One of my patients recently informed me that she had decided to charge for sex. After many affairs with men who had proven untrustworthy, she was abandoning her search for a genuine relationship.

“If you’re all rats,” she explained, “I might as well get some money for my time.”

A week before, we had spoken about whether she would be able to afford care at the clinic when her insurance coverage ran out. She made it clear that she would discontinue treatment if she had to pay a single dollar out-of-pocket.

I felt the two issues were connected. “Do you think your decision to sell yourself is related to the thought of paying to see me?” I asked.

“I’d just be selling my body,” she said, smiling.

I rent my soul. Patients who have the money must pay for me to listen to them and to help them make sense of their lives. Even when the feelings between us mimic parenthood or friendship, even if they truly border on love, patients must continue to pay or our relationship will come to an end.

My father, who has spent his life in sales, once challenged me to understand the difference between a calling and a job. “You, God willing, won’t have to sell anything,” he said.

I chose medicine partly for the luxury of earning a living by serving a basic human need rather than competing to create an artificial one. But I am finding traffic in empathy especially troubling.

My conscience should be calmed by tradition. Freud, who was ostracized by Viennese physicians for refusing charity cases, believed that his patients could not be helped unless they paid a fair price for treatment. The exchange of money defined the interaction as both professional and valuable.

Money continues to be regarded as a critical part of the therapeutic process. It helps to prevent the relationship from wandering toward friendship, violating the distance required for dispassionate observation. As part of this rigid structure, the issue of payment can even illuminate other conflicts in a patient’s life. The therapist may, for example, be imbued with attributes of a withholding parent. Issues of social power and position may be unearthed and discussed.

Indeed, some psychiatrists believe that dispensing free care would shift the balance of power precariously in the therapist’s direction, holding us out as secular saints somehow above the fray.

Knowing all this, and even enjoying the distance of a salaried trainee, I still feel embarrassed when my patients mention clinic fees. No matter how much I care for a patient, the fact that dollars are the lifeblood of the relationship seems to color my concern as impure — a hint of the prostitute feigning romance. My heart tells me it is wrong to charge to help someone who, having shared intimate details of his or her life, has become part of mine.

Moreover, I have not noticed that the state hospital patients I serve, who pay no fee, benefit from my services any less. Nor has any scientific study proven that paying for treatment has any therapeutic value.

A middle-aged woman I treated lost her job after meeting with me weekly for many months. She had not paid for several visits. When the secretary reminded her of her balance, she stormed out of the clinic and never returned.

I might have regarded the rage my patient felt at the mention of her bill as an irrational association of me with her cold and insensitive father. My professional distance had become an intolerable symbol of love denied. Money had served a purpose by becoming the screen upon which she had projected a real conflict.

But it seemed equally possible that our relationship had evolved to a point at which an exchange of money was, in fact, a kind of love denied. I knew her well and cared about her. We were connected. For a price. Therapy seemed more like another trauma than a repetition of a previous betrayal.

I have wondered whether any of my discomfort about money lies in my own doubt about the value of the services I provide. An ophthalmologist can restore vision by removing cataracts. The gain is immediate and objective. The benefits of my services are subjective. Patients may or may not find months of treatment helpful. My skills sometimes result in rapid and dramatic resolution of symptoms like psychosis, but more often they result in slow, subtle change. Sometimes I am unsure whether we have made any progress at all.

I don’t believe that these feelings are the core of my concern. The intrusion of commerce bothers me most, in fact, when the usefulness of therapy is apparent, and the connection between myself and a patient is strong. I feel worst charging for the best hour. My worry is not whether our work together is effective enough to merit payment, but whether it is too deeply moving to charge for.

I wouldn’t have nearly the trouble handing someone a pill and billing for it. Medicine is a tangible product; dispensing it introduces an accepted commercial entity — the pharmaceutical company — into the exchange. But demanding money for understanding, which is mine to dispense as I choose, makes me feel that I am withholding the help that any good person would offer another in pain.

As a boy, I resented my temple charging for seats to services at Yom Kippur and Rosh Hashana. Even though the poor were admitted free of charge, I didn’t think anyone should pay to participate in something spiritual. The connection between my feelings about money, religion, and psychiatry is not mere coincidence. It is the spiritual aspect of psychotherapy that I wish to insulate from commerce.

I think my protective feelings are justified. Psychiatry is falling in line with government and insurance company reimbursement policies based on the medical model of targeted, time-limited treatments aimed at specific syndromes. Pharmaceutical companies are funding massive research projects demonstrating the efficacy of psychiatric drugs. The examined life turns out to be hard to defend as cost-effective. So psychiatry’s perspective, in what we choose to learn and to teach, is shifting.

We don’t record grief as an admitting diagnosis anymore. We must find a corresponding condition in a psychiatric catalog of five-digit codes and enter the appropriate number. Otherwise, the insurance company won’t pay.

So how can psychiatry respond?

We can refuse the language of science when it fails to describe what we do. We can argue that mental health means more than the absence of cataloged diseases, that insight is at once valuable and hard to quantify by cost. We can learn a lesson about the limits of trade in human interactions. We can push for increased and equal access to psychiatric care for all.

Psychiatry’s wink at economics, the peace we have made marrying empathy and money, may ultimately erode the moral and spiritual underpinnings of the field. We defended payment as a necessary component of the therapeutic relationship, insisting it reflected the real world and could enhance our objectivity. But I believe it was always at odds with the heart of our work. If we had examined the conflict more deeply, we could have avoided some of the losses we have suffered as a result.

Keith Russell Ablow is a senior resident in psychiatry at New England Medical Center in Boston. This essay appeared previously in the Washington Post.

— Ed.