We all know “Steve.” He seems to have an uncanny knack for forgetting about his therapy appointments. The only thing more prolific than his ability to repeatedly miss appointments is his infinite store of excuses. The only thing consistent about Steve is his failure to keep appointments. While the excuses may be endless, the reasons that he can’t keep his appointments can be distilled into five core excuses.

By understanding the causes of missed appointments (and learning to look beyond the excuses,) you can help your clients keep appointments and work on improving your no-show rate. Learning how to reduce missed appointments will have a dramatic positive impact on your practice. The obvious benefit to you is certainly financially, but even more importantly, your clients maintain a continuity of care that is critical for treatment success.

5 reasons clients miss therapy appointments:
  • Logistics: transportation, childcare, schedule conflicts
  • Administrative: long lag times, poor reminder system
  • Relevance: a lack of clarity of how their treatment is providing benefits
  • Comfort: feeling disrespected, talked-down to or detached from their therapist
  • Personal: forgetfulness, embarrassment, skepticism of the treatment efficacy

Despite a myriad of excuses, the challenge of how to reduce no-shows boils down to understanding the following five reasons. Of course, these aren’t the only reasons for repeatedly missed appointments, however, almost every excuse you get can be mapped to these five.

1. Logistics

This is often the most common reason for missed appointments. This includes things such as transportation issues, finding childcare, being required to work unexpectedly. Essentially anything that prevents an otherwise willing client to attend their therapy session can be chalked up to a logistical challenge.

The difficulty with logistics is that you’re often unable to do much to completely prevent it. However, there are a few things that you can do to mitigate the issue.

Choose better appointment times

This can often be difficult in a busy therapy practice, however being especially sensitive to your client’s logistical challenges can pay dividends. By looking at a client’s appointment history and making note of the specific appointment time slots that have a tendency to be missed, you can attempt to avoid those times that have a high likelihood of being missed. For example, if your client often misses 4 pm appointments but rarely misses morning appointments, then attempt to schedule more morning appointments. You could always ask your client, however, many clients are eager to please and take their lead from your suggestions. They might not be realizing that they have a habit of missing specific times.

Offer alternatives such as online therapy

Online counseling isn’t always appropriate for every client. However, if the difference between having a client miss an appointment or conducting that session using video could be the difference between that client maintaining the continuity of treatment or not. Providing an option for online therapy, even if just occasionally, can help mitigate some logistical challenges.

2. Administrative

This is probably the reason that’s the easiest to solve in theory, however, reality sometimes makes it harder than it sounds! Administrative contributors to missed appointments include things like long waiting room times, difficulties communicating with your office, long appointment lag times as well as ineffective (or non-existent) reminder systems. Counseling office management is not a trivial challenge, but being aware of how your management decisions affect your no-show rates will have a significant impact on client care and your bottom line.

Long waiting room times

This is one that is less obvious however extremely important. If your clients have to routinely wait 15 minutes or more before they start their scheduled appointment, this increases the time investment for the client. A 1-hour appointment turns into 90 minutes or even longer. We’re all very busy, when appointments routinely take up longer than they should, that provides a powerful disincentive.

Overbooking

Economic realities sometimes require overbooking, however, if overbooking is a standard procedure within your practice, perhaps it would be wise to understand exactly what is requiring you to overbook. If it’s because of missed appointments, you have a chicken-or-egg problem: you overbook because of missed appointments but you have missed appointments because you overbook. Addressing the issues behind the missed appointments is a far more sustainable strategy than simply compensating for those missed appointments by overbooking. Over the long term, overbooking results in lower revenue than not overbooking.

Bad session time management

This one is certainly going to stoke the fires of controversy, but in terms administrative causes of missed appointments, this is a big one. You’ve certainly have been in a session where at the 53-minute mark, suddenly your client has some kind of breakthrough and you’re hesitant to end the session. By not practicing good session time discipline, you’re potentially harming other clients who are waiting. They’re waiting and watching the clock tick while you are still with the previous client. While occasionally this shouldn’t cause many problems, however by not respecting the time of your other clients, you are providing them with growing incentive to miss future appointments. Their time is just as valuable as yours!

You should be aware of the effect of your time management on your other clients. When the session approaches its scheduled ending, you can use any of those last-minute breakthroughs as the basis of the next session. Your client will likely be looking forward to the next session in order to continue the conversation. If you have a habit of going over-time, build this into your schedule. Provide a 15 minute (or more)  buffer between appointments. All of your clients will appreciate this. When you show respect for your clients’ time, they show more respect for yours.

Long appointment lag times

This can be a difficult one. Some clients don’t need to see you each week, but instead, they see you monthly or at some point far in the future. Appointments with long lag times have a high probability of being missed simply because by the time comes around for the appointment, many times the client might not feel that they need to see you again or they just forget. These types of appointments require a more proactive approach. For example, you might want to send an SMS and email reminder the week before, followed by a phone call several days before in order to not only remind your client that there is an appointment but to remind them of exactly why they have that appointment. Behavioral health scheduling can be a challenge!

Reminders

Using a text message reminder system can reduce missed appointments by 25%.There are several studies on the effect of SMS reminders on missed appointments and they are conclusive in the measurable effect on no-show rates. One study in London showed a 25-28% reduction in missed appointments by simply using text-message reminders!

Phone reminders the day before are also effective, however, they can be time-intensive for the small-practice therapist. iCouch offers an easy text message reminder system that allows you to schedule both text message and email reminders for your clients. Whatever system you use, a reminder process has the potential to substantially reduce your missed appointment rate — at a very low cost.

3. Relevance

If a client suffers from social anxiety and your approach involves spending considerable time understanding the client’s childhood, some clients might wonder what this has to do with solving their social anxiety issues. You might know, but you can’t take for granted that the client understands why you’re asking the questions you’re asking or how it will benefit them.

