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Psychoanalysis and fees
P s y c h o a n a l y s i s and Fees By
PAUL CttODOFF
'NLIKE THE MORE g e n e r a l s u b j e c t of tile c o s t of m e n t a l i l l n e s s w h i c h h a s b e e n q u i t e ch)selv, s c r u t i n i z e d , ~ to m v k n o w l e d g e , t h e l i t e r a t u r e o f p s y c h o a n a l y s i s d o e s n o t i n c l u d e a s y s t e m a t i c s u r v e y of t h e i n f l u e n c e o f its e c o n o m i c s t r u c t u r e o n its p r a c t i c e a n d its p r a c t i t i o n e r s . Yet, s i n c e psyc h o a n a l y t i c t r e a t m e n t is a l m o s t e n t i r e h , in t h e h a n d s o f i n d i v i d u a l s w h o e a n ] t h e i r l i v e l i h o o d s v e r y l a r g e l y f r o m t h e fees t h e y r e c e i v e f r o m t h e i r p a t i e n t s , o n e w a y of c h a r a c t e r i z £ n g a p s y c h o a n a l y s t is as a n i n d i v i d u a l e n t r e p r e n e u r s e l l i n g a sel-vice in d i r e c t c o m p e t i t i o n w i t h o t h e r s in his p r o f e s s i o n , a n d in i n d i r e c t or p o t e n t i a l c o m p e t i t i o n w t h p t u - v e y o r s o f s i m i l a r ser~,iees ira a l l i e d p r o f e s s i o n s . T h e p s y c h o a n a l y s t is n o t i m m u n e to t h e c o m p e t i t i v e p r e s s u r e s a n d s t r a i n s of s u c h a p o s i t i o n , a n d it s e e m s l i k e l y tJaat t h e s e m u s t h a v e s o m e e f f e c t o n his p r o f e s s i o n a l b e h a v i o r , p a r t i c u l a r l y " in his a t t i t u d e s t o w a r d s t h e f i n a n c i a l t r a n s a c t i o n s w h i c h t a k e p l a c e b e t w e e n his p a t i e n t s a n d h i m s e l f . H o w e v e r , a r e v i e w of t h e p e r t i n e n t l i t e r a t u r e o n t h e eeoraornics of p s y c h o a n a l y s i s i n r e l a t i o n to its p r a c t i c e i n d i c a t e s tJaat p e r h a p s this v i e w of t h e p s y c h o a n a l y s t h a s b e e n n e g l e c t e d in t h e d i s c u s s i o n s o f t h e r o l e o f f e e p a y m e n t o n v a r i o u s p r a c t i c a l a n d t h e o r e t i c a l a s p e c t s of t h e p r o f e s s i o n . M o r e o v e r , it a p p e a r s t h a t f e e s a n d t h e e c o n o m i c s of p s y c h o a n a l y s i s in g e n e r a l a r e l i k e l y to b e d i s c u s s e d m o r e f u l l y b y p s y c h o a n a l , v s t s in i n f o r m a l , s o c i a l s i t u a t i o n s t h a n in a f o r m a l or "'scientific" c o n t e x t , t h u s s u g g e s t i n g a c e r t a i n a n a o u n t of c o n f l i c t a b o u t t h e s e s u b j e c t s a n d p o i n t i n g u p t h e n e e d for a n a l y t i c a l s e l f s c r u t i n y ira t h i s a r e a . An e x a m p l e of this k i n d of p u b l i c d i f f i d e n c e is t h e o b s e r v a t i o n of G l o v e r z t h a t a n s w e r s to q u e s t i o n s a b o u t fees w e r e less f r e e a n d v o l u m i n o u s t h a n w e r e t h o s e to ( l u e s t i o n s a b o u t t e c h n i c a l p r i n c i p l e s in a q u e s t i o n n a i r e s u b m i t t e d to E n g l i s h p s y c h o a n a l y s t s . D o e s s u c h u n e a s i n e s s on t h e p a r t of p s y c h o a n a l y s t s a b o u t t h e e c o n o m i c a s p e c t s of t h e i r p r o f e s s i o n a l r o l e r e p r e s e n t a h a n g o v e r f r o m a h y p o c r i t i c a l era, d e c r i e d b y F r e u d , a w h e n t h e " ' p r o f e s s o r " w a s s u p p o s e d to b e n o t i n t e r e s t e d ira m o n e y , or d o e s it s u g g e s t s e n s i t i v i t y o n t h e p a r t of t h e p s y c h o a n a l y s t a b o u t h i s p u b l i c i m a g e , or e v e n i n n e r q u e s t i o n i n g s a b o u t h i s w o r t h ? A n a t t e m p t w i l l b e m a d e l a t e r in t h i s p a p e r to l o o k i n t o t h e r e a s o n s f o r s u c h a n a t t i t u d e , b u t a t t h i s p o i n t , I w a n t to p o i n t o u t t h a t p s y c h o a n a l y s t s in t h i s c o u n t r y , t h e m s e l v e s d e n i z e n s of a s t r i v i n g , c o m p e t i t i v e c u l t u r e w h i c h p l a c e s a h i g h p r e m i u m o n t h e a c q u i s i t i o n of m o n e y , w i l l b e h a n d i c a p p e d in t h e i r d e a l i n g s w i t h t h e i r p a t i e n t s if t h e y p a y i n s u f f i c i e n t a t t e n t i o n to t h e e f f e c t s o f f e e s o n t h e i r o w n i d e a s an'd practices. O n e issue, w h i c h , u n l i k e o t h e r s , to b e e x a m i n e d l a t e r , h a s l}een t h e s u b j e c t of f a i r l y e x t e n s i v e d i s c u s s i o n , is w h e t h e r r e l a t i v e l y h i g h fees, i m p o s i n g s o m e s a c r i f i c e on t h e p a t i e n t , a n d a h v a y s p a i d , e v e n w h e n t h e a p p o i n t m e n t is n o t k e p t , a r e n e c e s s a r y for e f f e c t i v e p s y c h o a n a l y s i s . O n e p o s i t i o n h e l d ]}v m a n y p s y c h o a n a l y s t s a b o u t f e e p a y m e n t s t e m s
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137 C{)MPtu-:lt~:~.,,tvt; l'svt:llt,vlnv, Vol.. 5, N{}. 3 (.JuN~:), 1964
138
PAUL
CHODOF1
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from l:reud's s t a t e m e n t s in " F u r t h e r R e c o m m e n d a t i o n s in the T e c h n i q u e of Psychoanalysis,"':¢ that f e e s are necessary to successful analysis, and that they m u st b e p a i d r e g u l a r l y a n d invarial)ly, without regard to w h e t h e r the p a t i e n t keeps iris a p p o i n t m e n t s , or to the reasons for his absence. These views are reiterated a n d e x p a n d e d in recent books b y Kubie 4 and b y ~Xl,e n n i n g e r 5 w h e r e it is f u r t h e r agreed that, although the analyst should m o d i f y his charges in line w i t h the patient's ability to pay,, the fee should represent a sacrifice to the patient. If it does not, the analysis will be h a m p e r e d , p e r h a p s fatally. T h e reasons for this d e p e n d partly on certain eonsequ enoes of p s y c h o a n a l y t i c theory, specifically on the equation of feces a n d money. As s u m m a r i z e d b y Feniehel," the child, d u r i n g his psychosexual d e v e l o p m e n t comes to regard feces as a v a l u a b l e b o d i l y possession whose periodic loss is felt as painful. In the process of sublimation, mone3', also a d e i n d i v i d u a l l z e d possession comes to b e r e g a r d e d s y m b o l i c a l l y as e q u i v a l e n t with feces and similar a m b i v a l e n t attitudes are a d o p t e d toward it. In certain individuals, particularly c o m p u l s i v e neurotics in w h o m this pa th of s u b l i m a t i o n is disturl)ed, these irrational attitudes b e c o m e reactivated, a n d m o n e y b e c o m e s an object for p l e a sure a n d p u n i s h m e n t , a substitute for feces rather than s o m e t h i n g objectively useful. Thus, the p a t i e n t must a n a l y z e his attitude toward m o n e y in order to help uncover repressed and d y n a m i c a l l y significant anal material; if periodic, i m p o r t a n t losses of m o n e y to the analyst do not occur, a very v a l u a b l e spin" toward b r e a k i n g through resistances in this area will be lacking, to the d e t r i m e n t of the patient's acquisition of insight a nd consequently, to therapeutic progress. In addition to this role of fee p a y m e n t in facilitating derepression of specific anal material, it has b e e n argued that the "strict" line in regard to fees is necessary for a n u m b e r of other reasons, As set out b y Haak 7 these include s t i m u l a t i n g the m~covering of sadomasochistic, d e p e n d e n t , a nd aggressive drives, m a k i n g the analyst a h e a l t h i e r object for identification, a n d p r o v i d i n g m o t i v a t i o n for the patient to face the difficult, p a i n f l d work of analysis. Also, the fact that he receives a fee, compensates the analyst for the emotional lmtt'eting h e endures so that he is less likely to externalize his own aggressive feelings on the patient. In s u m m a r y , the analyst must r e q u i r e sacrificial f e e s from his patient b e c a u se they provide motivation a n d analytical material a nd are beneficial in the eountertransference. T hese well reasoned a n d persuasive a r g u m e n t s represent the attitudes and the practice of ma ny, although certainly not of all, psychoanalysts and b e c a u s e of the prestigious position of psychoanalysis, they also h a v e an influence on other disciplines in whic h illdividual counselling t a k e s place. Thus, there is an increasing t e n d e n c y for social service agencies"':' to charge clients for the r a pe utic interviews and a m m l g the reasons for doing this are included the focal role of the fee in m o b i l i z i n g couwlertransferellce attitudes of the worker as well as the feeling that fees provide motivati¢m wllieh might otherwise be deficient. l lowever, argtlnlenls a r e llOt lacking opposing the doctrine that analysis flourishes only w h e n fees are high mlough to impose the element of sacrifice
PSYCHOANALYSIS
