Today is going to be a ranting kind of post, because this element of my profession frustrates the hell out of me.
There are occasions in therapy that sometimes leave me scratching my head in confusion.
Often, my clients are people who have never been to therapy before, and they have some type of an expectation for how things go:
You talk at the therapist; the therapist gives you advice, tells you what to do with your life, and you go about your day feeling better.
That isn’t quite how it works, although it is the expectation of what client’s anticipate is going to happen.
Prior to my clients coming in, I send them an email with clear guidelines and expectations.
Below is the text that I use, edited and worked on over a period of time, and after various experiences, to set the tone for therapy. And yes, I have had people driving a car while they have a therapy session. These rules exist because things happened.
Good morning,
My name is Rachael and I wanted to introduce myself to you before our first meeting. During our session, we have a few things to go over, and I look forward to getting to know you better during our time together.
Please read this email thoroughly.
Attached is an intake questionnaire. Please have this completed and returned to me. The questionnaire is lengthy; however, it allows me as your counselor to get to know you and create both a better treatment plan and diagnosis for you. Allow at least 40 minutes to complete the intake form; you may email or bring it in person to your session.
Here are some points regarding therapy and client confidentiality:
Patient forms need to be completed before the first session. These forms contain consent to treatment, provide liability protection for the client and provider, and provide information that the center uses for grant purposes; treatment cannot proceed until they are finished. Forms are located in your patient billing portal. If you have questions, please reach out to Client Support Services.
In-person and virtual sessions are 50 minutes.
Virtual sessions:
During virtual sessions, your screen and audio needs to be on during the session.
Please find a safe, quiet, private space to have your sessions. Having others be present during the session can be a distraction for the client, take their focus away from session time, and prevents the privacy necessary for confidentiality.
I will not conduct a therapeutic session while you are operating a motor vehicle of any kind, due to safety and liability issues. Sessions may be taken in your car if that is the only safe, quiet, private space available to you
Clients are responsible for keeping track of their appointments; reminders will not be provided.
Payment for the session is due at the beginning of the session, unless otherwise specified in your account, and will be run through the billing department.
If you are unable to make an appointment, you may call intake services to reschedule, or email me. I require 24 hours advanced notice of a cancellation if you cannot make a session. If prior notice is not given, clients will be charged a no-show fee.
I have a late check-in policy. Due to time constraints, I will wait 15 minutes for you if you are late to a session. The client will be billed for the loss of time for missed appointments. If you arrive late, the session will end at the appointed time, out of courtesy to other clients scheduled in the block after.
The use of cellphones during session is prohibited. Unless it is directly related to therapy (showing a specific picture, reading a note/email), phones need to be put away for the duration of the session.
I will refrain from sharing or discussing sensitive information in emails. Sensitive information will only be sent out with verbal or written permission from the client.
If I reach out to contact you via phone call, I will call from a blocked number, as I don't give out my direct number to clients.
As part of my training, I work under the supervision of a licensed professional. During holidays and time off, if you encounter an emergency, you may reach out to my supervisor.
XXXXX
If you have any questions, please feel free to email or ask them during session.
I look forward to speaking with you later this week!
Of course, these only cover expectations. It doesn’t account for all situations, and different practices and therapists may choose to conduct sessions differently than myself.
However, therapists are not consultants for how to help you fix other people!
Shoppers and Customers
During my first few classes as a counselor, we were given a framework for understanding the mentality of the clients who come in for counseling.
Under compulsion — there because they are being forced to—by a family member, the law, by court order
Shoppers — prospective clients who jump from therapist to therapist, who either aren’t sure what they want, or, are searching for a therapist who will tell them what they want to hear. Generally terminate after a few sessions.
Customers — prospective clients who approach therapy as a magic pill/quick fix, who are in and out. May emotionally vomit on you, usually stop appearing after a few sessions, either ghost or terminate without notice.
