Author – psychologist Natalia Kholina So many words have been said about the importance of psychotherapy, its capabilities and meaning for the client. I hope that many more will be heard. However, it is important for any psychotherapist - a beginner or a long-time practitioner - to understand and evaluate the limitations of their capabilities, and to know about those client cases with which this particular psychologist will not work. What these limitations may be associated with is a separate topic for clarification, and I will talk about the limits of my capabilities below, and I want to start the conversation about limitations in work with a quote: “Colleagues, you know this magical feeling when, having put aside household chores, you pass children to a nanny or grandmother (or after taking them to school or college), did you (instead of a supermarket or gym) come to the office for a meeting with a client who did not show up? This feeling is especially strong if you pay hourly rent for an office...” (c) Often I notice confirmation of one inexplicable idea. It is no coincidence that clients choose psychotherapists for themselves - even without knowing them. It is not always logically explicable, but almost always, in all the diversity of specialists, the client finds the right therapist (and the therapist, in turn, chooses to work with that client), as a result of whose joint work something is born that is endowed with some special meaning for both .I consider myself one of the psychologists who takes their work seriously, invests a lot of effort, time and money in constant training and professional development, loves their work and cares about its quality, as well as the ability to complete the process they have started. From my experience I see that, unfortunately, not all clients, when turning to psychotherapy or counseling, actually come for exactly this (that is, not everyone is ready to work for their goal, while also respecting the specialist they turned to). Therefore, in order not to become exhausted (and therapists are susceptible to this), not to waste your time and the time of clients (who sometimes expect from a therapist something completely different from what he really can), in order to do his work confidently and calmly, and at the same time still enjoy However, it is sometimes more useful for a therapist to refuse a client who calls or comes for the first consultation. So, I will share my observations of situations when I predict the chance of successful therapy to be minimal (I have already written about when the chance is higher than minimal here). The therapist can usually decide whether to take a person into therapy or whether it doesn’t make sense already during the first telephone conversation, or during one or several first introductory meetings. Now I will list the alarming symptoms, having noticed which, I consider it possible for myself to refuse to accept the client and/or long-term psychotherapy. During a telephone conversation --- the caller's request to record another person (at his request, without his knowledge, because he is shy, etc.). I very much understand that parents, spouses, children can suffer greatly and worry when they see the deplorable state of their relatives, and wish them well with all their might. However, in my experience, therapy with such clients is not very possible: the desire of relatives alone is not enough for therapy, and it is almost impossible to sentence a person to personal happiness. As one of my teachers said, “if a person is sick, but he is happy with it, then he is healthy.” Therapy has a better chance if the client himself finds the strength (overcomes embarrassment, if that is the case) and makes the first call on his own; --- please book yourself in for a distant date in advance (in my experience - more than two weeks). For For me, such a request may indicate a strong internal conflict: “I want help” and “I still doubt whether I need it.” Considering that a booked client is an automatic refusal to sign up someone else, perhaps more confident in the need for psychological help for themselves, I would suggest calling back closer to the specified date, and if there is still time left, then sign up;--- no can decide onchoosing the date and time of the first meeting. Also evidence of some strong internal disagreement, like what was described above. Therefore, I consider it useless to offer more than 2-3 alternative time options; --- attempts to influence changes in the conditions of my work: place of reception, cost of reception, offering alternative options. In other words, observing such attempts to bargain or give me advice on how he would be more comfortable undergoing therapy, I may suspect borderline personality disorder, and here I need to carefully weigh whether I am currently ready to meet with such a client (I believe that the therapist should evaluate his resources well, and if he nevertheless agrees to work with border clients, then very deliberately decide how many such clients, for example per week, he is ready to work);--- please make an appointment, without clarifying the address of the place work. Experience shows that such clients in reality will not reach the therapist (already realizing the futility of the appeal or often unconsciously refusing to work); - a call requesting an appointment received between 23:00 and 8:00. I have great doubts whether a person is testing reality at all if