Encounters in the waiting room.
Article Type: Report
Subject: Psychotherapist and patient (Analysis)
Therapist and patient (Analysis)
Author: Kasssan, Lee D.
Pub Date: 09/22/2008
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2008 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Fall, 2008 Source Volume: 11 Source Issue: 3
Accession Number: 187049615
Full Text: [ILLUSTRATION OMITTED]

The waiting room is a fact of life for most therapists. We provide a space for our clients to sit and relax (or not) before their sessions and to collect themselves if they need to before returning to the everyday world. We often pass by them if we use our time between sessions to visit the bathroom or the kitchen or to check the mailbox. Patients see each other weekly in the few minutes between appointments, sometimes for years. But we rarely think much about the waiting room, unless something happens there to call our attention to it.

This article was prompted by an interaction in my waiting room between two patients of mine who have adjacent session times. When I was made aware of it, I began to think about boundary issues and guidelines in regard to that situation. I thought perhaps I might find some references, articles about events in the waiting room, experiences of other therapists, or the like. Yet, after a long and thorough search, I found almost nothing in the literature about either the structure of the waiting room or the interactions that may occur there.

The Office Setup

Several basic introductory texts on private practice devote a few lines to the physical setup of the office and the waiting area. Typical of these is Wolberg (1977) who says, "The furnishings of the waiting room should be simple, consisting of a few chairs, coffee table, ashtrays, and selected magazines." Clearly this was written before the changed attitude toward smoking. Most waiting rooms today have no ashtrays, and many have signs specifically prohibiting smoking.

Wolberg also mentions that patients may make judgments about the therapist based on the kind of magazines provided in the waiting area. A psychologist with whom I used to share office space didn't want to put Rolling Stone in the waiting room (although we had received a complimentary subscription) because of the image associated with that magazine in his mind. One of my first supervisors had stacks of Time Magazine in his waiting room, but not one was more recent than 2 years old. I'm not sure why he thought anyone would want to read such old news, but that's what he provided.

To my knowledge, only Langs (1982) writes extensively about the physical setup of the therapist's office and waiting room. Langs insists that the only proper arrangement is to have a consultation room with two doors, an entrance and a separate exit that bypasses the waiting room completely. This arrangement tries to ensure that patients with adjacent sessions never meet each other.

We know from Jones (1953) that Freud's office had "a small waiting room giving on to the garden" with "an oblong substantial table down the middle, and the room itself was decorated with various antiquities from Freud's collection." Jones tells us that "an alteration was made to enable a patient to leave at the end of the hour without returning to the waiting room, so that two patients seldom encountered each other," but also that "the maid would at the appropriate moment retrieve the hat and coat and give them to the patient as he left." Perhaps the maid, because of her social status, was not considered a breach of patient anonymity, but today this intrusion would be unacceptable to most therapists.

Therapists in urban settings are likely to have office space in a large building, either residential or commercial, while therapists in suburban or rural areas may be able to set aside a portion of their own private house for professional use, and both of these arrangements are likely to include a waiting area. I think only a few therapists have no waiting area at all, and these are often people whom for whatever reason are practicing in their homes or apartments, a problematic arrangement because of the fuzzy boundary between professional and private space. These therapists often require their patients either to show up precisely on time or to wait in the lobby until the scheduled time.

Patient-Patient Encounters

Despite the fact that they spend only a brief time each week in the waiting areas, patients do form some sort of relationship with each other there. Perhaps it takes a long time to develop, but patients with a regular appointment time may see the same person emerging each week from the consultation room for years. As my door is briefly open at the end of a session, I can often hear people greet each other as one waits and the other gets ready to leave the office. On the whole these interactions sound friendly.

Sometimes, though, these meetings can evoke old feelings of sibling rivalry. A colleague told me of two patients who had adjacent hours and would often chat in the waiting room between sessions. Both were aspiring artists, and one developed the fantasy of joining the weekly therapy group, where he would be able to tell the other to "get on with it" and be more committed to his art. According to my colleague, this patient believed that the therapist would prefer him to the other patient if he were more committed and more successful.

Some patients make it a point to show up precisely at the time of their session, and this is often a conscious decision to avoid having to sit in the waiting room. Sometimes this is done to avoid dependency feelings that can arise as one sits and waits. Sometimes it is an expression of power and control issues, as in the "you wait for me, I don't wait for you" mentality. Other people actively dislike conversations of any sort with other patients. They want to be able to focus on their own thoughts and review topics for the upcoming session, and they find other people distracting and annoying.

Weekly therapy groups will usually collect in the waiting room prior to the scheduled session, and, since these people know each other well, they can have quite animated conversations. Several colleagues have mentioned being distracted by noise from the group of the therapist with whom offices and waiting areas are shared. One colleague, who shared his waiting room with three other therapists, told me of a patient in his group who had an affair with a patient in one of the other therapists' group. They had met in the waiting room before the groups met.

