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There’s a classic moment in psychotherapy when the client and psychotherapist both have to confront the cancellation policy that (most of the time) got announced during the first session, then (most of the time) forgotten about as therapy commences. In my 13 years of practice, it’s rarely not a powerful moment, because it’s where the boundaries of therapy become explicit rather than implicit, and sparks can tend to fly, quietly, or not.
In this article I want to make a case for why the cancellation policies of therapists are not merely logistic, or financial, in nature, but inextricably bound up in what makes therapy work. Or, as the title points to, why therapists charging for missed sessions is not an expression of greed or not caring, but rather is part of the foundation without which therapy tends to go off the rails. Admittedly, you (as client) might be skeptical of a therapist defending something that seems to benefit them, and bite you. Fair enough. But perhaps this might provide a credible counterpoint to a situation in which our otherwise trusted therapist feels like a “greedy bastard.”
My cancellation policy has evolved over the years from the standard 24 hour cancellation policy with wiggle room, meaning I’d sometimes let clients not pay for a missed session if it seemed to be “not their fault.” Child got sick, client got sick, car accident, sudden destructive hail storms. I’d also let clients not pay if they rescheduled within that week. Now, my policy has become 48 hours, outside of which we reschedule or cancel, and within which the client is responsible for paying for the session, no matter what reason. The wiggle I allow is that, during the same day as the scheduled appointment, if we can coordinate a time that works, then we can shift the time, or if we can do a phone session instead of in-person, that’s ok too. But if the client can’t make that scheduled session, and wants to book a different day during that week, then that’s counted as a second session.
This means that if a client is projectile vomiting two hours before the session and can’t get away from the porcelain shrine, or has anaphylactic shock from a bee sting and is unconscious in the E.R., I charge them for the session. At this point in my practice and clinical thinking, it is very, very rare that I allow an exception to this cancellation policy.
Which might lead to such a conclusion as: What a callous, and greedy, bastard.
Yet! What I’ve found over my decade plus of practice is that the firmer and more unbending my cancellation policy has become, the stronger outcomes my clients get from therapy, the less sense of “slop” and uncertainty there is in our work, and the greater the sense of safety there is to anchor the therapy, for both of us. So here’s my understanding of why this is, and therefore why the cancellation policy is a boundary that is there for the benefit of the therapy, not the therapist.
Let’s take the reactions first to the hurt of being, seemingly, punished for missing a session, carrying with it some flavor of cruelty or uncaring. We may not be fully aware of that reaction, but this classic exchange almost inevitably carries resonances of bad parenting, of lack of empathy, of self-serving behavior on the authority figure’s part, if not straight up exploitation. Even me (as client in my own therapy), who knows why these policies are in place, when I’ve had to miss a session for what is obviously a righteous reason, still feel this sting and hurt.
So, why is it not greed that drives the cancellation policy? Greed is the selfish desire to acquire wealth and resources, without caring about, or taking into account, the needs of the other. But if greed were the motivation, i.e., to maximize financial return at the client’s expense, a stiff cancellation policy is a stupid way to go about it. Much better to practice what a colleague refers to as “Nice old lady therapy,” meaning a therapy with no edges against which a client has to rub, a therapy based in a conventional “social niceness,” which seems to express care through allowance. Who doesn’t want a solicitous grandmother or grandfather to protect one from the harshness of this life? Who wouldn’t want to pay for that?
But with a rigid cancellation policy, what you often receive, as the therapist, is reaction, accusation, judgment, and (less than you might think) termination. If one was only interested in maximizing income (and not therapeutic outcomes), much better to avoid these painful and disruptive edges and, in a sense, pander.
In the case of the other “greed,” for an ease in work, where one’s own experience in therapy (low impact, emphasis on warm-fuzzy feelings) is more important than the outcomes of the therapy, then you (as therapist) are also going to practice “nice therapy,” because it’s actually tough to keep the cancellation boundary one’s set up. You get all the reactions above, and though there may be a few therapists out there who enjoy the conflict and dissonance with their clients, it’s probably fairly few. (Not to mention your own training in “social niceness,” and exposure to the same judgments one gets from clients, but lobbed at oneself.) Most somewhat evolved apes, including therapists, are not designed to like feeling separate or insecure about connection, so if my greed (as therapist) was only for pleasant sensations in my practice, I’d be better off being “forgiving” when a cancellation issue arises. Keeping a hard boundary is hard on the nervous system, and it’s been true that over the years, I’ve had to practice a kind of surrender and submission to my own policies, in order to not waffle when the heat was turned up by an angry or hurt client, or by my own internal judgments and shaming.
Thus, if money and ease were my prime goals, a rigid cancellation policy would be the exact wrong way to go about it.
Ok, so here’s how I understand what’s going on, such that being “conventionally nice” is actually counter-therapeutic.
There are always multiple clients in the room, a few talking, all listening. One of the great shocks for those clients new to therapy is that we humans are not in fact one unitary thing. We take that for granted at the physical level—there’s a liver, there’s a stomach, there’s a nervous system, there’s a lymph system, and when healthy, they are all functioning with integrity within themselves, and in harmony in relationship to each other—but at the mental and personal level, we have a naïve belief in “just Me here.” When you start looking, though, you very quickly find, or more often it feels like we’re confronted with, the multiplicity of our own consciousness.
The modern neurosciences are confirming in terms of neuro-anatomy and neuro-functioning that different parts of the nervous system and brain respond to and select for different kinds of information. The somewhat rough model of the “triune brain” gives a good shorthand for this: there’s a reptile brain, charged with survival; a limbic brain, charged with relationship, and a cognitive brain, charged with cognitive knowing (developing in that order, in evolutionary history).
Then, more particularly, there’s a part that’s interested in sex, that doesn’t much care about mathematics or ethics. There’s a survival part, which, in its purest form, doesn’t even perceive morality, and is only driven by a desire to continue, no matter what. Then there’s a part that is designed to organize all the streams of self, the integrating part of self, which wants to know and integrate the multiplicity. Then there’s the much-spoofed, but totally experientially true, “inner child.” It’s this child that is most important in relation to why, as I quip in the title of this article, “Paying for missed sessions is good for you!”
For instance, some therapy session, we might be having a totally adult conversation, centering on a work issue, negotiating the vicissitudes of office politics, focusing on doing things and knowing things. But by design, part of our brain is parallel processing information concerning social belonging and safety: Does Marty like me? Do the signals indicate he’s interested and wants to give attention? Does he care? Is he safe to be vulnerable to? Is anyone safe to be vulnerable to? Can I trust him? Is he truly on my side? Can I trust that he means what he says? Will I get hurt?
At it’s most basic level, you can’t shut this process off, though you can pretend you don’t care, or try to ignore the part of you asking the questions, or it’s not relevant (for instance, after the first year of settling into our work, a client admitted, “You know, at first, I just wanted you to be a vendor, without having to relate with you in any more fashion than with a pharmacist.”) But it’s not true. These somewhat-evolved-ape nervous systems really really care about safety and connection, and safety in connection, and don’t ever turn off. So as “adult” a conversation is going on in therapy, or even as “adult” a response to having to pay for a missed session, that child part which is so concerned about safety in relationship, is always listening.
And what does a child need to feel safe in relationship? In two words: compassionate boundaries. In my whole grade-, junior-, and high school experience, the teacher we kids hated the most was a junior high school man who tried to be very cool with us, and would not set firm boundaries with us. We hated him not because he was a dangerous man—he actually had a decent heart. We hated him because we felt unsafe with him, and the hate was a push-back that kept us from being vulnerable to someone we didn’t trust. We acted out, undermining his teaching, fussing with each other, testing limits regarding turning in homework, and when he didn’t respond to what were in essences demands that he change to provide the boundaries that we couldn’t, in order to feel safe, he responded with more “niceness.” And we hated him even more because the message was taken as him being too clueless, or worse, too uninterested in us, to do the work of giving us what we needed at that age to feel safe.
The same dynamic, like it or not, for both parties, is playing out in therapy. We don’t get to ignore the inner child without having to pay the consequences.
But since we can’t always be overtly and verbally addressing the inner child’s need to test for safety, there are structures that are set in place in order to keep answering the child’s questions: “Is this therapist safe? Can I trust him? Is this relationship secure?” The cancellation policy in therapy is one of these structures, which is there not for the needs of the adult aspect of self, but is there to meet the needs of the inner child. At home with a literal child, that might translate into a firm bedtime, or rules around chores, or ethics of communication. In therapy, the boundaries are money, time, and cancellation, and that’s what we’ve got to work with to help the child self, that young aspect of the nervous system, orient and trust a state of safety.
Just like the child is speaking with two voices when they say, “Can’t we eat the rest of the Halloween candy?” asking both from their pure desire for consumption, and more deeply, testing whether we really are serious and boundaried when we set a limit, which is really asking, “Are you safe and trustworthy to monitor that which I can’t?”—so in therapy, the missed session serves as the analogous moment of multiple questioning. On top is, “If you love me, you won’t cause any pain,” and below that, “If you love me, you’ll help me feel safe no matter what the cost.” It’s to the last question that the firm boundaries and limits concerning cancellations is geared. The adult, logical self does not need this, but the young aspect of self unequivocally does. With compassion, with understanding, with a willingness to explore the feelings and hurt around the boundaries, but at the end of the day, firmly and unwaveringly.
So what are the results of a therapist compassionately sticking to their policy, even to the point of a client leaving therapy? That child self feels safe, whether secondarily grumpy about not getting all the candy, not having a “nice old lady/gent” for a therapist. When that child feels safe, they settle down and stop testing the boundaries as much (because the question of “Is he safe? Can I trust his word?” has been essentially and observably answered). Trusting that you’re not going to drop him and instead actually meet the needs of all parts, not just the adult, the child self gives permission to go deeper, to be more vulnerable, and therefore signs off on allowing the more profound levels of healing and change. When we feel safe, we have substantially no reason to resist openness and exposure. It hurts, sure, and is scary, sure, but if we have an Other in the form of our therapist who we trust to know, love, and contain our various selves—most particularly our child self—then the appropriate resistance to going deeper is relaxed, like a handbrake being released.
Then what we are coming to therapy for actually has a chance of being realized.
This, then, is why, when therapists charge us for missed sessions and hew to their own cancellation policy the benefit is to our own therapy and our own desires for healing and transformation and integration. It is an inherently messy point in a therapy when one comes up on that sharp edge of a firm boundary (both client and therapist), but every relationship has to be tested to be trusted, and this moment in therapy is a primary one in which the client’s youngest self is asking, implicitly, even if bitchily, “Can I trust you?”