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.

Compassion, being a grandparent etc

Back from staying with psychoanalytic friends in London for New Year.  Interesting discussion stimulated by the review of a new book by a mutual friend Karen Armstrong about compassion.  Compassion doesn’t feature much in the psychoanalytic literature, especially as compared with ’third wave’ CBT – Paul Gilbert and others write a lot about compassion – towards self and others, and I suspect Armstrong has drawn on their work.  Compassion is implicit rather than explicit in psychoanalytic thinking perhaps – the idea of the modified superego – less harsh, more accepting of one’s faults and vulnerabilities – would be an outcome objective for many psychoanalysts, dating back to Strachey and beyond.  But compassion implies a moral stance which most analysts,  wanting to preserve neutrality,  would eschew.

Where do compassion, empathy and kindness stand in relation to each other?  Compassion could be seen as a rather distancing, patronizing , hands-off emotion.  Dickens’ Mrs Jellaby was compassionate – towards starving Africans, but utterly unempathic in relation to her own children, ignored and suffering under her nose.  Is the distinction between empathy – feeling ‘in/into’ another different from compassion – feeling ‘with’ but not necessarily accurately trying to understand what they are going through?  Empathy is a continuous process,   relevant only to suffering in the sense that all emotions are ‘suffered’, while compassion relates specifically to pain (mental or physical) and unhappiness. 

I am not sure that I want my analyst to be compassionate,  which smacks to some extent of control – but I know I want him/her to be empathic – to want to know and explore how I might be feeling.  Where does kindness fit in?  Kindness seems to relate to generosity of spirit, and also a propensity not to judge,  always to think in a forgiving way.  But I don’t want my analyst to be too kind – she/he needs to be able to be tough,  to challenge,  and not let me get away with self-and other-deceptions.  My kind analyst will pick me up on these things but won’t make me feel bad about them.  Perhaps it is a bit like the current coalition campaign based on ‘nudging’ rather than proscription and prescription, on banning and banishing.  That’s certainly what my wife says to me when I criticize her – if I don’t do it affectionately it simply makes her feel bad and want to defend herself and counter-attack.

Another interesting discussion was about the role of grandparents – which we all were.  My friend Robert described this as a ‘secondary role’ – and I think he’s right.  But still an important one – evolution has ensured that grandparents, post their reproductive role, have an extended adulthood paralleling their grandchildrens’  prolonged (by other species standards) childhood.  We grandparents are there as backups when things go wrong – one thinks of Aids orphans in Arica (back to Mrs Jellaby!) being looked after by their grandparents.  Another aspect is as a secondary resource source – whether this be grubbing for roots in near-starvation conditions, or helping pay for University fees, as no doubt we will increasingly be asked to do as the era of free tertiary education comes to an end in the UK.  The same might apply too of psychotherapy fees!

Hermeneutics; sex and the gospel story

I won’t be writing every day, but thought I’d write about Robert Caper’s Building out into the Dark which I’ve been reading recently.  I admire Caper – a West coast Kleinian – and especially his A Mind of One’s Own.  His is a radical psychoanalytic position – anything other than the search for truth, neutrality, and an impersonal Bionic and often tangential response to the patient’s material is to be eschewed, although he acknowledges that the analyst will always be pulled into potentially collusive, supportive, controlling judgmental positions – and that he/she need an ‘analytic attitude’ to wrench him//her away and back to analytic neutrality.

He tries to make the case that psychoanalysis is a kind of ‘science’, not the ‘reductive’ sort that depends on replicability, but nevertheless a systematic search for the truth with the analyst’s unconscious as the ‘instrument’, analogous to Galileo’s telescopes, the CERN LHA etc, through which the unconscious can be glimpsed.  It’s a nice metaphor, but doesn’t entirely convince – he’s very keen to avoid tendentiousness in the consulting room – as above, the analyst’s tendency to try to persuade, cure, etc – but there seems to be to be a tendentiousness or special pleading about his championing of the analytic attitude.  And I’m not convinced that  analytic discourse cannot be studied and measured using conventional scientific approaches – especially if qualitative methods are included.  I hang on to the idea of ‘triangulation’ – the need for a ‘third’ which if the analytic relationship is to be studied entails recording what goes on – by videotape, audiotape or even detailed post-session recall by both therapist and patient.  All of this is do-able,  and doesn’t depend of over-valuing the Bionic austerity of the well-trained analyst.

