These letters concern difficult and/or confusing therapeutic issues between clients and clinicians. They were originally posted to my advice forum, and I hope they'll be useful to you.
Q. I'm in private practice. My client got angry, wrote her check and stormed out of our session. I'm not sure how to handle this. Advise, please?
A. Are you familiar with personality disorders? Has it been your sense that this client runs 'hot and cold' with you during the time you've treated her? Anything may have triggered this response, as you might have unwittingly stepped on an old (emotional) land mine from her childhood. Whether she's borderline disordered or not, it's critical you attempt to make amends. Call and leave a voicemail with a sincere, heartfelt apology for having upset her (even though you may have no clue about how it happened). Take ownership of the rupture, and invite her to come back and talk with you about it. Be extra-sensitive and empathic to how this session made her feel, if/when she agrees to speak with you. Therapeutic ruptures can deepen a client's trust in you, if handled sensitively. If she doesn't respond or return, send a follow-up note with referrals to several other therapists, and wish her well.
Q. My therapist has abandoned me--just terminated our sessions. Does this seem fair or right?
A. Generally, no. But a professional won't do this, unless you've consistently demonstrated an inability or unwillingness to be compliant with treatment. If you've utilized his/her guidance and suggestions, there's no reason to end a therapeutic alliance--but if you haven't, and you're struggling with the same issues after a reasonable time frame (three to six months), then they have every right to determine that you will not benefit from continuing with them, and should refer you out to someone else.
Q. I'm a psychotherapist, and I'm on burn-out. At times, I wonder why I'm even in this business--even though I love my work. How do I get past this?
A. This is a common complaint I've heard for many years, and here's a multi-layered answer: First, if treating people is the only way you have of deriving a sense of accomplishment, you are in the "wrong business." Avocations or hobbies are essential for anyone in the helping/healing professions. This will give your life more balance--and enhance self-worth (because clients don't improve all that fast). Accept that you have other talents and abilities that want to be recognized and fed, discover what they are, and make time for them! These might involve activities or creative outlets from childhood that provided joy or satisfaction back then, but you abandoned later on. Making your own life richer and fuller will help you become a better therapist; you'll have more and better resources to bring to the party. Borderlines and Narcissists can be very difficult/demanding clients, as they're resistant to change or growth. If you have clients with these personality disorders in your practice, you're more likely to experience frequent burn-out. In either case, cerebral/spiritual energy expenditure of this type, means you must recharge your batteries on a fairly regular basis. Hang out with friends, watch too much TV, or sleep for a day or two. You'll feel brand new again.
Q. My sister's boyfriend is a psychotherapist in private practice. He recently announced to our family that he'd started treating a well known actor, and revealed the name of this person. Something inside me felt this was wrong, but I was reluctant to say anything at the time. Should he have done this? Should I have shared my feelings that this wasn't right? Disappointed.
A. Your feelings about this are very valid and astute. Many years ago when I'd first returned to school, an almost identical situation happened to me. I'd had the same feelings about it as you did, and felt that this must represent an ethical breach. My schooling much later confirmed these intuitions. Some of my colleagues share this kind of news among themselves, when they're treating someone with celebrity status--but revealing the identity of a client is absolutely wrong, regardless of who you're talking to. I've chalked these behaviors up to developmental deficits, poor boundaries/impulse control and an 'under-cooked' ego or sense of Self; yes, borderline traits and narcissism are fairly common within this community. It's appropriate to tell your sister's boyfriend, that sharing the identity of a client made you feel uncomfortable, and undermined your trust.
Q. For the past couple of years, I've been seeing a wonderful therapist who has helped me a lot. I feel like I'm ready to try it on my own for awhile, but I don't know how to approach this awkward topic with her. Any advice?
A. Why don't you think about saying just that? Most clinicians don't want to keep you in treatment, if you don't want to be there--even when they feel there's more work to be done (because you'll be acting-out these feelings, rather than communicating them). Given that you're having difficulty finding your voice and approaching this dialogue in a straightforward, adult manner, maybe you're not quite ready to fly solo.
