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Fee charging in a family service agency : an examination of fee charging experience and its relation… Moir, Ward Washington 1958

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FEE CHARGING IN A FAMILY SERVICE AGENCY An Examination of fee charging experience and i t s r e l a t i o n to family casework i n the Family Service Agency of Greater Vancouver, 1951-58 by WARD WASHINGTON MOIR Thesis Submitted i n P a r t i a l Fulfilment of the requirements f o r the Degree of MASTER OF SOCIAL WORK i n the School of Social Work Accepted as conforming to the standard required f o r the degree of Master of Social Work School of Social Work 1958 The University of B r i t i s h Columbia - i i i -ABSTRACT Fee-charging has been the subject of extensive discussion within voluntary family agencies. The trend toward i n i t i a t i n g fees, p a r t i -c u l a r l y i n American family agencies, has been growing s t e a d i l y . However, there has been l i t t l e research designed to evaluate the supposed objec-t i v e s of t h i s p o l i c y ; including the therapeutic values, the expansion of service, or the reinforcement of the professional status of s o c i a l work. In addition, the basic question of why fees should be charged at a l l , has been la r g e l y ignored. The present study i s necessarily an exploratory one. It i s con-fined to the analysis of a p a r t i c u l a r period of fee-charging experience i n the Family Service Agency of Greater Vancouver. The techniques, values, and appropriateness of t h i s p o l i c y were reviewed for (a) the t o t a l caseload i n a survey year; (b) cases selected for the analysis of spe c i f i c areas. The largest attention was given to "fee cases", and those cases where a fee was proposed, but not charged. The analysis suggests strongly that, while there can be thera-peutic benefits from fee-charging, the fee i t s e l f i s most often appropriate where i t i s based primarily upon a b i l i t y to pay. The task f o r the Agency i s to be selective enough i n determining which c l i e n t s should be t o l d about, and charged, fees. Client resistance to casework i s a significant factor, influencing worker attitudes toward fee-charging. Consistency i n the application of the present p o l i c y i s needed. It i s p a r t i c u l a r l y necessary to exclude the very dependent c l i e n t . A major premise i s suggested for fee-charging, after discussion of alternative premises, and of the reason f D r charging a fee under t h i s premise. Fee-charging practice would have a changed emphasis; there would be clearer administrative exclusions, and more s k i l l e d exclusions based upon casework judgment. Adequate a b i l i t y to pay would be primary data i n deciding between alternatives. - i i -TABLE OF CONTENTS Chapter I Why Charge Fees? Page The Pre-fee era; developments leading to fee-charging. Rationale f o r the establishment of fee-charging p o l i c i e s . Early doubts and anxieties. The recognition of therapeutic factors i n fee-charging. Trend to more consistent practice. Controversies about method and philosophy. •• ••• 1 Chapter I I Developments i n a Family Service Agency The development and philosophy of the agency. I n i t i a l r ejection of fee-charging. Reasons f o r i n i t i a t i n g fee-charging p o l i c y . Suggested change i n p o l i c y ; s t a f f discussion of s i g n i f i c a n t issues 23 Chapter I I I Fee-Charging i n Practice Reasons for not charging a fee; exclusions to the p o l i c y . The consistency of fee-charging practice. Therapeutic implications. Client resistance; cases involving personality d i f f i c u l t i e s . The appropriateness of fee-charging. •• 40 Chapter IV Fee-Charging; A Po l i c y Evaluation The development of the p o l i c y ; s t a f f reactions. The multiple rationale f o r fee-charging. A proposed major premise; suggestions f o r practice. Need for further research 65 Appendices: A« Fee Scale Guide 83 B. Questionnaire on Intake 84 6. Questionnaire on Closed Cases 85 D. Key to Intake Questionnaire • 86 E. Fee-Charging Procedures • 87 F. Reasons f o r Fee-Charging 88 G. Bibliography 89 Tables and Charts i n the Text Table 1. Clients not Charged a Fee 40 - i v -ACKNOYJLEDGEMENTS I wish to thank Mrs. Helen Exner for her continued encouragement and patience, and Dr. Leonard Marsh f o r his assistance with the structure of the t h e s i s . Miss Mary McPhedran, and Miss L i l l i a n Carscadden of the Vancouver Family Service Agency, stimulated early interest i n t h i s t o p i c , and gave d i r e c t i o n to i t s scope. Mr. Deryck Thomson, Director of t h i s agency, gave invaluable help i n the preparation of a l l the chapters, and cooperated f u l l y i n making material available. To these persons and other s t a f f members who so readily gave of t h e i r time, go my sincere thanks. CHAPTER I WHY CHARGE PEES? Fees for casework service are no longer an innovation. For many agencies the question of whether to charge, or not to charge, had changed to how much to charge, when and with which o l i e n t s . This i s true at least for voluntary family agencies i n the United States, although w i t h i n these agencies there i s s t i l l varying acceptance of the appropriateness of fee-charging. I t i s apparent that there i s also resistance to charging fees i n actual practice. There ce r t a i n l y remains much to c l a r i f y i n the techniques, the values, and the ultimate objectives of charging fees and these, of course, are related to the scope and future development of family agencies. To understand the current problems i n fee charging, i t w i l l be necessary to examine the origins of the p o l i c y . How and why has fee-charging developed? I t w i l l be necessary to do t h i s by studying the experience of American family agencies as no comparable movement has developed i n Canada. This development i s pertinent to the l a t e r development of fee-charging i n The Family Service Agency of Vancouver, as t h i s Agency has drawn i n s p i r a t i o n , standards and orienta-t i o n from i t s association with family s o c i a l work i n the United States. The wpre-fee era", as i t might be c a l l e d , i s covered by an 1 excellent pamphlet written i n 1938. Fee-charging began i n the early 1940*s. This pamphlet covers the a c t i v i t i e s of family agencies for the years 1935, 1936 and 1937. I t i s noted that: "the depression marked the end of the protected childhood of family s o c i a l work and the beginning of i t s adolescence," § 1. Family Welfare Association of America, Family Social Work i n Transition,: 1938, Mew York, pp. 1-2. 2. Ibid p. 4 - 2 -and that: "private family agencies could no longer ride comfortably on the popular notion that they were key agencies i n meeting the economic needs of a poverty-stricken people. Public agencies, too, were forced into a new status. They had to take the po s i t i o n on the f i r i n g - l i n e of r e l i e f previously occupied by private agencies." The family agencies were lo s i n g a major part of t h e i r c l i e n t e l e and, while seeing the d e s i r a b i l i t y of the entry of public agencies into the r e l i e f f i e l d , were wondering what new functions were ahead f o r them and, as noted i n the pamphlet: "an increasing number of agencies gave special names to family con-s u l t a t i o n aspects of t h e i r work i n order to indicate they were ready to serve the economically independent as well as those needing material a i d . " ^  Family agencies were ready to serve people from a broader economic f i e l d . They had behind them s i x t y years of experience i n helping people; an experience that had been geared to a sensitive attempt to develop the c l i e n t ' s i n t e r e s t s , capacities and strengths while ministering to his environmental d i f f i c u l t i e s . The t r a n s i t i o n a l period toward the end of the depression years and p r i o r to the advent of fee-charging was, of course, a period of uneven develop-ment amongst agencies, while the general movement away from r e l i e f giving was occurring. In some areas there were no public agencies and these had to be founded, necessitating a slower evolution f o r the agencies concerned. In general, the eastern .American agencies i n the larger c i t i e s changed most quickly, and here also the beginning learning from the f i e l d of 1 . Family Welfare Association, op. c i t . p. 4 2. Ibid p. 7 - 3 -psychiatry was more quickly assimilated and applied. The self-examination which occurred i n the family f i e l d i n t h i s period i s enlightening, and was preparatory to next steps. At the 1935 Annual Meeting of the Family Welfare Association of America i t was noted that: "whatever i t s own broader conception of i t s services may be, the private family welfare agency i s s t i l l generally t i e d up i n the public mind primarily with economic need. Although as an ultimate goal s o c i a l casework service i s p o t e n t i a l l y useful to a l l persons who have d i f f i c u l t y adjusting themselves to t h e i r fellows, regard-less of t h e i r economic s i t u a t i o n , i t was recognized that the private agency... .must generally s t a r t from where i t now stands, continuing to a s s i s t many families i n which f i n a n c i a l distress i s related to other family problems. But, as an immediate and prac-t i c a l goal, i t can gradually extend i t s services to the marginal income group who may not need r e l i e f but who cannot afford to pay for services which are v i t a l l y needed." 1 In addition to thinking of service to the marginal income group, private agencies developed c o l l a t e r a l programs such as homemaker service, special services to the aged, group discussions with mothers around the care of children, and other problems; and help with employment and re-education of those once again hoping to enter the labour market. A note of caution and uncertainty was also an inescapable part of t h i s period. In 1936, " s o c i a l work leaders began to ask whether private agencies were as ready as some once thought to abandon the r e l i e f function", and again as before, "To whom does the family agency address i t s e l f , what are i t s p a r t i c u l a r values, and who i s to pay f o r the service rendered?" 1. Margaret E. Rich - A B e l i e f i n People, Family Service Association of America, 1956, p. 132 2. Family Welfare Association of America, opp. c i t . , p. 9 - 4 -Family agencies did not have too long to wait before t h e i r s k i l l s were again v i t a l l y needed. With the st a r t of World War I I many new and d i f f i c u l t s o c i a l stresses appeared. This stage i s well-expressed by the following statement: "Family societies emerged from the depression years with a clear conception of purpose and program, a greater sense of unity, and a keen desire to study, analyze, and improve t h e i r services. The re-alignment of functions between public and private agencies made i t possible for the family societies to devote more attention to developing techniques f o r helping families with problems of personal adjustment and family relationships. The strengthening of the case-work program l a i d the groundwork for the many new counselling r e s p o n s i b i l i t i e s that family agencies were to undertake as the nation moved into mobilization f o r defense, and into World War I I . n I t i s important to note here the kinds of a c t i v i t y , problems and c l i e n t e l e of t h i s new period, as fee-charging began i n the early 1940s, and gathered most of i t s impetus throughout and shortly a f t e r the war years. As stated: "the expansion and relocation of war industries, and the increase i n work opportunities f o r both men and women brought t h e i r own problems. Men long unemployed found t h e i r wages garnisheed f o r debts contracted during the depression years. Others found t h e i r p a r t i c u l a r s k i l l s did not meet the needs of defense industry, and t h e i r previous employment had closed down because of the p r i o r i t y given to defense e f f o r t s Such scarcity i n the midst of plenty, so to speak, placed a great s t r a i n on family r e l a t i o n s , which was made more d i f f i c u l t i f the wife could get a job when the husband could not. .......The new pressures on family l i f e as the war advanced provided both an opportunity and a challenge to l o c a l family agencies The break-up of families due to separation, the tensions and anxieties due to war, the hasty, impulsive marriages of young men about to be inducted into the armed forces, called f o r s k i l l e d casework service i n helping hus-bands and wives work out t h e i r problems. For the most part, there  were families not i n need of economic help, and a few of the societies notably the Jewish Family Agency i n Mew York offered marriage or famiTy  counselling on a fee basis so as to reach the middle-income group who would prefer to pay for service. Special e f f o r t s were also made by many of the agencies to interpret family casework services to men and women i n industry - employers, ana to union stewards,- so that employees might f i n d help for family troubles that were i n t e r f e r i n g with t h e i r work." 2 L Family Welfare Association of America, op. c i t . p. 3 2. Rich, op. c i t . pp. 144 - 147 - 5 -I t i s clear that family agencies were intimately and v i t a l l y concerned with the giving of casework help to a higher economic group i n the community. I t i s clear also that through public relations a c t i v i t y and i n t e r p r e t a t i o n to key persons, e f f o r t s were being made to extend case-work help to a s t i l l wider group. Many of the e a r l i e r a c t i v i t i e s of agencies i n the early part of the t r a n s i t i o n a l period were s p e c i f i c i n nature, f o r example budgetting help and homemaker service, but with the strains on family l i v i n g brought about by war the core service of s o c i a l casework became more emphasized. Agencies i n gaining more conviction about the value of t h e i r services to a l l groups i n the community, sought c l i e n t e l e more vigorously. Fees were a symbol put f o r t h by the profession indicating readiness and a b i l i t y i n a concrete way, i n an economy where often the money value placed on a service i s related to the value of the service i n the minds of the consumer. As stated, "agencies began to see fee payments as a possible aid to d i s s i p a t i n g t h e i r e a r l i e r i d e n t i f i c a t i o n with the r e l i e f giving function and i n interpreting t h e i r role as a community service, with professional s k i l l s and knowledge appro-priate for the use of persons i n a l l income l e v e l s . " I t i s i n t e r e s t i n g i n retrospect, to wonder more s p e c i f i c a l l y why family agencies introduced t h i s p o l i c y . I t i s valuable to understand that the i n i t i a l movement started around the conviction that the necessary s k i l l s were present, and had been for some time, to serve a l l income l e v e l s . Unfortunately, the early connotation of charity s t i l l clung to family agencies i n the public mind. The primary objective then was to remove New York, 1. Community Chests & Councils of America Inc./ Fees for Health & Welfare Services, September 1949?. p. 2 - 6 -t h i s h a r r i e r to giving service. Fees were used as a t o o l to accomplish t h i s i n part, together with more widespread interpretation and demonstra-t i o n of the value of casework. Impetus was given the movement by emerging competition from a l l i e d professions i n the family consultation field,,and by increasing gains from psychiatry, i n helping to form a professional body of knowledge f o r diagnosis and treatment of family problems. An e a r l i e r a r t i c l e shows c l e a r l y the p o s i t i o n of the family agency on the threshold of the fee era. "There has been some discussion as to whether or not the family society i s the l o g i c a l medium i n which to develop soc i a l casework on a fee basis. The family agency has been the source of development of our f i r s t casework practice, out of i t came our schools of s o c i a l work and psychiatry. I t usually has a research point of view, i t has community status, i t has funds for experimentation, i t usually has a superior s t a f f . I do not believe, however, that t h i s would be the best set-up, because, as long as the family society must concern i t s e l f with r e l i e f , the community w i l l continue to look on i t more or less as a place f o r charity. The s i t u a t i o n i s analogous to- the tie-up between state hospitals and c h i l d guidance c l i n i c s . While many of our best c h i l d guidance people were trained i n state hospitals, yet i n establishing c h i l d guidance c l i n i c s i t did not seem wise to l i n k the two f o r fear the public would not accept the c l i n i c as a place f o r normal people as long as i t was associated with the state h o s p i t a l . " l , The above quotation,stresses the equipment possessed by the family agency f o r service, as w e l l as the d i f f i c u l t y caused by connotation of r e l i e f giving. The e a r l i e s t fee p o l i c y was established i n 1941 by The Family Society of Philadelphia. The New York Jewish Family Society established i t s fee charging policy i n 1942. The growth of fee-charging i n the early 1940s was slow, and agencies c h a r a c t e r i s t i c a l l y debated the issue f o r long periods before the f i n a l adoption of a d e f i n i t e p o l i c y . There were many anxieties and hesitations. Host agencies f i r s t accepted fees i f the c l i e n t 1. Lee R. Sterner, "Casework as a Private Venture", The Family, Vol .XIX, No. 6, October 1938, p. 196 - 7 -volunteered, then established an experimental p o l i c y before a d e f i n i t e pol i c y was adopted. The philosophy put f o r t h most often was that agencies were extending services to those accustomed to paying f o r professional services, and that a fee would therefore help these c l i e n t s a v a i l themselves of family casework service. The fact that fees were not to be considered a source of revenue was stressed, as was the philosophy that there would be no difference made i n terms of service to fee and non-fee c l i e n t s . The following i s a collected summary of the early reports on fee-1 charging by several family agencies. In 1943, the Community Service Society of New York raised the following points. There i s more apt to be c r i t i c i s m from people who are d i s s a t i s f i e d with help when they pay. I t was suggested that special caution be used i n p u b l i c i z i n g help, and fees, with marital problems. Workers f e l t that i t would be best to discuss the fee only conservatively at f i r s t , and on cases where the worker was f a i r l y sure i t would have constructive value. The fact was noted that i n our culture people expect to pay f o r services-. They prefer not to take "charity". I t was also noted that the person paying f o r service would l i k e l y invest more of himself i n the contact. The Agency wondered i f non-fee c l i e n t s would f e e l i n an i n f e r i o r p o s i t i o n . There was a beginning examination of reactions of the fee c l i e n t . I t was recognized that some c l i e n t s are motivated by h o s t i l e feelings i n offering to pay, and that some c l i e n t s may be h o s t i l e when payment i s suggested. There was the question of f e e l i n g obligation to devote more time to c l i e n t s who pay and the fear that the fee p o l i c y would increase intake 1. Community Service Society - Summary of D i s t r i c t s ' Discussion of Fee  Charging Services, March 7, 1943 - 8 -and thus reduce t o t a l time f o r case loads. The Family Service Agency of 1 Milwaukee raised some of the above points and others i n 1945. The thinking was that fees would l i k e l y extend the agency's services to families of adequate income but might, at the same time, discourage marginal income f a m i l i e s . Fee-charging was seen as not appropriate f o r "protective" services and "preventative" services to families with pre-delinquent tendencies, as fees may discourage such families from seeking help at the early stages of the problem. Also, fees were not considered appropriate i n cases where service was given at a point of family c r i s i s . This agency f e l t that i n view of l i m i t e d community understanding of what oasework i s , the in t e r p r e t a t i o n of the reasons f o r fee service would be d i f f i c u l t : also that i t would be d i f f i c u l t f o r one casework agency to embark upon a plan f o r fees when simi l a r services are given without oharge by other casework agencies, especially i f these are sectarian agencies. I t was f e l t that preceding a plan f o r fee service, there should be more intensive general interpretation of casework to the community at large. I t was suggested that extension of service v i a fees was not as important, as the need f o r other services which the agency can only p a r t i a l l y meet. For example, the need for more work with families of juvenile delinquents. I t was thought that public c r i t i c i s m of the agency might develop i f li m i t e d resources of the agency were diverted into service for families of more secure income. The above comments r e f l e c t some of the doubts and anxieties expressed by family agencies i n introducing fee-charging at the time when t h i s policy was generally tentative and exploratory i n the whole f i e l d . 