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No More No Shows

5 Tips to Stop Therapy Clients Missing Appointments

No More No Shows
It’s no good just hoping clients will show up. We need to make it as likely as possible.

Where was he? Final reminder bills were gathering round me like circling vultures. This was no time for a no show!

I was a struggling therapist with hungry mouths to feed, bills to pay, and a mortgage chasing me down like that big stone ball at the start of Raiders of the Lost Ark.

I checked my phone again. No message. I peered anxiously up the street. No sign.

Then he arrived… or so I thought. But no, that muffled sound at my front door was just the shuffle of an envelope popping through the letterbox. Another unfriendly brown envelope daring me to open it. Yes, another bill…

He never showed up. And he’d sounded so keen on the phone.

I’m fortunate that I never had that many clients miss appointments through the years, but back then even one was one too many. Should I quit and get a ‘proper job’? Or was there maybe another way…?

Waiting and hoping and praying

The words ‘therapy’ and ‘business’ don’t seem a good fit for each other. I’ve even had people say that therapists shouldn’t charge for their services! As if food, shelter, and clothing become suddenly unnecessary once you’ve qualified.

But, of course, the truth is that however much we want to focus on the human element of therapy of one human being helping another, you, I, and everyone do need to make a living. And anything we can do to minimize missed appointments will help.

It’s no good just hoping clients will show up. We need to make it as likely as possible. And if we do that bit right, we may even help ensure they feel more fully committed to their therapy once it starts.

But first, why do clients sometimes not show up?

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Dodging the issue

Some clients dread having to face their issues. Perhaps they have an image of therapy as inevitably being a painful, long, drawn out process. They may have got their ideas about what modern therapy is like from TV or movies. This is why website literature needs to be as friendly and reassuring as possible. People often feel scared of therapy.

Some clients are kept away by price. They might think you charge too little (and so conclude that what you offer can’t be all that good). Or they might think you charge too much (and conclude that this kind of help can’t possibly be worth that much). Alternatively, they may find nothing wrong with your charges, but they just can’t afford it.

Some clients may feel that your therapy promises too much. That it’s too good to be true and they can’t possibly really hope to be rid of their panic attacks, phobia, depression, or addiction. Some smokers have looked quite terrified at the prospect of ‘losing part of their identity’, while at the same time knowing they need to quit.

Managing expectations is a vital marketing skill as well as a vital therapy skill. Sometimes your clients will have the courtesy (or courage) to let you know they won’t be coming, sometimes they just won’t show up. Either way, here are five things I’ve found useful to maximize the chances that your client will actually keep their appointment.

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5 Tips to Ensure Clients Don’t Miss Their Therapy Session

Tip 1: Speak to your client before the session

Okay, this sounds obvious, but if you have actual personal contact (not just email, online, or through a third person), then you have more of a connection to your client.

If a partner, friend, mother, or any other person makes the appointment, then ask whether you can speak to the prospective client directly – even for a moment. If they’re unwilling to speak to you, it could indicate they might drag their heels to the point that therapy grinds to a halt before it’s even begun.

But we can do more.

Tip 2: Show understanding to build rapport

Feeling understood is an important human need. Think how you feel when someone really seems to understand your ongoing feelings or situation.

When you speak to your prospective client on the phone (see Tip 1), take the opportunity to ask them some questions that will both give you valuable information and demonstrate that you have a deep understanding of their plight.

By this, I most certainly don’t mean we should try to impress our clients with intimidating psycho-jargon. However, taking the example of depression, we know that depressed people wake up exhausted because they dream too much. We can use this piece of knowledge to help clients both understand what is happening to them and know we understand.

Simply asking your prospective depressed client if they find mornings really difficult – feeling like lead, finding it hard to get out of bed, totally unmotivated – can help them feel like you really know what’s going on.

You could even briefly explain the exhausting over-dreaming connection, which is like a lightbulb going on for many people. Most depressed clients will feel fundamentally understood when you say something like this.

Or if someone is experiencing Posttraumatic Stress Disorder [PTSD], you might ask things you know to be true for most people with PTSD, such as:

Do you sometimes find that some situations make you feel like you are re-experiencing what happened to you, even though those situations only faintly resemble the actual incident?

