Charging patients for missed sessions

When Sigmund Freud originally developed psychoanalysis (the precursor to dynamic psychotherapy), he likened treatment fees to those for music lessons:

“As to time, I follow the principle of payment for a fixed hour exclusively. A given hour is assigned to each patient, and that hour is his and he is responsible for it even if he does not make use of it. This practice, which for the music or language instructor is considered normal in our society, when it involves a physician sometimes appears harsh or unworthy of his role…”

Nowadays, similar missed-appointment penalties exist in dentist offices, hair salons, and many restaurants, hotels, and spas that require reservations. The rationale in all these settings is that another patient, client, or customer cannot immediately fill the place of a no-show. The time and resources of the doctor or business have been wasted.

Freud’s successors have modified and refined this policy in differing ways. At one extreme are analysts who charge for any missed session, planned or unplanned, regardless of reason. The analyst announces his or her vacation dates and holidays well in advance, and patients can choose to plan their own accordingly. A more lenient if less clear-cut approach is to waive the fee if the therapist can fill the hour with another patient. More commonly, therapists waive fees for sessions cancelled with advance notice; the amount of required notice is specified beforehand and varies considerably among clinicians. The APA code of ethics cautiously endorses this approach:

“It is ethical for the psychiatrist to make a charge for a missed appointment when this falls within the terms of the specific contractual agreement with the patient. Charging for a missed appointment or for one not canceled 24 hours in advance need not, in itself, be considered unethical if a patient is fully advised that the physician will make such a charge. The practice, however, should be resorted to infrequently and always with the utmost consideration for the patient and his or her circumstances.”

Under all three of these variations, the reason for the absence has no bearing on whether the fee is charged, although obviously it can be discussed and explored in the therapy itself. Conversely, some therapists are less concerned about advance notice, and will forgive even uncanceled no-shows if a compelling reason is offered. Since many psychiatrists and other therapists have policies that differ from the APA ethical standard and from each other, it is fair to say there is no consensus in the field about these policies. Here are my reflections on this morass.

There is a certain cold logic to the draconian standard of never waiving the fee for any reason. Aside from any selfish motive to maximize the analyst’s income, this policy provides the most consistent “therapeutic frame,” in that subjective judgments of the analyst never enter the picture. When analysands (patients) fall ill or are forced to remain at work during their therapy hour, they may pay the fee with gratitude that the analyst is holding “their” hour, pay with some regret, or pay while bitterly railing against the autocratic, unfeeling analyst. However they react, it’s all transference.

Well, sort of. For analytic theory also recognizes the “real relationship” (coined by analyst Ralph Greenson in 1967, I believe), which takes into account the realism and genuineness of two people engaged in analytic or psychotherapeutic work. Many would argue that never waiving fees, regardless of circumstance or even months of advance notice, is not very realistic for the world we live in. That is my view, too.

The next contender, to waive the fee if the therapist can fill the hour with another patient, is apparently not uncommon among psychoanalysts, although in my experience it rarely forms the policy of non-analysts. From the clinician’s perspective, this policy, too, guarantees that income will not be lost. However, in this case the outcome for the patient hinges on the analyst’s behavior, i.e., whether and to what extent the analyst attempts to fill the hour. Since the reality of these efforts, and therefore the actual likelihood the fee will be waived, are unknown to the patient, this approach also invites a wide variety of transferential fantasies: That the analyst strives tirelessly to fill the hour, or couldn’t care less; has no other patients, or has a long, eager waiting list; is meticulously honest, or charges the fee regardless of actually filling the hour; and so forth. These reactions can usefully shed light on the patient’s dynamics, moving the treatment forward.

The problem with this policy is that it trades away part of the therapeutic frame. Yes, potentially illuminating transference arises. But it would as well if the analyst unilaterally changed other aspects of the frame, such as the length or frequency of the sessions. Psychoanalysts and dynamic therapists know not to do this; consistency provides the container that allows emotional vulnerability (and therapeutic regression) to occur. Likewise, waiving the fee for a canceled session should not depend on how busy, diligent, honest, or popular the analyst is. If it happens at all, it should depend on patient factors, not analyst factors.

The most typical policy in dynamic psychotherapy is for the therapist to announce at the start of treatment how much advance notice is required to avoid being charged for a cancelled appointment. This can range from the 24 hours suggested in the APA code, to two weeks or longer. In my experience, it is most often one or two business days, although some therapists require notice by the previous session, often a week earlier.

This policy enjoys the therapeutic-frame advantages of consistency: The patient knows, based on his or her own behavior, whether a fee will be charged. This is analogous to knowing that therapy starts and stops on time, that if one is X minutes late, there are Y minutes left for therapy that day. The disadvantages are that cancelled sessions may result in lost income for the therapist, and that no distinction is made between frivolous cancellations (where the fee is still waived if announced well in advance), and dire emergencies (where the fee is charged, since such absences are generally unanticipated). Of course, therapists can break their own rules and refuse to waive the fee for a frivolous cancellation, or to waive it for a sudden emergency. The advantages of consistency are lost — traded away, in effect, for the “real relationship.” Nonetheless, this is probably the best approach overall for a problem with no perfect solution.

At the other extreme, a policy of deciding, on a case by case basis, whether to waive the fee depending on the reason for the absence, is fraught with peril. This strategy pits the therapist’s values against the patient’s, establishes a dynamic of judging the patient, and, in effect, metes out punishment when the patient’s rationale is “not good enough.” I can find little to recommend it.

How about having no policy at all? With each canceled or missed session, the therapist and patient could discuss whether the fee will be charged. I find it curious that I have never heard this idea even contemplated. It could mire the treatment in endless discussion about “the shape of the table” (a Vietnam-era reference to talking about the setting instead of the topic at hand). But that is what dynamic therapy is largely about anyway. It might not provide a sufficient therapeutic frame; it might be too anxiety-provoking for both parties. On the other hand, it would underscore the collaborative, co-constructed nature of therapy.

My own policy is to waive fees for sessions canceled at least a day in advance. I rarely if ever break my own policy. It is not particularly onerous, and patients seem to understand that I could not realistically fill a suddenly vacated hour, even if canceled for good cause. When patients cancel sessions only a few days in advance, I sometimes fill the hour and sometimes cannot, but I consider that my problem, not the patient’s. I feel this policy works fairly well for everyone involved. However, it isn’t perfect, as illustrated by this last case:

A patient recently called on the morning of her appointment to report a bad cold. She was willing to come to her appointment that day; however, she wondered if I might prefer to see her later that week when she would be less contagious. It was an interesting twist on the typical same-day cancellation. In truth, I did prefer to delay her visit. I had a suitable free hour later in the week, and didn’t want to catch her cold. By allowing me to decide, and since it worked to our mutual benefit, I obviously would not charge her for missing that day. We met at the rescheduled time, and all was well. Yet I confess to a nagging uncertainty: By solving this problem for both of us, i.e., agreeing to reschedule her at no charge, did I make a decision that really was hers? Assuming she is in insight-oriented dynamic therapy, would it have been better therapeutically for her to decide between (1) attending her hour while ill, and possibly sickening me, or (2) paying for a missed hour? I leave this as an exercise for the reader.

68 comments to Charging patients for missed sessions

  • Dr. J

    Dear Dr. Reidbord,
    A newish pharmacotherapy patient had missed an appointment with me and I charged for the missed session per our initial agreement. She then asked, if I were to miss an appointment with her — being human — is there a reciprocal policy that recognizes the value of her time? Never had this happen before. Made me pause. Short answer is, No, the system is one-sided….but, does this invite a discussion of the policy (beyond its dynamic significance)? Curious about your thoughts…
    Thanks.

    • Dr. J,
      It’s a good question, and I don’t have a fully satisfying answer. Here are some thoughts. Professional practice policies generally protect the practice, not the patient. Patients can vote with their feet, i.e., choose to see another clinician if they disagree with those policies. I suppose it could be a “selling point” for new patients if the office policy offered a free visit (or monetary compensation) for any appointment missed by the doctor. Similar offers might include one free session for every ten paid, a toaster for every new patient, … ok, I’m getting a bit carried away, but see the commentary after
      http://blog.stevenreidbordmd.com/?p=151
      about a free final session. To me, this sends the wrong message.

      The truth is, I am far more consistent about keeping my office appointments than some of my patients are. I’ve missed just a few out of thousands scheduled over the years. This is not surprising: It’s my livelihood and I have a good, consistent system for keeping track. It’s also more likely that a patient will miss due to transference than I will due to countertransference. I assume (well, hope) this is true for most mental health professionals. Thus, it seems unnecessary to me to have a policy for such a rare event.

      You could always make it up to your patients on a case by case basis, i.e., not by policy, bearing in mind that most would find a sincere apology sufficient. Thanks for writing.

  • Anonymous

    Hello
    I have been seeing my therapist for about 5 months. She was away for 2 weeks before we had our last session (she took a week off as well about 2 months ago). As we were reaching the end of our last session, I told her that I was going away on vacation and will not be able to come next week. She then asked if I wanted to make it up and have a double session after I returned. I said no. She then said that I am allowed 2 missed sessions in a year without having to make them up. After that I would have to make up the missed sessions, or pay for them. I was surprised and pretty upset. Especially that she had just returned from her vacation. We had a long discussion, one of the things I said is that in this case it would be only fair if I was allowed the same number of missed sessions as her. She then said that she usually takes 5 weeks off a year, and if I were allowed to do the same she would not have an income for 10 weeks!
    We ended the session with her saying that this will be an opportunity for me to discuss a difficult for me subject and grow. She also said that a lot of therapists charge their patients for sessions when they- the therapists- are away. I never heard of that, and I have seen a few therapists before. Also, she did not discuss this rule with me upfront when I started seeing her. She’s a great therapist and my life really has improved tremendously since I started seeing her, but I don’t feel comfortable with this rule she just happened to tell me about 5 months into therapy. I’d like to mention that we never discussed if this is going to be a long term therapy, and have been scheduling sessions as we go but on a very regular, weekly basis. Please let me know what you think.
    Best, Kathy P.

    • Thanks for writing, Kathy. This is a twist I hadn’t heard before. At first glance, it seems your therapist values her income over her therapeutic technique, if the only justification for a “double session” is recouping the lost revenue. The frequency and length of therapy sessions should be based on the needs of the patient, not the income potential for the therapist. (By the way, I never schedule double-length sessions, ever. I do occasionally schedule extra sessions, e.g., a second one that week, if a patient is in crisis.)

      I say “at first glance” because I can imagine a therapist arguing that the double session is in the patient’s interest. This would be based on the idea, which I do not share, that psychotherapy is dosed by time, much as medications are dosed by milligrams, and that the double session “makes up for” the session missed. To be honest, though, your description makes it sound like income is the primary motivation for the policy.

      Don’t get me wrong: Income is a perfectly legitimate basis for a cancellation policy. It should, however, be made clear at the outset — especially if it’s an unusual policy! — and it should influence payment, not the nature of the therapy itself. As mentioned in the original post, some psychoanalysts charge when patients miss sessions regardless of the reason or amount of advance notice. However, I’ve never heard of an analyst or any therapist altering the therapy to make up for the lost income. Nor have I heard of any who charge for sessions when the therapist is away, although I can’t guarantee it never happens. That one sounds unethical to me: charging for a service that is not actually available.

      Two last thoughts. First, it’s always best to announce vacations or planned cancellations as far in advance as possible. Telling your therapist at the last moment cheats you of the opportunity to give your absence the reflection it deserves in therapy, and it puts your therapist in the somewhat awkward position of trying to explore its meaning with you, with no time to do that. With more time available, her policy would presumably be the same, but you’d have more room to discuss it. My other thought relates to your praising her as a great therapist who has improved your life tremendously. Even if her cancellation policy is objectionable, you may find it worthwhile to tolerate it in order to work with her. Therapists are imperfect humans like everyone else, and all relationships involve taking the good with the bad. Only you can decide if this unpleasant surprise outweighs all that has been good in your work together.

