The power of custom in psychotherapy

It’s the kind of telephone call that every therapist gets and every therapist hates to get.

“I’m sorry to disappoint you on such short notice, but I can’t come in today.”

It was a patient who had come only once before, the week prior, and though he was articulate about what troubled him, one could discern that he was deeply conflicted about whether he even wanted help at all to solve his problems or even ease his difficulties. So it was no surprise to me when he attempted to cancel.

But here he was, live on the phone, the morning of his appointment, his words saying one thing, I’m not coming—but his voice full of conflict and ambivalence. One could sense the pulse of life in him, fragile and quivering.

Patients cancel with painfully short notice or sometimes with no notice at all. That is the way of the world. It’s a loss for them, for you, a loss of money and time. Most often there is little to be done. You put the receiver down and regrettably, you write them off. People will be people, you tell yourself. But every once in a while, you get a feeling that someone who ordinarily might cancel, ought to be encouraged, encouraged that is to keep the appointment. Was this one of those people, I wondered.

“Is there anything keeping you from making your appointment today?” I asked.

“Well, it’s just that as I explained last week, I wasn’t sure if I wanted to come at all…”

“Yes, you are in conflict, that’s true. But you know it is customary, usual and customary that is, to keep appointments unless they were cancelled with 24 hours notice. You’re aware of that custom, aren’t you?”

“Hmm…it’s a custom? I suppose it is,” he said haltingly, sparingly. Okay, I will keep the appointment.” And so it was.

What is it about customs that seem to excite less resistance while “laws” and commandments appear to excite more resistance?

From my own experience it would seem that “customs” act in some sense seem to lubricate the traumatized psyche to negotiate the torturous demands of id and superego while “laws” further tighten an already overloaded, cramped psyche.