1. Family Service of Milwaukee - General Conclusions of the Fee Service  Committee, July 8, 1946 - 9 -These agencies also expressed thinking on administrative procedures and method which w i l l he noted l a t e r . The above points were t y p i c a l but are not meant to be thought of as a l l - i n c l u s i v e . They do show agency caution and uncertainty. They suggest avoiding p u b l i c i t y , and seem f e a r f u l of the effect of fees on t h e i r t o t a l case load where t h e i r t r a d i t i o n a l area of service has been. They stress care i n the s e l e c t i o n of fee cases, and a desire to be sure of being able to do w e l l before charging. However, despite misgivings there seems a fe e l i n g that fees are appro-pria t e and that they are going to be u s e f u l . During t h i s period also, there appeared three publications by The Family Welfare Association of America which perhaps give a more general picture of thinking i n fee-charging. The f i r s t publication i n 1943 notes that there i s precedence for fee-charging i n other types of s o c i a l agencies. For example, i n some c h i l d guidance c l i n i c s , adoption agencies, day nurseries, and v i s i t i n g nurse associations. I t i s seen again that there i s i n part of the community a psychological b a r r i e r against the acceptance of free service - that private agencies are being freed from the r e l i e f role - and that fees are being charged by marriage counselling c l i n i c s whose work i s closely related to family casework. I t was f e l t that an agency, before introducing fees, must have a sound, community accepted program, and have shown s k i l l i n dealing with non-relief problems, and that i t i s important that the services emphasized are those with which the agency has worked successfully i n the past. "For instance, most agenoies are much more ce r t a i n now of t h e i r s k i l l i n dealing with p r a c t i c a l problems than i n marriage counselling. 1 , 1 1. Family Welfare Association of America - Fee Charging i n the Family Agency July 1943, p. 3 - 10 -I t i s also noted that a stable and s k i l l e d s t a f f i s e s s e n t i a l , and that the agenoy must allow time for s t a f f to learn how to handle fees without anxiety. In interpreting the fee service, i t was thought agencies should he careful that the community does not believe i t i s being asked to contribute to a self-supporting service, and that the preventative aspects of the agency be interpreted, "since i t c l a r i f i e s the fact that the community does have a r e s p o n s i b i l i t y for preventing deterioration rather than only the r e s p o n s i b i l i t y for providing f o r 1 the future effects of such deterioration." I t i s also noted that while the community may object to extending service to an economically independent group, there seems l i t t l e reason to deny service to the group 2 "who, equally needing i t , are able to pay f o r part of the cost." 3 In a l a t e r a r t i o l e , Miss A l i c e D. Taggart echoes many of the questions raised previously by agencies, f o r example, whether the Board and community w i l l accept such a trend away from the philanthropic motive? The author also asks i f agencies now have s u f f i c i e n t experience i n personal counselling; have s t a f f s repreatedly demonstrated t h e i r s k i l l s around the psychological values of money; and w i l l i t be possible to have available s k i l l e d psychiatric consultation? I t i s also suggested again that caution be used i n public r e l a t i o n s ! "announcing to the world through b u l l e t i n s and newspaper a r t i c l e s that we are now set up as counsellors on personal problems w i l l not insure success i n helping those we wish to serve. Here, i n f a c t , l i e s one of the most serious dangers to family casework development of the future. I f , i n the spotlight of a new venture, we do less than w e l l , we do irreparable harm to the cause of casework." 4 1. Family Welfare Association, op. c i t , p. 5 2. I b i d , p. 5 3. A l i c e D. Taggart - Some Broad Considerations f o r Agencies i n Establishing a Fee Service, Family ITelfare Association of Amerioa, May 1944 4. Ibid, p. 4 - 11 Miss Taggart suggests that word of mouth interpretation by s a t i s f i e d c l i e n t s and fey appreciative r e f e r r a l sources would be best. She feels that the key word f o r agencies i s '•service", that i s , that fees are incidental to helping people on whatever l e v e l they come to the agency. In her words, - "the great challenge i s to prove through our everyday service i n our everyday work that we are serving each according to his 1 need and with the utmost s k i l l . " The remaining a r t i c l e s i n t h i s pamphlet, while s p e c i f i c i n nature, do contain some general comments. Mr. Berkowitz speaks with conviction about fee-charging. He says that "as long as we are f l e x i b l e enough to lean over on the side of the c l i e n t ' s need and s c i e n t i f i c enough to examine our experience open-mindedly, the fee w i l l become a valuable addition to casework practice and w i l l augment the general 2 acceptance of casework by the community as a whole»tt The f i n a l a r t i c l e by Miss Penn stresses the f l e x i b l e nature of family casework and i t s sensivity to and r e f l e c t i o n of changes i n society. She says that philanthropy seems ready to support a broader program of s o c i a l welfare by extending to a new group casework help which has hitherto -3 "been the p r i v i l e g e of the under-privileged." She likens the introduc-t i o n of fee-charging to that of the a r r i v a l of a new baby into a family 1. A l i c e D. Taggart, opp. c i t . p. 5 2. Sidney J . Berkowitz, "U/s© of Fees i n Magnosis & Treatment", Family  Welfare Association o f ^ j ^ r i c a , 1944^ P« 14 3. Sonia E. Penn, "Fee Charging i n Actual Practice", Family Welfare Association  of America, May 1944, p. 16 - 12 -disrupting temporarily i t s alignment of r o l e s , and general organiza-t i o n saying: "thus the c h i l d , coming into i t s new environment, not only learns to l i v e i n i t and i s molded hy it; but by i t s a r r i v a l disturbs the existing environment, causes everyone to change and grow up a l i t t l e , and unwittingly contributes to the growth of the family unit i t s e l f . " 1 Miss Perm's f i n a l statement seems a prophetic one i n view of l a t e r developments i n the f i e l d . She feels that: "the disturbance to family casework, caused by the fee paying c l i e n t , — has growth value for casework and w i l l ultimately contribute to i t s maturity as a profession." ^ The development of fee-charging to the end of the 1940s continued i n a slow, careful manner. Emphasis was placed on the primary importance of f i r s t having a b a s i c a l l y sound programme with s k i l l e d s t a f f , and community knowledge and acceptance of casework and the agency. By 1948, twenty-two family agencies had a d e f i n i t e p o l i c y of fee-charging, and t h i s was increased to forty-nine agencies i n 1951. Some agencies con-tinued to have a permissive, voluntary pol i c y of fee payment by the c l i e n t . Others did not report on t h i s area, so that i t i s d i f f i c u l t to generalize. I t seems evident, however, that the introduction of fee-oharging was a function related to agency s i z e ; adequacy of programme and s k i l l s of s t a f f ; and community and professional t r a d i t i o n s . The larger, w e l l -established agencies tended to introduce fee-charging f i r s t , and t h i s was done more e f f e c t i v e l y where the agency had demonstrated success with help on non-relief cases f o r some period of time. This would be 1. Sonia E. Penn, opp. c i t . pi7 2. Ibid p.24 - 13 -i n areas where public agencies had moved most quickly and adequately into the major r e l i e f r o l e . I t i s also true to say that newer agencies were beginning to form fee-charging p o l i c i e s , and that they, i n general, tended to do so more e a s i l y , freed as they were from community expecta-t i o n of t h e i r service being l i m i t e d to lower income groups. TNhile the establishment of a fee-charging policy was occurring i n more agencies i n the l a t e 1940s, the l i t e r a t u r e i n the f i e l d began to explore i n d e t a i l the implications of t h i s p o l i c y to agencies, case-workers, and c l i e n t s . The l i t e r a t u r e was ess e n t i a l l y positive i n nature and seemed intent on encouraging the profession to grapple successfully with the related problems posed by fee-charging. I t was noticeable that when fee-charging was introduced at t h i s time by an agency, i t was because upper income c l i e n t s were already coming for service, and i t was seen as appropriate that they should pay. The establishment of the p o l i c y to a t t r a c t an abstract c l i e n t e l e was stressed to an increasingly smaller degree, although s t i l l present. The two concepts came together, of course, i n establishing a poli c y that would be l i k e l y to help the economically independent c l i e n t make more effective use of casework services, and would be l i k e l y to make the use of the service more acceptable to him. Fees were usually set on a s l i d i n g scale on the basis of income, c l i e n t In some agencies/Expenditures and general f i n a n c i a l circumstances were considered. Later, s l i d i n g scales were developed r e l a t i n g income and family s i z e . In any case, the consideration of a fee was a matter f o r - 14 -indivi d u a l discussion between c l i e n t and worker. The philosophy was to make creative and f l e x i b l e use of t h i s discussion - to relate fees to diagnosis and treatment. As stated by Mr. Berkowitz: "The successful use of fees i n casework treatment has to do, f i r s t , with the a b i l i t y to understand and to u t i l i z e the various attitudes expressed by people toward fees, and deal comfortable with feelings toward the caseworker, both p o s i t i v e and negative, which the c l i e n t may bring out more quickly and readily when he i s paying f o r service. The important question, then, i n the intake process, i s how can a fee be dynamically  related to the problem the c l i e n t i s expressing, and so d i s -cussed that the c l i e n t sees i t as part of the t o t a l plan f o r helping him."! In t h i s approach the worker makes a q u a l i t a t i v e judgment about whether or not to charge a fee; the timing of the interpretation of the fee; and the manner of intorudcing the fee as related to diagnosis, so that the fee w i l l help consolidate the c l i e n t ' s f e e l i n g that he has found an appropriate service of professional help. The question of fee payment i s not brought up u n t i l the caseworker and c l i e n t determine j o i n t l y whether casework treatment i s to be of value. Mr. Berkowitz states that "once the person sees the need f o r help and wants i t , he 2 i s usually more than w i l l i n g to pay for i t . " I t i s noted that there may be various forms and kinds of resistance to fee payment, but the worker i s to set the fee " i n a simple, warm, non-equivocal way, and leave further discussion of i t to succeeding interviews, i f t h i s appears necessary."^ Diagnostic information may arise from t h i s process as the c l i e n t may react 1. Sidney J . Berkowitz "Reactions of Clients and Caseworkers Toward Fees", Journal of Social Casework, A p r i l 1947, Vol. XXVIII, Number 4, p. 145 2. Ibid p. 145 3. Ibid p. 145 - 15 to the fee i n a way that i s d i s t i n c t i v e of his way of meeting other l i f e s i t u a t i o n s . This information may he d i r e c t l y helpful i n dealing with feelings around money, and the fee may provide entry into t h i s area. Ifhen fees are i n t h i s way a part of the treatment plan i t was f e l t that the c l i e n t who pays, participates more, and makes a more focussed and effective use of the service. Resistance to treatment becomes more obvious through h o s t i l i t y shown i n paying, or i n p a r t i a l payment, delayed payment, or non-payment of the fee. This careful approach to f ee-charging'*is a concomitant of the caution i n the general area of fee-charging. While fees are seen as pro-fe s i o n a l l y sound i n an agency, the application of the policy i s f l e x i b l e , s e l e c t i v e , and very i n d i v i d u a l . The po l i c y would not be consistent i n i t s application from worker to worker, and therefore from c l i e n t to c l i e n t , as the loose agency framework f o r the poli c y permits fee-charging when the worker feels i t i s appropriate. Recent fee-charging p o l i c i e s aim more consistently at charging c l i e n t s able to pay without the stress on how the c l i e n t i s able to use the service. I t i s d i f f i c u l t for the worker to mention fees a f t e r several interviews, as there i s the f e e l i n g that the c l i e n t has been involved under f a l s e pretenses. Further, intake and treatment processes often blend, so that i t i s d i f f i c u l t f o r the worker to s e l e c t the point f o r fee-charging-when he judges the c l i e n t i s ready to go into the treatment process. I t i s now generally f e l t that a professional service i s given during the exploratory period and i s thus chargeable. - 16 -Fee-charging was slow i n i t s development. By 1951, r e l a t i v e l y few of the two hundred and f o r t y American/family agencies had an established p o l i c y . Where the p o l i c y was established i t had f i r s t been t r i e d on a voluntary, and then an experimental basis. Where established p o l i c i e s were i n e f f e c t , the application of the p o l i c y was r e s t r i c t e d and cautious. In general, the income from fee-charging was small, and the number of fee cases i n agencies not s i g n i f i c a n t . In addition, the range of fees was generally only from $1.00 to |3.00 per interview. The maximum fee was well below the actual cost of the interview to the agency. P u b l i c i t y about fees was p r a c t i c a l l y non-existent. Why was the profession so apparently reluctant on t h i s issue? There would seem to be a m u l t i p l i -c i t y of reasons. The following quotation i l l u s t r a t e s the situations "The slowness of the extension of fee-charging i n the f i e l d of casework, the uncertainty with which i t becomes a part of agency programme when the practice i s adopted, the i n i t i a l blocking i t precipitates i n practitioners a l l attest to the fact that case-work, despite i t s growing recognition throughout the nation, has been slow i n catching up on i t s growth. In„ making t h i s observa-t i o n , I am not unmindful of agency problems and community factors which make a fee service unfeasible. I t i s obvious that the launching of such a programme pre-supposes adequate s t a f f and must be preceded by adequate community education, i f i t i s to grow rather than to prove a boomerange, ...... these and other problems make t h i s innovation untimely for various agencies. n^ The l a t t e r part of t h i s statement perhaps explains why more agencies had not adopted fee-charging. Some were undoubtedly not ready. Perhaps there was also a lack of s t a f f conviction about the val ue of i t s services and a lack of actual c l i e n t e l e , presently served, able to pay f o r such service. The uncertainty with which fee-charging became 1. Celia Brody - "Fee Charging, a Ifynamic i n the Casework Process", Journal of Social Casework, October 1949, Vol. XXX, Number 8, p. 65 - 17 -part of agency practice a f t e r being adopted, may have been p a r t l y because of unclear, overly permissive, administrative structure. The caseworker, as w e l l as anyone else, needs a functional framework. Without one the worker tends to charge fees i f the c l i e n t i n s i s t s ; i f hs feels t h i s w i l l be a "successful" case; or i f the c l i e n t can well afford the fee and w i l l not react to i t i n a h o s t i l e or manipulative manner. Some authors have pointed to what may be a fundamental reason underlying the resistance to fee-charging - a l i n g e r i n g sense of i n f e r i o r i t y . This i s referred to i n many ways as, f o r example - "the f u l l development of fee charging may be hindered by self-deprecatory tendencies w i t h i n the profession". 1 This same author points to two possible reasons f o r these tendencies. The f i r s t : "that the profession of casework has not been immune to the status of s o c i a l i n f e r i o r i t y attached to those i t has t r a d i -t i o n a l l y served," and "that the stigma attached to dependency tends to go beyond the c l i e n t group and to embrace persons connected with i t - an instance of i n f e r i o r i t y acquired by i d e n t i f i c a t i o n . " The second reason i s said to be related to a sense of indebtedness to psychiatry. Both of these reasons seem related to a lack of conviction that s o c i a l work i s t r u l y a profession, with professional s k i l l s , and a body of knowledge, appropriately integrated f o r service beyond the economically dependent c l i e n t . I r o n i c a l l y , the s o c i a l workers i n family agencies seemed to be saying on the one hand, that 1. Brody, opp. c i t . p. 65 2. Ibid p. 66 - 18 -they had developed valuable s k i l l s and knowledge which should be extended to serve a wider group, but acting as though t h i s could not after a l l be r e a l l y so. This i s time, at l e a s t , i n regard to setting a price on i t s service. This has been referred to as "massive masochism".1 This author points to our willingness to accept fees f o r board and care payments from c l i e n t s i n c h i l d placement agenoaes, and the fact that i n medical c l i n i c s charges are made f o r medical services, but usually not f o r the medical social worker's services. The case of charging for homemaker service i n a family agency as contrasted to resistance to charge for casework help i s also an example. The author sums t h i s up by saying "In short, we have found i t less troublesome to charge for someone else's service than f o r our own. This suggests a defective attitude about ourselves and our work 2 that i s not supported by r e a l i t y . " The introduction of fee-charging also had p a r t i c u l a r significance for the worker-client relationship. The actual necessity to charge fees aroused mixed feelings i n many socia l workers. This i s i l l u s t r a t e d by the following quotation: "so i t i s that the introduction of a fee service tends to precipitate a generalized discomfort, prompting us to question the value of the help we have been offering with conviction up to that time. We begin to wonder - w i l l people f e e l i t i s worth paying f o r ? . . . . s o c i a l workers are much more comfortable i n , and accustomed t o , a giving role rather than a taking r o l e , although neither i s completely inherent i n the role any of us assumes. This pattern and the philanthropic bases of the casework relationship from which i t stems are bound to be profoundly affected by fee charging.. .We have found that the symbolism of money payment for help implements i n a most powerful fashion whatever other means a worker u t i l i z e d to help the c l i e n t maintain a sense of his own i n t e g r i t y . The continued experience of our agency has proved that i n the hands of an emotionally free, d i s c i p l i n e d worker, the use of fees can become an important dynamic i n helping, p a r t i c u l a r l y i n situations i n which the c l i e n t ' s struggle fosters i t s e l f upon, or expresses i t s e l f through the fee. Conversely the use of fees i s bound to disturb the worker's role when i t plays into some unresolved or residual problem w i t h i n him, whether t h i s take the form of needing to be a benefactor, a r i g i d l y c o n t r o l l i n g authority, or of an individual who can f e e l his strength only i n r e l a t i o n to another's manifest weakness. Pee payment also tends to i t e n s i f y under-l y i n g f e e l i n g of s e l f doubt i n the worker who i s uncertain of his professional worth." 