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a n d t h a t a p p o i n t m e n t s m u s t b e p a i d for e v e n w h e n t h e r e a r e l e g i t i m a t e r e a s o n s w h y t h e y c a n n o t b e .kept, F r o m m - R e i c h n a a n TM b e l i e v e d tile f o r e g o i n g v i e w to t)e o u t m o d e d a n d u n t e n a b l e a n d s h e also felt t h a t t h e r e a r e c u l t u r a l d e t e r m i n a n t s to the i d e a t h a t fee p a y m e n t is a sine q u a non for sllccessful t r e a t m e n t . K u b i e , 4 w h o ~for the most p a r t e s p o u s e s t h e t r a d i t i o n a l a p p r o a c h in t h e m a t t e r of f e e p a y m e n t , expresses s o m e d o u b t a b o u t this point, a n d b e l i e v e s it s h o u l d b e critically r e e x a m i n e d . O n e point, w h i c h h a s p e r h a p s b e e n insufficiently e m p h a s i z e d is t h a t , a l t h o u g h it is u n d o u b t e d l y t r u e t h a t p a y m e n t of a fee p r o v i d e s a focus f r o m w h i c h p s y c h o d y n a m i c a l l y i m p o r t a n t m a t e r i a l c a n b e d e v e l o p e d in c e r t a i n p a t i e n t s , it is e q u a l l y t r u e t h a t t h e f a c t t h a t a f e e is n o t p a i d , t h a t t~e p a t i e n t is g e t t i n g s o m e t h i n g for n o t h i n g , c a n p r o v i d e a stiInuh, s to t h e u n c o v e r i n g of p r o b l e m s a b o u t d e p e n d e n c y a n d o n m i p o t e n t s t r i v i n g s w h i c h m a y p r o v e equally" m e a n i n g f u l . Also, since t h e r e a r e m a n y p a t i e n t s for w h o m p a y m e n t or n o n - p a y m e n t of a fee is n o t p a r t i c u l a r l y significant, s t a t e m e n t s a b o u t the i n v a r i a b l e n e c e s s i t y of p a y m e n t in t h e i n t e r e s t of t h e p a t i e n t ' s p r o g r e s s c a n n o t h a v e u n i v e r s a l a p p l i c a t i o n . It s h o u l d also b e m e n t i o n e d t h a t not all analysts, a c c e p t the s y m b o l i c cqm-"v'af e n c e of feces a n d m o n e y a n d t h a t t h e r e a r e o t h e r t h e o r e t i c a l f r a m e w o r k s f r o m w h i c h t h e q u e s t i o n of fee p a . v m e n t can b e c o n s i d e r e d . T h u s , in a r e c e n t p a p e r , G e d o , ~ h a s r e l a t e d n o n p a y m e n t of a n a l y t i c a l fees to a g e n eral t h e o r y of d e l i n q u e n t b e h a v i o r , a n d \ V e i n e r a n d R a t h s . TM e m p l o y ' i n g t h e c o n c e p t s of K a r e n I t o r n e v , s e e t h e p o s s i b i l i t y of c h o i c e b e t w e e n f r e e a n d p a i d for p s y c h o t h e r a p y as c o n s t i t u t i n g an a r e a of c u l t u r a l conflict w h i c h is r e f l e c t e d in t h e p a t i e n t . In this context, t h e conflict exists w h e t h e r t h e p a t i e n t p a y s or does not pa.v: p a y m e n t is not n e c e s s a r y to b r i n g it out. F ' o r t u n a t e l y , h o w e v e r , t h e k i n d of s c h o l a s t i c c o n t r o v e r s y I h a v e b e e n r e v i e w i n g is not t h e o n l y w a y a v a i l a b l e to c o n s i d e r t h e p r o l ) l e m of w h e t h e r 1)sychoanaI.vsis can flourish in t h e a b s e n c e of r e g u l a r f e e 1)ayment, s i n c e t h e r e exists e m p i r i c e v i d e n c e w h i c h c a n b e b r o u g h t to b e a r . I do not h e r e r e f e r to t h e k i n d of c a s e r e p o r t o f f e r e d b y F i n g e r O a w h i c h simply" p r o v e s t h a t fee p a y m e n t c a n b e a useful p s y c h o t h e r a p e u t i c l e v e r in c e r t a i n cases, b u t r a t h e r to a c c o u n t s of w h a t a c t u a l l y h a p p e n s w h e n p s y c h o a n a l y s i s is a t t e m p t e d u n d e r f r e e or low cost c o n d i t i o n s . P a r t i c u l a r l y r e l e v a n t is t h e r e p o r t of L o r a n d a n d Console. TM T h e s e a u t h o r s first list the difficulties " t h o u g h t b y m a n y " to b e i n h e r e n t in p s y c h o a n a l y s i s w i t h o u t fees. t h e n r e p o r t t h e a c t u a l e x p e r i e n c e of a n a l y s t s a n d super~,isors at t h e f r e e p s y c h o a n a l y t i c clinic of t h e N e w York S t a t e Clinic M e d i c a l C e n t e r . ~Xlanv t r a n s f e r e n c e a n d c o u n t e r t r a n s f e r e n c e p r o b l e m s r e v o l v i n g a b o u t t h e p a y m e n t s i t u a t i o n o c c u r r e d , trot it w a s f m m d t h a t t h e s e c o u l d b e u t i l i z e d as m a t e r i a l l e a d i n g to i n c r e a s e d i n s i g h t b o t h b y the p a t i e n t s a n d the c a n d i d a t e a n a l y s t s . A n v m g t h e s u p e r visors, all e x p e r i e n c e d a n a l y s t s , t h e r e w a s a h n o s t ~ m a n i m o u s a g r e e m e n t t h a t t h e r e w e r e o n l y m.;nor d i f f e r e n c e s l m t w e e n these a n a l y s e s a n d those c a r r i e d ollt in p r i v a t e offices for p a y m e n t , a n d t h a t t h e s e d i f f e r e n c e s r e p r e s e n t e d ¢l,mntitative a n d not q u a l i t a t i v e factors. In a discussion of this p a p e r . Clifford Scott ~:' d e s c r i b e d a s i m i l a r e x p e r i e n c e at t h e free clinic of t h e l . o n d o n P s y c h o a n a l y t i c Society. l l e said t h a t althougl~ " t h e feeling h a s
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a l w a F s b e e n t h a t t h e r e o u g h t to lye a d i f f e r e n c e w h e n a p a t i e n t d o e s n o t pay', n o g e n e r a l v i e w as to w h a t this d i f f e r e n c e was e v e r c a m e to t h e fore." A r e p o r t b y C r o w l e y ~; on t h e first y e a r of a l o w cost p s y c h o a n a l y t i c s e r v i c e in N e w York also i n d i c a t e s t h a t w h a t e v e r s p e c i a l p r o b l e m s a r o s e c o n c e r n ing t h e p a y m e n t s i t u a t i o n c o u l d b e d e a l t w i t h a d e q u a t e l F b y a l e r t a n a l y s i s a n d s u p e r v i s i o n . H a r o l d S e h j e l d e r u p , ~; in a f o l l o w ' u p r e p o r t on t h e results of n ' e a t m e n t w i t h t w e n t y - e i g h t ( 2 8 ) p s y c h o n e u r o t i c p a t i e n t s h e h a d psyc h o a n a l y z e d e i g h t to t w e n t y - f o u r y e a r s p r e v i o u s l y , has this to sa F on t h e ellcots of p a y m e n t on results: "'In s o m e cases a r e a s o n ' a b l e fee w a s p a i d , in o t h e r s a vet): s m a l l one, a n d in s o m e cases n o fee a t all. I h a v e f o u n d n o c o n f i r m a t i o n of t h e theor}, t h a t t h e e f f e c t i v e n e s s of tile a n a l y s i s i n c r e a s e s w i t h t h e size of t h e fee. S o m e of m y b e s t results h a v e b e e n o b t a i n e d b y a n a l y sis w i t h o u t p a y m e n t . " T h u s , t h e s e r e p o r t s of a c t u a l e x p e r i e n c e w i t h free a n d lox~, cost a n a l y s i s :ag, rc¢"~ t h a t such a p a v m e n t , m i l i e u is n o t fatally, i n i m i e a b l e to t r e a t m e n t ; it appears that despite theoretical preconceptions and individual instances to t h e c o n t r a r y , p s y c h o a n a l y s i s c a n p r o c e e d s u c c e s s f u l l y in t h e a b s e n c e of fees or w i t h l o w fees. T h e e v i d e n c e s u p p o r t s t h e v i e w t h a t m o t i v a t i o n for p a t i e n t s to w o r k a t p s y c h o a n a l y s i s ( o r in p s y c h o t h e r a p y g e n e r a l l y ) d o e s n o t d e p e n d on t h e w i l l i n g n e s s to s p e n d m o n e y for t r e a t m e n t . As M a r m o t ~'~ h a s p o i n t e d out, s u c h w i l l i n g n e s s is a n e v i d e n c e of m o t i v a t i o n b u t c a n n o t p r o v i d e m o t i v a t i o n o t h e r w i s e l a c k i n g a n d as every" e x p e r i e n c e d p s > ' c h o t h e r a pist c a n a t t e s t , m o t i v a t i o n to w o r k at a n a l y s i s ina F v e r y well b e p r e s e n t in a m p l e d e g r e e e v e n w h e n t h e t r e a t m e n t is free. I n d e e d , r e f e r r i n g b a c k to t h e v i e w I h a v e s u g g e s t e d of t h e a n a l y s t as h o m o e c o n o m i c u s , it m a y l)e m o r e p e r t i n e n t to look a t t h e m o t i v a t i n g f o r c e of fees f r o m t h e s t a n d p o i n t of t h e an'alvst, r a t h e r t h a n t h e p a t i e n t . T h e a n a l y s t w o r k s at his p r o f e s s i o n for a n u m b e r of r e a s o n s ; l e a v i n g o u t i n d i v i d u a l d e t e r m i n a n t s , h e a n a l y z e s b e c a u s e of s c i e n t i f i c i n t e r e s t a n d c u r i o s i t y , t h e p l e a s u r e h e gets f r o m t h e skillful exercise of a n i m p o r t a n t activit),, a n d t h e s e r v i c e h e is a b l e to r e n d e r , b u t also for financial r e w a r d . T h e r e l a t i v e i m p o r t a n c e of t h e s e m o t i v a t i o n s v a r y with individual analysts and with differing circumstances, but there are e e r t a i n l v i n s t a n c e s , o t h e r w i s e u n s a t i s f a c t o r y or u n r e w a r d i n g , w h e r e t h e fee pr¢wides m o t i v a t i o n w h i c h m i g h t o t h e r w i s e b e l a c k i n g , just as t h e r e a r e o c c a sions w h e n t h e fee is n o t n e c e s s a r y a n d t h e a n a l y s t can' w o r k s a t i s f a c t o r i l y in its a b s e n c e . T h e a b s e n c e of t h e n e e d to j u s t i f y e a r n i n g a fee m a y e v e n , in s o m e cases, p r o v i d e a g r a t i f y i n g flexibility a n d f r e e d o m to e x p e r i m e n t w i t h t h e lL-ngth a n d f r e q u e n c y o f sessions. q~le a c t u a l behavic)r of i ) s y c h o t l l e r a p i s t s , i n c l u d i n g a n a l y s t s , w i t h r e g a r d to t h e r e c e n t e m e r g e n c e of i n s u r a n c e p l a n s w h i c h p r o v i d e p a , v m e n t of fifty ( 5 0 ) p e r c e n t of fees for p s y c h o t h e r a p y ' , s o m e w h a t v i t i a t e s t h e c l a i m that sacrificial fees a r e c h a r g e d beca~lse, of t h e i r b e n e f i c i a l effect on t h e p a t i e n t . If ~me bt,lieves that the a b s e n c e of a fee is n o x i o u s to the l ) s y c h o t h e r a p e i l t i e rt, lationshil~, t h e n o n e s h o u l d also b e l i e v e t h a t t h e s p l i t t i n g of 1)a>'m~,nl l~etween the. l)atie~lt a n d t h e i n s u r a n c e c o m p a n y is at least s e m i p o i s o n o u s . p l a y i n g a rMe s i m i l a r to t h a t of the filter on a c i g a r e t t e . B u t t h e e v i d e n c e
PSY(]ItOANALYSIS
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141
a v a i l a b l e s u g g e s t s t h a t many' a n a l y s t s h a v e a c c e p t e d q u i t e w i l l i n g l y this m o d i f i c a t i o n of e s t a b l i s h e d p a y m e n t p r a c t i c e s w i t h o u t p r o t e s t or q u e s t i o n i n g as to its p o s s i b l y d e l e t e r i o u s effect on t r e a t m e n t , As a m a t t e r of fact, the p r e s s u r e t o in'elude d i d a c t i c a n a l y s e s w i t h i n this k i n d o f i n s u r a n c e c o v e r a g e was s t r o n g e n o u g h to p r o d u c e an official w a r n i n g ~:' a b o u t this p r a c t i c e in t h e B u l l e t i n of t h e N e w York S t a t e D i s t r i c t B r a n c h e s ; a n d it m a y b e o n e of t h e f a c t o r s c o n t r i b u t i n g to t h e c u r r e n t difi3culties of this k i n d of i n s u r a n c e . T h e p r e c e d i n g d i s c u s s i o n i n d i c a t e s t h a t e v i d e n c e is l a c k i n g for the b e l i e f t h a t sacrificial fees are t h e r a p e u t i c a l l y i n d i s p e n s a b l e ; t h a t t h e r e is i n d e e d r a t h e r c o g e n t e v i d e n c e to t h e c o n t r a r y ; a n d t h a t a n a l y s t s , w h e n p u t to t h e test, t e n d to b e h a v e as if it w e r e n o t true. T h a t s u c h a d o c t r i n e is, n o n e t h e less, a d h e r e d to f i r m l y b y m a n y p s y c h o a n a l y s t s , s u g g e s t s t h a t w h a t w e a r e d e a l i n g w i t h h e r e is a d o g m a , a n d t h a t e l e m e n t s of r a t i o n a l i z a t i o n m a y b e p r e s e n t c o n c e a l i n g a n o t h e r , a p p a r e n t l y less a c c e p t a b l e m o t i v e f o r c h a r g i n g r e l a t i v e l y h i g h fees. I w o u l d like to .su~Tc~est~m . t h a t w h a t has b e e n n o t e n t i r e l y i g n o r e d , b u t a t l e