Combative and reactive patients
The contemporary psychoanalyst in private practice is not seeing many 4-5-times-a-week, on the couch patients who pay full fee out of pocket. Indeed, it is unusual for patients to attend that often and unusual for patients to want to pay themselves instead of using insurance coverage that only provides 20-40 visits per year at a reduced rate of reimbursement to the analyst. Nor do our current patients typically attend for years and gradually work through their neurotic confl icts to a mutually agreed upon successful termination. The reality of current private practice is that we may have one or two such patients (Waska 2005, 2006) but even this is rare and mostly a stereotype of what only may have been a reality decades ago. External factors such as economic problems, time constraints, and either the lack of adequate insurance coverage or the constraints of managed care, make the establishment of a consistent and robust treatment requiem diffi cult or impossible.