Money and psychotherapy: Object, metaphor or dream
//International Journal of Psychotherapy-Abingdon. Jul 1998
Authors: Jeremy Holmes. Volume: 3. Issue: 2. Pagination: 123-133. ISSN: 13569082
Subject Terms: Therapy. Professional fees. Psychologists. Psychiatrists
Copyright Carfax Publishing Company Jul 1998
Money in psychotherapy can be a force for good or evil. Fenichel postulated a ‘pre-pecuniary’ stage of development, corresponding to the pre-oedipal stage, in which the infant can claim a right to a superabundance of love, unfettered by financial constraints. The oedipal stage by contrast means learning the value of things, their ‘rate of exchange ; and the limits of love and generosity. Therapy conceived as a pure labour of love cannot see beyond the pre-pecuniary stage; therapy that confines itself to fees and fixed numbers of sessions fails to reach the deepest levels of human encounter. The analogy between therapy and prostitution shows how pecuniary relationships can perversely masquerade as pre-pecuniary. The current crisis in publicly funded psychotherapy is discussed in the light of these ideas. Unforseen benefits of this crisis, leading to the possibility of a more tolerant and multidisciplinary psychotherapeutic culture are described.
According to Freud (1913) ‘Money matters are treated by civilised people in the same ways as sexual matters, with the same inconsistency, prudishness and hypocrisy’. From an evolutionary perspective there is nothing surprising about this: people will exaggerate or conceal their resources from others in order either to gain an advantage, or to prevent envious attack.
All relationships, however intimate, contain a balance between mistrust and trust, and the potential for both exploitation and mutual co-operation. Psychotherapy is on the side of trust, but recognizes the centrality of mistrust-or resistance, which for Freud was equal in importance to the unconscious as a defining feature of psychoanalysis. Money begets mistrust-yet honest dealing is often one of the most effective ways of acquiring it. In this paper I shall argue that money is both essential to the practice of psychotherapy, and inimical to its central values, basing my discussion around the role of psychotherapy as part of publicly funded medicine.
Money is one of the great inventions of civilization, comparable with the discovery of written language, fire or the wheel-although to state that quite so boldly sends a slight frisson of danger down the puritan spine. Money is primarily a means of exchange, and human relatedness is based on exchange. Mother and infant exchange smiles, parents exchange the labour of loving and upbringing for the chance of genetic survival. Exchange enables the diversity of the human race to be put to good use. You exchange the fruits of your labour for those of mine; I benefit from your special skills and opportunities and vice versa. But if I am to scratch your back, you to scratch mine, we have to be in physical proximitywhich feels good-but also imposes severe limits on those with whom exchange is possible. Money widens enormously the scope of reciprocal altruism, and allows exchange to take place at a distance and between strangers. But money also objectifies the arbitrary differences between people, breeding envy and greed as a consolation for emptiness and loss. It both brings us together and alienates us from others and ourselves.
Simple exchange, or barter, precedes the existence of money, and occurs in money-free societies or even among non-human primates-societies to which, as the corrupt grip of money tightens, late capitalism yearns to return. But the introduction of money into the system enables exchange to be extended both in time and space. I give you something, you pay me money, rather than goods; I can ‘cash in’ my gift whenever and with whomsoever I want. Money turns arithmetic into algebra; money is the universal ‘X’ in the equation of exchange, aBabelfish (Adams, 1979) that allows one good to be translated effortlessly into another.
Before the 20th century, money could be defined as a portable object of value that is convertible into other objects of value (Dickens’ Wemmick’s ‘portable property’ (Dickens, 1861/1994)). Thus money is both a desirable in itself-an object-and a symbol. To compare it with language, it has properties of both onomatopaeia and abstract meaning. The outcry when Britain went ‘off the gold standard’ marked a movement away from money as an object in itself towards its role as pure symbol. Today money is not so much gold in the bank or in a sock under the bed, but paper, plastic, and the flickering of electronic quicksilver.