Clients — people who are committed to “doing the work” and putting in the elbow grease to get “better”, whatever that may mean in their lexicon
At the start of the year, I had a new client schedule a virtual appointment; I do these to allow flexibility for people who really can’t come in person, for one reason or another, though after having done many virtual sessions, I have begun to lean toward doing in-person only. I have found a pattern that the people who request virtual sometimes need the most support and really should be seen in person.
The client was an older adult who was seeking a consultation for how to treat the mental health issues of a family member. The initial intake paperwork indicated that the client was seeking support in the wake of a family member’s illness—not an uncommon request, and seeking support in that way when you are overwhelmed as a caretaker is not unusual. The first inclination that something was off were the two emails the person fired off within two hours of our session.
For virtual clients, I include a virtual link for them to access, not included in the text above. The email had the tone of a demand.
“We have a session today, and I need the link.”
The second was much more blunt and impatient:
“We have a session in 25 minutes and you still haven’t sent me the link”
Before I responded, I went and checked the initial welcome email; indeed, the link had been included. The client had also not been able to fill out the intake survey I had sent—some people have reported issues, but it is not all the time, and some systems do not seem compatible with Word documents. I didn’t worry about the intake paperwork, as I can conduct an interview across several sessions to determine a diagnosis.
However, I was annoyed and irritated at the two emails; especially, since the link was in the initial email, which suggested that they hadn't perhaps read it, or read it closely. I gave them the benefit of the doubt, and sent an email politely pointing out the link had been sent in the initial email, but here it was a second time.
“Please hold onto it for future sessions,” I wrote.
Pretty much everything I do is in response to encouraging autonomy and self-discipline in my clients, rather than enabling dependency. I had to put the caveat about bookmarking the link after a client had to ask me for it repeatedly every week; they also frequently showed up ten or more minutes late or forgot their sessions, and the sessions were only 30 minutes in length to begin with.
Being charitable is moderately difficult at times. Most often, sessions go pretty well, boundaries and expectations are set up respectfully on both sides. And sometimes, as a former supervisor once told me, you walk away from a session feeling like you got pinned against a wall, wondering, “What the hell just happened?” hands up, fingers splayed, looking from side to side trying to make sense of the hale storm you just survived.
Without giving away identifying information, which is always tricky in case studies, the situation follows:
The client is an older adult who has worked abroad for the majority of their adult life. The client presently is helping an adult child with a severe, chronic illness that is debilitating, but not life threatening. However, the quality of life has decreased so to the point that, the adult child has become depressed, is unable to work due to the chronic illness, and has bargained to end their life in exchange for one more try at some kind of treatment. The client (parent) has complete and total access and control to all of their adult child’s medical access, records, care, and decisions. The adult child had been diagnosed with obsessive compulsive disorder, severe, without psychotic tendencies.
The client began the session by taking charge of the session, and beginning to unfold her situation, problems, and what she wanted me to provide her.
Generally, there is a preamble from me asking a few basic questions about have they been to therapy, what they understand therapy to be, what their goals and expectations are for treatment and progress, and a discussion of HIPPA, client confidentiality, and client rights, which is always a good reminder.
Absolutely none of that happened.
I don’t generally characterize clients in the way I’m about to, but based on the information I gathered from this client, the individual was very much a controlling person and striving to be in control of the intake, as well as being fairly entitled — there was a conversation about their judgment on the adult child being treated at a local teaching hospital full of “bums—they were homeless people”, versus the wealthier clientele at a more upscale facility —"Adult child met someone who was a diplomat, another person was an academic” in the rehab area.
About 20 minutes into the session, they finished telling me about how overwhelmed they are with the situation—scheduling doctors visits, seeking treatment for the adult child who’s condition is mysterious and rare, being disappointed that no one has been able to fix adult child and solve this—the client mentions adult child has repeatedly told them that they don’t like their current therapist.
