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.

95 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.

  • Sydney

    I know this is an older post but I’m curious to know whether or not you think my doctor’s policy (which he just sort of threw at me in the middle of a session after a year of seeing him weekly) is ethical. After two cancellations within 12 months, regardless of how much notice you give him (days, weeks, months,) I am responsible for the full amount of the session. I have a standing weekly morning appointment, which is difficult to come by, but I also have three children. Knowing that I am not able to get out of more than two a year without paying $300 (insurance does not cover missed sessions) is very stressful!

    • Hi Sydney,

      In my opinion, your doctor’s policy would be ethical if presented at the start. While it’s not a policy I’d use myself, it falls well within the broad range of cancellation policies that are considered acceptable in this field. Knowing about it beforehand, you could make an informed decision about whether to work with that therapist and his policies.

      Introducing it as a new restriction after a year is the questionable part. The onus is then on the therapist to justify changing the “frame” midstream. Any such change puts the patient in a difficult position: whether to abandon the “sunk costs,” i.e., time and money already invested, in the face of a new policy that feels unacceptable. A patient can reasonably protest that he or she would not have started therapy in the first place under this new policy, and that operating under the new rule is very stressful.

      In my view, it is unethical to institute a more restrictive (or expensive) policy without cause midway through a treatment. But sometimes there are rationales to justify it. For example, I invite my patients to call me after-hours if needed in a crisis. Most patients never do. However, rarely a patient abuses this privilege and starts calling repeatedly, e.g., several times a night, night after night. I then invoke a “new policy” that my after-hours line is no longer freely available to them. Despite the potential harm and “unfairness” of introducing this new policy in an ongoing treatment, I feel I can justify it: after-hours access was never intended to be used that way.

      Adding more restriction to a cancellation policy could similarly be justified if a patient pushed the existing rules to limits the therapist didn’t anticipate. I can imagine this happening in my own practice, for example, if someone canceled one day in advance, i.e., without charge, several times in a row. As in the crisis call example, I’d feel my permissive policy was being exploited, and that my cancellation policy was never intended to be used that way. Ideally, this is a discussion I would have with my patient, and not simply my surprise imposition of a new policy.

      From the therapist’s perspective, this illustrates the subtlety of balancing humanistic leniency and hard-edged limit setting. Swing too far to the former, and one’s own misgivings will lead to “unfair” mid-course corrections (or simmering resentment, which may be worse). Swing too far to the latter, and one’s treatment will lack human connection and warmth. It’s not possible even in theory to anticipate how a therapy will unfold, so the treatment frame is always an approximation, in dynamic tension between these two poles.

  • Yvonne

    What do you do for patients who have very unique situations? I had been seeing my therapist for four years when my child was suddenly diagnosed with an extremely rare (1/1,000,000) brain disease and we had to travel to Boston Childrens Hospital within two weeks after diagnosis for neurosurgery. That was almost a year ago. At first my therapist was very understanding and flexible, but our relationship became increasingly difficult over time. I did my best to keep our regularly scheduled appts and not schedule appts for my daughter during that time, but sometimes I had no choice. She also suffered frequent severe headaches post op and I would have to cxl bc I did not feel comfortable leaving her home with my teenage son when there was a chance she might have a TIA or stroke. He became increasingly less willing to be flexible and more annoyed with time if I was late due to making sure things were ok at home before I could leave. Our relationship completely fell apart a few weeks ago and he said he could no longer see me. This was a few weeks before we were scheduled to go back to Boston to go through multiply tests to see if her surgery had even worked and nothing has progressed, so a very stressful time to offload a patient. I started seeing him bc I had early onset Parkinsons and depression. The depression worsened over the years and untreated I was suicidal and self harming. So how flexible with scheduling would you be if presented with this type of unique uncontrollable situation? How would you work things out?

    • Yvonne,

      You describe a hard situation, and I have no easy answer. Your therapist was more understanding and flexible at the beginning of your crisis, which was the right thing to do in my opinion. However, eventually, over weeks or months, a crisis like yours becomes your new status quo, and your treatment relationship has to be renegotiated. Neither you nor your therapist could anticipate your daughter’s diagnosis and how your life would change so radically. It isn’t fair to you or your therapist to hold to a prior arrangement which no longer applies.

      I believe there’s a role for customized or ad-hoc therapy arrangements in special cases. These must be pursued with special care, as making exceptions and bending rules may unwittingly harm the patient through ethical and clinical miscalculation. To take an example similar to your situation, I’ve had patients whose ongoing work travel prevented regularly scheduled therapy sessions. Instead of refusing to see these patients at all, I agreed to meet with them on an ad-hoc basis, as their schedules allowed. As an ethical matter, I felt it was important to share with them my belief that a consistent therapy relationship is more effective and helpful — even if with someone else, not me. Ad-hoc therapy, I shared, is not nearly as good in my view, but better than nothing. (This kind of situation, and rationale, also suggests online therapy, where consistent accessibility may outweigh the potential drawbacks.)

      Ultimately it boils down to what both parties can live with, and what is apt to be helpful. Some therapists refuse to schedule sessions haphazardly due to a patient’s work travel, others happily do so without a care. As mentioned, I’m in between. Frequent lateness can be a deal-breaker for some therapists, a minor issue at most to others. Therapists are trying to make a living, and a consistent schedule certainly helps with that. But there are also good clinical reasons to insist on a consistent “treatment frame” — and sometimes good reasons to flex the rules. Balancing these is difficult, or should be, for any thoughtful therapist. Take care.

  • anonymous

    I’m really confused by my psychiatrist’s (who I also see for psychodynamic therapy) cancellation methodology. I’ve been seeing her for 4 years and really trust her so feel like there must be some logic based in psychiatric principles but I’m trying to figure it out and can’t. In short the strategy seems to be to cancel appointments if patients are in crisis?

    To begin with she schedules a bit untraditional – doesn’t see the same patients at the same time each week. This actually works great for me as my own on-call schedule at the hospital is inconsistent. I have only once ever canceled an appointment (with around 48 hours notice) and that was because I was stuck in the hospital with complications from a surgery (mine, not a patient’s).

    She has voicemail that she checks throughout the business day and a cell phone for 24/7 urgent situations. I have never called her cell phone. Only once in 4 years did I call her office voicemail (because of an ADR from a new rx). She has actually gotten frustrated in the past that I haven’t called her more often during crisis-type situations.

    Here’s where I’m really confused… I’ve been having the worse couple of weeks of my life and after a lot of contemplation I finally got up the nerve to call her office voicemail last Tuesday for any suggestions. (I had seen her on the Friday the few days before and my next appointment was the Monday a week later.) She called back a few hours later saying she was sorry that was happening but as a result would need to cancel my Monday appointment and push it back by another 4 days. I guess I was overstepping some boundary for calling in between appointments (even though in the past I had been criticized for not doing so enough) and the consequence was that I would have to wait even longer to get help? I trust that there is some reason to her methodology but I don’t understand what it is and really don’t feel like I can wait that long without understanding the reasoning.

    • Ok, you stumped me. Or your psychiatrist has. I even slept on it overnight, and still can’t think of any plausible reason to push a patient’s appointment back because of a crisis call. The only rationale I can think of, and it doesn’t sound very plausible, is if she believes you’re overly dependent, and wants to enforce a minimum number of days between contacts to discourage the dependency. Another long shot, which isn’t a good rationale at all in my opinion, is that she’s so busy that your call “counts as a visit” in her mind, because she doesn’t have the time to take all her calls and see all her patients.

      I’m really reaching here. The short answer is, I don’t know. I certainly hope you ask her the next time you talk.

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