In 2015, a TV commercial for an Argentine car repair service used, of all things, a psychoanalyst charging for a session to show how this company was different from other auto mechanics. The ad featured a therapist chatting right outside his office with the mother of a teenager who had just finished a vocational test. When the mother asks him how much she owes him for the test, the man explains that the test was 600 pesos, but that there were a few extra problems he found and fixed: “an issue with the superego,” “fears that were not original,” so the session would cost 1200 pesos. The mother, disoriented, replies that she only brought her son for a vocational test, to which the therapist responds: “Yeah, but you know what? If I return him to you like that, you’ll end up bringing him back in a month.” The commercial ended with a sign that said “Luckily, psychologists are not like auto mechanics. Luckily, our mechanics are not like auto mechanics.” The commercial comically played with the idea that certain forms of charging are appropriate for certain services, but not for others. One can expect an auto mechanic to add some extras that appear during the vehicle inspection, or that each new fix adds up to the final rate, but a therapist would never charge in the same way. The authors of the ad also trusted that the Argentine public would be familiar with the scene and the psychoanalytic language used.

This article analyses payment practices among psychoanalysts in Buenos Aires, Argentina, a city known for its high concentration of psychoanalysts. It examines direct private payments from patients to therapists, for sessions that are not billed through health insurance or therapeutic institutions, and which are very common in Argentina. Economic sociologists have asserted that payments always carry some degree of moralization, given that people craft appropriate monetary transactions to reflect on or avoid conflict with their values and relationships. The case of the fee for therapy that I examine here is an especially moralized transaction reflecting several converging values and tensions in the worldviews of psychoanalysts and their interactions with patients. The focus of the article is how psychoanalysts in Buenos Aires charge for their sessions, why payment happens in such way, and what the consequences of the use of these forms of payment are.Footnote 1

My argument is the following: While there are some benchmarks for price-setting among psychoanalysts, fees are not set in stone or the same for all patients, but are up for conversation with the patient. This price discrimination is not conducted using explicit sliding scales but rather by reaching an agreement with the patient in that conversation. Something akin to bargaining occurs but closer to gift-giving (wherein each party should try to offer more instead of less) than to competitive bargaining. I distinguish four factors to understand why payment and valuation take this form: 1) There are a few formally produced prices as well as market mechanisms that shape some diffuse bounds or benchmarks for the fee, but the peculiar service psychologists offer (which makes quality judgments hard), the way patients and therapists are matched, and the lack of public information about prices allow for high flexibility in price-setting; these are structural or institutional factors that remain unsaid in the conversation on fees. 2) A shared collective self-narrative, common to caring professions, that highlights a professional responsibility towards patients that should not be too contaminated by economic interest; this self-narrative is moderated by the notion that the psychologist’s work and expertise should be recognized and remunerated accordingly. 3) A moralization of payment that is distinctive to psychoanalysts about the particular meanings of the transaction, reflecting the singular intimate relationship between analyst and patient, as well as the commitment the patient should demonstrate towards her own treatment, which represents a cost and a loss that is not only economic. Rejecting as much as possible standardized price-setting reflects professional claims to the uniqueness of each patient and each bond, which are informed by psychoanalytic principles. 4) There are no intermediaries (neither a person nor an organization) to collect payment and separately discuss fees with the patient; they charge the patient directly in cash, face-to-face. Cash has a role in the relationship: it can help desacralize the analyst in the eyes of the patient and disentangle the session from the rest of the economic life of the analyst, but face-to-face cash transactions also impede evading moralization through conversation. Finally, as a consequence of the aforementioned reasons and the use of this rather informal form of payment, psychologists themselves often agonize over the payment and the valuation of the session, even discussing it with their own analysts. They have to be careful to ensure this flexibility results in a morally acceptable transaction for both parties, and not an arbitrary one or unjust one that may even affect the bond with the patient. It is, indeed, a delicate transaction.

The article is organized into nine sections. First, the next section locates the case studied in the context of relevant literatures in economic sociology. Second, I describe the data and research methodology. Third, I introduce the case of Argentine psychoanalysts and its specific features. Fourth, I discuss the structural features of the work and market of psychoanalysis in Buenos Aires and their role in price-setting. The following four sections present the core of the interview data to develop the argument above: I explain how psychoanalysts charge patients, how they reach a price in the context of what I call an ‘inverted bazaar,’ their views on the meanings of the fee, and the issues with the face-to-face character of these payments. The conclusion returns to the main argument, advancing some broader conclusions as well as the morals and markets lessons of this case.

Morality, payments, and valuation

In the last couple of decades, sociologists and anthropologists have taken money as a research topic increasingly more seriously (Bandelj et al., 2017; Dodd, 2014; Maurer, 2006). Classic sociological analysis of money often treated it as a neutral medium that homogenized social ties or, worse, destroyed them. The pioneering work of Viviana Zelizer (1994, 1996, 2005) in economic sociology has opened research avenues for a more nuanced view of the role of money and markets in modern societies. In what Zelizer (2005) calls “hostile worlds” accounts, when money comes in, intimacy, friendship and other human values go out. Zelizer demonstrates, however, that empirically money does not necessarily destroy, corrupt, or contaminate intimacy and social relations. Money is routinely used by people to mark social relations and to distinguish ties; in other words, money is not just an economic medium, but also a social medium that makes up meaningful social exchanges and social ties. Money exchanges that appear equal from a strictly economic point of view often take varied concrete forms (bonuses, gifts, bribes, compensation, entitlements) that each signifies something different in the context of the relationships in which they are used and the meanings actors assign to them (Zelizer, 1996). As Fourcade (2012, p. 1058) explains: “Money, Zelizer reminds us time and again, does not dry up social ties. Rather, it organizes them and reveals their nature.” Inspired by Zelizer’s insights and by the growing anthropological work on money and exchanges (Guyer, 1995; Hart & Ortiz, 2014; Maurer, 2006), research on money has moved from analysis of abstract money movements to analysis of its concrete uses on the ground (Carruthers & Espeland, 1998; Wilkis, 2017).

Morals and markets has come to designate a field of study shaped by the notion that the presence of market transactions does not mean absence of moral meanings; quite the contrary, these transactions are made possible by people infusing those apparently impersonal transactions with moralities (Fourcade & Healy, 2007; Livne, 2014). Market transactions do not simply eat up morality but allow enough space for people and institutions to realize moral values through those transactions, as the case of psychologists will show. But this is not easy. Zelizer’s critique of the ‘hostile worlds’ approach is mainly that sociologists and others had mistakenly granted unlimited power to commodification processes, not that commodification trends are a complete mirage (Zelizer, 1994, 2005). Indeed, people have to work hard to infuse market transactions with moral values, performing relational work (Bandelj, 2012, 2020; Block, 2012). Health care provision is generally a peculiar service, marked by social and moral obligations different from profit-maximization (Almeling, 2011; Arrow, 1963, p. 965; Bodenheimer & Grumbach, 1994; Healy, 2006). Recent research on health care has shown this convincingly. While market pressures, financial limitations, and maximization incentives increasingly structure health care provision, many care providers are able to sustain social values even within a competitive marketplace (Altomonte, 2020; Brown, 2021; Livne, 2014, 2019; Reich, 2016). Professionals (especially in care industries but not limited to these) usually want to link their work to the imperative of the common good (Cohen & Dromi, 2018), and payment transactions can be used to reflect those desires to the extent possible (Delaney, 2012).

