‘Being There’ In Psychotherapy

Here’s a tip.  It’s free, and well worth taking if you’re going into psychotherapy (or any type of counselling-type relationship):

Make sure you know what you’re paying for.

It sounds sensible, doesn’t it?  Actually it’s kind of obvious.  The thing is that I thought I knew what I was paying for (for eight years)… but I was wrong… apparently.

I should add that even if you’re in the very fortunate position of not having to pay for your therapy, it’s also worth knowing what is on offer before you start.

Jump back a month for a moment, and I was in England visiting my boyfriend.  One morning I was sitting in bed, drinking very nice, and very strong coffee, while I checked my emails that had come in overnight.  I was surprised to see one from my psychotherapist.

It’s just as well by coffee was good because his email attached his account for the six weekly therapy sessions I was missing while I was away.

My therapy is not cheap.  On the basis of the health system in New Zealand I really don’t think I should have to pay anything, but I realised (eight years ago) that if I wanted something that was actually going to make a difference, then I would have to pay cold, hard cash (not helped by the publically funded mental health system telling me a few years back that I was basically beyond their help).

And so I have paid myself, for around eight years now.  I’m not even going to dare to add up all that has cost.  That would be too mind-boggling, except to say that I know it has helped save my life, and therefore it must have been worth it.  It has meant living on an extreme tight budget for that time, but I dont’ regret that.

As I said, what my therapist offers is not cheap, and so the account was sizeable.  He wanted me to pay for each session I missed, regardless of the fact that I was out of the country, and regardless of the fact that I had given him three months notice that I wouldn’t be at those sessions.  Ouch!  That was a bit of a shock to my morning.  More coffee needed.

Right from the start of seeing my therapist I understood that if I missed, or cancelled the odd session, because I was sick or for any other reason, that I would have to pay for that session.  My understanding of that, for eight years, has been that this is a regular practise for many health professionals, used when a client doesn’t turn up or cancels the appointment at the last-minute.

I accepted that.  It’s hard to pay so much money for something you’re not getting, when you’re lying in bed sick and have to miss an appointment, but I could understand it from his perspective.  I just never expected that after giving three months notice of my intended absence from the country, that he would still charge me for those appointments I would miss.  And that’s where we have come undone.

Since receiving that email, and then in my weekly appointments when I got back to New Zealand, we have discussed this.  His expectations and mine are vastly different.  Apparently even though I wasn’t there for those appointments, and was not even in the country, he sees that he was providing me with a service.  He was ‘being there’ for me… even though I wasn’t there.

It made me ask the question of what it is I’m actually paying for.  From my perspective I always thought I was paying for a 50 minute appointment for therapy.  Outside of that weekly 50 minute appointment, I didn’t think I was paying for anything other than it being helpful if he would remember (in the way that works for him) the details we discussed from week to week.

He has always said I could telephone him in between appointments if I was really struggling and needed his help.  I guess (although am still not entirely sure) that was what he meant by ‘being there’.  It took a long time before I got a specific answer to my question… and then it wasn’t at all specific.

In eight years I might have rung for help outside appointments twice.  I find it very difficult to ask for help and have never felt comfortable with doing this, even though he made it clear that I could.  Actually that’s an whole other post just to cover why I haven’t used this.  But  it’something he and I have been very clear about in terms of my need.

As for the six weeks I was away, he had said (before I left) that I could speak to him by telephone, Skype or email if I needed to, although I made it clear that I wouldn’t telephone or Skype (I’m not good on those mediums), and doubted I would have the need to email him.  I guess he was saying if I needed help, then he would ‘be there’.  And from what I can ascertain, that is the basis on which he charged me for appointments I wasn’t there for.

Is this getting confusing?  Apologies.  It’s taken a bit of brain power for me to get my head around this but at the end of the day, it appears that he is charging for one thing, but I have been paying for another.  Yes, for eight years.  I actually don’t see any reason why I would pay anyone to ‘be there’ in this way for me.

My therapist knows that I am not willing to pay that money (nor do I have such funds).  I am also not prepared to be charged on that basis, anytime in the future.  I have never heard of anyone having to pay for therapy on that basis, and would be interested to hear, if you have.  Is this as odd as I think it is?  I’d also like to know what any therapists who might follow my blog, make of this arrangement of paying to ‘be there’, even if not there physically.

I’ve decided that I need to end this therapy relationship, because I’m not prepared to pay on this basis.  I’ve told my therapist this today.  Why is it that when you have to talk money that people start playing mind-games?  I have nothing I against my therapist but don’t appreciate the way he has handled this particular issue.  It was a relief to finish and leave today.

