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)

O
ne 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 psychoa-
nalysis starting with Freuds (1913) conceptualization of leasing time.1
I was then going to discuss permutations of this arrangement includ-
ing 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 for-
tune cookie, I became rather startled and amused by what I read. In a

3
4 U N U S U A L I N T E RV E N T I O N S

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 moti-
vated by a wish to amass wealth. From a standpoint of medical special-
ties, 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 distin-
guished 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 psy-
choanalytic achievements, the thing he was most proud of was that
he was able to make a living from his practice. In a more recent dis-
cussion 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 communica-
tion, 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 peoples mental suffering is problematic and lends
itself to the analyst becoming needy upon them and potentially exploit-
ing them (personal communication, February, 2011). He favours having
collateral sources of income to mitigate against such a countertransfer-
ence 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
 M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 5

having to live off ones 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 deci-
sively 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 dura-
tion and will blame the analyst for not moving more quickly. For exam-
ple, 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 analysts own views over what he is charging for may vary. Further-
more, there may be uncertainty in the patients 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 com-
panies are offering incentives in the form of increased reimburse-
ments 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
analysts 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
patients 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
6 U N U S U A L I N T E RV E N T I O N S

my own financial situation and stress at the time; another factor is

a potential analysand (1993, pp. 196197).

Hoffman (1998) states: There is a fixed routine in the psychoanalytic

process, a routine with a kind of symbolic, evocative and transform-
ing 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 typi-
cally 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 dif-
ferent 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 educa-
tion, more extensive experience, prominence and/or greater narcissism
charge more than their more modest counterparts, there is an assump-
tion 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 didnt 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 televisions famous Mafioso
leader, Tony Soprano. She was skeptical of her sons treatment with
the beleaguered Dr. Melfi. Olivia Soprano nastily remarked about
psychotherapy: Its 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
 M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 7

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
gods sake, if I had the audacity to charge for missed appointments,
shouldnt 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, shouldnt he be
entitled to part of the difference? Or, suppose he couldnt make an
appointment; couldnt he send anyone he wanted to in his place
to keep an eye on me and make sure that I didnt profit from his
absence? And on and on . Though he delighted in demonstrat-
ing his cleverness and trying to out-think me, there was a deadly
seriousness with which he fought for every penny in every transac-
tion 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 actu-
ally 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 patients obsession with money lent itself quite eas-
ily 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
8 U N U S U A L I N T E RV E N T I O N S

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 differ-
ence 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 patients mind.

Bartering
I have a colleague who practices in a small coastal town where fami-
lies 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 worlds 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. Uncer-
tainty 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.
 M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 9

An air of quiet desperation and great uncertainty pervaded this area

whose populace struggled with an epidemic of depression and anxi-
ety. My colleague would regularly be paid for his long hours of dedi-
cated 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 desper-
ately 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 dis-
comfort or unwillingness of the client or patient to accept free serv-
ice, or financial pressure on the part of the psychologist particularly
in economically depressed areas where many indigent clients may
need psychological services (pp. 5152).

In the socioeconomic climate of the fishing village, bartering with sea-

food 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 nor-
mative 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 mans mental stabilization
so his unique talent could be harnessed and he felt most appreciative.
10 U N U S U A L I N T E RV E N T I O N S

The two were in the midst of negotiating over a fair value for a given
work that especially caught the therapists 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 tak-
ing so much. Conversely, the therapist may have felt guilty over hav-
ing 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 therapists counter-
transference. Such patients are used to having their desires quickly
gratified and often find psychotherapy tedious. They want immedi-
ate satisfaction, exclusive attention, and are often intolerant of being
questioned. As a result, they stir up powerful countertransference reac-
tions 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 patients
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 convo-
luted family history replete with intrigue, great fortunes amassed
and lost and regained, violence, perversion, incest, alcoholism and
 M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 11

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 suc-
cess 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 ther-
apeutic 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 ina-
bility to wait were such that I came to expect regular telephone con-
tact. 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. Xs
demand for exclusivity. I had worked in a private hospital which
routinely accommodated the demands of many very wealthy and
12 U N U S U A L I N T E RV E N T I O N S

