Payment PDF

(1974).
International Review of Psycho-Analysis, 1:73-101

On Some Theoretical and Technical Problems Regarding the Payment of Fees for
Psychoanalytic Treatment
K. R. Eissler
I
The earliest medical help given to man by man probably took the form of magic rituals. It was dispensed
not by a specialist, but by a person to whom many other functions of import to the community had also been
entrusted. In later phases of cultural development, the fight against disease and illness did come to be
entrusted to specialists: Hippocrates was the most famous among those early figures who can be called
'physicians' in the modern sense. When protecting health became a specialized function, medical service
was rewarded; physicians were richly compensated by kings and by others in power. Yet the practice of
healing and that of charity remained intertwined for a long period, particularly during the Christian era. It
was not so long ago that the image of a physician was still surrounded by a kind of halo of saintliness—the
implication being that he would employ his arts of healing without compensation. In the Oath of
Hippocrates, which says: 'With purity and holiness I will pass my life and practise my art', there is already a
strong indication that this was so.
When Freud started his medical practice, the way in which a physician was compensated was different
from the customary way of compensating other professions. At the end of the year, he would send a bill that
covered all his medical services during the preceding 12 months. The patient's daily visits to the
psychoanalyst's office made it impracticable to render a bill on either a daily or an annual basis, and for that
reason the analyst's monthly statement—which, although many problems and doubts are attached to it, may
appear the only detail of psychoanalytic technique on which all analysts seem to agree—requires no
particular historical inquiry.1
'Ordinary good sense', Freud wrote (1913p. 131), 'cautions him [the analyst] … not to allow large sums
of money to accumulate, but to ask for payment at fairly short regular intervals—monthly perhaps', and he
added that that was not the usual practice of physicians in Europe. In this early publication on technique,
from which I have just quoted, Freud made certain other remarks that showed clearly the unique place that
the payment of fees holds in the psychoanalytic situation: it is more than the transfer of a given amount of
money from one person to another, but rather an integral part of the treatment itself, with possibly decisive
consequences for the course of treatment.
First, Freud warned against a very low fee, since this would not enhance the value of the treatment in the
patient's eyes (1913p. 131). Such a statement can be made with regard to any kind of treatment or service; it
describes what appears to be a general human attitude. Yet, while in other specialties the effect of treatment
is not dependent on the value the patient assigns to it, in psychoanalytic treatment, low esteem by the patient,
arising out of his low fee, may go undetected for a long time. It may therefore delay progress and even be
immune to interpretation, insofar as it is supported by a reality factor.
Freud also warned against giving treatment free, and not just in order to protect the analyst against an
inordinate burden, but because 'free treatment enormously increases some of a neurotic's resistances'
(1913p. 132). With the last statement Freud summarized his own clinical experiences of a decade, during
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Copyright © K.R. Eissler
1 However, I have found one exception to the rule in Menninger (1958p. 128), who refers to the 'monthly
or weekly statements' of the psychoanalyst.
2 Halpert (1972p. 124) rightly regrets that Freud did not elaborate on the difference in personality of these
two groups of patients.
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which 'I set aside one hour a day, and sometimes two, for gratuitous treatments'. Yet Freud did take notice of
the exceptions to his rule: unpaid treatment occasionally led to excellent results.2
In short, Freud ascribed a regulating effect to the payment of the fee, without which 'the whole
relationship is removed from the real world, and the patient is deprived of a strong motive for endeavouring
to bring the treatment to an end' (1913p. 132).
In the paper just quoted, Freud did not go into some of the unconscious meanings that the payment of fees
may have for the patient—such as pregenital and castrative implications, as well as the abundance of
fantasies and transference reactions that are attached to them and are so well known from clinical
experience. Instead, he presented what may be called the 'psychoanalytic mechanics' of a transaction
between analyst and patient, these being dictated primarily by the kind of society in which we are living. I
shall limit myself as far as possible to these mechanics; but first I wish to make a few brief remarks about
the societal factor.
During the 60 years that have gone by since Freud's paper, the patient–physician relationship has changed
dramatically. On the one hand, by virtue of its unexpectedly great advances, medicine has come to be an
integral and indispensable part of society; on the other hand, medical service is now more or less taken for
granted. The cure of an illness is no longer merely a wish, a hope or a blessing; it is now considered a right,
to which the patient feels that he has a just claim. concomitantly, the relationship of the patient to the
physician has diminished in personal meaningfulness. One might say it has become 'commercialized', were it
only for the fact that the diagnostic apparatus and the medical technology have built a wall between the sick
and the healer.
Thus the physician's fee no longer carries that tinge of immorality that it might have been marked by
earlier, nor is it the expression of the patient's gratitude for the unique gift he may have received, from a
person whom he considered to be irreplaceable. Particularly in the United States—where the absence of
feudalism has left money without the implication of dirt, money in general being regarded a value of virtue
—the physician's fee has become a price to be paid, as one pays for any other service or merchandise.3
It may therefore strike the contemporary reader, medical or non-medical, as strange when he reads the
following statement by Freud:
An analyst does not dispute that money is to be regarded in the first instance as a medium for self-
preservation and for obtaining power; but he maintains that, besides this, powerful sexual factors
are involved in the value set upon it. He can point out that money matters are treated by civilized
people in the same way as sexual matters—with the same inconsistency, prudishness and
hypocrisy. The analyst is therefore determined from the first not to fall in with this attitude, but, in
his dealings with his patients, to treat of money matters with the same matter-of-course frankness
to which he wishes to educate them in things relating to sexual life.
In both respects, this statement is no longer valid.
There are few today for whom sex is a matter of prudishness. The societal climate has changed: whereas
20 years ago, the initial interview with an unmarried student reached a difficult point when the question
came up whether she had had intercourse or not, since she might easily feel offended by the implication that
she had had it, it is now the reverse: she might easily take offence at the implication that she had not had it.
Likewise, no 'prudishness' surrounds the necessity for a fee for medical service; the only question is its
size. Some analysts may deny this to be a problem and determine the fee in accordance with the current
market rate, or in relation to the patient's income when it affords a higher fee than the prevailing one. Yet
others may look also at the fee as a 'psychological' factor, as Freud did.
But what is 'a very low fee'? A fee may be low in terms of what the social milieu expects a physician to
charge, yet quite high for the particular patient. what is the psychological definition of the 'right' fee? Such a
definition
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3 I may be mistaken in making such a generalization, for Kubie (1950p. 135) speaks instead of the
physician and patient behaving as if 'money did not exist'.
4 Cf. Menninger (1958)p. 32): The analysis will not go well if the patient is paying less than he can
reasonably afford to pay.' The influence of size of fee on the progress of treatment has been denied by many
(see Liévano, 1967); (Schonbar, 1967p. 277;); (Allen, 1971p. 136).
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would determine the extent of the patient's monetary responsibility solely in psychological terms. Freud
allegedly once said that the fee should be of such a size as to hurt the patient a bit. That is to say, the patient
should be subjected to an optimal frustration.4 It is, however, possible that Freud here referred to the
frustration of infantile wishes.
It is not too difficult to describe, in approximate terms, what an optimal frustration is. It deprives the
patient of some pleasure that he would have enjoyed otherwise; yet the pleasure or gratification lost should
not be one which is considered essential to him—either objectively or subjectively. To cite an extreme, a
patient who would have to go hungry in order to pay his fee could hardly be analysed: hungry people cannot
be analysed under any circumstances, since they are able to bring into association only imagery dictated by
the immediate physical urge. This problem is usually discussed under the heading of 'the acute conflict'. In
this instance, the acute conflict would be associated with a strong aggressive feeling against the analyst, such
as could not be dissolved into unconscious elements inasmuch as it is based on a reality factor, no matter to
what extent neurotic elements might have become attached to it. There are patients who are ready to make
sacrifices involving basic needs in order to secure psychoanalytic treatment; but, in my opinion, the analyst
should not consider treatment under such circumstances, since they provide masochistic gratifications of
such magnitude that a successful treatment could hardly be expected.
The application of the principle of optimal frustration finds its limits in the destitute and the affluent. In
the case of the former, the fee would have to be so low that the patient, knowing the correct fee, would
regard the analytic treatment as a gift, or feel in some sense ridiculed by its smallness. In the case of the
affluent, a fee that would cause them some frustration would have to go beyond the socially proper and
could not therefore be instituted.
II
(a) In 1919 Freud wrote about the prospect of psychoanalytic clinics for the poor. Subsequently,
psychoanalytic clinics were opened, first in Berlin in 1920 (see Deutsche Psychoanalytische
Gesellschaft, 1930), and two years later in Vienna (see Hitschmann, 1932). These clinics provided
regular psychoanalytic treatment for needy patients. In Vienna some of the patients were so poor that the
Clinic had to give them the car fare necessary for them to make the round trip from home to the outpatient
clinic or to the doctor's office. Psychoanalytic treatments were conducted successfully even under such
extreme conditions.
In two prefaces by Freud to publications concerning the Berlin Institute, it becomes evident that Freud
had changed his mind profoundly during the previous decade regarding the psychoanalysis of the indigent:
its feasibility was now taken for granted by him. Thus he wrote in 1923: psychoanalysis 'should be
accessible … to the great multitude who are too poor themselves to repay an analyst for his laborious work';
seven years later he acknowledged the Institute's contribution to the therapy of those 'who are not in a
position to meet the cost of their treatment'. One of the aims of this institution, he wrote, was to perfect 'our
knowledge of neurotic illnesses and our therapeutic technique by applying them and testing them under fresh
conditions' (Freud, 1930), thus indirectly cancelling out an earlier prediction that 'the large-scale
application of our therapy will compel us to alloy the pure gold of analysis freely with the copper of direct
suggestion' (Freud, 1919p. 168f.).5 Eitingon, the founder of the Berlin Institute, said that it had quickly
become evident that 'we have no metal for such alloys' (Eitingon, 1930p. 70). In 1930 there were 117
patients in analysis at the
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5 I do not believe that Freud's acknowledgement of the opportunity offered by analysis of the indigent to
improve the psychoanalytic technique and to extend knowledge indicates that Freud had changed his
clinical judgment of 1913 about fees in private practice. The passages quoted prove only that he had
changed his mind about the analysability of the indigent. I would surmise that Freud had deepened his
insight into the structure of social reality, particularly during the years of World War I.
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Institute. Moreover, every member of the German Psychoanalytic Society who lived in Berlin had the
obligation of treating one Institute patient free. In Vienna the same rule was introduced in later years.
Dr Kronold, who worked for years at the Psychoanalytische Ambulatorium in Vienna, has been kind
enough to inform me about some of the negative effects of free treatment that did make their appearance.
Acting out—such as missing hours and coming late for appointments—were two prominent features that
could be related to the treatment set-up, but they were amenable to interpretation. Further, the desire to
express gratitude by means of a Christmas gift was a frequent complication. In general, the treatments lasted
slightly longer than in private practice. Similar experiences, I believe, were encountered in other
institutions.
Despite the successes attained by free psychoanalytic clinics, I should like to report some reservations of
my own. It is possible that the types of disorders that can be treated under such circumstances with the
psychoanalytic technique (in the narrower sense of the word) are limited in number. I recall, for example, a
young man who was seeking free treatment in August Aichhorn's Consultation Service. It soon became clear
that his style of living was based chiefly on his poverty. He had been trying to get for himself all the
advantages he could by exploiting the pity he was indeed able to arouse through exhibiting himself as a
victim of societal injustice. In his case, a free psychoanalytic treatment would per se have provided a
gratification of a kind and intensity that are incompatible with a constuctive psychoanalytic situation. Under
such conditions, a pre-analytic treatment phase was necessary in order to straighten out a character defect
that called for the use of primarily educational means, and which would not have been amenable to free
psychoanalytic treatment.6 With the recent widening of the psychoanalytic scope, many syndromes other than
the classical neuroses are being taken into psychoanalytic treatment, and I wonder whether in disorders that
do not belong among the transference neuroses free treatment may not serve to create impediments to a
successful treatment course.
Here I wish to say a few words about the concept of poverty. A person may have little money, and he
may indeed be deprived of a great deal; nevertheless, this does not necessarily mean that he has the outlook
of the poor. The lower middle classes suffer deprivation, but they do not acquire such an outlook. In order to
come closer to the real meaning of the latter, one has to consider certain givens in the structure of the ego.
The psychology of the extremely poor is characterized by an outlook on life in which what is essential is that
possibility of choices is almost completely absent: whatever happens to these people is dictated by
necessities that are imposed by the outside world. The ego does not face a world in which alternatives exist
and individual choices are at least possible; what happens, what will happen is determined solely by the
iron rule of existing conditions, and these are not part of the acting self.
It is thus understandable that such psychological conditions create a state of affairs in which the making
of spontaneous decisions tends to coincide with acts of delinquency or crime. If a person who has thus been
severely mutilated by the impossibility of making choices of one's own falls into neurosis that is not one of
the transference neuroses, but rather a psychosomatic disorder or a character neurosis, it is very probable
that the personality structure is of such a kind that no psychoanalytic treatment can be instituted. (Since I am
discussing the question of fees within the framework of the non-modified psychoanalytic technique, it is not
necessary to pursue this problem any further at this point.)
