Monthly Archives: May 2016

How do you deal with a no-show?

“I work in public health, and I get a lot of cancellations from my patients (for all kinds of reasons). How do you deal with or minimize this problem? My strategy has been that as long as the patient feels less anxiety when leaving my office than when entering it, this should be a strong natural reinforcement to come to the sessions, but it seems this is not enough.” Thanks to Arvid for this question!

Sometimes patients have life emergencies that cause a cancellation. But most no-shows have a defensive function. They are a way to avoid feelings and issues arising in therapy. They are resistance to the therapeutic task. After all, we can’t heal an empty chair.

Whenever a patient cancels a session always explore the reason for the no-show in the next session.

Th: I notice you weren’t here last time. What happened?

Pt: I just didn’t feel like coming.

Th: I’m glad you are letting me know. I wonder what has happened here that made you feel like you didn’t want to come?

Pt: I didn’t like how you focused so much on the way I hurt myself.

Th: Sounds like you had a reaction to me focusing on that. I wonder what feelings might be coming up here toward me?

Often, the patient experiences anger toward the therapist. Rather than discuss that anger, the patient may act it out by cancelling a session. When patients come from backgrounds where they were punished for being angry, avoiding anger or the therapy is the best solution they can come up with. Then we need to help them find a way to face their feelings with us, so they can do so in the rest of their lives as well. After all, cancelling her session deprives the patient of the help she needs.

Th: I notice you weren’t here last time. What happened?

Pt: I feel like you want something from me. I had something else I had to do. There was this assignment I had at school that needed to get finished.

Th: The question is not what I want from you. The question is what you want from the therapy. When you don’t come, you deprive yourself of the help you want. Could this be a way you deprive yourself?

Missing sessions sabotages the patient’s goals. If a patient sabotages himself elsewhere in life, he will do the same in therapy. That’s the bad news. The good news is that a no-show allows us to exam self-sabotage in the here and now in the therapy.

Th: After such a successful session last time, you missed the next session. Could this be part a form of self-defeat after success like we have noticed at work?

Pt: I hadn’t thought of that. I just didn’t feel like coming.

Th: So I wonder what feelings might be coming up here toward me?

When the patient defeats himself in therapy, he defeats you too. So ask about feelings toward the therapist.

Always explore the reasons for missed sessions to understand what drives the patient’s self-sabotage.

Th: I noticed you weren’t here last time and you didn’t call. I wonder what happened?

Pt: My mom needed me to baby sit.

Th: I understand that, but I wonder why you didn’t call?

Pt: [sigh] I figured you wouldn’t mind having a free hour.

Th: You thought I would prefer to have a free hour instead of seeing you?

Pt: Yeah. I figured you wouldn’t mind.

Th: As if I would feel relieved not to have to see you.

Pt: [sigh] That’s it.

Th: So I wonder what feelings are coming up here toward me?

Sometimes a no-show gives us a good chance to examine character defenses.

Th: I noticed you weren’t here last time.

Pt: Yeah. Well my boss asked me to work overtime so I did.

Th: So you valued his demand over your own need. Could this be a form of self-dismissal that we’ve talked about?

Pt: I didn’t think it would be that big a deal.

Th: Exactly. You don’t think you are a big deal. You didn’t think it would be a big deal if you deprived yourself of the help you want. Instead, you valued what he wanted over what you needed. Do you see what I mean?

Pt: I hadn’t thought of it like that.

Arvid thought that if he helped patients feel better they would want to come back. That is true for some patients. However, many patients suffer from severe superego pathology. As a result, when they improve a little, they may punish themselves for that success by depriving themselves of a session. Thus, feeling less anxious is not enough. We have to help patients see how they punish themselves, and face the feelings underneath those self-destructive defenses. As long as we don’t help patients overcome their self-punishment and self-deprivation, they will sabotage their yearnings for growth by missing sessions.

