Impasse: A Tale in 3 Acts

(or When an Unstoppable Force Meets an Immovable Object)

Prologue: At the heart of every good therapeutic alliance there is an impasse – some insurmountable challenge that must be negotiated between client and therapist before the real work begins.  I know, from my own experience, that being in the depths of an impasse is intolerable.  It takes all the courage and energy you can summon to engage in the battle, to fight the good fight.  I share these stories because it helped me to know how others in my own therapeutic lineage tackled these ruptures, and because I hope my own impasse story gives others hope that there is a way through.  It’s messy and terrifying and may never be fully resolved, but it doesn’t have to spell the end.  It is, in fact, often just the beginning.

(Blogger’s note: I am recounting these first two stories as they were told to me.  I do not have firsthand knowledge of the actual exchanges that took place, but I have faith that I have captured the essence of the conflict in both cases.)

Act I: My therapist’s therapist’s therapist, who I am going to call T2R for “Therapist Twice Removed,” had a very strict cancellation policy.  His policy was that he held your appointment time for you, and you were responsible for the fee no matter what.  Even if you knew in advance that you couldn’t make the appointment, for vacation or illness or any other perfectly valid reason, you were still charged the session fee.  The rationale behind this policy was that it was your time, and the therapist was not going to fill that time with another patient, so you were then responsible for compensating the therapist for that time even if you couldn’t personally make use of it.  I have to guess that his client T1R, for “Therapist Once Removed,” knew of this policy and agreed to the terms of it before entering into treatment with T2R.  But then T1R’s father died and the funeral happened to fall on the day of his pre-appointed session.  T1R was furious, absolutely furious, that T2R charged him for that missed session, that he wouldn’t even make an exception for the death of a client’s father.

Act II: My therapist brought her then-boyfriend for couple’s therapy with T1R, whom she was already seeing on her own.  After she and the boy split up, T1R continued to work with the ex-boyfriend without my therapist’s knowledge.  Sometime later my therapist discovered this, when she was almost scheduled for an appointment at a time adjacent to the ex-boyfriend’s appointment – now that would have been quite the waiting room encounter!  She was furious, absolutely furious, that T1R could continue to engage with her selfish, nasty, no-good ex-boyfriend.  She demanded that T1R terminate the relationship at once.  And when T1R refused, the impasse unfolded.   For her, it wasn’t just about feeling violated by the lack of knowledge and transparency – if it had been, she would have just asked to be scheduled away from any conflicts in the waiting room and continued on.  The impasse was difficult because it made it clear how little she actually trusted T1R, or anybody for that matter.

Act III: About 10 months into working with my therapist, she received a letter from my insurance company asking for additional information.  The letter requested that she call the phone number provided and speak to a care manager about my case.  She flat out refused.  She reluctantly, after much pleading from me, agreed to communicate with the insurer in writing, via a form perhaps, but this was not an available option.  So a few months later, when the insurer did not receive the requested information, they started denying all claims, forever more, from now until eternity.  Sometimes I’ll submit a claim, just to see if maybe the clock has reset or the policy has changed.  But claims for my current therapist are always denied.

I know many things now that I didn’t know at the time.  The first is that my insurer requires this kind of review if you submit claims for 20 sessions in 6 months.  Since there are 26 weeks in 6 months, this review will get triggered even if you only see a therapist once a week.  From what I can gather, it’s a pretty standard and routine process.  You call up, answer a few questions, and the insurer continues to reimburse claims, especially if it’s for weekly therapy and it appears you are showing “progress” (which I think is set at a pretty low benchmark).

The second thing I now know is that my therapist has an immovable wall when it comes to dealing with insurance companies.  Very early in her career, decades before she met me, she had an unfortunate run-in with an insurer and swore them off for good, forever.  When we started working together, I knew that she didn’t accept insurance, but I did not realize that “I don’t accept insurance” actually meant “I will never, ever, under any circumstance speak or work with an insurer, ever.”  Period.  End of story.

She has since clarified her policy, the impact of our impasse forever etched into the fine print:

“Although I don’t accept insurance, most of my clients are reimbursed something by their insurance companies, depending on the plan. It’s generally worth it to call and find out what they reimburse for ‘out of network’ mental health services as it gives you a better sense of your financial options and restrictions. Rarely, insurers will contact me for additional information, treatment planning and benefit management even though I do not contract with them. I have chosen not to work with insurers in this way and it may affect your coverage.

She said I was asking her to commit insurance fraud since she did not feel that my insurance company covers the services she provides.  I just wanted her to pick up the phone and make a quick call.  I was furious  – no livid, absolutely livid that she wouldn’t, couldn’t make this call.

H: What happens when an unstoppable force meets an immovable object?

Heck: I haven’t got a bastard clue, I’m afraid.

Tessa: There you are, you see. Now we can let him get married in peace.

Luce: It never happens. If there’s a thing that can’t be stopped, it’s not possible for there to be something else which can’t be moved, and vice versa. They can’t both exist. You see, it’s a trick question is the answer.