  • anonymous

    This is appalling behavior from Kathy P’s therapist, and exactly the kind of thing that gives powerful ammunition to those who argue that therapists are nothing more than shysters who take advantage of individuals in their most vulnerable condition for the therapists’ own benefit. A therapist can point to anything, including something as clearly unscrupulous as charging a patient for services never even rendered, as “an opportunity for [the patient] to discuss a difficult for [the patient] subject and grow.” And to say that Kathy should weigh whether to tolerate this type of behavior in order to continue to work with her is absurd. Kathy should report her to the medical board and find help somewhere else. There are plenty of qualified, compassionate, skilled therapists around– there is no need to put up with this kind of quack. In any other profession, she would be run out of her industry.

    • Dentists, music teachers and other tutors, some restaurants, etc, all charge for services “never even rendered” — if the patient or client violates an explicit cancellation policy. I imagine this never makes a patient or client happy, but in therapy unhappiness, and even anger at the therapist, is fair game for discussion. It can, in fact, help a patient “grow.” Also, I am not so quick to dismiss Kathy P’s feeling that her “great” therapist has improved her life tremendously since she started working with her. To me, that sounds quite valuable. Reporting the therapist to a professional board is apt to be unproductive given the lack of consensus about cancellation policies among psychotherapists.

  • anonymous

    My reference to services never rendered was to Kathy’s therapist’s statement that many therapists even charge their patients for sessions when the therapists are away — as if to say that her own charges were less reprehensible, so Kathy should not complain. I agree that many professionals have a policy of charging for services not rendered if the patient or client violates an explicit cancellation policy, but Kathy has stated that her therapist had no such policy, and the therapist has no right to enforce a secret policy. Again, there are plenty of compassionate, skilled therapists out there who could also improve Kathy’s life, without taking advantage of her at the same time– there is no reason for Kathy to have to put up with this type of behavior.

  • Marie

    My therapist does charge for missed appointments if not canceled 24 hours in advance, except in the case of illness or emergency. This seems totally fair to me (same as at the dentist). If I’m in a car wreck and can’t get there, I can’t get there.

    I’ve only missed one (scheduled) appointment in two years of therapy, due to a snow storm. Neither of us could get there.

    We schedule appointments a week out, and both have to miss weeks occasionally due to vacations and such. Maybe it’s just the “style” of therapy, but I would never see a therapist who charged me when I went on vacation! (Vacations are good for mental health!)

  • Mariah

    My therapist was once thirty minutes to an appointment. I chilled my heels in the waiting room during this time. When he arrived, not only did he not charge me for the balance of that session (we had 20 minutes), but he also insisted that the next session would be at no charge as well.

    Want to know how quickly my righteous anger turned to my well-warranted gratitude at his understanding that my time is as valuable as his, and that he had the same responsibility to keep my appointment as I did? Real quick!

  • Pinot

    I’ve been with the same therapist for large swatches of time between now and 1997 (!). Today, I missed an appointment (my only missed appointment ever) purely by accident: I had transferred the appointment time down wrong onto my computer schedule. When I arrived too late, she told me I’d have to pay half the appointment, reminding me that her’s was a “business.” Which of course is true; however, I think ironically, I’d bent over backwards previously to treat her as if I owed her more than I might the average professional.

    An example? I had wanted to cancel that same appointment, but I would have had to do so just over 48 hours ahead of time. This would have probably have left her with an empty spot. Although it would have been permissible, I didn’t consider it to be fair to leave her in the lurch, so I didn’t do it. Plus, in the past, she herself had missed an appointment because of snow and called our house to let us know — well after my husband had had to leave to drive me to my appointment so that I’d be there on time. We reached her office, and she wasn’t there. We phoned her; she apologized and rescheduled, and (even though we’d made a dangerous, slippery trip in the snow) we were very easy-going with her about it. We didn’t have to be.

    I understand her comment that “it’s a business,” but it seems that flexibility, consideration, and dedication to long-term relationships should work *both* ways. Apparently, *my* flexibility, consideration, and more-than-20-year business was worth exactly $60 to her. I won’t be back. Charging me (even half) for the session, in this case, seems like a pretty short-sighted “business” decision on her part (and is pretty hurtful, after this many years of working with her and how hard I’ve tried to accommodate her as well).

    In my opinion, her decision may have been allowable and ethical, but it wasn’t humane or even a great business choice. Other professionals I’ve dealt with for that many years have made the very rare concession (like not charging for a once-ever missed appointment), on the occasion needed. I certainly do not make a practice of missing appointments (it almost never happens), by any means. This therapist felt that this single incident was enough to hang our couple-decade relationship on. Seems odd to me, but I’d very much appreciate a second perspective. Any thoughts?

    Thanks.

    • Yes, I have a couple thoughts. I just re-read my original post from over two years ago, and may not have said clearly enough that, in my view, missed-session charges should primarily serve the psychotherapy process, not guarantee income for the therapist. A 14 year treatment relationship with exactly one missed appointment is pretty remarkable in itself; the accidental miss should be cause for discussion and analysis, not a knee-jerk application of policy.

      But I also want to say that paying for such a missed session may be therapeutically useful, even if it makes you angry. It sounds like you’ve suppressed your anger at your therapist in the past, or bent over backward to be accommodating. This may have been left unexplored because it served to satisfy your therapist, and helped you avoid a conflict with her. Your resentment only surfaced when she failed to reciprocate. By exploring your feelings about your unreciprocated generosity, you may find yourself more comfortable in the future, for example, canceling with 48 hours notice, which I gather both served your needs and abided by your therapist’s cancellation policy.

      Rifts in psychotherapy, even ones that seem blatantly unfair and cold on the part of your therapist, can paradoxically move therapy forward in a way that “smooth sailing” can’t. It requires a willingness by both parties to discuss frankly what happened and what feelings were stirred up. Personally, I hope you are able to have that conversation, and that you don’t immediately end such a lengthy treatment relationship based on this single event. Even if you decide after some reflection that your therapist was dead wrong and that you can’t work with her anymore, the inquiry itself is bound to be a useful process for you. Thank you for writing, and best wishes.

  • Pinot

    Apologies for my math. Try 14-year; no where near 20. :) Plenty long, though.

  • Brian

    I am a therapist in provate practice . I usually forgive the first noshow no call or cancelled less than 24. Some insurances will not allow you to charge the patient for a missed/noshow. I have a informed consent describing the rules for missed appointments. After the free missed one i charge for the sessionthat is missed. if the patient has threeof these in less than 9 months they are referred to local counseling center for treatmetn and i close thier case. I do forgive the obvious extrmem illness, emergencies,terrible weather but it is necessary to stay in business or people will cancel at a whim without some pushback.. As far as charging for a sesion for a vacation its immoral and unethical you cant charge for a sesion that is not scheduled. Also no i do not refund money if i had to cancel im not going to see them they are comming to see me. If i make some one wiat longer than 20 minutes i do not charge a copay but i will usually send a text letting them know to show up 20 minutes later and they are free toreschedule witout penalty. atients respect this

  • art

    I am so glad you stated the following: ” in my view, missed-session charges should primarily serve the psychotherapy process, not guarantee income for the therapist. A 14 year treatment relationship with exactly one missed appointment is pretty remarkable in itself; the accidental miss should be cause for discussion and analysis, not a knee-jerk application of policy.”

    I am a high functioning person with dissociative identity disorder. In the four or more years I have worked with my therapist, I have missed one session. I am scraping bottom trying to earn enough to pay her, and in the summer its a real problem. She has been traveling a lot lately, and changing times and dates of therapy, which is very confusing to me, with DID. I messed up this week, thinking she was out of town. She called me at our scheduled time, and asked “where” I was. I told her I thought the session was off because of her travels. Apparently not. She said we could talk on the phone instead. I told her I had my daughter in the car, and could not. I asked if we could reschedule. Nope. I am being charged for this missed session now.

    I feel such dispair because of the money, and the unfairness. Butt her policy is clear: “pay up”. I just cant help thinking that at some level, the fact that we are working on a disorder that comes WITH memory problems, the fact that she is travelling and Im scraping bottom, and the fact that really her constant travels are what is affecting my ability to keep track of meetings— that at some level she might show a little flexibility.

    And as for “working on issues of transferrence”- I have to say that sounds a bit like saying its good that a friend died and you are suffering because there will be other in your life who will die.
    Sure it allows you to work on a side-issue, but it may not be the best focus at this point in therapy.
    Help, please.
    A

    • Art,
      I don’t know what help I can offer over the internet. Maybe you’d feel helped if I agreed that your therapist is unfair. However, my feelings here match my feelings about Pinot’s situation immediately above. You violated a cancellation policy and owe the fee. But as I wrote to Pinot, the point of psychotherapy is to discuss what happened, and how you feel about it — as opposed to silently and bitterly following a “rule” that your therapist imposed by fiat.

      I gather you feel “set up” by your therapist’s irregular schedule and cancellations, angry that she’s traveling while you’re scraping by, and that she’s insensitive to your memory problems. By discussing it together she may offer her own perspective on what happened, and you can decide if she’s truly unfair and insensitive. One of you may change the view of the other, and either or both of you may learn things about yourselves. While she isn’t obliged to waive the fee, she may anyway based on an open discussion about what happened. At worst, you may remain in disagreement and angrily pay the fee — which, after all, was the policy — but in the process you’ll express how you feel. Even this worst case scenario isn’t all bad.

      Working with transference is an essential part of psychodynamic therapy (the mainstream school of therapy practiced for about a century now). It’s never good to suffer. But if you are suffering, it’s better to learn something from it if you can. And while I have no way of knowing the best focus for your therapy at this point, feelings in the here-and-now of the therapy room are usually a top candidate. Thanks for writing.

  • Helen

    Hi, I was wondering if you could offer your thoughts on this situation.

    I have been with my therapist for about 18 months. I take the good with the bad, but it’s generally been a helpful and productive relationship. She recently decided to move out of the practice she was with where they accepted my insurance. She would not accept insurance. Because I valued our relationship, instead of choosing to inquire about another therapist in that same practice, I went through a long process where I tried to figure out how to afford her services. I found out my insurance will partially reimburse me. They will cover some of it. But it amounts to an extra $1600 a year so I felt that I was making sufficient financial effort to keep our relationship.

    During the first session in her new office, she explained that she will always charge for missed session even if there’s advance notice. I explained that I totally understand for last minute cancellations, and am willing to pay her to keep our relationship in tact when I am at fault. I asked her what if I let you know 3 months in advance that I’m going on vacation a certain week and I’m not able to come. She said she would charge regardless. She did not say anything about my having to value the therapeutic relationship but strictly because of income reasons: she has to pay rent on the office regardless of whether I come, and she needs to be paid for holding the time because she will most likely not be able to fill with another patient. Of course, insurance will not reimburse me partially for a missed session so I would have to pay the full fee of $150.

    When I explained that I didn’t think this was within my budget because keeping her as a therapist was already a stretch I was making, and the cost of missed sessions did not factor into those calculations. I needed a moment to process this new reality and she quickly filled in my silence by saying that I should use the life insurance money from my mother’s passing 3 years ago. I felt it was tacky of her to point out ways that I could pay her when I was simply trying to assess whether I wanted to pay for it at all – regardless of means. I feel like any person with common sense should know that a) Just because you have money, doesn’t mean you’re supposed or want to spend it and b) even if you have money, you don’t want to waste it and think through your purchases through before committing to it. And furthermore, inheriting life insurance money after a sudden, unexpected death does not cause you to breathe a sigh of relief for financial safety. I feel like someone who knows about grief should know that.

