bartering And The Codes Of Ethics
Following is a short summary of how the Codes of Ethics of the major psychotherapists' associations have dealt with bartering. For additional information for California psychotherapists on law and ethics regarding bartering see section below.
American Psychological Association (APA) Codes of Ethics have been evolving consistently over the last several decades in the direction of wider acceptance of bartering. The 1988 Ethics Code clearly denounced bartering as unethical. The 1992 Ethics Code section 1.18 on Barter With Patients or Clients states clearly: "Psychologists ordinarily refrain [italics added] from accepting goods, services, or other non-monetary remuneration from patients or clients in return for psychological services..." and it even goes further in giving it a rational: "because such arrangements create inherent potential for conflicts, exploitation, and distortion of the professional relationship" (APA, 1992, Section 1.18 para.1). Then it defines the two conditions under which bartering might be acceptable: when it is not clinically contraindicated and when the relationship is not exploitative. However, the wording of the standard still implies that bartering is inherently unethical and should be avoided. The cautionary language of the 1992 Code has been deleted from the 2002 Ethics Code, which now states in section 6.05 Barter With Clients/Patients: "Barter is the acceptance of goods, services, or other non-monetary remuneration from clients/patients in return for psychological services". (APA, 2002, Section 6.05, para. 1). In providing a somewhat more liberal guideline, the new standard repeats the 1992 Code's two conditions under which bartering may be acceptable.
American Art Therapy Association (AATA), Ethical Principle for Art Therapists (2003), Standard 1.5 states: "Art therapists may barter only if (1) it is not clinically contraindicated and (2) the resulting arrangement is not exploitative. Barter is the acceptance of goods, services, or other non-monetary remuneration from clients/patients in return for art therapy services" (AART, 2005, Principle 1.5)
California Association of Marriage and Family Therapists (CAMFT) 2002 Code of Ethical Standards for Marriage and Family Therapists refers to bartering of services in section 1, Responsibility to Patients, where it states in section 9.5: "Marriage and family therapists ordinarily refrain from accepting goods, services, or other non-monetary remuneration from patients in return for professional services. Such arrangements often create conflicts and may lead to exploitation or distortion of the professional relationship" (CAMFT 2002, Section 1, para. 5). Additionally, in the dual relationships section it states: "Other acts which would result in unethical dual relationships include, but are not limited to...hiring a patient..." (CAMFT, 2002, Section 1.2.2, para. 1).
The 1999 NASW Code of Ethics in section 1.13, Payment for Services, provides the following lengthy paragraph about bartering: "Social workers should avoid accepting goods or services from clients as payment for professional services. Bartering arrangements, particularly involving services, create the potential for conflicts of interest, exploitation, and inappropriate boundaries in social workers' relationships with clients. Social workers should explore and may participate in bartering only in very limited circumstances when it can be demonstrated that such arrangements are an accepted practice among professionals in the local community, considered to be essential for the provision of services, negotiated without coercion, and entered into at the client's initiative and with the client's informed consent. Social workers who accept goods or services from clients as payment for professional services assume the full burden of demonstrating that this arrangement will not be detrimental to the client or the professional relationship" (Section 1.13, para. 2).
Like so many other professional codes, the above, strongly cautious statement gives a double message. On the one hand the code surprisingly forbids dual relationships and on the other it reluctantly allows it under specified circumstances. The above statement on bartering seems to be in direct contrast with the statement regarding section 1.05, Cultural Competence and Social Diversity, which states: "(a) Social workers should understand culture and its function in human behavior and society, recognizing the strengths that exist in all cultures. (b) Social workers should have a knowledge base of their clients' cultures and be able to demonstrate competence in the provision of services that are sensitive to clients' culture and to differences among people and cultural groups" (NASW, 1999, Section 1.05 para. 1-4).
