Saturday, August 15, 2009

It's not me, it's you: Getting dumped by a client

Just when I thought things were going so well--when the therapeutic alliance was strengthening and my client and I were truly bonding--I got THE e-mail. The "I need a break" e-mail. Yes, I was dumped by my client a few days ago and, to add insult to injury, she did it over e-mail. Just so you know, I don't normally communicate with clients over e-mail, partly because of the lack of confidentiality on the internet, but mostly because it's too easy to do last-minute cancellations when you don't have to actually speak to someone who can tell that you're lying about your sudden bout of Swine Flu. Usually, when a client switches up how the medium they use to contact you, something's going on. This client, a particularly tech-savvy granny that I had yet to blog about, e-mailed me to re-schedule our previous session. This was the first time she e-mailed me and it raised a red flag in my mind. Alas, in an effort to be efficient, I responded and rescheduled. The other reason I don't communicate with clients over e-mail is that it's too easy for me to forget to write down our re-scheduled sessions when I get their note. That said, I missed our session. Yes, yes...I know that sounds like a totally abhorrent thing to do to a client but before you start hating me, let's discuss some background context, shall we?

This client, let's call her TSG (obviously for Tech-savvy-granny), sought counseling through my program and requested home visits. Ah, yes, home visits. I've done far more home visits than I truly care to do ever again. The only reason why I took this was that she didn't live too far from me and, because I'm no longer taking classes and am on fellowship (read: just getting paid without TAing or RAing), I would be home more, making this a convenient arrangement. Oh, she also requested a therapist with a sense of humor and I was flattered to know that my supervisor, upon hearing this, thought of me. (When you're in grad school, you take whatever positive reinforcement you can get, trust me.) When we met, things went very smoothly. We got along well and I felt that she had really started opening up to me, which suggested that we had developed a strong therapeutic alliance...or, at least it was getting there. As with the best laid plans, I soon realized that this arrangement was far from convenient. TSG did not, in fact, live as close to me as I had thought. The commute to her house became more and more annoying as I competed for road space with Hollywood's finest agents, starlets, and wannabes who tend to drive stupid fast while texting. I found myself thanking my lucky stars for my jungle cat-like reflexes whenever I made it to TSG's place in one, albeit shaky, piece.

One day, I arrive to TSG's condo for our session and, surprisingly, her son answered the intercom and told me he didn't know where his mother was and that he was a little worried. I became worried, too. She's an older woman and who knows what could have happened to her. My worst fear in working with older adults is that they won't make it through therapy. I thought, for sure, this was it, so I became panicked. I hung around for 20 minutes, brainstorming with TSG Jr. about her possible whereabouts and then decided to leave. FIVE HOURS LATER, I get a call from TSG that she had totally forgotten our session--she was absolutely mortified and apologetic. I was so relieved she was alive that I was uncharacteristically accepting of the snafu instead of spending a half hour discussing what her no-showing "means" to her. Another detail that should be noted is that we never had a set weekly meeting time. We scheduled sessions as we went along from week to week. I don't normally do this as it's hard for everyone involved to keep track of our sessions and it makes it too easy to reschedule and move things around. There's something about a weekly set session that communicates a commitment to therapy--that it's a priority and that this time is set aside specifically for our work together. Anyway, we didn't do that and that's my fault. In some way, I thought it would make my schedule-planning more flexible and, therefore, more convenient. (Yes, thinking of myself. Naughty therapist!)

So fast forward to TSG e-mailing me to reschedule. We reschedule. I miss the session. Halfway through what would have been our session, I e-mail her apologizing and offering to rearrange things just to see her. I hit send. I waited. At this point, I do believe I should've called her. Another mistake on my part. Actually, I think I should have called her when she e-mailed me the first time since I thought it was so odd. But, giving into my fear of being seen as reading too much into things, I didn't. God forbid I read too much into things--I'm a therapist, after all. (Note to self: Trust your gut!) Anyway, I get a response from her to the effect that she was so happy we met and thinks I'm a wonderful person but she felt she needed a break from therapy. Also, thrown in there, was something to the effect that this was the result of neither of us sticking to the program. (What program? Ab-hoc therapy isn't a program?)

