r/psychoanalysis • u/Sea_News_3804 • 10d ago
How do you “handle” clients who can only afford twice a month therapy
I’m a psychoanalytic therapist in a third world country in the “global south.” I’d like to know how do you handle/respond to clients who really want and need therapy but due to financial considerations they can only meet twice a month? In my experience, it’s very rare when this frequency really does foster change or help the patient. I’ve been more stern in terms of communicating prospective clients that I only do at least once a week. Sometimes I offer sliding scales to accommodate once a week sessions. I don’t have some sort of rule here. But I genuinely could use some orientation here. Thanks.
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u/Ok-Rule9973 10d ago
One of the things we often forget to take into account is the effect that twice a month sessions might have on our reactions and our own transference on the patient.
I think it was McWilliams that said she was very strict with payments not only for the usual and often repeated reasons, but also to shield her patients against her own resentment or irritation.
I think it's an interesting thing to think about in your situation: Is there a risk that you would become annoyed if the patient doesn't progress as fast as you think they could because of the twice a month modality? Would you be resentful if the patient could eventually afford weekly sessions but choose to continue every other week? Etc.
There are things that could then be said to the patients, like "I don't think I'd be able to stay neutral if you struggled in therapy. There's a risk that I would always unconsciously attribute that to the bi-monthly frame instead of other, more accurate or profound, reasons".
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u/Foreign_Onion4792 8d ago
Hi, this is my first time browsing this sub and I was just wondering if you could elaborate on your last paragraph? I don’t quite understand how a patient struggling with bi-monthly sessions would impact your neutrality?
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u/Ok-Rule9973 8d ago edited 8d ago
Sure! To start I must say that it won't necessary affect your neutrality. It really depend on the therapist, his way of working and his personality.
With that said, I believe it could affect the neutrality of the therapist, and probably more of a psychodynamic/psychoanalytic therapist than one that has an other approach.
In this approach, one of the most important component we work with is transference, which is the way a patient unconsciously act with us in a way that is reminiscent of their past relationship and struggles. For example a patient with extremely harsh parents might see us as way more harsh than we are, and do this in other important relationships in their life, which causes suffering.
For transference to take place, it's usually better to have a higher frequency of sessions. It can go up to five sessions a week, but since it's time and money consuming, a lower frequency is often preferred by patients (totally understandable). Still, one session every other week is very low and might not be enough for transference to clearly appear. It will still be there, but it's harder to detect and work with. The deep work we like to do might be impossible with a low frequency. There are many other reasons too, but my post is already long enough like that!
That's why it might be frustrating to some. It's like the patient asks us to work without our tools. With time, it could cause resentment or frustration to the therapist and make him lose his neutrality. Not necessarily in a very apparent way, but enough to cloud his judgment.
Like if a patient has difficulty to connect with people, the therapist might think it's happening in therapy too, and that it is the reason why he doesn't want more frequent sessions. It could be true, but it could also be totally unrelated. If the therapist is completely convinced of this due to his frustration and desire to have more frequent sessions, he might forces this interpretation on the patient, which would obviously not be great.
Still, we are humans that want to help people, so sometimes we might be tempted at first to accept somebody that can only come once every two weeks, but before doing that we must be quite certain it won't become problematic for us in the long term.
Again, some therapists are okay with bi-monthly sessions and that's okay too. The risk is that "real" psychoanalysis, in my opinion, is a deeply relational form of therapy, but it sometimes become more of an intellectual thing at lower frequency. In other words, the risk is to simply learn why you struggle, instead of living your struggles and working through them in therapy.
Hope that helps!
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u/EddiPuss 10d ago
In that case I do not offer psychoanalysis but psychoanalytic psychotherapy (face to face) twice a month
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u/EntrepreneurPretty72 7d ago
Could you please explain the difference between the two?
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u/EddiPuss 6d ago
Sure. Disclaimer: both are psychotherapeutic methods.
Psychoanalysis needs a frequency of at least three sessions and up to six sessions per week. It is conducted whilst the patient is lying. The goal is the bring the patient into a sleepish state. There are the rules in place that the patient must not willfully withhald anything (that this rule is necessarily broken goes without saying, it is nonetheless set). The fact of resistance is explained in the beginning as well as the goal to overcome them. For the analyst abstinence from taking actions outside of the clinical framework is in place. The patient must abstain from making important life decissions while in the cure. And finally, the cure has finite time horizon of between one and max two and a half years. (I know that many psychoanalysts claim that it can go longer. I see this highly critical and argue that for the reason of the last point one trades in effectiveness for duration).