This discrepancy in the social workers' Code of Ethics, in regard to its stance on bartering, is surprising in respect to the commitment and history of social work, which is embedded in helping the poor, disenfranchised, marginal and those of different cultures. It seems that in an attempt to emulate the strict guidelines of psychoanalysts or other mental health professionals, NASW Codes developed a firm and inflexible stance on bartering. This is probably also part of the social workers' attempts to gain professional legitimacy and parity by proving to be very strict on ethical matters.
American Counseling Association (ACA) Code of Ethics of 2005 dropped the 1996 statement, "Bartering Discouraged." Instead it introduces a more reasonable and flexible guideline, which states in section A.10.d. Bartering: "Counselors may barter only if the relationship is not exploitive or harmful and does not place the counselor in an unfair advantage, if the client requests it, and if such arrangements are an accepted practice among professionals in the community. Counselors consider the cultural implications of bartering and discuss relevant concerns with clients and document such agreements in a clear written contract."
American Association for Marriage and Family Therapy (AAMFT), 2001 Code of Ethics states in Principle VII of Financial Arrangements: "Marriage and family therapists ordinarily refrain from accepting goods and services from clients in return for services rendered. Bartering for professional services may be conducted only if: (a) the supervisee or client requests it, (b) the relationship is not exploitative, (c) the professional relationship is not distorted, and (d) a clear written contract is established" (AAMFT, 2001, Section VII, para. 5).
American Psychiatric Association (ApA) Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry (2010) does not include any reference to bartering (or to dual relationships).
United States Association for Body Psychotherapy (USABP) Ethical Guidelines of 2007 dropped its 2001 statement of "Body psychotherapists do not barter (including work exchange) for therapeutic services unless there is a compelling need to do so." and instead, appropriately and reasonably states that " Body Psychotherapists do not barter (including work exchange) unless the bartering arrangements are appropriate in the context of the therapeutic relationship, indicated by the needs of the client, and for the welfare of the client. bartering arrangements are appropriate in the context of the therapeutic relationship, indicated by the needs of the client, and for the welfare of the client. Where bartering is used, the therapist and client make agreements in writing related to the exchange of goods or services to ensure that both understand the scope and limitations of the agreement." (Section V.5)
Summary of the Codes of Ethics on Bartering
Many psychotherapists' Codes of Ethics view bartering as inherently unethical, potentially harmful and to be avoided. Some codes go even further and, in an atypical manner, provide the risk management-analytic type explanation, stating that bartering arrangements create an inherent conflict of interest, may be counter-clinical and are likely to lead to exploitation and distortion of the professional relationship. However, some recently revised codes, such as those by ACA (2005), APA (2002), and USABP, have taken a more flexible and less punitive attitude towards bartering. All of the codes deal with the reality that bartering is a common and normal arrangement in many communities and cultures and can be the only way that cash poor clients get counseling or therapy. Consequently, directly or indirectly, they state that bartering may not always be avoided, and the codes give certain conditions when bartering may be acceptable. These provisions usually include an assurance of what is obvious, that is, that the bartering is neither exploitative nor potentially harmful to clients.
There seems to be a consistent tension within all of the Codes between the cultural diversity and sensitivity and the bartering mandates. In fact all these Codes present inconsistent and incompatible messages. The Codes make a clear and strong statement that mandates therapists to attend to cultural diversity issues, which include knowledge, awareness and respect of different cultures' norms, values and behaviors. Obviously the cultural mandate is inconsistent with the general instructions to refrain from bartering arrangements, because many traditional cultures, such as Native American or Latino, look at bartering as a normal, healthy and integral part of living.
The way most Codes handle this conflict is by playing both sides of the net, on the one hand stating that bartering is ill-advised and on the other hand stating that bartering is acceptable under certain limited circumstances. The truth of the matter is that these Codes create a dread and prohibition around the bartering issue and only pay lip service to cultural diversity or care for the poor. Due to the mandate to avoid bartering and dual relationships, these Codes have been used as weapons against innocent and caring therapists. The Codes have been systematically used to prosecute, destroy and punish therapists when they did not follow the punitive and restrictive parts of the Codes (Lazarus & Zur, 2002; Williams, 2001). APA (2002) revised its Code partly in response to the realization that the Codes have been used as weapons against innocent and caring therapists.
