"I don't need therapy"

[birchswing]

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Sometimes chronic lateness in a patient is pathological though - now chronic lateness coupled with 'well I'll take up extra time yapping my ar5e off when my Psychiatrist has clearly informed me that we don't have much time, thereby forcing our Psychiatrist to run late for all their other patients', in my opinion at least, falls under the category of 'someone smack this idiot upside the head with a clue by four' (unless of course they're not exactly running on a full tank of gas neurologically speaking in which case the clue by four should probably be applied somewhat gently), but anyway, lateness can definitely be a sign of a lot of different pathology and it should be addressed in the appropriate manner for the individual patient's case.

I agree that it could be the case, but it's not necessarily the case. I think the jumping goes to pathological more quickly because the lateness is taking place within a psychiatrist's office. If we were to so easily take chronic lateness as a sign of mental pathology, then airports would be bedlams that are run by the patients (OK, someone will make a joke that they are . . . but in reality their chronic lateness is explainable by profit maximization, which isn't exactly a mental pathology as much as it's the vice our economy runs on).

 

[sunlioness]

That emphasizes my point. It's perfectly explainable for a psychiatrist to be late without pathologizing it. And I was saying the same could be true for patients.

Who's pathologizing being late? Not me. It happens. Most people call ahead, apologize, and are mindful of the time. I wasn't speaking about them. I specifically was speaking to those who unapologetically show up late and still persist in taking up a lot of time. Even when told at the outset exactly how much time was available to them and agreeing with it. Am I going to pathologize that? In a repeat offender, yes.

 

[splik]

That emphasizes my point. It's perfectly explainable for a psychiatrist to be late without pathologizing it. And I was saying the same could be true for patients.

i dont think anyone was saying otherwise. and i don't think anyone was necessarily pathologizing it, but sometimes in the course of psychotherapy if patients are persistently late it is worth exploring or wondering together. for example i was late once with a patient (i overslept! worst psychiatrist ever!) and they wondered if they had done something wrong and then the patient started turning up late. after we explored his hostility about coming to therapy they stopped being late.

i think people were talking about the "entitled demanders" - there are patients who turn up after their appointment time is up and demand to be seen for example. there are many reasons for this, sometimes people are so solipsistic they aren't aware of others. for some narcissistic patients the therapist doesn't exist except for them and when they are in session. they have no other patients and the the patient does not think about the therapy or therapist outside of sessions. less extreme, some patients don't seem to realize that when they are late and expect to be seen for the full time it means the therapist is running late too. this could also be a reason that psychiatrists run late.

 

[birchswing]

Who's pathologizing being late? Not me. It happens. Most people call ahead, apologize, and are mindful of the time. I wasn't speaking about them. I specifically was speaking to those who unapologetically show up late and still persist in taking up a lot of time. Even when told at the outset exactly how much time was available to them and agreeing with it. Am I going to pathologize that? In a repeat offender, yes.

I was comparing psychiatrists who are chronically late with patients who are chronically late (the two would be perfect for each other). I was saying that if you can rationalize in a non-pathological way why a psychiatrist is always late or why airplanes are always late, then you could do the same for a patient. As far as expecting the same amount of time, I know that I get shorter appointments on the days my psychiatrist is trying to make up time. I don't see it as pathological. She wants to leave the office at a certain time, which I understand. That a patient is trying to maximize his time after being late is not necessarily pathological. It could be cultural or it could be that they're stressed out with a lot of things, they're mad at the world for making them late or whatever, they've had a bad day etc, and just want what they see as their take. I'm not saying it's good, just that it's not necessarily pathological. There's all sorts of boorish behavior that is culturally normal. And for them it might not even be boorish. There are cultural values where you take until you're cut off. There are cultural values of meekness and appearing as a supplicant. To use an IR analogy, realists believe actors will always act to maximize their interests. They want to be late. They want all the time that they want. Until a more powerful force stops them from getting this, they will continue to act in their interests. There are some people who act that way. There are others who can't handle social backlash and wouldn't dream of it. I think it divides on cultural lines more than anything else. In some cultures being late is no big deal. In some cultures maximizing your interests even with bluntness and disregard for others is normal—because you know others will do the same and it will even out, so there's no need for tip-toeing.

I would think that if there were a personality disorder, there would be signs other than lateness and furthering one's interest of maximum appointment time (and pushing for one's interest isn't the same as saying it has to be given--that's up to the second actor). It could maybe add to a diagnosis, but in and of itself they sound more likely to be cultural values. And when I say cultural values, I'm not even imaging someone foreign to the US. In my mind's eye, I can see people who operate this way and they're not first, second generation American.

