Unusual Interventions

Alterations of the Frame, Method, and Relationship in Psychotherapy and Psychoanalysis

Salman Akhtar

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781855758971
• eBook ISBN: 9780429923647
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Radical departures from the set and familiar rules of technique often become necessary in the course of psychotherapy and psychoanalysis. These can include conducting a session outside the office, giving advice, not charging fees, talking about oneself, giving a gift to the patient, and so on. Such interventions have so far remained imbued with mystery or, worse, have been the staple of cocktail party conversations. Unusual Interventions brings a variety of exceptional measures together to highlight their indications, risks, and their potential anchors in psychoanalytic theory of human relatedness. In accomplishing this, the book itself becomes an unusual addition to the literature on the technique of psychotherapy and psychoanalysis.

Part I
Alterations of the Frame

Chapter One
Making extraordinary monetary arrangements

Ira Brenner

The analyst is determined from the first …. to treat money matters with the same matter-of-course frankness to which he wishes to educate [his patients] in things relating to sexual life. He shows them that he himself has cast off false shame on these topics, by voluntarily telling them the price at which he values his time.

—Sigmund Freud (1913a, p. 131)

One afternoon, I was enjoying lunch at my favourite Chinese restaurant and reviewing some notes for this chapter. I had a neat, orderly outline in mind where I would begin with a review of the classical description of fee arrangements in psychoanalysis starting with Freud’s (1913) conceptualization of leasing time.¹ I was then going to discuss permutations of this arrangement including the controversy over charging for missed appointments, paying in advance, deferred payments, pro bono treatment, treating the very wealthy and bartering. I was even going to mention an innovative program in China. While finishing up my tea and opening up my fortune cookie, I became rather startled and amused by what I read. In a moment of synchronicity, my fortune punctuated both my meal and my contemplation: It said: “Time is money”.

Is time money?

The well-known axiom though admittedly a bit coarse expression is, however, seldom applied to psychoanalysis. Furthermore, our field is not a lucrative profession and there are much better ways of making more money, especially, if as Fenichel (1938) has described, one is motivated by a wish to amass wealth. From a standpoint of medical specialties, psychiatry and psychoanalysis typically rank near or at the bottom of income compared to other medical specialists. Freud (1913) himself noted that the income derived from practicing this art would have to be quite limited. No doubt, the nature of it being based on an hourly wage and it being such arduous work are crucial factors. The distinguished North American psychoanalyst, Warren Poland, summed it up succinctly when, during his introductory comments to a paper he presented years ago in Philadelphia, he declared that of all of his psychoanalytic achievements, the thing he was most proud of was that he was able to make a living from his practice. In a more recent discussion with him, Poland added that at this point in his career, that is not the issue. He now is content with whatever fee he and his patient agree upon. It is only when he thinks of it as a “reduced fee” that he may experience countertransference problems (personal communication, January, 2011). One might assume that a prominent and successful practitioner, after decades of work, will have derived enough financial security such that monetary pressures are lessened and more sublime issues prevail. That does not seem to be the case.

Other analysts may view this necessary tension from different perspectives. Akhtar, for example, feels that being solely financially dependent upon people’s mental suffering is problematic and lends itself to the analyst becoming needy upon them and potentially exploiting them (personal communication, February, 2011). He favours having collateral sources of income to mitigate against such a countertransference pitfall. For those analysts like himself in institutional settings who earn a guaranteed salary upon which other activities contribute, such a risk is minimized. Also, those who are financially independent due to inherited wealth, other businesses, wealthy spouses, entrepreneurial success, winning the lottery, etc. are freed up from the pressure of having to live off one’s practice. This freedom, paradoxically, can have its own risks as counter-resistances in the analyst may build up over time precisely because this work is so challenging.

The expression, “time is money” is more commonly applied to the world of business where, for example, the energetic entrepreneur has created so many time sensitive opportunities that the failure to act decisively will “cost money”, or, there may be situations where delays in production or sales result in additional expense. Although the analytic patient who is in a “good enough” treatment much longer than expected may also register the same complaint that his “time is money”, he may not fully realize that his unconscious is contributing to the longer duration and will blame the analyst for not moving more quickly. For example, a patient complaining about the uncertainty of her progress and seeming endlessness of the process recently acknowledged her own ambivalence over termination “because then I will have to grow up”.