None of the Codes seem to consider the option that some clients, who are neither poor nor belong to a culture that supports bartering, may benefit from such an arrangement. The risk management focus and the analytical bias of the Codes blind them to the possibility, illustrated in this paper, that the bartering arrangement, like many dual relationships, can be a well-planned intervention aimed to enhance clients' welfare (Lazarus & Zur, 2002; Zur, 2007).
American Psychological Association (APA), American Counseling Association (ACA), United States Association for Body Psychotherapy (USABP) have all changed their position on bartering, dual relationships and other concerns in their latest codes. Generally, the new codes are more flexible, respectful of diversity of clients and cultures and generally more positive and accepting of bartering arrangements and dual relationships than the previous ones. They seem to have taken into consideration how the codes have been used as weapons against therapists and have taken some steps to reduce the likelihood of such a misuse of the codes. If history is the best predictor of the future, these positive changes are likely to be followed by many of the other professional Codes in their next revisions.
For a detailed of the stance of several more professional associations' codes of ethics on bartering in therapy and counseling, click here.
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Bartering Arrangements I Have Had With My Clients
While bartering arrangements have been relatively rare in my practice, over the many years I have been involved in some bartering arrangements with my clients. Each of the bartering arrangements was carried out with thorough consideration to each and every client's need, wishes, condition, personality, situation, gender, history and culture. Several of them required consultation with experts-colleagues before a final decision was made. These bartering arrangements resulted from discussions with the clients and concluded in the clients signing a document that detailed the bartering agreement. Following are some examples of the bartering arrangements I have had with my clients. Gender, professions, bartering items and other potential identifiers have been changed, altered and combined so no one example can be linked, related or associated in any way with a specific individual client.
- A cash-poor painter offered to barter a painting in exchange for therapy sessions. The fair market value of the painting was determined by the exact sticker price that was assigned to it by the gallery where it was already for sale and on display. The painting was valued at $900. My full fee at the time was $90, and consequently the client contracted me for ten sessions. Having the painting hanging in my office deepened our connection and enhanced our therapy. In vast contrast to her dismissive father, competitive mother and jealous brother, the client felt appreciated and valued by me, which translated to a better therapeutic outcome.
- Even though I was willing to see the client as a pro bono because he was very poor, he was a proud man and did not feel comfortable "just receiving" from me. He felt humiliated even considering the option of seeing me for free. After a long discussion, at his suggestion, we agreed that for each therapy hour he would donate two hours to a community service for an environmental cause that we independently supported. The arrangement brought a new sense of connection and significantly enhanced therapy with this rather cynical client, as he felt that we were, indeed, on the same political and spiritual path.
- A temporarily cash-stripped attorney in need of therapy, who, for very good reason, refused to get into "any more debt", suggested that he draw up a contract that I needed at the time (between a third party and me) in exchange for therapy sessions. He estimated that the drafting of the contract would take him six hours. His hourly fee was $325 and my fee was $130 per session. Aided by simple math, we agreed that I would see him for fifteen sessions in exchange for his drafting the contract. By the end of the fifteen sessions he had settled a big case, paid all his debt and was able and willing to continue therapy by paying me out-of-pocket. My willingness to accommodate him at a time of distress meant the world to him, which enhanced our connection and the therapeutic outcome.
- A sculptor-client had offered to barter one of his unique sculptures in exchange for twelve therapy sessions. However, therapy did not progress well, and the client felt he did not get his money's or, even worse, his sculpture's worth. He regretted making the arrangement and demanded his sculpture back. With the aid of consultations from colleagues, I came to the conclusion that his request was valid. While there is never a guarantee that therapy would yield the expected results, I nevertheless felt responsible for my part in the ineffective treatment. I shared with him my thoughts on the matter and gave him back the sculpture. Understandably, he also chose at that point to discontinue our therapy, which I, of course, fully honored. Learning to disengage, separate or terminate with integrity and responsibility, and the capacity to model such transition to our clients, is an unavoidable yet important aspect of psychotherapy.
