Control Cases, Out-of-Control: When a Low-Fee is no Bargain

Posted by | December 27, 2014 | Uncategorized | No Comments

Summary: I describe three consecutive referrals from a Psychoanalytic Institute’s Low-Fee clinic, in order to demonstrate the inherent organizational and possibly characterological difficulties in such cases that could interfere with successful analysis by a candidate. All three cases were discussed with at least two training analysts, both of whom recommended against accepting all three cases into treatment because of ego and superego difficulties that would have interfered with a successful psychoanalytic treatment, and in fact,
might have resulted in a pseudo analysis (as described by Winnicott, 1972). I discuss the specific challenges faced by candidates in communities with a shortage of low-fee cases and the countertransference issues specific to a middle-aged candidate hearing time’s winged-chariot beating behind. This brief reports’ intent is to open discussion of weighing advantages and disadvantages of any process for accepting low-fee analysands in a psychoanalytic training program, particularly when fewer patients come for analysis and more institutes and consequently candidates seek patients.

Because of institutes’ autonomy, there are varying approaches to recruiting control cases for candidates. Further, with shifts in cultural mores, fewer people pursue analysis, even at low fees. Finally, with the rise of additional institutes, particularly following the lawsuit in the USA (Wallerstein, 2000), more candidates seek patients. These synergistic forces result in greater vicissitudes for candidates seeking patients, particularly when compared to the ethos in the US during the 1950’s and 1960’s. Other pressures include external realities of lengthy training analyses, and idiosyncratic countertransference issues of the candidate – not only countertransference of childhood origins, but also of current life circumstances.

I describe and discuss the interaction among the character traits of three prospective control cases, the Institute’s referral process, and the candidate’s countertransference issues.

First, the circumstances of the Institute. The Institute chose to shift its evaluation and referral process of the low-fee clinic, established for finding control cases for candidates. In the past decade, rather than having prospective low-fee cases see a senior analyst over several sessions, patients would be seen once, possibly twice, then referred to a candidate. Patients were told that the fee would be negotiated with the candidate, based on the patient’s finances. But, many prospective patients told candidates that they had heard from others that the fee could be as low as $10/session. Child psychoanalytic candidates were so desperate for cases that they bantered amongst themselves about paying parents to bring children.

Candidates were expected to meet several times with the prospective patient, then present the case to a supervisory analyst to decide upon accepting the

case.1 The issue of “analyzability” was discussed, but with sensitivity that a patient may not be analyzable with one candidate/analyst, but may be with another. If the supervisor and candidate agreed not to accept a patient, he or she was referred back to the clinic for a referral to another candidate.

I will briefly report each case, then discuss their presentations and the difficulties for both the candidate and prospective patients.

Case One: Mr. Z., in his mid-30’s drove up to the analyst’s home office in a bright yellow, Hummer, with Burberry plaid interior . The analyst could see the details of the car, for Mr. Z. had parked on the sidewalk in front of the analyst’s home and partially blocking a neighbor’s driveway. He was a handsome, lean, tan, well-groomed fellow, who entered with a sense of self-assurance. He removed his butter-soft black, tailored napa leather jacket, folded it twice, and laid it upon the couch, smoothing, then caressing the jacket before he sat down. He smiled. He had bought this Armani jacket, he began, on his last trip to Italy; brought back good memories. He had changed careers. He had been in retailing, an executive, remarkably successful:
took early retirement to enlist in a psychology graduate program, at one of several new Psy.D. professional programs that had sprouted up in the last few years. After buying a house in a tony San Francisco suburb, he and his new wife agreed that they could live off his golden parachute from his last job.

He was delighted to be training in psychotherapy. He had majored in business in college, entered the family business, but really wanted to do therapy. He was pleased to be accepted in this graduate school, since his GRE scores were too low for the local traditional Ph. D. programs. Now, he wanted to have his own analysis, since he had heard much about Freud and thought that this would make him a better therapist. He did not think that he had neuroses, but he thought that an analysis would better help him understand his patients.

He missed his second visit and called afterwards. He arrived for the third visit, with a jaunty enthusiasm. They had a new baby and he looked forward to learning much about development even as he was in analysis; he had learned that the candidate was a child psychiatrist, specializing in infancy. He had never been in therapy, relished new experiences, challenges. Periodically, he reached over to smooth an unseen wrinkle in the leather jacket lying on the couch. He looked forward to using the couch.

