By Mamta Dadlani

I recently completed a referral consultation with an activist artist. She believed she had found a perfect fit… a therapist that was fluid in her particular language of justice and equity. This client felt understood and at ease sharing her story during their consultation until the last moments when the clinician shared their practice parameters: the clinician did not offer a sliding scale. Suddenly the treatment space that held such potential collapsed; the client could not afford the full fee.

Until we, as social justice-oriented psychoanalytic practitioners, examine and reconcile the discontinuity between our practice policies and the material realities of who we wish to serve, we are not doing the work of deconstructing inequity. There is no place where this is clearer than in how we use our practice policies to buffer ourselves from the social justice conflicts associated with social class and our fee structures.  

Our discipline’s commitment to and reinforcement of status is ubiquitous. We come into our roles being encouraged to “charge what you are worth.” Pre-covid, we designed our offices to reflect a particular air of professionalism. We balk against the idea that there is a client who is “best” for psychoanalytic work based on social class, but we silently embrace the idea that we are the clinician who can best offer treatment. We delight in the fantasy that we are special and different. 

That’s not to say we don’t try for equity.  The majority of us engage the usual treatment access maneuvers. We offer a few sliding scale spots, do pro-bono work, split our practices between private practice and community clinics. We may even insist on lowering a client fee or battle with insurance companies so clients can use benefits.  

But is this actually getting to the heart of what is possible as a psychoanalytic thinker who is committed to social justice? Or is it simply another recapitulation of capitalism and inequity?

A clinician client once shared their approach to the fee. They acknowledge with clients that they are entering into a mutual-aid healing community in the context of capitalism.  The clinician discusses the healthcare complex at large, states their standard fee, shares thoughts about sliding up and sliding down, and asks clients to decide how they want to engage in community, financially. Often, clients slide much higher than anticipated and those who need a lower fee access it without shame or excessive gratitude. By discussing equity regularly, the fee becomes a flexible site of mutuality that is not gifted by the clinician, but co-created by the dyad and community. 

Approaches like this, while beginning to dismantle individualism and the disembodied aspects of how psychoanalytic work all to often unfolds, are simply not enough to address the very real problems of capitalism that infiltrate our practices. However, I remain hopeful that we have the capacity to move beyond simply speaking about social and economic justice if we are willing to deeply examine and relinquish our own investment in racial capitalism and the status quo.