In the middle classes, even on that lower ('borderline') fringe that is exposed to severe deprivations, the
outlook on life is basically different. Among them, the possibility of making choices of one's own is not too
great either, but what has remained alive is knowledge about the character of choices, the possibility of
attaining a state in which such choices are possible, and the hope that such a state will indeed be attained
one day, whether by effort or good luck. An ego that is still capable of being nourished by
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6 Kubie (1950p. 140f.), however, has made the observation that the exploitation of 'an analyst's generosity
for neurotic reasons' can be successfully analysed.
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such hopes has not been irretrievably mutilated by the injuries that are caused by severe and permanent
deprivation; here the psychoanalytic technique can be applied, so long as the patient suffers from an illness
that falls within its scope. This is true even if the fee is low or the treatment is free.
The resulting transference difficulties should not be, to a competent analyst, insuperable (cf. Huffer,
1963). However, a distinction must be made here between analysts who are employed by a referring
institution (which sets the fee) and those analysts who provide low-paid treatment by their own decision,
and within their own private practice. The transference difficulties to be anticipated should be different in
each case.7 The question of low-fee treatment dispensed by the New York Psychoanalytic Treatment Center
has often been discussed, and I do not recall any instance in which that set-up caused noticeable difficulties.
I sometimes have the feeling, however, that we are a little too certain in our judgement of the effects of
relevant external factors on the course of a psychoanalytic treatment. The late Dr Federn brought out in one
of his seminars that many patients have a tendency not to talk about what happens in the analyst's presence,
or about things they are certain are known to him. They act, in short, as if there were no need to verbalize
what, in their opinion, the analyst is surely aware of. I can well imagine that, for that reason alone, the
associations of many treatment-centre patients do not touch upon the fee situation. One might obtain a
different impression, however, if one inquired directly, on a suitable occasion, how the patient feels about
the financial arrangement.
Furthermore, I should like to add a brief clinical vignette to Freud's statement about the low esteem in
which things are held when they are got cheaply. For eight years I had a young man in free psychotherapy,
with one session a week. Almost regularly, I made the appointment over the phone, as soon as I knew what
my schedule for the next week would be. It happened every so often that he did not let me know that he
would be out of town and thus out of reach. Likewise, upon his return he did not call, but waited for me to
do so. I repeatedly pointed out how strange this behaviour on his part was. On one occasion, when I finally
reached him on his return to the city, he could not make up his mind about his next appointment, due to a
heavy work schedule. I told him to call me as soon as he knew he would have time to come; he never called
at all.
It is striking that a patient would part from his therapist in such a way, after he had participated with
intensity in a treatment that had covered eight years, and moreover had been greatly helped, despite the fact
that the treatment had taken place under rather trying circumstances. Notwithstanding the patient's
undoubtedly severe disturbance in his object relations, I had the feeling that a patient who had been paying
for his treatment would not have acted in such a callous way. His internal responses were not callous at all;
he was, indeed, a rather sensitive person. One of the meanings of his peculiar behaviour was, I am certain,
an expression of contempt for what he had been receiving free.
Yet, in my practice, I have also had an opportunity of encountering the opposite experience. I was asked
for a consultation by a young woman whose disorder had made her suffer so much that she had spent one and
a half years in voluntary commitment in a state institution. She had been treated competently for a while as
an in-patient at a university hospital, but nothing seemed to be of help against bizarre clinical
symptomatology which she displayed and which covered an agoraphobic core neurosis. She was certain that
I would not be able to do anything for her, since she could barely make ends meet with the support she was
receiving from her family. Since I had just undertaken private practice, and had free time at my disposal, I
was glad to have the opportunity to fill an hour of my daily schedule. I therefore told her that I would take
her into analysis without charging her for it.
To my surprise, the patient appeared the next day in my office without any companion. For many years,
she had been incapacitated by an inability to leave her home unless she was
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7 Lampl (1930p. 46), summarizing his experiences, pointed out the difficulty that arose when a clinic
patient was taken for treatment into the analyst's private office. He thought that treatment on the premises of
the Institute was preferable.
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accompanied. Evidently she was returning what she had taken to be a great gift by making an even greater
one herself. When such surprising reactions of improvement occur at the very beginning of a treatment, they
are usually signs of resistance, purporting to prove that analysis is, after all, unnecessary. That was not the
case in this instance. Paradoxically, the disappearance of the symptom was a token of her desire to maintain
the analyst's help. A few weeks later, she spent the first evening free of anxiety; to her amazement, however,
she fell into a depression, and recognized that she was in need of anxiety. From that moment on, her
treatment took a progressively favourable course. The nonpayment of fees at no point caused any difficulties.
The question of fees is difficult to solve with regard to the wealthy patient. He is, not only economically
but also psychologically, in the opposite position from that of the poor patient: he does not know any set of
choices in the external world about which he is not able to make an effective choice of his own. There is an
abundance of alternatives—all of them luring and inviting him to choose. The resultant attitude that he is
able to buy anything he desires is a hotbed for the growth of a multiplicity of symptoms.
Extreme wealth may make an analysis impossible. One instance of this was told to me by Theodor Reik.
An American millionaire who had been suffering from a severe compulsive-obsessional neurosis came to
Vienna for the express purpose of being analysed by him. Reik never saw his patient, however, because the
latter—even though he sent Reik the arranged fee regularly—called him occasionally over the telephone to
ask a question, but never made a single appearance in his office. This is an extreme and therefore atypical
example; but it may, for just this reason, demonstrate some usually hidden facets of the psychopathology of
wealth. The not entirely unjustified fear of the wealthy person is his conviction, on the basis of frequent
experiences, that his company is sought solely for monetary reasons. It is important, therefore, to convey to
the patient's unconscious that money will be of secondary importance in the therapist's relationship to him.
The best way to do this is not to ask for the currently maximal fee. Since quality of service and the amount of
fee paid are often correlated by the affluent, it may happen that the wealthy person when he is not charged
the highest fee, may interpret this as a sign of his not receiving optimal service. This, however, seems to be
an easier hurdle to overcome psychoanalytically than would be the patient's tacit assumption that the
therapist's interest in him is based primarily on monetary considerations. At any rate, I believe it is a grave
mistake, under such circumstances, to go even beyond the current maximum.
A particular difficulty arises in the treatment of sons of the wealthy. The few patients of such background
whom I have seen have suffered from severe ego disturbances, and have posed particularly difficult
technical problems. Relative success was achieved when I treated them, for a while, without accepting any
fee from their fathers. Only by doing so was I able to get them to believe that I was really interested in their
recovery, and not in their parents' wealth. It is understandable that children who had previously had only
tenuous contacts with their parents and had instead been entrusted to the care of paid employees—even if the
latter were devoted to them—were unable to develop even the least bit of those sincere positive
transference feelings that are the absolute minimum for a psychoanalytic treatment.
I do not want to close this section without reporting a personal experience that greatly surprised me. For
years I worked in a psychiatric ward and out-patient clinic of a prestigious Middle Western university.
Patients of a variety of social groups were being treated there. I do not know the percentage of free
treatments, since that fact was not recorded on the patient's chart, but it must have been substantial. I never
had any difficulty in establishing contact with these patients, independently of their class, origin or income.
When I settled in private practice, I offered free service to a society that was providing treatment for the
poor. To my amazement, I was not able to treat the patients referred to me. I could not establish a workable
contact with them and, I must admit, I was unable to empathize—that is to say, I could not project myself into
the patient's personality. I draw the conclusion from this that there is an essential
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difference, in regard to psychotherapeutic treatability, between a person who, even though he is deprived,
has not evolved the psychology of the poor and a person whose poverty has become an essential part of his
personality (cf. Hollingshead & Redlich, 1958).
(b) I shall now turn to a discussion of the technical problems that are encountered when the fee is paid by
a third person. The third person may be a patient's relative—usually one of the parents or a spouse—or an
impersonal source, such as an insurance company or a government institution. The difficulties in these two
instances are quite different and they must be discussed separately (see Halpert, 1972p. 131).
Depending on the circumstances, an arrangement of the first type may not lead to specific difficulties; the
patient may even pursue his treatment with particular scrupulousness and devotion, precisely because he is
not personally responsible for its financing. I have observed this in adolescents who had been advised to go
into treatment because of an acute, seemingly desperate situation, which they had believed to be practically
unsolvable, but which was solved, to their surprise, with the help of the treatment situation. There remained
throughout the treatment a residue of gratitude, which served as a reliable barrier against their acting out.
A troublesome question may arise because of the demand that sessions missed by the patient be paid for.
Parents, even when they have been told by the analyst that he will charge them for such hours, feel very
indignant upon finding out that they had been so charged without having been informed about the lost hours.
The analyst, if he does not want to be a traitor in his patient's eyes, cannot, of course, let the parents know
how many sessions the patient had missed. I have heard of one instance in which the analyst received
payment over a rather long period of time under such circumstances; when this became known to the parents,
it aroused their severe distrust and suspicion. The question of the payment for missed hours will be taken up
later. In general, however, it may be said here that it seems preferable not to charge the parent for missed
hours. In some cases one may even strengthen the adolescent's sense of responsibility by telling him that his
absence will cause damage to his therapist.
The treatment paid by a third person may pose some special technical problems. The most frequent one
seems to me the patient's unconscious and sometimes preconscious wish to harm the person who is paying
for his treatment. This may create a serious situation, but one which, however, can usually be combated and
should not lead to an insurmountable resistance.
It does lead to a serious situation, however, in a certain type of young male, whose psychopathology is
focused in a sense of 'emptiness', and whose passivity is the only defence at his disposal against
considerable aggression. Such analyses often start moving only after the patient begins to make his own
monetary contribution. Only then will he start breaching the wall with which he has surrounded himself, and
some movement will thereafter occur in the therapy. I know of one psychoanalyst who had had such bad
therapeutic experiences in the analysis of younger people whose treatments were being paid for by their
families that he decided no longer to carry out an analysis under such conditions.
When some member of the family pays for treatment, there is, of course, the risk that the paying person
may renege. In the case of a young adult, one analyst solved the financial risk of such an undertaking by
having the person who was assuming responsibility for the fee sign a statement attesting to his obligation.
This measure apparently had no ill effect on the ensuing treatment. Such a precautionary step may be
necessary from the financial point of view, since it is only under special circumstances that the analyst is in
a position to continue the treatment when the patient's father stops payment, but—I must admit, on emotional
grounds—I hold such procedure to be incompatible with the analyst's dignity.
I have myself encountered significant difficulties in instances of third-person payments, mainly in the
treatment of delinquent male adolescents. To my surprise, fathers started almost regularly to oppose their
sons' treatment, when the first signs of an impending dissolution of the delinquent symptom made its
appearance. Strangely enough, until then I had had the father's respect and confidence, but it seemed that he
could not tolerate any proof of the fact that his son did not need to behave in a
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delinquent manner. The implication that the son's delinquency might be—and therefore might have been—
avoided evidently arouses a serious feeling of guilt in the fathers of delinquent sons.
One has to anticipate, therefore, the necessity of having to conduct the treatment for a while without
compensation, and can only hope that the patient will remember the service he had previously obtained and
compensate the analyst later—after he has become an integrated member of the community.
In general, as far as I have been able to observe, there are no serious complications when a patient's fee
is paid by the spouse. In our society, it is usually the husband who provides the means. Yet the situation may
take an unpleasant turn in case of a divorce. Depending on the circumstances, the husband may then refuse to
continue payments, and I do not know of any solution to that eventuality. The patient's need for therapy is
often particularly intense in such a situation, and the analyst may have no other choice but to bear the burden
of sacrifice in the form of a greatly reduced compensation.
From one instance, I have learned that one should be more cautious in this regard than I had previously
thought necessary. A husband turned to me, pleading with great intensity that I take his wife into treatment.
She herself seemed rather reluctant, but finally agreed, allegedly because of her husband's insistence. The
treatment started surprisingly well, for the patient had been aware how urgently she needed treatment. But
serious complications occurred when it turned out that the husband was unwilling to pay for his wife's
treatment, and instead demanded that she pay for it from a relative's funds, which she was administering. To
be sure, this did not involve any infringement of the law, but it did create for the patient an almost
intolerable subjective situation. Although analysis could proceed even under such aggravated conditions, I
obtained the impression that it may be preferable to make sure in advance, in each such instance, that the
husband is willing to finance his wife's therapy.
Of course, the difficulties that may arise as the result of third-person payments are manifold, and I am not
sure that I have enumerated even the typical contingencies. It stands to reason that this form of payment
should be avoided whenever feasible; but on the other hand I do not see any reason why one ought to refuse
treatment on a principled basis under such circumstances. If common sense and caution are employed in the
preparatory interviews, prior to a final decision, one should be able to select those cases that are not likely
to harbour later surprises. However, the possibility of divorce, together with its ensuing complications, can
never be excluded with any degree of certainty.
The problem of payment for missed hours, which I have mentioned previously, deserves special
discussion. Freud himself took a strict stand on the question. He categorically adhered to the 'principle of
leasing a definite hour' (1913p. 126)8 and advised that whatever may have been the reason for the patient's
absence, it should always be the patient's obligation to pay for lost time. For brevity's sake, I shall call this
technique the 'rule of indenture'. Freud had the surprising experience that, under this regime, intercurrent
illnesses rarely occurred and almost no time to speak of was lost (1913p. 127).9 When 'undoubted organic
illnesses' occurred, Freud broke off the treatment, felt free to take a new patient, and continued the analysis
that had been
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8 The German term vermieten used by Freud sounds harsher than the English word 'leasing'. Menninger
(1958), however, writes: 'The money paid by a patient to a psychoanalyst is not in payment for the
analyst's "time" (author's emphasis) but for 'the professional services of the physician' (p. 28). Menninger,
of course, is right, if the statement is taken literally. But Freud's formulation was aimed at marking off the
analyst's profession from others, such as the lawyer's, where compensation is often measured in terms of
success, or the surgeon's, where the fee varies with the kind of service he has rendered. On the other hand,
the analyst's service is compensated for exclusively in proportion to the time he has spent, that
compensation, of course, depending also on his experience and prestige.