- A successful interior decorator was legitimately appalled at the tasteless picture frames I had in my office. After a few months of therapy she finally expressed her opinion about my poor sense of color and design. She then offered to hand-make, her specialty, new picture frames in exchange for four sessions. While she did not need the money, it was important to her to feel that no one took her for granted. She was professionally successful but felt that if people only knew who she really was, they would not respect her or her work. My enthusiastic willingness to enter into the bartering arrangement was extremely meaningful, as she felt I took her seriously and respected her professionalism and talent "even though" I knew her emotional difficulties. The bartering arrangement helped her overcome low self-esteem and a deep sense of shame.
- A massage therapist, who, like many body workers, is used to bartering massage sessions with other massage therapists, offered to barter with me. I declined due to the nature of our therapy and the fact that she professed to be "in love" with me. She emphatically stated that her "in love" state would neither interfere with her professionalism as a masseur nor with our therapy. I shared with her my concerns and told her that I respectfully declined the offer. She felt rejected and discontinued therapy abruptly and angrily, an occurrence that supported, even further, my decision not to enter into a bartering arrangement with her.
- After one of my many basketball injuries a physical therapist client, who noticed me limping into the consulting room, suggested an exchange of a few physical therapy treatments with a new electrical stimulation devise he just acquired, for an equal amount of therapy sessions. The client had a very tumultuous history with his own dismissing father, who was openly disappointed and highly critical of his son not becoming a "real doctor". The bartering arrangement gave the client an opportunity to experience my appreciation and trust of his medical expertise. This time-limited bartering experience enhanced our therapeutic alliance and helped the client to feel more personally assured and professionally secure.
- This last example is about a very wealthy middle-aged, trust-fund baby, female client who recognized she was cursed by money. She had never needed to work or pay her way through life. She was spending her days shopping on E-Bay and immobile in her large and beautiful, however, neglected home. Money was always her way to buy love and effortlessly get want she wanted. Paradoxically, she was loveless and did not know what she wanted. After many months of therapy that did not yield any significant results, we discussed her relationships to me and to money. It became clear that as long as she paid for my "love and care" she and I would stay stuck. We decided that for two months, instead of paying me my fee, for each therapy session she would contribute four hours at the local battered women's shelter. This short term bartering arrangement, mobilized her to be active in the world for the first time in many years. This enabled her to finally trust me and, as a consequence, allowed me to help her in many other areas of her life.
In summary, even though it is infrequent, I obviously have been involved with a few types of bartering over my many years of conducting therapy. Each case presented a challenge. Each arrangement demanded of me to consider the client's need, condition, wishes, personality, culture etc. I also always have to look within myself to make sure that I am aware of my needs and desires and do not confuse them with what can be beneficial to my clients. I have used consultations regularly and relied heavily on my expert-colleagues' opinions. In any of the instances that I agreed to a bartering agreement, I knew that there was a risk and, like any aspect of life or therapeutic intervention, it may not have turned out as intended. I had to weigh the risk against the potential good that could come from it. I documented such risk-benefit analysis in my clients' charts and their signed informed consent was placed in their files. When things did not go well, I was prepared to change the course of action. In all of these situations, rather than fear of attorneys, ethics committees or boards, the client's welfare and integrity where of utmost important for me in my decision-making process.
