Enlightened Practice Podcast
Do you have a strategy to reduce your no-show rate? Is a second confirmation email sufficient to reduce no-shows, or does it become annoying for the majority of clients/patients who need to confirm only one time? In this new episode of the Enlightened Practice Podcast, Dr. Ken Braslow and Dr. Kari Kagan share their experiences around the subject and provide some helpful tips. Enjoy!
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Transcript of the podcast
Ken: Hi Kari, welcome back.
Kari: Hi Ken. Thanks for having me.
Ken: Sure. Today, we’re going to talk about no-shows and how to think through them from an administrative, but also I think more of a clinical perspective.
Kari: Yeah.
Ken: I got a feature request recently from one of our clinicians to have a way for patients and clients in their appointment reminder emails to confirm that they’re coming to the session and I was curious about that. We hadn’t gotten that request before and thinking it through with the clinician, their concern was that this would help reduce no-shows and that’s why they requested it. It got me thinking, I don’t think that there’s a technical solution here. Although, there are some things that could be useful technically, but my first thought was the people who are the ones who confirm that they’re coming to the appointment are not the ones that you should be worrying about no-showing.
Kari: Right.
Ken: And then what do you do with the people who haven’t confirmed? Now you’ve created another whole other set of work for you to do when the appointment reminders are supposed to do the work for you. So, I thought it would be better for us to have a conversation about what you can do from a workflow perspective and clinical perspective so that it reduces the need for other kinds of technological interventions which are not likely to have the intended effect and just create more work in the process.
Kari: Yeah.
Ken: So, I’m curious to hear from you. What’s your general approach to handling no-shows and what do you tell your clients when you’re first meeting with them?
Kari: Yeah. I was going to say, that’s the first place to address no-shows is in session number one when you’re going through your policies. I think that all clinicians in private practice or anywhere should have policies for cancellations or no-shows. So, I do talk to clients that there’s a charge and I do charge my full fee if they don’t show or if they cancel within the 48-hour window. I also would explain to a client that there are always exceptions, but I would of course need to hear from them to understand why they no-showed. So, if I came to know they were in the emergency room, I would probably forgive that but the first place I address it, just making sure that they are informed that there is a fee for no-shows. And that gets the conversation started around how we might handle that and then we might have more conversations once they actually do no-show. But I can tell you about those later. I was curious to hear if you also cover it in your policies or how you cover it?
Ken: Yeah, I definitely cover it in the policies. And I find it especially important with college kids, but really anybody in the population. It’s very meaningful because it speaks to how much they value time.
Kari: Yeah.
Ken: So, I can learn a lot about their commitment to our work and if they are ambivalent about it or not in exploring that with them. I definitely charge for the time and rarely have I had anyone push back against it. And of course, if they’re in surgery or they like psychically cannot make it and it’s a logistics issue, it’s anything other than being an emergency I’m pretty strict about it. If it’s merely logistics and they have a work meeting that came up, I feel for them, I use that clinically to discuss with them how stressful their life must be and how chaotic it could be but I don’t forgive the fee because I have plenty of patients who are wanting to get in and I’m happy to get people in last minute if I can, but if you just don’t show up then there’s no way that I can get them in.
Kari: Right.
Ken: So, it’s multi-level here. I’m curious, if you are given half a day’s notice, will you try and fill that slot with someone else or how do you approach that?
Kari: No. If someone no-shows or obviously not in that case, but if they give very, very short notice, then I would usually fill that time with catching up on notes or reading, or something like that because it often isn’t enough time to inform someone else that a new slot opened. If somehow I knew I had someone who could be available last minute I might try to fill it but that’s a big reason like you’re saying to charge the fee because it is really hard to fill that time very last minute and of course impossible to fill the time if they just don’t show. I could use the time other ways, but I would have planned to use it in those other ways other times, not during my working hours where I save time for paying clients. How do you use the time?
