Following a column on why patients are late, one of our Johns Hopkins students wrote to me asking, “what about when the psychotherapist is late”? In my opinion, that is a good question.
So, I’m reposting the comment, here, and my response to it, below.
Dr. Friedman, This post on patient lateness made me wonder what you do when the psychotherapist is 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 how to best 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, A+ student
When the Psychotherapist is Late
Though we try our best, it happens. Your car breaks down, a family member has a crisis, an earlier patient has an emergency, you are late. Not only that to add insult to injury there’s an inherent inequity in the situation: When the patient is late, you still end the session on time. In contrast, when you are late, you make an accommodation.
Patients are bound to have feelings about this. The key here, in my opinion, is to listen and clarify their feelings. And, whatever you do don’t make life more complicated by apologizing at the beginning of the session. Instead, say that you are late – if you are able to extend the session ask the patient if that is acceptable, if not, arrange a suitable alternative.
Why do I suggest that you not apologize at the beginning of the session?
It flies in the face of every consumer-oriented bone in your body. In fact, it flies in the face of being human. In any other context, you’d apologize.
So why don’t you apologize at the outset of the session?
If you apologize, the patient is, virtually, obligated to say, “that’s O.K.”. But, odds are, it’s not! And this is what you want to hear about. You want to hear exactly how the patient feels. They are not there to assuage your guilt; your guilt is your problem. That’s why you are paid the big bucks. So, instead, you announce that you are late. Then, ideally, you listen quietly.
If the patient is quiet you might say, “I wonder if you have any thoughts about your silence”? Or, perhaps, better yet, “I wonder if your silence has something to do with your feelings about my lateness”. Or, “perhaps you may have some ideas or fantasies about why I was late,” (you do not tell them why, as a general rule, with some real, significant exceptions.) And you encourage the patient to say whatever comes to mind.
The patient may not address your lateness directly. Instead, if you listen, carefully, you’ll find that you are hearing about a late boss who acts cavalier about when he comes and goes or the tardy parent who is insensitive to the patient’s needs for timeliness or some other bad-acting, key authority figure. This is because for many patients, their feelings about your lateness are quite unconscious.
If, indeed, the patient is talking about your lateness in the displacement, you can gently wonder if perhaps they experienced you — and, your lateness as akin to the cavalier boss – after all you might say, “if you are late, I don’t extend the hour – whereas when I am late I do – perhaps that feels that I am being highhanded as with your boss, etc,”
If the therapeutic alliance is strong or the patient has an unusual amount of ego strength, she may be able to tell you directly what her fantasies are about your lateness. The patient may worry that you had an emergency or were somehow not O.K. or she may fear (as you suggested) that it reflects your feelings about her. She may worry about whether you like her, whether you want to see her, whether you want to hear what she has to say or a myriad of other things. It’s very important to listen, in a non-judgmental, not defensive way and for you to tolerate her hurt or vulnerable feelings. As for your need to apologize, hold it for the end of the session. Often you will find that if you have understood and accepted her feelings, your unspoken apology has been felt.
I am looking forward to meeting you all!!! And, I look forward to talking about what to do when the psychotherapist is late! 🙂
I am a clinical psychologist, a Training and Supervising Psychoanalyst, based in Washington DC. I maintain a full-time, private practice in which I provide, evaluation, psychodynamic psychotherapy and psychoanalysis. Also, I provide supervision and clinical consultation for licensed clinicians who are wishing to deepen their skills in psychodynamic and psychoanalytic thinking. I welcome your calls: 301.656.9650.