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Beyond Risk Management: Clinical, Communal and Cultural Considerations
The opposition to bartering, led by many ethicists, attorneys and risk management experts, seems to be a knee jerk reaction identical to the reaction to dual relationships (Lazarus & Zur, 2002). The California Department of Consumer Affairs (1990), like the Association of State and Provincial Psychology Boards (ASPPB, 2003), state in their "Professional Therapy Never Includes Sex" pamphlet that "hiring a client to do work for a therapist, or bartering goods or services to pay for therapy" constitutes "inappropriate behavior and misuse of power." Hass and Malouf (1995), like Grosso (1997), Pope and Vasquez (1998), Woody (1998) and many others, give the classic defensive risk management advise: "In summary, though it is not inherently unethical to engage in bartering goods or services, it appears to us that a wise or prudent practitioner should avoid it in most if not all cases" (p. 141). Epitomizing the risk management attitude towards clinical decisions, Doverspike (2003) asks "Does anyone need to be reminded that one of the original lawsuits that sparked the debate on dual relationships involved a therapist who bartered for services with a client's father who was a house painter?" (Bartering section, para. 5). Besides fear of boards and courts, the main concern of those who oppose bartering seems to surround the issues of power and exploitation. While these two issues are indeed important, it is not clear why they are the focus of the opposition to bartering. Therapists can exploit and misuse their power regardless of whether the clients pay with cash, by check or are engaged in a bartering of goods arrangement (Lazarus & Zur, 2002). Bartering of services, as was mentioned above, is often more complex as it often involves a secondary employer-employee relationship and must be handled with more caution than bartering of goods (Cantor, et al., 1996, Koocher & Keith-Spiegel, 1998; Zur, 2007).
Risk management is often the case when therapists succumb to fear and defensive positions over what is decent, considerate, dignified and helpful to clients. This approach has been described by Lazarus and Zur (2002) as the ultimate ethical violation. Additionally, those who take a rigid and dogmatic stance against any bartering arrangement are out of touch with the economic and cultural realities of millions of Americans and thousands of psychotherapists who serve poor people, whose only way to be treated is by paying their therapists in goods or services. Those in opposition to bartering also deny the many agricultural and other communities where bartering is a normal and healthy part of the community. They ignore the numerous cultures that value and depend for their economic survival on mutuality and interdependency as expressed in bartering arrangements. Regretfully, only very few authors (i.e., Cooper, 2007; Corey, et al., 2002; Hill, 1999; Lazarus & Zur, 2002; Rappoport, 1983; Thomas, 2002) have presented a more balanced view on bartering in psychotherapy, were the clients' welfare is emphasized over fear, dogma and rigid risk management of boundaries in therapy.
A concern that is often raised in regard to bartering in psychotherapy is income tax considerations. The concern is that those involved in bartering may choose not to report the income in their tax filing. A therapist's decision of what income to report to the IRS or other tax agencies is a personal, ethical, professional and civic decision.
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Summary & References
Bartering has been an economic arrangement through most of human evolution. It is a dignified and honorable form of payment for those who are cash poor but rich, capable or talented in other ways. It is a healthy part of a norm for many cultures, such as Hispanic, Native American and many agricultural communities. The ethics codes of most professional organizations do not consider bartering as unethical, per se. Unlike the risk management and analytic mandate to avoid bartering, it can also be part of a clearly articulated treatment plan where the benefits of bartering are likely to help the client's mental health and enhance the therapeutic outcome. While bartering of goods is often easier to navigate, bartering of services can be equally beneficial. Bartering, as often stated, does not necessarily lead to exploitation, harm or sex. The slippery slope concept that describes how one deviation from rigid guidelines inevitably leads to harm and sex is a fear based, irrational and unproven concept. Probably for self-serving reasons (Zur, 2004b, 2005) psychotherapists have developed a dogma about the depravity of bartering and place it next to dual relationships on the risk management avoidance list. As the guidelines below outline, it is important to have good discussions, excellent documentation, thorough consultations and clear understanding when therapists and clients make a bartering arrangement.
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By Ofer Zur, Ph.D.
- Barter is the acceptance of services, goods or other non-monetary remuneration from clients in return for psychological services.
- Bartering is not inherently unethical, illegal or counter-clinical.
- Bartering is common with poor clients who seek or need therapy but do not have the money to pay for it.