a s t g l o s s e d over, a n d t r e a t e d d e f e n s i v e l y , t h r o u g h m e c l i a n i s m s s u c h as d e n i a l a n d i s o l a t i o n , a n d s o m e h o v ¢ r e l e g a t e d to an u n e a s y n o t m e p a r t of t h e p e r s o n a l i t v , is t h e p s y c h o a n a l y s t ' s p o s i t i v e i n t e r e s t in a n d n e e d for t h e a c q u i s i t i o n of m o n e y , a n d t h a t his f a i l u r e to c o m e to grips w i t h t h e i m p o r t a n c e of this fact has p l a y e d a role in p e r p e t u a t i n g , w i t h o u t a d e q u a t e evidence, the notion that be accepts m o n e y from his patients i ) r i m a r i l y as a s e r v i c e to t h e m . E s p e c i a l l y in t h e e a r l i e r s t a g e s of his t r a i n i n g a n d p r a c t i c e , a n inat)ility, h o n e s t l y a n d m a t t e r of f a c t l y , to d e a l w i t h his o w n a t t i t u d e s t o w a r d t h e fees h e receives, m a y c o n s t i t u t e for t h e a n a l y s t a n u n r e s o l v e d c o u n t e r t r a n s f e r e n c e a r e a . I-low o f t e n this o c c u r s c a n at p r e s e n t o n l y b e a s u b j e c t for speeul-~tion: a less d e f e n s i v e a t t i t u d e a b o u t the financiai a s p e c t s of p s y c h o a n a l y t i c p r a c t i c e w o u l d a l l o w t h e s e to b e c o n s i d e r e d as o n e amon(~ m a n y c o n s t i ' u e n t a t t i t u d e s w h i c h i n f l u e n c e t h e t r a n s a c t i o n a l p r o c e s s b e t w e e n t h e a n a l y s t a n d his p a t i e n t s . T h e r e a r e a n u m b e r of o c c a s i o n s in his t h e r a p e u t i c c o n t a c t w i t h his p a t i e n t s w h e r e d e c i s i o n s a r e a t t e e t e d t)v t h e p s y c h o t h e r a p i s t ' s f i n a n c i a l n e e d s to a d e ~O r e e w h i c h m a y 1)e o b s c u r e d b y-' a m b i v a l e n c e t o w a r d t h e s e n e e d s a n d 1)v t h e b a r r i e r s whic2h exist to t h e free a c k n o w l e d g m e n t of a n d d i s c u s s i o n o f t h e m . T h e p r o c e s s o f s e l e c t i o n of p a t i e n t s for t h e r a p y is o n e of t h e s e occasions a n d it is o n e in w h i c h f i n a n c i a l c o n s i d e r a t i o n s are, of c o u r s e , of g r e a t i m p o r t a n c e . It is m y i m p r e s s i o n t h a t in this a r e a , a n a l y s t s a r e u s u a l l y a b l e to l)e d i r e c t a n d e x p l i c i t , a n d discuss t h e t e r m s of t h e c o n t r a c t in u n e ( l u i r o e a l f a s h i o n w i t h p r o s p e c t i v e p a t i e n t s , l I o w e v e r , w h e n it exists, a n u n e a s y or a m b i v a l e n t a t t i t u d e t o w a r d s m o n e y on t h e p a r t of t h e a n a l v s t c a n l e a d to t h e s c a m p i n g o v e r or o b s c u r i n g ()f r e l e v a n t d e t a i l s , w i t h t h e p o s s i b l e d e v e l o p m('llt of seri(ms dif[icn]tie:; in t h e t h e r a p e u t i c r e l a t i o n s h i p l a t e r on. T h e r e m a y be, m o r e o v e r , some' t e n d e n c y [o m i n i m i z e l ~ n f a v o r a b l e i n d i c a t i o n s in f i n ~ n c i a l l v d e s i r a b l e p a t i e n t s t)v t i u ' r a p i s t s w h o feel t h e y s h o u l d t r e a t o n l y c('rtain d i a g n o s t i c c a t e g o r i e s . T h e "J a J'e -'"' g r o u p h a s m a d e c l e a r the e x t e n t to w h i c h p s y c h o t h e r a p . v a n d p s y c h o a n a l y s i s are c.lass-bound m e t h o d s of t r e a t m e n t and while m a n y other variables m besides the u n e q u a l distribu-
1.4:2
PAUL
CHOI)OFF
tion of w e a l t h in o u r s o c i e t y a r e r e s p o n s i b l e for this, it w o u l d b e f o o l i s h to d e n y t h a t it .is a r e l e v a n t factor. C e r t a i n l y , o n e r e a s o n w h y t h e t h e o r i e s of 1)sychoanalysts appeal" to b e a p p l i c a b l e chiefly to u p p e r a n d m i d d l e class p e r s o n s is t h a t , g e n e r a l l y s p e a k i n g , o n l y m e m b e r s of t h e s e classes can afford t h e fees w h i c h a d m i t t h e i n i n t o r e l a t i o n s h i p s w i t h p s y c h o a n a l y s t s f r o m w h i c h t h e l a t t e r d e r i v e t h e d a t a w h i c h t h e y use to c o n s t r u c t t h e i r theories. ~'' Also, r e l e v a n t to p a t i e n t s e l e c t i o n , a n a l y s t s a r e m o r e likely to b e o p e n a n d d i r e c t a b o u t t h e f i n a n c i a l status of p r o s p e c t i v e p a t i e n t s in t h e i r i n f o r m a l d i s c u s s i o n s w i t h e a c h o t h e r a b o u t r e f e r r a l s t h a n t h e y a r e in m o r e f o r m a l s e t t i n g s w h e r e the s e l e c t i o n of a p a t i e n t for t r e a t m e n t m a y b e t a l k e d a b o u t as if his a b i l i t y to p a y a n d t h e f e e l i n g s a r o u s e d in t h e t h e r a p i s t b y this, a r e n e g l i g i b l e factors. This suggests a k i n d of n i c e - N e l l y i s m a b o u t this a s p e c t of t h e i r dealings w i t h p a t i e n t s w h i c h F r e u d c l a i m e d d i d n o t affect p s y c h o a n a l y s i s as it (lid o t h e r b r a n c h e s of m e d i c i n e . In a p a p e r d e a l i n g w i t h t h e r e a s o n s for t h e d e c r e a s e in i n c o m e to t h e B o s t o n P s y c h o a n a l y t i c I n s t i t u t e f r o m c o n t r o l patients" fees, t e r m - " s e e m s to h a v e b e e n r e f e r r i n g to t h e s a m e p h e n o m e n o n w h e n h e states t h a t m a v,, b c ""s o m e o f the r e l u c t a n c e of a n a l y s t s to i n c l u d e d a t a c o n t e n t i n g fees a n d finances in case r e p o r t s is r e l a t e d in p a r t to . . . r e s i d u a l c o ~ m t e r t r a n s f e r e n c e resistance.'" I n c i d e n t a l l y , it is w o r t h p o i n t i n g o u t t h a t t h e r e a s o n for t h e d e c l i n e o f i n c o m e to t h e Boston I n s t i t u t e c o u l d b e q u i t e e l e g a n t l y p r e d i c t e d b y t h e a p p l i c a t i o n of a t h e o r y o f strict e c o n o m i c d e t e r m i n i s m t o t h e b e h a v i o r of t h e a n a l y s t s a n d s u p e r v i s o r s i n v o l v e d . I h a v e d i s c u s s e d a p r o b l e m , t h e t h e r a p e u t i c n e c e s s i t y for r e g u l a r sacrificial fees, w h i c h h a s r e c e i v e d a g o o d d e a l of a t t e n t i o n in t h e r e l e v a n t l i t e r a t u r e , a n d a n o t h e r , t h e r e l a t i o n of finances to p a t i e n t s e l e c t i o n w h i e h has r e c e i v e d less notice. T h e r e are, in a d d i t i o n , c e r t a i n a s p e c t s of t h e p s y e h o t h e r a p e u t i e process itself, its t e r m i n a t i o n , a n d t h e e v a l u a t i o n of its results, w h i c h are also a f f e c t e d b y financial c o n ' s i d e r a t i o n s to a deg'ree w h i c h veould n o t b e s u s p e c t e d if o n e j u d g e d o n l y b y t h e a h n o s t n e g l i g i b l e a m o u n t of m a t e r i a l p u b l i s h e d a b o u t t h e m . H e r e , I will b e c o n t e n t veith m e r e l y r a i s i n g s o m e q u e s t i o n s w h i c h s e e m p e r t i n e n t to m.v thesis t h a t t h e a n a l y s t ' s f i n a n c i a l n e e d s play, a r o l e in his b e h a v i o r w i t h his p a t i e n t s w h i c h is d i s p r o p o r t i o n a t e to the m n o u n t of a t t e n t i o n it r e c e i v e s . F o r i n s t a n c e , to w h a t e x t e n t is t h e n u m b e r of h o u r s a w e e k a p a t i e n t is s e e n a f u n c t i o n of this f a c t o r ? D o e s t h e a n a l y s t s o m e t i m e s d e c r e a s e t h e h o u r s so t h a t h e c a n r a i s e t h e f e e as G r e e n a c r e 24 h a s s u g g e s t e d a n d is this o n e of t h e r e a s o n s for t h e i n c r e a s i n g d e v i a tion f r o m t h e classical m o d e l seen in this c o u n t r y ? O n t h e o t h e r h a n d , d o e s the eflort of s o m e a n a l y s t s to m a i n t a i n a p s y c h o a n a l y , tic i d e n t i t y , w h i c h m e a n s s e e i n g l>atients four or five t i m e s a w e e k , t e n d to p r o m o t e h m g e r a n a l y s e s s i n c e it is difficult to find p a t i e n t s w h o c a n m a i n t a i n such a financial b u r d e n ? I n g e n e r a l , is t h e t e r m i n a t i o n of or t h e c o n t i n u a t i o n of t r e a t m e n t in p a r t i c u l a r cases i n f l u e n c e d by t h e a v a i l a b i l i t y of o t h e r p a t i e n t s ? l t o w a b o u t the o p t i m u m l e n g t h of t h e r a p e u t i c sessions? T h e n e c e s s i t y for b r e a k s bet w e e n sessions? T h e n m n l ) e r of p a t i e n t s a day" a t h e r a p i s t c a n see el]'eetivetv? V~qmt, in short, a r e the w o r k i n g c o n d i t i o n s w h i c h will f o s t e r t h e s t m t a i n e d in'terest a n d p e r c e p t u a l a l e r t n e s s w h i c h are t h e sine q u a n o n of
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frEES
1.43
effective p s y c h o a n a l y s i s ? U n l e s s I h a v e m i s s e d t h e m , t h e r e a r e ne s t u d i e s of t h e s e f a c t o r s as t h e y affect t h e r a p e u t i c results, y e t it s e e m s v e r y u n l i k e l y t h a t t h e y d o not exert an i n f l u e n c e on results, a h n o s t as un'likely as t h a t they, in turn, a r e n o t i n f l u e n c e d s t r o n g l y 1Lv t h e financial r e q u i r e m e n t s of the a n a l y s t . It m a y b e s t a t e d t h a t this p r o b l e m is n o t a u n i q u e one, t h a t a n y brain' w o r k e r m u s t m a k e a similar a d j u s t m e n t b e t w e e n ideal w o r k i n g conditions a n d his n e e d to m a k e his living for h i m s e l f a n d his family. U n d o u b t e d l y true, b u t s h o u l d n o t p s y c h o a n a l y s t s , w h o p r i d e t h e m s e l v e s on their m e t i c u lous a t t e n t i o n to all t h e m i n u t i a e w h i c h b e a r u p o n t h e t h e r a p e u t i c r e l a t i o n , also t a k e into a c c o u n t a f a c t o r w h i c h m a y a f f e c t so i n t i m a t e l y t h e i r t h e r a p e u t i c skills'," F o r e x a m p l e , if w e a r e t r y i n g to c o m p i l e figures .on p s y c h o a n a l y t i c results in say, o b s e s s i v e - c o m p u l s i v e states, it w ( n d d s e e m p e r t i n e n t to k n o w w h e t h e r a p a r t i c u l a r ease w a s seen d u r i n g f o r t y m i n u t e sessions b y a n a n a l y s t w h o sees ten or t w e l v e p a t i e n t s a d a y w i t h o u t a b r e a k b e t w e e n t h e m e x c e p t for ten m i n u t e s for h m e h , or b y a n o t h e r a n a l y s t w h o s p e n d s rift3, m i n u t e s w i t h e a c h of six p a t i e n t s , w i t h ten m i n u t e s b e t w e e n sessions. Incid