Money Talks

in Therapy, Society, and Life

Brenda Berger, Stephanie Newman, Brenda Berger, Stephanie Newman

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136740886
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychanalyse

Sometimes referred to as "the last taboo, " money has remained something of a secret within psychoanalysis. Ironically, while it is an ingredient in almost every encounter between analyst and patient, the analyst's personal feelings about money arerarely discussed openly or in any great depth. So what is it about money that relegates it to the background, both on the couch and off? In Money Talks, Brenda Berger, Stephanie Newman, and their excellent cast of contributors address this and other questions surrounding the tender topic of money, how we talk about it, and how it talks to us. Its multiple meanings are explored in the contexts of patients and analysts and the ways in which they relate, in the training and practice of the analysts themselves, as well as the psychological and cultural consequences of having too much or too little in both flush and tight economic times. Throughout, a clinical sensibility isbrought to bear onmoney's softly spoken place in therapy and life. Money Talks paves the way for an open discourse into the psychology of money and its pervasive influence on the psyche of both patient and analyst.

Chapter 1

Money

Some reflections on its impact on psychoanalytic education and psychoanalytic practice

Theodore Jacobs

A student in a continuous case seminar at an analytic institute is presenting the initial sessions in his analytic treatment of a young man. The student paints a vivid picture of his new patient and a detailed account of their first contact. With impressive openness, he recounts his reaction to the patient, including the mixture of feelings aroused in him by this individual as well as his fantasies about what it will be like to work with him. The candidate is also quite explicit in describing the way that he introduced the idea of analysis, the patient’s response to it, and the discussions that followed. He also described the practical arrangements that they made for the treatment. His account of the exchanges and, ultimately, the negotiations that took place were complete with one notable exception: There was no mention of the fee.

Initially, none of the other students in the class asked about the fee. When, finally, one member of the group, shyly, raised that issue, the analyst responded in a vague and general way. The patient, he said, had some resources from his family, and the fee had been negotiated in a satisfactory way. No specific figure was mentioned, and none of the candidates asked for that information. It was clear that they had gotten the message: The analyst did not want to disclose the amount of the fee, and the group respected his wish for privacy in this matter.

This is a scene that could have, and no doubt has been, repeated in various institutes throughout the country. It illustrates the secrecy concerning fees, and money in general, that exists throughout the analytic world, a phenomenon that pertains not only to students but also to analysts at all levels of experience.

Fees that analysts charge—or pay for treatment of their own—are rarely discussed openly even among close colleagues. It is as though there is something embarrassing about our interest in money. It is not a matter to be talked about. Many analysts are self-conscious about what they charge, whether it is more than the going rate, in which case they fear the criticism or envy of their peers, or lower than that, about which they might possibly feel ashamed. In the latter case, the analyst often fears appearing foolish, naïve, or lacking in self-confidence. Comparisons with others are regularly made, and in many cases, the judgment of one’s colleagues becomes a major source of anxiety.

It is also striking that despite years of personal analysis, many analysts still harbor considerable anxiety about money—a fact that contributes to the silence that surrounds this issue. Why these colleagues have not better resolved their neurotic anxieties over financial matters is an open question. One would have thought that the exploration of these problems would have constituted an important focus in the analysts’ own personal analyses. Perhaps this particular issue, having its roots very early in life and relating to many different aspects of the personality, proved particularly resistant to change. Or, maybe the same guardedness concerning money that colleagues often display outside the analytic setting has existed within it as well, making access to this important, but highly protected, area difficult.

It is entirely possible, however, that the issue of money, avoided in social relationships, is not sufficiently engaged in the analytic work, including the training analyses. If that is the case, it may be that an unconscious collusion between patient and analyst not infrequently takes place, one aimed at excluding the uncomfortable topic of money from the analytic discourse. For not a few individuals, being open and forthright about money is more difficult than talking about sexual matters. Money has been termed the last taboo (Krueger, 1986), and in a very real sense, it has become just that, not only for patients but also for analysts.

