Episode 6 Transcript: Why Clients Cancel — Boundaries, No-Shows, and Real-World Clinical Work

The Unmasked Therapist Podcast | Edited for readability

This edited transcript retains the substance and conversational tone of the recording while removing subtitle formatting and adding headings for navigation. Speaker turns are not labeled because the source captions do not identify speakers. The text is not a word-for-word certified transcript.

Opening: Why Cancellation Fees and Boundaries Matter (00:00)

Charging actually does benefit the client. It benefits the therapist, and it benefits your practice. It’s going to build value for your clients, and it’s going to help you build more value for your practice. Welcome to the Unmasked Therapist Podcast, the show where we explore the heart of therapy, authenticity, and connection. We are therapists from Keystone Therapy Group, located in Northern Virginia. In each episode, we’ll share stories, insights, and conversations about what it means to show up authentically for our clients, for each other, and for ourselves. Whether you’re a new therapist or a seasoned therapist, we’re

The Clinical, Business, and Human Sides of Scheduling (00:41)

glad you’re here. Today we are very excited to talk about a topic that is frequently discussed within our team at Keystone Therapy Group and it has frequently been discussed in every place that I have ever worked with clients. And that is how do I maintain a boundary or hold a boundary with charging my clients or scheduling or having issues like managing scheduling issues for clients who are late-canceling. There are no-showing appointments. They’re changing their appointments too often and it’s getting in the way of therapy. Our discussion today is going to be focused on how do you navigate that authentic feeling that we have as a therapist to help your clients and to support them. We want to give them the benefit of the doubt, but also balancing our boundaries and our needs as an authentic human being, right? How do we balance the clinical

side, the business side and the humanness of who we are with our clients so that our needs are met and we maintain that standard of care for our clients? Yeah. And I want to pick up on one specific thing you just mentioned in that beautiful explanation, because I think it is very important to talk about with this topic. You said if it’s affecting the clinical work. Yes, that for me at least. And I think as I’ve talked to some of our supervisees and other, you know, peers over the years, that part has been one of the most significant pieces of why clinicians might sacrifice their boundaries or allow their boundaries to be more flexible and really able to hold to what does clinical benefit actually look like for us to hold on to,

right? Yeah, that’s a great discussion.

No-Shows, Late Cancellations, and Inconsistent Attendance (02:39)

So there’s, there’s a few different, I think there’s a few different ways we can break this down in each of these scenarios, they kind of fall under this umbrella of maintaining boundaries, especially regarding scheduling and charging and charging for those cancellations. So in this context, we are going to talk about it as if the clients are either their private pay or they have a commercial insurance plan because you know, clients with Medicaid, Medicare or clients who are mandated in for sessions, we can’t necessarily charge for those, for those late-canceling or no shows. So we are talking about when you have the choice to be able charge for a no-show or a late cancellation, kind of how do you navigate that?

And some of these conversations, they will still apply. If you have somebody who is, let’s say they’re on Medicaid and they’re late-canceling or no-showing, you know, no, you can’t necessarily charge for that. But the conversations that you’re having with the clients are very similar, if not the same. So this can apply for all clients within kind of this like, you know, therapy space. But you know, take what you will that is most appropriate or applicable to the work that you do your clients. So the way that I see this breaking down under this umbrella is we kind of separate how we treat our clients issues or how we approach this with each client. The caveat is, obviously it’s different for every client, the standard answer that we’ve heard throughout our careers, but we’re gonna kind of go through

these generalized rules and how we navigate those with our clients. The first one that comes up is a no-show, right? Your standards might be a little bit more ridged with the no-show. So we’ll talk about how do we approach a no-show. And that means a client has scheduled a session. They confirmed that session and they just didn’t show up to the appointments, whether it’s in person or virtual, they did not show up and they did not give you any prior notice that they would not be showing up. So you’re sitting there waiting for them and they just don’t show up.

That’s what we call a no-show, then a late cancellation. And this varies by practice or agency for us, and this is this is the most frequently seen rule is what we see or what we use is the 24-hour cancellation rule. Whereas if you cancel more than 24-hours in advance of your scheduled appointments, there’s not going to be a fee for that. We’re going to do our best to reschedule you is if we can, if possible, but there’s no fee for that less than 24-hours notice before that scheduled session. If then a client is notifying us that they need to cancel a reschedule, we are within our rights to charge for that time because it is more difficult for us to fill that gap with another client.