9 It may be worthwhile to call attention to a mistranslation of Freud's original text on that same page:
Freud had noticed that before he applied the strict rule, an interruption for which the patient did not seem
to be responsible always occurred at a time when the analytic work was promising to become 'rich in
content'. Freud called such an interruption eine unverschuldete Pause, which was translated as 'a break
for which he (the analyst) cannot blame himself'. The context, however, leaves no doubt that what Freud
meant was a break for which the patient appeared to have been not responsible.
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broken off only after he had another hour vacant. Freud does not indicate the length of time for which he was
ready to wait in the case of an intercurrent illness. Freud's technical advice was written in 1913, and I
wonder whether he continued to employ the same technique in later years, when analyses lasted longer and
many of his patients came from abroad.
Freud's early paper, at any rate, sounded as if he thought that every interruption of the treatment was a
sign of resistance. In 1925 Freud added therefore a footnote to his 'Interpretation of Dreams' (1900p. 517),
in which he said that his statement should be taken as a warning only. He enumerated events that would lead
to an interruption of treatment and yet could not be connected with a resistance. But the effect of the
interruption, he noted, will depend on the patient's resistance, which 'shows itself unmistakably in the
readiness with which he [the patient] accepts an occurrence of this kind or the exaggerated use which he
makes of it' (1900p. 517, n.1). This undoubtedly correct clinical observation, however, makes the question
of fees for lost hours even more complicated.
I myself have made a rather surprising observation, which I must assume has been made by many others,
in view of the regularity with which I encountered it—namely that most patients regard the 'rule of indenture'
as an injustice, in view of the fact that they have to pay what they regard as a penalty for missed hours, while
the analyst does not meet the situation on equal terms when he misses an hour. It has never become clear just
what the patient expects the analyst to do under such circumstances. The fact that the analyst is deprived of
income when he fails to see a patient at a time set aside for him does not in general dawn on the patient as a
sufficient penalty, or even as a penalty at all. I do not know how many analysts apply the rule of indenture at
present. It is my impression that the younger analysts are more inclined towards it than the older.10 One
hears of compromises and, again for brevity's sake, I shall call all such techniques 'gentlemen's
agreements'.11 Such an agreement may grant the patient the right of non-payment, if the analyst was
forewarned on time about the patient's anticipated absence, or if the absence was enforced by vis major, or
the missed hour was unconnected with acting out (Schonbar, 1967p. 277).
Strict adherence to the rule of indenture may provoke strong aggression in the patient. If one believes that
such an upsurge of aggression on the patient's part is a desirable goal, then of course the rule will be
enforced. The argument against such reasoning might be that when a patient's aggression does not clearly
result from his own conflicts, but—at least in his view—is reality provoked, it usually cannot be
successfully analysed.
The decision between 'rule of indenture' and 'gentlemen's agreement' depends also on the general style of
the individual analyst's technique. This style is rather more contingent upon imponderables than it is upon
adherence to specific rules; as a result, styles of technique vary greatly from one analyst to another, even if
there is agreement among them on specific rules.
If the analyst's style of treatment is one of distance, with the strict exclusion of his own emotions,
following consistently the 'mirror model' of technique, as suggested by Freud in 1913, then it is quite
consistent for him to adhere to the rule of indenture. If, however, his style is more liberal, and the therapist–
patient distance is reduced,12 it may affect the patient as inconsistent for the analyst not to liberalize the rule
of indenture.
When the problem is viewed from the patient's point of view, one has to admit that there are patients who
would simply not be able to abide
—————————————
10 The rule of indenture is recommended by Kubie (1950p. 136), Haak (1957p. 193), Menninger (1958p.
33). Kubie says that, by not charging, the analyst induces the patient to escape unpleasant sessions, but after
'the patient is well launched in treatment' rigid adherence becomes unnecessary. Haak had excellent results
when he reverted 'to a rigorous system of payment', Glover (1955p. 319) reports the answers to a
questionnaire of his: a large majority of analysts have a standard rule of demanding payments for missed
hours, but only about half of them have adhered to it.
11 Fromm-Reichmann (1950p. 67) expressed herself against charging the patient under all circumstances
for missed hours.
12 Fenichel (1941p. 74) comments on the ambience that surrounds the analyst, and which can be also
expressed in terms of distance. Some of his patients who had previously been in analysis were surprised
by the 'freedom' and 'naturalness' he displayed as an analyst. (See also p. 25.) Glover (1955p. 308f.)
presents pertinent material with regard to the problem of distance. Cf. also Greenson (1967, passim.).
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by the rule of indenture. If it were instituted, it would lead to unnecessary complications, long detours and
even to alienation between analyst and patient. In extreme instances, it may even cause a premature ending of
the analysis—something that might have been avoided under a 'gentlemen's agreement'. There are, no doubt,
patients who are too infantile, too sensitive or too fixated at a pregenital level to be able to tolerate from the
beginning the frustrations that are concomitant with the rule of indenture. I do not believe that there is much
hope of being able to break such a patient's resistance by an act that he must almost necessarily experience
as one of forceful authority. Tarachow (1963), however, reported patients who felt rejected and complained
severely when he did not charge them for missed appointments. They felt 'pushed out' of the psychoanalyst's
life for that particular period of time. 'They would have willingly paid so that they could have had me in
their life, so to speak, for that particular time' (p. 121f.). This was a conscious reaction without reduction of
contact with reality, as Tarachow writes.
At any rate, the rule of indenture should not be followed with absolute rigidity. I knew a patient who had
evening appointments with his analyst, and whose family celebrated Christmas on the evening preceding the
holiday. For years he struggled with his therapist to be permitted to be at home on that evening, but the
analyst insisted that the patient come at his usual appointment time or pay for the cancelled hour. Although
such rigidity may have its rationale at certain turns of a psychoanalytic treatment, one has to acknowledge
that it does have its limits.
There is general agreement that technical rules should be adjusted to the structure of the patient's
personality, and it stands therefore to reason that the decision about the approach to be chosen should be
made contingent upon the patient's tolerance and ego strength (cf. Schonbar, 1967p. 278). However, some
analysts may look at the rule of indenture as a kind of acid test of the patient's analysability. If a patient, one
could reason, cannot tolerate the frustration of the rule of indenture, then one should not be analysing him at
all, for such lack of discipline is a harbinger of excessive narcissism and of acting out. In my opinion, such a
conclusion will not be confirmed clinically. There are patients in whose initial phase of treatment many
incidents of acting out do occur but later disappear. It seems to me therefore that it is best initially not to
broach the question of missed hours, but to follow the unfolding of the patient's story. No harm is done if
only later, after one or two incidents of unwarranted absence have occurred, the rule of indenture is
imposed.13 Once the patient discovers that it is his acting out that has led to his absence, it should not be too
difficult to make him understand and abide by a strict rule.
The rule of indenture may lead, particularly in the United States, to situations that are somewhat
ludicrous. Many analysts tell their patients at the beginning of the year just when they themselves will go on
winter or spring vacation, expecting their patients to organize their own vacations for the same time period
(see Menninger, 1958p. 36). It is, however, hardly possible for a married woman with children who are
attending different schools to arrange her vacation periods in conformity with the analyst's schedule,
particularly when her husband is in analysis to boot.
One must, moreover, consider the analyst's personal feelings in this matter. In discussing the effect of
what I have called the rule of indenture, Freud pointed out that, when the analyst follows the rule, he finds
himself only rarely in a position in which he would feel embarrassed about his enjoying leisure time for
which he is receiving payment (1913p. 127). One may feel a defensive innuendo behind this subtle irony,
and surmise that he was not entirely happy about the idea of unearned income. He thus referred to a point of
sensibility that may indeed cause embarrassment, depending on the analyst's own idiosyncrasies. For some it
may not be quite easy to devote an hour a day for two to three weeks to their own comfort while being paid
a considerable amount of money for
—————————————
13 Haak (1957p. 193f.) justifies 'a rigorous system of payment' which he considers 'to be an essential and
dynamically important factor in the analytic process', by means of which he had 'only therapeutically
favourable experiences'. Nevertheless, his arguments—the discussion of which would offer a welcome
opportunity to deal with some principles of psychoanalysis—did not convince me of the superiority of his
technique.
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that time. Once I wanted to charge a colleague for one or two hours he had missed because of an intercurrent
illness. When he told me—in an unaggressive way—that he himself did not charge patients under such
circumstances, I dropped the matter; for this I may easily be criticized.
It is highly probable that the analyst's decision in favour of either the rule of indenture or a gentlemen's
agreement will depend also on his own attitude to money.14
(c) I now want to discuss briefly two situations in which, I believe, it is legitimate to treat patients
analytically free of charge, at least for a while.15 There is a type of schizoid personality who is in urgent
need of psychoanalytic treatment and ready to undergo it—if he can obtain it without having to pay a fee.
The rationalizations for such a demand vary. One is the feeling of repulsion at the idea of mixing what such
patients call the spiritual, ethereal or incorporeal—such as baring their most intimate feelings—with, let us
call it, 'impure' elements, which in this instance would be money. There is no doubt that such a patient is not
able to generate initially a feeling of minimal trust under conditions in which he has to pay for the privilege
of talking about himself. There is also the patient who needs analysis and would be suitable for such
treatment, yet believes that he has contributed so much to the community, or that his character and
personality are so remarkable that he is not only entitled to free treatment, but deserving of it.
In the first instance, it is the patient's sensitivity, not to say fragility, that necessitates treatment in the form
of a gift; in the second, the necessity of paying a fee would constitute a narcissistic injury of such gravity
that, under the impact of such an obligation, the patient could not get himself to start the treatment. In both, of
course, deep-seated anxieties are at work. Once such a patient has started his analysis, it does not take too
long to provide him with insight into his resistance and the self-defeating impulses behind his strange
behaviour: he is then likely to agree to compensate the analyst. However, it is advisable at this point to turn
him over to another analyst, inasmuch as the transference situation has become too involved to be
disentangled; moreover, as a result of the analyst's initial willingness to comply, the transference has
become too libidinized to warrant any expectation of a promising course of treatment.
There is another disorder that requires a handling of fee payments that is different from the usual. In some
depressed patients, this disorder is of such a quality and reaches such an intensity that it is inadvisable to
discuss fees with them. In true depression, the entire personality has become absorbed in the process of the
illness. In view of the patient's almost complete alienation from the world, the need to pay a fee would
amount to a burden that goes beyond the limits of his strength. (I am here repeating what Paul Federn
frequently discussed in technical seminars.) The subject of fee must in such instances be discussed with the
depressed patient's family, since action in any area of life has become an unbearable stress for the patient
himself. The additional task of having to pay a fee would in itself amount to an extension and intensification
of the illness. Any action that causes such an aggravation is incompatible with
—————————————
14 Schonbar (1967p. 278) has made a pertinent remark:
'The therapist very likely selects the system which best suits his personal predilections, and although this
undoubtedly affects the nature of the therapeutic relationship, it seems clear that, despite statements to the
contrary, the choice is not primarily for reasons pertaining to the well-being of the patient. … Certainly his
[the therapist's] personality plays a part, in that he is likely to choose that policy which best suits his
general style.' Cf. also Glover (1955pp. 21f., 75).
15 Fromm-Reichmann (1950p. 67f.) calls 'the old psychoanalytic concept'—namely that a financial
sacrifice is a prerequisite of successful psychotherapy—'an unfortunate misconception engendered by
misleading teachings of our modern culture'. As mentioned before, Freud had already presented in 1919 a
new opinion, which was confirmed by clinical observation in the 1920s. However, in my opinion, Fromm-
Reichmann has herself become a victim of 'misleading teachings of our modern culture' when she speaks of
'the desirability of nominal payments where possible for the sake of the maintenance of the self-respect of
the patient, who does not wish to obtain something for nothing'. Here one can observe the pitfalls of the
sociocultural approach. When a patient loses self-respect because he has obtained something for nothing,
this belongs to psychopathology. When self-respect cannot tolerate the acceptance of something for
nothing, this attitude has to be analysed and should not be camouflaged by arrangement of token fees. What
a society regards as 'virtue' has to be analysed in the patient, as well as what it calls 'vice'. Indeed, it is in
the analysis of the patient's virtues that one often discovers the deepest sources of his psychopathology.
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the pursuit of basic therapeutic functions. The necessity of paying a fee constitutes, of course, in all cases the
addition of a task; in the common neuroses requiring psychoanalytic treatment, however, this task does not in
itself contribute to enlargement of the disorder.
Here is the proper place to discuss the delicate and difficult problem of what to do when the patient's
financial situation does not permit him to go on with the treatment. In the case of depressions, the answer is
clear. The treatment of a depressed patient must never be discontinued for reasons that lie within the
analyst's control. In my opinion, not even the number of sessions to which the patient has been accustomed
should be changed. Before the treatment of a depressed patient is started, the analyst must decide whether he
will be willing to make the sacrifices that he may be asked to bear.