For the young analyst, problems concerning money begin from the outset of training. There is no doubt that psychoanalytic education is one of the more expensive postgraduate programs that a student can undertake. The overall cost to the candidate varies from one institute to another, but the combination of the personal analysis, tuition, and supervisory fees creates a formidable financial hurdle for all but those few candidates who have substantial means.

The high cost of training, coming at a time when many candidates are young parents who are trying to meet rising expenses and to maintain a satisfactory standard of living, puts enormous pressure on them to earn a substantial income from their private practices. The amount of time, however, that the average candidate can devote to private practice is limited by several factors. Those female candidates who have children are obliged to ration their practice time to be available for their youngsters. In addition, many feel free to practice only during the school hours. Those with preschool children are often reluctant to leave them with caretakers for more than several hours at a time. Thus, in both of these situations the candidate is limited to a part-time practice.

Many of the single women and a majority of male candidates hold down hospital or clinic jobs on a half- to three-quarter time basis to have a steady income. Only gradually, over time, as their practices increase, is it possible for them to relinquish these paying positions. Such employment clearly restricts practice to several hours a day, thus increasing the pressure that many candidates feel to use those hours to maximum financial advantage.

This goal, however, is made difficult by the fact that as a requirement of their training, candidates are obligated to treat three analytic patients under supervision. In my own training in the 1960s, at least one, and usually two, of these patients were clinic referrals whose fees went directly to the institute. Thus, most of us gave 10 hours of practice time plus 2 hours of supervision to the training program without financial compensation of any kind.

The financial stress was great, and as partial compensation, we expected the clinic to send us good analytic patients, that is, patients who could utilize the analytic method and who could benefit from this kind of treatment.

When this did not happen—in my case, the two referrals from the clinic turned out to be troubled individuals for whom psychoanalysis was only marginally helpful—the resentment that I felt toward the institute, partially displaced onto my patients, created a countertransference problem that immediately complicated the treatment. This kind of situation is not unusual. Negative feelings toward the institute on which many candidates are dependent for the analytic patients that they treat at greatly reduced fees are often a source of this kind of troublesome indirect countertransference, one that Racker (1968) spoke about in his seminal book on this subject.

Today, the situation for candidates is somewhat improved but still requires much financial sacrifice. Most candidates treat at least two analytic patients at fees that not unusually are in the range of $10–$40 a session. And in many institutes, the candidate is expected to pay substantial supervisory fees.

It is inevitable, then, that the difficult financial situation that many candidates must contend with in the course of their training will increase their potential for acting out around monetary issues. In fact, enactments that have their roots in conflicts over money are among the problems most commonly encountered—and least talked about—in analytic training.

An issue of importance that can have profound implications for a young analyst’s career concerns his or her acceptance of analytic patients. Because of their perceived financial needs, not a few candidates are reluctant to accept more than two patients at reduced fees. Taking the view that they have done their share of low-fee work, such candidates hold out for a full-fee, or near-full-fee, patient for their third and subsequent analytic cases. Since they are required to treat three patients during their training and full-fee analytic patients are extremely hard to come by in the present economic climate, the progress and graduation of such candidates are often delayed for several years. In fact, a number of such candidates never graduate, as they become discouraged at not being able to find a suitable patient and, ultimately, withdraw from training. Those who do manage to graduate often encounter another problem linked to financial issues, as will be elaborated.

