How a Missed Therapy Session and Self-Disclosure Led to Therapeutic Gains

• Placing Therapist Needs First
• Case Illustration
• A Therapeutic Moment of Truth

Placing Therapist Needs First

They have always been uneasy feelings for me, ones that I’ve experienced over the years, mostly leading up to the major holiday break. Rarely, if ever, did they arise when I was a beginning therapist. I must admit now, that after having been a clinician for more than two decades, I find myself really looking forward to time to myself and engagement with family and friends over the holiday period — more than seeing patients. I also look forward in some instances to not seeing particular patients. Let me be clear though, that these feelings or desires are in no way a reflection on how I feel generally about working therapeutically or with my patients in general.

These feelings, I should add, typically arise in anticipation of a holiday break, and very rarely during the “normal” working periods during the year. In spite of my rationalizations, I still feel a measure of shame in making this admission. However, I believe that it is better to acknowledge my feelings and have the freedom to explore them without undue censure. I believe that this minimizes the chances of acting them out, although it is hardly a guarantee. My historic silence around this issue probably reflects an internalized taboo against choosing personal time over professional time, especially when clients’ wellbeing lies in the balance. I have chosen to break this silence here in hopes that doing so will benefit colleagues who struggle in similar ways.

I’ve learned that the cost to the client for repressing these feelings is enactment, in the form of forgetting appointments, double booking patients, or last-minute cancellations. While other periods leading up to non-major holidays may also be potential triggers for me, the end of the year is a seemingly more potent stimulus for these specific types of clinical acting out.

Case Illustration

I practice out of a large shopping centre, a setting that offers a combination of a relaxed atmosphere and buzzing intensity — a truly curious blend for me. Having a cup of coffee in the morning before seeing a patient is one of my favourite activities, part of my commitment to caring for myself in a rather small way. This particular day, I was especially excited in anticipation of treating myself to a Jamaican blended dark roast latte with foam. Its exquisite taste and heady aroma came hurtling to the forefront of my consciousness well before I arrived at my local coffee shop, assaulting my senses with feelings of anticipation.

I was nearly a week away from my upcoming year-end holiday and was looking forward to the well-deserved break. I was scheduled to see my first patient at nine o’clock — I refuse to do any earlier sessions because, in essence, I am not much of a morning person. Since I seemed to have plenty of time, “seemed” being the key word, I decided to indulge myself further, choosing to take my latte as a sit down in the coffee shop instead of the usual take-away. I sat at a table and settled in, motioned to the waiter, who took my order rather cheerfully as I made a brief nod to the barista, someone who I had become fast friends with over the past few months.

I made a mental note to stop and check in with him on the way out. He knew exactly how I liked my latte, so I felt I was in good hands. As I sat alone, sipping my delicious “nectar,” my thoughts drifted to the upcoming break. Spending long days at the beach whilst being unencumbered by work sounded heavenly at this point. As I was enjoying this moment of pure self-indulgence, I couldn’t help but reflect on a vague, yet growing recent feeling of not wanting to see patients. And those feelings did not reflect on my work with any particular one. The thoughts revolved around secretly hoping that patients wouldn’t arrive for their sessions (which indeed some did not). I hated the feeling even though I experienced it only dimly at times during this period. I tried to chase it from my mind so that I could continue with my sensory immersion of the moment. But it continued to nag at me.

The Rupture

Suddenly my attention was drawn to the time. It was 9:10 and I realized that my patient had been waiting for a full ten minutes for me. Panic ensued as I tried to unlock my phone. I had a missed call at 9:05 from the patient. I had “accidently” left the phone on vibrate and therefore didn’t hear it ring or pulsate. A rare lapse for me, but a lapse no less. I hastily returned the call hoping that the patient was still in my office, only to discover that they had gone. I detected no hint of anger in her voice, but I was not convinced when she said that I could talk tomorrow about setting up another session.

I apologized, but she rapidly talked me off the phone saying she had to go. I was dismayed, a sinking feeling of guilt and shame wrapped itself around me like a cloak, which I felt everyone could see. I hurriedly raced from the coffee shop in utter shame, upwards towards my rooms. Once there, I tried with profound difficulty to wipe from my mind the feelings of shame and guilt whilst I prepared for my next patient. But Jane drifted into my mind, and it became clear that as hard as I tried, it would not be so easy to forget what had happened. Jane had been a perfect patient in many ways, almost always on time, rarely cancelling a session, and paying on time for her sessions without any reminders. In many ways, she was one of my favourite patients (yes therapists do seem to have favourites, I’m afraid!).

Jane

Jane’s history made my infraction feel all the weightier. Jane and I had worked well together, after all, she took risks in her sessions and tried to be as open as possible. The one element that struck me was her reserve around expressing any criticism of me. Jane had grown up in a household where her parents seemed to discourage any form of criticism towards them. By all accounts, there was little to criticise in terms of their behaviour, but no parent is perfect, and when Jane tried to offer them any negative feedback on behaviour which she found less than desirable, she was immediately made to feel exceptionally guilty for doing so with words such as, “Was our behaviour towards you really so deserving of so much anger?”  

After leaving her parents’ home, Jane had remained in an unsatisfactory marriage out of fear of hurting her husband if she expressed dissatisfaction with his frequent, less-than-pleasant behaviour. When she did eventually muster the courage to complain, he reacted predictably; in a manner which she experienced as defensive and counter-critical. The marriage ended during our therapy, after many sessions spent examining in detail why she remained. I listened patiently and attentively, intervening in as neutral a manner as I could tolerate. I am almost certain that some of my disapproval of her staying in the marriage must have leaked out.