Finally, the candidate introduced the fee.

The patient was surprised; sat back with a jerk. What was to discuss? He had heard from fellow psychology students that the fee was ten dollars.

The candidate ventured that the Institute’s policy is that the fee would be based on his ability to pay.

The patient leaned forward angrily. Would the analyst take “food from the mouth of my baby” to charge a higher fee. He was outraged. He said that the analyst should think about this, since he knew that candidates were hungry for patients. He would return to the low-fee clinic, report the candidate and request another referral.

Case Two: Mr. R. was in his mid-fifties. He had just finished a graduate
program in fine art, having taken early retirement from a dot.com, after
helping found the company and bringing it public. His lover had urged him to
become a conceptual artist, perhaps do performance art, his dream. He enjoyed his three years in art school and now looked forward to devoting full-time to art. He would not work, but create art all day. He had been the oldest student in his school, but hoped that by doing art full-time, unlike his fellow students who had to work during the day or wait tables on weekends and evenings, he would have one-man shows soon.

He had had various psychotherapies. But, he thought analysis would be good for his art; after all, he had heard, read many stories about artists of the ‘50’s
and ‘60’s and their analyses. Look at Woody Allen. Analysis would help him
get in touch with his inner self, enrich his artistic processes.

He was glad to hear about the low-fee clinic. Otherwise, he said, he would have to return to work at least part-time to pay for his analysis. Ten dollars a session was a good deal, he said.

The candidate, after discussing the case with two training analysts, referred the patient back to the low-fee clinic.

Case Three: Ms. W. came to the first meeting, after a senior analyst, telephoned the candidate. The senior analyst really liked this patient; if the patient could afford a private fee, she would treat her herself. She was glad that they had but one meeting, otherwise the analyst would have developed too strong an attraction to the patient, an attraction – the candidate learned – which was mutual.

This training analyst had heard about the candidate; that he was a seasoned therapist and was looking for a fourth case. She thought that this would be an excellent case for the candidate. Could the candidate call back after the evaluation?
Oh, by the way, the patient was a neighbor and friend of Dr. X, a very prominent training analyst. Dr. X. had referred the patient saying that he wanted her to have a more senior candidate.

This women was poised, dressed in an understated, but classically elegant manner. Although it was winter in San Francisco, she arrived in a skirt and nylons, and a slinky, silk beige blouse with décolletage.

She had been through a terrible divorce from a very wealthy man who had “ripped her off” in the divorced because of a pre-nup. She had been a
successful writer before the four-year marriage, her first, then was out-of-work for almost a year. Finally, she just got a job that paid $60,000 a year, well below the standard of living to which she had been accustomed. They had no children, and she was relieved that she had gotten the house in _______(a desirable village), mortgage- free.

She felt that she had issues that had contributed to her marrying late and her unsuccessful marriage. She wanted to address these in analysis so that she would not repeat them. Dr. X., a very close friend, recommended analysis. He would treat her, but he explained that he could not because they were friends. He assured her that he would help her get a good candidate. I should call him

with any questions, she offered.

On the second visit, we discussed details of frequency, use of the couch and the nature of free association. The candidate raised the issue of fee. The patient drew herself upright. She was assured by Dr. X. that I would charge her ten dollars a session. She drew her chair forward, until her knees leaned against the candidate’s ottoman, her décolletage offered. She spoke huskily, “ I am making a commitment to this process already, offering to come four times weekly. I have a great deal to offer.“ Surely the candidate would take this into account in accepting the ten dollar fee.

On second thought, she felt as if the candidate was ripping her off like her former husband. She would be sure to telephone Dr. X. about this. This Institute would take notice, she insisted.

Discussion:

In all three cases, the candidate felt both internal and external pressures to accept the last control case, having waited two years. Externally, the director of the low-fee clinic had explained that there was a shortage of cases to refer. He gave preference to first year candidates. In one of the three cases, the
director of the clinic thought that since the patient had significant narcissistic issues, the patient would do well with an experienced candidate, who had had training in Kohut’s work during his residency.

The candidate also felt the peer pressures of colleagues seeking patients.

Most candidates insisted that it was better to get patients from one’s own caseload, rather than the low-fee clinic.

