BARTERING, by J. Lawrence Thomas, Ph.D.

 

A few times over the last two decades as a private practice psychologist, specializing in neuropsychology, I have entered into barter arrangements with patients. I have never felt completely comfortable about it, but in each case it seemed to be the best alternative. The major issue hinges around the following question: How should we act and what should we do when a patient has little or no money?

I find it curious that the meager literature on bartering in APA journals (e.g., Sonne, 1994; Woody, 1998) makes little mention of bartering as a means of helping the needy but poor patient. It can serve as a relatively dignified way for the patient to compensate the therapist for professional work. It seems as if the compassion that psychotherapy professes has been forgotten under the scepter of potential lawsuits. According to several authors, this is in fact the main reason barter arrangements should not be made: it opens the therapist up to liability. So far I have found only one article (Hill, 1999) that discusses bartering as a legitimate means of helping out a poor person, which seems the most obvious reason to enter into such an arrangement.

My view, in common with others articulated throughout this book, is that if we do not take some risks on a regular basis, as psychotherapy professionals we are not worthy of the job. A second and complementary theme I support is that venturing into any dual relationship requires careful, thoughtful judgment, which varies considerably from situation to situation. To preclude whole categories of arrangements because of legalistic or doctrinaire reasons (e.g., psychoanalytic views of the therapy relationship) serves only to narrow our work and contributes to an artificial and sterile context of psychotherapy.

There is an elephant in the room that no one is speaking about regarding the private practice of psychotherapy. And it is simply that many people who need our services cannot afford our fees. In recent years there has been less and less insurance coverage for psychotherapy, particularly if there is no “medical necessity,” which is most of the time. Currently in New York State, the official rate (No-Fault/Workers Compensation) for a psychotherapy session by a psychologist is $120; neuropsychological and psychological testing is $140 per hour. How many people can write out checks for a full neuropsychological evaluation (15-20 hours) or for psychotherapy week after week? Not many.

Thus, bartering should become more prevalent because of these cost considerations. I have rarely been challenged on the session fee per se. Clients often just don’t have the necessary funds. But the countervailing prospect of enduring a lawsuit, as Woody (1998) and others predict, outweighs making services possible by way of bartering.

A Higher Standard

There is an issue that must take salience in any discussion about dual relationships and the profession of psychotherapy. There is the “higher standard” which psychotherapists should strive for, and by this I only mean that the welfare of the patient should be paramount. Focusing on this higher standard as a basic stance in professional commitment is different in kind than most other principles we are asked to uphold as professionals. While this higher standard is mentioned in the preamble of the ethic manual of the American Psychological Association (APA, 1992), it is a prelude to the many things we should not do in order to protect ourselves. If bartering can be justified as a consideration for helping the patient by virtue of a higher standard, this should carry significant weight as to whether such an arrangement should be acceptable. A bartering arrangement should not be precluded because there is a slim chance that the patient may sue the therapist, but I do agree that it should occur infrequently. The vast majority of our professional work should be paid by the usual monetary means, if only for practical reasons. But when this is not possible because of the economic situation of the patient, some allowance should be made so that our services can be available. This has become salient in my own particular specialty of neuropsychology, since brain damaged people sometimes have a hard time earning a living.

I will present a few of my own cases and some situations from colleagues to describe some successful barter arrangements.

The Relevance of my Specialty

A main reason I have been occasionally involved in barter situations is that my particular treatment methods are not commonly available. I specialize in assessing and treating patients with mild brain dysfunction, and they frequently are not able to work in competitive society well enough to earn a living. Having mild brain dysfunction can be worse, in some ways, than having a severe head injury because the funding for their support and health care can quite problematic. A severely injured person stands out, and there is often no question that support in the usual arenas is needed- rehabilitation, medical and hospital care, follow up health care, and vocational training. Patients with mild brain dysfunction, however, often look quite normal, and a common view is that if they tried hard enough, they could overcome their problems. Little sympathy is elicited. Family members are confused, since their loved one is both the “same” and “different,” in the case of head injury. Funding for treatment is difficult. Justification for treatment to insurance companies can become torturous.

