No-Showing to Therapy: Is the Patient or Therapist to Blame?

The following is a modified excerpt from a leadership paper Dr. Henrie wrote while still serving in the Air Force. She shares it here as both a call to fellow mental health professionals and a spotlight shined to aid patients in better understanding their therapeutic process, which only stands to validate and empower patients as they engage in therapy.

Every group has its own nuanced culture. Mental health professionals are a peculiar bunch, and some would argue that we have to be peculiar to do the job we do. Perhaps that results in some ghastly senses of humor or wonky strategies for self-care. And perhaps that’s what we have to do or be to survive. Nevertheless, there’s tremendous room for professional and personal growth in our field. All things cannot be accurately attributed to the responsibilities or heaviness of our profession…or if we allow ourselves to persist in inaccurate attributions, we sell ourselves, and our patients, short. And shortcomings in the medical world can have fatal outcomes.

When I was a doctoral student, part of my training was working as a “clerk” (i.e., a supervised, student practitioner) at a private practice in the community. I had three supervisors there, and not one of them had demure personalities. Four and a half hours of supervision per week. Four and a half hours per week of critiquing my every comment, my every movement, my every reaction. Four and a half hours per week of being asked why I was so hard to read…why I didn’t “believe” the strategies I was being sold…why my life was filled with a series of one-way relationships. My early response was one of defense. I felt under attack and fraudulent. While sitting in sessions with my patients, I was sometimes distracted by thoughts of how I might be criticized for what I just said.

Over time, however, my guard started dropping as I gradually came to understand that there was merit in the feedback I received and came to witness how vehemently my supervisors wanted me to grow and succeed. It was the first place I had worked where I consciously recognized that my supervisors wouldn’t summarily cast me in concrete based on their first impression. These were supervisors that wanted to see me climb the proverbial ladder to success, and as I reached each new rung, they erased memory of the prior rung and celebrated the current version of me.

It wasn’t an easy clerkship, and I was certainly having a vastly different experience than my student counterparts. My clerkship emphasized introspection, hard conversations, and personal and professional discomfort. Yet the three years I worked in this clerkship permanently changed who I am as a person and as a professional. Perhaps most importantly, I learned to courageously look in the mirror and examine honestly and objectively my flaws and shortcomings, while simultaneously learning how these flaws and shortcomings insidiously crept in to the work of therapy.

In the mental health world, there is an unfortunate cultural phenomenon of placing blame on patients. One such way that my contemporaries do this is by blaming no-shows and treatment dropouts on patients. It’s common to hear mental health professionals say, “He wasn’t ready for treatment,” or, “She’s just being avoidant.” Frankly, it’s an easy and self-soothing dismissal, and the commonality of this trend allows each of us to comfortably regurgitate these excuses to stave off any professional responsibility of looking in the mirror. And who’s going to question us? We are allegedly the subject matter experts. We have advanced degrees…printed on intimidating-looking paper…hung in expensive-looking frames.

But my clerkship supervisors would allow no such mental laziness, professional negligence, or comforting lies. If one of my patients no-showed, they asked me why. I remember the first time I was saddled with this question, my internal reaction was, “How the hell should I know? I’m not a mind reader.” But this was my internal reaction only because I did not yet have the wisdom to truly understand the question. My supervisors continued to lob this question at me over time. At my next level of understanding, my internal reaction was, “Why are you insinuating it’s my fault? I can’t control what my patients do.” Again, this was my internal reaction only because I did not yet have the wisdom to truly understand the question. As my supervisors continued to mold and groom me (read: Chinese water torture), I eventually developed the wisdom to understand the question. What they were actually asking was, “What did the patient need at the last session that they did not get? What did you do differently? What was lacking that resulted in them not valuing their time with you? Were you fully present? Were you having internal reactions to them? Did they feel judged?…

Once I actually understood the question, it no longer felt threatening. It felt curious and purposeful. And I no longer saw the question as absolute. I came to realize that my supervisors understood that, at times, patients no-show or dropout of treatment for reasons we can’t control, but, at times, they do so because of us. My supervisors wanted me to first exhaust the possibility of my contribution before mentally casting blame on the patient. How can we be excellent, value-added practitioners if we can’t self-reflect or if we can’t understand our role and responsibility in our patients’ treatment investment?