The payment for psychoanalytic treatment that I analyze in this article has some of the features of health care in terms of being a peculiar service, but has its particularities that distinguishes it from doctors, hospitals, hospices, or fertility clinics (Brown, 2021; Craciun, 2016, 2019; Livne, 2019; Reich, 2016). Among these, the most salient are the comparatively personalized character of payment (with low mediation and relatively blurry calculation), and the (flexible) theoretical apparatus that psychoanalysts share, which provide several meanings for the patient’s payment. Psychoanalysts, for example, regard the payment as good for the payer herself, as it symbolizes one’s commitment to the treatment. They also resist market commensuration since that would threaten their claims to the uniqueness of each patient (although, as I will show, some degree of commensuration remains). This view blends elements of market and of gift-giving. Indeed, sociologists and anthropologists have shown that most real transactions combine elements of both types of exchange, even as actors and observers may interpret them as one or the other (Appadurai, 1986; Bird-David & Darr, 2009; Degenshein, 2017; Elder-Vass, 2016; Godbout & Caillé, 2000; Herrmann, 1997; Lainer-Vos, 2013).

Building on the literature on the social construction of markets, as well as studies of science and technology, the emerging field of valuation studies has analyzed socio-technical processes by which value is assigned to things. Valuation studies go well beyond economic value (i.e. rankings, reputation, quality, taste, and other determinations of worth), but an important focus within economic sociology has been the intricate processes by which goods or services (especially, but not limited to, those not easily traded in ordinary markets) are given monetary value in contemporary societies (Beckert, 2011; Fourcade, 2011; Karpik, 2010). These processes exceed presumably spontaneous mechanisms of supply and demand, but they also go beyond the cultural and symbolic meanings highlighted by the literature inspired in Zelizer’s work (Wilkis, 2018). The literature on valuation distinctively analyzes the technical aspects involved in valuation, which combine with moral, institutional, cultural, and political elements (Beckert, 2011; Calıșkan, 2010; Doganova et al., 2014). The way in which a market is organized, the quality and quantity of ties between buyers and sellers, the specific cultures of different commercial activities, the accounting tools used, or the characteristics of the products or services in each market give rise to distinct valuation practices (Callon, 1998; Callon & Muniesa, 2005; Garcia-Parpet, 2007; Helgesson & Muniesa, 2013; Wilkis, 2018). It is not the same to value a company, an industrial product, a tomato, beauty, a work of art, legal services, financial assets, human lives, or damage caused by a natural disaster, to name a few cases addressed by the growing sociological literature on valuation (Beckert & Aspers, 2011; Beunza et al., 2006; Fourcade, 2011; Haunschild, 1994; Heuts & Mol, 2013; Hood, 2017; Mears, 2011; Uzzi & Lancaster, 2004; Velthuis, 2013). Setting the fee for a psychoanalytic session entails an uneasy valuation where morality, relationships, disciplinary knowledge, and economic considerations intersect, in a context where formal organizations do not have a strong influence on price-setting, where accounting is fairly rudimentary (Geertz, 1963), and where there is scant public knowledge about providers’ prices. This makes the moral elements of valuation more visible than in more complex socio-technical arrangements, as they do not remain “hidden” in technical devices.

Data and method

Data for this article comes from thirty in-depth interviews with psychologists who treat patients in Buenos Aires. Interviews were conducted face to face in Buenos Aires by the author or a research assistant, and took place between 2015 and 2017, most times in the psychologist’s office (frequently located in their own home), and in a few cases in coffee shops. Although it is impossible to obtain a systematically representative sample in the absence of enough descriptive statistics of the universe of psychologists in the city, I selected interviewees considering some basic criteria to ensure variability and consistency (Small, 2009; Weiss, 1995). Almost all interviewees studied at the University of Buenos Aires, the largest program in the city, and a longstanding bastion of psychoanalysis. The sample roughly represents the estimated gender structure of the profession, approximately 80% female (Alonso & Klinar, 2014). Finally, respondents varied in generational and career terms, including graduates from each decade from the 1960s to 2010s. Most of the initial contacts to reach interviewees were obtained through personal networks. We asked each interviewee to refer colleagues, but avoided having more than five respondents who belonged to the same network or who originated in the same initial contact. Interviews lasted between 45 min and an hour and a half, although in some cases they were shorter and in a few cases they exceeded two hours. Interviews were coded and analyzed using qualitative data analysis software, in order to identify emerging patterns.Footnote 2

The case: Psychoanalysts in Buenos Aires

Argentina has a huge number of psychologists compared to other countries, considering its level of economic development and the strength of its health and welfare services. The available data confirms the reputation of Argentina and Buenos Aires in particular as a place of extraordinarily high supply of psychological care. According to the WHO, in 2005 the country had 106 psychologists working in mental health for every 100,000 people. The only nations that came even close to this rate in the same dataset were all Nordic countries –Denmark (85), Finland (79), Sweden (76) and Norway (68) (World Health Organization, 2005). A research team at the University of Buenos Aires estimated for the same year a rate of 133 psychologists/100,000, raising to 206 by 2014 (Alonso & Gago, 2006; Alonso & Klinar, 2015). This growth can be partly explained by the increase in the cohort size of psychology graduates since the 1980s, while older (and smaller) cohorts haven’t yet retired. Rates are higher than international standards in the most urban provinces, but the national rate is particularly skewed by the city of Buenos Aires (1211 in 2014). Psychology continues to be a popular career choice in public and private universities, consistently attracting about 5% of the student population in recent years (Ministerio de Educación, 2011, p. 46; 2013, p. 64). In 2015, psychology was the fourth highest degree choice in Argentine universities, behind law, business administration, and accounting (Costa, 2017).

Scholars and media alike have recognized the atypical character of Argentina’s professional field of psychology (Dagfal, 2009; Landau, 2013; Moffett, 2009; San Martín, 2006), and have linked it to the singular historical development and influence of psychoanalysis (Bass, 2006; Hollander, 1990).Footnote 3 While in the US and other countries psychoanalysis is often considered as a separate field from psychology, in Argentina the development of psychoanalysis was fundamental for the establishment of psychology as a profession (Marsilli-Vargas, 2016; Plotkin, 2001, p. 143). In spite of some decline in recent decades, and unlike the U.S., psychoanalysis still dominates the largest psychology programs and maintains a level of professional prestige rarely seen elsewhere. The extent of this is reflected in the fact that the main psychology program in the nation (the one at the University of Buenos Aires) largely provides psychoanalytic training.