Q. Shari, can a therapist date their client after treatment has ended?
A. Not unless he or she wants to lose their license to practice. A mandatory two year waiting period must be observed once therapy has ended, before a psychotherapist and client may become involved. Most BBS regulations are for the protection of the client/patient; this one's critical for the well-being of both parties. Clinicians who don't play by these rules can face disastrous outcomes professionally and personally. Therapeutic relationships seldom transition into balanced, healthy partnerships, because the established roles have to change. Both parties must adapt to an interdependent dynamic, and that's usually a tough adjustment. BBS is the Board of Behavioral Sciences.
Q. I ended a three year stint in therapy a couple months back, because I was pissed-off at my doctor. I sent him a letter telling him off, and stated that I wasn't going to be returning. I'm regretting this, as some issues have come up that I'm needing help with. I suppose I wanted to burn that bridge when I left, so contacting him now feels pretty awkward, and I'm afraid he won't be open to seeing me again. What should I do?
A. In my view, a solid therapist anticipates your anger as part of the healing process in treatment--and leaves his/her door open, should you ever want or need to return. Sadly, many individuals harshly judge their own anger, which makes it impossible to imagine that anyone else can accommodate it. These people typically abandon their relationships, rather than staying to resolve conflicts. This pattern was learned in childhood, when they had to suppress difficult feelings, because expressing them usually meant punishment, guilt or shame. Leave a brief message for your therapist, asking if you can make an appointment. He'll likely respond affirmatively--but if not, find somebody else to assist you.
Q. I'd like to give my therapist a gift, but I don't know if it's appropriate. He's given me extra time when I've needed it, and not charged me--so this is a kind of 'thank you' gesture. Any thoughts?
A. A one-time gesture of gratitude is fine--but how it's received, depends on the therapist. Regardless of psychotherapeutic guidelines discouraging this sort of practice, some clinicians readily accept gifts from patients (and give them as well). Rules and guidelines are designed to protect the client. I've been known to take a hard line in relation to this topic, as treatment can be contaminated by it. As an example, if gift-giving has become a standard in this relationship, what happens when someone leaves therapy? Should gift exchange continue indefinitely--and what interpretations/feelings will clients struggle with, if/when it doesn't? In my opinion, this complex issue muddies therapeutic waters, and should be avoided. Recommending someone to your therapist can demonstrate appreciation--aside from this, an impersonal gift (a plant, for instance) is best. (More on this topic can be found below.)
Q. Hello Shari, my partner and I decided to look for a therapist about a year ago. I had difficulty finding one within my small community, as it seems there's an incestuous trend among gay women knowing one another, and the therapists themselves often belong to that circle. My partner was consumed with wanting to go to a lesbian therapist. I wanted to remain open, so I agreed. We went to two sessions together--and upon completion of the second one, the therapist handed me information for group meetings in my area, and told my partner to continue (with her) alone. Two sessions, and this woman tells my partner that we have a love-addicted relationship, and she needs to run away from me as fast as she can! I was crushed. It's my understanding that even after multiple sessions, it's never a therapist's place to tell a client what to do, and I was angry--as after a total of only 2 meetings, she'd come to that conclusion. My partner had a lot of confusion in her life, and I feel she was easily swayed. Now, months after this first happened, she has it in the back of her mind that I have too many issues, and we are bad for each other. I know I have work to do, and I know my partner has her work. I believe that in relationship, each does their work, while coming (closer) together. I realize that time heals all. I guess I'm asking for some confirmation or support to keep us moving forward, while I try to keep this therapist's actions from haunting me each time my partner buys another book about love addiction. I'm an advocate of self help books--however without the proper direction (and I don't think two sessions allow for this), my partner keeps bringing up any symptoms she thinks apply to us, which may not have been there before they were suggested. Thanks for taking the time for me.
A. The two of you saw this therapist with the specific intention of helping your relationship--and in conjoint work, the couple is the client. It appears this woman has failed to respond to your desire for couples work, and her assessments and subsequent actions seem premature. A couples therapist cannot guarantee that the bond between two people will become stronger. Over time, his/her job might be to help them define and come to terms with irreconcilable differences, and separate in a manner that's as harmonious as possible. Responsible clinicians apprise you of this potential within the first session, but attempt to help you diffuse and resolve conflict. Solid conjoint therapy teaches couples verbal and listening skills, uncovers and explores background issues that have contributed to the difficulties, and encourages genuine empathy based on these insights. Time doesn't necessarily heal all, and it isn't designed to--but competent, unbiased support can go a long way toward helping a relationship heal.