For a young analyst to develop a largely analytic practice, a step that is necessary both for continued growth as a psychoanalyst and, ultimately, for advancement in the field, he or she must be open to accepting analytic patients at reduced fees. Senior analysts frequently see patients in consultation who would benefit from analysis but who are unable to afford a full fee. These consultants regularly seek to place these patients with younger colleagues at reduced fees. Those young analysts who are willing to accept these patients gain a reputation as individuals who are dedicated to doing psychoanalysis and to developing their skills. These are the graduates who tend to advance at institutes, are given roles of responsibility, and, eventually, are referred higher-fee patients. Those who decline to accept reducedfee patients, or accept them for psychotherapy rather than analysis in order to charge higher fees, are not looked on with favor. As a consequence, they find it much more difficult to develop an analytic practice. In fact, these graduates have few analytic patients, a situation that not infrequently leads to discouragement about their careers and to disillusionment about the field of psychoanalysis. Such individuals often give up doing psychoanalysis to focus on other modalities of treatment, and not a few of them turn against their institutes and the American Psychoanalytic Association, demanding changes in rules and procedures that, in part, are motivated by personal frustration and disappointment.

A student whom I was working with was extremely slow in picking up a second analytic case. The problem, he maintained, was money. Due to difficult family circumstances, he explained, he had to help support a number of dependents and simply could not afford to take on another low-fee case.

This student waited for months for a patient who would afford his regular fee, and as a result of not having a second case, he could not move ahead at his institute. All of his classmates managed to find cases and to progress to the next year, but this student was unable to do so. Feeling very much excluded, he became depressed and stopped looking actively for a case. Instead, he filled his practice with psychotherapy patients, and when a suitable case finally came along, he did not have the hours available to accept the patient. It took some months for the candidate to clear his schedule, and in the interim he was unable to continue his matriculation at the institute. Discouraged by this state of affairs, the student’s interest in analytic training declined, and he began to experiment with other modes of therapy. Eventually, he dropped out of the institute and became antagonistic to psychoanalysis.

Although the financial pressure on this student was great and there was a realistic need for him to earn a substantial income from his practice, it became clear that this was not the only factor that contributed to his behavior around money and fees. In fact, the student unconsciously made use of his realistic financial problems to screen out other issues that contributed in major ways to his reluctance to take on a second low-fee analytic patient.

The candidate’s father was a powerful and well-to-do industrialist who had risen through the ranks to become a top executive in his company. A hard-driving, self-made man, he measured success quite exclusively in monetary terms. He had devoted his life to the accumulation of wealth, and he had little use for those who did not share his values. In addition, he had little sympathy for the poor who, he maintained, squandered their money on gambling and drink and did not know the meaning of thrift. As a consequence, he was reluctant to give money to charities that helped those in financial straits.

The student had a strong wish to please his father as well as a fear of falling out of favor with him. This need to remain in his father’s good graces propelled him to want to prove to this parent that he had a financially successful practice and was doing everything possible to maximize his income. This attitude precluded his taking on another low-fee patient. He believed that if he did so, and suffered a loss of income, his father would regard him as a fool. Thus, this student’s need to maintain a particular image in the eyes of his father contributed in no small measure to his procrastination in taking a second analytic case. In other words, his focus on money as his central problem concealed factors in himself that he did not wish to examine.

Also important was this student’s ambivalence about psychoanalysis. He had doubts about the effectiveness of his own analysis and, in fact, harbored many negative feelings toward his analyst. Not having experienced many gains in his own treatment, he had difficulty believing that psychoanalysis could be an effective therapy.

Added to this problem was the fact that this candidate found it difficult to conduct an analysis in the way that he was being taught. An extremely active person, he was unable to tolerate the degree of passivity necessary to listen quietly for substantial periods of time. His impulse was to do something, to confront patients directly with their defenses and their underlying dynamics. He also found it anxiety provoking not to have answers to the dilemmas posed by his patients and to have to wait for lengthy periods of time before being able to understand a patient sufficiently well to be of help to that individual.

All of these factors played a role in influencing the student’s behavior and determining the pathway that he took. This is often the case when students cite money as the sole obstacle to their taking on analytic patients. As was true in this case, it is important for educators both to acknowledge the reality of a student’s financial situation and to look beyond it. For, often, it is other factors, ones concealed behind the issue of finances and acted out unconsciously, that prove to be as important as the manifest financial problem.

