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I was in Flapjacks with my friend Jerry on a Monday morning that looked like it had the potential to be a much-needed good day. But the pancakes were warmer than the conversation.
“How could you have embarrassed me like that? “
“You mean what I said last night when we were having dinner at Café Bernardo with those insufferable attorney friends of yours?” I knew darn well what he meant but I didn’t think it was such a big deal. I was wrong.
“Yes, I am. You’re always kicking up trouble. Everyone knows it’s your thing to be provocative. You know good and well why we charge for missed therapy sessions.”
“Sure, I do. It’s for the money.”
“That’s only part of it and you know that. We need to be compensated for our lost time. We have to have 24-hour notice. Not doing that is easy for you. You don’t live off the income, but most of the rest of us do.”
“Jerry, look, when you don’t cancel a reservation, does the restaurant charge you? No, they don’t”
“They’re starting to charge now. That’s why they take down your phone number.”
“Maybe $25. They don’t charge for a full meal. Same thing with our internist, maybe she tacks on a small extra fee. We charge for the whole session. What does the twenty-four hours get you anyway? You can’t see a new patient for only one session, even if you have a waiting list.”
“Steve, you’re just a cynical ex-professor. And you’re being manipulated. For an internist, rapport is important but the nooks and crannies of the relationship are secondary or not at all.. For us the relationship is primary for helping patients see the tie between how little control they had as a kid to how much more they have now. The problems and the way they viewed life then are causing them to distort similar ones now. They need to see how those painful events early in life can be seen more accurately and dealt with more effectively now than when they were younger.”
“It’s not always manipulation. What if it’s something out of the patient’s control, like being called by the principal because his hyperactive son pushed another kid in class?”
“Come on, Steve. Then, I’d make an ethical judgment. And what if the patient has conflicts about money and that’s why he skipped therapy. Maybe he told you he could afford to see you once a week because he was too embarrassed to say he couldn’t. You’d be missing the whole thing.”
“Of course, that’s all part of the therapy. But you can deal with it in the next session.”
“Steve, you just don’t have enough experience outside of the ivory tower. That’s all I have to say about it. But there’s something else, too.”
Oh, boy. I knew where this one was going.
“What you said about psychoanalysts. They deal with how the patient’s ways of relating to you reveals how he relates to people in his life. It’s very nuanced. Steve, you haven’t touched your pancakes.”
“Don’t say you agree with charging for phantom sessions when they go on vacation. A total rip-off.”
“Steve, think about your real estate. When the renter goes on vacation, you still expect to be paid the rent, right? And hardly any of those traditional analysts are left. Maybe in New York, Boston and Chicago.”
“That rent metaphor isn’t the same thing and you know it. But it shows you how abusive the profession can get. You’ve got to remember what happened to me when I was really depressed. I had only been in treatment for a couple of weeks when Dr. Gold announced he would be leaving for vacation and I would be responsible for all the sessions he missed. Was he kidding me? I’m not sure who had more issues with money, me or him. I just called him—to save $200—and told him sayonara.”
“Yeah, you had an incomplete analysis. That’s why you’ve never really dealt with your hyper-sensitivity to being humiliated by authorities. You’ve told me your father always said you didn’t have what it takes to be a landlord. You had an incomplete analysis. That’s why you’re so hyper-sensitive to getting taken advantage of. Always wanting a bargain is just a budget or personal values thing for some but for you, Steve, it’s a symptom.”
“Okay, Jerry, I guess I went overboard last night. I apologize.”
All that out of the way, the rest of our breakfast took on a much lighter tone. But my pancakes were cold, maybe a just punishment for my irreverence toward a field that has done so much for me, personally and professionally.
I’m no psychologist, but I seem to remember reading that the reason for charging for missed sessions was to make it harder for the client to skip a session when the analysis was getting difficult. But if a therapist had tried to charge me when she was on vacation I would have found a new therapist.
What an astute observation! I had never seen it put in quite that way. But I’m still suspicious of some analysts’ motives. The conflict of interest at termination is also an issue for me. How many times does a therapist delay recommending that a patient is ready to leave treatment when it’s in his financial interest to keep the patient hanging on?
Well, there is no question that there is a power imbalance, and no question that there are unethical therapists. One purpose of the therapy is to reduce the imbalance, and again, if that’s not happening you may need a new therapist, but I don’t imagine that that’s easy.
Right on all three:
There is a significant structural power imbalance, often exacerbated by a patient’s low self-esteem; a primary goal of therapy is to reduce that imbalance, often by increasing self-esteem; and yes, it’s really hard emotionally to change therapists. But when a a therapist is unwilling (or unable) to relinquish some power (and control), it’s time to go. Just like we need more courses in personal finance, we need a few on how to be a smart consumer of health-care providers.
Wow guess I wouldn’t want your buddy as a therapist. And did I read correctly that your own therapist wanted to charge you for the missed weeks that were due to his own vacation?
Yes, he did. He also wanted me to get off my medication—to assume even more control.
Wow. That surely can’t be ethical. No shows is one thing but ” give me vacation pay” is another order of entitlement.
Guess it’s ultimately no different from some of the absurd tipping expectations in some US customer facing services.
As a self employed person, my motto is…”All I have to sell is my time.” No freebies to clients.
Most self-employed people would agree with you. I’ve gone back and forth for what you say and there’s also the moral issue involved that a therapist that part of the work is to care for the patient regardless of the ability to pay.
Steve, I don’t have the training to follow all the psycho-behavioral back and forth between Jerry and you, but no-shows are a perennial topic in our clinic. Because of the population we serve, many patients have an issue with money, transportation, co-morbidities–including psych diagnoses–or just a personal ethos that doesn’t include respect for my time. Even so, I treat adults as adults with the expectation that they will keep their promise when they make an appointment. Meanwhile, I have to recognize that legitimate events lead to a missed visit.
We expect the therapist to call every no-show, which is hard for some, but is part of helping the patient show up to get the treatment they need. If I can discover the reason for the missed visit, I can help them work on a solution. In truth, the effort starts at the first visit, by building a quick rapport so the patient likes and trusts the therapist and wants to keep their appointment. I know you are aware of all this, and more.
In a meeting about this topic just this week, I conceded to the younger, mission-oriented therapists that dealing with no-shows is one of the hardest business tasks that they have to do. But I also shared with them the maxim “No money, no mission.”
Very balanced viewpoint. The patients at your facility are very lucky.