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!