A patient perspective on non-attendance for psychotherapy in psychiatric outpatient care for patients with affective disorders

Abstract

To explore the phenomenon of non-attendance for psychotherapy in psychiatric outpatient care for patients with affective disorders. Ten patients, seven women and three men, aged 25–51 years, agreed to participate in the study. The participants were recruited from a psychiatric outpatient clinic for patients with affective disorders at Sahlgrenska University Hospital, Sweden. A semi-structured interview guide was used during the interviews, which were audiotaped, transcribed and analyzed using content analysis. All informants expressed concern that they had been absent from booked appointments. The main reason given was that the mental illness that caused the need for treatment also caused the absence. They expressed ambiguity about the goals and method of treatment and showed ambivalence regarding the possibility of being helped and achieving change. The participants also highlighted shortcomings in communication with the psychologist regarding their non-attendance. Four themes were generated: A vicious circle, Processes without direction, Ambivalence and Inadequate communication. The study shows that missed appointments have a negative effect on the treatment process. If the patient and the psychologist jointly decide to start psychotherapy, it is thus important that the psychologist promptly addresses the problem of missed appointments and takes a professional responsibility for limiting the risk of another failed attempt at psychotherapy. In some cases, it is necessary to consider whether psychotherapy is an appropriate form of treatment or not.

Practitioner points

• The study shows the importance of a careful assessment phase, where questions about motivation, goals and previous experiences of missed appointments are examined.

• The informants were not able to raise the issue of missed appointments in a larger perspective; their but focus was rather on the current symptom burden. It is therefore the responsibility of the psychologist to raise the issue and maintain a dialogue about goals, direction and evaluation of the psychotherapy.

• The psychologist bears a professional responsibility to limit the risk of another failed attempt to provide psychotherapy.

Keywords:

• psychiatry
• affective disorder
• psychotherapy
• missed appointments

Introduction

In connection with the extension of psychosocial interventions within primary healthcare in Sweden, more patients with mental illness have been referred to their healthcare centre. Patients who are assessed as belonging to the target group for specialist psychiatric services have a high degree of moderate to severe symptoms and a low level of functioning. Besides anxiety and depression, a large number of these patients have personality disorders or PTSD, and a growing number are diagnosed with neuropsychiatric disorders. The rate of comorbidity is large (Swedish National Board of Health & Welfare, 2017). This means that those who receive psychiatric care have extensive symptoms, together with relational, emotional or cognitive difficulties. A potential assumption is that these factors reduce the patient’s likelihood of benefitting from psychotherapeutic treatment. Oldham et al. (2012) carried out a meta-analysis of research studies investigating different interventions that were intended to increase patients’ attendance in psychotherapy. They discovered that the various strategies had less effect on patients with two or more psychiatric diagnoses, compared to patients with only one psychiatric diagnosis. This demonstrates one aspect of the difficulty of maintaining continuity in psychological treatment within specialist psychiatric services, where comorbidity is common.

Clinical studies at psychiatric clinics show a similar pattern across geographical countries. A British cohort study by Killaspy et al. (2000) examined 1674 consultations in psychiatric out-patient care and found that 35% of the patients did not attend the initial consultation and 40% did not attend follow-up consultations.

A study by Self et al. (2005) showed that 60% of the patients in their study population cancelled their psychotherapy prematurely. A study in Israel found that 39.6% were absent from their first appointment in outpatient psychiatry (Elyashar et al., 2016); the corresponding figure in a Nigerian psychiatric hospital was 32.6% (Akhigbe et al., 2014), and 30% of patients missed more than half of their booked appointments in a study in Brazil (Giacchero & Miasso 2008). Missed appointments can thus be considered as a universal problem with both clinical and financial implications. In a meta-analysis of premature discontinuation in psychotherapy, Swift & Greenberg (2012) reported that they found a drop-out rate of 40% in an investigation of 125 studies from 1993. By 2012 this large proportion had decreased, but discontinuity still remained a significant problem with approximately one in five, or 20%, dropping out of treatment. In general, it appears that missed appointments are common and this has economic consequences as well as implications for the individual seeking psychiatric care who, for different reasons, finds it difficult to complete the treatment offered.