3 1. Carl M. Shai'er, "Fee Charging i n a Family Agency", Family Service of Pasadena, November 1956, p. 3 2. Ibid pages 2 and 3 3. Brody, op. c i t . pp. 66 - 67 - 19 -The above quotation expresses well the possible affects of fee-charging upon so c i a l workers. The author makes the further point that fee-charging - "stimulates a healthy kind of anxiety, which results i n a more thorough self-examination and deeper use of s e l f , serving ultimately as an a i d i n the worker's t o t a l professional development... and that i t offers a means by which the supervisor can cut through to a worker's 1 problem and help him recognize and work i t through". This author goes on to examine c l i e n t reactions to a fee and concludes that "the fee, among other common elements underpinning the agency's method of helping, serves as a f o c a l point around and through which the c l i e n t ' s f e e l i n g about his problems and his need for help are externalized and made manifest i n s p e c i f i c ways, instead of remaining 2 int e r n a l i z e d and i n v i s i b l e . " She warns however that " i t i s the rare s i t u a t i o n i n which the fee or any other s p e c i f i c element of contact..... g becomes the sole focal point of the c l i e n t * s c o n f l c t . " The author i l l u s t r a t e s these points by several case discussions which show the use which may be made of the c l i e n t ' s externalized reactions to the fee. With a parent-child problem f o r example, the parentis wish to pay the fee for an employed daughter externalizes the basic problem and permits the worker to help the daughter pay her own fee, and help, the mother accept t h i s . 1. Brody, opp. c i t . p. 67 2. I b i d p. 68 3. Ibid p. 68 - 20 In addition to the s p e c i f i c dynamics between worker and c l i e n t i n regard to fee-charging, there has been general controversy around the methods, philosophy, and ultimate aims of such a p o l i c y . A recent article"'' points up many of these issues and i s important enough to warrant review here. Miss Fizdale i s Executive Secretary of the Arthur Lehman Counselling Service, New York. This foundation-supported service was established i n 1954 as a demonstration project. The need for such a project came from the convictions and questions i n the minds of a small group of professional leaders and board members regarding fee-charging methods, and the profession's r e l a t i v e i n a b i l i t y to reach the middle and higher income group, and as Miss Fizdale remarks "this i s a project that i s attempting to of f e r case-work counselling i n a way similar to the 'private' services of other professions, 2 while maintaining the values inherent i n an agency s e t t i n g " . I t i s important to note that t h i s service, or agency, employed only h i g h l y - s k i l i e d and experienced caseworkers, and that direct service to the c l i e n t was emphasized. There i s no provision f o r the t r a i n i n g of students, or for a c t i v i t i e s connected with s o c i a l action or community leadership. In addition the workers were selected for th e i r a b i l i t y to be es s e n t i a l l y responsible for t h e i r own practice, so that supervision would not be a s i g n i f i c a n t item i n the cost of service. In establishing t h i s agency, i t was argued that while fee-charging practice had generally increased since i t s inception, s u f f i c i e n t attention 1. Ruth Fizdale, "A New Look at Fee Charging", Journal of Social Casework, JSbruary 1957, V o l . XXXVIII, No. 2, pages 63 - 69 2. I b i d , p. 68 - 21 -had not been paid to how to r e a l l y charge fees to the middle and higher income group. The oore of t h i s argument i s that family agencies have not differentiated between those c l i e n t s requiring a subsidized service and those able to pay the f u l l cost; and that the s l i d i n g scale of fees i s not psychologically appropriate for the higher income c l i e n t . I t was f e l t that the maximum fee charged by agencies was s t i l l not related to the cost of the service, and that the f u l l and e f f i o i e n t development of fee-charging was hird ered by the f i e l d ' s t r a d i t i o n a l concern for the economic welfare of the c l i e n t . The author suggests that other professions share t h i s concern but handle t h i s by v & r y i n g what i s e s s e n t i a l l y a f i x e d fee. This i s thought to be more acceptable to the c l i e n t group as contrasted to the fee being set a f t e r a discussion of income and sometimes of expenditures, which i s usually a "foreign and often confusing experience for the f i n a n c i a l l y secure c l i e n t " . 1 The author feels that the c l i e n t may wonder i f he i s an unwilling recipient of, or contributor t o , philanthropy and may wonder about the q u a l i t y of the service. There may also be problems which a r i s e out of the discussion of finances which create for the worker the d i f f i c u l t y of deciding whether to handle these at the time, or whether to postpone for l a t e r . The d i f f i c u l t y of exter-n a l i z i n g these problems i s often i n regard to timing as they are often a r t i f i c i a l l y raised early by the fee discussion. In any case, t h i s new agency began with a fixed fee of $10.00 per interview. They wished t h i s to represent the f u l l cost of service but were unable to anticipate costs i n any exact way. Their experience b r i e f l y stated was that t h i s was a 1. Fizdale, op. c i t , p.68 - 22 -successful approach, and that the f i x e d fee seemed more e a s i l y accepted by c l i e n t , and more e a s i l y handled by s t a f f . The agency found that few c l i e n t s requested a reduction i n the fee, and i t was f e l t that the f i x e d fee was equated by the c l i e n t with professional competence, and quality of service. There was a greater expectation of t h i s l a t t e r q u a lity, with more "drop-outs" than might occur i n a : t r a d i t i o n a l agency s e t t i n g . I t i s noted that about one-half of the c l i e n t s had incomes of between $7500.00 and $12,500.00 per year, and only 16% of the t o t a l c l i e n t group had ever been i n contact with a s o c i a l agency. The trend to charging fees within the framework of private family agencies, has been evolving now f o r some 16 years. The o r i g i n a l reason f o r charging fees, to achieve professional recognition f o r casework and to extend service to a higher income group, has been elaborated by the thought that various therapeutic benefits can also be obtained from t h i s p o l i c y . While some agencies enjoy r e l a t i v e success with fee-charging, t h i s i s s t i l l l i m i t e d i n terms of fee income, and number of fee-paying c l i e n t s . Clients are not yet paying the f u l l cost of service, and there i s some question about the effectiveness of the method of charging fees i n using a s l i d i n g scale of fees. The development of fee-charging has been uneven from agency to agency, and between workers. There i s no known research on the v a l i d i t y of charging fees, especially i n regard to the supposed inherent therapeutic values. This i s the present p o s i t i o n of fee-charging p r a c t i c e . I t s future development depends upon the changing status of s o c i a l casework, and upon the p a r t i c u l a r influences upon family agencies. CHAPTER I I DEVELOPMENTS IN THE FAMILY SERVICE AGENCY Fee-charging was i n i t i a t e d i n The Family Service Agency of Greater Vancouver i n 1951. This Agency has, since i t s inception i n 1927, been dn the vanguard of private agency practice, and has also been closely a l l i e d with American developments i n the family agency f i e l d . A major factor influencing agency practice and i n predisposing to a fee-charging p o l i c y , was the c l a r i t y of purpose and function attained by t h i s Agency from i t s inception. The terms of reference and scope of the Agency were generally stated before establishment of the Agency as follows: " I t i s recommended that i n Vancouver a non-denominational family case working organization be created to supplement the work of the excellent r e l i e f agencies and special services. In such an organization social adjustment and family r e h a b i l i t a t i o n would be stressed and material r e l i e f should be made as small an item as possible." From t h i s clear beginning the Agency held to the special role of a preventative family centred service which, as seen o r i g i n a l l y by the founders, would be a central bulwarS i n the community, geared to f i l l a d e f i n i t e s o c i a l need i n reaching and helping people before complete family breakdown occurred. The Agenoy's early efforts i n establishing the Social Service Exchange, i n acting as an information and r e f e r r a l centre because of i t s knowledge of resources, and i n p a r t i c i p a t i n g i n a v i t a l way i n -the establishment of The Council of Social Agencies, point to i t s acceptance of a key role i n the organization and co-ordination of a l l soc i a l services helpful to f a m i l i e s . This Agency has held to i t s r i g h t to be f l e x i b l y selective regarding intake i n order to maintain a "caseload balanceiwith cases representative of the vari e t y of so c i a l problems for which the community wishes service and the problems which are troubling individual families but are not yet creating general community concern." 2 It i s clear from t h i s that the Agency has 1. Report of B.C. Child Welfare Survey 1927, p. 37 2. The Family Service Agency of Greater Vancouver, Its Purpose, Administra- t i v e Structure, Functions and Services. January 1956 - 24 -striven to r e t a i n a major part of i t s resources f o r work with families where gross pathology does not yet e x i s t and where casework may be e f f e c t i v e . Recently the Agency has moved toward a more d e f i n i t i v e consideration of i t s role i n r e l a t i o n to other s o c i a l agencies. Thisnas based on case studies, and has been productive of a real and valuable basis f o r helping the c l i e n t to reach the resource best equipped to meet his p a r t i c u l a r need. The Family Service Agency early a f f i l i a t e d with the Family Service Association of America (formerly Family Welfare Association of America). This a f f i l i a t i o n buttressed the Agencyls c l a r i t y of function by supplying professional nurture over the years, and by serving as a guide and medium of exchange of ideas i n r e l a t i o n to best family agency practices. Thus the Family Service Agency acted w i t h conviction i n keeping a l i v e the standards necessary to the p r o f i c i e n t performance of the job of helping families through d i f f i c u l t depression and war years. The insistence on a professionally trained and s k i l f u l s t a f f and on appropriate working conditions has led to a well-recognized service. There has been conviction about t r y i n g to r e t a i n r e l a t i v e l y low caseloads; about continued s t a f f learning and s t a f f p a r t i c i -pation i n discussing casework s k i l l s i n diagnosis, treatment and other elements of practice. This conviction i s based on the r e a l i t y that the complexity i n -herent i n problems of deteriorated human interaction can only be understood, and individuals helped, by the adequate provision of time, s k i l l , and c o l l a t e r a l and direct study. Present Functions of The Family Service Agency. The present functions of The Family Service Agency have a direct relationship to present and future fee-charging p o l i c y . Of the f i v e functions of the agency only one, that of dir e c t casework service, has a fee carrying property. The others are research; community planning and action to improve s o c i a l conditions and service; educational a c t i v i t i e s aimed to strengthen family l i f e ; and contributions to s o c i a l work education. I n the l i g h t of t h i s , p a r t i -c u l a r l y i n view of the energy and time spent on some of these a c t i v i t i e s , i t can be seen that fee-charging i s not l i k e l y to sustain the agency f i n a n c i a l l y , nor i s i t l i k e l y that the agency w i l l develop into a specialized service to fee paying c l i e n t s . This i s supported, of course, by other facts such as agency readiness, and desire to give service to families regardless of income. I t i s also important to note that t h i s agency places a major stress upon i t s role of p a r t i c i p a t i o n i n community planning and acti o n to improve s o c i a l conditions. Movement Toward Fee-Charging. I t i s evident that t h i s agency would, because of i t s c l e a r l y kept preventative function, and because of i t s s k i l l s , have coming to i t f o r help some fomilies 0 f a middle or high income status, and that i t would be influenced to consider fee-charging. Fee-charging was a c t u a l l y considered as early as 1943 when the Director reported to the Board that an increasing number of c l i e n t s were expressing a desire to pay f o r service* This was sh o r t l y a f t e r the beginning of the American experience i n fee-charging. At t h i s time, however, i t was decided that the idea of charging a fee was one that would require care-f u l study as i t was h i s t o r i c a l l y contradictory to the philosophy of the "charity movement .* A f t e r t h i s decision, c l i e n t s were encouraged to pay to the Community Chest i f they wished to be oharged a fee. Onoe again i n 1948 the agency con-sidered fee-charging, but again decided there was not enough j u s t i f i c a t i o n or evidence that such a p o l i c y would be appropriate or b e n e f i c i a l to the agency»s functioning. The f i r s t p o l i c y was established i n August 1951 a f t e r considerable study by a s t a f f committee and the Board of the agency. Fee-Charging 1951 - August 1955 I n establishing t h i s new p o l i c y i n 1951 the following reasons were given: Fee-charging would be l i k e l y to extend service to more people of the middle and higher income brackets who were accustomed to paying f o r professional help. Fee-charging would also be an a i d i n the helping process. I t would "tend to give the agency status i n the eyes of those who do, and those who do not pay. I t w i l l help remove the f e e l i n g they are asking f o r ch a r i t y . I t i s thought that i n many instances c l i e n t s would work harder at understanding t h e i r s i t u a t i o n , and doing something about i t i f they were paying f o r interviews. The c l i e n t ' s response to a discussion of fee-charging w i l l be a help i n diagnosiso B ^ This committee gave examples of how fee-charging might help in. s p e c i f i c ways with c l i e n t s , f o r example, that fee-charging would add to feelings of adequacy and be a concrete test of the c l i e n t ' s a b i l i t y to deal with r e a l i t y . In another example, i t was questioned i f a woman coming from a home where there was deprivation would value the service unless she paid f o r i t , as securing money had a high value i n her family. In another instance, i t was thought the fee would have increased a dependent c l i e n t ' s status i n his own eyes, and i f he balked at payment i t was thought the discussion of his need to get something f o r nothing, and h i s i n a b i l i t y to give, would have been valuable i n giving him insight into t h i s problem. Fees were not to be charged where f i n a n c i a l assistance was needed -where service to other agencies was involved - or f o r c o l l a t e r a l v i s i t s * 1. A Report of The Coramittee on Fee Charging i n the Family Welfare Bureau of Vancouver, B.C. June 1951, p»l. -27-The following range of fees was recommended to be used as a guide i n establishing a plan f o r the i n d i v i d u a l . Adjustments were to be made according to the p a r t i c u l a r s i t u a t i o n . Incomes up to #2,500 per year - up to $1.00 per interview Incomes from #2,500 to #4,000 per year - #2.00 per interview Incomes of #4,000 per year and up - #3.00 per interview and up.* I t was recommended that detailed procedure f o r handling fees should be developed by the s t a f f and adopted as experience indicates. I t was not to be publicized f o r at least a year. Fees were to be paid to the receptionist, such practice emphasizing that services included the t o t a l resources of the agency. I t was emphasized by the committee that fee-charging would not be f o r the purpose of supplementing the budget; that neither the amount nor the quality of the service offered i s i n any way related to the fee paid by the c l i e n t ; and that the agency has a desire and r e s p o n s i b i l i t y to continue to serve without charge those who are unable or unwill i n g to pay* What i s important to note i s that t h i s was an experimental and highly f l e x i b l e p o l i c y which never quite got beyond t h i s stage u n t i l the recent r e v i s i o n of p o l i c y i n 1956. This experience followed olosely the usual pattern i n family agencies where there has been at f i r s t no r e a l p o l i c y , then a permissive, experimental p o l i c y , followed by a tightened p o l i c y a f t e r years of i n i t i a l t e s t i n g of the effect of fee-charging on c l i e n t and worker a l i k e . Thus the f i r s t p o l i c y stressed that t h i s proposed charge be based on i n d i v i d u a l willingness and a b i l i t y to pay* showing the agency's primary concern with giving s e r v i c e , and the fear that the fee might deter needful c l i e n t s who blocked about paying* Fees were to be discussed with c l i e n t s during the intake process on a selective 1. A Report of The Committee on Fee Charging i n the Family Welfare Bureau of Vancouver, B.C. June 1951, p.2. basis* The intake worker was expected to diagnose and to postpone the discussion of the fee i f the client appeared so immature that he seemed unable to give. In practice the fee schedule was to be shown the client, and the amount of the fee mutually agreed upon* Participation by the client in this process was stressed* No attempt was to be made to verify the client's income or to know this amount in any exact way* The client's non-payment or delay in payment was to be clarified with him, with such a discussion becoming part of the treatment prooess* In the years 1951 - 1955, there were frequent staff meetings-around this topio and much thoughtful and sensitive discussion of the qualitative aspects of fee-charging* The question i f timing of the fee discussion was presented with various alternatives* The fee might be mentioned toward the end of the first interview with the explanation of agency services, but this might arouse some hostility in the client which might not be evidenced until after he leaves the office* There was some feeling that while the intake worker might mention fees i n i t i a l l y , the final arrangements should be made by the district worker who would be treating the client* It was expected that the professional tone of the relationship would thus be fostered, and that the fee would help put the worker and client on an equalized, participating basis* It was also expected that because the client paid a fee, his use of the service would be more focussed, and that the payment of a fee would be likely to increase the efficiency of the casework offered* In short, the fee was seen as a tool to increase the effectiveness of casework service* The process of fee-charging was to be personalized, and aimed at eliciting client participation* It was also thought that i f the client was too threatened by the prospect of casework treatment, he had a socially acceptable excuse in the fee for withdrawing* He might, therefore, leave -29-with his usual defenses functioning and be better able to return l a t e r * Some c f the exceptions to t h i s fee-charging p o l i c y have already been stated. A f t e r s t a f f discussion i t was also decided to exempt those c l i e n t s obtaining homemaker ser v i c e , as t h i s was already on a budgetary basis. I t should be mentioned also that there was not to be a charge f o r service to unmarried mothers, nor those referred elsewhere a f t e r a single interview, as these were thought of as being included under the category of services to other agencies. Shortly a f t e r the inception of t h i s p o l i c y , an analysis was made of one month's oases; that of February 1952ft1 In August 1955 a s t a f f committee on fee-charging brought back t h e i r f indings. The committee reviewed the basis of fee-charging i n the agency since i t s inception and concluded that i t was now time "to consider how e f f e c t i v e fee-charging has been i n reaching new c l i e n t s and providing a more professional focus i n service to c l i e n t s i n p general." This committee noted that some s p e c i a l problems had arisen and they spoke of "the need f o r a consistent p o l i c y with regard to fee-charging i n the administrative set-up of the agency. Def i n i t e p o l i c y and uniform practice i n fee-charging would help workers to be more effec t i v e i n developing a fee 3 charging plan as part of agency service*" They also suggested r e v i s i o n of the scale to take into account the number i n the family, and stated that research and evaluation were needed about such things as "(1) consistency i n practice i n discussing fees at intake; (2) the extent to which fee -charging has helped us reach a wider group i n the community; (3) how a discussion of fees has helped i n understanding the c l i e n t ; (4) the effect of fee-charging 1. Analysis of Factors A f f e c t i n g Fee-Charging i n the Cases Accepted f o r Service by the Family Welfare Bureau of Fancouver, February 1952. 