This column, “lateness and ‘no shows’ in psychotherapy”, was previously published on Washington DC psychologist, psychoanalyst, Dr. Lynn Friedman’s blog for her Johns Hopkins graduate students.
After months of planning and laying the groundwork, you’ve opened your private practice. You’ve rented an office two evenings a week. And, at $60.00 a week, you have launched. A patient calls and you schedule an appointment. After a long day at work, you drive to your office and wait eagerly for your very first patient. The bewitching hour is 6:00 pm. 6:00 pm arrives and there’s no patient. Around 6:15 you begin to wonder if you’ve been ghosted. You’re tired. And if you are really honest with yourself, you are steamed because you’ve just driven all of the way to the office for no reason at all. The patient doesn’t bother to call to cancel. You are left cooling your heels.
How should you think lateness and “no shows” in psychotherapy? How should you handle this? Do you stay until the end of the hour? Do you call? Do you wait for the patient to call? How you respond depends on your theoretical orientation. Without any information about the patient, it’s hard to understand the meaning of his behavior. Is he frightened? Angry? Lost? But, understanding the meaning of the behavior is, of course, the task at hand. And it is this understanding that will inform your intervention.
Waiting until the end of the hour — since, after all, it is the patient’s hour, sends a powerful message: that the hour belongs to the patient and that she is responsible for how it will be used. This includes, not using it at all. In this way, if the patient arrives 20 minutes late, for example, she knows that you are there. Leaving, after 15 minutes, sends a different sort of message.
And if, indeed, she arrives, do you extend the hour? After all you have no subsequent patients. That, too, sends a powerful message about how you approach the situation. There’s not a right or wrong answer here EXCEPT that it’s important to have, in your own mind, a clear cut rationale for how you might handle this and why.
This will provide a conceptual framework for what you might say to the patient. In any case, it can be very useful to listen to the patient as they explain their lateness. Do they rush in huffing and puffing very anxious about what you might think of them? Or, do they act as if nothing has happened? How does their lateness sync up with their presenting problem? Learning a bit about their experience of lateness in other arenas might be very useful. However, in this early juncture it must be approached with the utmost tact. And if it can not be gotten at skillfully, it can be tabled until it reveals itself as a more persistent pattern.
What if the patient never shows? Do you call? Again there is some theoretical disagreement about this. Calling maybe experienced as caring. It can also be experienced as intrusive. Not calling may be experienced as respectful of the patient’s autonomy and as letting the patient take responsibility for themselves. It can also be experienced as indifference. Any option carries with it consequences and implications.
A key point to consider is that at this early juncture you are establishing a framework for how you will handle lateness and absence. At the very least, it seems important to clarify the meaning of the behavior. Of course, at this stage of the game the meaning can be very difficult to divine. Obviously, there’s so much to be said about this topic. I hope that you will write in with more questions.