Cancelation fees. We have all experienced them. I so distinctly remember the feelings I experienced when my daughter was a newborn and I was running late for her pediatrician appointment. I was frantically trying to get ready; she, of course, was not aware that the appointment was set at a specific time. She was hungry and made it known to me by communicating non-verbally. Finding it of utmost importance to listen to my children’s non-verbal cues, I sat down and nursed her. I did not rush her; I did not yell at her; I listened to her and I fed her. I also knew at that moment that I would probably be late for her doctor’s appointment. I called the doctor, while nursing, to explain the situation. I naively, at that time, thought they would completely understand.
“They are the pediatrician’s office,” I thought, “They would want me to feed my baby.”
Well, as you can imagine, that is not what happened; instead, I was told that if I was more than 10 minutes late I would have to reschedule and would be charged a cancelation fee. I remember her words hit me in the chest. I was young; I was confused; I was a parent to a newborn, and I was experiencing financial scarcity. I also should mention that this was my second child. Nursing my first child for as long as I desired was interrupted by severe physical illness and this was my opportunity to engage in the nursing experience I wanted not only for my child, but for my own healing journey as well. What is odd to me is that I actually do not recall what I did. Did I stop nursing and take my screaming child to the appointment in order to avoid a cancelation fee? I don’t know. What I do know is that I found a new pediatrician, and kept in mind that there is something wrong with cancelation fees.
Now, as a therapist, I do not have cancelation fees. It is not because I do not value my time, or because I am not a believer in the importance of boundary setting, but because, for me, not having cancelation fees enhances the relationship I want to create with my clients.
Income Inequality
There are so many inequities in health care. The list is endless. Racial inequity, ethnic stereotyping, class bias, sexual orientation denial, and gender disparity in health care are rampant and well-documented. Poverty has been linked to decreased health, and, in that vein, racism has been linked to economic inequality. The idea that there is great intersectionality between all of these health care disparities is undeniable and important to recognize.
Recently, the APA issued a statement apologizing for the inequities in care to black, indigenous and people of color.
It is my belief that cancelation fees feed directly into this systemic inequality. Clients who are working more to support their families, are parenting singularly, have experienced trauma, have/are experiencing systemic oppression, are not feeling psychologically well, and have less resources are all more likely to have to cancel a therapy session and after they are charged fees are probably most likely discontinuing their much needed care.
Respect
When clients ask about my cancelation policy I always say that it is respect. I will respect your time and I ask that you respect mine. Setting boundaries is respectful, and I believe that the act of a client setting boundaries should not lead to any kind of conflict or perceived punishment. Most clients come to therapy already concerned and confused about boundary setting, believing what they have been told, that boundaries are disrespectful and cause harm. If they try to set boundaries within a therapeutic arena and are charged for it, I wonder what impact that has on their understanding of boundary setting, as well as how it can potentially cause a rupture in the therapeutic relationship.
When a client communicates to me that they need to cancel, I always respond with some statement that reinforces the idea that I am glad they were able to voice their need to me and take care of themselves, even if they realized their need 2 hours before a session. Fees feel more like a punishment than a respect of a client’s personal boundary setting. One could ask at this point: “What about the boundaries of the therapist?” To this I reiterate that my boundary is respect and fees do not hold that boundary. In fact, when a client does not respond to a missed session with communication, but rather just says you can charge me a late fee, it is something I make note of. It usually leads me to open up a communication around respect, time, and boundary setting. I reiterate that I understand how their missed session was not an act of disrespect, but rather a human error. I also try to make sure to listen for whether or not we need to have a conversation about whether the time works for them or maybe about their guilt around making mistakes.
I want to build a relationship in which clients communicate if they feel that they cannot make a regular time and then we can create a plan that respects both of our needs. For some of my clients this means finding a different time every week; for others this means having some flexibility as to when the session begins. Also, I will always communicate with a client if their time constraints or needs are not working for me. Interestingly, when a culture of respect is cultivated, I find that clients usually reach out to me first if they are missing numerous sessions, to express that they do not want to disrespect my time and that they would like to no longer hold the specific time.
Trust
Trust is earned. It is not something that should ever be expected. I usually end up communicating this sentiment somewhere within the first couple of sessions. I hold the responsibility for creating a relationship that is based on trust and not the other way around; part of that creation stems from trusting that my clients know what is best for them. This should not be confused with whether or not I challenge my clients to see new perspectives or understand and honor responses that are no longer working because they are causing distress. It does mean that when I challenge them, I also listen to their answers and let their answers challenge my original perspective. It means that I trust when they say “I cannot come to therapy today,” or “I need to change my time,” or “I cannot handle a set schedule.” It is my belief that cancelation fees interrupt the building of trust and instead give the message that I do not trust their assessment of their needs and capabilities at the time, needs that cannot always be assessed 24 hours beforehand.
Mistake Making
We all make mistakes. I make them everyday. I forget things, lose things, say things in a way that I did not want to. If you would have asked my mother (z’’l) she would have agreed with this statement. As a child I was always the kid who left their mittens on the bus, left her book in the locker, or was certain that the teacher had not given instructions, even though they probably had. I was also the child whose mistakes were often met with anger, frustration, exhaustion, or neglect. I remember thinking as a child that I could list the plethora of mistakes I thought adults were making daily, but yet my mistakes were the ones highlighted and criticized. This double standard, this hypocrisy, left me feeling unseen and unloved. As a therapist I make just as many mistakes as my clients. How many times do I change the session date of a client and forget to take them off the first date, resulting in a phone call to them at a time they are not scheduled, followed by a second phone call that says I made a mistake? I have also experienced the internal rise of adrenaline that seems to come from the deep recesses of my heart when I see 2 clients sitting in the waiting room at the same time. I made a mistake. I feel awful. Do I want to be charged a mistake fee? At those times I am looking for empathetic responses and collaborative problem-solving. I think this is what my clients are looking for as well. It is okay that you forgot your session.
Mistakes happen. They happen to me as well.