“I’m not sure I can afford therapy but I am more or less sure that I can’t afford not to do therapy.”

I have heard a number of patients formulate this quandary in roughly these words. Psychotherapy is a developmental input. It works on conflicts that have not yet achieved full definition or recognizable shapes as well as on those which are painfully present, perturbing and pervasive. It is about achieving conflicts at least as much as about resolving conflicts.

Psychotherapy works to help the patient delineate the past, discover how it works in the present, know the present in depth and detail and imagine and intuit as well as realize possible futures. Psychotherapy is a dynamic disordering of past, present and future in the service of producing refinements or revolution in the approach to each one.

Psychotherapy is often a form of basic research.

Many patients come into therapy in search of themselves. They have agony of one or another flavor and also an inkling of who and how they might wish to be on the other side of the interior gulf..

The first emotional cost of psychotherapy is saying, “I need this.”

This can be a very high cost if a patient’s character is built around the denial of need, even the repudiation of need. Need-shame is a common and difficult problem. Some patients come to therapy so sealed against their own needs that any effort to help them approach their needs produces great upset.

There are patients who come to therapy saying that they are just curious about therapy, that they have a friend who seems to have benefited from therapy, that therapy is something that seems stylish and has a certain intellectual cachet.

Sometimes a patient may say that she will come for six sessions or ten sessions only so that, when people talk about therapy, she can be part of the conversation. A good proportion of these patients may still find themselves in therapy years later.

I have rarely if ever had a patient who did not have genuine and deep psychic pain and confusion. Despite what a patient may profess, coming to therapy is almost never a frivolous act. The poses, like being just curious, are a kind of anesthetic that may both mask the pain and provide ways in the beginning to save interpersonal face.

It is a frightening thing to seek out a therapist.
My first encounter with a therapist came when I was a junior in college. On the recommendation of a friend, I voyaged from Cambridge underground into the center of Boston. The therapist was exceedingly courteous, if somewhat emotionally removed.

Only twenty- five years later, after I was already a psychiatrist myself did I realize that part of what made the encounter feel so overwhelming and fantastical, was that he had the same name as my maternal grandfather, who died suddenly when I was five and to whom I was quite attached.

Many patients, like me all those years ago, arrive at their initial therapeutic encounter not able to sketch very clearly their predicament and leave the initial encounter at least as much disoriented as oriented, often in ways that go deep and prompt much feeling which is not easy to categorize.

This is all part of the price of entry into psychotherapy.

Of course, it is also true that psychotherapy can harm as well as help. It can rub salt in old psychic wounds, producing barren repetition rather than recall in the name of change. A psychotherapist can misunderstand without allowing for robust initiatives on the part of the patient to correct him.

Misunderstanding can be in the nature of a first approximation, if there is room for corrective pressure from the patient. In fact, most substantial understanding proceeds by cycles of successive approximation. When the therapist “knows” and insists on his “knowing” the result is an oppression which is not therapeutic. This is not uncommon, being an instance of premature closure. Psychotherapeutic understanding requires an open mind.

It is also the case that psychotherapists fall asleep, not just figuratively but literally. Somnolence may be caused by age, by illness or by medication. Or none of these may be at play. Falling asleep during therapy can even be a delinquent form of self-indulgence.

A young woman was not convinced that her therapist was paying attention to her. He seemed detached and she felt that a good bit of the time he might just be asleep. She got angrier and angrier but neither was able to communicate her wrath or to stop going to therapy with this therapist. So the result was that she was stuck bearing the unbearable. There may have been important elements from her past, but the fact was that her therapist was doing a shoddy job and asleep at the wheel.

I have long felt that the most common boundary violation in therapy was not the therapist’s approaching too close or taking sexual advantage of the patient . Of course, these happen and can be devastating and require professional disciplinary responses. I believe that the most common boundary violation is excessive withdrawal, too much not too little distance, inaccessibility, remoteness, even iciness.

These confront the patient with a barren wasteland along the perimeter of engagement. A consultant once characterized a patient’s experience of her therapy as “the sound of one hand clapping.” This was a very useful comment because it legitimized the patient’s feeling of what was lacking in her treatment. She felt understood and accepted, as if the consultant knew what she was talking about.

