Submit to Clinician's Quandary!

Let Us Know How YOU Would Tackle This Sticky Situation in Your Practice...

Psychotherapy Networker • 9/30/2018 • 13 Comments

Ever heard about a tricky clinical scenario and thought, "I know exactly how I'd handle that"? In the spirit of sharing and community, we're introducing a forum called Clinician's Quandary, where you, the reader, offer your take on how you'd address a clinical dilemma from a real practice.

On the first Tuesday of every month, we'll pose a Quandary and collect responses. Top answers from the previous month will be posted that same day and shared with your colleagues worldwide. See below for submission details.

Here's this month's Quandary:

I’ve been working with my client, Carla, for about six months. In the past, she’s been very good about paying for sessions on time, but she recently lost her job, tells me she’s short on cash, and has missed her last five payments. She still wants us to meet weekly, but says she’s unsure when she’ll be able to pay me in full. This isn’t sustainable for me, but I’m trying to be sensitive to her situation. How should I proceed?

We want to hear from you:

  • Send your response in 300 words or less to info@psychnetworker.org. Include "Clinician's Quandary Submission" in the subject line.* Include your name and country, city, or state.
  • Please provide detail in your response that paints a picture of what your solution looks like in practice. Don't be afraid to get creative!
  • Please allow up to one month for our editors to review your submission. We'll let you know by email if your response is selected for publication.

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*Responses may be edited for clarity.

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Topic: Professional Development

Tags: case study | Personal & Professional Development | Professional Development

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13 Comments

Sunday, June 3, 2018 8:04:12 PM | posted by Mark Glat
I would approach this situation by asking D what she thought the meaning of her recently ended marriage had been for her. By suggesting that she was still in a period of “mourning” the end of this relationship I would urge her to consider what this relationship and its demise meant to her in terms of how she saw herself in relationship to the world and what it signified in terms of how she imagined her future unfolding. Leading her through this process of reflection and “re-consolidation” (of her “emotional thoughts” and their relationship to making decisions and undertaking actions) would hopefully allow her to be better able to see the significance and the implications of her current plans. Note that this approach combines elements of several different theoretical perspectives ( e.g. grief counseling, attachment theory, the cognitive triad, and CBT) and provides a coherent focus and a rich set of words and ideas that can be used to increase both mindfulness and intentionality as she approaches this critical "learning task” of how best to move forward in her life.

Saturday, June 16, 2018 4:32:58 PM | posted by David Stewart
I am glad to see this feature added to the otherwise very comprehensive array of articles and resources for the clinican's on-going clinical development. What I have often wondered is why there has not been a regular feature focusing on clinical supervision. The consultation section does not really use that kind of lens. Thanks for this, keep it up. David Stewart, Victoria, BC, Canada

Saturday, June 16, 2018 5:56:44 PM | posted by Carol Gross
My first reaction is that of helping the client to determine her personal safety in this new relationship. Recognizing that she wants to heal and move forward, also means she will take on the need for self care and all that this implies. Checking on the person’s character and whether the person is trustworthy by doing a background check is just common sense before moving across the globe. Meeting for a vacation, letting your friends and family know where you are going to be might be a good first step. Putting these ideas into the form of questions: have you thought about - would be my approach. Thoughtfully considering what happened in previous relationships and what she is looking for now that she is willing to take the risk to ‘own’ her own life - and her successes and mistakes- and to have a return plan if the person is not who she thought, would all be important treatment points.

Saturday, June 16, 2018 7:51:39 PM | posted by Crystal Daniels-Reyes
First, you should find out exactly when Diane is planning to get married. This will let you know approximately how much time you have to intervene regarding this. I would explore any negative thought/beliefs Diane may have about herself as it pertains to being divorced. I would also explore Diane's reasons for getting married to someone she has never met, and the significance being married has for her. Having her weigh out the pros and cons of marrying someone she has met online could also be done as well. In the end, the ball is always in our client's court regarding decisions they make, unless they have expressed plans to harm themselves or someone else, or there are other risk/safety concerns reported.

Sunday, June 17, 2018 10:59:36 AM | posted by Glenda - UK
Assuming a strong working alliance and trust between us, I'd invite D to tell me all about her online experience with this prospective spouse, her plans and expectations for moving abroad and how she feels it impacts her, as yet, unhealed divorce. Encouraging D to share her narrative of this choice can offer multiple opportunities for therapeutic interventions to help D consider her decision and whether it is a distraction from the pain and challenge of what she has yet to resolve relationally. As pulled as we are as therapists to "solve" what we see as our patient's mistaken choices, it is for su to offer our patients the non-judgmental safe space to see this IF they are ready to see it.

Sunday, June 24, 2018 6:53:06 PM | posted by Shea Karam
My first intervention with this client is to deeply hear her story (active and reflective listening) in all its dimensions: her plan, emotions, hopes, worries - paying attention to her words, tone, conceptualizations, body expressions. I would encourage, highlight and reflect the qualities of the experience separate from her plan such as: her hopes, yearnings, excitement and any fears or sadness. I would validate these larger more global emotional and cognitive impulses as well as validating her ‘solution’ (proposed plan) as a path to meet her needs and wants. All the while I would be listening for the ‘problem’ with the plan and open that up for consideration through empathic clarification so that she doesn’t feel the need to defend the plan, but rather can hold the dialectic of her yearnings, needs and wants with any cautions. I would incorporate somatic reflection asking where she feels the different emotional qualities and impulses in her body. "As you imagine this plan, what do you feel in your body?" And then I would ask questions eliciting her values in the context of this transitional time and place: "where does this plan take you in life? What are you leaving behind?" The goal of this intervention is (moving towards) congruence of her values, beliefs, emotions and body messaging. Where there are incongruencies we would respectfully explore until the client gets to a place of understanding and a directional sense of alignment. Outside of therapy I would encourage the client to meditate, journal or some other form of mindfulness and experiential expression to more fully align with Self. Overall, this intervention respects and honors the client in the way she is moving through a difficult life transition.