It should be clear why this particular group of patients requires special consideration. First, there is
always the danger of suicide, when the patient's last half-way positive tie to the world in the form of
transference has been broken; secondly, an interruption of treatment for an extraneous reason would entail
such anguish in the patient that a therapist should be entirely unwilling to serve as the proximate cause of
such intensive pain, which he is in a position to avoid. The objection to my proposition will be that, by
accommodating wishes that are, in point of fact, lurking in the unconscious of every patient, one nourishes
the oral-dependency needs of the depressed patient, and thus contributes to aggravating his disorder. To be
sure, that would be correct with regard to a patient whose depression is part of (if old terminology is
permitted) 'psychopathy', as so often happens, but it is not valid with regard to bona fide depressions.
There is another group of patients who need special consideration and whose treatment must never be
discontinued for financial reasons. I cannot imagine an analyst discontinuing the analysis of a child, on the
grounds that the latter's parents are unable to pay a fee. The same should hold true with regard to the
adolescent or late adolescent. To discontinue a relationship that is so valuable to these patients, and in
which the analyst is functioning not only as a transference object, but partly, or even predominantly, also as
a reality figure—and to do so for monetary reasons—would surely have a deleterious effect on the patient.
To put it into the simplest possible terms: the child's ego, as well as the adolescent's superego, is still in the
process of vigorous growth and structurization—and this makes them particularly vulnerable to the
harshnesses of reality. The separation of an adolescent from his analyst because of the suspension of
payment will very likely have the consequence of impairing the former's superego. The trauma of
separation—especially if it is enforced by monetary matters—would in all likelihood turn the adolescent
into a cynic, a consequence that is incompatible with the responsibilities a therapist undertakes in starting a
treatment.16
A general remark about the analyst's motivations for taking a patient into analysis seems to be in place
here. It is not necessary to enumerate all the possibilities; these form a large arc, from research to financial
interest. Practice will show that, with few exceptions, there is actually a plurality of motives at work
besides those of curing the patient. Yet it should not be overlooked that the motive that is prevalent, besides
the therapeutic one, or the motive in whose absence the analyst would never accept a patient under any
circumstances, is the decisive point.
However, in a psychological evaluation of the analyst's motives, one does have to consider a special
point. It would be difficult to find an analyst who will accept a patient without fee, or with the payment of
only a token fee. This will be, in most instances, a matter of economic necessity, and it should therefore not
be considered as actually belonging to that aspect of the analyst's psychology that is under discussion here.
There are, of course, analysts who are wealthy, and therefore do not pay much attention
—————————————
16 In an excellent, stimulating paper Freudenberger (1971) has outlined the necessary deviations from
classical analytic technique that are required in the treatment of severely disturbed adolescents and late
adolescents. Such deviations also include new techniques of fee-setting. Although Freudenberger's paper is
primarily concerned with psychotherapy, his technique impresses me as being pertinent also for some
adolescent patients who will be taken into extensive psychoanalytic therapy.
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to the fee paid. Kubie (1950p. 140) reports that 'almost every psychoanalyst' carries patients 'for little or
nothing', and, when his schedule is full, guides a poor patient 'to another psychoanalyst whose schedule
makes it possible to accept him'. I wonder, however, how many regular psychoanalytic treatments are
conducted free of charge in private practice. It might have a beneficial effect if psychoanalytic societies
would suggest that their members analyse at least one patient at a time gratis—and this not only for its social
implications but also for the benefit of the analyst himself. I anticipate such a benefit in two areas: it will
broaden the analyst's knowledge of social groups which exist in his community, and would protect him
against a one-sided view of the social structure and its impact on the individual. Furthermore, it would
enable him to accumulate experiences from analyses in which the fee factor plays no role as a motivating
force (either in the patient or in the analyst) and should thus not only contribute to the refinement of the
psychoanalytic technique but also solidify and maintain the psychoanalyst's own freedom and independence
from the impact which the monetary factor may gradually exert on him, even if he had started out in practice
motivated by age-adequate idealism.
When, however, an analyst is ready to take a patient into treatment only if the highest current fee is paid,
that may be indicative of a pathological relationship on his part to money—and therefore also to the patient.
A balanced relationship to money would include a willingness on the analyst's part to treat occasionally
without fee, or with only a low one.
Yet, if we approach the problem in general terms, it is important to keep in mind that, however the
analyst may handle the question of fees, he is bound to gain a narcissistic pleasure from his profession (cf.
Greenson, 1967pp. 396–408). It goes without saying that every profession, if it is carried out proficiently,
must provide that minimum of pleasure that is called functional pleasure, Funktionslust (Karl Bühler)
—pleasure derived from being active. We find here gradations: when functional pleasure becomes too
intensive, it may be deleterious to an analyst's proficiency. My belief is that an analyst should not conduct
analyses only because the activity of analysing gives him so much pleasure, and it should not be forgotten
that functional pleasure also in optimal intensity is narcissistic pleasure. Furthermore, everyone will agree
that, whatever an analyst does in a treatment situation, whatever technique he believes may fit such a
situation, the choice should always be made from the standpoint of what is most beneficial to the patient. To
be sure, this is true not only of the psychoanalyst, but also of physicians in general and other professions.
Yet it is true of the analyst in a wider sense. Professions enter into a variety of sectors in the existence of
those whom they serve. But psychoanalysis enters into all sectors of the patient's existence. To a certain
extent, it may be said that the analyst's responsibility takes in the whole of the patient's existence. Correlated
with this large responsibility is comprehensiveness of technique. There is no detail in analyst–patient
contact that would not acquire technical importance, under the proper circumstances. An excellent surgeon
may be rude to his patients, but this defect will not stand in the way of the patient's recovery; yet I have
discovered, in one instance, that even so trivial a detail as the size of the analyst's room had a noxious effect
on the patient's treatment, which was blocked as long as the relevance of that factor was not brought to light.
This comprehensiveness of the technical aspect makes the psychoanalytic profession one in which the
narcissism of the practitioner must take far more subordinate place than it does in other professions. I am
aware that such a statement may easily be misunderstood and even be regarded as sanctimonious, for there is
no indication that analysts are essentially less narcissistic personalities than those that one encounters in
other professions. It means only that analysts must be more keenly aware of their narcissism, and must place
more severe curbs on it in the professional situation than is necessary in other professions.
It is this putting oneself completely in the patient's service that takes the question of fee out of any sort of
'matter-of-fact' context in the case of the psychoanalyst, in contrast to other professions. If it turned out that
the payment of fees is necessitated exclusively by the analyst's needs and does not also work out
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to the patient's advantage, the question could justifiedly be raised whether it is really proper for the analyst
to have his services paid. Freud seems to have been confronted with that question, although he never spelled
it out. At least, I had the feeling that it was the background of the passage quoted earlier about the
consequences of free treatment, which led to the conclusion: 'Free treatment enormously increases some of a
neurotic's resistances' (1913p. 132).
When the principle is formulated in the form of saying that psychoanalytic technique should be so
structured as to disregard the analyst's narcissistic needs, it acquires a sharper contour. It could be that
Freud had something of that kind in mind, when he built the customary and quite mechanical transaction
between vendor and purchaser as a dynamically significant process into the psychoanalytic technique.17 It
may be concluded from this that, in charging a fee, the analyst does not violate the principle that very detail
of technique is to be geared to the promotion of the patient's welfare. Charging a fee would thus create an
optimal atmosphere for the patient's recovery at the same time as it gratifies the analyst's narcissistic needs.
Yet it is evident that there are limits to this rule. Lionel Blitzsten discussed frankly the necessity for the
analyst's narcissistic needs to be gratified, if he is to function optimally. I agree with that point of view;
there is nothing to be ashamed of, if an analyst refuses treatment unless a high fee is paid, because the
treatment of that particular patient will probably be quite troublesome and expose him to unusually stressful
situations. Thus there are clinical situations in which the scope of the analyst's narcissistic gratification goes
beyond that of functional pleasure and the need to make a living. Glover (1955p. 20) warns against
pretending 'that arrangements about fees … have nothing to do with the analyst's own requirements and
convenience'.
It may rightly be asked how candid and frank an analyst should be to the patient, about his own feelings
regarding monetary matters. In Freud's writings there is at least one example that seems to show him
adhering to a principle of maximal frankness. It can be found in his 'Psychopathology' (1901p. 220f.) and is
of interest on several counts. He had promised to give a patient books about Venice, since the patient
intended to spend his Easter vacation in that city, but he had forgotten to do so, 'for I did not entirely approve
of my patient's journey, which I saw as an unnecessary interruption of the treatment and a material loss to
the physician' [my italics]. When the patient reminded him of his promise, Freud pretended that he had
already selected the books. He then went to his library to get them; but upon his return he noticed, to his
embarrassment, that he had made a mistake in the hurried selection of one of them.
'As I so frequently confronted my patient', Freud continued, 'with his own symptomatic acts, I could only
vindicate [lit. save] my authority in his eyes by being honest and showing him the motives … for my
disapproval of his journey.' From this we can learn that in 1907, when this episode was added to the first
edition of the 'Psychopathology', Freud was not yet adhering to the rule of indenture. But more importantly, it
indicates that Freud himself pursued a technique of scrupulous honesty towards his patients, particularly in
regard to money matters. On the occasion noted, Freud also averred that he was scarcely able to use white
lies any longer, as a consequence of his involvement in psychoanalysis. One may cite this episode also as a
sample of what I said earlier about the extent to which the gratification of the psychoanalyst's narcissism is
reduced in his professional activity.
It is not to be expected that every analyst can reach such a high level of frankness. The question may also
be raised whether it is always to the patient's advantage. One would therefore like to know what degree of
honesty is advisable in the analyst's discussion of the fee with the patient. I know of an analyst who takes
patients in the sequence in which they ask for treatment. Under such conditions, the size of the fee moves to a
secondary place, and the
—————————————
17 Menninger is right when he points out (1958p. 29)that this transaction is never mechanical; in almost all
instances, it is fraught with unconscious elements. Still, I believe that in no other procedure does the
monetary transaction as such, as well as every detail of it, have a psychological bearing on the total
situation that is comparable to the one it has in the psychoanalytic treatment situation.
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question of analysability is the only decisive one. But this will be found rarely. It is a luxury that only few
analysts can permit themselves. It may be difficult for an analyst to refuse a patient because the latter is
unable to pay the minimum fee. Schilder once answered a patient who had formed a strong transference and
urgently wished to be analysed by him, yet was unable to pay the full fee, by saying that he felt unable to
proceed at a lower fee, because it would be unfair to younger colleagues whose practices depended on
middle-income groups. That was an elegant answer; and a solution was found in the applicant's making part
payments and going into debt for the rest. Schilder's answer, which was given in Vienna, is not quite
applicable in the United States since analysts, on graduating, have several years of psychiatric practice
behind them and often charge higher fees than more experienced colleagues.
It may cause unnecessary pain to a patient to be told that it is for economic reasons that he is being
refused analysis by a therapist by whom he wishes to be treated. It may be preferable, in such a case, to give
'lack of a free hour' as the excuse. Here, however, I am uncertain about the extent to which my suggestion is
influenced by personal idiosyncrasies.18 Schonbar (1967p. 277)informs her patients of her regular fee and
then discusses their financial status with them. My guess is that many analysts proceed in this way, because
it seems to be a reasonable manner to proceed. Yet if the analyst should then decide to treat the patient for a
reduced fee, as Schonbar reports having done at times, this could well evoke intense transference fantasies,
the analysis of which may meet with strong resistance.
In general, I had bad experiences when, after I had set the fee, I responded to a patient's request for a
reduction, and made a compromise. I was struck by the fact that when such compromises have been
necessitated during the course of treatment, as the consequence of an upset in the patient's financial situation,
this has not been followed by untoward consequences. In general, I would therefore suggest that the
treatment should not be started at a lower fee than the one that was set initially.
There is also the technical question of when to take up with the patient the discussion of fees. Sometimes
one is asked the question over the telephone. Since I have a sliding fee schedule for consultations, and let
each patient determine the fee for such service, there is no need for me to commit myself to any fee before I
have met the patient.
If a patient is referred for treatment by a psychoanalytic colleague, the referring source usually indicates
what fee the patient is able to pay. Furthermore, under such circumstances, one does not usually need to go
into the question of the patient's analysability. I try to keep the first meeting as short as possible, just long
enough for the patient and myself to find out whether we got on each other's nerves or appear to have some
promise of making a good working team. Under such circumstances, the arrangement of the fee becomes a
rather casual matter.
It is different when a patient whose analysability has not been determined previously asks for treatment.
Usually this requires not one, but a few sessions. Schonbar (1967p. 277) generally postpones discussion of
fee 'until late in the initial interview'. I take up or answer questions regarding the fee only after I have
become acquainted with the patient, by way of several interviews. Since it is not an easy matter to ascertain
a patient's analysability, I try to keep the initial face-to-face interviews in flux as much as possible. The
determination of the fee, it seems to me, has a slightly hampering effect on the free flow of communication in
those initial interviews, which is one reason why I try to postpone it. I am aware, however, that I may be
mistaken in that respect.
(d) Schilder's compromise, which I have mentioned earlier—that of letting the patient make partial
payments—frequently misfires;19it may easily happen that, after the termination of treatment, the need to
continue payment arouses considerable anger, if not rage, and this
—————————————
18 Fine's dictum: 'If the patient cannot afford the therapist's fee, then he should be referred to another
therapist who will see him at a lower rate' (1971p. 104)does not impress me as being clinically altogether
satisfactory.