Part of the challenge in addressing this topic is the recognition that analysts do not agree on what exactly the analysand is paying for and the analyst’s own views over what he is charging for may vary. Furthermore, there may be uncertainty in the patient’s mind about the exact purpose of the fee so while there may be certain policies put in place at the appropriate time early on, the nature of the analytic process and the exigencies of life may require additional and specifically tailored arrangements.

In this era of “evidence based medicine” where scientifically based outcome studies are becoming the state of the art and insurance companies are offering “incentives” in the form of increased reimbursements to practitioners whose patients get “better” faster for less money, analytic treatment has become even more of an anomaly. Indeed, the implications of the recently passed health care reform bill, which seems more like insurance industry reform, remain to be seen. Clearly, the analyst’s charges are not based on results that are accrued in treatment nor are they based on the degree of difficulty of the treatment of a given patient’s problems. Mitchell (1993), however, candidly notes that his fees may vary. He says:

Should we regard the analyst wanting to be paid his full fee as a need or a wish? Speaking for myself, sometimes it feels more like one than the other. There are times when I feel I could offer a patient an hour for less and times I do not feel I can. One factor is my own financial situation and stress at the time; another factor is a potential analysand (1993, pp. 196–197).

Hoffman (1998) states: “There is a fixed routine in the psychoanalytic process, a routine with a kind of symbolic, evocative and transforming potential that gives it the aura of a ritual. There are fixed times, a fixed place and a fixed fee” (p. 219). Furthermore, the analyst typically does not have different fees for psychotherapy or psychoanalysis nor for treatment offered during different times of the day although one patient tried to negotiate for lower fees during what he thought were “off-peak hours”. So, if the analyst does not typically charge based on results nor charge different fees for different therapies nor for different times of day or seasons like telephone companies and airlines do, what indeed is he charging for? Is he charging for the delivery of his “services”, thereby adhering to a fee-for-service model? And, if so, what exactly is his service? And if analysts with more formal education, more extensive experience, prominence and/or greater narcissism charge more than their more modest counterparts, there is an assumption that what they are offering is worth more. But, still, the question remains: What are we charging for? Clearly, we analysts are charging for something related to the promise to spend time with the patient and analyse them which brings us back to the message in the fortune cookie: “time is money”.

Clinical Vignette: 1

One particular patient, referred to above, whose mind functioned like a calculator, bemoaned the fact that he was paying me $4.11 per minute regardless of whether I spoke or didn’t speak, regardless of how many words were emitted. As minutes ticked by, he would make the “ka-ching, ka-ching” cash register sound denoting the charges per minute. He further expressed his ambivalence by often quoting the words of the mother of television’s famous Mafioso leader, Tony Soprano. She was skeptical of her son’s treatment with the beleaguered Dr. Melfi. Olivia Soprano nastily remarked about psychotherapy: “It’s a racket for the Jews!” In a nasal, high-pitched falsetto, the patient would recite these lines imitating the voice of the character. The patient conveyed such a mistrust of authority and an expectation of being cheated that he had to anticipate all contingencies and take preemptive measures. For example, he asked how could he really know that he was getting his full allotment of time? After all, if our appointment was to be at 1:00 p.m., the clock might say 1:00 p.m. but in fact it could be one second away from 1:01 and he would be cheated. Furthermore, if I ended the session at 1:45 and had someone scheduled immediately afterward, who would pay for the seconds needed for him to exit and for the next person to enter? Or, did the session actually begin when I greeted him in the waiting room, when he entered the office or when he actually sat down? All these seconds add up in a year. And, for god’s sake, if I had the audacity to charge for missed appointments, shouldn’t I pay him if I had to cancel? Or, if he were responsible for missed appointments based on the Freudian model of leasing time, if I could fill the hour and charge more for it, shouldn’t he be entitled to part of the difference? Or, suppose he couldn’t make an appointment; couldn’t he send anyone he wanted to in his place to keep an eye on me and make sure that I didn’t profit from his absence? And on and on …. Though he delighted in demonstrating his cleverness and trying to out-think me, there was a deadly seriousness with which he fought for every penny in every transaction in his life. He would sit in sessions watching the digital clock on his cell phone, often taking calls and welcoming the disruption, but exploding with rage at the stupidity of his employees who would bother him during the sessions. After several weeks of this behavior, I began to have the distinct impression that he was actually cheating me on the time as there were occasional disparities between my timekeeping and his; he refused to leave until he was ready. During this early time when we were meeting only three times a week and, despite his downright provocations, he could be quite engaging with his humor, clever wit and great range of knowledge.