2. The Fee-Charging Committee of The Family Service Agency, History and Philosophy of Fee-Charging i n Family Service Agencies, August 30g1955 p#4» 3« i b i d p.25 -30-i n our relationship with other s o c i a l agencies and other professions. The committee also suggested that perhaps fee-charging had s t i r r e d up mixed feelings i n s t a f f and that i t s introduction had been premature; that there was th e o r e t i c a l acceptance of t h i s p o l i c y but a number of areas i n which the plan f e l l down, showing mixed acceptance on the part of the casework s t a f f . This committee also f e l t that the po l i c y was past the experimental stage and should either be adopted as a uniform p r a c t i c e , or discontinued on the basis of an evaluation. Following t h i s committee report, the Executive Director of the agency spoke to the Board, using the report as a basis f o r discussion* A f t e r consider-ation of the s i t u a t i o n , the Board adopted the following resolution as a dir e c t i v e to the Case P o l i c y Committee: "That the Board, approving i n p r i n c i p l e the practice of fee-charging, refers t h i s matter to the Case P o l i c y Committee i n order that a polic y be established f o r future practice*" ^  The agency Case P o l i c y Committee met on October 20, 1955,?'to consider the Board d i r e c t i v e . The general comments of t h i s committee were to the effect that i n framing a fee-charging p o l i c y , no c l i e n t should be refused help because he cannot pay a fee; that s t a f f members bear i n mind the high cost of a single interview i n discussing a fee with i n d i v i d u a l c l i e n t s ; and that the t o t a l agency budget would not be sub s t a n t i a l l y reduced by the income from fees. I n dealing with the scope of such a proposed fee-charging plan the committee thought that i t should become a practice to discuss fees with c l i e n t s at the onset of contact. Clients from whom i t seemed inappropriate to ask fees were: 1. Minutes of Board Meeting, Family Service Agency of Greater Vancouver, September 14, 1955. -31« (1) Those i n need of f i n a n c i a l assistance. (2) Those who at once are referred to another agency. (3) Persons who come f o r the purpose of r e f e r r i n g a r e l a t i v e . (4) Clients who are markedly disturbed (Fees may be discussed l a t e r i f appropriate or with the marriage partner or parent i f appropriate). (5) Extremely immature parents whose family problems centre around t h e i r s t i l l unmet need "to receive** from parents. These oases oould be called "borderline protection." (6) Clients asked to return i n the interests of research. ^ The Committee also raised other points. They f e l t that c l i e n t s at present receiving service should have the new fee plan explained i f they were not i n one-of the groups excepted from fees. Clients should choose whether they preferred to pay fees week by week or be b i l l e d . The receptionist was seen as the l o g i c a l r ecipient of the fee a f t e r the o r i g i n a l arrangement was made by the worker. I t was thought of utmost importance i f fees were once arranged, that the worker carry through with them. I f a c l i e n t became delinquent i n payments, i t was thought he should be b i l l e d at l e a s t twice and then t h i s delinquency discussed with the c l i e n t by the worker* I t was thought that seasonal workers might be b i l l e d when income i s a v a i l a b l e * I t was noted that the agency was presently studying the scale used by the Family Counselling Service of Portland, Oregon* This scale included consideration of family size, and a "family plan" f o r paying fees whereby a set rate i s charged per week f o r the t o t a l family use of the service. This l i m i t s the amount of family expend-i t u r e on fees on a budget basis, as against charging each member a single fee without consideration of t o t a l family budgetting. I t also was thought that t h i s might encourage both husband and wife to participate i n the service* The Committee also recommended a s i x month study period a f t e r inception of the new p o l i c y , and recommended that careful thought be given to measurement of the v a l i d i t y of the plan during t h i s period* The consnittee asked f o r s t a f f 1. Minutes of Case P o l i c y Committee, October 20, 1955, pp.1-2. - 3 2 -consideration of a l l of these points. There followed two s t a f f meetings devoted to a f a i r l y intensive discussion of fee-charging. While many questions were raised there was general agreement that the fee-charging p o l i c y needed to be revised to make i t more consistent, and to f a c i l i t a t e uniform practice. S t a f f discussions were shared with the Board, but i t was decided i n December that the i n i t i a t i o n of the revised p o l i c y should be held up u n t i l ways and means were found to remove current pressures wi t h i n the agency. I t was f e l t necessary also to provide time f o r further professional thinking i n regard to c r i t e r i a f o r tes t i n g v a l i d i t y , and time f o r the Public Relations Committee to examine a l l aspects of implications f o r the community. There were further meetings of a s t a f f Committee to consider administrative methods to s e t up the plan and test i t s v a l i d i t y . Methods were sought whereby some factors might be tested within a study period following inoeption of a new p o l i c y . Among these faotors were how to assess evidence that fees helped c l i e n t s come to the agency f o r help e a r l i e r , or helped reach a wider c l i e n t e l e of wider eoonomio resources; how fees helped i n understanding the c l i e n t or helped or hindered c l i e n t s i n the use of the service; and how to assess the effect on other agencies and on the community's concept of the agency. Further s t a f f meetings were held i n February i n conjunction with the Family Service Association of America f i e l d consultant, Miss L. Cochrane. F i n a l l y , i n March, i t was deoided to i n i t i a t e the new plan on March 15, 1956* St a f f Discussion of Controversial Issues There were some intensive s t a f f discussions of the various aspects of fee-charging. Often there was a d i v i s i o n of opinion amongst-staff, which - 3 3 -seemed to go beyond the techniques of fee-charging and which seemed to r e a l l y question whether fee-charging i n i t s e l f was an appropriate agency function. There were some questions f o r which no d e f i n i t e answers were secured. There was recognition of the effects of fee-charging on the indi v i d u a l worker. I t was thought that fees would be l i k e l y to sharpen the s k i l l s and self-examination of workers, or that workers might tend to avoid fee "charging because of these implications. Recognized also were workers questions about the value of t h e i r service i n terms of money, and the l i k e -lihood of a varied approach to fee-charging by workers because of the dif f e r e n t meanings of money to them. When s t a f f discussion centered on the higher fee payments, some workers blocked. Miss Cochrane epitomized t h i s by saying that as workers we wonder i f we have given a p a r t i c u l a r c l i e n t say $5.00 wcKih i n an interviews She went on to say that i n s p i t e of c l i e n t s with higher incomes coming to family agencies there i s s t i l l something of the t r a d i t i o n with s o c i a l workers that our main job i s to help people, and i t i s a p i t y that money has to be brought into the s i t u a t i o n . She also f e l t that we sometimes think of working with people who have less m a t e r i ally than we do, whereas t h i s i s no longer the case* Another area of discussion was the timing of fee—charging. I t w i l l be r e c a l l e d that the Case P o l i c y Committee had recommended that t h i s be done i n the f i r s t interview. There was some s t a f f d i v i s i o n on t h i s point with most favouring the committee's recommendation. Those who wished to delay fee discussion f e l t that i f done i n the f i r s t interview i t would precede diagnosis, and usually occur before the c l i e n t had time to gain awareness of the value of the r e l a t i o n s h i p and the service. Under these circumstances a needful c l i e n t might discontinue service. This group that fee-charging might be delayed u n t i l the c l i e n t begins to see and want the service, at which time the fee -34-would emphasize the beginning of a treatment r e l a t i o n s h i p . This was not related to purposeful delay where the c l i e n t i s markedly anxious or disturbed. On the other hand, i t was f e l t that i t would be d i f f i c u l t f o r the worker to bring up fees a f t e r not mentioning them during the f i r s t interviews, and the c l i e n t s might w e l l f e e l i r r i t a t e d about not knowing from the beginning and f e e l the worker had not been honest with them. There was general agreement that information about fees be related to the general interpretation of agency services, and be given early. When a delay was occasionally necessary, i t was agreed that the c l i e n t should not be charged f o r the preceding interviews. Some thought that i t would be a good idea to s t a r t the f i r s t interview by t e l l i n g the c l i e n t something about the service generally, and that fees might be worked into t h i s . Others thought i t better to mention the fact that fees were charged, and then leave t h i s to be picked up at a more appropriate time. This was l e f t to ind i v i d u a l workers to handle with t h e i r c l i e n t s . I t was established, however, that c l i e n t s were to be t o l d about fees i n the f i r s t interview. The wives who come alone f o r service, and who dp not share i n the handling of the family money, were thought to o f f e r a sp e c i a l problem. I t was thought that t h i s non-sharing was a basic problem i n the marriage, and i t could, and should, be faced with the c l i e n t . At times the wife might pay a small fee out of her housekeeping money, while perhaps l a t e r as she develops a better relationship with her husband, she might be able to raise the issue with him. A l l i e d to t h i s was a husband who might use fees as an excuse to withdraw from the contact. This was seen as a symptom of general resistance to casework help. I t was thought that termination might result i n any case without fees$ as such a husband would not be l i k e l y to r e a l l y involve himself ' 1 ' - 3 5 -i n the contact. Delinquency i n fee payments was discussed. I t was thought that with a better administrative structure t h i s s i t u a t i o n would occur less frequently, and that i t also depended upon whether the terms made with the c l i e n t were r e a l i s t i c . I f delinquency occurs, i t should be handled with the c l i e n t , and the c l i e n t should be helped to see why he has not paid, i f t h i s i s appropriate diagnostioally. I t was stressed, however, that non-payment should not deter the c l i e n t from his use of a casework help, i f the problem was one that could respond to further help. B r i e f service oases were discussed a l s o , although not to the degree necessary i n view of the large proportion of these cases i n the general case load. I t was thought that where we are helping c l i e n t s i n the one interview, either d i r e c t l y i n a beginning treatment sense, or i n c l a r i f y i n g t h e i r problem, we should charge f o r t h i s servioe. There was less clear agreement on whether to charge a c l i e n t who i s helped to sort out h i s problem, but who i s then referred on to a more appropriate agency. I t was thought that while these c l i e n t s could not be charged, they should be t o l d about fees. With the agency Bbmemaker Servioe, i t was decided that a charge should be made f o r concurrent casework interviews, and that t h i s would keep the homemaker and caseworker team clearer i n people's minds. The administrative problems of charging and c o l l e c t i n g were discussed. While some favoured the worker c o l l e c t i n g the fee to observe the c l i e n t ' s way of paying, or because the c l i e n t might be too upset to go to the r e c e p t i o n i s t , the majority of s t a f f favoured c o l l e c t i o n by the receptionist beoause uniformity and a business-like approaoh were desirable* The most controversial issue amongst s t a f f was the charging of a - 3 6 -nominal fee versus the use of a s l i d i n g scale. There seemed also to appear a r e s i d u a l resistance to fee "Charging - at least i n r e l a t i o n to asking about income, and against charging r e l a t i v e l y high fees. A nominal fee was thought by some s t a f f members to o f f e r advantages because i t would be a "set" or " f l a t " fee, thus avoiding the indiv i d u a l i z e d discussion and s e t t i n g of fees with c l i e n t s , and avoiding the necessity of asking income. Some c l i e n t s were observed to-ask i f there was not a "set" fee they might pay. This was sometimes because they are reluctant to reveal t h e i r income. I t was believed by some s t a f f members that i n an i n i t i a l interview the c l i e n t i s somewhat vulnerable, and i s assessing whether the worker i s r e a l l y concerned and can r e a l l y help. The c l i e n t may see the enquiry about his income as extraneous, and even possibly as unnecessary probing* In t h i s connection i t was thought question-able practice to avoid asking about income by showing the c l i e n t the printed fee scale, and l e t t i n g him set his own f e e . The d i f f i c u l t y of asking c l i e n t income was thought to be p a r t i c u l a r l y applicable to the higher income c l i e n t who was said to be unaccustomed to revealing his income. A nominal fee was said to have the advantage of being easier f o r the worker to charge, and to make f o r s i m p l i c i t y i n agency administration. The other arguments f o r a nominal fee r e l a t e to i t being a small fee, as some s t a f f members f e l t that a s l i d i n g scale up to a f a i r l y high maximum fee was a step backward i n view of current trends such as medical and hos p i t a l insurance. There i s evidence that present day families are s e c u r i t y consoious and wish to plan f o r t h e i r expenditures, and do not l i k e unexpected contin-gencies to a r i s e . However, i t was thought that people do not object to a nominal payment, nor do they object, f o r example, to a planned monthly payment f o r medical coverage. A few c l i e n t s have argued that t h e i r -37-contributions to the Community Chest should ensure s o c i a l s e r v i c e benefits f o r them, should the need a r i s e . At the same time, the charging of a nominal fee by such agencies as the V.O.N, and the Y.M.C.A., seems acceptable to people. In any case, most agency c l i e n t s come i n the group that would pay #1.50 per interview or l e s s , so that i n effect the agency i s most often charging what amounts to a nominal fee. The major consideration leading to the decision to adopt a s l i d i n g scale included that there should not be any d i f f i c u l t y i n asking about income -that the reluctance and the fears are wit h i n us rather than within the c l i e n t . At the l a s t s t a f f meeting i t was asked i f c l i e n t s have ever r e a l l y objected to being asked about income, and only one instance was given. I t was thought that a fee geared to income would be a more meaningful payment to the c l i e n t than a nominal fee. I n t h i s way a s l i d i n g fee would f o s t e r the therapeutic values inherent i n fee -charging, such as a sharpening of focus, diagnosis and treatment, whereas a nominal fee would not be so l i k e l y to accomplish t h i s . At the same time, f o r the lower income c l i e n t a nominal fee may not r e a l l y be nominal at a l l . This was connected to majority s t a f f thinking that the most democratic assessment would be based on a b i l i t y to pay, such as i s seen i n progressive income tax. From the public r e l a t i o n s point of view i t was believed that a s l i d i n g scale might help create interest and understanding Jrhat s o c i a l work i s a professional service, and the contributor to the Community Chest should be more s a t i s f i e d knowing that c l i e n t s were being charged according to a b i l i t y to pay. Perhaps the most s i g n i f i c a n t r e s u l t of these s t a f f meetings was the swing, at the f i n a l s t a f f meeting, to a pos i t i v e and enthusiastic acceptance of s t a r t i n g a new fee programme. Coming out of t h i s was the s t a f f ' s decision to t e l l a l l c l i e n t s about fees whether i t was appropriate to charge them or -38-not. This was fostered hy a desire to make fee-charging a widely known agency function, and i t was also thought by t e l l i n g even c l i e n t s i n need of f i n a n c i a l assistance and borderline protection cases, that t h i s would be a good way of broadening every c l i e n t ' s concept of the t o t a l agency service a v a i l a b l e . This a l l - i n c l u s i v e p o l i c y was even thought to apply to c l i e n t s who were disturbed or i n an anxiety s t a t e , as t h i s mentioning would not be l i k e l y to be meaningful to them, but l a t e r on might make a difference i n t h e i r use of service. Following thess discussions, the agency started on a three^nonth study period to test the effectiveness of the new fee-charging polioy. This was l a t e r extended to the end of J u l y 1956, making the period four and one-half months altogether. The general plan f o r charging fees, while s t i l l vague i n some respects, was to t e l l a l l c l i e n t s about fees i n the f i r s t interview, and to charge those not excluded on the basis of a s l i d i n g scale of f e e s . 1 The exclusions to fee-charging were l a i d down i n accordance with the recommendations of the Case P o l i c y Committee. These exclusions, together with questions related to fee-oharging p r a c t i c e , were printed on the back of the intake application forme 2 This questionnaire was to be completed f o r every case following the i n i t i a l contact with the c l i e n t . A second questionnaire was printed on the closing cards, thus enabling the workers to be more evaluative of fee-charging when the case was closed* A "Key to Questionnaire 1,** together with a b r i e f statement on Fee-Charging 4 Procedures and Philosophy, were di s t r i b u t e d to s t a f f . At the inception of t h i s study period there were fourteen f u l l time and three part-time s o c i a l workers on s t a f f . Toward the end of the 1. see Appendix "Aw f o r fee scale. 2. see Appendix WB" f o r Questionnaire 1. 3. see Appendix nC. w 4. see Appendices WD W "E" and n F . B study period three additional s t a f f members were s ecured. The f u l l establishment f o r the agency i s a professional s t a f f of nineteen, so that during most of the study period the agency was short-staffed. F i f t e e n s t a f f members had previous experience with fee-charging, l o u r of the s t a f f had no previous experience. Fourteen s t a f f members had more than f i v e years casework experience, and f i v e of these had more than f i f t e e n years experience. CHAPTER I I I FEE-CHARGING IN PRACTICE 4 questionnaire form was to be completed for each case i n i t i a t e d 1 during the study period for the months of A p r i l to July i n c l u s i v e . A major d i f f i c u l t y encountered i n evaluating fee-charging for the period was that these questionnaires were very often incomplete i n regard to general questions about income, and reactions from the community; and the recording i n the cases often made no reference to the particulars of why a fee was 2 not charged. In addition, i t i s d i f f i c u l t to t e l l i f a fee was mentioned at a l l to some of the c l i e n t s , with whom the workers did not actually make a sp e c i f i c fee proposal. The following table shows the reasons given by the workers f o r not charging a fee: TABLE 1. Clients Not Charged a Fee Reasons Number In s u f f i c i e n t income, or f i n a n c i a l d i f f i c u l t i e s 72 Supervised Homemaker Cases 23 Bri e f Service Cases 169 (a) Cases referred elsewhere 69 (b) No c l i e n t contact 19 (c) Telephone Contact only 44 (d) Contact with r e l a t i v e only 4 (e) Other b r i e f service cases 33 Client too emotionally disturbed 39 Fee-charging postponed 24 Client resistance 14 Fees not mentioned by the worker 4 345 1. See Appendix A f o r Form of Questionnaire 2. Out of the t o t a l intake of 425 cases, 402 questionnaires were completed. There were 34 cases where a fee was charged, 48 cases where a fee was only discussed, and 320 cases where a fee was not discussed. In addition to the above d i s t r i b u t i o n , there were 23 cases where no information was provided by the worker as to why a fee was not charged. The reasons given by workers f o r not charging a fee do follow the exemptions agreed upon before the star t of the four month study period. There are two exceptions to t h i s , B r i e f Service Cases and Supervised Homemaker Cases. B r i e f Service cases were not thought of as necessarily being excluded from the fee-charging p o l i c y . Supervised Homemaker cases were o r i g i n a l l y to be charged^ but i t was l a t e r decided to exempt t h i s group of c l i e n t s who were already contributing according to a b i l i t y to pay. There were 231 families who were c l e a r l y not e l i g i b l e to pay a fee. These were 72 families with f i n a n c i a l problems, 23 families using the Super-vised Homemaker service, and 136 families -who had no actual contact with the Agency. There were 160 families where the e l i g i b i l i t y f o r fee-charging was more questionable, or more to be decided by a qu a l i t a t i v e casework judgment; for example, 39 c l i e n t s were not charged because of personality d i f f i c u l t i e s , with the assessment of t h i s factor being a matter of casework judgment. In a simi l a r sense, workers decided to postpone fee-charging i n 24 cases^and not to charge with 14 c l i e n t s because of resistance. In a t o t a l of 46 cases, the reason f o r fees not being charged was unknown because workers either did not complete the Questionnaire or because the Questionnaire form was missing. There were 33 cases marked as "Brief Service" by the workers. I t i s possible that some of these families might have been seen f o r one interview, as opposed to a telephone contact only".