What Gets Under Your Therapist’s Skin?

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Many patients worry about alienating their therapist. Will he dump me? Am I wearing him out? Is my progress too slow?

Several behaviors can get a counselor irritated, though patients aren’t always aware of them.

Here are a few:

  • The Hand on the Door Disclosure: Therapists attempt to be mindful of the time left in your session. When possible, they hope to wind down the emotional intensity of the meeting so they don’t leave you in tatters. Clients who are hesitant to talk about something important will often wait until the very end of the meeting before dropping the bomb. Suicidal ideation or plans, sexual indiscretions, and self-harm are sometimes revealed in this way. The counselor now is faced with the dilemma of trying to deal with a fraught issue and insufficient time to do so. Mental health professionals do, of course, push back their schedules, ask the patient to wait in another room until the counselor is free, etc. Those clients who spring late surprises repeatedly do themselves and their clinician a disservice.
  • Failing to Work Between Sessions: Some patients don’t attend to homework the therapist and client agreed upon before the next meeting occurs. A few don’t even recall what was discussed. The doctor’s job is to determine why this recurs and try to create conditions in which the patient succeeds. A client who is dissociative, for example, may be unable to remember an unsettling conversation topic. Still, some people aren’t prioritizing their treatment and taking responsibility for their own healing. A therapist can be frustrated by this and should call attention to the troublesome behavior pattern.
  • Lateness: The session is the patient’s time. Every second. The counselor is expected to start on schedule, to be alert, and focus on his client. He should review his notes before opening the door. Yes, unexpected events happen in every life, but the client needs to be ready to go, not chronically missing. Even those diagnosed as ADHD, who therefore have an “excuse” for lateness, cannot be helped if absent. Everyone is tardy occasionally. The chronicity of such behavior, however, can erode the counselor’s patience.
  • I Must See You Today: New patients who believe they are in crisis sometimes plead for a same-day appointment. Therapists are inclined to help, both by nature and training, so they do what they can. Those who are experienced, however, know an urgent request from a new patient is potential trouble: he frequently doesn’t show up. Why? Since practitioners never meet the no-show new client he speculates that they may be narcissistic, histrionic, and self-indulgent; or so disorganized, erratic and impulse-ridden that the appointment takes second place to something else.
  • Money: Among the worst examples of a patient’s abuse of a therapist’s trust is financial irresponsibility. On occasion an insurance company will send reimbursement for the doctor’s services to the client, even though he assigned payment to the mental health professional. I recall a couple of egregious examples, one involving a psychiatrist and the other a psychologist, who treated two different people during long psychiatric hospital stays. Their fees amounted to thousands of dollars each. Although neither of the inpatients reported being unsatisfied with the treatment they received, both used the unexpected wealth to take vacations.
  • Overuse of Telephone and Email Contact: Clients need to realize their doctors have other patients, and their own lives outside the consulting office. Genuine emergencies justify telephone calls. Changes in scheduling are useful to complete by email. That said, many therapists direct patients to the emergency room if a crisis develops. Counselors are wise to talk about out-of-session contact with the patient and agree upon what does or doesn’t constitute overuse of the doc’s electronic time. Some therapists stipulate that any phone conversation lasting more than a few minutes will generate a fee. Over-reliance on being able to reach the therapist can also result in both over-dependence on the counselor and a failure to give oneself the opportunity to develop resilience and alternative coping mechanisms.
  • Appointments Made by Relatives: No one will be surprised about spouses urging their mate to go to therapy. Many of those reluctant clients hesitate. Thus, mental health professionals get calls from the non-patient to book a meeting for the future client. Ambivalence or disinterest by the latter points to a lack of motivation and the probability of a poor therapeutic result. The easiest part of treatment is to call the therapist, even if this isn’t easy. Doctors are smart to require the patient himself to arrange the appointment.
  • Passivity or Passing the Buck: The oldest joke about treatment is this: “How many therapists does it take to change a light bulb?” “One, but the light bulb must to want to be changed.” If you don’t desire change enough to give your best effort, the chance of a successful outcome is small. Patients who expect the doc to do all the heavy lifting should consult psychiatrists for the purpose of medication. They can then be passive, with the exception of remembering to take their meds. Therapists love patients who work hard and assume responsibility. The others, not so much.
  • Termination Issues: Termination in therapy is a bit like a romantic break-up. Assuming the therapist has not been inappropriate and the relationship has lasted several weeks, a face-to-face conversation concerning the end of treatment is usually best for both parties. The golden rule applies: do unto others as you wish them to do unto you. I’ve written about all the ways terminations are mishandled here, as well as the value of walking away with your head held high and a sense of mutual respect, even if the treatment didn’t achieve what you hoped.