Thus money-and here we are making a rather large leap-shares a significant characteristic with the unconscious. In both there is a total fluidity of meanings. In the language of the unconscious anything can represent anything else. Houses in dreams may have a tendency to stand for the self, or the mother, or one’s ancestors-or money-but there is no telling in advance, it all depends on the web of meanings which surrounds the particular house that is being dreamed of. Similarly, a sum of money can be exchanged for a myriad of different objects. For Freud money is particularly associated with anal eroticism: money equals faeces equals control. But faeces also equals babies, and penises, so money can mean these too.
Although in the unconscious meanings are freely exchangable, for Freud the body and its drives was the signified to which all the protean transformations of meaning could ultimately be traced. Similarly, money does have a universal ‘real’ characteristic in that it always implies quantity, and this is its ultimate reference point With money we are almost always interested in ‘how much?’. Money is therefore a measure of something: how big we are, how good, how much we are worth, how powerful, how loveable. Money is the universal measure of value. At the moment of paying a fee the patient confronts his or her own worth, and that of the therapy in its most abstract and concentrated form. But even value cannot always be equated with an amount-we can have too much of a good thing. Money can be equally a ‘good’ or a ‘bad’ thing, and this applies psychotherapeutically as much as it does in any other sphere. Let us look then at the positive and negative sides of the coin as they apply to psychotherapy.
In praise of money
While musing on money I came across the following passage in Graham Greene’s The Quiet American:
They had been corrupted by money and he had been corrupted by sentiment. Sentiment was the more dangerous because you could not name its price. A man open to bribes was to be relied upon below a certain figure, but sentiment might uncoil in the heart at a name, a photograph, even in a smell remembered. (Greene, 1955, p. 162)
For Greene, as a Catholic, corruption (i.e. sin) is inescapable-the only question is, what form will it take? In this passage Greene suggests that money provides a safer framework for morality than ideology or ‘sentiment’. The same is surely true of psychotherapy. A therapist who sees his or her patients for love will be far less predictable and professional than one for whom there is a sound financial contract. Therapists who sexually abuse their patients often claim that they were only meeting the patient’s need for closeness or helping them to overcome sexual inhibitions-following their ‘sentiment’ or instinct that their patients need sexual help. But such therapists are highly selective in their favours, and never provide them to all patients, irrespective of gender or attractiveness-they are driven by ‘sentiment’, not money.
Financial exchange forms part of the framework of safe therapy, akin to the need for regularity of time and place, and consistency of approach. In private practice this is an explicit part of the therapeutic contract. In publicly funded therapy patients who show excessive gratitude, worrying perhaps that they are getting ‘something for nothing’, may sometimes have to be reminded that in the National Health Service (NHS) they have a right to treatment, that they have paid our salaries via taxation, and that if they were not ill and ‘bothering’ us, we would be out of a job.
In private practice, patients need to know that therapists are not simply holding them in therapy as a meal ticket, and that, faced with a choice between the patient’s best interests and their own, the therapist would always opt for the former. Reich (1922) tells the story of a millionaire who offered him indefinite financial security in return for one therapy session a day. At first he was tempted by this prospect which would have enabled him to devote the rest of his time to writing and research, but realizing how this arrangement would compromise his therapeutic freedom, quite rightly refused.
Publicly funded therapy might seem to offer better prospects for disinterested practice. Therapists can be as tough as they like with patients, knowing that their salary does not depend directly on any particular case. But removal of direct financial links between therapist and patient may breed therapeutic arrogance (hence the need to audit and evaluate the effectiveness of therapy (NHSE, 1996)) and cosy collusive relationships have attractions beyond the narrowly financial. What are psychotherapy patients paying for?