* Tyro 0 f these types of cases were actually 1. A Brief Service case i s defined as a case where there are less than two " i n person" interviews, regardless of the number of telephone c a l l s or lett§j»s, and where a casework service has been given. - 42 -charged a fee, one being charged on the basis of a completed service i n the one interview, and the other on the basis of an exploratory i n t e r v i e w y i n which the c l i e n t was helped but did not wish to continue* I t i s possible that some of the previously mentioned 33 cases could have been charged on t h i s basis. The workers were not so l i k e l y to do t h i s consistently because a f i r m decision had not been made about t h i s group of cases. The remaining cases are those where, with four c l i e n t s , the workers forgot to mention a fee. I t i s d i f f i c u l t to assess the potential range of fee-charging because of these variable fac-tors mentioned, and the lack of d e f i n i t i v e standards as a basis f o r making a casework judgment. I t i s evident, however, that a large proportion of families are not presently e l i g i b l e to pay fees. The Incomes of Clients Information i s incomplete regarding the income levels of c l i e n t s coming to the Agency. In only 122 cases was there an income shown on the Questionnaire. The median for t h i s t o t a l group of families was $300.00 per month. The median income f o r those c l i e n t s not charged a fee was $275.00 per month. There were 63 cases where the income i t s e l f was s u f f i c i e n t f o r fee payment but where these c l i e n t s did not pay a fee. I t would seem possible also that a proportion of those cases where income was not shown by the workers would also be f i n a n c i a l l y e l i g i b l e f o r a fee payment. The range of incomes for the fee-paying group was $125.00 to $1,000.00 per month. The incomes here were not as widely dispersed as those i n the group which did not pay fees. I t i s interesting to note that only 9 fee-paying c l i e n t s were asked d i r e c t l y about t h e i r income. - 43 -The Consistency of Fee-charging Practice A major objective i n i n i t i a t i n g a revised fee-charging p o l i c y was to charge fees on a more consistent basis. I t was hoped that there would be uniformity as to when, and how, c l i e n t s were charged, and which were to be excluded. More consistency was sought i n charging a l l of those c l i e n t s who were e l i g i b l e f o r payment. I t i s evident, however, that considerable v a r i a t i o n s t i l l e x ists i n res-1 pect to the main areas i n need of t h i s consistency. 1. The Timing of Fee-Charging: There was considerable v a r i a t i o n i n when the c l i e n t s were t o l d that a fee might be charged. Perhaps t h i s was because of the dual need to t e l l a l l c l i e n t s about fees, and to charge a fee with some of them. In the fee-paying cases, nine c l i e n t s were informed about fees i n the f i r s t telephone contact and fees were l a t e r charged i n the f i r s t interview. With twenty-two c l i e n t s , fees were i n i t i a l l y discussed i n the f i r s t interview, and with the remaining three c l i e n t s , i n the second interview. There was somewhat of a different d i s t r i b u t i o n i n the non-fee cases. Eight of these c l i e n t s were f i r s t told.about fees during the i n i t i a l telephone contact, but only two cases continued beyond t h i s point. The remaining 27 c l i e n t s were t o l d about fees i n the f i r s t interview. The most usual, and successful technique was to discuss a fee at the end of the f i r s t interview i n a manner related to the explanation about how the Agency would offer help. The s t a f f e f f o r t to t e l l a l l c l i e n t s about fees early i n the contact was not appropriate with some c l i e n t s . This is p a r t i c u l a r l y true i n the 17 cases where the c l i e n t was t o l d about fees on 1. Based on the study of 34 cases where a fee was charged, and 36 cases where a fee was discussed but not charged. - 44 -•fchs telephone* Where these c l i e n t s did continue beyond the telephone c a l l , i t was evident that the i n i t i a l explanation had not been e f f e c t i v e . This was par t l y because of unsureness on the part of the workers, and p a r t l y because of the inherent d i f f i c u l t y of communicating i n t h i s way, as contrasted to an interview where the c l i e n t has the opportunity to begin to use help, and where the reactions to a proposed fee may be observed. Some c l i e n t uncertainty and anxiety persisted to the f i r s t interview, and t h i s seemed an unnecessary test of c l i e n t motivation. I t was also d i f f i c u l t to assess the c l i e n t ' s a b i l i t y to pay and to comfortably waive fees i f indicated, so that some cl i e n t s came prepared to pay despite being f i n a n c i a l l y i n e l i g i b l e . Some of the c l i e n t s who did not continue said, for example, that they had decided to see a minister, or to t a l k things over between themselves f i r s t . While some of these reactions may have occurred i n any case, a premature mentioning of fee-charging seemed to add a deterrent factor. I t i s in t e r e s t i n g to note that on very few occations was the c l i e n t charged a fee after the f i r s t i n t e r -view. This seems to indicate that i t i s d i f f i c u l t to introduce t h i s topic l a t e r i n the case, i n spite of the fact that workers marked twenty-four Questionnaires to the effect that fees might possibly be discussed l a t e r . 2. Setting the Fees There were only fourteen cases where the fee was charged r e a l i s t i c a l l y on the basis of family income. Three other c l i e n t s were charged according to the fee scale but on the basis of in d i v i d u a l rather than family, income. There were nine cases where the fee was not based on the fee scale, - 45 -but was rather a nominal fee. In s i x other cases, the c l i e n t s set t h e i r own fees, and i n the remaining two cases fees were lowered i n an attempt to f a c i l i t a t e payment* The reasons varied for charging what amounted to a nominal fee* In four cases, the i n i t i a t i v e about fee-charging was taken by the c l i e n t and while these c l i e n t s were a l l below the fee scale, the workers did accept a nominal payment. Mrs. Monk, for example, asked about fees anxiously during the i n i t i a l phone c a l l . Her husband was not working, and according to her, had not yet recovered from a recent period at Crease C l i n i c . Despite some reassurance during the telephone c a l l , Mrs. Monk announced at the end of the f i r s t interview that she had come prepared to pay. The worker accepted t h i s payment and, i n t h i s case, as with the others, the chief reason for accepting payment was a feeli n g that i t might be therapeutic for the c l i e n t to pay. In these p a r t i -cular cases, i t seemed that i t would have been more therapeutic to comfortably waive the fee. These were housewives, with l i t t l e access to what l i m i t e d family income was available. A nominal fee was more v a l i d l y proposed on two other cases; with one to encourage p a r t i c i p a t i o n , and with -the other to l i m i t the c l i e n t ' s prolonged, but not constructive, use of service. While there was possibly some therapeutic gain from charging fees with these two c l i e n t s , the d i f f i c u l t y with a l l of these cases i s that consistent charging according to a b i l i t y to pay i s s a c r i f i c e d to f l e x i b l e casework judg-ment. I t i s inevitable that some degree of casework judgment i s necessary* - 46 -However, i t i s perhaps more important to f i r s t seek uniform, consistent procedures which are acceptable to c l i e n t s , and to the community, A separate but related problem are those cases where the c l i e n t s set t h e i r own fees. In some cases the c l i e n t was shown the fee card and allowed to piok out t h e i r own category of fee payment* There seemed to be two major d i f f i c u l t i e s i n t h i s procedure. In the f i r s t place, the actual income does not always become known^ so that e l i g i b i l i t y f o r fee payment cannot r e a l l y be v e r i f i e d . The c l i e n t may choose a low fee but may not r e a l l y be e l i g i b l e f o r fee payment. This was the. case with Hr. Rowe who hesistantly agreed to a $1.00 fee a f t e r looking at the fee card. I t seemed l i k e l y from l a t e r knowledge about finances that he should not have been asked to pay. With Hrs. Cook, the worker was fortunate i n fe e l i n g l a t e r that something was wrong about the amount of the fee. He asked Mrs. Cook about the actual income, and found that the charge should have been |6.00 per interview rather than the $10.00 fee i n i t i a l l y chosen by Mrs. Cook from the fee card. A different s i t u a t i o n exists where the c l i e n t seems to have some reluctance to disclosing income. This was the case with 4 c l i e n t s . For example, Mrs. Robinson decided she should pay $2.00 per interview, and by her manner indicated that further exploration of t h i s would not be welcome. While the other c l i e n t s did not block t h i s much, the workers di d choose to accept the figure set by the c l i e n t . In the f i n a l two cases the c l i e n t s had gone along f o r several interviews, preceded by only a rather vague discussion about the amount of the fee. - 47 A f l a t amount of $10.00 was f i n a l l y paid by one c l i e n t to cover 3 interviews. In the other case, the worker suggested a compromise settlement, and while t h i s seemed agreeable to the c l i e n t , the fee was not paid* 5. General Consistency; The present pol i c y of fee-charging i s not being con-s i s t e n t l y applied, with the exception of those cases where t h i s i s adequacy i n the matter of income, and c l i e n t use of service. These c l i e n t s were f a i r l y w e l l motivated f o r casework help, and accepted fees as an appropriate charge f o r a professional service. Aside from t h i s area there was considerable v a r i a t i o n i n the approach to c l i e n t . Some c l i e n t s were just t o l d about fees, without there being known e l i g i b i l i t y , while a considerably larger number of c l i e n t s i n a similar category, were not t o l d about fees. Some c l i e n t s , below the fee scale, were charged for therapeutic reasons, while others were not s i m i l a r l y charged. When c l i e n t s i n i t i a t e d fee discussion, the workers seemed uncertain whether t h i s indicated a desire to pay, or some anxiety and resistance. There were 39 c l i e n t s excluded because of personality d i f f i c u l t i e s , while some 14 c l i e n t s were asked to pay a fee despite what seemed to be i n h i b i t i n g personality d i f f i c u l t i e s centered around a need to receive, not give. There was considerable v a r i a t i o n i n the manner that workers charged fees. Some workers seemed to charge comfortably, on a r e a l i s t i c f i n a n c i a l basis, while with others the approach seemed more tentativ e , leaving the onus of fee s e t t i n g , and payment, largely with the c l i e n t . The degree to which the f u l l development of fee-charging took place i s hard to measure. An analysis of the large number - 48 -of cases necessary to determine t h i s , i s beyond the scope of t h i s present study. However, there are some indications that the coverage of fee-charging was not in c l u s i v e of a l l c l i e n t s . Fees were only charged by nine s t a f f members. I t i s true that the supervisory and intake duties of other st a f f members would reduce the opportunity for charging fees, but they probably should have been represented by a few cases. In addition, there were 46 c l i e n t s whose e l i g i b i l i t y f o r fee payment i s not known, and some question about the 24 cases where the fee was to be discussed l a t e r , and with some of the Brief Service cases. These variations i n consistency seemed pa r t l y due to a lack of conviction about fee-charging, and on un-certainty about techniques. This l a t t e r d i f f i c u l t y was p a r t l y due to an overly f l e x i b l e choice of methods available to s t a f f , together with some uncertainty about t r y i n g a new technique. In addition, at the beginning of the new fee p o l i c y , the administrative structure was somewhat cumbersome, and not conducive to smooth fee s e t t i n g , or to making business-like payment arrangements. A major s t a f f d i f f i c u l t y seemed to be i n the area of asking c l i e n t income, and the reluctance to obtain t h i s v i t a l information, made a s i g n i f i c a n t contribution to many of the inconsistencies that appeared. Therapeutic Implications of Fee-Charging I t i s thought that a money payment by the c l i e n t w i l l perhaps have a positive influence on the way he values and uses casework help. This therapeutic effect i s influenced by the degree to which the fee process i s personalized between worker and c l i e n t and by the manner i n which the worker introduces the fee proposal. I f the worker i s to charge and c o l l e c t the fee, t h i s i n t e n s i f i e s the personal element, and - 49 -i n t e n s i f i e s the therapeutic climate between worker and c l i e n t . In a simil a r way, i f the worker charges the fee i n a tentative, voluntary way, the proposed fee payment contains a greater degree of emotional content. In the majority of cases, a fee was charged i n a way which did not en-courage undue c l i e n t emotional response. While t h i s matter-of-fact approach was probably the best technique, i t did mean that there were few overt reactions from which to assess the v a l i d i t y of the therapeutic values of fee-charging. There does seem a general i n d i c a t i o n that the necessity to charge fees was a good reminder to focus on the interpretation of Agency service. In addition, there seemed a general "sharpening" of the degree to which workers evaluated diagnostic elements, and planned treatment, i n the fee:cases. The workers answered a Questionnaire at the time the cases were closed, evaluating the various therapeutic factors. The analysis of these factors i s , however, l i m i t e d because responses were only Yes or No, and there was l i t t l e qualifying material i n the case records. 1. Did the Fee F a c i l i t a t e the Client's Seeking Help?; The workers in d i c a -ted that fee-charging helped 13 c l i e n t s come to the Agency. I t i s d i f f i c u l t to i s o l a t e the effect that the fee might have had i n bringing the c l i e n t to the Agency f o r help. Techniques other than evaluative case reading, such as matching fee and non-fee cases, or comparing changes i n caseloads from year to year, would be l i k e l y to be more objective and meaningful. This observation holds true for the evaluation of a l l of these therapeutic factors. The question f o r these families i s would they have sought help i n any case? This can only be answered with any - 50 -degree of certainty f o r 3 cases. The doctor that referred Mr. and Mrs. Colt suggested that a fee would help them come and help them work harder on t h e i r problem. This was confirmed by the reactions of both husband and wife. Mrs. Colt said "thefe w i l l be a charge, of course?". Mrs. Ford said, a f t e r the fee was set, "Now I can f e e l free to c a l l you". The Henrys probably would not have come to the Agency i f the fee had not been a part of the interpretation of professional Agency services, as opposed to the well-meaning sympathy of neighbours about a serious family d i f f i c u l t y . In six other cases there were positive reactions. For example, Mrs. Hardy said she and her husband could pay the maximum fee and "would be glad to do so". Mrs. King was also helped by being able to pay the maximum fee. In these, and i n some cases where there was no spec i f i c reaction, the fee seemed to have a def i n i t e part i n the acceptance of help by the c l i e n t s , but cannot be said to have s i g n i f i c a n t l y affected t h e i r seeking help* 2. The Fee and Client Participation*. Again, i t needs to be asked i f the fee was to any degree s i g n i f i c a n t i n bringing about t h i s thera-peutic factor. The workers thought that the fee did have the effect of f a c i l i t a t i n g c l i e n t p a r t i c i p a t i o n i n seventeen cases, and t h i s i n i t s e l f needs to carry some weight. There was s u f f i c i e n t q u a l i t a t i v e evidence i n s i x of these cases to indicate a d i s t i n c t or noticeable difference because of the fee payment. Mrs. Ford " f e l t free to c a l l the worker when she needed t o " . Mrs. Dorgan was strengthened by the contact and able to take decisive steps to free herself from an "impossible" marriage. The fee enhanced t h i s process of ego buil d i n g , and increased her p a r t i c i -pation because of her growing b e l i e f i n herself, and i n the value of the service f o r her. The fee was an important element i n holding the Henry-family i n contact with the Agency. This was a case where the worker had to "reach out" to the family and yet respect t h e i r right of self-determination. The fee seemed to r e a l l y help t h i s process. The fee enabled the family to come and to p a r t i c i p a t e , and also gave them freedom to express t h e i r need to terminate f o r a while when the burden of the loss of a c h i l d was best borne alone. With Miss MacDonald the fee was a strong element, representing professional help as opposed to "friendship" counselling. She had a tendency to "shop around" for casual help, but seemed careful not to become too involved i n the process. Her decision to offer fee payment coincided with her beginning to r e a l l y use Agency help. Mrs. Hardy was "glad to pay the fee". The casework objective with Mr. Sharp was tohslp him f e e l more adequate, p a r t i c u l a r l y i n r e l a t i o n to his business, which was f a i l i n g . The worker saw a small fee as a way of reinforcing his feelings of adequacy and helping bring him back to greater independence. In the remaining nine cases, there were varying degrees of probab-i l i t y that the fee aided c l i e n t focus and p a r t i c i p a t i o n . For example, the Colts probably "worked harder on t h e i r problems" as suggested by the referring doctor, because of the fee payment. Money was r e a l i s t i c a l l y important to Mrs. Hobart. She wanted to pay a fee, and kept the amount well within her a b i l i t y to pay. The f a c t that she paid seemed to make a difference i n her use of the service. To Mr. Todd money meant power and status. I t seems probable his evaluation of the Agency, and of his own f e e l i n g of status, were increased by fee payment, with consequent values i n increased p a r t i c i p a t i o n . In a t o t a l of four cases, including MacDonald and Hobart, a delayed decision to pay meant the beginning of the treatment re-l a t i o n s h i p . - 52 -3. Did the Fee Help the Client Recognize the Agency's Function?; In answering t h i s question, workers interpreted i t to mean that the fee helped the c l i e n t see the Agency as a source of professional service© They indicated that the fee aided t h i s process with 22 fa m i l i e s . There were few cases where there was a sp e c i f i c enough c l i e n t reaction worthy of comment. A l l c l i e n t s seemed to accept the fact that professional help was being offered. With a few c l i e n t s there was some evidence that the fee enhanced the status of the Agency. In t h i s way Mrs. Rogers was helped to see that she could not prolong a p r o f i t l e s s use of service, and Mr. Sharp saw the Agency as having professional authority and