Inside/Outside

Tuesday, September 16, 2014

Cancellations

“What do you mean you’re going to charge me for last week’s session? I cancelled!” Carly says indigently. 

I’ve been working with 22 year old Carly for well over a year.  She knows that my cancellation policy is 48 hours’ notice or she gets charged for the session. There was a time that therapists allotted various time slots to their patients and that the patient paid for that time whether or not they came. It was as if someone paid a fee for a semester of classes. The person would pay that fee, regardless of how many classes were attended. Some therapists still follow that procedure, believing both that it increases the patient’s commitment to the process and insures that the therapist’s income is not subject to the whim of a particular patient. Still, that line of thought has been waning and I’m more comfortable with my 48 hour policy.

Except that I’m not always good at enforcing it. On the positive side, I could say that I’m flexible and willing to take my patients’ individual needs and circumstances into account. There can, however, be negative consequences as well. A patient might feel more unsafe about other boundaries in the treatment room – or in life in general - if I’m unable to be firm about my own policy. Or not standing firm, might lead a patient to feel increasingly entitled and therefore to become more demanding both in and out of the treatment room.

Either way, Carly knows that I won’t always stand firm. Her mother fell and had to go to the hospital. I didn’t charge her. Her car broke down on her way to the appointment. I didn’t charge her. She woke up with an attack of vertigo and was afraid to drive. I didn’t charge her. But this cancellation crossed my line. “My friend Charise came into town and needed someone to play tennis.”

“You know that my cancellation policy is 48 hours, Carly,” I say evenly.

“But you didn’t charge me when I got dizzy that time and couldn’t come!” she says.     

I sigh inwardly. The problem with not following my own rules is that I’m then in a position of having to pass individual judgments on what I deem worthy or not worthy of a forgiven cancellation.

“Does it seem to you Carly,” I ask, “that there’s a difference between being dizzy and unable to drive and going to play tennis with your friend?”

“But I see her so infrequently,” she exclaims.

“I understand that, but you could have played tennis with her later or earlier or on a different day,” I say. Even while speaking, I realize this is a ridiculous conversation. Although Carly is young and somewhat immature, she’s smart and clearly knows the difference between sickness and tennis.

I think about what might be going on here. Was there something that happened in our session before the cancellation? Is there something in Carly’s past that’s being repeated with me in this room? Nothing springs to mind, so I decide to ask Carly herself.

“How did you feel about us not meeting last week?”

”What do you mean?”

“How did you feel about cancelling last time?”

She glances out the window and down at her hands. “I liked it. I felt like I was playing hooky from school.”

Now we’re getting someplace, I think.

“And you wanted to play hooky because…?”

“Because I could. I never could as a kid. My parents would have killed me. And besides I would have felt way too guilty. Always have to be good, especially when it comes to school.”

I get that. I so internalized my family’s attitude towards education that I too could never have imagined playing hooky. But I rebelled in other ways, allowing me the separation from my parents that was necessary for my growth. Carly has been pretty much the consistently good kid. Now I’m in a bind – both wanting to support her need to pull away, while enforcing the consequences of her rebellion.

“I understand, Carly,” I say. “I understand that you’ve been the all-too-good kid and that playing hooky can be an important step for you towards independence. But I suspect if you were able to come in here and talk about your desire to play hooky with me, we could help to be your own person in relation to your family where it really counts.”

“You’re still going to charge me, aren’t you?”

“Yes, I’m still going to charge you. And I’m definitely going to want us to continue talking about how you feel about that and what it means to you.”

“It means I’m being punished for being my own person,” Carly says angrily.

“I hear you, Carly. It’s fine for you to be angry and we will continue to talk about it.”

6 comments:

Douglas Wolter said...

I think it would be helpful in the beginning to inform patients of what type of cancellations will be charged for.

Linda Sherby said...

You're correct, Douglas. The problem is that it is my intention to charge for any cancellation that is given in less than 48 hours. Despite this intention, however, I invariably find that I cannot enforce my own policy because it feels too rigid and unbending. But, as I stated in the blog, that may well be my own problem with enforcing rules, as opposed to a need to be flexible.

Steven Reidbord MD said...

Hi, nice post. There seems to be no ideal cancellation policy for dynamic psychotherapy. My imperfect solution is an almost-no-exceptions policy of charging for same-day cancellations or no-shows. Even canceling the evening before waives the fee, although I'll explore it the next time we meet, as described in your post. But if it's the day of the appointment, even car breakdowns and illnesses are not "excused" absences. My very rare exceptions have involved patients suddenly hospitalized, and of course any situation where the scheduling error might be mine.

I discuss the pros and cons of various cancellation policies in this blog post, which has attracted much commentary in the 5 years since I wrote it:
http://blog.stevenreidbordmd.com/?p=9

Linda Sherby said...

Thanks for commenting, Steven. I read your blog, found it very thorough in discussing the various options for regarding cancellations, and thought we were very much on the same page. It does seem, however, that it is impossible to imagine every possible scenario and to capture it under one policy that we use in every possible instance regardless of the circumstances under consideration. I suppose that's because ours is an "impossible profession," where individual circumstances must always be taken into account.

Again, thanks for your comments.

Claudia Luiz said...

I think she felt safe enough with you to test you. Her parents would have killed her - she needs to push boundaries and enjoys you not killing her - but does she want to be "killed"? I love how you opened the door and started to get her talking about how other people get angry with her...she's definitely working on something and I suspect it won't be the last of her "cancellations"!!

Linda Sherby said...

Thanks for your comment, Claudia. I suspect you're correct. It won't be the last of her cancellations.

I continue to enjoy your book. Gabriele was correct, our styles are similar - very present, immediate and human.