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?