On the power to cancel psychotherapy sessions

For the last 15 months, I have been in (psychodynamic) psychotherapy. During this time, I have attended all sessions. Alas, last week, I said to my therapist that I had to cancel this week’s sessions for professional reasons (I have meeting that cannot be re-scheduled), giving the therapist a week’s notice. I was asked to pay for the session anyway. I will not. Here is why.

There were several reasons that the therapist mentioned for demanding their fee for the cancelled appointment. Here is a summary, in no particular order:

  • It’s a normal/usual and common practice.
  • There will be a two-week break in the process.
  • They will lose out financially.
  • I made commitment to attend sessions, if I don’t, it’s a problem (psychological resistance and all the rest of it), so, by implication, I need to be disciplined.

Fair enough? Yes, sort of, all those arguments have some merit. But at the same time, all of them can easily be dismissed, which I will do as I go along.

My main problem is that my therapist also cancels sessions. In the last half a year or so, perhaps 5-7 (I haven’t counted) sessions were cancelled (not counting their scheduled holidays in July), consistently without a reason. So, at the end of a session, I would be told that the following week’s session would not happen. Once three sessions in a row were so cancelled.

And here, I hope, you can see the problem with the above arguments. The concerns for a break in the process seem to apply only when I cancel. The same applies to financial loss. When the therapist cancels, the financial loss is miraculously acceptable. I also think that the commitment to the process is a symmetric relationship. Yes, I make a commitment to the process, but, surely, so does the therapist. So, where is the commitment when they cancel?

And so, what really irritates me that I suffer the consequences in the case of all cancelations. When I cancel, the consequences I suffer are financial, when the therapist cancels, the consequences I suffer are psychological. After all, no matter how much I may need a session, I will not have it. Tough sh.t.

When I was preparing to write this post, I did a quick internet search for policies on cancellations. What struck me was that most documents I read (and I read about 10 of them) concerned cancelations by clients. It is only ‘our’ cancellations which are an issue, the therapist can do no wrong, and can cancel all they want (just like my therapist).

There is a consensus in seeing charges for cancelled sessions as a favour to the client. It’s all good for me. Have a look at what Megan MacCutcheon says:

I want to model healthy and clear boundaries and empower people to be responsible in their lives and assertive in their ability to communicate regarding their circumstances. Therapy is about helping people to develop a sense of awareness about themselves and how their actions impact those around them. (Link here)

Bloody hell, I truly doubt you can be more patronising. Charging me for a session that I don’t attend is really a way to empower me to be responsible. I’d better stop here, as I will quickly go beyond the boundaries of a polite academic blog. So, let me just say, thank you for your empowerment, I’d rather not pay.

As I mentioned, I found one reference to a policy of therapist-initiated cancellations. Counselling Matters say:

Occasionally, circumstances might prevent us from delivering a session as agreed. We will give you as much notice as possible if this happens. We will not charge you for appointments we cancel and will do our best to re-book at a time that best suits you. (Link here)

And I hope you see the issue. As I pay for my cancelations, which have a strict time frame, you will only give me as much notice as possible. I have a significant problem with this.

Now, psychotherapy is an inherently asymmetric process, especially in terms of communication. The therapist and their client have very different communication rights. That is to say, what is and what is not sayable by a therapist and the client, differ considerably. For example, as the therapist can ask me sometimes very difficult and intimate questions, I can’t ask them any questions about themselves. Also, if you want psychotherapy, you must accept that you’re going there to talk, rather than to stay shtum, and if you go psychodynamic, this is even more important. There is no such pressure on the therapist.

But does it mean that the asymmetry and the power differential apply to everything in therapy, also its logistics? Common sense would suggest not. I would argue, for example, that punctuality is fairly symmetric – we both should arrive in good time for a session. You could even argue that, perhaps, punctuality might be potentially asymmetric in my favour. In other words, the therapist should come earlier, so that they can prepare for the session.

So, what about cancelations? Well, I think that cancellations are complex but way more symmetric than communication. Let me start with a bottom line. I think what my therapist (and many like them) did is construct a relationship between us which is so asymmetric that I find it utterly unacceptable. In other words, I completely reject the therapist’s right to cancel our sessions, while at the same time disciplining me financially for doing exactly the same thing.

Accepting their request to pay would be accepting a relationship which is more suggestive of a royal court not therapy. This would be a relationship between the therapist-as-monarch setting the rules that they do not have to abide by and the minion having to oblige. And I reject the idea that I am a courtier serving at their majesty’s pleasure being (financially) whipped into discipline by someone who does not see fit to stick to their own rules.

And here, I think, where my problem with the commonality of the paying rule starts. I think the practice is utterly unreflected on. This is because, it seems, only cancelations by clients are visible, as therapists’ own practices are blanked out. And when they do become visible (as in the quote above), they are played down. And if anything, they contribute to the construction of the monarch-courtier relationship between the therapist and the client.

Incidentally, as I was writing this, I was reminded of a discussion with Dr Richard Gipps on Twitter. Richard argued that the relationship between the therapist and the client is that of love. I rejected it and I continue to do. And indeed, it seems that this wondrous love ends at the threshold of therapists’ cancelation policies. Love or not, I must pay. Your love must be quite harsh.

This is all why I can’t pay. I refuse to play by the rules set by someone who refuses to do so. It relegates me to a position so inferior, so subjugated that I cannot countenance it.

Is there a solution, though? Well, next week, I will make a suggestion to my therapist. My solution is that I can pay for cancelled sessions only if they don’t cancel at all. In other words, if I am to be disciplined for my apparent lack of commitment to the process, their commitment must be unimpeachable. Alternatively, if they cancel, I cancel (as I mentioned earlier, I don’t, anyway).

Speaking more generally, it’s not enough to have a ‘cancelation policy’. Your cancelation policy must include you and it should be symmetric. You cannot and must not play by different rules from the ones you yourself set. I must admit that, if you were strict in your thinking about principles, your cancelation should mean a free session for me. If I pay you for not attending, you pay me for not attending. But this is so radical, no one would even think about it.

I suspect my therapist will refuse to accept what I propose. Mostly, I think, it will be because I propose it, the client. This will be seen as an assault on their power. And, yes, to a considerable extent it will be. But the alternative is unacceptable. I will not become a patsy. And to be honest, the request itself has undermined the relationship significantly.

I fully realise that it might be the end of the process and I will be sorry if that turns out to be the case. But I also hope that it will give rise to some serious reflection on what my therapist and, perhaps, through supervision (my therapist is a respected supervisor), what others do. What you do at the moment is, in my view, completely unacceptable.

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