e n t a l l y a n d also g e r m a n e to t h e p r o b l e m of the e v a l u a t i o n e f t r e a t m e n t results, e n e m a y w o n d e r w h e t h e r the a m o u n t of m o n e y the p a t i e n t h a s s p e n t influences, e i t h e r positively, or negatively', his or h e r t h e r a p i s t ' s j u d g e m e n t a b o u t t h e a m o u n t of i m p r o v e m e n t w h i e h has t a k e n place. T h e r e is c e r t a i n l y no o n e s i m p l e ex-planation for t h e }'allure of ps.vchoa n a l y s t s to e x a m i n e h o w a n d to w h a t e x t e n t t h e f e e s t r u c t u r e u n d e r w h i c h m o s t of t h e m o p e r a t e i n f l u e n c e s their b e h a v i o r in r e g a r d to t h e s e v a r i o u s a s p e c t s of t h e i r r e l a t i o n s h i p s w'ith t h e i r p a t i e n t s . P h y s i c i a n s w h o e a r n their living t h r o u g h p s y c h o t h e r a p y a r e p r a c t i c i n g an h o n o r a b l e p r o f e s s i o n . T h e y w o r k h a r d , they: b e n e f i t a c o n s i d e r a b l e p r o p o r t i o n o f t h e i r p a t i e n t s , m o s t o f t h e m s p e n d a g o o d deal of time a n d effort in t r y i n g te i m p r o v e tlleir results, t h e y p r o b a b l y m a k e less m o n e y t h a n m o s t o t h e r m e d i c a l m e n . T h e r e is c o n s i d e r a b l e d e m a n d for t h e i r services. O n e r e a s o n for the s e o t o m a t a I h a v e s u g g e s t e d may.7 b e t h e rigors a n d financial h a r d s h i p s of the l o n g t r a i n i n g p e r i o d u n d e r t a k e n a t a c o m p a r a t i v e l y " late p e r i o d of t h e i r p r o f e s s i o n a l c a r e e r s w h i c h , as p o i n t e d o u t b y G e o d e n o u g h , Klein a n d P o t t e r , '-'a m a y i n c u l c a t e in p s y c h o t h e r a p i s t s , b i a s e s in the d i r e c t i o n of t h e profit m o t i v e r a t h e r t h a n service. I t this is true, s u c h a t t i t u d e s w o u l d b e likely to b e h e l d a n a b i v a l e n t l y a n d t h u s k e p t o u t of awaren'ess. J u d d M a r m o r '-'~; h a s called illusions e f o m n i p o t e n c e a n o c c u p a t i o n a l h a z a r d o f p s y c h i a t r i s t s , a n d it m a y b e t h a t in s o m e i n s t a n c e s u n r e s o l v e d conflicts o v e r t h e s e may" g i v e rise to guilt a b o u t a n inabilit.v to b r i n g a b o u t m a g i c a l r e s u | l s , r e s u l t i n g in an u n e a s y f e e l i n g t h a t m o n e y is b e i n g t a k e n u n d e r false p r e t e n s e s . T h i s t e n d e n c y w o u l d b e s h a q ) e n e d b y r e c e n t e v i d e n c e s "-'7-'2:' of a n e e d to r e - e x a m i n e p s y e h o t h e r a p e u t i e results g e n e r a l l y a n d by., p o p u l a r i m p a t i e n c e w i t h w h a t a r e r e g a r d e d as t h e p r e t e n s i o n s of p s y c h o a n a l y s i s as e x e m p l i f i e d b v t h e c a r t o o n s of Feiffer a n d t h e N e w Y o r k e r steres of t i l l i a n Hoss. T h a t p s y c h o a n a l y s i s is as m u c h the v i c t i m as t h e p r o g e n i t o r of the f a n t a s v t h a t it trains d o c t o r s of h a p p i n e s s -~.'~ is no help. P s y c h o t h e r a p i s t s , a l o n g w i t h p h y s i c i a n s g e n e r a l l y , b e a r t h e u n f a v o r a b l e c o n s e q u e n c e s of a f u n d a m e n t a l split b e t w e e n their i m a g e s as
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priests a n d healers on the o n e h a n d a n d , on the other, as lm s i n e s s m e ~ e n g a g e d in the sale of service; b u t u n l i k e most o t h e r p h y s i c i a n s , p s y c h o a n a l y s t s at least, h a v e h a d an o p p o r t u n i t y to r e v i e w a n d r e s o h e their conflicts over this d i c h o t o m y , in t h e i r p e r s o n a l analyses. It m a y he, h o w e v e r , t h a t this conflict is not a l w a y s g o n e into t h o r o u g h l y e n o u g h in d i d a c t i c a n a l y s e s , thus c o n t r i b u t i n g to l a t e r u n e a s i n e s s a b o u t it. A psy, c h o a n a l y t i c i d e n t i ~ , is f o r m e d l a r g e l y b y the p r o c e s s of i d e n t i f i c a t i o n w i t h s e n i o r a n a l y s t s w h o t h e m s e l v e s m a y not h a v e r e s o l v e d this conflict a b o u t t h e s e roles, m e n t i o n e d a b o v e , or w h o s e s u c c e s s f u l a n d s e c u r e p o s i t i o n s may, h a v e r e n d e r e d t h e m i n s u f f i c i e n t l y a l e r t to the p r e s s u r e s e x p e r i e n c e d b y y,ounger m e n 1)eginn i n g to e s t a b l i s h p r a c t i c e s in a c o m p e t i t i v e field, a n d w h o thus m a y unc o n s c i o u s l y d i s c o u r a g e tlm k i n d of i n d i v i d u a l a n a l y t i c or s e m i n a r d i s c u s s i o n w h i c h w o u l d p e r m i t v e n t i l a t i o n a n d i n c r e a s e d a w a r e n e s s of real p r o b l e m s a b o u t m o n e y , its effect on t r e a t m e n t in g e n e r a l , a n d p a r t i c u l a r l y on c e r t a i n a t t i t u d e s of t h e a n a l y s t as t h e s e affect t r e a t m e n t . B e c a u s e of the i n t e n s i v e n a t u r e a n d long d u r a t i o n of p s y c h o a n a l y t i c treatm e n t , its f i n a n c i a l aspects r a i s e issues w h i c h a r e social a n d m o r a l as well as t e c h n i c a l . A l t h o u g h these issues a r e diflqcult to resolve, g i v e n t h e c h a r a c t e r of the c u l t u r e w i t h i n w h i c h p s y c h o a n a l y s t s f u n c t i o n , t h e y d e s e r v e o p e n a n d f r a n k d i s c u s s i o n not o n l y 1)ecause of t h e i r i m p a c t on the r e l a t i o n s h i p b e t w e e n the a n a l y s t anti his p a t i e n t , b u t also b e c a u s e of t h e i r effect on t h e r e l a t i o n s h i p b e t w e e n m e d i c a l p s y c h o a n a l y s t s a n d the rest of the m e d i c a l profession. T h e e c o n o m i c s of m e d i c i n e is u n d e r g o i n g a r e v o l u t i o n in the U n i t e d States. A l r e a d y , s e v e n t y - f i v e ( 7 5 ) p e r c e n t or m o r e of t h e e n t i r e p o p u l a t i o n of the c o u n t r y p a y s its d o c t o r bills w i t h the h e l p Of various k i n d s of v o h m t a r v p r e - p a y m e n t h e a l t h i n s u r a n c e , a n d t h e c o n t i n u a t i o n of this t r e n d s e e m s i n e v i t a b l e . I n s u r a n c e c o m p a n i e s h a v e d e m o n s t r a t e d a w i l l i n g n e s s to experim e n t w i t h p a r t i a l p a y m e n t for e x t r a m u r a l p s y c h o t h e r a p y b u t t h e y b e c o m e b e w i l d e r e d a n d d i s c o u r a g e d by ~ t h e thicket o f u n e x p e c t e d p r o b l e m s r e s u l t i n g f r o m this k i n d of c o v e r a g e . P e r h a p s a d e t e r m i n e d effort on the p a r t of p s y c h o a n a l y s t s a n d m e d i c a l p s y c h o t h e r a p i s t s g e n e r a l l y , to set s t a n d a r d s a n d c r i t e r i a for the k i n d of p s y c h o t h e r a p y w h i c h c a n l e g i t i m a t e l y b e c o v e r e d b y i n s u r a n c e p a y n ; e n t w o u l d r e v e r s e the p r e s e n t t e n d e n c y w h i c h t h r e a t e n s to m a k e of p s y c h o a n a l y t i c a n d p s y e l m t h e r a p e u t i e m e d i c i n e an e c o n o m i c a n a c h r o n i s m , dix'ovv.ed, b.v its p a y m e n t p r a c t i c e s , from t h e m a i n s t r e a m of m e d i c i n e . REFERENCES 1. Kein, R.: E c o n o m i e s of N l e n t a l Illness. N e w York, Basic Books, 1958. 2. (;lover, E.: An Investigation of the "l\-chniques of Psychoanalysis. Baltimore, Williams & ~,Vilkins Co., 1942. pp. 99--100. 3. Freud, S.: lrurthcr r e c o m m e n d a t i o n in the techniques of psy,ehoanalysis, in Collected Papers, Vol. XI. L o n d o n . I-lo/garth Press, 1946. -1. Kuhie, L.: Practical and Th(,oretic'al
Aspects of Psycho-umlysis. N e w York, Int. Univ. Press, 1950. 5. Menninger, K.: T h e o r y of P s y c h o a n a lytic T e c h n i q u e . N e w York, Basic Books, 1950. 6. Fenichel, O.: P s y c h o a n a l y t i c T h e o r y of Neurosis. N e w York, \V. \V. Norton & Co., I945. 7. Haak, N.: C o m m e n t s on the analytic situation. Int. J. P.~yehoanal. 3 8 : 1 8 3 95. 19.'57.
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PSYCHOANALYSIS AND FEES 8. Boggs, M.: Administrative and casework aspects of fee charging. J. Soc. Casework 30:353, 1949. 9. Brody, C.: Fee charging~A dynamic in the casework process. J. Soc. Casework 30:65. 1949. 10. lZromm-Reichman, F.: Principles of Intensive Psyclmtherapy. Chicago, I11., Univ. of Chicago Press, 1950. I1. Gedo, J.: A note on non-payment of psychiatric fees. hat. J. Psychoanal. 44:368, I963. 12. \Veiner, I). N., and Raths, O. N.: Cultural Factors in Payment for PA Therapy. American J. of Psychoanal. 20:66, 1960. 13. Fingert, H. H.: Comments on flae psychoanalytic significance of the fee. Bull. Menninger Clinic 16:98, 1952. 14. Lorand, Sandor, and Console, Win. A.: Therapeutic results in psychoanalytic treatment without fee. Int. J. Psychoanal. 39:59-6.5, 1958. I5. Scott, W. C. M.: Discussion of Lorand, Sandor (see reL #14). 16. Crowley, R.: A low cost psychoanalytic service; the 1st year. Psychiat. Quart. 24:462, 1950. 17. Schjeklerup, H.: Lasting effects of psychoanalytic treatment. Psychiat. 18: 109, 1955. 18. Marmor, J.: In Modern Concepts of Psychoanalysis. Leon Salzman and Jules Massennan, (exks.). New York, Philosophical Library, 1962. 19. Bulletin of the New York State District
Branches, April, 1961. 20. Hollingshead, A., and' Redlieh, F.: Social Class and Mental Illness. New York, Wiley, 1958. L 21. Schaffer, L., and 3h:3'ers, J.: Psychotherapy and social stratification. Psy. chiat. 17:83, 1954. 22. lhmt, R. G.: Social Class and Mental Illness. Am. J. Psychiat. 116-1065, 1960. 23. Levin, S.: A study of fees for control analysis. Bull. Philadelplfia Assn. Psychoanal. 8:69, 1958. 24. Greenacre, P.: The role of transference. J. Am. Psychoanal. Assn. 2:671, I954. 25. Goodenough, 1). R., Klein, H. R., and Potter, H. W.: Problems related to personal costs of psychiatric and psychoanalytic training. American J. Psychiat. 113:1013, 1957. 26. Marmor, J.: The feeling of superiority: An occupational hazard in the practice of psychotherapy. American J. Psychiat. 110:370, 1953. 27. Sehmideberg, M.: Vahws and goals in psychotherapy. Psych. Quart., April, I958. 28. Heilbnm, G.: Psychoanalysis of yesterday, today and tomorrow. Arch. Gen. Psychiat. 4:321, 1961. 29. Frank, J. I).: Persuasion and Healing. Baltimore, The Johns Hopkins Press, 1961. 30. Chodoff, P.: Identi~'. In Science and Psychoanalysis, Vol. V. Grime and Stratton, Inc., 1962, p. 249.
