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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 20 of 20. This is the beginning of the thread.
Posted by Dinah on January 23, 2012, at 10:51:54
He knows and wants me to tell why. I'm not willing to tell why because it isn't reasonable of me to be upset. He's done nothing wrong.
I brought up the fact that I think I need to reduce sessions because of the decrease in flexible spending account contributions in 2013. After discussing it for a while, he said that finances are a part of the therapy arrangement, and that everyone needs to make decisions based on that. He said he's had clients decline to come to him because the co-pay was higher on out of network providers. He said he thought we'd discussed going down to three times every two weeks, or maybe once a week.
I did tell him the anecdote about the people unwilling to pay the higher copay bothered me, since I've paid enough over the years to finance a small house. And he said he didn't mean to say the two cases were comparable. Just that finances were often a problem in therapy.
I don't know altogether why I'm upset. I know that other times when it's come up, he's mentioned reducing his fee so that it's still more than what he gets from insurance but less than I'm paying now. I always told him that I wouldn't do that, ask him to take less. But maybe I'm upset that he didn't offer that this time? Or maybe it's just the entire talk of cash is bothering me? Maybe it's because I think he should be willing to see me for the same cost he sees most of his clients, even if I reject his offer?
It's likely he'll bring it up last time because he often does when I leave upset. I don't want to talk about it with him. I'd rather handle it alone. He's not doing anything wrong, but it's hurtful to me. I hope he doesn't press.
Posted by Raisinb on January 23, 2012, at 14:16:06
In reply to I'm upset about an exchange with my therapist, posted by Dinah on January 23, 2012, at 10:51:54
I'd say there are a few likely triggers here: the intrusion of yucky business reality into an intimate relationship, the discussion of other clients (don't they realize that is almost never helpful?), and the suggestion that he might not treat you as good as them (which I am sure he would, but still!)
Is it certain that you have to reduce your session frequency, or just a distant possibility? If it is the latter, maybe you can just avoid this upsetting conversation for the time being. I always felt like there were enough emotional spikes to fall on and avoided that which was not absolutely necessary. Probably not "ideal" client behavior, but whatever.
Posted by Dinah on January 23, 2012, at 16:38:03
In reply to Re: I'm upset about an exchange with my therapist, posted by Raisinb on January 23, 2012, at 14:16:06
Yes, I think that's probably best. I just need to get through his nagging me to tell him what's wrong. I wonder if "I find it a distressing topic, and I'd rather not discuss it" would suffice?
I ought never to have mentioned it. It's been on my mind for a while, but it should have stayed there.
There are still two topics I don't feel comfortable discussing. Therapy finances and body image.
Posted by Anemone on January 23, 2012, at 18:57:13
In reply to I'm upset about an exchange with my therapist, posted by Dinah on January 23, 2012, at 10:51:54
Dinah, here is a hug if you want it. Of course you are upset. You said so many times that he didn't do anything wrong, so you have no reason to be upset. But if I were you I would be upset too.
You paid so much over the years, any other business would give a loyal customer some rewards. And this is not just any business, it's a special therapy relationship, so it feels yuckier. He's mentioned reducing his fee but now he doesn't offer? And he mentions that thing about other clients? I imagine this will continue to bother you unless he hears from you how much it hurt. He needs to be more sensitive about why it upsets you, at least.
Posted by Dinah on January 23, 2012, at 20:58:56
In reply to Re: I'm upset about an exchange with my therapist » Dinah, posted by Anemone on January 23, 2012, at 18:57:13
I'm sure he'd try to understand. I'm not sure he ever could. It's just different on his side of the couch.
I'm also afraid that if he insists I discuss it, I may say some bitter things that won't do any good for our relationship. It will upset me, alienate him, and not really do any good.
Sometimes dogs are better than people. Though come to think of it, I wouldn't trust most of mine if someone else offered them steak.
