When it is not the patient who pays

Summary

This paper looks at the question of third-party payments in psychotherapy and psychoanalysis. This is of particular relevance in Holland, where the Dutch government makes substantial payments for psychoanalytic treatment via a state insurance system. The literature concerning third-party payments is reviewed. Freud himself was inconsistent about this matter and cannot therefore be relied on to give a clear guideline. The majority of writers are heavily in favour of ‘personal sacrifice’ and show a strong bias, especially against insurance payments for fees. These arguments are examined in detail and the two main conclusions are explored, namely that (1) certain unconscious conflicts cannot be mobilised where there is external financing, and (2) that the absence of personal sacrifice engenders too much wish-fulfilment. Both these arguments are rejected as being biased and are found not to stand up to detailed scrutiny.

The effects that different types of payment have on the development of the therapeutic situation, and the different types of transference and countertransference problems that each engenders, are explored. There is some speculation as to the reason for the persistence of this view if it is so patently false. Finally there is some consideration of the positive effects third-party payments can have on psychoanalytic practice.