disturbed individuals so this patients demands were an extreme

example of such a pattern. Having observed well-respected sen-
ior 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, assum-
ing that it was bona fide, explored my countertransference reac-
tion 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 maintain-
ing all of my analytic patients and working towards ending my
less intensive psychotherapy patients over time. Having had a half-
time inpatient job for many years and not having a full-time private
practice at that time in my career, I had such a template in my mind
and it was not out of the realm of possibility to imagine taking on
another half-time job.
Would such a grandiose and privileged individual even enter-
tain such a counteroffer, having just half of me instead of all of
me? What would it feel like to have such a fabulously wealthy and
important patient as my half-time job? How special would I feel?
A celebritys analyst After much reflection and a growing cer-
tainty that there was much more to this offer than I knew, I did
end up hinting at the possibility that I might consider a partial
arrangement with her. Perhaps it was my way of testing her since I
felt I had been feeling so tested myself. Not surprisingly, she flatly
refused. It was all or nothing. An imperious display of splitting.
Shortly after this interaction, the evaluation started to wind down
and came to a rapid close. I could not be bought at her price under
her conditions and she went into a quiet, but seething, narcissistic
rage. Subtle evidence of a deep vindictive spirit surfaced and I felt
a great relief to have ended this most unusual exercise. While it was
too soon to know for sure if this dynamic informed some of Ms. Xs
motivation also, it was clear that she came across as someone who
was quite used to getting her way and was quite willing to pay
exorbitant amounts of money to have people under her control.

Aside from the obvious humane and ethical issues associated with pre-
cipitously terminating ones patients in order to take a better offer
financially, it would be completely untenable to be owned in such
a way and still think that one could maintain any sort of an analytic
 M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 13

stance. Yet, I was intrigued by the outrageous nature of her sense of

entitlement and was quite curious about where all this would lead.
As the evaluation continued, I found myself having fantasies about
wanting to negotiate with her. Imagine cutting back my practice to
about half-time over many months and accepting half of the retainer.
I then realized that her offer was unconsciously determined to test ones
greed and corruptibility especially when she said she would be pre-
pared to wire the sum in advance directly to my bank account as soon
as I were to agree to her terms. So, the issue of payment in advance also
entered into the clinical picture.

Payment in advance
My experience with several analytic patients who had wanted to pay
in advance also came to mind. In each of these situations, while the
requests were consciously based and well rationalized (e.g., for tax
purposes to prepay a number of months at the end of a calendar year),
they invariably betrayed an underlying fantasy relating to holding onto
the object. Whether it was due to fear of object loss due to illness, death
or outright rejection, or an omnipotent fantasy that the patient would
stay alive and healthy indefinitely, the common denominator was guar-
anteeing a continued union with the analyst. On a deeper level, there
was a desire for a reunion with the pre-Oedipal, idealized mother sym-
biosis and to maintain the idyllic dyad.
In one case, the patient was a woman who was adopted at birth into
a family who subtly reminded her of how lucky she was for hav-
ing been taken in by them. Her status as an adoptee was invoked to
induce guilt and obedience in her as she feared being sent away if she
did not live up to whatever demands her loving and generous fam-
ily would make of her. Her deep insecurities over truly belonging and
being acceptable continued into her adult life despite all the trappings
of a successful life. In the transference, she insured her place on my
schedule through periodic advance payments. Rationalized and heav-
ily defended, this enactment was not amenable to interpretation until
she ran into financial difficulties at which time her deep fear of being
summarily dismissed came to the fore.
In another case, a man in analysis with severe heart disease was
undergoing tests and procedures to determine if he were a candidate for
an operation. In his situation, the operation would have been extremely
14 U N U S U A L I N T E RV E N T I O N S

risky in that he might not have survived it so it had to be carefully

considered. Were he not to have this operation, however, then it was
quite likely that his life would have been quite foreshortened. During
this very tense and uncertain time, he received a bonus check from work.
Consciously concerned that he might squander the money, he wanted
to apply these funds to future analytic sessions. His underlying fantasy
was deeply repressed, the handling of which required great delicacy
and tact given the life-and-death situation he was contending with.

Deferred payment
A senior colleague who was well known in his earlier days for hav-
ing the highest fees around taught his students that psychoanalysts
should not have to apologize for charging money for their services.
It was an important and healthy message for those who might be feel-
ing guilt or a sense of inadequacy early on in their careers. He even had
a credo which was a parody of the sacred Latin expression in the finest
Hippocratic tradition Primum non nocere (First, do no harm). His
motto was primum, suscipio tributim (first, get paid). In other words,
before undertaking a course of analysis which could reasonably extend
over a number of years, it was important to carefully evaluate the pro-
spective patients capacity to pay for the services and determine what
kind of resources might be there in case of an emergency.
Although this esteemed analyst had good reason to have a high
opinion of himself, some thought his attitudes were a bit mercenary
when, during an economic downturn when analytic patients became
even more scarce than usual, he began advocating a deferred payment
model. After a careful assessment of the patients analysability, he sug-
gested an equally careful financial analysis including their monthly
budget, a review of their annual income tax forms. Then, based upon
these figures, he would then offer them a payment plan which included
an affordable amount of his standard fee per session up-front and the
balance to be paid at a later date, possibly near or after termination.
This deferred balance would then accrue an interest charge consistent
with the banks fluctuating rates for comparable loans. The patients
would then be required to sign a legal contract before analysis could
begin. In this way, he argued, analysis could be offered to many more
patients even during difficult times and he felt certain that all the issues
associated with such an arrangement were analysable.
 M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 15

