Professional Documents
Culture Documents
O
ne afternoon, I was enjoying lunch at my favourite Chinese
restaurant and reviewing some notes for this chapter. I had
a neat, orderly outline in mind where I would begin with a
review of the classical description of fee arrangements in psychoa-
nalysis starting with Freuds (1913) conceptualization of leasing time.1
I was then going to discuss permutations of this arrangement includ-
ing the controversy over charging for missed appointments, paying
in advance, deferred payments, pro bono treatment, treating the very
wealthy and bartering. I was even going to mention an innovative
program in China. While finishing up my tea and opening up my for-
tune cookie, I became rather startled and amused by what I read. In a
3
4 U N U S U A L I N T E RV E N T I O N S
Is time money?
The well-known axiom though admittedly a bit coarse expression is,
however, seldom applied to psychoanalysis. Furthermore, our field is
not a lucrative profession and there are much better ways of making
more money, especially, if as Fenichel (1938) has described, one is moti-
vated by a wish to amass wealth. From a standpoint of medical special-
ties, psychiatry and psychoanalysis typically rank near or at the bottom
of income compared to other medical specialists. Freud (1913) himself
noted that the income derived from practicing this art would have to
be quite limited. No doubt, the nature of it being based on an hourly
wage and it being such arduous work are crucial factors. The distin-
guished North American psychoanalyst, Warren Poland, summed it
up succinctly when, during his introductory comments to a paper he
presented years ago in Philadelphia, he declared that of all of his psy-
choanalytic achievements, the thing he was most proud of was that
he was able to make a living from his practice. In a more recent dis-
cussion with him, Poland added that at this point in his career, that is
not the issue. He now is content with whatever fee he and his patient
agree upon. It is only when he thinks of it as a reduced fee that he
may experience countertransference problems (personal communica-
tion, January, 2011). One might assume that a prominent and successful
practitioner, after decades of work, will have derived enough financial
security such that monetary pressures are lessened and more sublime
issues prevail. That does not seem to be the case.
Other analysts may view this necessary tension from different
perspectives. Akhtar, for example, feels that being solely financially
dependent upon peoples mental suffering is problematic and lends
itself to the analyst becoming needy upon them and potentially exploit-
ing them (personal communication, February, 2011). He favours having
collateral sources of income to mitigate against such a countertransfer-
ence pitfall. For those analysts like himself in institutional settings who
earn a guaranteed salary upon which other activities contribute, such
a risk is minimized. Also, those who are financially independent due
to inherited wealth, other businesses, wealthy spouses, entrepreneurial
success, winning the lottery, etc. are freed up from the pressure of
M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 5
having to live off ones practice. This freedom, paradoxically, can have
its own risks as counter-resistances in the analyst may build up over
time precisely because this work is so challenging.
The expression, time is money is more commonly applied to the
world of business where, for example, the energetic entrepreneur has
created so many time sensitive opportunities that the failure to act deci-
sively will cost money, or, there may be situations where delays in
production or sales result in additional expense. Although the analytic
patient who is in a good enough treatment much longer than expected
may also register the same complaint that his time is money, he may
not fully realize that his unconscious is contributing to the longer dura-
tion and will blame the analyst for not moving more quickly. For exam-
ple, a patient complaining about the uncertainty of her progress and
seeming endlessness of the process recently acknowledged her own
ambivalence over termination because then I will have to grow up.
Part of the challenge in addressing this topic is the recognition that
analysts do not agree on what exactly the analysand is paying for and
the analysts own views over what he is charging for may vary. Further-
more, there may be uncertainty in the patients mind about the exact
purpose of the fee so while there may be certain policies put in place
at the appropriate time early on, the nature of the analytic process and
the exigencies of life may require additional and specifically tailored
arrangements.
