“This is our ninth session,” says Penny, a petite, anxious 29 year old, adjusting the pillow behind her back as she settles into the chair across from me.
“And that means…?” I ask.
“We only have one session after today.”
Startled, I ask, “Why is that?”
“That’s all the insurance company allows.”
“I’m confused, Penny. I thought I explained to you that I’m not on any insurance panels and that you decided to see me anyway.”
“For 10 sessions,” she says, squirming in her seat. “That’s what my husband said I could do because you were so highly recommended. He said I could see you for the same 10 sessions the insurance company allowed and if you were as good as they said you should be able to help me in the same amount of time.”
Thoughts swirl through my head: I’m not on insurance panels because I don’t believe therapy can work in 10 sessions; you were sexually abused by a brother-in-law as a child, have to force yourself to endure sex and want to be “cured” in 10 sessions; you’re a scared, passive woman with three small children at home and have no one in your life to talk to other than me; I wanted to see you at least twice a week and we compromised on once, but I’m not a miracle worker.
I settle on a far more mundane response. “How would you feel about us ending after ten sessions?”
“That’s what my husband said I could do.”
“I understand, but how do you feel?”
“I don’t want to. Talking about all that childhood stuff, I don’t know, it’s brought it all back up. Now I really can’t stand to have my husband touch me. He’s not happy about that either.”
“Have you told your husband how you feel?”
She shakes her head, morosely.
“It won’t make any difference.”
Penny’s passivity is difficult for me, but I know that’s always been her way of being in the world, the obedient little girl who did what adults told her – including her brother-in-law – and now the obedient adult who follows her husband’s dictates. I’m in a bind. I don’t want to become another person who tells Penny what to do, but I also can’t help her if she doesn’t stay in treatment.
“What are your options, Penny?”
“I guess I’ll just have to stop after next week.”
“You wouldn’t consider talking to your husband about what you want? After all, he must also want you to become more comfortable with sex,” I say, aware that I am coaching her.
“Do you think that’s possible?” she asks, more brightly.
“It would certainly be my hope, but I know we can’t accomplish that overnight.”
“Would you talk to him?” she asks, plaintively.
Oops, I think, I should have seen that coming. “Penny, why do you think my talking to your husband would have more weight than your talking to him?”
She shrugs. “I don’t know. It just would.”
“But maybe it's important for us to understand why you feel he'd listen to me more than to you.”
“I just know he would.”
“Let me ask this, how are you and I different?”
“What?” she says, giggling, “In every way. You’re smart, educated, a doctor. You know what you’re talking about. There’s nothing about us that’s the same.”
“It’s impressive how much you put yourself down, Penny, how little you think about yourself, how you so easily give up your power. If you think so little of you, I understand that it would be difficult to present what you want in a convincing manner to your husband or anyone else.”
“So you’ll talk to him?”
I groan inwardly. “Is the answer for me to talk to your husband or for you to feel better about yourself and to be able to stand up for what you want?”
“But we’re running out of time,” she says.
“You definitely have a point,” I say, glad to be able to support her statement. “It would be difficult for us to sufficiently help you feel better about yourself in one remaining session.”
“So you’ll talk to him?”
I remain reluctant to step into the role of the authority who might save the day – assuming, of course, that her husband would listen to me which is clearly uncertain. Instead I say, “How about this idea, Penny? How about if you ask your husband to come in to a session with you and you can tell him how your feel and I can be here to support you?”
“What if he won’t come?”
“I guess we won’t know until you ask.”
Very nice Linda...loved this one. Thanks for writing....
Thanks, Dr. T. I appreciate your feedback.
I recently encountered a similar problem. My patient had insurance through her husband. He hit 65, retired and got Medicare. She initially selected insurance "just for emergencies" and said she would like to come back in April. I felt the work she was doing was important and she, like many others, would not pass this way again. I decided I make enough money and told her I would see her for the co-pay only until her own Medicare started in April. She came in the next session, said she and her husband had talked and decided it was "worth it" to stay on her insurance which pays well until she retires. I see the change of financial status of any sort as a barometer for sorting out how worthwhile the patient feels psychotherapy is. I would not have done this for a new patient and I cannot see patients with ridiculous insurance plans. It makes me sad to (mis)-treat them by tacitly promising to be a therapist and instead being a bean counter
Name that tune therapy never works. Patients must have freedom to see whom they wish and when they wish. I no longer take any HMO at all.
That's an interesting scenario, Kathleen. I wonder if she experienced your willingness to see her for her co-pay as an indication of your true caring for her, thereby making it "worth it" for her to continue on her insurance.
The issue of money and treatment is so difficult and fraught with multiple meaning. I wrote a blog about that too some time back entitled, "Money Matters" if you're interested in checking it out.
Thanks for your comments.
I agree, Anonymous, that only the patient and therapist should decide therapeutic issues, including length of time and treatment goals, which is why I too have not been on any panels for years.
Thank you so much for this - and your other excellent posts, Linda. You are for me, quite inspirational.
Thank you very much, Bob. I greatly appreciate your feedback and support. Glad you find my posts so helpful.
I've pondered this since I wrote the first note. By far, most of the patients I see have insurance and I bill them only for their co-pay. I see most patients multiple times weekly and over a period of years rather than weeks. I think psychoanalysis should be affordable for everyone who needs and wants it and I often deal directly with insurance plans to assure that my patients get what they and their employer pay for when they get insurance. When I re-read your scenario, I realized it was not the insurance that was declining to continue, it was the patient. If the patient actually wanted to leave instead of sobbing as my patient did since she felt it was her last session due to a lack of insurance, I would, of course, wish her well and expect to see her back in awhile. And yes,with this patient, beneath the countertransference, I care about her.
Thanks for writing back, Kathleen. There are several points I would like to respond to. First, I think that your willingness to see patients for their co-pay so that they can afford psychoanalysis - as well as dealing with the insurance companies - is extremely laudable. I, too, believe that not only the wealthy should be able to afford psychoanalysis or, for that matter, psychotherapy and so I will frequently adjust my fee. But the thought of dealing with insurance companies gives me a headache just thinking about it.
If you prefer not to answer I certainly understand, but could you give me an idea of what the range of your co-pays are? And if a patient is wealthy and still has insurance, do you only charge them the co-pay as well?
Regarding my patient, I thought it was interesting that you said she didn't want to continue. That, of course, could well be her unconscious motivation, but at least as she presented it, her husband was insisting that she terminate in ten sessions and she felt impotent in going up against him.
Lastly, I think we care about most of our patients and, in time, even come to love some of them. How to partial out what is the "real relationship" vs. countertransference seems to me a fruitless endeavor for they are hopelessly intertwined. If you are at all interested you could take a look at my book, "Love and Loss in Life and in Treatment," to get an idea of how I see the continual meshing between patient and therapist.
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