he calls to make an appointment after 23:00 or early in the morning (this also raises the question of whether he is able to respect the time and boundaries of the Other). Such behavior may mean a psychotic state or indicate a psychotic organization of the personality of the caller; --- a request to accept on the basis of a recommendation, with a categorical refusal to name the person who recommended. This behavior looks very contradictory, so it is a good reason for the therapist to think about what is happening; --- uncontrollable sobbing with slurred speech at the first call. People often turn to a psychotherapist when “they have already had peritonitis,” and excitement, anxiety, a trembling voice and an unintelligible narrative happen. However, if a person calls in a state where he cannot control himself at all and explain what he wants, it means that he is calling the wrong address. It makes sense for the therapist to redirect him to a toll-free helpline; --- detailed questions over the phone about qualifications, work experience, experience, etc. The client has the right to find out all this (I will say more - during the first meetings I invite clients to ask me questions that interest them questions). However, such a “biased interrogation” over the phone is most likely an attempt by the client to find reasons for himself why he still does not need psychological help (“yeah, I told you that the psychologist graduated from the wrong institute to be able to heal me” etc.);--- request during the first conversation to accept outside the schedule (immediately). From my own experience I will say that such a spontaneous, impatient momentary desire fades away very quickly, and such a client either will not come at all, or will come with a clear misunderstanding, how a psychologist can help him (demanding “magic”). Therapy in such cases is practically impossible. --- an attempt to non-stop dump out “the whole essence” of the problem during the first telephone conversation. I understand that the caller is experiencing hope, excitement and anxiety, and by sharing his situation, he hopes to make sure that the psychologist understands, what’s the matter, and am I ready to take on such a case? Therefore, if the psychologist expressed his understanding and suggested continuing the discussion in a face-to-face meeting, the client who is ready to work will most likely pause his narration and be able to move on to the business part of the conversation. A client who ignores the words of the psychotherapist is most likely not calling for future collaboration. Such a person either needs “free” help over the phone (with a tendency to “squeeze to the last drop” everything possible from this conversation, to bargain for himself “a bunch of advice”), or he is very lonely, he is extremely mentally unstable, or he just wants to vent his suffering , to free himself from accumulated difficult feelings, and therefore uses the psychologist as a “drain bucket”. No collaboration herethe conversation, most likely, will not work; --- the requirement to provide first aid over the phone. I do not deny the importance and, in some cases, the extreme necessity of telephone psychological assistance, but I myself work in this format extremely rarely. And if the caller persistently asks to continue counseling only by telephone, without giving serious and clear arguments for this request (such as immobility), I will certainly refuse; --- an exaggerated aggressive form of conversation. Sometimes it happens that a person calling a psychologist for the first time so frightened that he unconsciously begins to try to take control of the dialogue situation and, as a defense, “tests” the psychologist in a somewhat exaggerated way, asking some questions or giving out his distorted fantasies (most often negative) about his personality. This is not an indication to declare psychotherapy with such a client pointless. Often the initial negative reaction quickly passes, and even during the first conversation, following a decrease in anxiety, the tendency of such a client to “attack” the psychologist decreases. But, although rare, people still call who begin to attack and fight right out of the gate, expressing their dissatisfaction in a rather rude form. This manifests itself in different ways: from phrases like “Do you even have any idea what depression is?! I’ve never suffered from it myself, I suppose!” and even to the point of outright swearing. For me, this is a sad symptom of the weak sanity of the caller; here, again, I can assume the presence of a psychotic state, and I do not work with clients who seek help in a state of psychosis. Now I’ll tell you about the alarming symptoms that a therapist can identify during the first meetings with a client, and from which he can conclude that the client who came to his office is not psychotherapeutic. During consultations: --- the client disrupts or postpones one or more of the first ten meetings. I will not continue to work with a client who misses an appointment (without warning in advance that he will not show up). This behavior speaks of disrespect for the specialist and his time (which, however, also speaks of a lack of self-respect). Such acting out will most likely be repeated in the future. Frequent delays at the beginning of work indicate that the client still has an immature desire to take the issue of helping himself seriously. And we are not talking about even a