Psychiatric Annals

Therapeutic Process and an Unpaid Bill

Arthur E Reider, MD

Abstract

1. Freud, S. On beginning the treatment (1913). In Complete Psychological Works, standard ed., vol. 12. translated and edited by Strachey, J. London: Hogarth Press, 1958, pp. 121-144.

2. Ferenczi, S. Sex in Psychoanalysis. Boston: Gorham Press, 1916, pp. 319-331.

3. Fenichel. O. The Psychoanalytic Theory of Neurosis. New York: W. W. Norton & Company. 1945.

4. Freud. S. Lines of advance in psychoanalytic therapy (1919 [19183), op. cit.. vol. 17, 1958, pp. 157-168.

5. Pulver. S. Freud and third-party payment: A historical note. Am. J. Psychiatry 131 (1974), 1400-1402.

6. Haak, N. Comments on the analytical situation, int. J. Psychoanal. 38 (1957), 183-195.

7. Wiener, D" and Raths, O. Cultural factors in payment for psychoanalytic therapy. Am. J. Psychoanal. 20 (1960). 66-72.

8. Gedo, J. A note on non-payment of psychiatric fees. Int. J. Psychoanal. 44 (1963), 368-371.

9. Ruben, M. Delinquency - A defense against loss of objects and reality. Psychoanal. Study Child. 12 (1957). 335-355.

10. Winnicott, D, Transitional objects and transitional phenomena. Int. J. Psychoanal. 34 (1953), 89-97.

11. Uevano, J. Observations about payment of psychotherapy fees. Psychiatr. O. 41 (1967), 324-338.

12. Schwartz, E., and Wolf, A. Money matters. Int. Ment. Health Res. Newsl. ff:2(1969), 1-7,

13. Chessick, R. Ethical and psychodynamic aspects of payment for psychotherapy. Vo/ces3:4 (1968). 26-31.

14. Schonbar, R. The fee as a focus for transference and countertransference. Am. J. Psychother. 21 (1967), 275-285.

15. Hilles, L. The clinical management of the nonpaying patient: A case study. Bull. Menninger Clin. 35 (1971). 98-1 12.

16. Allen, A. The fee as a therapeutic tool. Psychoanal. Q. 40 (1971). 132-140.

17. Balsam, R. M.. and Balsam, A. Thinking about money. In Becoming a Psychotherapist: A Clinical Primer. Boston: Little, Brown & Company, 1974, pp. 113-132.…

"Part of me feels that if you liked me or found me interesting you wouldn't charge. But, if you didn't, then I'd wonder what you were getting. I'd feel you were in control of me - that you owned me."

Modern psychiatric practice distinguishes between a deep, warded off, emotional pain derived from life experience and a superficial, symptomatic dysphoria. It is often difficult to demonstrate the deep pain; yet it keenly interests the empathie clinician because of the strong correlation observed between its assimilation and the maturation of adaptive potential. Considerable attention has been given to the problem of helping the patient perceive the warded-off emotional pain. It is well known that intellectual explanations, divorced from the painful experience itself, may impede rather than catalyze the ameliorative process. Clear, boldly outlined, actual experience of the pain is much more clinically useful. In the case that follows, an unpaid bill heralded the assimilation of chronic pain.

CASE REPORT

The subject of this account was a woman in her early 30s who was a part-time professional, the mother of two daughters, and a wife for five years. Her therapy lasted two years, with sessions once per week for the first year and then twice per week.

She had come for therapy in the midst of an extramarital affair that had been going on for several months. She was angry at her husband for his devotion to a needy adolescent orphan boy whom he had befriended and insisted on having as a house guest. The early phase of treatment predominantly dealt with her love affair. She was ecstatic over her paramour's sexual prowess but despondent after their motel i encounters. In therapy she referred to her need for sex with him as an "addiction."