Posted by emmanuel98 on January 23, 2012, at 21:02:14
In reply to I'm upset about an exchange with my therapist, posted by Dinah on January 23, 2012, at 10:51:54
Well the whole relationship is hard. I once said to my DBT therapist, concerning my p-doc, that I feel like the whole set-up is arranged to cause pain. You love this person, depend on them, but somehow they never forget to ask for their fee, to remind you that you are not their friend or loved-one. But the fee is important. It's how they make a living. I think I mentioned before that I agreed to pay my DBT therapist 3x the required co-pay because the insurance payment was so little and she felt that, if she was going to take responsibility for my suicidality, which she and my p-doc agreed would be best, she needed compensation sufficient for the risk and distress I caused.
I have learned to live with this. But it's hard. My p-doc once said he would see me even if I lost my insurance and couldn't pay, that he would charge whatever I could afford, even $10 or $20 dollars. But he wouldn't, I don't think, accept nothing. The payment is the representation, whether they need it or not, of the limits and nature of the relationship. And that's hard to handle sometimes.
Sometimes I just wish he would see me because he loved and cared about me. He does love and care about me, but the boundaries are there, for your protection as well as his. I have realized that his boundaries, including his asking me for the co-pay even if I am in tears, have kept me from destroying my marriage and life for him, which I would have done gladly, had he allowed it.
Glen Gabbard, who writes these textbooks for psychiatrists on dynamic therapy, says that a good therapist creates and "as if" space or a "play" space. It is as if they are your parent, but they are not. Asking for their fee is part of reminding us that it is "as if" and not entirely real.
Posted by emmanuel98 on January 23, 2012, at 21:15:06
In reply to Re: I'm upset about an exchange with my therapist » Dinah, posted by Anemone on January 23, 2012, at 18:57:13
Well, he does have other clients. He must. He couldn't pay for his office or live on his earnings if he didn't. My p-doc has never been shy about this or encouraged me to feel that I am the only one. When I've gotten upset about whether he cares about me, he says he does. He cares about all his clients. You're not the only one, you know. I know I'm not. I try not to think about that. Irvin Yalom wrote this essay -- many patients, one therapist. Hard to accept, but we all know it to be true. I got upset once about this because I compared it to teaching college. I have many students. They ask me for things and I forget, because I have 90 or more a semester. My p-doc said therapy is not the same. You see 25 -30 patients a week, sometimes less (in his case less because he is semi-retired) and spend an hour with them a week or sometimes twice a week. You really get to know and care about them and remember everything.
You worry, Dinah, about cutting back sessions, but really, after all this time, do you need to see him twice a week? Why not once a week? My p-doc never wanted to do more than once a week. He said more than that would be too intense and make me too dependent on him. I think he was correct in this. I needed to learn to develop and improve and rely on other relationships. The goal is not to see a therapist indefinitely, but to grow, change, move away. This is hard. Harder than I had expected. But I do understand that this is the point, the reality, the reason for the relationship in the first place.
Posted by sleepygirl2 on January 23, 2012, at 21:41:00
In reply to I'm upset about an exchange with my therapist, posted by Dinah on January 23, 2012, at 10:51:54
A discussion about decreasing the number of times you see him + knowing he gets more money seeing you then he might get seeing other folks, that'd leave me unsettled too.
Sure, I know that finances are part of therapy, but it'd bother me still.
Posted by sleepygirl2 on January 23, 2012, at 21:53:01
In reply to Re: I'm upset about an exchange with my therapist » Dinah, posted by sleepygirl2 on January 23, 2012, at 21:41:00
I got that wrong.
People just choose not to see him if the copayment is too high.
Maybe it's the reminder about there being other patients?
Therapy can certainly add up.
I've been lucky with my therapist, he's kept his fees affordable for me.
I do wonder though... What would happen if I wasn't working? No insurance, couldn't pay. Would I go without therapy, go without meds? I don't like to think about it.
