What does it truly mean when a patient begins to miss sessions or arrive late?

Where is the boundary between flexibility — accommodating the realities of a patient’s life — and the need to maintain the structure of the therapeutic process?

How can we determine when a missed session becomes a significant signal — a sign of devaluation, fear of intimacy, omnipotent control, or covert aggression?

The problem of poor attendance may appear self-evident—therapy cannot happen if the two parties are not present—but this problem is not necessarily an easy one for the therapist to address.

Appeals are often made by the patient on the basis of the impossibility of regular attendance:“I had an urgent matter to attend to”, “The nanny couldn’t come today, so I had to stay home”, “It takes me a long time to get  to your office, and it’s hard for me to arrive on time”, “I left home, but a panic attack started, and I had to turn back”...

Sound familiar? 

Such explanations may occur occasionally and sometimes come with advance notice. However, when they become repetitive, they should be regarded as a potential signal to explore further — offering insight into the patient’s internal processes, the course of therapy, and the dynamics of the patient’s transference.

The therapist may begin to feel that the simple requirement of attending sessions is a harsh, rigid, or even sadistic demand. However, when the therapist begins to think of the basic requirements of therapy as demands, it is a sign to reflect on what is developing in the transference and countertransference. 

On the most real level, although the patient’s getting to sessions may indeed involve considerable effort, the therapist should not forget the importance of treatment for a patient whose life may be threatened by his or her illness. The simple fact that must be communicated to the patient at this point is that the treatment cannot happen if he or she is not there, and this reality, although obvious, should be stated to a patient who is missing sessions. 

One variant of the primitive defense of omnipotent control is for the patient to imagine that someone else can take care of him or her even though that person does not have the means to act effectively in any real way. 

If a patient who had been attending regularly begins to come late or to miss sessions, the therapist must first make it clear to the patient that those actions are a form of acting out that is disabling and could effectively end the therapy. 

The therapist can then go on to explore the meaning of the behavior. 

Therapists still in training often ask themselves: “How many sessions can a patient miss before I end the treatment?” This way of phrasing the question suggests that two key concepts have not yet been appreciated. 

First, it is not the therapist who would be ending the treatment; it is the patient who, through his or her undermining actions, may make the treatment impossible and thereby end it. The therapist’s responsibility is to point out that this is happening. 

Second, the idea that there is an absolute number of missed sessions that determines when the treatment is rendered ineffective suggests that the therapist is abdicating his or her clinical judgment in favor of an objective rule that applies to every patient in every therapy. 

Although such a rule might seem easier to the therapist, it is his or her responsibility to decide when missing sessions constitutes a pattern or trend that makes it pointless to continue. 

To choose a fixed number of missed sessions in advance may play into the patient’s projection onto the therapist of a rigid and punitive person who imposes rules to which the patient must submit. This strategy may also lead to a “game of chicken” in which the patient gradually approaches the magic number of sessions, usually at a time of apparently compelling crisis, as though to dare the therapist to carry out his or her “threat” of ending the treatment. 

Regular attendance is a necessary condition for maintaining the therapeutic process.

But what about psychological availability?

A patient’s physical presence in a session is not always equivalent to psychological availability.

At times, a patient may be present, yet their condition — for example, under the influence of psychoactive substances — may make productive therapeutic interaction impossible.

In such cases, the task is to identify these factors promptly and assess their impact on the course of therapy.

A corollary of the requirement of attending sessions is the need for the patient to be psychologically available in them.

If there is any indication that the patient may be under the influence of alcohol or drugs, the therapist should explain that this behavior would make any effective work impossible and would lead to the end of the particular session and, if it becomes a pattern, to the end of the therapy. 

In general, substance abuse issues are addressed in the contract setting phase. It may, however, occur that a substance abuse problem emerges in the course of treatment or that a patient does not adhere to the initial agreement and continues or returns to substance abuse. The role of the therapist in such an instance includes doing enough of an assessment to determine whether it is safe for the patient to return home or whether the patient requires hospitalization. 

The therapist should make it clear that when they next meet, they will explore the meaning of the patient’s breach of the contract and review the parameters around substance abuse. 

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(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy