FEATURES

Tuning into Therapy: Using Music to Address Client No-Shows in Marriage & Family Therapy

 

You’re a marriage and family therapist (MFT) expecting a new client for an intake session. Your eyes dart to your clock—it’s time for the intake and your client hasn’t shown up. You tap your feet, play some sudoku, and look over their demographic information and consultation notes. Ten minutes pass and you call your client. The call rings, then goes to voicemail. You email your client about the late policy, and hope to see them shortly. Another few minutes go by, and you disappointedly open Simple Practice to change the little box from green to red.

“*Sigh* … another no-show. Hopefully they reach out to reschedule…”

This situation is all too familiar to both new and the most experienced of MFTs. Not only do therapists share the moral dilemma of sticking to billing-late policies and debating charging clients for services they need and did not receive, but they have spent the time investing in a person’s story to never be seen again. It also—to speak frankly—can impact career development and financial stability. MFT trainees and associates need hours to become licensed, and licensed MFTs need paid sessions to support themselves and their families. Using national averages in recent years, potential financial losses to no-shows and missed establishment of longer-term care are in the tens of thousands of dollars, if not more.

You start your day rushing out the door to make it to work on time. You repeat to yourself, “Remember, therapy session at lunch. This’ll be good. You need this – you deserve it.”

You arrive on time to your desk at work and you realize that you have a big presentation at noon that you completely forgot about that you are not quite ready for. You stumble through it and then get right back to work grinding out on an assignment you need to have by the weekend for the stakeholders of your company. When you finally finish your assignment, you realize it’s 5:30, the time you usually pick your kids up from daycare. You rush to pick them up and scramble to make them dinner before their 7:00 p.m. practice. You finally make it home, take your shoes off and lay in bed and breathe out the stresses of your day. You are affirming yourself of how much you accomplished throughout the day, and as you are going through each task you completed in your schedule, the rumination starts to kick in. How much more do I have tomorrow? Is the kids’ game home or away? Then it hits you. You missed the therapy appointment you scheduled during your lunch.

This example is just one of many for the experience of an MFT and client when a no-show occurs. Client no-shows negatively impact symptom reduction by both frequency and severity during the course of therapy, especially when no-shows occur in the first three attempted sessions. These no-shows along with cancellations at the initiation of a therapeutic relationship often serve as warning signs for treatment drop-out and poor therapeutic outcomes. In short, if a client is not attending therapy, they will not see their desired improvement and will likely leave before real progress can be made.

Reasons for client cancellations and no-shows can vary: fee deemed too high, general time conflict, found another clinician, and just plain forgetfulness. Therapy sessions, like any other scheduled meeting, can easily become lost in a schedule – particularly for those with busy, stressful lives (lives of those who often need extra mental health support). Especially since the COVID-19 pandemic, the majority of people began to stack their lives full of activities in every open slot in their calendar due to everything being online. Now, life has generally moved back to in-person modalities – but our calendars have remained just as full. This can leave people running late from work, to family, to personal matters with no time to breathe in between. MFT therapists know, have seen, and personally experienced this systemic stress post-pandemic.

What if there was something different? Like, functional behavior – different. Following the logic mirrored in cognitive-behavioral therapy, behavior activation, as well as solution-focused theory, having clients integrate a new, low-effort activity may be able to systematically address the barriers clients face in attending their initial therapy sessions. What behavior could fit this bill? Many great musicians, artists, and music therapists would agree: music can fix this problem.

When looking at attitude towards therapy and severity of depression, a common thread is avoidance.

How can music bring clients to session? The literature surrounding the benefits of music therapy shows how music can increase motivation, self-efficacy, confidence, mindfulness as well as decrease anxiety, stress, and maladaptive coping – among other relevant outcomes (Heping & Bin, 2022; Huang & Chen, 2021; Karageorghis, 2020; Ballman et al., 2021). Music’s entrancing effects on the human psyche can be the very thing that gets clients’ minds to take a break from their busy schedules and to focus on the present—and on themselves. Additionally, research has shown non-logistical reasons for clients not showing up to a therapy session. Murphy et. al in 2014 found that severity of depression and negative attitude towards therapy had the biggest effect on influencing client attendance rates for the very first session. When looking at attitude towards therapy and severity of depression, a common thread is avoidance. If you don’t like something (attitude), why go to it? If something seems hopeless (depression), why go? If something scares you (anxiety), why move towards it?  Negative attitude, depression, and anxiety are often the reasons why clients seek therapy but also often the very reason why they miss initial sessions. Breaking a client out of an avoidance cycle with something as universally liked and beneficial as music might make them start to sing a different tune.

What kind of music should clients listen to for this effect? According to research, listening to music that is historically and/or episodically linked to memories of joy, happiness, and accomplishment for the individual is more likely to inspire current positive feelings (Völker, 2021).

Going back to the opening vignette, what would it look like if the therapist utilized the proposed music intervention?

“Now, before our first session, I would like to ask you to try something for me. About an hour before our session, listen to music that gets you pumped-up, something you might want to dance to. Think of it as a session hype-up. I will ask you about the music you listened to when we meet as a chance to start getting to know you beyond the problems you described in the consultation. Therapy can get heavy at some points, but I would like to start us off by experiencing something personal, yet fun.”