A good therapist is one who will tell you if something is troublesome about the therapy relationship (from his end) and try to work the issue out. His default stance is not to give up on you. Misunderstandings are in the nature of human contact, not necessarily deal-breakers. If you think you offended your doctor or caused upset, raise the issue. Psychotherapy depends on words — those you say and he says. A mute conversation partner makes for a long and unproductive 45 or 50 minutes.

It doesn’t have to be.

The smiley is called Thumbs Down by Cäsium 137 (T.). It is sourced from Wikimedia Commons.

22 thoughts on “What Gets Under Your Therapist’s Skin?

  1. A great post Gerald, another very tricky part of the relationship. I went through a period of time in my 20s where I was waiting for ‘the miracle’ of someone to come along and make me better, which didn’t happen of course. All that happened was I got worse and my life got out of control and the consequences very quickly told me that I needed to start helping myself because no one was going to do it for me. It can be very problematic if due to early family disfunction you weren’t taught the basics of personal responsibility and you end up in therapy and think the therapist is going to make you better. Sometimes patients legitimately need a level of reparenting even though they are adults to overcome this kind of disfunctional behavior. A very difficult situation for both therapist and patient to work through.

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  2. Mind you alot of what you speak about here comes down to good manners. Its hard in any relationship to hold positive feelings if your time and effort are being taken forgranted. I to have had jobs in the past where I had to fight to get paid for it brought so much pressure and distress and ill feeling it would be even harder for a therapist to concentrate on helping a person, it would be very important to bring it up with the patient and work it through to be able to focus on the job at hand.
    I’m starting to seriously think that a therapy training video for patients is a great idea.

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    • drgeraldstein

      I will look forward to your training video, Claire! As I note in my response to Ms. Loewy, the things we take for granted about civility and responsibility are not always in the behavioral repertoire of others. There are doubtless an enormous number of reasons for this: more single-family homes, more homes in which the parents are away from the house working, an entitlement ethic, stagnant wages which fuels frustration, the example of reality TV, and the frank rudeness of some in the political class. Therapists do well to model civility and, as you’ve suggested, work through whatever words or actions their patients use that may undermine their lives; all the while also looking at themselves.

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  3. joanne Loewy

    Some of these should not be listed as such-sorry–in my opinion-especially termination issues…therapy does not fit in a perfect size box. A “good” therapists expects issues to come out, particularly in termination. I think it is naive to think good manners will be part of everyone’s process. I wonder if we could take a step back, and rephrase this title-because, in reality, each client is different AND, what tweaks a therapist, and how the dynamic takes place, is an important part of the process and is certainly a part of the countertransference-we as clinicians should address. Though some relationships between therapist and client, have a coda, or ‘swan song’ upon termination–not many would argue, that endings are difficult. Therefore, holding the boundary, and reflecting on the recapitulation of issues might be the best way to make some of these “annoyances” clean. Sure-we have all encompassed this list-but point blank is to utilize what gets ‘under our skin’-as part of the process-and indeed, the therapy. You can bet, if the clients are ‘doing’ these with us, then they’re doing it to others…..how can we utilize this list as part of the dynamic-rather than simply be ‘bothered’?