It was never clear how many people he attempted to analyse were

agreeable to such an arrangement. Moreover, I am not aware of his
ever having written about this experience or shared his feelings in any
methodical fashion. What was clear was that as he got older and near
the end of his career he became very outspoken about the need for
young training analysts to be willing to sacrifice in the name of further-
ing the cause of psychoanalysis and accept drastically reduced fees for
candidates. It appeared that this analyst, once having achieved financial
security in the autumn of his career, adopted a rather different attitude
for analytic fees for others. Whether the new attitude reflected hypoc-
risy or an enlightenment based on his failed experiment functioning as
both an analyst and a loan officer simultaneously was not clear. To his
credit, however, I believe a number of analysts became more willing
to consider accepting some deferred payments from their analysands
but did not levy interest charges on the agreed-upon unpaid balances.
These analysts did, however, make it clear to their analysands that all
aspects of such arrangements were subject to analysis.
Leaving aside the outlying stance (and its later transformations)
of the senior colleague mentioned above, one has to address the clini-
cal situations where the policy of deferred payment might serve as a
stop-gap measure. Individuals who have started new employment,
out-of-town college students, and workers who have been temporarily
laid off fall into this category. Their inability to pay as originally agreed
upon is generally transient and poses few problems for their ongoing
treatment process. This is not to say that the therapists willingness
to defer payments under these circumstances can never get caught in
transference distortions. It certainly can but, by and large, such prob-
lems are resolvable by ordinary analytic means and do not become
entrenched. All in all, when it comes to deferred payment, Freuds
(1913a) guideline remains valid till today. He said that ordinary good
sense cautions him [the analyst] not to allow large sums of money to
accumulate, but to ask for payment at fairly short regular intervals
monthly, perhaps (p. 131).

Gratis treatment
As is so often the case in Freuds writings, one might come across
conflicts or contradictions in his thinking. This is the case in his attitudes
about offering gratis treatment. He notes that the analyst should
16 U N U S U A L I N T E RV E N T I O N S

also refrain from giving treatment free and make no exceptions to

this in favour of his colleagues or their families (Freud, 1913, p. 132).
Having set aside an hour or two a day for ten years for such treatment
in the hopes of learning more about how to reduce patients resist-
ances to analysis, he concluded with a fair amount of certainty: Free
treatment enormously increases some of the neurotics resistancesin
young women, for instance, the temptation which is inherent in their
transference-relations and in young men, the opposition to an obligation
to feel grateful, an opposition which arises from their father-complex
The absence of the regulating effect offered by the payment of a fee to
the doctor makes itself painfully felt; the whole relationship is removed
from the real world, and the patient is deprived of a strong motive for
endeavouring to bring the treatment to an end (Freud, 1913, p. 132).
Freud (1913) also recognized the special problems associated with
poverty and observed that in trying to deal with the neurosis of a poor
person by psychotherapy [one] usually discovers that what is here
required of him is a practical therapy of a very different kind (p. 133).
Then he makes a tantalizing remark: Naturally, one does occasionally
come across deserving people who are helpless from no fault of their
own, in whom unpaid treatment does not meet with any of the obsta-
cles that I have mentioned and in whom it leads to excellent results
(p. 133). Unfortunately, he does not offer any criteria for these deserv-
ing people and leaves it open to our imagination and subjectivity.
Perhaps this statement foreshadows his vision of establishing psycho-
analytic clinics which he outlined in 1918:

The conscience of the community will awake and admonish it that

the poor man has just as much right to help for his mind as he now
has to the surgeons means of saving life; and that the neuroses
menace the health of the people no less than tuberculosis, and can
be left as little as the latter to the feeble handling of individuals.
Then clinics and consultation-departments will be built to which
analytically trained physicians will be appointed, so that the men
who would otherwise give way to drink, the women who have
nearly succumbed under their burden of privations, the children
for whom there is no choice but running wild or neurosis, may be
made by analysis able to resist and able to do something in the
world. This treatment will be free (Freud, 1918, quoted in Lorand
and Console, 1958, p. 59).
 M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 17

In an attempt to operationalize the parameters of free treatment,

Akhtar suggests the following preconditions

(i) The financial situation of the patient must be explicitly and

shamelessly evaluated before the decision for gratis work is
taken; (ii) Gratis work should not be undertaken by therapists who
are themselves struggling with finances; (iii) Even those who have
financial security should not take more than one or two patients on
a pro bono basis; (iv) An attitude of flexibility must be maintained
and fees should be introduced if the patients reality changes
(p. 92).