What emerges unequivocally is that missed appointments in previous treatment are the most important marker for identifying patients who are least likely to attend renewed psychiatric treatment interventions (Defife et al., 2010; Mazzotti & Barbaranelli, 2012; Soendergaard et al., 2016). Previous studies do not show a clear connection between the severity of patients’ psychiatric problems and the tendency to miss their appointments (Defife et al., 2012). Of greater importance are, for example, motivation and having their own stated goal for the self-reflection that psychotherapy brings about (Murphy et al., 2016). Clinicians can assume different attitudes on this issue: at one extreme of the continuum, the clinician attributes treatment failure to a lack of motivation and/or inability to assimilate psychotherapy, while, at the other end of the continuum, a clinician may see the phenomenon unconditionally as an integral part of the treatment that can be understood and contained in the psychotherapeutic process. Johansson and Eklund (2006) explored which client factors are relevant for establishing a psychological alliance and predicting interruptions in treatment. They found no clear association between the patient’s diagnosis or the severity of the mental illness itself and the formation of an alliance; rather, they noted more specific aspects of a person’s problems, particularly relational ability and interpersonal functioning. However, a previous study (Centorrino et al., 2001) showed that patients were more likely to show up to their appointments when they felt acutely ill than patients with chronic conditions or those whose condition had improved, which contradicts the assumption that the severity of mental health has significance for non-attendance. Fenger et al. (2011) found that patients with the lowest and highest level of functioning were more at risk of dropping out of treatment. A specific obstacle in the group with lowest functioning levels could be social deprivation. For this reason, they would probably benefit from social interventions rather than psychotherapy. According to Berghofer et al. (2002), poor relationships with family members or significant others could increase the risk of disrupted treatment.

Defife et al. (2010) examined how often, during a three-month period, patients failed to attend their psychotherapy sessions at a psychiatric outpatient clinic and what reasons were given. The majority of patients who were on regular psychotherapy missed about 25% of the sessions, while a small group had a much higher frequency of missed appointments. The main reasons given were clinical symptoms (28%), practical circumstances (26%), motivational factors (17%) and adverse treatment reactions (13%). One conclusion drawn from the study was that psychiatric severity was only associated with missed appointments at the extreme ends of the symptom spectrum, in other words, patients who were acutely mentally ill and those whose symptom burden was low. In a follow-up study, Defife et al. (2013) examined what psychologists consider important to increase treatment attendance, interviewing therapists with the lowest degree of missed appointments. The main points that emerged were the importance of increasing the patient’s motivation, developing a positive working alliance, establishing a clear outline of the treatment, being reliable regarding appointment times and having a dialogue about non-attendance. The importance of developing a positive working alliance was also emphasized by Meyer (2001), who argued that psychiatric care has tended to abandon the issue of relationship building in favour of effective processes and a focus on solutions; this can be unfortunate in cases where the patient enters the treatment with pronounced ambivalence, as it is too easy for the psychotherapist to blame later non-attendance on the patient’s lack of motivation or resistance to treatment. Furthermore, Meyer argued that although non-attendance early in a course of psychotherapy is a bad prognostic sign, it is important to try to understand the reasons behind it, based on the patient’s history of relationships; above all, it is important to raise the specific issue of non-attendance to avoid the patient and psychotherapist ending up in a locked position of anger, guilt and mutual helplessness.

Aim

Given that most studies that examine non-attendance in psychological treatment are quantitative and thus based on predetermined possible causes, the purpose of the present study was to examine patients’ subjective experiences of non-attendance and how it can be prevented in general psychiatric outpatient care.

