When the psychotherapy patient comes late or “no-shows”

June 20, 2015

What do you do when the psychotherapy patient comes late or “no shows”. This article was previously published on Dr. Lynn Friedman’s Johns Hopkins blog on psychodynamic psychotherapy psychotherapy.

How do you understand when the psychotherapy patient comes late?

In the last post, we talked about when the psychotherapy patient comes late or “no shows”, in the case of a new patient. Let’s focus today on the current patient who comes late. The most important task, during the hour, is to listen to the patient’s concerns. What has brought them to psychotherapy, or counseling or psychoanalysis, at this time? That is, what is their, “presenting problem”? And if this problem has persisted for a long time, why are they coming now? Often, there is a precipitating event or situation that prompts them to make the call.

Some psychotherapy patients are able to discuss their lateness, directly

As for their lateness, many patients will explain it to you. Some will be able to tell you, spontaneously, that they were apprehensive about coming. The fact that they can tell you this is an extremely good sign. Also, it allows you to empathically ask what sorts of worries or concerns they had about coming. Right away, they are opening the door for an alliance in which you partner with them, helping them to join with you to get a perspective on their concerns. Their candor is a very good thing, indeed.

Others are less aware of the unconscious factor that may drive their lateness

Others may tell you they didn’t allow enough time, didn’t realize that your office was so far away or that they had trouble parking. Although these concerns can be taken literally, it is important for you to make a note to yourself about the unconscious anxieties they may reflect. Beyond unconscious anxieties, their explanation may reveal something about how they navigate the world. For example, the patient who tells you that they didn’t allow enough time may be telling you something about how they approach new situations. They may be a person who has trouble with transitions or who has difficulty allowing themselves to acknowledge that the treatment is important to them. Contrast that to the patient who arrives a half an hour early. Each may be revealing something very important about their personal psychology.

Think in terms of metaphor

The patient who says that they did not realize that your office was so far away may be telling you something, albeit via metaphor, about how far away and foreign treatment or counseling seems to them, at an intrapsychic level. And, what about, “trouble parking”? Is the patient saying that they had trouble allowing themselves to settle down and settle in with the idea of coming? Of course, (as Freud never said) “sometimes a cigar is just a cigar” and it could be¬†premature to make such an interpretation without more data to support the idea. The key here is not to barrage the new patient, who you do not yet know, with interpretations. Instead, it’s more helpful to reflect that it’s not so easy to get started and, depending on your theoretical approach, you might assert that you are glad that they found their way.

Should you extend the session? And, if so, how?

As for whether to extend the session, often you will have no choice but to end the session on time. How do you handle this situation? Again, that depends on how you work. Some clinicians might extend the session noting that they were able to do that tonight whereas, in general, they are not. If done gently, this indirectly conveys to the patient a ground rule of the work (aka the psychotherapy framework; that they have a time set aside for them to use as they see fit. Others might simply end the hour at the regular end time. This too, conveys the same message as the other approach.

New clinicians often make the mistake of allowing the session to go over without comment. An unfortunate aspect of that approach is that it sends an implicit message to the patient that if they come late, than the hour will be extended. Down the pike when the clinician finds themselves filled with resentment and wants to establish new ground rules this can become dicey. More importantly, it can make it difficult to analyze the dynamic occurring between patient and clinician. When the patient keeps the clinician cooling their heels, it’s important to wonder, what’s going on here? And what does it reflect about how the patient is feeling? Does it occur outside of the clinical setting? And what does it reveal about the patient?

Obviously, there is much more to be said about this important topic and I look forward to your future emails about it.

(c) 2019 Lynn Friedman, Ph.D. All rights reserved

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