Most clients know what it feels like when they meet with a therapist and it isn’t a good fit. Maybe you leave the initial session feeling misunderstood or knowing that the therapist’s personality or style isn’t a good match for you. Maybe the therapist reminds you of someone in your life for whom you have negative feelings. Or maybe you can’t stand her office or the location, or you recognize that the fee she charges is more than you can reasonably afford.
But what about when you think it’s a good fit and the therapist doesn’t? This can be uncomfortable — particularly if it doesn’t match your perception of the connection you made. When a therapist tells you that she or he doesn’t think it’s a good fit or she doesn’t believe she is the best person to help you, this can understandably be a little confusing. Maybe it even feels like a rejection.
There are multiple reasons why a therapist may not believe it is a good match, and unfortunately, we often don’t offer detailed explanations to clients. Sometimes there are good reasons for being less specific about it.
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A good, comprehensive article from a different perspective. Thank you, Dr. Kolmes.
If a patient being turned down or moved on by a therapist asks “Why are you doing this,” doesn’t that patient deserve a complete and honest answer, whether that answer is caseload, counter-transference, etc? This doesn’t seem to me to be a time for a therapist to dodge, obfuscate, or fib.
Here’s why: Without an actual, complete, and honest answer and explanation from the therapist — even if it is disclosing something as uncomfortable and dicey as sexual attractiveness countertransference — the patient going elsewhere will ipso facto NOT be able to talk accurately and completely through the event with his or next next therapist.
@TPG, Thanks for your comment. You make a good point. Do you think that level of detail makes sense no matter how soon in the process this occurs?
I should have mentioned that the level of disclosure about the decision may appropriately vary by the amount of time the clinician has spent with the client. For example, a clinician referring someone out after three or four sessions is likely to offer a more comprehensive explanation and time to process it than someone who decides it’s a poor fit after just one session.
I would expect that the client’s need to talk through the event (in subsequent therapy) would vary depending upon the amount of time spent with the referring therapist and the level of attachment that was made.
Given the APA’s Ethics Code prohibition against Sexual Harassment (Standard 3.02) “Psychologists do not engage in sexual harassment. Sexual harassment is sexual solicitation, physical advances, or verbal or nonverbal conduct that is sexual in nature, that occurs in connection with the psychologist’s activities or roles as a psychologist…” most of us would be unlikely to share with a client that we had sexual feelings towards him or her as a reason for referral. I also think such comments could easily be misconstrued and really aren’t the concern of the client.
Whilst I think the reasons listed for the therapist’s terminating therapy are absolutely valid, I agree with TPG that this needs to be outlined to the patient / client. Most of us are intelligent enough to ‘get it’, yet the nature of emotional disorder and psychiatric illness is such that if the therapist neglects to detail his/her reason, it will often be assumed that we did something wrong. Simply advising us that we didn’t is unlikely to be enough, and as TPG said, the uncertainty will lead to difficulties with other therapists (and possibly others), not to mention intense speculative rumination.
It may be a strange form of inverted narcissism for us to make assumptions that we have done something of which the therapist does not approve, and indeed oftentimes we will recognise intellectually that it is not personal. Unfortunately, in my experience at least, no amount of self-imposed rationalisation can ever convince me of something.
Dr. Kolmes poses this important question…
“Do you think that level of detail makes sense no matter how soon in the process this occurs?”
I have a one response: Absolutely.
The situation that Dr. Kolmes posits is one where the patient is satisfied enough with the therapeutic alliance to want to continue it, but the therapist is the one who pulls the plug against the patient’s will. As she writes in her original post…
“But what about when you think it’s a good fit and the therapist doesn’t? This can be uncomfortable — particularly if it doesn’t match your perception of the connection you made.”
Good grief. Could one think of a more upsetting scenario for a patient, to have invested psychologically in a therapy of three, five, fifteen, or fifty or more sessions, and then have their therapist tell them that they have to move on, even though from the point of view of the patient, the THERAPY IS WORKING? (Sorry for the all caps, but the point had to be made emphatically).
Shattering, potentially. I could see people leaving therapy never, ever to return.
So I would say, yeah. No matter what the length of the therapy — even a single session — the right therapeutic move for the patient would be for the therapist to open up and share. (Obviously, there’s more to share in a longer therapy. But even after a single session, there’s going to be plenty to say.)
I can see how a rupture like this could be terribly upsetting after even one session. I could see how it could be doubly upsetting even after one session if the therapist is coy, or obfuscates, fibs, or merely tells 50% of the truth.
This does not mean that the therapist ought be insensitive in choice or words or tone. But if there’s an error to be made, it ought to be made on the side of fully and truthfully communicating any and all the information that the patient would need in the future to process this harsh event, even if the disclosure is unflattering to the therapist.
