This goal of this article is to provide insight into the “back office” of behavioral health care practitioners, especially for our patients, and the administrators who work with us.
Even though I tell new patients that they need to allow for some “wiggle room” at the top of their session and at the end of their 45-50 minute therapeutic hour, there are always some who are hurt and upset when I am not perfectly punctual, and that would be for anywhere from five to 10 minutes. I am writing this article for them… and my fellow behavioral health care practitioners, who may appreciate this illustration of what goes on while our patients are waiting for us.
One factor to keep in mind is that there are many different opinions on the “therapeutic hour.” Most insurance companies reimburse for a 45 minute session, a unit of time that they deem is appropriate for treatment. There is an ongoing debate on this matter.1
My patients know that they will get their full time here, whether we start at 2 PM or 2:10 PM. Most of the people I work with have no problem if I am a few minutes past the hour. They understand the ebb and flow of a behavioral health care facility, or they are conditioned to wait from previous appointments with other practitioners. There are just a handful of people that are in more pain in the Waiting Room, and this article will hopefully soothe their concerns.
What do therapists typically do in that 10-15 minute gap between patients? We are usually reviewing or writing notes, returning phone calls, making appointments, visiting the restroom, and perhaps eating lunch, dinner or some kind of metabolic adjustment.
Then we have the Unavoidable Delays which occur during these gaps:
Delay #1: Collateral calls between sessions. What is a collateral call? That’s when we return urgent calls to your doctors, nurse practitioners, teachers, guidance counselors, lawyers, judges, concerned family members or call your insurance company.
For example, when I have a patient in the hospital, and her doctor wants to talk to me, he leaves a message in the morning “Please call me today as soon as you can before 1 PM.” So what happens at 10:50 AM or 11:50 AM when I am returning his call during a 10 minute gap? I call the doctor, and then his secretary tells me to “Please hold while I page him.” I can be on hold for more than 10 minutes at times — waiting to find out how our mutual patient is doing. Naturally I am concerned for my hospitalized patient’s well being and may also need to respond to the doctor’s questions. Plus, Medical Release forms may need to be signed and faxed so that we can speak without violating the HIPAA Privacy Rule2.
Am I concerned about you being in the Waiting Room? Yes, I regret when this happens. But to remedy this challenge, when I have a collateral call to place — which may guarantee a delay — I immediately send you a “Courtesy Notice” via text. I let you know that I am being detained, and that we will most likely meet closer to 11:15 AM, or 12:15 PM, or whatever is 15 minutes past your original appointment. I am always doing the best I can, given the urgent and timely nature of these collateral calls.
I am honoring your time as much as I possibly can, and I deeply care that you are waiting, but I also need to make these calls between seeing patients in my office. You need to know that I am not thoughtless, careless or indifferent to your waiting time. That would be an extremely false assumption.
Delay #2: Longer sessions. Sometimes a client is delving into a very difficult thought or memory, and is having a breakthrough at the 43rd minute of the 45 minute hour, often referred to as “Doorknob Therapy.”3. Do I stop the client at the stroke of 45 minutes and say, “Sorry, we will pick this up next week.” No, I allow them to finish their thought, or complete their process, especially when they are releasing a traumatic memory or having a major breakthrough or insight. Again, it’s just a few extra minutes past their usual time.
Delay #3: Engrossed listening, not watching the clock. The good news and the less good news…I am listening to your story, you have my full attention, and I do not watch the clock every minute. I sometimes lose track of time while I am deeply concentrating on your words, and what is happening with you. This is a natural hazard of working in this field4. Yes, there are ways to keep track of the time despite the process of intensive reflective listening, putting together symbolic themes and meaningful interpretations for you.
Possible solutions for Delay #3: How would you feel if I set a timer for 43 Minutes? Would you mind if a chime went off right before your time was up? That is one solution for this delay. Other solutions involve keeping one eye on the clock and thereby removing myself from total immersion in your story. When I go over the hour due to engrossed listening, it is rarely more than 5 or 10 minutes. Yet this does anger some patients in the Waiting Room who feel miffed that I am a few minutes past their appointment time.
Delay #4: Clinical meetings off-site. Sometimes I perform home visits for my elderly patients, or teens without wheels. Traveling from another location, where I was in a clinical meeting that ran later than expected, could cause a small delay. Again, when I see that coming, I send a text with a Courtesy Notice. During home visits, sometimes there are extra complications, or equipment needs to be ordered, and urgent paperwork needs to be processed which takes a bit longer. This is all part of the unavoidable delay caused by this off-site work.