About a week following the “incident” of running late, I left a voice message for Jane saying again that I was sorry for the error, and wondered when she would like to come in again. I offered her a free session as I had wasted her time by not being there for her. I knew deep down that the offer of a free session was meant in part to assuage my own sense of guilt and shame over missing the session, although I hoped it might go some way in making amends for my “transgression.” Another two weeks passed without any word from Jane, and I resigned myself to never hearing from her again. To my surprise, she called up one day almost four weeks after the missed session and apologised. She had gotten my messages but had become very busy with a work project and therefore hadn’t had the time to call me. She asked if I could schedule a next session, which I promptly affirmed for the following week at her usual time.

A Therapeutic Moment of Truth

Prior to that next session with Jane, I thought deeply about how I wanted to address the issue of missing her session. While I typically follow the dictum that the patient is responsible for initiating the session, I felt that this was one of the rare instances where I would take the lead. It was an opportunity for me to understand what my error had meant to Jane, to assist her in exploring any thoughts and feelings she had towards me for having committed this error and giving her an opportunity to decide whether she would like to continue seeing me. A hint of reservation regarding this pre-planned intervention did waft through my mind just before seeing Jane, but I ignored it completed (perhaps therapeutic instinct should not be so easily dismissed by us) and decided to proceed regardless. As soon as Jane entered the room, and even before I could speak, she immediately began speaking about her difficulties.

I decided to interrupt her, thinking that the error I committed was plaguing her as it was me. In retrospect, that was just a tad narcissistic of me. I began, “I know I missed our session three weeks ago and I noticed you didn’t bring that up. I realize that you’re having challenges at work currently and that the work issue is at the forefront of your mind, but please indulge me for a moment. We can certainly return to your workplace concerns before the end of the session.” “What are your feelings towards me for missing your session?” A long silence ensued from Jane which was not her typical manner of responding to me. Something was wrong. “Jane, I am aware that you have been quiet for some time after I asked you for your feelings towards me for not arriving for your session.” Again, Jane looked away and continued in her silences. Finally, she said, “There’s no feelings, I am sure it was an honest mistake. You're making a mountain out of a mole hill.”   

Usually, I would let it go at this point, but not that day. I pressed ahead. Perhaps Jane was again refusing to complain, reprising both her marital and childhood roles. Was she passing up an opportunity to do important work? I persisted, “But Jane, I noticed that you didn’t respond to my initial communications with you and even today there appears to be something off in your manner of speaking to me. This isn’t the Jane I know.” I continued, “Please try to look inside for a moment, Jane, and tell me what’s happening between us right now.”

Jane hesitated momentarily but then as if in a fit of fury, the likes of which I had never seen from her before, she spat out, “You could have at least simply apologized to me face to face instead of trying to analyse my feelings!” I was shocked, Jane had never spoken to me so directly and with such anger. I took a second or two for me to gather myself as she pierced me with her gaze. I retorted, “Jane, you’re absolutely right. I haven’t offered much of an apology to you in the flesh. Thank you for me telling me that now. Indeed, my focus on your feelings must have come across as self-serving. I can see that now. I am deeply sorry for having missed our session and I do regret my error; please can you say more about it?”

To my amazement, Jane immediately settled down, looked me straight in the eye and said, “I thought you missed our session because you forgot about me, perhaps I wasn’t as important to you as I thought I was.” I knew that this had something to do with Jane’s early history, after all, she had little experience of being taken seriously if she complained. But I choose instead to focus on the here-and-now between us.

I was not about to waste this golden opportunity to self-disclose, repair the rupture, and help Jane, all at the same time. I replied, “Jane you’re misreading the situation. The fact that I missed our session has nothing to do with you, in fact, it has something to do with me.” I paused and noticed that Jane was now concentrating intently on my words. I continued, “In fact, it had everything to do with me. I missed the session because I was caught up in my own imagination and enjoying some personal time just prior to our session, which caused me to lose track of the time. You see, I was distracted with rather pleasurable thoughts of my upcoming holiday break, and this was the reason for me losing track of the time. In fact, I always look forward to our sessions, however at that point in the year I am susceptible to thinking about my break.”

I anticipated a wave of criticism from Jane, clearly a moment of countertransference, but the opposite occurred. For the first time in our work together, Jane shared her feelings of not being good enough and her feelings of competitiveness with my other patients. In truth, I had no real way of knowing exactly how my self-disclosure would impact Jane, but if I expect honesty and self-revelation from my patients, then I too must take a calculated risk in sessions as much as I expect them too.

***

I’ve learned that self-disclosure does not always facilitate the therapeutic process. It remains a high-risk/high-gain intervention. I may have succeeded in this instance, as I banked on my clinical judgement that my disclosure would be more effective than merely exploring her fantasies about whether she was important to me or not. My disclosure provided concrete evidence to Jane that she was indeed likeable, and while we did work on her need for approval in future sessions, this disclosure on my part led to her feeling more confident in asserting herself both inside and outside sessions and in taking such incidents less personally.

Questions for Reflection and Discussion

What are your thoughts and feelings about the therapist’s experience following the missed session?

How do you balance the demands of clinical practice and your personal life?

How might you have conducted that follow-up session with Jane?

How do you know when you’ve reached your limit on seeing patients and how do you address that clinically and personally?  

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