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    • drgeraldstein

      I’ve not suggested the therapist, if “bothered,” should simply leave it at that. As I’ve said, it is his job to try to work things out. Countertransference, which I’ve written about often on this blog, is crucial to look at. The therapist must have a mirror for himself handy at all times. That said, he is also dealing with two other considerations. 1) We are all human beings, on both sides of the therapeutic relationship, and neither party is wise to expect a dispassionate, all-knowing perfection in the other, even if the other person is a therapist. 2) We live in a society of increasing acceptance of incivility. Some of our clients, frankly, may not know better than to say and do things that were historically inconsiderate, but might not be today in a frankly increasingly vicious and thoughtless age. The therapist is obliged to address whatever issues in the therapy room that might well, as you say, be interfering with the patient’s life outside of it. The termination process, as you have indicated, is complicated. But, since so many of our patients have trouble with being direct, it is of particular usefulness to them (and one measure of treatment success) if they are able to address the issue face-to-face rather than flee the challenge. As to the title, I’d be delighted to hear any suggestions you might have for an alternative. In summary, thanks for your thoughtful and important comment, which has allowed me to say a bit more on the subject and perhaps clarify my own ideas a bit.

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    • I have to agree with a lot of what you write here joanne. me being a client of therapy for 9 years now, I took offense to some of these things listed above. Looking at it from the client aspect, its not always easy to talk about hard things in the time allotted, and if it comes out last minute, I am sorry it may bother a therapist, but it takes a lot of courage to talk about anything hard at all.

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      • drgeraldstein

        Thank you, Karen. I haven’t suggested anybody wants to be a bother. Nonetheless, it is important (as I’ve suggested in my response to Joanne Loewy) to realize that a good part of the therapist’s concern here is for the condition of the client as he is about to leave, and what that condition may be in one hour or five days, or until the next session, whenever that is. The goal is to make the treatment work, the best possible outcome for both parties, especially for the patient.

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  4. I know this takes things in another direction but I am thinking of all the people who use a gun on others and themselves in moments of mental crisis. And, our crippled response is that we need more “mental health” professionals. The therapist’s role is dangerous on top of all the rest.

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    • drgeraldstein

      It absolutely can be dangerous, Joan. I was threatened on a very small number of occasions. Once a patient brandished a knife. I think, however, the danger of battery in an outpatient therapy practice is pretty small. On the other hand, one out-of-work, highly religious, and much mistreated patient did contemplate assaulting an abortion clinic. Fortunately, he got a job that was satisfying and his rage was set aside.

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  5. A job can solve a lot of problems. Seems so clear to most of us, doesn’t it?

    Liked by 1 person

  6. Hello, thank you for your wonderful website and all your advice.
    I’m struck by your comment about a silent partner (patient) making for a long therapy session.

    I feel quite stuck since I am not good at talking (even with friends or family). I simply cannot think of things to say most of the time. My depression has made this worse than ever in recent months.

    I go to therapy super anxious because I cannot think if things to discuss, it’s like all my problems are so deep in my subconscious that I can’t reach them.

    I’ve been considering ending my therapy but somehow I still hope I can somehow find value in it. Can you please give me any advice? I’m really desperate. Thank you so much.

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    • drgeraldstein

      As I don’t know you beyond what you’ve written, I can only say some general things for you to consider. First, you might talk about your silence, when you first became aware of it, and whether there have been occasions when you were more talkative. Second, you might keep a journal, writing the ideas as they appear and then speaking about them in session. Your comments also raise the question of whether you do have some ideas, but you judge them less than worthwhile. I’d also guess there are a variety of things going through your head, including what you believe might be the things about which you are depressed. Don’t take any of this to the bank, but perhaps something in what I’ve written will trigger some thoughts or actions. In any case, best of luck and thanks for your kudos.

