Question for those who do psychodynamic/psychoanalytic therapy

I’ve been doing psychodynamic therapy for over 2 years now and see my T twice/week. I have set days and times, so I don’t need to schedule because those times are always mine. If I cancel within a certain timeframe I won’t be billed and I essentially release my spot for another client if they would happen to need a different time that particular week. If I don’t cancel in time, I pay for the session. This arrangement has worked fine for me. I have always been able to give my T plenty of notice for my vacations and he does the same for me. My question is this: if I don’t cancel in time, and am therefore still paying for the session, is it appropriate for him to give my spot to someone else? It doesn’t seem right to me as he’d essentially be billing both of us for the same spot. He hasn’t done this that I know of but recently suggested that he could and I’m just trying to think it through.

I actually like my T and therapy has generally been a positive experience for me, so no therapy-bashing comments, please.

I would suggest talking to him more about it.

My opinion is that if he is actually seeing someone else in your spot then he shouldn't bill you. Some time ago a saw a T who offered two options for cancellations: either I pay for it and no one will be seen in my spot, or I agree that he can see someone and in case he actually does then I don't have to pay for it. Although I never cancelled, I know I would have always chosen the first option.

My current T does no cancellation what so ever - I pay anyway and he never sees anyone else at my time.

Thanks, I plan to bring it up when I see him later this week but have been stewing about it and am having trouble waiting. I can be pretty ambivalent about therapy and a couple of weeks ago emailed him saying I wasn’t coming that week. I ended up showing up anyway (probably should have given him a heads up, but didn’t) and we talked about it, but he happened to mention that he had almost given my spot to another client who needed a different time that week. He ended up saying that he will never give my spots away, whether I cancel in time or not. I felt nice about that at the time as it was meant to be a kind gesture, but as I’ve thought about it more, it seems unethical to ever give someone’s spot away if they are paying for it, whether they show up or not. I’m frustrated that he hasn’t come to this conclusion on his own. I don’t think that he is unethical at all, but I’m left wondering how he could think this is ok. I feel like he’s led me to believe my spots are mine when perhaps they are not. He can’t have it both ways.

I know my T has a similar cancellation policy, I can’t remember if it is 24 or 48 hours notice. In that short a time the logistics of filling my time slot are difficult unless someone asked to be on a cancellation list (which I am not sure my T does). My T would state it as an always rule but I can see him telling me the following session that I didn’t have to pay if he filled it. He would much rather give someone good news (you don’t have to pay) than bad news. If he did not fill my spot and was going to charge me for it I believe he is the kind of T that would still use that time for me. I can see him reviewing my file, revising my treatment plan or reading something that connects to what we are doing. I am also confident that if I canceled and was willing to pay for the time slot because I didn’t want someone else in it he would do that as well. I am not very attached to my time slot but he would totally understand if I told him I didn’t want him thinking about (much less seeing) another client at “my” time slot. I cannot imagine a situation where he would charge me and someone else for the same slot even though legally I guess he could. Morally, to my T, he would find that cheating.

I don't do psychodynamic/psychoanalytic therapy, but my T does have a 24-hour cancellation policy, where he'd technically charge if a client gave less notice and he'd try to put another client in the spot. I recently talked to him about his 24-hour notice policy (came up for a particular reason). He said he doesn't charge clients if they're sick (or their kid is sick), even if it's within 24 hours. I said yeah, that I'd canceled at the last minute when I was in the ER in August and he didn't charge--he said it would have been really s****y for him to have charged me in that circumstance. He also said that if he does charge a client, it tends to be for a no-show with no explanation (like, if they were in a car accident or something on the way to session, he wouldn't charge them). And he doesn't usually charge his full fee either. (He also said that because I've been so reliable, if I did no-show once, he likely wouldn't charge me, but not to take advantage of that!) The other thing is, if I've had to cancel but am able to reschedule for later that week, he wouldn't charge.

So I wonder how strict your T is about charging in general? I'd like to think he wouldn't charge you if he got someone to take the slot. In part, charging a client for a last-minute cancellation or no-show is to compensate the T for their time, as they'd be less likely to be able to get another client to come in with short notice. However, it's also likely meant as a deterrent to clients just not showing up or letting them know at the last minute. (Like I might think, "I'm not sure if I feel like going today. But I'd have to pay the fee anyway at this point, so may as well show up.") And then it would be up to the T whether they actually charge that fee, based on the client's circumstance. Like it might not be an absolute.

I'd definitely talk to your T about it.

My experience with psychodynamic therapy is that any factors relating to his practice (or indeed any element of "him": his personal life, previous experience, approach to clients etc) were not just casually mentioned. He said very little about those kinds of matters and so anything he did say was pointed and said with a deliberateness. So, your phrase that he "happened to mention" stuck out for me. I wonder if it was a casual, incidental mentioning or if it was a window into his counter-transference. Was he indirectly expressing his frustration or defensiveness - "well, there are plenty of other clients who do want me even when you don't".

Perhaps that's the relevant piece. He would have given it to an existing client who otherwise has a standing appointment but needed a different time this week. I think I could understand that situation because overall, the T would not earn twice from the same time because the standing spot of this other client would then be unused anyway.

You could think about it that way - the other person is paying for their time but they cannot attend their own session time at this week. You are paying for your time but you are cancelling. Thus, the other person comes at your time while no one comes at their time.

I think in those circumstances it would not be unethical. I would consider it unethical if the T would cram a totally new person to the now free session time, effectively earning two times for the same spot.

Although I don't think what your T was thinking and planning was unethical per se, I think he should take into account your preference when making these decisions. I think it is perfectly reasonable to want that if you are paying for your spot that it not be given to someone else, even if you are not attending and even if someone else who cannot come at their regular time would like to reschedule for that spot that week. However, that means that you yourself cannot be expected to be able to reschedule too if for some reason you need it sometimes because then you should expect that other people do not like you to come at their spot too, even if they are not themselves using that time that week.

I don't think I have ever hired a therapist who was so busy they immediately filled the time I released, but if they did, I doubt I would care. I never didn't call in time -but I always thought such policies were punitive rather than remunerative.

Talk to your T about it and stop mulling over the ifs and whens and maybes.

I'm in Europe, psychoanalytical T, seeing her twice per week, I also have "my personal spots".

Insurance pays for my sessions. As she cannot bill insurance if I don't show up, she will charge me a (reduced) fee, if I cancel less than 48 hrs before my session. If she can fill my slot at short notice even though I cancel less than 48 hrs, she won't charge me. But this is not a given, that she'll find someone who'll take my cancelled spot.

This is pretty much standard where I live. The window when you can cancel might vary (48 or 24 hrs.) but most Ts will handle their cancellation policy in such a way, or very similar.

Also I noticed, that having to pay out of my own pocket for a missed session that I didn't cancel in time (the rest is paid by insurance), is some strong incentive for showing up for my sessions, no matter how ambivalent I might feel about T or this therapy in general. So instead of fostering my ambivalence, this cancellation policy 'forces' me into my sessions, thus providing me with reality checks (versus my own ambivalence running wild in circles...).

I realize this might be different for you, since you're paying for your sessions anyway?

My T’s cancellation policy is 14 days which I realize is an outlier, but maybe not so much for a psychoanalytic therapist. He says he chose that amount of time because that’s what his analyst did. I get that he runs a business and although I was skeptical at first of that long of a cancellation window, it has worked out just fine. I wouldn’t typically try to get out of paying as I understand that I’ve agreed to pay if I don’t cancel with at least 14 days. I just don’t like the idea of someone else taking my spot if I pay for it. Or if they do take my spot, I don’t think I should be billed for it.

My work is such that I could never have dealt with a 14 day notice period. I don't think one should pay for a spot they otherwise have filled but if someone can make double for the same hour and absolve themselves because of their own policy - I think most would take it. What I don't understand is how you would know whether they scheduled another appointment after you cancelled.

