How to handle clients missing appointments

When a client does not turn up for an appointment, it can be a worry for the therapist, a sign of therapeutic rupture or a simple misunderstanding. In this article, we'll explore some of the things to think about when a client does not attend.

Cognitive appraisals

One of the first things we will do when a client does not show up is to try and guess why. As therapists, this is an important step as we will discuss later. But we also need to ensure we don't fall into negative thinking traps.

For example, if a client with anxiety says "my friend did not show up to our meeting because they do not like me" we might challenge that thinking and examine the negative interpretation of ambiguous stimuli: there could be plenty of reasons why they did not show up.

Similarly, there are lots of reasons why our client may have missed their session that is nothing to do with us. Maybe they forgot, had a childcare emergency, were stuck in traffic or had an emergency at work.

It could be that it is something to do with us, but when we examine these ideas we should do so lightly and with an open and accepting mind, rather than judging ourselves or defaulting to the worst-case scenario.

Are we at fault?

There are multiple therapeutic reasons why a client may not show up. Maybe the work is moving too fast for them and feels overwhelming. Maybe something we said upset them last session. Maybe other things are going on in the client's life and that has lowered their tolerance to below the point that can attend therapy this week.

In therapy, we wouldn't talk about "blaming" the client but we would look at the causes of problems. Here Too, we want to take an objective view of what may have gone wrong without blaming ourselves.

Addressing the issue

The first step is to contact the client, inform them of the missed appointment and agree on the date and time of their next one. Further exploration can take place then.

One of the most powerful tools we have is to address the issue with the client in their next session. Resistance is not always conscious in the client so asking direct questions might not yield clear results. But we can explore the issue.

Take a look at this dialogue:

Therapist: "I noticed you didn't show up for our last session. How did you feel that morning?"
Client: "I'm sorry, I just forgot."
Therapist: "That's okay, but I think it would be useful for us to explore that. How did you feel that morning?"
Client: "I'm not sure."
Therapist: "Sometimes clients feel tired, or frustrated, or like therapy seems extra hard work. Did any of those feelings come up for you?"
Client: "Yes, I guess I felt extra tired that morning."
Therapist: "Okay. Did you experience that tiredness at any point in our previous session?"

Here, the therapist begins exploring how the client was feeling. We could expand this to how the client is feeling about therapy in general, their feelings towards us and anything that may indicate a therapeutic rupture.

Is it a pattern?

Another useful indicator is a client's previous behaviour. If the client never misses a session, it will be more of a surprise than a habitual avoider. If a client has missed previous sessions, is there a pattern between the work you were doing and the times they missed sessions before?

Another question to ask yourself is "how do I feel about the client not showing up?" Are you usually excited and disappointed today? Or maybe you are feeling the opposite: the client is normally one of your least favourites and you are relieved they did not come. Noticing our reaction can give us insight into the therapeutic relationship.

Clear policies

Do you charge the client for the missed session? Do you count it as one of their sessions or discharge them in public health? That will depend on the policies of your organisation or private practice.

These situations are why it is important to have clear policies set out in the contracting stage of therapy. If everyone has agreed on the rules up front, there is little arguing.

Conclusion

When a client fails to turn up for an appointment, it could be a genuine mistake or it could be telling us something about the therapeutic relationship and how they are feeling about therapy.

Responding to missed appointments involves practical matters (rescheduling, enforcing cancellation policies) and carefully exploring the issue non-judgementally, both with ourselves and with the client to see what insights we can gain from the experience.