From my perspective a hermeneutic interpretation can never be a ‘fact’ in the way that the speed of light or mass of a pound of sugar can be.  It’s an emotional response in an interpersonal and linguistic framework.  This is not far removed, I have to admit, from Bion’s formulation, expounded by Caper of the combination of a physical sensation, ‘passion’, and a ‘mythological’ component, the latter two of which I would translate into affective and ideological aspects of interpretations.

25/12/10

At Christmas Carol service last night + readings,  surprising how explicit the gospels are about Mary and sex and virginity and Joseph wanting to divorce her when he discovers she’s pregnant and then brought round when told it was only the holy ghost who ‘came over’ her!  Seems to fit well with the Ron Britton model of Oedipus – i.e. the post-Oedipal child needs to be able to let his/her parents get on with it without being crippled by envy or intrusiveness.  The message is:  a child is born:  you will inevitably want to know how that’s possible, but it’s a sort of happy mystery – and when your time comes you’ll find out the real story (and anyway you’re in a stable, and you only have to look around at the animals which surround you to work out where babies come from)!  Now it’s all about attachments – gifts, the devoted mother etc.  So we get not just the alternation and difference between the generations and between the sexes a la Chasseguet-Smirguel,  but also the difference between Attachment and Sex and the life-cycle rhythm of the alternation between them.

Advertisements for myself?

Is this no more than an advertisement for myself? It’s true I do want to publicise my new book – which I believe in, and feel perhaps hasn’t fully had the coverage it deserves. But it’s not entirely a narcissistic exercise – I want just to see how a sort of psychotherapist’s diary would work out.

It’s Xmas – my last two work days have yielded 1/8 clients. What is that makes some fight through, others not come? True, both were men, both had 4X4 vehicles. I’ve been away in Peru and so the snow was a perfect opportunity for people to express their ambivalence and annoyance at my having abandoned them. No doubt it will all manifest itself again in the new year – and no doubt I shall loose one or two clients.

Peru went well – a two day brief therapy workshop, and then a half day with the child and adolescent therapists. Oddly I didn’t meet a single psychiatrist. All psychologists and therapists. On the whole I was very impressed – one has the sense that psychoanalysis has a significant mainstream cultural presence in Peru and is an important part of middle class value system – especially in a post-Catholic, post-Marxist era. As always, most of the therapists were women maybe in the 30-50 age group – perhaps more soignée that their UK counterparts! I suppose the main thing I tried to bring was a sense of freedom and autonomy to their work. They are perhaps slightly hidebound by wanting to be analytically ‘correct’. Also to have a clear sense of the purpose of therapy – there is a slight danger I picked up in viewing therapy as an end in itself rather than something people seek when in trouble and relinquish when they are in a position to solve their own problems. Trying to help them to be less worried about being ‘real’ in relation to their clients when it comes to contract, boundaries etc. In one case I supervised – a 12 year old who was being bullied at school – I merely suggested that he come once rather than twice a week. The therapist was surprised – the main reason for my suggestion was that the logistics of getting to therapy were very difficult for him (Lima traffic is awful!), and it seemed to be he might be less likely to drop out if it was only a journey once a week. It was as though the therapist assumed that only twice a week was worth considering. So from one point of view the Peruvian therapists are generally more sophisticated – and not just sartorially – that their UK counterparts! But with that goes a lack of flexibility.

I’m working on a paper on theory at the moment. Had a very helpful response from Paul Renn – someone I’ve never met, but admire through his contributions to IARPP online fora – in which he has forced me to think about hermeneutics v science. My paper is in part a critique of the anti-theoretical stance implicit in ‘beyond memory and desire’ – but now I am thinking of turning the paper round, and saying that a theory of hermeneutics implies a clearing of the mind and allowing of the imagination to flourish, and that entails getting beyond memory…etc. Anyway – I am following advice I often give but I am usually to impatient to follow, which is to let the paper gestate before submitting. I shall go back to it after Xmas, hopefully with some more comments from a couple of good friends to whom I’ve sent it.

Exploring In Security: Towards and Attachment-Informed Psychoanalytic Psychotherapy

My new book came out last year. Here's the last summarising chapter which gives you an idea of what it's all about – but no substitute for getting hold of a copy!

