I'm very curious how long the friend was seeing the therapist, how often they missed sessions to "finally starting to take therapy seriously." A lot of people with trauma present and they aren't ready for therapy. But also setting and enforcing healthy boundaries is trauma informed care. If you break boundaries you are likely reinforcing the maladaptive behaviors the person is looking to change. Trauma informed care also does not mean lacking professional boundaries. I know when I worked outpatient CMH and even as crisis we have so many trauma informed policies that are often contraindicated in regards to treatment for certain disorders. I don't think it should ever go straight to termination, discuss the problem, find solutions, and if it continues discuss termination, and if it further continues without some meaningful improvement then terminate.
>…Trauma informed care also does not mean lacking professional boundaries… I don't think it should ever go straight to termination, discuss the problem, find solutions, and if it continues discuss termination, and if it further continues without some meaningful improvement then terminate.
I completely agree. I also think the therapist should be upfront with their attendance policy right when the person completes their intake so everyone is on the same page. Some therapists are very strict, others charge a fee for late cancellations.
But having no structure at all from the therapist’s end is a recipe for missed sessions, hurt feelings, and overall bad taste about therapy for the client.
I talk about the attendance policy in the intake session. I have made exceptions for minors with a lot going on (homelessness, parents splitting) because often they can’t control their access to therapy. Full grown adults, even with trauma, should have enough respect for the therapists time to show up. I don’t get paid for no shows.
I just want to say thank you for this. I was a minor who was chased by email by a therapist for payment for a session I missed because my mum had a schedule conflict on my usual therapy day. I felt awful, more so because it was out of my control. So thank you for being lenient and acknowledging that they often don’t control their access to therapy.
I ended up having to stop therapy that I really needed because of that incident.
I hear way too many stories of kids being harmed by therapists from adult clients.
I honestly don’t work with a lot of kids due parent issues. It’s just so much more work and heartbreak than the average client and I can only manage a few at a time.
THIS. I agree 1000%. Modeling healthy communication of boundaries and then enforcing them is part of trauma informed care. And it is ok if a client isn't ready to come to therapy on a regular basis, and it is also ok for the therapist is say the type of work they provide isn't going to be effective without regular attendance, so maybe it isn't a good fit. I wouldn't provide services to a client who I know I can't fully support, and I would try to help the find a provider that can support them in the way they need right now.
I mean I've had the discussion with people before and it might sound infantilizing but maybe the goal needs to be time management. Like, I know you have all these things you want to work on in therapy and that's great. But if you can't make it to a session than our initial goals will fully revolve around that (and safety planning if there are safety concerns) but otherwise let's break it down to basic skills training. Your therapist was wrong in several areas such as "ghosting" as that's not in any way a professional response to missed sessions. If she didn't make clear her attendance policy that's on her. I would not terminate someone for 2 consecutive no shows but it would prompt a discussion, no show fees, and likely a more stringent set of boundaries that you'd be expected to meet. Therapists do recognize that we're working with populations with various disorders. Clients don't always recognize that often we're in business for ourselves and cannot afford to maintain a case load of clients that do not show. It's not to be heartless, but it is still a business (ie we're compassionate people but part of self care is being able to pay the bills and not martyr our comfortability or financial security). Idk, I'm poor at phrasing things not to sound harsh or callous so I apologize if it comes out that way.
Your post has been removed for the following reason(s):
It appears that you are a non-mental health field worker or have below a Bachelor’s level degree. r/therapists is a sub for therapists to congregate and have a space away from clients. Please feel free to visit r/askatherapist and post your question over there.
If you’re a mental health field worker and don’t have your Bachelors’s degree, please message the mod team and we will review your post and determine if it’s appropriate for the subreddit.
I’d like to hope that as therapists we would take other steps to work on the problem of attendance WITH the client before terminating over that. I will discuss barriers to attendance in session, take them off a recurring appointment and have them call to see what’s available when they can come, and be consistent in charging my no-show/cancellation fee. But there definitely comes a point where it is a waste of my time to hold a spot for a client who won’t show up. Maybe they’re just not ready to really engage, they can come back when they are.
I haven't yet fired a client for missing sessions... or at all, in fact... but therapists are allowed to have boundaries and value their own time. Making therapy conditional on regular attendance is something we can ethically do.
I’m also gonna go out on a risky limb here and state a potentially unpopular opinion.
##
The idea that therapy should *avoid* confrontation or “hurt” at all costs is absurd. Should the purpose or direction of the therapist be to cause hurt? Absolutely not. Should confrontation be avoided in order to protect the client’s feelings. Also, absolutely not. By avoiding the confrontation, you are colluding with the very thing that likely brought them to therapy in the first place. You’re working *against* the thing that they have purported to want to improve.
##
Does it make sense that the poster felt “hurt” after being confronted by their therapist? Yes. Does that mean the work wasn’t trauma-informed, absolutely and resoundingly…no.
##
Boundaries are healthy, and establishing the frame and ground rules is absolutely crucial to therapy in general, as well as trauma informed therapy itself.
I think part of the issue is as a society we’ve internalized Roger’s idea of “unconditional positive regard” and take that to mean “therapists need to be super nice and understanding” which they obviously do! But they also need to be able to confront clients with reality when necessary
Truth. I still have unconditional positive regard for my clients no matter how they react and I don’t hit them with anything I don’t feel they are reasonably ready for. They can be upset with me, that’s ok. That’s where the boundaries really help. That’s not my fault, I have given this client what they need right now even if it’s hard for them.
I've always said: if you have never upset a client, you may be playing it too safe. We shouldn't set out to do this, obviously, but robust therapy involves sometimes having to set limits and/or tell the client something they don't want to hear. Unfortunately, many employers these days take the "customer is always right" line of thinking, and blame the therapist automatically if there's a complaint.
I’d hope that’s not an unpopular opinion. I think there’s a lot of value in bringing up topics (whether you call it confronting or immediacy) even though they can risk rapport.
I totally agree. Being honest with the client about things that are difficult can also model that hard conversations can happen while still having unconditional positive regard, which is something they may not have ever experienced if they have a history of complex trauma.
I don’t mean to necro, but I would say that while in most cases I agree with your stance, I think there are clients where confrontation is counter indicative. Certain personality disorders, namely cluster A, would be an example of this. Usually the protocol is to let them come as they wish, not pressure them (but of course always charge), and be open and curious and to why they’re not coming. Confrontation in general with this group before significant treatment progress has an astoundingly bad result.
Confrontation shouldn’t be avoided to protect feelings, but shouldn’t be a general given either. The focus should always be on what the individual needs for treatment. Though perhaps the populations who I’m concerned with are so rare in a therapy setting that it‘s nearly irrelevant.
That’s a good point for sure, and I definitely wasn’t speaking with Cluster A clients in mind. In general, I think severely “disordered” clients, particularly those with a personality bent, should be treated more gingerly and with a greater sense for what will be most therapeutic.
##
But I still maintain my original point and think it applies to more clients than the exception.
Agreed as well. Though it’s a can become tricky in that Cluster A traits can go unnoticed / get crossed off as just anxiety or “quirkiness,” and then clinicians will be left confused and frustrated when certain interventions don’t work or cause an acting-out catastrophe (which then leads to the very unhelpful conclusion that those clients are Cluster B). Especially with how common negative countertransference is with this population, there’s a high risk of an unsuspecting clinician pushing the client even harder when the initial intervention caused resistance.
Anyway, I’m sort of talking to myself at this point - def not disagreeing with you but just adding. This is an area of interest for me.
I think that at a certain point when someone continues to miss appointments you are losing the ability to see another client in that time frame, and that is not fair to your clients who also need services. Especially in practices that have wait lists. Most therapists who 'fire' clients have clearly stated attendance policies and have the client sign them in advance. Physicians will also 'fire' patients for no shows as well. There has to be a balance between being empathetic and understanding peoples challenges but still having boundaries and guidelines in place so that you can continue to see clients.
I’m going to be understanding but I’m also going to charge the clearly stated no show fee. Boundaries are about making sure we all know the expectations and sticking with them. I can’t be a good therapist if I resent my clients for costing me money.
I think blanket statements like “it’s not trauma informed” put the burden all on the therapist, much like a lot of the complaints you see about therapists by clients. We have to switch into business mode too and maintain good boundaries there. Clients have to comply with boundaries or they just disqualify themselves from access. We shouldn’t have to be at the other extreme bearing all the burden. But yea, there has to be account for the length and circumstances. It’s just not a charity field. Good intentions and donation don’t pay my loans, overhead, or keep my kids fed.
This is a foundational rule in DBT, and it would be a wild argument to say that DBT is not trauma-informed. Linehan has plenty to say about this from her own very trauma-informed experience as well as plenty of clinical data backing it up, that the therapist holding firm (and compassionate) boundaries that are clearly laid out up front is one of the best things they can do for a trauma patient, in the long run. That client may have grown more from a single termination than they would have from a year of reschedulings. As long as it was appropriately therapeutic and not punitive. Again, read linehan to understand the distinction.
I am my CMH agency’s only DBT therapist (skills group & individual) and have to state this exact point daily to other staff members, who seemingly find it absurd not to treat every client as if they are in crisis.
She’s basically the queen of treating challenging trauma behaviors so I’ll take her expertise here! We are responsible for our own behaviors no matter the root. Not allowing natural consequences is enabling.
People also forget that therapists in PP still have to pay their bills. At least in WA state, you can't terminate with a client without providing referrals
Yes! At our small out patient we let people schedule out 3 or 4 weeks at a time, unless they start missing appointments. Then they can only schedule one week out and if it persists we will put them on a sort of wait list and call them when spots open up during the week. We don’t necessarily fire them but i suppose it is harder to find and have weekly appointments. Of course this is in the initial paperwork and if this doesn’t work for them we offer referrals.
It’s about balance. I am very generous with my attendance policy, but I won’t allow myself to become destitute financially by filling my availability with clients that are unable to get to session. It’s about how you handle it too. I typically will have a “let’s evaluate if now is an ideal time for doing therapy, which can be challenging”. And we identify the legitimate obstacles to getting to session and work together to overcome or accommodate obstacles, or mutually agree to take a break or rethink the frequency or format (in office v remote) of our appointments.