Paul Chodoff, M.D., Dept. of Psychiatry, George Washington [/mverslly, ~t'ashmgton, D. C. Address: 1904 "R" Street, Washington, D. C.
PAUL CttODOFF
'NLIKE THE MORE g e n e r a l s u b j e c t of tile c o s t of m e n t a l i l l n e s s w h i c h h a s b e e n q u i t e ch)selv, s c r u t i n i z e d , ~ to m v k n o w l e d g e , t h e l i t e r a t u r e o f p s y c h o a n a l y s i s d o e s n o t i n c l u d e a s y s t e m a t i c s u r v e y of t h e i n f l u e n c e o f its e c o n o m i c s t r u c t u r e o n its p r a c t i c e a n d its p r a c t i t i o n e r s . Yet, s i n c e psyc h o a n a l y t i c t r e a t m e n t is a l m o s t e n t i r e h , in t h e h a n d s o f i n d i v i d u a l s w h o e a n ] t h e i r l i v e l i h o o d s v e r y l a r g e l y f r o m t h e fees t h e y r e c e i v e f r o m t h e i r p a t i e n t s , o n e w a y of c h a r a c t e r i z £ n g a p s y c h o a n a l y s t is as a n i n d i v i d u a l e n t r e p r e n e u r s e l l i n g a sel-vice in d i r e c t c o m p e t i t i o n w i t h o t h e r s in his p r o f e s s i o n , a n d in i n d i r e c t or p o t e n t i a l c o m p e t i t i o n w t h p t u - v e y o r s o f s i m i l a r ser~,iees ira a l l i e d p r o f e s s i o n s . T h e p s y c h o a n a l y s t is n o t i m m u n e to t h e c o m p e t i t i v e p r e s s u r e s a n d s t r a i n s of s u c h a p o s i t i o n , a n d it s e e m s l i k e l y tJaat t h e s e m u s t h a v e s o m e e f f e c t o n his p r o f e s s i o n a l b e h a v i o r , p a r t i c u l a r l y " in his a t t i t u d e s t o w a r d s t h e f i n a n c i a l t r a n s a c t i o n s w h i c h t a k e p l a c e b e t w e e n his p a t i e n t s a n d h i m s e l f . H o w e v e r , a r e v i e w of t h e p e r t i n e n t l i t e r a t u r e o n t h e eeoraornics of p s y c h o a n a l y s i s i n r e l a t i o n to its p r a c t i c e i n d i c a t e s tJaat p e r h a p s this v i e w of t h e p s y c h o a n a l y s t h a s b e e n n e g l e c t e d in t h e d i s c u s s i o n s o f t h e r o l e o f f e e p a y m e n t o n v a r i o u s p r a c t i c a l a n d t h e o r e t i c a l a s p e c t s of t h e p r o f e s s i o n . M o r e o v e r , it a p p e a r s t h a t f e e s a n d t h e e c o n o m i c s of p s y c h o a n a l y s i s in g e n e r a l a r e l i k e l y to b e d i s c u s s e d m o r e f u l l y b y p s y c h o a n a l , v s t s in i n f o r m a l , s o c i a l s i t u a t i o n s t h a n in a f o r m a l or "'scientific" c o n t e x t , t h u s s u g g e s t i n g a c e r t a i n a n a o u n t of c o n f l i c t a b o u t t h e s e s u b j e c t s a n d p o i n t i n g u p t h e n e e d for a n a l y t i c a l s e l f s c r u t i n y ira t h i s a r e a . An e x a m p l e of this k i n d of p u b l i c d i f f i d e n c e is t h e o b s e r v a t i o n of G l o v e r z t h a t a n s w e r s to q u e s t i o n s a b o u t fees w e r e less f r e e a n d v o l u m i n o u s t h a n w e r e t h o s e to ( l u e s t i o n s a b o u t t e c h n i c a l p r i n c i p l e s in a q u e s t i o n n a i r e s u b m i t t e d to E n g l i s h p s y c h o a n a l y s t s . D o e s s u c h u n e a s i n e s s on t h e p a r t of p s y c h o a n a l y s t s a b o u t t h e e c o n o m i c a s p e c t s of t h e i r p r o f e s s i o n a l r o l e r e p r e s e n t a h a n g o v e r f r o m a h y p o c r i t i c a l era, d e c r i e d b y F r e u d , a w h e n t h e " ' p r o f e s s o r " w a s s u p p o s e d to b e n o t i n t e r e s t e d ira m o n e y , or d o e s it s u g g e s t s e n s i t i v i t y o n t h e p a r t of t h e p s y c h o a n a l y s t a b o u t h i s p u b l i c i m a g e , or e v e n i n n e r q u e s t i o n i n g s a b o u t h i s w o r t h ? A n a t t e m p t w i l l b e m a d e l a t e r in t h i s p a p e r to l o o k i n t o t h e r e a s o n s f o r s u c h a n a t t i t u d e , b u t a t t h i s p o i n t , I w a n t to p o i n t o u t t h a t p s y c h o a n a l y s t s in t h i s c o u n t r y , t h e m s e l v e s d e n i z e n s of a s t r i v i n g , c o m p e t i t i v e c u l t u r e w h i c h p l a c e s a h i g h p r e m i u m o n t h e a c q u i s i t i o n of m o n e y , w i l l b e h a n d i c a p p e d in t h e i r d e a l i n g s w i t h t h e i r p a t i e n t s if t h e y p a y i n s u f f i c i e n t a t t e n t i o n to t h e e f f e c t s o f f e e s o n t h e i r o w n i d e a s an'd practices. O n e issue, w h i c h , u n l i k e o t h e r s , to b e e x a m i n e d l a t e r , h a s l}een t h e s u b j e c t of f a i r l y e x t e n s i v e d i s c u s s i o n , is w h e t h e r r e l a t i v e l y h i g h fees, i m p o s i n g s o m e s a c r i f i c e on t h e p a t i e n t , a n d a h v a y s p a i d , e v e n w h e n t h e a p p o i n t m e n t is n o t k e p t , a r e n e c e s s a r y for e f f e c t i v e p s y c h o a n a l y s i s . O n e p o s i t i o n h e l d ]}v m a n y p s y c h o a n a l y s t s a b o u t f e e p a y m e n t s t e m s
U
137 C{)MPtu-:lt~:~.,,tvt; l'svt:llt,vlnv, Vol.. 5, N{}. 3 (.JuN~:), 1964
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CHODOF1
~
from l:reud's s t a t e m e n t s in " F u r t h e r R e c o m m e n d a t i o n s in the T e c h n i q u e of Psychoanalysis,"':¢ that f e e s are necessary to successful analysis, and that they m u st b e p a i d r e g u l a r l y a n d invarial)ly, without regard to w h e t h e r the p a t i e n t keeps iris a p p o i n t m e n t s , or to the reasons for his absence. These views are reiterated a n d e x p a n d e d in recent books b y Kubie 4 and b y ~Xl,e n n i n g e r 5 w h e r e it is f u r t h e r agreed that, although the analyst should m o d i f y his charges in line w i t h the patient's ability to pay,, the fee should represent a sacrifice to the patient. If it does not, the analysis will be h a m p e r e d , p e r h a p s fatally. T h e reasons for this d e p e n d partly on certain eonsequ enoes of p s y c h o a n a l y t i c theory, specifically on the equation of feces a n d money. As s u m m a r i z e d b y Feniehel," the child, d u r i n g his psychosexual d e v e l o p m e n t comes to regard feces as a v a l u a b l e b o d i l y possession whose periodic loss is felt as painful. In the process of sublimation, mone3', also a d e i n d i v i d u a l l z e d possession comes to b e r e g a r d e d s y m b o l i c a l l y as e q u i v a l e n t with feces and similar a m b i v a l e n t attitudes are a d o p t e d toward it. In certain individuals, particularly c o m p u l s i v e neurotics in w h o m this pa th of s u b l i m a t i o n is disturl)ed, these irrational attitudes b e c o m e reactivated, a n d m o n e y b e c o m e s an object for p l e a sure a n d p u n i s h m e n t , a substitute for feces rather than s o m e t h i n g objectively useful. Thus, the p a t i e n t must a n a l y z e his attitude toward m o n e y in order to help uncover repressed and d y n a m i c a l l y significant anal material; if periodic, i m p o r t a n t losses of m o n e y to the analyst do not occur, a very v a l u a b l e spin" toward b r e a k i n g through resistances in this area will be lacking, to the d e t r i m e n t of the patient's acquisition of insight a nd consequently, to therapeutic progress. In addition to this role of fee p a y m e n t in facilitating derepression of specific anal material, it has b e e n argued that the "strict" line in regard to fees is necessary for a n u m b e r of other reasons, As set out b y Haak 7 these include s t i m u l a t i n g the m~covering of sadomasochistic, d e p e n d e n t , a nd aggressive drives, m a k i n g the analyst a h e a l t h i e r object for identification, a n d p r o v i d i n g m o t i v a t i o n for the patient to face the difficult, p a i n f l d work of analysis. Also, the fact that he receives a fee, compensates the analyst for the emotional lmtt'eting h e endures so that he is less likely to externalize his own aggressive feelings on the patient. In s u m m a r y , the analyst must r e q u i r e sacrificial f e e s from his patient b e c a u se they provide motivation a n d analytical material a nd are beneficial in the eountertransference. T hese well reasoned a n d persuasive a r g u m e n t s represent the attitudes and the practice of ma ny, although certainly not of all, psychoanalysts and b e c a u s e of the prestigious position of psychoanalysis, they also h a v e an influence on other disciplines in whic h illdividual counselling t a k e s place. Thus, there is an increasing t e n d e n c y for social service agencies"':' to charge clients for the r a pe utic interviews and a m m l g the reasons for doing this are included the focal role of the fee in m o b i l i z i n g couwlertransferellce attitudes of the worker as well as the feeling that fees provide motivati¢m wllieh might otherwise be deficient. l lowever, argtlnlenls a r e llOt lacking opposing the doctrine that analysis flourishes only w h e n fees are high mlough to impose the element of sacrifice
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a n d t h a t a p p o i n t m e n t s m u s t b e p a i d for e v e n w h e n t h e r e a r e l e g i t i m a t e r e a s o n s w h y t h e y c a n n o t b e .kept, F r o m m - R e i c h n a a n TM b e l i e v e d tile f o r e g o i n g v i e w to t)e o u t m o d e d a n d u n t e n a b l e a n d s h e also felt t h a t t h e r e a r e c u l t u r a l d e t e r m i n a n t s to the i d e a t h a t fee p a y m e n t is a sine q u a non for sllccessful t r e a t m e n t . K u b i e , 4 w h o ~for the most p a r t e s p o u s e s t h e t r a d i t i o n a l a p p r o a c h in t h e m a t t e r of f e e p a y m e n t , expresses s o m e d o u b t a b o u t this point, a n d b e l i e v e s it s h o u l d b e critically r e e x a m i n e d . O n e point, w h i c h h a s p e r h a p s b e e n insufficiently e m p h a s i z e d is t h a t , a l t h o u g h it is u n d o u b t e d l y t r u e t h a t p a y m e n t of a fee p r o v i d e s a focus f r o m w h i c h p s y c h o d y n a m i c a l l y i m p o r t a n t m a t e r i a l c a n b e d e v e l o p e d in c e r t a i n p a t i e n t s , it is e q u a l l y t r u e t h a t t h e f a c t t h a t a f e e is n o t p a i d , t h a t t~e p a t i e n t is g e t t i n g s o m e t h i n g for n o t h i n g , c a n p r o v i d e a stiInuh, s to t h e u n c o v e r i n g of p r o b l e m s a b o u t d e p e n d e n c y a n d o n m i p o t e n t s t r i v i n g s w h i c h m a y p r o v e equally" m e a n i n g f u l . Also, since t h e r e a r e m a n y p a t i e n t s for w h o m p a y m e n t or n o n - p a y m e n t of a fee is n o t p a r t i c u l a r l y significant, s