Therapy is for losers
On the ethics of the fee
Hi friends,
I was asked to contribute a short entry for a dictionary on ‘Psychoanalysis and Money’ that my colleagues at the FreePSY project are publishing, on ‘the ethics of the fee’. I thought I’d also share it with you:
The dedication to Winnicott’s Playing and Reality reads: ‘To my patients who have paid to teach me’.
In these stark terms, Winnicott captures the fundamental question underlying the psychoanalytic fee: why should the patient pay?
Freud addresses the fee in ‘On Beginning the Treatment’. While drawing a link between society’s contradictory attitudes towards money and sex, he appears primarily concerned with the importance of the analyst securing a livelihood, against the pressures he may face ‘to act the part of the disinterested philanthropist’.
This seems to leave open whether the fee has any value for the patient. Could an alternate arrangement — such as the salaried doctor employed by the state — equally solve this problem, without requiring the patient to pay? (We might acknowledge the current direction of travel: the therapist as gig-economy worker, no longer charging directly, but receiving their pitiful sum from a ‘therapy platform’ that profits off patient and practitioner alike.)
However, Freud makes a brief statement on the danger, for the patient, of receiving free treatment:
The absence of the regulating effect offered by the payment of a fee to the doctor makes itself very 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.
The patient must pay, Freud suggests, so that he is motivated to get better. Implicit here is the theory that, at some level, the patient is invested in his suffering: the symptom provides a ‘substitutive satisfaction’. The pain of the fee helps the patient reconsider the worth of his investments.
We should however note Freud’s reference to ‘the real world’. If we did not live in a world governed by the market, would the economy of psychic suffering — and thereby, the function of the analytic fee — take a different form?
What may underlie the contingency of monetary payment within a capitalist economy is the universality of loss. Winnicott’s statement implies it: my patients give me money and knowledge — what do they get in return? As Lacanians often put it: in analysis, you pay to lose (chiefly, the perverse satisfaction or ‘jouissance’ underlying your suffering). This loss must be inscribed within the treatment, and words alone do not suffice. The child analyst Françoise Dolto famously asked her unwaged patients to bring her a symbolic object as payment — a drawing, a pebble, a stamp.
In the Communist Manifesto, Marx and Engels discuss the potential of the working class to overthrow the bourgeoisie and, in so doing, abolish class itself. They write: ‘They have nothing of their own to secure and fortify; their mission is to destroy all previous securities for, and insurances of, private property’.
Their idea is reformulated into the slogan: ‘Workers of the world unite, you have nothing to lose but your chains!’
Loss, in this formulation, becomes the precondition for liberation. Only through recognising our shared experience of dispossession can we take hold of our destiny.
Though they charge a fee, analysts do not exploit patients in the Marxist sense: if the patient’s suffering has a ‘surplus value’ it does not enrich the analyst, but is given to be lost. Thus, at its most ethically precise, the fee — however it is configured — may confront us with the possibility of loss not for their gain, but ours.