In an earlier blog, I wrote about last-minute cancellations. One of our readers asked for some tips on practical things we can do to deal with this issue.
In this blog, I’ll give you my thoughts about how to address the problem of last-minute cancellations and no-shows, but first, I want to talk about resistance to therapy.
Resistance to therapy is just what it sounds like: the person feels some hesitation or unwillingness toward the process of psychotherapy and this affects not just how they engage in their therapy sessions but whether or not they show up for them.
Usually, resistance is due to fear – the fear of discovering things about oneself or one’s parents that might be upsetting. Sometimes, the resistance is due to an unwillingness or inability to do the hard work of therapy. Occasionally, the resistance is due to the individual being overly self-centered and disrespectful toward the therapist, and sometimes it’s caused by an unconscious need to act out.
If someone is afraid to face themselves in therapy, they might cancel at the last minute but they don’t mean to be disrespectful. Their fear is making them behave this way. You could call this person avoidant.
If someone is finding that therapy feels overwhelming, they might cancel at the last minute. This individual isn’t trying to be disrespectful; they just can’t face the work of therapy. This would also be an avoidant individual.
The third group – those who are self-centered and disrespectful to the therapist – will cancel at the last minute if something comes up that they’d rather do or if they just don’t feel like going to the appointment in the moment. This type of individual is most likely narcissistic.
Another type of individual is unconsciously trying to re-enact conflicts that they experienced as a child. They’ll behave in ways that are meant to provoke the therapist to anger and to rejection. They have a profound unconscious fear of these things and at the same time, a need to recreate such a scenario in an unconscious attempt to gain some control over it.
This is the client who will show up 40 minutes late for a 45 minute session, or someone who will not show up for a session and then insist that you hadn’t scheduled them for one.
This person often has Borderline Personality Disorder and is engaging in the unconscious defense mechanism of Reaction Formation; that is, provoking the other person to behave in a particular way.
The sad truth is that the hurts and losses of childhood can have a detrimental effect on the personality structure. Some individuals come out of a traumatic past with avoidant traits that make it difficult for them to commit fully to therapy and some have narcissistic or borderline traits that can make it difficult for them to behave respectfully toward others.
The avoidant group is easier to deal with, as they mean well and don’t want to be disrespectful. Members of the personality-disordered group, unfortunately, may be too wounded to behave in a way that would be conducive to a therapeutic alliance.
Some of it depends on the therapist’s tolerance level, of course. If you’re okay with a client canceling at the last minute or showing up 20 minutes late for a session then theoretically, there’s no problem. Although, I do think that allowing this type of behavior without commenting on it can end up enabling the client to continue avoiding or behaving disrespectfully and can sabotage the therapeutic alliance.
My policy for last-minute cancellations or for missed appointments is the same for everyone. I ask for 48 hours notice for cancellations and expect the person to pay for the session if they’re unable to do this.
I have something written out that I give to everyone on their first session, and they have to sign it and bring it back on their next appointment. The majority of people who come to see me are happy to do this.
The few individuals who refuse to sign the paper are making it clear that they aren’t willing to comply with my policy. This is good to know in advance, as I can tell them that we won’t be able to work together.
As I said in my blog on the therapeutic alliance, therapy requires mutual respect as well as mutual trust. If a prospective client refuses to comply with my missed appointment policy it’s clear that they aren’t willing or able to accord me the respect I require.
I have found that if I tolerate disrespect in my practice, I end up feeling exhausted and frustrated and even resentful, and then I feel less inclined to work with the rest of my patients. Taking care of myself in this way prevents burn-out or compassion fatigue.
The client who feels inclined to avoid therapy because of a fear of self-discovery needs some reassurance that they can look at themselves with compassion rather than self-recrimination. An attitude of self-compassion makes self-discovery more tolerable and minimizes resistance.
If they’re avoidant because of a fear of painful realizations about their family of origin, you can reassure them that knowing the truth is always better, as it will enable them to heal and move on with their lives.
The client who feels overwhelmed by the work of therapy can be reassured that the therapist will go as slowly and gently as is comfortable for them. If the client knows they’re able to take therapy at a pace and intensity that’s comfortable for them, they’re less likely to skip appointments or show up late for them.
The narcissistic client is unable to empathize with the therapist. They aren’t inclined to think about the fact that this is how the therapist earns their living. They will continue to flout the rules until the therapist makes it clear that this is unacceptable. This person may or may not learn to abide by a missed appointment policy. They might leave in a huff if you set a limit on their behavior, but ultimately, that spares you more aggravation.
The client who’s engaging in reaction formation may not be able to change, even if you point out to them that you’re not their bad parent and you’re not about to reject them. If they can’t let go of their negative transference and learn to trust you, therapy cannot proceed. Their missed appointments are just the sign that a therapeutic alliance can’t be established here.
In therapy, as in medicine, some people can be healed, some can be helped and some are beyond help. I have never seen it as my responsibility or my capability to fix everyone. I’m there to help those who are able and willing to be helped. And I’m not willing to sacrifice myself in the process.
A therapist is a facilitator of growth and change; not a martyr to the cause. I don’t believe that we ought to sacrifice our needs for the sake of our clients. Putting our needs first is good for us and it teaches our clients to do the same for themselves.
The vast majority of my patients are happy to pay for a missed appointment if they were unable to give me adequate notice. They respect my boundaries and they model after me in the world, expecting others to respect their boundaries as well.
For those who are on a limited budget, I let them pay for the missed appointments in installments of as little as $10 or $20 at a time. They pay as they can but they understand the contract and are committed to complying with it.
It’s empowering for my patients to go along with my policy. They’re not being coddled and they feel like responsible adults. It brings out the best in them and enables them to take responsibility in other aspects of their lives as well. In my therapy practice, having a missed appointment policy is a win-win. I hope it can be the same for you.