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Thursday, January 24, 2013

The Therapy Relationship-Is It For Real?

The juxtaposition of the personal and the practical in the therapy relationship

Sometimes the practical aspects of therapy come up smack dab in conflict with the personal relationship between the therapist and the patient.  When this happens, it can be very hard on both.
Because this has occurred in my practice-sadly, a number of times-I try every way I can think of to derail it in advance.  So, for example, when a new patient begins I am quite careful to make clear the cancellation policy, the fee for extra paperwork, how the appointment time frame works and anything else I can think of that might trip us up!
Unfortunately, sometimes people agree at the outset and then either forget what the policy is or decide, when it actually comes up, that they have objections to it.  Several times this has happened with long-term patients, who occasionally 'no-show' an appointment and pay the fee, then suddenly decide on the next time that it happens, that they want to argue about it.  It surprises me when it occurs that way.
Then, they don't want to hear the explanation for the policy!   And, in fact, most private practice therapists have similar policies for the running of their practice and they really are reasonable.  But, if you don't know the why of it, they can seem unreasonable.  Indeed.
Having been on the other side of the fence (which as said before, all therapists should do from time-to-time), I know what it's like to suddenly be reminded that I had to pay for a session I didn't get!  In my case, I woke up with a cold, called as soon as I knew I wouldn't be able to make it, but, as my therapist said when I went in the next time:  "It wasn't 24 hours notice."  Yikes!  Well, of, course, I paid it without complaint since that was her policy and I had agreed to it.  This is many years later and here I am writing about it so it is obvious that this is a hard pill to swallow.
In this case, though, therapists are not like doctors who have people lined up in the waiting room to fill in if an appointment doesn't show up.  Even so, docs charge a standard fee for not cancelling the appointment.  We, however, dedicate a full hour for each person (not the usual 15 minutes that doctors allot), usually about 45-50 minutes for the session and a few minutes in between for notes, catching our breath and preparing for the next appointment.  Also, we prepared for the appointment that didn't come.  We paid the rent for that hour, the phone bill---well, anyway, you get the idea.  Basically, as a therapy patient in a private practice, you are the therapist's employer for each hour that you reserve.
(There is no invisible entity who pays your private practice therapist a salary.)
Another thing that can happen, in the case where a patient is using insurance to pay a portion of the therapy fee, is that the insurance changes.  Maybe the employer changed plans and the new insurance doesn't list the patient's therapist.  Collision! 

Most people, who have been used to paying a small co-payment for therapy are shocked when they are faced with paying the actual fee.  The collision is between the personal value both the therapist and the patient may have on the therapy relationship and having to pay out of pocket for that value.  
It's tough.  I've been on both sides of that dilemma.  Once I saw a Dad and son who had left the son's therapist for this very reason and were shopping for a new therapist.  The boy was very unhappy at the prospect of losing his therapist; I tried to encourage the Dad to return to her.  But, the Dad was adamant, refusing to even consider paying for the sessions.  (In this case, it's always worthwhile to attempt to negotiate with the therapist.  You may be able to agree to a reduced fee.  It would still be more than you are used to paying but may be worth it to maintain an established therapy relationship.) 

In another instance, it happened in my own practice where the insured had a job change which came with a different plan on which I was not listed.  It is such a conflict when this occurs because everyone wants to continue the way it was; yet, changes have to be made and sometimes, unfortunately, the therapy relationship ends up getting lost.

I don't have a sliding fee scale but some private practice therapists do-especially in the beginning of building their reputation.  What if two neighbors in the same community have different fees?  They compare notes.  Next comes an objection to why their fee isn't as low as their neighbor's.
These are of 3 examples of many.  So, you can see that thorny issues can come up about money and therapy.

