A vast majority of analysts reduce analytic fees, and a substantial majority have had no insurmountable clinical problems as a result. These empirical data were obtained as part of my 1997 graduation project from the UNC-Duke Psychoanalytic Institute, when I surveyed 300 members of the American.
I was aware that analytic caseloads were down all across the country, in part due to evaporation of third-party reimbursement for psychoanalytic treatment. I knew that some analysts, especially candidates, lowered their fees in order to do analysis. I set out to discover why analysts choose to lower or not to lower their fees (defined as a 50 percent or greater reduction of the usual fee) and — perhaps more important—what effects lowering fees has had on the analytic process and the outcome of treatment.
Not much has been written on the subject of fee reduction, and so far as 1 can tell there has been no previous empirical research on the subject. Earlier psychoanalysts who wrote about fees include Kubie, Fenichel, Fromm-Reichman, Karl Menninger, Glover, and Freud himself. Anna Freud said in 1980:
If in the past a patient could afford only a small fee, this did not alter [the analyst's] belief that he needed his full treatment time. The smaller fee was divided between the requisite number of hours, which meant that the analyst earned less but the patient still received his time. It is a deplorable step in recent developments that now the number of sessions given is usually regulated according to finances instead of according to the conditions favorable for psychoanalysis.
Menninger took the opposite view. In his textbook The Theory of Psychoanalytic Technique, he admonished:
The patient should not expect to pay for his analysis out of his current earnings. It is a capital investment, not a mere expense. The analysis will not go well if the patient is paying less than he can reasonably afford to pay. It should be a definite sacrifice for him. [Emphasis added.]
Three hundred members of the American were chosen at random: 100 each of regular, certified, and life members. All were guaranteed anonymity. A respectable 143 questionnaires were returned (a response rate of 48 percent), and 131 returns were usable.
The returns were almost evenly divided among the three membership groups. The range of experience was fairly evenly distributed, with one exception. Most of the respondents (35 percent) had more than thirty years of analytic experience; 25 percent had twenty-one to thirty years; 31 percent had eleven to twenty years; only 6 percent had five to ten years' experience. The lower rate of five- to ten-year responders could be either because fewer such analysts belong to the American or because this cohort lacks interest in the subject at hand. The overwhelming majority of analysts surveyed do in fact lower their standard fees for analytic patients. Of the 131 usable responses, 120 (91.6 percent) respondents do lower their fees. The percentage of the 120 respondents who lower their fees was approximately the same across membership groups.
To the question, “Do you think that you would have more patients in bona fide psychoanalytic treatment if you charged less than you do now?” the majority (53 percent) answered “No.” Thirty-seven percent thought they would have more patients if fees were lower, while 11 percent gave no answer at all to this question.
Of those analysts who have lowered their fees, the vast majority reported that the lower fee either positively affected the treatment outcome (43 percent) or had no appreciable effect on the analysis (56 percent). Of the total responses, 38 percent suggest a slightly negative effect from a lowered fee; only 7.6 percent, or ten out of 131 respondees, reported that lowering the fee engenders serious or insurmountable complications in the analysis. (These figures total greater than 100 percent, since a respondent may check more than one of the four responses to any question.)
One respondent noted, “I do not feel fee reduction has diminished the quality of treatment, though it certainly can cause problems as the treatment progresses. I have not found these problems to be different from the large number of other problems that always come up in the course of an analysis.” Another offered, “No ill effects; fees are part of reality — not a test of endurance, compliance, or masochism. These can be analyzed in the course of treatment.”
When analysts were asked which actions they would take if an analytic patient's insurance changed for the worse, 76 percent said they would reduce the fee and 63 percent might reduce session frequency. Forty-one percent would offer to partially defer payment.
Of the eight analysts who said they do not lower analytic fees, two refused to lower the fee out of “theoretical and philosophical reasons” and five refused because of “personal financial considerations.” Only two out of the entire sample agreed that “Lowering the fee will irrevocably interfere with the analysis.” Along these lines, one analyst opined, “Effects of lowering the fee are: heightens omnipotence and entitlement which is nearly always linked with unconscious contempt. Fee reduction does lead to devaluation of the effort and the quality of the treatment.”