So it’s a loss of time and hours for us. Another thing, and that’s usually where the blurriness kind of starts to kind of creep in for supervisees is that late cancellation. And then in the third part, I think of the clients who are inconsistent, who they are cancelling more than 24-hours in advance or both, you know, outside of your no-show or late cancellation fee or timeline, but the sessions are still very inconsistent. You know, they’re scheduled weekly, but they cancel maybe one or two a month or they keep asking to reschedule and you just don’t have openings. So they’re just like, oh, I’ll just wait till next week. And it creates a lot of disruption within the therapy process with that client.

But also, so within your own schedule, so you’re spending a lot of time and energy managing them. So I think those are the three spaces that I find that how I kind of break them down and I’d like to kind of approach each one of those. OK, let’s start with the no-show because that’s I think straightforward 1.

A Note About Clinical Supervision (06:09)

If you’re a resident therapist or early career clinician who’s craving A supervision space that feels real, not performative, this is for you. The Unmasked Therapist Clinical Supervision Group is where authenticity meets growth. Led by Kaitlyn Steel, LMFT, and Kim Rippy, LPC therapist at Keystone Therapy Group, this 12 week virtual group invites residents to drop the I Have It All together mask and explore the person behind the therapist. You’ll get to present real cases, receive honest feedback, and learn how to integrate your authentic self into your clinical work, all while meeting your Virginia Board of Counseling supervision hours.

Groups are small, safe, and supportive. Learn more or join the wait list at https://www.keystonetherapygroup.com/supervision/ because the best therapy you give starts with the therapist you are.

How Keystone Approaches No-Shows and Emergencies (07:00)

Yeah. So Our standard at Keystone Therapy Group is we charge for no-shows unless there is an emergency or something like the client or maybe the client’s child or somebody that they care for is bleeding, dying or dead. That’s my role. Like it’s an emergency. Like they’re like, you would not have like it would have been inappropriate for you to take out your phone and e-mail me that you were not going to be there, right? For those I will waive and obviously like we’re going to have a discussion with a client about it and talk to them about it and first make sure that their needs and you know, are you OK? Are you been able to kind of continue therapy at this time? What do you need?

But just as our like kind of basic standard, that’s the standard that we have. And I will also say a lot of practices do this too is when we have a new client, we are very articulate about that informed consent piece of this is our standard, this is what we do we have for our cancellation. And I will tell my clients when I start with him, I usually like, I will waive the first one. And I tell them, you know, we are, you know, kind of getting into this process together. We’re learning.

I also tell them, and I do have more confidence in doing this because I’m a licensed therapist and I’m further into my career, again, as an authentic therapist. I tell them in the first session together, I have little kids, my kids are going to get sick, I’m going to get sick. Most of my clients, just based on my specialties of who I work with, are also parents. So I told them we’re going to get sick. Things are going to happen. You’re going to have to leave to go get your kids or kids are going to stay home. Things are going to get thrown off will be as flexible as possible for rescheduling as much as I’m able to, right? And I will give grace with that.

And I hope that you will give me grace with that as well. With that. I also will tell them again with a no-show, if your kids sick in the morning and our appointment’s at 2:00 PM and you just didn’t show up, that’s like a I’m going to charge for that right now. If your kid is sick in the morning and your appointment’s at 2:00 PM, you know your kids not go to school that day, send me an e-mail and say, hey, so and so has been homesick. I have to stay home with him, OK, If we reschedule, yes, absolutely. And I will waive that fee because to me, the humanness is more important than like the repercussion, right? I don’t want to create a consequence for that client for taking care of their child or

taking care of themselves. If clients join the session because they don’t want to incur a fee and they are so sick they can’t focus or they’re coughing and I’m expecting a lung to pop out of their throat. It’s so bad. So that humanness has to come. And so with no-shows, I wanna have that humanness. But there also is an

Setting Expectations for Late Arrivals (09:39)

expectation. Yeah, I think for me, the no show kind of like you said a few seconds ago, the no-show is the one that I usually am most comfortable being strict. About. Because again, it’s if you are especially at our level of care, if you are one of our clients, you probably have a general ability to take care of yourself to a basic level right And so. Over private practice, right For my clients coming to private practice therapy, there is like you’re able to make a private practice, you’re able to make a therapy appointment. You’re able like your daily care routine is not a struggle. Most of our clients hold on jobs, you know, and or manage family members.