My own weekly group has many times referred to their conversations in the waiting room as being very different from those in the actual group session. Talk in the pre-group conversations is more casual, more informal, less charged than the topics and levels of interaction in the session. Issues, events, and other topics get discussed in the waiting room that are never brought up in the therapy session (a form of group resistance).

Patient-Therapist Interactions

Many therapists practice in a suite with a number of offices sharing a common waiting area. Each additional office multiplies the likelihood that interactions will occur in the waiting room. Although these are primarily between patients, other kinds of encounters can occur.

For years I shared a suite of offices with a psychoanalyst who was very strict about self-disclosure to his patients. My own patient, whom I saw for almost 10 years in that one location, was used to seeing him in the waiting room, and from time to time would complain to me that he would not reply to her greetings. She was mystified by what she experienced as his cold and unresponsive manner when she was only trying to be polite. As she said, "After all, he's not my therapist--what difference would it make?"

A colleague told me of an incident that occurred while he was sharing a suite of offices in a suburban setting with a male therapist who was going through a difficult divorce. My colleague was treating a very attractive female patient, and the other therapist, after some small talk with her in the waiting room, used the license plate number on her car somehow to obtain her name and address, and then called her at home for a date. The patient informed her therapist of these events and accused him of arranging the whole thing. Although he managed to convince her that he had nothing to do with it, she never returned to treatment because it had become so unsafe for her.

A Clinical Example

An example from my own practice occurred in an office I was sharing with two other therapists but could have just as easily happened in a single office.

I had been seeing Jim, a 41-year-old man, weekly for about 5 years. He had had the same appointment time since the beginning of treatment. Jim was an incest survivor and was extremely sensitive to interpersonal boundaries and boundary violations. At that point, I started seeing a new patient in the hour before Jim's. Allan was a 52-year-old man experiencing some frustration in his marriage and his career.

One week, Jim came into his session very angry at me, because Allan had come out of his hour, sat down in the waiting room next to Jim, and "wanted to chat." Jim had no interest in talking to anyone and was angry with me for not making the waiting area, as I had with the consultation room itself, a safe space for him. Since this was the first and (at that point) the only time this kind of thing had occurred, I did nothing about it. We explored Jim's anger briefly and then went on to other topics.

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Two weeks later, Jim again came in very angry, because this time Allan had, according to Jim, thrown his briefcase and coat on a chair and stomped around the room slamming bathroom and closet doors. Jim found this behavior very threatening and dangerous, not so much to him (he was proficient in martial arts) as to me. What if Allan blew up and destroyed me? I would be unavailable to Jim in the later hour. Much of his anger was in response to being made aware again of his dependency feelings and need for me. Another fantasy Jim had was that he would wind up murdering Allan, literally "taking his head off" and bringing it in to me, at which point I would have to call the police and turn him in.

As we explored the incident further, it also became clear that Jim felt much the same way he had felt as a child trying to tell someone about the sexual abuse. His fear was that he would not be believed again and that he would be punished for even bringing it up. I made it clear (I hope) that I had indeed believed him (it was easy for me to imagine Allan behaving that way), and that I had no punishment in store for him.

This did, however, leave me in a difficult position. I thought it would be inappropriate for me to say anything to Allan because of confidentiality, yet I couldn't feel comfortable allowing the circumstances to continue making Jim feel unsafe. At first I couldn't think of a solution, except to move one of the two patients to a different hour. My own schedule, which was quite full at the time, would make that difficult to do, and Jim was angry at any suggestion (such as changing appointment times or coming to the office precisely at his scheduled time) that would make him feel as if he were readjusting his life because of another person and a perceived threat.

Later it occurred to me that I could, rather than take my usual 10 minutes between sessions, begin the later session immediately following the earlier one, so that Jim would come into the office as Allan left, and they would spend no time together in the waiting room. Jim said that this reminded him of being rescued as a child from school bullies by his mother, and that this solution would also feel as if he were running away from something that frightened him, rather than facing it directly.

Jim said he would have to think more about the various solutions that we had discussed. He said nothing about this until a month later, when he mentioned that he had, in fact, dealt with the situation by delaying his arrival at the office until immediately before his scheduled appointment time. In the time following, the issue did not resurface.

Discussion

In this particular example, the issues for Jim were boundary issues: between him and Allan, between him and me, and between him and his mother. They were highlighted within a space where the boundaries are ambiguous--the waiting room is not a public space, but it is not entirely private either. This ambiguity resonated with the ambiguity of Jim's personal boundaries, which often felt to him to be quite permeable and without definition. Although a totally private waiting area would have prevented this interaction from happening, a lot of important and useful material did emerge in discussing it, and I wonder if it would have come up otherwise with such intensity.

The murderous fantasies, both toward the other patient and (to a lesser extent) toward me, the fantasies of my punishing and abandoning reactions, and the rage at being infringed upon were all evoked in ways that they had never appeared before. Trust and dependency issues, while always an important part of this treatment, were also highlighted in a different way.