Monday, July 2, 2018 11:06:44 PM | posted by Cheri Armstrong
I'd just lay it on the table. I'd look at ;him quizzically and ask, "Are you asking what I'd THINK or FEEL in this type of situation, or are you asking me for a date?" And then let him answer. He'd probably be embarrassed, but I'd just deliver this with a smile, a bit flippantly. That would get it out in the open, perhaps displaying your discomfort, but in a convivial way. And then use it therapeutically, of course noting that going on a date with a client is not appropriate.

Saturday, July 14, 2018 3:34:31 PM | posted by Renee
I would respond by saying to him: "Well, because of the nature our relationship we cannot go to a movie together. But I hear a deeper question. I think you are trying to tell me that you are feeling close to me and you're wondering how I feel towards you".

Friday, September 21, 2018 1:54:25 PM | posted by Suze Smith
Dual relationships in small towns are often unavoidable. Since the client invited you to the event and wants to foster a relationship between your children, I think it is perfectly appropriate to attend with some caveats. I would first discuss with her (again) your commitment to confidentiality and then set strong, appropriate boundaries for when you are together socially. In those cases, she must understand that you are off the clock and discussions about therapy are not acceptable. I would also stress your integrity in providing professional services to your clients and that blurring the line could be detrimental to both of you. Social and professional relationships are very different from friendships and it is incumbent upon you to maintain the boundaries. Keep the social discussions light and friendly but be careful about too much self-disclosure or in talking about her problems. Judgment about her husband must be suspended! If she is unwilling to adhere to your boundaries, a discussion about why you must terminate services is crucial. A break in services, with a referral, would be the next step. You are the professional and are in charge of the situation. And, of course, document, document, document. Let the kids have fun together!!

Saturday, September 29, 2018 7:59:08 PM | posted by Susan
While I understand the desire to resume dating, it does not seem appropriate to be on public dating sites disclosing personal information & enabling clients to be involved in any way in your personal life. The fact they have already seen you on the sites & reviewed your personal information is concerning. Social media sites should be private & Clients should not be allowed to follow You or vice verse. It is definitely more difficult to keep these parts of your life more private, but perhaps there are Apps or dating sites that are for medical professionals? If not, perhaps it would be a good idea to start one ;)

Monday, October 1, 2018 11:20:37 AM | posted by Pallavi Kumar
I see this as a moment where the therapist can show a humanistic side of living. While she is terrified of having some of her clients identify her as a single person and wanting to date she can use this to jumpstart many discussions. The trick will lie in balancing the self-disclosure and processing. Instead of using the content that comes up in the sessions for any client who may want to make a statement or a comment use that moment to dive in the process. This conversation could bring up some interesting and deep psychodynamic material as well as that connection when a client can realize that such issues can be universal. There is something to be said of sessions when a client all of a sudden realizes that we therapists don't have our lives all put together perfectly. We seek and struggle against the same as all humans....sufferings, goals, desires and all things that come in between.

Sunday, October 21, 2018 7:30:40 PM | posted by Wayne Meluney
I would strongly encourage you to discontinue the use of online dating sites. It may be the best way is to develop a rich network of contacts through friends, relatives, professional groups, civic organizations, and, if appropriate, religious organizations. Good luck!

Sunday, November 11, 2018 9:38:31 AM | posted by Lisa Jaynes Johnson
I have encountered this is several cases and have handled it differently based on the client's situation and their overall relationship with money, and based on my connection o the client. One case where I have worked with this client on and off since she was in high school, she based her self worth on her credit score. Debt for her was a symbol of her low self worth. We talked about incurring debt with me and how that affected the therapeutic relationship. Plus the reason for her debt was related o her partner's disability and workman's compensation claim, she was still working hard o manage their finances. She has always been conscientious about paying deb in the past, so I trusted that after she got through her difficult period, she would pay it off, and she did. The second time, her insurance had changed to a plan I do not accept, and she continued working with me with the intention of paying me, but after several months, we agreed that being referred to another provider who accepted her insurance was the best decision for her and her family. In another similar case, a young woman I had seen for many years aged out of her parents plan and now works in an industry that doesn't offer health insurance. She had seen many therapists as a child and is bonded to me. She also has very complex PTSD and complicated grief so this bond is very important to her. When times are hard she comes up with the money to pay for a session and we stay connected between times through email or text. I know this is a non-traditional therapeutic relationship but because I know her so well I can provide effective interventions when she comes in and support between sessions. Many times the reason for the debt is a change in insurance or the clients do no understand what a deductible is. or how much hey will have to pay out of pocket. this often disrupts the therapeutic process as it is forming, so in these cases I do my best to educate myself and my clients about how to use their insurance coverage most effectively. In one case, I am in a quandary because I am no longer on an insurance panel and I am getting paid more as an out of network provider than I would in network. This means higher out pf pocket expense for the family per session, yet I am not allowed to waive her copayment to make it more affordable for the family while accepting a higher rate from the insurance plan.