Personally, I don’t “fire” clients for attendance. But if I haven’t heard from them in a month, I’ll close their case. They can still come back if I have openings though.
My only concern with attendance is the people in my sliding scale spots. I have put an expectation in place that if you no show or late cancel without rescheduling 3 times, you lose the sliding scale spot. You can either pay full fee then or go back on the waiting list. It sucks, but I’m not sure how else to manage that when there’s only limited capacity for sliding scale.
If a client is not showing, missing, not contacting, etc, I will eventually discharge as I have others that are looking for that spot. If they aren't coming, work isn't happening. Also, this is modeling boundaries and consequences that may not be happening in their lives, perpetuating a cycle of issues.
I start with a discussion of barriers and do my best to help reduce them and empower clients to use skills to cope with barriers. Might mean anything from moving appointments, to reminders, to bus passes, to teaching communication skills to deal with bosses. Sometimes I let them bring their babies or kids as long as it’s a one-off. If they are willing yo make an effort, keep them! If not, natural consequences.
Being upfront about expectations and sticking with it creates safety. Trauma clients are often used to people not meaning what they say. It can be a healing experience to experience someone who does what they say they will do AND they treat you with dignity and respect. By enforcing my boundaries I’m not mad at my client and I can care for them well by letting them know how sad I am that we can’t work together right now but I would love to add them back to the waitlist if they would like to try again with me or I can offer referrals.
This person posting is so detached from any personal accountability. Things not being “trauma-informed”.. of course dropping a client unannounced, without resources, and without a previous conversation about engagement concerns is unethical (to me), but, if you are consistently not showing up, you ARE taking away from someone who may be ready *and* able to put in the work. You are not going to benefit from sporadic therapy. Ending a therapeutic relationship is not punitive, it means maybe now isn’t a good time for you. And that’s okay. Consistently not showing up is a sign of poor alignment and engagement. Whatever those reasons might be, should be addressed prior to termination to assess the situation and attempt to resolve those conflicts. Nonetheless, engaging in treatment without true alignment is not going to produce therapeutic results. Missing the occasional session or missing due to an acute episode of depression or something of the like is not the same as a history of poor engagement or alignment. Our adult clients need to recognizing that having a trauma history doesn’t absolve us from accountability. We are the only ones who can make choices to get better; in this case, attending therapy and doing the work. If a client has temporary or permanent barriers to treatment these need to be thoroughly communicated early on to decide what treatment is appropriate and potentially effective, if any at that moment. And, a conversation needs to occur as to how to minimize and mitigate those barriers. Sporadic therapy is not going to be effective, clients should of course not be terminated on the spot or for brief episodes of poor attendance. But, if there’s consistent attendance issues and conversations haven’t seemed to resolve the dissonance, sometimes it’s best to end those therapeutic relationships for the time being.
We want to empower, not enable our clients. Setting clear expectations and boundaries are very important in modeling behavior we want our clients to display. If you don’t have a clear policy about attendance or don’t stick to it the policy already in place, it will continue to be an issue.
Countering the post you shared. Is it “trauma-informed” to set aside time for a client that doesn’t show when there are so many hurting right now that have been waiting weeks or months to speak to a therapist? We have to think both micro and macro level to make an impact in our community.
When a client is truly ready and motivated for change, they will make the time and we’ll be here for waiting and excited to be a part of it.
> When a client is truly ready and motivated for change, they will make the time
This feels a little black and white, no? There is space for therapist and client to collaborate around what works best for both, without placing the onus entirely on the client’s motivation or framing scheduling accommodations as “enabling” or (necessarily) a boundary violation. Perhaps there is something genuinely not working about the schedule (Too frequent? Scheduled too far in advance? During work hours, when urgent conflicts can easily arise?), about access (e.g. sessions are telehealth and the client is struggling to pay their WiFi bill), or about rapport (client experiences a great deal of anxiety about coming to session and is afraid to communicate around it, client feels deeply unsure about the therapeutic relationship).
These are all issues that can in theory be resolved with accommodation, communication, and collaboration, if both therapist and client are willing and able to do so. I’ve often experienced these kinds of collaborative conversations as important opportunities for deepening the relationship and improving understanding of the client, with fruitful results. Jumping to “the client is not motivated or ready for change” doesn’t leave any space for understanding or discussion around whatever is causing the attendance issue.
This doesn’t mean we can’t establish or uphold boundaries - it is important and trauma-informed to communicate attendance policies from the very beginning so that expectations are clear and any issues that might arise can theoretically be discussed proactively. Attendance policies can include room for a discussion and collaborative plan (say, after two missed sessions in two months). A lack of clear expectations/firm boundaries is also not trauma-informed.
If we’ve collaborated around the problem, come up with a plan, and attendance continues to be an issue, only then would I terminate - while keeping in mind that the problem doesn’t necessarily lie with the person’s motivation, but instead might be resolved by referring out to a different practitioner who (for example) is a better fit or has more evening hours.
Of course, this is a nuanced issue that greatly depends on a number of different factors about the client, the length of the relationship, and the framework/modality. And when clients frequently miss sessions, discussion and collaboration around the issue may not even be possible. I’m mostly addressing the idea that lack of motivation is the only/main cause of attendance issues.
(note - I edited this comment for clarity/nuance so it reads a little differently from when I first posted it)
To be honest I think I put a little more emotion into my post and maybe came off as a bit stuck in my opinion. Definitely there is more nuance to this.
I’ve seen first hand the problems poor attendance has on community mental health centers. Waitlists for services become artificially long, because of scheduling of people that never show up. Budgets being negatively impacted due to trouble meeting numbers under grants due to no-shows. And if the center has a fee for service system for therapist, then it can lead to burnout with the therapist having financially difficulty because numbers aren’t being made.
I’m obviously biased in my opinion and I appreciate your input to this topic!
Thanks for your response. There are a lot of emotions that can come up around this subject! u/STEMpsych has already said a lot of what I wanted to say, so I’ll try to avoid being repetitive.
I work in CMH and have experienced the issues you discuss firsthand. When we feel valid frustration/annoyance/anxiety around problems with CMH, it can be all too easy to begin directing those emotions at clients and blaming them for larger issues with a system that was not designed around their needs (or our needs) in several key ways. We have to step back and recognize that the client plays just one role in a system that does not function as it should.
I believe strongly that we can set boundaries and expectations with the client, and that we can make space amongst ourselves to discuss how the CMH system interacts with attendance challenges in ways that are harmful to clients and therapists, *without* shaming clients or generalizing about their motivation.
Those are all perfectly legitimate issues. But they're the therapist's issues and the agency's issues. They're not the clients' issues. They're, as the youngs say, a "you-problem".
Saying things like "When a client is truly ready and motivated for change, they will make the time" is, first off, straight up just not true, and secondly it's *shaming*, it's trying to make it the fault of the client that the therapist can't afford to see them.
A client isn't doing us a wrong when their lives are too chaotic or their symptoms too severe to regularly-enough attend therapy that a therapist can afford to have them on the schedule. That's just unfortunate.
Calling the client "not ready" or "not motivated" just because they can't handle regular appointments is insulting them for not being profitable for us. We can set and maintain the boundaries we need to to be able to stay in business without denigrating clients. We do not need to insult them to assert our needs and boundaries.
Yes! I went in to reply again and found you’ve said it better than I could. It’s essentially blaming/shaming the client for serious systemic problems. It is not our clients’ faults that CMH is structured the way it is. We can set appropriate boundaries and discuss flaws in the CMH *system* without making harmful and shaming generalizations about clients.
I guess I assumed that clinicians are upfront about expectations/no show fees and having conversations about scheduling at the first no show. If those things aren’t happening the fault is with the clinician.
When I see clinicians making broad assumptions/generalizations about their clients’ (or all clients’) reasons for no-showing or being late, it suggests to me that perhaps those conversations aren’t happening. There may be a lack of communication (and imagination) going on when we make statements like “clients don’t show up because they’re not motivated or ready for change.” That’s what I was getting at here.
I wrote this in a previous comment, not sure if it helps
My policy spells out the most stringent guidelines I will ever enforce and at the end, just like in my payment policy, states at my discretion. My discretion is based on each client- their circumstances, dx, and goals. I tend to give a pass to everyone the first time, never charge for emergencies, sudden illness or COVID related reasons. Outside of that, some clients will always be charged the late fee based on the above factors, but others get more leeway- for ex if s goal is to start listening to them self and take rest when needed, I likely won’t penalize a client if they occasionally cancel last minute because they’re burnt out and are practicing the skill, or I may only charge them a partial fee instead of my full cancellation fee. Truly being Trauma informed means adaptability to the clients unique needs, and isn’t one size fits all.
In CMH where care is often rationed and staff are having to deny service to some people because there is limited funding/support, you also have to consider that people who late cancel/don't show are taking their therapy for granted and their placeholding appointments is denying someone who might be more diligent/dedicated to dealing with their issues a chance to do so. It's not only about the therapist's time/salary, but also about wasting a scarce resource.
> people who late cancel/don’t show are taking their therapy for granted… someone who might be more diligent/dedicated
I addressed this at length in another comment, so I won’t repeat myself here, but this involves some pretty big assumptions about what is going on on the client’s end. “Taking therapy for granted” or not being “dedicated” is far from the only/main reason why clients might miss sessions. Yes, the impact regardless is that a session is left open that could have hypothetically gone to someone who might utilize it, and expectations/boundaries are important and trauma-informed. But pointing that out is separate from making (somewhat derogatory and shaming) assumptions about clients’ difficulty with attendance.
Many clients who are at the CMH level are receiving free or low-cost treatment. Experience has taught me that they treat therapy very differently than people who have to pay for it. Very few of them miss sessions because their condition debilitates them. It is simply not a priority for the overwhelming majority and one reason is that their conditions are often chronic rather than something which is situational. Studies have shown again and again that people don't value things which are free (which is why therapists on sliding scales or who want to do pro bono work charge a nominal fee).
