Or at least I do.
I'm going to say what most of us are thinking about what we wish people knew regarding how therapy in private practice actually works. This may be uncomfortable to read. So, hold on to your butts folx, I'm about to get real with you.
I Am Not An Urgent Care.
In private practice we don't generally deal with emergencies. If you are suicidal or if you are in crisis we are not the care you need. That is a higher level of care than we can offer. Most clinicians' answering machines and email responders will say "if this is an emergency, please call 911 or proceed to the nearest emergency room or crisis center". Of course, if you are my client and you go into crisis, it would probably be a good thing to let me know, but I am not equipped with the proper assessments, ability to monitor you, house you to keep you safe, or the ability or credentials to give you the medication you may need to re-regulate yourself. You need to go to a crisis center so that they can assess the level of care that you need (ie. in-patient, Partial Care, or Intensive Out Patient programs).
But even more than this, I am not on-call. I am a human being who works very hard and deserves time off just like anyone else. In fact, part of my job is preaching about the importance of self-care and the work-life balance. There's a big possibility that if I am off and you text me (especially in the wee hours of the night or morning) I may not get it. So if you're panicking and you need something, the first thing you want to do is go through all of the coping skills we've talked about, check back with all of the emails of homework and other things I've sent you, reach out to your social supports, go to social settings that have a positive distracting effect for you, or change your physical stimuli (take a cold shower, a hot bath, go for a run, etc.).
It isn't realistic to think that your therapist is waiting by the phone for whatever you need whenever you need it. And even if it wasn't in the wee hours of the morning, I could be in an environment where privacy is not possible or service is not available. And to be perfectly frank, even if I could be available, I don't want to be. My job can be socially/emotionally taxing and I need time where I don't have to be "on". When I say, I don't want to be available it is absolutely not a personal thing towards you, it is an important and healthy boundaries thing for me. It's not that I don't care what's going on for you, I just need you to understand the expectations and boundaries of our relationship and respect them. I would not be doing my job if I did not embody and model the old airline adage of "please put on your oxygen mask before helping the passenger next to you." I have to have my own life too.
2. My Time is Important
My time is important but it isn't more important than yours. It's equally as important. When someone schedules an appointment with me I am committed to being there and generally am early for it. I do not appreciate being ghosted by clients. Firstly, I will indeed charge my no show fee. Some therapists are hesitant to do that, I am not. This is a boundary for me in my business. The reason is because these days, and often certain times of year, the therapy business is very busy. I have several people on a wait list and the phone rings off the hook every day. If you aren't going to make your appointment or if you decide you don't want to come anymore, please be respectful and let your therapist know so that we can offer that spot to someone who can come. It's fine if you don't like it, if you aren't ready, or whatever the reason is (you don't even need to give a reason), just give me some notice so I'm not sitting in my office or in front of the computer with my thumb up my butt. Because even if I don't have anyone who wants that spot, I could still use it to be with my own family or do things that need to get done in my life as well. And, as far as the no-show fee goes, it's meant to help supplement the loss in income. In this industry no session = no money. No money = no groceries. My 24-hour cancellation policy remains and continues to serve my need for consideration and flow of income. The amount is still a loss of income for me since I get paid more when someone shows, but it's still something. It's not a discriminating charge; it is a personal and business decision
3. Please Don't Write Me a Novel
Not only is email and text messaging not the most secure form of communication especially when it comes to protected health information, but it's not the place you want to update your therapist. You may not know this, but sessions aren't the only work we're doing as clinicians. We may not see 40 clients in a week, we may only work 4 days a week, but we are working more than you think. Therapists put in countless hours of paperwork, documenting the session progress, doing disability paperwork, sending letters to doctors, billing insurance companies, battling insurance companies, fixing bills, sending invoices, making phone calls, etc. It's a lot. In the end, an average week can become more than 40+ hours spent with all the work combined. This is why our off time is so important. On our off days, or even in between sessions, therapists do not want to get an email that consists of a 3 page term paper regarding who said what to whom at home. Make an appointment. If you have an appointment, write these thoughts in a journal and bring it with you to your appointment. We don't have the time to read these things outside of the session and we certainly would like to be able to dedicate the time and attention these issues need, but you have to bring it to session. Your sessions are the appropriate designated space to safely explore these thoughts and concerns.
4. There's No Winning, So Don't Cheat Yourself
You're therapist should not have any expectations of you. Sure, we make goals together, but we are supposed to meet you where you are. If you don't do your homework or you relapse into old behaviors, we're not disappointed we're concerned. We want to help. But we don't want you to be something you're not. So please do not hide the truth of your circumstances with us. You can't "win" therapy by saying everything's fine when it isn't. You've come to us to get better so if you're not it wouldn't be helpful to say that you are. We want to know if things have gotten worse, that helps us dig into our own tool set so that we can better help you. Sometimes helping you better can mean sending you to another specialist. This doesn't mean we don't care and we want to pawn you off on to someone else, it simply means we do care and we know that we don't have the education or the training to take you on the next leg of the journey. That can be hard, but it may be important for your health and well being.