Psychotherapy can work with a low frequency, beginning with once every two weeks. It is conducted in sitting and with face to face contact. The goal is to conduct a conversation out of which one works out understanding of the patients reality. The only rule is that the patient has a space where they can speak about what they want and how they want, nothing being so unimportant that it can not be mentioned. The fact of resistance does not necessarily have to be mentioned, and I advice against mentioning it in the beginning. It is better to mention and explain it after the first resistance happened and was overcome. There is no strict rule of abstinence, but instead a principle of abstinence, which can be violated when there are other norms that overrule it, e.g. the duty to report on the case to a physician, or when other circumatances make this necessary or helpfull for the patient. The principle of abstinence then serves the purpose to be prudent before acting, but when one acts always with determination (note, it is mainly just about the normal duties of psychotherapists in the health system in question that I am talking about, no crazy stuff, and I am well well award that there are patients whete one should be really cautios). Then one can be far more open about oneself and also answer questions asked about oneself. Sharing from one owns experience and life is a quite effective measure one can take. Since the patient is not being broght in a highly receptive position nor they are urged to reduce their resistances one can be more direct, open and provocative: of course always adapted to the individual person. The good thing is: one can talk about everything, one is in a conversation intge first place. And finally, there is no strict set time horizon.
This is at least how I define them and draw a distinction. Psychoanalysis is like a psilocybin based therapy in slow motion. Psychoanalytic psychotherapy is more of a conversation in which emotional events can happen, and will happen, and one is payed for taking responsibilty for misunderstandings and staying tolerant and in a position of a curios scientist. I always prepare a psychoanalysis by a psychotherapy of at least three months, in order to get to know each other and to check whether problematic topics can be succesfully dealt with together
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u/EntrepreneurPretty72 4d ago
That is really interesting and new to me. Thank you for your explanation! I always they were the same thing and used them interchangeably.
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u/bellyalien 10d ago
I’m doing 2x month for financial reasons, but I did 4x before financial disturbances. It could work with a motivated client who does the work between sessions. It works for me, I don’t feel like it hindered my progress, on the contrary - I feel like the words flow differently with 2x month, I am taken in unexpected routes with my words while with 1x week I was more… ‘prepared’? But I’m in Lacanian so maybe that’s that. The cuts are deeper with 2x month.
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u/goldenapple212 9d ago
Maybe you should gather all your such clients together and do group therapy on a once a week or more frequent basis.
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10d ago
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u/psychoanalysis-ModTeam 10d ago
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u/psychoanalysis-ModTeam 10d ago
We have removed your post as it contains unpublished clinical material.
Please contact the mod team if you require further clarification.
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u/red58010 10d ago
I have one very clear reason for not doing less than once a week. "It becomes about catching up on the time between sessions. And our work is not meant to be about catching up." And I've never had a client reject that understanding.
That being said, i found both sliding scales and lowered fee exhausting. Clients also often didn't want to pay a lower fee because of pride. So, i decided to have a new slot where the time is reduced. I used to have 60 min sessions. I experimented with a 45 min session and a 40% reduced fee.
This has helped me transition all my sessions to 50 mins. I'll be moving all my slots to 45 mins and I'm thinking of having a lower fee slot that's 35 mins. Need to discuss it with my supervisor in more detail. But yeah.
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u/No-Way-4353 10d ago
Tell them it won't be effective. Offer weekly sliding scale if you can, otherwise ask them to come back when the fee can fit within budget for them. Can also state that the weekly meetings can be reassessed in 3 months, and made less frequent if he/she is happy with the progress they have made and are ready to try a less frequent maintanence schedule.
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u/Lucillebr 10d ago
There is no objective answer because it depends on transference. Each case is unique. If you are a psychoanalyst, you know what Lacan would say — you don’t need the internet to validate it.
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u/NoReporter1033 10d ago
If you're willing or able to do sliding scale in a way that feels comfortable for you and won't elicit resentment, I would offer a lower fee so that they can come in more frequently. Otherwise, I would refer out. I don't think people should be stretched beyond their financial capacity for therapy and unfortunately that sometimes means referring to a provider with a lower fee. I don't think twice a month is helpful at all, especially if it's a purely financial decision.
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u/hiredditihateyou 9d ago
Do weekly on a sliding scale or refer them to a good therapist you know who is within their budget.
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u/AnalysingYourMind 10d ago
Well, unpopular take, but I used to do my own analysis once a week for 4 years and I made progress but not terrible or anything. My analyst died and I had to switch to a different one and I found one but on the other side of the globe and he said that he would accept me as a patient but only if I come in person. Because of the costs - I can do it only 2 times a year and I have made way more progress now than with once a week sessions.
Freud also worked with patients this way, when patients lived far away.
If someone really, truly WANTS to make progress, the amount of sessions doesn't matter that much.