“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.”
I’m not good about money. I never have been. Managing my own finances has never been a problem, but setting patients’ fees is an entirely different matter.
Early in my career I was treating Sharon, an artist, who told me how much she made yearly from her art. It wasn’t much. My regular fee wasn’t much in those days either. Still, I reduced my fee. Several months passed. In the course of one session she began to talk about the apartment buildings she owned that had been left to her by her now deceased parents. I was shocked, and angry, too angry to say anything at the time. The next session I was ready.
“Sharon,” I said, “Last session you talked about being a landlord. Can you say why you didn’t tell me you owned apartment buildings when we first discussed your income and your fee?”
“It never came up,” she replied. “We were talking about the money I made from my art.”
“That’s true. But don’t you think not mentioning your other income was dishonest?” I asked.
“No,” Sharon replied blithely.
“Really? You don’t feel you were hiding your rental income so that I’d reduce your fee?”
“My father used to say never offer any information you’re not asked for,” she said.
“You experienced your father as a ruthless, indifferent, uncaring man. And now you’re modeling yourself after him?”
“I never thought of it that way. It’s not something I decided to do. I guess I just do it automatically when I deal with something business related. I’m sorry. You’re right. It wasn’t fair of me.”
So that situation had a satisfactory ending both financially and therapeutically in that we were now able to explore Sharon’s identification with her father.
More recently, the result wasn’t as positive.
I receive a call from Jackie, referred to me by a former supervisee. We set up an appointment and as we are about to get off the phone she asks my fee. Although I prefer to discuss fees in person, I answer her question and tell her my regular fee is $250 a session. She gasps. Without a moment’s hesitation, not knowing anything about her finances, I offer to see her for $150. She agrees and comes in at the designated time.
Jackie sought treatment because she and her husband just learned that he is sterile and are now wrestling with whether or not to adopt. Jackie is also trying – not very successfully - to not be angry with her husband for a medical condition beyond his control. Being a mother has always been Jackie’s dream. Her mother died when she was only a year old, leaving her to be raised by rigid, rejecting grandparents. We discuss her desire to give her own child an experience she herself cannot remember ever having. She understands, but remains focused on her anger at her husband and his failure to give her what she has always wanted.
As the therapy progresses, I learn that their marriage has never been fulfilling for her. She describes her husband as both withholding and an inadequate lover. She stays in the marriage because she’s dependent on him. And for financial reasons. She has a seven-bedroom home on three acres of land, horses, a cook, and a housekeeper.
I am not happy. I reduced my fee for a woman with huge financial resources! And it’s my own doing. She hadn’t lied to me. She hadn’t withheld information about her wealth. All she had done was gasp and I lowered my fee!
As we approach the new year, I tell Jackie that come January I will be raising her fee to $250. I understand that a $100 increase is a lot, but given her financial circumstances, it doesn’t seem unreasonable.
“Well,” she says, “I was planning on stopping anyway. All this talking isn’t getting me anywhere. My husband is still sterile and I just have to stop being angry at him and decide whether or not adoption will work for me.”
“Do you think your decision to stop is related to my talking about increasing your fee?” I ask.
“No, not at all. You’re right. I can afford it. But I don’t think this is helping. So why should I bother continuing?”
“Can you say, Jackie, how you felt about my raising your fee or, for that matter, how you felt when I lowered it when we talked on the phone.”
“I don’t know. I didn’t think about it.”
“Can you think about it now?”
She shrugs.
“Do you think you felt given to when I lowered your fee, given to in a way you haven’t experienced much in your life and that now you feel I’ve deprived you yet again?”
“You’re making too much of this. You always do. You over analyze. It’s just time for me to leave.”
And so I lost Jackie. As a result of my difficulty dealing with money.