Client insists that the current therapist is the only person who can treat the adult child, as they are the only person qualified for a particular type of therapy that can treat adult child’s OCD and no one knows adult child nearly as well as this current therapist. When I suggested perhaps letting adult child discontinue with the present therapist to find someone they think they can work with, the client instantly dismissed me and, though I didn’t catch it at the time until I thought about the conversation later, they leveled a threat of, “I need guidance for how to help my child with their depression. Can you help me or not?”
This places me in a bind. It’s really saying, “If you can’t help me/give me what I want, then I’m going to leave.”
It’s a demand.
I took a different tact, and in order to gather the biographical information I needed to complete the intake, I asked the client to tell me about what their child was like before the chronic illness.
It was enough information to paint a concerning picture of control, dismissal, and treatment for a severe condition (OCD) by medication instead of a combination of medication and therapy, as I might suggest for the severity of this particular situation, and has been suggested to me by other professionals and the literature.
My guess is, the additional chronic illness is probably psychosomatic, or a reaction to so much internal repression, that the body, in some way, is eating itself alive by manifesting the issue. Such cases are not uncommon, and The Body Keeps the Score has a good accounting of how many autoimmune diseases stem from chronic stress and repression of emotions related to long-term trauma or neglect.
From an ethics standpoint, the client is essentially asking me to give her advice (which good therapists don’t do) and to help her treat her child, potentially undermining the efforts of medical staff and mental health practitioners treating the adult.
In school, we’re often warned that these situations may happen. We can no more treat a family member than you can. The adult child’s response to commit suicide if their situation does not improve is, in my best estimation, a final effort to exert some level of control over a life that feels out of it.
I offered to meet the client again and discuss with her what her needs were in the situation. The client terminated two days later (Friday) that she had found a therapist willing to work with her to treat the adult child — mind, you, they already had a therapist, and having two creates a conflict and undermining of treatment of one by the other — before sending me a follow-up email on the weekend (Saturday) demanding that I cancel her next session immediately, when it’s not a work day.
My reaction:
In a more recent case, an older woman in her 60s came in for help regarding a difficult situation with her spouse.
The woman appeared 30 minutes late, and asserted that I had sent her the wrong address for her appointment. The organization I work for had moved buildings in the last year, so the new address has been out in the world for seven months and has been correctly listed in Google Maps for that period of time. She insisted that it was on the forms I sent her.
I wrote up my own intake forms. There is no address on either my forms, the client forms sent through the patient’s portal, and the address in my email signature is our correct address. I checked after we were finished.
I began session by stating we would go to about 12:55 to give her a little more time, but that I had another client coming in at 1pm and we would be finished. The woman vomited her situation (something I’m accustomed to), and began by asking what I recommend she do for her husband who has a spending/shopping and potential gambling issue, to the point of driving up massive amounts of credit card debt, hiding it from her, and not taking accountability.
I gave some recommendations for Gamblers Anonymous and other types of support groups that she could check out, and that we could continue the discussion for the next session. Generally, I don’t have to stand up, as clients respect the end of the appointment time and begin to leave on their own. The client continued to needle me with questions how to modify her husband’s behavior. At this point, we were in danger of being five minutes past the hour, and the woman would not take the verbal or tonal cues that the session was concluded. I stood up.
The client continued to sit and ask questions, and would not budge. It was at this point that I had to gesture toward the door and moved past it, and stated that the session was over, I would send a follow-up email, and that we could continue discussing the following week. The atmosphere was tense and she very clearly did not want to leave. However, she did, and nearly forgot her coat in the process. After my 1pm — who is very gracious and understanding — I checked my email to see that the 12pm client had terminated and requested to be transferred to another therapist.
We don’t fix people for you
Each example above really happened. The first client is an example of a shopper; the second can qualify for both a shopper and a customer.
Each were seeking me to give them permission, tell them what to do, or engage in a way that does not meet ethics codes for the ACA or my training. Engaging with clients who have these types of expectations or demands is always difficult. You don’t want to turn them away with a bad experience of therapy, but you do have to maintain professional standards and boundaries.
