I was reminded this week (by a client that went missing in action) that seasoned professionals can easily get sloppy . . . and when we do get sloppy, our practices can suffer.
I have a client who has recently come to terms with his dependence on drugs. In an unusual turn of events, he figured out that he was in trouble and voluntarily sought out a treatment program and private counseling with me. I was thrilled to not have to work through the stages of denial that are often expected when working with chemical dependence.
Week after week we are meeting, doing really good work, and moving right along . . . or so I thought. And, then he went MIA!
"The Awful Truth . . . " by Socar Myles / Big Fat Rat
I called the day he stood me up. I dropped him a note when he didn’t answer the phone. A week later I called again. And, here I am on week number three calling one more time. . . .Here’s what I think happened. I think he relapsed . . . as is often the case. And, here’s the reminder I got . . . when your client is doing well, that’s great!
But, when you client is doing unbelievably well, take a breath and prepare yourself. And, prepare your client. Don’t get carried away with their enthusiasm. Try to slow them down. Slip ups happen and what you don’t want is for your client to have to deal with your disappointment in addition to their own. It’s easy for shame and embarrassment to get in the way of your client’s recovery. And, if your client’s recovery suffers, so will your practice.
Hi Tamara. After attending a conference on DBT for substance abuse, I, like you, call and send notes to clients who stop showing up. One thing mentioned at the conference was the need to get a list of hangouts and using friends from a client at the beginning with an understanding that you may try to track them down. The research behind this is promising, but not all of us can do this kind of thing. I recently had a client who missed an appointment. I called and left a message. He did not call me back. As I was going to be on vacation, I called one more time and left a message, asking him to call me if he was going to continue with me. He did not call me back, then showed up for his appointment when I was not there! I called and he told me he rarely listens to his messages. Ha. In his case, maybe a note would have been a better choice. Thanks Tamara…I love to read your posts…they are always so helpful!
Linda! It’s good to hear from you! Thank you for suggesting that list of hangouts and friends! I think that mental health professionals spend so much time learning the theoretical stuff that it’s easy to overlook the practical things that we can do to help our clients and protect ourselves, too!
Hi Tamara and Linda. Two things that occur to me…
One, if you’re going to visit your client’s hangouts and talk to his friends/associates to try and track him down, you’d better make darn sure you don’t violate his confidentiality in the process.
Second, if and when you do reconnect with him, you may want to explore (non-judgmentally, of course) whether his not returning your calls then showing up when you were on vacation, were acts of self-saboutage. This kind of behavior often occurs with precontemplative clients as well as those who have attained recovery but are now in the early stages of relapse.
Thanks, Jim. I had similar thoughts, too. I wouldn’t be tracking down my clients’ friends or their hangouts. However, these days I am working with high functioning clients. In past settings, obtaining permission to contact friends / associates would have been both proactive and well-advised with some populations. I’m thinking those with Axis III symptomology.
I absolutely agree with your second point, too, and would not limit that exploration to those dealing with addictions. Although Linda did not specify the population that she was considering when she made those recommendations, I’m realizing that I did make some assumptions. Your points and hers both remind me that context matters, doesn’t it?
The longer that I’m engaged in social media – and other writing that is open to public scrutiny – the more I recognize that clarity in communication matters, too! Thank you for the reminder!
Hi Jim,
Thanks so much for your thoughts on this! I do not consider myself an addictions counselor and at this point only have one client where this is the primary focus. I did not ask him for his friends or hangouts, but if I did, I would get a release from him to do this first. It is a good question for Linehan, and one I cannot remember being answered. It’s been several years since I took the training. Also, I thought of your point about supposedly not checking his messages. This client is without a job and is reportedly looking. Why would you not check your messages? Good fodder for our next session, for sure. Thanks again Jim!