Posted by Dinah on January 23, 2012, at 22:30:56
In reply to Re: I'm upset about an exchange with my therapist, posted by emmanuel98 on January 23, 2012, at 21:02:14
I absolutely agree with you.
That's why I said he didn't really do anything wrong.
It still hurts.
There may be a few other aspects that bother me. He's said about the possibility of paying through insurance (which would mean a lower rate for him) "You have the right to do that of course." in a very unhappy tone of voice. And he's sort of intimated that I might not like his diagnosis code - without actually saying so. Perhaps I'm imagining the threat. I guess that's similar to the feelings you're having about the DBT therapist? It's never pleasant, no matter how reasonable it is, to have someone say they don't want to see you at the same rate they see others.
Yet if I'm totally totally honest, I'll say that I like the feeling of power I get by paying him 1 1/2 times his insurance rate. I would hate having him cut his fee for me, because it would alter the balance of power and I'd feel obligated. Even if it's ridiculous to feel obligated if I still receives more from me than most of his clients. If he likes receiving money from me, there's some part of me that likes to pay him. It puts him in his place somehow. There's just something about handing him a check at the end of a session where he's hurt my feelings that somehow feels satisfying in an almost vicious sort of way. It protects me on one level even as it makes me feel insecure on another level.
That sounds absolutely terrible when I write it down, doesn't it? I like to think it's more a statement about my ambivalent feelings about the structure of therapy than it is about my personality. I don't have the impulse to throw a check at the feet of anyone else in my life, just to watch them pick it up off the ground. (Not that I've ever done that. Just in fantasy.)
Posted by Dinah on January 23, 2012, at 22:36:31
In reply to Re: I'm upset about an exchange with my therapist » Dinah, posted by sleepygirl2 on January 23, 2012, at 21:41:00
You didn't get it wrong. There are layers to the issue, and those are definitely among them.
Posted by Dinah on January 23, 2012, at 22:39:35
In reply to Re: I'm upset about an exchange with my therapist, posted by emmanuel98 on January 23, 2012, at 21:15:06
I think our issues are likely different. I still have real problems holding on to a sense of who he is after even a week. For that matter, I still have problems holding on to a sense of who *I* am even after a week.
For me, seeing him more often both maintained the connection, and reduced the intensity. Just as a child clings less when they are certain their mother is near. It's contradictory I know.
Posted by Dinah on January 23, 2012, at 22:41:17
In reply to sorry, posted by sleepygirl2 on January 23, 2012, at 21:53:01
It's scary. I think maybe it's best for me not to think of it either.
I also feel strangely ashamed.
Posted by Twinleaf on January 24, 2012, at 0:18:34
In reply to Re: sorry » sleepygirl2, posted by Dinah on January 23, 2012, at 22:41:17
Dinah, you are being so honest and insightful with us. Don't you feel kind of sad and alone not to be able to discuss it all with him? I hope you will feel more like giving it a try - for me, therapy kind of comes to a halt when I avoid what's really bothering me,
There are a couple of very difficult issues here: you do have a special status as a long-term, higher-paying client, which is a complex issue, and your status is being threatened if you become lower-paying. Even your frequency seems to be now related to how much you pay..I think. We all have constant painful security issues, or we would not be seeing therapists. I think he has placed two additional obstacles to your trust in him; working that out is SO important ( the anger behind it on both sides I mean)
Posted by Dinah on January 24, 2012, at 19:09:38
In reply to Not wanting to discuss it.., posted by Twinleaf on January 24, 2012, at 0:18:34
I suppose I don't trust him to be sensitive on this issue. He likes money a lot. It's not just about therapy. It comes through in his other comments on life. I suppose I consider it a virtue that he's open about it. It's not as if I don't like money myself. But somehow I think I might like it differently than he does. Which is ok. People value different things. Maybe the things I don't feel comfortable discussing are the things I really shouldn't feel comfortable discussing with him. They aren't his strengths.