In Conclusion
It remains questionable as to whether the 45-50 minute hour can be effective when processing deep trauma and chronic grief. I do the best I can during this standardized treatment window, but you need to know that there are methods and techniques which do require longer time for maximum benefit, including Dialectical Behavior Therapy (DBT), Eye Movement Desensitization and Reprocessing (EMDR), Hypnotherapy and other trauma treatments. These do not always fit into the 45-50 minute hour5.
In sum, this work occurs in a non-linear, sometimes timeless space that cannot always be boxed into a precise unit of time if the practitioner is working with true empathy, compassion and a commitment to excellence6.
So the next time you are sitting in the Waiting Room, I hope you consider that one of these four delays are probably happening and that’s why you are waiting, hopefully patiently.
Suggestion: It would be an excellent use of your time to make a list of topics that you want to discuss with your therapist, or sit quietly with your eyes closed and scan your body and mind for what you are feeling in the moment, to get in touch with your inner world in the Waiting Room. This will contribute to your having a more effective and successful quality of session and therefore you will be using your time with deeper purpose and meaning in the Waiting Room. You could also write your check for your fee or copayment while you wait, also a good use of those minutes. [Please refer to my article on “The Art of Waiting,” for your enjoyment and better understanding of this issue7.]
Finally, this is an important issue to discuss with your therapist. Chances are if you are impatient in the Waiting Room, you are impatient everywhere. You are not behaving this way only at this time. It’s how you roll, your Modus Operandi. You may also discover that you are avoiding dealing with your painful issues and interpersonal conflicts by hyper-focusing on the 10 minutes you are waiting.
You may be triggered by this short wait, and it is bringing up important tender golden threads from your childhood when you were neglected or kept waiting by a harsh relative. But being condemning, critical and complaining of your therapist’s time delay will not help you in dealing with your inner troubles and your personal transformation process unless you discuss it openly with your therapist. Ultimately, railing about your therapist’s time delay to your friends will just keep you feeling like a victim, and you will stay stuck right where you are until you process this out with your therapist.
We are your Practice Human. In the best of all possible therapeutic relationships, you will feel safe enough to say anything to us, tell us exactly how you feel, what you think, and how frustrated you are with your waiting experience (or any other issue you are having with therapy). This is all very useful and helpful in your journey towards wholeness.
When you practice improving your communication with us, you increase your interpersonal effectiveness in the world. I always tell my people “This is the Huddle! You come in here to defrost painful feelings, get some relief, regroup, strategize, learn some new skills, tools and methods, and then go out and practice. The real work is done out in your life.”
If waiting for your therapist continues to be a huge issue for you, speak to your therapist about getting treatment for practicing Radical Acceptance8. Or if none of this fits for you, then just get a referral to see a different therapist.
At the end of the day, you are always 100% accountable for your life. As the captain of your ship, you can always sail on to the next safe harbor.
Onward and Upward!
Lisa Wessan
NOTES
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1. Goleman, D. (1984). The New York Times. Therapy: Critics Assail ‘Assembly Line’ sessions. By Daniel Goleman.
2. Health Insurance Portability and Accountability Act of 1996, aka the HIPAA Privacy Rule.
3. Gould, C. (2014). PSYCHED. Getting to “The Good Part” of therapy.
4. Lazarus, A. (1997). Brief But Comprehensive Psychotherapy: The Multimodal Way. New York: Springer Publishing Company.
5. Ibid.
6. For this reason, some of my patients have double sessions, where we can do accelerated work and have the advantage of a 90 or 100 minute session to cover a broad reach of material successfully.
7. Wessan, Lisa (2016). PULSE. The Art of Living is the the Art of Waiting.
8. Brach, T. (2004). Radical Acceptance: Embracing Your Life With the Heart of a Buddha. Bantam Dell: New York, New York. [There are many sources for learning about Radical Acceptance, and it’s also included in the Distress Tolerance module of Dialectical Behavior Therapy. Tara Brach’s book is a wonderful source for delving deep into the process of learning to accept reality and find peace with the imperfections of your life.]
© Copyright 2019 by Lisa Wessan. All rights reserved.
The Lighter Side of Transformation 