19 Kubie (1950p. 139) seems to warn against the patient's going into debt with the analyst, and Menninger
(1958p. 33) sees in it 'a handicap' that can be 'disastrous'.
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may cause the patient to renege on his earlier promise. It also seems to me that the prospect of having to pay
a substantial amount of money after termination may occasionally induce the patient to discontinue treatment
at a time that is suitable to him—that is, at a point when the treatment has not yet shown its full benefit. He
then rationalizes his refusal to pay the debt by way of the supposed failure of treatment.
One question which an analyst must decide in accordance with his own taste and preferences, and for
which no rule can be established, has to do with procedures for collecting debts. It is not against
professional ethics, of course, to use collection agencies for that purpose. I prefer to send a statement; if I
receive no reply, I follow it with another, marked as being the second reminder. I repeat this a few times and
then, if nothing happens, I give up. Monetary difficulties of this kind are always due to transference
complications, as is evident; in my experience they have usually been caused by a faulty handling of
transference. Therefore I feel reluctant to pursue the payment of debts by any other means than a friendly
reminder.20
Special attention is to be paid to the type of patient who leaves treatment with a debt, as the result of not
paying for the last month or the last two months of treatment. Sometimes this is an act of revenge. One patient
who had to move to another state, and therefore left treatment before recovery, had recently been cheated by
a friend. He felt he had been 'taken' as a sucker and, evidently in order to regain confidence in his
masculinity, he set out to make the therapist a sucker and he did not pay for the last treatment month. Another
patient—an addict who, it seemed to me, belonged to the group of ambulatory schizophrenics—discontinued
treatment which had taken an unsatisfactory course. When he terminated, he left a bill for one month unpaid
which he had skipped paying about half a year earlier. I had overlooked it and thus did not send him any
reminder. A few weeks later, he called and asked whether he did not owe me money. When I denied it, he
reminded me of that unpaid bill, which I had to verify. Yet he never paid the bill. It is my impression that he
had felt disappointed by my never having demanded payment, and wanted to make sure that I would feel hurt
by being brought face to face with the loss.21
Another patient told me that when his therapist died at the beginning of a month, after he had paid the
previous monthly statement, he never sent the therapist's widow the fee for the four hours he owed to the
estate of the deceased. He insisted that he would not have paid the last bill, had it still been outstanding, and
denied having had any mourning reaction as the result of his therapist's sudden death. Only much later, when
a friend reminded him of a depression that he had suffered at that time, did he recall that he had indeed been
deeply affected by the loss of his therapist. Non-payment of his debt was a thinly disguised revenge for what
he had experienced as an intentional abandonment by his therapist.22
Failure to pay a small amount of money at termination is a relatively frequent occurrence. In general, this
is caused by a remnant of undissolved transference. It is often a magical gesture, designed to establish a
long-lasting protective tie to the analyst, and it usually serves the purpose for which it is meant. This is
particularly true of the borderline case, whose future is always precarious. Under such circumstances one
should not try to interfere with the patient's acting out of a magic ritual.23 The fact that such patients require
the activation of an archaic mechanism in order to maintain a state of adequate functioning ought not to be
regarded as a sign of therapeutic failure. I am not certain that such patients would be well
—————————————
20 Tarachow (1963) reports that he has 'sued patients and collected' (p. 132).
21 It has probably happened to a good many analysts that they made a mistake in calculating the fee at the
end of the month. It would be worthwhile to study the ensuing reaction in the patient. It is interesting to note
that Tarachow (1963p. 109) reports: 'I have been soundly reproached by patients for undercharging by one
session.' The patient censured the analyst for having forgotten 'that I had come to see you'.
22 Gedo (1963) correlates non-payment of fees with the relation to transitional objects. In my experience,
conflicts pertaining to later phases of development are relevant in such instances.
23 Tarachow (1963p. 131) warns against following this technique with a neurotic or with a psychopath,
but recommends it 'with certain types of borderline problems'. However, he adds that there are borderline
patients on whom such an arrangement has a detrimental effect.
24 Allen (1971p. 133) reports the experience of an analyst who was unable to collect a long-standing debt
from a former patient, but succeeded quickly when he wrote her: 'Don't you think it's time you cut the
cord?' It is not reported what effect this sort of reminder had on the patient, but one wonders why the
analyst had not pondered upon that question while the patient was still under his treatment. One may also
ask whether it is fair to use an unanalysed transference for the collection of a debt.
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24
served if a total dissolution of the transference—if that were at all possible—were to be instituted.24
One often hears the opinion that one should not accept a patient for treatment whose spouse is at that same
time paying a higher fee to his or her analyst. It has even happened that when the spouse started treatment
while the patient was in therapy and he refused to equal the spouse's fee, the ongoing treatment was
discontinued. In my experience, this is not justified: the fact of the spouse's fee being higher does not have
the assumed effect. In the instances I had an occasion to observe, the treatment of the person who was paying
the lower fee was more successful than was the other's, but this was, I am certain, only accidental.
A question which, I think, has been rarely discussed concerns the change of fee during the treatment.
There are three situations that may induce the analyst to ask for a fee higher than the one that was determined
initially. In view of the inflationary spiral, economics alone may suggest the need for a higher fee. As far as I
have been able to find out, this sometimes leads to considerable complications. Others prefer to wait until
the patient raises the question, which may entail a very long time. I myself feel that, once the fee has been
agreed upon, no increase should be demanded on the grounds of the analyst's needs. To me, it seems
somewhat offensive to the rules of the game when the analyst requests, not to say demands, a change of
contract in the midst of a treatment that has by that time led to the establishment of a transference. A more
appropriate situation can be possibly established if the patient is told at the beginning of treatment that he
may be requested to pay a higher fee, which will be correlated to the inflationary decline of the value of
money. Having never tried this out, I cannot report on the effect that such an initial understanding may have,
but I would anticipate that, in some instances, such a preliminary reservation may create in the patient a
sense of insecurity, an expectation of trauma, such as would be difficult to combat.
Another situation suggesting the demand for higher fees occurs when the patient's earnings have increased
considerably during the course of treatment. Such changes are generally attributable to a wholesome effect
of treatment on the patient's capacity for dealing with reality, a fact which is usually acknowledged by the
patient. In general, no difficulty arises when the fee is then adjusted to the new level of income. Especially if
the original fee was lower than the customary average, many analysts quite rightly tell the patient before
starting treatment that he may have to pay more once his finances have improved.
A third and more difficult situation arises when it turns out that the patient had originally concealed the
true state of his finances in order to obtain a more favourable financial arrangement.25 One patient tried to
test the analyst's interest in money by thus falsifying his financial standing. The patient himself was most
eager to earn a great deal of money, and he looked with disdain on those who were not well versed in
financial matters. He wanted to have an analyst who was charitable and not 'money-minded', yet at the same
time lived up to the patient's ideal of astuteness and sharpness in money transactions. It stands to reason for
the therapist to demand from the patient, under such circumstances, a fee that is commensurate with the
latter's true assets.
Yet caution is nevertheless indicated. In the case just mentioned, it turned out that the patient had been
traumatized years earlier, when he had been living under dire circumstances, and had been unable to find an
analyst who was ready to treat him for the low fee he was able to pay at that time. What he was trying to find
out, when he concealed his true income from me, was whether or not I would have helped him at the time
when he had been helplessly striving to find a therapist. His concealment seemed to serve, among other
things, as an attempt to heal an old scar.
—————————————
25 Tarachow (1963p. 132f.) reports such an instance and his way of handling it.
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When the fee is too soon brought into line with the patient's true financial ability, the feeling of guilt
brought about by the previous concealment may escape proper analysis. I would surmise that in such
instances it may often be more appropriate to wait until the patient himself is prompted to rectify the
situation. The psychoanalyst is not likely to incur a loss by pursuing this technique; instead, he may find the
patient ready later on to compensate him retroactively for the loss incurred during the initial treatment stage.
If the patient's concealment was an act of unneurotic aggression, accompanied by no or only minimal
feelings of guilt, then of course no compromise should be made, and immediate restoration has to be
demanded.26
A quite different problem, which does not have to do with a truly psychoanalytic question, but rather with
one that has been created by social custom, is that of the treatment of medical colleagues and members of
their families. As is well known, in those instances Freud's advice was to charge the patient in the same way
as one would any other. In Freud's times, it was quite unusual to charge a colleague or a member of his
family for medical service, and he was severely chided at the time for this breach of the Hippocratic oath.
Emil Raimann (1872–1949), professor of psychiatry at the University of Vienna, who reviewed the article
by Freud in 1913 that served as introduction to the first volume of the newly founded Zeitschrift, was
incensed about Freud's handling of fees—so much so that he made a special point of Freud's practice of
charging colleagues and their families. He thought what Freud said about analytic fees sufficient reason to
'strike psychoanalysis out of the "therapeutic lexicon"' [dass die Psychoanalyse aus dem therapeutischen
Lexikon zu streichen sein wird].
The question of fees was the only topic Raimann selected for review, even though Freud's paper
discussed many other subjects, and three numbers of the first volume of the Zeitschrift lay before him. Of
course, he did not even mention that Freud had been dispensing free treatment to patients for a long time. At
the end of the review, he announced that, in view of the 'financial implications' of psychoanalysis, it would
probably be 'unnecessary' for him to review future volumes of the journal.
It is also noteworthy that, on another occasion, Raimann made use of the same topic to discredit
psychoanalysis and Freud. In 1920, in a public hearing of an official commission to investigate military
violations, Freud was called on to express his opinion about the electrical treatment of war neuroses, which
had been used by Wagner-Jauregg, then chief of psychiatry at the University Clinics in Vienna. On the
second day of the hearing, when Freud was no longer present, Raimann, the other expert witness, who was a
pupil of Wagner-Jauregg, launched an attack against psychoanalysis, culminating in the following reproach:
'… there are limits set to psychoanalytic treatment. One of these limits is the question of money. One cannot
psychoanalyse patients who are without means. It is not even possible to treat the wife of a physician in that
way' [… der psychoanalytischen Behandlung Grenzen gesetzt sind. Eine dieser Grenzen besteht in der
Geldfrage. Psychoanalysieren kann man unbemittelte Kranke nicht, es ist nicht einmal möglich die Frau eines
Arztes so zu behandeln]. When the presiding officer inquired into the reasons thereof, Raimann allegedly
gave an explanation that sounds somewhat strange. He said that every treatment has not only physical but
also psychic effects, and in each instance of success the question of expenses plays a role [spielen die
Kosten mit]. 'If someone is unable to pay any longer, he declares himself to be cured. In Prof. Freud's article
this is not clearly expressed, yet one can hardly interpret it in any other way' [Wenn jemand nicht mehr
zahlen kann, so erklärt er sich eben für gesund. In dem betreffenden Artikel von Prof. Freud ist das nicht klar
ausgesprochen, es lässt sich aber kaum anders deuten]. Although the Minutes of that hearing may have
recorded Raimann's statement inaccurately to a certain extent, it is nevertheless clear that he again
introduced the way a physician's family was treated as an implication of the untrustworthiness, if not to say
bizarreness, of psychoanalysis.27
—————————————
26 According to Glover (1955p. 319), only one third of those analysts who answered his questionnaire had
raised their fees during the course of analysis.
27 Apparently, as early as 1897 Freud was criticized for accepting a fee from the wife of a colleague. See
Freud (1950p. 221).
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In justifying the charge of fees in cases of members of a physician's family, Freud added to the
psychological reasons previously cited an economic one—namely the severe reduction 'of the working time
available to him [the psychoanalyst] for earning his living, over a period of many months' (Freud, 1913p.
132)—a duration to be expressed nowadays not in months but in years. At this point, the economic point of
view was expressed openly, and Freud compared the reduction of earning capacity in the case of two or
three free treatments 'to the damage [to the physician's earning capacity] inflicted by a severe accident'
(Freud 1913p. 132).28(Cf. Kubie 1950pp. 142–4)
Although the question of free treatment to physicians and their families seems to be of little importance on
the present American scene, the experiences I have had in that context were occasionally so surprising that
two of them seem worthy of being recorded here. To be sure, the frequency with which one finds oneself
asked to treat a person who belongs to one's own profession makes it impossible for the analyst to follow—
at least, when a full analysis is required—that part of the Hippocratic oath that forbids the acceptance of
fees from colleagues or members of their families. But I usually take the attitude that this can easily be done
when a psychotherapy is indicated that requires only one or at maximum two sessions per week. The strange
thing I had the occasion to observe was the resistance that this technique is apparently able to evoke.
A well-situated physician came to me in need of sporadic psychotherapy. He objected to my not
accepting any fee from him. Although the compromise was made that he would make donations as he saw fit
to an organization I suggested, he felt indignant about the arrangement. Thinking that it would have a bad
effect if I permitted the patient to overrule my standards, I insisted on my request. The patient was
dissatisfied with the treatment in general; but when he discontinued, the financial arrangement did not seem
to have been the least of reasons that made him leave.
Some time later he returned in great excitement: an unforeseen event had brought into his life a true crisis.
There was no doubt that the patient now needed treatment urgently, if only for the sake of immediate succour
and solace. I therefore told him that this time I would not impose my own standards, but would instead abide
by any financial arrangement he demanded. The patient seemed pleased, and the next appointment was fixed.