An internal pressure was the candidate’s approaching his fifth decade with a family to support. These countertransference issues were discussed in supervision. He discussed specific countertransference issues raised with these patients. The artist, only a few years older than the candidate, had rubbed against the grain when he said that he was pleased that he would not have to work to pay for his analysis. The candidate had worked as an ICU nurse during medical school on the graveyard shift to pay for his first analysis. It is quite possible that another candidate (or analyst) who did not have these experiences, would not have reacted adversely to the artist’s remark.

The same issues applied to graduate student/former retailer. Stepping back, one could see with greater empathy that the student’s driving a Hummer, wearing Armani leather, laying his “skin” and caressing it on the couch, were manifestations of a narcissism in which external valuables might be covering

a core emptiness, worthlessness. One can’t be certain from only two interviews. But the sense of entitlement and remarkable wealth, evoked feelings in this candidate that permitted only an intellectual formulation of the patient’s narcissism, without sincere empathy. One training analyst, upon hearing the case, offered trepwerter, “after thoughts,” that he might have said: “I don’t blame you for trying to get away with anything. You’re welcome to try.

But, do you expect me to be blind and dumb?” He recommended against accepting this as a training case.

The third case, if I described it clearly, raised additional difficulties. As this attractive woman leaned forward, the candidate felt a sense of seduction. He did not find that this was an idiosyncratic countertransference, rather one being brought in by the patient very early in the evaluation. Her case raised additional complications of the special patient, first discussed

by Thomas Main (Main, 1956; Szajnberg, 1985; 1994). The ”special” patient brings along complications that are not necessarily in the patient’s best interest. (The senior training analyst, Dr. X, did call after the woman’s
last visit, expressing disappointment that the “experienced” candidate would not reconsider his decision and accept the patient into treatment. Of course, Dr. X., did not want to interfere in the process, but wanted to let the candidate know that she was a very fine person.)

Onetraininganalyst,whowassupervisingthecandidateinanothercase, was concerned that the characterological issues in two of the cases were so severe that a several-year course of exploratory psychotherapy would be necessary before an analysis (one that fulfills the criteria for certification) were feasible. Given the candidate’s age and desire to complete his training, the analyst recommended against accepting both patients. In fact, he thought that both patients would present challenges to an experienced analyst.

In each case, I want to emphasize, a different candidate or analyst might have been able to treat the patients successfully, addressing issues such as entitlement, seductiveness and certain aspects of narcissism.

Freud first wrote about entitled patients in his “Some Character Types met within Psychoanalytic Work” (1916). His paper is remarkably atheoretical, more a descriptive account of three character types – “exceptions,” wrecked by success, and criminals from a sense of guilt — in which he did not give clinical material, using references to literature. While Freud initiated our inquiry into what we now call character analysis, of the three character types, the “exceptions” present with the expectation that the analyst make special exemptions. “They say that they have renounced enough and suffered enough and have a call to be spared any further demands…” such as psychoanalytic work expects. On exploration, these patients give a history of early “suffering…of which they new themselves to be guiltless…’ (1916; 312-3).

But it is Kohut’s work (1967) that brought the character disorder of narcissism to the fore. To a significant degree, such patients have become the coin of the psychoanalytic realm. While Kohut eventually developed a detailed theoretical developmental model of two lines of parallel development and a lack of parental empathy, his early work focused on revised psychoanalytic technique with such patients. Kernberg (1975), Giovacchini (2000) and Andre Green (2002), among many others, have suggested that the narcissistic character is along a continuum of character disorders. Further, Giovacchini and Kernberg in particular have articulated healthy aspects to narcissism, distinguishable from that in character pathology.

Ironically perhaps, it was a social historian, Christopher Lasch (1974), who raised our awareness of narcissism as a characteristic of American culture arising in the late twentieth century. In an encyclopedic review of changes in American society — a shift in capitalism, bureaucratization of work, government and decrease in family power and responsibility – Lasch describes narcissistic elements in society, including a sense of entitlement, emptiness and associated pursuit of desires, trivialization of personal relations, and a pseudo-self awareness and self-absorption with a search for identifications (as opposed to identity) and various “therapeutic” modalities of self- realization or self-improvement. That is, Lasch sees the Narcissitic Personality Disorder only as an epitome of an ailment in contemporary American society. In terms of the patients who presented here, this complicates our diagnostic challenge: we need think not only in terms of specific character pathology, but also an overlay of entitlement (and underlying emptiness) in the culture.

