This text consists of a series of reflections that arose and developed from two events—one personal, the other relayed to me—concerning the act of payment in psychotherapy as well as the therapists’ own attitudes toward it.
The two incidents are the following:
- My psychotherapist was quite clear and strict. Payment is made in cash at the end of the session—50 euros—and it’s best to have the exact amount. One day I had 60 euros (I can’t recall the reason for this “oversight” of mine), which obviously would have required her to give me 10 euros in change. At the time of payment, when I showed her the three 20-euro bills and told her that unfortunately I didn’t have the exact amount, I noticed an expression of obvious uneasiness on her face as she hurriedly opened her wallet and handed me the change for this transaction. This reaction struck me as particularly odd, as if she preferred to avoid such minor interactions in her psychotherapeutic practice.
- The following incident was communicated to me by a friend. During a session in a psychoanalytic training program, the training psychoanalyst noted that payment in psychotherapy is of the utmost importance and must always be required. In one instance where a patient of his could not pay, the psychoanalyst urged him to take a day job at the Varvakios Market (the biggest market in Greece) so that he could raise the necessary amount to continue therapy. When the patient asked the psychoanalyst if he himself would go to do such labor, the analyst replied that he certainly would, but simply did not have the time. Note that the analyst charges 70 euros per session.
I think these two incidents demonstrate, in their own way, that the issue of payment in psychotherapy is treated somewhat paradoxically and ambivalently. On the one hand, it is considered important and is treated with (sometimes inflexible) strictness; on the other hand, it can be an extremely uncomfortable topic, capable of “contaminating” the therapeutic process itself and is sometimes met with evasiveness on the part of the therapist, if addressed at all.
One reason, I believe, that payment is an uncomfortable topic is that it represents an intrusion of the outside world into the supposedly pure intersubjectivity of the therapeutic process. In a 50-minute session, various processes may have unfolded; the client may have cried, been moved, gotten angry, relived traumatic moments, and/or simply gotten bored, irritated, etc. The session ends, and after all these moments, the client opens their wallet and hands over (in my case, I was leaving the money on the table) the payment for all these processes, usually with a serious, if not cold, gesture. One can’t help but feel that one has purchased either a kind of empathy or, more often than not, a technical service (of which compassion is merely one component) and wonder whether all the preceding reactions, transference, and psychological processes would occur, if they were not accompanied by this transaction.
I think we could insert here some thoughts expressed (better than I or anyone else could put them) by David Foster Wallace (1999) in his story “The Depressed Person,” in which he describes the psychotherapy of a woman suffering from depression:
“[…] the depressed person shared long-distance, she had discovered and struggled in therapy to work through her feeling that it was ironic and demeaning, given her parents’ dysfunctional preoccupation with money and all that that preoccupation had cost her as a child, that she was now, as an adult, in the position of having to pay a therapist $90 an hour to listen patiently to her and respond honestly and empathetically; i.e., it felt demeaning and pathetic to feel forced to buy patience and empathy […]. The depressed person also knew perfectly well, she had acknowledged, that it was in fact the $90 an hour which made the therapeutic relationship’s simulacrum of friendship so ideally one-sided: i.e. the only expectation or demand the therapist placed on the depressed person was for the contracted hourly $90; after that one demand was satisfied, everything in the relationship got to be for and about the depressed person […] and yet the depressed person confessed to the therapist that she nevertheless still felt, on a more basic, emotionally intuitive or “gut” level, that it truly was demeaning and insulting and pathetic that her chronic emotional pain and isolation and inability to reach out forced her to spend $1,080 a month to purchase what was in many respects a kind of fantasy-friend who could fulfill her childishly narcissistic fantasy of getting her own emotional needs met by another without having to reciprocally meet or empathize with or even consider the other’s own emotional needs…” (pp. 44–46).
These observations by David Foster Wallace, though part of a fictional story, illustrate how the market-driven nature of psychotherapy may create a kind of split consciousness in the patient: If I didn’t pay, would the therapist really put up with me, really sit there for 50 minutes to listen to me, really engage with me, really care? At the same time, part of this dual consciousness is the thought that all these processes are determined by money and are therefore subject to a system of exchange, purchase, demand, and consumption. Thus, the money paid at the end of therapy is, in a sense, already present as a third party within the session, determining the very possibility of the therapeutic relationship and mediating the interaction between therapist and client. At the same time, it places the client within a framework of utility and practicality, expecting a product or result in exchange for payment.
