Thank you to everyone who responded to our June Clinician's Quandary. Here are some of the top responses! Submit to next month's Clinician's Quandary here.
June Quandary: As a new clinician, I’d been working with Sara, 26, every week in therapy for three months. We’d developed concrete strategies together to help her manage her depression and anxiety, and whenever I’d check in to track our progress, she reported feeling better. I thought we’d developed a strong bond, but she’s missed her last two sessions. I texted her after the first missed session to ask if everything was okay, but still haven’t heard anything from her. I keep replaying our sessions in my head, thinking I did something wrong. What should I do? Do I reach out again?
1) Make Getting Feedback a Regular Practice
Although it might not be the biggest help to Sara’s therapist at the moment, one of the essential lessons all therapists must learn is that our role in our clients’ lives may be limited. After all, assuming a client sleeps for eight hours a night, that leaves them with 112 waking hours a week, only one of which usually involves us. No wonder research tells us the single greatest factor that contributes to client change is what happens outside therapy!
Our work demands humility from us, an understanding of our limitations. Most times, obsessing about what we might’ve done wrong is neither helpful nor healthy. As a therapist with supervisees and students, I often try to help them work through their worry about what they say and how clients might react.
Going forward, I’d recommend that, instead of simply relying on occasional client feedback, Sara’s therapist formally seek feedback in each session. Personally, I use Scott Miller's simple feedback instruments, the Outcome Rating Scale and the Session Rating Scale, and encourage my supervisees to do the same. Having a process for getting formal, weekly feedback might help this therapist avoid feeling blindsided again.
Michael Morad-McCoy, PhD, LPCC
2) Get Help Exploring Your Reactions
As a new clinician myself, I can relate to this Quandary. We work in a field that relies heavily on empathetic skills, caring qualities, and joining, so it can be easy to get triggered or interpret a client's actions or feelings as a personal issue. Who knows? Maybe Sara's symptoms were improving and she was ready for termination, but her therapist wasn’t ready or couldn’t spot the signs to end treatment.
If Sara was my client, I’d call her to see if she’d like to reschedule, terminate therapy, or get a referral to another provider. However, at this point, I’d only call once to follow up, and leave a voicemail if she doesn’t answer. I believe this is ethical practice and provides support for someone who’s still considered a client.
Additionally, I’d also speak about my feelings in supervision or with my own therapist to help me explore why I took her actions personally, why parts of me were triggered, and how to better handle my emotions around sudden or unplanned terminations in the future, as this can be a harsh reality in our work.
Emberleigh Luce, MS, MFT
New London, CT
3) Get Off the Emotional Roller Coaster
As a fellow counselor (and someone with anxious tendencies!), I can completely relate to Sara’s therapist repeatedly replaying and scrutinizing interactions. But when we hinge our sense of competency on the behaviors of our clients—or anyone else, for that matter—we put ourselves on an emotional roller coaster.
I’d encourage Sara’s therapist to consider four things. The first is around the ethics of texting. Is the therapist texting from a personal number? If she works for an agency, what’s the policy on contacting the client after missed appointments? Second, she might want to evaluate her own feelings toward Sara. Would this clinician have the same reaction if another client missed an appointment? Does Sara remind her of anyone in their life, from the past or present? What feelings come up for her when she thinks of this? Rejection? Confusion? Disappointment?
Third, I’d recommend Sara’s therapist try doing a little self-CBT. Can she come up with alternative explanations as to why Sara might have missed her appointments? I’d recommend she look for evidence contrary to her belief that she’s done something wrong, and consider the worst case, best case, and most likely scenarios where Sara ghosts. Last, I’d recommend Sara’s therapist continue to seek consultation and supervision. It’s a good idea no matter where we are in our career.
Kristen Bjerke, LPCA
4) Don’t Be Afraid to Use Your Voice
If I was Sara’s therapist, I’d reach out to her with a voicemail this time. She needs to hear the strength and vulnerability of her therapist’s voice, rather than read mechanical words on her smartphone. I’d give her room to make an autonomous, adult decision to terminate our relationship, but also express my heavy feelings about the confusion and ambiguity surrounding her silence. Sara needs to know that her therapist is a human being with feelings. I’d make sure to avoid infusing this message with guilt or shame, and would speak from my heart gently but with boundaries.
I hope Sara’s therapist can appreciate that while it might feel as if she’s been dismissed as inconsequential, clients who suffer from depression and who've begun to internalize their therapist as a reparative force often feel compelled to reject the therapist when their symptoms begin to lift. My intuition tells me their journey together will continue once Sara has recalibrated herself in the vulnerability that their psychotherapeutic alliance has provided.
Paul Hokemeyer, JD, PhD
New York, NY
5) Don’t Take It Personally
The challenge facing this therapist is to read Sara’s behavior and interpret it in the most compassionate way possible. In my practice, when a client chooses not to return to treatment, I want them to know I’ve heard the message, understand it, and have no hard feelings.
When I work with clients struggling with avoidance issues, I know they may have a hard time ending therapy. Sometimes, I even mention this directly in a session. With Sara, I’d assume she’s ended therapy for now, and most likely feels badly about doing so abruptly. Chances are likely she’s done this before in complicated relationships. Of course, it’s natural for conscientious clinicians to wonder what might have gone wrong: it’s how we hone our skills, track our effectiveness, and retool as needed.
Ultimately, ghosting belies a struggle within the ghoster to be direct and honest about what she wants, especially when she predicts it may cause hurt feelings, pressure, or guilt. My best advice is to send her a note, briefly telling her you enjoyed your work together and that you’re always available should she wish to resume therapy in the future. Sometimes, this is what clients want to hear the most.
Alicia Clark, PsyD, PLLC
We'll post a new response to each Clinician's Quandary on the first Tuesday of every month! See how to submit to next month's Quandary here.
July Quandary: When I first started out as a therapist, I loved the work. In the midst of all the challenges, it felt a privilege to be doing it. Recently, however, I’ve found myself losing steam. I catch myself mentally checking out when clients are talking. I constantly feel exhausted and worry this could be affecting treatment. I learned about burnout in graduate school, but never thought it would happen to me, let alone this early in my career. Money is tight, and I worry about who’d manage my caseload if I took a few weeks off. Has anyone else ever felt this way? What are some good, realistic forms of self-care beyond just taking a vacation or going to the spa?
Photo © iStock/pick-uppath
Topic: Professional Development
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