But as it happened I worried in vain. He didn't bring it up. It's possible that he forgot it entirely. His memory isn't great. Or it's possible he's joined me in a conspiracy of silence on a topic we both think ought to be left alone.
So I was able to feel like a client rather than a john. And I was able to see him as a therapist rather than convert my own feelings of shame into feelings of contempt for him as a whore.
Posted by emmanuel98 on January 24, 2012, at 20:48:52
In reply to Re: I'm upset about an exchange with my therapist » emmanuel98, posted by Dinah on January 23, 2012, at 22:30:56
I guess that's similar to the feelings you're having about the DBT therapist? It's never pleasant, no matter how reasonable it is, to have someone say they don't want to see you at the same rate they see others.
This didn't bother me at all though. I got her concerns and my p-doc met with us both and brought it up as an issue. I told her at first that I didn't think I could pay as much as she was asking, that my husband would object to that monthly outlay and that I would talk to him. She said in the meantime, she would search her heart and decide what she could handle. I found this impressive and so did my p-doc. She would search her heart and think about how much I meant, how much she felt concerned and responsible, how much she might resent me for paying so little. I felt we came to a fair and reasonable agreement. I am well aware that I have been a difficult patient.
>
> Yet if I'm totally totally honest, I'll say that I like the feeling of power I get by paying him 1 1/2 times his insurance rate.This is interesting. I've never thought of the money in terms of power. Maybe because insurance pays. But I've always felt like my p-doc holds the power, since I love him more than he love me and need him more than he needs me. Maybe part of it is knowing that he is fairly well-to-do. He once told me, when I worried out loud that he didn't want to see me, that he didn't need the money.
Posted by Dinah on January 25, 2012, at 1:17:45
In reply to Re: I'm upset about an exchange with my therapist, posted by emmanuel98 on January 24, 2012, at 20:48:52
Hmmm... Perhaps it's a dynamic unique to my therapist and me.
And perhaps not even all of me. Although that cold whisper sometimes influences the most trusting part of me. Particularly when we discuss money.
Nasty topic, money.
I'm glad the DBT therapist's concerns didn't bother you. Perhaps I'm oversensitive.
Posted by Twinleaf on January 25, 2012, at 14:24:05
In reply to Re: Not wanting to discuss it.. » Twinleaf, posted by Dinah on January 24, 2012, at 19:09:38
I hope it works out all right, Dinah. I'm pretty sure I would feel hurt and angry, if I were you - and also very afraid that I would make things worse if I got up the courage to say how i really feel. This has happened to me many times, either through misteps of his or misinterpretations of mine. When we work it out, we're in a slightly better place than before. You may be under- representing his and your abilities in these areas right now...
Posted by Dinah on January 25, 2012, at 18:13:40
In reply to Re: Not wanting to discuss it.., posted by Twinleaf on January 25, 2012, at 14:24:05
Perhaps.
At least in talking about it here, I do realize that he did do some things wrong. Or if not wrong, then at least not well. He *should* have said that we would look at all alternatives, in a positive sort of way. Not that while he may not be pleased at the prospect of a lower rate, it was of course my right to pay with insurance. In that flat tone. And his attitude about my potential diagnosis is not what I would have wanted to see in a person I admire. It did make me feel like I was an income stream. And wonder at his motivations. And feel a bit sleazy.
I'm not being *totally* unreasonable. Slightly unreasonable, yes.
I sometimes think that there is benefit in the constant disappointments and downgrading of expectations in therapy.
Posted by Dinah on January 25, 2012, at 18:34:55
In reply to Re: Not wanting to discuss it.. » Twinleaf, posted by Dinah on January 25, 2012, at 18:13:40
Sometimes I realize I'm like one of those people who complains so much about a spouse then can't quite figure out why other people think so badly of him.
I do tend to complain about the bad more than I recognize the good. And I might be guilty of at least a wee bit of transference.
He's not as bad as I sometimes claim.
This is the end of the thread.
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