A Trio of Unfulfilled Requests

Periodically clients are unaware of some of the subtle, unique features of the therapeutic experience. They will occasionally make erroneous comparisons to traditional medicine or other businesses. This isn’t based on stupidity; rather a lack of experience. It’s understandable for a new client to see a Psychologist with “Doctor” in his title and assume he’ll have a prescription pad on hand. Or he may expect to receive a periodical invoice from his therapist as he does from his lawyer, only to be told that payment is expected at the time of service. “Oh, you mean like at a restaurant?” one college-aged client asked me.
“Exactly,” I said. “You eat, drink, pay the bill.” Of course this is only true if you’re name isn’t Dr. John, who attempts to run up a 12-month tab at the local pub. “If you’re only paying once per year those shots don’t seem nearly as costly.” I have to respectfully disagree as a three thousand dollar bill from a bar would make my drinks seem very expensive.
Because some clients are na├»ve about certain aspects of seeing a shrink it’s generally a good idea to educate them on not only the therapeutic process but also the business/financial aspects of treatment. A new client whom I’ll call Mark needed a crash course in this within the first two weeks. Having just completed a second session with me regarding relationship difficulties, Mark had some interesting takes on the details of payment.
“Today didn’t really help so I don’t think I should have to pay” he said.
“Excuse me?”
“You weren’t particularly helpful today like you were in the first session, so I don’t want to pay. I’ll hit you up next time if it goes better.”


Months prior I had seen a solicitation on Craig’s List for a healthcare provider who specialized in sleep difficulties. The person placing the ad stated that he was a wealthy man who had struggled with poor sleep for many years. He had traveled the world seeking help. He had tried pills, relaxation exercises, meditation, acupuncture and even hypnosis but nothing had worked. Any professional who could improve his sleep would be “paid handsomely” for their work but was only to be rewarded if he or she was successful in fixing the problem.
I disregarded the ad and thought about who might take on a case that was contingency-based, despite the possibility of a large financial reward. All shrinks know that therapy isn’t personal injury law. Dr. Steve perhaps? No, even he would know that no matter how good you are, success is never guaranteed.
“It’s interesting you say that because I recently read about someone else who wanted to work with a professional on a contingency basis.”
“That makes perfect sense to me.”
Mark’s logic was flawed due to certain assumptions. One is that therapy will have you feeling better each and every session. Therapy is a process, not an event. Most people in therapy do get better but that improvement is often over time. Some sessions actually make people feel worse if the discussion is on emotionally heavy material and it’s only by going through the process (what Freud called “working through”) that people get the results they seek.
Another faulty premise is that therapy is similar to traditional medicine in that it’s a somewhat passive experience. In other words, when you take medicine, you swallow your pill and wait for the results. Therapy is an opposite experience. It is an active process, one that you do for yourself with the guidance of the therapist. The therapist doesn’t “cure” you the way drugs or surgery do. The onus to improve is on both the client and therapist and only when each party does his share does change occur.
That being said, therapy is in fact like other medically-related fields in the sense that you pay for it independent of success. I’ve never had a doctor refund my co-pay if the antibiotic she prescribed didn’t eliminate my sore throat and my chiropractor had no interest in working on contingency when I hurt my back. He would have made very little money from me if he had.
“I’m sorry, but it doesn’t work that way. And I apologize because I probably should have explained this to you during our first meeting.”
“Oh. That’s unfortunate. Well if we’re not going to do a contingency-based set-up regularly, can you at least waive the fee for today? You can afford it.”
I immediately pictured the stack of bills on my kitchen countertop. “I can?”
“Yes. In fact I calculated your annual salary after last session.”
I attempted to quickly work through the math while wondering if all clients think about their therapists’ income.
“Before you bother,” Mark said, probably noting the pain in my face from all the calculations I was trying to complete, “you charge me $150 per session. Multiple that by eight people per day and that by five days per week.” He gave me a wink at that point, suggesting that he was on to some sort of grand plan that I had concocted in graduate school to become rich.
I immediately thought of every possible factor that made his logic off-base: Cancellations, no-shows, decreased payments by managed care, denial of payment by managed care, bounced checks, rent, overhead for the office, sliding scale, my pro-bono and, finally…Mark, who doesn’t want to pay his fee today.
“I’m not going to go into the details of my financial picture, but I can say with great confidence that the model you’re working from is tremendously oversimplified.”
“Alright, fine,” Mark said as he scribbled out a check. “Could you at least change my diagnosis on my receipt?”
“Why?”
“My insurance company reimburses me more money if I have a more severe diagnosis. Can you say I have Schizophrenia? Or at least a manic-depression?”
“Actually I don’t think that is true, but no, I cannot do that. That’s insurance fraud and illegal.”
“My God you’re such a tight-ass sometimes, Dr. Rob,” he said and walked out.
As I sat down to process what happened he poked his head into the doorway. “Same time next week?”
“Of course. But you have to pay for the session.”
“Fine” he said and gave a small smile.
I’m sure there are hundreds of people who would agree with Mark’s “diagnosis” of me, but that’s how the practice runs. Without rules, there’s anarchy. And unless I concluded everyone suffered from Schizophrenia and cured them in one session I’d have no money and stripped of my license. Try experiencing that and not be a tight-ass.

(Visited 95 times, 1 visits today)

14 Responses to “A Trio of Unfulfilled Requests”

  1. Blank says:

    Nice post, Dr. Rob.