t a t e m e n t s a b o u t the i n v a r i a b l e n e c e s s i t y of p a y m e n t in t h e i n t e r e s t of t h e p a t i e n t ' s p r o g r e s s c a n n o t h a v e u n i v e r s a l a p p l i c a t i o n . It s h o u l d also b e m e n t i o n e d t h a t not all analysts, a c c e p t the s y m b o l i c cqm-"v'af e n c e of feces a n d m o n e y a n d t h a t t h e r e a r e o t h e r t h e o r e t i c a l f r a m e w o r k s f r o m w h i c h t h e q u e s t i o n of fee p a . v m e n t can b e c o n s i d e r e d . T h u s , in a r e c e n t p a p e r , G e d o , ~ h a s r e l a t e d n o n p a y m e n t of a n a l y t i c a l fees to a g e n eral t h e o r y of d e l i n q u e n t b e h a v i o r , a n d \ V e i n e r a n d R a t h s . TM e m p l o y ' i n g t h e c o n c e p t s of K a r e n I t o r n e v , s e e t h e p o s s i b i l i t y of c h o i c e b e t w e e n f r e e a n d p a i d for p s y c h o t h e r a p y as c o n s t i t u t i n g an a r e a of c u l t u r a l conflict w h i c h is r e f l e c t e d in t h e p a t i e n t . In this context, t h e conflict exists w h e t h e r t h e p a t i e n t p a y s or does not pa.v: p a y m e n t is not n e c e s s a r y to b r i n g it out. F ' o r t u n a t e l y , h o w e v e r , t h e k i n d of s c h o l a s t i c c o n t r o v e r s y I h a v e b e e n r e v i e w i n g is not t h e o n l y w a y a v a i l a b l e to c o n s i d e r t h e p r o l ) l e m of w h e t h e r 1)sychoanaI.vsis can flourish in t h e a b s e n c e of r e g u l a r f e e 1)ayment, s i n c e t h e r e exists e m p i r i c e v i d e n c e w h i c h c a n b e b r o u g h t to b e a r . I do not h e r e r e f e r to t h e k i n d of c a s e r e p o r t o f f e r e d b y F i n g e r O a w h i c h simply" p r o v e s t h a t fee p a y m e n t c a n b e a useful p s y c h o t h e r a p e u t i c l e v e r in c e r t a i n cases, b u t r a t h e r to a c c o u n t s of w h a t a c t u a l l y h a p p e n s w h e n p s y c h o a n a l y s i s is a t t e m p t e d u n d e r f r e e or low cost c o n d i t i o n s . P a r t i c u l a r l y r e l e v a n t is t h e r e p o r t of L o r a n d a n d Console. TM T h e s e a u t h o r s first list the difficulties " t h o u g h t b y m a n y " to b e i n h e r e n t in p s y c h o a n a l y s i s w i t h o u t fees. t h e n r e p o r t t h e a c t u a l e x p e r i e n c e of a n a l y s t s a n d super~,isors at t h e f r e e p s y c h o a n a l y t i c clinic of t h e N e w York S t a t e Clinic M e d i c a l C e n t e r . ~Xlanv t r a n s f e r e n c e a n d c o u n t e r t r a n s f e r e n c e p r o b l e m s r e v o l v i n g a b o u t t h e p a y m e n t s i t u a t i o n o c c u r r e d , trot it w a s f m m d t h a t t h e s e c o u l d b e u t i l i z e d as m a t e r i a l l e a d i n g to i n c r e a s e d i n s i g h t b o t h b y the p a t i e n t s a n d the c a n d i d a t e a n a l y s t s . A n v m g t h e s u p e r visors, all e x p e r i e n c e d a n a l y s t s , t h e r e w a s a h n o s t ~ m a n i m o u s a g r e e m e n t t h a t t h e r e w e r e o n l y m.;nor d i f f e r e n c e s l m t w e e n these a n a l y s e s a n d those c a r r i e d ollt in p r i v a t e offices for p a y m e n t , a n d t h a t t h e s e d i f f e r e n c e s r e p r e s e n t e d ¢l,mntitative a n d not q u a l i t a t i v e factors. In a discussion of this p a p e r . Clifford Scott ~:' d e s c r i b e d a s i m i l a r e x p e r i e n c e at t h e free clinic of t h e l . o n d o n P s y c h o a n a l y t i c Society. l l e said t h a t althougl~ " t h e feeling h a s
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a l w a F s b e e n t h a t t h e r e o u g h t to lye a d i f f e r e n c e w h e n a p a t i e n t d o e s n o t pay', n o g e n e r a l v i e w as to w h a t this d i f f e r e n c e was e v e r c a m e to t h e fore." A r e p o r t b y C r o w l e y ~; on t h e first y e a r of a l o w cost p s y c h o a n a l y t i c s e r v i c e in N e w York also i n d i c a t e s t h a t w h a t e v e r s p e c i a l p r o b l e m s a r o s e c o n c e r n ing t h e p a y m e n t s i t u a t i o n c o u l d b e d e a l t w i t h a d e q u a t e l F b y a l e r t a n a l y s i s a n d s u p e r v i s i o n . H a r o l d S e h j e l d e r u p , ~; in a f o l l o w ' u p r e p o r t on t h e results of n ' e a t m e n t w i t h t w e n t y - e i g h t ( 2 8 ) p s y c h o n e u r o t i c p a t i e n t s h e h a d psyc h o a n a l y z e d e i g h t to t w e n t y - f o u r y e a r s p r e v i o u s l y , has this to sa F on t h e ellcots of p a y m e n t on results: "'In s o m e cases a r e a s o n ' a b l e fee w a s p a i d , in o t h e r s a vet): s m a l l one, a n d in s o m e cases n o fee a t all. I h a v e f o u n d n o c o n f i r m a t i o n of t h e theor}, t h a t t h e e f f e c t i v e n e s s of tile a n a l y s i s i n c r e a s e s w i t h t h e size of t h e fee. S o m e of m y b e s t results h a v e b e e n o b t a i n e d b y a n a l y sis w i t h o u t p a y m e n t . " T h u s , t h e s e r e p o r t s of a c t u a l e x p e r i e n c e w i t h free a n d lox~, cost a n a l y s i s :ag, rc¢"~ t h a t such a p a v m e n t , m i l i e u is n o t fatally, i n i m i e a b l e to t r e a t m e n t ; it appears that despite theoretical preconceptions and individual instances to t h e c o n t r a r y , p s y c h o a n a l y s i s c a n p r o c e e d s u c c e s s f u l l y in t h e a b s e n c e of fees or w i t h l o w fees. T h e e v i d e n c e s u p p o r t s t h e v i e w t h a t m o t i v a t i o n for p a t i e n t s to w o r k a t p s y c h o a n a l y s i s ( o r in p s y c h o t h e r a p y g e n e r a l l y ) d o e s n o t d e p e n d on t h e w i l l i n g n e s s to s p e n d m o n e y for t r e a t m e n t . As M a r m o t ~'~ h a s p o i n t e d out, s u c h w i l l i n g n e s s is a n e v i d e n c e of m o t i v a t i o n b u t c a n n o t p r o v i d e m o t i v a t i o n o t h e r w i s e l a c k i n g a n d as every" e x p e r i e n c e d p s > ' c h o t h e r a pist c a n a t t e s t , m o t i v a t i o n to w o r k at a n a l y s i s ina F v e r y well b e p r e s e n t in a m p l e d e g r e e e v e n w h e n t h e t r e a t m e n t is free. I n d e e d , r e f e r r i n g b a c k to t h e v i e w I h a v e s u g g e s t e d of t h e a n a l y s t as h o m o e c o n o m i c u s , it m a y l)e m o r e p e r t i n e n t to look a t t h e m o t i v a t i n g f o r c e of fees f r o m t h e s t a n d p o i n t of t h e an'alvst, r a t h e r t h a n t h e p a t i e n t . T h e a n a l y s t w o r k s at his p r o f e s s i o n for a n u m b e r of r e a s o n s ; l e a v i n g o u t i n d i v i d u a l d e t e r m i n a n t s , h e a n a l y z e s b e c a u s e of s c i e n t i f i c i n t e r e s t a n d c u r i o s i t y , t h e p l e a s u r e h e gets f r o m t h e skillful exercise of a n i m p o r t a n t activit),, a n d t h e s e r v i c e h e is a b l e to r e n d e r , b u t also for financial r e w a r d . T h e r e l a t i v e i m p o r t a n c e of t h e s e m o t i v a t i o n s v a r y with individual analysts and with differing circumstances, but there are e e r t a i n l v i n s t a n c e s , o t h e r w i s e u n s a t i s f a c t o r y or u n r e w a r d i n g , w h e r e t h e fee pr¢wides m o t i v a t i o n w h i c h m i g h t o t h e r w i s e b e l a c k i n g , just as t h e r e a r e o c c a sions w h e n t h e fee is n o t n e c e s s a r y a n d t h e a n a l y s t can' w o r k s a t i s f a c t o r i l y in its a b s e n c e . T h e a b s e n c e of t h e n e e d to j u s t i f y e a r n i n g a fee m a y e v e n , in s o m e cases, p r o v i d e a g r a t i f y i n g flexibility a n d f r e e d o m to e x p e r i m e n t w i t h t h e lL-ngth a n d f r e q u e n c y o f sessions. q~le a c t u a l behavic)r of i ) s y c h o t l l e r a p i s t s , i n c l u d i n g a n a l y s t s , w i t h r e g a r d to t h e r e c e n t e m e r g e n c e of i n s u r a n c e p l a n s w h i c h p r o v i d e p a , v m e n t of fifty ( 5 0 ) p e r c e n t of fees for p s y c h o t h e r a p y ' , s o m e w h a t v i t i a t e s t h e c l a i m that sacrificial fees a r e c h a r g e d beca~lse, of t h e i r b e n e f i c i a l effect on t h e p a t i e n t . If ~me bt,lieves that the a b s e n c e of a fee is n o x i o u s to the l ) s y c h o t h e r a p e i l t i e rt, lationshil~, t h e n o n e s h o u l d also b e l i e v e t h a t t h e s p l i t t i n g of 1)a>'m~,nl l~etween the. l)atie~lt a n d t h e i n s u r a n c e c o m p a n y is at least s e m i p o i s o n o u s . p l a y i n g a rMe s i m i l a r to t h a t of the filter on a c i g a r e t t e . B u t t h e e v i d e n c e
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a v a i l a b l e s u g g e s t s t h a t many' a n a l y s t s h a v e a c c e p t e d q u i t e w i l l i n g l y this m o d i f i c a t i o n of e s t a b l i s h e d p a y m e n t p r a c t i c e s w i t h o u t p r o t e s t or q u e s t i o n i n g as to its p o s s i b l y d e l e t e r i o u s effect on t r e a t m e n t , As a m a t t e r of fact, the p r e s s u r e t o in'elude d i d a c t i c a n a l y s e s w i t h i n this k i n d o f i n s u r a n c e c o v e r a g e was s t r o n g e n o u g h to p r o d u c e an official w a r n i n g ~:' a b o u t this p r a c t i c e in t h e B u l l e t i n of t h e N e w York S t a t e D i s t r i c t B r a n c h e s ; a n d it m a y b e o n e of t h e f a c t o r s c o n t r i b u t i n g to t h e c u r r e n t difi3culties of this k i n d of i n s u r a n c e . T h e p r e c e d i n g d i s c u s s i o n i n d i c a t e s t h a t e v i d e n c e is l a c k i n g for the b e l i e f t h a t sacrificial fees are t h e r a p e u t i c a l l y i n d i s p e n s a b l e ; t h a t t h e r e is i n d e e d r a t h e r c o g e n t e v i d e n c e to t h e c o n t r a r y ; a n d t h a t a n a l y s t s , w h e n p u t to t h e test, t e n d to b e h a v e as if it w e r e n o t true. T h a t s u c h a d o c t r i n e is, n o n e t h e less, a d h e r e d to f i r m l y b y m a n y p s y c h o a n a l y s t s , s u g g e s t s t h a t w h a t w e a r e d e a l i n g w i t h h e r e is a d o g m a , a n d t h a t e l e m e n t s of r a t i o n a l i z a t i o n m a y b e p r e s e n t c o n c e a l i n g a n o t h e r , a p p a r e n t l y less a c c e p t a b l e m o t i v e f o r c h a r g i n g r e l a t i v e l y h i g h fees. I w o u l d like to .su~Tc~est~m . t h a t w h a t has b e e n n o t e n t i r e l y i g n o r e d , b u t a t l e a s t g l o s s e d over, a n d t r e a t e d d e f e n s i v e l y , t h r o u g h m e c l i a n i s m s s u c h as d e n i