Q. I've been needing some help to deal with a relationship crisis. I've left my phone number and message at various therapists' offices for the past couple of weeks--but nobody's gotten back to me! I'm wondering how long it should it take for a professional to call me back, and is this sort of delay usual or standard practice?
A. This is definitely not considered standard practice. A responsible clinician will return your call within 24 hours--even if he/she just needs to arrange a more convenient time to speak with you, and assess whether (or not) they can provide solid help with your immediate struggle. The only exception to this, would be if the therapist is on vacation, or some type of necessary leave from their practice--but this should always be indicated in their outgoing voicemail. Frankly, I've heard similar reports from quite a few people, and it's utterly astounding to me that this kind of thing even happens! Perhaps the only saving grace in all this, is that you're somehow being protected from engaging assistance from people who are (obviously) incapable of responding to your needs.
Q. Shari, one of my clients persists in giving me gifts. We've explored the meaning of these gestures (therapeutically), and I've strongly discouraged this practice, but he keeps showing up with "little things" he thinks I'll accept, and I'm not sure what to do about it. Any ideas?
A. Clinicians seem pretty divided on this issue, regardless of established psychotherapeutic guidelines that strongly discourage it. Aside from wanting to convey affection, there could be myriad reasons why your client is maintaining this behavior despite your interventions, and here are several possibilities: 1.On some level, he needs to control the therapeutic dynamic, and thinks this will make you like him more. 2. He could have issues with entitlement, which make it difficult for him to receive from you, without feeling guilty and obliged to reciprocate (and your fee might be too low). 3. He may not have been able to develop object constancy in infancy, so he's unable to hold/maintain a sense of you and this connection, in-between sessions. This can derail his ability to trust that you care about or consider his needs when he's away from you, and drives a powerful urge to leave tokens (of himself), which he hopes will remind you that he exists. 4. He's never felt intrinsically lovable, so the compulsion to give you things, helps him feel more worthy of your attention and care. This compensatory behavior is generally tied to a lack of self-worth; continue your deeper work with him surrounding this (core) issue, for it surely impacts his other relationships. Graciously thank him for the gifts, but have him leave with them at the end of sessions.
Q. I phoned a trusted buddy a few nights ago, because I'm conflicted about a woman I'm dating. His feedback was very helpful, but when I told my therapist about this, she seemed upset with me. She acted like I'd done something wrong, and I'm feeling ashamed and afraid that she's mad at me. I'm really wondering if I screwed up. Did I violate some sort of "therapy rule" by calling my friend for help?
A. Part of meaningful inner work involves some initial dependency on your therapist, but solid therapeutic intervention encourages reliable, supportive relationships in your interpersonal world. It may be that yours somehow felt threatened by this reliance on your friend's help. Given that you feel shamed by her reaction and appear to be fearing her abandonment, she might have borderline personality features, which could have prompted a 'split' in her perceptions of you (good client/bad client). You did nothing wrong, and no "rule" was broken. Hold onto that friendship.
Q. Shari, my therapist has recently gotten her state license (for the past several months, she's been seeing me as an "intern"). The other day, she informed me that my fee ($40.00) would be doubling in two weeks, as she's starting a private practice. There's been a good connection with this woman and I don't want to leave, but I can't afford to pay her $80.00 a week! She's very aware of my financial situation, and I'm now feeling she doesn't even care. I'm really bummed out about this, and angry! Is it customary to force clients out, due to a change in professional status?
A. I think your anger is warranted. Your therapist is certainly entitled to make business decisions in any way she pleases, but that doesn't mean her methods are ethical or sensitive to your needs. In my view, you're describing therapist abandonment, which is damaging to you, and terribly unfair. A standard fee increase is customarily no more than $10.00 per session, and should be anticipated after a full year in ongoing treatment. The fact that she's "aware" of your financial status and isn't willing to make allowances for this, could be viewed as self-serving. I've always believed that healing professionals had a certain level of 'response-ability' to their clients, and this sort of practice doesn't seem to fit under that umbrella. I encourage you to share these sad/angry feelings with your therapist over the next couple of weeks, and see what comes of that. You may also state that you'd like to continue working with her, if she'll consider a more gradual increase in her fee scale. Given that she's just starting out, she'll likely have room in her schedule and could agree to your request, but this may be moot. If you feel your trust has been undermined by her actions, it's understandable that you might choose not to return.
