Developing a Private Practice - Course blog: Dealing with the patient who comes late - Johns Hopkins -Dr. Lynn Friedman

The Patient's Lateness by Dr. Lynn Friedman, Johns Hopkins

In the last post, we talked about the new patient who is late or who, "no shows".  Let's focus today on the patient who comes late.  The most important task, during the hour, is to listen to the patient's concerns. What has brought them to therapy, or counseling or analysis, at this time?  That is, what is their, "presenting problem"? And, if this problem has persisted for a long time, why are they coming now?  Often, there is a precipitating event or situation that prompts them to make the call.  

As for their lateness, many patients will explain it to you.  Some patients will be able to tell you, spontaneously, that they were apprehensive about coming.  The fact that they can tell you this is an extremely good sign. And, it allows you to empathically ask what sorts of worries or concerns they had about coming.  Right away, they are opening the door for an alliance in which you partner with them, helping them to join with you to get a perspective on their concerns.

Others may tell you they didn't allow enough time, didn't realize that your office was so far away or that they had trouble parking.  Although these concerns can be taken literally, it is important for you to make a note to yourself about the unconscious anxieties they may reflect. Beyond unconscious anxieties, their explanation may reveal something about how they navigate the world.  For example, the patient who tells you that they didn't allow enough time may be telling you something about how they approach new situations. They may be a person who has trouble with transitions or who has trouble allowing themselves to acknowledge that the treatment is important to them.  Contrast that to the patient who arrives a half an hour early. Each may be revealing something very important about their personal psychology. 

The patient who says that they did not realize that your office was so far away may be telling you something, albeit via metaphor, about how far away and foreign treatment or counseling seems to them, at an intrapsychic level.  And, what about, "trouble parking"?  Is the patient saying that they had trouble allowing themselves to settle down and settle in with the idea of coming?  Of course, "sometimes a cigar is just a cigar" and it's likely premature to make such an interpretation without more data to support that idea.  The key here is not to baffle the new patient, who you do not yet know, with interpretations. Instead, it's more helpful to reflect that it's not so easy to get started and, depending on your theoretical approach, you might assert that you are glad that they found their way.

As for whether to extend the session, often you will have no choice but to end the session on time. How do you handle this situation? Again, that depends on how you work.  Some clinicians might extend the session noting that they were able to do that tonight whereas, in general, they are not. If done gently, this indirectly conveys to the patient a ground rule of the work; that they have a time set aside for them to use as they see fit.  Others might simply end the hour at the regular end time. This too, conveys the same message as the other approach.  

New clinicians often make the mistake of allowing the session to go over without comment. An unfortunate aspect of that approach is that it sends an implicit message to the patient that if they come late, than the hour will be extended.  Down the pike when the clinician finds themselves filled with resentment and wants to establish new ground rules this can become dicey.  More importantly, it can make it difficult to analyze the dynamic occurring between patient and clinician.  When the patient keeps the clinician cooling their heels, it's important to wonder, what's going on here?  And, what does it reflect about how the patient is feeling? Does it occur outside of the clinical setting? And, what does it reveal about the patient?   

Obviously, there is much more to be said about this important topic and I look forward to your future emails about it.

Best to all, LVF 

(c) 2010 Lynn Friedman, Ph.D. All rights reserved 

P.S. The waiting list to take this class has grown. Therefore, Johns Hopkins has added a second session to be taught April 30/May1. Already practicing professionals and graduate students from elsewhere are welcome to enroll as special students. The course will run from 9:00 am - 4:00 pm on Friday and Saturday. Information about registration may be obtained through the university. 

P.P.S. A list of all blog posts can be found at: http://www.drlynnfriedman.typepad.com

Confidentiality Policy: Please note for reasons of confidentiality and copyright all letters to the blogger will be summarized and edited. Also, I will not write about real patients. Instead, I will create fictionalized vignettes. When you pose a clinical question, please ask it in a general way. DO NOT write about real patients. Thank you.

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Lynn Friedman, Ph.D.

Psychologist, psychoanalyst, work-life consultant

Faculty Associate, Johns Hopkins University

5480 Wisconsin Avenue

Chevy Chase, MD 20815

301.656.9650

Follow the private practice blog

http://www.drlynnfriedman.com

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Dr. Lynn Friedman welcomes referrals for supervision or consultation,feel free to call.

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Comments

[Michael Krass, PhD]

I was just discussing this very issue with a supervisee today. How timely! I will direct her to this blog posting the next time I see her. Very clearly written and useful for clinicians at any level.

[Lynn Friedman, Ph.D.]

Thank you, Dr. Krass. Best, LVF

[Sarah Gilden]

Dr. Friedman,

This post made me wonder what you do if you, the therapist, is the one who is going to be late.

How do you make sure that your client does not feel as if your lateness is a reflection of your feelings for them? Have you ever has an experience (or heard of someone else's experience) where there was a negative impact on the therapeutic relationship as a result of the therapist being late and/or cancelling/rescheduling sessions?

This also brings up the question of best how to handle vacations or time away. Obviously there is someone covering for you in some way, but what does that really look like for both you and the client, and how do you decide who is a good person to do this for you?

Thanks so much,
Sarah

[Lynn Friedman, Ph.D.]

Thank you, Sarah. This is a terrific question. Let me handle it in a separate blog post. Best, LVF

[Kelly Walsh]

In reading this blog, I feel that I have developed a better understanding of how a psychoanalyst may conceptualize a client’s lateness. I cannot help but ponder now, how different schools of thought would conceptualize a client’s initial and/or continued tardiness to treatment. Would a client-centered therapist unconditionally accept and reflect upon a client’s lateness? Would a reality therapist ask, “how is being late working for you,” accept no excuses and insist upon doing something differently? Perhaps a narrative therapist would conceptualize tardiness as an outside force that happens to the client, negatively affecting their life and necessitate a re-write.
As a new counselor, I have found that I have spoken directly to the tardiness of a client and clearly defined the timeline of our session in a strictly boundary-setting fashion. Now however, I feel that I will look beyond the clock and more towards the core of the lateness itself.