Methods

Participants

The inclusion criteria for participation were patients who in 2017 underwent psychological treatment in psychiatric outpatient care. The patients were diagnosed with personality disorder, anxiety, depression, ADHD, OCD or PTSD. (Patients with psychosis or addiction do not attend the outpatient clinic.) Those who were judged by a psychologist to have excessive symptoms were excluded from participating. The study included patients who were absent from psychotherapy once the patient had formally agreed to undergo treatment and the therapy sessions had been booked. Missed appointments and late cancellations (appointments cancelled less than 24 hours before the scheduled time) were treated as the same phenomenon (non-attendance), because in both cases it is about something other than planned interruptions to psychotherapy.

All participants underwent psychotherapy during 2017, with at least ten booked sessions. The psychotherapeutic interventions were: mentalization-based therapy, dialectical-based therapy, cognitive-based therapy and psychodynamic therapy. All patients except one had experience of previous psychological treatment through child and adolescent psychiatry, a youth clinic, primary care, a school counsellor, maternal and child health care or other psychiatric outpatient clinic.

The mean value for non-attendance was 35% (range 26%–52%). By comparison, the current rate of non-attendance at the outpatient clinic where the study was conducted is approximately 20%.

Procedure

The participants were recruited at a psychiatric outpatient clinic for patients with affective disorders at xx.

Patients were identified and contacted by the head of the outpatient clinic. Ten out of 14 patients, seven women and three men, aged 25–51 years, participated in the study. The participants were asked to attend the interview at their current outpatient clinic. The face-to-face interviews were conducted from July to November 2018 and lasted between 20 and 40 minutes.

Ethics approval and consent to participate

The study was reviewed and approved by the Regional Ethical Review Board of Western Sweden (approval number: 1005-16). All participants were informed about the study by their healthcare contact person by phone and by written information. They were informed that participation was voluntary, and that confidentiality would be assured, and they signed a written consent form.

Interview

The interviews were performed according to the principles described below, with an openness to the perspective of the informants and an active deepening of their responses, in order to obtain a rich description of their experience of the investigated phenomenon.

A semi-structured interview guide was used during the interviews. The interview guide was created, in the light of previous research, to cover the most relevant areas for the purpose of the study: previous experiences of psychotherapy, expectations of treatment, reflections on the high rate of missed appointments, how they view the outpatient clinic and the role of the psychologist, and possible consequences of non-attendance.

Data analysis

The interviews were audiotaped, transcribed and analyzed using content analysis, which is considered a useful method for clarifying the informant’s perspective (Granheim & Lundman, 2004). Furthermore, content analysis was used as it offers a flexible tool for finding similarities and differences between parts of the transcripts. It also offers opportunities to analyse both manifest and latent content (Graneheim & Lundman, 2004), which were considered a useful approach for the present study. In addition, Yardley’s (2000) guidelines for qualitative research were used to achieve quality through the analytic procedure.

Initially, the transcribed interviews were read to gain in-depth understanding of the interview content. During the second reading, meaning units that were relevant for the specific aim were identified and condensed with the intention to find the essence of each utterance. After this phase, all condensed meaning units were given descriptive codes. One of the authors was responsible for the coding procedure. Thus codes were frequently discussed with one of the authors (JS) who also had read the interview transcripts. This process was considered important in order to achieve the quality criteria transparency (Yardley, 2000), and to avoid that pre-conceptions characterised to coding procedure. Subsequently, the codes were organized into 12 subcategories given labels such as “lack of motivation,” “unclear process” and “mutual avoidance.” However, a challenge was to find a level of abstraction that covered numerous codes but still were grounded in data. This challenge was to some extent solved by systematically going back and forth between the interviews, the basic codes and the subcategories. Thus, it is important to bear in mind that qualitative research always involve, as well as encourage, a certain degree of interpretation (Yardley, 2000). At the final stage, the subcategories were merged into the four main themes: “A vicious circle,” “Ambivalence,” “Processes without direction,” and “Inadequate communication.” Possible themes were discussed between all three authors. The goal of the discussions were to find a thematic structure that corresponded to the study aim and that were characterised by the quality criteria “rigour” (Yardley, 2000), i.e. that the results have both depth and breadth.

