Although cash is the legal tender in mainstream American culture, in other cultural traditions and other historical periods people commonly paid in-kind or traded for goods or services. I sometimes traded works of art for psychotherapy services, along with many of my colleagues in the 1980’s.

My clients and I lived in a sophisticated, non-agrarian suburb of a metropolitan area where I had my private practice. We were part of a subculture that subscribed to unconventional values of cooperation, feminism, fluidity of roles, non-hierarchical authority structures, and left-wing politics, including alternative economic models. Within this subculture, bartering represented an affirmation of shared values, sidestepping the mainstream economic system, and contributing to a climate of social experimentation.

Professional codes of ethics in the 1980s did not address the issue of bartering, per se. Current codes of ethics for social workers and marriage and family therapists strongly discourage bartering in exchange for psychotherapy services. The concerns are with the potential for conflict of interest, financial exploitation, dual relationships, and boundary violations. (National Association of Social Workers, 1996, Section 1.13(b); California Association of Marriage and Family Therapists, 1997, Section 9.5)

In the decades since my experimentation with bartering, my development as a clinician along with the climate of heightened professional vigilance regarding dual relationships and boundaries has led me to rethink my experiences. One of the difficulties I have discovered is that the transaction interferes with the therapist's ethical responsibility for setting reasonable fees, disclosing fees and maintaining accurate billing records. Another problem is that bartering creates a dual relationship because the therapist assumes a second role with the client, which has the potential for exploitation. The delivery of the goods or services to the therapist’s satisfaction may also impair his or her judgment. If the client's goods or services don't meet the therapist's expectations, it may be the therapist who feels exploited. Therapist and client have moved outside the structure created by professional standards of practice making it difficult to examine the interpersonal exchange within the psychotherapeutic frame. The boundary is violated and the treatment is compromised.

Clinical Illustrations

Marion was a stained glass artist whose family was struggling financially. Accustomed to working on commission, she suggested making a stained glass piece for me to pay for therapy. The financial arrangement was clear-cut, and I felt it was a fair exchange of goods for services.

Joy was also a stained-glass artisan who had chronic difficulties managing money and often got behind in her payments to me. I accepted her offer to create a piece for me as a trade and we discussed a design. Although Joy felt defensive and ashamed of her difficulties with money, the bartering arrangement went smoothly. She was confident about her artistic abilities and bartering fit her non-materialistic lifestyle.

Deborah was an artist who sold her artwork in a cooperative gallery. When Deborah's insurance denied her claim I offered to reduce my fee, but she felt ashamed to pay me less than my usual fee. We agreed she would pay half my fee in cash and the other half in-kind. This bartering arrangement did not go smoothly. She became paralyzed, couldn't decide what to make and worried it wouldn't be good enough. Instead of relieving her of financial pressure and enhancing her self-esteem, the project made her feel pressured and worse about herself. It was clear the agreement was interfering with her therapy. I decided to discontinue the arrangement and we both felt relieved.

The Impact of Bartering on Clinical Treatment

On the positive side, bartering allowed me to provide treatment to people who did not have enough money to pay for therapy. Accepting art products as payment was also a way to demonstrate my belief in the value of my clients’ work and their identity as artists.

In working with Marion and Joy, bartering was straightforward and fair. The dual relationships were part of the subculture we shared in which bartering was seen as an ordinary transaction. With Deborah, on the other hand, the agreement was problematic from the start. The other artisans were accustomed to charging for time and materials, but Deborah and I had no system for determining the value of her work. In retrospect bartering with Deborah closed off paths we needed to explore. Even though at the time I thought that bartering was an appropriate arrangement for therapy with Marion and Joy, I now believe that it likely closed off important areas such as the meaning of the clients’ money problems and, more importantly, its impact on the therapeutic relationship. Upon reflection, I believe that bartering muddied the therapeutic waters.

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Whitney Van Nouhuys, M.F.T., is a student at CICSW and has a private practice.

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