The Introduction to Psychoanalytic Concepts I and the Practical Analytic Subjectivity I courses dovetail nicely this week for both address the fee aspect of the analytic frame. Bass advocates for flexibility
Because analysts work within different frames over the course of a day's work…a notion of the analytic frame is misleading… Rather, analytic frames come in many different shapes … constructed out of a variety of materials, varying in intent …understanding and articulating the particular ways in which the frame doesn't fit inevitably becomes an integral aspect of an evolving therapeutic process.
flexibility in negotiation of each dyad’s unique frame, paying “attention to the vicissitudes of the ongoing negotiation”, a negotiation that is ongoing as both patient and therapist change over the course of treatment. [Levine, too notes that “[t]he frame is established and re-established daily From his relational perspective, Bass recognizes that the analytic frame is co-created and contextual. He may actively enjoin the participation of the patient, even inquiring about her experience of him in negotiating the fee so as to invite in possibly disavowed aspects of his subjectivity. He writes “My unconscious life with any given patient is implicated”. Furthermore,
the establishment of the frame serves both as a relatively fixed, clearly defined container for the therapeutic work and as a point of departure for the negotiation of transference-countertransference elements, and enactments, and the working through of such enactments in an intersubjective field.
Bass reminds us (from Mitchell, 1993)
what is most important is not what the analyst does, as long as he struggles to do what seems, at the moment, to be the right thing; what is most important is the way in which analyst and analysand come to understand what has happened.
In class, we discuss again the fee, including an easy to read, brief paper by Allen which, despite it’s use of the meta-psychological language such as strengthening of the ego and superego, and more importantly, the not yet considered (in 1971) importance of including the patient in the negotiation of the analyst’s dilemma (such as: ‘I charge for missed appointments and need to make a living but worry I will be re-enacting your “rigid overly demanding mother who never gave an inch” ‘-case 4; or conversely, ‘I am of two minds about charging for missed appointments when you were so ill, but worry I will be failing to expect you to be the responsible adult that you are just as your laissez faire parents failed to see you as capable‘ –case 5), it makes several helpful points:
when a therapist ignores or fails to properly deal with the whole area of payment or nonpayment of his patient's bills, he too is violating an explicit and agreed upon responsibility—namely, that of effectively functioning as his patient's therapist
Gedo states: 'When a patient in psychotherapy fails to pay his bill he has violated an explicit and agreed upon responsibility'. I would like to add that, conversely, …as I understand it, is that the withholding of payment for psychotherapy is best explained in the conceptual framework of the transitional phenomenon of Winnicott (6): when the withholding of payment is an attempt by the patient to deny his separateness from the therapist, the retained money represents a transitional object.
And the long arc of the analytic attitude where the patient is
being recognized by the analyst as something more than he is at present
Expanding [see post March 10, 2011] the idea of the frame is my favourite of the class papers this week, by Miller and Twomey, not because of its ideas about salary and fee for service, but because it brings in the idea of the Third as an essential component of the frame.
In the analytic situation, this third element is supplied by the analytic setting…[and]“triangular space” in analytic work is the therapist's symbolic thinking… both influenced by and independent of the patient's mind. … [T]he Third keeps the analytic situation from degenerating into nothing but a personal encounter… Without the Third to structure the relationship between patient and therapist the dyad falls prey to the danger of merger and incoherence in which everything outside its relationship is excluded and denied.
Allen, A. (1971). The Fee as a Therapeutic Tool. Psychoanal Q., 40:132-140.
Bass, A. (2007). When the Frame Doesn't Fit the Picture. Psychoanal. Dial., 17:1-27.
Levine, A.R. (2009). Bending the Frame and Judgment Calls in Everyday Practice. JAPsA., 57:1209-1215.
Miller, L., Twomey, J.E. (2000). Incoherence Incognito: The Collapse Of The Third In A Fee... Contemp. Psa., 36:427-456.