Exploration of this "addiction" led to her painful feelings of isolation as a child with her parents and older sister. A welcome relief was her Uncle Clarence, an exciting and ostentatious visitor who brought gifts and took her to restaurants alone for treats. He seemed to be patient, understanding, and warm. By the time of junior high school, she had a romantic interest in him; once, while they were alone in the car, she kissed him playfully on the ear - an action not typical of her. Coinciden tally, she had an intense crush on her junior-high-school teacher. She had fantasies of herself and the teacher alone together after an atomic explosion, but her fantasies always faded out when the two of them walked towards each other.

She kept in touch with her Uncle Clarence, who was a well-known public figure, during high school and college. When she graduated from college, he wrote to her strongly implying interest in having an affair with her. Safe in the knowledge that he was far away, she could write a provocative letter and sign it, "With lust and wickedness." The affair never materialized; however, the yearning for an Uncle Clarence remained strong and, at times, dominated the sessions in therapy.

After six months of treatment, the marriage stabilized and the orphan was sent away. The patient recognized that she loved her husband and enjoyed their family life. At an intellectual level she scorned her fruitless "addiction." She saw, at least in words, that her "ordinary" life offered more. However, until the last six months of therapy - when the issue of the unpaid bill came up - she lacked confidence in being able to keep her ship on course. She was uncertain how much she could count on herself, especially in the face of disappointment frustration, and the inequities she saw in comparing herself to others.

HISTORY

Since at least age 16, the woman had often felt inadequate, although she was of above-average intelligence, attractive, and by no means a social misfit. She was chronically subject to frequent and intense reactions of shame about her intellectual and academic work, as well as a repulsion about herself as female. She had recurrent dreams of being naked and laughed at by boys. Bookish and distant from most of the other girls in high school and at college, she did well academically and dated boys who were highly esteemed.

After college she took a full-time job, had her own apartment, and prided herself on her apparent independence. However, she could not stand being alone and began picking up one man after another in bars, sleeping with them indiscriminately. When she recognized how little she cared about the kind of man she was picking up, she went to a psychiatrist for a short time and received some benefit. At age 26 she married her husband, an athletic man who was professionally competent and who fluctuated between boyish overestimation of his abilities and periods of helplessness and demandingness. She had had no affairs before the one precipitating therapy.

TRANSFERENCE ISSUES AND THE UNPAID BILL

Until the final six months of therapy, the transference feelings towards the therapist were largely positive and idealized. The patient was open, saying what came to mind, but her expression of discontent about many painful memories had a note of qualification. It was as if she were saying, "Maybe I got gypped as a child, but now I've got you, and that makes it all better."

The issue of her unpaid bill brought with it an undeniably real affective experience that lay beyond interpretation, avoidance, or softpedaling of one kind or another. With this experience came a noticeable change in her everyday life and an ability to cope with previously intolerable situations. In the approximately 15 sessions dealing with the unpaid bill, a shift in the therapeutic relationship occurred. For the first time she perceived the therapist as both understanding her and yet definitely separate from her. She terminated treatment by her own choice about three months later. A year after termination of treatment, she spontaneously wrote a letter describing in detail her continued progress.

Space does not permit recapturing in detail the evolution of the sessions dealing with the unpaid bill; on the other hand, leaving out verbatim material, fragments of dreams (the patient was a prolific dreamer), and verbal interchange would reduce the therapeutic phenomena to a lifeless collection of facts. I have chosen to compromise, giving therapeutic vignettes at the cost of a more comprehensive clinical discussion of the case.

At the beginning of the series of interviews to be described, she began to bring up material about her father; heretofore she had recalled him as an ineffectual man, bitter about his lowly job and disinclined to risk achieving more. She had remembered his awkward compliments to her as an adolescent, but little else. The therapist had just been away on vacation for a week. Upon his return she greeted him with the report of a dream in which he (the therapist) had gone away to deal with an explosion. A friend had then told her (in the dream) that the patient's marriage could be annulled on a technicality. There was a pretty girl in the dream; the patient's ex-lover ran off with her.

We might expect that the patient's interpretation would be that she wanted to be with her vacationing therapist but could not, possibly because of her explosive anger. She might further have said that the second part of the dream gave her a way out of being angry about the vacation interruption; after all, if the marriage bonds do not hold, she, like the pretty girl in the dream, could be with the man of her desires. However, the patient did not interpret the dream that way. What she did say was more revealing of the direction the therapist would take. She said that if she paid the therapist money or if she were prettier, he would not have gone away. Interesting!