This in itself is somewhat curious, yet it is nonetheless consistent with the psychologization and individualism of contemporary neoliberalism. The support that one would once have received from the community is now expected to be sought privately, with the therapist embodying this service. As Wallace (1999) also notes, the “degrading” nature of buying empathy may stem from the fact that it has been stripped away from an individual’s social environment—that the lack of social cohesion, collective movements, and caring communities leads to the purchase of warmth, friendliness, and compassion from the therapist, who offers them as products. Wallace’s depressed character, in fact, describes the people in her friendly circle as a “support network,” friends she hasn’t seen in years and calls them on the phone to tell them about her depressive symptoms: her loneliness is evident even to herself, and she herself acknowledges that she pays her therapist to serve as a substitute for companionship and/or friendship. In psychotherapy, then, neoliberalism manifests itself both in the individualization of the patient’s problems—an individualization that usually reflects (urban) isolation—and in a transactional logic with an abstract demand for utility (Teo, 2018). We will return to these ideas below.
It is certainly worth noting that psychotherapy is not simply the provision of empathy (as Wallace’s text might imply), but also the creation of an allowing framework so that the client can process and reflect on certain “psychological” issues. I believe, however, that one cannot exist without the other; that is, it is the attitude of empathy, impartiality, and acceptance that distinguishes psychotherapy from other practices or interactions (e.g., a conversation with a friend about the same issues) and that helps the client process “psychological” issues. Consequently, even if therapy is viewed as a set of techniques, it cannot be separated from this provision of empathy—something for which one might feel they are paying $1,080 a month.
However, beyond the client’s perspective, the payment structure in therapy also creates a false sense of security for the therapist themselves, perhaps regarding the potential sincerity of their own therapeutic stance. Here I am using a somewhat extensive collection of excerpts from David Smail (2015) because I believe he can articulate this better than I can:
“ […]I think it not entirely shocking to suggest that psychotherapists are to be found in a role closely analogous to that of prostitutes. […]Just as prostitutes supply sexual favours to those who find them difficult to obtain in any other way, so psychotherapists provide for a price the kind of individual attention many of us need to get from someone in order to survive in a cruel world. Therapists may feel that the attention (love) they give their patients is more genuine, more worthwhile and respectable than the sexual ‘love’ dispensed by prostitutes. But this, I think, is debatable. The prostitute’s is a very specific and very frank service – though she may not feel love for her clients, she unequivocally makes her body available to them on terms which are clearly understood. She may well feign an affection or enthusiasm she doesn’t feel, but such deception, even if necessary for the successful conduct of her business, is perhaps relatively innocent and uncomplicated. The psychotherapist, on the other hand, may be helping patients through the provision of what they experience (even if inarticulately) as love, but under the guise of performing a psychological service of a technical nature. In this way psychotherapists may be appropriating their patients’ ability to understand their own situation and think clearly about themselves, and by technicizing, and in fact mythifying, psychological understanding they make it the property of a professional class – that is, they become ‘professional usurers’ in the way discussed in the previous chapter. Furthermore, the love through which their therapeutic function is actually achieved is but a pale and uncommitted version of what it would be in an ideal world, but is not acknowledged as such. Patients, it is true, may sometimes ruefully comment that ‘you wouldn’t put up with me if you weren’t being paid to’, and most therapists would be unlikely to deny, at least to themselves, that this is indeed the case; however, when not faced directly with this element of hypocrisy, therapists are quite likely sentimentally to deceive themselves about the ‘deeply meaningful’ significance of the therapeutic relationship. […] To turn love into a commodity, especially without realizing that that is what is being done, may turn out to be one of the most disabling professional feats of all. On the other hand, to recognize that the provision of therapeutic love in a far from perfect world may be better than nothing at all, to accept, that is, that psychotherapy is like a form of prostitution, may be to achieve a quite healthy perspective” (Smail, 1984/2015, pp. 143–144).
Here, of course, we must maintain some distance from Smail’s potentially critical stance toward sex work. However, I believe that Smail does not hold this view in order to demonize sex therapy, nor to take a provocative stance toward psychotherapy. What he emphasizes—I believe—is the structural relationship between the psychotherapist and the sex worker, that is, a position that arises from the use of their services within the free market and the subjectivity that this symbolic position entails. It is precisely this market that constructs this symbolic position, which compels (although this compulsion may often be experienced as a voluntary action) both parties to adopt a specific attitude toward the client and toward their own body/self, an attitude that often would not be maintained were it not for the mediation of payment.