Psychologists who treat patients privately in their offices can set their fees independently and the money is transferred directly from the patient to the professional. Those who work with patients affiliated with private insurance or obra social receive a fixed amount per session.Footnote 4 The latter usually see patients in their office and the patients select them from a network of providers. Many professionals also treat patients as part of independent institutions that bring together psychologists and provide offices. These institutions are not just treatment centers, but hubs for courses, study groups, supervisions, and other collective activities that socialize psychologists in particular strands or schools within the profession. In these cases, patients pay a fee to the institution, and part of it goes to the professional (who may either get also paid to teach courses at the institution or pay to attend courses). Although many providers work exclusively under one of these modalities, the same professional may work within different systems throughout the day or the week, or shift along their careers. This article examines the subset of payments for private care, in which there are no formal organizations that intervene directly in price-setting through copays or reimbursements. Although there is no quantitative data available, private therapy in Argentina is very frequent, partly because of the popularity of psychoanalysis (Plotkin, 2001, p. x). At least in Buenos Aires, “doing therapy,” as it is often called among patients, is not synonymous with suffering a codified pathology, and therefore is not generally stigmatized (Marsilli-Vargas, 2016; Peiró, 2017).Footnote 5Obras sociales and private insurers place limits on the number of covered sessions and also have to independently determine initial diagnoses and need for treatment, so many people do not use them for their therapy when there is not a specific mental health diagnosis at play. Several interviewees also said they treat only privately (or prefer it) to avoid the hassle, delays, low fees, or paperwork of prepagas and obras sociales.

One more feature of the Argentine case plays a role in price-setting. The rate of psychoanalysts per capita is not the only one Argentina is known for. Annual inflation rates have been between about 9 and 53% in the last decade, which makes valuation for this kind of service particularly challenging, requiring periodic price renegotiations. Each nominal price increase may roughly keep up with inflation, or may involve further changes (up or down) in the real price of the session. In addition to decisions about price, therapists often need to manage the timing for fee increases for each patient, considering that patients’ incomes may lag far behind inflation for a while depending on their occupation.

Benchmarks: Valuation before the therapy session begins

Psychologists are part of what Karpik (2010, pp. 15–16) calls an economy of singularities, in which products or services are not easily comparable and require fairly opaque quality judgment. As Callon et al. (2002) would put it, in this market there are not tests and measurements that create “qualifications” that may link goods or services through clearly identifiable categories. Psychologists charge by the session, which is a comparable unit, but as I will show later, they endow sessions and patients with a unique character. From a patient’s point of view too, the information needed to choose a therapist and assess price and quality is not transparently available, and there are relatively few “judgment devices” (Beckert, 2011, pp. 775–778; Karpik, 2010). In Argentina psychologists do not regularly advertise their fees (they do not even provide them by phone), and in the vast majority of cases they do not publicize themselves in the eyes of patients (although advertising is not banned, as Karpik (1999, pp. 158–160) found for the case of French lawyers). They do so through participation in professional networks and formal and informal institutions, attending conferences, or for those with higher status, via publications through which they can establish their reputation and obtain referrals. Although some of these status signals may reach patients, they are not intended for laypeople but for other experts. It could be said that to have more work, psychologists do not have to seek patients, but seek psychologists instead. Patients choose an analyst based on informal recommendation networks, both among patients and among analysts (for example, when a patient asks their analyst to suggest a colleague who can treat a family member or friend). DiMaggio and Louch (1998) show that consumers use their personal networks for both search embeddedness (i.e. getting referrals to identify potential transaction partners) and within-network exchange (i.e. trading with people already known non-commercially). The in-network exchange is forbidden in this case because psychologists do not usually treat close friends and family members, but preferably derive them to colleagues.Footnote 6 Furthermore, as Karpik points out for the case of psychoanalysts, the evaluation of service quality is based on relatively opaque information, partly because of the very elusiveness of the notions of ​​“cure” and optimal duration of treatment.Footnote 7 Informal networks and status thus become a fundamental part of the market for psychoanalysis and the level of prices that may be offered (Beckert & Aspers, 2011, pp. 15–19; Karpik, 1999; Mears, 2011, pp. 161–164; Uzzi & Lancaster, 2004). Therefore, due to the singularity of the service and the relative lack of information for price and quality comparison, there is little in the way of “extensive bargaining,” where the buyer seeks offers for comparison before committing (Geertz, 1978, p. 31). A great deal of price-setting happens at the encounter between analyst and patient.

When treating privately, psychologists in Argentina have freedom to set their own fees and to charge however they like, and they indeed widely use this freedom, as I will show in the next sections. However, some prices do circulate among therapists and patients, which leads to certain fuzzy bounds or benchmarks established before the therapy session begins.Footnote 8 Some of these prices are somewhat centralized. Professional associations in some provinces provide minimum guideline rates, which may influence prices. These rates are signals to members to avoid harming the whole sector by charging too little. Although interviewees occasionally mentioned these suggested rates, they were often not even aware of these suggestions, in part because they don’t come from strong organizations. Fees established by insurance, obras sociales, or NGO institutions partly shape private prices, given that most professionals charge a higher fee for a private consultation than the standard rate provided by insurers. One interviewee, for example, said that she calculated her private fee as double the one paid by OSDE, the best payer among obras sociales. She then may alter the fee according to the patient, but that was the benchmark or starting point. Patients who arrive via insurance or obra social or through an institution often have a limited number of sessions and may continue the treatment in private, resulting in a new valuation for out-of-pocket cost, but with some reference to the earlier price. Those benchmarks are directly available only to those who work in those modalities but has an indirect and implicit effect on prices.

Market stratification also conditions the bounds for fees offered by each therapist. For example, fees vary by the socioeconomic level of the neighborhood where the office is located, the level of professional experience, or the need to attract patients. This mere distribution of prices among the population of psychologists naturally requires social and cultural mechanisms that go beyond supply and demand, such as understanding social distinctions between neighborhoods or valuing the experience and reputation of professionals (Karpik, 1999). A central point of the new economic sociology is that there is no market without social embeddedness, and therefore there is no price that does not rest on a social and cultural basis (Beckert, 2009, 2011; Beckert & Aspers, 2011; Wherry, 2008, 2012). This is especially true in this case because a key moment of market stratification is when a psychologist calls a colleague to derive a new patient (for example, a friend or relative of a current patient). Besides the occasional informal chat about how much a colleague is currently charging, it is in the moment of deciding who to reach out to and what to say when deriving a patient that the aforementioned status considerations are central. This decision may include the status of the analyst as well as the financial situation of the patient, which shapes how much they may be able to charge. Also, since psychoanalysts are often patients themselves, some -particularly the younger ones- use their own therapist’s fee as a benchmark to estimate their own.

Handcrafting the fees in conversation

The benchmarks mentioned above initially shape the price levels that each professional may be able to offer their patients. However, prices are not defined by the time analyst and patient meet. Psychoanalysts do not charge all patients the same price. The latter is rather up for conversation with the patient. Indeed, they see this conversation as very important. If a new patient inquires about the fee on the phone, they politely deflect, suggesting that they have the first interview in person where they will discuss the fee. Even those who do give a price on the phone, may say “I charge this amount but let’s get together and talk first,” as Rubén told me. Psychologists often want to embed the conversation about payment in the context of the beginning and “frame” of the therapy and distinguish it from a regular experience of shopping for prices.

If someone calls you and says “Ok, well, how much do you charge,” I generally tell them that we will talk about it in the first interview, but that generally speaking an agreement is reached. Because I think this also accommodates/welcomes [aloja], whoever calls for a therapy consultation, it’s generally because they have a certain malaise, and most times it was very hard to make that call, it was a lot of effort. So I think it’s good to be welcoming [alojar] and say “ok, let’s see.” The economic part is often a great concern for many people, so it’s like saying “ok, well, if you need this space, the space is available for you.” (Elizabeth)

It is important for Elizabeth that the patient does not see economic factors as an obstacle to addressing his or her issues. Communicating a price on the phone would mean disembedding the fee from the relationship established in the first interview. Most psychologists do have an idea in their mind of the value of the session, which Luisa, a psychoanalyst graduated in 2003, calls a “mental fee,” but it does not necessarily translate into the actual fee charged to the patient:

I have a mental fee... but the truth is that it’s very flexible, because it depends on many things, depends on the case, the patient, their possibilities, on what’s happening with the patient, depends on my scheduling ability, too. So this is generally something that I try to talk with the patient, I don’t work with a fixed fee, I can propose what I charge and then the other person can say ‘I can’ or ‘I can’t,’ I can make it or not, it's ok.