It is true, of course, that the financial hardships faced by many young analysts and the sacrifices they have to make to obtain training are realities that contribute in no small measure to the unwillingness of some analysts to take on additional patients at reduced fees. Other factors, too, as we have seen—often less-conscious ones—may influence this decision. Important in this regard is the issue of self-esteem and its relation to money.

For many analysts, as with much of the population, their personal sense of worth is closely linked to financial success. This connection, which often is only loosely tied to reality considerations, begins early in life with the unconscious association of money with bodily products, particularly feces. In the child’s mind, these bodily products are linked with objects of value and often offered as gifts. To this association, in time, is added unconscious identifications with parental attitudes toward money and its use as a vehicle of personal security and self-esteem, as well as an object of envy. Important, too, is the parents’ attitude toward the productivity of their offspring, an attitude often linked to financial success, which is internalized by the child, and in later life not infrequently becomes a goal that is pursued without recognition of its roots in a wish to win the love of parents by living out their aspirations.

In the case of analysts, this multidetermined self-esteem issue often lies behind, and is concealed by, their focus on the reality of their financial situation. In fact, their insistent focus on the reality aspect of their financial circumstances is often utilized defensively to avoid recognition of the deeper and more pervasive issues. In the best-case scenario, these underlying problems can be understood and the unconscious link to childhood anxieties and parental attitudes worked through in the analyst’s own analysis. The analyst will then be free to pursue his or her analytic career without excessive concern about financial matters. However, as I have noted, such an outcome is achieved less often than one might wish. More commonly, one encounters candidates and young analysts whose ongoing conflicts over money are expressed in countertransference enactments that may create much difficulty for both patient and analyst.

Because of such unresolved problems, certain analysts are unable to make a sound assessment of a patient’s financial situation and arrive at a fair fee. Not infrequently, they will set a fee that is higher than the patient can reasonably afford. In one such situation, when the patient, a young man striving to become independent of his family, stated that the proposed fee was beyond his means, the analyst strongly suggested that he ask his parents to finance the treatment. And when the patient protested that this request would undermine his goal of gaining independence and removing his treatment from the influence and interference of his parents, the analyst interpreted this objection as a resistance against undertaking the analytic work. In fact, the analyst was an able candidate who, under other circumstances, would clearly have appreciated the importance of the patient’s paying for his treatment himself. But, under the sway of his wish for a substantial fee, a fee that, in his eyes, would add to his stature and help confirm his self-worth, he was unable to make an objective clinical assessment of the situation.

Another problem that arises with some frequency concerns the question of terminating analyses of clinic or low-fee patients (McRae, 1980). These are the patients who the analyst has taken into treatment as candidates to gain experience and to satisfy the requirements of his or her training program. In most cases, the analyst has been willing to accept the financial sacrifice involved in exchange for the benefits of having an analytic case.

Once the analyst has graduated, however, and may need only to have a terminated case for purpose of certification by the American Psychoanalytic Association, this situation has changed psychologically for a young analyst. At that point, the not-infrequent wish to bring the low-fee case to an end, both to obtain a better-paying patient and to achieve the goal of terminating a case, may be quite strong. Most often, this wish is not conscious, but the analyst finds him- or herself thinking in terms of ending the treatment and may, without being aware of it, subtly suggest to the patient either that the patient is ready to end or that the analysis has progressed as far as it can go. The patient gets the unspoken message that the analyst wants to terminate the analysis and, usually sooner rather than later, the treatment comes to a close. I have seen a number of patients who have been in that situation. Looking back on what happened in their analyses, these patients had a distinct feeling of having been pushed out of treatment—and shortchanged—by an analyst who, once graduated, was no longer invested in working with them.

At the other end of the spectrum is the practice of holding on to patients who pay a substantial fee for unduly long periods of time. This situation, an increasingly common one in today’s climate, in which analytic patients are hard to come by, involves graduate analysts far more than it does candidates.

Most analysts are dependent on th...