This becomes even more compelling if Smail’s observations are viewed from the therapist’s perspective. The therapist may often hide behind the professionalization and technicalization of their field to mask the potential immoral position of feigning empathy and sympathy in exchange for payment. Even if this empathy is a sincere reaction (as it often is), it owes its existence to a system of payment—that is, to the fact that if payment was withdrawn, so too would the empathy. In a sense, it is a simulacrum of sincerity. As Smail puts it, perhaps the assumption that a sex worker charges for her services and admittedly offers them solely for payment entails greater sincerity than the therapist’s evasions around the subject of payment, which usually allure to the significance of therapy or the use of highly specialized technical vocabulary, which often renders the therapist’s practice almost mystical.
Perhaps this is the reason for the intense psychologization of payment. Freud (1958), for example, in his text on the beginning of therapy, frames payment as a matter of psychological significance: failure to pay may increase the temptation a woman feels during transference, while for a man it may heighten his ingratitude, particularly toward father figures. As Freud (1958) also notes, a lack of payment would mean that therapy is detached from the practical realities of real life (the “practical” world outside the therapy room) and thus delays its conclusion. Setting aside whether these observations are true or not, we can see modern therapists engaging in similar psychologizations of money. If someone delays payment, it is considered resistance to therapy; if they refuse to work (e.g., at a street Market) to pay for the session, then this indicates a lack of commitment, etc. Engaging (unfortunately) in a form of “meta-psychologization” myself, I believe that these psychological interpretations used by therapists are partly a defense against thoughts about the potential immorality of their position, namely, that they may be offering empathy only in exchange for money, and that for this reason the monetary exchange is significant.
Furthermore, these psychologizations also serve a de-ideological function; that is, they attempt to separate the economic reality from psychotherapy and psychotherapy from economic reality: the fact that a client is unable to pay is reduced to a kind of personal indifference, hidden reluctance, or weakness on their part, rather than an outcome of economic structures and inequalities. By psychologizing payment, psychotherapy avoids confronting its economic and ideological foundations, and the therapist avoids confronting his or her ethical position. When payment is psychologized, psychology gets paid—at least more easily.
Of course, psychologization is just one of many approaches to the issue of payment in therapy, and it may often be absent or even present (e.g., a wealthy client who actually “forgets” to pay). Its existence, however, is precisely either a side effect or a symptom of the uneasy relationship a therapist may have with their practice and the fact that, in order to maintain it, they must be paid for it.
We can also add that the relationship with payment is reciprocal. In other words, the therapist is not paid simply because he or she is a professional, but often is—or appears to be—a professional because he or she is paid. In other words, payment restores the therapist to the symbolic role of a specific professional class (therapists) that possesses a special kind of knowledge. Of course, this does not happen solely because of payment, but payment functions as a symbolic pillar that further entrenches the therapist in the position of prestige as the subject-supposes-to-know.
A preliminary reader of a draft of this article pointed out to me that the issue of payment in therapy is a symptom and that it should be treated as such. This is true, but I believe that the logic of the symptom must be reversed or expanded: it is not simply the awkwardness surrounding payment that is a symptom of the relationship between money and the provision of psychological services, but rather therapy itself that is a symptom of money—if by “money” we mean the structuring of relationships within capitalism. The therapist-client relationship is not merely a relationship between creditor and debtor, seller and buyer, service provider and beneficiary, but rather a relationship between two indebted parties. Their encounter is grounded in the fact that the relationship between individuals is based on commodity fetishism, that it is replaced or mediated by relationships between things. The Thing re-emerges in therapy through the form of money (even if no one pays). The Third, the Other in therapy (which we briefly mentioned above)—the external world that, as Freud (1958) said, is reintroduced by money—is the commodified form of relationships, which is maintained in therapy in an abstracted form: although therapy is embedded in Western capitalist societies and the logic of Capital, it simultaneously promises (through empathy or certain technical knowledge) a supposed escape from the commodified form of social non-relationship via a supposedly positive, non-alienated, authentic, therapeutic relationship (Tomsic, 2015). Nevertheless, this exit is actually a re-entry, precisely because this technical knowledge and empathy are offered in the form of a commodity and often operate on the promise of readjustment back into the society of commodified -relationships. The symbol for this re-entry into the relationship between things is the payment and the gesture that transfers money (and thus the commodity of the relationship) from the client to the therapist.
In neoliberalism, as has been said, this relationship takes not simply the form of a commodity, but more specifically that of entrepreneurship. Therapist and client come together not simply as indebted parties (from Marxist primitive accumulation), but as variants of Homo economicus, one such variant being Homo psychologicus. Under neoliberalism, the human being is not simply a commodity for sale (e.g., labor force), but a business to be managed (for this classic analysis, see Foucault, 2008). Psychotherapy, of course, can also serve as a crack in this line of reasoning, revealing the negativity and the impossibility inherent in the supposed self-management and self-actualization of neoliberal subjectivity (Teo, 2018), but often this realization is either not addressed or does not occur.