    We never finished the conversation about whether I’m going to pay her the missed sessions or not. Because she brought up the topic of my mother’s life insurance money, we got on that subject. I explained that since I have no financial safety net, I do not want to use this money for every day expenses. I could use it for grad school or to finance a wedding or something more momentous, where I can look back and think of my mom. I expressed her policy was slightly unfair, and that I took offense at her suggestion that I use money that I need for a financial safety net to pay her for a period of time she’s not providing me a service for a time I’m letting her know in advance. She said that while I see it as unfair, from her perspective, it could be seen as trying to take advantage of her by not paying even though I have the financial means to do so. She then went onto say that maybe my friendships since my mother’s death – something we talk about in therapy – haven’t been good because I treat my mother’s death like this “hallowed thing” (she made quote marks with her fingers) no one can touch and that it makes them feel distant. She went onto say maybe I should just look at this as a rainy day fund and use it for a rainy day – which is what missed sessions would be. Inside my jaw was dropping that a) she would take an issue I vulnerably confided in her (my friendships) and use that to try to manipulate me into abiding by a policy which would financially benefit her and b) that she would criticize the fact that I mourn my mother’s death alone in the context of trying to get me to use my mother’s life insurance money to pay her. It’s fine if she suggests things about my friendships, or tells me I should grieve with others – but this basically felt like a personal attack saying that my mother’s death isn’t a big deal as I think it is, and that I should move on. And that I’m to blame for my own misery, basically. (I guess we’re all partially responsible, which I’m willing to accept, but this was not the most tactful way to bring it up.)

    I now feel like this therapeutic relationship is no longer a safe space for me to express my vulnerabilities without it getting thrown in my face (I’m fine with her giving me critical feedback as something therapeutically challenging/helpful in the long run). I get that she’s starting a new practice and she may feel financially insecure or annoyed that her patient isn’t so accepting of one of her policies. But I feel like she could have been firm on the policy without going the insulting/manipulative route. How is it that I could be more empathetic of her situation than she is of mine? I would never say to her, I see you have lots of expensive shoes – maybe you should stop buying those so I don’t have to pay for my missed sessions.

    I want to let her know how she came across and that I need to end the relationship because I no longer feel emotionally safe in the space. But I don’t want her to think that it was because of her policy. Can you give your take on this, and how I might approach her to discuss her reaction to my reaction to the policy?

    • Hi Helen,
      As I wrote in my original post, I’m unable to justify a policy of charging patients for absences regardless of advance notice. But some psychoanalysts, apparently including Sigmund Freud himself, have had such a policy, and presumably feel it is justified. The fact that I haven’t personally heard of a non-analyst with this policy may not mean very much — maybe I just run in the wrong circles. In any case, cancellation policies should be explicit from the start, especially if, as with this policy, they are non-intuitive for most patients. I gather that your therapist did not invoke this policy back when she accepted your insurance, but only now that she doesn’t. In my view it is fine for you to reassess your decision to work with her under these new conditions. Why wouldn’t you want her to think it’s because of her policy?

      (It’s worth mentioning that any decision you make can potentially be discussed and reflected on in therapy. This includes how you spend, or don’t spend, your mother’s life insurance money. Meanwhile, it’s still your money and you get to decide how to spend it —including choosing not to spend it on psychotherapy if that is your preference.)

      You asked how to approach your therapist to discuss her reaction to your reaction to the policy. You did a good job of “approaching” this topic here on a public blog; I have little doubt you could say much the same to your therapist directly. You offer articulate points about life insurance and finances, feeling manipulated by what you’ve confided in her, and so forth. You imply you might have agreed to see her even under the new policy, had she not made you feel emotionally unsafe. I know of no better approach than the one you already have.

      A productive 18 month therapy doesn’t have to stop immediately even in the face of a fatal impasse. Take the time to express yourself — her expensive shoes and all. Suppressing conscious anger at your therapist seems polite and professional, but in reality it’s counterproductive. If you let the chips fall where they may, you’re apt to get something out of the encounter, even if it ends up being one of the last with this particular therapist. Thanks for writing.

  • Rosemarie

    I read this post and the related comments with great interest. I’ve been struggling with the problem of charging for the missed session for quite a while. I am a psychoanalyst who not only believes but has discovered from my own experience that maintaining a frame of weekly sessions is important to keep the patient’s feelings about the therapist and the treatment IN the treatment. Furthermore, paying for missed sessions is likely to bring the patient’s anger into the treatment for analysis.

    Ultimately, paying for missed sessions symbolizes experiencing a loss (of treatment, of the therapist, of a choice made – FOR a vacation and AWAY from therapy) through paying for it. In life, we all have to make choices and they all involve giving up the choice not made. An ongoing therapy is an ongoing relationship and missing a session symbolizes a loss. As dealing with loss by learning to mourn is an important life skill, the patient’s reactions to paying for a missed session are crucial to analyze so to help him learn to deal with loss through mourning.

    My problem is as follows. When the patient – at the beginning of therapy – is unable to express his anger (or even disagreement) in any way other than running away, or cannot accept from the outset the “rule of indenture” (i.e. that the contract is for X sessions per week, and one pays for that just as one pays one’s rent whether one is living at home or off on vacation), then it is impossible to use the symbolization of money for the purpose of interpretation. How then would you deal with this kind of patient – at least at the beginning? More to the point: I don’t want to throw out the baby with the bathwater by discarding the rule of indenture – for the sake of those patients who benefit from it, but I wish I could find a better way of introducing the idea of paying for missed sessions that would not chase away those who are intolerant of even discussing it.

    • Rosemarie,
      Thank you very much for writing. This discussion sorely needs a psychoanalyst to argue for the “rule of indenture.” While I hadn’t heard the term before, the analogy with paying rent is clear enough. And it’s certainly crucial to explore losses in psychoanalysis, not to mention how patients handle trade-offs that are inherently frustrating.

      As I’ve already written, I’m not an analyst myself. The “rule of indenture” feels too harsh and unrealistic to me personally. Just paying for a vacation — and being away from work, perhaps losing income — provides plenty of grist for many patients to explore losses and trade-offs. Moreover, analogies are tricky. Is psychotherapy like “renting the hour”, or is it more like making a recurrent appointment, as at a dentist or hair salon, where advance notice excuses the cancellation? I suspect there is no universally satisfying answer. Perhaps analysis can lay claim to the rule of indenture to a degree that other dynamic psychotherapies cannot.

      Your specific question is a tough one. Sticking with the rule of indenture (and losing some patients at the outset), or discarding the rule (and throwing out the baby with the bathwater) don’t sound like good options from your perspective. I was going to suggest invoking the “rule” after assessing the patient’s ability to live with it, but then you run into the problem of changing rules in midstream, the very thing Helen complains about above. I’m dubious about intentionally changing the frame and then analyzing the patient’s response. Responses of anger, and uncertainty about continuing the relationship, are normal and healthy in that context. To me, this feels too much like a provocation by the therapist, and a type of empathic failure.

      I’m left with the suggestion that you could have different policies for different patients. I imagine you already thought of that. Whatever policy you have, formation of the therapeutic (or working) alliance comes first. One’s policies regarding cancellation, and everything else, must be established in that light. I have no magic words to ease the introduction of this topic to your patients, but it will surely be more acceptable if justified as a therapeutic benefit for the patient, and not as an income guarantee for the therapist.

      If there are other psychoanalysts reading along, I hope they’ll comment on this. Thanks for writing.

  • Anonymous

    I’ve never cancelled an appointment or been late. My therapist is regularly not in the building until 10 minutes after my appointment time. I just wait. I’ve accepted this about her behavior. What I’m finding harder to accept is last-minute cancellations on her part. I have an appointment at 9 tomorrow. Today at 5 she called to say she had ordered some furniture and needed to be home for it to be delivered. I use 1/2 day sick leave from work each time I see her. This is the 3rd cancellation she’s made with less than 24 hours notice in 5 months. How many are too many?

    • There’s no right answer, although I would not blame you if you feel it’s already too many. While sudden illness could necessitate a last-minute cancellation by a therapist, accepting a furniture delivery is a weak justification indeed. Regularly starting your appointments late is at least as concerning to me, even if she extends your time accordingly (although it’s much worse if she doesn’t). A sloppy therapeutic “frame” such as you describe makes it harder for patients/clients to trust and confide in their therapist. You might be better off finding a therapist who respects you, and her own profession, more than this person does. As usual, I suggest you raise your concerns with her before unilaterally deciding to stop. Thanks for writing and good luck.

  • Pip

    I’d love some tips on how to handle this situation…
    I’ve just started working with a new-ish therapist and I like her, I think she’s got a clearer understanding of my issues than the ones I’ve seen before, and I think she could be helpful.
    But I’ve just discovered (4th session) that she has this ‘rule of indenture’ which I think is unethical. Personally I’m a social worker in training and my ethics would never allow for this in my own practice, it is counter to my values as I feel it places the therapist’s value above the client’s, and if I’m totally honest I think a therapist is exactly like any other person who works in private practice – doctor, vet, osteo, naturopath, music teacher, tutor, mechanic, whatever – not entitled to be paid for work they don’t do. The nature of working for yourself is such that the pay per hour is high for the very reason that the work is unpredictable, that’s not the fault of the client, and a therapist is no more entitled to money they didn’t work for than anyone else. So this is not just about me seeing it as unfair at a personal level, it’s that the practice is counter to my values.
    My therapist used the rent analogy, but to be honest it just doesn’t hold true – if I were renting a house, the landlord wouldn’t decide he wanted to holiday in that house and kick me out at random intervals, while expecting me to pay for my own time away from the house. I believe the therapist can’t have their cake and eat it too, if they want to take leave they must allow the client to take leave as both are human beings with lives and needs and a right to adequate personal boundaries.
    The problem is that my therapist seems to think this is a useful learning experience for me – anything can be a useful learning experience, but I take exception to her saying that when clearly she has monetary gain to be made, it is in her interests. I won’t be following this ‘rule of indenture’ as we don’t live in the early 20th century any more as Freud did, we live in a market-driven society where the consumer with the money has the right to decide how they use that money, and I won’t be coerced into obeying a rule I see as unethical.
    That means that I can work with her once per week if I want to (she doesn’t use the same rule for one appointment per week), but I’m not sure whether that will always be adequate or whether I should seek another therapist who doesn’t have this rule; it’s a shame though as I’ve already invested in 4 appointments and as I said, I thinks she might be a good person to work with in many ways.
    I would like to be able to discuss this with her, but her perspective of constantly asking what it is that’s scaring me about therapy, and why I’m trying to avoid coming more often by not wanting to pay her for missed sessions, etc makes it absolutely impossible to have a converstaion. Instead of just reading into what I’m saying and seeing the unconscious, she should listen to me at a literal/surface level. I will not be coerced into obeying an unethical system. I am a very quiet, non-confrontational person but this is a matter of ethics for me, I am also extremely reliable and don’t miss appointments unless it’s unavoidable (I wouldn’t miss more than a couple a year and they would be due to university commitments with plenty of advance warning). I’m more than happy to pay for cancellations made within a week or even a month, but I won’t be held to an indefinite rule as I feel it would be devaluing myself.
    But how on earth do I get this across to my therapist without her turning it around and making it about me trying to ‘avoid’ hard work. I’m just trying to avoid giving her money she’s not entitled to when paying for therapy is already a struggle.
    Any tips on how to explain my view to her would be much appreciated as I’m not sure she can hear me since she believes she’s right.
    Thanks in advance.

    • Rosemarie (a couple of comments above you) and many other psychoanalysts feel that the rule of indenture is principled and ethical. And that, moreover, it brings into focus feelings you might not otherwise face. I can’t speak for them, but I will point out that many other service providers — doctors, music teachers, tutors, etc — charge for broken appointments. The issue is that a late cancellation or no-show means a loss of income for the service provider, who reserved that time and is unable, at the last minute, to fill it with another paying client. This is also similar to non-refundable deposits made for certain entertainment or travel tickets, where the rationale, again, is a practical inability to fill the space with someone else on short notice.