What is the ‘good’ which we offer our patients in return for money? A patient comes to therapy searching for an escape from alienation, or alleviation of mental pain. A therapist is quintessentially a stranger-someone who is ‘outside the system’ within which the patient feels trapped, not infrequently experienced as a system bounded by instrumentality and the power of money. Patients hope that therapy will restore them to themselves. They are more or less aware of the need for the impartial undivided attention, benign concern, and the capacity to set limits that is our biological birthright, and which has so often been lacking or perverted in their lives. It may seem curious that the message of therapy is often a painful one-learning to cope with loss and separation is intrinsic to most successful therapy outcomes. But people will pay for almost anything that offers them greater autonomy and an ability to feel more deeply: rock climbing, the painful acquisition of musical skills, or psychotherapy.
The parable of the talents emphasizes the transformative power of money: put to work, money can multiply itself a thousand-fold; buried for security, it lies idle and tarnishes. If therapy is to be successful patients have to take risks and invest something of themselves in it-time and commitment at least, and in private practice money as well. Therapy is ‘work’ in the sense that it implies that effort needs to be applied for some change to come about.
Resistance is central, and resistance implies labour. In the course of therapy the patient may discover something ‘that money cannot buy’, but in our society the overwhelming metaphor for value is money (Haynes & Wiener, 1996). I often ask patients at assessment what they would choose if they could have their heart’s desire, or had a fairy godmother who could grant their every wish. Some understand immediately, others look blank-but since the inception of the national lottery all now understand if asked what would they do if their numbers came up.
Therapy usually come to an end when the patient feels that the ‘return’ on their investment no longer justifies the outlay, and they can make better use of their money. Often when patients come into therapy they are out of touch with their resources-their talents-by the end there is often a feeling of excitement at the prospect of the surplus that will now be released which therapy has up to now consumed.
The discussion thus far illustrates the universality of the money metaphor. Money represents both reality-the reality which safeguards the boundary of therapy-and the dreams which arise within the safe space enclosed by that boundary. Payment for therapy counteracts patient and therapist omnipotence: therapists are not so wonderfully ‘good’ that they do not need recompense for a treatment that depends on their skills as well as their personal qualities, and patients are not so magisterial that the therapists are privileged to treat them for nothing. Within that framework anything is possible, fantasy is bounded by reality of which a fee is a key component.
Therapy is sometimes compared with prostitution. Perhaps the therapist’s attention or ‘love’ is no more the ‘real thing’ than the prostitute’s temporary exchange of her or his body in return for sex. What difference is there, so the argument goes, between the prostitute who ends her ‘session’ by saying ‘time’s up love’, and the therapist who callously interrupts the patient’s distress to announce that it is time to stop, with the implication that there is another patient waiting, not to mention a fee to pay? There are obvious parallels, but also vital differences. The prostitute, like all professionals, has to split her private from her professional self. She may be feeling fear, pain, disgust, hatred, boredom or exhaustion, but these must be concealed from the client so that she can continue to act her part. The therapist by contrast is required to attend to her countertransferential emotions and to make use of them in the service of therapy. To be effective the prostitute must abandon authenticity; the therapist must be true to herself.
A brothel is a place in which fantasy is translated into enactment. In the consulting room this process is reversed: the patient learns to distinguish fantasy from reality and to substitute thought for action. Some patients, especially if they have been sexually abused, approach treatment as though it were a kind of prostitution. Some offer themselves to the therapist, hoping that by divining his or her every need they will gain the attention and admiration they so desperately crave, even at the expense of prostituting themselves. Others view the whole process as a form of whoring; they can only see themselves as one in a line of clients, accusing therapists of betrayal and callousness as they switch their attention promiscuously from one person’s distress to another as the hour chimes.