We can see where the "pretty girl" part of the statement came from, but where did the money fit in? The only mention of money had been at the beginning of therapy, when she explained that she could not afford to pay the fee on the basis of their income but that her husband's company would reimburse them substantially for medical expenses over and above the 50 per cent covered by the insurance company. She explained that the company would not reimburse them until the end of the year and asked if the therapist could wait until then for part of the payment. He agreed. There was a large unpaid balance at the time of the session under discussion, and the therapist had not yet said anything about it. The patient had said several times that she felt guilty about not paying the bill and that she was compulsive about not being in debt.

In the next session the patient reported a dream of being teased by the therapist, which led to the question of whether she had felt teased by her father. She explained that she had but that it went both ways. She felt teased but also that she could get her father to do what she wanted. It emerged in the next session that her father had largely ignored her but that she had also perceived an implicit message from him that he felt that he should make up for his ignoring and depriving her. She realized that she had come to feel that she deserved something because her father had ignored her. She recalled that as a girl she had wished that her father were different - in fact, that he were Uncle Clarence. As these realizations occurred, she became much more overtly demanding in sessions, especially at the end as she was about to leave. It was clear that she now felt that her father/the therapist owed her something if he was going to end the session.

In the next session she began talking about her anger at someone who had been reviewing her work; it seemed that this was a hidden anger at the therapist. She then told the therapist that she had been cooperative and had trusted him with dreams and other intimate material but that he was being too confrontational and that this was not according to the "deal" or "bargain." "Deal?" the therapist repeated. "Bargain? The only deal I know of is that you pay your bill." She immediately said that she felt guilty. The therapist said that she felt her father had let her get away with things, and he suggested that they be on the lookout for a repetition of her feeling that way now in therapy. "What is going on with the payment?" he asked.

She said she was waiting for money from her husband's company. The therapist did not comment. Quietly, she then added that she had used some of the money that the company had sent her during the previous year (as reimbursement for psychiatric expenses) to pay their other bills.

It was clear that she was making private "bargains" with the therapist, about which he had known nothing. She believed that if she "cooperated," was "good," and "gave" dreams, she deserved to get away with things. The therapist had no business confronting her with facts that she did not want to know. In reality, she had run off with the therapist's money. Now that "deal" was out in the open.

The patient was quite unaware that the money had any meaning in therapy at the time. For the following six sessions, she kept unclear the question of just how much money she owed her therapist. She also avoided making any critical judgments concerning her father's treatment of her. Her dreams, however, were quite revealing.

The next time she came, she was clearly angry, although she did not say so. She told of a dream she had had the night before. The time was junior high school. She had lived with a man, and he had died. She went back to her apartment and found a man there. He tried to rape her. She fought him but could not kill him. She pushed her fingers into his eyeballs. The dream closed as follows: She had to stop therapy because she did not have the money.

We can now see that she could practically kill the therapist for asking her about the unpaid bill but would settle for destruction of vital orbs. Dreams have a way of furnishing immediate convenient solutions; what better excuse for putting his eyes out than that he was trying to rape her. Of course, she had no sexual feelings at all - lust was all on the part of her therapist, the lascivious father, crudely complimenting her in her junior-high-school days. She would have to stop therapy, not because of her violence but because she had no money. The money problem is rendered solved and beyond discussion. She can quit therapy and get away from the infuriating psychiatrist, who does not respond to her "cooperation." He will not make a "deal."

At the outset of the following interview, she gave the therapist a small check that had come from the insurance company. She said she was unclear about how much was due from the insurance company, how much was from her husband's company, and how much was due from her. In the next session she was still confused about how much money she owed, and the therapist asked if she wanted to keep the matter confused. She did not answer. Then he asked if her father was stingy with her. She said, with much hesitation, that she could not say he was stingy. The therapist suggested that calling her father stingy would take away the pleasurable deal with him. We can see that if she was good - and exempted her father from her usual judgment of him - she deserved something special. She was silent for a while and recalled a childhood memory: When the family went to the movies, her mother would prod her father for money for candy and then tell the children to thank him. "But," said the patient, "it wasn't his idea."

