Clinical Social Work Journal

, Volume 39, Issue 3, pp 253–261 | Cite as

When Absence Speaks Louder than Words: An Object Relational Perspective on No-Show Appointments

  • Michelle KwintnerEmail author
Original Paper


The rates of no-show appointments in community mental health are reported to be as high as 50%. Yet there is a striking scarcity of clinical literature on this subject compared with the abundance of articles written from an administrative point of view. This paper describes a variety of countertransference responses to missed appointments. Drawing from object relations theory, the author maps out different pathways to guide thinking about the use of countertransference, listening to clinical material following a no-show appointment, and responding to organizational pressures. The paper aims to help practitioners make greater sense of the patient’s inner world and of what is going on in the transference-countertransference matrix.


No-show Missed appointments Countertransference Object relations theory 



I would like to express my gratitude to Chris Erskine for helping me find room to think and write, Gerald Schamess for guidance and discussion of earlier versions of this paper, and Michael Weiss for unfailing encouragement.


  1. Adler, I. M., Goin, M., & Yamamoto, J. (1963). Failed psychiatric clinic appointments: Relationship to social class. California Medicine, 99, 388–392.PubMedGoogle Scholar
  2. Altman, N. (1993). Psychoanalysis and the urban poor. Psychoanalytic Dialogues, 3, 29–49.CrossRefGoogle Scholar
  3. Altman, N. (2005). Manic society: Toward the depressive position. Psychoanalytic Dialogues, 15, 321–346.CrossRefGoogle Scholar
  4. Benway, C. B., Hamrin, V., & McMahon, T. J. (2003). Initial appointment nonattendance in child and family mental health clinics. American Journal of Orthopsychiatry, 73, 419–428.PubMedCrossRefGoogle Scholar
  5. Bion, W. (1962). Learning from experience. London: Heinemann.Google Scholar
  6. Booth, P., & Bennett, H. (2004). Factors associated with attendance for first appointments at an alcohol clinic and the effects of telephone prompting. Journal of Substance Use, 9, 269–279.CrossRefGoogle Scholar
  7. Buie, D. H. (1982–1983). The abandoned therapist. International Journal of Psychoanalytic Psychotherapy, 9, 27–31.Google Scholar
  8. Carpenter, P. J., Morrow, G. R., Del Gaudio, A. C., & Ritzler, B. A. (1981). Who keeps the first outpatient appointment? American Journal of Psychiatry, 138, 102–105.PubMedGoogle Scholar
  9. Casement, P. (1985). Learning from the Patient. New York: Guilford.Google Scholar
  10. Chariatte, V., Berchtold, A., Akré, C., Michaud, P. A., & Suris, J. C. (2008). Missed appointments in an outpatient clinic for adolescents, an approach to predict the risk of missing. Journal of Adolescent Health, 43, 38–45.PubMedCrossRefGoogle Scholar
  11. Coodin, S., Staley, D., Cortens, B., Desrochers, R., & McLandress, S. (2004). Patient factors associated with missed appointments in persons with schizophrenia. Canadian Journal of Psychiatry, 49, 145–148.Google Scholar
  12. De Figueiredo, J. M., Boerstler, H., & Doros, G. (2006). Treatment history versus clinical characteristics in the prediction of use of outpatient psychiatric services. Social Psychiatry and Psychiatriac Epidemiology, 41, 130–139.CrossRefGoogle Scholar
  13. Fairbairn, W. R. D. (1954). Observations on the nature of hysterical states. British Journal of Medical Psychology, 27, 106–125.CrossRefGoogle Scholar
  14. Folkins, C., Hersch, P., & Dahlen, D. (1980). Waiting time and no-show rate in a community mental health center. American Journal of Community Psychology, 8, 121–123.PubMedCrossRefGoogle Scholar
  15. Hochstadt, N. J., & Trybula, J. (1980). Reducing missed initial appointments in a community mental health center. Journal of Community Psychology, 8, 261–265.PubMedCrossRefGoogle Scholar
  16. Jaques, E. (1955). Social systems as a defence against persecutory and depressive anxiety. In M. Klein, et al. (Eds.), New directions in psycho-analysis: The significance of infant conflicts in the patterns of adult behaviour (pp. 478–498). London: Tavistock.Google Scholar
  17. Joseph, B. (1989). Psychic equilibrium and psychic change: Selected papers of Betty Joseph. London: Tavistock/Routledge.Google Scholar
  18. Kernberg, O. (1985). Borderline conditions and pathological narcissism. New York: Jason Aronson.Google Scholar
  19. Klein, M. (1935). A contribution to the psychogenesis of manic-depressive states. International Journal of Psychoanalysis, 16, 145–174. In The writings of Melanie Klein (Vol. 1, pp. 262–289). London: Hogarth Press, 1981.Google Scholar
  20. Klein, M. (1952). Some theoretical conclusions regarding the emotional life of the infant. In Envy and gratitude and other works 1946-1963 (pp. 61–93). London: Hogarth Press, 1975.Google Scholar
  21. Lewin, K. (1951). Problems of research in social psychology. In D. Cartwright (Ed.), Field theory in social science: Selected theoretical papers. New York: Harper & Row.Google Scholar
  22. MacDonald, J., Brown, N., & Ellis, P. (2000). Using telephone prompts to improve initial attendance at a community mental health center. Psychiatric Services, 51, 812–814.PubMedCrossRefGoogle Scholar
  23. Menzies Lyth, I. (1959). The functions of social systems as a defence against anxiety: A report on a study of the nursing service of a general hospital. Human Relations, 13, 95–121. In Containing anxiety in institutions: Selected essays (Vol. 1, pp. 43–88). London: Free Association Books (1988).Google Scholar
  24. Meyer, W. S. (2001). Why they don’t come back: A clinical perspective on the no-show client. Clinical Social Work Journal, 29, 325–339.CrossRefGoogle Scholar
  25. Ogden, T. (1982). Projective identification and psychotherapeutic technique. New York: Jason Aronson.Google Scholar
  26. Racker, H. (1968). Transference and countertransference. London: Karnac Books.Google Scholar
  27. Rusius, C. W. (1995). Improving outpatient attendance using postal appointment reminders. Psychiatric Bulletin, 19, 291–292.CrossRefGoogle Scholar
  28. Schnitzer, P. K. (1996). “They don’t come in!” stories told, lessons taught about poor families in therapy. American Journal of Orthopsychiatry, 66, 572–582.PubMedCrossRefGoogle Scholar
  29. Shapiro, E. R. (1997). The inner world in the outer world: Psychoanalytic perspectives. New Haven: Yale University Press.Google Scholar
  30. Shapiro, E. R., & Carr, D. A. W. (1993). Lost in familiar places: Creating new connections between the individual and society. New Haven: Yale University Press.Google Scholar
  31. Sherman, M. L., Barnum, D. D., Nyberg, E., & Buhman-Wiggs, A. (2008). Predictors of preintake attrition in a rural community mental health center. Psychological Services, 5, 332–340.CrossRefGoogle Scholar
  32. Williams, M. E., Latta, J., & Conversano, P. (2008). Eliminating the wait for mental health service. The Journal of Behavioral Health Services & Research, 35, 107–114.CrossRefGoogle Scholar
  33. Winnicott, D. W. (1969). The use of an object. International Journal of Psychoanalysis, 50, 711–716.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.IthacaUSA

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