In this era of evidence based medicine where scientifically based
outcome studies are becoming the state of the art and insurance com-
panies are offering incentives in the form of increased reimburse-
ments to practitioners whose patients get better faster for less money,
analytic treatment has become even more of an anomaly. Indeed, the
implications of the recently passed health care reform bill, which seems
more like insurance industry reform, remain to be seen. Clearly, the
analysts charges are not based on results that are accrued in treatment
nor are they based on the degree of difficulty of the treatment of a given
patients problems. Mitchell (1993), however, candidly notes that his
fees may vary. He says:
Clinical Vignette: 1
One particular patient, referred to above, whose mind functioned
like a calculator, bemoaned the fact that he was paying me $4.11 per
minute regardless of whether I spoke or didnt speak, regardless of
how many words were emitted. As minutes ticked by, he would
make the ka-ching, ka-ching cash register sound denoting the
charges per minute. He further expressed his ambivalence by often
quoting the words of the mother of televisions famous Mafioso
leader, Tony Soprano. She was skeptical of her sons treatment with
the beleaguered Dr. Melfi. Olivia Soprano nastily remarked about
psychotherapy: Its a racket for the Jews! In a nasal, high-pitched
falsetto, the patient would recite these lines imitating the voice of
the character. The patient conveyed such a mistrust of authority
M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 7
In this case, the patients obsession with money lent itself quite eas-
ily to it becoming embroiled in the transference. Every aspect of our
financial dealings took on such exquisite meaning that at times his
analysis had an absurdist quality to it. Yet beneath the humour and
one-upmanship, he was enacting a deadly serious game of trying to
8 U N U S U A L I N T E RV E N T I O N S
Bartering
I have a colleague who practices in a small coastal town where fami-
lies have made their living for many generations by harvesting the
sea. The fishing industry has been a central part of the local economy
which until recently was a thriving, seemingly never ending bounty
for all concerned. A casualty of its own success and the well-known
factors plaguing the worlds oceans, such as pollution, climate change
and human greed taking precedence over long-term conservation
measures, this area had fallen on hard times in recent years. Uncer-
tainty over the future and rising unemployment cast a pall over this
once thriving area resulting in a westward migration of some of the
more ambitious, hopeful and talented young people. Those left behind
continued in their old ways hoping and praying for things to improve.
M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 9
The two were in the midst of negotiating over a fair value for a given
work that especially caught the therapists eye a month before that
particular piece happened to win a prestigious art competition. Then,
almost overnight it became worth many thousands of dollars and,
depending upon if and when the barter had taken place, either the
patient may have felt cheated for accepting too little or guilty over tak-
ing so much. Conversely, the therapist may have felt guilty over hav-
ing acquired such a great work in return for offering a few sessions or
indebted to the patient for an extended period of time were he to pay
the new value of the work. Wisely, the therapist continued to analyse
the complexities of such a barter and stayed with the original financial
arrangement until the patient could actually pay more money. Seeking
consultation with a knowledgeable colleague at such times might be
helpful in sorting out the nuances and complications that might arise.
Clinical Vignette: 2
Ms. X, a prominent and somewhat mysterious woman purporting
to possess enormous wealth, consulted me many years ago as one
of several analysts she was interviewing to continue her treatment
following the death of her analyst. She told of a long and convo-
luted family history replete with intrigue, great fortunes amassed
and lost and regained, violence, perversion, incest, alcoholism and
M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 11
Aside from the obvious humane and ethical issues associated with pre-
cipitously terminating ones patients in order to take a better offer
financially, it would be completely untenable to be owned in such
a way and still think that one could maintain any sort of an analytic
M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 13
Payment in advance
My experience with several analytic patients who had wanted to pay
in advance also came to mind. In each of these situations, while the
requests were consciously based and well rationalized (e.g., for tax
purposes to prepay a number of months at the end of a calendar year),
they invariably betrayed an underlying fantasy relating to holding onto
the object. Whether it was due to fear of object loss due to illness, death
or outright rejection, or an omnipotent fantasy that the patient would
stay alive and healthy indefinitely, the common denominator was guar-
anteeing a continued union with the analyst. On a deeper level, there
was a desire for a reunion with the pre-Oedipal, idealized mother sym-
biosis and to maintain the idyllic dyad.
In one case, the patient was a woman who was adopted at birth into
a family who subtly reminded her of how lucky she was for hav-
ing been taken in by them. Her status as an adoptee was invoked to
induce guilt and obedience in her as she feared being sent away if she
did not live up to whatever demands her loving and generous fam-
ily would make of her. Her deep insecurities over truly belonging and
being acceptable continued into her adult life despite all the trappings
of a successful life. In the transference, she insured her place on my
schedule through periodic advance payments. Rationalized and heav-
ily defended, this enactment was not amenable to interpretation until
she ran into financial difficulties at which time her deep fear of being
summarily dismissed came to the fore.
In another case, a man in analysis with severe heart disease was
undergoing tests and procedures to determine if he were a candidate for
an operation. In his situation, the operation would have been extremely
14 U N U S U A L I N T E RV E N T I O N S
Deferred payment
A senior colleague who was well known in his earlier days for hav-
ing the highest fees around taught his students that psychoanalysts
should not have to apologize for charging money for their services.
