Cancellation

Early in a treatment – often in the first session – I ask a patient if they would like to schedule regular, recurring sessions with me. If the patient agrees, we look for times that work for both of us (I tend to see patients more than once a week). When we agree on times, I say something like the following:

Let me tell you about my cancellation policy. What we are doing right now, as we schedule a recurring time to meet, is making a mutual agreement: I’m agreeing to hold these times for you, and you’re agreeing to pay for them. Inevitably, it will happen that you’ll have to reschedule. When that happens, I’ll be glad to try to find a time that can work for us within seven days or so* on either side of the session you can’t make. I would expect that in general, we would be able to find a time to meet, but, in the event that we aren’t, I will ask you to pay me nonetheless. There are two exceptions to this:

Vacations (yours and mine): as long as we discuss vacation plans in advance*, I won’t charge you for sessions missed because of either of our vacations. In addition, I will, generally, give you substantial advance notice of any vacation plans I make – often, months in advance, but in any event, as soon as I’m aware of them.

And my absence: if I’m sick, or have an emergency, or for any reason need to cancel a session, I will not charge you.

I have this policy for two reasons: first, because this is, actually, how I make a living. When I “reserve” a slot on my calendar, when I remove it from the times available to see new/other patients, that has a cost to me. And second, I do this because I want to be sure that patients explicitly engage with the feelings they have about missing sessions with me. If a patient doesn’t pay for a session, they may find it easier not to think (let alone talk) about the missed session, or about the feelings associated with it. This policy provides a structure to encourage them to do both.

In general, this policy makes sense to most of my patients.

Some patients, though, have questions: “What if I have to travel for work? What if you’re sick? What if I have an emergency?” And, most pointedly, “Why should I pay you for a session that doesn’t happen?!?”

I like these questions, when they come up. They help me communicate how I work, how I think. That said, they don’t often come up; as I just said, this policy makes sense to most of my patients.

When patients ask those questions, I explain that, in all those instances – and indeed, in almost any instance* – I will gladly try to reschedule, and in general, I’m able to do so. Once in a great while, whether because of my schedule, my patient’s schedule, or the interaction of the two, this isn’t possible. In such instances, I typically remind my patient of my policy (if I need to) when I hand them their bill at the end of the month, and they pay for the missed session.

Sometimes, this leads to fortuitous results: a once-a-week patient may have an anomalous two-session week – and they may find it useful. A twice-a-week patient may have a three-session week, and they may find that useful. Sometimes, it leads to painful, resentful discussions: inevitably, these too are useful. When a patient gets angry at me, there’s always an opportunity to explore, to learn. When a patient gets angry at me for having needs, that’s especially rich.

Sometimes, patients want to argue: “But you get to use that time!” To which I say (here, to you; not generally to the patient), “Yes, and no….” I may well get to put that time to some use other than serving the patient – although I’ll note that at least one therapist I know makes it a practice of “thinking about [his] patient” during any session for which the patient pays. But. Whatever use I put that time to, it almost certainly will not make me incremental income. Substantially all of my income comes from providing either therapy or supervision in recurring, scheduled sessions, so a “free” hour doesn’t provide an opportunity for incremental revenue.

Sometimes, patients want to argue: “But I’m not getting anything for my money if I miss a session.” To which I say, “Maybe….” I like to bring up other examples of similarly structured relationships: apartment or house rent; garage spaces; gym memberships. In all these cases, we understand that the value of what we buy does not derive directly from our usage – and intuitively, we never would ask a landlord for a reduction because, say, we took a vacation, or spent a night at a lover’s house.

Often, I will add that, to my mind, just because we aren’t together doesn’t mean that our work together doesn’t continue in the time of the “missed” session. The patient may think about me, about our work together, about my office, during the time we otherwise would be meeting. I may think about them. We both may have feelings about one another, about the missed session, and whatever those feelings are (anger? resentment? longing? gratitude? relief?), they will be useful to our work together.

* I’ve placed asterisks next to several things I’ve written here. In each instance, the asterisk indicates that every treatment is unique, every patient is unique. My presumption is that I will do as I’ve said in these asterisked passages, but occasionally, it become apparent that I need to change how I handle things:

A patient who asks me to reschedule every session an hour before the scheduled start, for example, may prompt me to suggest that we revisit my flexibility. One who never reschedules a session but then has an unexpected two-week work trip will likely get some flexibility from me about rescheduling “within seven days.” And a patient who tells me on a Tuesday that they’re leaving for a four-week vacation the next day has completely failed to engage in the thought, the feelings, the conversation, I had hoped my policy would encourage, and I therefore – not punitively, but lovingly – might encourage the patient to handle the next such situation differently. And likely give them a pass the first time, but not the second.

COVID has, necessarily, presented some similar challenges: when a patient is sick, I’ll gladly try to reschedule when they’re better, but with current CDC guidelines, that may not be prudent within my seven-day window.

All of this, I find, helps patients engage in treatment constructively, productively, and – and for some this is quite important – it helps them to see me as a real, separate person – a person with needs, whom their actions affect.

I have a final, straightforward reason for this preferred policy, that I mentioned previously, but it bears repeating: it’s the only policy that makes sense to me. It simply doesn’t make sense to me that I should incur the costs associated with reserving a time for a patient and not be paid for it. I have only so many possible recurring times a week. Holding one for any given patient has a cost for me, and that cost is the same whether the patient attends a session or not. If a patient wants me to hold a time for them, I want them to pay me to do so.