- Bartering for psychotherapy is also very common in cultures and communities where bartering is an accepted norm for compensation and exchange.
- Bartering that is likely to benefit clients can be part of a clinical intervention, negotiated with clients and articulated in the treatment plan.
- Bartering can be of goods (chicken, painting, furniture, etc) or of services (automobile repair, plumbing, graphic design, etc.).
- Some poor agriculture communities may have more flexible bartering schedules where the arrangement is a chicken and some fresh produce for each session.
- Most analytically oriented therapists, consumer protection agencies and risk management experts frown upon bartering. The traditional analysts view bartering as interfering in transference analysis. Licensing boards, ethics committees and risk management experts often view bartering as potentially exploitative and damaging to the therapeutic work.
- Most of those who oppose bartering reluctantly acknowledge that bartering can be an acceptable practice with poor people and is a normal and healthy aspect of certain cultures and communities.
- Bartering has often been equated, mistakenly, with dual relationships and boundary violation. While bartering of services is, indeed, dual relationships, bartering of goods is generally not. As with many types of dual relationships, bartering of services can be clinically beneficial and ethically sound. All bartering is boundary crossing but not necessary (harmful) boundary violation.
- Bartering does not necessarily lead to exploitation, harm or sex. The slippery slope concept that describes how one deviation from rigid guidelines inevitably leads to harm and sex is a fear based, irrational and unproven concept.
- Almost all ethical guidelines do not mandate a blanket avoidance of bartering. All ethical guidelines prohibit exploitation of clients.
- Bartering arrangements also have tax implications. Consult your tax preparer and make informed decisions regarding your legal, civic and professional responsibilities.
- Avoiding all bartering agreements will abandon thousands, or even millions, of people who are in need of therapy but do not have the cash to pay for it.
- Most graduate and post graduate education not only instill a fear of licensing agencies and lawsuits, but also deliver inadequate instruction in personal integrity, individual ethics and how to navigate the complex issues of bartering and other boundary issues in therapy.
Clinical and Ethical Considerations:
- In planning on entering into a bartering agreement, therapists must take into consideration the welfare of the client, his/her culture, gender, history, condition, wishes, economic status, type of treatment, avoidance of harm and exploitation, conflict of interest and the impairment of clinical judgment. These are the paramount and appropriate concerns.
- Make sure that the client involved in the negotiation fully understands and consents, in writing, to the agreement.
- Include the bartering arrangement in the document that explains the payment agreement, and have the client sign the appropriate informed consent.
- Make sure that your office policies, when appropriate, include the risks and benefits of bartering and that they are fully explained to, read and signed by your clients before you implement them.
- The bartering arrangement must be well documented in the clinical notes.
- Make sure that the bartering agreement is consistent with and is not in conflict with the treatment plan.
- It is important to realize that bartering can be counter-clinical in some situations such as with borderline clients or those who see themselves primarily as victims.
- Do not let fear of lawsuits, licensing boards or attorneys determine your fee agreements, treatment plans or clinical interventions. Do not let dogmatic thinking affect your critical thinking. Act with competence and integrity while minimizing risk by following these guidelines.
- Remember that you are being paid to provide help and care not to practice risk management.
- Differentiate when and what types of bartering are best suitable to each client and situation.
- Consult with clinical, ethical or legal experts in complex cases and document the consultations in your clinical notes.
- Attend to and be aware of your own needs through supervision and consultations.
- At the heart of all ethical and clinical guidelines is the mandate that you act on your client's behalf and avoid harm. That means you must do what is helpful, including bartering when appropriate.
- Keep excellent written records throughout treatment if or when problems and complications arise with regard to the bartering agreement.
- Evaluate the effectiveness and appropriateness of the bartering arrangement regularly and change it if necessary through discussion with and, hopefully, consent from your client.
- If complications, negative feelings or disagreement arise due to the bartering agreement, discuss it with your client, get consultations and change it in a way that will be most helpful to the client and conducive to therapy.
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