Results

In this study, the categories refer to the central psychological themes which emerged from the narratives of the informants. Individual examples are given as illustrations of their experiences of non-attendance in connection with their psychological treatment. The ambition has been to describe mutual experiences in the informants’ stories.

All informants expressed concern that they had been absent from scheduled psychotherapy visits. The main reason given was that the mental illness that caused the need for treatment also caused the non-attendance. They also expressed ambiguity about the goals and method of treatment and ambivalence regarding the likelihood of being helped and achieving change. The informants also highlighted shortcomings in communication with the psychologist regarding their non-attendance. These experiences form the basis of the four main themes: A vicious circle, Processes without direction, Ambivalence and Inadequate communication. The four themes are explored below.

A vicious circle

The informants felt that the mental illness for which they had sought help was also the biggest obstacle to visiting the psychologist by appointment. Some informants commented that some days they were so depressed that it was impossible to go out.

It is mainly my illness that puts a spanner in the works, which says no, you should not get up today, you should be apathetic today and lie in bed. (Informant 2)

All informants experienced stress over having to keep appointments. Several talked about difficulty sleeping in connection with booked appointments, and one participant gave examples of her obsessive–compulsive symptoms getting worse on the days she had to be at the clinic at a given time. There were also several stories of getting to the clinic but feeling unable to enter the door, or experiences of such severe anxiety on the journey there that the patient got off the bus and returned home.

Because I always try to set off, but then I get caught up in this stress. So I have a very hard time if I have something planned, then I get really stressed and afraid I will miss it and then the compulsions increase. (Informant 5)

None of the informants said that they forgot their booked appointments with the psychologist; indeed, it was clear that they were very much aware of these appointments. However, they expressed a strong concern about whether they would be able to go to the outpatient clinic, which in turn became an obstacle. The concern appeared to be divided into two main areas, both of which were mentioned by the majority of the informants. Firstly, their mental illness caused them to have a high degree of anxiety and a lack of confidence in their own ability to cope with challenging situations. Secondly, the treatment itself elicited anxiety because emotionally charged themes were addressed, which could lead to the patient choosing not to attend the following session.

Painful and agonizing, yes it is. It brings to the surface a lot I have been good at suppressing. I often find it difficult to come here. So I know a few times when I kind of panicked and did not set off. (Informant 10)

Several informants described feeling a temporary relief when they decided to stay at home but that the relief quickly turned into anxiety. All informants described strong feelings of shame and guilt and an experience of being a failure when they didn’t attend their appointments. Anxiety, guilt and shame as a result of the non-attendance made it more difficult to go to the next scheduled appointment. Thus, a vicious circle was created which the informants themselves mentioned.

I feel guilty at the same time when I don’t come. So then it gets even worse because I kind of trigger myself in a bad way as well. Because there are long queues and stuff like that. That you then don’t come, it feels damn bad as well. It will be extra negative then. (Informant 2)

In addition to the specific anxiety that made it more difficult to meet the psychologist at the following appointment, the informants also described their increased anxiety about the future and about their prospects for improvement. They expressed concerns that they were incurable because they repeated a familiar pattern of behaviour, as well as a more concrete concern that the treatment would be terminated. They were all well aware that it can be difficult to get access to psychological treatment in public health care, and many said that they blamed themselves for not using the opportunities they were given. Some commented that they found it hard to believe that the psychologist was left waiting for them to turn up, but above all, they pointed out their own feelings of shame and guilt.