      This type of policy makes good sense to me, which is why it’s the policy I use myself. I do differ with the psychoanalytic “rule of indenture” in its blanket insistence that there is no time limit. Psychoanalysts may have schedules so regimented that it is practically impossible to fill an open hour even months in advance. But I feel like drawing a line somewhere and saying it is unreasonable to expect any individual patient to accommodate so regimented a schedule — that after a point it becomes the analyst’s problem and not the patient’s. Nonetheless, I recognize room for disagreement, and see why psychoanalysts might defend an explicit policy that not all potential patients like or agree with.

      Regarding your specific situation, it seems you have a choice. You can angrily accept the rule, regretfully decide to find another therapist, or persist in efforts to change your therapist’s mind. I doubt the third option will be successful, and I suspect at some level you know that. So I wonder why you’d persist in it. If you stick with this therapist, I predict your choice of this third option will end up teaching you something about yourself. Whether it is worth the frustration and money is another matter of course, one that I imagine many analysands face. Please note that until your therapist actually charges you for a planned absence, nothing in reality has happened that is unfair or contentious. The struggle is in your own mind, more or less. I’m not saying you need to put up with this — in fact you certainly don’t — but it’s curious, isn’t it, how easy it is to find ourselves engaged in struggles over right and wrong. Thanks for writing, and I hope you find a satisfying solution.

  • Lynn

    I have been a therapist in private practice for 13 years. I have a thriving practice with no shortage of clients. I have never charged for a missed apt. and I have very few times when this has even been a issue. Most people have “life” going on and there are rare occasions when that might interfere with their therapy apts. I personally think it is unethical to charge for missed sessions unless you devote that hour to the client. If I am going to charge my client for an hour of time, I better be working on something that pertains to that client. If I am using that time for drinking my coffee of doing my own unrelated (to the client) paperwork, and then charging the client for the time that “belongs” to them, since they are paying for it, seems to me to be unethical. If a client is prone to missing sessions with me, then it is clearly a therapeutic issue that we address in therapy and it gets resolved in a way that is beneficial to the clients healing. My pocket book has never been hurt by these policies and my clients have felt cared for and valued. I don’t know why therapisits feel that the only way that clients will learn and grow is by taking these hard lines with them, where the therapists clearly benefit and the clients rarely do. I find my clients heal more by having a therapist who addresses their needs and offers them compassion. There is already so little compassion in this world, that I don’t want to subject my clients to more punitive rules that resemble much of what they already grew up with.
    Thanks for the blog.

    • Hi Lynn. As I just replied to Pip above, most psychotherapists feel an appointment is a social contract: The therapist reserves a time that will not be offered to anyone else, and in return the patient/client promises to pay for that time, however he or she ends up using it. (In some therapies this may include long stretches of silence, for example, which are not refunded or pro-rated even though “nothing is being said.”) To me, the similarity with other reserved-time activities is very close. Dental offices, hair salons, live music and sports venues, college and evening classes, and many other activities will charge even if no service is offered to a person who cancels late or simply fails to show up after reserving a spot. The promised service was offered and available, and therefore the buyer’s failure to use it was not the responsibility of the service provider.

      Of course, you are free to choose a different policy, such as never charging for a missed appointment. As you say, your clients may feel more cared for and valued under this policy, and your ability to foster these feelings may overshadow any regret over lost income you’d otherwise feel. If it works for you and for them, great. I will note, though, that most therapists would consider this policy a devaluation of their own worth and time as professionals; also, the policy begs the question of why you charge anything at all, since clients would presumably feel even more cared for and valued if you saw them sheerly out of compassion. Again, I’m not arguing that you change your approach if it works for you and your clients, just that there are arguments for and against any of these policies. Thank you for writing.

  • Pip

    I find this quote of yours very interesting:
    “To me, the similarity with other reserved-time activities is very close. Dental offices, hair salons, live music and sports venues, college and evening classes, and many other activities will charge even if no service is offered to a person who cancels late or simply fails to show up after reserving a spot. The promised service was offered and available, and therefore the buyer’s failure to use it was not the responsibility of the service provider.”

    The reason I find it interesting is that you’re likening apples and oranges. There is absolutely no debate about whether a psychologist should charge someone who “cancels late or simply fails to show up” – of course they should! The debate is regarding whether it is ethical for a therapist to take leave at will, while expecting the client to pay for an appointment when they have given significant notice of inability to attend. I guess my issue here is that I’m not a fan of psychoanalysis (I didn’t realise my new therapist was a psychoanalytic psychotherapist at first) and I tend to see the whole approach as very ‘blaming’ and in fact quite unscientific. I am inclined far more towards strengths, empowerment and relational cultural theory in my own (emerging) practice, so perhaps it’s just not a good fit.

    And obviously I haven’t been charged as yet for a missed appointment because I haven’t missed one, but I have invested in 4 appointments with a new therapist only to find out she has a policy that by my own system of values is not ethical. It would have been nice to be told at the 1st appointment. But yes, such is life.

    However, my strengths-based ideals do rail against claiming I am the only one who needs to learn from my reaction. Personally I see growth in that I had the courage to say I felt it was inappropriate; I see resistance as a good thing when it’s against an injustice… and given this is a subjective argument, there is no right or wrong – she’s entitled to her opinion and I to mine, so she could just easily learn from it as well. But that’s the beauty of psychoanalysis, it’s a theory that supports the deflection of any responsibility (and possibly potential growth) away from practitioners.
    Hence why it’s not a method I will ever use as I plan to learn from my clients’ wisdom too, but each to their own.

  • Lynn

    Dear Dr. Reidbord,

    Thanks for taking the time to respond to my post and I really appreciate that you have taken the time to offer this forum for discussion.

    OK, I have a couple of responses. I just want to be clear that I would not keep scheduling appointments with someone who doesn’t show up. I don’t think it is ethical to keep scheduling appointments with someone who is not coming to therapy and not benefiting from the service. So, again, if someone was prone to not showing up for therapy, that is a bigger issue that would need to be discussed and figured out. And, again, on the rare cases where a client does need to cancel, my experience is that they generally have a legitimate reason to not be there and it is not the end of the world. I have been a single mother and I know the difficulties that can happen that are often out of your control and I know how stressful it is to feel like you have an appointment and you have to choose between cancelling that or attending to your child, or your broken car, or whatever. When these situations arise, I feel a little compassion is a nice thing to offer. I think the world is a little hard on people enough as it is. Also, I think that many clients have childhood issues that this can further exacerbate. For instance, variations on the theme of a child doesn’t perform or do something the parent or teacher wants. The child then got punished in some way. The parent or teacher made no extra effort to understand why the child did not complete the task, or do what they were supposed to do, they just got punished. Well, most children are not intentionally trying to not succeed of complete their task, in fact they usually try quite hard to do so, so when they fail, they usually need understanding, not punishment. As a therapist, we have the opportunity to give their “inner child” a different experience, and I personally think that is very therapeutic for the client.

    Also, if you are going to charge clients for missed sessions, then it is only fair to offer them a free session if YOU miss a session with them. Where is the parity? I believe that my client’s time is as valuable as my time. I think they are as valuable of a person as I am. And I know that some therapists do offer this parity and I respect them for that. What I don’t understand is how a therapist can charge a client for a missed session, yet the therapist can cancel because they have a sick child or whatever, and nothing happens. They just reschedule with the client, even though the client was able to make the time that was reserved for them. This doesn’t make sense to me. What makes more sense to me is that we schedule a time together and we both do our darndest to make it happen. And we are both given equal consideration and understanding, we both respect each other and each other’s time and commitment to the process. This is a respectful relationship.

    You offer examples of dentists, hairdressers, sporting events, classes, etc. First of all, I have never been charged by a doctor, dentist or hairdresser when I was not able to make an appointment. I don’t know if there are doctors and dentists that actually charge patients for appointments that the patient never attended. Maybe there are, but if so, I have never experienced it. As for concerts, sporting events, etc. yes, if you don’t go, you don’t get to see the event that is happening whether you’re there or not. But also, if that event is cancelled, you get a refund. So there is parity in that way.

    And respectfully, in response to your question about why charge my clients at all, wouldn’t they feel more cared about if I never charged them. This is my response: I charge my clients for my time, my training, my education, and my experience. My love and compassion I give them for free. They will not benefit from these things if they do not show up and do therapy with me. I make every attempt to find ways that insure that my clients show up for therapy with me and they usually do. So, for me, the rare times when they are unable to make it, they will be met with compassion and understanding, not a $100 charge for a service they never recieved.

    Also, I have trouble understanding why therapists feel devalued if a client misses a session. I don’t know about you, but I have tons of paperwork, reports, other work that I can be doing. Why not just get that work done, and reschedule with the client. I just don’t understand why it is such a big deal. Again, if a client was always blowing off our appts, that clearly is a big deal and would need to be addressed.

    Anyway, again, thanks for providing this forum. I think this is an important issue that doesn’t get talked about enough and I appreciate the dialogue.

    Warm Regards
    Lynn

    • Hi Lynn, and thanks for taking the time to write your detailed reply. As I see it, your approach would make sense if clients only missed sessions for perfectly conscious, rational reasons. Of course, this does happen sometimes: cars don’t start, there’s an emergency at work, etc. But in my experience, at least as often there’s meaning in the act of missing a session. For example, recently a patient failed to show because he got drunk earlier in the afternoon. I think most substance abuse professionals would consider it “enabling” to forgive a miss like that. A more common example is anger at me — let’s call it transference — that the patient cannot express in words, and maybe even explicitly denies, but that leads to him showing up late or not at all. Often working through such anger is very therapeutic for patients. But it’s clearly part of the work I’m doing, and I did reserve the time for them, so I charge for it.

      The parity argument feels to me like “much ado about nothing.” It’s extremely rare for me to miss a scheduled appointment. It’s happened about five times in my 16 years of private practice. Maybe I’m atypical that way; comments above suggest that therapists are standing up clients to await furniture deliveries and such. I take my job a lot more seriously than that. So, as I think about it, I actually do follow your parity guideline: On the very rare occasions that a patient missed a session because he suddenly needed to go to the hospital I didn’t charge him — just as I didn’t offer a free session to my patient when the medical emergency happened to me. All the other times we, patients and me both, are financially on the hook for late cancellations and no-shows. I just make sure I don’t do that. As you say, it’s the essence of a respectful relationship.

  • Lynn

    Thanks for your reply. Again, I appreciate the opportunity to dialogue about this topic. In reality, it feels like we are pretty much on the same page, when it comes to the brass tacks. I, like you, take my work very seriously and rarely miss a session with a client. And maybe my clients are atypical in the sense that they rarely miss sessions either. I think my commitment to being here for my clients often translates into them being here too. If a client fails to show up, I religiously call them at 10 minutes after the hour and try to ascertain what is happening. They know I am there and waiting for them and both of our time is valued and I am working with them and for them. If a client missed a session due to being drunk, my guess it that would be a client that would fall into a “prone to missing sessions” category, and it clearly would be a therapeutic issue that would be dealt with. I didn’t get into how I would deal with it, since every client situation is different. But depending on the client/issue it would of course, be addressed, whether it is transference issues, new boundary agreements put in place, whatever. Otherwise, I don’t think I would be doing my job. :) Anyway, again, thanks for providing this forum. I know every therapist will deal with this issue in the way that they want to. I can tell by your writing, that you do take your job seriously, and that you do put a lot of care into your clients and don’t schedule “furniture deliveries” when you have clients scheduled. :) I’m sure your clients feel that from you and I beleive that goes a long way in helping them heal. Take good care, and again, I appreciate the discussion.
    Warmly
    Lynn

  • Lynn

    P.S.

    I guess, ultimately, what I am trying to say, and I think what you are also saying (I don’t want to put words in your mouth, but what I am hearing) is that it ultimately boils down to what is in the best interest of the client, therapeutically. That takes awareness on the part of the therapist. Can we make good judgement calls on what is therapeutic? Well, clearly you and I both look at what were the circumstances for the missed sessions and what, if any, was the “meaning” behind it, and consequently, what would be the right therapeutic response to the situation. My hope is that therapists will do that. Virtually, every thing we do with a client has meaning, including how we respond to missed sessions. Whether we would arrive at the same conclusion, who knows, but one thing I do know is I keep trying to increase my awareness and hopefully, keep learning. Which, again, is why I appreciate you providing the forum. Learning never stops. Anyway, Have a great day.

