Navigating cancellations in clinical practice

When I first started my private practice, cancellations were a regular occurrence. Almost every week, someone would cancel or not show up for a session. Clients would often provide seemingly legitimate reasons for not attending and I didn't like charging a cancellation fee (which I now realise was more about my own discomfort than my right to be compensated for my time) which would leave me feeling both frustrated and resentful.

After more than 20 years in practice, I am more comfortable charging for missed sessions, but I still rarely charge a cancellation fee. This is because I very rarely get cancellations outside of my specified cancellation period of 48 hours. I have found ways to reduce no-shows and late-cancellations through clear policies, communication and the way I set up the therapeutic relationship, which I will share with you below.

Cancellations are an inevitable part of clinical practice, but navigating them effectively is important for maintaining the therapeutic process and respecting both the therapist's and the client's time. In this article I will discuss how to minimise cancellations and how to handle them constructively when they occur, including decisions around when to charge, setting clear limits, and using cancellations therapeutically.

1. Setting Clear Expectations:

From the outset, it's important to establish clear expectations about session attendance. This includes discussing the importance of consistent attendance for effective therapy prior to and during the initial session.

2. Implement a clear Cancellation Policy:

A well-defined cancellation policy should be both signed by the client and discussed verbally. Many practices include their cancellation policy on their website and also as part of the intake process, where the client signs to indicate that they agree to these terms. This should then discussed and reinforced in person at the initial session, to ensure the client has a clear understanding of these expectations and the reasons why a cancellation policy is in place. For example, it can be helpful to discuss how consistent attendance contributes to therapeutic outcomes and how cancellations can disrupt the therapeutic process. It is also appropriate to note that the psychologist has put aside the time for the session, and when sufficient notice is provided, this time can be offered to a another client who might need it.

3. Set up automated Reminders:

Life can get busy, and clients may have several other commiments, so utilising automated reminder systems can help reduce forgetfulness. Most practice management systems have the option to send reminders via text or email, and scheduling these to send a day or two before appointments can prompt clients to confirm or reschedule their sessions in a timely manner. A reminder of the cancellation policy can also be included in these reminders.

4. Scheduling sessions at consistent times:

Providing consistent appointments with a regular session time and day can help integrate therapy into the client’s routine. This can enhance commitment and reduce cancellations due to scheduling conflicts. This also has the added benefit of providing a reliable and predictable therapeutic container where the client knows what to expect from the therapy space.

Sometimes clients inform us at short notice that they are unable to attend a session, but there may be times when the client does not turn up. In these instances I generally call the client to check that they are ok, and to see whether they are running late or have forgotten to attend. If I am able to get through to the client and find that they have forgotten the appointment, I give them the opportunity to attend via telehealth for the remainder of their session time.

When you have a clear cancellation policy in place, you are entitled to charge for missed sessions regardless of the reason, however there may be times when you decide to waive the cancellation fee. Whatever your policy, it should be consistently implemented.

Clients cancel appointment for a range of reasons, and often these reasons seems legitimate. I tend to categorise cancellations into emergencies and non-emergencies.

Valid Emergencies:

These situations are rare and can include things like suffering an injury or being involved in an accident on the morning of an appointment, having to unexpectedly collect a sick child from school or daycare, or if the client has suddenly fallen ill and they are too sick to attend.

I personally do not charge clients for missed sessions in the event of an emergency or unforeseen circumstances. These are instances where the client displays a clear wish or willingness to attend the session, but they are are prevented from doing so for reasons that are outside their control. My cancellation policy states that all missed sessions will charged for, so I can determine whether to waive the fee on a case by case basis, and whether the cancellation meets my definition of an emergency. When I decide to waive the fee I explain my reason to the client, as I feel this can build trust, understanding and show support for the client’s real-life challenges.

Another option to waiving the fee in these instances is to offer the client an alternative appointment time in the same week, but only if you have the space available in your calendar.

Non-Emergencies:

If a client simply forgets their session or decides not to attend at short notice, charging for the missed appointment can reinforce the value of the therapist’s time and the importance of commitment to therapy. If a client's schedule changes or they realise there is a clash in their calendar, the client is choosing to forego therapy over other commitments, and this would warrant a cancellation fee.

Where the therapist is able to schedule an appointment with another client

If a client cancels outside of the required notice period but there is sufficient time to schedule another client into this timeslot, this does not result in lost income for the therapist and it would therefore be considered unethical to charge for the session (as the therapist would effectively be charging twice for the same timeslot). In these situations the reason for not charging a cancellation fee should be made clear to the client, and should not be set up as an expectation for future cancellations.

Cancellations can also be an opportunity to explore deeper client issues:

Exploring Underlying Reasons:

Discussing the reasons behind cancellations can uncover themes of avoidance, fear, or resistance, providing valuable material for therapeutic work, particularly if we begin to notice a pattern of non-attendance or changes to appointment times, even if this is within the cancellation policy.

Reinforcing Limits:

Discussing cancellations can also reinforce the importance of boundaries and limits within the therapeutic relationship. This can also refer to starting and finishing sessions on time, such as always arriving late or finding it difficult to leave sessions after the allocated time.

Modelling boundaries and self-care:

Valuing and charging appropriately for our time also models good self-care and a sense of self-worth. It is also important to pay attention to our own internal messages and responses around charging for missed sessions, and to implement a policy that works for our individual circumstances, and one that leaves us feeling fairly compensated.

Sometimes therapists get sick or need to change sessions at short notice. It is essential that we take care of our own needs rather than "pushing through" when we are sick, and that we attend to urgent issues in our own lives when required. This models good self-care to our clients. However, it is also important to model good boundaries around our own cancellations and to handle these professionally by informing clients as soon as we can and rescheduling as promptly as possible.

Impact of Cancellations on Clients

When clients consistently cancel sessions, therapeutic progress can be disrupted and delayed, due to extended time between appointments which can impact the momentum of treatment. Discussing and exploring this with clients may help to increase insight and awareness of the therapeutic process.

When therapists cancel sessions due to illness or unforeseen circumstances, they are generally aware of the impact this might have on their clients. Missing planned sessions at short notice can particularly affect clients with attachment issues, who may interpret this as abandonment or rejection. It is helpful to be mindful of this and to acknowledge and discuss how cancellations by the therapist may have impacted the client. Addressing any underlying attachment dynamics may also have a positive impact on the therapeutic relationship.

If you are interested in learning more about how you can reframe some of the challenges we face in the therapy room into opportunities to deepen the therapeutic relationship, take a look at my Therapeutic Relationship, Attachment-Informed Therapy and Psychodynamic Therapy supervision groups. I show you how to apply some of the principles of psychodynamic therapy into your preferred model of choice, so you can feel more connected with your clients.