Long post - Mad at husband's therapist - reportable ethics violation?

[Lalu22]

I have a situation that I can't let go of. I'll try to keep this as brief as possible, but it is complicated. I have been in therapy for years, am a recovering alcoholic as is my husband, and determined last year that my relationship with H was holding back my progress in T. H has a mild traumatic brain injury and my T had previously identified that as an issue in some of our problems. He suggested a neuropsychologist for him. He went for several months before saying he'd learned all he could. We also saw a marriage counselor for two or three years. Not much progress.

Last year my T diagnosed me with a dissociative disorder and we started doing EMDR. I began experiencing extreme anxiety, sleep difficulties, etc. as part of the process of doing the internal work, and my relationship with H was definitely destabilized. T's partner, senior in the practice, is an expert in trauma and dissociative disorders and he agreed to see my H and me for relationship stuff. H is primary and his insurance is billed. So we signed releases so the two docs could consult.

Here is my issue. This guy is an egomaniac. He is published and cited in the literature and a professor. He is chronically late - has kept us waiting for 40 minutes more than once and 20 - 30 minutes is probably the norm. He said that is the cost of having a late afternoon appointment (H doesn't want to leave work during the day), that the accumulated latenesses of the day build up. I think it shows disrespect for clients and incompetence in his timekeeping responsibilities.

Last December both H and T were late and I sat in the unstaffed waiting room for over 1/2 hour. H had been late a previous appointment and cooled his jets while T and I met for at least 20 minutes until I suggested we check for him. Then the 3 of us met for 5 - 10 minutes and H's insurance was billed. T said in future if either of us was late, just to come back unescorted to his office.

The appointment in December was the last time I went to this doc. My H had gotten distracted at work and when we got in touch with him by phone, T noted the time (about 5 minutes after T had been available for the appointment, i.e. 40 minutes after the scheduled time) and said we could not meet and he would bill the full undiscounted rate for a missed appointment ("no show").

I think this is outrageous. Since insurance was not billed and I was there, he should have met with me and kept the focus on relationship issues with my H, his primary client. H works 10 minutes away and he could have gotten there, late, but in time for a good chunk of the session. Then insurance could have been billed. As it stood, we got no services and I paid full price for the privilege of sitting in the waiting room for over 1/2 hour. It was T's decision to dismiss me and bill.

I have all kinds of rejection and abandonment issues and I promptly dissociated. (My mom used to get me to confide in her, then use it against me and tell me I was nothing, cf a "no show.") I wasn't quite sure how I got home. That night I hallucinated a voice saying "Nobody is ever going to help you" and experienced flashbacks. After getting the bill I asked my H to ask his T to reconsider. T said no, it was his policy, I wasn't the patient, etc. but I could call him to try to change his mind. I wrote a letter and the only response was for him to collect the $135 from my H at his next appointment.

At that point I found the man so triggering I discussed the situation with my T and asked for a no contact boundary to keep down my fear level in the office. A few weeks later the great man saw me in the waiting room and apologized (perfunctorily) for not responding, saying he could get back to me in whatever way I wanted. It was all I could do to look at him and say I wanted nothing from him. I was shaking. T later said he hadn't succeeded in communicating the exact nature of my desire for no contact to his partner.

Now I am wondering if I should report him to the licensing board. I understand the reactive nature of my response to his behavior, but I still think what he did was grossly unfair, unprofessional, and even dangerous.

[Mark]

I don't have any answer for you, but I can contribute a few comments.

Most therapists that I've known are pretty diligent about keeping to time boundaries with their patients. This means that they do not allow latenesses to accrew across the day, becuase they end sessions on time even if they aren't able to start them on time (e.g., becuase of a patient's lateness). If lateness is due to the therapist's own issue, you'd hope that the therapist would call and reschedule patient's appointments who were inconvenienced, or if that is not possible, to push back everyone's appointments during that day so that all get the time they have understood they would get.

It is normal practice for therapists to bill for no-show appointments. Such policy is supposed to be communicated in advance during early informed consent sessions so that it is not a surprise to patients if it should happen later on.

As I think about it, it's odd to me that psychologists are held to stricter standards of behavior than are physicians, who are routinely late and keep patients waiting all the time. Lateness should not be acceptable in either professional group, I don't think.

