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The Symbolic and motivational significance of payment for psychoanalytic therapy has been discussed by several writers including notably Freud,1 Fenichel,2 and Kubie.3 Seldom have the cultural factors related to payment received equal attention. Generally, the giving and withholding of payment has been described in terms of “instinctual drives” involving orality, sexuality, and anal-sadistic strivings. Freud4 has also discussed the secondary gain aspects of psychoanalytic therapy, and difficulties concerning payment which can arise on a realistic basis between therapist and patient.
No one, however, appears to have described the full impact of cultural factors on the significance of payment in psychoanalytic therapy, or to have structured the meaning of payment within the framework of relationship between conflict and civilization described so well by Horney:
“The kind, scope, and intensity of conflicts are largely determined by the civilization in which we live. If the civilization in which we live is stable and tradition-bound, the variety of choices presenting themselves are limited and the range of possible individual conflicts narrow…. But if the civilization is in a stage of rapid transition, where highly contradictory values and divergent ways of living exist side by side, the choices the individual has to make are manifold and difficult.”5
The conflicts about payment to which our particular civilization gives rise revolve essentially around the question of who shall pay for treatment. Should it be the individual patient who, since he pays for most of his other personal services in our mainly capitalistic society, might feel uncomfortable, inadequate, or dependent, if he does not buy his own psychoanalytic services? Or should it be paid for by the community, or state or Federal government, as part of its responsibility for the maintenance of the health and welfare of its citizenry?
Obviously, different cultures can produce different areas of conflict.