The Case of the Late Client

When a new client arrives late to sessions, it can be a stumbling block to establishing therapeutic rapport. Gabor Maté—bestselling author and creator of Compassionate Inquiry—and Janina Fisher—world-renowned Sensorimotor Psychotherapy trainer and developer of Trauma-Informed Stabilization Treatment (TIST)—are about to show you how they’d turn this clinical challenge into an opportunity.

Meet Lorelei

Lorelei, a woman in her late 30s, wants to learn relaxation techniques to reduce her stress. In her initial email and call, she mentions a lack of social connections, financial problems, and a host of medical issues including fibromyalgia, migraines, ulcers, and IBS. A contentious legal battle with her former girlfriend over ownership of their small event-planning business has worsened her symptoms.

At your first session, Lorelei arrives 20 minutes late because there was a lot of traffic. She expresses excitement about working with you and getting her life on track. You validate her overwhelm and help her clarify her goals. When you mention you’re approaching the end of your session time, she begins rocking in her chair and says, “I think I’m having a panic attack.” You go 10 minutes over time to help her get regulated enough to leave your office.

At your next session, Lorelei apologizes for again arriving late and says she hopes you can give her the full 50 minutes anyway because the parking lot was full and she has a lot to discuss after a bad week. You express empathy; then, you gently ask whether there might be a pattern developing of late arrival and extended session time. She appears angry and stunned.

“What?! Are you saying it’s my fault there was traffic last week and I couldn’t find a space in your parking lot today?”

You invite her to explore this strong reaction to your intervention, but she avoids eye-contact and responds to you in monosyllables for the rest of the session.

Accepting Your Client

By Janina Fisher

Next session, as I wait for Lorelei to arrive, I plan a reset. I suspect she’ll arrive late again, though I’m ready to be surprised. I’ve realized that I made a mistake last time, and that I need to do things differently today. We hadn’t yet developed a relationship in which we could have a meaningful conversation about a pattern of lateness—I’d jumped the gun, and she’d felt confronted rather than curious. To develop a trusting relationship, I need to start by accepting Lorelei as she is while still holding time boundaries. And I need to do this gently, but firmly.

When Lorelei rushes into my office discombobulated and out of breath, I notice that she’s only 15 minutes late today—an improvement over last week. I greet her with a warm smile. “So glad you made it—good to see you! You probably have lots to tell me.”

She says she does, and updates me on her physical problems and the legal issues she’s facing. As I nod, smile, and communicate my support verbally and nonverbally, she begins breathing more easily, and I can see her body relaxing.

As our session time wanes, I take a deep breath. “I realize we have to end in just about three minutes. Would you like to go through a quick relaxation exercise before you go? Or did it help you just to vent today?”

She’s surprised and appears disappointed that I’m not giving her the full 50 minutes. “I was hoping to share about an issue I’m having with my ex,” she says.

I empathize but explain that unfortunately, I have to be on time for my next client. “It’s always safest to come 10 minutes late, if possible,” I say. “I build a 10-minute time buffer into my sessions. This means that if you come 10 minutes late, I can give you the full 50 minutes of your session time. Unfortunately, anyone who arrives later than that needs to make do with whatever time we have remaining before my next client session begins.”

I’m no stranger to being late, and because I’m habitually late myself, I’ve built this way of working into my practice. If I’m five to 10 minutes late, we start the 50-minute clock then. If a client is late within 10 minutes, they still have 50 minutes to go. Given that an hour has 60 minutes, we can play within that window and give each other more grace.

Lorelei gazes at me skeptically. “Okay,” she says with a shrug. “Hopefully I can leave work a little earlier next week.”

I reassure her: “But now we’re covered if you can’t.”

My plan to accept her lateness goes a bit awry in the fourth session. She arrives only 10 minutes late as I’d suggested, just as I’m in the middle of sending an email. But I’m happy to see her, and I close my computer so we can begin our work.

“I’m so glad we’ll have enough time today so you can vent, and I can show you some ways of relaxing and regulating—if that’s still what you want, of course.”

“That’s exactly what I want,” she says. “I’ll just keep talking your ear off unless you remind me about what my goals are here.”

“Well, you have several choices in terms of goals,” I say. “We can work on managing your symptoms through relaxation techniques—that’s one option. Or we can explore what’s at the root of the difficulties you’re having and see if we can heal them. Or we can do both! Which sounds best to you?”

“I think I want to do both,” Lorelei says hesitantly. “But I want to relax first.”

“Then let’s focus on that,” I say. “Start by just heaving a big sigh.” I model the sigh so we’re sighing together. “Does that feel better or worse?”

“A little bit better,” she says, “but then I start worrying again.”

“Of course your mind keeps going back to the anxiety, and every time it does, just sigh again. And again . . . and again.” I sigh with her. “Now your mind will go back to the worry, and you’ll have to sigh again, but let’s sigh before the worry gets here!”

A few mutual sighs later, she’s calmer and ready to leave the office.

As Lorelei’s therapist, my goal is to build a relationship with her that acts as a container for whatever emerges over the course of our time together. Because my primary focus, particularly when we’re still getting to know each other, is the relationship, I’m unlikely to address her lateness as having any particular meaning. If I address it at all, it’ll be when she raises it as an issue.