Patients with these and other mild brain dysfunction diagnoses are repeatedly misdiagnosed and poorly treated over the course of their problems. Generally, this is a “difficult” patient who is lumped into a familiar category by the doctor or therapist, with the response less than optimal. Through my experience with this population, I have developed a number of ways to address the problems of mild brain dysfunction.

Case # 1: George
George met me at an Adult Attention Deficit Disorder (ADD) Support Group in Manhattan, and arranged to see me in consultation. Although he had attended an adult ADD therapy group of mine for a few sessions, he chose another direction–to get a complete neuropsychological evaluation to clarify the diagnostic picture. It was at this point that the barter system began.

I first performed an extensive neuropsychological and learning disability evaluation, including assessment of psychopathology. I then administered neurofeedback with him for what I understood to be his partial complex seizure disorder. The detailed neuropsychological and personality evaluation took about 20 hours of professional time by itself. The neurofeedback treatment, which is still ongoing, I estimate to be about 70-100 sessions. All this adds up to about $15,000 worth of services-for someone on public assistance. The fact that he had a profession (cabinetry) which was of value to me made it convenient for my professional services to be provided. Let me present this case of a barter arrangement more completely.

History. George is single and currently 43 years old. He has regularly sought help from a number of professionals over the last 20 years. He has an enormously large dossier of medical records. He related his history to me in some detail, and it included a number of strange experiences as a child and throughout his life, with varying degrees of frequency. These experiences could alternately be interpreted as psychotic, borderline, or symptoms consistent with sub clinical temporal lobe partial complex seizure phenomena. When the SCID was administered (Structured Clinical Interview), the results indicated that he satisfied the diagnostic criteria of almost every disorder. He has in fact had all of these diagnoses given to him over the years.

Testing. Neuropsychological testing was done in order to clarify his diagnostic picture with the goal of determining the degree and nature of brain dysfunction, and, in this case, to distinguish this from a long-standing learning disability. It was also important to determine the degree of psychopathology. This took about 20 hours of professional time. The results revealed that George appeared to have some degree of brain dysfunction and showed impairment on several measures. He used this report that was written to get psychopharmacological treatment and in obtaining the proper treatment. He also seemed to have some kind of sub clinical seizure disorder, absence status epilepticus. This means he has blanking out periods that can last as long as a few hours.

As a cabinetmaker, he had been inhaling lacquer and lacquer thinner in his non-ventilated wood shop regularly for over 15 years. Toxins such as these (and there were others) can be harmful to cerebral functioning (Hartman, 1988), and he was completely unaware that these fumes probably made his condition worse.

Treatment. Because George had a history of not responding well to medications, I decided to use neurofeedback with him to help stabilize his brain physiology. Very briefly, this involves biofeedback of one’s own brain waves. One’s electrophysiological information, or brain wave information, is displayed on a computer screen. The patient is asked to raise or lower certain waves, and over time, the patient learns how to do this. This is experimental work, and it is unlikely George could find this help in a low cost clinic that would accept his public assistance insurance; insurance companies have also been very reluctant to pay for this treatment. A popular book (Robbins, 2000) and a text (Evans & Abarbanel, 1999) are recommended for those interested in learning more about this area.

A major problem in utilizing neurofeedback for diagnoses such as seizure disorders and ADD is that 20 to 40 sessions are recommended, preferably twice per week, for 10 to 20 weeks in a row. For more complex cases, 40 to 100 sessions are often required. George was a complex case, and my estimate was that he needed at least 100 neurofeedback sessions. We agreed upon a schedule and the exchange rate, and we began the sessions. We agreed on a retail-to-retail exchange, meaning that he and I would use the usual fees in a proportionate exchange of hours. He would build me designs in exchange for my professional time. We would keep track of our hours and see where we stood every month or two.

Within a few sessions, George reported that his seizure problems were getting better. Each week he stated that his periods of being able to function were longer and he was more productive. He appears to be improving, and I have a few possessions I have wanted to build. We both benefited from this arrangement.

The Three Way Barter. When I began to entertain the idea of barter as a way to provide services, I also arranged to provide some of my professional services to my chiropractor, Dr. Lewis, who was treating me. Dr. Lewis (not his real name) wanted a desk and cabinet for his office, and we agreed to barter retail-to-retail for this. As part of my former profession (architecture), I have designed cabinets, bookcases, and similar items for many years. In this situation, I designed a special cabinet for Dr. Lewis, showed him the drawing, and we discussed the design. I then asked George to build it as part of our barter arrangement. I still have some misgivings about this arrangement, particularly involving a third party in the barter, even though it eventually worked out. The reason is that George was very slow in completing this cabinet (over a year late), much to my embarrassment. However, this awkward situation finally turned out well.

The Benefits and Problems with George’s Bartering Arrangement. This case illuminates some potential problems with the bartering situation, which other authors have mentioned. What happens if patients do not live up to their part of the bargain? How do you treat lapses on the patient’s part? Similar to a missed payment? Or do you consider this as “water under the bridge,” and simply take it as a loss? My recommendation is to take it as a loss. First, however, the snag in the arrangement should be discussed because this often signals a more general problem in the patient’s life. Indeed, it is safe to assume that the problems patients have in their lives are going to be reflected in the bartering arrangement between therapist and client. Discussing and resolving as much as possible the “barter snags” is a unique side benefit to these kind of arrangements: The therapist can experience first hand the frustrations of relating to this patient! The idea of using the barter arrangement as integral to the therapeutic work has been developed to a significant degree by Rappoport (1983), and is discussed below.

Case #2: Rachel
Rachel, aged 32, was a highly skilled graphic artist prior to her head injury. She was walking out of a subway entrance in New York City when a large heavy object fell on her head. In fact, it bounced three times on her head. To make matters worse, it bounced on her right parietal-occipital area–the worst possible place for a graphic artist to sustain an injury. I performed the neuropsychological evaluation and followed up with treatment. After about a year, the insurance company cut off payments to me, but I kept treating her anyway (usual for me).

Rachel desperately needed someone to talk to who believed in her complaints: Many health professionals dismissed her symptoms as “psychological” as there was no hard evidence of her brain damage in MRI or CT scans. Later, when a SPECT scan showed that there was a brain injury and deterioration in her right hemisphere, her complaints were more respected. But she had to endure a few years being labeled hysterical or having psychological problems as explanations for her neurological symptoms. I was the only health professional who believed her and was willing to explain her symptoms to her. In addition, since I had been a visual designer (architect) in an earlier career, I believed I was especially well qualified to understand and help her.

During the time of treatment, the insurance company cut off payments to Rachel for lost wages, and she was desperately poor. She came from rural Idaho, and her parents were also of modest means. No help from her family was available. During this two-year period of time I recall Rachel going to her church and getting emergency money to pay the rent. But this could be done only a few times, and she was desperate.

Now to my “bad deed,” the act of bartering. During Rachel’s very poor period, I hired her and paid her money to help me with some of my office matters, for a day or two per week. She readily admitted when she was having cognitive problems in doing some things, and I understood these processing problems when they occurred. The work was therapeutic for her, even though she did it poorly, which enabled me to see another side of her. I saw how she functioned in “real world office tasks.” It became painfully obvious why she was not able to function in the competitive marketplace–she could not process directions rapidly enough to make her abilities accessible, and therefore valuable. She could not function as a professional graphic artist for the time being. Or perhaps ever.

The Job Trial. In the field of rehabilitation it is common for a patient recovering from a head injury to go on a “job trial.” When I worked at the Head Injury Program at NYU Medical Center, the patient volunteered in some part of the hospital complex, and was supervised carefully by one a Head Injury Program staff member, usually the Vocational Counselor. Real work would get done, but the level of productivity would often be understandably low.

Having a patient perform real work related tasks could be a way to assess how they would function in the real world of employment. Thus, one might see gaps in memory that might not have been apparent in the ordinary therapy sessions. As a neuropsychologist, I can see the cognitive problems better than an ordinary employer, and I can obtain a multi-layered impression of the possible impact of these deficits on work performance.

The strategy of doing job trials is well known in the world of rehabilitation. But it is essentially bartering. Regardless of whether I paid Rachel or not, I would consider this arrangement as bartering. In both Rachel’s case and in traditional job trials, the patient gives time and energy in exchange for a head injury professional’s assessment as to the quality of work performed. Even in the protected environment of a hospital-based situation, however, I am sure there are a number of ethical snags. For example, a classic one is that it is hard to fire a volunteer. What if the work is far below a satisfactory level? What if the therapeutic agenda (of helping the patient’s self-esteem, for example) conflicts with the workplace standards? Even with these caveats, it does not take much persuasion to convince caring family members and professionals that going through this kind of experience is likely to be in the best interests of the patient. Also, in my years of working with job trials, I have never heard a complaint that the patient was being exploited.

Rachel is doing much better now. She eventually won a modest settlement, moved back to Idaho, and recovered slowly. She has changed the direction of her career and is doing fine artwork, but at a slower pace. And her artwork is beautiful. The commercial world of being a graphic artist is too fast paced for her.

Case #3: Jane
Jane is an artist, and had problems in her relationships with men. We worked well together, but after a year and a half she ran out of money. Over time, I mistakenly allowed the bill to amount to several thousand dollars. She offered to pay off some of her bill with one of her paintings. I saw the painting, and agreed, and I have it today over my couch. I am still not sure whether this was the best thing to do, but it appeared to be reasonable at the time. My guess is that many therapists receive artwork from patients for professional services, but no one knows about it other than the active parties.

Cases from Colleagues
I asked a few colleagues about bartering, under the assumption that trade-offs happened much more than is reported, especially with professionals who have been in practice for many years. Every one admitted that they occasionally bartered services with a patient, but they have been hesitant to reveal these arrangements to colleagues. Most of the time, the bartering emerged out of a previously established relationship. Every story was different and had a special twist to it. Nicholas Cummings (N. A Cummings, Personal Communication, July 11, 2001) states that all bartering arrangements he has had over the years were benign, with no negative effects. Along with founding a number of organizations (more than 10) in the field of psychology over a span of over 40 years (Thomas, Cummings, & O’Donohue, 2002), he has had a private practice for over 50 years. It was his custom to always see some patients pro bono, and this was his arrangement with a man we will call Henry, who was in one of Cummings’ therapy groups in the 1950s. Henry felt he wanted to “give back” something, and Cummings relates this story below:

I do not remember too much about the patients who bartered their fee, as they were all straightforward with no negative effects. In my private practice I always reserved some slots for patients who could not pay. Most of these volunteered bartering, stating they would feel better about it. I remember one patient who was in one of my agoraphobia groups, and I will call him Henry Sturgeon. Because of his agoraphobia, Henry had not been able to work for several years and was accepted on a no fee basis. At this point I should describe the building I owned for over 20 years on Judah Street in San Francisco. It was one-story and faced on three sides a classic city courtyard paved in antique bricks. On the fourth side was the blank wall of the three story building next door. The group room not only faced the courtyard as did most of the offices, but French doors allowed the group to go into the courtyard on nice days for the group session. The only handicap was that to enter the courtyard one had to go through the building. Therefore, I had no regular gardener for obvious reasons, and periodically had someone go into the courtyard to trim and clean.

Well, Henry decided he would re-do the courtyard, arranged it with my receptionist, and over a 2 week period transformed it into a showplace. He got several of the patients to chip in for new plants and trees, unbeknown to me. The group had a bronze plaque made stating the date and “Garden by Henry Sturgeon.” They held a dedication ceremony during the group meeting and declared Sturgeon’s agoraphobia gone forever, and embraced the new Henry Sturgeon who subsequently created his own successful landscaping business. The bronze plaque remained for several years, and Henry maintained the courtyard regularly on his own time and expense, stating his usual fee should go to another worthy no-fee patient. In 1987 I sold the building and it was torn down and replaced with a multi-story building. Henry called me in tears, but stated his agoraphobia never returned and he no longer needed the “Garden by Henry Sturgeon.” (N. A. Cummings, Personal Communication, July 11, 2001)

According to the American Psychological Association ethics committee, I am not sure whether this would be considered bartering, since Dr. Cummings never asked that these services be performed. But if we assume at some point a quid pro quo was understood between them, would the therapist be obliged to terminate the activity? I would assert that the patient’s “giving back” was of therapeutic benefit in this case and similar ones.