Therapists have to be sensitive to these ways in which money may permeate the matrix of therapy, without denying the fact that doing therapy is a job for which they expect to be paid. Therapists who insist that they ‘do it for love’ are in danger of colluding with the fantasy of a child’s exclusive possession of the mother. Money, like language in the Lacanian framework, is the guarantor of oedipal reality. Here money comes to stand for the power of the father to withstand these regressive forces. But it is not just therapists and their other patients who have the power to separate the individual from their heart’s desire; the fact that, indirectly or directly, the patient pays, provides a developmental push towards differentiation that is the positive side of the oedipal situation.
If denial of money stands for denial of three person psychology, over-valuation of money is equally fraught with psychological danger. Midas discovered that money cannot buy you love-you cannot eat or drink gold, be warmed by it, or lie comfortably on it at night. ForSt Paulit was not money, but love of money that was the root of all evil. Money and love are separate realms: the danger lies in confusing them. When Christ said ‘render unto Caesar’ he underlined his remark by pointing to a coin with Caesar’s head on it. God and Caesar should not be confused. But what if Caesar becomes a God? This was what Marx (Bottomore & Reubel, 1963) saw as the essence of capitalism. In his discussion of Timon of Athens he shows how Shakespeare depicts the ‘yellow slave’, the ‘glittering precious gold’
…that will make black white, foul fair; Wrong right; base, noble; old, young; coward valiant… Will knit and break religions; bless th’accurst; Make the hoar leprosy ador’d; place thieves…
Thou common whore of mankind… (Bottomore & Reubel, 1963, pp. 180-81) But money is not just earth; it is earth transformed by labour. Marx saw both the transformational quality of money and its capacity for perversity:
…the transformation of all human and natural qualities into their opposite, the universal confusion and inversion of things; it brings incompatibles into fraternity. …It is the universal whore, the universal pander [Pander was the go between who spoke Troilus’s love to Cressida]…the divine power of money resides in its essence as the alienated and exteriorised species-life of men. …What I as a man am unable to do…is made possible for me by means of money. Money therefore turns each of these faculties into something which in itself it is not, into its opposite. (Bottomore & Reubel, 1963, p. 181)
For young Marx money disrupts a natural order, just as for Lacan language separates the infant eternally from the realm of true desire. Both retain a prelapsarian vision which is ‘pre-oedipal’, and, in Fenichel’s (1946) phrase, ‘pre-pecuniary’. The deification of money is a perverse response to pre-oedipal emptiness. If I cannot have love, then at least I will have money; my unsatisfied greed turns to money-lust as I amass my fortune; by seeking riches at least I deprive others of the goods which I imagine them to enjoy. In Orson Wells’ Citizen Kane, all Kane’s money cannot bring Rosebud back from the fire, but at least it can comfort him in his loss and, through inciting envy, punish the world for having inflicted it upon him.
In therapy, love without money is an illusion, a denial of oedipal reality; money without love is a perverse attempt to compensate for pre-oedipal failure. Therapists who are simply in it for the money will be unable to reach their patients’ deepest longings; therapists who pretend that money does not matter risk creating a collusive denial of reality. Money belongs to the oedipal phase and the advent of the father in the child’s mind. The pre-pecuniary world is maternal, pre-oedipal. We need to experience boundless love-and its limits.
The paradox of money is that it can be the reality, but symbolize the fantasy. For something new to emerge there has to be intercourse between these two principles. Sex is ‘spending’and, with luck, leaves us ‘spent’-but what it produces is something that is not just sex. Money is needed for new birth, but money that only begets money is sterile.
In a typical piece of early analytic brilliance, Ferenczi (1952) traces the origins of the love of money from the infant’s excitement and interest in faeces (his first ‘gift’), through playing with mud and sand, to collecting stones until the coprophilic patient becomes a miser admiring his heap of gold. He even suggests that the love of music may have its origins in farting! These classical psychoanalytic theorizings are a manifestation of the monadic universe of early Freud, for whom music can only arise from the child’s own body, rather than from the interactive pattern of singing and rocking of the mother-infant dyad-not to mention genetic ability and social conditioning! A contemporary interpersonal perspective sees the world of the infant as interactive from the start. Neither love nor money can be understood outside of relationships. What matters is the symbolism of the use to which the object is put, its relational co-ordinates, rather than the object itself. How a person handles their money-or their sexuality, or their attitude towards death-becomes the main issue.