So lifestyle wise, there’s really unless somebody blips every now and then like and just forgets. There is an expectation of our clients have the ability to maintain regular appointments. Yes, exactly. And so that’s one of the things I kind of talked to myself about as I’m as I’m I’ve worked through this, increasing the comfort with charging or withholding those boundaries. And one of the things though that I also do that I think is really helpful is at the five-minute aftermark, I will send a reach out e-mail. Hey, are you joining for our session today? That’s all I say.

Our practice has the in our informed consent. And again like Kim said, these are things we also verbalize. We encourage people to verbalize with their clients in that first session that at the 10-minute mark is when we will shut down the session and that is the appointment is officially missed, OK. So if a client is 10-minutes late, that impacts our ability to do good clinical work with them because it shortens that flow of time with the client. So yes, there are clients where we could probably do some information, some good work, but it’s not gonna be what the client is paying for, to be totally honest.

Absolutely. And then there’s also a factor where if a client is coming in five minutes late, it might only take them 2-3 minutes to kind of like re regulate or reground to get back into the mindset of the session. If a client is coming in 10-minutes late, they’re usually racing in traffic was bad, they were driving fast or you know, they were on a work meeting and it went over. So now they’re race, you know, they’re rushing to kind of log in. It creates such a different mindset to not only did you lose 10-minutes off of your 50 minute session time, but now it’s going to actually take you another 10 to 1five minutes to even kind of get in the therapy mindset.

At that point, you might only have 20 minutes left because we need some time at the end to wrap up, review, confirm next session. So it’s really not worth your experience, your time. You’re not getting the value of the money that you’re paying for, and we really want to have that value. Right. And so that’s why our practice has decided that the 10-minute mark is when we’re going to cut off. Other practices have different, you know, cut offs for that. That’s, you know, everybody. There’s no exact right way to do that. That’s just something that we have found important for us. And so I will send that e-mail at the five-minute mark and then I will send a follow up e-mail at the 10-minute mark letting them know I’ve closed the session. I am charging the fee.

I will put that in that e-mail to let them know that this is going to happen. And I usually say something like, I hope you’re OK. Please let me know if everything’s OK because I usually am worried about my client. Absolutely. But I think that’s the that’s the part that we really want to highlight here because again, this podcast is the MMS therapist, we’re showing up with authenticity, right?

Caring About Clients While Holding Boundaries (13:10)

So while yes, a lot of this conversation today is the business side and how do you approach a client from the kind of like logistics and scheduling and charging and all this, but it’s also we have to balance our authenticity, right? If money was not an object, I would not. Well, obviously I wouldn’t charge clients, but like I wouldn’t even think about that. It’s just you. OK, come on in. Let’s do what we can. But it does create a limitation when a client’s late or even no showing, like, OK, we don’t have any work that we can do with that client. But the very first thing, and maybe this is also from us because we’re more anxious people just in general, but we genuinely care about our clients, even if that hour is like a lost hour for us.

Like yes, business wise, that’s a lost hour. Genuinely. I’ll speak from my own experience for that entire hour and for longer, probably into my next in a couple sessions. I’m worried about my client, especially if it’s somebody who doesn’t usually reschedule or like they’re very consistent with their appointments. If I don’t hear from them or you know, it’s just it’s, it worries us, even if it’s not for me who has like, you know, something that’s really risky that they’re working on or carrying, if they’re just anxious or if they’re just coming in for like a life transition or they’re overwhelmed or like something that’s quote UN quote, like a lighter thing to talk about. We still worry, right?

We still worry. We’re human beings. What if they were driving and they got into an accident? We worry. All that I say is if you’re a client listening, please respond to your therapist.