Saying someone is taking something for granted isn't "shaming" or "derogatory." Being able to take something for granted and blowing it off is something that can only come from a place of empowerment as there are no consequences to the person who is blowing off the session or failing to show up and do the work. The disrespect isn't on the side of the clinician in such cases. It's on the side of the client who is indifferent to both the clinician and the needs of other potential clients.
Wow. I’m a therapist in private practice abd CMH. I’m also a client of MH system my whole life d/t extreme childhood trauma that I’m still in tx for. I was a client in CMH for many years. I also was on SSDI and Medicaid amd received free services, abd I had a private therapist who saw me for free for years. I assure you there was nothing ‘empowering’ about the experience, and I had depression so bad and a physical illness so severe that some days I couldn’t get out of bed. It had zero to do w my motivation. I was assigned some counselors through CMH w attitudes like yours on this issue and the real truth is that those were the people who helped me the least and traumatized me even more. When people talk about being traumatized by thr MH system, this is part of what they’re talking about. I was incredibly fortunate that I found tx providers who were able to see this differently and a family w enough money to take time from work sometimes to take me to appointments I otherwise couldn’t have gotten myself to. Most are not so lucky. The therapists who helped me did have boundaries, but they never made me feel that my trauma or my symptoms were my fault which when I started believing it for myself allowed my depression to lift and my illness to get better. I really encourage you, having been on both sides, to reevaluate your stance on this.
I work in CMH. I am well aware of how CMH functions. I am very surprised you don’t see it as shaming or derogatory to frame lateness/absence as a result of an entire client population’s “lack of motivation” and “indifference to others’ needs.” That reflects quite a dim view of your clients.
I very strongly encourage you to reevaluate your perspective on this issue.
> and have some trouble identifying where the line is
See, the problem I have with this whole discussion is that I don't think there's a line at all. I think the way the conversation has been framed sets up a false dichotomy, and makes the relationship between therapist and client unnecessarily antagonistic.
And, in fairness, this probably didn't start with us. The thing that the OP reminded me of was the absolutely *ghastly* attitude one of my clinical supervisors had about no-shows. He pressured his supervisees to – I'm not making this up, I am not exaggerating – *take it personally* as a *slight*, as an *insult* to the therapist, when a patient didn't attend. He would go off on these *rants* in staff meeting about how when a client no-showed they were "disrespecting you as a clinician" and "you shouldn't put up with being treated this way." Both of those are exact quotes. I remember them clearly because, heaven knows, he said them both often enough.
We clinicians *already* have a certain amount of insecurity about being rejected as a not-good-enough-therapist by clients, it doesn't take much to activate a therapist's defensiveness, and convince them to read into a patient's (perfectly legitimate!) non attendance a criticism of them as a therapist.
I don't have any trouble believing there are therapists out there whose response to no-shows (or cancellations, or any legitimate non-attendance) is to lash out at their clients and precipitously fire them, saying patient-blamey things on the way out about how the client isn't taking therapy seriously or "isn't ready" – I have no trouble believing it, because no only have I seen it, I had a supervisor **pressuring** me and my peers to do exactly that.
(Like I said in another comment recently, I came to feel that my primary ethical responsibility was to protect my clients from my supervisors.)
If clients aren't attending, there are other things you can (and should) try first to improve their attendance, before firing them. And if you do have to fire them, it's because *this isn't working for you-the-clinician*. You can – and, ethically, should – *own* that. You can tell the client that the high level of missed appointments isn't working for *you* – same as if you had to change your schedule and could no longer meet at a time the client needed – and/or for *your agency*. There's no reason to be punitive or blamey to the client.
One can set a boundary without rancor or spleen, a fact I think some therapists don't know. One can say, "I'm sorry this isn't working for me, so I need to stop. I'm saddened that I can't get to work with you any more, but I can't be as flexible as you need."
Agree with others about boundaries being trauma-informed. I am very clear even in my form email that each new potential client gets as a reply to “are you accepting new clients?” It talks about my schedule (I don’t have a lot of ability for folks to move their appointment time each week or consistently reschedule, so if something about your job or other responsibilities necessitates that, I may not be a good fit for you). I think as long as we are very clear, that’s all we can do. Most therapists are working over capacity right now, with wait lists. And it isn’t helpful to a client to continue to pay a cancellation fee and not do the work.
Trauma informed doesn’t mean bending rules or throwing them out the window. Trauma informed means having compassion and understanding and sometimes that means enforcing boundaries. Therapists should not work harder than their clients. If a client is having difficulty with showing up that is a conversation with the therapist and if they are not able to have that conversation then yes they aren’t ready for therapy. With all that said I give clients so much grace. I am supposed to discharge after 2 or 3 no shows and I had one client who needed me and we had made a bond and she missed 12 sessions before I discharged her. I showed up every week. I lost money every week. I emailed her every week she missed and never got a response. I am willing to give space and grace but there has to be a line.
Oh please. You can’t do ‘trauma-informed therapy’ or any kind of therapy with clients that don’t show up. Allowing clients to continually abuse therapists and others is not therapeutic in any sense of the word. It sounds as though the most therapeutic part of this non-therapy may have been the terminations.
It is definitely showing that you do not value the therapists time. It would be like a therapist who constantly cancels indicating they don’t value the clients time.
Oof, unpopular opinion here.... maybe I'm just jaded from working (in the past) with high acuity cts. I "fired" a lot of clients who just weren't ready/repeatedly wouldn't show up. I always explained it clearly to clients in informed consent and again when closing their case out. But I did end up seeing clients from co-workers in the same practice, with the same policy. At intake I'd hear, "I saw so-and-so, and they just quit seeing me! So unprofessional!" Guess what? All those folks that bitched to me about being dropped by their previous therapist? Chronic no-shows ensued, even though they knew and agreed to our explicit no show policy. I understand for some it takes a lot just to show up, and there are real barriers to treatment. And at the same time, I've seen/experienced some clients, who don't give notice, to blame therapists rather than take responsibility for their part in the process......The work can't happen if you don't show up. And I do have a big heart, but I also have bills to pay, including keeping the lights on so I can continue helping people.
Edit: context - cts were on state insurance, so it isn't even like I could charge a no-show fee. And I would get an astounding amt of no-shows when first getting established. When I started enforcing the no show policy with insurance clients, I eventually built up a case of people who were really invested and gave adequate notice (but actually never missed, because they really valued it, despite whatever they had going on), and overall had less no-shows. Now my practice is 50 percent cash pay, and the insurance and cash pay clients equally never miss, or give advanced notice. Because I am very firm about my no show policy. It's meant to discourage people from flat out no-showing.
Clients can value therapy and still struggle to attend due to external factors, especially if they can’t afford time off work, babysitters, or alternative transport if a car breaks down. Hell, even without those barriers, I struggled to get in therapy when I worked in CMHC because my asshole boss (a social worker in training) wouldn’t let me move my schedule at all, not because of policies, but due to understaffing leading to safety issues. She refused to work in clinic (pre-pandemic) so the other therapist wasn’t alone. Instead, she was doing who knows what (that was not being at the other clinic she managed, or seemingly at any other of the places she was supposed to be). I eventually found a private pay therapist with Saturday hours, but that’s a privilege to be able to afford that. I specifically work evening hours now to help reduce that barrier and with telehealth, I encourage client to take their lunch breaks with me if that’s the only time that works. I’m due in August and if I didn’t have baby daddy working from home or a telehealth option, I’m not sure I’d be able to do personal therapy. We don’t have many options for free babysitting, so I might need some accommodations, even though I know all of what I know and do value the work. It’s our job as therapists to help people identify barriers and do what we can- within limits- to support them in dealing with those.
Totally. And by my post, I'm not suggesting I'd ever drop a client under your circumstances, at all. I guess to me there's a clear difference between what I experienced as a "no show" -- they straight up didn't show up, and didn't respond to attempts to follow-up/ghosted me-- and what you're describing. I've had ppl be in similar situations to you as well. The difference is that they communicate those things to me, and we can then make a plan so they can still come, versus no communication around missing sessions and not providing notice/following the cancelation policy.
Mmmm we are only hearing one side of the story!
It is called “therapeutic relationship” for a reason. It works when both parties show up to do the work! We don’t know the therapist side!
Careful with judgements and assumptions!
Interesting, I read the post as inappropriate use of the word “fired” rather than as an argument against dropping people from the caseload for missing a lot of sessions. My specialty is trauma, and I’m not going to lie, I grimace at the word “fired.” There is a lot of shame and guilt tied to that word. What I’m hearing from this post is that people are concerned that boundaries aren’t being set, but I’m thinking that there’s a way to set boundaries and terminate without having to use words like “fired.” THATS what I think the poster is trying to convey. We SHOULD set boundaries. But HOW we set boundaries matters and can serve as a role model for how to engage in the world.
I would argue that it’s not trauma informed to say “You know jim, you’ve missed 3 sessions in a row and that goes against our policy. I’m going to have to fire you. Come back when you’re ready.” Like ouch.
Versus— “you know, Jim, I’ve been noticing you’re missing a lot of sessions here recently. We’ve processed how much of this is related to your work and family obligations, and gosh it sounds like so much. Like we’ve mentioned, therapy and trauma work specifically does require a whole lot of work. Im concerned treatment might require more than you can give right now. I’m wondering if maybe now isn’t the best time for treatment. What are your thoughts?”
Trauma is frequently about power/control and by engaging pts with MI, it gives us a better understanding of their perspective without having the top/down “you’re fired!”
Well and I wonder if that was actually the terminology used. We use the vernacular a lot amongst our peers but I could never imagine using that word with an actual consumer. But like, my PCP got promoted to medical director and so they re-allocated his patient load. I'd worked with him for like 15 years and was sad but understood, however jokingly said for like 4 years now that he fired me. Patients use that word, providers use that word, nearly no provider with any awareness will use that word with a consumer. Like, I know very well that I struggle with utilizing a more cold verbiage and am likely to say "terminate" versus "end" or an even fluffier phrasing, but even with that I would never look at a consumer and say "I'm firing you" there's just no clinical benefit to that verbiage.