As for a reveal of an erotic counter-transference being tantamount to sexual harassment under the APA guidelines? I’d love to have you pose that question to Dr. Jeffrey Barnett at APA, on his public psychotherapy ethics blog.
http://www.divisionofpsychotherapy.org/category/ask-the-ethicist/
My guess would be that’s highly, hugely unlikely, but I’m just guessing. In any case, the literature is not without discussion of this kind of reveal (see Jarl Jorstad’s 2002 piece in the Scandinavian Psychological Review, for starters).
In all cases, a therapist acting on erotic counter-transference is unethical and even criminal. This is, however, a far cry from discussing it in the room at a final termination session where the therapist is terminating the relationship, particularly in the context of specifically telling a patient that a therapist is terminating due to an unresolvable erotic or love countertransference. That’s about the opposite of sexual harassment as I see it.
Besides. Patients know a lot more than they often get credit for. One only remember Irving Yalom’s essay about the overweight female client her wrote about in LOVE’S EXECUTIONER — his countertransference was profound. At the end of the therapy, he revealed some of his feelings. As he said to her…
“Well, what I mean is that I hadn’t worked before with heavy patients, and I’ve gotten a new appreciation for the problems of.. “ I could see from her expression that she was sinking even deeper into disappointment. “What I mean is that my attitude about obesity has changed a lot. When we started I personally didn’t feel comfortable with obese people.” In unusually feisty terms, Betty interrupted me. “Ho! ho! ho! Didn’t feel comfortable. that’s putting it mildly. Do you know that for the first six months you hardly ever looked at me? And in a whole year and a half you’ve never, not once, touched me? Not even for a handshake!”
He’d never said a word. Yet the patient knew.
***
So again. In this fraught situation? Full disclosure to the patient. Please. Anything less is a disservice.
Many, many thanks, Dr. Kolmes, for making this original post. It has set in motion a very interesting and important discussion, and I wonder what some of the other therapist professionals here think.
@Pandora @TPG Thanks again for your perspectives.
I think posing the question of erotic countertransference as an “Ask the Ethicist,” question is a wonderful idea and I’d love to hear Dr. Barnett’s take on it.
As with many ethical issues, I would expect his answer would not black or white but would be more gray and would depend upon a number of issues, including the therapist’s comfort, level of safety, the developmental level of the client, and whether or not the information provided could be useful clinically (or personally) vs. harmful to *this particular* client. I also expect that discussing countertransference in the context of a longer therapy vs. after just one session would make a significant difference.
I would hope all therapists are weighing these factors when deciding what to disclose, rather than applying a blanket policy to all scenarios.
Lastly, @TPG, you mention: how harmful it can feel to a client to be told it isn’t a good fit after s/he’s “invested psychologically in a therapy of three, five, fifteen, or fifty or more sessions…”
Let me be clear: I do not consider 3-50 sessions to be the time for any therapist to determine it’s not a good fit and offer no explanation. I am in full agreement with you there. The time to assess the fit is early on, together, with you and client both acknowledging that this is what you are doing. My piece refers to the first one or two sessions, and not something longer.
If the two of you agree to work together and then *later* during the therapy process the therapist feels it isn’t a good fit, this is quite a different situation than the one I wrote about and I fully agree that it should be managed differently with accompanying levels of disclosure and processing. Also, therapists do have a duty to bring up ending therapy or referring out if they feel they are not being helpful to a client. And this should not be a secret to the client.
Thanks again for your contributions to this discussion.
It is my belief, after spending some time thinking and researching this topic, that it is the therapeutic alliance (interpersonal rapport b/t client and therapist) that is the most important factor leading to a positive outcome for therapy (ala Carl Rogers). TA trumps technique.
My sense is that if the therapist doesn’t sense the TA, they are less inclined to terminate the relationship, even though doing so would be in the best interest of the client.
This is based on my personal experiences: I have been to over 10 therapists (in Los Angeles) in my life and NONE of them have have terminated the relationship, even when I didn’t really trust them (this is before I became interested in the topic).
Bottom line is that sometimes, therapists are forced to make compromises because they need to make money. Depending on the ethical compass of the therapist, I imagine that this line can be hard to walk, given conflicting factors: making money and what’s in the client’s best interest.
@Dr.Kolmes, that’s a very important point: The time to assess the fit is early on, and you absolutely started your original post off by talking about first-time meetings between therapist and potential patient.
There are certainly a goodly number of times when the lack of fit is apparent to the therapist out of the chute.
There are also a good number of times when the lack of fit doesn’t show up until session three, five, or fifteen. Maybe the therapist thinks that the patient is presenting with A, and then comes to see over time that it’s B. Maybe the patient doesn’t reveal until session #4 she’s a neo-Nazi, or he’s brutally homophobic, or whatnot. Maybe it doesn’t come out until session 6 — or 16 or 26! — that Mr. X (or Ms. X!) sitting across from us is the same X person who broke our sister Marcy’s heart in graduate school…or that we’ve developed a crush on Monsieur or Madame/Mlle. X that no amount of supervision is going to allay.