I know that a few times when I kind of panicked and didn’t set off. Then I get a really bad conscience and am ashamed of myself. So I really have to make sure I get going the next time so it doesn’t happen again. It is precisely because you don’t want to end up cancelling and disappearing and then it becomes very hard to come back. (Informant 10)

Processes without direction

In this theme, it can be seen that the informants experienced psychotherapy as important, but that it was unclear in what way they hoped that the treatment would be helpful. Some perceived an unclear goal for the therapeutic conversations while others reported feeling that the goal and method were explicit. However, there was no difference in the non-attendance rate based on whether or not the goal and method had been clarified at the beginning of the treatment. Rather, the informants seemed to relate to their clinic visits as isolated events and not as part of an ongoing process. It was mainly the upcoming appointment that was in focus when the informants struggled with whether to go or stay at home. Their thoughts about the consequences of missed appointments were usually about the present and the near future, although they could have concerns about the long term outcome of treatment in the background.

If I stopped coming and quit altogether, I wouldn’t make any progress, of course. So it’s better than nothing I suppose. (Informant 3)

Many informants talked about powerlessness over their own mood, and all had previous treatment experiences that had not proven helpful in dealing with the problem. Notably absent in the interview material was an optimism about a future in which the psychotherapy could fulfil a function for a period, to stimulate positive change. Only one of the informants described clear thoughts about the negative impact of non-attendance on the possibility of working through the problem.

So I lose where we are in the conversation, it becomes kind of hard to find your way back to where we were. Then it takes almost one session to find your way back. It’s not good when that happens. (Informant 10)

One informant wanted more support from his psychologist in establishing clarity about the treatment process itself: where they started from, what they were working on and where they were going. However, he was an exception. For most informants, the most important thing was to remain in the present and get emotional support for their anxiety; their hope was mostly that the treatment would improve their current mood. However, the informants felt that this was not fulfilled, which thus reduced their motivation to come to the next appointment.

Of course, if I felt better after each visit … Then I would of course feel more motivated to show up. (Informant 2)

In summary, it seemed difficult for the informants to hold on to a view of the treatment as a step towards recovery. Their lack of confidence led to reluctance to come to the next appointment, and hope for the future seemed to be largely absent.

After several years in therapy before, I had no special expectations—every week for several years. Yes I do not expect to get better but I need someone to talk to. (Informant 3)

Ambivalence

Under the category Processes without direction, the informants expressed doubts about whether the psychological treatment could make a difference to the mental disorders that led them to seek health care from the beginning. At the same time, they had all requested contact with a psychologist. During the interviews, a general ambivalence emerged throughout. The informants described both hopes for change and hopelessness caused by previous experiences of failure; they reported repeated attempts to find the right help combined with difficulties in taking advantage of the opportunities offered, and they described how they saw the treatment as indispensable yet had limited faith in its beneficial effects.

I do not feel that I get what I need in any way. And it doesn’t exactly motivate me to continue either, but at the same time I cling to it because that is the alternative I have. (Informant 3)

The informants gave various reasons for their request for contact with a psychologist. Some stated that people in their vicinity had advocated psychotherapy, while others had felt a strong need to have someone to talk to about their everyday lives and their difficulties. In some cases, the informant remembered periods when life was easier and wanted to be able to get back there. However, these previous experiences seemed fragile and did not motivate them enough to engage in a new treatment.

I remember what it was like when I didn’t feel bad. Yes I wanted to go back there. I often want to but sometimes it makes no difference. I had no expectations at all at first, thought we’ll see what happens. I was pretty indifferent. (Informants 1)

Despite having requested contact with a psychologist, the informants described an increasing anxiety before each visit and difficulties in overcoming the obstacle of getting out of their homes. All described how they gradually began to perceive the treatment as demanding, despite the fact that they participated on their own initiative. It appears that they initially felt that psychological treatment was necessary and helpful, but also perceived that the framework and content of the treatment was problematic. Despite the perceived discomfort caused by the visits to the psychologist, no one expressed a desire to end the treatment.