  • am

    Hello, I am having a difficult situation with my therapist of about 7 months. Therapy seems to be going well, but this is my first time doing this and I am still not sure what to expect. Therapy is a financial burden for me. When I have discussed this with therapist, she told me to ask my father for money, which, given my difficult relationship with my father seemed a little bit inappropriate. Since that time, I do not discuss financial concerns with her, which of course is a block in our therapeutic relationship. AT my last session, we were talking about my vacation to see my family. Toward the end of the hour, she said, “You’re not going to like this, but I charge for missed sessions, but I will work hard to reschedule with you”. When asked to clarify, she said that if I don’t come at all that week, I will be charged, but if possible, we can do it a different time that week. I have one opportunity before I leave, even though it meant cancelling plans, so I reluctantly agreed to give her that time, even though I felt bullied into doing so, as we could not talk about it because she had another client waiting. She said we could discuss the policy next week (at the appointment I was bullied into making!). Further, I will be gone for two weeks and do not know when I will be able to reschedule the second missed appointment. I was so angry at her for springing this on me that I walked out angrily. I feel that this policy is unethical in general, and specifically because she waited until the end of our last session before vacation to tell me about it. When we talk about it this week, she will talk about transference, and “what I am really angry about”. What I am really angry about is this policy and my not knowing about it earlier! I will go to our rescheduled appointment, and I will feel like I am wasting money talking about my anger at an unfair policy and lack of disclosure of said policy. I would not have anger right now if it weren’t for this policy. Are therapist allowed to make clients angry (by charging for vacation sessions, just so they can talk about anger?!?) This feels highly unethical and I am not sure if I can get past this seemingly manipulative behavior. Therapy with this person has been a financial strain because she is out of network on my insurance. Further, it felt like she was protecting her interests, and maybe not mine, when she told me to ask my father for money. I have been with her for seven months which equals a lot of time and money spent. I have no idea how to proceed. Help!

    • In my view, it isn’t ethical or helpful therapeutically to “tell” patients where to get money for therapy. Raising possibilities for discussion is fine, pressure is not. Your therapist should have been sensitive to your difficult relationship with your father, assuming she knew about it, and how you’d feel about asking him for money. Your avoidance of financial concerns is an unfortunate consequence. Telling your therapist how this affected you would move your therapy forward.

      If I understand correctly, your therapist knew of your immanent vacation for most or all of your last session, but waited until the end to announce a cancellation policy that had never been discussed before. This was a mistake on two counts. First, such policies should be made explicit well in advance. Many therapists offer a printed page to new patients detailing payment, cancellation policies, and the like. Others do it verbally. Seven months is a long time for this to go unmentioned. It was also a mistake to raise the issue near the end of the session. As a general rule, announcements related to the “frame” of therapy should happen early in the hour, to allow time for discussion. This includes the therapist’s planned absences, fee issues, policies, and so on. The way you describe it, it sounds as though your therapist was uncomfortable mentioning her cancellation policy and therefore delayed bringing it up, which only made matters worse.

      It isn’t clear from your note whether your therapist never waives session fees (the “rule of indenture” discussed above), or whether you simply didn’t give enough advance notice. Either way, you should have known about the policy in advance. Offering a reschedule is a kindness over simply charging you for the miss, but it may not feel that way if you didn’t expect to be charged at all.

      An ethical therapist is not manipulative, and rarely if ever makes a patient angry on purpose. However, angry points of disagreement or miscommunication almost always arise even in highly successful psychotherapies. At this point you may be feeling that your therapist puts her own interests over yours, which understandably makes you very angry. As I’ve written in reply to several commenters above, the best solution I know is to talk frankly to your therapist about your reactions. A good therapist will not deflect here-and-now anger by passing it off as something else, although linking it to anger from the past, and to anger in other current situations, is a time-honored therapeutic technique and often very helpful. Please do discuss the policy when you meet. It’s possible you’ll feel less manipulated and mistreated. Conversely, you may conclude that you can’t continue to work together. In any case, if your therapy “seemed to be going well” for seven months, I would not consider your time and money wasted. Thanks for writing.

  • sjw

    I’ve been seeing a therapist for a few years. At my last session, I mentioned that the long commute to her office (I moved recently) and the way my appointments were eating up my Saturdays was starting to wear me down. I’ve also been wondering if I still need therapy every week and might want to switch to coming less often, taking some breaks, etc. She then informed me that her cancellation policy had changed and that clients have to come every week except for 4 weeks vacation a year, or make the sessions up. I was very shocked by this sudden change; it feels unethical to me to do this in midstream. Shouldn’t I have options other than coming every week even if i don’t need it, or terminating completely? I’ve NEVER had a therapist do this before, and it’s clearly about her income rather than what’s best for me.

    • “Springing” a new policy on a psychotherapy client is bound to be upsetting. It should happen rarely and with plenty of consideration by the therapist beforehand, as well as lots of discussion afterward about the (presumably negative) feelings it stirs up. In this case, it sounds less like a cancellation policy, and more like a declaration by your therapist that she won’t see anyone less often than weekly. Personally, I wouldn’t limit myself and my patients to such an inflexible policy, although I do share with my own patients my belief that most psychotherapy is best conducted at least weekly.

      (I have to confess I don’t understand “making the sessions up,” mentioned by a few commenters in this thread. Unless this is purely to address lost therapist income, it seems poorly worded at best. Maybe a therapist out there with such a policy can tell us what they have in mind.)

      In my view, there are good arguments for not meeting less than weekly, and also for not “tapering” therapy or taking breaks. It is often more helpful for the client to continue psychotherapy at a constant frequency until termination. Whether this is true in a particular case depends on the type of psychotherapy, the issues the therapy has addressed, the personality of the client, and so forth. In other words, it can’t sensibly be determined in advance by policy, but only by careful discussion and exploration of feelings.

      From what you’ve written, I can’t say whether your therapist’s new rule aims to serve you (and other clients), or only herself. I hope you’ll raise your concerns with her in the context of having worked together a few years, and how her rule forces you to choose between two unsatisfactory options. I hope and trust she’ll be sensitive to your dilemma. One thing to consider is whether your wish to come less often or take breaks is an avoidance of outright termination. If you “got what you came for,” especially given your recent move, maybe it’s time to stop.

  • sjw

    Thanks for your feedback. This isn’t about advice about termination, as my situation is such that I’m likely to need therapy to some extent for the rest of my life. It’s not so much about curing things and then terminating as some chronic issues that needs steady or periodic monitoring, but not every week of the year. If I weren’t coming every week, I wouldn’t expect here to leave an hour open for me but would fit into her scheduel.

    I talked with her briefly last week and will do so again next time. She explicitly stated that this is about ensuring a steady income supply for her. I feel sometimes stuck in a therapy hothouse, when I don’t have things that need attention for maybe a few weeks and would be better off just living my life. I also wonder if it’s ethical to charge insurance if she requires sessions that I may not need. However, when I asked her once what reimbursement she gets from my insurance, she wouldn’t answer, so I don’t even know what I’d have to pay her if I wanted to skip a week.

    My questions aren’t about seeing advice but about wanting to get some sense of what the ethical standards of the profession are. (She’s a psychologist, not psychoanalytic.) I’ve had previous “frame” and boundary issues with therapists. One sold me a car, which turned out to be a lemon. Another made me pay for my own sessions during a stretch when he said my condition wasn’t legitimately covered by insurance, but I believe now that he was wrong and was just acting out his own aversion to filling out insurance forms. This present therapist says she doesn’t have a written policy but will answer questions. It seems that it should be required to be contractual in some way, since it sounds from your comments like some of what she’s doing is iffy.

    This failure on her part in dealing with the frame issues forthrightly is damaging my trust in the therapeutic relationship. I’m likely to print this out and share it with her.

    • I appreciate your clarifications. Since you are asking about ethical standards for psychologists, please see the American Psychological Association (APA) code of ethics. As a psychiatrist I’m not intimately familiar with the psychologists’ code, and I couldn’t find any section that clearly condemns your therapist’s policy. Section 3.06 may come close: It prohibits psychologists from taking on a professional role when financial interests “could reasonably be expected to impair their objectivity, competence or effectiveness in performing their functions as psychologists.” I’d argue that insisting on weekly sessions purely to ensure steady income falls under this description. Anyway, the practice sounds plainly unethical to me. The frequency of sessions should depend on the client’s needs. Indeed, each session needs to be “medically necessary” for insurance to pay for it. Insurers consider it fraud if practitioners falsely claim medical necessity in order to assure steady income.

      Your insurance company can tell you how much they pay your therapist. You should already be getting EOBs (Explanation of Benefit reports) from your health plan with this information.

      Neither psychologists nor psychiatrists are required to put contracts or policies in writing. However, the ethics codes of both professions require a clear explanation of the services offered and the fees expected in exchange. For better or worse, there is a lot of variation, and a lot of latitude, in how therapists practice. One thing I can say for sure: Never buy a car from your therapist. This is a great example of a “multiple relationship,” explicitly prohibited by section 3.05 of the APA code.

      I don’t blame you for losing trust in the therapeutic relationship. If you decide to share these comments with your therapist, I’d be curious how it goes. Take care.

  • sjw

    The buying the car is quite a cautionary tale. I was moving to a new city and driving across the country, had a very decrepit old car and little money, and he offered to sell me one of his cars, I believe with helpful intentions. I needed to get a loan to pay for it. The car was several years old and he told me it had a whole new engine. Important point: because of my emotional attachment to him, including romantic transference, there was no way I would have refused the offer. To sit in the driver’s seat where he had sat had great emotional resonance for me. I didn’t do the due diligence of having a mechanic look at it, partly because I assumed he was trustworthy.

    On my cross-country trip, the radiator started leaking badly and ended up being very hard to fix. The first rainy day, I went outside (non-covered parking) and found inches of water in the car. This was an unfixable windshield problem with the VW Rabbit. I had two potentially dangerous brake failures while driving. This all cost me a lot of money that I didn’t have. The car was the worst lemon I’ve ever had. When I traded it in, there were mushrooms growing on the floor because of all the dampness. I told him about all these problems, hoping he’d offer to refund me the money, but didn’t challenge him because we still had ongoing phone conversations and I didn’t want to jeopardize the relationship.

    It was only years later that a later therapist told me that of course the whole car sale was completely unethical.

  • Miss G

    Hi Dr. Reidbord,

    I have two separate comments/questions:

    1. I have currently been seeing my psychiatrist for 7 months. He has helped somewhat but I’m not sure if I can attribute my improvement to the therapy or a change in medication. Recently, his make up policies and insistence that I need to be seen twice a week have been angering me to the point that I am looking for another therapist. Initially, his make up policy was full payment for sessions canceled without at least 24 hours notice. He changed that policy several months into treatment and now, even if I give him a month’s notice, he requires me to make up the session which would mean coming 3+ times in one week or pay in full. I agree with what you said about discussing my anger with him but I truly don’t believe it will make any difference in his policies. I was curious if you knew any psychiatrists in the Syracuse, New York area that you would recommend.

    2. I was wondering if you had any thoughts on romantic feelings in the supervisor/supervisee relationship between psychologists; whether it was important that such feelings be disclosed by the supervisee or if it was possible to have a productive relationship without openly acknowledging said feelings.