"Was he stingy?" The patient did not answer. The theme of vagueness persisted in the next session, when she reported a dream of receiving a check that was not clearly a check and the amount of which was also uncertain. She asked a woman in the dream for an explanation, and the woman was "vague." She recalled then how her father had not paid for anything at her wedding, even though he had done so for her sister, married several years previously. She pointed out that she did not complain about this at the time, nor was she complaining now. The therapist reminded her of the costs of therapy, and she said that it cost too much and that others complained about their fees but she did not. The therapist pointed out that she did not complain about the fee in therapy, nor had she complained about her father's not giving her money at her wedding, but that she did have resentment that was hidden by keeping the facts vague.

In the following session, the patient explained that she owed her father $2,000 as the result of a loan he had given her several years earlier. She told of the fantasy, still present, that somehow her father would change into someone wonderful - that the question of the loan would somehow disappear. She explained that, on one hand, she would not feel right until she repaid all the money she owed her father and, on the other hand, there persisted a feeling that she could not afford to pay him anything. The therapist said that by approaching her father in an all-or-nothing way, she kept alive the fond hope that her father would change from a frog to a prince. At this point, she had another memory about her father. When she graduated from high school, he promised her a typewriter (he had bought her sister one three years before for her high-school graduation). At the patient's graduation, however, her parents said they did not have the money and asked her to pay for the typewriter until they could pay her back; then they "forgot." The patient was silent. The therapist asked, "What are you feeling?" The patient replied, "I don't feel I deserve the money."

She began the next session by saying, "Whoops, I forgot to write out a check. I forgot to put checks in my checkbook." The therapist asked her what her decision was about paying him. Reluctantly and in a low voice, she said that she and her husband had finally discussed their finances and had decided to pay him $500. She said that she was not aware of not wanting to pay; in fact, she wanted to pay more. The therapist said that the incident with the typewriter seemed unfair to her, that - in reality - her father had said it would be a present. He asked what the understanding had been about paying for therapy. She said the understanding was that it was okay to postpone payment until the company reimbursement came through. And there she stopped. The fact that she did not continue and go on to explain how she intended to pay the therapist was evidence that she was continuing to misperceive him - seeing him as the father who should allow her a special deal. She did not want to acknowledge that an agreement had been made and that she had her part to keep. Because of this misperception, pointing out to her that she had used the medical reimbursement to pay other bills would have been as useless as talking to a sleepwalker. So the therapist set the kind of limit her father had never set. He said, "We cannot have the balance be more than $1,000." There was a long pause filled with tension. She finally said, "I feel reprimanded. I feel you're saying you're not going to make up for what my father didn't do."

For several sessions she had not let enter into her consciousness the reality that she would actually be required to pay the bill. At the beginning of the next session, she handed the therapist a check for $550, which met the limit. Then she explained, "I felt after last time like I'd broken up with a boyfriend. Of course, you were being realistic - I shouldn't go over $1,000." She then said that when the therapist had set the limit, she felt it was being mean - that she deserved something. Part of her, she said, felt that if the therapist liked her or found her interesting, he should not charge. "But," she went on, "if you didn't, then I'd wonder what you were getting. I'd feel you were in control of me - that you owned me." The therapist added, "Then you wouldn't have to worry, because you wouldn't be held responsible for anything."

In the following session, she thought of a magazine article on skin cancer that had brought to her mind recurrent thoughts about something's being wrong with her body. She then put into words for the first time in therapy a memory of her mother's being admiring of her. Specifically, she recalled that her mother had said she was a very beautiful child. She smiled with pleasure as she recalled this and said, "I really like my mother. She enjoyed me.