Although verbal exploration and insight may provide a context for understanding a client’s thoughts and perceptions, I’m far more interested in what triggers Lorelei and how she responds to triggers. When Lorelei is triggered, it means she’s experiencing feelings and body memories related to some wounding or trauma in her past. By helping her sit with her distress and understand it as an emotional memory, rather than a present-day reality, I’m helping her regulate her overwhelm and develop a friendlier relationship to the emotions she’s always struggled with.

I remember what happened in the first session when she was so badly triggered by the end of the session. She’s much more fragile and easily dysregulated than she presents. Over time, a clearer picture will emerge. She might believe that I’m teaching her to relax, but what I’m really doing is helping her befriend herself.

My approach is to work with whatever feeling or issue is “up” for her because change can only take place in the present moment—we can’t change the past or the future. I ask questions like, “Is this feeling familiar? Is there an image or memory that goes with it?” These somatic questions from Sensorimotor Psychotherapy help clients to deepen without stimulating defensive responses.

My goal is to approach our work with playfulness, acceptance, curiosity, and empathy, to quote Dan Hughes. Together, Lorelei and I will get to those deeper places with less pain and more interest in whatever we discover together. Hopefully, we’ll laugh as well as cry, and if she continues to be late, that’s okay with me. The lateness is not a statement about me or the therapy. It says something about her brain and her executive functioning that we can discuss when organizational problems arise. In the meantime, I plan to enjoy her.

Honoring Boundaries

By Gabor Maté

I perceive two issues here or, to be more accurate, two sets of issues: The clinical problems Lorelei presents with—fibromyalgia, migraines, IBS, ulcers, social isolation, and an inability to regulate her stress responses—and her self-identified solution of “relaxation techniques.” The client’s repeated tardiness for appointments and expectation that the therapist go overtime to accommodate her, and her apparent resistance to taking responsibility for her lateness. The two sets of issues are clearly linked, because they both have to do with boundaries—I’ll come back to that. Having said that, the first set cannot be approached before addressing the second.

The initial and essential step is to establish a mutually respectful working relationship. Here the therapist’s job is not to make Lorelei understand anything about herself, e.g., that there might be “a pattern of lateness and expectation of extended session time.” That may be the case, but we cannot force insights on people, no matter how accurate. In fact, in that potentially valid insight there may lurk an element of passive aggressivity on the part of the therapist.

The real question is, How does the therapist feel about this recurrent situation and how do they wish to handle it?

If the therapist feels some anger, which would not be surprising, it’s their issue to deal with. The client isn’t causing any feelings on the part of the therapist—triggering them, perhaps, but not causing them. Still, it’s important to come up with a strategy to deal with the practical problem of the client’s lateness and unrealistic expectations of being accommodated with extra time.

It would be honoring both the client and the therapist to agree on a clear boundary. This might sound like the therapist saying: “I understand and respect your intention to heal, which is what impelled you to consult me. In that spirit, we need some working rules: We begin at the agreed time. And that means leaving enough space for our appointments. I understand that on occasion unexpected circumstances may intervene. Traffic or difficulty parking are not unexpected circumstances. Therefore, if you’re late, I’ll still charge you full fees and must end at the required time, out of fairness to myself and to my next client, as well. If we can’t agree on that, I’m not the right person for you to work with.”

Such an approach is respectful to both therapist and client, because it honors the therapist’s requirements and it gives complete agency to the client. It recognizes her as capable of taking responsibility for how she approaches the therapeutic process. If a clear agreement is achieved, we can then move to resolve the clinical issues. The client presents wanting “relaxation techniques.” She likely doesn’t recognize that the real problem is not a lack of stress-reduction techniques, but how she unwittingly generates stress in her life. Relaxation techniques, useful as they can be, only reduce symptoms. They do not deal with fundamental causes. So, in that sense, they function like the cup with which we ladle water out of a leaky boat. Until the leaks are discovered and addressed, the boat will still keep taking on water.

Fibromyalgia, migraines, IBS, and ulcers have all been related by voluminous research to childhood trauma. For readers wishing to learn more about that, I recommend my books When the Body Says No and The Myth of Normal. The title of the first sums it up: people who develop such chronic conditions have perennial difficulty saying no to the demands, judgments, and expectations of other people and of the culture in general. Because they do not know how to say no, their bodies say it for them in the form of illness. They do not know how to set boundaries. That’s why they are so stressed. It’s not their fault: it’s how they adapted to their childhood’s traumatic environment, by suppressing their own needs to serve those of others. So, resolving problems like Lorelei’s is never simply a matter of learning new “techniques.” It’s a matter of connecting with one’s authentic self and learning how to set firm boundaries. Then one won’t be so stressed.

Lorelei’s presenting difficulty in recognizing the therapist’s necessary boundaries has to do with her lifelong, trauma-induced failure to honor her own. In setting the boundaries that will support their work, the therapist will have taken the first step towards helping Lorelei develop the essential boundaries she needs to take better care of herself in her own life.