Not so long ago, a young woman I’d been seeing in psychotherapy for a few months didn’t show up for her regularly scheduled session. Thirty minutes into what would have been her appointment I called and got her voicemail, leaving a message letting her know I was wondering what had happened, and asking her to call me back. She was in her early 20s, and not particularly reliable—her tendency toward what she labeled “irresponsible” behavior had been one of the things that brought her to my office. Of the 11 times we had been scheduled to meet, she had actually shown up only six. I charge for no-shows, and she had amassed a considerable bill. As her mother was the one supposedly footing it, I’d suggested to Tanya that skipping our meetings was an angry gesture toward her mom. It turned out I was wrong, or at least only partially right: as Tanya’s debt was never to be paid, it would later seem to me that I was the ultimate target—if only a stand in—for much of her considerable pent-up resentment.
I am an early-career psychologist. After years of working in clinics where I was rarely paid directly by my patients, I started a private practice two years ago. In graduate school we’d been encouraged to try our hand at negotiating fees, and so this aspect of my nascent endeavor didn’t feel so new to me, but no one had ever introduced the idea that a fee, once agreed upon, might quickly become a moot point. I figured it was some sort of beginner’s error, but then I mentioned the incident to a former classmate, and was surprised by her response. “It happens to the most seasoned people about once a year. A patient disappears with a really big bill,” she confided. She’d only recently heard this herself, delivered as an aside at a case presentation she’d attended at the institute where she’s doing additional training.
Curious about the phenomenon as much as I was hoping to safeguard against it, I went to see Muriel Dimen, PhD, an anthropologist and psychoanalyst on the faculty of NYU’s Postdoctoral Program in Psychotherapy and Psychoanalysis, who has written about the role money plays in the therapy relationship. “When the bill adds up to three months—and it’s happened to me, too—you may be in trouble,” she told me. Dimen also reminded me that in letting the issue go as long as I did (I’d billed Tanya on the first of each month, so three bills had gone unanswered), I wasn’t quite doing my job as her therapist. “You didn’t have much of a chance given that you saw so little of her, but you weren’t adhering to the rules you had laid out. If she can’t count on you to maintain that framework, the relationship doesn’t feel safe.” As is all too common, the boundaries in Tanya’s family had not been sufficient, and neither in this case were mine.
Dimen added that the tension between the intimacy of the therapy relationship and cold cash—between love and hate—is also the central paradox of what we do, and that patients don’t fail to notice it. “Paying your therapist is complicated. It can be a relief because money is all that you need to give her. She doesn’t want anything else from you. But having to pay for what you should have gotten ‘at mother’s knee’ can also make you angry. And then you have a conflict.” Dimen does not find it useful to identify specific character traits of stiffers, though it would be easy to chalk the whole thing up to sociopathy. “They may never have done something like that before, and may never do it again,” she said.
As successive phone calls to Tanya went unreturned and my own resentment grew, I looked to one of my former supervisors, Dr. Andy Eig, a psychologist and faculty member of the Adelphi Postgraduate Program in Psychoanalysis and Psychotherapy, for advice. He told me via e-mail that in his 13 years of practice his former patients had left him with little more than a wink and a smile “more often than I would like to admit,” and suggested that we meet for coffee and war stories. “I find it happens more with people who have money than with people who don’t, the ones who work in dog-eat-dog industries like real estate and fashion, very different cultures than the one we’re accustomed to.” Eig added that many therapists he knows are becoming more comfortable with collecting payment each week—if only until trust has been established in the relationship—despite the fact this it goes against old unwritten rules about standard operating procedures. Eig has never taken outstanding bills to court or collection, instead simply sending letters reminding patients of their debts. In his experience, legal pursuit of past-due notices is uncommon in the field. “Therapists are afraid that the patient will turn around and sue them in return,” he said. (Another psychologist, who preferred to remain nameless, was advised by her attorney to wait until the statute of limitations on malpractice had run out—in New York State, that’s two and a half years—to call a litigious former patient to task.)
The rub about becoming someone’s therapist is that you have to continue to behave like one even when—especially when—strong feelings get stirred up. While I fantasized about ruining Tanya’s credit by turning her over to a collection agency (a breach in confidentiality allowed by psychology’s code of ethics, as long as other means of collecting have failed, and the patient is notified in advance), I did not act on the impulse, instead finally writing her a letter in which I tried to make meaning of what had happened between us—which is exactly what she had hired me to do. I invited her in for one more session, at which I hoped we could put words to what she’d only been able to communicate in action. I imagined without one last conversation I’d remain frozen in Tanya’s mind an angry persecutor, a tyrant in absentia. This was no way to end a treatment, even one that had barely begun.
Tanya failed to take me up on my offer, or to send me a check. But you never can tell what the future holds with a patient from your past. In one of my earliest training experiences, a young woman named Dana had not paid her bill at the clinic where I was seeing her. I was reimbursed by my employer for the sessions nevertheless, and felt some guilt about the whole thing. A year or so later, Dana tracked me down at a new job, and called to schedule an appointment. “You have a lot of nerve coming to see me after not paying for the work we did!” I told her with exaggerated dismay in order to give us a jumping off point. In our second go-around, Dana and I were able to take a serious look at the entitlement she felt in the wake of a childhood where she had not gotten much from her parents—an attitude that had complicated her life in disastrous ways. The second time around, I also made one adjustment to the therapy’s parameters: she paid cash up front for every session.