Part of being authentic in the counseling room is also verbalizing when something doesn't feel right between you and the therapist. If the therapist has said something that has irked you, bring it up to them! A good therapist will be able to take your feedback and use it in a therapeutic way for both of you. One of the things we are meant to model is good boundaries and safe spaces. You should feel safe enough to voice your concerns and know that your therapist can handle that. We won't be mad, we won't attack you. We can discuss it like adults and work through it together. If you find that your therapist did get angry and defensive, well, that's not about you. That's a bad apple...
5. And There Are Bad Apples
Maybe "bad" isn't the right word. Maybe it's more like therapists with unresolved personal stuff that they allow to leak out sideways into their sessions. It happens more than I wish I knew, but it's true. Many therapists are resistant against getting their own therapy. It's a shame because it's such an amazing opportunity for deeper work inside and out. Personally, I think all the best therapists have therapists. As I always say"if you think your sh!t doesn't stink, you're not breathing in deep enough". The biggest thing I want clients to know is to trust your instincts here. Is your therapist actually helping you? Does he or she talk too much about themselves? Do you know more about them than they know about you? Have they ever gotten defensive or angry with you (even if you were angry at them)? Do they not respond to needs to schedule/reschedule? Are they 15 minutes or more late to every session? Do they just sit there and ask you "how does that make you feel?" but don't teach you any skills or use any methods to decrease your symptoms? Your therapist should be working for you and your betterment and if these things are showing up in session, it's time to find a new therapist. There are, unfortunately, people in this field that go into it for themselves. But there are also great therapists out there who can really make a difference for others. No two therapists are going to be alike and I'm not just talking personality-wise, I am also talking about their clinical approach (IFS, CBT, DBT, ACT, EFT, etc. and if you don't know what these mean you should do a quick google search), their tool set and certifications (EMDR, play therapy, mindfulness, hypnosis, etc.) and their specializations (anxiety, depression, substance use, panic, OCD, phobias, grief, etc.). If you get a "bad apple" please please please do NOT give up. Do not let that tarnish your view of what therapy could be. But finding a good therapist that is a good fit can be a long trial and error process. I promise you, though, when you find a good one, it's worth it.
6. You Can't Doordash Your Therapy
Technology is brilliant. It can be immensely helpful in our everyday lives, but we've gotten really comfortable with having everything at our fingertips and having things happen instantaneously. When clients reach out with very specific demands for appointments (ie. "I need a 6pm appointment this week") this is our face:
Like most of the working world, most people need evening appointments and the less flexible you are with scheduling the more you may have to wait for a spot. It would be nice if we could whip out your preferred date and time at a moments notice but we've probably been booked for weeks and that just isn't feasible. This isn't Burger King, you can't "have it your way" at least not all the time. This is more like Jerry McGuire, "help me, help you". We're only one person carrying a caseload of 40+ other clients that we need to jam into 4-5 days a week. Having rigid parameters around how and when therapy will happen is going to make the process challenging for you. If you fall out of the schedule for whatever reason, please don't expect to just slide back in after weeks, months or even years. We've already fill the spot with someone who needed it. There's no savesies and you can't get your therapy in 30 minutes or less and with fast and free delivery.
7. And Speaking of Fast...
Therapy is a process. And if there's any trauma in your history, and dollars to doughnuts there is, this is going to take us some time. Please throw out any expectations that your 6 EAP (Employment Assistance Program) sessions are going to be enough to "fix" you. The mind is a complicated place to explore and there are tons of factors that create the conditions for your symptoms to exist. It's important that we take our time looking at all of that. Most private practice clinicians are not doing acute care, meaning we aren't doing short-term treatment or triage for your mental health. So if you start therapy, please have the understanding that this takes dedication and make sure you're in it for the long-haul. We cannot tell you how long it will take. There's no way to know that. But, we will show up for as long as it takes.
Ultimately, it's up to you how long you stick it out. Your therapist should be gauging your need for sessions based on your progress (or lack thereof). If you stop having anything to talk about, we should be suggesting you titrate down in your sessions (ie. go from weekly to biweekly or biweekly to monthly). And if all the treatment goals we've established have been met and you are feeling great, discharging you from therapy is suitable. Honestly, in my personal opinion, I don't think you need problems or a particular issue to benefit from therapy (although insurance companies would disagree). But until you get to the point where things are good and you feel stable, therapy can be a journey on a long road. It just so happens, you don't have to walk it alone.
Some of these opinions may sound harsh but when you really think about it, it's all about both our time and energy. While therapy is often seen as a one-sided relationship, that should not include boundaries and respect. A mutual understanding of where the lines in our relationship are, are important in doing this difficult work together. The difficult work needs to be contained to the counseling room (or the telehealth platform) in order to be effective and we both need to practice taking care of ourselves in order to move through this process. Sometimes, when we aren't used to boundaries we can view them as abandonment or apathy, but in truth these are meant to keep both, you and me, operating in a healthy mindset mentally, emotionally, and relationally.