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I normally write about overeating, but having been raised in a family of 17 therapists, being a psychologist is literally in my blood. So lately I've included a focus on the surprising answers to the questions most frequently put to people like me about the experience of being a psychologist itself:
- How do you sit with people all day and listen to their problems, doesn't that affect you? How do you learn to let the feelings bounce off you? (Hint: You don't! You let them pass through you instead)
- Are you analyzing me right now? (Hint: No! That's very hard work and requires a very specific social contract and structure.)
- What's the single best thing about being a psychologist? (Hint: The stories that get inside you.)
I'd like to continue today with a brief article about the third most common question I get as a psychologist "Can you help everyone?" The answer to this is an emphatic no! Not only are there a myriad of diagnoses and life problems with which I have little experience—and the older I get the more I value diagnosis-specific experience—there are two factors required to establish a constructive treatment relationship no matter how much knowledge I may have on the client's problem: Motivation and Cooperation.
MOTIVATION: There's an old joke, "How many psychologists does it take to change a light bulb? Just one, but the light bulb really has to want to change!" As silly as it sounds, this couldn't be more illustrative. In the modern world, unless you're working in an situation where you can totally control the patient's environment, clients are free to continue old behavior patterns and the reinforcements which keep them in place. You can't remove someone's free will nor would you want to if you could, so the option to continue self-destructive action remains available no matter how good a doctor you may be. You simply must have a motivated client. You can lead a client to water but you can't make them think.
COOPERATION: Most people wouldn't think twice about a surgeon requiring their patients to come in on time, lie down on the operating table, and let their doctor perform procedures with the appropriate routine, structure, and anesthetic, etc. But for some reason they view a psychologist differently and are much less likely to respect the doctor's authority and structure.
For example, most psychologists require patients to come on time (which includes showing up for the waiting room a few minutes beforehand to prepare), say what's on their mind, pay on time, and leave on time. In the absence of this structure it's very difficult to perform the "operation," but clients don't see it this way. Many feel it's no big deal to come late on a regular basis. They hide things from us, or leave us with potent "doorknob comments" at the very end of the session which require an urgent, depthful focus. I'll always remember the client who mentioned a serious cancer diagnosis as they were rushing out the door and my next patient was coming in! "By the way doc, I'm dying. See ya next week!" Or another who said, "I'm pregnant and have no idea who the father is—talk about it next time OK?"
Other clients make it very difficult to end sessions on time. I mean, I've never had a buzzer that goes off while I shout "Hey! Time's up!" On the other hand when clients don't cooperate in at least a rudimentary manner with session ending times it becomes difficult to manage your own day. Psychologists need to take care of personal needs between sessions so they can be appropriately present for the next patient. There's only so much you can compensate with extra spacing between sessions, and for many doctors insurance requirements necessitate seeing way too many people per day to be very flexible with this at all. We simply must have clients who are time-cooperative.
Then there are clients who don't pay, don't pay on time, or only partially pay. While it may sound selfish to focus on this, the truth is it's very difficult to lend a client your soul and give them your full presence if you're worried about how to pay the mortgage at the end of the month. I've yet to encounter a banker who says "Oh! You're a psychologist? And you're helping people? Why didn't you say so! No need to pay your mortgage on time, we can just let it slide because you're such a good guy." Nope, not going to happen.
To help someone we need a diagnosis relevant to our expertise, motivation, and a least a modicum of cooperation.
For this reason we tend to develop screening mechanisms that assess for these things. I'll leave you with mine. Before giving a client a full session I'll offer them fifteen minutes without charge via telephone or zoom. I'll offer very specific times and ask for a call (or email) to confirm so I can protect the time. If they don't confirm, I don't hold the appointment and don't answer at the time mentioned. If they do confirm but don't show up, I do not chase them unless there was something I was legally required to follow up on.
Then, when I do give them an appointment, I assess how cooperative and motivated they were within the appointment itself. Did they show up a few minutes beforehand in the waiting room? Did they talk to me in a reasonable manner about what was troubling them, cooperate with my inquiries, make emotionally present contact to at least some degree, and show at least some respect for the basic structure? Were they at all interested in the fee and payment arrangements?
If the answers to these questions are satisfactory I give them another appointment. Otherwise I refer them to another professional or wait to see what they do next if there was nothing urgent that required follow up. And I never give clients regular, weekly appointments unless and until I've had three successful appointments as per above. Ideally they report some positive progress during this time so I'll know we indeed have established a constructive and cooperative relationship. I've found that's a very good prognostic indicator of how the relationship will progress.
It took quite a few years, but once I figured this all out I was able to screen for patients who actually got results from working with me, and my life as a psychologist became infinitely more gratifying and meaningful.
So no, I absolutely can't help everyone! But with the right screening there are more than enough people out there I can help that I'm flooded with largely happy, cooperative clients. It's a good life!