Yet, after all these deliberations, he suggests that an ultra-low token

fee is usually possible and preferable to gratis treatment. I agree with
his position as it maintains the analytic frame and is more amenable to
analytic exploration than an absent fee.

The CAPA experience

The Chinese American Psychoanalytic Alliance (CAPA), has been
making history in its efforts to bring psychoanalysis to China.2 The
American Psychoanalytic Associations recent outreach to interested
and qualified mental health professionals in China has resulted in a
number of analyses being conducted using the latest technology availa-
ble via the Internet. American psychoanalysts who may have never met
their Chinese analysands in person have evaluated and been conduct-
ing psychoanalytic treatment via Skype, a videoconferencing program
which allows for face-to-face telecommunication in real time. While
the efficacy of the treatment itself utilizing such innovations is a crucial
topic, it is too soon to know for sure and being such a complex subject
that undoubtedly much will be written about it in future publications
elsewhere. For the moment, however, the aspect of payment for the
analytic sessions is more relevant to our discussion here.
Payment is arranged through the Internet via PayPal which is a
financial intermediary where those who have accounts set up online
have their credit cards linked to these services. Access is gained through
entering an ID name and secret password. In this way, those who use
PayPal may, for example, buy items from others whom they have never
met who are advertising them online and know that there will be a safe,
18 U N U S U A L I N T E RV E N T I O N S

reliable exchange of money for that given piece of furniture, jewellery

or automobile. While there may not be a guarantee about the quality of
the item itself, unless yet another agency get involved to appraise and
authenticate it, the passing of funds from one to another is assured.
Therefore, the use of PayPal to collect analytic fees from the Chinese
being analysed over Skype was a logical plan under the circumstances.
Of course, the yen would have to be converted into dollars as part of
their transaction and, given the fluctuation of currency on the world
market, the cost of the session could vary considerably from day to day.
And, given the economic disparity between the two cultures, greatly
reduced fees or even pro bono fees have been necessary for many. Fur-
thermore, some analysts have reported that there have been delays in
receiving payments for their services and it has not always been clear
whether or not the problem has been due to resistance and acting out
on the part of the Chinese analysand or a technological problem in the
transfer of funds (Fishkin, L. & Fishkin, R., 2011). It is, therefore, quite
evident that those extremely dedicated and daring analysts who are
participating in this remarkable project have much to analyse about
money issues with their analysands. The extent to which it is possible
and what will be learned that may further our understanding about this
aspect of payment will become more evident over time.

The missed appointment dilemma

There is perhaps no other issue pertaining to the ground rules in treat-
ment is as contentious and central to the process as the handling of
missed appointments. I entered analytic training at a time when the
classical approach was the preeminent model and many still thought
it was the pinnacle of ideal technique to say as little as possible for as
long as possible and wait for the right moment to deliver the perfect
interpretation which would result in the necessary structural change in
the psyche. That was all that was needed. If this sequence did not occur,
then either the analyst was practicing poor technique or the patient was
not suitable. In either case it simply was not psychoanalysis. In this
climate, charging for all missed appointments was axiomatic and fail-
ure to do so was seen as a reflection of the fledging analysts inability
to maintain the proper analytic posture and/or the inability to tolerate
the patients aggression. After all, how could the analyst render a judg-
ment over which absences were legitimate? Moreover, how might a
liberal policy on cancellations undermine the analytic process through
 M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 19

an unconscious collusion with the analysands resistance to addressing

painful and conflictual material? In addition, how could the analyst
rely on a steady and predictable source of income if he, unlike medi-
cal professionals, did not double-, triple- or quadruple-book patients
at the same time, have them set up in different examining rooms and
circulate between them at a time vaguely corresponding to their given
appointment time? In that model, a patient who cancels or does not
show up is hardly even missed. Needless to remind the reader that
this position represents Freuds (1913a) stance; the rationale for this
classical perspective is best explicated by Ursano, Sonnenberg, and
Lazar (1998), who assert it to be:

the most neutral and fundamentally respectful stance for the thera-
pist to take. Otherwise, the therapist takes the position of making a
moral judgment about whether the absence was justified. In such a
case, the therapist, in effect, volunteers to make a personal financial
sacrifice if an absence is deemed worthy of being excused. If the
patient is angered by paying for a missed hour, there is then an
opportunity to explore the dynamics of the anger and why the
patient feels that the therapist should absorb the exigencies of the
patients life. Similarly, the therapist operating on these guide-
lines can more appropriately set fees reflecting a known stability
of chargeable hours and therefore potentially lower per-session fee
(p. 174).