The feelings that sometimes emerge in these situations can be quite profound.  This is why I do my best to get all the business aspects to therapy out on the table at the beginning before any personal feelings between the patient and therapist have developed.  On the patient's part, it usually has to do with feeling uncared for.  In the example with the neighbor, the patient might think, Doesn't my therapist care as much about me as about that other client...  Or, if the patient doesn't really think it through, when they have to pay for a missed appointment, they may feel that the therapist is being unfair to them and must not really care.  
Of course, the therapist can have similar feelings come up.  Doesn't this person have any value on our relationship?  Don't they realize I am a person too?  Do they think so little of what they are receiving in therapy?  Therapists may have thoughts like that when patients start wrangling with them about money.
When a long-standing patient quits over a money disagreement, it is very hard for the therapist:  They are involved, invested in the issues they are working on together with the patient; they have a personal connection to the individual, they've been putting out their best effort-isn't the patient aware of that...? These might be some feelings that will emerge for the therapist in this situation. 
It's tricky territory and has lots of potential for misunderstandings and hurt feelings.  As a patient, what you can do, instead of refusing to listen to your therapist when they offer to explain the rationale behind a practice policy, is listen and try to understand it.  (There is a lot of work and activity that goes on in a therapy practice that is invisible to the patient)  
If you do have to part ways  due to financial constraints, be clear with your therapist about whatever your feelings are-maybe that you feel a great loss in leaving but that it is financially impossible to continue, or whatever your feelings are.  
When you cut a therapist off abruptly (without that kind of discussion) due to dissatisfaction with financial matters, it leaves a therapist stunned and sad.  They have been sincerely devoted to trying to help you sort out whatever you were bringing to therapy and suddenly they seem to be treated as if they can be easily replaced.  Disposable.  Some therapists burn out and quit the field.  It's often thought that this is due to an overload of dealing with heavy problems.  I think it may more likely be-at least for private practice therapists, who don't usually have support staff-dealing with the sense of being unappreciated when these money struggles come up.
One of my colleagues who is also a long-term friend was expressing something like this to me the other day.  She was talking about "...what has happened to our field"  and saying she could imagine closing her practice because of being so disillusioned.  That would be a great loss as she is a seasoned, conscientious, bright therapist.
On the patient's side, you may wonder, when money matters come up, "...does my therapist really care about me?"  I say, the therapy relationship-as different as it is from all other relationships in life-is for real.  I do care about my patients and I think most therapists do.  Maybe a way to think about it, as the patient, is that you are paying for their training and experience--------and think of that part as separate from the genuine caring relationship that usually develops.

Comments?  Any ideas about traversing these treacherous waters?  Have you had experiences with this dilemma?


  1. Such a helpful post! I like the part about the client being the employer for that hour.

    I think it would help people to realize that true altruism doesn't really exist. And that's ok -- a therapist has to eat!

    Every relationship is an exchange. In therapy, I'm paying for the therapist to keep his or her own issues out of my way. And I'm paying for the expertise and time. I know we're not friends.

    My friendships are full of beautiful give and take. My friends aren't professional listeners or empathizers, they don't have the experience and training that a therapist does. And that's ok - because I give my friends my time and my listening ear and my company in return for theirs.

    In therapy at first, I needed a way to work myself out of an anxiety crisis. I still do maintenance therapy where I'm paying for a safe space to take a time out and reflect upon my life and relationships with someone who knows my story.

    Money forces efficiency! We should all be willing to pay for what we value.

    I switched off of my insurance and began to pay directly once I realized that my insurance didn't reimburse the full amount.

    But my therapist and I still had thorny issues around response times with scheduling appointments. I expected a response within a few days, but often had to wait more than a week. I hurtfully realized that "I'm sorry, I was busy" was just another way of saying, "You are not a priority."

    That hurt, especially because I was so good and timely about paying. Maybe I expected more because I paid in real time for every session and without protest and without asking the therapist to fill out insurance paperwork. It's funny how expectations and demands creep up in all relationships, don't they? :)

  2. Actually, Anonymous, I think it's reasonable to expect your therapist to respond to a scheduling message, barring unusual circumstances (out of town, very ill, etc.) in a few days. You seem to be very understanding of the therapist's point of view and on that note, in fact most therapist's do have to do their own secretarial work (unfortunately!) but, still in my opinion, professional conduct includes timely responses to one's patients.

  3. It's a tricky area and, yes, it is best dealt with early and explicitly in contracting. I have heard that some therapists are uncomfortable with the idea of charging for such an intimate relationship with clients who, more often than not, are in such urgent need for support. However, the same could be said about supermarkets: how dare they charge us for something as basic as food?! As Anonymous says, therapists need to eat.

  4. Thanks for weighing in, Steve. It's helpful to have both a client's comment and a therapist's comment on this post.

  5. Thank goodness that I've never had financial issues with any therapist I've been to. I pay the entire fee until I meet my $750 deductible then I pay 20% after that. I can see where it could cause a strain in the relationship, just like in any other type of service and/or personal relationship. I like your idea (and most therapists) of giving clear rules at the beginning before any issues can arise. Very interesting post.

  6. Thanks for sharing your thoughts on this difficult subject. I've mostly done clinical supervision in private practice (I have a full-time job as a music therapist in a facility, so I do have a salary), and, mercifully everyone I've worked with has been great about paying for missed sessions.

