The blogosphere is full of worried therapy clients. They believe they are “not enough:” not interesting enough, not clever enough, not progressing fast enough. What then are therapists looking for? Are worried patients right to be worried?
Research is limited. An over 50-year-old model based on a survey of 377 counselors by William Schofield revealed what was believed to be the perfect client — the so-called YAVIS prototype: one who is young, attractive, verbal, intelligent, and successful. Schofield saw this as a bias toward patients who exhibited these traits, not careful science identifying those who actually were best suited to treatment. Psychotherapy was then a male-dominated profession, perhaps also contributing to a preference for female clients.
Psychologist Paul Meehl, among others, critiqued this model. He feared practitioners would make “hidden” or biased decisions toward YAVIS therapy candidates and against those who were not YAVIS. A counselor might, for example, work harder with YAVIS individuals because he thought them more likely to benefit from treatment. A self-fulfilling prophecy in other words. By the same token, the mental health professional would perhaps instinctively recommend medication for someone who, according to the YAVIS model, was not typical of those who profit from “talk therapy.” The YAVIS syndrome raises the possibility of other biases, not all of them conscious, including the possible refusal to take on patients of certain racial, ethnic, or socio-economic groups.
We don’t know who today’s mental health professionals would pick for their ideal client. Nor do we understand what attitudinal differences toward patients exist among practitioners depending on their own personal characteristics. Do older clinicians, for example, prefer different kinds of clients than younger ones? Do male counselors hold the same patient preferences as female therapists?
I’ll offer a few thoughts on the broad subject of “ideal” patients. No gospel is here offered, just one person’s ideas. I’ll start by considering the YAVIS profile:
YOUNG: Let’s set age 40 as our arbitrary limit on “youth.” Let’s also stipulate that you can be “old” before your time. Meaning what? Too set in your ways, rigid in attitude and behavior, closed to new ideas and risk-taking. By this standard, youth holds the advantage of openness to change. Moreover, those clients who are “too old” have an increased likelihood of experiencing regret that cannot be erased by future action: the inevitable foreclosure of some opportunities in life when we pass the “use by” date on our early, fleeting talents. I’m speaking not only of career possibilities (athletics is an obvious example), but regret over having been a poor parent to offspring who are now adults. The absence of children would be another loss for women of a certain age who desired off-spring of their own flesh.
We can come to terms with some of our past errors, but we don’t always get a “do over.” Youth, therefore, owns the advantage not only of its openness to change, but a plethora of doors not shut to entry. Yes, there are other avenues to pursue for most of us who are past our physical prime, yet they are now different and fewer in number.
ATTRACTIVE: Although one might discuss this characteristic in several ways, I will opt for the obvious: a patient who is sexually appealing. I would be lying if I said I never noticed a beautiful new client in the waiting room. A colleague described the “energy” within the office when treating such a person, at least on early visits. The energy he spoke of was his own.
While feminine beauty has a potential downside (read Beautiful and Smart but Unlucky in Love), a male therapist can unconsciously work hard at his profession to achieve an appealing woman’s approval. The man might seek a beguiling female’s admiration unaware of what is driving him: captured by his senses but not his sense. The counselor, however, should give his best for every patient. His first steps toward reducing bias are to recognize the danger, look at his reaction to a beautiful new client, and be certain he gives equal effort to all. Indeed, this was possible even though some women made obvious attempts to draw my attention or offered themselves to me as sexual companions.
Experience and conscientiousness, not to mention adherence to professional ethics, reduce a client’s distracting physical desirability. Moreover, I discovered — as I suspect you have — that my perception of another’s external qualities changed as I got to know them. Some become more attractive, others less. A few days ago on a New York subway I noticed myself looking at a rather plain (to me) young woman sitting opposite me. Lost in her thoughts, she had the most touchingly pensive expression concentrated in the unconscious, tender positioning of her mouth. Put differently, a good therapist can find almost all his patients attractive. Indeed, we look for the best in people on every level.