Regardless of the structural factors mentioned in the previous section, it is important to note that psychologists consciously embrace this flexibility in price-setting as an integral part of their clinical practice. As put by Patricio, who has seen patients for over thirty years, “this work is a handcraft, it is human-powered [tracción a sangre].” Standardized pricing would not fit the job he does. This is true at the beginning of the therapy but also throughout. Argentina’s high inflation rates means that conversations about the fee have to happen quite regularly. Most psychologists adjust their fees once or twice a year, yet those adjustments are usually not homogeneous. For example, Gabriela said:

In general, not all patients pay the same... It’s not that I have a rule... I am quite disorderly, and absent-minded [colgada], sometimes I forget to raise the fee. Sometimes I should raise it and I think they’re not going to be able to afford it and I let it go, but generally when I am a little more organized I think how much the fee is, because many times if they start with a low fee I will not raise it. If they are paying 250, I’m not going to raise it up to 400, it has to be reasonable in relation to, well, inflation, and it could be that there is a patient who was already paying me less and then I was a bit behind the fee which I consider to be the fee the session is worth, then some patients pay me that amount, what I think it’s worth, and other patients out there pay a little less, that's what happens.

The value of the session (either at the beginning or when the fee is readjusted) is discussed with the patient, within certain limits, as shown by Muriel, a recently graduated psychoanalyst:

One can readjust the fee. For example, it’s August, I raise the fee because there is inflation, but with each patient it is thought differently. You cannot grab a calculator and say “well, I increase 20% to everyone.” There are patients and patients. When a patient comes directly to the private practice I have a floor that I propose, that is always up for conversation [charlable] with the patient… My patients do not all pay the same, basically that’s what I'm trying to say.

Muriel’s image of “grabbing a calculator” illustrates the refusal to perform accurate and standardized price-setting. Elizabeth expands on the absurdity of precise calculations to set the fees for this kind of service:

Look, many years ago, a psychoanalyst we studied with made a formula, and said how you had to calculate the fee. I could never apply it. Never ever. I don’t even remember the formula, I should find it in my notes, but it was a formula from hell, with amount of years, hours, how many hours divided by working hours, sleeping hours… It was impossible, and the fee was ridiculously high, ridiculous everything. I never used it.

Elizabeth strongly rejects the notion that the valuation of the psychoanalytic session can be simply delegated into a standard formula. Interviewees refused a one-size-fits-all approach to payment and always pointed out that they can only think on a “case by case” basis.Footnote 9 Treating patients “case by case” is an important basis for psychoanalytic treatment, and it extends not only to the clinical practice but also to the way they charge. They refuse commensuration in pricing as it would reflect an aberrant commensuration between singular patients. In the following passage, Muriel again explains that different patients react differently to the news of a fee increase, but that in any case the continuity of the treatment is more important than the price:

I always try to say that it’s up for conversation, I say “look, I'm thinking of increasing [the fee] this much,” there are patients who say “no, you don’t have to tell me anything, tell me how much it is” and perfect, and other patients who are more upset or confused and require more explanation. Well, I generally don’t have problems explaining and if the patient says “look, I can’t sustain that fee,” well, sometimes it happens. And here the vocation maybe plays a role... I prefer to charge a little less and to maintain that space, than to have the patient stop coming for 50 pesos, which doesn’t make so much difference.

This idea appeared consistently: non-economic motivations, like a professional commitment to helping others (“the vocation plays a role”), the interest in working with a patient because of the professional challenge or a special patient’s need, or the request by a colleague to treat a patient that cannot pay much are more important than achieving an imagined fee. Negotiating and agreeing on a price is seen as a positive thing, to the extent that both parties are satisfied:

It doesn’t mean that you have to work for free, but it means that it’s possible to reach an agreement. Reaching an agreement for me means that the patient can pay an amount that is affordable for him/her and that I feel comfortable working for that amount. It’s no more or less than that. (Elizabeth)

Achieving a fair price: Balance in an inverted bazaar

Psychologists share with other forms of care work the practice of price discrimination. As put by Rubén: “we have to be disposed to negotiating always, and be sensitive to the economic issues of others.” Economic situation, life stage, and job circumstances of the patient must necessarily affect the value of the fee, favoring the “continuity of an analysis” over the ability to pay a specific fee:

One takes into account different aspects, and with all that one makes a kind of... a mix and says good, this is my fee, but it is between this much and that much. It’s not the same, like, a business owner that a junior colleague, a university student, or a university professor, someone who has... or a teacher... I try to privilege that there is more continuity of an analysis. (Patricio)Footnote 10

You may not know how much you will charge, or you can have categories of fees, because the truth is that for me it’s not the same a patient who is taking their first independent steps or a guy who is a professional, my fee is different and I assume it as different, because they don’t have the same possibilities… It’s also cumbersome to have different fees, it becomes a mess [se te arma despelote]. The truth is that if someone comes who got their first job, is supporting themselves, or moved out of their parents' home, how will they pay the same that if someone like me goes [to therapy]? So ... the strictness turns into handcraft [artesanal]. (Perla)

This price discrimination means that psychologists need to secure patients who will pay more in order to make  the practice viable (i.e. like having a balanced portfolio of patients). In the following passage, Rita, a psychoanalyst with forty years of experience, considers this a fair and satisfying arrangement:

To me it’s not a problem, I have minimum and maximum fees with which I feel equally well paid, and I consider that there are people who really need treatment and whom I am interested in treating, and although they pay me much less, for me it’s very good, there are people who may have more purchasing power and it's kind of an offset… you should also know that I have patients to whom I don’t charge.Footnote 11

Rita feels “equally well paid” regardless of what the specific fee is, drawing an equivalence in her subjective satisfaction with payment that goes beyond the monetary value. Rita in the previous case, Muriel earlier, and Ruth in the following case see their own commitment and passion for clinical practice as reason enough to charge a patient much less, although they must also “offset” or “balance,” by treating patients who pay more:

In general, I have worked with patients who have been able to cover some amount more necessary for me, more stable, and then others that I can take them as patients even if they don’t cover the full fee, because well, I am interested in clinical practice, for me it’s like living, it’s every day, that is, there is no difference between that and life for me. I do not exclude someone because they cannot pay a certain fee... but I don’t keep only a certain population, because it would be difficult, it’s a balance, I try to balance [hacer un equilibrio].

The interview passages above show that despite the commitment to case-by-case and the explicit resistance to commensurate mentioned earlier, there is in practice some commensuration in that therapists are able to sort patients out in (fuzzy) categories. However, despite the offsetting mechanism described by Rita and Ruth, which is at least implicitly categorical, there is no explicit scale based on the patient’s concrete income. Sliding scale fees are used in a variety of services and memberships (Torres, 2015; Zuckerman, 2014) to achieve fairness in pricing. In most cases, the scale is explicit and visible to the payer. As the following passage from Gabriela shows, for the patient price discrimination may not always be completely visible:

e: And do these patients know that you are charging them less?