knowledge, i n helping him gain recognition of his need f o r psychiatric help. 4. Did Fee Payment Aid Diagnosis?? The workers judged that fee-charging provided diagnostic information i n nine cases. In two examples, the worker made t h i s judgment because discussion of the fee revealed d e t a i l s about income, and the handling of money w i t h i n the family. In a general way, the c l i e n t s ' reactions to the fee did not add new information for the.workers. These reactions t y p i c a l l y served to substantiate knowledge already known about the c l i e n t s ' c h a r a c t e r i s t i c functioning. I t i s true that some overt reactions to a proposed fee seemed to a l e r t the worker, and to confirm other diagnostic information with more certainty for the workers. Mr. McGrath's strong reaction against the fee, for example, confirmed the knowledge about his f r u g a l i t y , and his punitive attitude to his w i f e . This r e a c t i o n also consolidated the worker's impression that t h i s c l i e n t would not be able to r e a l l y use casework help. - 55 -With some c l i e n t s , the major diagnostic information given took the form of a "capsule" re-enactment of a source of c o n f l i c t . Miss MacDonald handled the fee payment i n a way which acted out her c o n f l i c t about giving and getting. She said of herself that she gives to some people "to obtain friendship", or conversely, she takes from others to obtain the love she needed. In delaying fee payment, Miss MacDonald indicated her indecision about what role to assign to the worker. At f i r s t , she took from the worker, but her decision to pay, after delaying, indicated growth i n being able to accept help, and also t o give w i t h i n the same rel a t i o n s h i p . In a si m i l a r way, Mrs. Main's reaction to fee payment was r e a l i s t i c and conforming. One of her major c o n f l i c t s was whether she wanted to be conforming or non-conforming. She was helped to stop pretending the l a t t e r . Mr. Brown needed to assert his masculinity by taking over fee payments for his wife; while Mr. Cooper showed an i n a b i l i t y to give generally, through his resistance to fee payments. In another group of c l i e n t s , the manner of approaching a proposed fee payment was c h a r a c t e r i s t i c , Mrs. Hardy was aggressive and business-l i k e , while Mr. Rowe's manner was hesitant. Reactions, i n other cases were ind i c a t i v e of family relationships. Thus Mr. Rogers allowed his wife to pay the fee, while Mrs. Sharp wanted her husband to pay f o r her. Mrs. Gordon revealed an almost i n f a n t i l e need to "receive" from her husband i n her reaction to the fee. In several other cases there was revealed an i n a b i l i t y to share - 54 -between husband and wife. F i n a l l y , the fee payment served to externalize feelings about reoeiving help. Mrs. G i l l ' s response to fee-charging was to ask, "How long w i l l i t take?". In a l l of these cases, the usefulness of the c l i e n t ' s reaction to the charging of a fee was dependent upon how i t could be used i n a treatment sense, rather than the contribution i t made to diagnosis. Client Resistance The analysis of c l i e n t reactions to a fee-charging proposal was made d i f f i c u l t because such reactions were most often not overt; and because i n those cases where elements of resistance seemed to appear there were a number of variables present. These variables such as a b i l i t y to pay, resistance to casework service, and personality factors were often i n t e r - r e l a t e d elements i n respect to the understanding of the c l i e n t s ' reactions to fee-charging. Any attempt to i s o l a t e a single variable and offering of t h i s as the s i g n i f i c a n t reason f o r a group of c l i e n t s ' p a r t i c u l a r reactions inevitably reduces the perception of the t o t a l forces operating i n single cases. This d i f f i c u l t y i s compounded where, as i n the cases under study, there were f a i r l y wide variations between workers i n t h e i r handling of fee-charging procedures. With t h i s i n mind, the following i s an attempt to examine c l i e n t resistance to fee-charging • A. Cases Involving Personality D i f f i c u l t i e s In the fee cases there were fourteen cases where the c l i e n t s ' personality d i f f i c u l t i e s s i g n i f i c a n t l y influenced t h e i r a b i l i t y to use casework help, and also influence the pattern of fee-charging. There - 55 were also seven non-fee cases where t h i s was true. These personality d i f f i -c u l t i e s can most usefully be divided into those where the c l i e n t exhibited varying degrees of unmet dependency needs, or where there was some degree of f i x a t i o n at the "anal" stage of personality development. 1. D i f f i c u l t i e s i n Dependency; There were eleven cases where the c l i e n t exhibited disturbed functioning i n the area of solving t h e i r dependency needs. They were variously described by the workers as being immature, n a r c i s s i s t i c , dependent, passive, or as having feelings of worthiessness, i n f e r i o r i t y , or anxiety. Mr. Cash i s f a i r l y t y p i c a l of t h i s group. Mr. Cash came to the Agency seeking help i n affecting a r e c o n c i l i a t i o n with his wife. The worker recorded that Mr. Cash appeared to be a dependent, anxious man who was quite agitated about his problem. Mr. Cash's reaction to the worker's explanation about fee-charging was to accept the fee i n a "cursory" way, although r e a l l y avoiding any arrangement about payment. Mrs. Cash was seen. She said her husband needed constant reassurance about his masculinity; that he seemed pre-occupied about his sexual v i r i l i t y , and had sought extra-marital a f f a i r s . Mrs. Cash had decisive feelings about not going on with the marriage. In view of t h i s , the worker closed the case w i t h the comment that Mr. Cash showed a lack of any interest i n s e l f change. There was no issue made about fee payment, and no payment was made. There were f i v e other cases very s i m i l a r to the Cash case, i n that the c l i e n t was passive about the proposal to charge a fee, but did not pay. A l l of these c l i e n t s needed to "receive" rather than giving themselves. They sought help f o r some modification of t h e i r environment rather than f o r any change i n themselves. The attitude of the workers was permissive. There were attempts made i n two of these cases to bring the matter of the fee to some conclusion. The worker with Mrs. Scott attempted to set a compromise amount, much lower than the scale i n order to help the c l i e n t f e e l comfortable about not having paid. The c l i e n t seemed to accept t h i s compromise, but did not ac t u a l l y pay even then. In the other case, the worker was successful i n resolving the problem of g u i l t about non-payment, without l e t t i n g t h i s be used by the c l i e n t to withdraw from the contact. Mrs. M i l t came f o r help about her husband's drinking. Fees were mentioned on the telephone and the worker "detected a s l i g h t resistance". There was no more said about a fee u n t i l i n the fourth interview Mrs. M i l t asked the worker i f there would be a charge, as she was rather worried about i t . The worker re-assured her about t h i s , t e l l i n g her that the fee was adapted to income. In the previous interview, Mrs. M i l t had shown signs of growing dependency upon the worker. After the fourth interview the worker recorded that Mrs. M i l t had brought up the fee payment f o r two reasons: She had a certain resistance to coming now she was beginning to be r e a l l y involved, and perhaps she had wanted the worker to t e l l her she would give some-thing for nothing. In the f i f t h interview the worker took the i n i t i a t i v e - 57 -i n verbalizing Mrs. M i l t ' s resistance. The worker asked i f Mrs. M i l t f e l t that too much was being asked of her. Mrs. M i l t relaxed and said she knew she had to do the most i n the marriage. Fees were discussed again, t h i s time not from the point of view of being used by the c l i e n t to break the contact, but on a more r e a l i s t i c b a s i s . Mrs. M i l t said she would prefer not to pay since "her husband would notice any unexplained payment". This was accepted by the worker. While t h i s case was handled s k i l l f u l l y , the question for a l l of these cases i s whether to attempt to charge a fee at a l l . Certainly the telephone explanation about fees was destructive i n t h i s case. There were a further two cases where the workers did not attempt to charge a fee with the husbands, because of personality factors. In one case, the worker brought up fees with Mrs. Gray, who was very immature and n a r c i s s i s t i c . She brushed aside the proposal saying her husband would be the one to t a l k t o . Mrs. Gray was very demanding about her dependency needs. She was asking to be looked a f t e r and protected by her husband. Mr. Gray seemed more mature than his wife, but quite withdrawn. The worker evidently was influenced by t h i s couple's impaired a b i l i t y to use help i n not following up the fee-charging proposal. S i m i l a r l y , Mr. Tracy was not asked to pay a fee. The question with these l a t t e r cases i s the degree of adequacy present, and whether t h i s might be reinforced by fee payment. Mr. Gray may have been helped to f e e l more adequate i f the worker had helped him pay for himself and his wife. These were both objectives of case-- 58 -work treatment. Both of these husbands would be aware of fees through t h e i r wives, and probably somewhat uncomfortable about non-payment. This t o t a l group of cases require careful casework judgment, or an administra-t i v e structure designed to exclude them more d e f i n i t e l y . There are d e f i n i t e l y some c l i e n t s where the severity of unmet dependency needs r e a l l y means that fee payment cannot be accepted. I t i s also true that these c l i e n t s can make only very l i m i t e d use of casework help. In other cases, such as with Mr. Colt, there was a greater degree of ego strength or better super-ego development, or more adequaoy i n the area of income and work accomplishments. Mr. Colt was described as s t r i v i n g f o r masculinity, as being unable to relate successfully to people and as being disturbed i n the sexual area. He seemed able to pay because of r e l a t i v e l y good ego strength, his success as a professional person, and the factor of social conformity i n paying his way. There was one case where the husband was aggressive i n seeking satisfactions to meet his dependency needs. He i s described as being immature, n a r c i s s i s t i c , and demanding. Mr. Cooper was asked to pay a fee i n the f i r s t interview. He earned $400.00 per month and seemed agree-able to paying a fee. However, he and his wife got into an argument that night which seemed to center around fee payment. Mr. Cooper was angry because his wife had t o l d him there would be no charge for t h i s service. In the next interview the worker recorded that, "I attempted to bring up the question of fees but he said simply that he didn't expect to get something for nothing, and he f e l t he would have to pay - 59 -for anything that he got. My attempts to get at his fee l i n g a l i t t l e more i n t h i s area were unsuccessful". The worker f i n a l l y said fees would be waived for the present, and soon a f t e r closed the case as "the cl i e n t s did not seem able to use help, and did not wish to continue". This was a d i f f i c u l t s i t u a t i o n f o r the worker to handle. There were two possible ways of handling i t . One way, where as i t happened, the worker decided to t r y waiving the fee, the other way might have been to point out that whether the c l i e n t was helped - whether he "did get something" - depended upon him. In t h i s way the worker, i n holding to fee payment, might also be helping the c l i e n t p a r t i c i p a t e . 2. D i f f i c u l t i e s Related to "Anal" F i x a t i o n of Personality; These cases show somewhat simi l a r characteristics to the ones described above, yet are different i n that disturbances i n dependency were not as central to the cl i e n t ' s functioning, as are characteristics of f r u g a l i t y , retentiveness, or compulsiveness. These c l i e n t s seem to be functioning at the "anal" l e v e l of personality development. There were three c l i e n t s i n t h i s category, where there was direct enough evidence about reactions to casework service and to fee-charging. Mr. Hardy i s described as prim, r i g i d and withdrawn. Mrs. Hardy seemed capable of using help, but Mr. Hardy was reluctant to come to the Agency. The worker recorded that, "Because of Mr. Hardy's attitude that he had come en t i r e l y at our request and because he did not require any service, I did not f e e l j u s t i f i e d i n discussing fees". Mrs. Robinson was con t r o l l i n g - 60 -and retentive. She was c r i t i c a l of a previous contact with the Agency and would not disclose income. The worker was permissive i n allowing Mrs. Robinson to continue without making an issue about fees. F i n a l l y i n the t h i r d interview, Mrs. Robinson began to use help, and decided to pay the fee. Mr. McGrath was said to be punitive to his children and persecutory to his wife. He provided his wife with M a t o t a l l y inadequate budget" and then accused her of poor management. He reacted strongly against the idea of paying a fee, setting a fee f a r below his scale'rate, and then did not pay. B. Cases Where There Were R e a l i s t i c D i f f i c u l t i e s Connected With Fee payment There were several cases where the c l i e n t reactions to fee-charging were based more on r e a l i t y factors i n t h e i r environment, than on personality d i f f i c u l t i e s or resistance to casework service. With some c l i e n t s , there were r e a l i s t i c f i n a n c i a l d i f f i c u l t i e s . Mrs. Monk said her husband was out of work, had been at Crease C l i n i c , and seemed to be worsening again. She asked about fees on the telephone and although reassured, needed to pay a $1,00 fee. Mrs. Perry was anxious about the fee on the telephone, as she only had a r e s t r i c t e d housekeeping budget. She also paid a nominal fee of $1.00 per interview. Both of these were short term cases with l i m i t e d c l i e n t a b i l i t y to use help. I t i s questionable i f a fee was appropriate i n t h i s kind of case. There was more anxiety about a fee than resistance to payment. The Henry case i l l u s t r a t e s a different - 61 -problem. The worker needed to reach out to the family i n an aggressive way. The worker charged a fee i n i t i a l l y to help the c l i e n t see the Agency as a source of professional help, but with l a t e r v i s i t s did not charge. The service did change i n character from help to the parents, to service directed to evaluating the adjustment of one of the children. In a s i m i l a r way Mr. Merry paid a fee for the i n i t i a l o f f i c e appointments when he could participate i n discussing the d i f f i c u l t i e s ; but l a t e r when the worker needed to be more aggressive because of Mr. Merry's assault on his wife, a charge was not made. Mrs. Ford could not at f i r s t pay a fee because her husband was opposed to her going to the Agency, and more opposed to paying f o r her. Mrs. Crag seemed to f e e l " l e f t out" of the casework contact because her husband only paid for himself, and obviously wanted the service centered around his point of view. There were a number of other wives, whose husbands paid the fee f o r the family and who were passive' recipients of casework service. While t h i s pattern of payment w i l l be the most frequent, and probably the most acceptable to c l i e n t s , there seemed sometimes the need to have the wife pay a small fee herself. This again i s dependent upon overall diagnosis and treatment goals. The Appropriateness of Fee-Charging 1 In spite of the d i f f i c u l t i e s encountered i n fee-charging practice there i s good evidence that t h i s p o l i c y can be an appropriate one for the Agency and i t s c l i e n t e l e . During the four month study period, the income 1. Based on the study of 34 fee, and 36 non-fee, cases - 62 -from fees exceeded that i n any previous yearly period. With the exception of those c l i e n t s with severe personality d i f f i c u l t i e s related to early deprivations, the fee i t s e l f was accepted as an appropriate charge, where i t was based r e a l i s t i c a l l y upon the a b i l i t y to pay. Client resistance to, or an i n a b i l i t y to use, casework help was a s i g n i f i c a n t factor i n deter-mining the opportunity to charge a fee with those c l i e n t s who did not con-tinue, and i n influencing the attitudes of workers i n proposing a fee payment. There was more d i f f i c u l t y encountered i n charging low fees, than in charging high fees. Five c l i e n t s paid more than #4.00 per interview, and these were a l l r e l a t i v e l y long term cases. Four c l i e n t s paid the maximum fee of $10.00 per interview, and three of these c l i e n t s continued f o r more than ten interviews. Common elements i n successful fee cases were, the a b i l i t y to pay, worker's knowledge of income, s u f f i c i e n t ego strength and maturity to use casework help, and a c u l t u r a l l y p o s i t i v e reaction to the proposed fee payment. Additional complementary elements were, some remaining a b i l i t y to share and communicate between marital partners where t h i s was necessary according to the nature of the problem presented, and a d i r e c t , comfortable approach to charging fees by the workers concerned. There were f i f t e e n cases where these circumstances prevailed to a s u f f i c i e n t degree. Five were cases where the husband and wife both participated i n using casework help, and i n the fee-charging process. There were two single persons, and f i v e cases where one marriage partner was seen. In these l a t t e r cases there was either a separate income,, or s u f f i c i e n t sharing between the couples so that the fee could be paid from the family income. Three cases were charged a fee prima r i l y for therapeutic reasons, but a b i l i t y to pay was s t i l l present. - 63 -This kind of f l e x i b i l i t y should be possible, once a p r i o r i t y has been given to f i n a n c i a l e l i g i b i l i t y , A further group of clie n t s were charged a fee i n an appropriate way, but did not pay. Contributory reasons for t h i s f a i l u r e to c o l l e c t the fee were that some of the husbands were not approached, a d e f i n i t e method of payment was not settled, and the early administrative structure was not businesslike enough to clinch the payment with those c l i e n t s paying on a per-interview basis. Some situations existed that were borderline i n respect to the appropriateness of charging a fee. There were ten such cases. Some were charged on a therapeutic basis, to bolster c l i e n t adequacy and use of service. These were not real l y e f f e c t i v e , i n view of non-payment of the fee, but apparently t h i s did not add a deterrent element to the casework process. In the majority of the remaining cases there were varying degrees of personality d i f f i c u l t i e s . These were borderline situations be-cause the factors of income, personality disturbance, and a b i l i t y t o use help, did not occur i n a conjunctive disabling way on any one case. Incomes ranged from $250.00 to §400.00 per. month, and a l l were within the fee scale. Six of these c l i e n t s did not pay a fee, and two c l i e n t s paid only a p a r t i a l fee. T/l/hile i t i s sometimes d i f f i c u l t to assess these factors w i t h i n the f i r s t interview, i t does seem appropriate to attempt to charge fees with these c l i e n t s , providing there i s a b i l i t y to pay. Collection techniques could be improved, with more b i l l i n g done, f o r exaaple, and the issue of - 64 -the fee payment made less of a personalized matter between worker and c l i e n t . I t would also be advantageous i f there could be pre-knowledge of income, so that t h i s information i s available before the c l i e n t i s seen for h i s f i r s t interview. In general, the appropriateness of fee-charging i s dependent upon the administrative selection of which cases w i l l be charged and upon the conviction and s k i l l of s t a f f members i n operating w i t h i n t h i s administra-t i v e structure. Workers were too often unsure about c l i e n t e l i g i b i l i t y for fees, and not comfortable or direct enough to determine t h i s f a c t . They found ftt d i f f i c u l t to discriminate between mentioning fees and charging them with the result that the fee often became an unresolved issue be-tween worker and c l i e n t . A major need i s to f i n d a practice which w i l l select the most appropriate c l i e n t s and which w i l l most e f f e c t i v e l y enable workers to function comfortably. CHAPTER IV.  