What Gets Under Your Therapist’s Skin?


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.