E: It’s not that I say ... “hey, for you it’s...,” it’s preferable not to... “because you are special I don’t charge you [the full fee],” or “because you are poor...,” I don’t know if it makes much sense, maybe in some case but I can’t imagine... sometimes they know because at some point when they started you told them “I charge this much” and they go like, “it seems a lot,” “well, how much can you pay?.” And well, they finally pay less than what I said I charged.

From the patients’ point of view, the clarity regarding how much they are paying compared to other patients may vary, although in general it is low. Sliding scale fees often depend on payers reporting in good faith to which category of income they belong (as in, for example, professional associations membership fees). However, the analyst does not ask the patient directly what her income is (although they can get a sense of it based on information provided by the patient), but rather discusses how much he or she may be able to afford.Footnote 12 In this way, neither party sees the other’s cards: neither the psychologist knows exactly the patient’s accounting process nor does the patient know the distribution of fees among the patients (although of course patients can know the range of fees if they were part of the initial conversation).This opacity might introduce an undesirable tension if not appropriately managed. Given that the nature of therapy means that patients are expected to be sincere, they will likely disclose information about their economic life, some of which may change the perception the analyst has about a patient’s finances. In some cases, this may lead a psychologist to lower the fee if, for example, the patient’s good progress in therapy is detrimental to their financial situation (i.e. a divorce, moving alone, changing jobs, etc.). But information disclosed in sessions may also introduce a conflictive element in the relationship, as Elizabeth shows:

There are analysts who say “I have to stand that my patient travels and eats in all the expensive restaurants.” Because the patient comes here and tells you about their lives, “I went to Cancun for twenty days, I went with my family here, we eat there, I bought the kids the latest PlayStation, I have this, I have that,” but they want to pay you pennies, and it makes you angry, I’ll be honest.

Without an explicit scale and with the estimate of affordability left to the patient, a lower fee may unintentionally signal that the work of the therapist is not appropriately valued vis-à-vis other consumer expenses by the patient. Therefore, if not adequately managed, flexible price-setting may sour the relationship, making patient and therapist appear as economic adversaries. It may also be an issue if the therapist mentions an initial value or range in the first conversation about fees. In that case, they may not go too low. As Patricio says:

In general, the patient says how much he can afford, and then, well, if what he can pay is not very far of what he’s been asked, a transaction is reached, if he’s far away one will have to say “no, look...” Why? It’s an ethical issue, you have a fee, you can cut a percentage of the fee, but you can’t reduce, I don’t know… 50%, because then the patient will say “but then what were you asking me? You asked me this much before and now you ask me for half of it.” But in general if there is a will to do a psychoanalysis, you reach an agreement.

Reaching a price in this way in such an intimate relationship has to be carefully managed. So much flexibility results in a thin line between the legitimate practice of price discrimination and the illegitimate practice of charging “according to the customer’s face” (as one interviewee put it), i.e. identifying visible markers of wealth or naiveté. The latter is common in clandestine or informal markets (Beckert & Dewey, 2017) or in tourist destinations where there is too much information asymmetry between seller and buyer and no institutional resources or regulatory mechanism to protect the latter. The absence of well-defined prices in the “bazaar economy,” as Clifford Geertz points out, gives rise to a phenomenon similar to what occurs in the case of psychologists, where prices are reached through a conversation:

The continual haggling over terms is to a degree a mere reflex of the fact that the absence of complex bookkeeping and long-run cost or budgetary accounting makes it difficult for either the buyer or the seller to calculate very exactly what, in any particular case, a “reasonable” price is. Pricing is much more a matter of estimates in a situation where highly specific comparative and historical data are simply not available; instead of exactly calculated prices, one finds the setting of broad limits within which buyer and seller explore together the finer details of the matter through a system of offer and counteroffer. (Geertz, 1963, pp. 32–33)

Psychologists do not have a universal price for their service, do not have abundant and accurate information about market prices, and do not usually keep very detailed accounts, as some excerpts from interviews showed. Gabriela above said that she was very disorderly and “absent-minded” and she forgot to increase her fees, while Perla said that having many fees “becomes a mess.” These conditions of rudimentary accounting and low regulation generate, according to Geertz, the haggling that he observed in an Indonesian bazaar.Footnote 13 However, in the case of psychologists, the absence of a fixed price does not lead to competitive bargaining, because it does not seem reasonable for the type of intimate bond and trust established between patient and analyst. It is a reverse bargaining of sorts: unlike the bazaar, the moral economy of the relationship between patient and analyst dictates that buyer pays as much as she can and seller charges as little as she reasonably can. This resembles classic gift economies, in which participants compete to give more than they receive (Cichello, 2010; Mauss, 2000; Torres, 2015, p. 259). The search for a reasonable price is personalized and “up for conversation” as in the bazaar economy, but under different rules: the parties must accept that it is a fair and well-intentioned exchange although there is a certain degree of arbitrariness, or the transaction may fail. These payments are best defined as a moral transaction that combines elements of both market exchange and gift-giving (Appadurai, 1986; Lainer-Vos, 2013). This hybrid framework is also reflected in psychologists’ commitment to the singularity of each patient while maintaining some market commensurability whenever they compare patients (albeit informally) to establish who deserves more or less discount. These types of transactions have to be carefully managed to avoid confusion and conflict (Lainer-Vos, 2013).

The meanings of payment: Deprivation, commitment, loss, and disentanglement

Some of the rationale for price-setting examined above is not too different from care work in general, given that the latter is often treated as a “labor of love” which excludes relying on pure market logics (England et al., 2002; Torres, 2015; Wolfson, 1999; Young, 2021).Footnote 14 However, there are some specific factors that are distinctive to psychoanalysts. One I already examined earlier: the notion that charging a standard price would conflict with the psychoanalytic dictum of treating patients as unique. This section analyzes another crucial factor: the meanings of the payment itself. Psychoanalysts think of the bond with the patient in a complex way. The payment is embedded in that bond, acquiring meanings from it but also helping to shape it. Treating a patient is seen neither as a simple provision of a service like any other, nor is it strictly about “helping” patients (as other forms of care work would be). For example, one respondent said:

Why charging? Why does a psychoanalyst charge? And why is it expensive?: because the task of a psychoanalyst is to deprive, not to give. (Elena)

Elena’s assertion is inscribed in Freudian and Lacanian psychoanalytic theory. Freud (1992, pp. 158–160) stated in 1918 that the analyst should deprive the patient from satisfactions that would mitigate symptoms momentarily but which would jeopardize the cure in the long run. In Lacanian psychoanalysis, the analyst does not seek to provide relief or a feeling of fullness, but rather serves as a vehicle for the patient to accept and cope with his or her own incompleteness. The analyst “deprives” the patient of a quick answer or an illusory solution for their symptoms that would replace the subject’s inherent lack. Given this role of the analyst, the payment is embedded in a broader set of interactions between analyst and patient, defined in psychoanalytic language as “transference” and “countertransference.” A fundamental focus of treatment are these interactions themselves and the ongoing bond between patient and therapist, which cannot be defined as simply obtaining something (a service, a cure, a time, a knowledge) in exchange for money. In this context, the transfer of money does not mean that the client must be satisfied (as would be the case when paying for most other services or products), given that the patient should engage in the often painful and lengthy process of cure that psychoanalysis entails.Footnote 15 Although the analyst is a professional, her involvement has an intense and even bodily character that does not resemble the idea of detachment or distance that the term “professional” or the conventional idea of market exchange convey. This is reflected by Elena’s explanation of what the patient pays for:

In order for the possibility of the patient's desire to arise [the psychoanalyst] has to empty him/her of a symptomatic position, of a joyful position that the patient has in regard to his symptoms, and that has to pass to the analyst's body, in the transference, like a medium who suffers from jaundice and the medium turns yellow… well, you have to extract the disease through transference. [...] So let's say that the patient pays me for doing that, for withdrawing myself, he pays me so that I inscribe in him the possibility of withdrawing himself too from the demands that make him a neurotic.