Psychology/psychotherapy often uncritically accepts the positive subject of capitalism and functions like a business, as evidenced by the endless advertisements for mental health and the online platforms for psychotherapy that have sprung up. Paying for psychotherapy is therefore a symptom, precisely because psychotherapy itself is, for the most part, a symptom of capitalism’s commodity fetichism and relationship built around utility (Teo, 2018); psychotherapy functions so well precisely because it promises to abolish these capitalistic relations, only to keep them in a state of perpetual postponement—a postponement that is symbolically renewed by the presence of the signifier of money in therapy.
I think that for this reason, the paradox we mentioned at the beginning may in fact be a coherent position. Payment in therapy is treated very strictly precisely because it constitutes an uncomfortable issue, an uncomfortable gesture, a move (both symbolic and real) that signifies the potential rupture of empathy as well as the inevitably mediated therapist-client relationship, with the barrier of the transaction and the market standing between them. Strictness around payment serves to mask the awkwardness in a blunt manner, often aided—as mentioned—by intense psychologization, the professionalization of the field, and appeals to the therapist’s authority and training.
If we return to the two incidents mentioned in the beginning, it becomes clear why they too—though unrelated—are connected. My therapist’s attitude—her indignation over the change—is a “passive” reaction to the intrusion of external life, money, and materialism into the supposedly pure psychotherapeutic process; the psychoanalyst’s attitude in the second incident is an “active” behavior that seeks to shield the necessity of therapy and the necessity of being paid handsomely for providing this service, to the extent that it pushes the patient to work day jobs to support it. At the heart of both these cases, I suppose, money is positioned as both a cancer and a treasure, and the act of payment (hand-to-hand? on the table?) as a gesture of both immorality and necessity.
However, this would likely hold true even in the case of supposedly positive and generous actions on the part of the therapist, such as “pay me when you can” and “give me whatever you can.” The therapist’s generosity in these examples suggests, in a way, that he is already in debt; he is simply keeping the debt either in denial or in deferral.
I would not want this text to be read as a moralistic plea for the abolition of psychotherapy or for the elimination of payment for therapy sessions. In my opinion, psychotherapy is just another kind of relationship, and like any relationship, it works for some people and not for others, depending on the compatibility between therapist and client. At the same time, the therapist is a person who gives up their time and needs to survive and make a living, so obviously payment becomes necessary from this perspective (though this need to make a living, in turn, turns psychotherapy into a transactional situation, which may intensify the therapist’s potential pretense of empathy).
In my opinion, a “solution” to the issue of payment would be universal free therapy or, even better, community-based interventions, the strengthening of collective and social groups, and, on a theoretical level, the dismantling of the mystique and professionalization/technicization of therapeutic practice itself, the demystifcation of the psychologization of payment, and the thematization and critical theorization of the symbiotic relationship between psychology and neoliberalism.
Personally, I am a pessimist and do not believe that these could be realized, at least not anytime soon, as they would require an overturning of the “Psy-discourse” (Rose, 1998), the neoliberal way of life, individualism, and perhaps therapy itself as an institution and therapists as a professional class. This text was obviously not written to provide a solution (how could it, anyway?), but to highlight some thoughts and ways of approaching a topic that is often avoided with a sense or gesture of awkwardness.
What we could actually do now is examine the cost—both literal and figurative—of someone paying money to gain empathy and/or a set of technical skills to “work through” certain issues. In my opinion, money will always, in some way, serve as a mediator between therapist and client and will be a source of suspicion toward therapy, even when it produces results. In other words, the therapist will struggle not to see themselves as a “prostitute” selling compassion (and for this reason will employ the defenses mentioned above), while the client will strive not to feel a slight sense of shame for purchasing an imaginary friend who offers the empathy, companionship, and comfort that their environment cannot provide. In other words, a hidden simulacrum of the structural non-relationship—the relationship between commodities and entrepreneurs within neoliberal capitalist society.
Acknowledgments
I would like to express my sincere thanks to my friend Ioannis Giannikos, who introduced me to David Smail and lent me his book, and who also gave me David Foster Wallace’s book as a gift, a gift that prompted me to read a challenging author I had always been afraid to tackle.
***
Bibliography
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Wallace, D. F. (1999). “The Depressed Person,” in D. F. Wallace, Brief Interviews with Hideous Men (pp. 31–58). Abacus.
