Commentary on “Jihad, McWorld and Enactment in the Postmodern Mental Health World” by Eric M. Plakun

This is a carefully and beautifully articulated paper dealing with the reality of the insurance company as a present third object in the psycho-therapeutic situation. It is a presence that must be recognized and to which the clinician must relate in some fashion, even though the analytic dyad or the individuals comprising it may have negative or mixed feelings about it. On reflection, this “third” party is always present in any treatment, be it in the form of managed care company, wealthy family, Medicaid, trust fund, or economically deprived circumstances of the patient's life. Frequently, for the psychoanalyst of former days dealing with financially comfortable clients, this third object functions as a benign, noninterfering presence, providing nurture without interference, a kind of “good-enough” Winnicottian “father.” The object's significance is appreciated but it makes no demands in any distracting or overly stressful way, and can be easily invisibilized. Nevertheless, this does not mean that the third object is absent.

In today's economic circumstances, matters have changed for many of us, and there is a necessity for us to at least give attention to and acknowledge the financial reality as objectified here in managed care. Interestingly, Eric Plakun covertly criticizes the senior analyst, who seems to operate from that prior generation when ignoring and denying the third presence could be done more easily. Unfortunately, her “containment” of feelings about it and how it was affecting the treatment arguably stunted rather than fostered growth. While the patient was intrapsychically trying to deny his relationship and connectedness with the analyst, he was also supported by her in denying his and her relationship with the managed care company. By dealing with it openly, the analyst might well have served as a model for relating to “a not perfectly welcome” presence (as hers was with the patient). Additionally, such openness might have demystified a certain omni