Friday, November 16, 2007

Dropping By

My office is in a building with lots of other offices and some stores. It's not uncommon that friends will mention they've been in the building for a reason, or they might say they're going to be there and might drop by. I generally suggest that they not do that-- I see patients back-to-back most days, it's more than a bit awkward to have my personal life intrude on my professional life, though I don't want my friends to think I don't love seeing them, just not during the work day.

Yesterday, between sessions, I got this text message from a friend, "I'm in the building. U there?"

I called and said, "I have to see a patient quickly, come up in a little bit."

It felt like a funny, meant-to-be sort of thing set up by the cosmos. I didn't tell the friend all the details, but I did have a patient scheduled that hour only the night before she'd called and said she forgot what time the appointment was. I told her (same time as friend showing up), but as an afterthought I added that I had another time available later if that was more convenient. It was, she took it, thereby freeing the cosmic time slot. And you know I don't do "med checks" but the patient I'd scheduled into that time is the only patient in my entire practice that I see for brief med checks-- a patient who came to me completely stable with no symptoms or side effects, no desire for psychotherapy, who could easily be managed by an internist (and has been told that) but he wants a psychiatrist to write his prescription.

Friend came up and we chatted. He sat where the patients sat, I sat where I sit. I'm not the quietest of therapists, but when I'm doing psychotherapy, it's all about the patient. I got to talk about me. He looked around, asked about the position of the clocks. Why doesn't the patient get to see a clock? Why don't I have a desk? We talked about some other stuff. I didn't ask if he needed more meds. He left when the hour was up. I wondered if he felt funny that the patient in the waiting room must have thought he was a patient.

It was nice to see you, Roy.


Gerbil said...

Aw, how sweet! :)

Roy said...

Thanks, Dinah. It was nice to check out your therapeutic digs. I had stopped by to find a card for a special new friend (and did find one, btw, at the store you suggested, next to the xmas cards).

FYI, 3 floors below Dinah's office exists a grocery store, Rite-Aid, book store, Radio Shack, photo shop, movie theater, pizza joint, and several gift shops.

I'll bet some of your patients plan their grocery shopping around their therapy appointments.

Anonymous said...

Why don't patients get to see the clock, out of curiosity?

Anonymous said...


My uneducated guess is that by keeping clocks out of sight it helps keep the focus on the therapy. It cuts out a little bit more of our every day lives — the pressures of jobs, kids, other appointments, to-do lists.

And about the lack-of-desk: It functions as more than a physical divide. It's a psychological divide that puts the person behind the desk, the shrink in this case, in a position of authority and power. I imagine it being sort of like the misbehaving student who's been sent to the principal's office.


Dinah, correct me if I'm wrong :P

Anonymous said...

It's not that the patients don't "get to look at the clock" it's just never occurred to me to put up a clock behind myself. No one has ever complained. As I told Roy, once in a while someone looks at their watch or asks if time is up, or asks me to let them know when it's a certain time, but no one has ever requested it and I've never felt inspired to just stick one up. Oh, and people often turn their head to look at the one on the wall (there's no rule against that).

Do people like to watch a clock while they talk?
Maybe I'll do a sidebar poll on this after I'm finished with the med run-through....

Anonymous said...

No desk: moved into the office in a hurry, quickly furnished, didn't buy a desk and planned to (to work at, not to see patients across). Makeshift, I wrote notes in my lap, had a small table next to my chair with pens/scripts, and stuck a stapler and desk-y things on a bookshelf. And then I realized this was fine, I'd have to rethink where to place a desk, and I really didn't need one. Clutter does collect next to my chair. Computer is in my home office, my email addiction means I can't have email on my phone or in my office (I'd be wishing for the end of sessions so I could check my email.)

It's not as thought out as jon would suggest.

Anonymous said...

It's not as thought out as jon would suggest.

Aww, poop.

I blame 8 years of art school — I can come up with stuff like this for just about anything.

Rach said...

How nice! What a nice way to break up your day...

