Abstract
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.
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Notes
I have decided to use the word “patient” rather than “client” here. Patient, from the Latin patior ‘to suffer’ has associations that seem relevant to the subject of this paper. Client, from the Latin cliens, related to the Latin verb reclinare ‘to recline’ and cognate with the Greek verb klínein meaning ‘to lean’ harks back to the ancient Roman social institution of clientela in which a poorer client and a powerful patronus ‘patron’ had certain mutual social and financial obligations. Consumer smacks especially of a relationship based on capitalism. As one man joked to a staff member when signing an agency document under the line for consumer: “I’ve consumed all your time, so you’ve run out of patience.”
One study was an exception. Chariatte et al. (2008) studied attendance and the waiting periods between appointments at a university hospital outpatient clinic for adolescents aged 12–20 years old in Switzerland with a multi-disciplinary staff ranging from physicians to dieticians to psychologists. They found that a longer wait between appointments increased the chance of missing.
In an organization that is already managing anxiety through depersonalization and denial of the significance of the individual, the values of capitalism and managed care add further pressure to treat the patient as an exchangeable commodity rather than as a unique individual. Our cultural preference for manic defenses may interact with the culture of the agency to create an environment that cheapens the therapeutic relationship when we need to cherish it (Altman 2005).
Anyone who has watched the HBO series The Wire, which so artfully captures the workings of the Baltimore Police Department and its interactions with other social systems, is aware that without ongoing reflection or rebellion, organizational pressures make it virtually impossible to focus on the primary task, in this case police work, rather than on keeping the system running without undue stress, undesirable statistics, or danger to the budget.
For example, patients who tend to no-show may repeatedly have their cases closed and repeatedly return to the clinic in crisis or even require costly hospitalization. Does this arrangement result in a better use of resources? Edward Shapiro (1997, p. 15) has argued that administrative management of resources without attention to intrapsychic and interpersonal dynamics may result in an apparent reduction in expenditures that is, in fact, merely a shift from the psychiatric column to the medical column. He cites one example of administrative cost-cutting, in which patients “with mental illness who received no definitive treatment ended up in emergency wards and internists’ offices with behavioral and physical manifestations.”
One common method of releasing this tension is to rush to close the case. Is it an accident of the English language that when we close a case we fill out a discharge summary, a concrete way to temporarily discharge our tension when we do not have a supportive relationship to help us manage in a more psychological or symbolic way?
Kurt Lewin (1951, p. 169)
References
Adler, I. M., Goin, M., & Yamamoto, J. (1963). Failed psychiatric clinic appointments: Relationship to social class. California Medicine, 99, 388–392.
Altman, N. (1993). Psychoanalysis and the urban poor. Psychoanalytic Dialogues, 3, 29–49.
Altman, N. (2005). Manic society: Toward the depressive position. Psychoanalytic Dialogues, 15, 321–346.
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.
Bion, W. (1962). Learning from experience. London: Heinemann.
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.
Buie, D. H. (1982–1983). The abandoned therapist. International Journal of Psychoanalytic Psychotherapy, 9, 27–31.
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.
Casement, P. (1985). Learning from the Patient. New York: Guilford.
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.
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.
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.
Fairbairn, W. R. D. (1954). Observations on the nature of hysterical states. British Journal of Medical Psychology, 27, 106–125.
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.
Hochstadt, N. J., & Trybula, J. (1980). Reducing missed initial appointments in a community mental health center. Journal of Community Psychology, 8, 261–265.
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.
Joseph, B. (1989). Psychic equilibrium and psychic change: Selected papers of Betty Joseph. London: Tavistock/Routledge.
Kernberg, O. (1985). Borderline conditions and pathological narcissism. New York: Jason Aronson.
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.
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.
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.
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.
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).
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.
Ogden, T. (1982). Projective identification and psychotherapeutic technique. New York: Jason Aronson.
Racker, H. (1968). Transference and countertransference. London: Karnac Books.
Rusius, C. W. (1995). Improving outpatient attendance using postal appointment reminders. Psychiatric Bulletin, 19, 291–292.
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.
Shapiro, E. R. (1997). The inner world in the outer world: Psychoanalytic perspectives. New Haven: Yale University Press.
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.
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.
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.
Winnicott, D. W. (1969). The use of an object. International Journal of Psychoanalysis, 50, 711–716.
Acknowledgement
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.
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Kwintner, M. When Absence Speaks Louder than Words: An Object Relational Perspective on No-Show Appointments. Clin Soc Work J 39, 253–261 (2011). https://doi.org/10.1007/s10615-011-0313-x
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DOI: https://doi.org/10.1007/s10615-011-0313-x