Arnold Lazarus (A. A. Lazarus, Personal Communication, August 5, 2001), shortly before this book was sent to press, was invited by a professional group to talk about dual relationships. It was revealed that the licensing board in this state was going to prohibit bartering in their newly revised state code. Lazarus wrote to them:

This troubles me for several reasons. Let’s assume that an impecunious man in need of therapy consults me. I could refer him to a clinic, or treat him pro bono, but I believe that this would only hurt his pride and render him inappropriately beholden to me. He happens to be a good carpenter, and so I strike up a deal. I will buy some wood, and he will build me a bookcase that I need. In that way, although he is unable to pay me, he will have given me a “fee” for service. He derives benefit from my professional ministrations, and feels happy that he was not a “taker.”

The Board gets wind of this and I am censured. This harks back, in my opinion, to the McCarthy era. The harsh penalties that are often meted out by the Board to psychologists who may be completely innocent, or have committed a minor infraction, have totalitarian overtones. (A. A. Lazarus, Personal Communication, August 5, 2001)

This raises an important point about the effects of bartering: What is the likelihood that the vast majority of bartering is benign? That is, both parties are satisfied (or at least the patient is), and there is little likelihood of a lawsuit. Only when the arrangement goes awry does the ethical principle appear to come into play. The American Psychological Association (APA, 1992) supposedly represents a profession guided by evidence in human behavior. Where is the evidence to support their discouragement of bartering? How often does bartering turn sour? Is there any hard evidence that this is a bad thing to do? Should the stories and commentaries of Koocher and Keith-Spiegel (1998) and others guide our behavior?

Apparently a number of bizarre stories of ethical violations have been reported to state and APA officials, and these are then published in volumes about our ethical principles (Canter, Bennett, Jones, & Nagy, 1994; Koocher & Keith-Spiegel, 1998). These probably represent a tiny fraction of the professional activities of psychologists (probably similar to other professions). Even admitting that bartering is risky for professional psychologists, I doubt that other professions have the degree of sanctions that we do. Are we being held to standard that is much higher than other professions, and which is therefore unfair?

Literature Review

The American Psychological Association is in the process of revising its code of ethics, but at present the quote related to bartering (from the 1992 American Psychological Association Ethical Principles), is noted below:

Psychologists refrain from accepting goods, services, or other non-monetary remuneration from patients or clients in return for psychological services because such arrangements create inherent potential for conflicts, exploitation, and distortion of the professional relationship. A psychologist may participate in bartering only if 1) it is not clinically contraindicated, and 2) the relationship is not exploitive. (APA, 1992, p. 1062).

This passage says almost nothing. In other words, you should not do bartering if it is contraindicated or if it is unfair. But no precise circumstances or criteria are stated. Nevertheless, as has been pointed out in some articles on bartering (Sonne, 1994; Woody, 1998), psychologists have been punished for bartering, with our vague ethics code being used as a weapon against them. Incidentally, those of us who have entered into these arrangements often find that if anyone is exploited in a bartering arrangement, it is likely to be the therapist.

There is another fundamental area that merits some consideration. If a group in the name of a profession puts a code in writing, everything in that code can be taken quite literally, and can taken out of context–to the detriment of someone in a circumstance for whom that particular interpretation was never imagined. I would assert that psychotherapists are bad lawyers, as a general rule, and should not try and put into words what essentially is a simple moral stance of trying to do the right thing. When we write down a lot of conditions, often ambiguously worded, we open ourselves up to all kinds of possible abuse. This is because someone skilled at doing this (e.g., lawyers) can use each sentence as a weapon against us. Every time we write down a rule, recommendation, principle, or aspiration, we fashion a noose for ourselves. In recent times, the APA (1992) ethics code has been used to prosecute psychologists for violations in dual relationships, with nooses of our own making.