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  7. I admit it — I “door knobbed” my therapist one time. That’s what she called the instance of bringing up something big as a “by the way.” Good news is another session I said, “I don’t wanna door knob you,” and she laughed that I remembered the term. 🙂

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  8. Hi Dr Stein.
    As reported on another post, I had a devastating experience with my former therapist and therapy ended abruptly.
    I have severe chronic pain from spinal diseases, plus, I got a concussion and re-injured my spinal injury, causing more pain and lack of sleep for the past 4 months.
    I found a new therapist two three weeks ago, but I feel like I might be in too much of a crisis for just starting therapy.
    In other words, I was just sent to the ER last week for severe pain and anxiety from th his situation.

    My last therapist encouraged making people dependant on her. Yet, I do feel I need to talk to my new therapist more than once a week.

    How do I let her know that I AM going through a tough patch and am not normally this “needy”?
    I don’t want to alienate her.

    Thank you Dr S.

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    • PS What I mean is, I feel like I mouth Jr be bothering her. I’ve never had a crisis like this that I couldn’t handle myself.
      Would a new therapist understand this, or would it be a red flag? I don’t want her to think I’m always in crisis mode. I’m quite worried about my health, as my physical pain is not being treated properly.

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  9. drgeraldstein

    Physical problems and pain swamp everything. All most of us can do is to tell others we are going through a rough patch. Seeing someone twice a week is not a crime. Best of luck with this, Sheila.

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  10. Thank you for this post. I was guilty of “Overuse of Telephone and Email Contact”. But a couple of weeks ago my therapist and I discussed this issue, and have agreed on some very necessary boundaries. I appreciated the way in which she did it. I wasn’t left feeling angry or hurt, but rather heard, understood and that we had worked on a compromise together. I particularly appreciate how she reassured in our past couple of sessions that I had been doing really well in that department.

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  11. I am looking at this list from a “client” aspect .. being a therapy client for 9 years with the same therapist now, like I said above, I took offense to some of the things listed here. As I know its hard for a therapist to do his job day to day with many different clients, you have to really put yourself in the clients shoes. Therapy is not an easy process! The first one hit me the most on your list, “the hand on the door disclosure” .. many times a client (and myself I must admit) have been in this position because with there being little time at the end, you feel safest to talk about hard things because you know you can escape out of the session after talking about something hard and don’t have to face it. You have to remember that a client that is about to share something hard feel vulnerable, and sometimes it easier to share something with little time left than it is to face it the whole 55 minutes of session. I don’t think this is the manipulate therapist into more time, or to “aggravate” the therapist, this is truly a hard process sometimes. Maybe you can use this frustration when this happens as a healing opportunity. Tell the client before leaving “thank you for sharing this with me, I will hold this for you, and if you have any problems with what you shared towards the end, lean in and let me know and we will work with this together at the next session”.. instead of looking at it as something frustrating, look at it as an opportunity and courage coming from the client. Now I know that may be hard to do when a client shares something more “serious” at the end of a session, but again, not something to be frustrated over, but more so knowing that no matter how much time left to session, it took courage for the client to share whatever it is he or she shared.

    I write about my therapist healing process in my blog, and it has helped me to heal through that process as well. Healing is a process, and one that takes courage and vulnerability.

    I agree with some of your list from the client aspect of things, but other things I think you truly need to get in the shoes of the client and truly see what it takes to do what we do as clients. that’s just my opinion. I hope you take this as an opinion, not criticism.

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    • drgeraldstein

      I agree with you. Therapy is hard and I do appreciate that much courage is required, as I have said many times on this site. I am not at all suggesting that patients are trying to be manipulative in this type of disclosure. I am rather attempting to indicate that a therapist is put in an awkward situation and the client may be putting himself into a dangerous one. The counselor can’t easily establish the patient’s motive and emotional state and doesn’t have the time to do much to help, which is what he is there to do. If he extends the time, he disadvantages the next person. If he doesn’t, he may be seen as insensitive. Moreover, what I’m talking most about is when these kinds of things happen repeatedly. A therapist does his best and the best is expected of him. When clients work with him to create the conditions where the best outcome is most likely to happen, that is what both parties are working toward. Thanks for your comment.

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