 

[Ceke2002]

I was comparing psychiatrists who are chronically late with patients who are chronically late (the two would be perfect for each other). I was saying that if you can rationalize in a non-pathological way why a psychiatrist is always late or why airplanes are always late, then you could do the same for a patient. As far as expecting the same amount of time, I know that I get shorter appointments on the days my psychiatrist is trying to make up time. I don't see it as pathological. She wants to leave the office at a certain time, which I understand. That a patient is trying to maximize his time after being late is not necessarily pathological. It could be cultural or it could be that they're stressed out with a lot of things, they're mad at the world for making them late or whatever, they've had a bad day etc, and just want what they see as their take. I'm not saying it's good, just that it's not necessarily pathological. There's all sorts of boorish behavior that is culturally normal. And for them it might not even be boorish. There are cultural values where you take until you're cut off. There are cultural values of meekness and appearing as a supplicant. To use an IR analogy, realists believe actors will always act to maximize their interests. They want to be late. They want all the time that they want. Until a more powerful force stops them from getting this, they will continue to act in their interests. There are some people who act that way. There are others who can't handle social backlash and wouldn't dream of it. I think it divides on cultural lines more than anything else. In some cultures being late is no big deal. In some cultures maximizing your interests even with bluntness and disregard for others is normal—because you know others will do the same and it will even out, so there's no need for tip-toeing.

I would think that if there were a personality disorder, there would be signs other than lateness and furthering one's interest of maximum appointment time (and pushing for one's interest isn't the same as saying it has to be given--that's up to the second actor). It could maybe add to a diagnosis, but in and of itself they sound more likely to be cultural values. And when I say cultural values, I'm not even imaging someone foreign to the US. In my mind's eye, I can see people who operate this way and they're not first, second generation American.

In a situation like yours, where you're only seeing your Psych for med checks and maybe a quick chat about how you're doing in general, chronic lateness probably wouldn't need to necessarily be pathologised or looked at further (except maybe just to inform the patient that it's unacceptable if they were obviously acting in an entitled or inconsiderate manner). That is of course completely different to a patient seeing a Psychiatrist for psychotherapy, where, as Splik pointed out, that sort of stuff may need to be further explored and may indeed turn out to be part of a patient's deeper psychology.

 

[birchswing]

In a situation like yours, where you're only seeing your Psych for med checks and maybe a quick chat about how you're doing in general, chronic lateness probably wouldn't need to necessarily be pathologised or looked at further (except maybe just to inform the patient that it's unacceptable if they were obviously acting in an entitled or inconsiderate manner). That is of course completely different to a patient seeing a Psychiatrist for psychotherapy, where, as Splik pointed out, that sort of stuff may need to be further explored and may indeed turn out to be part of a patient's deeper psychology.

That's a good point. With my psychologist, he is always exactly on time because sessions are 50 minutes (with 10 minutes between), and they actually take 50 minutes, so there's not a lot of room for that to get messed up during the day. And I do know that if I were late, I would just use the remaining time in my slot.

I guess going to the psychiatrist is a bit more like going to your PCP or the airport. You have an appointment time, but you know that once you get there it's going to be a bit of a slog waiting. It's more of an ordered list than it is an appointment schedule. You know where you come in line, but only approximately when you'll be seen (although they're never even really close).

I can see how that's different than an environment where you know that you'll always be seen on time and that your time will be limited by exactly how late you are. In that case if someone were to always be late, yes, then you'd definitely talk about it in therapy. Plus you would have time to explore it. Although in the context of therapy, I'm not sure that being late would necessarily correlate with narcissistic personality but maybe more insecure attachment issues and separation anxiety. I don't know. My therapist has mentioned before that chronic lateness could be some sort of hostility, but I forget exactly what he said. He said something before about what it means when people cancel, but I forget that is as well. Demanding the session be extended is just odd--I'm not sure what you call it. I can see how believing you're entitled to the full session time after being late is narcissistic.

Edit: Thinking back on this more, yes it makes even more sense to me now. When I said that it could be culturally normal for someone to maximize their time, I didn't mean to make an absolute edict. Rather to push for more time through social cues. But I was imaging it taking place in which the time that the next patient was seen was already flexible, not like a psychologist's practice. In fact I was thinking in my head but didn't want to say it as I thought it might come off as overgeneralizing that I couldn't imagine how a patient even could be chronically late because given my experiences you would have go to go out of your way to be really late each time to be late. Most places I've seen a psychiatrist you'd probably be safe in being "on time" arriving an hour late--although they tend to still want you there closer to the scheduled time, presumably to keep their flow going as much as possible. @Ceke, you connected the dots that weren't connected in my head. I shouldn't be writing so much anyhow. I just finished a four hour exam and I'm probably a bit punchy.