Thus, as mentioned, denial of the significance of money may represent a regressive wish to return to the pre-pecuniary state of mother-infant mutual absorption. Hoarding money may be a manifestation of the more general tendency to cling to objects based on insecure attachment patterns in childhood. Money fills the psychic void and is clung to in the absence of a reliable primary object. In the contemporary Kleinian model, negotiating the oedipal situation depends on the capacity to cope with separation, and to view the parental couple from the outside with relative equanimity. Perhaps the beginnings of the capacity to understand algebra and therefore to exchange money productively starts here, since the child may identify with one or other parent, and begin to sense how family positions are interchangeable.
Some patients insist on paying, usually in cash, at the end of every session. These are people who can never forget money. A monthly bill enables one temporarily to abandon the world of necessity and to enter the pre-oedipal world of desire, but for some this is too dangerous. Nothing must be left owing, no trace of dependency is allowable. Not to pay immediately would mean to depend on trust, on a word that is a bond, and this must be avoided at all costs. One such man had never forgiven his mother for producing two further sons after him, when he was convinced he was all she ever wanted. How could he possibly trust his therapist not to take advantage of his dependency and to betray him too?
Other patients cannot bear to be reminded of their financial obligations to the therapist. Forgetting to pay a bill, or announcing that one cannot afford to go on with therapy is not necessarily aggressive or retaliatory, but can arise out of a sense of overwhelming deprivation. Here the therapist is seen as the perverse one: ‘all you really care about is my money’. Therapists who insist on their fee may have to tolerate powerful projections in which they contain the patients’ greed, and are seen as unreasonable, callous and grasping. They have to be able to hang on to their own sense of value without guilt, to acknowledge that we do live in a deeply unfair world without resorting to martyrdom and self-deprivation. Here the existence of publicly funded psychotherapy is crucial since it acknowledges that the ability to pay should not be the main criterion for receiving therapy.
Psychotherapy and the NHS-can we afford it?
Let us turn therefore to the battle for resources for psychotherapy within publicly funded mental health services, and to see how some of the themes so far outlined underpin that struggle and its difficulties. The last 10 years have seen a determined assault on public psychotherapy throughout the Western world. Until the last decade or so, indefinite in-patient or out-patient psychoanalytic therapy was fairly freely available in theUSAfor those who were insured. The same was largely true of publicly funded therapy in Canada, Germany and Australia. TheUKwas anomalous in that mental health here has always been relatively underfunded, and within mental health services, psychotherapy has always been a poor relation-a cinderella of cinderellas. Nevertheless, the College of Psychiatrists has always had a flourishing psychotherapy section, and the repute of British psychoanalysis meant that centres such the Tavistock Clinic, and the Cassel and Henderson Hospitals commanded an international reputation, and not-ungenerous NHS funding.
Today all is utterly changed. In theUSAthe average length of stay in the Menninger Clinic, a famous in-patient psychoanalytic unit for very difficult cases, was 11 months in 1989; today it is 9 days (Gabbard, 1997). Care managers require therapists to justify the prescription of psychoanalytic therapy and will only pay for treatments if the published evidence supports its efficacy. There is an increasing trend towards short bursts of brief therapy, which often produce immediate gain only to be followed by relapse. Intensive in-patient care is replaced by less highly staffed hostels. The same trend is to be seen in theUK. The Tavistock Clinic,HendersonandCasselHospitalshave all been subject to intensive external audit and review, only saved from closure by determined campaigns. Psychotherapy Departments have come under threat, and at the time of writing several are in danger of being closed.
