The relationship between a client and a therapist is a unique and significant bond. Naturally, as a psychotherapist in private practice, it’s important to determine if I am the right therapist for a client seeking help. To make this determination I start out with a psychological consultation. I utilize this assessment tool to gather past and current psycho-social information in order to evaluate a prospective client’s needs and risk.
Since I specialize in treating complex trauma I also assess for the prevalence of child abuse, rape trauma, narcissistic abuse and domestic violence. During a consultation I am evaluating if the prospective client is a candidate for the type of therapy I offer, or if they would fare better with a different type of treatment or a higher level of care, meaning a level of treatment that exceeds what is plausible or possible in a private practice setting.
By gleaning a comprehensive understanding of an individual’s history and presenting issues I not only assess if weekly therapy in a private practice setting is the appropriate level of care, I and the client can also figure out if it feels right for us to embark on this collaborative journey. Are we comfortable with each other? Are we on the same page about the direction treatment would take? Does the client feel understood? Do I feel secure about my ability to help them successfully navigate through their healing?
If it turns out for sundry reasons we are not suited to proceed with setting up therapy sessions we will discuss why it’s necessary to seek treatment elsewhere. I will do my best to recommend appropriate facilities that address their concerns.
In a nutshell, the six levels of therapeutic care starting with the least to the most intensive are;
- A Private practice is when a degreed, state licensed and credentialed social worker, psychologist, psychiatrist, counselor or nurse clinician with adequate training requirements and experience may have their own offices where they provide treatment services in accordance with a set schedule. A private practice is a self governing business that operates in accordance with state guidelines and policies (HIPPA) and offers the delivery of treatment services reflective of the treatment orientation and philosophy of the practitioner.
- An Outpatient clinic is more comprehensive than a private practice setting in that it offers sundry mental health services inclusive of individual psychotherapy, group therapy, medical consultations, and psychiatry. Outpatient programs are suited for those who are transitioning from inpatient care and require more intensive monitoring than a private practitioner can provide. Those who are grappling with the early stages of addiction and present with intrusive symptoms not responsive to weekly therapy sessions can benefit from the structure and frequency afforded by outpatient clinics.
- An Intensive Day Program involves intensive daily treatment (full or half day sessions) on an outpatient basis for several weeks at a time for folks whose mental distress is causing impaired functioning with school, work and relationships. A comprehensive blend of individual and group mental health counseling and educational services to cultivate life skills are provided. Additional modalities may include family counseling, crisis intervention and behavior modification.
- A Partial Hospitalization Program is similar to an intensive day program, albeit is more highly structured. This level of care stipulates attending at least five hours/day, five days/week and is specifically designed for treating serious mental disorders. It is typically viewed as an alternative to inpatient care and is geared towards assisting the client with maintaining a functional level, and preventing relapse or full hospitalization.
- Inpatient Hospitalization provides a protected closed environment in which severe mental illness and suicidal or homicidal intent can be given round-the-clock medical and emotional support. Detox units are also examples of inpatient treatment. The highly structured inpatient milieu provides intensive monitoring and clinical interventions and strategies that encourage rapid stabilization.
- Residential Treatment (aka rehabs) provides longer-term 24-hour care than inpatient hospitalization, typically ranging from thirty days to six months. Residential treatment centers generally address addictive disorders and eating disorders through the use of various forms of evidence-based treatments such as FDA approved medications, behavioral modalities and motivational interviewing. Many rehabs incorporate holistic support such as equine therapy, yoga and art therapy.
Sometimes knowing whether the type of treatment and level of care I offer matches what is needed is not that clear or immediate. This was the case with Hillary. Signs of severe symptoms and comorbidity were revealed following our consultation. Comorbidity means she presented with the simultaneous presence of multiple psychological conditions. This realization resulted from being on the receiving end of a week of non-stop mercurial communications revealing substance abuse, reckless sexual acting out and unreasonable demands for continuous support, interspersed with a litany of complaints as to how I was failing her. We had yet to even begin treatment.