I like the fact that more and more shrinks don't sit behind desks. Mine doesn't - sits with a clipboard in his lap. I think i'd be very uncomfortable sitting and talking with/to someone behind a GIANT desk. Very paternalistic methodology IMHO.

Roy said...

Unfortunately, as we move more and more to electronic records and e-prescribing, there will be an increase in docs, including us psychiatrists, sitting behind an LCD panel in lieu of the ubiquitous paper chart on the lap. That's where an Apple iTablet (or whatever they will call it) will come in handy, as the desk would be unnecessary.

Here are my thoughts about a clock in view of the pt...
There are pros and cons, as everyone is different.
If the clock is right in front of them, it helps them gauge whether there is time to bring up a topic, without them having to guess or be concerned about looking at their watch or phone (which many will fear may trigger an unwanted interpretation). I've had a number of pts tell me that without a clock, they are less likely to bring up involved topics for fear that they won't have time to re-compose themself prior to walking out the door.

Arguing against a visible clock is, as Jon stated before, "it helps keep the focus on the therapy. It cuts out a little bit more of our every day lives — the pressures of jobs, kids, other appointments, to-do lists."

I'm sure the analysts out there have much more to say on this topic.

Alison Cummins said...

1) I defininitely prefer a clock, pretty much for the reasons Roy gives.

2) I've never been given one (though I am occasionally reproached for running over time).

3) I do not ask for a clock because I assume that would be challenging the boundaries of therapy. If the therapist thinks it's therapeutic not to let me gauge when my hour is going to be up, then my disagreeing would just prove me to be dysfunctional and probably borderline. I don't want to pay someone $75/hour to argue about clocks when I need to talk about other things.

Anonymous said...

Why would he feel funny that the patient might have thought he was a patient?

Roy said...

I didn't (feel funny). I *have* been in the patient chair before (though not with Dinah) and didn't "feel funny" leaving his office, either.

I guess some folks carry that stigma with them and allow it to affect their choices, and others do not. I am decidely in the do-not category, and wish others were too (that includes my non-psychiatrist physician colleagues, especially.)

Anonymous said...

Roy: From things you have said before I doubted that you felt funny. I was wondering why Dinah had the thought that you might. Oh, never mind.

FooFoo5 said...

Roy, when are you planning to drop in on Clink when you're in the area? :-)

Gerbil said...

Jon: well, even if you are not right about Dinah's office, you are right in general about the shades of meaning in furniture placement. In one of my first courses on "how to do therapy" we actually spent a good chunk of time in class discussing where to put the desk, the chairs, etc. Even a low coffee table can be a divider between the therapist and the client!

We also spent a lot of time talking about the offset between the therapist's seat and the client's seat--the angle as well as the distance. It's like Goldilocks and the Three Bears. Or maybe psychotherapeutic feng shui.

NeoNurseChic said...

Roy - that was nice of you to stop by!

Re: the grocery store nearby... On the way home from my psychiatry appts, I often stop at Target or even at the petsmart or food store. This is because every store every possibly needed lies between his office and my apartment! For a long time, I had no Target anywhere near me, so I was excited that there was one only 5 minutes from his office! Now that there is a Target near me, I still only stop at the Target near his office because it is convenient to do so after appts. I also try to line up refilling my gas tank with my appts since his office is in NJ and makes for MUCH cheaper gasoline! haha...

Re: the clock issue. My psychiatrist's old office had a clock he could see and a clock the patient could see. Now he doesn't even have a clock in his tiny little hole in the wall. He stands his watch up on the desk so that he can see it! I've only been caught with the end of the session coming at a bad moment for me a few times, but that definitely wasn't a good thing. Once I had finally felt comfortable asking his thoughts on something that had haunted me for YEARS, and the session had to end, which ended up making me bawl the whole time I was trying to schedule my next appt. I wished he would have just taken a few extra minutes to bring a little more closure to the topic instead of ending there. That was hard. But most of the time I feel like I can "sense" when the end is coming. Every once in awhile I feel ready to end early, but that is rare - and usually happens when we're talking about something that makes me uncomfortable. He is very punctual.