There are a number of frustrating issues here.

one is that the pattern seems to be that you are being penalized for the doctor's lateness. He is building his 20-30 minute lateness into your session - so that if I correctly grasp what is happening, you'd sit in the waiting room for 30 minutes and then see him for 20 and he'd bill for a full 50 minute hour? If that is the case, that is fraud in as much as the insurance company is concerned because they are paying for a full 50 minute hour.

Another is that during the appointment that was declared a noshow, you were present but your husband was late but could have gotten there for a few minutes. The power to decide was taken from you, which doesn't make sense (as the therapist was there already and charging for the hour anyway - he might as well let you spend it as you needed to).

Another is that the nature of the couples counseling relationship doesn't seem to have been clarified. Some therapists will tell their couples clients that they cannot be seen independently - only as a couple becuase the couple is the client and not either partner independently. This could have been the therapist's rational for declaring the no-show when you were there, but if that was the case, he really should have made the rule he was working on clear to you and in advance of pulling it out and using it.

In sum, yes, there may be some unethical behaviors present in your interaction, but it isn't clear whether they would rise to the ocassion of a licensure board doing anything more than slapping a wrist. Lateness and failure to provide perfect informed consent (so long as some informed consent has been given) are not truly serious ethical violations as violations go. They need correction, but I doubt someone would lose their license over them.

If there is insurance fraud/misrepresentation happening, that is another matter (but I'm not sure that I'm understanding what has really occured here).

[Lalu22]

Thanks for your reply. Let me clarify the situation.

If a T is 35 minutes late for a session it is not right to bill the client for a missed session, in my moral universe.

As I was typing this, my H who happened to have a 5 pm appointment today, called from his car to say he had been waiting 30 minutes and was leaving. I told him to go back and tell the T, or else we would be billed again. I then left a message on T's machine that my H had been there, had had to leave after waiting 30 minutes, and I sincerely hoped he would not attempt to bill.

H is the patient of record for "family therapy," H's insurance was billed for our joint sessions, and back in December he was late, and ultimately did not come since the T said he couldn't wait for him. However the reason it was so late in the day when this decision was unilaterally made, is that T himself was very late. This therapy was initiated to help H deal with my changes as a result of my own work with the T's partner, also a PhD level psychologist, and to help preserve our marriage. I have a different insurance company.

I'm not after the "offending" T's license: I would love for him to get a slap on the wrist, and have the $135 - or part of it - returned to me. I don't know whom to complain to, since my appeal to him with my views was perfunctorily rebuffed. The Board of Examiners is the only place I know of that hears complaints against licensed psychologists.

Most therapists that I've known are pretty diligent about keeping to time boundaries with their patients. This means that they do not allow latenesses to accrew across the day, becuase they end sessions on time even if they aren't able to start them on time (e.g., becuase of a patient's lateness).

Yes, this is my experience. My T will refund part of the fee if I have to leave at the end of the scheduled time withour having received 45 - 50 minutes because of his not starting on time. I assume if I were late, which I never am, he would still end on time out of consideration for his next patient.

If lateness is due to the therapist's own issue, you'd hope that the therapist would call and reschedule patient's appointments who were inconvenienced, or if that is not possible, to push back everyone's appointments during that day so that all get the time they have understood they would get.

Yes, he lets everyone have their time and then some. He gets so focused on what's going on with his therapeutic interactions behind his office door, he habitually runs late. So his patients put up with it, or never reschedule with him if they can't tolerate the potential for disruption to their own schedules. Both my H and I have heard other patients express extreme irritation with this man, but that is the cost of doing business with him. I think it would be considerate to push his late afternoon appointments back 15 - 30 minutes. This is an issue of ethics to me, habitually being so devaluing of patients' time.

It is normal practice for therapists to bill for no-show appointments. Such policy is supposed to be communicated in advance during early informed consent sessions so that it is not a surprise to patients if it should happen later on.

Yes, it was made clear. My H, with his MTBI, was absent when the good doctor was finally ready for us 35 minutes after our scheduled time. I, however, was there, had been there, and the session could have begun with me. It is not as if there was no one to whom to deliver services. Since he did not bill the insurance company, there is no suggestion of insurance fraud as far as seeing me and billing them. Because it was late in the day, almost the time he would have been going home (in the unlikely event he had maintained his schedule), he unilaterally decided to send me away, but billed anyway. I had waited 5 weeks for this appointment and had a number of questions related to my H's MTBI (doc had received a copies of two of his neuropsych reports). I was not expecting him to "do therapy" on me as an individual, although I had met with him before and had signed releases.