An opposite point of view is expressed by Schlesinger (2003) who never

charges for missed appointments. Akhtar (2009a, 2009b, 2009c), while
also leaning in this direction, attempts to strike a sort of compromise
between the conservative position of Ursano, Sonnenberg, and Lazar
(1998) and the more liberal, if not radical, position of Schlesinger.
He suggests that the analyst should consider not charging for missed
sessions due to:

(i) developmentally appropriate out-of-town interludes (for vis-

iting parents, studying abroad) of college students; (ii) serious
medical illness of the patient, and, according to Pasternak (1986)
of the patients immediate family members; (iii) family vacations
which the patient, despite earnest effort, could not manage to
match with the therapists time away; and (iv) natural disasters
(pp. 8182).
20 U N U S U A L I N T E RV E N T I O N S

My own position has evolved over time. Having experimented at

both ends of the spectrum with short- and long-term psychotherapy
and psychoanalytic patients, it is clear that, as the saying goes, One
size does not fit all. Having said that, however, not having a consist-
ent policy would make it difficult to recognize certain enactments as
they emerge in the relational matrix. As a result, my current policy is
to charge for missed appointments unless they can be rescheduled that
week or unless I can fill the hour. Since other patients are often waiting
for additional hours, it is frequently not a financial issue but remains an
essential topic for psychoanalytic exploration, as other issues emerge,
such as the fantasy of being easily replaced.
Coming back to Schlesinger (2003), I cannot fail to note his claim
that none of his patients have ever abused this policy on his part. This
is remarkable, in my experience. In another context, I had heard that
Harold Searles once confronted a presenter making a claim about
treatment of psychotic patients and asked, Why is it that I never see
such patients like that? The following vignette describes charging
for a missed appointment and the implications it had for the analytic
process.

Clinical Vignette: 3
Simon was a young, single man who entered analysis with a history
of depression, homosexual anxiety, low self-esteem, difficulty in
intimate relationships and chronic rage against his very successful
but aloof and caustic father. He was very engaging and likeable, but
did not realize his own assets. He carried an enormous burden of
unconscious, predominantly neurotic guilt which was periodically
expiated through enactments of victimization which alternated
with a wish to be treated specially. He had only an inkling of aware-
ness that this pattern had psychological significance which related
to perceived danger of his Oedipal strivings for his overstimulat-
ing and unavailable mother. Early in the second year of treatment
when derivatives of this material were becoming manifest in the
transference, he was rushing for an appointment in his habitual
way of cutting it close which often resulted in several minutes of
lateness. This time, however, he never made it to his appointment
and I waited for him past his usual time of arrival.
 M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 21

It was uncharacteristic of him to miss an appointment as he

was quite involved in the process and in general a responsible
individual. I turned the ringer on to my telephone, sat back down
and started to read a journal. A few minutes later, the phone rang
and it was Simon calling in a very excited state. He was speeding
to his appointment and was hit by another motorist. Physically he
was okay but had to wait for the police. He would not make it to
the appointment. Oh, and by the way, he mentioned, he was just
around the corner It was clear to me by the tone of his voice and
the way he spoke that he was quite shaken up and as he lingered
on the phone an unspoken question was being asked of me in
the maternal transference: Will you walk over and see how I am
doing? At that moment, my own parental protective feeling welled
up as I heard his scared, little boy voice break through his brave,
self-sufficient veneer. I immediately sensed that this event and all
of its ramifications could have enormous significance for Simons
analysis. What was enacted in both of us during this unexpected
moment of an averted tragedy would take years to analyse but for
the present there were immediate technical considerations. The end
of the month was approaching and I needed to consider the impli-
cations of how to handle his missed session.
At this point in my career many years ago, as noted above, the
culture of having been trained in a rather classical institute was
such that charging for missed appointments was quite normative.
Despite whatever theoretical or humane rationale to behave to the
contrary under extenuating circumstances, such as bad weather, ill-
ness or attending funerals, those who publicly espoused making
exceptions would risk furtive glancing among certain colleagues
who were concerned about such exceptions. Making such excep-
tions might be an enactment of childhood special treatment and
serve to reinforce the patients pathological narcissism, rendering
it less analyzable. Moreover, the analysts anxiety over tolerat-
ing the patients aggression has been seen as an important factor
in why such exceptions would be made. Indeed, such a difficulty
in tolerating aggression in the patient is for psychoanalytic can-
didates, perhaps one of the most frequently discussed topics in
progression committee deliberations over whether the analyst-in-
training is ready to take on another case, graduate or need more
22 U N U S U A L I N T E RV E N T I O N S