You start your day rushing out the door to make it to work on time. You repeat to yourself, “Remember, therapy session at lunch. Listen to Britney Spears after that meeting with Jeff at 11 … OH RIGHT, headphones!”

You arrive on time and immediately start on the quarterly report. You crank out a few spreadsheets, take a coffee break, and jump on the call with Jeff.

11:02: You put on your headphones and scroll to your Britney playlist, and the shrill violin of “Toxic” begins to play. Your eyes dart to your calendar and to-do list, “ok, so … therapy, and then meet with Cheryl about the presentation, dinner with the kids … and volleyball practice at 7pm … doo-do-do-do-do-doodo-dooo …  I’m slippin’ under …”

11:55: You find yourself tapping your foot when the session notification alerts on your phone to join. “Wow,” you think, “I never thought I’d be this ready for a therapy session!”

Julie Payne, DMFT, LMFT, is an AAMFT Professional member holding the Clinical Fellow and Approved Supervisor designations and a Clinical Assistant Professor at Chapman University in the Marriage and Family Therapy Program. She has over 17 years of clinical experience working in community-based mental health and private practice settings. Dr. Payne is currently licensed and practicing in California and Texas specializing in working with families and individuals living with chronic illness/pain, military families, children and adolescents, and trauma.

Zoe.Shehan

Zoe Shehan, 2nd year MFT Trainee at Chapman University, hopes to work with clients who are recovering from trauma utilizing EMDR therapy in the future. She also likes to integrate creative, expressive, and art interventions with clients to develop tailored emotional processing.

Brooks Massey, 1st year MFT student at Chapman University, grew up playing the piano and guitar. He is currently working in the ABA field as an instructional assistant. In his work in ABA, Massey has noticed that music has a strong impact on the clients he works with and is interested in how that can translate to the MFT field.

Michael Ting is a 2nd-year MFT graduate student at Chapman University. He has been a high school performing arts educator for nearly 20 years, where he discovered the therapeutic power of music on his students. Ting is passionate about group therapy and desires to work with couples in private practice. He currently serves as the Program Vice President for Delta Kappa Phi at Chapman University.


Ballmann, C. G., Favre, M. L., Phillips, M. T., Rogers, R. R., Pederson, J. A., & Williams, T. D. (2021). Effect of pre-exercise music on bench press power, velocity, and repetition volume. Perceptual and Motor Skills, 128(3), 1183–1196. https://doi.org/10.1177/00315125211002406

Heping, Y., & Bin, W. (2022). Online music-assisted rehabilitation system for depressed people based on Deep Learning. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 119, 110607. https://doi.org/10.1016/j.pnpbp.2022.110607    

Huang, Y., & Chen, X. (2021). Efficacy of group music therapy based on emotion-regulation skills on male inpatients with alcohol dependence: A randomized, controlled pilot trial. Frontiers in Psychology, 12. https://doi.org/10.3389/fpsyg.2021.697617

Murphy, E., Mansell, W., Craven, S., & McEvoy, P. (2014). Approach-avoidance attitudes associated with initial therapy appointment attendance: A prospective study. Behavioural and Cognitive Psychotherapy, 44(1), 118–122. https://doi.org/10.1017/s135246581400023x

Pettit, J. A., & Karageorghis, C. I. (2020). Effects of video, priming, and music on motivation and self-efficacy in American football players. International Journal of Sports Science & Coaching 15(5–6), 685–695. http://dx.doi.org.chapman.idm.oclc.org/10.1177/1747954120937376

Völker, J. (2021). Personalizing music for more effective mood induction: Exploring activation, underlying mechanisms, emotional intelligence, and motives in mood regulation. Musicae Scientiae, 25(4), 380–398. https://doi-org.chapman.idm.oclc.org/10.1177/1029864919876315

Other articles

Gray Divorce: Splitting Up Later in Life
Feature

Cultural Blindness in Mental Healthcare: Navigating the Barriers for Asian Americans

An Asian American woman in her early 20s, her voice barely a whisper, tentatively joins a telehealth therapy session. The marriage and family therapist, perhaps well-intentioned but lacking cultural sensitivity, fails to grasp the gravity of her whispered greeting. Oblivious to the weight of familial burdens she carries, the therapist presses on, asking what’s wrong.
Julie Payne, DMFT, Katie Sy, & Julie Koh

Meaning of Aging in a Time of Crisis
Features

The Need for Both Mental and Physical Health Services for Incarcerated Women

In 2010, 65,000 incarcerated women in federal and state prisons reported as mothers to around 147,000 children under 18 (Cooper-Sadlo et al., 2018). In terms of race and ethnicity, African American incarcerated women have higher rates of having children prior to incarceration or being impregnated during the incarceration, compared to people of other races (Goshin et al., 2017).
Eman Tadros, PhD

Gray Divorce: Splitting Up Later in Life
Feature

Are You Even Intimacy-informed?

The couple sitting on the couch in front of you is looking for guidance as they navigate their marital distress. As a marriage and family therapist (MFT), you begin your intake session with this couple. Your new clients Adam and John have been married for five years. They share with you their recent marital issues and their fears of the inability to repair their relationship.
Julie Payne, DMFT, Pablo Arias, & Julianna Franco