FEE -^ CHARGING; A POLICY EVALUATIQ1 In deciding to charge fees, The Family Service Agency of Greater Vancouver followed a trend amongst American family agencies. The reasons for the development of t h i s trend are pertinent here. The experience of American family agencies i n the years 1935 to 1940 l a i d the foundation for the l o g i c a l development of fee-charging. These agencies were generally moving away from a primary r e l i e f giving function to a counselling function, with family problems not necessarily associated with f i n a n c i a l need. These were years of t r a n s i t i o n , during which i t was said s o c i a l work moved from a protected childhood into adolescence. This t r a n s i t i o n was, as might be expected, accompanied by many doubts and anxieties. Would the family agency f i n d the c l i e n t e l e needed to ensure i t s v i t a l i t y and usefulness i n t h i s new role? Would the family agency r e a l l y be able to offer s k i l l e d help with non-economic problems? These and other questions were asked. In the l a t e 1930s, agencies began to experiment with new c o l l a t e r a l programs such as homemaker service, special services to the aged, group discussions with mothers about c h i l d care, and help with the emotional problems associated with employment d i f f i c u l t i e s . With the advent of World War I I , family agencies found new scope for t h e i r s k i l l s as war tensions, separations, and housing d i f f i c u l t i e s , caused anxieties and family breakdowns. Family agencies gradually gained more assurance and found a r e a l place f o r themselves i n t h e i r community. This development gained impetus i n the 1940s, as there was increasing need f o r p s y c h i a t r i c a l l y oriented s o c i a l work s k i l l s . The development of the p o l i c y of charging fees i s a l o g i c a l sequence of the t r a n s i t i o n s which occurred i n family agencies. In the l a t e 1930s family agencies were most a c t i v e l y seeking a new role with economically independent c l i e n t s . The idea of charging fees was put f o r t h as one way -66-of emphasizing the professional nature of casework help, and of di s s i p a t i n g the connotation of "charity" associated for so long with family agencies. However, family agencies did not actually begin charging fees u n t i l the early 1940s, and t h i s was a slow, cautious development as i n d i v i d u a l agencies found they had s u f f i c i e n t s t a f f s k i l l s , and community acceptance. By 1948 twenty-two family agencies had a d e f i n i t e p o l i c y of charging fees, and t h i s was increased to 49 agencies i n 1951. The trend was beginning i n earnest, but the introduction of fee "charging i n agencies usually precipitated further anxiety, and self-examination by administration and s t a f f . Social workers were becoming accustomed to providing casework with non-economic problems, but fee-charging usually strained t h e i r confidence that t h e i r s k i l l s were indeed worthy of payment. In the l a t e 1940s the profession began generally to chide i t s e l f f o r i t s anxiety i n t h i s respect, and gradually more agencies became confident i n the fee charging area. However, i n family agencies generally, fee charging i n practice s t i l l represents a r e l a t i v e l y small proportion of the t o t a l agency income, and a s l i g h t l y higher proportion of t o t a l caseloads. Family agencies usually started to charge fees because higher income c l i e n t s were already coming for service, and i t was f e l t that the fee would help extend service further to the group of c l i e n t s who wanted to "pay t h e i r way." There followed beginning thinking about the therapeutic values i n charging fees. For example, i t was thought that the f e e paying cl i e n t would invest more of himself i n the contact, and that resistance factors might be externalized because the fee payment placed the c l i e n t on a more equalized footing with the worker. The early techniques of fee -charging were selective i n t h e i r application, and aimed at making f u l l and individualized use of these therapeutic values. Later*: agencies t r i e d to develop consistent fee -charging p o l i c i e s based more on a b i l i t y to pay than - 6 7 -dn therapeutic factors. These two developments have not yet been reconciled, as s o c i a l workers retained t h e i r concern about the effect of fee-charging on the i n d i v i d u a l , and yet were aware that fees needed to be charged on some structured and consistent basis. The development of fee-charging practice i n Vancouver Family Service Agency was influenced by t h i s agency's early a f f i l i a t i o n with the Family Service Agency of America, and followed closely the pattern of development i n American family agencies. However, the Family Service Agency did not accept the trend to fee—charging without reservations. In 1943 t h i s matter was considered, but fee-charging was rejected because i t was incompatible with the "charity movement." In 1948 once again t h i s p o l i c y was rejected. In 1951, the agency did i n i t i a t e fee -charging, as there was evidence that some higher income c l i e n t s were asking i f a payment could be made. A permissive voluntary p o l i c y of charging fees continued u n t i l 1956, when a s t a f f committee and the Board of the agency suggested a re-examination of t h i s p o l i c y . Probably the most important recommendation made was that the fee p o l i c y be more consistently applied from c l i e n t to c l i e n t , subject to clear exclusions to the p o l i c y . Staff Reactions to the Proposed Change i n Fee-Charging P o l i c y . The major p o l i c y change proposed was that a more rigorous, and in c l u s i v e , attempt be made to charge each c l i e n t on the r e a l i s t i c basis of a higher fee scale. S t a f f reactions were mixed. Most of the s t a f f accepted the need for a more consistent fee-charging p o l i c y , but there was considerable v a r i a t i o n i n the acceptance of higher fees, and variations i n thinking about the effect these would have on c l i e n t s ' use of casework se r v i c e , i f the fee po l i c y was to be more rigorously applied. Concern was expressed f o r the many c l i e n t s with varying degrees of deprivation which indicated the t r a d i t i o n a l concern for the welfare of c l i e n t s , the need to give to c l i e n t s , and an - 68 unwillingness t o seem to be asking anything of the c l i e n t that might add to his problems. This concern was also based on a r e a l i s t i c knowledge of the degree to which agency caseloads contained dependent f a m i l i e s . An effor t to reconcile these views with an already e x i s t i n g fee p o l i c y , and the necessity for consistency i n the application of fee-charging, l e d to the suggestion of a nominal fee. Additional arguments for a nominal fee were that i t would make fee-charging a more businesslike, automatic, and easy process, as contrasted w i t h the necessity t o ask the c l i e n t ' s income, and set an individualized fee. The necessity to ask about income appeared to be a major block with some s t a f f members. The f i n a l decision was to mention fees to a l l c l i e n t s , to r e t a i n the s l i d i n g scale, the high maximum fee, and to charge fees i n the f i r s t interview on a more consistent basis. This changed attitude at the f i n a l s t a f f meeting hid many residual feelings of resistance. A major d i f f i c u l t y , i n entering the study period, was that the basic question of whether the agency should charge fees at a l l was not d i r e c t l y tackled. Nor was there fundamental discussion about why fees were being charged i n t h i s p a r t i c u l a r f a n i l y agency, or discussion about the direction and goals of the agency i n giving community service. The Multiple Rationale f o r Fee-Charging A basic d i f f i c u l t y with the practice of charging fees, i s that multiple reasons are given fo r having such a p o l i c y . Equal weight i s placed on the objectives of the fee reinforcing the professional status of s o c i a l work, of i t enabling therapeutic values i n the worker-client relationship, and of i t explanding service to higher income c l i e n t s . This multiple rationale does make possible the selection of an appropriate reason f o r fee-charging to suit a p a r t i c u l a r interpretation of the p o l i c y , and provides a broad basis from which Agency s t a f f may choose to bolster t h e i r p a r t i c u l a r convictions. The d i f f i c u l t y i s that i t also fosters inconsistent fee practice within the Agency, and complicates the problems of deciding upon an e f f i c i e n t administrative structure for charging fees. Por example, while fees were most often charged according to a b i l i t y to pay, there were other instances where -the c l i e n t was f i n a n c i a l l y i n e l i g i b l e , but was charged mainly for a "therapeutic effect". The s t a f f decision to mention fees to a l l c l i e n t s seemed to be aimed c h i e f l y at enhancing the professional status of the Agency, but t h i s practice had a negative effect on very dependent c l i e n t s , and on some of those c l i e n t s making a tentative approach to the Agency. Staff discussion about the degree to which workers should participate i n the charging, and c o l l e c t i o n of fees i s i l l u s t r a t i v e of the attempt to reconcile the two objectives of simply charging according to the a b i l i t y to pay, and having therapeutic goals. An equal l y weighted, multiple rationale for fee-charging tends to increase the d i f f i c u l t y of interpretation to c l i e n t s of the reason for charging, contributes to uncertainties i n the interview about whether or not to charge a fee, and adds to any lack of conviction present with s t a f f about the merits of such a p o l i c y . Too much f l e x i b i l i t y and choice of method appears to have produced anxieties i n s t a f f , and inconsistent variations i n practice. I f a major objective f o r fee-charging was selected, then the administrative structure and the casework techniques, should be those best suited to promoting t h i s p a r t i c u l a r objective. This major premise should also-be consistent, i f possible with other known values of fee-- 70 -charging, with Agency philosophy and function, and with community accep-tance of the p o l i c y . I f the major reason f o r charging fees was to gain therapeutic benefits, the effectiveness of such an objective would depend upon i n -creasing the degree of worker-client p a r t i c i p a t i o n i n a l l aspects of fee-charging. The worker would discuss the fee t e n t a t i v e l y with the c l i e n t , noting any sign of resistance. I f resistance was present, fee-charging would be postponed u n t i l l a t e r interviews when t h i s might be used to re-inforce the increased adequacy of the c l i e n t . As an alt e r n a t i v e , the worker might decide, i n the f i r s t interview, that t h i s p a r t i c u l a r c l i e n t should pay a fee, i f casework help was t o b e used constructively. In that case, the worker might either attempt to c l a r i f y c l i e n t resistance to the fee, or to casework service. The worker would c o l l e c t the fee, and deal with delinquencies i n payment, guided by therapeutic considerations. While some of the techniques used might apply to any fee p o l i c y , t h i s p a r t i c u l a r approach would need to be f l e x i b l e , s e l e c t i v e , l a r g e l y voluntary, and dependent p r i m a r i l y upon casework considerations. The value of such a po l i c y would be measured by the degree t o which the fee was made an i n t e g r a l , helping part of the casework process. Agency consistency about fee payments would be based upon the best use of staff s k i l l s i n ind i v i d u a l situations. Fee-charging could be based on a fee scale, but the primary basis for charging would be the therapeutic ef f e c t , not the a b i l i t y to pay. Any attempt to apply t h i s p o l i c y consistently on t h i s l a t t e r basis would p a r t i a l l y defeat the former purpose, and i n v i t e mixed practice. In a similar way, the major premise for fee-charging might be - 71 -to reach new c l i e n t s i n the upper income group, who are accustomed to paying f o r professional services. I f t h i s was the case, the fee p o l i c y would need to be similar to that of other professional services. An effective p o l i c y f o r t h i s purpose would be to have a f l a t fee, of a f a i r l y high order, to be paid by a l l those c l i e n t s above an adequate income. There i s probably merit i n the suggestion that c l i e n t s would prefer to pay a f i x e d fee. However w i t h i n a family agency setting t h i s fee would need to be either a high or a low amount, i n order to either charge high income cl i e n t s exclusively, or i n order to set the fee at a l e v e l which 'could be paid by a l l c l i e n t s . An i n between fee would not s a t i s f y either group as i t would tend to lower the status of the service f o r the high income c l i e n t , and be too much to pay f o r the low income c l i e n t . It i s true that a low fixed fee might be accepted as an appropriate nominal payment by a l l c l i e n t s . This would r e a l l y be equivalent to not charging a fee. The only real choices are not to charge, or to charge on the basis of a b i l i t y to pay. I f a fixed high fee were to be charged, there would be a tendency for the Agency to develop separate f a c i l i t i e s based upon differences i n income. This would be so because the advantage of a fix e d fee i s that i t can be charged a l l c l i e n t s , and that i t would become known in the community that there was t h i s professional service at a known fee l e v e l . Arrangements for paying t h i s high fee, and f o r i t s c o l l e c t i o n , would be l a r g e l y c l e r i c a l duties. The structure would be simple, business-l i k e , and the fee would not be a s i g n i f i c a n t element between worker and - 72 -c l i e n t . The reinforcement of the professional status of social work, or the need for additional income, as major objectives, would s i m i l a r l y affect the structure of fee-charging practice. A Proposed Major Objective It i s , therefore, necessary to make the choice of a major objective before suggesting changes i n current fee-charging practice. The best choice i n view of present circumstances, would be to charge a fee based simply upon a b i l i t y to pay with more emphasis upon t h i s factor than i s now the case. A more fundamental problem i s why charge a fee at a l l ? There i s no other profession, except perhaps the ministry, serving a comparable group i n an individual way, which does not charge a fee. There i s no other compar able service to be obtained p r i v a t e l y i n the community, so that the Agency should not be i n the position of a free c l i n i c . The community should not be asked to support an expensive service for the c l i e n t group who are able, and indeed w i l l i n g , t o pay. These cl i e n t s should be charged according to a b i l i t y to pay, so that the service given %o them i s not wholly subsidized. I t may s t i l l need to be p a r t l y subsidized because there remains with these c l i e n t s , an Agency responsi-b i l i t y to remedy so c i a l i l l s as they p r e v a i l i n a l l income groups. This means that the Agency w i l l not always charge according to income, where there are f i n a n c i a l d i f f i c u l t i e s , f o r example, or where there i s i n h i b i t i n g c l i e n t resistance to a fee, yet a p o s s i b i l i t y that exposure to casework service w i l l strengthen the c l i e n t . There w i l l also be cases where the Agency makes aggressive attempts to help f a m i l i e s , and where i t may be unwise to charge a fee. However, consideration must be given to f i x i n g the - 73 -maximum fee more i n r e l a t i o n to the actual per-unit -cost of service to the c l i e n t . Under t h i s premise, the s l i d i n g fee scale would be retained. I t might be preferable i f there were a way to arrange for casework help through a broad insurance program such as M.S.A. However, t h i s i s not possible at present. The individual's contribution to the Community Chest i s not r e a l l y comparable to •this anymore than a $2.00 general membership i n the Y.M.C.A. e n t i t l e s the ind i v i d u a l to a f u l l use of f a c i l i t i e s . I t i s important to consider whether t h i s major premise of charging those c l i e n t s able to pay, i s compatible with t o t a l Agency functioning. There e x i s t s , i n some measure i n the Agency a healthy dichotomy of interest and philosophy. This i s p a r t l y due to the existence of two trends i n the Agency. The f i r s t "trend i s the conviction about the Agency's r e s p o n s i b i l i t y to provide a community service with a broad range of c l i e n t s exhibiting problems i n social deviation including the dependent, poorly motivated family. The concern i s often f o r the children i n these families as the Agency i s keenly aware that emotional problems can be perpetuated from generation to generation. The second trend i s toward service to the more emotionally independent family whose use of casework help i s usually at a different l e v e l . These dual interests are not necessarily contradictory, but they do to some degree require different s k i l l s and orientation, and they do also have d i f f e r e n t attractions f o r s t a f f members. A simi l a r dichotomy of orientation prevails about fee-charging. Once again, these orientations are not necessarily contradictory, but i t does mean that there i s a varying acceptance of the goals inherent i n fee-charging practice. No fee p o l i c y could s a t i s f y a l l s t a f f members. - 74 -However, the proposal of this major premise i s 1 consistent with both of the Agency trends, i f fees are charged i n a way which aids the one trend, and does not i n h i b i t the other. I f there i s an increase i n higher income c l i e n t s coming to the Agency, they should pay fees, to a reasonable degree, for the necessary expansion i n s t a f f . Service to other c l i e n t groups would be l e f t l a r g e l y unaffected i f support from the Community Chest and Council i s based upon the l e v e l of demand for t h i s service. An increase i n the income from fees would mean an increase i n the number of higher income c l i e n t s coming to the Agency. I f other areas of service remained s t a t i c , Community Chest and Council support would remain r e l a t i v e l y the same. There may be temporary periods of lag while t h i s growth catches up with i t s e l f , where there i s a drain from one area of service to the other. There may be a general trend toward service to c l i e n t s more generally able to use help, but fee-charging would follow rather than i n i t i a t e such a trend. The Agency must be firm about i t s p o l i c y of offering equal service to a l l c l i e n t s regardless of income, and must r e s i s t any pressure to charge fees where t h i s might be a deterrent to the use of service. Charging fees on the basis of a b i l i t y to pay need not be i n f l e x i b l e , nor need i t e n t i r e l y exclude other c o l l a t e r a l values of fee-charging. I f , f o r example, fee-charging does enhance the professional status of social work, then t h i s value w i l l accrue under the proposed p o l i c y . However, there i s a difference between t h i s and a more conscious e f f o r t to achieve professional status through charging fees. Social work i s a profession now. I t did not become one because fee-charging was introduced to, and accepted by, i t s c l i e n t e l e . Fee-charging, perhaps, - 75 -gave so c i a l work a chance to show that i t s s k i l l s were useful to a l l income groups. The fact that people are w i l l i n g to pay r e l a t i v e l y high fees for casework help w i l l support the status of soc i a l work, but maturity i s needed now rather than exploitation of t h i s fact. The primary goal of charging fees according to a b i l i t y to pay would have the effect of placing the therapeutic values i n an a u x i l i a r y r o l e . A money payment may s t i l l have the effect of "sharpening" c l i e n t and worker p a r t i c i p a t i o n , but the handling of fees would be depersonalized. Consistent fee practice based on a b i l i t y to pay i s more understandable to the c l i e n t and to the community. There i s a need for t h i s consistency. There has been, so f a r , no r e a l evidence of the v a l i d i t y of therapeutic factors. Feelings about money are so complex and at such different levels of consciousness, that the addi-t i o n of t h i s element to casework practice introduces more complications than benefits. In addition, the meaning of the c l i e n t ' s responses can be understood through the usual casework process, and c l i e n t reactions to the fee usually only substantiate t h i s knowledge. By removing the worker from the role of being the re c i p i e n t of the fee, personal