While this is a really big step for me, because I know this therapy has helped me considerably over the years, I know too that I can make it without his help from here on.  It’s not going to be easy to not have that sounding board or the unique understanding of me that he has had.

My therapist has been really good.  I have no doubts about that.  But I feel that while everything is not perfect in my life, and never will be, I am at a good point to do this.  Hindsight is always a great thing, but I don’t think I would have gone into therapy with him, if I had understood what it was I was paying for… some obscure idea of ‘being there’.  I’d go so far as to say that it’s a little spooky for me.  But that’s just me.  I like to know that someone is there in front of me, and that is what I pay for.  I actually don’t want anything else.

I think I will do more writing, and drink more tea (or coffee).  Maybe I will finally take up meditation.  Oh, and talk to my teddy bear more.  He doesn’t charge for ‘being there’…  regardless of whether he is (or I am) there.

“A combination of fine tea, enchanting objects and soothing surroundings exerts a therapeutic effect by washing away the corrosive strains and stress of modern life. [… It] induces a mood that is spiritually refreshing [and produces] a genial state of mind.” 

―    John Blofeld,    Chinese Art of Tea

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18 thoughts on “‘Being There’ In Psychotherapy

  1. It doesn’t done here. If you cancel in advance a specified amount of time (usually 24 hours), you don’t pay either. You also don’t get free phone service. If you call, and need actual help or support (and not just an appointment time or two minutes of reassuring words), you pay for that. There is usually a few schedule for this. Your fee for 50 minutes does not cover anything outside of that time. I can understand your dismay. He charged you for a service you didn’t want and didn’t need and that he never had to provide. It’s kind of like charging someone for towing service when they don’t have a car. There is something unethical about–especially when you are talking 6 weeks of a service you didn’t want and he did not have to provide. I would love to get paid for doing nothing, but I’m not sure it’s my right.

    1. I’m with you on that one Ashana. I can imagine many of us would like to be paid for doing nothing. Of course, I admit that he thought he was doing something and I guess that is the issue, but whatever it was, it wasn’t something I agreed to.

  2. John Richardson

    I’m with you Cate. I don’t see why you would owe this and find it interesting that your thearpist waited until you were out of the country to send you his bill for the missed appointments. Had he had sent if promptly, say two weeks after you notified him that you would be absent for a while, your obvious recourse would have been to end the relationship before you missed any of these “appointments.” It also makes me question, regarless of how good he is, whether he is more committed to taking care of you or his pocket book. Why would anyone want to see anyone who was more interested in their own pocketbook that taking care of the person that was in their care? I’ve got no idea what the “common practice” is in this situation but I would think someone could give you reliable information on this point.

    1. John, I admit I was wondering what your take on this would be. The rest I got the bill while I was away is that it was his normal practise to bill me at the end of each month. Usually he would hand me the bill at my appointment in the last week, but this time he had to email to me. I’m curious to see what common practise is for this, as most people in NZ would be getting therapy provided by the public mental health system.

  3. I find this a very interesting topic, but I am approaching it from an extremely different perspective, and mine is actually twofold.

    First, as far as psychotherapy, while I do have a regular therapist, I don’t have regular therapy sessions. I established long ago (with her and with many others) that my brain just doesn’t “therapize”, as I put it. The reason she and I have maintained our relationship is because she gets this, she respects it, and she doesn’t try to “solve” me or fix anything that I don’t feel is especially broken. The way it tends to work for us is that a few times a year, when I run into a concrete problem I feel she would be helpful in solving, I call her up and make an appointment. Usually she gets me in the same week. So of course if I didn’t turn up, I would fully expect to be charged — but in no way is she, to use a legal term — “on retainer”. She is not paid a fee “just in case”.

    On the other hand, we have my psychiatrists, past and present. Now, the one I have at present hasn’t had to deal with me in crisis as much, we haven’t had as many regularly scheduled, three week appointments like I had with my former doctor, and I haven’t had to cancel very often. But their policies have been pretty much identical.

    First, if I have to cancel with little or no notice because I am too ill to come in — after having demonstrated this is not a pattern, mind — they have not charged me a cent. Things happen, and they can afford to cut me some slack much more than I can afford to pay it. Second, whether my appointments have been scheduled regularly or not, they are paid to “be there”. As far as I’m concerned, this is built firmly into any doctor’s job description, but especially a psychiatrist. You are “there” 24 hours a day, 7 days a week, 52 weeks a year, and when you are not (because everyone needs a break), you provide an adequate, competent substitute in the form of another “on call” psychiatrist. None of this, by the way, is at any charge additional to what I pay for my regular office visits, frequent or infrequent though they may be. It is a package deal.