It has been very much that I’ve got into a state of anxiety, which makes me stressed, which means that I get even more compulsions and I get nowhere. So then I get anxious and I stress myself out, then I’m stressed and all the vocal tics start to get worse and then I stand there by the sink or whatever it is I’m doing. Since then, I have been afraid of not being allowed to come back here, because I do want to. Because there have been some discussions about whether I should be allowed to have any treatment. (Informant 4)

The informants appeared to have begun the psychological treatment without expectations, but with the feeling that ending it would mean an even stronger hopelessness regarding their mental illness. One participant said that even in the most difficult moments there was an awareness of this ambivalence but that it was not possible to bridge it.

You turned inwards and then showed your claws to those you know want to help, those who are closest and those who want to help. You don’t accept help and it’s not because you don’t want to. It’s actually that you can’t. You simply can’t handle it. (Informant 6)

Inadequate communication

Communication was the theme that was most evident during the interviews. The results have been divided into two aspects. Firstly, the informants experienced difficulties getting in touch with their psychologist and the outpatient clinic, especially on the occasions when they missed their appointments. Secondly, in sessions with the psychologist, they experienced a lack of communication about the process.

All informants described that they experienced it as a problem that they could not reach their psychologist directly but had to leave messages via the hospital call centre for patients. The majority expressed a desire to get in touch with the psychologist when they had missed an appointment and that the detour of having to talk to another person meant that they hesitated to make contact. The main reasons why informants wanted to get in touch with the psychologist were to get confirmation of the next appointment, to explain their non-attendance and to reduce their anxiety about how the psychologist had interpreted their unexplained non-attendance.

You get such a bad conscience because she doesn’t know why I’m not coming and goes out to the waiting room and looks for me and I’m not there. Especially after I have panicked and gone home. (Informant 3)

Some informants expressed a desire to receive a call from their psychologist when they didn’t come to the appointment. In most cases, they justified this on the basis that it would relieve their anxiety because they felt even worse after missing their appointment.

A few informants expressed the opposite opinion: that their guilt increased if they were reminded in that way. Several informants stated that reminders would be a good strategy for others with similar problems, but that it would not make a practical difference for themselves. Above all, they sought immediate emotional relief and perhaps felt a desire to re-establish the connection with the psychologist when their feelings of guilt and fear of causing the treatment to be terminated became too strong.

If you call Kontaktpunkten [the hospital call centre for patients] and then I get no answer … then thoughts build up in me, am I allowed to come here? Am I not allowed to come here? (Informant 1)

The informants’ stories revealed that their pattern of non-attendance was not mentioned to any great extent by their psychologist. Most described how the psychologist might make a brief remark the next time they met, but that the phenomenon of missed appointments seldom led to a joint exploration during their conversations. Several informants commented that it was a relief not to dwell on this, as the issue itself generated shame and guilt. However, one of the informants described how she, by raising the issue with her psychologist herself, got help to resolve her mental blocks and then experienced reduced anxiety and less need to miss appointments.

It was like a circle, I come here for help and it feels like a quick check-up. And that makes me feel stressed. These days I feel better because we cleared the air a lot. (Informant 9)

Few of the other informants had similar stories about sorting out these issues together with their psychologist that then made it easier to come to the clinic. The following quotes represent how most informants perceived that the psychologist responded to the issue of non-attendance.

It is not handled at all. We’re not talking about it. (Informant 4)

We have not discussed it. She mentions that there has been a break and that we have not seen each other for a while. But we have not talked much about it. (Informant 10)

Discussion

The purpose of the study was to examine patients’ experiences of reasons for not attending psychological treatment and how non-attendance can be reduced in general psychiatric outpatient care. In summary, the findings show that non-attendance is a result of the patient’s original mental illness, that the patient lacks motivation and direction in the treatment and that inadequate communication from the psychologist tends to reinforce the patient’s pre-existing problems.