elements are reduced and the c l i e n t would not use the fee with the worker f o r the indirect expression of c o n f l i c t s about being helped. Specific Elements i n Fee Charging P o l i c y The practice of charging fees should be structured to achieve simple, eff e c t i v e procedures i n charging appropriate fees based upon a b i l i t y to pay. One way to handle the intake procedure would be to have the c l i e n t complete an intake card at the time of h i s f i r s t interview. In addition to i d e n t i f y i n g information, t h i s intake card would have monthly income categories i n intervals of $50.00, to be ticked by the - 76 -c l i e n t . This card could be taken to the worker before the interview. The worker would then be i n the po s i t i o n of being able to set a fee, i f appropriate, with pre-knowledge of income, together with the knowledge gained by the end of the f i r s t interview about the c l i e n t ' s adequacy of functioning and attitude toward receiving casework help. This card, or another fee payment record card, could become a permanent record of fee payments, going to the worker before each interview, or i f fees were not charged t h i s card could be f i l e d f o r l a t e r administrative compilation. Yflien the worker has set a fee, he would either go with the c l i e n t to the receptionist to arrange for payment procedures, or t e l l the c l i e n t about these and return the card to the receptionist complete with instructions for the method of payment. I f the c l i e n t i s paying on a per-interview basis the receptionist would col l e c t further payments. The worker vrould not be involved again unless a delinquency i n payment occurred. There should be more use of at least one routine b i l l i n g on per-interview cases before the worker takes up the matter of non-payment with the c l i e n t . The manner of t a k i n g t h i s up with the c l i e n t should be from the point of view of whether the fee represents a f i n a n c i a l hardship, not whether t h i s means resistance to service. There should be some l i t e r a t u r e i n the waiting room which includes the fact of fee-charging according to the a b i l i t y to pay. Fees should not be mentioned to every c l i e n t , but rather simply and matter of i k c t l y charged where appropriate. Some such general procedure as suggested above, should be adopted i f fees are to be charged comfortably and consistently. The procedures suggested above would be subject to the following considerations. There are a certain group of c l i e n t s whose dependency needs - 77 -are so deeply rooted that fee payment i s a l i e n and disturbing to them. They want to "receive" rather than to "give". Within any fee p o l i c y f l e x i b i l i t y i s needed, and the necessity for making judgments about these cases would rest with the workers. The fee scale might be changed so that i t started at a higher l e v e l i n order that low income cl i e n t s with coincident personality d i f f i c u l t i e s would be administratively excluded. A nominal fee of $1.00 per interview could apply u n o f f i c i a l l y below t h i s l e v e l i f , for example, a c l i e n t i n i t i a t e d discussion about a fee and wanted to pay. In t h i s area, i t i s important f o r workers to consider that i t may often be more therapeutic not to charge a fee than to charge one. In the cases studied, the most d i f f i c u l t y was encountered with low or average income c l i e n t s . The most successful fee-charging experience was with c l i e n t s whose income was above $400.00 per month. In today's society, families with average incomes usually have l i t t l e extra to draw upon for unexpected payments. Higher income families may have a comparable standard of l i v i n g , but can usually arrange for fee payment by a temporarily different d i s t r i b u t i o n of expenditures. F l e x i b i l i t y i s also needed i n dealing with those families coming for help for the emotional problems of children. This group of c l i e n t s should not be excluded from the fee-charging p o l i c y , but d i s -cretion should be used where t h e i r approach to the Agency i s f e a r f u l or tentative. I t i s true that, before the children can be helped, the parents must begin to recognize and seek help for t h e i r part i n the d i f f i -c u l t i e s . This i s a d i r e c t service to the parents and can hardly be said to be less valuable than any other agency service. However, parents may - 78 -need time to see and accept t h i s as direct help for themselves. In t h i s i n t e r v a l i t may or may not be appropriate to charge a fee. With some parents the fee would help them see that the service required p a r t i c i p a t i o n , with others the fee might be a deterrent. An additional element i s that these c l i e n t s frequently come at an acute stage of the problem so that the question of a fee may seem irrelevant to worker and c l i e n t a l i k e . Remaining Problems Many areas of fee-charging remain i n which d i f f i c u l t i e s e x i s t , and for which clear solutions are not e a s i l y found. A major d i f f i c u l t y arises when the wife comes to the Agency and i s not sure whether the husband w i l l come l a t e r . I f the husband and wife do share r e s p o n s i b i l i t y for the planning of the family income, the problem i s easier. As i n some of the cases studied, the wife could be charged on the basis of f a a i l y income, providing the husband i s aware that she i s coming to the Agency. I f the wife continues alone, t h i s charge could continue i f the worker can determine that the wife real l y has access to family funds. I f the husband does come i n l a t e r , he could be charged the same amount, or the fee could be a weekly amount under the "family plan". The problem i s not so d i f f i c u l t , either, where the wife i s working. A charge could be made on the basis of her separate income, taking into consideration the amount she contributes to the maintenance of the home. I f the husband provides for the home, the wife could' be ;.charged as a single person. Depending upon the use of the j o i n t incomes, i t might be preferable to suggest a fee based upon t h i s t o t a l income, with the plan that the f i n a l amount of the fee w i l l be held i n abeyance u n t i l i t i s seen i f the husband part i c i p a t e s . In either case, i t would seem possible to review the basis - 79 g of the fee, i n view of l a t e r developments. In general, the fee should be a single one based on family income. In t h i s area, more attention should be given to the c u l t u r a l l y accepted pattern of the husband as head of the family. The husband usually should pay the j o i n t fee and be approached about the basis of the fee, even i f t h i s has been once reviewed with the wife. A s i g n i f i c a n t number of c l i e n t s coming to the Agency have disturbances related to t h e i r masculine or famine r o l e . The Agency should, where appropriate, reinforce the c u l t u r a l l y accepted roles of husband and wife, and i t can do t h i s often through the manner of arranging fee payment. The wife who comes alone, without her husband's knowledge, and with a very l i m i t e d a b i l i t y t o pay, presents the most d i f f i c u l t problem i n t h i s area. In the cases studied, women did have more concern about getting help with t h e i r problems, and a more conforming attitude toward fee payment, than did t h e i r husbands. A fee proposal made to these wives may add a further burden i n regard to her interpreta-tion' of Agency service to her husband. I f the husband i s negative about the fee and about casework help, the wife may be deterred from returning because of her husband's attitude, and because a fee has been proposed. I f the fee i s not mentioned, the husband may come l a t e r under fa l s e premises. Perhaps i t i s the manner of interpreting fees to the wife that needs attention. The worker might say that the Agency does charge a fee on the basis of a b i l i t y to pay, and c l e a r l y leave t h i s as a matter t o be discussed with the husband. I f the wife continues alone, and has only access t o a l i m i t e d housekeeping budget, a fee should not be charged and the wife should know t h i s . - 8 0 -In general, i t seems desirable to s e t t l e the question of fee payment, rather than to have i t continue as an unresolved issue between worker and c l i e n t . I t i s better to waive the fee, than to set a com-promise amount, or to wait for the c l i e n t to resolve the issue. This probably applies i n the a l l i e d area where the c l i e n t i s aggressively opposed to fee payment. Casework techniques, rather than the fee, should be used to help the c l i e n t use service, or to help the c l i e n t face the fact that the problem w i l l not be solssd unless there i s more genuine p a r t i c i p a t i o n . This has been an exploratory study of fee-charging experience i n a p a r t i c u l a r family agency, during a l i m i t e d period, while a revision of t h i s p o l i c y was being tested. The findings suggest mainly that the Agency i s not being selective enough i n determining which c l i e n t s should pay fees. Fee-charging to selected c l i e n t s was found to be appropriate, but i t was not found appropriate to t e l l a l l c l i e n t s about fees. A considerable amount of attention needed to be given to the general thinking about the place of fees i n voluntary family agencies, and to the c o n f l i c t i n g philosophies about fee-charging i n the Vancouver Family Service Agency. I t was necessary to discuss the fundamental question of why a fee should be charged, before recommending changes. A si m i l a r process needs to take place i n the Agency. The changes suggested are mainly those of emphasis and philosophy. Workers and c l i e n t s a l i k e , were uncomfortable where fee-charging was not appropriate. These experiences tend to perpetuate uncertain practice, and add to any doubts i n workers about the v a l i d i t y of fee-charging. A period of successful - 81 -experience i s needed. The suggested administrative changes should f a c i l i t a t e consistent fee-charging with appropriate c l i e n t s , and should add to the comfort and directness of the fee-setting process. There i s the need for increased s k i l l on the part of s t a f f i n making casework judgments w i i i i i n t h i s structure. The present scope of fee-charging may be r e l a t i v e l y l i m i t e d but t h i s i s not of primary concern. The important issue i s to f i n d ways of charging appropriate c l i e n t s that are now coming to the Agency. Recommendations for Future Research There i s a need for continuing research i n certain areas of fee-charging. These can be conveniently divided into areas for Agency research, and those topics suitable f o r a Thesis. A. Areas for Agency Research? 1. The degree of consistency i n the application of the Agency fee-charging p o l i c y . This i s a matter f o r continued review. 2. Agency study of B r i e f Service cases. As a separate area to determine why a high proportion occurs, and those cases which might legitimately be charged a fee. 3. A study of those cases where the wife i n i t i a t e s the contact with the Agency. In p a r t i c u l a r , those cases where the wife continues alone, and various economic circumstances p r e v a i l . 4. The techniques i n handling cases where there i s c l i e n t resistance to casework help, and the study of more precise ways to evaluate perssnality d i f f i c u l t i e s i n r e l a t i o n to a b i l i t y to pay a fee. -82-5. The v a l i d i t y of the Fee Scale i t s e l f , and of excluding minimum income c l i e n t s . A study of what kinds of f i n a n c i a l d i f f i c u l t i e s to allow as the basis f o r exempting the c l i e n t . The consideration of assets or savings as a basis f o r fee payment. B. Areas Suitable f o r a Thesis; 1. A more intensive, longitudinal study of the therapeutic factors i n fee charging. 2. The effect of fee charging upon the balance of cases carried by the Agency. 3. The study of variations i n attitude toward money between men and women. The influence of c u l t u r a l factors. Voluntary family agencies are v i t a l community organizations whose functions are continually subject to modification and experiment-ation. Fee charging can be viewed as a growth phenomena w i t h i n these agencies which, i f appropriate, needs to be resolved with the same vigor as that applied to other internal problems. - 83 APPENDIX A: FEE SCALE GUIDE (Based on 1 or more interviews per week) GROSS SINGLE SMALL FAMILY MEDIUM FAMILY LARGE FAMILY MONTHLY INCOME PERSON (3 or less ) (4 - 5) (6 or more) #150.00 (1800) | 1.00 -0- -0- -0-200.00 (2400) 2.00 | 1.00 -0- -0-• 250 (3000) 3.00 1.50 | 1.00 -0-300 (3600) 4.00 2.00 1.50 -0-350 (4200) 5.00 2.50 2.00 $1.00 400 (4800) 7.00 3.00 2.50 1.50 450 (5490) 10.00 4.00 ••,3.00 2.00 500 (6000) 10.00 5.00 4.00 3.00 550 (6600) 10.00 8.00 5.00 4.00 600 (7200) 10.00 10.00 6.00 5.00 650 (7800) 10.00 10.00 10.00 6.00 700 (8400) 10.00 10.00 10.00 10.00 700 and above 10.00 10.00 10.00 10.00 . FEE PER INTERVIEW 84 APPENDIX Bs QUESTIONNAIRE ON INTAKE FEE CHARGING - INTAKE Questions for Yellow Application 1. Were fees discussed Yes I f not: (a) Need f i n a n c i a l assistance (b) Referred on ~~~ (c) Referring r e l a t i v e (d) Too disturbed ~ ~ (e) Personality factors ' 2. Were fees charged? I f no: (f ) Research function (g) Possible, w i l l discuss l a t e r (h) Other Yes No 3. Income (a) Income (b) Extenuating circumstances (c) Client blocking (d) Other ? or approximation No 4. Reactions from community or other agency? Yes 5. Client aware of fees? Yes 6. Did c l i e n t i n i t i a t e discussion? Yes 7 . I f a fee case: (a) Scale followed Yes (b) Manner of payment planned Monthly (c) Client resistance? Yes (d) Worker d i f f i c u l t y ? (borderline protection: immature parents (E.G. undue anxiety, "resistance, etc.) ? Occupation Yes No No No No Per interview No No (1) Interpretation (2) Timing (3) Appropriateness (4) Amount of fee (5) Other - 85 -APPENDIX C: QUESTIONNAIRE ON CLOSED CASES 1. Reactions from community or other agency? 2. I f not, did t h i s affect relationship? Yes Yes 3 . Indication fee aided c l i e n t to focus? Yes Indication fee f a c i l i t a t e d diagnosis? Yes Indication fee f a c i l i t a t e d c l i e n t participation? Yes 4. Any indication: Fee f a c i l i t a t e d c l i e n t seeking help? Fee deterred c l i e n t seeking help? Agency function - c l i e n t helped to recognize? 5. Any misuse of fee by cl i e n t ? Yes Yes Yes No No No No No No No No Early? Yes___ No Early? Yes No~ understanding? Yes No Confused Yes No (e.g. used to manipulate?) - 86 -APPENDIX D: KEY TO INTAKE QUESTIONNAIRE 1. Question ffiL This does not refer to any preliminary informing or general explanation of fee-charging with the c l i e n t . I t i s to be ticked yes i f the -worker decides to i n i t i a t e a focussed and p a r t i c u l a r i z e d discussion of fees. I f the worker decides i t i s not appropriate to discuss fees i n t h i s sense, he should t i c k the reason (a) to (g) as indicated. I f these categories do not apply t i c k "other". It maybe possible that more than one of these categories apply to a p a r t i c u l a r case, but the category "Possible, w i l l discuss l a t e r " should only be ticked on those cases where worker delays because the si t u a t i o n with regard to fees i s unclear ei-ther because of c l i e n t anxiety, etc., or i n a b i l i t y of worker to judge appropriateness of discussing. 2. Question $2 This question applies i f fees have been discussed as per above #1, and i t aims at seeing on how many cases discussion of fees carries through to actual charging. Answer N/A i f NO to Question #1. 3. Questions $L to #6 are to be answered for a l l c l i e n t s . 4 . Question §7 (c) i s to see what resistance to fees i s present even i f fees are agreed to and paid by the c l i e n t . These cases may be valuable to review for the treatment values of fee-charging. Question #7 (d) relates t o worker d i f f i c u l t y even i f fee i s being paid 5. Question $3 i s aimed at obtaining an overall idea of the median or average income l e v e l of c l i e n t s coming to the agency. I f information on income i s not readily available on non-fee cases, an approximation or occupation of the c l i e n t would be h e l p f u l . - 87 -APPENDIX E: FEE-CHARGING PROCEDURES A. General Procedures} Clients should he informed of the f a c t that agency does charge fees as early i n the contact as possible. In any case discussion of fees should take place i n the f i r s t interview as atpart of the interpretation of agency services. I f the c l i e n t does not seem to come within the fee-charging group nothing further i s to be done unless the c l i e n t volunteers a wish to pay, or there i s a change i n circumstances. On appropriate cases and subject to exclusion to po l i c y l i s t e d , the worker may follow the i n i t i a l discussion with a focussed consideration of a fee-charging plan for the c l i e n t . This may be postponed i f i n the judgment of the worker, the c l i e n t i s not ready to p a r t i -cipate because of undue anxiety, resistance, etc. At the time the fee i s set i t should be understood by the c l i e n t that the matter can be re-discussed at any time i n the future. B. Discussion of fee with current under-care cases w i l l be carried out at the discretion of the worker through interpretation of the fee plan. C. Cards showing the fee scale w i l l be available to the c l i e n t so that he can p a r t i c i p a t e with the worker i n setting the fee. D. Payment Plan. Payment may be made by cash or cheque at the end of each interview, or monthly b i l l s may be sent. The c l i e n t should decide which plan he prefers. E. Mechanics of Fee Collection? 1. Fees w i l l be collected by the receptionist. 2. The worker sh a l l upon setting a fee have typed i n duplicate a card showing the following information: Name; Address and case number of c l i e n t ; Payment plan; Date and amount of payment; Name of worker. 3. When the fee i s i n i t i a l l y set, the worker w i l l introduce c l i e n t to o f f i c e procedure f o r payment. I f the c l i e n t desires to pay f o r t h i s f i r s t interview, t h i s may be done at the same time through the receptionist. 4 . When a fee i s set and cards made, the receptionist s h a l l p u l l cards f o r c l i e n t s having interviews, and w i l l have these available when c l i e n t leaves and i s ready to make payment. If c l i e n t does not make a payment for an interview, receptionist w i l l have card pulled and at end of day w i l l n o t i f y workers on lapses i n payment. APPENDIX F: REASONS FOR FEE- CHARGING 1. It i s appropriate to charge for a professional service. Case-work has proved helpful to individuals and families regardless of income and no comparable service i s available i n the community. It i s therefore f e l t that i t i s appropriate to charge an ind i v i d u a l fee to those c l i e n t s able to pay, providing the fee w i l l not l i m i t the c l i e n t ' s use of service. 2. The payment of a fee for each interview should help some c l i e n t s make better and more economic use of the service. 3. I t i s f e l t that because of the cul t u r a l pattern of paying for a professional service that a fee system may reach a wider c l i e n t e l e and help them come e a r l i e r f o r service, where previously there may have been resistance to accepting a free service. 4. Fees may be helpful with the i n d i v i d u a l c l i e n t i n externalizing the problem of taking help, i n handling aspects of resistance, transference and other treatment phenomena. They may be d i r e c t l y helpful i n diagnosis and treatment w i t h some c l i e n t s where the taking, giving, or withholding of money assumes central importance i n t h e i r problem. 5. There sh a l l be no difference in service between fee and non-fee c l i e n t s . - 8 9 -BIBLIOGRAPHY Berkowitz, Sidney J . "Reactions of Clients and Caseworkers Towards Fees" Journal of Social Casework, A p r i l 1947 Boggs, Marjorie "The Administrative and Casework Aspects of Fee Charging" Journal of Social Casework, October 1949 Brody, Celia "Fee Charging, A Dynamic i n the Casework Process" Journal of Social Casework, October 1949 Fizdale, Ruth "A New Look at Fee Charging" Journal of Social Casework, February 1957 Rich, Margaret E. A B e l i e f i n People Family Service Association of America, 1956 Shafer, Carl M. Fee Charging i n a Family Agency Family Service of Pasadena, November 1956 Sterner, Lee R. "Casework as a Private Venture" The Family, October 1938 Taggart, A l i c e D. Some Broad Considerations f o r Agencies i n Establishing a Fee Service Family Welfare Association of America, May 1944 Additional reference material included pamphlets, reports, and Committee Minutes from several Family Agencies i n the United States, the Family Service Association of America, and the Family Service Agency of Greater Vancouver. 

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