It requires a lot of self-control. Because what is left out of the above descriptions is the tone of voice, the angry facial expressions, the eye-rolls, heavy sighs, being interrupted, or just the demanding attitude of one complete stranger toward another.
I write this post not to deter any of the people who subscribe or the people who stumble upon it to think that you are the problem or that all therapists are like myself, or that all clients are this way. It is merely to provide an example of the different kinds of client situations that pop through, and to understand that mental health providers who provide therapy cannot treat your spouses or members of your family, especially if they are adults, without the adult’s consent.
Children are a different matter, and I will save that discussion for another time.
But we don’t fix people. We provide tools, sometimes help provide insight or guidance, but we don’t give advice — not generally. We aren’t life coaches, who will give more explicit directives about what you can and should do. Therapists are trained to provide options, at least insofar as they have resources themselves or insight, and allow clients the freedom to either choose from the list of options themselves, or reason through what they want to do and pick the best path.
That’s not it, but in a very boiled down nutshell, it is. Plus, providing a lot of strong emotional support when needed, at times.
If your expectation is that a therapist is going to tell you what to say and do to make someone else change, here’s a few reminders.
Doing this, is, essentially, placing responsibility on the therapist to tell someone else what to do. “Well, my therapist said you had this problem, and that for you to get better and show you love me, etc., you need to do xyz. They’re the expert.” This will not work. People have to choose to change for their own sake and a desire to change for their own good. Usually, that takes some form of hitting rock bottom — whatever it looks like to that particular person. And I nor any other ethically-minded therapist is going to foster the orchestration of that.
Looking for someone to tell you what you want to hear isn’t going to make you better. If you’re a diabetic and/or overweight, and you are trying to find a nutritionist who will tell you that eating constant amounts of sugar and processed foods, and lack of exercise isn’t the problem, it’s everyone else, I’m afraid the problem isn’t the nutritionist or the tests.
General Housekeeping
My subscription-based serial novel Heart of Stone came out March 11 (last week). If you’re interested in a subversive fantasy novel about a secluded group of people living in a cliff trying to solve a murder and get revenge, please consider a paid subscription, as paid subscribers will receive a printed copy of the book once it finishes in June 2025.
How Heart of Stone was a spite novel, as opposed to a spite house. I didn’t have the money to build that, so I chose something more within my skillset.
Chapter 1 will be coming out on Monday, so please check it out — you can either read part of the preview or unlock the free edition.
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I’m still working on a children’s story — Christmas 2024 may be a bit ambitions. If you are an illustrator or can recommend a good one. Paid subscribers can also send an email to thepracticaltherapist@substack.com. Or, you can message me by clicking that button down there:
I did a lot more listening to podcasts this past week, so here are some things to read and a worthwhile interview to put on.
Democrats tend toward the belief of an external locus of control, while more conservative followers hold a worldview of an internal locus of control. Independents fall somewhere in the middle. The study was one of those fascinating rabbit holes that made me wonder, why exactly is the case? Probably has more to do with personality than people realize. Partisan Personality: The Psychological Differences Between Democrats and Republicans, and Independents Somewhere in Between
Chris Williamson of Modern Wisdom (a gem I recently discovered) interviewed Psychologist Dr. Orion Taraban. Good commentary on motivation and modern mental health worth listening to. Modern Wisdom
Interview with
for her new book “Bad Therapy”. Also an excellent journalist’s take on some of the real failings of therapy culture — and no, I don’t disagree with her points.
And now, back to the grind that is paperwork and constant administrative chores.
Till next time,
Pax Christi 🕊️
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Rachael Varca is a pre-licensed therapist and writer of more than fifteen years experience. She writes at The Practical Therapist and Inking Out Loud, a collection of essays, poems, and home of the serialized novel, Heart of Stone.
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