  2. Esther says:

    Wow. I’m still wondering if the guy was joking around. He seems a little removed from reality to say the least. I have never felt upset that I have to pay my shrink even on the days (and they happen) when I feel worse after therapy. I usually think about what I want to talk about at the next appointment and reassure myself that some things take time to change.
    Out of curiosity, how many people follow a therapist’s suggestions/ideas to be proactive in changing the way they think/feel/act in everyday life? I mean, from your perspective. Obviously it’s an anecdotal question.

  3. Joe says:

    Its interesting you should compare psychology to personal injury law. I work in a personal injury law firm and the thing that immediately jumps out at me is the incentive inherent in the contingency fee system: it encourages lawyers to screen cases for the “real winners.”
    These are cases easily resolved, hopefully without the cost of discovery and trial, or the cases that possibly have a monster payout in the end. That’s a little oversimplified, but most firms tend toward one approach with the expectation that, in the aggregate, they will make more money by taking “better” cases.
    Of course, this is the opposite of what psychologists should do. If you guys worked on contingency, your incentive would be to treat the people with relatively minor problems which are easily resolved, or only treat rich, desperate people who will pay grand sums for the treatment.
    In PI cases, the stronger cases rise to the top, in psychology, the most desperate cases would fall through the cracks. Just saying.

  4. To avoid confusion, I would either have the payment process as part of the first conversation of therapy and/or provide an agreement that needs to be signed. It is so logical to not want to pay for service that you feel wasn’t satisfactory, but it IS a business transaction. My therapists would never have gotten paid if I were only paying for satisfactory therapy.. or what about when I leave feeling worse? Do I get paid for that?

  5. PJ says:

    My first therapist was a staff member at my college, so I never paid him at all, but my second therapist gave me a bill at the end of each month.
    I wish I had had that “active” attitude when I first went into therapy. My attitude was more like, “Alright, I’ve struggled with this for a long time, I can’t fix it, so I’m swallowing my pride and coming to you. Fix it for me, please.”
    $150/hr is a whole lot to pay for something that might not work. But insurance companies minimize the risk of high-priced, ineffective treatments.

  6. My aunt is a licensed therapist, and I can’t imagine her reasoning with a patient like you did. In fact, I’m playing out your conversation in her voice and laughing my @** off!
    How could an intelligent adult even think they could pay a psychologist only if they felt better following a session?

  7. Colleen says:

    I second the above person who suggested a written agreement that is signed at the first session (maybe this is a faux pas, but it makes logical sense to me). At my research job I deal with the same problem – participants who don’t understand how things work, specifically reimbursement. I’ve had people ask if they’ll be paid for appointments that had to be rescheduled, as if we pay people for doing nothing! I explain compensation verbally 2-3 times before people enroll and of course it’s in our consent form, but we added yet another brief, written explanation just for added clarity. People still hear what they want to hear, but we have more documentation that they’ve been given the correct info.

  8. marcia says:

    I agree with the others who suggest getting the business part of therapy taken care of upfront. Isn’t this part of boundary setting in a therapeutic relationship?
    Back when I could afford therapy, I always paid before the session (helps if you have office staff to take care of this for you), so my thoughts were rarely on money when the session ended (except for the times when the entire session revolved around the therapist’s problems, and ran over almost an hour, which I was still expected to pay for).

  9. Wayland says:

    Rob…this guy needs help. If this dude has relationship problems they probably stem from a controlling and manipulative demeanor that he has somehow developed and maybe they’ve come about as a defense mechanism. Nice post man.

  10. Avrila says:

    To play devil’s advocate, I’ve been to five different shrinks, between moving and changing insurance, and only one of them managed to help me at all. Of course paying by the individual session wouldn’t work, but on the other hand, I’ve heard of people going every other week for years and still being just as messed up; the shrink can’t be doing that well if they’re not making any progress.

  11. Savi says:

    Rob, good call. Therapy is like buying something with a receipt. Part of therapy is go “go there”- to talk about things and experiences that are undesirable, which is often where the problem came from in the first place. This is unavoidably part of therapy. People will naturally come away angry and sad at times, but one has to put the past behind them in order to move forward. Otherwise, their initial problems will simply repeat over time (best predictor of future behavior is past behavior).
    Therapy does not come with a receipt or a warranty, it is about self-growth and maturation.

  12. Ahh…the “value” discussion. I often see it as a form of resistance and the first challenge of trust, since it typically occurs in the beginning of the therapeutic relationship. Also, the passive v. active commitment….wouldn’t life be so much easier if people didn’t have to actually commit and work towards something, while risking failure?

  13. Anonymous says:

    YOU ONLY CHARGE $150??????????!!!!!!!!!
    good lord, i charge more and i don’t live in the city.

  14. Ashley says:

    Again, years-old discussion, but what the hell.

    I LOL’d at this guy. At the same time, I understand clients who think like this or question the “value” of sessions. Like Avrila, I’ve seen multiple therapists who haven’t helped me (and not because I wouldn’t put any work into it and expected to passively be “fixed”), and honestly I do resent the idea of paying that kind of money if I try again, with those previous useless and painful experiences hanging over my head. Any ideas for how I can talk about this with any therapist I might see now? Maybe it is resistance or distrust, but how can I get past it?

Leave a Reply