For new therapists, and insecure old ones

I thought I might make a few observations about starting up a new psychotherapy practice in a new state.  I have no pre-established theme, insight or agenda in mind.  Just a matter of some casual looking outward and inward.  For one, I’m not really building a practice in the way a pioneer would – getting an office, cold-calling the insurance companies to begin the arduous process of getting paneled, advertising for clients in simple ways (Psychology Today ad) and effortful ways (giving talks or seminars).  I’ve joined a group practice where all that is done for me and the other clinicians.

My situation is that I essentially close my eyes, open my hand and accept whatever referrals (and insurance company part-disbursements) are given to me.  I suppose I could question how clients are distributed among the counselors, but it would be neurotic to suspect I’m being differently treated.  I was informed that “the new guy” will receive more of the psychiatric hospital discharge referrals, and that these people rarely keep the appointment (this has proven to be true so drastically, and so different from my experience in Ohio, that I wonder if the area hospitals do a terrible job of promoting the value of crisis follow-up).

So I see, from scratch, a fair number of more plausible ones not returning after Intake; a portion of these reacting enthusiastically or anxiously when I text-message them, and rescheduling; yet some of these still failing to show up.  And others who begin to engage without fanfare (that is, they don’t say: “Gosh, this is what I need!  Write me down for the whole year!), and return week after week.  I don’t know if their motivation is AA “one day at a time”-like, or if they’ve made an unspoken commitment to the long-term, like buying a puppy.

Is there anything to be said about this beyond the obvious fact that people are different, with different qualities of courage, need, commitment, desperation, loneliness?  Yes – but this is where my cynicism and hubris come in.  I sometimes believe that new, fresh-faced and possibly ingenuous counselors retain more new clients than I do.  I believe they will not have the initial gravity of approach, potential and confidence that I have at first contact, but that therefore they might put the nervous person more at ease.  I will admit that I do not know anything of the “atmosphere” produced by the many therapists who have a more “solution-focused,” “strength-based,” cognitive and here-and-now approach.  For their clients, the room may feel brisk, actionable.  Solutions to their problems may feel, agreeably, like a matter of thinking different or receiving delivered insights that had eluded them.  The atmosphere of my room – carrying the humor and compassion and standard questioning – is historical, almost immediately four-dimensional.  Before the first hour is over, most will get a sense that we will have to go exactly where they feel most uncomfortable.  Those not in denial may think, Yes, I knew this was going to happen.  But those who deny that there are roots beneath their eyeballs and their overthinking brain may turn away from therapy as they have always turned away from themselves.

Sometimes I wonder if there are ways, beyond my care and energy, that other therapists use to draw clients back again and again.  Do they say, “Let’s put you on the schedule for next week!” in a way that makes it sound like a necessity?  Are they better looking than I am?  Am I not a strong enough father figure?  I have known for a long time that some of my chronic clients are those who do and get and know only the shallowest work; that those I feel so poignantly about, knowing I can save them (I mean this in literal ways) may soon not return.  I admit, with embarrassment, that I’ve even wondered if these other therapists have some magical speech, delivered during the orientation session, that commits the stranger to the unique relationship (then I remember – I have that speech!).  Or that they are simply the “right” personality that wins friends and influences people.*

Whatever is going on, I’ve had to cultivate some serenity and remind myself of certain things.  I know what I’m doing – or think I do – and this has been corroborated by some long-term client friendships, complimentary Satisfaction Surveys and a good income.  People are terribly difficult to change – an empowering yet burdensome piece of knowledge that the cognitive therapists may think they grasp, but don’t.  People, myself included, are childlike, want free gifts and quick transcendence and feel – legitimately and profoundly and invisibly – that there is something wrong and undeserved about enduring weekly pain and self-searching just to feel OK in their life.  And, therapists are troubled people who daily feel the ineffable pressure at the border zone of giving more and better than they have ever received in their life.  I don't know that this affects the work.  Yet it must.

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* Dale Carnegie, How to Win Friends & Influence People, 1936.