My heart sunk. I sat back in my chair letting a powerful wave of sadness, fear, and sense of failure swish around me on the inside. I suck, I thought to myself. I missed a session and she dumped me. But wait a minute, she stood me up once before...we were actually even! She sucks! I started reflecting on our past sessions and realized that there wasn't much that was coming out of our supposed work together, anyway. Honestly, I was doing all of the work. She was quite stubborn and was always getting herself into pickles, often by her putting her swollen, arthritic foot in her mouth. But I couldn't find a way to share my feelings about her communication style, which was that her style wasn't working and was usually offensive to others. I guess the therapy wasn't working and, perhaps, the therapeutic alliance I thought was growing in strength wasn't there at all. This was like that period after a breakup when all of the tell-tale signs of a failing relationship become clear upon reflection. Of course she wants a break! How could I have been so blind?!

Losing a client can be a difficult experience for even the most seasoned psychologists. For a one in training, it can be devastating. I don't have years of successful cases to make me feel like I'm a decent therapist and that this one just didn't work out. Losing a client, to me, means that I suck, suck, suck. When I was just starting out in grad school, I used to have this mantra: I suck, I suck, I suck. I would say this quickly, kind of like Jan Brady's "Marsha, Marsha, Marsha!" I used it as sort of negative reinforcement to motivate myself to work harder (not very healthy, I know). Now, in addition to softly repeating that old mantra, I'm holding onto the first few lines of TSG's note for dear life, the ones about her being happy we met and thinking I'm a lovely person (yes, she said that). I feel like that's all I've got until I meet with my supervisor. I know I'll go through the anger phase soon (Who makes home visits anymore anyways? You were so lucky to have me! Lucky, ya hear!?!) and eventually get over her but the wound is too raw right now--the suck-age a bit too great. Now you know breaking up, romantically or professionally, is hard to do. Pass the gelato, please.

Monday, August 10, 2009

Everybody's talkin' at me...

It's easy to get, and stay, burned out in grad school. I think clinical psychology students in highly research oriented programs are particularly vulnerable to short circuiting. I don't know if this happens to PhD students in other fields, but for me, everyone just keeps talkin' at me. I meet with clients who talk about all of their problems with their lives, which you would think would make me feel relieved that I'm not in their shoes, but it doesn't. I usually sit there felling like, "Oh hell, now how the heck am I going to get them outta this pickle?" It's a lot of pressure. When I meet with my advisor, all she talks about are her problems with my work. I usually sit there and think, "Oh hell, now how the heck am I going to get myself outta this pickle?" Does it stop there? Certainly not. I get calls from family and friends requesting advice (aka free therapy). The sweet thing about working with clients is that if the advice doesn't work, we agree to try something else and I don't seem them for a week, sometimes more if I'm lucky and they cancel. With family and friends, it's a totally different story. There's a certain level of comfort, and lack of filter, between loved ones so if something you suggest doesn't work out, you'll hear about it...over and over again. Getting together for Thanksgiving? "Remember when you told Uncle Vinny to let go of self-imposed limits and follow his dreams? Yeah, well, he ran off to Las Vegas to "find himself", but all he found was a stripper and a pile of debt. Some advice. Your Aunt Stella will never be the same." You're welcome. Always happy to help.

Even people I don't know talk at me incessantly. Strangers often come up to me and just start talking about whatever the hell they seem to think I would be interested in. Lord only knows what message I'm sending out while squeezing peaches at market that seems to convey I'd be interested in hearing about your gastrointestinal complications. I'm not interested in hearing about this, or about your kids, or about the economy, or about how I look exactly like someone you know. While it may seem like I'm an approachable gal, it's just a facade. Don't approach me. I bite.