Elena is specific in her response, invoking Lacanian terminology, but most analysts suggest in one way or another that payment plays an important role in the patient’s commitment to their treatment and say that charging too little (or nothing at all) can be harmful to the patient and to the bond between patient and analystFootnote 16:

Not always charging little or nothing at all (or not charging for some time) is necessarily good. There are people to whom it can make them feel worse, or feel guilty ... or feel lacking, or feel that you are doing them a favor, or [who wonder] why you are seeing them without a fee. (Luisa)

In the latter passage, one can see the logic of the gift at stake, as opposed to a “pure” market transaction. Paying less would obviously allow the patient to remain in a better economic position by preserving resources, but they may remain in symbolic debt with the therapist. As in the potlatch, unreturnable favors may be a vehicle for the humiliation and symbolic domination of the recipient (Bourdieu, 1998; Godbout & Caillé, 2000; Mauss, 2000). Therefore, the patient has to “give” and the payment implies putting something of his/her own being:

It may also be counterproductive if you charge very little, being in a position of supporting the patient. It may be counterproductive for that particular patient, or what happens in the hospital, where patients don’t pay anything. Because money is supposed to have a value... payment has as a value of ceding jouissance, a cession of a mode of satisfaction. So... well, when you're treating a patient in the hospital and the guy is like... is not putting anything… [Payment] is a way of putting something, something of his being, ceding something, and well, money in psychoanalysis has this function, there’s something that is exchanged there and has a meaning beyond the monetary. (Gabriela)

Psychologist see the payment partly as a compensation for what they do, but also as a representation of something that happens to the patient when they engage in therapy. The following quote shows this:

Look, it is a payment for a service, I take it as... in general my patients have a need for much support [contención], because they are going through a very critical moment, so they thank, those who can come and settle in the treatment, they are grateful, to themselves, right? Because they have made the effort to come, to insist, to hold on to it, and the payment is partly that recognition. (Mabel)

On the one hand, Mabel says that the payment is for a service. However, she immediately follows that assertion by stating that the payment is a thank you gesture the patient gives himself, a recognition of the patient’s efforts (represented by money paid to the therapist). The importance of payment is thus seen as the symbolic representation of the patient’s valorization of his own commitment to be treated or cured, or at least to open up a space to think about himself or herself. Thus, payment ought to come from the patient because it reflects his or her commitment:

Sometimes, perhaps a college student who is studying and [whose therapy] is paid by a relative, or a person who is unemployed and paid by the sister, that can happen… When that happens, I try to encourage the patient to pay for his own treatment. Why? Because it has to cost him, economically and psychically, there has to be an idea of effort, there are many patients who, even if they can afford it, they want to avoid the psychic effort of elaboration. And they have a bulky bank account, that’s not a problem. But they want neither effort, they ask for some miracle drug, for the psychiatrist to medicate them. (Patricio)

The problem with prepagas and obras sociales is that the patient sometimes has to pay very little, and it’s very little commitment, too. The reason for consultation is often not very real, like “since I have it, I’ll use it, it’s covered by insurance,” it’s like going to the hair salon, and that’s a bit annoying. (Elizabeth)

Patricio draws an equivalence between “the psychic effort of elaboration” and the economic effort to pay for the treatment. The term “cost” is attached here both to the psychic and the economic. Confronting the difficult self-exploration and possibly painful process is not independent of the payment. On the other hand, either doing and not doing therapy have for Patricio both psychic and economic costs for the patient:

The suffering that one can call neurotic, which is avoidable, has a cost. You have to be able to assume that it has a psychic and economic cost, anyone who is willing to face both the psychic and economic cost, can carry out an analysis or prolonged psychotherapy. People don’t realize how much they pay for the neurosis, Freud used to say that the most expensive things in this life are disease and stupidity.Footnote 17

Similarly, Pablo below says that the payment goes beyond affecting the patient’s budget, and must express a loss in more general terms (not just economic):

[The payment] is a mark you give to the patient: are you willing? If you are willing to pay, but not because of the purse. It involves a loss, an analysis necessarily involves, in clinical terms, putting a loss at stake. (Pablo)

In all these cases, there is a degree of ambiguity about what the payment represents. If it were exclusively a loss and a token of commitment, it would not be necessary to transfer the money to the professional (as when people suggest donations to a non-profit in lieu of gifts, or when precious objects are destroyed in the potlatch). For other reasons, however, the provider obviously must be the recipient of the payment, regardless of the benefit this loss has for the patient.

The description of payment in terms of loss and the link between psychic cost and economic cost fits well Zelizer’s (1994, 2011) and the morals and markets literature’s perspective that money and commercial transactions can be a vehicle for expressing meanings (in this case commitment and loss) and marking social relationships (by negatively affecting the bond if too little is paid). But since money symbolizes something outside of it, it is therefore not the only possible means of payment. In certain cases, the patient’s commitment can be detached from monetary payment. Psychologists may recognize non-quantifiable currencies as “payment” or “cost.” Thus, it is also possible for patients to “pay in other ways” when money is not used or the amount paid is very little:

What happens with money is that patients sometimes work in the therapeutic space and pay not only with money, so there is commitment. (Luisa)

It has also happened to me that a patient told me that at that moment she could pay a certain number, and said: “Look, the truth is that I know this is a lot less than a normal rate, but right now this is what I can afford and I need this space a lot, can we talk again about this in three months?” And you hear there that there is desire... and a gamble on a space that allows her to alleviate certain malaise or certain ailment, and that's where I say, well, patients sometimes pay in a different way, which is not necessarily the economic one. (Mariana)

The presence of money has a meaning in the treatment, and it’s not the same if there’s payment or not. When there’s no money involved, it often turns into welfare. And one has to figure out what to do in public hospitals, where it’s free, so that the patient is committed to the treatment and put something of herself/himself, which may not be money. Money has to do with putting something of yours, letting go of something. (Gabriela)

Going back to the parallel Patricio drew earlier between psychic cost and economic cost, these passages show that the two may be detached when needed. A patient might pay with the commitment itself, affording the psychic cost even if they are not paying money.

