Please Come Back!

Please Come Back!

Building long-lasting relationships with clients is a skill to aim for if you ever plan to have a private practice.  Treatment attrition is something I frequently experienced at the beginning of my career, and it took me several years to figure out how to provide better services.  The number of assertive therapeutic interventions per session increases only with time and practice.  There are, however, some pitfalls that a beginner therapist can avoid.

At the beginning, I often took a lot of notes on the first session and designed elaborate treatment plans.  Doing all of this at once was as complicated as learning to fly an airplane.  The problem is that I often failed in creating a safe emotional container for the client.  Although finding appropriate techniques and designing remarkable treatment plans were some terrific strategies I learned in school, I wish somebody had pointed out the basic and avoidable mistakes I was making.  I did not understand why some clients canceled sessions or stopped coming altogether.  After more practice, I observed some patterns that clients showed before they left the treatment, those hidden but normal signals that everybody can see but us.  I was passionate and determined to have a full time private practice (and I had had it for several years in Mexico), so I scheduled myself time with more experienced practitioners to address this challenge.  Hence, if you are reading this post, I will assume you also are a curious and independent learner.  Good for you!  Thus, I will share some lessons learned.  I will also share some ideas for improvement that you can use to work with other cultures.

Common pitfalls of a beginner therapist:

  • Focusing on paperwork rather than being present with the client.
  • Formulating a diagnostic too soon, sticking to it, or sharing it with the client as your professional opinion rather than exploring the person’s uniqueness.  We never know what a person will do after hearing that he or she “is” bipolar or “has” depression.
  • Thinking of the client as an isolated being rather than a person who is part of a family and a social system.  Most out of place behaviors make sense and could be even appropriate when you consider the whole system despite your favorite therapeutic approach.
  • Confusing passionate statements and normal life decisions with signals of mental illness. For instance, I often hear sentences like “I want to die” or “I wish I could disappear” from Mexican women.  If I take it as a passionate expression and listen to the need behind the expression, we often get a terrific laugh together after few sessions.  If I take it the American approach, I would probably need to hospitalize them and miss the opportunity to listen to their deepest needs.  As a new American clinician, I do believe in drastic actions in some cases, but sometimes following rules blindly is not the best answer.
  • Calling a client Latino (or Asian) rather than being precise about the nationality or origin of the person.
  • Not arriving on time or providing low quality services to those who we see in public agencies.  Being an intern or in practicum is a perfect excuse to practice high quality services.
  • Confusing being bilingual with being culturally sensitive.  Speaking the language of the client does not make you expert in his or her culture.  Some of my Spanish-speaking clients are grateful when I ask about the traditions of their hometowns.
  • Rushing into a CPS report.  Using clinical judgment before doing a CPS report in a Latino family is a terrific idea.  Most chances of mistreatment are preventable once the person learns better strategies of communication.  Do not take me wrong: I am the first to run to CPS when someone is in immediate danger.  However, I had a colleague that did a CPS when a girl said to him in her broken English that her father hit her the night before. Of course, the police immediately went to the family’s home only to find out the girl was coughing and the father stroked her chest to help.  The problem is that the family is undocumented, and this report made the family afraid of coming back to therapy.  The whole situation could have been avoided by speaking with the parents first.  I believe there is a stereotype about Mexican men being potential abusers, and I may be wrong. What I do know, however, is that machismo is not in every Mexican family; trust me!
  • Failing to reflect back the presenting problem in his or her words.
  • Failing in memorizing most of the specifics of the client’s situation.  Forgetting names and situations that clients told us in previous sessions is a common mistake.  Just admit you forgot it and say you are sorry.  It is as simple as that.
  • Charging low fees. Actually, low fees could be a signal for the client that you are not confident in the service you provide.  At the beginning I felt sorry for my clients and believed I was here to save the world; therefore, I charged low fees. Yet, I often listened to their expensive hobbies in therapy while I was a starving recent graduate.  It would be better to have a percentage of pro-bono clients or donate some money to the community if you want to be helpful.  By the way, I did not learn how to be assertive on my fees from other psychologists; I learned this from dentists, lawyers, and businesspeople.  Keep in mind that our profession is relatively new in the market and we need to learn from other fields.
  • Getting scared when a client questions your ability as a therapist.  When a client tries to intimidate me with questions about my expertise, I do my best to not take it personally and respond freely.  If I do not know what to do in a session, I will sincerely admit it.  Yes, after so many years, I still at times have no idea how to treat some clients.  Acknowledging my inabilities sets me free to do a referral or to train myself in a new topic.

The client may soon leave the treatment if he or she. . .

  • Is quiet most of the time and you have talked more than 50% of the time.
  • Agrees with 90% or more of what you say.
  • Is clearly not prioritizing the treatment whether on monetary or time issues.
  • Corrects you several times about the specifics of her case or the way you rephrase it.
  • Shares the disagreement of other family members about coming to therapy particularly those who are a figure of authority.
  • Tells you that he or she will show up late the next session or will not come without an important excuse.  The 24-hour cancellation policy is an excellent way to prevent this.  I often talk about the normal resistance when we are deepening the process so they are prepared to identify it and still show up.

Practical considerations to maintain a long-standing therapeutic relationship:

  • Be present during the session.  It is better to listen than to offer elaborate conclusions.
  • Make a call 15 minutes after a no show.  Follow-up phone calls are a great tool. Expressing your concern if the client leaves the treatment without telling you is OK.  I often ask the person if they would like to continue or if they would rather not receive any phone calls from me.  In the Latino community this is considered a friendly gesture from your doctor.  During the phone call, try to be genuinely curious about the reasons and do not take it personally.  If possible, make an appointment for the next session.
  • Explain the differences between an informal conversation with friends and therapy.
  • Be clear about confidentiality and mandatory reports.
  • Explain the importance of being on time and do not compensate the time of their session they lost.  Be gentle about it; blame your busy schedule if you wish.
  • Be clear about payments and do not let late fees accumulate beyond one or two payments. Talk about lowering the price if the client is in temporarily need or suspend the treatment.  They will have better commitment if they come back.
  • Clients may cancel because they have family commitments.  Remember, the family is crucial to Latino community, so do not take it personally.
  • Explain the difference between psychotherapy and other medical visits.  Frequently my new clients think they need only to attend when they are in crisis but do not know about the benefits of continuity in their treatment.  In my experience, once my clients learn about therapy, they will be committed.
  • Answer as best as you can any personal questions a Latino client may ask you.  They may find it rude if you do not answer whether you are married or have kids.  I often answer and gently go back to their topic.  Later on, I will casually remain them of therapeutic boundaries or explain to them that being concerned about me can be a distraction in their treatment.  Remember:  Latino clients may consider you part of their family and want to know you are ok.
  • Be assertive with your fees.  Do your homework and research fees and policies of other colleagues in your area. Have a list of low fee agencies to refer clients if needed.

I hope you find your new career positively challenging.  Question or comments?  Feel free to write to me at counselingmexicans@yahoo.com or comment on this post.  Do not forget to share or like this article on Facebook.

 

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3 Comments

  1. Thank you for your sharing!
    I’ve learned a lot from it.
    But i wonder why client may leave if he or she agrees with 90% or more of what you say.
    Could you explain it?
    Thanks again!

    Reply
    • Does it mean that the client was not really agree with you and was just being polite?

      Reply
  2. In my experience a client may leave for various reasons even though he or she agrees with us and enjoys the session. Some reasons may include lack of resources, other priorities in life, feeling better, etc.

    Reply

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