In the next session she said she had written her parents that she would pay them $25 a month to pay off the $2,000 loan. At a restaurant, she had given her daughters 25¿ each to go to the counter and buy apple turnovers. She was pleased with her daughters' independence, just as she was pleased with the letter she had written her parents. Her husband had just left on a business trip, and she was feeling differently about his being away. She realized that she could be competent on her own and recalled a previous conviction that if she were competent - for example, in driving - she would not be cared for.

The next time, she reported a dream that she was on a commercial airliner. "It seems I didn't have enough money. There was a cafeteria. It was a huge plane. I didn't get anything to eat. I was flunking I couldn't get any of the main dishes because I didn't have enough money." She saw a magazine and wanted to take it without paying but did not. She said the magazine reminded her of the one she read in the waiting room. "The whole business about 'Do I have to pay?' I really wanted to read the magazine. It seemed very attractive. The big thing in my mind was whether I should pay or end up owing you $10,000 or whatever the bill would have come to."

Later in this session she thought that she was contradicting a statement of the therapist's and became anxious. She thought of another recent dream in which she was screaming hatefully. "I was surprised. I was like a firehose with water pouring out." She went on to talk about how she had never allowed herself to have differences of opinion with her sister-in-law and recalled a time when the latter had minimized the patient's accomplishments by saying they were "a dime a dozen." Now she said she could have retorted that she, herself, was not a dime a dozen. As she said this she reported that her heart was pounding.

The patient's assertiveness was emerging. The wish to get something for nothing and her devalued view of herself were undergoing change. This took place as painful memories of her father entered into the therapeutic work and became undeniably clear because they were reexperienced as a present reality with the therapist. It is interesting that we do not hear about the father in the material after that reported above. What followed in the subsequent two months was much more about siblings, peers, and her husband. Of course, the intrapsychic struggle went on. In a Labor Day dream the patient depicted herself with railroad workers in 1900, deciding not to throw stones because it was useless and running off with a cash box instead. Now the patient had, as it were, joined a union, a brotherhood or sisterhood, and that is what her real-life activity reflected.

There was a change in the patient's use of her aggressive energies. The fuss at the end of the session did not recur. She approached everyday decisions about her children's schooling, her role in an organization of women, and her parttime career more realistically, less granthosely, and less fearfully. She tolerated her husband's trips away from home without excessive anxiety.

She recognized a new sense of freedom of choice. At a country club dance she realized that she did not have to play tennis with an overly competitive man and instead was free to dance. (A year earlier she had felt such a fierce compulsion to "prove herself" every time she played tennis that she hated, yet could not say "No" to, the game.) She noticed her pleasure in the jams and bread she made herself. After a particularly enjoyable episode of sexual intercourse with her husband, she jokingly told him that sex was like "money in the bank." She began to notice that she could "take pleasure" - a significant phrase because it combines the active, aggressive word "take" with "pleasure." Her aggression, one could speculate, had been detoured in a sexualized childhood game of "You owe me and I hate you" with her father. And as long as she remained bound to her father in this manner, her libidinous yearnings remained checked and stunted, bound up with the filmy and insubstantial substitutes for the father she had wanted. She had been bound to her Uncle Clarence, her lover, and an image of the therapist. These substitutes made her feel at times aroused and powerful but did not permit her freedom.

DISCUSSION

There is universal agreement in the literature that questions of money produce considerable emotional reaction in psychotherapy and psychoanalysis. Freud,1 Ferenczi,2 and Fenichel3 attributed the heightened charge in the concept of money to its tendency to be invested with strong basic instinctual energies.

In his early paper on technique, Freud1 stated that it is preferable for the therapist to be frank and realistic about fees rather than to grumble in secret or make complaints about patients' ingratitude. His belief that financial sacrifice on the part of the patient can be an incentive for successful treatment is well known. He held that when the treatment was free, "the whole relationship is removed from the real world."

It is less widely recognized that Freud also said he had found exceptions when free treatment was very successful1 and that he was an advocate of free psychiatric treatment for the poor.* Freud even took on an American psychiatrist as an analysand, with payment made by a third party.5 The few discussions of money in the brief analysis included Freud's interpretation of a dream about truancy as indicating the analysand's wish to skip sessions and keep the third-party payment for himself. In that case, in contrast to the present case, the patient had no awareness of such a motive.

