Cultural Norms And The Patient's Experience Of The Analyst's Business Practices

I recently had a conversation with a Norwegian analyst that stimulated my thinking about the ways that social norms and expectations might operate “behind the backs” of analyst and patient. My colleague mentioned that his patients rarely complained about his practice of billing for missed appointments that he could not fill. He told me that he rarely volunteered—nor was asked for—a rationale. I told him that in my practice, and in those of my colleagues, many patients tended to feel burdened or even exploited by this policy. Sometimes they voiced their complaints, other times not, but they seemed more or less able to understand, tolerate, and even appreciate the need for financial security that generates this kind of billing practice.

I wondered if his patients might be compliant with authority or engaged with the analyst in some type of unanalyzed collusion. I said that my own experience and theoretical bias—not uncommon in the United States—led me to be particularly sensitive to the subtle ways that uncontested dimensions of certain analytic arrangements often involved covert resistances, collusions, or enactments in which the “reality” of the analyst's self-interest was disavowed in order to avoid conflict, protect the patient's narcissism, or mitigate the analyst's guilt. I said that in my experience my nondefensive acceptance of my impulses (including those related to my financial needs), my willingness to candidly acknowledge the underlying “reality” within which the analyst's and the patient's interests conflict, and my readiness to analyze the transference -countertransference fantasies around these issues were extremely important.