Again, thanks for the great original post! I look forward to reading your next one.
I’ve had this happen to me a number of times. It’s really rough. No matter how the phrase it, it still comes down to that they were okay with meeting with me until they met me then they changed their mind. it’s hard because often I’ve waited weeks for that appointment holding out for it. Sometimes they’ve given me a referral name, but those referrals never came through (usually the person wasn’t taking new patients or didn’t take my insurance). Sure a therapist shouldn’t meet with a patient for all the reasons listed in the post, but when they realize this is an issue there should be some sort of ethical obligation to help the person find someone else. And I don’t just mean handing them a list of names and forgetting about them.
I saw a therapist when I was in the throes of depression. A depression which had descended without cause; there was no interesting reason for it. I could barely talk, and when I did, it was in
monosyllables. He referred me straight on to another therapist.
In retrospect, I had bored the man to death. If he had said so, I might have jumped in front of a bus on my way home. How could he have been both ethical and honest?
Good in-depth article on this situation with therapists. I went through a horrible termination with a T over a year ago and it’s taken a lot of therapy to recover from it. I was kicked out of a Group T. due to the T. feeling terrified I was going to harm her when in fact no threats or behavior were made to her by me. The group was shocked about it too and several members left as a result of it. I didn’t find any of this out until I finally had a phone discussion with that T. and she told what she was feeling at the time and apologized for how everything ended between us and the group. The ethical issues here is complicated.
A close friend of mine who also saw this woman for individual T. committed suicide in her office. And she claims she suffered PTSD and couldn’t handle me anymore if I got angry. She thought I was going to retaliate over my friends death. There were some very painful transference & countertransference issues at stake here.
As I look back on it I wish I had never seen her. It caused immense emotional pain and rejection for me in the end. My friend was also in the midst of a terrible transference with her. He was madly in love with her. I think she should have referred him out or told me that it might be too complex to treat us both.
I’m not clear on this or not but she had me talk about my sexual fantasies with her when I told her I was attracted to her. She’s very beautiful. I noticed those fantasies were hard for me to disclose but she wanted to hear them. I couldn’t tell if there was some counter-transference going on here but it sure seemed like there was some sort of erotic arousal during this time.
In the Ethics code it states that any type of sexual innuendo even if it is verbal is a violation. I felt like this was a very grey area to interpret in my situation.
I think in almost all situations, it’s best to tell the client who you didn’t like, had issues to close to home, or you had a crush on that this other therapist or program would better suit their needs. Or if it’s at all accurate, say you don’t deal with this particular issue or that you specialize or primarily deal with another problem. (I wouldn’t lie out right though because the former client could talk to another one of your clients who has an issue similar to theirs or have another therapist say, “What?, Dr. x is an expert in your problem!”).
I noticed it is written it is unethical to practice outside or your scope of expertise. Well, mine should not have taken 4 years to realize with her Ivy League education and years of “experience” that she was totally clueless in her profession and crossed many boundaries.
She got so scared of the licensing board knocking on her door that she refused to handover my client file when i asked. She ran to the police and said I threatened her and she was terrified. I have no history of crime or threats but the point is ..she twisted the law to make her the victim of a “threatening client.” Is this common? She altered my file and if discovered by the Board is it a serious crime in California. Also, if the Board discovers how she intentionally harassed me and lied to the Judge. She got an ex parte restraining order…she had a lawyer and I did not….it was not a fair hearing. She lied about why she terminated which leads me to believe she must have tampered with my file.
Thanks.
That’s the surfing video I like! Magnificent!
I came cross this because I have no answers My T just terminated me, I have been seeing her for a year
she gave me nothing but a letter and will not discuss it..she just shut the door and left me to rot. I think this is criminal, pure criminal…How dare she screw up my life after I told her so much..its fraud, she wont call me or e-mail me back…nothing…Her referrals…huh? they do not take new clients and 1 has been out of business for 2 years..Fraud
Feeling sick
I believe that a therapist owes it to any and every patient to give them a plausible explanation of why they are not being accepted as a client. This vital skill ought to be required training during the therapist’s initial education and should be added to the agenda of any follow-on seminars and conferences. The patient should never feel simply refected. The therapist should be guided by the hypocratic oath, “Do no harm!. John W. McAlister
It seems like a prevailing issue with therapists and doctors is that they are trained to think, act, and practice in a specific manner, under specific guidelines, without the flexibility (and sometimes legal flexibility) to adapt to certain situations. Some clients require a different kind of care and some solutions not taught in traditional, formal education end up ultimately limiting the effectiveness of these professionals which, consequently, results in more physical and mental illness. Fortunately, there are some professionals in these fields that expand their learning after their traditional education and offer a huge advantage to their clients (see Depak Chopra).
There are multiple reasons why a therapist may not believe it is a good match, and unfortunately, we often don’t offer detailed explanations to clients
very informative answer, caddick. Spoken like a true psychotherapist! bravo!