Haak,6 a Stockholm psychoanalyst, wrote about the important role of firmness on fees in enabling the patient to work out maladaptive passive, self-sacrificing tendencies. The patent feels that "he has entrusted himself to a strong person who knows what he wants, who will not allow himself to be directed or frightened, who will stand up to various kinds of provocations and testing attempts . . . who lives as he teaches," he said. "All this also counteracts the patient's illusion of being in a privileged position - the favourite child." Haak warns against excessive "kindness" about fees, which may inhibit the patient's aggression. Being "kind" may mean that the analyst "has guilt feelings, that he is masochistic, that he is in love with the patient, that he wants to bribe the patient to love him, that he is afraid of the patient and that he is afraid of being considered greedy." Covert aggression and playing the all-giving mother can also be involved.

Wiener and Raths7 describe the cultural conflict caused by the coexistence of private and public services. They assert that the cultural inconsistency over fees can negatively influence therapeutic outcome.

Gedo8 reviewed 242 of his consecutive cases in the previous six years and discussed the 7 per cent of nonpayers. To explain the pathologic common denominator of this group of "deadbeats," he referred to Ruben's concept8 of delinquency in children as a defense against object loss and to Winnicott's concept10 of the transitional object and transitional phenomena. The nonpaying patients were compared with deprived young children with anaclitic depression; their distress was relieved by the therapist's external presence. "But the maintenance of the internalized representation of this object depended on the illusion of symbiosis. When disillusioned by reality, these patients used the transitional phenomenon of withholding payment to deny their separateness."

Gedo distinguished between those of his "deadbeats" who "did not deny their indebtedness but maintained an unpaid debt as a way of ensuring regular communication with me after formal therapy came to an end" and those "who used paranoid defenses to justify their retaliative withholding. ..." He suggests realistic management of delinquent fees but adds that collection can be carried out with therapeutic concern rather than with vindictiveness. In cases where nonpayment is a new symptom, arising from therapeutic regression in the transference, Gedo says, it is the therapist's responsibility to help the patient become aware- of the underlying impulse. He believes that for the patients of his more primitive "deadbeat" category, "the price for not having some difficulties in collecting one's fees is failure to deal with the core problems of these patients."

In 1967 Lievano11 published the results of his study of 20 patients in a state outpatient clinic. Some paid their bills completely, others in part, the rest not at all. Lievano admitted his bias in favor of being lenient with clinic patients about payments, but he was unable to find any clear relationship between outcome of therapy - as measured by a rating scale - and payment or nonpayment.

Schwartz and Wolf12 and Chessick13 criticize the depiction of therapy as a form of counterfeit love or friendship. The former refer to failure to collect a fee as "a way of inappropriately loving the patient, being responsible for the patient in a way the therapist should in fact be responsible only to his family and perhaps some friends." Both articles find a correlation between mismanagement of money matters by the therapist and neglect of other aspects of therapy. Chessick sees the integrity of the therapist as the key variable in the therapy, not any "right answers," and provides examples of his own straightforward approach to money matters.

Schonbar14 described a relatively "flexible" approach to money along the lines of FrommReichmann. Two case histories illustrate patients' feelings of victimization and distrustfulness about money issues.

Hilles' case study15 of a clinic patient offers the most detailed description in the available literature of money in therapy. Her patient stopped payment when the treatment began to mean something to her. She saw paying as a sign of commitment. She had never completed a single plan or followed through on any relationship in her life. Paying, the patient felt, was tantamount to giving up her negative relationship with her mother, whom she had consistently pushed away. She feared further intimacy because she was afraid that "total surrender" would be demanded by the therapist. When the patient did begin paying again - after an interlude of nine months - she developed visual symptoms, which she viewed as an expression of "protest" against her progress toward health. The therapy of this "borderline" patient was interrupted by the therapist's move to another city.

