Third-Party Payment: Can Its Transference Significance Be Analyzed?

When the patient pays his bill regularly without any sign of unconscious conflict we tend to consider this behavior part of the real relationship or the unobjectionable positive transference. If he “forgets” to pay we interpret this as transference resistance. But the patient does not behave ex vacuo and “without the contribution of the doctor” (Freud, 1925, p. 42), and the analyst is not a blank screen even in the sense of deprivation in intimacy, but contributes to the transference in many decisive ways, often inadvertently (Gill, 1982; Gill and Hoffman, 1982). In this paper I shall examine in detail one aspect of the psychoanalytic setting, namely, the procedure that is required in order to procure payment for psychoanalysis and psychotherapy from the mandatory health insurance system in Germany. I shall scrutinize not only the repercussions of this type of third-party payment on the transference and on the psychoanalytic process, but also the analyst's and patient's attitude toward this procedure.

In Germany, 92% of the population belongs to the mandatory health insurance system, 20% have some form of additional private insurance, and 8% are privately insured. There are several public health insurance organizations. In cases of psychoanalytic or psychotherapeutic therapy, the patient files an application with the insurance company, accompanied by an extensive report that has been written by the patient's medical-psychological