The literature on bartering in psychotherapy is sparse. There seem to be two main issues. First, barter can be an avenue for the poor but needy patient to obtain psychological services. I found only one article that discusses this in depth (Hill, 1999), plus one book on the subject (Rappoport, 1983). The second issue is whether bartering opens up the professional to possible sanctions from either a lawsuit or an ethics complaint. These two broad issues are in conflict with one another, and most writers agree that caution is the watchword. Although bartering might be a last resort, it is worth keeping in mind that this may take place more than one might suspect if it is seen as a possibility by the patient. Thus, the writers who advocate avoiding bartering at almost all costs have some moral obligation, in my opinion, to provide an alternative. In Woody’s 1998 article, the examples he points out about the problems psychologists have gotten into with respect to bartering appear to rest on strikingly bad judgment. One psychologist, he reports, concludes his justification for bartering with “…besides I needed another car for my teenager” (p. 174). Another example was a psychologist who invested in a patient’s business, but the business had troubles, and the psychologist sued the patient and his partner. In my opinion, the barter was foolish and the lawsuit was even more ill considered. Woody comes to the conclusion that bartering should be avoided, despite his providing guidelines for bartering. Since Woody is both an attorney and a psychologist, it is not surprising that he errs on the side of caution. But there is no evidence presented as to what percentage of the time bartering situations go awry. My guess is that bartering happens far more than is admitted, and that the vast majority of the situations are benign, with no ill effects. Professionals get themselves into jams when they do not think through the pros and cons, and subsequently mishandle the arrangement.

What is disturbing about Woody’s article is that he opens it by discussing the fact that since many people cannot afford therapy in the current era of managed care, bartering might be considered. He goes over all of the problems of getting involved with bartering, but has no solution for the poor person who cannot afford therapy. He then advises the therapist not to engage in this kind of arrangement. What happens to the prospective patient, besides being told that the therapist cannot see them because of a remote possibility of a lawsuit? Where are the values that psychotherapy professes? Woody offers no solution, leaves the therapist helpless, and the patient adrift–an arid solution, and ultimately irresponsible.

In an article by Marcia Hill, Ph.D. (1999), however, much more discussion is given to trying to help poor people who need therapy. Bartering is considered a viable, if cautious, alternative. This article is one of the most sympathetic articles about bartering. Hill writes about barter in the context of feminist therapy, and is one of the few to deal extensively with the fact that many people needing or wanting therapy may simply not have the money. She reviews the pros and cons, as well as going over in some detail the considerations as to whether one would engage in a barter arrangement in the first place. For example, she and Lazarus (1994) would agree that getting involved in dual relationships with borderline or histrionic patients is best avoided. If the barter appears to reach a “threshold of consideration,” then other concerns emerge. These could be whether one is bartering goods or services, with the latter being inherently more problematic because providing services suggests a new relationship, which is commercial and evaluative. In addition, Hill (1999) explores whether the particular relationship is appropriate for barter, whether there is a power differential, which may end up tilting the barter too much in favor of the therapist, thereby increasing the potential for exploitation. She also discusses a number of psychodynamic considerations, such as transference and the possible symbolic aspects of such arrangement. I would recommend any professional considering bartering with a patient to study this article, since she discusses a number of issues in detail; reviewing these could save a therapist a great deal of discomfort.

The Koocher and Keith-Spiegel book Ethics in Psychology (1998) has a chapter entitled “Multiple Role Relationships and Conflicts of Interest,” and there is a section on bartering. For some reason, these authors insist on giving silly names to all of the (asserted) true stories of ethical violations reported to the APA and state licensing boards. For example, a psychologist named Alan Groupie, Ph.D. went into business with a famous rock star, and billed him $150 per hour for 24 hours a day, 7 days a week. It is as if Koocher and Keith-Spiegel were treating as a joke that psychologists sometimes act stupidly, and/or end up with ruined careers. The problem is that these bizarre and presumably true stories are the foundations for those writing the ethics code. Besides Koocher and Keith-Spiegel’s bad taste (or conflict of grammar), however, the conclusions reflect mainline APA (1992) Ethics Code reasoning. I wonder if there is another side to these bizarre stories? To base a code of ethics code around extremely untoward stories is unreasonable, and is ultimately patronizing to our entire profession.