More generally, waiting room interactions between patients can bring up all sorts of sibling issues, most commonly a sibling rivalry, but sometimes a positive feeling of connection through the therapist. Specific issues for each patient depend on their own specific experiences in the family.

Conclusion

Although almost nothing has been written about it, the waiting room can be the site of encounters that highlight a number of interpersonal issues. Interactions can occur there between patients, and between patient and therapist, stirring up many different kinds of feelings and reactions that can then be productively explored in the treatment room.

Patients, of course, react to everything we present, personal and impersonal. But the waiting room is a special instance because of the ambiguity of the boundaries. It is neither public nor private space, but somewhere between. In setting up our offices, I suspect that, as with many particulars of private practice (e.g., fee payment, session length, etc.), we consciously and unconsciously use the models of our own analysts and supervisors. In all my training and supervision, I am sure that I never discussed with a supervisor the physical arrangement of my office space. In my book Shrink Rap (Kassan, 1996), I discuss the need for training to include more discussion of the basic structure of private practice, including the setup of the office.

Every therapist tries to make the office a safe place, separate from the rest of the world, run according to different rules. The waiting room is a transitional area, only partly under the control of the therapist. Patients, on the other hand, may consider the waiting room an integral part of the office, and expect the therapist to exercise the same degree of control as in the consultation room.

One way to do this would be to follow Langs' recommendations and set up a solo practice, without colleagues whose patients would share the waiting area. One would have to find an office (or have one remodeled) with a separate exit from the treatment room that does not lead back into the waiting room. In most available office rentals, this is simply not possible. Interestingly, in the new HBO series In Treatment, the psychologist played by Gabriel Byrne practices in his home and has both a waiting room and a second exit out to the street. He appears to be careful that patients do not leave back into the waiting room.

Aside from the realities of architectural design (how many rooms actually have two entrances?), the requirement of absolute anonymity and secrecy has always been objectionable to me on two counts. First, it encourages the patient's unconscious (sometimes conscious) fantasy of being the only patient and having the therapist all to him or herself. Second, it seems likely to reinforce feelings of shame about being in treatment, that the patient's presence is an important secret that no one, not even a stranger, is allowed to know. Wolberg (1970) comments specifically that separate exits are not necessary, and they merely play into the patient's idea "that it is shameful to possess an emotional problem."

Not having a waiting room at all presents its own problems. Patients are asked to wait in a lobby, a public space, which is quite different from waiting in a private waiting area. They may feel exposed and vulnerable. The other option is for them to time their arrival exactly to coincide with the session time, which can be tricky, or may involve waiting outside in inclement weather.

For most of us, a communal waiting area is something we will have to live with and manage. If we pay attention to what goes on there, it may be a valuable source of material.

Music Reduces Tension?

Waiting rooms are not typically regarded as the most calming environments. The anxiety caused by the idea of seeing a doctor or therapist can be nerve wracking, and the other patients waiting alongside can cause additional mental anguish. The James Graham Brown Cancer Center at the University of Louisville has found a way to ease the stressful nature of the waiting room. The answer is live piano music.

A few hours per week, musicians volunteer to perform piano solos for the waiting patients. Edward Halperin, Dean of the School of Medicine and an amateur musician, came up with the idea because he knew how stressful the environment was. With patients receiving news of cancer treatment, surgery, and other bleak evaluations, he wanted to add to someone's day with music. "I thought it was important to brighten the days of the patients and their families with something other than reruns of the Oprah Show and soap operas droning on the television," Halperin said.

The volunteer musicians play everything from Mozart, to jazz, to showtunes. With the live music lifting the spirits of those who hear it, it is evident that it provides more distraction from the task at hand than the usual array of magazines or network television. One volunteer noted, "People who are receiving cancer treatments are very much in need in so many ways, so I thought this would be a good way to help."

Brown Cancer Center waiting room gets piano; volunteers play for patients. (2008, August 1). University of Louisville Retrieved August 15, 2008, from http://php.louisville.edu/news/ news.php?news=1199

References

Jones, E. (1953). The life and work of Sigmund Freud. New York: Basic Books.

Kassan, L. (1996). Shrink rap: Sixty psychotherapists discuss their work, their lives, and the state of their field. Northvale, N J: Jason Aronson.

Langs, R. (1982). Psychotherapy: A basic text. New York: Jason Aronson.

Wolberg, L. (1977). The technique of psychotherapy. New York: Grune and Stratton.

Lee Kassan, MA, CGP, DAPA, is a licensed psychoanalyst, licensed mental health counselor, and certified group psychotherapist in private practice in New York City. He is also Associate Editor of the journal GROUP. His previous books are Genius Revisited: High IQ Children Grown Up, Shrink Rap: Sixty Psychotherapists Discuss Their Work, Their Lives, and the State of Their Field, Second Opinions: Sixty Psychotherapy Patients Evaluate Their Therapists, and Who Could We Ask?: The Gestalt Therapy of Michael Kriegsfeld. His Web site is www.leekassan.com.
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