Why Therapists Charge Cancellation Fees (14:34)

Yes, please respond to your therapist. And so I will say that like so yes, so we have that standard for our no-show, right. So part of that and the charging process, I think we should also explain the charging process like why do we even charge? Because that goes into more information about the late-cancellation reasoning or reasoning. Personally, so I have I think I’ll answer this from my perspective and then because I think there’s a business perspective and a clinical perspective, and I think that’s important to differentiate between the two because I think they both play into it from a personal perspective. I need to make a living.

I love what I do. I do this because I love what I do. And like you said a few minutes ago, if we could do this for free and it didn’t, you know, and it didn’t negatively impact like my life or whatever, like I would do it for free all day long. But the reality is we have to earn, especially in private pay. We have to earn our income. The situation that happens when a client just no-shows if you don’t charge them, you’re not paid for that hour. And for me specifically, I’m a parent and I pay for childcare the hour I pay for other things that are directly impacted by me having a job.

So if I cannot have consistent income or even, you know, cuz again, like it’s not that a client’s not allowed to cancel by any means, but it’s, you know, we have to be able to survive and financially do what we need to do on our side. It feels uncomfortable to say that because it makes it sound like, oh, I’m only here to make money, but that’s not true. I think if we’re being and leaning into this authenticity, we have to live, earn a living. That is why people work. And so it is OK for us to know and to say this impacts my cost of living, This impacts what I can do.

I wish therapists were paid beaucoup bucks but the reality is most of us are not paid enough so it is OK for us to charge for those. That would be a reason that I would charge.

Financial Investment and the Perceived Value of Therapy (16:39)

That would be a personal reason. There’s the clinical reason of sometimes not sometimes when somebody is financially invested in something they are doing, they do tend to follow through and keep it as and have it be an important thing, right. And I think for the client side of this, that is one of the benefits of a client having some financial, you know, whether ever the amount is some financial investment also turns around and motivates them to be more connected and invested. Love the word investment for this to me, it really is an investment. I think I even have that on our like insurance and fees page of our website is investing in therapy because it’s, it’s if you think about buying a car, if you buy a Honda Civic or you buy Lamborghini, which one are you

more likely to take care of right. That price tag is so high for that Lamborghini, you’re going to spend a lot more time and energy taking care of it, even if it’s not anything monetary after the purchase itself. Like you don’t have to pay for a detailer, you don’t have to pay for all this extra stuff. Let’s say once the car is purchased, how are you going to approach it? Most people, their value is going to be tied to that price tag too. Another piece to that analogy here too, because the other, the other way I look at it is let’s just say somebody gave you a Honda Civic.

Yeah, that’s why I was thinking about it if I should change it or not. Yeah, if somebody, if somebody you know, gave you a car, let’s not even put a specific model make because we don’t need to good all that. If somebody gave you a car and you knew that no matter what happened to that car, you could get another car. And you knew no matter what happened to that car, you could get another car. You might not take as good of care of it. And it’s not because there’s a moral flaw on you. That’s kind of just how human nature is. It’s the value, yeah.

If something is common or easily accessible, then we take it for granted. Absolutely. Right. It’s like, I don’t want to say that. So it’s, it’s this, yes, that money is important, but it’s also an exchange of value. That’s why you see therapists, you have way more experience or

What Clients Are Paying For (18:50)

certifications or specialties. They’re charging 300, three, $25350 a session because they have so much more experience and quality to the therapy they’re doing. That can also communicate the value to the clients. Those therapists are probably having far fewer cancellations right than the resident therapist, the intern therapist working at the agencies who are only charging 20 to $50 a session. You don’t see a lot of Lululemon in thrift stores. Right. Walmart brand. That’s so true. That’s so true, so true. Yes, so to say all that it’s, it’s right. There’s, there’s a value that we have to also communicate to our clients.

