The Many Reasons Clients No-Show

I wrote about the financial side of "no-shows" in a previous post, but the clinical aspects of no-shows also deserve attention.

My clients have complicated lives. Most are low-income, many are single mothers, some work multiple jobs, have court obligation, or complex medical conditions. I understand how they might get overwhelmed and forget an appointment here and there. Buses and childcare can be unpredictable, money might run low toward the end of the month, and if the phone is shut off, there's no reminder phone call. All legitimate explanations for a missed appointment.

I wouldn't be doing my due diligence, however, if I didn't at least consider the possibility that there's more to it. No-shows can have clinical significance on at least two levels.

First, they may be diagnostically significant. Does the person often forget to do things, in spite of reminders? If so, common causes for memory impairment must be considered, including attentional deficits, cognitive disorganization, or even dementia. If they remember but can't work up the motivation to come in, or even call, that's also informative - avolition is a symptom of mood and thought disorders. Or perhaps they both remember and are motivated to come to their appointment, but 1) oversleep (sedation from meds? staying up late, or even day/night reversal? a new infant, or graveyard shift?), 2) can't find their keys, miss the bus or get off at the wrong stop, get sidetracked on an errand...... (overall disorganization, issues with attention, poor time management, or impulsivity?), 3) had to handle a crisis at work, with the kids, with their health or their aging parents (an isolated incidence, or a pattern, perhaps related to low self-worth, co-dependency, or even narcissism?). I could continue, but you get the idea - sometimes the functional impairments causing someone to seek treatment interfere with their ability to seek treatment. In these cases, managing symptoms well enough to make it to appointments could very well be a treatment goal.

However, even when someone no-shows for perfectly legitimate situational or diagnostic reasons, there's still a deeper clinical level that should be considered - the potential meaning of the missed session in the context of the work between therapist and client. Does the no-show happen right after the client allowed him- or herself to be particularly vulnerable? After the therapist confronted something, or assigned homework? Around a particular date (the first of the month, a holiday, etc)? Or even, predictably, every other session? The client may be - knowingly, or more likely unknowingly - either reverting to avoidance, expressing their ambivalence or resistance, or making a protest.

I'm not suggesting that there is always some deeper meaning to a no-show (sometimes the cigar is really just a cigar). But, sometimes there is something else going on, and if so, the no-show is an opening to address it. If you don't, at best it's a missed opportunity, and at worst, the no-shows will continue until the issue they represent is resolved.

What do you see as the clinical significance of no-shows? How do you address these clinical issues when no-shows happen?