The Cancellation

      Ruthie, thirty-three, has not seen me in over a year. At that time, she cancelled her last appointment saying she was “better” and she no longer needed my services. She came to me through her psychologist who felt that her medications could be managed better by me than by her primary care doctor. I prescribed psychotropics which by her account “changed her life.” I connected with her internist who felt that the psychotropics he was prescribing seemed to “do the trick” such that he did not understand why she was being referred to me. I explained to him that certain medications change how people feel such that even though she was stable, the patient felt better on different medications. The internist, Dr. Yee, said, “yes, but couldn’t that be a placebo effect?” “Of course,” I say, “that is always possible.”

   Recently, Ruthie called me on a Friday afternoon, saying that although she has not seen me in a “long time” and she is no longer seeing her previous therapist, she has a new psychotherapist, and she has changed back to her psychotropics prescribed by Dr. Yee, she wants to come back and see me. . Now she says “it is time for a change.” I remember Ruthie well and I look forward to seeing her again, although from our conversation, I am not sure what “time for a change” means. I offer her appointments for the following week, but she says “oh, no I cannot do those times, I have a busy week, how about the next week?” she asks. “Monday,” I say; she enthusiastically accepts. Nine days later, on Sunday, I pick up my messages. “Hi, it’s Ruthie, I need to cancel my appointment for tomorrow since my new therapist sent me to a psychiatrist and I think we are on the right track. If things don’t work out, I will call you back.”

     When did she see the psychiatrist? I wonder. When did she decide not to keep her appointment with me on Monday? I wonder still. Why did she not cancel with me the moment she finished with seeing her new psychiatrist? Maybe she was ambivalent about changing psychiatrists. Maybe on Sunday,  she looked at her calendar for Monday and realized that she no longer needed to see me and she should let me know. I think back to my conversation with Dr. Yee. Maybe he was on to something when he mentioned the placebo effect. Maybe Ruthie is the kind of patient that is vulnerable to placing halos over new doctors. For many people, new represents improved, even though cognitively that makes no sense. New could be improved, but new could  be a lateral move, or a downward step.

     Cancellations, generally speaking, are stimulating. Some colleagues consider cancellations to be aggressive acts against the therapist. Other colleagues spell out cancellation policies which do not allow for personal emergencies. Psychoanalysts, historically speaking, consider their time “leased” meaning that holding the time, whether the patient uses it or not, warrants a fee; it makes therapy  similar to an apartment.

    In Ruthie’s case, I doubt she thinks that I am think about the underpinnings of her cancellation. Ruthie sees me as a psychopharmacologist who at one time in her life helped her, but at this time, maybe another psychiatrist can do even better. Ruthie is not thinking about the relationship she has with me; she is thinking about my psychopharmacological skills. As such, another psychiatrist might have a different skill set which can help her in a new way. By contrast, I am wondering about Ruthie. How has her life changed in the past year? Why now did she decide to make a change? I will miss seeing her.