Re: the desk. Believe it or not, my psychiatrist does not write a single thing down during my appts. And yet, he often remembers things I said months ago - and in a few occasions, a few years ago! He'll remember it down to the sentence. And he remembers details that I'm sure are so insignificant that *I* would hardly remember it! I have wondered how he does this. During the first year we worked together, he asked if he could record the appointments, but I refused, stating that it makes me feel too much on guard. (I've always used recording for my music ever since I was a little kid, and I can't tell how many times I delete recordings because they aren't "good enough" - recording things always feels like a performance to me, and it makes me nervous.) He has never revisited the idea. I have thought on a few occasions that I wish I was recording the appts in order to go back and listen, but I have never asked if I could do this - nor do I know how I could record the volume of appts - nor do I know if I want to re-listen to myself. Mostly I think not to that last thing. I really do wonder how he recalls the entire appointment, though! He keeps a paper chart for me....not sure if he uses electronic records at all at the behavioral health center he works at, but I have seen inpatient charts floating around various offices, so I suspect that most of what they do is paper charting.

Interesting what different people do with their offices, however. Turboglacier at Shrink or Fade recently wrote a very interesting post about using a colleague's office. The post can be found here I would definitely be interested to see how the 3 of you keep your offices!

Take care,
Carrie :)

Rach said...

I don't remember my own name and phone number on a regular basis (no joke). So how does Carrie's shrink remember her whole life? My shrink takes meticulous notes - and refers to them throughout sessions - and from one session to the other... Which is comforting to me, in case I ever have any problems - it's all there on paper.

Re: Electronics - I'm not sure how comfortable I'd be with having my entire file available electronically even though there are several layers of privacy/confidentiality protection, etc. I'm nervous as it is knowing that my shrink has my number in his palm pilot. I'm weird.

jcat said...

Between pdoc and tdoc I have all the different options mentioned, and I feel OK about both varieties.
Mostly because I like both docs.

Pdoc has a desk, no clock at all (but his receptionist phones once when time is up), a huge chart with squiggles that only he can understand and copies of all scripts or instructions as well. If we are talking about something intense when time is up, he normally carries on for a bit.

Tdoc works from home, has no desk, comfortable chairs (although I only ever sit in the one right in the corner!!) and three clocks. She mostly tries not to book appts back-to-back, so it allows for a bit of overrun if needed. And, like Carrie's doc, she remembers EVERYTHING! Without taking notes at all! When I asked, she said she makes brief session notes at the end of the day - but she remembers names and details about people I might have mentioned once. Sometimes I think that she remembers more about my life than I do. Actually - around the times I've had ECT, that's true!

Roy said...

"psychotherapeutic feng shui"
Love it! Sounds like a new blog title. What do you think, Rappers, should we adopt it?

We had that same lecture, on furniture and the angle of the chairs (about 30 degrees in from being parallel, so that you are sorta facing the same direction, promoting the feeling of working together towards a common goal rather than facing each other like in a chess game). Don't recall a clock discussion.

Carrie, there's an interesting idea. Record your sessions on your iPod (it's easy) then post them as a weekly podcast, with narrative commentary. Sounds like a reality show coming on.

Foo, since there are no neat little stores or Giant near Clink's office, my visit to her will have to await the next time I am in need of a bail bondsman or a payday loan or a check cashed for 5% of the check amount.

(word verification=jailzey... I swear!)

Roy said...

"new reality show"... meant to include the link.

Gerbil said...

Carrie: do they still pump gas for you in NJ? My friends and I used to get so confused by the lack of self-service when we crossed the border from PA!

Roy: I would be honored :)

NeoNurseChic said...

Rach, He definitely does write things down, but not during our appts. I'm actually rather curious to know just what he does write much, what things does he choose to write down, etc. I've never seen any part of my chart except for stupid treatment plans I had to sign when he was a resident. I still don't know how he remembers it all, though! During my appts, he doesn't look at any papers - just at me. This is actually very difficult for me because that intense of a focus makes me feel like a deer in the headlights - I don't like anybody to focus on me while I'm talking about difficult things.