It’s always best to involve your client in your approach. Help them understand how what you’re asking relates to why they’re in your office. For example, if you are asking about childhood for a social anxiety client, explain just why that might be important. Don’t assume your client understands your cognitive-psycho-analytical-behavioral-humanist-hybrid methodology. By making the therapy treatment relevant with clear goals and expectations, your client will be more likely to continue treatment.

4. Comfort

Comfort is more than just a nice couch or cushy chair. It about how your client feels during the session. It’s more of a meta-level feeling rather than specific to the session. For example, if the client feels that you’re talking down to them or judging them, then that might influence their decision to blow-off an appointment. Therapists are generally well trained on being non-judgmental, but therapists are human too!

Be aware of subtle, unconscious reactions to shocking, disturbing revelations. If your client’s lifestyle choices are incompatible with your values, be aware of your own bias that might be revealed during a session. This is all standard stuff for therapists, however, it is worth remembering as this can affect your client’s likelihood of keeping future appointments. It’s assumed that you always act like a professional, but be aware of your own potential to send signals that might make your client feel uncomfortable. Facial expressions can be extremely important.

It also warrants mention that you should be careful not to insult your client’s intelligence. More importantly, you should be careful not to talk down to clients. If you use a difficult word or scientific term, don’t assume they don’t understand, however, you certainly should verify understanding. The other half to this is that don’t always assume they understand either. Be careful to speak at their level — not above it and not below it. This is a difficult balancing act, however, luckily, most therapists are trained in exactly this. Just keep it in mind in order to maximize the comfort of your clients as well as build the trust needed to keep them from missing appointments.

Of course, it’s also true that sometimes a therapist and client just don’t “click.” Rather than continuing the therapy relationship when you are fairly certain it won’t be as productive, perhaps help refer the client to another therapist that might be more appropriate. You certainly don’t want to lose business, but at the same time, a bad therapist-client relationship will result in more missed appointments as well prevent the client from making progress! Always remember that your client’s best interests should be your highest priority. You aren’t an expert in everything; recognize your limitations.

5. Personal

Some clients are prone to embarrassment. For example, if you have a client who went on a dangerous drinking binge the night before an appointment, they might feel embarrassed to come to their session. There’s not much you can do specifically to prevent this type of missed appointment other than building trust and making sure they understand that you are there to help them, not criticize or judge. This relates to the Comfort section above, however, the difference is that clients that miss appointments for personal reasons aren’t generally responding to something you’ve done, but how they feel about what they’ve done. By creating a welcoming and accepting environment, you can mitigate some of these concerns.

The forgetful client seems to be a common species. Aside from the obvious answer to use reminders, another strategy is to find ways to engage the client between appointments. Using homework, assigned reading or a checklist of things to do before the next appointment, you can engage them to where their treatment is something they’re thinking about between appointments. By keeping you in their mind between appointments, they’re not only helping themselves, they’re helping you reduce their likelihood of forgetting their next appointment.


Missed appointments are a significant challenge for every therapist. You’ll never be able to eliminate them completely, however being aware of some of the big reasons clients miss their sessions should help you develop a strategy to reduce no-shows.

What do you think? What are some clever or innovative methods you’ve used to reduce appointment no-shows? Please add a comment and share your experience!

Do you want to reduce your missed appointments? You can try iCouch for free right now. Please have a look and sign up! Learn more here.

Published by Brian Dear

Brian is the cofounder and CEO of iCouch, Inc. He has an extensive background in software engineering, inbound marketing and mental health practice management.

Join the Conversation

2 Comments

  1. Brian, Thank you for this post. I am just starting out in private practice and find myself still learning about why clients miss/cancel appointments. Your post helped me see what aspects I can and can’t control and how to plan for them! I especially appreciate your section around client comfort and being aware of subtle facial expressions or responses. Thank you!

    1. I am a Former Social Worker having worked with Foster Children/Families. I am now however, now on the other side of the couch. I am a Client who just missed 2 therapy sessions consecutively because I feel that my therapist has dismissed the impact of terminating my privilege to email her, and the “check in’s” via phone on the weekend. It is such a tremendous loss and I am upset, angry and not wanting to see her ever again. I didn’t call to cancel. I just didn’t show up. She called me after having missed first session, and I didn’t answer the call. She left a general message “We had an appt. today, I’m sorry I missed you. I look forward to seeing you on Friday.” Her general unsympathetic message, proved to me that she has no idea I am feeling self-destructive and suffering, I cut after that difficult session where she told me about no more emails (something about emails being un-encrypted, no privacy, Clinic policy) and the next day I took 6 muscle relaxants to sleep all day. I know I am communicating my distress thru avoidance which is never good, but she should have called to talk to me. Doesn’t she want to know why I missed a session which I never do, unless something is wrong, but I didn’t call her to cancel. This proves to me that she doesn’t genuinely care that no emails/checking in weekends, is not a big deal. I can’t imagine having effective treatment with just 2 sessions a week, and no calls or emails during difficult times. Please I suggest to all Therapists who have a difficult session with a client and then the next session client doesn’t show up without cancelling, that is often a RED FLAG to make an extra effort to call your Client. While you don’t ever want to give clients the message that “acting out” by missing a session without cancelling is their way of manipulating you so that you will respond in a comforting way, like what they needed after that difficult session, the client’s safety is always more important that figuring out whether it’s a form of manipulation. Please people who are Trauma survivors deserve your genuine care, attention, and extra effort to ensure their safety. If not you will indirectly be sending them the same negative invalidating message, their abuser sent, “I know I did something that is causing you great pain, but I don’t care, you are not a child anymore, deal with it.”

Leave a comment

Your email address will not be published. Required fields are marked *