According to the informants, the main reason for not showing up to their appointments was the mental illness for which they sought help. That is, the anxiety they sought help for also became the obstacle to their treatment. Although a majority of the informants expressed a hope that the treatment would lead to improvement, their anxiety before the visits increased to such an extent that they were unable to come on the day. These breaches of the psychotherapeutic framework can be seen as an expression of a basic problem and should be prioritized by the psychologist as a main issue for therapy.

The present study thus shows the importance of an accurate assessment phase regarding previous failure to attend treatment. In this way, the psychologist and the patient can focus on this problem from the start and avoid further experiences of a failed attempt at treatment. The informants felt that the psychologist did not address their non-attendance in depth, and both patient and psychologist appeared to be at a loss to break the repeated pattern. The mutual helplessness can be seen as a consequence of the psychologist’s inability to raise the issue in a respectful but clear way (Meyer, 2001).

One possible explanation for the psychologist’s avoidance is a desire not to be accusatory by pointing out the importance of regularity in treatment, out of concern about increasing the patient’s anxiety. Another possible explanation is that the psychologist fears that raising the issue with the patient will result in a mutual non-verbalized abandonment. Regardless of the reason, it is clear that the psychologist’s strategy of not verbalizing the problem was perceived by the informants in this study as aggravating their problems. The importance of having an active communication regarding non-attendance is in accordance with Defife et al. (2010), who found that the therapists who had the lowest number of cancellations were those who initially clarified the importance of maintaining the regularity of the therapy.

The informants attached great importance to the psychotherapy appointments, but the very fact of having to come at a particular time caused them anxiety and difficulty sleeping before the visit. The decision not to attend could be made the night before the appointment or on the bus on the way to the clinic, which provided a temporary relief, but the anxiety and feelings of failure were reinforced when they failed to maintain continuity of treatment. Their anxiety, guilt and shame in connection with this non-attendance made it harder to go to the next booked appointment, and thus a vicious circle was created. From the results, it is clear that the informants themselves were not able to raise the issue of failure to attend appointments in a larger perspective; there focus was on their current symptoms, for example, anxiety.

Several informants stated that they found the aim of the treatment unclear and that there was no clear direction for the conversations. Some also expressed a lack of hope for improvement but a need to talk to someone regularly. This is in line with the findings of Centorrino et al. (2001), which showed that patients with chronic problems are less likely to attend scheduled appointments than those in an acute phase of illness. If the patient’s problems are of a chronic nature, as with anxiety and depression, it is conceivable that the patient does not associate the treatment with hope for change, which indirectly reduces the motivation to come regularly. In contrast, patients who feel acutely mentally ill may also perceive the treatment as more indispensable and thus be more likely to attend their appointments. If the patient’s is not able to participate in a psychological process but is more in need of supportive conversations, this should be clarified, and the treatment planned accordingly. Murphy et al. (2016) pointed out that patients need to have their own stated goals for psychotherapy in order for it to contribute to improvement. If such an objective is lacking, it is reasonable that these patients should be offered support calls rather than psychological treatment. Fenger et al. (2011) made an important observation, that people who are struggling in many areas of life and who generally experience conditions of social deprivation need social interventions in the first instance, rather than psychological treatment.

None of the informants suggested forgetfulness as the main reason for missed appointments. Thus, the digital reminders of coming appointments, which are increasingly used in healthcare, do not seem to make it easier for these patients. In their meta-analysis, Fenger et al. (2011) concluded that patients with the most social difficulties also benefited less from reminders or other direct strategies to prevent disruption of treatment. This corresponds with the conclusion drawn by Oldhman et al. (2012) from their meta-analysis, which studied interventions to increase attendance in treatment, such as digital reminders or text messages. These methods only had low to moderate effect on attendance and were primarily beneficial for patients without any psychiatric comorbidity.

