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.

89 comments to Charging patients for missed sessions

  • Anon

    (1.) What is your policy on the patient paying you if they go on a planned vacation with plenty of notice?

    (2.) Do you expect the patient to pay you for their regular session time when you go on vacation?

  • Ms. Sharkey

    After reading all these comments and responses, I am even more appreciative than usual of my therapist’s sensible and respectful cancellation policies. As long as I cancel with more than 24 hours notice, I am not charged for appointments I do not attend. I do not pay my therapist when he is on vacation. He does not expect me to pay when I am on vacation. Nor does he expect me to schedule my vacations to coincide with his. I am appalled that there are therapists who think that last stipulation is in any way reasonable.

    You keep insisting that other service providers have cancellation policies and therefore therapists should too, but you consistently conflate “no show” appointments with “cancelled in advance” appointments. If I don’t show up for a scheduled appointment with a service provider, then I should be charged for it. If I notify the service provider in advance that I will be away on vacation, business etc., then I do not expect to be charged. I would stop working with any service provider that expected that of me.

    I reject the idea that therapists are allowed to charge for services not rendered because it holds the therapeutic frame and the therapy relationship is so very unique. Nor am I swayed by the argument that I need to guarantee the therapist’s financial stability. A responsible therapist realizes that clients have a life outside the office that involves vacations, business trips and other work obligations, family obligations etc. A responsible therapist realizes there will be inevitable cancellations and budgets accordingly.

    I am very appreciative that my therapist treats me like the fully-rounded adult that I am and respects that I have a full and busy life outside the therapy room.

    • Thanks for your comment. I’ll take as a compliment, as my own cancellation policy matches your therapist’s. I agree with you that this type of policy feels respectful to both parties. Personally, I rarely have any problem in its application.

      Yet you sound peeved that I “insist” there are rationales to alternative cancellation policies. Of course, I’m just stating a fact, I’m not endorsing these policies. Freud based his cancellation policy on music lessons: at least in his day, a student paid the music instructor whether or not the lesson was attended. Advance cancellation didn’t waive the fee. We can argue all day over whether this is fair, or unreasonable on the part of music teachers, serves a justifiable purpose, or whatever. The bottom line is, every psychotherapy cancellation policy has precedents in cancellation policies from other fields. It’s important for therapists (and music teachers) to state clearly such policies up front, not to change them unilaterally mid-stream, and to apply them without prejudice. Beyond that, it’s up to the client or patient to decide whether to obtain services under the stated policy. I’m glad yours works for you — and for my own patients.

  • Ms. Sharkey

    Am I the only one who finds it downright odd that we’re discussing the merits of basing current business practices on what music teachers in Austria did over a century ago? Frankly, I think their stance was unethical, bad business practice and bad customer retention practice. I think that holds trues for anyone who adopts a similar stance today.

    And you do keep contradicting yourself. An earlier poster commented that her therapist has a flexible cancellation policy and you replied that such a policy is not in the patient’s best interests. Even though you yourself have what sounds like a similarly flexible policy. So are your policies not in the best interest of your patients?

    I have ongoing relationships and appointments with many service providers, including a massage therapist, psychotherapist, chiropractor and hair stylist. If I have to miss an appointment due to work or vacation, my chiro/stylist/RMT do not charge me. I pay them only when I come into their office and use their services. To use another example, I take pre-paid classes at a local gym. If I miss a class due to last-minute work issues or illness, I forfeit that class. If I know in advance that I will be away, I have the option (and I always take it) of scheduling a make-up class.

    In short, no other business that I am aware of penalizes clients for going on vacation or business trips.

    • Even today many businesses do not forgive cancellations “known in advance.” Many airline tickets are completely non-refundable. If I sign up for a lecture series I pay for the whole series whether I go or not. Same for season tickets at the symphony or ballpark, and for classes at my local community college. It wouldn’t surprise me if some music or language teachers still charge as they did in Austria over a century ago.

      You pay rent or mortgage whether you’re home or not, even while on a long vacation or business trip. Same for your internet provider and cable tv. Lawyers on retainer, concierge medical practices…

      Life’s too short to get worked up over this. If it irritates you to pay for a service you might not use, then be happy you found service providers with a different policy. As you note, there are plenty who operate more to your liking.

  • Ms. Sharkey

    If life is too short to get worked up over this, then why did you write a blog post about it?

    And many of your examples do not hold up. Airline are non-refundable only if you choose not to buy cancellation insurance. If have sport or symphony subscriptions and will have to miss an event, I can recoup my loss by selling the ticket or choose to gift someone the ticket. The key being that it’s my choice. If I’m signed up for classes and know I’ll miss one, I can ask to borrow notes from a fellow student.

    Your rent/mortgage analogy is particularly flawed. My house stores my belongings while I’m away on vacation.

    I do not agree that it’s unreasonable to get “worked up” over being subjected to unethical business practices. My reasoning is influenced by the fact that I am a consultant. I charge and get paid for only the hours that I work. If I take a day off, I lose a day’s pay. I knew that before I accepted my first consulting job and I manage my finances accordingly. I expect service providers I work with to do the same.

    • I wrote the post to discuss all the ways psychotherapists think about this issue. Not to say there’s one right way and everyone else is an unethical fool.

      As I outlined, there’s quite a range of policies. You write as though 24 hours notice is the only “sensible and respectful” option. But why not 48 hours, or 12 for that matter? Or only pay if you actually show up, and not if you decide to skip it at the last moment? The 24 hour figure is entirely arbitrary. I happen to like that policy myself, but there’s nothing sacred about it.

      You seem most focused on therapy policies with no cancellation options at all. As I wrote in my original post, I find these too draconian. I feel they ignore life’s realities. However, I wouldn’t call them unethical… unless nonrefundable airline tickets and prepaid college classes are unethical too.

      You said you were unaware of any other business that penalizes clients for going on vacation or business trips. I gave you nearly ten examples. Your workarounds — cancellation insurance, reselling your tickets, etc. — don’t change their no-refund policies. If you can borrow notes to make up for a missed class, you can equally read a self-help book or engage in self-reflection to make up for a missed therapy session. (Not that I think this is a real substitute in either case.) I stand by what I wrote earlier: no-cancellation policies exist across many service industries. Caveat emptor.

  • Anonymous

    Thanks for this post. I am seeing a psychiatrist in Toronto, Canada and am frustrated with the ambiguous cancellation policy. I feel I am left with the responsibility to ask the appropriate questions to understand her policy. I’ve brought this up with my psychiatrist: that I find the inflexible cancellation policy frustrating, but she doesn’t budge. I’m at my wits end. What is your suggestion at this point? Keep negotiating, or end the relationship?

    I am tapering my antidepressants with her currently. I am cognizant of the fact that I want this done under her authority; but I sense that she is being very conservative about seeing me weekly.

    Looking for an objective opinion.

    • I’m a little confused. Is your psychiatrist’s policy “ambiguous” i.e., unclear, ill-defined? Or is it clear but “inflexible”? If the former, I suggest you try at least once more to talk to her about how the lack of clarity regarding this “treatment frame” issue is making you uncomfortable. Maybe she’ll be more clear. If the latter — if you disagree with her clearly-stated policy — then you’ll likely frustrate yourself in a continued attempt to make her “budge.” You may be happier with a doctor who has a more agreeable cancellation policy. Take care.

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