She was able to change therapists, which represented a major liberation. What was behind the difficulty in letting herself be free to do what she felt she needed to do was her relationship with her massively narcissistic mother who was mostly unaware of her daughter’s existence as a separate person.

The form of violation consisting of too much distance, production of a barren zone of interpersonal space goes mostly undetected and is rarely, if ever, the basis for any kind of professional disciplinary action. In fact, to some degree, it is encouraged by doctrines of neutrality, professional distance., equanimity and so forth.

It is virtually a secret dimension of harm.

This brings us to the topic of the monetary costs of psychotherapy and how to think about them. I had what seemed to me at least a minor epiphany as a patient was berating me about how much psychotherapy cost her and how little it did for her. This was one of her favorite topics.

At core she believed either that psychotherapy should be free or that she should be remunerated for how painful it was to come to therapy. Surely, she felt, if psychotherapy were properly conceived or if her therapist were genuinely competent, then the level of pain would be much lower.

This was a patient who had made substantial progress and whom I was seeing at a reduced rate. So there were a number of dimensions of fine irony available to me as I listened to her lamentations. She was bitter and biting and very smart. Her sallies hurt, as they were meant to do.

In the midst of one of her tirades I had a new thought. It occurred to me that no one could pay me enough to put up with her and her attacks, that I did it out of the goodness of my heart and of my own free will. It was a gift freely given because it made sense to me to give it, because I felt for and with her in her numerous predicaments, because her predicaments had enough resonance with some of my own life experience that I could enter into them with feelingf and imaginatively.

The money that she paid for therapy represented part of a stipend that enabled
me and my family to live a comfortable but by no means lavish style of life . If money was fundamentally what I had been interested in I would never have become a psychiatrist, let alone a psychotherapist who saw people for sessions of 45 minutes or an hour.

I did not go over any of this with my patient, but it was a help to me because it seemed to make a valid distinction between what amounted to an existential gift freely given and an amount that represented a contribution to sustaining me so that I could sustain the work. It was a help to me in understanding what I was doing and why, so it was a help in containing my feelings and responses to the patient. In this way it helped me contain her feelings. It made our shared plight more habitable.

Psychotherapy began as the purview of a troubled and exploratory cultural elite, many of whose members had no need to work for a living Then it came to the United States and became, in a period of rising resources and changing societal norms, much more democratized. Insurance companies became involved and tried to set standards using the club of threatened non-reimbursement.

Psychotherapy is still the province of a wide variety of small producers who practice in quite diverse ways and charge widely varying fees. I, myself, have been a solo practitioner throughout my career. This has to do with my temperament, my rather pronounced taste for autonomy and also my wanting to be both in control and responsible for the care of my patients. Institutional affiliations both make a lot possible and a lot impossible.

I have had the vaguely chagrining experience of discovering that a resident I was supervising was charging more than I did in a private practice he was running on the side. I have supervised younger colleagues who have both charged more and earned a good deal more than I did. It is not unheard of to notice an inverse correlation between the therapist’s experience and the cost of a session.

Of course, there are some factors that make at least partial sense of this. Less experienced, younger therapists may have school and college expenses to pay for, may be carrying significant mortgages, whereas more experienced therapists who are older may have already met these expenses and be at a point in life where acquisitions are not the issue.

Psychotherapy is not a fungible commodity, like sugar or corn or coal. In many respects, the psychotherapist is the psychotherapy. It is not a matter of theories but of an encounter. Not only does the cost of psychotherapy vary, psychotherapy itself varies, It will be impossible to make psychotherapy submit to the rule of manuals because these leave out crucial dimensions of attachment, attunement and invention. Of course, it can also be said of the patient that the patient is the psychotherapy.

So what does the adventure of psychotherapy cost in money terms? It costs a good deal less than what most lawyers charge. It costs a good deal less than tuition at a private college. It costs a good deal less than a house or apartment. It costs less than most procedures in medicine.

What is the payoff? The payoff depends on what the patient and the therapist can make of therapy. Many patients who stay in therapy tend to earn more. Many find that self-knowledge leads to more peace and more happiness, to the shedding of dread, goods that are hard to value in money terms.. Of course, as I have been at pains to note, it does not always work out so well

“I am not sure I can afford to do therapy and I am not sure that I can afford not to.”

This expression of a quandary can serve as a good stopping place just as it served as a starting place.

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