How can we understand this attack on psychotherapy? First, we should not forget that the attacks come from institutions which are themselves beleaguered. Health Authorities are cash-strapped, insurance company shareholders want minimum payouts, managers are fighting for their jobs. Psychotherapy, a traditional focus for medical scepticism, is a soft target. Closure of a psychotherapy unit is a token of managerial potency less likely to cause public outcry than shutting down a paediatric unit.
Second, in an increasingly technology-based medical culture, psychotherapy almost uniquely requires no ‘kit’-just a room, two chairs and a well-trained professional. Modem medicine mints money for the pharmaceutical companies and medical supply industry. Its pre-eminent place in national economies-around 10% of most GDPs-cannot be put down to the altruism of governments alone, but depends on the multinational enterprises who profit from supplying (and in some cases creating) the need for treatments generated by ill-health. When governments try to limit the use of an expensive drug, the pharmaceutical industry immediately mounts a complex and subtle counter-campaign for the hearts and minds of doctors, including showing how more expensive drugs are really much cheaper in the long run. But there is no well-funded ‘lobby’ for psychotherapy other than that which professionals can generate themselves.
Third, there is a pervasive masculine culture within medicine which views psychotherapy as ‘women’s work’, and so not worth paying for. A recent survey showed that only about a fifth of labour in theUKwas paid employment. ‘Wages for housework’ was a slogan of 1970s feminism which has perhaps had some impact via the attendance allowance for which carers for ill relatives are eligible, but the housewife who is a compulsive cleaner is more likely to be referred as a case of OCD than become a millionaire! Just as men returning from work ask their partners ‘what have you been doing all day’, implying that housework consists of unskilled tasks which they could have completed in half the time, so medical men view psychotherapy as ‘just chats’, an optional extra-which they themselves would love to do if they were not tied up with the important business of techno-med-and certainly not requiring any special expertise or training.
Fourth, psychotherapy is a victim of the short-termism that is endemic in our culture. Dawkins (1977) makes the point that resistance to the theory of evolution is largely due to the inability of the human brain to comprehend the immensity of geological time. Once that is grasped, often via computer models, the logic of natural selection becomes inescapable. Similarly, despite the undoubted value of brief psychotherapy in selected cases, the evidence suggests there is a ‘dose-response curve’ in psychotherapy, and that the more the therapy the greater the gain (Orlinsky et al., 1994). As with child development, change in therapy is often imperceptibly slow unless monitored with sophisticated measures over a period of time. The benefits of psychotherapy may well take 3-5 years or even longer to manifest themselves, and this is outside the thinking time of many research-funding bodies and almost all managers and politicians on short-term contracts. Psychotherapy needs not just money, but money sustained over time.
Unforseen benefits of the attack on psychotherapy
This assault on public therapy has, paradoxically, had positive consequences. The past decade has seen determined moves towards the establishment of a psychotherapy profession prepared to justify its expertise, training, and unique contribution to social and health care, and hence legitimate expectation of funding. Adversity has concentrated the mind of the profession in some useful ways.
There have been several studies looking not just at the effectiveness of psychotherapy, which is now well-established (Roth & Fonagy, 1996), but its cost-effectiveness. Cost-effectiveness can be measured in a number of different ways. First, it can be straightforwardly compared with the cost of other treatments such as drugs. Thus in schizophrenia, family intervention greatly reduces relapse rates and hence hospitalization and so is highly cost-effective (Brooker et al., 1994).
Second, ‘offset-costs’ compare the utilization of medical services before and after an intervention, and are useful for looking at the impact of expensive psychotherapeutic interventions such as inpatient therapy.