Ken: Well, it depends on how much notice I’m given and if I know that somebody is really wanting to get in I will offer it to them. It’s a win-win if we can pull that off. But if it’s a, “Hey, I just got called into a meeting. I can’t make today’s session.” It’s obviously not enough time to get somebody to come in and then it creates a whole new set of work on my end that wasn’t there in the first place.
Kari: Right.
Ken: Sometimes I will use a little bit of the time to review their chart and see if there’s anything I’m missing. I’m also anticipating that they’ll want to refill if there’s just a med-check. So, I’ll go ahead and queue up all those refills so that way when they inevitably request it at least most of that work is done. So, I try and use as much of the time as possible for their benefit even if they’re not physically present. But, if it’s just too late in the day it’s not going to happen. But I do say, you need to give me two business days’ notice and that’s because with two business days that’s a reasonable amount of time for me typically to fill the slot. Not always, but the key is the business days because if you have a Monday appointment and you let me know on Saturday, no, not going to happen.
Kari: Yeah, right.
Ken: So, I’m pretty strict about the business day’s aspect.
Kari: Yeah, definitely the same.
Ken: So, that said, I often talk with patients about how much are they having to rearrange their schedule, how much are they no-showing for other meaningful things in their life? So what predictions could they make about our work and when they commit to an appointment will they be able to follow through? What kind of conversations do you have with your clients about it?
Kari: Yeah. I think that it’s really important to address the no-shows if you get a chance to see them again the following week because I do find that actually, they become patterns with certain people. Some people never do it and some people are frequent offenders if I can use that word. So, I do think the earlier you can address it the better. I will explore it with them in the context of our clinical work and I guess that depends where we’re at in the clinical work, but if it happens at some point where I feel like we have a good relationship and a good understanding of our work together. I might try to help them draw connections between their approaching our work together and how they might be approaching things in their lives in a similar way, like maybe flaking on friends or something like that. So, I do try to help, not in a judgmental way but really just trying to explore what is the pattern around something like not showing up for something, and how is that working for them? And really try to use it as an opportunity to enhance our work and goals together. I think addressing it that way and of course, in a non-judgmental way, it can help hold clients accountable for the next time but also, maybe help them address an issue that otherwise goes missing for a long time in their lives outside of therapy because not many people are going to sit down and try to help them understand why they missed an appointment. So, I think it’s an opportunity for them to really slow down and reflect on their behavior for their own benefit, for their lives outside of therapy. And the added bonus is hopefully they also show up to our sessions. And I find that most clients are willing to do that work with me and feel safe doing it, understanding that I’m not shaming them or judging them for not showing but genuinely wanting to help them in understanding that is part of a larger pattern.
Ken: That’s really well applied. I think, in my experience half the time people no-show is an executive functioning issue. I find this really useful data so we’ll use it as a springboard to talk about better executive function in general. Other times I don’t think it’s an executive functioning issue. There’s some psychodynamic issue, that’s usually my punch if I don’t think it’s an executive functioning issue, or just an unfortunate logistics issue. Although, sometimes I say the psychodynamic issues get disguised as unfortunate logistics issues. And people say, oh, I just got called into a meeting when really they didn’t have to go to that meeting. But either they wanted to avoid the material that they knew we would be processing, or they let’s say have trouble with being assertive. And they didn’t know what to say or they were afraid to say it. Other times, I wonder if they’re avoiding conflict with me or being emotionally authentic with me and perhaps there’s some conflict that they are not addressing and maybe that’s what happens outside of our work. Anyway, so I try and give them the opportunity to justify their no-show with any of those and validate it for them that those would be understandable reasons why somebody would not want to be present with those kinds of difficult feelings either with me or with somebody else that they’re having to deal with, like a boss, or another authority figure.
Kari: Yeah.
Ken: I want to say, one other sub-category would be, it has nothing to do with me. It’s not executive functioning, it’s not something with authority figures, but it’s their own internal shame. They got into a fight with their spouse or significant other, or they’re just doing really poorly at work and they don’t want to talk about it. I can understand that. I don’t blame them.
Kari: Absolutely.