In this case, the patient’s obsession with money lent itself quite easily to it becoming embroiled in the transference. Every aspect of our financial dealings took on such exquisite meaning that at times his analysis had an absurdist quality to it. Yet beneath the humour and one-upmanship, he was enacting a deadly serious game of trying to outwit the perpetrators of his childhood. Money was both an aspect of the frame and the central part of the treatment. Dimen (1994), in her work related to fee, notes that:

Money, along with its coordinates, space and time, belongs conventionally to what has been labeled the analytic “frame”. I would like … to argue that the frame which Langer (1973) calls “ground rules” ought to be treated as part of the picture too. To put it more concretely, unless money may leave the frame and enter the picture, psychoanalysis might renege on its promise (1994, p. 97).

Milner (1952), in her original conceptualization of the analytic frame notes: “The frame marks off the different kind of reality that is within it from that which is outside it; but a temporal spatial frame also marks off the special kind of reality of a psychoanalytic session … it is the existence of this frame that makes possible the full development of that creative illusion that analysts call the transference” (p. 182). She then observes that as the patient becomes more tolerant of the difference between the symbolic reality of the analytic relationship and the literal reality of libidinal satisfaction outside the frame of the session, his condition improves. Clearly, the payment and all of its associated details have enormous psychodynamic significance and the failure to recognize and analyse these aspects of the relationship will overlook unprecedented opportunities for understanding the patient’s mind.

Bartering

I have a colleague who practices in a small coastal town where families have made their living for many generations by harvesting the sea. The fishing industry has been a central part of the local economy which until recently was a thriving, seemingly never ending bounty for all concerned. A casualty of its own success and the well-known factors plaguing the world’s oceans, such as pollution, climate change and human greed taking precedence over long-term conservation measures, this area had fallen on hard times in recent years. Uncertainty over the future and rising unemployment cast a pall over this once thriving area resulting in a westward migration of some of the more ambitious, hopeful and talented young people. Those left behind continued in their old ways hoping and praying for things to improve. An air of quiet desperation and great uncertainty pervaded this area whose populace struggled with an epidemic of depression and anxiety. My colleague would regularly be paid for his long hours of dedicated service to his patients in fish. Haddock, scallops, salmon, halibut, lobster, and cod filled his freezer constantly. He never complained. He saw this as a sign of whatever was available for appreciative patients and family members to repay in a way that was feasible for them and meant something to them. He always accepted it even if there was no room in his freezer. While patients’ health insurance may have paid for some of his services, he was never fully compensated. Bartering was acceptable, would have been an insult if refused and was a way of life. To feel that one was at least offering something in exchange for desperately needed psychiatric care helped maintained a sense of pride and avoided any further narcissistic injury.

As Canter, Bennett, Jones, and Nagy (1996) summarize it:

Pro bono services, although certainly at times an option, may not always be possible either because of the therapeutic issues, the discomfort or unwillingness of the client or patient to accept free service, or financial pressure on the part of the psychologist particularly in economically depressed areas where many indigent clients may need psychological services (pp. 51–52).

In the socioeconomic climate of the fishing village, bartering with seafood was congruent with cultural mores. It was used as currency not only for psychological services but for other goods and services as well. It was not seen as out of the ordinary and was perhaps as normative as bartering with produce would be in a farming community. For example, Russian colleagues who studied with us in the United States shortly after glasnost and perestroika nonchalantly told us of being paid with sacks of potatoes and chickens for their work in rural areas. The situation becomes more complex in a heterogeneous urban culture when, for example, a starving, young artist trades his paintings for treatment. In this case, the value of the work may be very difficult to appraise given the subjectivity and the uncertainty of his ultimate fame. In one such instance, a patient paying a substantially reduced fee was on the cusp of “making it big”. The therapist rightly felt that his efforts figured prominently in the young man’s mental stabilization so his unique talent could be harnessed and he felt most appreciative. The two were in the midst of negotiating over a fair value for a given work that especially caught the therapist’s eye a month before that particular piece happened to win a prestigious art competition. Then, almost overnight it became “worth” many thousands of dollars and, depending upon if and when the barter had taken place, either the patient may have felt cheated for accepting too little or guilty over taking so much. Conversely, the therapist may have felt guilty over having acquired such a great work in return for offering a few sessions or indebted to the patient for an extended period of time were he to pay the new value of the work. Wisely, the therapist continued to analyse the complexities of such a barter and stayed with the original financial arrangement until the patient could actually pay more money. Seeking consultation with a knowledgeable colleague at such times might be helpful in sorting out the nuances and complications that might arise.