An important UK example of the latter approach is the Henderson study (Dolan, 1996) which looked at total ‘cost to the exchequer’ of personality-disordered patients before and after spending a year at the Henderson. The total spend in terms of social security benefits, use of medical and psychiatric resources, and drug costs was calculated. Despite the relatively high cost of therapy itself (around 440,000 per patient), they found that the treatment had ‘paid for itself’ within 2 years of discharge, in reducing patients’ dependency on services and benefits, helping people to get jobs and pay taxes. The preliminary results of this study played a significant part in saving theHendersonfrom closure. Similar reasoning has enabled our own district Health Authority to set aside a sum of money for what in NHS terms is intensive psychotherapy (twice-weekly for up to 2 years), based on the argument that this will in the long run save money which would be spent on costly referrals to other agencies (ECRs).
These are subtle (and costly!) studies, which focus on the immediate financial consequences of successful treatment of mental illness. The ‘social cost’ of psychological ill-health is still probably underestimated however, since the impact of depression, alcoholism and drug addiction on the economy and the environment generally is much greater than can be captured by current research methods. There is a need for a third generation of cost-effectiveness studies looking at these aspects.
Another benefit of the intrusion of money into the organization and planning of public psychotherapy has been the emergence of a much clearer view of what kinds of therapy, delivered by what level of skilled practitioner, are most appropriate for what kinds of patients, suffering from which kinds of difficulties. Now that psychoanalysis is no longer ‘the only game in town’ (Eisenberg, 1986) we can more successfully match patient to therapy. Family intervention in schizophrenia is helpful, psychoanalysis, on the whole, is not; cognitive behaviour therapy is good for mild to moderate depression, but probably less useful than psychoanalytic psychotherapy in borderline personality disorder, and so on (Roth & Fonagy, 1996). In a public health context we can go beyond the needs of the individual patient to the psychotherapeutic needs of a defined population and begin to exercise psychotherapeutic triage with a clearer conscience, concentrating our efforts on those patients for whom our efforts are most likely to make a real difference, while offering the less ill brief counselling in general practice, and the more intractable cases less expensive supportive therapy. We can, like any good capitalist, spend our psychotherapeutic money wisely (Holmes & Lindley, 1998).
Does all this mean that Mammon now rules psychotherapy just as it does every other aspect of modern society? In accepting the language of cost-effectiveness are psychotherapists betraying the essence of our discipline. Or, on the other hand, do we retreat into the private world of the consulting room as compensation for our feelings of powerlessness within society?
I believe there is a genuine dilemma here. If psychotherapy is to be valued by society, recognized as a profession, and seen as worth paying for as a vital contribution to mental health services, then we have to argue that what we offer is our skills, not merely our selves. We need to make the case that those skills are as important as those of heart surgeons with their training and their ‘kit’. Our ‘interpersonal technology’ has to rank with the biomedical technology of other branches of medicine.
And yet we know in our hearts that our skills are inseparable from who we are. A ‘good therapist’ is much more than someone who has spent a lot of money on training and been to the right institutes. We know that at one level Ferenczi (1952) was right when he said that ‘it is the physicians’ love that cures the patient’. This is underlined by the evidence from psychotherapy research which suggests that ‘common’ or ‘nonspecific factors’-reliability, nonjudgementalness, consistency and warmth-contribute as much or more to good therapy outcomes as do specific techniques such as interpretations or cognitive interventions. The evidence seems to suggest that with difficult patients training and experience make a difference, but this is much less easy to show with less ill cases (Stein & Lambert, 1995). There is almost a conspiracy of silence about this, since to admit it might undermine our professional aspirations.
Our income and our status seem to depend on being able to demonstrate that psychotherapy is just another technical procedure: that people with schizophrenia need family therapy in the same way that diabetics need insulin. Yet we know that few people go into psychotherapy as an occupation purely for the money. Ultimately, psychotherapy is a labour of love, a vocation. We do it because we enjoy it and it provides its own reward-that is the privilege of our profession. Society envies the rich, but even more so artists and sportsmen, people who do what they do for its own sake, out of some inner necessity rather than external compulsion. At some level we sense that the market is ultimately devoid of meaning and can never offer the love and understanding we crave. In the end, the pre-pecuniary world comes first.