It’s the value of our time, of our experience. It’s the value of we are allocating this hour of our life to this client and we are hoping for the same investment from them. Right. I don’t think of it as like people will say, oh, with therapy, you’re just like paying for somebody’s hour. Like I can get an hour from somebody else, like, OK, go to somebody else. But to me, the clients are not paying for my hour. I am exchanging my hour for their hour. We both invested our time in this time together, but their fee, their payment is paying for my experience and my expertise. But we are changing that time, right? So when the client no-shows or late cancels, to me, it’s not necessarily like I have to pay for this. I have to charge for this hour

that I walked off, this time of my experience and my expertise. To give to you or now I can’t give to you or somebody else. And I want to see another piece of this, whether you start

The Business Realities of Private Practice (20:31)

mentally prepping for this client, you know, a minute or two before the session or maybe it’s a couple hours, maybe it’s a couple days, depending on the situation. You also, as the clinician, do a lot of prepping yourself to be present for your. Client. Absolutely. So that also you don’t need to be paid for that, but that’s a part of you come in prepared. There’s still an investment there that you’re making for the client. Right, I’m interested in your perspective. Yeah. So from the business side, there are expenses to every business.

When I hire a clinician, a therapist, that therapist time is finite, right? You can’t see an unlimited number of clients. So just keep making money working in agencies. Our experience was, yeah, you need to be seeing 253040 clients a week, if not more groups. And that’s just not possible. It’s just not possible, all right? And people who don’t work in our industry, they will never understand this. And there’s a lot of criticism of like you’re only seeing, you’re only working 30 hours a week. It’s like, no, I’m seeing 30 clients a week, right?

That’s very different. So my approach is I actually prefer my therapist to see fewer clients so that they can be more balanced for their clients, provide better care. But with that also means that the therapists aren’t making more money to cover their expenses of the business. My client lay cancels or no-shows the loss of income to the practice is that much more impactful on our bottom line. As the business owner, my job is to make sure that the practice is profitable, whether profitable by a dollar or profitable by $1,000,000. It still has to be profitable.

Otherwise we would have to close the doors. My therapist would lose their jobs, my admin would lose her job, and our clients lose their therapist. So the business has to be profitable to be able to provide care. And that feels icky to say because again, we’re a therapist first, but that is my job as a group practice owner. So with my therapist seeing fewer, it’s better for them. It’s better for their mental health, it’s better for the quality of care we offer for our clients. But again, that means that a late cancellation or no-show is that much more loss of income for the practice. Whereas in that moment, our expenses didn’t decrease cuz that client didn’t show up.

The expenses are all the same, right? We don’t get charged less on our EHR because we have fewer people in our schedule. It’s the same. Our insurance doesn’t go down, our office rent doesn’t go down. It’s all the same. So we need to be able to maintain that expectation and that income for the practice as well from the business side. So just to summarize that part, we charge for the to communicate and maintain the value to the

Closing Reflections and What Comes Next (23:10)

clients of committing to that time. We charge personally as an authentic human. We need to be able to make money too. We’re doing this to support ourselves and our families and that is OK and to support the practice, which in turn supports both the therapist and the client. So today we have a really great show for you. This is going to be a 2 parter, our first two parter where we’re talking about the very hot topic of charging clients and maintaining boundaries and expectations for clients who are no-showing appointments or late-canceling their appointments or they have frequently rescheduled or cancelled appointments outside of your late cancellation boundary.

That is the first part of this conversation that we’re having regarding charging clients for no-shows cancellations and how to talk about that process with our clients. We’ll add that on how to talk to them about it in our next episode. But really kind of I want you to understand what that’s that’s kind of mindset you have. Understand that mindset that you have. Take this, it’s time to explore what is my mindset on charging, what is my approach, kind of what are the hold UPS that I have with it. Notice what’s coming up for you in the next week, working with clients, especially those who cancel or no-show in the next week.

And then next week for our second part of this conversation, we’re going to talk more about this and pick up where we left off on talking about now how do we approach late cancellations and then clients who frequently rescheduled or canceled outside of our boundary, but it still impacts the quality of our care. The why we do what we do and then turning into the how we do what we do. Right, and maintaining our authentic self throughout difficult conversations. Yep. Thank you guys for joining us today and we’ll see you next week. Bye.

Podcast Outro (24:59)

We hope today’s conversation allowed you to reflect and gain new ideas for becoming an authentic therapist. We would love to hear how this podcast is impacting you. To learn more about us, visit keystonetherapygroup.com, where you can find information about our services for clients as well as our supervision program. Remember to subscribe for new episodes and please rate us five stars. This helps us reach new therapists like you who are learning to step into their authenticity. We’ll see you next time.