Incoherence Incognito: The Collapse Of The Third In A Fee-For-Service Structure*

Certain Conceptual Problems are inherent in doing psychodynamic psychotherapy within the typical fee-for-service setting, a structure that has become increasingly common in the provision of outpatient psychotherapy services. Although there is a growing body of psychoanalytic literature on a number of issues involved in managed care as it affects the practice of psychodynamic psychotherapy, we have found no analytic discussion regarding a different aspect of the changing culture of the mental health care system in this country: namely, the shift from salaried to fee-for-service positions for clinicians practicing in outpatient clinics. Decisions by mental health clinics to pay the therapist in this manner are made for purposes of cost-savings and survival in an increasingly competitive marketplace. The particular clinical and theoretical implications of that arrangement for a psychodynamic treatment have not, to our knowledge, been examined.

We consider the structural and dynamic dilemmas in fee-for-service practice with respect to the presence of what is commonly termed the Third in analytic work, and highlight the problematic place of the therapist in relation to the analytic space and its frame. The problems we discuss here are most clearly seen in the circumstance of the absent patient, the missed appointment. We illuminate and give life to that issue through a clinical vignette. Because the flaws that we identify relate to the analytic space and to the context that holds the dyad, however, such problems are not limited to particular clinical circumstances, but simply manifest themselves most obviously in relation to the missed session.

For a number of reasons, this topic is significant to practitioners and supervisors of psychodynamic psychotherapy. Some of those reasons we mention here without elaboration, but not because they are insignificant.