But, in terms of these three patients, there were specific aspects of narcissism that (combined with this analytic candidate’s needs for a timely finish of training) mitigated the likelihood of successful analysis: an overarching sense of being an exception, being entitled; an unusual lack of awareness of their presumptuousness; a sense that they could appeal to higher powers to prevail on the candidate (or others); and a demeaning of both the analytic situation and the analyst/candidate. In terms of demeaning, all three prospective patients were from monied backgrounds, were prepared to pay well for what they valued. None of these aspects are insurmountable in a sufficiently lengthy analysis with an analyst aware of the countertransference issues involved – countertransference in the more recent sense of counteridentification or evoked response, rather than Freud’s thoughts of a more idiosyncratic countertransference.

In the early psychoanalytic institutes, “free” or low fee clinics brought many, many patients (Makari, 2008). When Eitigen and colleagues opened the free psychoanalytic clinic in Berlin2, there was a press of patients, almost overwhelming the capacity of the clinic. Circumstances have changed profoundly.

What does this imply for candidates? There were at least three interacting factors here: the manner in which prospective patients were referred; societal valuation of this matter of psychoanalysis; the candidate’s need to finish particularly nearing training.

Any institutional decision about screening and referring has implications with advantages and disadvantages. The advantages of this Institute’s minimal screening — include brief patient contact with a training analyst and accepting that a patient may not be treatable by a particular candidate, but possibly by another — theoretically provides greater openness, receptivity to patients; avoiding disappointment associated with extended assessments by a training analyst before referral; and offers greater hope that lack of “fit” with one candidate does not preclude “fit” with another. The disadvantages include referring to a candidate before an experienced analyst can assess not only the patient’s formal diagnosis, but also what Winnicott (1972) or Schlesinger (2002) referred to as assessing the nature of analytic process.

My paper addresses possible complications of a more “open” screening process. This is simply a caution to training centers.

Now, as a training analyst, I have discussed these three cases with colleagues. Reactions have been complex. One suggested at first, that she would have tried to interpret their attitudes, such as seeing the analysis as a “good deal,” a cheap treatment — but, she could not think of an interpretation at the moment. Then, she described a recent referral – a graduate student in psychology — who insisted on either a lower fee or lower frequency, as she was planning to buy a new car. Another colleague recounted a more complex situation: in his Institute, one must be in analysis for one year before applying for training. An older therapist came for analysis, as she had heard he was highly regarded at the Institute and on the Education committee. But, she warned him, that if she were not accepted at the Institute, she would not continue her analysis. He was concerned that a false analysis was in process.

I write this paper as a caution, without offering solutions. I write this to open discussion among candidates and Institutes to recognize the dilemmas associated with any referral process, particularly low-fee cases.

The low-fee clinic may attract prospective patients with specific characterological constellations: entitlement, a pseudo-investment in psychoanalysis, and possibly, a not- too-subtle demeaning of the analyst/analysis. If this is the case, then it is useful for Institute clinics, training analysts and candidates identify and address such issues in order to facilitate more successful referrals and psychoanalytic treatment, less encumbered by character traits that may require lengthier analyses.

1 I thank Drs. Robert Wallerstein, Alan Skolnikoff, and Owen Renik for supervising the intake of these cases and others.

2 This clinic and the one in Hungary were funded in large part by Eitigen’s family’s fortunes from the fur business.

References:
Freud, S. (1916). S. E. Volume XIV. Some Character-Types Met with in Psycho-

Analytic Work. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XIV

Giovacchini, P. (2000). Impact of Narcissism: The Errant Therapist on a Chaotic Quest. Jason Aronson.

Green, Andre (2005) Psychoanalysis: A Paradigm for Clinical Thinking. Karnac.

Kernberg, O. (1975) Borderline Conditions and Pathological Narcissism. Jason Aronson.

Main, Thomas (1956), “The Ailment.” The British Journal of Medical Psychology, 29.
Makari, G. (2008) Revolution in Mind. Harper Collins.

Schlesinger, H. (2002) The Texture of Treatment. NY: Analytic Press.

Szajnberg, N. (1985), “Staff Countertransference, in the Therapeutic Milieu: Creating an Average Expectable Environment.” The British Journal of Medical Psychology, 58; 331-6.

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Szajnberg, N. (1994). Educating the Emotions: Bruno Bettelheim and Psychoanalytic Development. NY: Plenum.

Wallerstein, R. (2000), The Talking Cures NY: IUP.

Winnicott, D.W. (1972) True and False Self, In The Maturational Processes and the Facilitating Environment. NY: IUP.

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