Or if you learn that they are getting flashbacks:

When you get flashbacks, is it like actually being back there again? More like re-living the experience rather than just recalling a memory?

Or given that we know that traumatic memories don’t fade the way normal memories do:

Does the memory of that trauma feel like it could have happened only yesterday, even though it was (perhaps) years ago?

Your new client may have the need to talk on the call, so don’t do all the talking! But when you do talk, that’s a time to show real understanding.

Okay, so that can help build initial rapport, but of course we need to reassure and offer hope, too.

Tip 3: Open loops to raise their motivation to see you

“Hold fast to dreams,
For if dreams die
Life is a broken-winged bird,
That cannot fly.”
― Langston Hughes

Clients need hope.

To use a marketing term, hope (or any kind of expectation) ‘opens a loop’ that a person feels the need to close by coming to see you. So in addition to demonstrating your understanding and empathy, you need to open loops that they feel will only be closed by actually coming to see you.

Writers open loops by starting a tale (setting an expectation) and making it compelling that you fulfill that expectation and find out how the tale ends. Expectation is powerful and some kind of positive expectation, however unconscious, is vital.

When a client makes it into your therapy room, use the presupposition:

What improvements have you noticed since we spoke on the phone?

You’ll be amazed by how many will tell you they have already noticed improvements, even if it’s ‘just’ feeling more hopeful. That improvement should be used in the therapy.

So when talking with a prospective client about the exhaustion of depression, you might open a loop by saying:

As you start to feel better, one of the first changes you’ll notice will be that you sleep more soundly and wake up again feeling hopeful and more energized.

You’ve given them hope. And they’ll want to see that hope realized.

Or for a client with PTSD:

Once we’ve dealt with that trauma so the memory no longer bothers you, what you’ll notice is that it starts to feel like any other memory and it won’t feel bad to think about, even though you’ll still know it was bad at the time. Nightmares will stop and you’ll feel so much calmer for so much more of the time.

Open loops that they’ll need to complete by coming to you for help. But don’t overwhelm them with bureaucracy…

Tip 4: Don’t be a petty official

When clients come for therapy they are often at crisis point, desperate, hoping against hope you can help. They may even be suicidal. It’s a crying shame when the first contact with a supposedly kind and caring therapist feels more like battling your way in to some kind of soulless bureaucratic institution.

Requiring lots of form filling and information gathering in the first instance can be really off-putting for new clients, especially if they’re depressed or anxious and are primarily in need of reassurance.

I like to find out about my clients the old-fashioned and human way – by having a conversation with them. If you have to get them filling out forms, do it after the human bit.

And lastly…

Tip 5: Be friendly!

I know you are a lovable, affable, kind, and smiley person. But oftentimes when we are ‘being professional’, we forget that part of being professional is also being who you are. Professionalism should never mean humourlessness.

One client told me that she’d phoned ten other therapists before deciding to come and see me. I asked her why she’d chosen me and she said I was the only one who sounded relaxed and friendly on the phone. I had to wonder what on earth those other therapists sounded like!

Some final thoughts

Of course, some therapists choose to charge clients in advance or require a deposit and that can work too, in the ‘I’ve paid for this, so I’m going to get what I paid for’ kind of a way. You might also require people to pay for missed appointments, although chasing money can be tough.

And of course, the tried-and-tested text before an appointment is worth considering, if your client is comfortable with that. Using their name in the text is a good idea.

But sometimes no shows will still show – just at a later time. I had one of these quite recently. She didn’t call, text, or email. I emailed her saying I was sorry she couldn’t make it, that it was no problem, and that my door was open if she wanted to come and see me in the future. A few weeks later, she emailed me (with no mention of her no show) and became a reliable client.

Bizarre as it sounds, sometimes not showing up may be an (irritating) ritual that some clients seem to need to go through – maybe a kind of unconscious test of the therapist, but regardless a first step towards a journey of better mental health.

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Mark Tyrrell

About Mark Tyrrell

Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.

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