Hi, Linda! Thanks so much for staying engaged in this discussion. It’s helping many of us stretch and take a second look at some of our practices, I’m sure. Just thought I would say that I’ve had many clients over the years (and a few friends, too) who – during times of financial crisis – quit listening to their voice mail messages. My understanding is that, in hindsight, they were in a bit of denial and did not want to hear the debt collectors. That’s just one possible reason a client may not want to check messages. I’m sure there are many more. But, in this particular example, of course, it probably is a subject worthy of exploration and a discussion or two!
I think that you make some good points in this article. We have to remember that many addicts also get overconfident when things are going well. Thank you for your thoughts.
Michael! Welcome to Private Practice from the Inside Out! You’re from Oak Lawn – my old stompin’ grounds! So glad to have your voice here and appreciate the nod to our clients that are struggling with addictions. It absolutely happens.
I hope you’ll drop back in often to join the discussions here. We are building a strong and vibrant online community of mental health professionals who are supportive of each other in growing our practices. Your voice is welcome here.
Dear Tamara,
At present my focus is in working with couples where betrayal large and small is the presenting issue. Since 1974 I worked in the addictions field and can tell you that you can process the risks of flights into health or stand on your head – it will not make a difference.
Relapse is beyond our control no matter how skilled we are. It is the nature of the illness. What I do is talk about the feelings of the aftermath of relapse to hopefully allow the client to return even though they feel ashamed. This sometimes prevents the MIA effect but it may take a long time for the return. Unfortunately, this is a life threatening illness and many of my MIA’s have wound up DOA’s.
Hi, Roberta! Welcome back! You are absolutely right that relapses and flights into health do happen. I so appreciate you mentioning the benefit of talking about the feelings of the aftermath of relapse with your clients. That is not only a good clinical strategy but also a smart business strategy that often does help a client to return to treatment after a slip. I also use a good dose of predicting slips, poor choices, relapses and normalizing them. Sometimes clients will bend over backwards to prove me wrong:)
I used to send follow up letters to folks if they missed and I could not reach them by phone stating that they missed and to call by a certain date before I closed their file. Part of it was to cover myself and part of it was to try to get them to return to therapy. I rarely got calls back, but once and a while I would get someone call me back and want to schedule. I am thinking of doing this sort of thing with clients I had ongoing for a while that dropped out but maybe not so much with folks who come once or twice and then drop out.
Hi, Jill! I don’t send a formal type-written letter although that would certainly cover my tail. I send a handwritten note – and I do that intentionally. I want my client to feel like my effort to reconnect with him / her is personal. I use a little fold-over, professional-looking note and usually say something like “Hey, John, I’m dropping you a quick note to let you know that I missed you today. We had an appointment scheduled at 10 a.m. Hoping all is good with you and that you just forgot. Let me know when you are ready to reschedule! Tamara ”
While clinically, I’m always looking for patterns of behavior and do address those during therapy, in the note, I always give them the benefit of the doubt and an easy “out.” We all make mistakes. Even therapists forget appointments or double book on occasion. I don’t reinforce or avoid discussion of patterns of last minute cancellations or no shows. But, I try to remember that relationship comes first. (And, if you are looking for the clinical rationale for those handwritten notes, check out some of the solution-focused literature.)
The truth is I have very few missed appointments or last minute cancellations. I attribute that to two things . . . (1) building solid relationships between me and my clients and (2) an equally solid cancellation / no show policy with monetary consequences and no shaming. And, in truth, I believe that the latter reinforces the former.
I like the handwritten note idea. I think I will incorporate it somehow. We have a no-show cancellation policy where we charge as well, however for my medicaid folks I am not allowed to charge so I have to tell them that if they no-show or miss more than 2 times then we end therapy. I don’t know any other way to handle it.
Hey, Jill – Whose policy is it that you cannot charge clients who receive / pay by Medicaid for missed appointments? I don’t work with Medicaid but I am skeptical of that being a rule of Medicaid. And, if it’s your agency’s rule, I would recommend that you work to change it. Like other insurance companies, I suspect that Medicaid will not pay for missed appointments but certainly clients can be billed directly for those no shows . . . can’t they?