Yes, I do pay for my own and that has kept my ambivalence in check a bit. I mean, if I’m paying for the session anyway I might as well go in and at least talk about my ambivalence. And he is always super understanding about it. I do cancel or threaten to cancel now and then, but often end up asking for my time back. His cancellation window is 14 days so I find that a lot can happen emotionally in that time period. In some ways I’m quite a flake in therapy in ways that I’m not in the rest of my life.

I think I completely caught him off guard by showing up when I had sent an email several days earlier saying that I wouldn’t be there. So that’s why it came up that he considered offering my spot to someone else. I doubt he was trying to be hurtful. Maybe it could be counter transference though. I’m not really sure. It’s an interesting idea.

Well that’s an interesting way of thinking of it. Maybe I’m being too possessive of my time. He’s running a business after all so I can understand your logic. Maybe I’m blowing everything out of proportion!

Well, if your experience shows that (let's say) 9 out of 10 you'll be asking for your timeslot back after cancelling, what about trying to stop cancelling (out of ambivalence) altogether? And see what will happen and unfold then? What purpose and significance does this 'cancellation game' hold for you? Is it about power and control? Or wanting to avoid too much closeness? Cancelling again and again doesn't really help you to get to the bottom of this, or does it? So how about sticking it out, and trying to make cancellation a no-go for a while while at the same time trying to stay mindful and become aware to the things that might unfold?

Just wondering: Could it be possible that his extremely long cancellation window might actually exarcerbate your ambivalence? But then, his cancellation window isn't set up for ambivalences anyway but for scheduled holidays, business trips etc... How does he deal with sudden bouts of flu? I mean, you normally don't know a fortnight in advance that you might catch a virus, do you?

I don't think you are too possessive of your time. I was just trying to show that he would most probably not earn twice for the same spot. Considering your pattern of cancelling and then non-cancelling it is perfectly reasonable to not want him to give your spot to someone else this week because you actually might need that spot yourself.

Perhaps if you would be cancelling out of necessity (business trip with short notice or something like that) and not due to your ambivalence towards therapy, then you would not feel so possessive about someone else being temporarily using that spot, assuming that the T is not billing twice for the same time.

Wow, 14 days? I was also wondering, as someone else mentioned, what he does in terms of client illness? Or something that came up at work with, say, a week's notice?

ETA: Also, I'd think with a cancellation policy that long, he'd be more likely to be able to get someone in to fill the slot. Like if you canceled, say, a week in advance, which is still within the time that he'd charge you.

I have actually never been ill (and neither has he) so I’m not sure. I tend to think he’d be reasonable about an emergency but I can’t say for sure. I know one time, a little over a year ago, I told him that I didn’t think I should have to pay for a late cancellation because I was upset about something he had done and he was completely and utterly fine with that.

I felt so passionate about this that I sent him a brief email last night saying I wanted to talk about it when I see him on Wednesday. I was polite about it and I thought it would be nice to give him a heads up about it so it didn’t seem like I was going in there on the attack. But now I feel almost sick to my stomach about it, like I’ve made a big deal out of nothing. What do I care how he bills and what he does with cancelled appointments.? Of course, all of this conflict makes me think about what it might be like to skip so I just don’t have to deal. Everything makes me think about skipping, so no surprise there. Anyway, I will likely go, but my stomach is now in knots. It’s so much easier just to talk about the weather or a tv show or whatever, isn’t it? I appreciate all of your responses.

I may be totally off base here, but I imagine some of this could be tied into the "does my T really care about me, or is it mostly about money" thing. Because I've had some feelings like that. Especially when my T at times will emphasize how it's a "professional" relationship. Or once when I had an extra session with him and felt a little bad about it, and he was like, "Well, this will enable me to buy a solar charger for my phone." Which...I know he was trying to make me not feel bad about the extra session, but it also felt like, "Well, now I can get this sort of luxury item." At times, he tells me that I need his services and he needs to buy groceries, so it works out. But it still feels really weird at times.


Could this be at all tied into what you're feeling?