Q. I've been seeing my therapist for about 18 years and have grown very fond of her, but feel it's time for me to move on. Over the years when I've talked about leaving, she has strongly discouraged this due to my "unresolved issues," and I'm concerned that this time will be no different. I feel I owe her a great deal; she's helped me get through some terrible times with my ex-husband, guided me in raising my child, and assisted me with many other issues. I almost feel like she's family. We exchange presents during the holidays, and she never neglects to give me something special for my birthday. I'm in a wonderful relationship now, and I don't feel I need her nearly as much as I once did. I'm afraid that my leaving therapy will hurt her, which makes me feel guilty and ungrateful. This is hard, and I could really use some guidance.
A. It seems your therapist has fostered/promoted an enmeshed relationship with you. Some keep their clients in treatment far longer than necessary, to gratify a personal need to be needed or bolster financial resources. Along these lines, receiving presents from clients is strictly discouraged by psycho-therapeutic guidelines; it blurs the boundaries of a professional relationship, and contaminates the therapeutic process. You pay this woman for her time and expertise; in accepting your gifts, she lets you infer that you may pay her (extra) to care about you, and this undermines your progress on many levels! You have fulfilled your obligation as a compliant participant in your treatment, by showing up on time for your appointments, following sound guidance and suggestions, and working hard to integrate any insights gained while under her care. Anything she sanctions beyond this, suggests a lack of ethical standards. Your trouble with "leaving," indicates how acutely you've been affected by this, and surely parallels childhood experiences that forced you to put other's needs before your own; this tendency should have been dismantled throughout this inner work, not exacerbated! Hopefully, you've moved into a maintenance schedule (fewer visits per month) in recent years, which has helped you experience/exert more emotional self-reliance. A solid professional works with you in a manner that helps you trust that his/her door will remain open in the future, should you hit a 'speed-bump' or crisis, and need to return. Say "thank you, and goodbye" in a note or card if this is easier for you at present, and get on with your Life.
Q. Shari, I recently went to see a psychotherapist in my area who was recommended by a friend. This woman asked a few questions about me, and then proceeded to tell me (unsolicited) material about herself; how and why she got into this business, her emotional background, etc. At first I felt confused about why this was happening, and then became increasingly annoyed that roughly 2/3's of my session time was spent having to listen to her go on about herself! The way I see it, I was paying a substantial fee for this visit, and while I don't have another frame of reference (this is my first time in therapy) I felt like this shouldn't be happening--especially on MY dime! Basically, I feel like I flushed my $150.00 down the toilet. Is this kind of thing standard practice? CB
A. Dear CB, I applaud your instincts in sensing this wasn't professional behavior, and it appears this therapist's practices should come under closer scrutiny (can you stop payment on that check?). In my view, any clinician who neglects to respond to your needs, and charges you for hearing him/her talk about their issues, shouldn't be working in this field. There be may instances during the course of ongoing treatment where self-disclosure is appropriate, but this should be carefully assessed by the therapist, as to how (and if) this serves you in context of what you're working on at that time. Therapeutic professionals should be willing to answer your questions about their schooling, training/qualifications, but be extremely discretionary when it comes to sharing intimate/private material, as he/she is being paid to assist You! The more personal information you're aware of concerning your therapist, the more responsibility you may assume for his/her frailties or needs. This contaminates your therapeutic process, as it can reconstitute and perpetuate childhood obstacles you had with a narcissistic parent, derail your ability to be open and expressive with your feelings or thoughts, and potentiate boundary issues between you! Any of these outcomes inhibit your capacity to make solid progress. Don't be afraid to state your position in a follow-up call or note. Seems to me, you're entitled to a refund or (at least) reimbursement for two-thirds of your "session" fee.