It’s a medicaid policy. I don’t know why, one would think that medicaid folks would be held accountable just like the rest. In fact the group I am with charges a fee for no-shows.
Hmmm – thanks, Jill! Good to know. Anyone else encountering the same thing? Is there anyone in private practice that can speak to this issue?
Jill,
I work with Medicaid clients as well, and we are not allowed to charge for no-shows either. We, too, have a policy where we send the letter after two no-shows and if they do not reply within a certain time period, their case is closed. I also recently found out that if we have a client who begins to receive Medicare benefits (who we refer to another agency) and they have the finances to pay for our services privately (and depending on their reason for being given the care funding, occasionally they do), we are not permitted to charge them at all because they have Medicare benefits. Have you heard anything about that? I’m wondering how or if this principle applies to private practice.
Lauren, thanks for sharing what your experience has been with Medicaid. Can you drop back in and let us know if these are agency or Medicaid policies?
Unfortunately, our agency is not very transparent about reasons for such things, when asked, we are typically told the same thing again without any reasoning. I have tried to ask about other issues similar to this one. If I find any information regarding privately billing clients with Medicare in private practice, I will let you know about that — I really need to know the answer to that one. If I come across Medicaid information in the process, I’ll pass that along.
Thanks so much, Lauren! (Hey! Just realized . . . you don’t have a “little me” picture i.e. avatar! What’s up with that?)
You know . . . those clients and employees who are digital natives aren’t really going to stand for that lack of transparency very long. I completely understand that it is typically those of us that are the digital dinosaurs who have set up the systems and institutions that the natives are currently working in. But, as the natives gain experience and move into positions of more power, I suspect that we will see our institutions transformed into places of greater transparency.
I wanted to follow-up on this discussion about being able to charge clients who have Medicare. I spoke with someone at the American Counseling Association. If a mental health professional is not an “in-network provider” for Medicare, the client can pay an “out of network” fee for counseling (whatever rate we choose to charge). The problem comes in when an agency accepts Medicare because each client may have to pay a different percentage of a predetermined Medicare rate.
Lauren! Thanks so much for dropping back in to share what you have learned! This makes perfect sense to me.
Tamara,
Thanks for the article and follow-up comments. In contacting MIA clients, do you prefer the hand written note to the follow-up telephone call? The TC seems a bit aggressive to me and you often wind up having to leave a message. Also, I wonder if the person may be caught off guard and agree to reschedule only later to miss or cancel. Truthfully, I hate talking on the phone and would prefer that you say that the note is the better option 🙂
Thanks for your insights.
Allen Young, LPC
Oh, Allen, this is a really good question. Actually, initially I follow up with a phone call – often leaving a message if I have permission to do so. The reason I do this is related to risk management and liability. I don’t want a client to be in a really bad place, thinking about suicide, and to feel ignored or all alone. What we know about suicide is that those who attempt . . . in the moment . . . feel very alone. So . . . if you stand me up for an appointment, I’m calling you first – typically within the first 15 minutes. And, if you don’t answer, I’ll ask you to contact me to let me know that you are OK. If you, as the client, fail to contact me within the next day or two – assuming that I have no other reasons to be alarmed like prior suicidal ideation, history of self harm, etc. – then I’ll follow up by dropping you a note as a permission-giving “tickler.”
Thanks for the response, Tamara. Setting aside safety concerns, do you think it is a better idea to call or to send a not when following up on a “missing in action” client.
Thanks,
Allen
Safety concerns aside, I still think that a phone call is the first step. Not wanting to be intrusive but at the same time wanting to add a little “glue” to the relationship, I would then follow up with a note if I did not hear from the client after I left a voice mail message.
This is so true! It is almost as if we therapists need to see good times as the calm before the storm and do some preparations for the possibility that there are potential downturns coming or client related factors such as approval seeking or avoidance. I love how your blog posts can be so short but such good reminders!