a l a n d i s o l a t i o n , a n d s o m e h o v ¢ r e l e g a t e d to an u n e a s y n o t m e p a r t of t h e p e r s o n a l i t v , is t h e p s y c h o a n a l y s t ' s p o s i t i v e i n t e r e s t in a n d n e e d for t h e a c q u i s i t i o n of m o n e y , a n d t h a t his f a i l u r e to c o m e to grips w i t h t h e i m p o r t a n c e of this fact has p l a y e d a role in p e r p e t u a t i n g , w i t h o u t a d e q u a t e evidence, the notion that be accepts m o n e y from his patients i ) r i m a r i l y as a s e r v i c e to t h e m . E s p e c i a l l y in t h e e a r l i e r s t a g e s of his t r a i n i n g a n d p r a c t i c e , a n inat)ility, h o n e s t l y a n d m a t t e r of f a c t l y , to d e a l w i t h his o w n a t t i t u d e s t o w a r d t h e fees h e receives, m a y c o n s t i t u t e for t h e a n a l y s t a n u n r e s o l v e d c o u n t e r t r a n s f e r e n c e a r e a . I-low o f t e n this o c c u r s c a n at p r e s e n t o n l y b e a s u b j e c t for speeul-~tion: a less d e f e n s i v e a t t i t u d e a b o u t the financiai a s p e c t s of p s y c h o a n a l y t i c p r a c t i c e w o u l d a l l o w t h e s e to b e c o n s i d e r e d as o n e amon(~ m a n y c o n s t i ' u e n t a t t i t u d e s w h i c h i n f l u e n c e t h e t r a n s a c t i o n a l p r o c e s s b e t w e e n t h e a n a l y s t a n d his p a t i e n t s . T h e r e a r e a n u m b e r of o c c a s i o n s in his t h e r a p e u t i c c o n t a c t w i t h his p a t i e n t s w h e r e d e c i s i o n s a r e a t t e e t e d t)v t h e p s y c h o t h e r a p i s t ' s f i n a n c i a l n e e d s to a d e ~O r e e w h i c h m a y 1)e o b s c u r e d b y-' a m b i v a l e n c e t o w a r d t h e s e n e e d s a n d 1)v t h e b a r r i e r s whic2h exist to t h e free a c k n o w l e d g m e n t of a n d d i s c u s s i o n o f t h e m . T h e p r o c e s s o f s e l e c t i o n of p a t i e n t s for t h e r a p y is o n e of t h e s e occasions a n d it is o n e in w h i c h f i n a n c i a l c o n s i d e r a t i o n s are, of c o u r s e , of g r e a t i m p o r t a n c e . It is m y i m p r e s s i o n t h a t in this a r e a , a n a l y s t s a r e u s u a l l y a b l e to l)e d i r e c t a n d e x p l i c i t , a n d discuss t h e t e r m s of t h e c o n t r a c t in u n e ( l u i r o e a l f a s h i o n w i t h p r o s p e c t i v e p a t i e n t s , l I o w e v e r , w h e n it exists, a n u n e a s y or a m b i v a l e n t a t t i t u d e t o w a r d s m o n e y on t h e p a r t of t h e a n a l v s t c a n l e a d to t h e s c a m p i n g o v e r or o b s c u r i n g ()f r e l e v a n t d e t a i l s , w i t h t h e p o s s i b l e d e v e l o p m('llt of seri(ms dif[icn]tie:; in t h e t h e r a p e u t i c r e l a t i o n s h i p l a t e r on. T h e r e m a y be, m o r e o v e r , some' t e n d e n c y [o m i n i m i z e l ~ n f a v o r a b l e i n d i c a t i o n s in f i n ~ n c i a l l v d e s i r a b l e p a t i e n t s t)v t i u ' r a p i s t s w h o feel t h e y s h o u l d t r e a t o n l y c('rtain d i a g n o s t i c c a t e g o r i e s . T h e "J a J'e -'"' g r o u p h a s m a d e c l e a r the e x t e n t to w h i c h p s y c h o t h e r a p . v a n d p s y c h o a n a l y s i s are c.lass-bound m e t h o d s of t r e a t m e n t and while m a n y other variables m besides the u n e q u a l distribu-
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tion of w e a l t h in o u r s o c i e t y a r e r e s p o n s i b l e for this, it w o u l d b e f o o l i s h to d e n y t h a t it .is a r e l e v a n t factor. C e r t a i n l y , o n e r e a s o n w h y t h e t h e o r i e s of 1)sychoanalysts appeal" to b e a p p l i c a b l e chiefly to u p p e r a n d m i d d l e class p e r s o n s is t h a t , g e n e r a l l y s p e a k i n g , o n l y m e m b e r s of t h e s e classes can afford t h e fees w h i c h a d m i t t h e i n i n t o r e l a t i o n s h i p s w i t h p s y c h o a n a l y s t s f r o m w h i c h t h e l a t t e r d e r i v e t h e d a t a w h i c h t h e y use to c o n s t r u c t t h e i r theories. ~'' Also, r e l e v a n t to p a t i e n t s e l e c t i o n , a n a l y s t s a r e m o r e likely to b e o p e n a n d d i r e c t a b o u t t h e f i n a n c i a l status of p r o s p e c t i v e p a t i e n t s in t h e i r i n f o r m a l d i s c u s s i o n s w i t h e a c h o t h e r a b o u t r e f e r r a l s t h a n t h e y a r e in m o r e f o r m a l s e t t i n g s w h e r e the s e l e c t i o n of a p a t i e n t for t r e a t m e n t m a y b e t a l k e d a b o u t as if his a b i l i t y to p a y a n d t h e f e e l i n g s a r o u s e d in t h e t h e r a p i s t b y this, a r e n e g l i g i b l e factors. This suggests a k i n d of n i c e - N e l l y i s m a b o u t this a s p e c t of t h e i r dealings w i t h p a t i e n t s w h i c h F r e u d c l a i m e d d i d n o t affect p s y c h o a n a l y s i s as it (lid o t h e r b r a n c h e s of m e d i c i n e . In a p a p e r d e a l i n g w i t h t h e r e a s o n s for t h e d e c r e a s e in i n c o m e to t h e B o s t o n P s y c h o a n a l y t i c I n s t i t u t e f r o m c o n t r o l patients" fees, t e r m - " s e e m s to h a v e b e e n r e f e r r i n g to t h e s a m e p h e n o m e n o n w h e n h e states t h a t m a v,, b c ""s o m e o f the r e l u c t a n c e of a n a l y s t s to i n c l u d e d a t a c o n t e n t i n g fees a n d finances in case r e p o r t s is r e l a t e d in p a r t to . . . r e s i d u a l c o ~ m t e r t r a n s f e r e n c e resistance.'" I n c i d e n t a l l y , it is w o r t h p o i n t i n g o u t t h a t t h e r e a s o n for t h e d e c l i n e o f i n c o m e to t h e Boston I n s t i t u t e c o u l d b e q u i t e e l e g a n t l y p r e d i c t e d b y t h e a p p l i c a t i o n of a t h e o r y o f strict e c o n o m i c d e t e r m i n i s m t o t h e b e h a v i o r of t h e a n a l y s t s a n d s u p e r v i s o r s i n v o l v e d . I h a v e d i s c u s s e d a p r o b l e m , t h e t h e r a p e u t i c n e c e s s i t y for r e g u l a r sacrificial fees, w h i c h h a s r e c e i v e d a g o o d d e a l of a t t e n t i o n in t h e r e l e v a n t l i t e r a t u r e , a n d a n o t h e r , t h e r e l a t i o n of finances to p a t i e n t s e l e c t i o n w h i e h has r e c e i v e d less notice. T h e r e are, in a d d i t i o n , c e r t a i n a s p e c t s of t h e p s y e h o t h e r a p e u t i e process itself, its t e r m i n a t i o n , a n d t h e e v a l u a t i o n of its results, w h i c h are also a f f e c t e d b y financial c o n ' s i d e r a t i o n s to a deg'ree w h i c h veould n o t b e s u s p e c t e d if o n e j u d g e d o n l y b y t h e a h n o s t n e g l i g i b l e a m o u n t of m a t e r i a l p u b l i s h e d a b o u t t h e m . H e r e , I will b e c o n t e n t veith m e r e l y r a i s i n g s o m e q u e s t i o n s w h i c h s e e m p e r t i n e n t to m.v thesis t h a t t h e a n a l y s t ' s f i n a n c i a l n e e d s play, a r o l e in his b e h a v i o r w i t h his p a t i e n t s w h i c h is d i s p r o p o r t i o n a t e to the m n o u n t of a t t e n t i o n it r e c e i v e s . F o r i n s t a n c e , to w h a t e x t e n t is t h e n u m b e r of h o u r s a w e e k a p a t i e n t is s e e n a f u n c t i o n of this f a c t o r ? D o e s t h e a n a l y s t s o m e t i m e s d e c r e a s e t h e h o u r s so t h a t h e c a n r a i s e t h e f e e as G r e e n a c r e 24 h a s s u g g e s t e d a n d is this o n e of t h e r e a s o n s for t h e i n c r e a s i n g d e v i a tion f r o m t h e classical m o d e l seen in this c o u n t r y ? O n t h e o t h e r h a n d , d o e s the eflort of s o m e a n a l y s t s to m a i n t a i n a p s y c h o a n a l y , tic i d e n t i t y , w h i c h m e a n s s e e i n g l>atients four or five t i m e s a w e e k , t e n d to p r o m o t e h m g e r a n a l y s e s s i n c e it is difficult to find p a t i e n t s w h o c a n m a i n t a i n such a financial b u r d e n ? I n g e n e r a l , is t h e t e r m i n a t i o n of or t h e c o n t i n u a t i o n of t r e a t m e n t in p a r t i c u l a r cases i n f l u e n c e d by t h e a v a i l a b i l i t y of o t h e r p a t i e n t s ? l t o w a b o u t the o p t i m u m l e n g t h of t h e r a p e u t i c sessions? T h e n e c e s s i t y for b r e a k s bet w e e n sessions? T h e n m n l ) e r of p a t i e n t s a day" a t h e r a p i s t c a n see el]'eetivetv? V~qmt, in short, a r e the w o r k i n g c o n d i t i o n s w h i c h will f o s t e r t h e s t m t a i n e d in'terest a n d p e r c e p t u a l a l e r t n e s s w h i c h are t h e sine q u a n o n of
PSYCI-IOANAL'YSIS
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effective p s y c h o a n a l y s i s ? U n l e s s I h a v e m i s s e d t h e m , t h e r e a r e ne s t u d i e s of t h e s e f a c t o r s as t h e y affect t h e r a p e u t i c results, y e t it s e e m s v e r y u n l i k e l y t h a t t h e y d o not exert an i n f l u e n c e on results, a h n o s t as un'likely as t h a t they, in turn, a r e n o t i n f l u e n c e d s t r o n g l y 1Lv t h e financial r e q u i r e m e n t s of the a n a l y s t . It m a y b e s t a t e d t h a t this p r o b l e m is n o t a u n i q u e one, t h a t a n y brain' w o r k e r m u s t m a k e a similar a d j u s t m e n t b e t w e e n ideal w o r k i n g conditions a n d his n e e d to m a k e his living for h i m s e l f a n d his family. U n d o u b t e d l y true, b u t s h o u l d n o t p s y c h o a n a l y s t s , w h o p r i d e t h e m s e l v e s on their m e t i c u lous a t t e n t i o n to all t h e m i n u t i a e w h i c h b e a r u p o n t h e t h e r a p e u t i c r e l a t i o n , also t a k e into a c c o u n t a f a c t o r w h i c h m a y a f f e c t so i n t i m a t e l y t h e i r t h e r a p e u t i c skills'," F o r e x a m p l e , if w e a r e t r y i n g to c o m p i l e figures .on p s y c h o a n a l y t i c results in say, o b s e s s i v e - c o m p u l s i v e states, it w ( n d d s e e m p e r t i n e n t to k n o w w h e t h e r a p a r t i c u l a r ease w a s seen d u r i n g f o r t y m i n u t e sessions b y a n a n a l y s t w h o sees ten or t w e l v e p a t i e n t s a d a y w i t h o u t a b r e a k b e t w e e n t h e m e x c e p t for ten m i n u t e s for h m e h , or b y a n o t h e r a n a l y s t w h o s p e n d s rift3, m i n u t e s w i t h e a c h of six p a t i e n t s , w i t h ten m i n u t e s b e t w e e n sessions. Incid e n t a l l y a n d also g e r m a n e to t h e p r o b l e m of the e v a l u a t i o n e f t r e a