Another respondent discussed both the pros and cons of lowering the fee:
Lowering fees has intensified guilt in the patient [and] decreased motivation to feel things that are painful and arouse anxiety and promote dependency. At times [this has caused] resentment in me. On the positive side: It has made analytic treatment possible in severely traumatized patients and freed them ultimately for a normal life. I believe all the difficulties in lowering the fee can be overcome through self-analysis and interpretation.
Sixty-four percent of the analysts rejected the notion that “psychoanalytic fees are too high, given the widespread lack of insurance coverage today.” Forty-six percent endorsed the notion that if patients are motivated to sacrifice, they will come up with the money for analysis.
One respondent wrote:
The reality is that, for the most part, insurance has discontinued paying for analysis. We are pretty much back where we were when there was no expectation of insurance coverage for it. Analysis will continue to be possible to the extent that (1) patients see fit to make the investment in it and (2) analysts are sufficiently motivated to do analysis that they will accept suitable patients for a fee they can afford out of pocket.
Only 6 percent of the 131 respondents (eight analysts) believe that lowering fees poses “insurmountable problems for the patient and reflects technical and countertransference problems in the analyst.” Finally, a clear majority (69 percent) believe that “significantly reducing the fee may cause problems in the analysis, but these can usually be satisfactorily addressed by the usual interpretative methods.”
High fees are certainly an obstacle to some patients obtaining psychoanalytic treatment.
Allan A. Bloom, Ph.D., is a graduate of the UNC-Duke Psychoanalytic Education Program and has taught in that institute. He maintains a private practice in Raleigh, N.C., where he does “a lot of analysis — much of it at a reduced fee.”
But the absolute numbers of analytic patients were — and always will be — limited by other factors: rigorous standards for analyzability; other-than-financial sacrifices demanded of the patient in terms of emotion, time, commitment, etc.; the restricted number of analysts available; competition from faster and more facile therapies that pander to infantile longings; and, of course, drug therapies.
Since the significant majority of the opinions collected in the study came from analysts with more than twenty years of analytic experience, these findings should carry substantial weight. As one respondent nicely put it, “If the fee settled upon makes sense to me and the patient, that's an optimal starting point for an analysis of the issues that brought the patient to seek analysis. In my experience, the amount of the fee, while of practical importance, doesn't significantly affect the analytic search.”
As psychoanalysts, we are accustomed to addressing most aspects of the analytic situation through interpretations. We do not reflexively acquiesce to the demands of the patient. Nor do we routinely alter our usual neutral position upon encountering resistances to treatment, internal or external. Patients who have suffered some harsh emotional and financial deprivations in childhood would not be expected to materially improve (by our rigorous structural definition) merely through warmth, kindness, and generosity.
The thoughtful analyst approaches each patient with a spirit of open-mindedness and rigorous flexibility, tailored to the unique individual needs of the patient. All aspects of the analyst's technical approach should consistently reflect a thorough grounding in and acceptance of the immutable fact of the power of psychic reality over external reality. It is, of course, exactly here that we psychoanalysts part company with other schools of therapy and offer a uniquely helpful perspective on the human condition.
The fact is that the fee intersects and intrudes into the analyst's life in a way that nothing else in an analysis does. This truth, however, should not prevent us from trying to maintain as neutral and objective an attitude or stance in this respect as our individual financial situations permit. Setting a lower-than-usual fee will certainly reverberate clinically. So will a very high fee. So will the age, looks, sex, marital status, height, weight, taste, etc., of the analyst. We should no more set and hold to rigid, a priori rules of behavior concerning the fee than we would any other factor.
Lowering fees will not, of course, rescue psychoanalysis from the professional doldrums. But those analysts who can afford to reduce their fees should take comfort in these two points: First, their patients, at least, will benefit greatly from their largess. Second, the analyst will be contributing to the wider enhancement of our profession and to the general welfare of humanity by treating someone who otherwise might not be able to afford it and planting seeds for other patients and analysts to come.
Readers wishing a copy of the complete survey study should contact Allan A. Bloom at 919-787-7307.