Freud made the early observation that “money matters are treated by civilized people in the same way as sexual matters―with the same inconsistency, prudishness, and hypocrisy.” Since then, an unconscious equation between sex and money has been grist for the analytic mill, at least in dealing with one’s patients. The general belief is that a most revealing window of intrapsychic life can be peered into, using the handling of money as a mirror of inner conflicts. The negotiations and exchange of financial currency―spending or saving, hoarding or squandering, and the complex interplay of need and greed, or more metaphorically, the fundamental acts of giving and receiving as basic expressions of human commerce―become a symbolic measure of the capacity for love, sense of worth, and the value placed on self and others.
From the standpoint of all medicine, Sandor Ferenczi observed that even the most prosperous individual spends money on doctors most unwillingly. Something in us seems to make us regard medical aid, which in fact we all first received from our mothers in infancy, as something to which we are automatically entitled. The therapist seems to be the mother a priori. Ferenczi as psychiatrist, further contended that at the end of each month, when our patients are presented with their bill, their resistance is stimulated into producing their concealed or unconscious hatred, mistrust, and suspicion all over again.
At the same time, psychotherapists have themselves been chronically criticized for their preoccupation with money, not merely with having a professional penchant for exploring its meaning. Is it because the “purchase” of psychotherapy is like no other commercial transaction? You usually have no idea what you’re getting―and there are no written warrantees.
So, how do you respond to a patient who complains that therapists are too well paid, and even directly inquire, “Why are you so expensive?” A few years ago a patient asked me this question in a stern manner of thinly disguised resentment. After all, there’s no big overhead, no expensive equipment, no staff salary, no material, no storage. For centuries man has been pulling strings, to which nothing is attached. What is it that you and other therapists do to justify your fee?! You’re sitting there in a comfortable chair in your own home/office, listening (attentively, yes), occasionally making some statements (interesting and thoughtful, yes)―but that’s it. Why would such a distorted conversation be translated into $300 an hour? One patient retorted, “You must be giving brand-name psychotherapy. Can I get a cheaper, generic version of it?” Incidentally, the patient’s reaction to the therapist―ambivalence, or in more severe psychopathology, the expression of primitive, excessive, and unintegrated love and hate―is no measure of the durability of the relationship. In fact, I would say that it’s the one criterion that I count on the least.
Some patients exalt the therapist and wouldn’t mind spending a large portion of their income on therapy. Others tend to resent paying the therapist, no matter how wealthy they are―especially when it’s for something they deny having bargained for, such as having to explore their innermost feelings. Such a patient of mine defined the psychiatrist as a doctor some people go to slightly cracked and leave completely broke. Therefore, I have come to understand and accept the fact that I will be both praised and resented for my help by all who receive my treatment, and that any financial arrangement can bring out the patient’s mixed emotions. Sandor Ferencz tells of an early encounter with one of his patients: “’Doctor, if you help me, I’ll give you every penny I possess!’ ‘I shall be satisfied with thirty kronen an hour,’ the physician replied. ‘But, isn’t that rather excessive?’ the patient unexpectedly remarked.” Well, we now know that the patient’s reaction is not really so unexpected. Although this verbal exchange explicitly revolves around money, it symbolizes the larger unconscious issue of the nature of the ambivalent patient–therapist relationship. In this sense money does matter.
Patients in treatment may be justly reminded of the care their mothers provided. Unconsciously expecting such nonreciprocated succor from the therapist, it is only those who are extremely demanding, with an accentuated sense of entitlement, who deserve the most attention, as they are looking for a mother they never had. If the therapist has grown out of his need for reciprocation and does not make too much of the money issue, so will the patient.
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T. Byram Karasu, M.D. is the author of The Psychotherapist as Healer