Rather than talking about specific strategies to facilitate their attendance, the informants in this study expressed a desire to be able to contact the psychologist before a visit or after a missed appointment. They saw this as a means of re-establishing contact for the moment but did not describe it as a solution to the problem itself. On the other hand, the results indicate that the patients feel a need to maintain the treatment alliance, which in itself is a good indicator of a positive treatment outcome (Defife et al., 2010). Johansson and Eklund (2006) studied the importance of alliance in the therapeutic process. The subjects in this study expressed a need to overcome a gap in communication with their therapist, which should be dealt with by the care providers in question to decrease the risk of disrupted treatment. Based on previous research as well as this study, it is clear that the relationship between patient and therapist and the ease of communication have a larger effect on decreasing disruptions in treatment than technical tools such as digital reminders, particularly in the case of patients who have complex symptoms, poor social support and a lower level of functioning.

Limitations and strengths

One of the limitations of this study is the number of participants. Still, most studies within this field is quantitative and there is a lack of targeted groups of specific patients belonging to psychiatric outpatient care. Although the aim of qualitative studies is not to generalize the results, it is important to point out that more informants could have contributed both to more nuanced findings and to more in-depth understanding of regular psychiatric outpatient care. Since a majority of the informants in this study were women, a more balanced group of patients would have made it possible to focus on possible variations related to gender.

One strength of the study is that the informants represented a wide range of diagnoses and various forms of psychological treatment. Despite this variation, the informants presented a similar perspective on the phenomenon of non-attendance.

Conclusions

The informants in the present study all had a high frequency of missed appointments. The results show that missed appointments have a negative effect on the treatment process. The study also shows the importance of a careful assessment phase, in which questions about motivation, goals and previous experiences of missed appointments and cancellations are examined. It is essential to identify the patients who do not feel ready or motivated for time-consuming work towards change, but primarily want more immediate support. In order to avoid the risk of excluding patients with comorbidity, who primarily are in need of social interventions from psychotherapy, early intervention such as supportive counselling psychotherapy should be considered. In these cases, the psychiatric team should consider not making a new attempt at a course of psychotherapy, not least in view of the strong feelings of failure and hopelessness created in the patient if another treatment attempt eventually fails due to non-attendance. By making the importance of continuity explicit from the beginning of the treatment, the psychologist can raise the issue of missed appointments and have an active dialogue about it with the patient when it occurs. Together, they can investigate the underlying causes of the patient’s failure to attend. In the study, it is clear that the informants themselves were not able to raise the issue of failure to attend appointments in a larger perspective; their focus was on their current symptoms, mainly by anxiety. As they themselves had few suggestions for how they could deal with the problem, it should be the psychologist’s responsibility to address the issue and maintain a dialogue about goals, direction and evaluation. It has become clear that the treatment cannot progress if the problem of non-attendance is ignored; the psychologist bears a professional responsibility for limiting the risk of another failed attempt at psychotherapy.

Authors’ contributions

JG contributed to data collection and analysis, and wrote the initial draft of the manuscript. JS contributed to the study design, qualitative data analysis and interpretation, and reviewed and revised the manuscript. PS conceived the initial idea for the study, led the implementation, and reviewed and revised the manuscript. All authors read and approved the final manuscript.

Consent for publication

Consent was obtained from study participants for the publication of anonymized quotations.

Ethical approval and consent to participate

The study was reviewed and approved by the Regional Ethical Review Board of Western Sweden (approval number: 1005-16). All participants were informed about the study by their healthcare contact person by phone and by written information. They were informed that participation was voluntary and that confidentiality would be assured, and they signed a written consent form.

Sharing of data

The authors do not wish to share their data, as relevant parts of the raw data are published in the manuscript in the quotations.

Acknowledgements

We would like to thank all the patients who participated in this study. Thanks should also go to Peter Asplund, MSc in Computer Science.

Data availability statement

The authors do not wish to share their raw data, as all relevant parts of the data are provided in the manuscript in the quotations.

Disclosure statement

The authors declare that they have no competing interests.