~ Imagine Me and You (2005)

I know that the impasse wasn’t entirely about insurance and finances, although that was certainly part of it, both then and now.  The reason why it felt so violating and caused such a rift is because of the parallel dynamic with my coming out process.

I know now that my therapist unknowingly bumped into a big old festering wound that had been untended to for years, and that triggered all kinds of anxieties – about love and abandonment and trust and money and security.  And this happened a time when she was under extraordinary strain in her personal life that impacted her reactions as well.

When I came out, I asked my mother to do something that didn’t seem an unusual or burdensome request to make of a mother: love me, just as I am, because I am asking you to and because I am your daughter.  And she couldn’t do that.  No amount of begging or pleading could get her to shift.  For years afterwards I searched for ways to make myself lovable to her, but always came up short.

Likewise, here I was, asking my therapist to do something for me, something that made her uncomfortable, simply because I was asking.  It did not seem an unusual or burdensome request to make of a therapist: call my insurer so that we can continue working together without causing financial (and emotional) harm to either one of us.  And she couldn’t do that.  No amount of begging or pleading could get her to shift.

How many times do we hear our children challenge us with a “why do I have to do that?”  And how many times do we respond with a “because I asked you to.”  I know I have this fallacy in my head, with both my mother and my therapist, that says “if she really cared about me, she would do this just because I asked.”

Perhaps both situations were also influenced by the power imbalance in each relationship.  As children, we often expect our needs to supersede our parents.  My need, as a child, for love should be more important than my mother’s need to pledge allegiance to the church.  My need, as a patient, to have my therapist call my insurer, should be more important that her need not to ever negotiate with such oppressive corporations.  Both promised to take care of me, to protect me… until my needs crashed into their shadows.

The crux of the impasse on my end was of not feeling understood.  My therapist admitted to me that she had a hard time understanding where I was coming from and why this meant so much.  She has never had a client who felt more attached to an insurance company than her, and she didn’t understand why I wouldn’t just negotiate a new contract with her, directly, a pact between the two of us without any outside interference.  But it wasn’t about that at all.

My mother couldn’t understand, and in fact has never understood me all that well, and as a result acceptance and love have been withheld.  To be connected to her requires that I kill off a piece of myself at the risk of being annihilated all together.  I’ve spent hours dreaming of ways to re-write my coming out experience… what if I did this or that or told them this way or that way?  What could I have done to orchestrate a different ending, one that didn’t leave me so hurt and alone?

And I did the same with the impasse, trying desperately to change the outcome and searching for paths that would not have led us to where it did.  I just wanted to make my therapist understand and it felt that the only way she could demonstrate that she really understood was by complying with my request.  I risked having to kill off a piece of myself to stay connected to her or else I would have to leave.

Heck: Oh come on Rachel. We both know you’d have left me in the end.

Rachel: That’s not true.

Heck: YES IT IS! Yes it is. I want you to be happy. More than anything else I wanted to be the cause of happiness in you. But if I’m not, then I can’t stand in the way, you see? Because what you’re feeling now, Rachel, is the unstoppable force. Which means that I’ve got to move.

~ Imagine Me and You (2005)

We’ve moved on from the impasse and found a way to work together.  I don’t know if we ever found the mystical “third, synthesizing, transformative space” that she always talks of – the place where there is room for both our needs to be heard, voiced, respected, together.  Even now, years later, it is still present and never that far from the surface.  It comes roaring back to life any time we have to re-negotiate the fee or when my trust starts to waver.

But here is the gift at the end of this long battle – we both showed that we care about each other enough to have not hidden our experience from each other, to fight through our fear to remain connected, to be honest and authentic with each other.  This is what we should expect from all healthy/healed relationships in life – that others can care enough to stay connected and love me just as I am,  despite the ways I have disappointed them.  And I can offer the same for the people I love and care for.

Epilogue: So in summary, T1R and my therapist both allow cancellations and never charge for an excused absence.  I don’t know about T1R, but my therapist has never charged me for a missed appointment, even when I’ve had to cancel with less than 24 hours’ notice.  Despite my threats to be a no-show, I’ve never followed through on such wishful thinking, so I don’t know if she would actually charge for that missed session.

Further, my therapist will never ever ever see people who come to her for couples counseling as individuals – unless all parties are aware of the arrangement and explicitly agree to it.  But once that transition is made, she is no longer available to the other half of the couple.

I suspect that if I were a therapist I would adopt all of these policies.  I would allow people to cancel appointments, even last minute if there is a valid and understandable rationale for the miss.  I would be mindful of how I worked with individuals who first presented as a couple.  And I would do everything in my power to help clients navigate the pitfalls of insurance coverage.  Perhaps I am being naïve, but I would never want to leave someone whom I care about feeling hurt or abandoned by any of these transgressions.

I’m sure there would be something else though – you can’t prevent future mistakes from happening, but you can learn from the past.  And that’s what navigating an impasse is all about – finding ways to adapt and compromise, to balance wants and needs, to survive and come out the other side still intact – while staying true to your core and connected to another.  It’s difficult, but not impossible, and the heart of most healing.  I wish you bravery and courage on the therapeutic impasse battlefield.

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