Seen in this way in which payment is something broader than an economic transaction, which may be represented by other non-monetary efforts, money seems to be just another vehicle for meanings, as could be any other. However, psychoanalysts also frame money in a way that opposes what Zelizer’s analysis reveals, closer to more conventional views of money as homogenizing. For psychoanalysts, who, as I mentioned, oppose generalization, money represents a common and recognizable value, a universal instrument of valuation for the expression of loss. As Luisa said, “it’s like giving up something that has value, at least a social value, common, established, and often difficult to earn.” Elena evokes in the following passage an anti-Zelizerian view of money, seeing it as decontextualized and unmarked from social bonds:

What happens is that money is the signifier of all meanings,Footnote 18 we say, it’s not “with this patient I paid my utility bills, with this payment my children’s school tuition, with this...” because if the patient leaves... she was the one who paid me the utility bills, she remains as taken in my life in relation to my needs or my desires. Instead, money is a signifier of all meanings, I do with money what I want, he pays me with a coin that allows me to do what I want.

Although money can be earmarked in order to tie its origin to its destination (Zelizer, 1994), in the case of Elena what makes money attractive is the chance of disconnecting the patient and the analyst, and keeping no meaning whatsoever. In the context of such an intimate and complex relationship, payment in money appears as the possibility of detaching the bond created in the analysis from the social situations that would connect people outside that bond. In spite of the deep connection between fee and social bond, money to some extent allows the parties to disentangle (Callon, 1998) the patient’s payment from the analyst’s utility bills or her children’s school tuition. Money is appreciated here precisely because individuals use it to downplay social relations and avoid reminding the analyst of its precise origin. While stock market traders do not immediately come to mind when one think of psychoanalysts, Zaloom (2007, pp. 257–258) found a similar disentanglement of money as it appears in traders’ everyday life from the market money that they trade during their workday. Zaloom proposes that Zelizer’s insight that people use money to mark and sustain social relations should be considered a starting point. Money must then be transformed from this condition if it is to operate within a pure market logic, and traders labor hard to transform it because they believe they would fail in their job if they don’t. In the case of Elena above, it is the theoretical insight she takes from Lacan, not just the inherent qualities of money, what allows her to use money as something that isolates spheres. While money can be used to personalize and earmark, people can also employ it together with cultural scripts as a standardizing vehicle when it fits their purpose.

Face-to-face payments and the predicament of the psychoanalyst

The irony of making money a disentangling and de-personalizing device is precisely a certain degree of impossibility. Money can be the signifier of all signifiers as Elena, echoing Lacan, stated. But in every transaction there is a particular social relationship that, however ephemeral, potentially replenishes money as a vehicle of meaning. Payments are a material reality. It is partly the personal, face-to-face mode in which payment to psychoanalysts occurs (which they actually embrace) that precludes the complete realization of the abstraction and disentanglement Elena above expects money to provide. The highly personal payment for therapy cannot be isolated from the rest of the intimate and therapeutic relationship between patient and analyst. In the context of the high flexibility in price-setting, payment can be an uncomfortable subject, even for the analyst herself. Several therapists stated that the issue of payment, regardless of their training, experience, and professional skills, is often difficult for them (including some that stated that it’s perhaps the most difficult issue for many colleagues):

I sometimes feel that it’s me who feels discomfort rather than the patients, to tell you the truth... Yes, in fact, it's always been an uncomfortable, difficult issue, it’s a very unique payment. It’s not like when you go buy something and pay, it’s a payment with a very special weight, very direct, very face to face. It’s not like going to the doctor and well, the secretary... it’s a strong act, the payment, within a session, and I believe that even to this day I still find it difficult. [...] It's an issue, I'd rather have a secretary, [laughing] you see, “go through the secretary.” (Ruth)

Ruth compares “face-to-face” payment with a mediated payment (through a secretary), in which money is disconnected from the intimacy of the analyst-patient bond. Ruth jokes that she’d rather disentangle the economic transaction from the rest of the interaction, avoiding the discomforts that money entails when it is transferred directly. As mentioned earlier, psychoanalysts see the payment transaction as a part of the analysis and of the bond between patient and analyst, so outsourcing it to avoid the discomfort would not make much sense either (I do think Ruth was indeed joking or fantasizing). Face-to-face payment and negotiation provide a vivid reminder that payment is a part of the analysis. Unlike Ruth who saw face-to-face payment as a complicated, stressful factor, others see the mundane look of a cash transaction as a way of facilitating a de-sacralization of the analyst in the eyes of patients:

It’s like I’m not an idealized thing, no, because I also become mundane… It’s like I’m saying ‘I also receive your money in my hand. You see, psychologists don’t use a secretary, it’s all cash, no bank transfers, you give it in my hand, I take it, count it, give you your change, maybe I didn’t have enough change, right? It’s mundane, so I become just a person, the patient doesn’t owe you or put you in a place of ‘I have to be a good patient.’ I mean, I [the patient] can bring my miseries here because she [the analyst] has hers, she also needs the money to live. So money is a vehicle for something that liberates. (Gilda)

In other words, money partly shapes the relationship between patient and analyst. A more impersonal payment might solve some issues but create its own downsides for the therapeutic bond.

In his practical writings, Freud warned that when treating patients psychoanalysts should free themselves from the hypocrisy and prudishness about money that prevailed in modern society, just like they do with sexual issues:

[The analyst] is able to cite the similarity in the attitudes of civilized people to sex and to money matters; there is the same ambivalence, prudishness and hypocrisy. He is therefore determined in advance not to lend himself to all this, but to treat financial relations with the patient in the same natural and candid manner as he employs in attempting to educate him in sexual matters. By announcing unbidden the value he places on his time, he demonstrates to him that he has cast off any false shame. (Freud, 2002, p. 52)

Despite Freud’s admonition, that is not what usually happens. Freud’s or Lacan’s recommendations do not have an absolute performative effect on the way practitioners solve practical matters. The commitment to only consider patients “case by case” and refuse generalization forces them to think and solve practical issues without following rigid rules:

The analyst is free as to how, no one will tell you “you have to charge this, you have to do it in this way,” because that means losing the singularity of the case by case. In each case there are no rules on how to intervene, one just intervenes. And one intervenes thinking about that case and thinking about what you’re aiming for, what is being addressed, what is the purpose in that cure. (Gabriela)

Gabriela rejects rigid rules, like Patricio, for whom his work is to forget the theory and to “reinvent” according to the problems that appear in clinical treatment:

Lacan said that the analyst must be in the position of a dead person... he doesn’t have to appear as a person, only in his analytic function. However, one is a person (I can attest to that!), and the same goes with patients, each patient is each patient. So the theory helps you in thinking global, theoretical issues, but then with each patient, you have to reinvent and forget the theory, when you are working you have to forget the theory.

