Dear Young Therapist: You Don’t Have to Be An Idealist and Try to Save the World

Millennials are whiners.

God, I’ve heard that so many times. An article by a prominent psychiatrist was recently published in Psychology Today. In it, he not-to-subtly noted how mature he was as a clinician. What made him so? Taking on difficult clients with a stiff upper-lip. The article began with him chastising a colleague by referring to him as being “not very bright,” presumably as retaliation for that individual referring to his clients as “crappy patients.” Before I explore the errors in his approach, I want to focus on the experience of a young therapist, any young therapist, leaving graduate school to enter the world.

Before licensure and after graduation, some of us are warned about the ensuing two years, though not in school. It’s a well-established fact that clinicians with limited permits (the piece of paper that allows you to practice without being licensed) are treated as second-class citizens. Paid only for the individuals who attend their sessions (called fee-for-service), young therapists are expected to coordinate treatment with hospitals, psychiatrists, and schools; reach out to child services because they’ll have one or more ACS cases; create treatment plans and keep pristine notes; and carry caseloads of 30-50 moderately to highly difficult clients (the therapist isn’t allowed to choose).

And if you’re feeling overwhelmed or burned out? Tough luck. There are deadlines and regulatory agencies are watching. And god forbid if you make a mistake; you’ll never hear the end of it. (I had a director send me a long Trump-like text message berating me for a clerical error.) Therapists have to become just as competent with the administrative work as with the clinical side, meaning that if you struggle with time-management, you’re out! From supervisors who are and have been struggling (although I admittedly had some good ones) to the overworked and cynical directors, you’re constantly reminded of the expectations. You’re a cog, and we’ll replace you if we need another.

Burnout and suicide aren’t high among clinicians because of bad clients; they’re high because of bad employers. And I can’t stress this enough.

So, when therapists begin their own solo practices or form group clinics, they want to take on as few difficult clients as possible. The years of abuse wear them out. Now, to return to the article mentioned in the beginning: shaming a young, overwhelmed clinician is a terrible way to convince her to take on difficult patients. She’s doing what any of us who find ourselves in chaotic environments do: running away. The clinician mentioned was certainly wrong for calling his clients “crappy,” but the author was just as wrong for retaliating, exhibiting no curiosity or empathy whatsoever. My hunch is that the psychiatrist felt overwhelmed and believed himself to be incompetent. The latter part of the article provides the reasons why therapists should take on difficult clients, all of which I agreed with. But, there also has to be a limit. Most of us, with caseloads of 20-30 individuals can’t take on more than a handful of difficult clients; that’s just how it is. And that’s okay.

In finding a balance between stability and care, we have to remind ourselves that it isn’t our job to take on every difficult client that other clinicians refuse to see; we wouldn’t last if we did. And, honestly, I wonder how many challenging patients the author takes on. Does he choose to see each one who reaches out to him? Probably not. Does he have boundaries, accepting his own limits? Likely. After the two year period mentioned, most of us want a break, and that’s fine with me. However, in order to grow in our field, eventually you’ll have to resume seeing difficult clients. Young therapist, I know you want to run away, but you’re so much better than that, and your skillset and bravery are desperately needed.

https://www.psychologytoday.com/gb/blog/dsm5-in-distress/201503/dont-give-the-difficult-patient?amp&__twitter_impression=true