It was an important and healthy message for those who might be feel-
ing guilt or a sense of inadequacy early on in their careers. He even had
a credo which was a parody of the sacred Latin expression in the finest
Hippocratic tradition Primum non nocere (First, do no harm). His
motto was primum, suscipio tributim (first, get paid). In other words,
before undertaking a course of analysis which could reasonably extend
over a number of years, it was important to carefully evaluate the pro-
spective patients capacity to pay for the services and determine what
kind of resources might be there in case of an emergency.
Although this esteemed analyst had good reason to have a high
opinion of himself, some thought his attitudes were a bit mercenary
when, during an economic downturn when analytic patients became
even more scarce than usual, he began advocating a deferred payment
model. After a careful assessment of the patients analysability, he sug-
gested an equally careful financial analysis including their monthly
budget, a review of their annual income tax forms. Then, based upon
these figures, he would then offer them a payment plan which included
an affordable amount of his standard fee per session up-front and the
balance to be paid at a later date, possibly near or after termination.
This deferred balance would then accrue an interest charge consistent
with the banks fluctuating rates for comparable loans. The patients
would then be required to sign a legal contract before analysis could
begin. In this way, he argued, analysis could be offered to many more
patients even during difficult times and he felt certain that all the issues
associated with such an arrangement were analysable.
M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 15
Gratis treatment
As is so often the case in Freuds writings, one might come across
conflicts or contradictions in his thinking. This is the case in his attitudes
about offering gratis treatment. He notes that the analyst should
16 U N U S U A L I N T E RV E N T I O N S
the most neutral and fundamentally respectful stance for the thera-
pist to take. Otherwise, the therapist takes the position of making a
moral judgment about whether the absence was justified. In such a
case, the therapist, in effect, volunteers to make a personal financial
sacrifice if an absence is deemed worthy of being excused. If the
patient is angered by paying for a missed hour, there is then an
opportunity to explore the dynamics of the anger and why the
patient feels that the therapist should absorb the exigencies of the
patients life. Similarly, the therapist operating on these guide-
lines can more appropriately set fees reflecting a known stability
of chargeable hours and therefore potentially lower per-session fee
(p. 174).
Clinical Vignette: 3
Simon was a young, single man who entered analysis with a history
of depression, homosexual anxiety, low self-esteem, difficulty in
intimate relationships and chronic rage against his very successful
but aloof and caustic father. He was very engaging and likeable, but
did not realize his own assets. He carried an enormous burden of
unconscious, predominantly neurotic guilt which was periodically
expiated through enactments of victimization which alternated
with a wish to be treated specially. He had only an inkling of aware-
ness that this pattern had psychological significance which related
to perceived danger of his Oedipal strivings for his overstimulat-
ing and unavailable mother. Early in the second year of treatment
when derivatives of this material were becoming manifest in the
transference, he was rushing for an appointment in his habitual
way of cutting it close which often resulted in several minutes of
lateness. This time, however, he never made it to his appointment
and I waited for him past his usual time of arrival.
M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 21
to make decisions for him on his behalf which freed him up from
taking any responsibility. Through a passive pseudo-helplessness,
others would do for him or to him. As Simon railed on and on
about my unfairness about the missed appointment, his analysis
unfolded and actually blossomed. In time, he could begin to appre-
ciate the nature of transference and how it was colouring his per-
ceptions of me. Yet, it continued to offend his sensibilities that he
might have to pay for the hour. He tried hard to empathize with the
analysts point of view over paying for missed appointments but
still insisted that it would be unjust to pay for the session in ques-
tion. But, maybe he should and maybe he wasnt because he was
being obstinate. He wondered whether or not I had gotten enough
out of this exercise with him.
Couldnt I just tell him it was okay? How much sadistic
enjoyment might I be deriving from watching him squirm over
all of this? On the other hand, maybe he could end some of his
own anguish if he resolved some of his own guilt. After all, he
was speeding. He did have destructive, aggressive thoughts and
he did become more conscious of feeling guilt. Psychological guilt,
however, could not be easily distinguished from culpability and
guilt in a legalistic sense so why didnt I just put him out of his
misery?3 Yet, we persisted and material continued to flow. In each
subsequent months bills, the questionable charge was carried over
and he paid for everything except for that fee. It remained a major
annoyance for him and, like the proverbial irritating grain of sand
in the shell of the oyster which over time is worked over and over
until it becomes a smooth pearl, so, too, did Simon work and re-
work the issue in the transference. In time and begrudgingly so, it,
too, became very valuable for him.
