How should you handle this? Do you stay until the end of the hour?  Do you call? Do you wait for the patient to call? How you respond depends on your theoretical orientation. Without any information about the patient, it's hard to understand the meaning of her behavior.  Is she frightened? Angry? Lost?  But, understanding the meaning of the behavior is, of course, the task at hand. And, it is this understanding that will inform your intervention.  

Waiting until the end of the hour --- since, after all, it is the patient's hour, sends a powerful message: that the hour belongs to the patient and that she is responsible for how it will be used. This includes, not using it at all.  In this way, if the patient arrives 20 minutes late, for example, she knows that you are there. Leaving, after 15 minutes, sends a different sort of message.

And if, indeed, she arrives, do you extend the hour? After all you have no subsequent patients.  That, too, sends a powerful message about how you approach the situation.  There's not a right or wrong answer here EXCEPT that it's important to have, in your own mind, a clear cut rationale for how you might handle this and why.  This will provide a springboard for what you might say to the patient.  In any case, it can be very useful to listen to the patient as they explain their lateness.  Do they rush in huffing and puffing very anxious about what you might think of them?  Or, do they act as if nothing has happened?  How does their lateness sync up with their presenting problem? Learning a bit about their experience of lateness in other arenas might be very useful. However, in this early juncture it must be approached with the utmost tact.  And, if it can not be gotten at skillfully, it can be tabled until it reveals itself as a more persistent pattern.  

What if the patient never shows? Do you call? Again there is some theoretical disagreement about this.  Calling maybe experienced as caring. It can also be experienced as intrusive.  Not calling may be experienced as respectful of the patient's autonomy and as letting the patient take responsibility for themselves. It can also be experienced as indifference.  Any option carries with it consequences and implications.

A key point to consider is that at this early juncture you are establishing a framework for how you will handle lateness and absence.  At the very least, it seems important to clarify the meaning of the behavior. Of course, at this stage of the game the meaning can be very difficult to divine. Obviously, there's so much to be said about this topic. I hope that you will write in with more questions.

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 the last weekend in April. Practicing professionals and graduate students from elsewhere may 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.

I received an email from a clinician asking about how to manage what they referred to as the "business aspects" of the practice. By this they meant, setting up appointments, handling the ending of a therapy session, establishing and collecting fees, handling of cancellations and, "no shows", dealing with insurance companies, consents to share information and related fare.  I'll be addressing these and related issues in this blog in the weeks to come.  

Yesterday's post brought a question about what to do when patients/clients call and they can not afford private fees.  

This difficulty is extremely commonplace especially in this economy. And, it's important for clinicians who receive these calls (whether or not they are actually in private practice yet) to do their best to help patients/clients to connect with low fee and sliding scale resources.  Fortunately, here is the Greater Baltimore Washington area, there are a plethora of low fee and sliding scale resources. In other locales, this can be more challenging - that is, it is more easily said then done.  

Yesterday's post detailed a situation in which the counselor was doing outreach related to substance abuse prevention in teenagers.  Prior to giving the workshop, it's important that she familiarize herself with the resources in her locale.  In that case, she could identify both organizations/individuals who treat substance abusing teenagers and their families. Also, she could identify counseling/therapy resources in general.  Beyond this, prior to making referrals, I'd encourage her to call these organizations/individuals to make sure that they are accepting new clients/patients. In doing this, they will become familiar with who she is and what sorts of expertise she has to offer.  In fact, she might even offer to give her talk to their counseling staffs.

How can she learn about places with sliding scale referrals?  She might check out the local Departments of Psychology and Counseling to see if they have low fee clinics. Similarly, she might look into the local Departments of Psychiatry.  Here in Washington, the GW PsyD program has a very low fee clinic and the GW Department of Psychiatry also offers a sliding scale for those in their catchment area.  Beyond this, the Washington Center for Psychoanalysis offers sliding scale clinics for both psychotherapy and psychoanalysis.  Also, the Baltimore Washington Institute has a similar clinic. Both are excellent resources. To find a list of these sorts of clinics, nationally, look here:  www.washingtonpsychoanalyst.com/lowfeepsychotherapist.html

When she contacts these settings, it will be important for her to make a special point of learning how their referral process works.  Then, she can talk with the client about what to anticipate. This is critical as many patients/clients become so frustrated with the maze of phone calls, holding patterns, etc., that they give up before treatment starts.  As we've discussed, being referred to another clinician can be hurtful to the patient.  Streamlining the process and functioning as their, "ombudsmen" can go a long way to ameliorating the hurt. Also, it is a way to ensure that patients receive good care.  For those of us committed to the profession this is a very important part of our role.  In fact, when we fall down on this part of the job we erode the public's trust.

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 the last weekend in April. Already practicing professionals and graduate students from elsewhere may 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.

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What are examples of some ways in which counselors, psychologists, social workers, psychiatrists and other mental health professionals might reach out to counselors in independent (private) schools?  

A counselor was very knowledgeable about substance abuse. While she was in graduate school, she wrote a number of papers on the topic. And, beyond this, she had, "personal experience". Her brother had been through numerous rehabilitation programs. During the course of his difficulties, the family (including her) received family therapy.  One of her placements was in a rehabilitation center. Also, she had had a significant amount of her own personal therapy.  At this juncture, she felt that her therapy had given her maturity and perspective on this important area and her placement supervisor had been very impressed with her clinical work.

She decided to design talks for teachers, students and parents  on substance abuse with the thought that, "an ounce of prevention is worth a pound of cure".  Her goal was to teach teachers, students and parents to recognize the early indicators of substance abuse AND to teach them how to take early and effective steps to address these concerns.  Because she was new to the field, she decided to tag team with a senior clinician with significant expertise in this area. She approached him with a proposal.  

She suggested that she would design a workshop for independent schools. He would review it, provide input and suggestions.  They both would conduct the workshop together.  She would do all of the legwork. She would reach out to the schools, provide the mailing and schedule the sessions.  

She was not yet licensed.  However, she was doing this spadework so that she could establish herself as having emerging expertise in the field. Collaborating with an expert allowed her to (a) establish a relationship with a senior person in the field (b) have a role model as to how to present a workshop (c) begin to develop visibility.  Beyond this, she and her senior colleague would do the workshops on a fee-for-service basis. In addition to making a bit of money in the process, people began to contact her (and her colleague) for referrals. Since she was not yet ready to accept patients, she began referring to colleagues in the area. Thus, she developed her own network.  By the time she was licensed, she was already well-connected in the field. Within 6 months she had a full practice.