I have been assigned to see a 47-year-old man who told the intake worker he had been depressed for over a year but isn’t willing to take medication. I was finally able to reach him by phone after trying 3 times, and he scheduled a first appointment. Since then, he has cancelled twice saying he is too depressed to come in. I don’t know what more to do and don’t know whether I can help him if he can’t even come to the office.

It is difficult and often frustrating to have multiple phone interactions and messages with a client you haven’t met who seems unwilling or unable to participate in therapy. One way to think about this situation, which is covered in Chapter 2 of my book, is that the therapy begins with your first contact with the client. Sometimes we think of our first telephone interactions as administrative or business tasks taking place before the therapy itself. However, the therapeutic relationship actually begins when you first learn about the client, and you are likely to have the best chance of engaging him when you approach these initial conversations as the beginning of the therapy.

In this case, thinking therapeutically begins with evaluating the meaning of the information you have so far. Your client is developmentally in mid life, and his depression could be related to circumstances that commonly occur in that life stage—loss of a job, ending of a relationship, onset or exacerbation of a medical condition, or death of a parent or another loved one. It can be more difficult to recover from disappointments and losses at mid life, when people begin to experience the narrowing of opportunities that seemed open in earlier in adulthood. His sense of worth and value may be at a low ebb, and asking for help is associated with admitting weakness in many cultures, especially for men.

You also know he says he isn’t willing to take medication. Although you don’t know why he has made this decision, it is meaningful that he shared this with the intake worker. I would hypothesize that he wishes to maintain a feeling of control in the course of his treatment, probably offsetting other ways in which he feels helpless, frightened, and despairing. He is most likely to engage in therapy if he is able to feel a sense of control with you, and so far he seems to be exerting this control by cancelling scheduled appointments.

Before contacting your client again, I would encourage you to think about how you could approach a conversation with him with the goal of communicating a view of him as capable, rather than weak, and an approach to therapy that is collaborative rather than hierarchical. He might respond well to you reframing his decision to cancel your appointments and to not take medication, then you can move on to putting the decision about scheduling in his hands. An example would be “It seems like you’ve been able to reach some clarity about what is most helpful for you in managing your depression. Would it work best if I wait for you to contact me about setting up another appointment?” If he says yes, you could ask if he would like you to be in touch in a week if you don’t hear from him or if he would prefer to contact you when he feels ready. If he says he wants to schedule a session, I would recommend offering him at least two different times so he can retain a sense of control. For example, you could say “I’m in the office three days a week, and right now I have openings on Mondays at 2, Wednesdays at 10, or Thursdays at 6. Are any of those times possible for you?”

It is possible that using the approach I recommend will result in him not beginning therapy, but I believe it represents your best chance of engaging him. Regardless of the outcome, I believe you always will be most effective as a therapist when you think about establishing a therapeutic relationship with your client from the first contact.

I hope you found these comments helpful in your initial interactions with clients before seeing them in person. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.