Q. I've gotta run something by you, Shari. I've been seeing a therapist for a couple of months in relation to a difficult break-up with my girlfriend. At first, this doctor seemed effective in helping me with my feelings surrounding this loss, gaining insights about myself, etc. But in the last few sessions, she's been dressing more provocatively and making comments that feel suggestive. I've been pretty revealing about the sexual aspects of my last relationship (and others), and I'm now wondering if this was wrong to do. While I'm flattered by her compliments and they help me feel better about myself, I can't help sensing she's coming on to me. I'd like to remain in therapy until I'm stronger and more resolved about this recent crisis, but I'm starting to feel uncomfortable with her. Maybe it's my imagination, but I think she's being seductive with me, and it's distracting. I'm not sure what I should do.
A. First of all, therapy NEVER includes sex! Any psychotherapist who crosses this line is subject to fines, imprisonment and revocation of his/her license to practice. Your self-revelations are perfectly normal/natural within this context (how else can a clinician learn about you, understand what matters to you, and assist you?). Feeling like you've shared something too personal can be a direct outcome of working with someone who has undermined your trust. Whether this woman is being inappropriate with you or not, your feelings about this situation must be honored. Are you able/willing to share these, as well as your observations with her? Your therapist's handling of this material will give you a sense of how to proceed: If she appears to take in what you've said, and gently asks questions about how you've arrived at these impressions and what they've meant to you, that's a good start. If she confirms your suspicions or reacts defensively to your words, invalidates your perceptions and/or makes this about "your issues," leave and find a professional who can work with you in a manner that's healing as opposed to harming. If this therapist has physically touched you in any way that feels inappropriate, or suggested you meet outside of her office, file a complaint with the Board of Psychology or the Board of Behavioral Sciences.
Q. Hi Shari. I'm a Marriage & Family Therapist with a practice in northern California. My problem is, I have difficulty asking for money owed to me from clients. These are mostly people who've seen me for a relatively short time and either failed to show up for scheduled appointments, or cancelled without adequate notice. A couple of them have bounced checks, and asked if they could pay me "when they have it." My caring nature makes me reluctant to press, even though my instincts tell me they have the money. My therapist has worked with me on addressing the feelings that are triggered in these instances (and I think this is helpful), but she hasn't actually helped me deal with the problem. Asking clients to pay me what they owe is extremely difficult; I want them to know that I care and that this door is open, should they (one day) choose to return--but lately, it's been tough making ends meet. I'm not even certain I should approach this issue, but I'm torn! "Miss Giving"
A. As a therapist, it's common to have 'misgivings' about collecting from clients. Frankly, I know very few professionals who've successfully worked through this predicament, due to unresolved entitlement issues (difficulty with receiving). The same elements that drew you into this work, are the ones that presently keep you disempowered (and broke), as you've likely been conditioned from early childhood to put everyone else's needs before your own. Here's an important question: If you're up against survival concerns(you can barely pay your rent/mortgage and you're wondering where your next meal's coming from) how effective do you think you can be for your clients? OK, here's the solution: First, you should (always) send clients home with a written statement of your policies at the start of their treatment, and have them sign an intake form that clearly details your cancellation policy. To recover your money: Begin by mailing a brief/straightforward letter, nicely asking them to pay their "unpaid balance." Let them know you're willing to set up a payment schedule if they cannot afford to send you the entire amount, but give them a reasonable deadline to respond with their first check. If a second letter is necessary, let them know that while it's not your preference, their debt will be turned over for collection if they do not respond with a money order or cashier's check within a deadline/date of several weeks. If they're still unresponsive to your request, find an attorney who's willing to work for a debt-recovery fee of about 20 - 30% and put him/her in charge of this matter. Your attorney's letters to these clients should be professional, firm and not too wordy, and you should look them over before they're sent. If debt collection is your lawyer's primary area of specialization, you may not need to be this involved, but make sure you're comfortable with what's sent under his/her letterhead; remember, this person represents you! Clients are usually asked to send payments directly to his/her office. Your attorney can send you photocopies of these checks and settle up with you as the money arrives, or calculate his/her total fee at the end of this process. Most people want to avoid judgments against their credit, or having to show up in small claims court. These clients have treated you with careless disregard, and there's undoubtedly a pattern of this with others as well (how you do anything, is how you do everything). Will they ever return? It's very unlikely. And if they did, wouldn't your counter-transference get in the way of your trusting them enough to treat them again? Nobody can pay you to "care" about them(that either comes with the territory, or it doesn't), but they must pay you for your time & expertise. In context of this, you may find my article (link above) very helpful. Best of luck!