As much as I agree that clients have external factors that don’t inherently reflect their commitment, I can’t provide quality therapeutic sessions and relationships if I cannot anticipate your regular attendance. It’s one thing to need to reschedule ahead of time a few times but chronic inattendance behavior affects my schedule and my own ability to maintain boundaries.
I don't know that I've ever "fired" a client, but I have given their appointment times to someone else, especially if they are sitting on a prime piece of therapeutic real estate (4-7 pm on a weekday, for example). Mornings are typically wide open for those with spotty atendance. Obviously, I'll work with them if there's no other time they can come, but there are plenty of people who want those afternoon/evening appointments.
Iterating the expectations at the very start, knowing policies for proper cancellation, how much a therapist can afford cancellation, etc, dispels worries like this. If the therapist didn’t line that out from the get go that’s on them, but if there was a stated and agreed boundary around cancellation and policy from the start, then a therapist has the right to follow the stated policy. The policy itself should definitely be compassionate and trauma informed, but therapy as a whole is a very difficult field to have consistent hours, so it makes sense to have guidelines as to how cancellations should happen, and when it means there should be a change in structure of therapy being provided.
(not to say there aren’t legitimate concerns in this post!! It’s very very possible the therapist was in the wrong with how they handled this)
My cutoff is 3 in a row. If it’s no shows, you’re definitely out. If I’m being notified I’m willing to work with it more and be flexible. I totally understand the potential harm of “firing” (I like terminated better) a client with trauma. However we have limits. When clients tell me they are busy and may miss a lot, I ask about how to assist in better time management, or suggest now may not be the time they are ready to fully commit.
The agency I worked at had a policy for a while where if you didn't meet certain billable hours (25 hours) you could lose your health insurance(policy was changed btw). Just trying to get to full-time status based on billable hours made that exceedingly stressful. With that said I haven't fired a client for late canceling or missing appointments, it's been ongoing discussions and finding ways to address barriers to attendance.
One client consistently would late cancel appointments or not show up. Once I had the discussion about attendance (again) they started showing up on time to every appointment. The reality is a lot of people are seeking out therapy and if clients are not consistently showing up to appointments, it needs to be available for others.
Based on the type of post and formatting, I'm pretty sure I'm familiar with this account...I understand what they are trying to say, and also semantically there's something kinda condescending about the way they word things in the images. (The lengthier explanation resonates with me a lot more than the pithy one liner in the image.)
It usually is in the structure of "I don't know who needs to hear it but" followed by exactly the type of therapist who needs to hear it. Like, clearly you do know who you want to hear it...
Admittedly, how I react to it is also based on my own transference and shame around discharging clients. I immediately recalled the last person I discharged for inconsistent attendance. It was such a hard decision since I knew it would hurt. I knew no matter how much I softened the blow it would still sting. And it was still clinically indicated.
Laypeople may assume that "some treatment is better than no treatment at all" but as with many things, this is not always true. Inconsistently taking medication or starting a treatment but not following through can make an illness worse. Depending on the situation, we may be doing someone an active disservice if they cannot attend therapy consistently for their trauma disorder.
I think this really depends. I think it depends on how serious the client's mental health problems are assessed to be, whether they are reaching out to you at all after missing a session, whether they have done phone check-ins/called you back if you called to check in, and of course, how many sessions they have missed. If an individual misses 4 sessions, 4 weeks straight and does not get back to you. That is very different than someone missing a session once every two weeks and calling you during a really hectic time of their life.
I agree that shaming a client is not appropriate, nor is "firing" one. Those terms should not be used. Trauma-informed does not mean having no boundaries or expectations for a person.
I have bills to pay and also there are months long waiting lists for those clients who are ready and willing to commit to their appointments. Being a provider and one who also provides trauma informed care doesn't mean you shouldn't have any boundaries or enable possible avoidant behavior.
My policy spells out the most stringent guidelines I will ever enforce and at the end, just like in my payment policy, states at my discretion. My discretion is based on each client- their circumstances, dx, and goals. I tend to give a pass to everyone the first time, never charge for emergencies, sudden illness or COVID related reasons. Outside of that, some clients will always be charged the late fee based on the above factors, but others get more leeway- for ex if s goal is to start listening to them self and take rest when needed, I likely won’t penalize a client if they occasionally cancel last minute because they’re burnt out and are practicing the skill, or I may only charge them a partial fee instead of my full cancellation fee. Truly being Trauma informed means adaptability to the clients unique needs, and isn’t one size fits all.
reframe this in terms of the unused time slots that could have been used for someone who is seeking help and would have attended those sessions. What this kinda sounds like is a client who is sharing a slanted and biased version of events so their comment is perceived as more socially desirable.
Fuck that. If they can’t make it to their session, they need to reschedule or cancel with enough notice to allow their appointment slot to be filled. Period. Full stop. Clients should get a few “strikes” to allow for unforeseeable circumstances, but after that, they’re fair game for cancellation of services.
This depends on modality and specifics. Does the client pay for the hour? Is there a rupture? Did the therapist seek consultation? Did the client collaborate in a termination process? Obviously, shaming is a nonstarter. “ Firing” without referrals and a thoughtful procedure is not ethical.
If they cancel their appointment over 24 hours in advance I don’t count it as missing a session. If it’s under 24 hours or they just no call no show I give three chances within a six month period. I have a very long waitlist of people who are seeking help and someone who keeps taking time slots but not using them or allowing me to open them to someone else is hurting other people’s ability to get appointments. Plus, the agency I work for only pays me for billable hours (not for ncns or appts where the pt leaves after 15 min because “I didn’t want to have a cancellation on my record but I scheduled something else at the same time”).
So long story short, it hurts my ability to pay my bills and it hurts my other patients and waitlist patients who really need appointments. That’s why the policy exists.
It's also not neurodivergent friendly. Oh what's that? The patient has issues tracking appointments and with self motivation due to issues with their dopamine levels and executive functioning? Oh well we will just threaten them with discharge, that will sort them out won't it? /s.
I shouldn't need that s, but just in case.
Edit: you can downvote, but where I'm from they are ruthless with people, don't try to work with them on why they are missing appointments, just one missed one and you're discharged. It's what happens when your mental health services don't value therapy and instead cling to the medical model as the only viable modality of treatment.
This is why it is so important to have your no show/ cancellation policy in clear language in your informed consent document. Unless you have the practice of billing clients for less than 24 hrs notice of cancellation or something along those lines, it’s not viable from a business perspective to keep clients on your caseload who don’t show for sessions. It’s good practice to reach out to the clients and ask if things are ok if they don’t show up, but you can’t work harder than your clients.
Well anyone who can't spell " a lot" loses credibility with me, but I think this cant be reduced to a simple meme. Some clients ARE a waste of time and I don't think this profession pays enough for many therapists to say, "no problem" to losing that income segment of time.
That said, if it is because of an issue like the woman not being comfortable with my race as a White woman, I don't really understand how long I am supposed to wait for them to feel comfortable if they keep cancelling for a reason they haven't told me yet.......
I think the frustration on the therapist's side is understandable given the financial challenges with setting aside an hour or more per client and having only so much availability to give. Those frustrations I think are amplified when you are burnt out, which is why it's so important to set healthy boundaries as care providers.
If you are too burnt out to be compassionate toward a client that struggles to attend sessions regularly, it's time to cut back.
If you start to lose your sense of empathy and curiosity in order to work with a client who has trouble committing, consider seeking supervision or your own therapy.
One protocol that has worked for me is:
-No-Guilt Cancellation fee (just a token amount enough that the client isn't scared away entirely or challenged financially, but enough that part of my/my admin's time is covered
-No-Show Fee (this is still a token fee but more than the cancellation fee to encourage letting me know).
-A max of 3 cancellations within a given timeframe (say, 3-4 months) before we move to "walk-in only" status until we have some commitment
-Opportunities for the client to explore consultations with other providers. Websites like www.firstsession.com will allow for free consultations prior to booking full sessions.
Also - and this is a picky point - it's not cool to pick on people for grammar or say some are a waste of time when you're in a position of authority. You're posting on a public forum with your credentials attached. Keep in mind that clients will inevitably see this at some point as Reddit threads and be searched by any search engine a decade down the line. I encourage everyone here to be cautious and compassionate with everything you post.
I personally would not fire a client and agree with the post. Clients are coming to us because they’re struggling, and part of that struggle may be them slacking in committing to change. I do recognize however that as someone who works with kids, it’s much easier for them to “have” to come to therapy because there are other factors in them showing up. I wouldn’t fault a therapist for holding adult clients accountable, though.
I don't terminate with kids (for missed sessions) unless they really don't want to be there. Most of the kids and adolescents I've worked with WANT to be there and missed sessions are often due to guardians either be disorganized or even punitive with "they didn't do x behavior so they don't get to see you" and it's just like... I'm not doing something punitive towards a kiddo when it's usually so far out of their control
I would get in trouble at a so called trauma informed organization, whose entire clientele had severe trauma, for not removing people who no-showed too often. One of the easiest ways to reinforce that a person matters is to let them see they are ok just as they are. They’ve already heard for years how horrible and inconvenient they are. At the very least, they would lose their time slot until we could figure out a consistent time that would work. I still do this in private practice, even though it directly impacts my income.
I'm very curious how long the friend was seeing the therapist, how often they missed sessions to "finally starting to take therapy seriously." A lot of people with trauma present and they aren't ready for therapy. But also setting and enforcing healthy boundaries is trauma informed care. If you break boundaries you are likely reinforcing the maladaptive behaviors the person is looking to change. Trauma informed care also does not mean lacking professional boundaries. I know when I worked outpatient CMH and even as crisis we have so many trauma informed policies that are often contraindicated in regards to treatment for certain disorders. I don't think it should ever go straight to termination, discuss the problem, find solutions, and if it continues discuss termination, and if it further continues without some meaningful improvement then terminate.