    I think you are very wise to put across the message that you need to know what you are paying for. My former doctor, I could wake from a dead sleep at four a.m. on a Sunday and he would get it together to help me out somehow, and pleasantly, even. My present doctor, there were several very bad moments on a Friday afternoon before I sat him down and told him, ‘Look, this is what I pay you for, this is what I expect from you, now will you provide it going forward, or will I find myself a doctor who will?’ I’m happy to say our relationship has improved.

    Sorry to have run off a bit here, but, well you know by now what happens when you get me thinking, Cate! 😉

    1. Hi Ruby, now first, you should never apologise for running off. I like it and getting you thinking always results in good things as well as food for thought. Firstly I love the sound of your therapy arrangement. I’m inclined to think that at this stage, that is the type of arrangement which would suit me down to the ground. Now just to find someone who will meet the other end of the arrangement. Therapists of any sort don’t seem to be thick on the ground in my city.

      As for psychiatrists and doctors, I agree with you. What I’m thinking though is that sadly not everyone has thought through this matter let alone discussed it with their doctor/psychiatrist but it’s something that really needs to be addressed. What concerns me is that many people when they’re seeking help, from doctors and/or therapists are not in a well enough position to deal with such a conversation. I mean, when you start therapy you can be, but not always, be in a state of crisis. Discussing the finer points of the patient relationship is beyond us. So food for thought is, how does this matter get raised and addressed?

      In my country I would say that there is no standard approach mongst health professionals. They all appear to do largely what they want in their own practices and while individuality isn’t a bad thing, it does leave it up to the patient to make sure they know what they’re paying for. I’m thinking it would be helpful if these health professionals spelt out (in writing) what basis they work from in maybe some type of say, ‘Terms and Conditions’. Is that too much to ask? Personally I thik it’s a basic requirement.

  4. Cate it sounds to me like what lawyers do for their big (think rich) clients — they are kept on a retainer fee in order to be at the beck and call (supposedly) of their big clients. They get paid so much a month to just be there, just in case their client needs a lawyer for whatever reason — criminal or civil lawyering.

    This being said, I’ve never heard of any psychiatrist, psychologist or counselor who practices this unless it involves an extremely wealthy family with an extremely poor mental health family member who constantly needs their services.

    Again, it seems to be, at least to my limited knowledge, only for the extremely rich people who apparently need lawyers, psychiatrist, psychologists and counselors at their beck and call, anytime, anywhere, for anything.

    As for a poor peon like me . . . well, I have to take what I can get and sometimes it hasn’t been at all beneficial. In fact, sometimes it has been detrimental.

    Good luck with whatever way you decide to go — to leave him, to find another, to do it on your own with what I hope is, as they say, a healthy support system in place in case of emergencies.

    It’s just so incredibly difficult to find a counselor you can mesh with — really hit it off, click with them, whatever terminology you might use. The bottom line is trust — and it takes a long time to build that trust — for you must be able to trust the one you’re baring your soul to. When I first started going to counselors, never having been to one in 36 years of living, I told them it felt like they wanted me to get naked in front of them, a stranger, and not be the least bit uncomfortable about it. Unless you are someone without any inhibitions or modesty, that just isn’t going to happen.

    May God lead you to the place where you can get the help you need — even if it’s just to talk to your teddy bear!! 🙂

    Love,
    Kathy

    1. Thanks Kathy. Firstly, let me say that my teddy bear is pretty damn good. 🙂 Your point about the lawyers of retainer makes sense and is something I hadn’t thought about. Probably because I am far from rich and could never have the luxury of such a service. Then again, I’m hoping I don’t need such a legal service either. As for for finding counsellors you can mesh with, you are so right. The analogy of stripping naked in front of them is very accurate. Not something I would feel comfortable doing with most people. It reminds me that actually the therapy relationship is a very difficult one to get right. I have been fortunate that, apart from this issue, the therapist I had (I finished with him yesterday) has been very good and has recognised how hard it was for me to do that ‘stripping off’. As for what happens now, I will just take each day as it comes for now, oh, and talk a lot with Ted. 🙂