A recent meta-analysis of treatment noncompliance (i.e., no-shows and premature dropouts) revealed a mean noncompliance rate of 42% (Defife, Conklin, Smith, & Poole, 2010). To put the economic gravity of that in perspective, the current TRICARE reimbursement rate for a psychologist’s hour of therapy (in my area) is roughly $132 (see CMAC procedure rates). So if a psychologist sees six patients a day, five days a week, the annual gross would be $205,920. If 42% of patients don’t show up, the psychologist’s annual gross reduces to $119,434. But that’s a rather selfish analysis.

More broadly, high noncompliance rates also mean that slots are “reserved” for patients who often aren’t using them, which results in new patients seeking care not being able to establish services, which is a serious problem in areas where there are shortages of mental health professionals. And if new patients can’t establish mental health services, they can’t get the help they need. It also means that the original patient, the “non-complier,” isn’t getting the care they need, which puts them at higher risk for myriad negative outcomes. And so on.

Countless researchers’ hours and countless government grant-funding dollars have been dedicated to trying to figure out the “vexing” problem of treatment noncompliance (Defife et al., 2010), yet these studies have largely examined the demographics or logistical constraints of patients who no-show. (Notice how patient-blaming that angle of analysis is.) Hell, even the word “noncompliance” suggests that we (the professionals with the fancy paper and fancy frames) order them to do something, and they willfully and belligerently disregard our orders. Only in the last decade or so are researchers starting to ask if something in the therapeutic process happens that results in no-shows. Lo and behold, they’ve found that “perceived disrespect from health care providers…, skepticism of health care service efficacy, and emotional discomfort or embarrassment” (Defife et al., 2010), for example, all contribute to missed appointments.

So back to what I learned in clerkship: My supervisors got me in the habit of asking myself why a patient missed an appointment…what I did differently or inadequately…what was going on with me that influenced the missed appointment. When I asked myself this question honestly and objectively, I was often able to identify the cause…things such as (brace yourself for some real-talk): being annoyed by the patient, being creeped out by the patient, being distracted by other things going on in my head, being emotionally rattled from some other event that just occurred in my life (professionally or personally), feeling lazy (poor investment), or remaining emotionally distant (often due to burnout or the strain of life).

The better I got at identifying my contributions to treatment noncompliance, the better I got at predicting when a patient would no-show to or cancel the next appointment. So I eventually got the message loud and clear. I came to believe that I am directly responsible for my no-show rates, and that my no-show rates are one metric by which I can gauge the quality and competency of my work. Once I acknowledged and took ownership of this phenomenon, my no-show, cancelation, and treatment dropout rates dropped dramatically, and at every place I have since worked, I have had the lowest such rates among my peers. In the Air Force, my average no-show rate was 5%, and in my year first year in private practice, my average no-show rate was 3%.

Sure, it’s hard sometimes to dig deep and be fully present and invested, but I remind myself of the consequences of not doing so. When it feels too overwhelming to think about potential negative, long-term outcomes for patients, I think selfishly. I think about the mess I’ll create by not doing the right thing…about the inevitable no-show, the inevitable arrival at the subsequent session, and the damaged relationship with the patient…that I will be responsible for repairing. And when I’m already feeling stressed out, the thought of having to clean up that mess sounds more taxing than doing it right in the first place. That keeps me honest.

Had I not learned the criticality of self-reflection from my clerkship supervisors, I’d likely have no-show rates similar to industry average. And I’d likely blame patients for those rates. And I’d likely feel professionally impotent to change those rates, which begs the question: What would be the point of practicing as a psychologist if I can’t identify the antecedents to and mechanisms of human behavior…including my own?

 

Joye L. Henrie, PhD

July 2018

 

Defife, J.A., Conklin, C.Z., Smith, J.M., & Poole., J. (2010). Psychotherapy appointment no-shows: Rates and reasons. Psychotherapy Theory, Research, Practice, Training, 47(3), 413-417. doi:10.1037/a0021168