As I think about it, it's odd to me that psychologists are held to stricter standards of behavior than are physicians, who are routinely late and keep patients waiting all the time. Lateness should not be acceptable in either professional group, I don't think.

Agreed, with the possible exception of obstetricians.

There are a number of frustrating issues here.

one is that the pattern seems to be that you are being penalized for the doctor's lateness. He is building his 20-30 minute lateness into your session -so that if I correctly grasp what is happening, you'd sit in the waiting room for 30 minutes and then see him for 20 and he'd bill for a full 50 minute hour?

If that is the case, that is fraud in as much as the insurance company is concerned because they are paying for a full 50 minute hour.

That is not the case.

Another is that during the appointment that was declared a noshow, you were present but your husband was late but could have gotten there for a few minutes. The power to decide was taken from you, which doesn't make sense (as the therapist was there already and charging for the hour anyway - he might as well let you spend it as you needed to).

Yes, precisely. I fantasize he decided to take the extra $$ he got from private billing at the undiscounted rate, and the time he gained by sending me away, and do a little Christmas shopping. This is why I feel victimized. My particular trauma history is that I was brought up by a borderline mother who couldn't care less about my opinion of things, or my rights, or my feelings. T had seen me for several appointments with my husband, had access to info about me via the releases signed with his partner in the practice, my T, so I think it is reasonable and predictable that he would know I would be very hurt by his behavior. First do no harm.

I will continue this absurdly long communication in another reply.

[Lalu22]

Another is that the nature of the couples counseling relationship doesn't seem to have been clarified. Some therapists will tell their couples clients that they cannot be seen independently - only as a couple becuase the couple is the client and not either partner independently. This could have been the therapist's rational for declaring the no-show when you were there, but if that was the case, he really should have made the rule he was working on clear to you and in advance of pulling it out and using it.

Yes, precisely. Given the fact that there was precedent for proceeding in the face of H's tardiness, I was particularly unsettled by the arbitrariness and inconsistency of his behavior. I asked H to ask him to reconsider his billing decision. H did and told him I was very upset. T said "No, it was just business, not personal." (A line from The Godfather!) I wrote him a letter recounting the facts and the timeline and asked if there were some rationale behind his actions. H and he went over the letter in their next session, according to H, and T said he would not change his mind and deposited our check. At this juncture this man became a trigger for me and I had difficulty going to the office to see my own T, knowing he was there. I told my T his partner was a trigger for me and I could no longer participate in "family/relationship therapy" with H's T. My H promised to work really hard to make amends for blowing off the session. I asked T to ask his partner to not look at me or acknowledge me in the office so I could feel safe. He said he would. A couple weeks later offending T made a loud approach to me in the waiting room apologizing for not responding to my letter and asking me how I wanted him to proceed. I said I wanted a no contact boundary. (I was almost fainting at the nearness of him. Later I made the connection with my mother looking at me and saying "You are just a nothing! Begone!) That's how it stands. My T agreed to reinforce to his partner that the no contact boundary is a firm one.

The irony for me is twofold. 1) I was put in a double-bind trying to get help for my H's MTBI issues, then penalized because my H was distracted at work and temporarily forgot the appointment. 2) This T is a recognized trauma expert, a former university professor, and has written a book on treating dissociative disorders which I have seen cited in the literature. He is the biggest trigger I have run across, since I, a traumatized, dissociative person went to him for help with healing a relationship and helping my H to cope with my abreactions. Like my mom used to be who I went to for help, only to be betrayed again and again.

In sum, yes, there may be some unethical behaviors present in your interaction, but it isn't clear whether they would rise to the ocassion of a licensure board doing anything more than slapping a wrist. Lateness and failure to provide perfect informed consent (so long as some informed consent has been given) are not truly serious ethical violations as violations go. They need correction, but I doubt someone would lose their license over them.

As stated above, I am not after his license. Far from it. I support my husband in continuing to see him, because, despite being habitually tardy, I think he has a lot to offer as a clinician. (They have a lot in common, apparently ) I just hate going to him as a petitioner with the "no show" billing thing, and having him be judge, jury and executioner, as it were. I don't want to be rendered voiceless. I think he is wrong, although perhaps legalistically entitled to his geld. As far as protecting his income stream by the no-show billing policy, I think if he is going to be 30+ minutes late on a regular basis, he is not ethically entitled. And to demand private payment at twice his insurance discount rate seems outrageous. I just want a fair hearing. I may be ready to ask him to state his rationale. Now that I made the mother-exploitation/therapist-apparent-exploitation connection, I may not dissolve at the prospect of contacting him again.