Yet, before leaving, the patient came back from the hall and said: 'You see, the nice thing about your
accepting a fee is that it enables me to tell you that I will not come back to see you.' And, indeed, I never did
see that patient again. I am unable to explain why my willingness to accept the patient's terms should have
led to his abandoning treatment, which he not only needed more than ever, but also seemed to be quite eager
to obtain. I must draw the conclusion that, for whatever reason, if I had been stubborn enough to persist in
my previous technique, the patient would not have left me.
The only guess I can offer is that what was operative in the patient was a fundamental basic ambivalence.
This episode reminds me of another one, to illustrate what I have in mind. Another patient once responded to
an interpretation with: 'You can't possibly know how right you are.' Here the patient's basic ambivalence is
compressed into one single sentence.
Apparently there are patients who are moved to hit you right over the head at the time when you are in
process of doing something constructive for or about them. The last-cited patient suffered from an
intermittent schizophrenic-like psychosis, with relatively long free intervals. She was in a relatively good
phase when the remark was made. Her unusually strong ambivalence was well documented by her social
behaviour and object relations. But the physician mentioned earlier was free from any sign that would mark
him as particularly ambivalent, and his symptoms did not suggest in any way a more serious disorder.
The other experience worthy of being mentioned here is one I had during the treatment of an analyst's
adolescent offspring. In this instance, too, I told the patient that I would not charge for the occasional
psychotherapeutic
—————————————
28 Freud may have changed his mind in general on that question. Two examples are known of free analyses
that he carried out in later years.
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interviews that were necessary. To this, the parent's response was an extremely negative one: it consisted of
an acute anger, approaching rage, along with some rather serious accusations against the therapist. I have
been unable to find out what was at the bottom of this negative reaction, which was so severe that, at the
time, it caused me considerable worry and embarrassment.
I wonder whether there may not have been some sociological implication. I recall the delightful reply that
a wealthy man gives, in some English comedy, to an ambitious person who has offered to do him a favour: 'I
am sorry, young man, but I am not rich enough to accept your favour.' I have noticed on other occasions that
one may easily arouse suspicions by choosing not to charge for services that customarily are compensated
for.
Be that as it may, in both these last instances I was clearly employing the wrong technique. The correct
way, it seems to me, is to tell the patient when one feels that free treatment would be proper and then to let
him decide which procedure he prefers. Whatever the patient's decision may then be, his choice has to be
interpreted on the proper occasion. I also have had to admit to myself that there was hypocrisy involved in
my attitude. Since the analyst is unable to carry out the oath of Hippocrates is unable to carry out the oath of
Hippocrates in every instance, why should he feel constrained to adhere rigorously to it when it is a matter
of small amounts, even to the extent of antagonizing the patient?
(e) One has to consider also the type of patient who offers a fee that is too large in terms of his income
(Glover, 1955p. 22); (Menninger, 1958p. 32). In general, it is necessary to weigh the extent of sacrifice a
patient is ready to make in order to organize his treatment. Some patients are ready to cover long distances
to see the analyst of their choice, although another one may be available at closer quarters. The masochistic
element involved will later lead to resistances of such intensity as to make treatment impossible. The actual
deprivations that the patient suffers as a result of treatment arrangements may satisfy his desire for
punishment and thus constitute an obstacle to the proper analysis of his feelings of guilt, which cannot be
removed by interpretation, since the fee he is paying is the equivalent of a self-punitive acting out.29
A patient from a moderately wealthy family offered to pay any fee the analyst might demand. It turned out
that, if the analyst had accepted the fee offered by the patient, this would have resulted in a deep dent in the
patient's trust fund, from which he derived his income. It quickly became clear that the patient's reasoning
was based on his conviction that no sacrifice was too large to make for the stupendous change he was
certain to derive from treatment. The patient's expectations were, of course, unrealistic, and acceptance of
his offer would have confirmed some of the irrational attitudes that lay hidden behind his willingness to
make any sacrifices for his treatment.
Since the outcome of an analysis is always a matter of uncertainty, one should try to avoid a patient's
paying a fee that may endanger his savings.30
One part of the mechanics of the money transaction between analyst and patient is the way in which the
patient is informed about what he owes the analyst at the end of the month. This will strike most people,
particularly outsiders, as an utterly trivial matter, and yet, like any other detail of the treatment process, it is
of psychological significance. The matter does not need much discussion, since notwithstanding these
psychological implications, the different varieties of forms practised do not lead to any related difficulties.
Many analysts in Vienna did not present statements; instead, they made it the patient's responsibility to
calculate the correct amount of the monthly fee. By leaving the carrying out of his obligation entirely to the
patient, this way of
—————————————
29 Mowrer (1963) has used this possibility as a rationalization to reject entirely the treatment of neuroses
in the secrecy of a private office and to justify group therapy instead. See, however, Davids (1964) who
tries to prove in a theoretical paper on the grounds of Festinger's (1957) theory of cognitive dissonance
that the psychoanalytic fee situation is expected to have a beneficial effect on the course of treatment.
30 Menninger (1958p. 32) expresses himself against the patient's expecting 'to pay for his analysis out of
his current earning'. Kubie (1950p. 137) advises that the decision to pay from income or capital, or both,
should be made after a careful study of the patient's financial situation by both analyst and patient. Glover
(1955p. 23), on the other hand, considers the payment of fees from income to be preferable.
31 In Freud's case such bills were kept as cherished treasures. But, in general, when the statements are
handwritten one must keep in mind the various meanings it may have for the patient, when he possesses
items that carry his analyst's personal handwriting.
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handling the payments of fee may be advantageous in some cases inasmuch as it may enlarge the field of
transference reaction. Freud himself presented his patients with a small piece of paper with the patient's
name, the number of sessions and the amount of money owed—all of it written in his own hand.31
In the United States, analysts send their statements by mail (cf. Wilmer, 1967p. 801) or present them to
the patient directly. The former strikes me as being overly formal. I would expect the patient to interpret it as
a sign that the analyst wishes to keep the money transaction out of his office—as if it were something that did
not belong primarily to the patient's personal relationship to the therapist. In other words, it would mean to
the patient that the analyst does not want to hear anything about that side of their relationship. As Menninger
(1958p. 128)remarks, some analysts prefer to hand the statement to the patient in person, because 'it is
helpful to say, by this act, "This is reality. This is what it costs you."'
Some patients have criticized me for presenting the bill without putting it in an envelope. I fear they were
right, but my lack of savoir vivre was not followed by any serious consequences. One patient, who held fine
manners in high esteem, expressed her disapproval by handing me her cheque in the same way; each time she
made a special point of this, complaining that it was I who forced her to behave rudely. As can be learned
from this example, the way in which the analyst proceeds in even such a seemingly minor matter gives the
patient an opportunity to form a picture of the analyst's peculiarities. It is impressive how far some patients
go in this regard. One patient checked the date on which his cheque was cancelled, in order to ascertain how
quickly I was accustomed to cash it; he was interested in finding out, by this means, whether or not I took
any great interest in money.
It has happened that occasionally I have handed the patient my monthly statement not on the first of the
month, but on the second or third, if not later (cf. Schonbar, 1967p. 281). This was a chance event, by no
means planned for clinical purposes, but I was surprised by the wealth of transference fantasies with which
some patients responded to this minor deviation from regularity.
Some analysts have their statements typed by secretaries, and do not seem to be aware that, in so doing,
they are revealing their patient's identity to an outsider. I consider this to be a breach of confidentiality, and I
feel that it should be avoided under all circumstances. To be sure, it is not always possible to protect a
patient's identity, since he may call and leave his name. But while the analyst is not responsible for such
unavoidable leakage, in the matter of typed statements he is taking an active part in violating a basic element
of the psychoanalytic covenant.
An almost regular item of interpretation is the patient's manner of paying the fee, particularly his
promptness or his slowness in so doing. One patient regularly paid his fee at the end of the last hour of the
month (before I even had the opportunity to give him the bill)—a compulsion that can be rationalized so
well that its analysis was not an easy matter.
There are patients who delay payment for a variety of reasons, one of which is to test the analyst: they
wait patiently to see when and how the analyst will bring up the subject, or whether the analyst will get
angry. Of course, there are many other motives. In my experience, since these motives are unconscious or
deliberately kept out of treatment, they are bound to be worked into the patient's dreams, so that the context
of dream interpretation is usually the most suitable opportunity to approach the subject. To take the lead in
calling the patient's attention to his slowness in paying has its hazards, since one is thereby interfering with
the patient's spontaneous and ego-syntonic flow of free associations. That is also one of the reasons why
some analysts prefer to mail their statements, since they regard the personal handing over of them as risking
just such an interference. I am in the habit of putting the statement on a table at the patient's side. In this way,
it is entirely up to him either to respond in the course of ensuing associations, or to pick up the bill more or
less automatically, as most patients do, without any further reference.
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In evaluating the time it takes for the patient to pay the fee, class differences must be kept in mind. There
are upper-stratum groups among whom it is traditional to pay bills only at the end of the month; a delay in
payment, therefore, even though it is psychologically meaningful in most patients, may be psychologically
neutral in others. It is precisely in the interpretation of the purposes for which the patient is using his
payment of the fee that one should avoid skewed situations.
A serious problem, only indirectly connected with the psychoanalytic mechanics of fees, should be
discussed here, even though only briefly. I find that one of the most troublesome clinical situations arises
when the patient's disturbance calls for a regular analysis, yet his financial means are sufficient only for
psychotherapy. There are two different schools of thought on this question. One says that, however
inadequate the measures may be, they should be organized in keeping with the patient's financial situation.
The other says that only measures that are adequate to the clinical exigencies of the situation should be
instituted. The rationale of the former is that a palliative is better than nothing, while the latter rests on the
belief that it is unfair to a professional person to have to carry out half-measures, of whose inadequacy he is
convinced, just as it is unfair to the patient to have him exposed to a treatment that is hardly likely to benefit
him—and to have him pay for it, to boot. Indeed, I have met instances that suggest that, in the long run, it
might have been better to let the situation continue as it had been, rather than to make a compromise and
advise makeshifts. There is no doubt, however, that instances are known that have looked almost desperate,
and yet were greatly helped by measures no analyst would have considered to be equal to the requirements
by a long shot. Nevertheless, these measures seemed at least to have averted the worst, and sometimes even
to have accomplished more. It must also be considered, of course, that the effect of half-measures carried
out at the advice of a psychoanalyst may be to bring disrepute on the profession.32
III
I shall now turn to another aspect of the problem. I was once told a story whose truth I cannot vouch for,
although it struck me as probably having happened. After a prolonged and successful treatment, an analyst
once reduced the number of weekly hours, yet continued to charge the patient the same monthly amount as
before. Upon being asked by the patient for some explanation, he said that he was now charging him for the
time he was spending thinking about the patient. These same tactics were allegedly repeated whenever the
number of visits was reduced, until the patient stopped coming altogether.
I find the story reflecting a certain amount of charm in its ingenuousness. I record it here because it shows
one instance in which the effect of the analyst's own attitude to money was conspicuously brought to the
surface.33 Due to the difficulties of investigation, one hears little about this problem in inquiries into
countertransference (Schonbar, 1967p. 278), but it would be a matter of great interest to know the extent to
which the patient's wealth reflects on an analyst's technique.
The question I am raising here must be seen in a broad context. Maus has cogently demonstrated that, in
primitive societies, the ego structure of a group member depends on his position in the social hierarchy. The
border between group member and group is not as solid as it is in subsequent stages of societal
development. Therefore a person who fills a place at a higher level is not only viewed by the community as
being thereby endowed with a different structure, but apparently the structure of the self actually does change
in accordance with the social position. A German adage 'Mit dem Amt kommt der Verstand' [when you are
appointed to an official function, you also get the mental
—————————————
32 Moore (1968) has studied the motives that may induce psychoanalysts to resort to half-measures. Kubie
devoted a whole section to the problem of 'Dangers of Palliative Psychotherapy' (1950pp. 28–31).
33 Likewise, I would not hesitate to look at the following objectionable technique of fee handling as an
outgrowth of the analyst's subjective relationship to money: In this instance, patients who were unable to
pay the full fee were asked to pay half of it and the sessions were reduced to 25 minutes. However, I am
not certain whether this technique was limited to psychoanalytic psychotherapy or also applied in
psychoanalysis.
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powers you will need for it] reflects an archaic truth.
At this stage of civilization, we should be able to see a person in terms of what he really is, and to
abstract such external trappings as wealth, prestige, social position. In general, however, I think that the
archaic attitude of merging personality and trappings is very frequently observed also in modern man.
Occasionally, it becomes outspoken—for example, when an attack against the President is called an offence
against the highest state function. The hierarchical position per se may serve as an independent variable,
spreading awe without regard for what sort of person the bearer of that position really is.
The psychoanalysis of a famous person, or of one who promises to become famous, probably harbours
particular dangers to the analyst's countertransference. He may be not only tempted but even seduced into
trying to share the mana that is deposited in his patient. Since the analyst may derive an all-too-great
narcissistic gratification from the treatment of that particular patient, the consequent loosening of ego
boundaries may have a detrimental effect upon the course of treatment. The mixture of closeness and awe
may even lead to the attempt on the part of the analyst to direct the patient's mana into channels that are
suggested by his own ideals and ambitions—which would be an abuse of the transference situation.