I made no attempt to push him to get closure on the issue. Even-
tually he reached a point of mental exhaustion over it and decided
he should just pay the fee and be done with it once and for all.
Since, however, the magnitude of the issue was such that it could
not simply go away, his deciding that he wanted to pay needed
to be anald also. This experience was not an exercise in behavior
modification masquerading as psychoanalysis whereby I covertly
wanted him to pay me and eventually come to that conclusion on
his own. Each of us had a conflict over whether he should indeed
be charged. Therefore, whatever he decided was less important
26 U N U S U A L I N T E RV E N T I O N S
differently, we cannot know for sure. Conversely, what might have been
missed, overlooked or simply not having entered into the transference
because of how I handled it needs to be considered also.
Conclusion
In this report on variations of payment, I have tried to illustrate some
of the modifications of the usual model. It was not intended to cover
all possibilities but, rather, to extend the discussion and to invite oth-
ers to describe their experiences also. For example, I did not discuss
extending professional courtesy in an initial consultation. This practice
is not uncommon when dealing with colleagues and their families and
acquaintances. Nor did I address issues of payment associated with
child analysis, a topic worthy of extensive study. One aspect of this
area would be the transition of payments by the parents for the treat-
ment to payments by the patient himself in late adolescence or early
adulthood.
I also did not elaborate upon the myriad details that characterize
our usual practice, those subtle nuances that may fluctuate which
communicate so much consciously and unconsciously to our analytic
patients about our attitudes about money, our sense of self-worth, our
professional work and our feelings about the patient. These tiny vibra-
tions in the analytic field may send huge ripples which have important
repercussions in the analytic dyad. For example, how timely are bills
given to the patient each month? How accurate are they? Who prepares
them? How aware is the analyst of the patients current payment sta-
tus in the treatment? Are the bills hand-delivered or mailed? With or
without an envelope? Typed up or handwritten? How legible are they?
Do they include diagnoses and treatment codes for insurance compa-
nies? If so, how are these issues decided and analysed? When in the
session are the bills given? How long does the analyst usually wait to
be paid after the bill is given before it becomes an issue for the ana-
lyst? Does that period of time vary from patient to patient? And why?
How actively does the analyst then listen for material referable to
the nonpayment and actively make interventions? Are these interven-
tions more active than other interventions? And why? How does the
analyst handle fee increases? Does the fee stayed fixed throughout the
duration of the treatment? If so, then why? If not, then how much and
how often are such increases levied? How are these changes decided
28 U N U S U A L I N T E RV E N T I O N S
and how they are analysed in the treatment? And, finally, how is the
last bill of the analysis handled? What effect, if any, does when and
how it is presented have on the termination process if that payment
occurs weeks after the last session and is not analysed with the analyst?
Clearly, there are many more questions than have been generated here
which highlight the multitude of details that may take on undreamed
of significance.
The analysis of the payment arrangement is an essential aspect of
the treatment situation. Whatever is negotiatedbe it a reduced fee,
standard fee, deferred fee, advance payment, credit card payment, Pay-
Pal payment via the Internet, barter, daily payment, weekly payment,
monthly payment, or annual paymentit all has meaning. Moreover,
the handling of missed appointments, I would contend, is at the heart of
the analysis of money and whatever financial arrangements are made
for the patient. The psychology of the analyst, and where he or she is
on the professional life cycle, are crucial considerations in understand-
ing the complex communication that occurs intersubjectively over the
exchanges of money in the treatment.
Notes
1. In his paper, On beginning the treatment, Freud (1913) elucidated his
stance in the following manner. In regard to time, I adhere strictly to
the principle of leasing a definite hour. Each patient is allotted a par-
ticular hour of my available working day; it belongs to him and he is
liable for it, even if he does not make use of it (p. 126).
2. This is by no means to diminish the outstanding contributions of the
IPA China Committee and the associated work of such distinguished
colleagues as Peter Loewenberg (USA), Sverre Varvin (Norway), Alf
Gerlach (Germany), and Maria Teresa Hooke (Australia). My focus on
CAPA is solely due to my greater familiarity with its work; many of my
Philadelphia colleagues are involved in it.
3. There is a curious aspect of this situation about which a thoughtful con-
sideration is warranted but is beyond the scope of this paper. That is
the fact that this patient did not develop any posttraumatic symptoma-
tology following the collision. In the past he had suffered from recur-
rent nightmares and traumatic reliving associated with other terrifying
and possibly life-threatening incidents. So, it was known that he was
susceptible to have such a psychological reaction. In this situation the
patient realized that there was going to be a collision, could not have
M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 29