Tales from the Couch

Seeing the patient from psychiatry’s perspective

Stiffing the Shrink

Unfinished Business

Unfinished Business


Annie B and Henry R were two patients I’d been seeing in psychotherapy early on in my psychiatric career. Both were interesting, with vastly different problems. Annie was extraordinarily emotionally dependent on her parents. Henry suffered in an unhappy marriage and a frustrating career.


I saw each of them once-weekly for insight-oriented sessions where they made significant progress. After nearly one year in treatment, Annie decided to move to Chicago, which was emblematic of her being able to leave her parents and begin a more independent life. Henry and his wife separated after a four year conflict-ridden marriage. He decided to move to Boston, where a new job with better opportunities awaited him. 

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As was my custom, I gave each patient a bill at the end of every month. Over the time I’d treated Annie and Henry, they had always paid their bills promptly. However, after their respective last sessions, I did not receive a check from either of them. They had both terminated and left with their last bill unpaid. I mailed additional invoices, assuming they would be forwarded to their new addresses. I never heard from either of them again and was never paid for the last month of sessions.


Before these two instances, I’d never been “stiffed” by a patient. I began wondering about it. Both Annie and Henry had negotiated what I regarded as helpful—even successful—psychotherapies. They terminated treatment with positive feelings about their progress and presumably, about me.


I was dumbfounded by their apparent unwillingness to settle a just debt. But I began thinking back to what a sagacious, older psychoanalyst had said about unpaid bills, when I’d been a psychiatric resident.


Dr. William Console (his real name) said, among many wise things, “When you’ve had a good relationship with a therapy patient who leaves without paying the last bill, it has enormous meaning. It’s not about the money. As hostile as it may seem at first, it’s the patient’s way of holding on to you…of not letting go. It’s staying in touch with you without really having sessions anymore. It’s the patient saying, ‘Don’t forget me. I’m still out there….somewhere.’ It’s a way the patient has of remaining memorable in your mind. It’s unfinished business, and you won’t forget that patient.”


How right he was.


Here I am, many years later, writing about the unfinished business Annie B and Henry R left behind. So I guess I will never truly forget them.


Mark Rubinstein,

Author of Mad Dog House, Love Gone Mad and The Foot Soldier


Mark Rubinstein, M.D., is a former professor of psychiatry at Cornell. His most recent book is the novel Mad Dog House.


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