    Thanks so much :)

    • Hi Miss G,

      1. I have no objection to a therapist insisting that psychotherapy needs to happen twice a week, as long as that insistence is based on the needs of the patient/client, and not on income considerations or other self-interest. As mentioned above, I don’t understand “making up” sessions, but maybe this is just because the wording is misleading. It sounds like your psychiatrist requires payment for canceled appointments even with plenty of advance notice, but does allow you to move an appointment without penalty. I find this a clearer way of putting it, as missing a session does not render anyone “session deficient” in a way that needs to be “made up.” It’s up to you, of course, whether you are willing to work with your psychiatrist under these conditions, which I will note could be acceptable and quite beneficial to certain patients. I can’t say whether they would be for you. I don’t know any psychiatrists in Syracuse.

      2. When romantic feelings arise in psychotherapy, it’s helpful, even important, to discuss them to understand oneself better. In contrast, psychotherapy supervision is not therapy; it isn’t aimed toward self-knowledge in the same way. (There is debate over the degree to which supervision should resemble psychotherapy. While there are some areas of overlap, there are crucial differences too. I believe they should be clearly differentiated.) Romantic feelings in a supervisory relationship strike me as similar to those that may occur by a student toward a teacher, or by an employee toward his or her boss. The APA code of ethics, section 7.07, forbids sexual relationships between psychologists and their students and supervisees. So in theory it’s safe to admit such feelings and not have the admission serve as an invitation. But there is no obligation to do so, and it’s not immediately apparent to me what good it would serve. A productive supervisory relationship is certainly possible regardless. It would be far more helpful to discuss such feelings in one’s own psychotherapy, assuming the supervisee is in treatment. Thanks for writing.

  • Bruce

    I am *genuinely* disgusted by the hypocritical behavior that is accepted and even self-justified and encouraged by the people writing comments on this page. You will charge people for missed appointments, but excuse yourself for the same behavior? Even if people in other fields of work do that, it is outrageous. Your cognitive dissonance is astounding!

    I suppose this self-centered and twisted perception of one’s self-importance is fostered in medical school, where group think takes over. That does not excuse it. Despite your inflated sense of entitlement, I have never heard or read of a single consistent moral system that affords a physician such a one-sided cancellation policy. While you may make excuses that some things just can’t be helped and therefore it is OK for you to miss an appointment, you fail to accord your patients the same degree of forgiveness in accountability. You can all congratulate each other all you want on how you must all be right. After all, if a group of ‘wiser-than-thou’ physicians agrees on something, they must be right! Group validation validates the morality of a decision, not just the feelings. You can all knowingly nod your heads in (smug?) mutual agreement that you have surely given the issue impartially due consideration. Your group has been *compelled* by logic AND compassion to conclude that you are all justified in your deluded belief in your exceptional superiority and special status.

    In reality, all of that changes nothing. You are charging patients for the value of *your* time while you make excuses to find their time (DE FACTO, their lives!) less valuable than yours. But don’t let that stop you for charging money for every missed appointment. Those student loans, business loans, vacations, mansions, and education savings accounts need funding – that makes it OK! You are the masters of morality and judgment and you deserve your geld – keep on collecting those coins for your master race.

    Of course, you can read this and smear it as over-the-top and emotionally charged and unreasoned, but in the end, none of that changes the circumstances of *your* behavior. You are simply elevating your time above that of your patients. That is disgusting, regardless of how special you think are for what you do.

  • Eric

    I am being charged for a session with the psychiatrist I spaced on and no showed. The place sends me a bill every month that has this 60 dollar charge for a missed 15 minute appt. that never lasts more than 6 or 7 minutes. and a couple of old copays. Several weeks ago, I had to reschedule my therapist appt. at the same place. My guy give me a time over the phone, and I go at that time, but he didn’t. He didn’t come to the office at all that day. (So he spaced). Ok, I left, but then a month ago, I wrote them to say I wanted to be forgiven for my no show, since the same thing was done to me, and I actually wasted a good part of the day around going to the appt. he never showed for. I proposed deducting that part of the bill, then I would pay. Nobody ever got back to me, but rather they just sent me the same bill the next month. So I wrote in and paid my bill minus the no show charge, since they never did me the courtesy of even telling me no, I can’t do that.
    By the way, I’m a psychologist myself, and to my mind, they’re wasting my time (much more of it really), is just as bad as the reverse, and I never got an apology or even an acknowledgement when I brought it up. What about this one?

    • Eric,

      If a mental health practice — or a medical practice, or hair salon, or music school — has a stated policy of charging for missed appointments, then you are contractually and ethically bound to pay. The fact that “15 minute” appointments last only 6 or 7 is immaterial, although it may well influence whether you want to be a patient there going forward. The no-show by your therapist is, or should be, a rare event that may best be handled on a case-by-case basis instead of by policy (as I replied to the first commenter in this thread, “Dr J”). This should include a serious exploration of your feelings, which are at least as important as deciding how and whether money changes hands.

      One argument in favor of keeping payment strictly between psychotherapist and client is to allow reflection on its meaning in the therapeutic relationship. When “the place sends me a bill” and “nobody ever got back to me” with an apology or acknowledgement, you’re dealing with the frustrations of institutional stonewalling, not the already complex arena of an interpersonal relationship. Thanks for writing.

  • Leslie Sulllivan

    I have to take PTO every time I see my shrink. He averages about 30 minutes late, for a 15 minute visit. He is wonderful, but it is ironic that my lost productivity does not count in this arrangement. He also bills for missed appointments. I never did when I was a practicing surgeon, and I was rarely late, I always scheduled extra time for each patient. Why are Psychiatrists so entitled? I do not know a single Surgeon who bills for missed appointments.

    • Dr. Sullivan,

      I won’t defend your psychiatrist or any doctor who routinely arrives late to his or her own appointments. It’s poor time management at best, and rude entitlement at worst. Repeated lateness should, in my view, factor into the assessment of how “wonderful” one’s doctor is.

      On the other hand, I don’t know any service providers who “count” the lost productivity of their clients or patients when setting fees. My dentist certainly doesn’t, and I’d wager you didn’t when you were practicing. Indeed, rather than being compensated for lost productivity, there’s a contrary argument that high-income earners can afford to pay higher fees.

      There are several reasons why psychiatrists, unlike surgeons, bill for missed appointments. Psychiatrists bill for time, not procedures. Psychotherapists cannot overbook their outpatient clinics, unlike surgeons. Freud set the historical precedent, as quoted at the top of my post. But the most important reason is that billing for missed sessions aims to maintain the therapeutic frame, a container in which a patient may experience regressive thoughts and feelings without destroying the therapy itself. The truth is, most beginning psychiatrists and other mental health professionals are reluctant to bill for missed appointments (or to ask for money at all, in some cases). It takes experience to see that, in the context of psychotherapy, it nearly always benefits patients to hold them responsible for their actions.

      Admittedly, these arguments are weaker with regard to medication visits. The remaining argument, which applies to psychiatric med visits as well as to many other appointment-based services, is economic. Thank you for writing.

  • Anonymous

    My next session falls on a holiday, and so does the following one (Christmas, New Year). My therapist insists we reschedule, I’m really busy and would rather just see him after the holidays. Am I obligated to reschedule those sessions?
    Thank you for your input.

    • Regardless of holidays, if you’re really busy and prefer to cancel a session or two, your freedom to do so without penalty (i.e., without paying for the session) depends on your therapist’s cancellation policy as discussed above. This should have been discussed beforehand, so there’s no misunderstanding. Also as mentioned above, I believe it makes all the difference whom this insistence aims to benefit. There may be good therapeutic reasons to advise you not to skip two weeks of therapy. If there isn’t a good therapeutic reason, and if the need to reschedule holiday appointments wasn’t raised before, then I wouldn’t see it as an obligation on your part. In traditional psychodynamic therapy, it would be more typical not to automatically reschedule around holidays.

  • sjw

    A followup on my comments from last April. The therapist told me I could miss 8 appointments during the rest of the year. I decided to let it go at that and not take time discussing the issue further. I cancelled two sessions well in advance for work-related out-of-town trips. Then a few weeks ago, I’d been feeling dissatisfied with my therapy and wanted a week off, so cancelled with two days notice. There’d also been an issue that I’d changed insurance and she was slow in billing so I didn’t know what the new copay was.

    She phoned me with some billing info, and then asked why I’d cancelled. I explained that I was doing better and just wanted the day to do other things. She basically scolded me! She said I’d already used up my 8 days – not true – and seemed to think she’d set some condition for “excused” absences. I told her I wanted to take a break, especially since I was now owing her hundreds of dollars for 3 months of copays for sessions she hadn’t billed for yet. She called back a few days later and said she wanted me to come in and discuss the insurance copays and the reason for the break. I agreed because I felt pressured, but later left a message later that I wasn’t willing to come in for a session that I felt no need for. Also of course there’d be no legitimate medical reason to bill insurance. This proposed session seemed more about her needs than mine.

    My therapy has been feeling unfocused and this was the final straw, because she’s made it clear that this cancellation issue is about her income stream, not my needs from week to week, and that she had a secret agenda of what constituted legitimate cancellations. I think sometimes for me, at least, coming to therapy every week can be a defense against actually making change in my life, particularly if the therapy isn’t going much of anywhere, and this self-admitted focus on her income rather than what’s best for me feels like a clear conflict of interest on her part, and a bit of a betrayal of the therapeutic relationship. The scolding me was the last straw. I’ve been dealing with a workplace bullying situation and she walked right into a “you’re a bad girl” dynamic.

    Therapists really need to look at this issue carefully, and be vigilant about lines of thinking about it that are just rationalizations of self-interest, particularly when insurance billing, which requires medical necessity, is involved.

    • Thanks for the followup. Offering to “forgive” a fixed number of missed appointments seems to imply that the amount of advance notice and the reason for the absence don’t matter. I would never consider such a policy myself, but can see how it might work if applied consistently. However, your therapist didn’t object to your canceling well in advance and for good cause, whereas she scolded you for canceling with short notice and because you were dissatisfied and perhaps angry with her. Apparently these factors do matter.

      I agree that therapists need to look at this issue carefully, although perhaps not for the reason you had in mind. There’s a big difference between these two types of cancellations. The latter calls for much more discussion (not scolding) than the former. Given your other comments about delayed billing etc, the bigger issue seems to be your mutual anger. The cancellation skirmish sounds like a concrete example of this larger issue, one that will not be resolved at the level of policy.

  • michelle

    re Lynn and the Parity issue: I too consider the clients time as valuable as my own. If I late cancel or am significantly late for an appointment I do something to make up for it: waive the copay for example or charge a prorated amount plus apologies.. but I also agree with the idea that the hour is theirs to use if they schedule it and mine to be paid for. When a concert is cancelled the customer gets a refund– of money they already paid; the concert doesn’t pay a customer for something the customer did not pay for. the money flows toward the seller or it does not. the money never flows toward the buyer. if that were the case I would pay the client for every session they came to!

  • sjw

    I decided to write one more time about this situation. I wasn’t looking for advice in my last post, but wanting to help therapists who visit this site to think about the issues. I was indeed angry, but the point is the policy, which had been defined as “8 cancellations a year” with no conditions mentioned. I told her I was taking a break and that should could bill me for the remaining copays. That was 3 months ago, and I never heard from her again. I had decided not to go back because I realized that she had never talked with me about goals for therapy, questioned whether I still needed it, etc., as previous therapists had done, and that I didn’t have the trust to believe that she was acting in my best interests rather than just seeing me as a billable hour. I’m actually doing better outside of therapy.
    I think the only fair way to do this “rule of indenture” is if it’s made clear from the beginning, before treatment starts, and that the therapist commit to a regular discussion of where the therapy is going and when the endpoint will be. I think there’s also an ethical issue about billing insurance without continuously monitoring for medical necessity.