Ethical and Practical Issues in Bartering

1. The Patient’s Welfare Prevails. Much of the rhetoric about dual relationships is concerned with the exploitation of the patient by the therapist. If this is viewed from another angle, so that the therapist holds to the higher standard of the patient’s welfare, then the issue of exploitation is solved. Within the ethical guidelines is the higher standard, and that is the meat of our code. If this is not kept in perspective, we invite problems.
2. That Help Exists. One issue I have rarely seen raised in our professional ethical principles is whether bartering allows services to be provided at all. In the case of George, the services would not have otherwise been available, since the treatment I was able to provide is relatively obscure. There are additional caveats in modern psychotherapy practices: Besides insurance companies not approving innovative treatments, more and more practitioners are refusing to deal with insurance companies. Bartering is one avenue of providing help outside the insurance reimbursement system for the less affluent.
3. A Well Lit Room. Haas and Malouf (1989, cited in Hill, 1999) have used an illuminating analogy about the prospect of bartering with a patient for psychotherapy. Their phrase conveys the principle that this arrangement should be able to be scrutinized by one’s colleagues in a “a well lit room.” This honesty with yourself might help shape your decisions and guide your prospective bartering situation.
4. Review the Dilemma with the Patient. We can assume that the initial stage of embarking on bartering arrangement is benign, and that the patient is eager to move forward in such an arrangement. Go over the basic issues in creating a barter arrangement, and create a written contract. Specify in the contract a regular period of time in which to review the agreement, particularly in terms of hours spent (my preference) by each party. People sometimes forget their arrangements, and tend to let certain matters slide. Having the barter arrangement as part of the therapy, to whatever extent, is an interesting and potentially powerful way to get extra therapeutic mileage out of the arrangement.
5. Document the arrangement. A good way to protect one’s self is to make notes about the bartering and discuss the situation at regular intervals with the patient. These notes go directly in the chart. Documenting helps make the agreement clear, but also could help us defend ourselves if this becomes necessary.

Conclusion

Bartering is still a troublesome topic. This chapter has explored some of the potential advantages and disadvantages. This topic confronts us as to where we stand in our contribution to society, specifically helping those who cannot ordinarily afford our services. Our stance in this matter points to our professional character, and asks us if we are doing the right thing. Our Ethics Code (APA, 1992) should support us, and not make us to turn away those in need. Thus, some re-examination of the underlying values and implications is needed in our ethics code so that the higher standard is the focus.

References

American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 1597-1611.

Canter, M., Bennett, B. Jones, S., & Nagy, T. (1994). Ethics for psychologists. Washington, DC: American Psychological Association.

Evans, J., &, Abarbanel, A. (1999). Quantitative EEG and neurofeedback. San Diego: Academic Press.

Haas, L. J., & Malouf, J. L. (1989). Keeping up the good work: A practitioner’s guide to mental health ethics. Sarasota, FL: Professional Resources Exchange.

Hartman, D. E. (1988). Neuropsychological toxicology. New York: Pergamon.

Hill, M. (1999). Barter: Ethical considerations in psychotherapy. Women and Therapy, 22 (3), 81-91.

Koocher, G., & Keith-Spiegel, P. (1998). Ethics in psychology. New York: Oxford University Press.

Lazarus, A. (1994). How certain boundaries and ethics diminish therapeutic effectiveness. Ethics and behavior, 4, 253-261.

Rappoport, P. S. (1983). Value for value psychotherapy. New York: Praeger.

Robbins, J. (2000). A symphony in the brain. New York: Atlantic Monthly Press.

Sonne, J. (1994). Multiple relationships: Does the new ethics code answer the right questions? Professional Psychology: Research and Practice, 25 (4), 336-343.

Thomas, J. L., Cummings, N. A., & O’Donohue, W. (Eds.). (2002). The entrepreneur in psychology. Phoenix, AZ: Zeig, Tucker & Theisen.

Woody, R. H. (1998). Bartering for psychological services. Professional Psychology: Research and Practice, 29 (2), 174-178.

 
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