I sometimes half-jokingly ask colleagues and friends, out of all the myriad interpretations they have given and received over their long years of analysis and therapy, how many they can now recall. There is a shocked pause while memory files are hurriedly scanned; when the answer does come, it is invariably in single figures. Whatever it is that helps people about psychotherapy in long run, it seems unlikely that specific interpretations can be the whole story. It is the medium, not the message, that lasts, although language remains an indispensable ‘fixative’ of developmental change. In that spirit, this valedictory summary below lists ten main points that have informed the making of this book, hoping that some at least may endure once the rest has faded.

The attachment typology. In Bob Dylan’s words, psychoanalytic therapy: ‘ain't lookin' to block you up /Shock or knock or lock you up/ Analyze you, categorize you/ Finalize you or advertise you…’ all it really wants ‘to do/ Is, baby, be friends with you’. Therapists need diagnostic typologies, including those that differentiate healthy from sub-optimal and unhealthy developmental pathways. The secure, and tripartite insecure organised and disorganised, dividing lines are sometimes blurred, and may co-exist in one individual, but nevertheless form a useful and evidence-based rubric for thinking about the clinical presentations, and appropriate therapeutic strategies.

Mentalising, or awareness of awareness of awareness. An alert dog is aware; an awake human is aware that she is aware. Psychotherapists, or people trying to repair ruptured interpersonal situations, are aware that they are aware that they are aware. Awareness is needed for effective repair-ness. The essence of mentalising is the Kantian distinction between the thing-in-itself and our appreciation of it. The human mind is inherently fallible, especially when it comes to understanding itself and others’ emotions, wishes, and projects. Mentalising factors in that fallibility.

Triangulation. With the help of an empathically attuned, reflexive, mirroring, responsive other (mother, lover, therapist) we compare our experience of the world with another’s experience of our experience and so have a better change of arriving at emotional truth.

Recursiveness. Psychoanalytic psychotherapy is a relationship whose object is the relationship itself. A relationship in need of repair needs to be able to look at itself. The therapist’s skill lies in the ability both to participate in a relationship and to observe that participation.

Child development as a model for the consulting room. The scientific basis for psychotherapy is the study of intimate relationships. The most extensive body of this work comes from our understanding of the emotional growth of the infant and child, not extrapolated in the consulting room from couch to cradle, but painstakingly built up in the Attachment laboratories of child development researchers. We know that security-promoting parents combine empathy and mastery in equal measure and suspect the same is true of good therapists.

Polysemism. Psychoanalytic psychotherapy is centrally concerned with generating meanings. Attachment theory sees secure children basking in an exuberance of meanings. The more secure, the more and better the meanings. The psychoanalytic framework is a crucible for promoting this ‘higher level ambiguity’. Equipped with a wider range of meanings, analysands have enhanced options for negotiating the interpersonal jungle of intimate social life. Paraphrasing Gramsci – the aim of psychoanalysis is ‘polysemisim of phantasy, triangulation of the truth’.

Attachment v exploration. In conditions of attachment insecurity, the exploratory, meaning-seeking drive is inhibited in favour of security. By promoting security, psychotherapy indirectly facilitates exploration. Evolution deals in compromise, finding the best possible adaptation to a changing and potentially hostile environment given a particular genetic endowment. With a sub-optimal care-giver, a measure of a child’s exploratory freedom has to be sacrificed for the sake of security. Psychotherapy helps re-set archaic compromise-formations in ways that are more adaptive to current circumstances.

The inevitability of loss. In Buddhist psychology, suffering is the starting point: only by acknowledging suffering, can suffering be endured. Attachment and loss are likewise two sides of the same coin. Attachment behaviour evolved as a bulwark against vulnerability to loss. The pain of separation is alleviated by the comfort of the secure base. Healthy protest on separation ensures smooth reunion; secure attachment promotes courageous risk-taking and acceptance of the inevitability of loss.

The relational multiverse. The artificial separation between inner and outer worlds is a philosophical error. The ‘inner’ world is relational from its inception; the ‘outer’ world is a manifestation of the collective inner world. Psychoanalytic psychotherapy has yet fully to embrace this dual perspective.

New paradigms. The cutting edge of contemporary psychoanalytic psychotherapy rests in the combination of accurate phenomenological accounts of what happens in the consulting room with emerging findings from neuroimaging, genetics, and child development. Together these offer the possibility of a new paradigm for psychoanalytic psychotherapy as a science of intimate relationships.