I suppose listening to the trials and tribulations of others wears on a person, whether it's your job or not. I'm learning, albeit slowly, how to handle this from supervisors and colleagues. Sadly, my own therapist, one of the few people I feel comfortable unloading on, tends to look very bored during our sessions. I'm just hoping he's doing his own kind of self-care to be able to find a nugget of wisdom for my sad lot. Usually, all that comes of these sessions is him showing me a therapy-related New Yorker cartoon, typically ones with dogs in them. Yeah, that's useful. I missed the page in the handbook where you hand a client a cartoon about a dog therapist when you have nothing to say. Note to self...

Summertime fun? Meeting DT

Summer is a time of leisure and a touch of laziness where you do just enough to get by in order to savor the down time. What did I do this summer? I took on 3 new cases! Way to take a load off, huh? Anyway, since I haven't talked about my cases in a while, here's a lil nugget to get things started.

DT, or as I fondly call her Deet (yes, like the toxic chemical), was referred to me from a colleague who I consider one of the best therapists in our program. She let me know immediately that Deet was not easy. Upon hearing this I knew immediately that this would be an Axis II case: personality disorders. Well, actually, to be accurate, Axis II is really about "underlying personality conditions" (i.e. longstanding traits) and it includes mental retardation. What would I have given for Deet to be mentally retarded! By their very nature, personality disorders are extremely difficult to treat. For one thing, the "disordered" individual usually doesn't think that there is anything wrong with them. Quite the contrary, they often think that they're great...and better than least when you're dealing with the narcissistic types. As luck would have it, Deet was diagnosed by my colleague as having Narcissistic Personality Disorder. Awesome. "You probably won't like her at first," says my colleague, "I sure didn't." This from someone who I think may be the kindest person I know. Double awesome.

As you may recall, my last run-in with Axis II was with Mrs. P. I have since terminated her case. I miss her feisty, albeit racist, comments about her caregivers. There was something truly endearing about her that made me not hate her so much. Maybe it was the fact that she was closing on 90 and just waiting to die, I don't know. I hoped that Deet would be a tragic hot mess, like Mrs. P, so that I wouldn't hate her immediately. She'd grown on me, like a fungus (thanks, Mermaids).

So, I met with Deet. She's a small specimen...tiny in every which way and I felt like a monster in her presence. She looked me up and down...and I mean UP and DOWN, no inch went unexamined. This made me feel uncomfortable, which then made me angry. I thought to myself, I don't like her and she hasn't even said a word to me. I then gave her a once-over, my instinctive reaction when feeling judged. Not very mature, I admit.

What are her presenting problems?
1. She has trouble with her relationships (shocker). She longs for a romantic partner but that hasn't happened. According to Deet, people just don't get her, especially "non-creatives". These are people who do not have careers in the arts and, therefore, shouldn't exist. She also doesn't have very many female friends. Allegedly, women don't get her, either. Whenever a woman says that she has trouble having female friends, a red flag goes up in my mind. It usually means that they have trouble communicating and may often put the ole foot in the giant gaping mouth.

2. She's stuck in her career: a struggling composer. She's been working on an epic opera about parrots for the past 20 years. Yes, the past 20 years. "What I do is really hard, you see. How can I make you understand. OK, it's like imagine you're working towards your PhD, only it's really really hard. Imagine you're doing that for 20 years. You know what I mean?" In my head, I think: No, I don't know what you mean. After all, I'm just a silly PhD student working on a useless and mindlessly easy degree. It took all the strength in me not to deck her. No wonder no one likes her. She’s not likable. I try to shift my inner monologue from the hateful/judgmental place to a more empathetic one in order to stay calm and acknowledge that this person is in pain and needs help...lots of help. Maybe I'm not qualified? Maybe I should transfer her? (teehee)

As she progresses with her tales of woe, letting me into her darkest corners of her current life, her childhood, and her most intimate thoughts, I felt my muscles ease up and I started to really feel for her. She's sad, lonely and scared. Who wouldn't have their defenses up when first meeting someone in that state. I actually had to admit that she could be somewhat amusing when she wasn't being hypercritical of everyone in her life and a total hater. The problem is that she thinks she’s pretty awesome just the way she is. Um, I guess she was sick the day they taught social skills in kindergarten. It’s funny how therapy often acts as make-up classes for missed kindergarten days—only there’s no milk and cookies or nap time. Sigh.