Mosak's Meanderings:

THE INITIAL TELEPHONIC CONTACT

Many people regard therapy as beginning with the initial interview. Actually therapy begins long before. In one sense it begins when the patient starts considering therapy, when s/he does such things as contemplating whether s/he needs therapy, can afford therapy, whether insurance will cover it, what form of therapy to seek, consults others about their experiences in therapy, who mght be a good therapist for them, and like matters. It is only after resolving or at least partially resolving these issues that the would-be patient makes a telephone call (or uses some other form of communication) to make an appointment. While possibly the majority of such telephonic contacts take only a few moments, some patients use the contact to play telephone games with the therapist or his/her receptionist. I should like to address some of these games because in many instances they can provide important diagnostic information.

RECURRENT MAKING AND CANCELLING OF APPOINTMENTS

The cancelling of an appointment may occasionally be necessary but when it becomes recurrent, the underlying motivation becomes suspect. Often the patient is ambivalent. "One day I'm sure I need therapy and the next day I don't." An occasional caller may do this just to bedevil the therapist just as some hackers love to infect computers with a virus. It may even give them a sense of power. Some others are being pressured to seek therapy and they make an appointment when pressured and promptly cancel it when the pressure is lifted. All of the people in these groups hardly ever make and keep the appointment, and one is best served by not continuing to play the game with them.

"THE ONLY TIME I CAN COME IN IS SUNDAY AT MIDNIGHT"

Whatever time you offer some patients, they just can't make it at that time.If you play their game with them, it will take a lot of your or your receptionist's time. Often the patient is not seeking therapy but trying to get someone off his/her back. "I called that therapist just like you asked me to but s/he was so busy, s/he had no time to see me. I did try." There are also some patients who wish in this manner to impress you with how busy or important they are. Some patients want to manipulate you and control the therapy. No time that you offer them is suitable. Only one that they offer is suitable. One patient called me, rejected all of the times that were offered him, and then made me a counteroffer. "I start work at 6 in the morning and when I finish at 2PM, I'm tired and I don't think that in that state I could really benefit from therapy. But I'm willing to make this sacrifice. I"ll come over to your house every Sunday afternoon at 2PM when I'll be rested." If you succumb to such offers, you'll not only lose your Sunday afternoons but your patient, having won the first round, will continue to attempt ot run your therapy. On the other hand, if you agree, the patient may perceive you as a weak theapist who will give in to his/her demands, and not make an appointment after all.

"LET ME TELL YOU MY STORY SO I CAN DETERMINE WHETHER YOU'RE THE RIGHT THERAPIST FOR ME"

The commonest motivation is to obtain a "freebie" after which, in some cases, the patient may thank your for being so helpful and not make an appointment at all.

"I'M DESPERATE"

This statement is generally accompanied by sobbing, silence or threat. An obvious goal is to capture your attention. We don't turn away casually those who are desperate or threatening to commit suicide or homicide. It gets people immediate attention but also gets them to the head of the line. A man phoned me and asked to be seen "right now." I informed him that I saw my patients by appointment and was fully booked that day. He reacted by telling me, "I'm right across the street from your office, and if you don't see me now, I'm going to walk in front of a bus," to which I replied,"OK. Come up to the office right now." When I saw him, I thought he was genuinely suicidal and made arrangements for his hospitalization.

"BEFORE I MAKE AN APPOINTMENT, CAN I TALK WITH THE DOCTOR?"

Reaching the receptionist the patient makes the above request. If the therapist is not with a patient, the receptionist rings the therapist.The patient then asks the therapist for an appointment and the therapist responds with, "I'll turn you back to the receptionist who will give you an appointment." What may be going on here? One possibilty is the patient is a self-inflated individual who only deals with the chief honcho, not with the help. Another possibility is that the patient wants to hear what the therapist sounds like. If the therapist sounds accepting, s/he makes the appointment. If the therapist's tone sounds hurried or non-accepting, the patient may tell the receptionist something like, "Let me think it over and I'll call you back."

"HAVE YOU EVER TREATED ANYONE LIKE ME?"

The most common thrust of this question is to establish the uniqueness of the person or his/her pathology. The book has not yet been written which descirbes them or their pathology and certainly not their treatment. They are warning you that you are going to work particularly hard when you treat them and they will reject any efforts to describe them or treat them like "just another patient."

"MY NEIGHBOR REFERRED ME TO YOU AND SHE SAID THAT YOU PERFORM MIRACLES"

As with the above question, the patient is often informing you that you are going to have to work hard. Ordinary therapeutic methods will have to give way to miracle making. Some patients will use this ploy to attempt to place you in an omnipotent role with all of its attendant therapeutic dangers. Others will state this to elevate you so that they can later prove that you have "clay feet." In any case,one ought not succumb to flattery. The above are representative rather than inclusive.

PATIENTS WHO PHONE AND DON'T MAKE APPOINTMENTS

There are patients who phone who not only don't make appointments; they have no intention of making appointments.

THE SHOPPER

In this age of consumerism it has been suggested that prospective patients ought to interview several therapists before deciding on a particular therapist. Some make an appointment, come in for a session, tell you that they are shopping, and will let you know when they have made a final choice. Others try to do this on the phone without making an appointment. Some therapists handle this by inviting the caller in for a free session.

THE MIDNIGHT CALLER

There are people out there who are lonely or unhappy who call you in the late hours and take up your time telling you about their loneliness and unhappiness. Some pick a different therapist to phone each evening. Generally they do not wish to make an appointment; they merely wish to vent. It may be their only social contact. You may wish to make referral, but it is often doubtful whether they will act upon it. I haven't covered all the possibilities. I merely wish to alert you not to miss diagnostic information which may be useful.

THE RELUCTANT DRAGON

This person is not seeking therapy but is usualy under pressure from someone to undergo therapy. They will find all kinds of reasons not to make an appointment. Their call is pro forma.