  • JM

    I wonder if anyone else is still reading this.
    My therapy of two years seemed to be going generally well however it has got so yucky recently and I feel sad about it. I did not understand from the beginning that psychotherapy takes so ling
    My psychotherapist advised me of her indenture type policy at the first meeting so contractually she was not dodgy but the thing is I did not expect to be going for more than two years. I thought I could bear that contract for about a year but not forever. I am angry because I feel tied to her holiday dates as I feel stung by being charged for holidays during the third summer. I have been diagnosed with Lacanian paranoiac structure and obviously there is much to say about transference and my angry feelings about being used. Technically she has not tricked me as she said at the first meeting but I feel that if I need very long term psychotherapy I should not be tied all my life to a very strict contract and it feels like too much after two years to change to someone else. I was so angry on holiday emailing her and being possibly more psychotic than ever that the whole thing feels disgusting and painful. I know the contract was there at the beginning but it was not properly thought through by me because I hoped I would only come for about a year. She gets her patients from a sex abuse charity and that also made me angry as I was referred by them and feel that women like us are not good at negotiating and did not shop around as we were recommended by the charity. I would be able to give her a couple of months notice and so I don’t see how she wouldn’t be able to feel the slot. I just paid her this evening because I don’t want things to get any worse and I try not to feel angry but I feel very confused about whether she wants me to get better or whether its just a job. I don’t like thinking I am a paranoiac but I obviously am and I wonder whether it would be better not to know and just to lose my temper with people every now and then like I used to

    • I hope people are still reading this. The topic obviously touches a nerve with many readers, and as such, it may be a particularly problematic aspect of many psychotherapies.

      Your situation is unique in its details — frankly, I’m always apprehensive when commenters include deeply personal material, even anonymously — but common in its broad outlines. You were uncomfortable with the “rule of indenture” from the start, but you contained your anger for a year or two, and can do so no longer. You imply that since your therapist was not dodgy and “technically” didn’t trick you, you have no right to complain about her policy (except anonymously on the internet). On the contrary, your anger is a valid, even necessary, topic to discuss with her. It’s exactly why you’re there. Expressing that you feel used, that she appears to exploit your poor negotiating skills, that therapy with her feels like continued abuse, that you can’t trust your own “paranoid” reactions — that’s what you’re there to explore and clarify. I can’t predict the outcome: Maybe you’ll see her policy differently, maybe you’ll decide not to work with her anymore, maybe something else will happen. But I assure you the process will be valuable and well worth it. Thank you for writing, and best wishes.

  • Jane

    I have been following this and have a couple of observations/experiences. I have recently terminated with my therapist after several years in part because of this issue even though he’s, generally speaking, helped me feel better than I ever thought I could. It’s that improved feeling that delayed my termination, but I finally couldn’t get over the lack of trust engendered by his handling of this policy. He was very straight about it when I began about having the policy, very up front, so, while I didn’t like it, I got it.(Although the idea that it’s of therapeutic value has always seemed like a convenient line of BS.)
    I noticed several things – keeping in mind I was seeing him twice a week and paying out of my own pocket at great sacrifice.
    1. My work schedule changed so that, about once a quarter, I had to work on a session night. I had no choice but I could tell him months in advance what those dates would be. He never yielded. He never offered to change a session. Nothing. After a couple of years of this, he did offer to do the therapy those nights over the phone while I sat at work in a bullpen atmosphere.
    2. I went in the hospital. Again, he never yielded. Never offered to cut the fees, nothing.
    3.On weeks when a holiday, or something similar, fell on one of our therapy nights – that is, when HE would have to cancel and would not be paid, he not only offered a different session. He’d schedule it. If it was inconvenient for me, guess who still paid.
    4. If the idea is to “hold” time for people – and he was really big on “this is OUR time” – then no one else should be scheduled into those sessions. After all, if the time is paid for and so sacrosanct, he’s not losing money. Yet, on three occasions I know of, he did just that. So he essentially collected two payments for those sessions.
    My conclusion, and the reason I quit, is that he worships the almighty dollar and cares about it not the patient. That’s okay, I know he’s not doing it for fun or his health. But I did get really irked that he seemed to think I was so stupid as to buy his “I care about you and what happens to you” line of BS. No, he cared about the money.
    Now, one other observation – if I’m paying the money anyway, I feel no obligation to go to the session. If I want to lose the money, then fine, charging me to get me to show up is not going to work. What will get me to show up and show up consistently is good therapy. But I don’t think it’s out there.
    Thanks for letting me vent.

  • Jen

    I’ve been in practice for just over a year and run into this issue time and again. I do charge for no-shows and cancellations under 24 hours. However I always give one free pass and I never charge for a family emergency, illness, car breaking down, etc. The times I have had to charge I’ve been clear about the reasoning, that I’ve reserved the hour and was unable to fill it. Most people have expressed understanding and only a few times have I gotten resistance to paying. I don’t really think it’s a clinical issue but more of respecting one’s time. The one time I missed a patient’s appointment, I was really embarrassed so I apologized and offered them a free session. I like to think I can be flexible. I’m horrified to read some of these people’s experiences with clinicians who are so rigid and inflexible by charging for missed appointments even with plenty of notice. That seems they have put their bottom line way ahead of the need of the person.

    • Hi Jen,
      I’m curious: How did you decide not to charge for certain absences? Are you distinguishing between “avoidable” and “unavoidable” ones? How do you handle reasons such as oversleeping, grossly mismanaging one’s travel time, or simply forgetting to come? I’d personally find this distinction difficult to make in many instances — especially when I consider that people are often influenced by unconscious motivations. You also mention being unable to fill the hour. Do you then waive the fee for any canceled hour you can fill, and only charge for “avoidable” misses you can’t fill?

      The reason I ask is that charging for missed sessions can serve several purposes. It sounds like you do it reluctantly (“The times I have had to charge…”), which suggests to me you don’t see clinical value in it. If a therapist views such a charge as punishment, a form of behavior modification, or a way to assure income, she is apt to feel guilty about asking for it, and apt to see those who do so freely as callous and selfish. My own view is that there are solid, well-founded clinical reasons to charge for missed sessions. I don’t “have to” charge, I do so with a clear conscience, and with faith that it ultimately serves the patient. The sad fact that some therapists apparently charge these fees unthinkingly, or simply to assure their income, doesn’t negate the clinical benefit this policy may otherwise have. Thanks for writing.

  • Amanda

    My psychiatrist (whom I use for therapy) has always been lovely and flexible about missed appointments. Like previous posters said, life happens. Unfortunately, sometimes one is just unable to make an appointment regardless of how hard they try. The last time I had to cancel, my flight back from Paris was delayed for 4 hours and thus, I had to reschedule all my morning meetings (therapist included). He was very gracious and suggested I come in the following afternoon and that he would use the missed hour as an admin session for himself.

    I am a professional and cannot in some way “charge” my clients when they have to cancel (for whatever reason they may have). If I miss a meeting with my attorney (who is always paid hourly, he does not charge). I feel like this is considered professional courtesy. If one has a patient or client who has an exemplary track record of being on time, doing good work and being a pleasant patient to have, I feel like they need to be flexible and understanding. It is not uncommon that I have to change or reschedule an appointment, but always make a point to do it as close to 24 hours as possible. If one has a busy enough practice and a waiting list, it should not be hard to fill a missed hour. Alternatively, the therapist could always stay late one evening or forgo a lunch hour to “make-up” a missed appointment so as not to lose the income from that client.

    For those that have used masseuses, dentists, hair dressers etc. as examples, in my entire life, I have never had to pay for a missed service unless there was less than 24 hours notice– even then, most places will be flexible if you have been a good client for years. I would not see a therapist who felt it appropriate to charge me for a missed appointment as I always “make up” my appointments and in the past, have even offered to do my session over Face Time or Skype if I am unable to take the time to go to the office.

    • Hi Amanda,
      Lovely and flexible are fine attributes, and I’m glad you and your psychiatrist work well together. As I tried to convey in the original post and in my comments that followed, cancellation policies serve several purposes, not all of them explicit or straightforward. Guaranteeing income is only one motivation, ideally a very secondary consideration.

      Psychoanalysis and dynamic psychotherapy are unique — peculiar if you like — relationships with all sorts of apparent rigidity maintained in the service of the treatment itself. In addition to “inflexible” fee and cancellation policies, there is therapist non-disclosure, a reluctance to accept gifts from patients, a refusal to socialize outside the office, and so forth. Even doing a session over FaceTime or Skype instead of in person is a “flexibility” that many such therapists cannot abide.

      Perhaps your psychiatrist doesn’t identify as a psychoanalyst or psychodynamic therapist. No problem, many therapists don’t. And many patients prefer other types of treatment. No problem there either. But for traditional analytic/dynamic psychotherapy, the kind of flexibility you cite — forgiving absences, “making up” sessions, “professional courtesy”, giving special consideration to “good clients” — is not in the patient’s best interest. Being liked is not the goal of such therapists, and therapist flexibility is not the engine that leads to patient change. Other professionals do not act like this because they are not engaged in this type of work. On the other hand, I never fly to Paris. Thanks for writing.

  • Cinders

    There is an aspect that I’d like to add to this discussion, which is that I have found that good therapy requires respect. And respect works both ways. The therapist respects the clients feelings, confidentiality and therapeutic needs, etc, and in return the client respects the therapist time and business needs. I charge for less than 24 hours cancellations with upfront policy statements. The one time I missed someone’s appointment session I gave them a free session and a sincere apology. If a client doesn’t arrive I don’t always have paperwork on hand to do. It is logistically very difficult to rebook clients with less than 24 hours, even with a wait list generally those clients cant come in with less than 24 hours notice either. A client wanting to avoid any consequence for their own ‘no show’ or lack of planning or time management is about their not wanting to own the consequences of their own actions. A client who expects the therapist to suffer economic loss because of something the therapist cant control is about clients wanting someone else to rescue them from the randomness of life. The fact that some other professions don’t charge a cancellation fee is likely due to them not being able to assert this sometimes ‘unpopular’ rule. Dentists, hairdressers etc always ask me ‘how do you enforce the cancellation policy’. Clients – consider this – if you disrespect a therapist’s time by not showing up or cancelling on the last day – how is this likely to effect the therapist’s willingness to respect your emotions and needs? Respect works both ways and therapists are humans, with needs too. Ours are to be able to run a business where our workloads can be managed so we can be effective clinicians and our income is stable enough to ensure we can stay in business.

  • Considered

    I have an interesting situation I would welcome opinions on. I’m a client.

    Context/background

    I have been seeing a female therapist on and off for 5 or so years. I sought therapy for a number of issues, predominantly stemming from issues surrounding control/manipulation regarding my mother. It is also relevant that I previously saw a male therapist who breached the boundaries of our relationship by sending (albeit jokingly) emails about sex/genitalia and i felt it was highly inappropriate – i stopped seeing him and told my therapist about this in our first meeting – boundaries both from my relationship with my mother and my previous therapist have been a very strong issue.

    My therapists’ cancellation policy is absolute – there is no minimum or maximum cancellation time – you will be offered an alternative appointment(s) and if you cannot make any of the re-offered appointments, you are liable, irrespective of any circumstances whatsoever.

    I recently cancelled 2 appointments when my mother had a brain heammorage. The first session was cancelled by voicemail (to which she then left a message saying that appointment time would be kept free or i could call to re-arrange, despite my cancellation message saying i would be in touch ‘whenever’) and the second was cancelled on the day by text, stating that care had to be withdrawn and my mum was going to die that die, that i didnt want further sessions and would be in touch when/if i did).

    4 weeks since my mum died, i got in touch and arranged a session last week. At the end of the session, i was told that she wanted to charge for both sessions. I said i felt that was ‘harsh’ and wouldnt pay – she said it was for my benefit, and that we should discuss at my next session – which was tonight.

    I have no reason to doubt the integrity of my therapist. She has helped me make significant progress, and for 4 months when my circumstances changed dramatically financially, she let me pay about 50% of the usual rate. My issue with paying is not about the money, i have no evidence this is about greed, but i do not feel the rules are realistic nor, if push came to shove, enforceable. Overall, we spent the whole of tonight discussing it, i still refuse to pay, she does not accept it.

    My points were as follows.