Roy - Ha...that would NOT be an idea I would go for!! I'd record it onto my ipod to listen to it myself, but certainly not to post with commentary!! haha I can imagine that some people might be okay with that, but not me. The stuff I talk about has taken me years to open up to anybody, and there is still a lot more that I still can't say. That's partially why it's nerve-wracking for me to think about even re-listening to my appointments because I hear myself, and then all I think are negative thoughts about myself! Most of the time, I think it would be good to have recordings of the appts just to refer back to, but I would never ever share them as podcasts! That would make me afraid to say a lot of the stuff I talk about, for fear of what people would think!

Gerbil - They do indeed! Confused by lack of self-service? REJOICE in lack of self-service!! One time in my life where someone does something for me! It's awesome! haha... NJ gas is such a great thing! I actually really like my drive to my psychiatrist's office, once I get into NJ - on my side, I have to go on the Schuylkill (76E), Vine Street Expy, and then over the Ben Franklin Bridge, but once I get there, the drive is kinda neat. Long drive, but that gives me lots of time to think.

Take care,
Carrie :)

Dinah said...

I grew up in New Jersey. The ONLY thing I miss about the state is full-serve gasoline.

NeoNurseChic said...


It's one of the few good things about NJ! I also happen to like the shore - or at least our yearly vacation to Stone Harbor. But otherwise, I'll stay in PA thank you. :)

Take care,
Carrie :)

Gerbil said...

Carrie: wow, that is a long drive. And I bet it's extra fun at rush hour!

Dinah: yes, I can hear it in your accent :)

What does this have to do with psychiatry? Um, I don't know. But my dear undergraduate psychiatrist was also from the Garden State... perhaps New Jersey is a psychiatrist factory?

NeoNurseChic said...

Gerbil - I wouldn't ordinarily search for a psychiatrist in NJ (and a good bit into NJ at that!), but I started seeing my psychiatrist when he was a resident and worked in the building across the street from my hospital. Then he transferred to a different hospital system for fellowship, and I had to travel a shorter distance from my home but it was a lot farther if I came right from my hospital. Then this year he started working as an attending psychiatrist and started in NJ. He's not from there originally (I'm not entirely sure of this, but I really don't think he's from this area originally), but that's where he is now! Each time he moved, he gave me the option to see someone else or I could follow him to where he was going. I am willing to drive super far because 1. I click with him and I don't have many close people I say that about - it is difficult for me to truly connect with people, 2. I don't want to start all over with someone new, 3. He has always helped me by keeping his fee low for me, even though if I went back to the original resident's clinic, I could get a low fee, but I'm not sure they'd take me back now that I have a full time job, even though I still have financial needs due to medical costs/loan repayment/very high cost of living for Philadelphia, and 4. Did I mention that I click well with him? haha... That's better than all the rest of the reasons combined. I went to therapists before, and I was never able to tell them the things I've managed to tell my psychiatrist, and I can't imagine that it would be very easy for me to find someone else that I'd trust to that level.

So for all that, it is easy for me to make the drive into NJ, despite the gas mileage, bridge toll, and so on. At least I'm not commuting from my parents' house which would also make me have a turnpike toll! When I move next year, though, I'm not sure what will happen since Jason and I are looking to move a little bit further west of Philly - I have the feeling I will still make arrangements to see my psychiatrist, however. He's helped THAT much. :)

Oh and as for NJ producing psychiatrists, perhaps that's a statement of need. If I lived in NJ, I might need a psychiatrist, too! KIDDING!! :) (Go PA...)

Take care,
Carrie :)

P.S. I don't know if I hear NJ in Dinah's accent... Clink and Dinah have similar accents to my ear... My mom says that I have acquired quite the Philadelphia accent over the years of being here, but I suspect it's mostly from working in the city with people from NJ - NJ and Philly itself have a thicker accent than most other areas around here. My accent worsens when I'm around people from Philly as it brings it out for me!

Anonymous said...

clink and dinah sound very, very different.