analysis. With this traditional foundation imbued in my analytic

superego, I had maintained a consistent policy of charging for
missed appointments unless I were able to fill the hour. At that time
it was rare to be able to fill the open hours so, as a result, Simon was
often charged if he were on vacation. He understandably thought
it rather unfair. Given his characterological difficulty in express-
ing anger towards authority, his protests were meek, tentative and
oblique complaints about the rigidity of my rules. He would then
berate himself for having such a weak-minded confrontation with
me, rationalizing and at times defensively empathizing with the
plight of the analyst. He also felt a debt of gratitude for my having
negotiated a lower fee with him so he could proceed with analysis
in the first place. This kindness on my part intensified his conflict
over being angry lest he feel ungrateful and more guilt-ridden. At
the time of the automobile accident he was on the threshold of an
appreciation of the phenomenon of transference, i.e., he was still
in the phase of resistance to the awareness of transference (Gill,
1983).
It was striking that during his next analytic hour the day after
the accident, of all things that might have come up in his associa-
tions, it was his question over whether he would be charged for
the appointment! Still very unsettled over what could have been a
catastrophic accident, he quietly waited for my response as though
my verdict of his financial responsibility would have either exon-
erated him from his guilt over the accident itself or condemn him
to be indicted for some unconscious crime. At the same time it felt
a bit cold on my part to hold him to the rules, given the terrify-
ing nature of the accident and the impossibility of his being able
to keep the appointment. I was also aware of perhaps wanting to
let him know that even though I did not walk over and see him I
still did care about him, i.e., that I was a good and attentive parent
unlike his own. However, I was concerned at the time about losing
an important analytic opportunity if I did not remain consistent.
On the other hand, I was also concerned that he might become so
hurt by my seeming callousness that he might drop out. I was not
sure that our therapeutic alliance was strong enough that he could
appreciate the ambiguity of the analytic situation enough to experi-
ence me as anything other than being truly indifferent to his suf-
fering. Yet, I was also aware of his tendency towards an idealized
 M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 23

homoerotic transference and his wish that I would relieve him

of his suffering. He no doubt wished that if I had not stepped out
of my office literally and walked over to comfort him, the least I
could do would be to waive the fee for the session. I was not sure
what to do.
After an extended silence when the patient was waiting for
my response, I made an empathic remark about recognizing how
frightened he had been, how well-intentioned he had been to make
the appointment and how apparently unavoidable the collision had
been. I made no mention of his confession that he had exceeded the
speed limit at the time. I also told him that I thought the whole
incident had psychological ramifications that when he felt better
we would explore. Simon listened carefully and was not satisfied
with what he experienced as my evasive answer. He seemed to
need more in order to contain his mounting anxiety and I felt a bit
pressured to give him something, mindful of the regressed state
that he was in following the collision. I then told him I would think
a lot about this dilemma as I wanted to make a decision that would
be best for his analysis. While it was not entirely clear to me that
there was indeed one decision that was better than the other, the
worst case scenario of either decision, i.e., an unanalyzable, grati-
fying enactment or hurt and enraged patient who dropped out of
treatment, loomed in my mind.
The patient was mollified in the short term and more associa-
tive material began to follow which pertained to fantasies about
the other motorist and how many close calls and fender-benders he
had had in the past. Medical concerns over musculoskeletal strain
as well as police reports, insurance claims, his familys reaction and
childhood reminiscences came to the fore. Then, on the last day
of the month he apprehensively and excitedly awaited my hand-
ing him the statement. This ritual was well-known to us by now,
but this time it had assumed the import of opening the envelope
at an Academy Awards ceremony where the winner of an Oscar
would be announced to a tense and eager crowd. Having tolerated
the suspense for several days as the shock of the collision began to
wane, the patient was certainly hoping to find the good news in
his envelope.
With tentative optimism he tore open the bill and was confused
by what he saw. In my own deliberations, I concluded that the best
24 U N U S U A L I N T E RV E N T I O N S

way to handle it was to actually postpone making the decision

until the decision itself could be analysed. I therefore communi-
cated that stance by including the charge for the session in question
and then literally writing in a question mark next to it. The question
mark was intended to say that I was open to questioning to charge
also and would be willing to take as much time as necessary to
anal it with him. While I myself felt mildly pleased with this inter-
vention, Simon was dismayed. Like a disgruntled crowd at a box-
ing match which sits through many rounds of a fight only to have
the referees not declare a winner and call it a draw, he was disap-
pointed and puzzled. Why didnt I take a stand? Did I really want
him to pay and was too polite to tell him right away? Did I hope to
wear him down so that he would ultimately submit to my demand?
Or if I didnt want him to pay why was I being so cagey? Or were
there other nuances that he was not yet able to see? Why couldnt
I just be clear with him? Why did we have to drag it out? Wasnt
I being cruel and unjust making her languish in his uncertainty?
Why couldnt I just decide and let it be over? These and other ques-
tions enraged him over subsequent months as our analytic explo-
ration of the missed appointment became a central issue around
which virtually all of his transferential issues crystallized. From
capricious parental authority and domination/submission issues
associated with sadomasochistic enmeshment with the object, to
compliance/defiance and issues associated with autonomy, Simon
struggled with this challenge. Over time he began to see that
the significance of our plight went way beyond the actual dollar
amount of the appointment itself. Indeed, he bemoaned how many
more dollars he was spending just talking about that damn ses-
sion but refused to come to his own conclusions about how best to
handle it. Paying the fee at times felt like humiliating and passive
surrender to his fathers imperious demands which then merged
with frightening, early sexual experiences in adolescence where he
found himself in vulnerable situations with older boys who forced
him to perform fellatio, but in so doing exonerated him of any guilt
over his own homosexual wishes.
The disowning of his instinctual strivings, both sexual and
aggressive, then emerged as an important dynamic incorporated
into his character structure. It became evident over time that
through projective identification he could subtly induce others
 M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 25