VERBAL/INTELLIGENT: In talk therapy — a treatment involving many words — an inarticulate client is a challenge. I recall a bright man who lacked verbal fluency and had a limited education. He progressed well, but the demands on me to understand ideas and emotions he could not express with ease made treatment challenging. I was able to overcome the obstacles, in part, because of his patience and my persistence. Just so, those whose intelligence is below average may have trouble understanding concepts like transference. On the other side, one also deals with individuals lost in their own intellectual/verbal juggling act — preoccupied with the word play in their heads. A different form of challenge, then. Still, a therapist prefers a patient with a decent command of language.
Understand please, I’m not referring to those who are afraid to be open with their feelings and thoughts, but rather men and women with difficulty expressing themselves while trying hard to do so. Fear of self-disclosure is a different story. Counselors find female patients are generally more comfortable revealing their emotions, no small point when the individual comes to treatment because of mood issues. Thus, the therapist faces some clients frightened to say what they feel, others who don’t have the words to make themselves clear, and a few who struggle with both. The clinician does his best regardless.
SUCCESSFUL: A lack of “success” can prevent the patient from affording treatment, adding an additional hurdle to the therapeutic project. Many clients, however, came to my office thinking themselves unsuccessful. Some were correct from an objective, financial standpoint. An absence of success as defined in the materialistic USA is no automatic impediment to a good psychotherapeutic result. Success did, however, sometimes signal I was in the presence of a person who had surmounted past life challenges, and therefore predicted a capacity to take on those emerging in therapy. To me, high accomplishment by itself never meant the course of treatment would be easy. Indeed, some of the wealthiest clients I met were poor patients, often because of ballooning egos and a narcissistic inability to look into the mirror and witness an accurate reflection.
What else made a client into a promising therapeutic prospect in my mind?
- MOTIVATION: In the best case these folks led the therapy, doing everything they could to make their lives better. More often it was enough if they were responsive to homework assignments, thought about the sessions rather than forgetting them after they were over, brought in issues for discussion, and recognized treatment needed to be a joint effort, with two people pulling the same sledge to a better place.
- OPENNESS AND A LACK OF RESISTANCE: Some clients fight the therapist, summarily discounting any ideas or interpretations suggested by him; reflexively saying “I’ve already tried that.” They were like giant tin cans in human form, well-versed in how to resist the can opener, aka the doctor. The best clients are emotionally available or learn to trust the clinician enough to permit a gradual revelation of difficult issues and feelings. They don’t make the “fifty-minute-hour” into a battle.
- CONSISTENT ATTENDANCE AND PAYMENT: Regularly missing sessions makes it impossible to get anywhere. Woody Allen denies saying “Ninety percent of life is showing up,” but (whoever said it) there is truth in the expression, even if one might disagree with the exact percentage. With respect to payment, a counselor doesn’t want money to be an issue between himself and his client. Many accept either pro-bono or sliding-scale patients who pay nothing at all or something less than the customary fee. Others will let clients in difficult circumstances run up large tabs. Usually you get paid at some future time, sometimes you get stuck. Such is life, but again, if a therapist has a choice, he’d prefer to deal with what makes sense, not cents.
- THE ABILITY TO TOLERATE DISCOMFORT: Change is rarely easy. The more damaged the patient, the more courage required. As a mental health professional you bring people along slowly not to overwhelm them. Nonetheless, therapy is a challenge and at least a bit of heroism is necessary.
What is left to say? It’s all very good to minister to a “perfect” client, but most therapists don’t waste time dreaming of that impossibility. By definition we receive those who are struggling. The entry to my office didn’t resemble an amusement park ride with a height requirement and a linear measure to make certain you were tall enough.
Sublimely well-functioning creatures, if there are any, don’t seek mental health professionals, nor do counselors have a waiting room runway for beauty pageant contestants. If patients were motivated, hard-working, communicative, showed up without urging, and were open to the challenge and pain of the process; then, in general, I had all I needed to do my best work. A sense of humor was a bonus. Most counselors are patient and don’t believe in miracle cures. Nor do we need to be entertained.