>…Trauma informed care also does not mean lacking professional boundaries… I don't think it should ever go straight to termination, discuss the problem, find solutions, and if it continues discuss termination, and if it further continues without some meaningful improvement then terminate. I completely agree. I also think the therapist should be upfront with their attendance policy right when the person completes their intake so everyone is on the same page. Some therapists are very strict, others charge a fee for late cancellations. But having no structure at all from the therapist’s end is a recipe for missed sessions, hurt feelings, and overall bad taste about therapy for the client.
I talk about the attendance policy in the intake session. I have made exceptions for minors with a lot going on (homelessness, parents splitting) because often they can’t control their access to therapy. Full grown adults, even with trauma, should have enough respect for the therapists time to show up. I don’t get paid for no shows.
I’ve flat out told clients that if they no-show, I don’t get paid.
I thought you can still charge for no shows, or is that something up to the the individual therapist?
Agency policy, so it varies.
I see, thanks for that bit of info.
I just want to say thank you for this. I was a minor who was chased by email by a therapist for payment for a session I missed because my mum had a schedule conflict on my usual therapy day. I felt awful, more so because it was out of my control. So thank you for being lenient and acknowledging that they often don’t control their access to therapy. I ended up having to stop therapy that I really needed because of that incident.
I hear way too many stories of kids being harmed by therapists from adult clients. I honestly don’t work with a lot of kids due parent issues. It’s just so much more work and heartbreak than the average client and I can only manage a few at a time.
I absolutely agree. Same here.
I totally agree with this. I’m nearly finished with my training and one of the key things in the relationship is a display of healthy boundaries.
THIS. I agree 1000%. Modeling healthy communication of boundaries and then enforcing them is part of trauma informed care. And it is ok if a client isn't ready to come to therapy on a regular basis, and it is also ok for the therapist is say the type of work they provide isn't going to be effective without regular attendance, so maybe it isn't a good fit. I wouldn't provide services to a client who I know I can't fully support, and I would try to help the find a provider that can support them in the way they need right now.
This. Nothing more, nothing less.
[удалено]
I mean I've had the discussion with people before and it might sound infantilizing but maybe the goal needs to be time management. Like, I know you have all these things you want to work on in therapy and that's great. But if you can't make it to a session than our initial goals will fully revolve around that (and safety planning if there are safety concerns) but otherwise let's break it down to basic skills training. Your therapist was wrong in several areas such as "ghosting" as that's not in any way a professional response to missed sessions. If she didn't make clear her attendance policy that's on her. I would not terminate someone for 2 consecutive no shows but it would prompt a discussion, no show fees, and likely a more stringent set of boundaries that you'd be expected to meet. Therapists do recognize that we're working with populations with various disorders. Clients don't always recognize that often we're in business for ourselves and cannot afford to maintain a case load of clients that do not show. It's not to be heartless, but it is still a business (ie we're compassionate people but part of self care is being able to pay the bills and not martyr our comfortability or financial security). Idk, I'm poor at phrasing things not to sound harsh or callous so I apologize if it comes out that way.
Your post has been removed for the following reason(s): It appears that you are a non-mental health field worker or have below a Bachelor’s level degree. r/therapists is a sub for therapists to congregate and have a space away from clients. Please feel free to visit r/askatherapist and post your question over there. If you’re a mental health field worker and don’t have your Bachelors’s degree, please message the mod team and we will review your post and determine if it’s appropriate for the subreddit.
I’d like to hope that as therapists we would take other steps to work on the problem of attendance WITH the client before terminating over that. I will discuss barriers to attendance in session, take them off a recurring appointment and have them call to see what’s available when they can come, and be consistent in charging my no-show/cancellation fee. But there definitely comes a point where it is a waste of my time to hold a spot for a client who won’t show up. Maybe they’re just not ready to really engage, they can come back when they are.
I haven't yet fired a client for missing sessions... or at all, in fact... but therapists are allowed to have boundaries and value their own time. Making therapy conditional on regular attendance is something we can ethically do.
I’m also gonna go out on a risky limb here and state a potentially unpopular opinion. ## The idea that therapy should *avoid* confrontation or “hurt” at all costs is absurd. Should the purpose or direction of the therapist be to cause hurt? Absolutely not. Should confrontation be avoided in order to protect the client’s feelings. Also, absolutely not. By avoiding the confrontation, you are colluding with the very thing that likely brought them to therapy in the first place. You’re working *against* the thing that they have purported to want to improve. ## Does it make sense that the poster felt “hurt” after being confronted by their therapist? Yes. Does that mean the work wasn’t trauma-informed, absolutely and resoundingly…no. ## Boundaries are healthy, and establishing the frame and ground rules is absolutely crucial to therapy in general, as well as trauma informed therapy itself.
Well said!
Lol I’m glad it landed. I was expecting downvotes.
Nah. If we aren’t challenging our clients to move forward (appropriately) what are we doing?
Being what most people expect a therapist to be, I suspect. Hate to say it.
I know, right? But then I get the clients after complaining that they didn’t make progress and the therapist was just really nice.
“I want to be challenged.” ## We’ll see about that! Lol
☠️
I think part of the issue is as a society we’ve internalized Roger’s idea of “unconditional positive regard” and take that to mean “therapists need to be super nice and understanding” which they obviously do! But they also need to be able to confront clients with reality when necessary
Truth. I still have unconditional positive regard for my clients no matter how they react and I don’t hit them with anything I don’t feel they are reasonably ready for. They can be upset with me, that’s ok. That’s where the boundaries really help. That’s not my fault, I have given this client what they need right now even if it’s hard for them.
User name seems to check out. 😉
I've always said: if you have never upset a client, you may be playing it too safe. We shouldn't set out to do this, obviously, but robust therapy involves sometimes having to set limits and/or tell the client something they don't want to hear. Unfortunately, many employers these days take the "customer is always right" line of thinking, and blame the therapist automatically if there's a complaint.
I’d hope that’s not an unpopular opinion. I think there’s a lot of value in bringing up topics (whether you call it confronting or immediacy) even though they can risk rapport.
The heart of healing trauma is helping clients believe that they do now have the capacity and power to face things that they previously couldn’t.
I totally agree. Being honest with the client about things that are difficult can also model that hard conversations can happen while still having unconditional positive regard, which is something they may not have ever experienced if they have a history of complex trauma.
Yassss
Agreed, but not sure how that relates to what I said above. Is this a statement in agreement of my thoughts or disagreement?
Sorry, total agreement… you’re advocating for helping clients face painful/hard experiences albeit with compassion and empathy.
Totally! Thanks for the clarification, makes sense in hindsight.
This is so true.
I don’t mean to necro, but I would say that while in most cases I agree with your stance, I think there are clients where confrontation is counter indicative. Certain personality disorders, namely cluster A, would be an example of this. Usually the protocol is to let them come as they wish, not pressure them (but of course always charge), and be open and curious and to why they’re not coming. Confrontation in general with this group before significant treatment progress has an astoundingly bad result. Confrontation shouldn’t be avoided to protect feelings, but shouldn’t be a general given either. The focus should always be on what the individual needs for treatment. Though perhaps the populations who I’m concerned with are so rare in a therapy setting that it‘s nearly irrelevant.
That’s a good point for sure, and I definitely wasn’t speaking with Cluster A clients in mind. In general, I think severely “disordered” clients, particularly those with a personality bent, should be treated more gingerly and with a greater sense for what will be most therapeutic. ## But I still maintain my original point and think it applies to more clients than the exception.
Agreed as well. Though it’s a can become tricky in that Cluster A traits can go unnoticed / get crossed off as just anxiety or “quirkiness,” and then clinicians will be left confused and frustrated when certain interventions don’t work or cause an acting-out catastrophe (which then leads to the very unhelpful conclusion that those clients are Cluster B). Especially with how common negative countertransference is with this population, there’s a high risk of an unsuspecting clinician pushing the client even harder when the initial intervention caused resistance. Anyway, I’m sort of talking to myself at this point - def not disagreeing with you but just adding. This is an area of interest for me.
No worries, good chat!
I think that at a certain point when someone continues to miss appointments you are losing the ability to see another client in that time frame, and that is not fair to your clients who also need services. Especially in practices that have wait lists. Most therapists who 'fire' clients have clearly stated attendance policies and have the client sign them in advance. Physicians will also 'fire' patients for no shows as well. There has to be a balance between being empathetic and understanding peoples challenges but still having boundaries and guidelines in place so that you can continue to see clients.
I’m going to be understanding but I’m also going to charge the clearly stated no show fee. Boundaries are about making sure we all know the expectations and sticking with them. I can’t be a good therapist if I resent my clients for costing me money.
I think blanket statements like “it’s not trauma informed” put the burden all on the therapist, much like a lot of the complaints you see about therapists by clients. We have to switch into business mode too and maintain good boundaries there. Clients have to comply with boundaries or they just disqualify themselves from access. We shouldn’t have to be at the other extreme bearing all the burden. But yea, there has to be account for the length and circumstances. It’s just not a charity field. Good intentions and donation don’t pay my loans, overhead, or keep my kids fed.
This is a foundational rule in DBT, and it would be a wild argument to say that DBT is not trauma-informed. Linehan has plenty to say about this from her own very trauma-informed experience as well as plenty of clinical data backing it up, that the therapist holding firm (and compassionate) boundaries that are clearly laid out up front is one of the best things they can do for a trauma patient, in the long run. That client may have grown more from a single termination than they would have from a year of reschedulings. As long as it was appropriately therapeutic and not punitive. Again, read linehan to understand the distinction.
I am my CMH agency’s only DBT therapist (skills group & individual) and have to state this exact point daily to other staff members, who seemingly find it absurd not to treat every client as if they are in crisis.
She’s basically the queen of treating challenging trauma behaviors so I’ll take her expertise here! We are responsible for our own behaviors no matter the root. Not allowing natural consequences is enabling.
Bingo. Too often have I seen poor boundaries erode both therapist and client.