Money is the most general concretization of mana in modern society, and, because of the kind of
countertransference that may be aroused in the analyst, I would draw the tentative conclusion that a person of
great wealth has less chance of obtaining an adequate analysis than one of moderate means. Furthermore, it
goes almost without saying that, unless the analyst's own irrational attitudes regarding money have been
profoundly scrutinized in his training analysis, sound handling of fees in his relation to the patient can hardly
be expected. Since irrational attitudes toward money are sanctioned by society in the form of either
overrating or underrating its meaning and importance, it is highly probable that the whole complex problem
of money is only rarely treated in a satisfactory and sufficient way.
I should like to discuss here a technical paper on fees which, notwithstanding its merit, will give me an
opportunity to show one of the pitfalls that are involved in this difficult problem. Allen (1971) has presented
six case vignettes, in which he has demonstrated the advantages and disadvantages of insisting on payment,
or allowing for non-payment, in regard to missed hours. One of the patients was in regular psychoanalysis,
four were in psychotherapy, and in one instance the type of therapy is not stated. It would be challenging to
discuss the author's technique in detail, but it may suffice to summarize by saying that the author uses the fee
question for purposes of educating the patient. 'Selective firmness' and 'selective permissiveness' are
employed on dynamic and genetic considerations for the purpose 'of defining and affirming reality,
providing structure, strengthening the ego and superego', through which the therapist is offered 'as a model
for identification'.
This educational implication may be viewed historically as an extension of the general remarks Freud
made when he introduced the topic in 1913. I doubt that the author's principles can be set up as an
acceptable model of psychoanalytic technique, as it has developed since then. To be sure, it may be
excellent in the treatment of patients with dubious character structure, such as was true of a number of the
patients referred to in his paper.
Thus a patient who had cancelled appointments for ostensibly realistic reasons had actually been using
the time '"to take it easy"'. The analyst—quite rightly—said he would charge the patient for lost time; to this
the patient objected. Although the author did not spell it out, it seems evident that the analyst made the
payment a prerequisite of further treatment, this being an example of 'selective firmness'. He wrote: 'Had I
not charged him, I would have been seen as weak and destructible. Had I backed away in the face of his
threat to quit, I would have been viewed as being as corruptible as his mother and himself.'
Of course, there is no realistic reason to back away, once a legitimate demand has been raised. But it
seems more appropriate to let the patient continue to be in debt for the amount in question, until he is ready
to pay, of his own accord, rather than give him an ultimatum. With this, one bars any progress to further
revelation of
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repressed material; on the other hand, the necessity of payment, if not enforced but rather kept in suspension,
still constitutes a stimulus to which the repressed will respond with dreams and fantasies. When Allen
writes that he indicated in the treatment of a patient who had missed an hour 'that I had enough respect for
her to do the mature and responsible thing, and therefore I would insist that she pay for the missed hour', I
should call this 'psychoanalytic hypocrisy', and incompatible with the treatment technique for a neurotic
patient, even though this manoeuvre was proximately successful, and the patient 'seemed genuinely elated
that for the first time in her life someone "cared enough" to impose limits on her' (p. 138).
Although Freud has occasionally called psychoanalytic treatment a Nacherziehung, this cannot have been
meant as advice to introduce measures of a directly educational character into the psychoanalytic technique,
but rather as reference to an educational effect that is brought about by interpretation leading to insight—an
effect that earlier educational measures ought to have brought about during the patient's formative years.
The fact that an analyst switches from analysing to educating within the context of fees may serve as an
example of what is probably true of all analysts—namely that we are not always able to keep our attitudes to
money free of what may be called irrational infusion.
Yet this does not necessarily have to take place. A paper like that by Hilles (1971), which seems so far
to be the most thoroughgoing analysis of specific problems and difficulties caused in treatment by the
necessity of a patient's having to pay fees, reflects an analytic approach at its best. The therapist well knew
that the patient had stayed in debt with an earlier therapist, but she did not let herself be goaded into any
moralistic superciliousness or authoritarian demands; instead, she consistently analysed the patient's
practice with regard to making payments and defaulting. It may not be coincidental, and be even highly
significant that this penetrating analysis was not the result of a psychoanalysis conducted in private practice,
but of one that was carried on within the framework of a state clinic. Is it possible that there is a veil of
unintended secrecy covering the triangle: the private practice analyst, the fee and the patient?
It is further my impression that in the course of time—and particularly, if I am not mistaken, among the
younger analysts—concern about money has taken on an importance that has proven to be detrimental to the
refinement of psychoanalytic technique.
IV
An interesting historico-sociological question is linked with the problem of fees and their function in the
psychoanalytic treatment. If it is true that the payment of fees for psychoanalytic treatment not only serves the
purpose of gratifying the therapist's narcissistic—or, better, self-preservatory—needs, but is in addition an
integral, possibly even an essential part of the treatment course, this may favour the argument of certain
Marxist sociologists who have tied the discovery and development of psychoanalysis to a certain phase of
capitalism (see Bernfeld et al.). After all, psychoanalysis was originally a treatment for people who were
members of 'the Establishment'. Brody (1970) made an interesting statistical study of Freud's patients, whose
number he established—as far as this can be reconstructed from Freud's writings—as 133. He was able to
identify the social class of only 26, and he assigned them to the upper class, no attempt being made to
differentiate between the upper and middle classes. In one instance, Brody was mistaken—namely the case
of Katharina (Breuer & Freud, 1893–5 pp. 125–34), who unquestionably belonged to the lower class and
might have served Freud as a test case for the class independence of those mechanisms that led to hysteria
(if he had any doubt about this).34
But the original social setting of psychoanalysis was undoubtedly that of the wealthy or the upper middle
class. One may compare it in that respect with the treatment for tuberculosis
—————————————
34 After all, Freud had received an essential stimulus to his investigation from Charcot's clinic, which
served the lower class; and Bernheim, whose treatment technique influenced Freud, had told him that his
treatment had a better chance of success in hospital practice—that is to say, among patients who belonged
to the lower class (Freud, 1925p. 18).
- 96 -
recommended at the turn of the century. Only a person of some means was able to make use of it.
It is hardly possible to trace here the historical prerequisite of psychoanalysis. That both the Zeitgeist
and the economic system—which are, after all, so intimately allied—stood at the cradle of psychoanalysis is
obvious. But if one is looking for specific societal conditions that might have provided the necessary
background for Freud's discoveries, one would do well to turn instead to the loosening hold of religion on
Western man's mind, the general decline of religion, and the lessening of sexual impulsivity. Whether the
latter was due to the imposition of repression or actual weakening need not be discussed here. At any rate,
only a few decades earlier it would hardly have been possible for two people to be together in a room
alone, discussing such precarious questions as are common in psychoanalysis, and in so doing to have
preserved the minimal distance required by the psychoanalytic situation.35 It is quite possible that this
sexual climate was in turn correlated with economic conditions. However that may be, if psychoanalysis
could be successfully used in its classical form only under the condition that the analysand had to separate
himself from one part of his monetary possession, as Freud was close to formulating it in 1913, then the
Marxian view would find in this fact support for the claim that the use of psychoanalysis and the economic
system at the time of its rise were cognate. It would, if it were true, greatly strengthen the arguments of those
who see in psychoanalysis a product of bourgeois decadence and late capitalism, in the form of finance
capitalism.36
We now know, as Freud had indicated as early as 1919, in his recommendation of psychoanalytic clinics,
that the payment of fees is necessary only for those patients who are well provided with money, while even
the destitute, despite their poverty, are amenable to psychoanalytic treatment. Thus one may at best draw the
conclusion that perhaps the discovery of psychoanalysis was favoured by the contemporary economic
system, but by no means does it follow from this that its content is bound to a specific societal structure and
valid only within it.
However, a new complication has been brought about by economic development. The number of patients
is increasing whose treatment is being paid for by health insurance plans or governmental agencies. Thus it
happens with increasing frequency that a person who has the means of paying for psychoanalytic treatment
nevertheless has it paid for him, usually in part, by an institution. Chodoff (1972) has impressively
described the possible complications that proceed from prepaid psychiatric treatment (cf. also Richman &
Bezeredi, 1963); (Myers, 1963); (Glasser, 1965); (Wylie, 1965); (Goldberg & Kovac, 1971); these
complications are likely to hold even more for analysis. Halpert (1972), who had the good fortune to
analyse a patient whose treatment had first been paid by the father and later by Medicaid, made valuable
observations, which I can only confirm. It is more difficult to combat the effect of payment by agency than of
payment by a source personally known to the patient, particularly when that source is close to him. In the
latter case, the situation is more precisely defined, and the resulting feelings of guilt, the implied aggression
and the parasitic imagery are analysable, at least in the average case. When an agency is involved, then the
source of fees is quasi-anonymous, and the patient is the recipient of what he considers to be his 'right'. Yet,
despite this feeling of enjoying a right, he has the feeling of being smarter than others, often even of having
'duped' the company.
By contrast, in the case where the patient's family pays for his treatment, it is the goal of the treatment,
tacit or outspoken, to help the patient to become independent of that source of funds. This
—————————————
35 Every historical period imposes certain restraints. The experiments of Masters and Johnson, for
example, were not at all feasible at the time when the 'Three Contributions' were being written, and for
quite a few decades thereafter. If Freud did not investigate man's sexual life experimentally, that was not
necessarily due to resistances, but rather to the sort of curbs that operate automatically, since they are the
givens of history and society.
36 Some statements one finds in the literature could be used in defence of that theory: 'Sometimes it is wise
to look upon health as a form of capital, thus justifying the use of a certain amount of financial capital in
paying for the treatment' (Kubie, 1950p. 138). 'Usually, if money is a serious problem, psychoanalysis is
not the treatment of choice. The patient should not expect to pay for his analysis out of his current earnings
…; it is a capital investment, not a mere expense' (Menninger, 1958p. 32).
- 97 -
goal is non-existent vis-à-vis an agency. Halpert describes the difference succinctly:
When a parent or spouse pays for an adult patient, the conflict, fantasies and stirrings of childhood
memories surrounding the feelings of greed, deprivation, guilt and dependency are real and
immediate. They come alive in the transference. When an anonymous, amorphous third party …
pays a major part of, or the entire fee for an adult patient, these feelings and conflicts are removed
from both reality and immediacy, and resistance is fostered (1972p. 131).
He believes, in fact, that patients whose main defence mechanisms are isolation and intellectualization
may not be analysable, so long as the full fee is being paid by an agency (1972p. 132).
Allen (1971p. 135) found no problem in the case of fee payment by agencies. He told his patients that the
financial responsibility remained solely theirs, and that payments received would be credited to their bills.
'In this way the patient's responsibility for payment has been preserved, and the relationship is entirely
between the patient and the third party, and never between the therapist and the third party.'
It is difficult for me to imagine that such simple manipulation of externals can 'solve' a problem that must
necessarily have a profound effect upon transference and the unconscious imagery. I am inclined to believe
that Halpert's earlier mentioned inquiry went far deeper, into those regions to which the psychoanalytic
scalpel should penetrate.
Be that as it may, Chodoff (1972), who is aware of the web of complications resulting from payments by
third parties such as agencies, finds no reason to believe that the outcome of therapy under such
circumstances is 'in any way inferior to … [that] produced in direct-payment settings'. Interesting and
important as this statement is, much will depend on the standards to which the psychoanalyst is adhering—in
particular, whether he is aiming primarily at the disappearance of symptoms, or setting his goal beyond the
symptomatic border. It is quite possible that if third-party payment (by agencies) spreads sufficiently to
become the usual way of financing psychoanalytic treatments, an imperceptible lowering of standards of
psychoanalytic technique may occur. Of course, such a statement, if it is correct at all, cannot be applied to
individual cases, which may be analysable like any other, despite third-party payments, and it certainly
cannot be extended to psychotherapeutic techniques.
A general consideration seems to be indicated at this point. It seems to many that the establishment of
socialized medicine is now only a question of time. The cure of disease has become a right—almost one of
those 'inalienable rights' of which no citizen may ever be deprived. At present, however, we are in a period
of transition in the United States, in which society has to solve mutually exclusive tasks—namely that of
nursing a dying organism on its way to its grave and that of suffering the birth pangs of a new one.
Transitional periods harbour their own specific difficulties. It is my impression that complications of the
type under discussion, which will make themselves increasingly felt from here on, are the direct expression
of the hybrid state in which our society finds itself, and which throws its shadow over practically all areas
of professional pursuit. Once a new, balanced, well-equilibrated state (transitory as it in turn will be) has
been reached, many of these complications will fall away.
Once a national health programme has been established, it has to be anticipated that initially regular
psychoanalytic treatment will not be included, in view of the enormous expense involved in the treatment of
an individual case. It is not probable that the full salary of a physician will be expended for the care of 10
patients whose treatment would cover a period of, let us say, four years, since this would amount under
optimal conditions to the cure of two and a half patients per year. It is more probable that at the beginning
only such therapies will be nationally supported as limit themselves to those clinical goals that are now
being attained by drug treatment and psychoanalytic psychotherapy, or any other kind of psychotherapy.
Clinical experiences will show, however, that there does exist a core group of patients who are not
helped by such techniques, and I envisage boards that will select those patients who are indeed immune to
short psychotherapy and clearly require under all circumstances a full-fledged psychoanalysis. In such
instances, a compromise may be made, and the patient
- 98 -
may be required to pay a fee that would vary with his capacity to make payments, and would be
complemented by an agency. I foresee, however, a possible loss arising out of socialized medicine to the
patient who is suffering from damages that can be straightened out clinically by the application of minor
psychotherapy, but who should yet be the beneficiary of an extensive psychoanalytic treatment, in view of
his great potentiality and possible contributions to the community, which may not come to full fruition if
these are not awakened and released by means of prolonged depth analysis.