  5. Hmmmmm…. Noooo, this is just wrong on so many levels. If you were to have decided that his services no longer were needed, or wished to quit your weekly sessions with this doc, how long ahead of time would you have had to let him know that you no longer would be using him as a therapist? Or is he somehow under the impression that you’ve signed a lifetime contract with him? 3 months notice that you will be out of the country or for whatever reason, gives him plenty of time to fill up your scheduled spots with another patient. When you were on vacation, did he just sit in his office twirling his thumbs during the time he expects you to pay for? If he had other patients that he was counseling, I can’t see how he should be able to charge you for your sessions. It’s not like he can be there for more than one patient at a time. Me thinks it’s time for you to move on and find a new therapist. Even if you’ve had this one for eight years and it’s been good for you. Sooner or later in order to move further on and get even better, you need a new perspective/approach and a fresh set of ears. Same as we sometimes need a different type of medication when we’ve been on the ones we have been for years, they stop working as they should. Sounds like this doctor just lost his meal-ticket. Seriously, I’d check into the legal aspect of him demanding you pay, considering you gave him 3 months notice ahead of time.

    1. You and I are clearly on the same page on this one. Thank you. Sometimes it’s good to know that I’m not being totally unreasonable in my expectations. Twiddling thumbs while I’m on vacation really doesn’t seem to me like something I should pay for. That said, it is clear that he and I had different understandings of what I was paying for. It’s an issue that I suspect all therapists/counsellors/doctors should address with their patients, preferably at the start of the arrangement. I guess whether or not, they woudl listen to me is debatable but I intend to keep saying it (having found myself in this position). Thanks for your comments. 🙂

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  7. Yeah… that wouldn’t fly with me either, Cate. I’m certain that’s not the situation with my therapist, but I’m going to check next time I’m in!

    About getting what we’re paying for, I’m running into that notion now as well, but in an entirely different way. My therapist has been okay – though he’s the first/only I’ve had, and so have nothing with which to compare – okay, but never in my mind great. He’s helped with a few things to some degree, but I’m finding that he doesn’t have the expertise or knowledge I had hoped for. My issues and my questions of late are at the core of everything else that’s happening with me, and so are big deals. When I bring these few, simple but BIG, notions, his response is nothing more “that’s tough, I’m sure” and other equally unhelpful things.

    I need to sack him like you did, and I need to find someone to fill the vacuum that will leave me in. My ever-nearing trip is going to be more therapeutic than any professional could offer – it IS going to be, dammit! – yet I know I’ll need more long term help.

    Anyway, I applaud your gumption and hope you are indeed able to get along fine with Teddy and without your therapist!

    1. Hi Sid, You made me smile and I so, needed that today… thank you. The whole therapist thing is so hard to get right and what I learnt very early on is that every therapist works in a completely different way. I wouldn’t appreciate the “that’s tough” line either. I’d like a bit more for my money I suppose but also I’d like get have some impression that s/he had some empathy beyond “that’s tough”

      One thing I do know is that it’s worth hunting for a therapist that works for you. The therapist I ‘dumped’ actually did work for me for a long time but I couldn’t work with this idea of paying him to exist, but not be doing anything for me. I’m just not that generous, although I’m kind of thinking that perhaps it would be a good career option. 😉 I digress. It’s hard but go therapist hunting.

      When I was doing it I had a list of questions so that I didn’t get side-tracked. My problem was that I simply failed to ask what I was paying for.

      So yes, now it’s just Ted and me. For now that’s ok for now but I do miss that input I had. So often I think I could talk about a particular topic with him (therapist), but he’s not there anymore. It takes a bit of getting used to.

      Then again my doctor told me he thought I was too dependent on my therapist, so he was pleased I’d ended the therapy. Time will tell what happens next.

      I’m just sorry I can’t lend you Ted. Good luck in your hunt.

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  9. What I want to do is scream at that therapist spooky idea of “being there” – what a bloody cheek!!! I wouldn’t want a therapist to be there for me outside sessions. Yes, I can understand charging if you cancel last minute due to ill health, but after 3 months’ notice of being out the country. NO WAY!! It’s like paying him holiday pay….tut!

    I cannot help feel the Therapists behaviour was a little sneaky. When you gave 3 months’ notice of being out the country, he could have at least clarified the agreement then, not hit you with the bill while you are out of the country. I would not be able to trust or relate to the therapist again and understand why you would decide to end your sessions. I really hope you did not pay!

    1. I like the idea of someone screaming at him as he looked and spoke to me as if I was the strangest person in the world for objecting to his system. And be assured, I didn’t pay him a cent. 🙂

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