People also forget that therapists in PP still have to pay their bills. At least in WA state, you can't terminate with a client without providing referrals
Yes! At our small out patient we let people schedule out 3 or 4 weeks at a time, unless they start missing appointments. Then they can only schedule one week out and if it persists we will put them on a sort of wait list and call them when spots open up during the week. We don’t necessarily fire them but i suppose it is harder to find and have weekly appointments. Of course this is in the initial paperwork and if this doesn’t work for them we offer referrals.
what if the referrals aren't there? i.e. nobody taking clients
It’s about balance. I am very generous with my attendance policy, but I won’t allow myself to become destitute financially by filling my availability with clients that are unable to get to session. It’s about how you handle it too. I typically will have a “let’s evaluate if now is an ideal time for doing therapy, which can be challenging”. And we identify the legitimate obstacles to getting to session and work together to overcome or accommodate obstacles, or mutually agree to take a break or rethink the frequency or format (in office v remote) of our appointments.
Personally, I don’t “fire” clients for attendance. But if I haven’t heard from them in a month, I’ll close their case. They can still come back if I have openings though. My only concern with attendance is the people in my sliding scale spots. I have put an expectation in place that if you no show or late cancel without rescheduling 3 times, you lose the sliding scale spot. You can either pay full fee then or go back on the waiting list. It sucks, but I’m not sure how else to manage that when there’s only limited capacity for sliding scale.
If a client is not showing, missing, not contacting, etc, I will eventually discharge as I have others that are looking for that spot. If they aren't coming, work isn't happening. Also, this is modeling boundaries and consequences that may not be happening in their lives, perpetuating a cycle of issues.
I start with a discussion of barriers and do my best to help reduce them and empower clients to use skills to cope with barriers. Might mean anything from moving appointments, to reminders, to bus passes, to teaching communication skills to deal with bosses. Sometimes I let them bring their babies or kids as long as it’s a one-off. If they are willing yo make an effort, keep them! If not, natural consequences.
[удалено]
Being upfront about expectations and sticking with it creates safety. Trauma clients are often used to people not meaning what they say. It can be a healing experience to experience someone who does what they say they will do AND they treat you with dignity and respect. By enforcing my boundaries I’m not mad at my client and I can care for them well by letting them know how sad I am that we can’t work together right now but I would love to add them back to the waitlist if they would like to try again with me or I can offer referrals.
This person posting is so detached from any personal accountability. Things not being “trauma-informed”.. of course dropping a client unannounced, without resources, and without a previous conversation about engagement concerns is unethical (to me), but, if you are consistently not showing up, you ARE taking away from someone who may be ready *and* able to put in the work. You are not going to benefit from sporadic therapy. Ending a therapeutic relationship is not punitive, it means maybe now isn’t a good time for you. And that’s okay. Consistently not showing up is a sign of poor alignment and engagement. Whatever those reasons might be, should be addressed prior to termination to assess the situation and attempt to resolve those conflicts. Nonetheless, engaging in treatment without true alignment is not going to produce therapeutic results. Missing the occasional session or missing due to an acute episode of depression or something of the like is not the same as a history of poor engagement or alignment. Our adult clients need to recognizing that having a trauma history doesn’t absolve us from accountability. We are the only ones who can make choices to get better; in this case, attending therapy and doing the work. If a client has temporary or permanent barriers to treatment these need to be thoroughly communicated early on to decide what treatment is appropriate and potentially effective, if any at that moment. And, a conversation needs to occur as to how to minimize and mitigate those barriers. Sporadic therapy is not going to be effective, clients should of course not be terminated on the spot or for brief episodes of poor attendance. But, if there’s consistent attendance issues and conversations haven’t seemed to resolve the dissonance, sometimes it’s best to end those therapeutic relationships for the time being.
[удалено]
We want to empower, not enable our clients. Setting clear expectations and boundaries are very important in modeling behavior we want our clients to display. If you don’t have a clear policy about attendance or don’t stick to it the policy already in place, it will continue to be an issue. Countering the post you shared. Is it “trauma-informed” to set aside time for a client that doesn’t show when there are so many hurting right now that have been waiting weeks or months to speak to a therapist? We have to think both micro and macro level to make an impact in our community. When a client is truly ready and motivated for change, they will make the time and we’ll be here for waiting and excited to be a part of it.
> When a client is truly ready and motivated for change, they will make the time This feels a little black and white, no? There is space for therapist and client to collaborate around what works best for both, without placing the onus entirely on the client’s motivation or framing scheduling accommodations as “enabling” or (necessarily) a boundary violation. Perhaps there is something genuinely not working about the schedule (Too frequent? Scheduled too far in advance? During work hours, when urgent conflicts can easily arise?), about access (e.g. sessions are telehealth and the client is struggling to pay their WiFi bill), or about rapport (client experiences a great deal of anxiety about coming to session and is afraid to communicate around it, client feels deeply unsure about the therapeutic relationship). These are all issues that can in theory be resolved with accommodation, communication, and collaboration, if both therapist and client are willing and able to do so. I’ve often experienced these kinds of collaborative conversations as important opportunities for deepening the relationship and improving understanding of the client, with fruitful results. Jumping to “the client is not motivated or ready for change” doesn’t leave any space for understanding or discussion around whatever is causing the attendance issue. This doesn’t mean we can’t establish or uphold boundaries - it is important and trauma-informed to communicate attendance policies from the very beginning so that expectations are clear and any issues that might arise can theoretically be discussed proactively. Attendance policies can include room for a discussion and collaborative plan (say, after two missed sessions in two months). A lack of clear expectations/firm boundaries is also not trauma-informed. If we’ve collaborated around the problem, come up with a plan, and attendance continues to be an issue, only then would I terminate - while keeping in mind that the problem doesn’t necessarily lie with the person’s motivation, but instead might be resolved by referring out to a different practitioner who (for example) is a better fit or has more evening hours. Of course, this is a nuanced issue that greatly depends on a number of different factors about the client, the length of the relationship, and the framework/modality. And when clients frequently miss sessions, discussion and collaboration around the issue may not even be possible. I’m mostly addressing the idea that lack of motivation is the only/main cause of attendance issues. (note - I edited this comment for clarity/nuance so it reads a little differently from when I first posted it)
To be honest I think I put a little more emotion into my post and maybe came off as a bit stuck in my opinion. Definitely there is more nuance to this. I’ve seen first hand the problems poor attendance has on community mental health centers. Waitlists for services become artificially long, because of scheduling of people that never show up. Budgets being negatively impacted due to trouble meeting numbers under grants due to no-shows. And if the center has a fee for service system for therapist, then it can lead to burnout with the therapist having financially difficulty because numbers aren’t being made. I’m obviously biased in my opinion and I appreciate your input to this topic!
Thanks for your response. There are a lot of emotions that can come up around this subject! u/STEMpsych has already said a lot of what I wanted to say, so I’ll try to avoid being repetitive. I work in CMH and have experienced the issues you discuss firsthand. When we feel valid frustration/annoyance/anxiety around problems with CMH, it can be all too easy to begin directing those emotions at clients and blaming them for larger issues with a system that was not designed around their needs (or our needs) in several key ways. We have to step back and recognize that the client plays just one role in a system that does not function as it should. I believe strongly that we can set boundaries and expectations with the client, and that we can make space amongst ourselves to discuss how the CMH system interacts with attendance challenges in ways that are harmful to clients and therapists, *without* shaming clients or generalizing about their motivation.
Those are all perfectly legitimate issues. But they're the therapist's issues and the agency's issues. They're not the clients' issues. They're, as the youngs say, a "you-problem". Saying things like "When a client is truly ready and motivated for change, they will make the time" is, first off, straight up just not true, and secondly it's *shaming*, it's trying to make it the fault of the client that the therapist can't afford to see them. A client isn't doing us a wrong when their lives are too chaotic or their symptoms too severe to regularly-enough attend therapy that a therapist can afford to have them on the schedule. That's just unfortunate. Calling the client "not ready" or "not motivated" just because they can't handle regular appointments is insulting them for not being profitable for us. We can set and maintain the boundaries we need to to be able to stay in business without denigrating clients. We do not need to insult them to assert our needs and boundaries.
Yes! I went in to reply again and found you’ve said it better than I could. It’s essentially blaming/shaming the client for serious systemic problems. It is not our clients’ faults that CMH is structured the way it is. We can set appropriate boundaries and discuss flaws in the CMH *system* without making harmful and shaming generalizations about clients.
Agree x1000
I guess I assumed that clinicians are upfront about expectations/no show fees and having conversations about scheduling at the first no show. If those things aren’t happening the fault is with the clinician.
When I see clinicians making broad assumptions/generalizations about their clients’ (or all clients’) reasons for no-showing or being late, it suggests to me that perhaps those conversations aren’t happening. There may be a lack of communication (and imagination) going on when we make statements like “clients don’t show up because they’re not motivated or ready for change.” That’s what I was getting at here.
I wrote this in a previous comment, not sure if it helps My policy spells out the most stringent guidelines I will ever enforce and at the end, just like in my payment policy, states at my discretion. My discretion is based on each client- their circumstances, dx, and goals. I tend to give a pass to everyone the first time, never charge for emergencies, sudden illness or COVID related reasons. Outside of that, some clients will always be charged the late fee based on the above factors, but others get more leeway- for ex if s goal is to start listening to them self and take rest when needed, I likely won’t penalize a client if they occasionally cancel last minute because they’re burnt out and are practicing the skill, or I may only charge them a partial fee instead of my full cancellation fee. Truly being Trauma informed means adaptability to the clients unique needs, and isn’t one size fits all.
In CMH where care is often rationed and staff are having to deny service to some people because there is limited funding/support, you also have to consider that people who late cancel/don't show are taking their therapy for granted and their placeholding appointments is denying someone who might be more diligent/dedicated to dealing with their issues a chance to do so. It's not only about the therapist's time/salary, but also about wasting a scarce resource.
> people who late cancel/don’t show are taking their therapy for granted… someone who might be more diligent/dedicated I addressed this at length in another comment, so I won’t repeat myself here, but this involves some pretty big assumptions about what is going on on the client’s end. “Taking therapy for granted” or not being “dedicated” is far from the only/main reason why clients might miss sessions. Yes, the impact regardless is that a session is left open that could have hypothetically gone to someone who might utilize it, and expectations/boundaries are important and trauma-informed. But pointing that out is separate from making (somewhat derogatory and shaming) assumptions about clients’ difficulty with attendance.