Hang in there. Do your considerable part. Misguided therapists surely have dumped patients in an unfortunate fashion, but this is rarer than suggested by tragic internet stories. Even if you don’t see over the hill yet, keep going. I never treated a walking, talking, human work of artistic perfection, a painting of Monet or Rembrandt in the form of a mortal being. If you were “ideal” I never got to meet you, in or out of the office.
Mental health professionals are not like the ancient Greek philosopher Diogenes, holding his lantern in a fruitless search for an honest man. We do not make our own nightly, flash-lit quest for a perfect patient.
Since no ideal therapist exists, neither is an ideal client required to achieve the best that therapy can do. Indeed, I learned far more about courage from imperfect patients than they ever learned about it from their imperfect therapist: me.
The first image, Lilium Pink Perfection, is the work of Ulf Eliasson. The second photo displays Claire Parker with Her New MGI Crown, photographed by Ecprpageantnews. A Portrait of Albert Einstein by Hermann Struck follows. All of these were sourced from Wikimedia Commons. The final image is a cartoon figure long associated with the game Monopoly.
I love this! Thanks so much for sharing this.
Motivation: I have loads of that. I like it when my therapist gives me homework… Even the hard ones that I wish I could just not do. But it’s always worth pushing through. Openeness and lack of resistance: I trust my therapist, and her take on things. I always learn so much, and it encourages me to consider and form new ways of looking at things. Sometimes a lightbulb goes off in my head, and certain things make so much more sense and helps me connect the dots. Of course, I DO get frustrated sometimes when she says something I already know, but I don’t really ‘fight’ her too much. And we get through it quickly. Consistent attendance and payment: Having BPD (although I know it’s not just clients with BPD that do this), I’ve wanted to not show up to therapy plenty of times, especially when I felt that she’s going to abandon me anyway, so I might as well do it my way. But I always show up anyway, and am never sorry that I did. As for payment, I make sure to pay her on time, and even if she offered to drop her session fee for me (I struggle financially, but still manage to make a plan), I wouldn’t be comfortable with that and will probably not accept it. She’s also trying to make a living. The ability to tolerate discomfort: I’m a veteran in this, haha! Therapy is most definitely a challenge, and extremely hard work sometimes, which pushes me to want to give up. But I know it’s the path to healing. If I’m having too much of a hard time, my therapist will tell me that we can come back to it at a later stage instead. I’m grateful for that. I’m so grateful for her.
I’m sorry for this long comment. I’m basically just looking at my therapy and processing it here, haha! So I’m the ‘perfect’ patient, yet so imperfect. Perfect doesn’t exist. And that’s okay. 🙂
No need for an apology at all, Rayne. I’m happy to hear that you liked the post. Sounds like you have something a mentor of mine called “therapeutic integrity.” Your enthusiasm and dedication to the project can diminish the importance of lots of short comings. You seem to be on the right path. Congratulations and thanks for commenting.
There are times when it seems I’ve wondered off that right path. But that’s part of life, and we always find our selves going the right way again. Thank you for your lovely reply.
Dr. Stein, I’m not a therapy client so don’t share the concerns raised in your article. Working with what we may regard as perfect patients or perfect clients (my case as a service provider) would indeed make our work much easier and more rewarding. But we don’t live in a perfect world. If we did, we wouldn’t need therapists!
You have understood the world correctly, Rosaliene.
I think clients/patients worry so much about it because it’s such a one sided relationship with the patient bearing their heart and soul and not always receiving much feed back about what the therapist really thinks of you. I’m a bit scared to ask my T as I don’t think I could cope with any sign of rejection. He does tell me how he thinks I’m progressing but I think it could become problematic if he said how he feels about me. Possibly that kind of knowledge could lead to trying to give the therapist the answers he wants to hear than actually working through the issues and maybe pretending to be better than you actually are. Do you think therapists can tell when a client is doing that?