If there is insurance fraud/misrepresentation happening, that is another matter (but I'm not sure that I'm understanding what has really occured here).

I have tried to be as clear as I can in explaining. I wrote the particulars down shortly after the incident and I believe my reality testing is intact. I am a trauma survivor, not delusional, and it really bothers me to have to ask this guy to validate my reality and determine what is fair and have him be the court of last resort.

If anyone had made it this far reading this post, you get my personal perseverence award. Thanks. It feels good to get this out.

[Mark]

I understand how upset you are, to have written so much about this interaction. Still, as I read about it, I'm thinking the following:

1) this therapist you're so upset about has some time issues and a case of unawareness as to how those time issue affect some of his patients

2) the time issues are frustrating but not really the issue here - the issue here has to do with the seemingly arbitrarry decision making and no-show billing

I just hate going to him as a petitioner with the "no show" billing thing, and having him be judge, jury and executioner, as it were. I don't want to be rendered voiceless.

and 3) your own issues have set you up to uniquely react to this particular frustrating scenario with particular fury.

So - I don't think this guy is so bad - I think the combination of what happened (which was frustrating but not necessarily terrible) and your own issues of being controlled in the past have collided to create a very bad situation.

the irony of it is that what is happening may be a transference, where you are transfering your frustration with how your mother controlled you onto this therapist who has triggered that old resentment and fury by similarly (but in a much more small way) controlling you. This could be an opportunity to work on your becoming aware of how the past plays out in your present, but given how this has all gone down, it seems like a lost opportunity. that is a shame.

[Lalu22]

I appreciate the subtlety in your choice of words "may be a transference!" I was instantly aware my reaction was way out of bounds "here and now" and communicated that to the man when I asked for fee reconsideration. (I told him, with irony, I was weighing whether to walk out in traffic or pay him $135.) I think his failure to reply to my letter was also unprofessional, and given the extreme effort it took me to confront him, particulary invalidating.

My mother used to bind and gag me, and I had to wait patiently for her convenience to move and talk, and when she would decide it was time she would untie me and speak in reasonable, well-modulated, quasi-therapeutic, "for your own good" tones, but I don't recall ever receiving a bill from her. :mad:

[Lalu22]

It had to be pointed out to me that probably the reason I am so spun up about this therapist, and about my husband's leaving the front door open so the dog escaped (after he let her escape and almost get stolen last week), and every other thing in the world which is ticking me off, etc., is that my father died three weeks ago today. The dog didn't get far, btw, and she is safe now. (The mother used to get rid of my pets because she wanted me to love only her - the father didn't stick up for me or the pets.)

Funny how we forget about the elephant in the room.

[Mark]

Lalu22,

I'm so sorry to hear about your father. Of course that has complicated things.

I'm even more sorry to hear about how you were abused as a child. That truly sucks.

I appreciate the subtlety in your choice of words "may be a transference!"

Hard to know with these sorts of messages, but I gather you've taken offense at my comment. I did not mean my comment to come off as flip or patronizing, for the record. I am certainly not trying to insult your intelligence. I didn't mean my observation to be subtle; I meant it to be something you could think about if you hadn't thought about it.

This therapist you're upset with sounds like not the most empathic therapist ever (understatement), but not a true monster is all. There are lots of people like him in the world, and part of the task of living is to figure out how to co-exist with such people and not make your life worse than it has to be. The situation is, while very frustrating, an opportunity to learn about yourself.

[Lalu22]

Lalu22,

This therapist you're upset with sounds like not the most empathic therapist ever (understatement), but not a true monster is all....The situation is, while very frustrating, an opportunity to learn about yourself.

At some level I think a therapist with very little empathy is kind of like a surgeon with shaking palsy. Lots of knowledge and skill to bring to bear, but watch out! Fortunately, I have a T who can help without driving me out of therapy. No, Dr. I'm-Going-Home-But-Give-Me-Your-Money-Anyway is definitely not a monster. Lots of his patients like him and I think my H benefits.