Thursday 6 January 2011

Asking patients to pay for missed sessions -- how ethical is is?


Yesterday’s work brought up the issue of payment for missed sessions.    Most therapists these days expect patients to pay irrespective of whether or not they turn up, even if this is due to a booked holiday.  The case for this system is that  when a contract is agreed, the patient hires a specific time in the therapist’s working calendar and it is then up to them whether they ‘use’ that time or not.  At one level this seems entirely reasonable – after all that is what theatres do if one books a ticket, and similarly our Yoga teacher expects us to pay up front at the beginning of term, and then if we miss a couple of session—tough!  We argue that she should have a two track system so that one can pay for individual sessions – and therefore not for those one misses --  but at a slightly higher rate.  (It occurs to me that therapists could do the same).

As a ‘hobby therapist --  my main income has always come from my NHS work  rather than directly from therapy --  perhaps I am not best placed to have a view about this.  But I have never used this ‘pre-booked’ system.  If patients let me know by 9.00 am on the day of their session they aren’t charged.  This has the practical advantage for me that I reciprocally feel free to take breaks when I chose – obviously letting patients know well in advance – rather than being tied to ‘analytic breaks’.  So perhaps in my way I am just as self-serving, as at one level, I believe the standard system to be. 

Nevertheless, ‘my’ (I am sure there other who work this way too) system has a better feel.  I am not controlling my patient’s choices.  If their ambivalence is such that they don’t want to come (and what psychotherapy patient isn’t ambivalent) they are not punished financially – only by missing the experience of the therapy.  Since the prime aim of therapy is to enhance people’s autonomy,  it seems to me the official system is disadvantageous in that has a controlling aspect, and also forces the patient to think about the therapist and his/her financial needs,  thereby introducing an extra element of reality into the frame which can potentially distort the transference.  It implies in a superegoish way that the patient ‘ought’ to come to sessions, and for ‘role reversal’ patients make them thik they are looking after the therapist rather than vice versa.  In a way it trades on ambivalence.  And yes, therapists, need to make a living, have to pay for the hire of a room etc – but then we have chosen to go into this profession, so should take the consequences.  I suppose my view is that in the end if the therapy/ist is any good the patient will turn up;  if not then they won’t and it is unethical to set up a system in which patients pay for one’s own inadequacies.

The counterargument to this is that the system helps patients overcome their ambivalence, and the resentment that having to dance to the therapist’s tune arouses is all grist to the transferential mill.  The wonderfully paradoxical highest expression of this is the German state-subsidised system in which patients only pay if they miss sessions – although there too that is avoided if they give five days notice (so still pay if seriously ill which doesn’t seem right; but  might help using a minor illness to miss session).  As always in our work there is no right answer.  I wonder what others think.

7 comments:

  1. With the help of a psychotherapist, you will be able to recognize the resource of your despression symptoms, if you haven't already. You will also be able to come up with some alternatives and alternatives that may indicate why you are susceptible to this sickness (genetics, etc.).

    Psychotherapist Sydney

    ReplyDelete
  2. I think first of all we need to clarify about what are you talking about paying when cancelling or paying in advance, because these are two different topics. Then the fact that you are a "hobby therapist" is very important when taking a stand in this topic for those who are not and are full time therapists. Also client's ambivalence is something that can be worked on once the cancellation fee is applied, sometimes it works sometimes no, it depends but in my opinion is protecting both the therapist and the clients from pathology and unconscious patterns of behavior. Last but not least we are not only paying for a room etc., we are paying for our own therapy and supervision and training and books, in order to be a healthy and strong presence fro our clients, it is important for clients to know what we need the money for!!! "I suppose my view is that in the end if the therapy/ist is any good the patient will turn up" this is a phrase I did not like, because it is not scientific, it is something too general and too simple to say. Being a good therapist in my opinion is beside having studied and read a lot of theory is also having an important experience in working with clients and this takes time to happen! so although the theme is interesting I think it requires a better and more serious approach when writing about it!

    ReplyDelete
  3. Asking to pay for missed sessions, in my opinion, is not about protecting the therapist but about protecting the therapeutic process from unconscious resistance. Protecting the rithm of the sessions is paramount and this is the rationale behind this rule.

    ReplyDelete
  4. Totally agree with Gabriela. Not charging clients for missed sessions may be an "easier" option emotionally as it may protect therapist from clients anger in the transference which however deprives the client of opportunities to explore and understand the symbolic meaning of such anger and work it through in the therapeutic relationship. The conversations about paying missed sessions are most often not comfortable ones but if the primary reason for seeing clients is to help them achieve profound change then they need to part of the therapy work. More flexible systems where patient is allowed to miss a small number of sessions per year may give more middle ground while they would still provide opportunities for difficult emotions to be worked through.

    ReplyDelete
    Replies
    1. I agree with you. Not charging misses a golden opportunity to work something yhrough

      Delete
  5. We receive this question regularly on welldoing.org.
    It is always up to the individual therapist to decide based on their client relationship, but a starting point, we suggest late or no notice cancellations should be chargeable. As with all professionals, the value of time should be respected.
    I hope you dont mind, I have shared your blog on LInkedIn. I couldnt find a profile to connect to you, but if you have one, please let me know and I will be happy to edit.
    Thanks

    ReplyDelete