Socialized medicine, if it comes to include regular psychoanalytic treatment, will, in my opinion, confirm
that the payment of fees is not an integral part of the psychoanalytic set-up, as has already been demonstrated
repeatedly in the past.
The psychoanalytic situation is a model situation, which is essentially historically not subject to
variation. As far as I can see, only two societal factors must be fulfilled: first, the confidentiality of the
analysand's communications must be guaranteed beyond any doubt—that is to say, no government power
must be given the right to force an analyst to testify in matters concerning his patient (this possibly makes the
practice of psychoanalysis under a dictatorship impossible). Secondly, a certain level of self-observational
ability must have been reached within society.
The form in which the analyst is compensated for his work is, however, a historical variable; and it is
important to state that this variable is a peripheral one; although it does have an effect on the psychoanalytic
situation, there is nothing about it that could not be mastered by psychoanalytic technique. On the other hand,
the two aforementioned societal factors are central and indispensable to the psychoanalytic situation.
The variable factor of fee payment depends on the societal climate. In a society whose metabolism is
predominantly based on success, and in which money, wealth and affluence are accepted as high prestige
values, the matter of fees will have implications for the analyst and the patient that are quite different from
the ones they will have in a society in which community welfare prevails over individual gain, and in which
community action on behalf of the protection of the individual is taken for granted. It is quite possible that in
a future society the rare sensitivity of a patient of our own times, for whom revelation of the most personal
area of his mind is incompatible with a financial arrangement, will be the generally accepted standard. In
such a society this should not constitute an impediment to the psychoanalysis of resistances. In such a society
the resistance may appear in the form of the patient's regret that he is not permitted to pay fees, just as so
many patients at present regret that the rules of the game make the giving of gifts to the analyst impossible.
Psychoanalysis might flourish all the more in such a society.
The reader will have noticed that the question of fees has been discussed under two different viewpoints.
One is concerned solely with the psychological implications of various forms in which fees are paid, a
viewpoint that disregards the psychoanalyst's needs. The other takes into consideration the psychoanalyst's
ambition and desire to earn money. Although the two viewpoints were not discussed separately, I hope that
in no instance did I leave it in doubt to which viewpoint I was referring.37
ACKNOWLEDGEMENT
The author expresses his gratitude and indebtedness to Mrs Phyllis Rubinton, librarian of the New York
Psychoanalytic Institute, for her invaluable bibliographical help.
ADDENDUM
Only lately, a way of paying analytic fees has come to my attention, which, although rarely used, is not
without interest. It sometimes happens that impecunious artists pay their analytic fees in the form of the
products of their art, usually paintings. At first hearing, one may feel inclined to accept this way out of a
difficult financial situation. Yet I would surmise that this solution harbours dangers. Evidently, this concerns
artists who are not successful, at least in terms of producing marketable products. If a psychoanalyst
nevertheless accepts them in lieu of money, this must have a realistic meaning for the artist to be analysed:
either the analyst obtains personal pleasure from the artistic product, or he believes that it will be valuable
in the future.
As a matter of fact, physicians have occasionally made close to a fortune by accepting the works of an
unknown artist who later became famous. The reality situation thus becomes unclear, not only through the
patient's fantasies but because of the actual fuzziness of the reality situation.
More serious, however, is the fact that something which the patient has produced and which,
understandably, he regards as being part of himself or of his body, will become the analyst's possession,
will be touched by him and will, according to the patient's fantasy, be admired. I could enumerate, of course,
many other complications, which it is unnecessary to spell out in this context, because each of them proves a
burdening of the transference situation, which will become unmanageable under such circumstances. In
addition, it is to be expected that it will not be possible to analyse adequately problems connected with the
patient's resistance as an artist.
Another problem which might occur with greater frequency than the one just mentioned concerns the
payment of psychoanalytic fees with undeclared taxable money. To a certain extent, almost all analysts in the
United States tacitly participate in such a scheme with their patients, since many people do not pay their full
share of income tax, and thus a percentage, small though it may be, of money that legally belongs to the U.S.
Government finds its way into psychoanalytic coffers. This is true, of course, of all physicians, but in
psychoanalysis the physician thus paid is aware of it, and by accepting the fee he indirectly supports and
consciously shares a patient's illegal gain. Since 'chiselling' on one's income tax is an accepted pastime in
the United States, not to participate in which may even be a sign of compulsion and inhibition, it is not
advisable to insist on a scrupulous payment of taxes before accepting a fee.
The situation is quite different if the fee is paid with 'hot' money. The patient then usually prefers to pay
cash, with the implication that the therapist will take advantage of it, and, in turn, will not pay tax on the cash
fees received. If the therapist accepts this offer, it is bound to impair the psychoanalytic situation, and is thus
unacceptable. I would not know, however, on what grounds a payment of a fee in cash could be refused, but
somehow it must be conveyed to the patient that 'the deal' will not be carried out. It may even be advisable
to refuse acceptance of a fee in principle, when the patient pays it out of a concealed (and untaxed) source of
money.
An interesting question is whether one should accept a fee when one analyses a call girl. I would surmise
that the analysis has a far better chance of success if the payment of a fee is postponed until such time as the
patient has made a new professional choice.
K.R.E.
REFERENCES
ALLEN, A. 1971 The fee as a therapeutic tool Psychoanal. Q. 40:132-140 [→]
BERNFELD, S., REICH, W., JURINETZ, W., SAPIR, I. & STOLJAROV, A. 1970 Psychoanalyse und
Marxismus: Dokumentation einer Kontroverse Frankfurt/Main: Suhrkamp.
BRODY, B. 1970 Freud's case-load Psychotherapy 7 8-12
CHODOFF, P. 1972 The effect of third-party payment on the practice of psychotherapy Am. J. Psychiat. 129
540-545
DAVIDS, A. 1964 The relation of cognitivedissonance theory to an aspect of psychotherapeutic practice
Am. Psychol. 19 329-332
DEUTSCHE PSYCHOANALYTISCHE GESELLSCHAFT 1930 Zehn Jahre Berliner Psychoanalytisches
Institut (Poliklinik und Lehranstalt) Vienna: Internationaler Psychoanalytischer Verlag. [→]
EITINGON, M. 1930 Ansprache bei der Einweihung der neuen Berliner Institutrume In Deutsche
Psychoanalytische Gesellschaft 1930
FENICHEL, O. 1941 Problems of Psychoanalytic Technique Albany, N.Y.: Psychoanal. Q., Inc. [→]
FESTINGER, L. 1957 A Theory of Cognitive Dissonance Stanford: Stanford Univ. Press.
FINE, R. 1971 The Healing of the Mind: The Technique of Psychoanalytic Psychotherapy New York:
McKay.
FREUD, S. (with BREUER, J.) 1893-5 Studies on hysteria: Katharina S.E. 2 [→]
FREUD, S. 1900 The interpretation of dreams S.E. 5 [→]
FREUD, S. 1901 The psychopathology of everyday life S.E. 6 [→]
FREUD, S. 1913 On beginning the treatment. (Further recommendations on the technique of psycho-analysis.
I.) S.E. 12 [→]
FREUD, S. 1919 Lines of advance in psychoanalytic therapy S.E. 17 [→]
FREUD, S. 1923 Preface to Max Eitingon's Report on the Berlin Psycho-Analytical Policlinic (March 1920
to June 1922) S.E. 19 [→]
FREUD, S. 1925 An autobiographical study S.E. 20 [→]
FREUD, S. 1930 Preface to Ten Years of the Berlin Psycho-Analytic Institute S.E. 21 [→]
FREUD, S. 1950 The Origins of Psychoanalysis. Letters to Wilhelm Fliess, Drafts and Notes: 1887-1902
New York: Basic Books.
FREUDENBERGER, H. J. 1971 New psychotherapy approaches with teenagers in a new world
Psychotherapy 8 38-43
FROMM-REICHMANN, F. 1950 Principles of Intensive Psychotherapy Chicago: Univ. of Chicago Press.
GEDO, J. 1963 A note on non-payment of psychiatric fees Int. J. Psychoanal. 44:368-371 [→]
GLASSER, M. A. 1965 Prepayment for psychiatric illness Am. J. Psychiat 121 736-741
GLOVER, E. 1955 The Technique of Psycho-Analysis New York: Int. Univ. Press. [→]
GOLDBERG, A. & KOVAC, A. 1971 A new concept of subsidy in determining fees for service Soc.
Casewk 52 206-210
GREENSON, R. R. 1967 The Technique and Practice of Psychoanalysis New York: Int. Univ. Press.
HAAK, N. 1957 Comments on the analytical situation Int. J. Psychoanal. 38:183-195 [→]
HALPERT, E. 1972 The effect of insurance on psychoanalytic treatment J. Am. Psychoanal. Assoc. 20:122-
133 [→]
HILLES, L. 1971 The clinical management of the nonpaying patient Bull. Menninger Clin. 35 98-112
HITSCHMANN, E. 1932 Zur Geschichte des Ambulatoriums Int. Z. Psychoanal. 18 265-271
HOLLINGSHEAD, A. B. & REDLICH, F. C. 1958 Social Class and Mental Illness New York: Wiley.
HUFFER, V. 1963 Fee problems in supervised analysis Bull. Philadelphia Ass. Psychoanal. 13 66-83
KUBIE, L. S. 1950 Practical and Theoretical Aspects of Psychoanalysis New York: Int. Univ. Press.
LAMPL, H. 1930 Die Sprechstunde der Poliklinik. In Deutsche Psychoanalytische Gesellschaft (1930)
LIVANO, J. 1967 Observations about payment of psychotherapy fees Psychiat. Q. 41 324-338
MENNINGER, K. A. 1958 Theory of Psychoanalytic Technique New York: Basic Books.
MOORE, W. T. 1968 Some comments on the 'unavailability' of psychoanalytic patients Bull. Philadelphia
Ass. Psychoanal. 18 76-82
—————————————
37 In the foregoing, I have kept away from the question of the role that money may actually play in the
unconscious motivations of psychoanalysts. Not only would I have gone beyond the limits of this paper in
embarking on the discussion of this question, but I would have also entered a territory in which no
investigation has been made, and to which I feel unable to make a contribution. Schonbar's (1967p. 278)
comment impresses me as relevant and would deserve a special inquiry. She writes: 'The fact that the
analytic community consists of a high proportion of upward mobile people with minority group
backgrounds, as well as the fact that it occupies an ambiguous position in both medicine and psychology,
may heighten any anxiety that attaches to money by way of any number of symbolic meanings money may
have for the practitioner' (1967p. 278). She discusses counter-transference possibilities and protection
against them that are offered by a rigorous fee system, as well as by a looser one. These are thought-
provoking remarks, whose validity I cannot judge. At any rate, popular caricatures of analysts and jokes
about them frequently refer to an alleged greed for money, with the resulting implication that frequency of
sessions and length of treatment are instituted for the purpose of greater earnings. The suspicion that
frequency and length are connected with ulterior motives is, of course, the upshot of misunderstanding, but
as far as a covert monetary interest is concerned, one may ask whether the satirical mind has hit, as so
often happens, upon a truth. After all, it would not be surprising if the restraint to which the psychoanalyst
is subjected by the psychoanalytic technique, and the concomitant deficit in his narcissistic gratifications,
were to lead in a compensatory way to an overvaluation or overconcern with money. (After I had
completed the manuscript, Dr Paul Kramer was kind enough to call my attention to Dr Greenson's
statement, reported in The Psychiatric News, 6 December 1972, in which he objects to the custom of many
analysts of seeing one patient after another without an interval necessary 'to work through his [the
psychoanalyst's] thoughts, fantasies and puzzlement'. This 'revolving door policy', Dr Greenson asserts, is
'primarily motivated by financial gain'. He criticizes the profession for its attitude to money. 'So many of us
have become comfortable and want to remain comfortable.' It is not clear from the report whether Dr
Greenson's assertion should be understood as a hypothesis or is based on actual inquiry. At any rate, his
comment—being one of the few statements about monetary motives which may have a bearing on the
behaviour of psychoanalysts—deserves to be cited in this context.)
- 99 -
MOWRER, O. H. 1963 Payment or repayment? The problem of private practice Am. Psychol. 18 577-580
MYERS, M. J. 1963 Doctor-patient relationship Can. Psychiat. Ass. J. 8 60-69 [→]
RAIMANN, E. 1915 Review: Internationale Zeitschrift fr rztliche Psychoanalyse Wien. klin. Wschr. 28 127
RICHMAN, A. & BEZEREDI, T. 1963 Health insurance prepayment for psychotherapy in private
psychiatric practice Can. Psychiat. Ass. J. 8 121-131
SCHONBAR, R. A. 1967 The fee as a focus of transference and countertransference Am J. Psychother 21
275-285
TARACHOW, S. 1963 An Introduction to Psychotherapy New York: Int. Univ. Press.
WILMER, H. A. 1967 The envelope and the psychiatrist: a study of patients' envelopes Am. J. Psychiat. 123
792-802
WYLIE, H. L. 1965 'The fee' is obsolete J. child Psychiat. 4 341-345
- 100 -
Article Citation [Who Cited This?]
Eissler, K.R. (1974). On Some Theoretical and Technical Problems Regarding the Payment of Fees for
Psychoanalytic Treatment. Int. Rev. Psycho-Anal., 1:73-101

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