Treating wealthy patients

The dual challenges of working with “phenomenally wealthy patients” (Olsson, 1986) relate to their entitlement and the therapist’s counter-transference. Such patients are used to having their desires quickly gratified and often find psychotherapy tedious. They want immediate satisfaction, exclusive attention, and are often intolerant of being questioned. As a result, they stir up powerful countertransference reactions in the therapist; these include envy, defensive contempt, undue deference, and excessive accommodation of schedule changes. Further complications arise if the therapist begins to feel proud at having a rich individual in treatment and gives in to gossiping about the patient’s wealthy lifestyle (Akhtar, 2009a, 2009b, 2009c; Olsson, 1986; Stone, 1972). The following clinical vignette illustrates the conundrum that can occur in the treatment of such patients.

Clinical Vignette: 2

Ms. X, a prominent and somewhat mysterious woman purporting to possess enormous wealth, consulted me many years ago as one of several analysts she was interviewing to continue her treatment following the death of her analyst. She told of a long and convoluted family history replete with intrigue, great fortunes amassed and lost and regained, violence, perversion, incest, alcoholism and suicide. Currently embroiled in a legal battle with other heirs of the remains of the estate, she worried that the loss of her beloved analyst, a man who had seen her through many years of great success and suicidal despair, was more than she could tolerate. In the midst of this personal turmoil and grief, she exuded a seductive, childish helplessness and a deep sense of entitlement. Having had a prior experience with another deeply troubled woman whose very wealthy husband compensated for her ego weakness and lack of frustration tolerance through instant gratification of her material wants, I knew that the pleasure principle can often predominate over the reality principle in such individuals. I therefore expected that certain demands and expectations would accompany the therapeutic situation with this patient also.

Indeed, it emerged over the extended consultation lasting weeks that Ms. X wanted to have her personal psychoanalyst to have no other patients than herself. She was offering an exorbitant annual retainer, almost the three times the total amount of my total income from my practice, to her new analyst. She was utterly serious and conveyed an air that anyone who would be privileged enough to be chosen to work with her should be prepared to terminate all of his patients and devote himself exclusively to her. I began to wonder about her former analyst, an individual who had lived quite well and was somewhat peripheral in the professional community. Had indeed such an arrangement had been made with him? I would never know. What I did know was that in my work with Ms. Y, a former patient who had bouts of suicidal despair and multiple hospitalizations, she would frequently call in crisis and would insist upon extended conversations on the telephone. Even though we were meeting five times a week, her sense of urgency and inability to wait were such that I came to expect regular telephone contact. While I did charge her for the telephone calls as they became part of the treatment itself, I began to feel that I had to be on call 24 hours a day, 7 days a week. Moreover, I began to feel like hired help despite being adequately compensated and realizing that her voracious oral needs and object hunger were intensified by severe early trauma. I was, therefore, not totally unfamiliar with this character type but, nevertheless, felt somewhat amazed at Ms. X’s demand for exclusivity. I had worked in a private hospital which routinely accommodated the demands of many very wealthy and disturbed individuals so this patient’s demands were an extreme example of such a pattern. Having observed well-respected senior colleagues tending to these special inpatients in that climate seemed normative and part of the culture at that time. I consulted a colleague about the nature of this spectacular offer and, assuming that it was bona fide, explored my countertransference reaction to this “opportunity”. I wanted to better understand the mind of someone who could actually enter into such an arrangement with a therapist. I let myself imagine the possibility of maintaining all of my analytic patients and working towards ending my less intensive psychotherapy patien...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• CONTENTS
• ACKNOWLEDGMENTS
• ABOUT THE EDITOR AND CONTRIBUTORS
• INTRODUCTION
• PART I: ALTERATIONS OF THE FRAME
• PART II: ALTERATIONS OF THE METHOD
• PART III: ALTERATIONS OF THE RELATIONSHIP
• REFERENCES
• INDEX