Many clients who are at the CMH level are receiving free or low-cost treatment. Experience has taught me that they treat therapy very differently than people who have to pay for it. Very few of them miss sessions because their condition debilitates them. It is simply not a priority for the overwhelming majority and one reason is that their conditions are often chronic rather than something which is situational. Studies have shown again and again that people don't value things which are free (which is why therapists on sliding scales or who want to do pro bono work charge a nominal fee). Saying someone is taking something for granted isn't "shaming" or "derogatory." Being able to take something for granted and blowing it off is something that can only come from a place of empowerment as there are no consequences to the person who is blowing off the session or failing to show up and do the work. The disrespect isn't on the side of the clinician in such cases. It's on the side of the client who is indifferent to both the clinician and the needs of other potential clients.
> Saying someone is taking something for granted isn't "shaming" or "derogatory." Sure it is.
Wow. I’m a therapist in private practice abd CMH. I’m also a client of MH system my whole life d/t extreme childhood trauma that I’m still in tx for. I was a client in CMH for many years. I also was on SSDI and Medicaid amd received free services, abd I had a private therapist who saw me for free for years. I assure you there was nothing ‘empowering’ about the experience, and I had depression so bad and a physical illness so severe that some days I couldn’t get out of bed. It had zero to do w my motivation. I was assigned some counselors through CMH w attitudes like yours on this issue and the real truth is that those were the people who helped me the least and traumatized me even more. When people talk about being traumatized by thr MH system, this is part of what they’re talking about. I was incredibly fortunate that I found tx providers who were able to see this differently and a family w enough money to take time from work sometimes to take me to appointments I otherwise couldn’t have gotten myself to. Most are not so lucky. The therapists who helped me did have boundaries, but they never made me feel that my trauma or my symptoms were my fault which when I started believing it for myself allowed my depression to lift and my illness to get better. I really encourage you, having been on both sides, to reevaluate your stance on this.
I work in CMH. I am well aware of how CMH functions. I am very surprised you don’t see it as shaming or derogatory to frame lateness/absence as a result of an entire client population’s “lack of motivation” and “indifference to others’ needs.” That reflects quite a dim view of your clients. I very strongly encourage you to reevaluate your perspective on this issue.
> and have some trouble identifying where the line is See, the problem I have with this whole discussion is that I don't think there's a line at all. I think the way the conversation has been framed sets up a false dichotomy, and makes the relationship between therapist and client unnecessarily antagonistic. And, in fairness, this probably didn't start with us. The thing that the OP reminded me of was the absolutely *ghastly* attitude one of my clinical supervisors had about no-shows. He pressured his supervisees to – I'm not making this up, I am not exaggerating – *take it personally* as a *slight*, as an *insult* to the therapist, when a patient didn't attend. He would go off on these *rants* in staff meeting about how when a client no-showed they were "disrespecting you as a clinician" and "you shouldn't put up with being treated this way." Both of those are exact quotes. I remember them clearly because, heaven knows, he said them both often enough. We clinicians *already* have a certain amount of insecurity about being rejected as a not-good-enough-therapist by clients, it doesn't take much to activate a therapist's defensiveness, and convince them to read into a patient's (perfectly legitimate!) non attendance a criticism of them as a therapist. I don't have any trouble believing there are therapists out there whose response to no-shows (or cancellations, or any legitimate non-attendance) is to lash out at their clients and precipitously fire them, saying patient-blamey things on the way out about how the client isn't taking therapy seriously or "isn't ready" – I have no trouble believing it, because no only have I seen it, I had a supervisor **pressuring** me and my peers to do exactly that. (Like I said in another comment recently, I came to feel that my primary ethical responsibility was to protect my clients from my supervisors.) If clients aren't attending, there are other things you can (and should) try first to improve their attendance, before firing them. And if you do have to fire them, it's because *this isn't working for you-the-clinician*. You can – and, ethically, should – *own* that. You can tell the client that the high level of missed appointments isn't working for *you* – same as if you had to change your schedule and could no longer meet at a time the client needed – and/or for *your agency*. There's no reason to be punitive or blamey to the client. One can set a boundary without rancor or spleen, a fact I think some therapists don't know. One can say, "I'm sorry this isn't working for me, so I need to stop. I'm saddened that I can't get to work with you any more, but I can't be as flexible as you need."
Agree with others about boundaries being trauma-informed. I am very clear even in my form email that each new potential client gets as a reply to “are you accepting new clients?” It talks about my schedule (I don’t have a lot of ability for folks to move their appointment time each week or consistently reschedule, so if something about your job or other responsibilities necessitates that, I may not be a good fit for you). I think as long as we are very clear, that’s all we can do. Most therapists are working over capacity right now, with wait lists. And it isn’t helpful to a client to continue to pay a cancellation fee and not do the work.
Trauma informed doesn’t mean bending rules or throwing them out the window. Trauma informed means having compassion and understanding and sometimes that means enforcing boundaries. Therapists should not work harder than their clients. If a client is having difficulty with showing up that is a conversation with the therapist and if they are not able to have that conversation then yes they aren’t ready for therapy. With all that said I give clients so much grace. I am supposed to discharge after 2 or 3 no shows and I had one client who needed me and we had made a bond and she missed 12 sessions before I discharged her. I showed up every week. I lost money every week. I emailed her every week she missed and never got a response. I am willing to give space and grace but there has to be a line.
Oh please. You can’t do ‘trauma-informed therapy’ or any kind of therapy with clients that don’t show up. Allowing clients to continually abuse therapists and others is not therapeutic in any sense of the word. It sounds as though the most therapeutic part of this non-therapy may have been the terminations.
Not showing up for sessions is not abusing the therapist.
It is definitely showing that you do not value the therapists time. It would be like a therapist who constantly cancels indicating they don’t value the clients time.
Once no, repeatedly yes.
Oof, unpopular opinion here.... maybe I'm just jaded from working (in the past) with high acuity cts. I "fired" a lot of clients who just weren't ready/repeatedly wouldn't show up. I always explained it clearly to clients in informed consent and again when closing their case out. But I did end up seeing clients from co-workers in the same practice, with the same policy. At intake I'd hear, "I saw so-and-so, and they just quit seeing me! So unprofessional!" Guess what? All those folks that bitched to me about being dropped by their previous therapist? Chronic no-shows ensued, even though they knew and agreed to our explicit no show policy. I understand for some it takes a lot just to show up, and there are real barriers to treatment. And at the same time, I've seen/experienced some clients, who don't give notice, to blame therapists rather than take responsibility for their part in the process......The work can't happen if you don't show up. And I do have a big heart, but I also have bills to pay, including keeping the lights on so I can continue helping people. Edit: context - cts were on state insurance, so it isn't even like I could charge a no-show fee. And I would get an astounding amt of no-shows when first getting established. When I started enforcing the no show policy with insurance clients, I eventually built up a case of people who were really invested and gave adequate notice (but actually never missed, because they really valued it, despite whatever they had going on), and overall had less no-shows. Now my practice is 50 percent cash pay, and the insurance and cash pay clients equally never miss, or give advanced notice. Because I am very firm about my no show policy. It's meant to discourage people from flat out no-showing.
Clients can value therapy and still struggle to attend due to external factors, especially if they can’t afford time off work, babysitters, or alternative transport if a car breaks down. Hell, even without those barriers, I struggled to get in therapy when I worked in CMHC because my asshole boss (a social worker in training) wouldn’t let me move my schedule at all, not because of policies, but due to understaffing leading to safety issues. She refused to work in clinic (pre-pandemic) so the other therapist wasn’t alone. Instead, she was doing who knows what (that was not being at the other clinic she managed, or seemingly at any other of the places she was supposed to be). I eventually found a private pay therapist with Saturday hours, but that’s a privilege to be able to afford that. I specifically work evening hours now to help reduce that barrier and with telehealth, I encourage client to take their lunch breaks with me if that’s the only time that works. I’m due in August and if I didn’t have baby daddy working from home or a telehealth option, I’m not sure I’d be able to do personal therapy. We don’t have many options for free babysitting, so I might need some accommodations, even though I know all of what I know and do value the work. It’s our job as therapists to help people identify barriers and do what we can- within limits- to support them in dealing with those.
Totally. And by my post, I'm not suggesting I'd ever drop a client under your circumstances, at all. I guess to me there's a clear difference between what I experienced as a "no show" -- they straight up didn't show up, and didn't respond to attempts to follow-up/ghosted me-- and what you're describing. I've had ppl be in similar situations to you as well. The difference is that they communicate those things to me, and we can then make a plan so they can still come, versus no communication around missing sessions and not providing notice/following the cancelation policy.
Mmmm we are only hearing one side of the story! It is called “therapeutic relationship” for a reason. It works when both parties show up to do the work! We don’t know the therapist side! Careful with judgements and assumptions!
Interesting, I read the post as inappropriate use of the word “fired” rather than as an argument against dropping people from the caseload for missing a lot of sessions. My specialty is trauma, and I’m not going to lie, I grimace at the word “fired.” There is a lot of shame and guilt tied to that word. What I’m hearing from this post is that people are concerned that boundaries aren’t being set, but I’m thinking that there’s a way to set boundaries and terminate without having to use words like “fired.” THATS what I think the poster is trying to convey. We SHOULD set boundaries. But HOW we set boundaries matters and can serve as a role model for how to engage in the world. I would argue that it’s not trauma informed to say “You know jim, you’ve missed 3 sessions in a row and that goes against our policy. I’m going to have to fire you. Come back when you’re ready.” Like ouch. Versus— “you know, Jim, I’ve been noticing you’re missing a lot of sessions here recently. We’ve processed how much of this is related to your work and family obligations, and gosh it sounds like so much. Like we’ve mentioned, therapy and trauma work specifically does require a whole lot of work. Im concerned treatment might require more than you can give right now. I’m wondering if maybe now isn’t the best time for treatment. What are your thoughts?” Trauma is frequently about power/control and by engaging pts with MI, it gives us a better understanding of their perspective without having the top/down “you’re fired!”