Haha- Thanks, Kat! I love to devour information but rarely have time to read as much as I would like. Just assuming that the same is true for most of the folks here, too!
Once upon a time, I went to counseling. (Actually a few times to a couple different ones!) Often, I utilized my EAP program and got a whopping 3 visits (because we all know that that’s all anyone needs, right?)! At any rate, usually I was having situational issues and didn’t “need” much more (maybe I went two or three sessions beyond on my own dime).
Sadly, when I would go back with EAP, I’d often get a different counselor….crazy, huh? I digress…. one of the counselors mailed a letter to me, even after we had finished. It might not have been officially terminated but I didn’t schedule another session and felt it was completed. It was a nicely worded letter saying something like “I haven’t seen you a while and I hope that is because you are doing so well. If you ever need services in the future, I’m here to serve you.”
I took that letter in a positive light and made a mental note to use it in the future.
Fast forward to now. I’m not really in private practice (hope to be). I do counseling for an agency and I subcontract (which is another story for another time) a couple of clients on the side. I haven’t ever sent a note or letter to any of them. I’m liking the idea of the no shows….and maybe I need to explore this more. And I did notice that you said “ideal clients.” I do know sometimes folks try therapy out and schedule a second or third session and never intend to go….they are terminating on their own terms. Now I don’t know your no show policy….but, I am wondering if you send these notes if the client relationship is very near the beginning…..
Jamie, thank you so much for dropping back in today! Yours is another voice that I’ve missed around here!
Yes, I actually do send notes early and often to clients not just for missed appointments and not just to my old timers. Even those who come just once. Perhaps I should back up and say that I believe that I am the glue in the relationship. That means I actively look for opportunities to send a note or other ways to add more glue between me and the client – especially in the early days of working with a new client. And, it works for me. I have not lost a client after the first 1-3 sessions more than once in the last 7 years. I believe that this is a better return (literally!) rate than most counselors have. (I really need to find some research to verify that that is the case . . . . Anyone got that research handy?)
I really like the idea of this…have had a client give birth recently as well as another get married. I wanted to acknowledge these events but I was “shy” about sending a card b/c I didn’t want to jeopardize my client’s confidentiality….someone else seeing that I sent them a card. Maybe I’m over-thinking it (which is SO VERY possible) but do you put a return address and/or confidential notice on the envelope and/or ask if correspondence is alright?
Also, you could do some informal research with something like survey monkey and ask other professionals who visit here (or other circles where you participate) to give statistics or estimates of “losing clients”…I know for a fact, your record beats mine (although I am gleaning from your experience and will have a much better record when I go into private practice)!
Hi, Jamie. You remind me that I need to be really clear here . . . . Everything I do with a client needs to have a clinical rationale. Be careful not to play word games with yourself to justify contact. The notes I referenced focus on cancellations, clinical work that we are doing i.e. homework, providing resources, etc. or have a clinical and strategic focus. I would not send a personal Hallmark wedding or graduation card to a client; however, I might send a fold over note on my business stationery with a note that says something like “So glad your hard work has culminated in your big day! Congratulations!” Be careful to not say anything that the client or anyone else could misinterpret. When in doubt, don’t send it.
And, on a related note, assume that clients will show your card to other people – who may turnout to be your clients either currently or in the future! (Yes, it happened to me. And, yes, with certain clients . . . that, too, complicates matters!)
Jamie, thanks for the suggestion to survey folks here. I haven’t formally done that but have asked for others to share their stats. Let me look into how to make that happen! Great idea.
And, in case I have failed to say so already . . . I so appreciate your willingness to engage with me and others here on Private Practice from the Inside Out. It enriches our online community so much when you and others are willing to contribute your ideas, your resources, your questions, and concerns! So glad you are finding this blog and conversations useful to you! Please let your friends and colleagues know, too!