The establishment of the NHS, ‘free at the point of entry’ in Britain was a socialist attempt to remove money from one central arena of public life. That principle has survived the Thatcher years-just. As money increasingly infiltrates the workings of the health service, psychotherapy is a bastion of the doctor-patient relationship, of the narrative as opposed to the technological aspects of medicine (Roberts & Holmes, 1998). Like art, therapy represents an opposing principle of non-instrumentality, of ‘being with’ rather than ‘doing to’ the patient (Wolff, 1971). As Marx suggested, the greater the emptiness of the inner world the more the perverse search for external power and riches, a search which in turn fuels even greater feelings of emptiness. The attack on psychotherapy in medicine is often an envious assault from a system frenzied in its craving for the latest technological advance or a means to stave off death: ‘If only we had enough money all the problems of living and dying could be solved’. Taking money from psychotherapy (robbing the poor to pay the rich) comes from a half-conscious envious recognition that therapy can face realities which those whose world is driven only by money find unbearable.
However, it is unwise for therapists to retreat to a precarious moral superiority. We must learn to live in two worlds, rendering unto Caesar as well as our own Gods (Holmes & Lindley, 1998). As psychotherapists we are perhaps trustees of a deeper reality. But, in order to keeping working for the joy of working, to celebrate things as they are as opposed to things that can be bought, to offer real therapy rather than retail therapy-money is needed.
Resume L’argent, en psychotherapie, peut etre une force du bien ou du mal. Fenichel a postule un stade de developpement «pre-pecuniaire», correspondant au stade pre-oedipien, pendant lequel le petit enfant peut reclamer le droit a une surabondance d’amour, libre de contraintes financieres. Par opposition, le stade oedipien signifie apprendre la valeur des choses, leur «taux de change», et les limites de l’amour et de la generosite. Une therapie confue comme un pur travail d’amour ne peut pas aller au-dela du stade pre-pecuniaire; une therapie qui se limite a des honoraires et i un nombre fixe de consultations n’arrive pas a atteindre le plus profond des relations humaines. L’analogie entre la therapie et la prostitution montre comment des relations pecuniaires peuvent se deguiser de fafon perverse en relations pre-pecuniaires. La crise actuelle de la psychotherapie financee par les fonds publics est consideree i la lumiere de ces idees. Les effets benefiques imprevus de cette crise, envisageant la possibilite d’une culture plus tolerante et multidisciplinaire, sont egalement consideres.
Zusammenfasung In der Psychotherapie kann Geld eine negative oder positive Macht darstellen. Fenichel postulierte ein Entwicklungsstadium «pra-pekuniar’; die einer praodipalen Phase
entspricht, in der das Kind sein Recht einfordern kann auf ein UbermaB an Liebe, unbehindert durch finanzielle Zwange. Im Gegensatz dazu bedeutet das ddipale Stadium, daJ3 man den Wert der Dinge erlernt, ihren «Kurswert» und die Grenzen von Liebe und GroBzuaiakeit Therapie begriffen als eine reine Liebesarbeit, kann nicht hinter das «pra-pekuniare» Stadium blicken, Therapie, die sich auf Gebuhren und eine festgesetzte Anzahl von Sitzungen beschrankt, kann nicht die tiefsten Ebenen menschlicher Begegnung erreichen. Die Analogie zwischen Therapie und Prostitution zeigt wie finanzielle Beziehungen sich widernatirlich als «pra-pekuniar» maskieren konnen. Die derzeitige Krise in offentlich finanzierter Psychotherapie wird im Lichte dieser Ideen diskutiert. Unvorhergesehene Vorteile dieser Krise, die zu der Moglichkeit einer toleranteren und multidisziplinaren psychotherapeutischen Kultur fahren, werden beschrieben.
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JEREMY HOLMES Department of Psychiatry,NorthDevonDistrictHospital, Barnstaple,DevonEX31 4JB,UK
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