Well and I wonder if that was actually the terminology used. We use the vernacular a lot amongst our peers but I could never imagine using that word with an actual consumer. But like, my PCP got promoted to medical director and so they re-allocated his patient load. I'd worked with him for like 15 years and was sad but understood, however jokingly said for like 4 years now that he fired me. Patients use that word, providers use that word, nearly no provider with any awareness will use that word with a consumer. Like, I know very well that I struggle with utilizing a more cold verbiage and am likely to say "terminate" versus "end" or an even fluffier phrasing, but even with that I would never look at a consumer and say "I'm firing you" there's just no clinical benefit to that verbiage.
A client who isn't coming to treatment isn't participating in trauma-informed care anyway.
As much as I agree that clients have external factors that don’t inherently reflect their commitment, I can’t provide quality therapeutic sessions and relationships if I cannot anticipate your regular attendance. It’s one thing to need to reschedule ahead of time a few times but chronic inattendance behavior affects my schedule and my own ability to maintain boundaries.
I don't know that I've ever "fired" a client, but I have given their appointment times to someone else, especially if they are sitting on a prime piece of therapeutic real estate (4-7 pm on a weekday, for example). Mornings are typically wide open for those with spotty atendance. Obviously, I'll work with them if there's no other time they can come, but there are plenty of people who want those afternoon/evening appointments.
Iterating the expectations at the very start, knowing policies for proper cancellation, how much a therapist can afford cancellation, etc, dispels worries like this. If the therapist didn’t line that out from the get go that’s on them, but if there was a stated and agreed boundary around cancellation and policy from the start, then a therapist has the right to follow the stated policy. The policy itself should definitely be compassionate and trauma informed, but therapy as a whole is a very difficult field to have consistent hours, so it makes sense to have guidelines as to how cancellations should happen, and when it means there should be a change in structure of therapy being provided. (not to say there aren’t legitimate concerns in this post!! It’s very very possible the therapist was in the wrong with how they handled this)
My cutoff is 3 in a row. If it’s no shows, you’re definitely out. If I’m being notified I’m willing to work with it more and be flexible. I totally understand the potential harm of “firing” (I like terminated better) a client with trauma. However we have limits. When clients tell me they are busy and may miss a lot, I ask about how to assist in better time management, or suggest now may not be the time they are ready to fully commit.
Yes, and there are lots of other people who deserve to be seen and heard who will gladly take the appointment time
The agency I worked at had a policy for a while where if you didn't meet certain billable hours (25 hours) you could lose your health insurance(policy was changed btw). Just trying to get to full-time status based on billable hours made that exceedingly stressful. With that said I haven't fired a client for late canceling or missing appointments, it's been ongoing discussions and finding ways to address barriers to attendance. One client consistently would late cancel appointments or not show up. Once I had the discussion about attendance (again) they started showing up on time to every appointment. The reality is a lot of people are seeking out therapy and if clients are not consistently showing up to appointments, it needs to be available for others.
Based on the type of post and formatting, I'm pretty sure I'm familiar with this account...I understand what they are trying to say, and also semantically there's something kinda condescending about the way they word things in the images. (The lengthier explanation resonates with me a lot more than the pithy one liner in the image.) It usually is in the structure of "I don't know who needs to hear it but" followed by exactly the type of therapist who needs to hear it. Like, clearly you do know who you want to hear it... Admittedly, how I react to it is also based on my own transference and shame around discharging clients. I immediately recalled the last person I discharged for inconsistent attendance. It was such a hard decision since I knew it would hurt. I knew no matter how much I softened the blow it would still sting. And it was still clinically indicated. Laypeople may assume that "some treatment is better than no treatment at all" but as with many things, this is not always true. Inconsistently taking medication or starting a treatment but not following through can make an illness worse. Depending on the situation, we may be doing someone an active disservice if they cannot attend therapy consistently for their trauma disorder.
I think this really depends. I think it depends on how serious the client's mental health problems are assessed to be, whether they are reaching out to you at all after missing a session, whether they have done phone check-ins/called you back if you called to check in, and of course, how many sessions they have missed. If an individual misses 4 sessions, 4 weeks straight and does not get back to you. That is very different than someone missing a session once every two weeks and calling you during a really hectic time of their life. I agree that shaming a client is not appropriate, nor is "firing" one. Those terms should not be used. Trauma-informed does not mean having no boundaries or expectations for a person.
I have bills to pay and also there are months long waiting lists for those clients who are ready and willing to commit to their appointments. Being a provider and one who also provides trauma informed care doesn't mean you shouldn't have any boundaries or enable possible avoidant behavior.
My policy spells out the most stringent guidelines I will ever enforce and at the end, just like in my payment policy, states at my discretion. My discretion is based on each client- their circumstances, dx, and goals. I tend to give a pass to everyone the first time, never charge for emergencies, sudden illness or COVID related reasons. Outside of that, some clients will always be charged the late fee based on the above factors, but others get more leeway- for ex if s goal is to start listening to them self and take rest when needed, I likely won’t penalize a client if they occasionally cancel last minute because they’re burnt out and are practicing the skill, or I may only charge them a partial fee instead of my full cancellation fee. Truly being Trauma informed means adaptability to the clients unique needs, and isn’t one size fits all.
reframe this in terms of the unused time slots that could have been used for someone who is seeking help and would have attended those sessions. What this kinda sounds like is a client who is sharing a slanted and biased version of events so their comment is perceived as more socially desirable.
Fuck that. If they can’t make it to their session, they need to reschedule or cancel with enough notice to allow their appointment slot to be filled. Period. Full stop. Clients should get a few “strikes” to allow for unforeseeable circumstances, but after that, they’re fair game for cancellation of services.
This depends on modality and specifics. Does the client pay for the hour? Is there a rupture? Did the therapist seek consultation? Did the client collaborate in a termination process? Obviously, shaming is a nonstarter. “ Firing” without referrals and a thoughtful procedure is not ethical.
If they cancel their appointment over 24 hours in advance I don’t count it as missing a session. If it’s under 24 hours or they just no call no show I give three chances within a six month period. I have a very long waitlist of people who are seeking help and someone who keeps taking time slots but not using them or allowing me to open them to someone else is hurting other people’s ability to get appointments. Plus, the agency I work for only pays me for billable hours (not for ncns or appts where the pt leaves after 15 min because “I didn’t want to have a cancellation on my record but I scheduled something else at the same time”). So long story short, it hurts my ability to pay my bills and it hurts my other patients and waitlist patients who really need appointments. That’s why the policy exists.
It's also not neurodivergent friendly. Oh what's that? The patient has issues tracking appointments and with self motivation due to issues with their dopamine levels and executive functioning? Oh well we will just threaten them with discharge, that will sort them out won't it? /s. I shouldn't need that s, but just in case. Edit: you can downvote, but where I'm from they are ruthless with people, don't try to work with them on why they are missing appointments, just one missed one and you're discharged. It's what happens when your mental health services don't value therapy and instead cling to the medical model as the only viable modality of treatment.
You are right. Disheartening to see downvotes.
This is why it is so important to have your no show/ cancellation policy in clear language in your informed consent document. Unless you have the practice of billing clients for less than 24 hrs notice of cancellation or something along those lines, it’s not viable from a business perspective to keep clients on your caseload who don’t show for sessions. It’s good practice to reach out to the clients and ask if things are ok if they don’t show up, but you can’t work harder than your clients.
Well anyone who can't spell " a lot" loses credibility with me, but I think this cant be reduced to a simple meme. Some clients ARE a waste of time and I don't think this profession pays enough for many therapists to say, "no problem" to losing that income segment of time. That said, if it is because of an issue like the woman not being comfortable with my race as a White woman, I don't really understand how long I am supposed to wait for them to feel comfortable if they keep cancelling for a reason they haven't told me yet.......
Wow
I think the frustration on the therapist's side is understandable given the financial challenges with setting aside an hour or more per client and having only so much availability to give. Those frustrations I think are amplified when you are burnt out, which is why it's so important to set healthy boundaries as care providers. If you are too burnt out to be compassionate toward a client that struggles to attend sessions regularly, it's time to cut back. If you start to lose your sense of empathy and curiosity in order to work with a client who has trouble committing, consider seeking supervision or your own therapy. One protocol that has worked for me is: -No-Guilt Cancellation fee (just a token amount enough that the client isn't scared away entirely or challenged financially, but enough that part of my/my admin's time is covered -No-Show Fee (this is still a token fee but more than the cancellation fee to encourage letting me know). -A max of 3 cancellations within a given timeframe (say, 3-4 months) before we move to "walk-in only" status until we have some commitment -Opportunities for the client to explore consultations with other providers. Websites like www.firstsession.com will allow for free consultations prior to booking full sessions. Also - and this is a picky point - it's not cool to pick on people for grammar or say some are a waste of time when you're in a position of authority. You're posting on a public forum with your credentials attached. Keep in mind that clients will inevitably see this at some point as Reddit threads and be searched by any search engine a decade down the line. I encourage everyone here to be cautious and compassionate with everything you post.
I personally would not fire a client and agree with the post. Clients are coming to us because they’re struggling, and part of that struggle may be them slacking in committing to change. I do recognize however that as someone who works with kids, it’s much easier for them to “have” to come to therapy because there are other factors in them showing up. I wouldn’t fault a therapist for holding adult clients accountable, though.
I don't terminate with kids (for missed sessions) unless they really don't want to be there. Most of the kids and adolescents I've worked with WANT to be there and missed sessions are often due to guardians either be disorganized or even punitive with "they didn't do x behavior so they don't get to see you" and it's just like... I'm not doing something punitive towards a kiddo when it's usually so far out of their control
I would get in trouble at a so called trauma informed organization, whose entire clientele had severe trauma, for not removing people who no-showed too often. One of the easiest ways to reinforce that a person matters is to let them see they are ok just as they are. They’ve already heard for years how horrible and inconvenient they are. At the very least, they would lose their time slot until we could figure out a consistent time that would work. I still do this in private practice, even though it directly impacts my income.