t m e n t results, e n e m a y w o n d e r w h e t h e r the a m o u n t of m o n e y the p a t i e n t h a s s p e n t influences, e i t h e r positively, or negatively', his or h e r t h e r a p i s t ' s j u d g e m e n t a b o u t t h e a m o u n t of i m p r o v e m e n t w h i e h has t a k e n place. T h e r e is c e r t a i n l y no o n e s i m p l e ex-planation for t h e }'allure of ps.vchoa n a l y s t s to e x a m i n e h o w a n d to w h a t e x t e n t t h e f e e s t r u c t u r e u n d e r w h i c h m o s t of t h e m o p e r a t e i n f l u e n c e s their b e h a v i o r in r e g a r d to t h e s e v a r i o u s a s p e c t s of t h e i r r e l a t i o n s h i p s w'ith t h e i r p a t i e n t s . P h y s i c i a n s w h o e a r n their living t h r o u g h p s y c h o t h e r a p y a r e p r a c t i c i n g an h o n o r a b l e p r o f e s s i o n . T h e y w o r k h a r d , they: b e n e f i t a c o n s i d e r a b l e p r o p o r t i o n o f t h e i r p a t i e n t s , m o s t o f t h e m s p e n d a g o o d deal of time a n d effort in t r y i n g te i m p r o v e tlleir results, t h e y p r o b a b l y m a k e less m o n e y t h a n m o s t o t h e r m e d i c a l m e n . T h e r e is c o n s i d e r a b l e d e m a n d for t h e i r services. O n e r e a s o n for the s e o t o m a t a I h a v e s u g g e s t e d may.7 b e t h e rigors a n d financial h a r d s h i p s of the l o n g t r a i n i n g p e r i o d u n d e r t a k e n a t a c o m p a r a t i v e l y " late p e r i o d of t h e i r p r o f e s s i o n a l c a r e e r s w h i c h , as p o i n t e d o u t b y G e o d e n o u g h , Klein a n d P o t t e r , '-'a m a y i n c u l c a t e in p s y c h o t h e r a p i s t s , b i a s e s in the d i r e c t i o n of t h e profit m o t i v e r a t h e r t h a n service. I t this is true, s u c h a t t i t u d e s w o u l d b e likely to b e h e l d a n a b i v a l e n t l y a n d t h u s k e p t o u t of awaren'ess. J u d d M a r m o r '-'~; h a s called illusions e f o m n i p o t e n c e a n o c c u p a t i o n a l h a z a r d o f p s y c h i a t r i s t s , a n d it m a y b e t h a t in s o m e i n s t a n c e s u n r e s o l v e d conflicts o v e r t h e s e may" g i v e rise to guilt a b o u t a n inabilit.v to b r i n g a b o u t m a g i c a l r e s u | l s , r e s u l t i n g in an u n e a s y f e e l i n g t h a t m o n e y is b e i n g t a k e n u n d e r false p r e t e n s e s . T h i s t e n d e n c y w o u l d b e s h a q ) e n e d b y r e c e n t e v i d e n c e s "-'7-'2:' of a n e e d to r e - e x a m i n e p s y e h o t h e r a p e u t i e results g e n e r a l l y a n d by., p o p u l a r i m p a t i e n c e w i t h w h a t a r e r e g a r d e d as t h e p r e t e n s i o n s of p s y c h o a n a l y s i s as e x e m p l i f i e d b v t h e c a r t o o n s of Feiffer a n d t h e N e w Y o r k e r steres of t i l l i a n Hoss. T h a t p s y c h o a n a l y s i s is as m u c h the v i c t i m as t h e p r o g e n i t o r of the f a n t a s v t h a t it trains d o c t o r s of h a p p i n e s s -~.'~ is no help. P s y c h o t h e r a p i s t s , a l o n g w i t h p h y s i c i a n s g e n e r a l l y , b e a r t h e u n f a v o r a b l e c o n s e q u e n c e s of a f u n d a m e n t a l split b e t w e e n their i m a g e s as
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priests a n d healers on the o n e h a n d a n d , on the other, as lm s i n e s s m e ~ e n g a g e d in the sale of service; b u t u n l i k e most o t h e r p h y s i c i a n s , p s y c h o a n a l y s t s at least, h a v e h a d an o p p o r t u n i t y to r e v i e w a n d r e s o h e their conflicts over this d i c h o t o m y , in t h e i r p e r s o n a l analyses. It m a y he, h o w e v e r , t h a t this conflict is not a l w a y s g o n e into t h o r o u g h l y e n o u g h in d i d a c t i c a n a l y s e s , thus c o n t r i b u t i n g to l a t e r u n e a s i n e s s a b o u t it. A psy, c h o a n a l y t i c i d e n t i ~ , is f o r m e d l a r g e l y b y the p r o c e s s of i d e n t i f i c a t i o n w i t h s e n i o r a n a l y s t s w h o t h e m s e l v e s m a y not h a v e r e s o l v e d this conflict a b o u t t h e s e roles, m e n t i o n e d a b o v e , or w h o s e s u c c e s s f u l a n d s e c u r e p o s i t i o n s may, h a v e r e n d e r e d t h e m i n s u f f i c i e n t l y a l e r t to the p r e s s u r e s e x p e r i e n c e d b y y,ounger m e n 1)eginn i n g to e s t a b l i s h p r a c t i c e s in a c o m p e t i t i v e field, a n d w h o thus m a y unc o n s c i o u s l y d i s c o u r a g e tlm k i n d of i n d i v i d u a l a n a l y t i c or s e m i n a r d i s c u s s i o n w h i c h w o u l d p e r m i t v e n t i l a t i o n a n d i n c r e a s e d a w a r e n e s s of real p r o b l e m s a b o u t m o n e y , its effect on t r e a t m e n t in g e n e r a l , a n d p a r t i c u l a r l y on c e r t a i n a t t i t u d e s of t h e a n a l y s t as t h e s e affect t r e a t m e n t . B e c a u s e of the i n t e n s i v e n a t u r e a n d long d u r a t i o n of p s y c h o a n a l y t i c treatm e n t , its f i n a n c i a l aspects r a i s e issues w h i c h a r e social a n d m o r a l as well as t e c h n i c a l . A l t h o u g h these issues a r e diflqcult to resolve, g i v e n t h e c h a r a c t e r of the c u l t u r e w i t h i n w h i c h p s y c h o a n a l y s t s f u n c t i o n , t h e y d e s e r v e o p e n a n d f r a n k d i s c u s s i o n not o n l y 1)ecause of t h e i r i m p a c t on the r e l a t i o n s h i p b e t w e e n the a n a l y s t anti his p a t i e n t , b u t also b e c a u s e of t h e i r effect on t h e r e l a t i o n s h i p b e t w e e n m e d i c a l p s y c h o a n a l y s t s a n d the rest of the m e d i c a l profession. T h e e c o n o m i c s of m e d i c i n e is u n d e r g o i n g a r e v o l u t i o n in the U n i t e d States. A l r e a d y , s e v e n t y - f i v e ( 7 5 ) p e r c e n t or m o r e of t h e e n t i r e p o p u l a t i o n of the c o u n t r y p a y s its d o c t o r bills w i t h the h e l p Of various k i n d s of v o h m t a r v p r e - p a y m e n t h e a l t h i n s u r a n c e , a n d t h e c o n t i n u a t i o n of this t r e n d s e e m s i n e v i t a b l e . I n s u r a n c e c o m p a n i e s h a v e d e m o n s t r a t e d a w i l l i n g n e s s to experim e n t w i t h p a r t i a l p a y m e n t for e x t r a m u r a l p s y c h o t h e r a p y b u t t h e y b e c o m e b e w i l d e r e d a n d d i s c o u r a g e d by ~ t h e thicket o f u n e x p e c t e d p r o b l e m s r e s u l t i n g f r o m this k i n d of c o v e r a g e . P e r h a p s a d e t e r m i n e d effort on the p a r t of p s y c h o a n a l y s t s a n d m e d i c a l p s y c h o t h e r a p i s t s g e n e r a l l y , to set s t a n d a r d s a n d c r i t e r i a for the k i n d of p s y c h o t h e r a p y w h i c h c a n l e g i t i m a t e l y b e c o v e r e d b y i n s u r a n c e p a y n ; e n t w o u l d r e v e r s e the p r e s e n t t e n d e n c y w h i c h t h r e a t e n s to m a k e of p s y c h o a n a l y t i c a n d p s y e l m t h e r a p e u t i e m e d i c i n e an e c o n o m i c a n a c h r o n i s m , dix'ovv.ed, b.v its p a y m e n t p r a c t i c e s , from t h e m a i n s t r e a m of m e d i c i n e . REFERENCES 1. Kein, R.: E c o n o m i e s of N l e n t a l Illness. N e w York, Basic Books, 1958. 2. (;lover, E.: An Investigation of the "l\-chniques of Psychoanalysis. Baltimore, Williams & ~,Vilkins Co., 1942. pp. 99--100. 3. Freud, S.: lrurthcr r e c o m m e n d a t i o n in the techniques of psy,ehoanalysis, in Collected Papers, Vol. XI. L o n d o n . I-lo/garth Press, 1946. -1. Kuhie, L.: Practical and Th(,oretic'al
Aspects of Psycho-umlysis. N e w York, Int. Univ. Press, 1950. 5. Menninger, K.: T h e o r y of P s y c h o a n a lytic T e c h n i q u e . N e w York, Basic Books, 1950. 6. Fenichel, O.: P s y c h o a n a l y t i c T h e o r y of Neurosis. N e w York, \V. \V. Norton & Co., I945. 7. Haak, N.: C o m m e n t s on the analytic situation. Int. J. P.~yehoanal. 3 8 : 1 8 3 95. 19.'57.
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PSYCHOANALYSIS AND FEES 8. Boggs, M.: Administrative and casework aspects of fee charging. J. Soc. Casework 30:353, 1949. 9. Brody, C.: Fee charging~A dynamic in the casework process. J. Soc. Casework 30:65. 1949. 10. lZromm-Reichman, F.: Principles of Intensive Psyclmtherapy. Chicago, I11., Univ. of Chicago Press, 1950. I1. Gedo, J.: A note on non-payment of psychiatric fees. hat. J. Psychoanal. 44:368, I963. 12. \Veiner, I). N., and Raths, O. N.: Cultural Factors in Payment for PA Therapy. American J. of Psychoanal. 20:66, 1960. 13. Fingert, H. H.: Comments on flae psychoanalytic significance of the fee. Bull. Menninger Clinic 16:98, 1952. 14. Lorand, Sandor, and Console, Win. A.: Therapeutic results in psychoanalytic treatment without fee. Int. J. Psychoanal. 39:59-6.5, 1958. I5. Scott, W. C. M.: Discussion of Lorand, Sandor (see reL #14). 16. Crowley, R.: A low cost psychoanalytic service; the 1st year. Psychiat. Quart. 24:462, 1950. 17. Schjeklerup, H.: Lasting effects of psychoanalytic treatment. Psychiat. 18: 109, 1955. 18. Marmor, J.: In Modern Concepts of Psychoanalysis. Leon Salzman and Jules Massennan, (exks.). New York, Philosophical Library, 1962. 19. Bulletin of the New York State District
Branches, April, 1961. 20. Hollingshead, A., and' Redlieh, F.: Social Class and Mental Illness. New York, Wiley, 1958. L 21. Schaffer, L., and 3h:3'ers, J.: Psychotherapy and social stratification. Psy. chiat. 17:83, 1954. 22. lhmt, R. G.: Social Class and Mental Illness. Am. J. Psychiat. 116-1065, 1960. 23. Levin, S.: A study of fees for control analysis. Bull. Philadelplfia Assn. Psychoanal. 8:69, 1958. 24. Greenacre, P.: The role of transference. J. Am. Psychoanal. Assn. 2:671, I954. 25. Goodenough, 1). R., Klein, H. R., and Potter, H. W.: Problems related to personal costs of psychiatric and psychoanalytic training. American J. Psychiat. 113:1013, 1957. 26. Marmor, J.: The feeling of superiority: An occupational hazard in the practice of psychotherapy. American J. Psychiat. 110:370, 1953. 27. Sehmideberg, M.: Vahws and goals in psychotherapy. Psych. Quart., April, I958. 28. Heilbnm, G.: Psychoanalysis of yesterday, today and tomorrow. Arch. Gen. Psychiat. 4:321, 1961. 29. Frank, J. I).: Persuasion and Healing. Baltimore, The Johns Hopkins Press, 1961. 30. Chodoff, P.: Identi~'. In Science and Psychoanalysis, Vol. V. Grime and Stratton, Inc., 1962, p. 249.
Paul Chodoff, M.D., Dept. of Psychiatry, George Washington [/mverslly, ~t'ashmgton, D. C. Address: 1904 "R" Street, Washington, D. C.