Ken: And trying again to use their experience in our work clinically to figure out how to apply that to those other contexts and talk about the shame they might be feeling with their supervisor or their spouse, and how to be authentic and process that in real-time and in a way that’s constructive.
Kari: Right.
Ken: Often times it hasn’t been processed constructively in the past and so they don’t know what that looks like or they just don’t want to go there.
Kari: Yeah. I agree on all fronts and I’ve had all those experiences, the reasons being related to executive functioning, or shame, or shame/avoidance, or poor planning which could fall under executive functions. So, yeah, all of those reasons. I’ve seen it all and as uncomfortable and as frustrating as it can be in the moment, it often does actually really lead to important clinical work. And I actually just wanted to comment on that too. It takes some managing of our own emotions as the therapist when a client no-shows, to really try to see it from their perspective and not take it personally. Like, if they really cared they would show up or something like that because it can be especially for people who do it. Most times it can be frustrating and of course, every therapist should know their boundaries and this is why you have your policies. So, some people have the policy that they won’t continue to work with you if you don’t show for a certain number of sessions. It’s important to know your boundaries and make sure the client knows them too. But it can be hard at the moment when the client doesn’t show, to be sitting there you’re all ready to go. You’ve moved your schedule around, and to not feel frustrated yourself and of course, it’s okay to feel frustrated. I think it’s important to know, how am I going to manage those emotions that I can productively address this with the client without those feelings getting in the way.
Ken: That’s a great point. And perhaps, at times sharing your own experience with the patient or the client could help them understand what it’s like for when their partner or other important people in their life to be no-showed upon. So, there’s a lot of utility in the material that’s generated by no-shows. I’m curious what you think about appointment reminders, in that our lives are busy. It’s really nice to get reminders. On the flip side, if somebody was either unconsciously having to deal with these issues or consciously not dealing with them, and they get a reminder if they hadn’t gotten a reminder, do you think it interferes with any of what we’re talking about on a psychodynamic level or even a cognitive-behavioral level? That they see the reminder and go, oh my god, I forgot. Okay, yeah, I’m going to go to the appointment. Now we’ve lost out on this data that they were likely not going to make the appointment.
Kari: Right.
Ken: On the one hand, of course, you want them to come to the appointment, but on the other hand, you’re probably not going to say to them, did you almost no-show today, but the reminder kept you from no-showing?
Kari: Right.
Ken: So, I’m just curious what you think about how reminders when they are system-generated affect the therapy or the therapeutic relationship?
Kari: That’s a good question. To be honest, I hadn’t thought of it that way. I think, I would weigh it the way I would approach that, especially if someone’s deciding what are the rule reminders? It could potentially interfere with therapy or interfere with my perspective or understanding of this person. I think, in my opinion, that the benefits probably outweigh the downside. The main benefit is that it increases the chances of a client showing and it’s ultimately what the purpose of a reminder is. I don’t necessarily view the reminders or lack thereof as a tool for learning more about the client. The hope is that I can just those sides of them in therapy. So, I feel like the benefits outweigh the downsides, but it certainly is a downside worth considering which is you might miss some important information. But I will say in terms of appointment reminders, that probably almost all types of doctors that I go to do offer that as a courtesy. So, I do kind of just view it as standard practice. As a courtesy, a lot of doctors send out reminders and I’m just one of them. I don’t think every therapist sends out reminders, but in my experience with patients and in other fields is that reminders are pretty standard. So, I think that’s part of what drives me to do it. It’s just of the courtesy factor. Do you defend reminders?
Ken: I think it’s a win-win. It’s a courtesy for them. They’re less likely to no-show. For me, my hunch is in other fields, like my dentist, I get 14 reminders before each appointment. They really don’t want me to no-show because I think they have a much harder time billing for no-shows. They don’t typically address it the way that we might at the beginning. So, it’s just easier not to have to deal with it by having the patient come in for the appointment and it’s a moot issue.
Kari: Yeah.