 

[smalltownpsych]

If a psychiatrist or psychologist is chronically late, then pathologize away. Some of us are narcisstic and entitled or they flaky, immature, and irresponsible or as mentioned work for an agency that double-books. I actually have a lot less of a problem with patients who are late than I do with the no call/no shows. Those patients take up slots that other patients could use and they cost me money. I don't give them very many chances. I also think that when I get the patient right on the hour as scheduled for first appointment, then it sets that as the expectation.

 

[touchpause13]

It sounds like you might be treating my Mother...good luck with that.

(sorry I don't have anything useful to add )

False.
This was clearly my MIL

 

[Ceke2002]

If a psychiatrist or psychologist is chronically late, then pathologize away. Some of us are narcisstic and entitled or they flaky, immature, and irresponsible or as mentioned work for an agency that double-books. I actually have a lot less of a problem with patients who are late than I do with the no call/no shows. Those patients take up slots that other patients could use and they cost me money. I don't give them very many chances. I also think that when I get the patient right on the hour as scheduled for first appointment, then it sets that as the expectation.

I was a really bad patient with no calls and no shows when I first started working with my Psychiatrist. Obviously with me it wasn't a case of 'oh I just can't be bothered going to therapy today so I'll mess my Psychiatrist around and not bother to attend or call ahead to cancel', but it still doesn't stop me feeling bad about my behaviour back then as I'm not generally one to disrespect a Doctor or their time. I do feel very lucky (and grateful) that my Psychiatrist didn't just turn around and say "you don't show up, I can't treat you", because he would have had every right to. As it was I think he almost did throw in the towel a couple of times, because he'd obviously already sussed out that I had possibly had some past history of abuse in therapy, but at the same time I just wasn't relaxing or responding to any approach he was trying with me and from later conversations we've had he has indicated that he did get to the point where he was more or less racking his brain trying to think of anything else he could do to try and make some sort of connection with me, and seriously doubting if it would even be possible. Long story short, for whatever reason he decided it was still worth persisting with me, things eventually turned out alright, and now we have a really solid therapeutic bond/alliance, but I certainly wasn't what you'd call an ideal patient in those early days (not by a long shot).

So I'm assuming that part of a therapist's training is to be able to tell the flakey no shows, from the 'there's something else going on' type no shows.

 

[Ceke2002]

False.
This was clearly my MIL

We should arrange a cage match for all our screwed up family members and see who comes out on top.

 

[touchpause13]

We should arrange a cage match for all our screwed up family members and see who comes out on top.

I would pay serious money to watch that

 

[Ceke2002]

I would pay serious money to watch that

We could have themed rounds - "Round 1 - Throwing a Histrionic Temper Tantrum", "Round 2 - Manipulative Attention Seeking", "Round 3 - How Much Money Are Your Kids Paying For Therapy"....

 

[Therapist4Chnge]

No Shows are my biggest pet peeve bc I only see ppl for neuro/capacity evaluations, so any NS can often waste 1/2 to a full day of time (and wait lists can be 1-3+ mon).

 

[smalltownpsych]

I was a really bad patient with no calls and no shows when I first started working with my Psychiatrist. Obviously with me it wasn't a case of 'oh I just can't be bothered going to therapy today so I'll mess my Psychiatrist around and not bother to attend or call ahead to cancel', but it still doesn't stop me feeling bad about my behaviour back then as I'm not generally one to disrespect a Doctor or their time. I do feel very lucky (and grateful) that my Psychiatrist didn't just turn around and say "you don't show up, I can't treat you", because he would have had every right to. As it was I think he almost did throw in the towel a couple of times, because he'd obviously already sussed out that I had possibly had some past history of abuse in therapy, but at the same time I just wasn't relaxing or responding to any approach he was trying with me and from later conversations we've had he has indicated that he did get to the point where he was more or less racking his brain trying to think of anything else he could do to try and make some sort of connection with me, and seriously doubting if it would even be possible. Long story short, for whatever reason he decided it was still worth persisting with me, things eventually turned out alright, and now we have a really solid therapeutic bond/alliance, but I certainly wasn't what you'd call an ideal patient in those early days (not by a long shot).

So I'm assuming that part of a therapist's training is to be able to tell the flakey no shows, from the 'there's something else going on' type no shows.

I have had patients whose resistance gets in the way and when I feel that is more the case then I will make an effort to work through it and we usually can. When it is more so an overall pattern of irresponsibility I think that terminating the patient is more helpful and it is easy to see the difference because the former expresses regret and the latter is shocked that anyone would call them out on inappropriate behavior. The most heartbreaking cases are when a kid is benefiting from treatment and the caregiver is too irresponsible to bring them in consistently.