When it becomes evident that a dysregulated client like Hillary is also dependent on substances and impulsively acting out, concerns about ancillary treatment modalities emerge, such as detox, medication management and the need for greater structure and frequency of sessions. If these concerns are also coupled with the clients’ unrealistic treatment expectations, fueled by unbearable suffering and unmet dependency needs, an immediate attachment can make a referral to a more appropriate level of care feel like a betrayal. Abandonment panic can set in even after an initial consultation.
Nevertheless, the writing was on the wall. Weekly sessions via a remote private practice setting would not suffice for Hillary. I had to address her need for a comprehensive multi-disciplinary treatment team in a structured clinical outpatient or partial hospitalization setting so that effective monitoring and stabilization could result. I also needed to preserve my own mental health in order to service those clients who were responsive and suitable to engage in weekly and bi-monthly psychotherapy sessions.
Although it was undeniable that Hillary and I and the level of care I provided were not the right fit, my telling her this did not go over well. While it is clearly a responsible and ethical decision to direct a client towards the type of treatment suited to their needs, an emotionally fragile, untethered person can experience this form of re-direction as a huge rejection.
Indeed, when a client relentlessly blames a therapist for not satisfactorily showing up as either a savior or a whipping post, this pattern of idealization and devaluation often signifies a serious and debilitating psychiatric condition known as Borderline Personality Disorder. Treatment for BPD can periodically require an intensive outpatient, or even an inpatient setting due to significant impairment. A structured and comprehensive form ofCognitive Behavioral therapy known as Dialectical Behavioral therapy is the recommended course of action. Likewise, substance and alcohol abuse disorders also require a multiplicity of services ranging from detox to psycho-educational groups, 12-step support, medication management, group therapy and ongoing phone support.
Complex cases consisting of co-current psychiatric conditions and symptoms such as substance abuse, trauma, psychotic features, and personality disorders are typically not realistic for a private practice clinician to take on.
Yet many do.
As self-help author, Melody Beattie wrote in her groundbreaking book Codependent No More: How to Stop Controlling Others and Start Caring for Yourself,
“A codependent person is one who has let another person’s behavior affect him or her, and who is obsessed with controlling that person’s behavior.”
The codependent therapist’s need to ‘fix’ and control interferes with effectively evaluating what a client needs to heal and recover.
Indeed many psychotherapists become polarized and over-identified with a caretaker role and become consumed by it. Should this happen, the therapist’s self-worth and identity can become destructively invested in ‘fixing’ the client. When a psychotherapist falls into the trap of feeling it’s their mission to achieve the impossible they may tout unassailable truths and groundbreaking remedies. The therapist’s weak boundaries and misguided personal motives obscure realistic therapeutic goals.
Under these circumstances, a disconcerting reciprocal dependency and even enmeshment can ensue. Vacillating between extreme rigid posturing, enabling, and unprofessional rescue-driven behavior takes over. The dynamic becomes toxic. Hence, this ego driven quest to treat anyone and any condition is a recipe for disaster. The therapist who succumbs to believing one is the final and sole source of healing, is not only denying the client access to an appropriate level of quality care, but is also setting themselves up for burn-out.
Having the humility to recognize limits and fallibility is critical. It is essential for establishing realistic expectations of oneself and others. Clinicians must have the receptivity and insight to honor our personal foibles and shortcomings. Essentially, we have to acknowledge first and foremost our own needs in order to be of service to others. This is particularly critical when we are beset by trials, losses, and challenges.
Realistically gauging what I can offer as a therapist is the trajectory to mapping out treatment plans or referrals to forms of therapy that compliment the needs of the client. It is our ethical responsibility as therapists to lead a client towards the type of therapeutic care necessary to healing. Equally as important is our ethical responsibility to curtail the impulse to promise more than what is possible.