Th: I could understand if you missed a session because you were sick. But we are seeing a pattern of missing sessions. And this deprives you of the help you need. If a robber stole one third of your paycheck, how would you feel?

Pt: I’d be furious. I need that money.

Th: And here we see how this mechanism of self-deprivation and excuses steals one third of your therapy from you. I would love to help you. You need it. But as long as you miss these many sessions, your progress will be doomed and you will continue to suffer. Why do that to yourself? Why do you ask me to agree to your habit of self-deprivation? Why do you treat yourself as if you don’t deserve the best treatment? Why do you treat yourself as if you don’t deserve to get well?

Take home point: missing a session is a form of therapy suicide. It’s an attack on the patient’s wish to get well. It’s a way the patient mistreats herself and starves herself of the help she needs. Point out this self-harming behavior so the patient can stop hurting herself by missing sessions. It’s not enough she feel less anxious. She must stop hurting, depriving, and stealing from herself the help she deserves from you. Always address missed sessions to stop the patient from sabotaging herself.

 

I’m afraid I’ll become my father!

“I am working with a highly socially anxious man who was verbally and physically abused by his angry father when he was a child. He says he is afraid of becoming his father (i.e., abusive) and has in fact become verbally cruel to his ex-girlfriends. So he drops friends and lovers at the first sign of disappointment/conflict rather than face his anger. He is afraid that his anger will make him like his father. How can I address this fusion of him and his father?” Thanks for sharing this common problem!

This kind of patient fears that if he explores his feelings he will become like his abusive father, something that is morally repugnant to him. Thus, he cannot join us in a therapeutic task that he fears would make him a worse person. Without addressing his concerns we cannot establish a therapeutic alliance. So we must help him differentiate himself from his father and differentiate the therapeutic task from an anti-therapeutic task.

Differentiate him from his father:

Th: “Being angry doesn’t make you like your father, losing control of it does. Would you like to face this anger so that you could express your strength but without his intent to hurt?”

Th: “Being angry with a girlfriend does not make you like your father, but discharging it through verbal abuse would. Would you like to face this anger so you could express yourself in a healthy assertive manner and let go of this verbal abuse? Wouldn’t be nice to express your concerns in ways that strengthen the relationship rather than damage it?”

Reinforce his healthy concerns:

Th: “Obviously these girlfriends did not deserve the rage did they? Wouldn’t it be nice to face this rage where it belongs (toward your father), so it wouldn’t have to go out onto the wrong people?”

Differentiate the therapeutic task from an anti-therapeutic task:

Th: “I’m so glad we are in agreement. Obviously, the last thing we want is for you to lose control and verbally abuse others. After all, that would damage your relationships and only make you feel worse about yourself. So to be clear about our task, would you like to be able to express yourself more effectively in relationships so you could handle conflict in the future? Would you like to be able to channel your anger into effective communication? Would you like to be able manage conflict in relationships so you can finally keep a loving woman in your life? Would you like me to help you learn how to deal with your anger so you could achieve those goals?

Deactivating Defiance:

Th: “If at any time you think our exploration might lead you to act out, would you let me know right away so that together we can help stop that?

Th: “You certainly don’t have to explore your anger. After all, it’s your problem and you have the right to handle it the way you think is best. But if I don’t explore your anger with you, I’d be as useless to you as your father was. How do you suggest we proceed?”

Prevent acting out in therapy:

Th: “You say that you leave as soon as you are disappointed. What impact would that have on our relationship? After all, if you leave as soon as you are disappointed with me, we would not be able to help build the capacity to deal with disappointment. Would you be willing to commit to working with me when you are disappointed so we can help you reach your potential?”

Take home points: always validate the patient’s healthy concerns so that you can make sure he sees that you have the same goal and that therapy is designed to achieve his goal. Differentiate the patient from his father and his father’s defense. Mobilize the patient’s will to a goal he wants and task to achieve it.