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.
In my last post, I highlighted diagnostic challenges related to borderline personality disorder (BPD): Sometimes dramatic, self-destructive behavior leads to reflexive, inaccurate use of this label, while other times eagerness to diagnose a medication-responsive illness such as bipolar disorder can lead to overlooking BPD. Naturally, this barely scratches the surface. Thousands of books have been written about BPD. This editorial from the May 2009 issue of the American Journal of Psychiatry provides a concise summary of controversies surrounding the diagnosis. Even the Wikipedia entry on BPD has extensive useful information. Today I'll focus on another central feature of BPD that has proven challenging to residents I've supervised (and me): parasuicide.
Parasuicide refers to self-harming behavior identified by the patient as suicidal but unlikely to actually result in death. Sometimes termed a "suicide gesture," typical examples include taking a handful of pills, and cutting one's wrists to draw blood, but not deeply enough to damage veins or arteries. Often the patient realizes later that suicide was not "really" the aim of the behavior. (Aim and intent become complex philosophical issues once the idea of a dynamic unconscious comes into play. Can one intend something without knowing it? Can intent be discerned by a therapist over the patient's heartfelt disagreement?) Many patients in therapy eventually describe a very unpleasant, difficult-to-name emotional state that is relieved by these activities — especially painful, self-mutilating actions such as cutting or burning oneself. There is a sense of tension release. A communicative aspect is also often apparent, as in showing one's anger or rage to important others, and eliciting an emotional reaction from them in return.
Just as I was formulating a few thoughts on borderline personality disorder (BPD), I see the NY Times beat me to it. Jane E. Brody's 6/15/09 "Personal Health" column, "
