Questions and Answers

I have been in psychotherapy for approximately 3 years with my current therapist. . . . I was also in therapy with her approximately 10 years ago for about 1 year. I left my first round of therapy . . . because I left the area. . . . Originally I began to see her due to severe depression, anxiety attacks, and bipolar II issues. When I began to see her 3 years ago I went back because I was in an immediate crisis . . . and needed the help no matter the cost.   She has helped me dramatically, not just with my presenting problems, but with deep issues that have prevented me from being happy. I feel I have learned a lot of things and have changed many ways of thinking. I am now able to do a lot of things for myself (emotionally) that I originally needed her for. I have also been able to make many positive changes in my life. I do still feel, however, that I have a long way to go.   I find myself in a situation where I am having difficulty paying her. I have considered seeing her an investment ($180 a session, weekly session, no mental health insurance) and it has been a wise investment. I’ve been able to make changes in my life that I wouldn’t have been able to make otherwise. I talked with her about seeing her twice a month as opposed to weekly.   I feel very angry and confused and sad about my conversation with her regarding my seeing her less often. She told me in the past that she identifies with me and that my problem of suppressing emotions to the point of truly not even knowing that I’m having them was one of her main issues in her therapy as well. She has said that she cares for me and feels a genuine connection with me that she thinks we would have if we had met under different circumstances. I feel there is a genuine connection and I do believe she is concerned for my welfare and happy with my progress. When I talked with her about not seeing her as often yesterday, I didn’t ask her to cut her fee, but she said, “I wish I were a wealthy woman where I was able to offer a sliding scale fee to some of my clients, but I am unable to—especially because of my health situation and all the work I missed last year.” (She did not work for approximately 2 months.)   We did not have time to discuss her comment as it was the end of the session, but I am very angry that she is not willing to cut her fee. It makes me feel that doesn’t care for me and my progress as much as I thought she did. It reminds me of my parents, who care about me, but have never been there for me in any emotional way that I’ve needed them. It reminds me of my mother, who cares about me, but could not get over her own issues to even ever hug me. It feels like she cares about me only if I’m paying. Seeing her has been a great financial sacrifice and I feel if she really cared about my progress like I thought she did, she would be willing to sacrifice some too—especially considering I make a fraction of what she makes. One of my friends and my boyfriend are both practicing therapists and have said that they have cut fees in similar circumstances. My friend said that with one client she truly enjoyed the work she did with the that client and cared about her progress, therefore she was willing to cut her fee.   I’ve looked around on the internet, but have not been able to find information on standards and guidelines to fees/cutting them/changing them/etc. From a business standpoint I understand my therapist’s position, but I also feel that if she cared and identified with me the way she said she has then she would be willing to cut her fee. On the other hand, I think that my boyfriend and friend may be telling me that they sometimes cut their fees to show empathy towards me and aren’t looking at the situation objectively. And beyond all of this, I’m also not sure I can feel intimate with her in the future because of this situation.   There are actually two issues here. First, the issue about the treatment fee represents a metaphorical obstacle that you have encountered within the treatment. This obstacle derives from what can be called a fundamental narcissism of human life. I refer here to the fact that every child born into the world goes through a psychological phase in which it feels as if he or she is the center of the universe. After all, for a child to survive, he or she must receive a great amount of attention from the parents. But eventually, to achieve a mature relationship with the world, each person must learn that “it is not the task of the world to know that I exist, it is my task to know that the world exists.” Thus the child will be able to locate itself psychologically within a network of social relatedness and responsibility, thereby outgrowing a preoccupation with the self. If, however, the child does not receive adequate attention initially, then the child will carry on into adulthood a certain unconscious anger at having been short-changed, so to speak. In other words, when the child’s initial narcissistic needs are not met properly, then his or her attitude to life will remain stuck in a sort of narcissistic short circuit: a preoccupation with making the self feel important as an unconscious defense fueled by the constant bitterness and resentment about what hasn’t been received. That’s what depression, anxiety, and mania are all about, symbolically. Depression is anger turned inwards; anxiety is a fearful preoccupation with what is lacking; and mania is a flight into an imaginary feeling of self-importance. In the present case, your resentment about the treatment fee represents your resentment about having been short-changed by your parents. Your task in psychotherapy is to understand how that emotional short-circuit causes so many of your symptoms, and then to resolve the problem by facing the pain of the original wounds, whatever the cost. Second, you say you have a boyfriend. Well, if he really “cared” about you as he most likely says he does, then why isn’t he helping you pay for your treatment? All of which goes to show that healing from fundamental narcissism does not come from others caring about you—or “loving” you. This common love is just a form of bribery to make you feel desired, and it will always fail in some way. Healing comes from your willingness to give real love—emotional qualities such as patience, forbearance, compassion, mercy, and understanding—to others despite the pain and disappointment they inflict on you. So, to learn real love, you must learn to pay the full cost of life. And once you learn to give real love, rather than be stuck in the resentment of not feeling loved, your wounds will be healed, and your defensive symptoms will dissolve.    Back to the list of questions

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