to make decisions for him on his behalf which freed him up from
taking any responsibility. Through a passive pseudo-helplessness,
others would do for him or to him. As Simon railed on and on
about my unfairness about the missed appointment, his analysis
unfolded and actually blossomed. In time, he could begin to appre-
ciate the nature of transference and how it was colouring his per-
ceptions of me. Yet, it continued to offend his sensibilities that he
might have to pay for the hour. He tried hard to empathize with the
analysts point of view over paying for missed appointments but
still insisted that it would be unjust to pay for the session in ques-
tion. But, maybe he should and maybe he wasnt because he was
being obstinate. He wondered whether or not I had gotten enough
out of this exercise with him.
Couldnt I just tell him it was okay? How much sadistic
enjoyment might I be deriving from watching him squirm over
all of this? On the other hand, maybe he could end some of his
own anguish if he resolved some of his own guilt. After all, he
was speeding. He did have destructive, aggressive thoughts and
he did become more conscious of feeling guilt. Psychological guilt,
however, could not be easily distinguished from culpability and
guilt in a legalistic sense so why didnt I just put him out of his
misery?3 Yet, we persisted and material continued to flow. In each
subsequent months bills, the questionable charge was carried over
and he paid for everything except for that fee. It remained a major
annoyance for him and, like the proverbial irritating grain of sand
in the shell of the oyster which over time is worked over and over
until it becomes a smooth pearl, so, too, did Simon work and re-
work the issue in the transference. In time and begrudgingly so, it,
too, became very valuable for him.
I made no attempt to push him to get closure on the issue. Even-
tually he reached a point of mental exhaustion over it and decided
he should just pay the fee and be done with it once and for all.
Since, however, the magnitude of the issue was such that it could
not simply go away, his deciding that he wanted to pay needed
to be anald also. This experience was not an exercise in behavior
modification masquerading as psychoanalysis whereby I covertly
wanted him to pay me and eventually come to that conclusion on
his own. Each of us had a conflict over whether he should indeed
be charged. Therefore, whatever he decided was less important
26 U N U S U A L I N T E RV E N T I O N S

than the process of deciding and understanding the meaning that

it had to him. Feeling that he had gone as far as he could go, he then
included the payment in his next monthly check to me about a year
after the accident.
Not surprisingly, the issue never really left the analysis and
coloured all future absences on his part. As the treatment pro-
gressed and he neared termination, the issue resurfaced during
times of reminiscing over the high and low points of the treatment.
I sensed a continued grievance on his part about how it was han-
dled. Expressing himself in a much more enlightened way as his
observing ego and insight into his psyche had grown, he maintained
that I had erred in levying a charge under such circumstances. And,
what do you think, he insisted? Inviting me to confess to having
made a mistake, I empathized with his continued hurt and wanted
to point out to him how much grist for the mill we had been able
to derive from this incident but I doubt he would have felt that the
end justified the means. Frustrated with me that I either could not
see the error of my ways or refuse to acknowledge it, I interpreted
the continued grievance he had towards his parents also. Perhaps
if I could acknowledge my error then it might compensate a bit for
all the unacknowledged errors his parents had committed. Without
protesting, he accepted my interpretation but felt I was avoiding
the immediacy of our situation, nonetheless.
As a testament to his persistence, up to the last hour of his analy-
sis, which occurred on a date which had been set many months in
advance and had been carefully considered after years of produc-
tive analytic work, Simon gave me one last chance: So, tell me, he
asked with a wry sense of humor, if you had it to do over again,
what would you do? Would you have charged me? Would you?