I think though my T has a similar outlook to you so reading your blogs is like proxy answers to my questions without making problems in the therapy relationship 🤐
I do think therapists can sometimes tell when the patient is answering in a way to please them, but not always. I do know, Claire, that I have inadvertently become something of a “stunt double” for other therapists, but, as I know you know, I’m only speaking for myself. In any case, your thoughtful comment raised an interesting idea for me, one which I may write more about: to what extent do clients come to therapy initially looking for a remediation of their problems and gradually change their objective to include a desire to win the therapist’s approval and affection (this, is all well known), while the therapist’s objectives remain the same as they were from the start. And, therefore, to what degree are the therapist and patient inevitably trying to pull each other in a different direction because of it?
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Yes I do know you are speaking for yourself. From your comments it’s obvious you care about people and have ability to empathise, so alot of what you say I can see reflected in my therapy relationship. I also work as a psych nurse in our local hospital so I can see alot of my own responses when dealing with patients under my care. Its very much a case of seeing both sides of the story, I can empathise with the clients perspective because I’ve been a patient on a psych ward in the past as well. And I can identify from the carers or the practitioners point of view and how much the patient relies on you to care about them as a person, not just another patient, but at the end of the shift you need to have the ability to live your life and let the patient live theirs. It all just helps me to see that we are all subject to the human condition, we all need to see ourselves reflected in another person, the yearning for someone else to fulfill your needs and the reality that getting that brings its own complications. Its all helping to see that I have joined to the rest of humanity as an equal now, no longer the victim. seeing the similarities we have together but appreciate the experiences that make us unique.
“Its all helping to see that I have joined to the rest of humanity as an equal now, no longer the victim.” Well done for achieving this, Claire, and beautifully said for communicating it so well.
Fascinating essay, Gerry. Now I understand why when I started in therapy it was important for women to find women therapists. Presumably, mainstream therapy has matured. Didn’t Freud say if the patient did not pay for therapy himself therapy couldn’t succeed? Last gasp, I guess.
Thanks, Judy. Yes, the conventional wisdom re: payment is that patients need to have a stake in their treatment — financial/emotional, etc. — in every way. I suspect most therapists continue to agree that a person’s commitment to improving his/her own life and his receipt of another’s effort to help should be worth something concrete to him/her, however, little that concrete thing might be.
I find this rather depressing. Just the idea of focusing on an “ideal” patient to the point of such detail is disconcerting. Youth may be open for change but is also lacking in wisdom and more prone to obsession. What’s so terrible about helping an older person deal with regret? What about the older therapist stuck in his ways? So the therapist is allowed to get older but not the patients? The YAVIS model sounds more like a dating profile. Do female therapists also prefer hot male patients? I think not. Sigh.
I’ll try to respond to a few points, Evelyn. First, patients express concerns about not being adequate, not measuring up to their therapist’s expectations, and fear getting terminated. Thus, while I won’t disagree that the topic is not a light one, the worries are there whether one addresses them or not. As I have written elsewhere on the blog, wisdom and maturity definitely have an important place, just as you suggest. I am not at all advocating one should refrain from treating those who are older, but there are some genuine impediments to this, only a few of which I’ve noted. Indeed, many older adults don’t want to enter therapy for fear that it will be too painful. With respect to the parenting example I gave, I can tell you that the parents of those patients most harmed by their elders were, in fact, the least likely to admit and apologize for their actions, thus making them unlikely ever to turn up at a therapist’s office in search of a remedy for regret. On the subject of therapists being allowed to age, I guess we are, but no one has to come to our door except voluntarily. But, your are right that too many therapists in my view don’t do an adequate job of reinventing themselves based on new developments in treatment and a lack of research support for their own therapeutic model. I’d go so far as to say this is a big problem for the field and one I have touched on in previous posts. As far as the YAVIS syndrome as a dating profile, I think you are spot on, and this is part of what Professor Schofield was getting at when he talked about various biases. I don’t know of any data about female therapists desiring hot male patients. I share your hope that they don’t, though I suspect a few might. Thanks for giving words to your frank reaction, Evelyn.