Ken: But I like the way you put it in terms of the benefits outweighing the downsides and ultimately, there’s plenty of good work to be done in therapy around executive functioning that usually presents itself anyway especially with paying bills. That’s a whole other podcast.
Kari: Right.
Ken: And how to have those kinds of conversations. I’m curious in terms of executive functioning, do you ever have your clients write down the appointment while they’re in session with you, or is that not as big of an issue?
Kari: Yes. I wouldn’t start there with a client, but once we start to learn, okay, this is getting tricky for them to remember to come to therapy, then I would make it more of a habit and it might just be my style as a therapist, I’d probably ask them for permission to do that. Like, would it be okay if we put this in our calendar at the same time at the end of every session? Just to kind of make sure that they’re on board and it doesn’t feel like I’m a teacher or something, because I want it really to come from them. But yeah, I have done that with people and I will also model that too. I don’t think I’ve ever no-showed to a session. But I have certainly forgotten things that I said I might send to someone and I will model that for people myself. Like, I’m going to put this in my reminders now while we’re here, to model that this is a strategy that can be really helpful. So, I would definitely help the client use that as a strategy as well. Do you do that with your clients?
Ken: I do and I like how you do it in a collaborative way. If it’s a med-check I’ll book the appointment right there with them in the present and they get an email reminder instantly, or an email confirmation instantly. But I’ll say, what do you think about actually going ahead and putting this in your calendar right now? And that can be useful data right there.
Kari: Yeah.
Ken: I haven’t had too much push-back against that and I’m usually saving especially for college students or high school students. I really push for that. It’s such an awkward position if they are no-shows and their parents are paying for the session. I will talk with them about that, it’s a terrible dilemma to put them in. it’s also a terrible dilemma for me. I say it’s a terrible dilemma for them because your parents are going to get the bill and that’s just how it works. And that’s the last thing any of the three parties want.
Kari: Right.
Ken: So, what can we do to prevent that?
Kari: Yeah.
Ken: It’s interesting how you said you’ve never no-showed. I’ve not no-showed but I have had patients, I don’t know what the converse of it when I’m not scheduled, but they still show up and are pinging me, where are you? We have an appointment.
Kari: Right.
Ken: And maybe it’s a different kind of conversation. And sometimes that’s an executive functioning issue also, other times it’s not.
Kari: Yeah. I don’t know that I’ve had that experience, but I have forgotten things for sure, where I forget to follow up with a worksheet or something and I think it’s important to model and that’s why when it happens with a client where they no-show or something, I always try to understand. I think that’s the most important thing. I still hold firm on my boundary of enforcing the policy that I’ll charge for the session if it’s not an emergency and all of that. But I really do try to understand because we all do forget things from time to time. And kind of similar with raising kids or something like that. Like punishment is often not that effective. So, I try not to look at it as a punishment and if they ever experience it that way, I do try to talk to them about that, that it’s not a punishment getting charged the full fee. And really try to create a space for exploring and understanding what’s behind the connection with that.
Ken: Yeah. That’s great. Well, we’re coming up on time for today’s thinking-out-loud session. Any closing thoughts, any advice you’d have for our colleagues?
Kari: My final thoughts are, it is inevitable that you will have no-shows. So, to prepare in advance for how you want to deal with them and to talk with other clinicians because you are not alone and many people have this experience so you can get some ideas what works for you in terms of how you want to deal with it.
Ken: That’s great. Yeah, and I’ll just add, if you feel uncomfortable talking about it with patients, there might be useful material there for you to process with your colleagues or in your own therapy or wherever you think it would be useful to process that because running a successful business and being emotionally and therapeutically connected with your patients and clients can be in alignment, hopefully always is but also can sometimes feel like they’re at right angles and you have to be able to tolerate that imbalance or that dissonance in your practice as you go forward.
Kari: Yeah.
Ken: Well, thanks, Kari. Who knew there was so much to say about no-shows?
Kari: I know. Thank you, Ken! Good to talk to you.
Ken: Talk to you soon. Take care. Bye.
Kari: You too. Bye.