Allen16 points out how management of the fee can function for limit setting, constructive permissiveness, and other helpful therapeutic effects. He gives brief summaries of several cases, most of which demonstrate limit setting. In one of the "permissive" examples, as did Schonbar with one of her cases, he decided not to charge so that a negative distortion of the therapist would be undercut. Regrettably, neither Schonbar nor Allen discusses possible complications of deliberate noncharging for purely therapeutic purposes.

Balsam and Balsam17 provide the most comprehensive coverage of the subject. In addition to brief cases (one of which resembles Hilles' case), a balanced overall therapeutic approach concerning money is presented. On the basis of experience in the British National Health System, R. M. Balsam states that the "savior fantasy" is to some extent promoted by the British system, in which the therapist can avoid confronting, and thus working out, his own conflicts about money.

SUMMARY

Money has a particularly strong investment of irrational meaning and thus, as a reality factor, can be a potent catalyst (or obstacle) to the therapeutic process. Frequently the transference cannot be seen clearly, by either patient or therapist, until vagueness about payment is cleared up.

In the case described in the first part of this article, the patient intellectually recognized early in therapy that reality could be more substantially satisfying than her "addiction." It was not until the work on the unpaid bill occurred, however, that she could part with the rewards of a distant, fantasied relationship.

It should be clear that confrontation with money matters cannot always bear therapeutic fruit. Much depends on the development of an alliance with the patient, the patient's conscience, and the therapist's sense of timing. Sadness and rage were mobilized in the sessions reported. When the patient accepted the reality of the financial arrangement of her therapy, she felt as if she had broken up with a boyfriend and her rage, although contained, was of violent intensity. The unpaid bill was like a seed crystal in the precipitation of these components of "emotional pain." In the words of another patient, the therapy gave this patient "a cup to put her bitterness in"; she could then "leave the bad behind and take the good with her."*

BIBLIOGRAPHY

1. Freud, S. On beginning the treatment (1913). In Complete Psychological Works, standard ed., vol. 12. translated and edited by Strachey, J. London: Hogarth Press, 1958, pp. 121-144.

2. Ferenczi, S. Sex in Psychoanalysis. Boston: Gorham Press, 1916, pp. 319-331.

3. Fenichel. O. The Psychoanalytic Theory of Neurosis. New York: W. W. Norton & Company. 1945.

4. Freud. S. Lines of advance in psychoanalytic therapy (1919 [19183), op. cit.. vol. 17, 1958, pp. 157-168.

5. Pulver. S. Freud and third-party payment: A historical note. Am. J. Psychiatry 131 (1974), 1400-1402.

6. Haak, N. Comments on the analytical situation, int. J. Psychoanal. 38 (1957), 183-195.

7. Wiener, D" and Raths, O. Cultural factors in payment for psychoanalytic therapy. Am. J. Psychoanal. 20 (1960). 66-72.

8. Gedo, J. A note on non-payment of psychiatric fees. Int. J. Psychoanal. 44 (1963), 368-371.

9. Ruben, M. Delinquency - A defense against loss of objects and reality. Psychoanal. Study Child. 12 (1957). 335-355.

10. Winnicott, D, Transitional objects and transitional phenomena. Int. J. Psychoanal. 34 (1953), 89-97.

11. Uevano, J. Observations about payment of psychotherapy fees. Psychiatr. O. 41 (1967), 324-338.

12. Schwartz, E., and Wolf, A. Money matters. Int. Ment. Health Res. Newsl. ff:2(1969), 1-7,

13. Chessick, R. Ethical and psychodynamic aspects of payment for psychotherapy. Vo/ces3:4 (1968). 26-31.

14. Schonbar, R. The fee as a focus for transference and countertransference. Am. J. Psychother. 21 (1967), 275-285.

15. Hilles, L. The clinical management of the nonpaying patient: A case study. Bull. Menninger Clin. 35 (1971). 98-1 12.

16. Allen, A. The fee as a therapeutic tool. Psychoanal. Q. 40 (1971). 132-140.

17. Balsam, R. M.. and Balsam, A. Thinking about money. In Becoming a Psychotherapist: A Clinical Primer. Boston: Little, Brown & Company, 1974, pp. 113-132.

10.3928/0048-5713-19770201-04

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