    1. I did not realise, whilst i was given the terms, that in no circumstances was cancellation possible. I would never had agreed to that. I also feel there should be something in the terms that specifically states ‘no circumstances whatsoever’ – i feel it was reasonable for me to assume that emergencies outside my contract would not attract a cancellation fee.

    2. I was a contract lawyer for 4 years – under english law, no court would enforce an ‘unconscionable bargain’, and a situation where one party would be liable where that party cannot perform a contract due to circumstances beyond their control is unenforceable – the contract would be void, or at least that clause would.

    3. Leaving aside the law, practical reality trumps psychoanaltic theory and must protect both parties fairly. There is no gain for me therapeutucal or otherwise in paying where there are circumstances beyond my control. I learn nothing about myself (other than i should always read the smallprint) as my behaviour wasn’t a factor in why i didnt go. I absolutely understand that loose or flexibile terms would be open to abuse and that the therapist isnt my friend or mother – it is a professional relationship and time is money – i have paid late fees on 2 or 3 occasions for no shows, minor illness and choosing a social occasion over therapy – not too bad for a 5 year relationship. She said part of the lesson is that things happen in life that are unfair, and that she should not be made liable for my misfortune, as it is not her fault either (i accept that).

    4. In the UK, we have the ‘rule of law’, stating that no one (monarchs, the police etc) is above the law. If she seeks to enforce a contract that no court would uphold, then again this is stating therapists are above the law – they are not. The nature and benefit of the therapist/client relationship, the acting out, transferential issues does not provide special exemption in circumstances such as these. The law is the law and i dont blame my therapist for this, it is the professional body who have told her these are acceptable guidelines (unless she has breached these and done her own thing). The governing body is wrong if it thinks these are agreements are enforceable in cases where contracts are ‘frustrated’ by circumstances.

    5. My issues with her reasoning are

    5.1 on the point of ‘why should i suffer for her misfortune’, why should i suffer for hers? It is unfortunate if therapists cannot get insurance for emergency cancellations, but I should not suffer for it. I said i felt it is unrealistic and that this contract wasnt balanced – i gave the example of making the reason for the cancellation less emotive eg what i got stranded in a foreign country due to a plane strike, to which she said i would be liable as there is ‘no scale of reasons for a cancellation’- you make it or youre liable. I then said, for example, if there was an agreement between one party to manufacture 10,000 cds for another party, and if the party who was making them’s factory was hit by lightening the day before, they would not owe damages for not delivering them on time. She agreed and said it would an insurable event – i agree, but see above on insurance and it not being my fault she cant get any.

    I could go on, but that is the gist of it. I think unfortunately it is going to end our relationship – more than anything, if i pay, it means i agree to the premise and agree to be bound by it going forward, and at the time of writing, i dont think i do. There may also be issues in the way the debate ensued about her feeling she would lose positive influence over me if she concedes, and also that there were other cases with other clients in which she possibly shouldnt have asked for payment. There is an obvious inconsistency in her well meaning logic and lesson – if she shouldnt suffer for my misfortune, why halve her rate for 4 months when my financial circumstances changed – she could have seen someone for twice the price. The message isnt consistent and has now made me ponder her motives for keeping me on – is there a control issue for her (obviously that would be transferiental, but that doesnt mean i can’t feel controlled if someone is trying to control me).

    This does not feel abusive and i believe this is someone who believes ardently in her practice and that it is the right thing to do (but apparently intellectualising and rationalisation are two key defences i use to distance myself from emotion, so maybe i am seeing her point of view to stop engaging in those feelings, but no part of me is conscious of that).

    I think she is a great therapist, but if she cant change her mind about things and is that hardlined, will she notice or accept changes in me that no longer fit the model she has for me?

    Not looking for vindication, just healthy opinion. Therapists do an amazing job and this one ultimately has been great.

    Like her, I am firm in my views and perhaps i have simply outgrown her (and this is all part of the master plan for the friendly overthrow of my mother that i needed to make)

    Therapy is a noble profession – but there is nothing noble in fining your clients because you cant get insurance. If people cant accept that, and if life is about choice, then choose another profession.

    • Thanks for writing. I waited a few days to see if other readers would respond — I confess to a vague hope that discussions on this blog will someday sustain themselves without me chiming in. But you asked for opinions, so here are mine.

      Agreements between therapists and clients about how to work together are not legal contracts. Legal enforceability is moot, because an adversarial legal model precludes the “alliance” required to do therapeutic work. A common example is the “contract to no self harm,” where the therapist obtains a verbal or written promise that the client will not harm him- or herself before their next encounter. This so-called “contract” is unenforceable: its power is emotional and interpersonal, not legal. Therapists and clients agree to work together for their mutual benefit under conditions which are never fully articulated and are always subject to revision.

      Near the top of your comment you wrote: “My therapists’ cancellation policy is absolute… if you cannot make any of the re-offered appointments, you are liable, irrespective of any circumstances whatsoever.” Yet later you say you “would never had agreed to that.” It’s unclear to me whether you knew of her policy in advance but did not believe it, or only learned about it after your mother’s medical tragedy. It’s very important that psychotherapists clearly spell out their cancellation policies, so as to avoid misunderstandings. However, there is a vast difference between misunderstanding a policy and being angry about a well-understood policy. My sense in reading your comment is that you sound angry with your therapist for charging you — perhaps it feels like “kicking you when you are down” — and that your careful intellectual arguments about the policy cover this more elemental reaction. This is not to invalidate your points — the concept of insurance for emergency cancellations never occurred to me, and may be a fantastic business opportunity for some enterprising entrepreneur. But they are really secondary to psychotherapy’s focus on feelings, and using the relationship between you and your therapist to shed light on how you relate to others in general.

      Condolences for the loss of your mother. Take care.

  • Considered

    Steven

    Thanks for the reply.

    Re my knowledge of the policy, I think you have hit upon an interesting point. I was made aware of the policy at the beginning of our relationship, but both the therapist herself and the contract was silent regarding emergency situations. This of course allows for room for interpretation/uncertainty on either side. I would have thought, as you say, that this key issue needs to be covered very clearly. I wasn’t aware of it – all of the examples given when discussing it centered on ‘moving’ appointments – there is simply nothing in there re emergencies. There was mistake on both sides, and clearly no meeting of minds. I am sure my therapist will feel that reflects her position that no situation is distinct from another, but I think the contract needs work. I don’t really feel kicked when I am down, and it was a very useful discussion, listening to each other’s point of view and I am pleased I did not sulkily capitulate. It was very beneficial to have a ‘real life’ interaction, but I believe we will simply have to agree to disagree.

    I don’t take the point that the law itself is moot – I can’t speak about the US position, but the whole point of having these cancellation policies is to underline the fact that this is a business relationship. All professional services relationships are subject to the rule of law. It is, however, moot to the extent that neither of us will be taking legal action over a £90 dispute – but it would be very interesting if we were talking about fees of say £1500 per session).

    Thanks for the condolences, and happy hew year.

    • Just a small clarification. While all professional-service relationships, including psychotherapy, are subject to the rule of law, I disagree that the point of having cancellation policies is to underline the business nature of the relationship. Cancellation policies are part of the structure of the relationship, called the “therapeutic frame” in the psychotherapy literature. Other aspects of this frame include the predictable (some may say rigid) timing of meetings, the consistent location in which sessions take place, the agreed-upon focus on the client, and so forth. Even non-business relationships have these frame features, but they are crucially important in psychotherapy. Indeed, dynamic psychotherapy could not occur without careful attention to the frame, whether or not it is conducted as a business. Happy new year to you, too.

  • Katrina

    I could see if it’s more than once or if the visit was never cancelled but I have a dentist wanting to charge me for a cancelled visit because I was sick!. Granted my case was not contagious, but it is bad practice for a healthcare facility to encourage sick people to come in to an office and spread their germs to other patients and staff. Not to mention, it’s incredibly unfair for a dentist’s office to make someone not feeling well come to their office. Dental work is uncomfortable at best. If you are feeling under the weather it is unbearable. Is it too much to expect healthcare professionals to have a little compassion for sick people?!!

  • Amber

    I had been seeing a therapist for 2 years and in that time only missed one session. I have now been seeing a new therapist for about 2 months (off and on as she was away for some time).

    I was not given any cancellation policy nor ever I advised there was one. I did however say that I may not be able to attend some appointments due to work commitments and she said to let her know in that case.

    Two weeks ago I had a family funeral to attend overseas and the appointment slipped my mind. I emailed her to let her know. The following week I emailed apologising that I needed to reschedule due to work commitments. And she said to reschedule to today.

    I am a lawyer and need to take half a day off for which I am not paid to attend. And it is not always possible to leave the office.

    Today when I saw her I apologised and she did not respond. Then she said she would let it go this time but I will be charged next time if I don’t give 24 hours notice. It appeared to me that she thought it necessary to set boundaries with me.

    Frankly whilst I think it completely fair that she should have this policy, this should have been explained fully to me prior to me meeting with her. I don’t think it should have been an issue and not in my time.

    As a lawyer the first thing I always do is give clients a copy of any fee agreement and conditions relating to service. This should be no different. I am now left feeling slightly unsafe because of how she approached this. And am not sure about going back.

  • Hyman Rosen

    I’ve been seeing my doctor for a bit over a year. I’ve missed a couple of sessions for reasons that relate to why I’m there in the first place, and had no problem with paying for those sessions. But today I told him that I was going on vacation over Passover, over a month from now, and he told me that I would have to pay for those missed sessions. I didn’t know about this policy (or at least I don’t remember being told it), and as with other people here, I got quite annoyed about it (and told him so – I called him a rent-seeker on a par with the RIAA and the rest of the copyright and patent industry :-) I’m thinking of putting the ball in his court by telling him that I refuse to pay for sessions cancelled well in advance, and that he can decide whether he wants to keep me as a patient. Thoughts?

    • Hello,
      Your comment, as well as Amber’s just above, concern poor communication by the therapist about his or her cancellation policy. I agree with Amber that therapists should explain such policies “fully” in advance. (I put “fully” in quotation marks because not all contingencies can be anticipated in advance by policy. However, the major expectable ones should be. In general, “frame issues” should not be left to interpretation by the patient or client.)

      In your situation, you don’t recall if your doctor told you about his cancellation policy when you started a year ago. This is a good argument for issuing such policies in writing, although I only do it verbally myself. Ideally, you would raise your dismay or frustration with your therapist, including your inclination to refuse to pay for sessions canceled well in advance. You may learn something about yourself in such a discussion, which is the whole point of therapy, plus it’s possible your therapist may reconsider. Making him “decide whether he wants to keep you as a patient” sounds to me like you’re daring him to reject you. This isn’t really a constructive way of looking at it. How about you deciding whether you want to keep him as a therapist? That way of looking at it gives you more power. Either way, I hope you try to talk it out before one of you rejects the other. Thanks for writing.

  • NextInLine

    I find this all incredibly sad, when the whole point of therapy is to work together. I have never been charged for a missed session, I have been able to double up when needed or go out of town when family obligations call for it. My therapist has also needed to reschedule due to his own vacation/family plans and that is fine as well. I think I would feel burdened and obligated if our schedule was so rigid as to be unchangeable, and that would completely affect my therapy in a negative way. When I say missed session, I do mean if I have been sick (although I do give him the choice to see me or not) or needed to change appts because of a conflict. I have never missed a scheduled session, so I cannot address that, but I feel my therapist is a consummate professional who maintains boundaries extremely well, but is also flexible and understanding of the complications of daily life. As a client, I also think I would eventually resent such a rigid structure. I absolutely respect his time, he respects mine, and we work from there. That being said, my son’s therapist (apple, tree, not so far) gave him a free pass the first time he missed an appt and charged him the second time, and I made him pay the cost as a lesson in responsibility. But she is also more than willing to work around work schedules and change appt times. I don’t understand why anyone would be so inflexible, whether it is therapy or medical appts or whatever.

Leave a Reply

  

  

  

You can use these HTML tags

<a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>