    As I was reading your post I started thinking about something: Once you've established the fees and made sure clients understand you need to be paid for a missed session and so on, I'm wondering if, when payment issues come up in the course of therapy, you address these as a part of the therapy process- i.e., what it means to the client to pay someone for therapy, issues around resentment, the power differential, transference, etc. I'd love to hear your (or anyone else's) thoughts on this.

  7. Dear Roia-Excellent point. Any event or issue that comes up around the "frame" of the therapy can be seen as an opportunity for learning/exploration.
    Therapy clients: How would you receive this direction from your therapist for your work in therapy?

  8. This was a very interesting read for me, Paula. It wasn't until I started working with my current therapist that I began to understand the nature of the therapeutic relationship. I will admit that I have left therapist's in the past - not because of financial reasons - without so much as a farewell, in part, because I never thought of the therapist as a person, nor our work together as a relationship. So grateful that I have a therapist that has so clearly delineated the policies and boundaries as I now realize what this kind of work entails.

    To answer your second question: Everything is fodder for the therapy couch. I've talked about things that I'd never have wanted to bring up regarding the therapeutic relationship. It's very awkward, still, to talk about my therapist with my therapist, but it has made for a very honest and respectful relationship with my therapist. It almost makes me want to contact the previous therapist that I left with no notice to apologise for what I did.

  9. Dear Purple Dreamer, Once those never thought about to bring up things have been brought it and the awkward things to talk about have been talked about, it can be experienced as a relief and as quite enlightening I think.
    You also brought up a good point about how the sometimes odd-feeling boundaries that a therapist puts and keeps, in place can facilitate the work and make the relationship more possible by making it safe and predictable in some ways.

  10. Dear Paula. Thank you for this blog! I am relatively new to therapy (7 sessions in). I am surprised but I have been able to trust my T and feel that we have a good connection (although to be honest I do fear that what feels real may actually be contrived, and I feel a little bit scared by that). Anyway, what confuses me is that as soon as I sit down in my T's office, I experience a rush of emotions and confusion and I do 't know how to react. I have told her so much, and she is still there, not-judging me, but part of me is thinking "sure, she knows this and this and she is still here, but if she knew THAT she would feel differently". This makes me anxious and makes me feel this frantic urgency to tell her EVERYThING, now, quickly, while she is still here. And then part of me tells myself to be quiet. To sit and listen and learn and stop talking. But the majority in my heart (if you know what I mean) just wants to sit and cry. And I wonder what would happen if I cried for an entire session? I am afraid if I let go I will not be able to come back. So then I sit and I just feel totally overwhelmed. Is this normal? Thank you so much for your help. Camille

  11. Dear Camille, If I read between the lines, it seems like most of these worries and internal rumblings have to do with loss. It could be a very enlightening question for you to just think about former losses in your life and how is this welcoming situation that your therapist is providing bringing those back into your current experience. I hope you will continue checking in here as you proceed through your therapy process. And thank you for sharing in such a personal and candid way, Paula

  12. Hey Paula,

    I have strong borderline personality disorder tendencies and possible rapid cycling bipolar. I have finally found a therapist I could trust deeply in the past couple of months. It has been tumultous at times, but it has been well worth the growth and healing I have gone through. It is dialectical behavioral therapy. So Individual and group therapy. The DBT therapist-client relationship is a little different than most therapies, but it has been the most helpful.

    It took a couple of months for me to learn that my therapist cared and to validate her feelings. As you probably know BPD's can be difficult to deal with. I never had a problem with paying, but more the aspect that I was paying for her to care. I would often throw her under the bus and say she didn't care or the relationship is bullshit because I pay for it. She calmy asserted that wasn't the case, why she needed to get paid, and if she really cared about the money she wouldn't be a therapist or she wouldn't work with the population that she does. Eventually it got to the point where she was just honest with me and said it hurts for you to say that and that stopped me and lead me to believe her. I know she cares. I put her through so much, but in the end she has helped me grow so much and all the relationships in my life have improved as a result of our work together. I appreciate her immensely. Therapists can be life savers - I've had three serious suicide attempts.

  13. Dear Sebastian, It sounds as if you are fortunate in having found a very devoted therapist and that the two of you have been committed enough to hammer out a solid relationship. Your concern about paying someone to care is one that does come up for some therapy patients. My solution to that question is in bold type at the end of this post.

    1. Yeah. It is a good solution. Thankfully, I have gotten to the place where I don't question why I have to pay her and I don't say to her when I'm emotional that I pay her to care. It is a sign of my growth : D.

      I am very thankful for her. I am learning how to deal with the ebbs and flows of an intimate relationship through DBT. It is nice.

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