This need to “reinvent” is partly why, as can be seen in the following case, even professionals with decades of experience may find it difficult to establish and provide their fees, regardless of Freud’s exhortations to do away with “false shame” about money:

It’s an issue how one sets fees, personally it’s something I am seeing in my analysis, I’ve had several difficulties with the subject of fees… always rather low, not high, and well, it’s a topic that I am working on especially in this last analysis, it’s not easy... what’s the value that ... it’s always relative, of course I have what I would call a range, I have a value that I aspire to charge (for private service), and I also take into account the situation of each patient. Anyway, I have difficulties, it’s not easy for me. [...] And every time I have to communicate the fee I always find myself talking in excess, and appeasing myself and the patient too. (Patricio)

For Patricio and other psychologists, the difficulties with the fee are included in the issues they discuss as patients in their own analysis. Even though they have lots of freedom to set fees, this freedom often becomes a source of stress as they confront their personal issues about money and their work (Lasky, 2000). This is also the case of Muriel and Gabriela:

The subject of money was hard for me, because I have a bit of a tendency --and I don’t say this to look good, it’s a problem-- It’s hard for me to charge, I say it in present tense, although I’m getting better, at first it was like ... I had to say the fee and I almost blushed, I had a hard time charging for my work, but hey, this was my personal problem, where I had to put to work in my analysis ‘what was my issue with that,’ well, and it gradually came together. (Muriel)

If you have a hindrance in relation to some point or some situation with a particular patient or patients, it’s good to visit it in your own analysis. For example, how to charge, how to raise fees, why I don’t dare... how to handle some issues. (Gabriela)

Conclusion

Even for experienced psychoanalysts, how much to charge is not a trivial issue. Price discrimination among Argentine psychoanalysts is ubiquitous but with specific characteristics. Analysts reach a price in a conversation with the patient, one that they embrace as part of their practice. This conversation resembles in part the economy of the bazaar. However, the rules of this conversation are opposite to those of bargaining, as parties are expected to seek a reasonable price based on moral signals of disinterest, appreciating the situation and recognizing the efforts of the other party. In this sense, payments reflect the complexities of the specific activity for which they occur (psychoanalysis), one in which instrumental rationality is an imperfect match and a lot of information remains implicit –two central features of gift economies (Godbout & Caillé, 2000).

Payments to psychoanalysts show that market transactions can be crafted to reflect values and professional commitments. This case in particular shows that payments can be made to match narratives about the meaning of money within a professional group and service provision. Psychoanalysts are partly an ‘economy of care,’ in which intimacy, morality, and economic transactions intersect and in which the economic element must be negotiated carefully. Therefore, it is not surprising that the economic situation of the patient must be taken into account at the time of price-setting. But psychoanalysis is a specific form of care given the particular bond established in psychoanalytic therapy –even to define the role of the analyst as deprivation more than care. Payment is understood as crucial to that bond (defined in psychoanalysis as transference). In this context, charging a standard price or avoiding a conversation on payment would amount to not treating patients as unique, with the care each one deserves. Paying is arguably good for the patient to symbolize commitment, represent a loss, and match “economic cost” and “psychic cost.” But it is also possible to treat patients for little or no fee, although this may create an undesirable imbalance just as the relationships of the gift can produce symbolic domination by the party that gives more. Thus, this is a delicate payment that has to be treated with care.

The medium –cash face-to-face transaction- is crucial to understand these payments. Unlike other health care services in which morals and markets routinely interact (Brown, 2021; Reich, 2016), there is minimal distance between the payment, the service itself, and the payer and payee. There is no complex organization with an accounting and finance department to which the patient is referred to, or a secretary to whom payment is derived. All negotiations happen face to face, materially embedded in a complex intimate one-on-one relationship that takes time and effort to build. Of course, the Covid-19 pandemic have likely altered both the sessions and their payments. Before Covid-19, cash remained the preferred medium of payment even as electronic transactions became widely available. Due to the forced shift to virtual therapy, patients may set up automatic e-payments, somewhat reducing the frictions of the face-to-face cash transaction in each session, yet not precluding the conversation on fees. Over the years, Argentine psychoanalysts have adjusted to recurrent economic crises and many abandoned rigid orthodoxies while still proudly clinging to core psychoanalytic principles. New payment technologies might be folded into their worldviews and commitments, at least to some extent. New therapy apps developed by global tech companies are now pricing treatment by the word, the minute, or the amount of text messages exchanged (Fischer, 2021), but it seems unlikely that anything like this will become popular among Argentine professionals.

The case of payments to psychoanalysts in Buenos Aires has quite specific features that I highlighted throughout this article. But I would like to mention some broader conclusions that can be drawn from this case and expressed in slightly more abstract terms, which may be useful to understand other instances of payments and valuations. First, this case presents a complicated dynamic of singularity vs. commensurability of a peculiar service. It shows that actors can maintain a commitment to singularity yet in the end, there are quantities and common units like the ‘session.’ The session is both a unit and a sacred space to which each relationship patient-therapist confers a unique character. Goods and services can be comparable yet unique. Second, prices tell a rich story, especially in cases where valuation is not straightforward or simple. One can understand the story of a social bond, a patient’s trajectory, or a provider’s choices by following prices. The more flexible the prices, the more likely that they will tell a richer story. Third, structural features of this market make price-setting flexible and complicated, yet a decisive factor is the conscious decision by providers to configure pricing and payments in a way that match professional identities, theoretical outlooks, and value commitments. The structure of the market sets up the conditions, but the desire to perform relational work is also crucial. Fourth, while the idea of payment as expression of loss is rather specific to psychoanalysis, people can use payments to express sacrifice, commitment, and loss, as for example when they invest in social and political causes, in self-improvement, in fanhood-related activities, or even when they gamble. Payments matter not only to remunerate recipients, but also to allow buyers/givers to express or symbolize something about themselves. Fifth, money can be used to disentangle if actors need to. Using specific cultural scripts, money can be put to the service of isolating spheres, not just sustaining relationships. This makes Zelizer’s insights on the uses of money even more powerful, partly because this case shows that it is not so easy to remove meaning from money. Finally, the notion of “inverted bazaar” allows us to understand bargaining practices in commercial settings that are not as competitive as Geertz’s bazaar. Scholarly attention to hybrid exchanges combining market and gift-giving has grown in recent years, and the idea of inverted bazaar might help interpret some of these hybrids better.

There is, of course, an alternative way of interpreting the flexible price-setting examined here. For example, when a psychoanalyst lowers the fee so that the patient continues in therapy, the therapist also “objectively” benefits from not losing the income stream from a patient. Flexibility brings economic benefits. A hostile-worlds interpretation would say that, in the end, this interest in keeping patients is all that matters (Zelizer, 2005). Bourdieu (1998) might say that psychoanalysts misrecognize their objective interests when they talk about the meanings of payments, especially when they emphasize how important paying is for the patient. But these views deny the ability people have to try to craft commercial transactions that are acceptable to their values as well as their economic needs. Livne (2014, 2019), for example, shows that transferring patients to hospice care earlier results in higher revenue for hospices, but it also reflects an hospice ethic of minimizing invasive treatment at the end of life and accepting death as part of life (an ethic that emerged long before it became entangled with money). The fact that the two may be aligned does not mean that economic interest is the determining factor that shapes the transaction. Psychoanalysts are aware of the multiple tensions involved in the payments for therapy, and they work on making transactions as acceptable as possible to their values, activity, knowledge, and professional commitments. This includes economic considerations like balancing higher and lower fees to make their practice sustainable, but not for example offering a cheaper treatment with a lower chance of success, as happens in some fertility clinics (Brown, 2021). Most important, this relational work entails partly disentangling the meaning of the payment from the psychoanalyst’s own individual financial concerns and self-interest. As Muriel reacted when a patient once offered to pay more than the fee she offered: “I had to see what this meant for this person. Maybe it was good for me economically, but that’s not the priority; if I have economic problems, I’ll have to figure them out on my own, it’s not the patient’s problem.” Crafting acceptable transactions is an ongoing effort that psychoanalysts perform with each patient or, as they call it, case-by-case.