Simons analysis continued up to the last minute of the last hour

(Lipton, 1961). Just as a patient may try to engage the analyst in a dif-
ferent kind of conversation before the session starts or after getting
up from the couch on the way out the door, so, too, did Simon want his
answer before he left for the last time. Regardless of whether I answered
him or not, the profound meaning of the question for him is the impor-
tant issue here. It took on such significance in his mind that much of his
analysis crystallized around it. While it certainly may be that we might
have gotten to the same dynamics of his character had I handled things
 M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 27

differently, we cannot know for sure. Conversely, what might have been
missed, overlooked or simply not having entered into the transference
because of how I handled it needs to be considered also.

Conclusion
In this report on variations of payment, I have tried to illustrate some
of the modifications of the usual model. It was not intended to cover
all possibilities but, rather, to extend the discussion and to invite oth-
ers to describe their experiences also. For example, I did not discuss
extending professional courtesy in an initial consultation. This practice
is not uncommon when dealing with colleagues and their families and
acquaintances. Nor did I address issues of payment associated with
child analysis, a topic worthy of extensive study. One aspect of this
area would be the transition of payments by the parents for the treat-
ment to payments by the patient himself in late adolescence or early
adulthood.
I also did not elaborate upon the myriad details that characterize
our usual practice, those subtle nuances that may fluctuate which
communicate so much consciously and unconsciously to our analytic
patients about our attitudes about money, our sense of self-worth, our
professional work and our feelings about the patient. These tiny vibra-
tions in the analytic field may send huge ripples which have important
repercussions in the analytic dyad. For example, how timely are bills
given to the patient each month? How accurate are they? Who prepares
them? How aware is the analyst of the patients current payment sta-
tus in the treatment? Are the bills hand-delivered or mailed? With or
without an envelope? Typed up or handwritten? How legible are they?
Do they include diagnoses and treatment codes for insurance compa-
nies? If so, how are these issues decided and analysed? When in the
session are the bills given? How long does the analyst usually wait to
be paid after the bill is given before it becomes an issue for the ana-
lyst? Does that period of time vary from patient to patient? And why?
How actively does the analyst then listen for material referable to
the nonpayment and actively make interventions? Are these interven-
tions more active than other interventions? And why? How does the
analyst handle fee increases? Does the fee stayed fixed throughout the
duration of the treatment? If so, then why? If not, then how much and
how often are such increases levied? How are these changes decided
28 U N U S U A L I N T E RV E N T I O N S

and how they are analysed in the treatment? And, finally, how is the
last bill of the analysis handled? What effect, if any, does when and
how it is presented have on the termination process if that payment
occurs weeks after the last session and is not analysed with the analyst?
Clearly, there are many more questions than have been generated here
which highlight the multitude of details that may take on undreamed
of significance.
The analysis of the payment arrangement is an essential aspect of
the treatment situation. Whatever is negotiatedbe it a reduced fee,
standard fee, deferred fee, advance payment, credit card payment, Pay-
Pal payment via the Internet, barter, daily payment, weekly payment,
monthly payment, or annual paymentit all has meaning. Moreover,
the handling of missed appointments, I would contend, is at the heart of
the analysis of money and whatever financial arrangements are made
for the patient. The psychology of the analyst, and where he or she is
on the professional life cycle, are crucial considerations in understand-
ing the complex communication that occurs intersubjectively over the
exchanges of money in the treatment.

Notes
1. In his paper, On beginning the treatment, Freud (1913) elucidated his
stance in the following manner. In regard to time, I adhere strictly to
the principle of leasing a definite hour. Each patient is allotted a par-
ticular hour of my available working day; it belongs to him and he is
liable for it, even if he does not make use of it (p. 126).
2. This is by no means to diminish the outstanding contributions of the
IPA China Committee and the associated work of such distinguished
colleagues as Peter Loewenberg (USA), Sverre Varvin (Norway), Alf
Gerlach (Germany), and Maria Teresa Hooke (Australia). My focus on
CAPA is solely due to my greater familiarity with its work; many of my
Philadelphia colleagues are involved in it.
3. There is a curious aspect of this situation about which a thoughtful con-
sideration is warranted but is beyond the scope of this paper. That is
the fact that this patient did not develop any posttraumatic symptoma-
tology following the collision. In the past he had suffered from recur-
rent nightmares and traumatic reliving associated with other terrifying
and possibly life-threatening incidents. So, it was known that he was
susceptible to have such a psychological reaction. In this situation the
patient realized that there was going to be a collision, could not have
 M A K I N G E X T R AO R D I N A RY M O N E TA RY A R R A N G E M E N T S 29

avoided it and had a fleeting awareness that he might be killed, yet

he did not suffer from any of these phenomena. In analysis he had a
daily opportunity to associate to it and analyse any and all aspects of it.
It may be that his suffering in the transference and the issue of paying
for the missed appointment served as an externalization of his conflict,
which perhaps prevented the crystallization of PTSD symptoms.