little cooperation here. Rather, we can talk about expecting miracles from a psychologist who will do everything himself, while the client either observes from the sidelines, or even worse - unites with his problem and opposes the psychologist, providing all possible opposition to therapy (which includes absence from the session); --- several delays in a row. This may indicate too high resistance to therapy, overwhelming anxiety or suppressed, passive aggression. Here it is important for the psychologist to think very carefully and evaluate what he may encounter in working with this client, if these symptoms arise at the very beginning of work, while there is still no working alliance; --- the client’s decision to postpone therapy due to some external non-catastrophic reasons: touring, registering a child for kindergarten, moving, exchanging apartments, changing jobs, etc. I am sure that whoever needs it will find the opportunity to continue working. Those who don’t need it will find reasons why it is impossible to continue. Sometimes a client, for example, wants to continue therapy, but with another psychologist, but does not dare (is afraid, ashamed, feels guilty) to voice his decision directly, so he does it indirectly or fraudulently; --- the client's age is up to 20 years. I believe that for serious psychotherapy it is necessary to achieve a certain level of personal maturity, so for people under 20 years old, up to 10 meetings may be enough, after which there is a decrease in nonspecific anxiety and their motivation for deep, long-term work is also noticeable decreases. The same thing happens, however, with some people over 20 years old. For example, infantile, immature clients, as well as people with a narcissistic personality structure. However, according toThis cannot be revealed by age alone; a diagnostic meeting is still needed, and sometimes more than one. In my practice, there have been rare exceptions when fairly young clients were able to remain motivated and continue long-term therapy. Also, for a number of reasons, I prefer not to work with some clients whom I classify as non-psychotherapeutic, namely: - people who have obviously reduced intelligence (which is typical, for example, for mental retardation in the stage of debility (IQ < 75) or in the case of some organic brain disorders);—socially dangerous individuals who tend to act out their aggressive and destructive impulses, that is, capable of causing harm to others and themselves;—clients with insufficient motivation (who came to therapy under the coercion of a third party and refuse to communicate in the process of work and/ or not ready to invest, spend their time, money, energy on psychotherapy, occupy their minds with it, etc.); --- with parents, children, spouses and close friends of those who are my current clients (or who were them in the recent past ), as well as with my friends, neighbors, specialists, whose client I myself am, and with colleagues with whom I have experience in joint group or other work. This restriction is not related to a personal attitude, but is an integral part of the Code of Ethics. In these cases, I will always readily and responsibly offer recommendations from my colleagues, whose professionalism I have no doubt about; I also admit that joint work with clients may be interrupted due to my decision, if already in the process of the therapy that has begun it turns out that: - the client violates important conditions and agreements that were discussed at the beginning of the joint work, and which he initially accepted (conditions of the setting , conditions for ending therapy, responsibility of the parties, etc.).--- the client violates the promise not to harm himself during the period of psychotherapeutic work (without notifying the psychologist of the emergence of such an intention), which is a violation of the anti-suicidal contract; violates the promise not to drink alcohol before or during meetings (as well as drugs and other drugs, with the exception of medications prescribed by a doctor), etc. In other words, I cannot help people suffering from alcoholism, drug addiction or chronic suicidal tendencies if these symptoms are completely impossible to control; - the client has a real history of being a rapist and/or child killer; - the client has diagnosis of schizophrenia, bipolar affective disorder, etc., made in an official medical institution, but hid it from me before starting work. In addition, I will most likely refuse to work if the client is a pronounced antisocial personality prone to physical violence; I wrote here about obvious facts that are an obstacle when concluding a psychotherapeutic contract or even making an appointment for the first time. Although there are exceptions here that require more detailed observation before making a decision. In addition to these cases, sometimes other circumstances come to light in which I quickly enough (usually within the first 3-4 meetings) can understand that our alliance with the client most likely will not work out (personal incompatibility, for example, when I have no relationship with the client basic acceptance, unconditional respect, background sympathy arose, without which it is simply impossible to build a normal supportive and then a working alliance). In this case, I prefer to honestly express to the client my doubts about the success of working with me as a therapist and, if necessary, suggest that he turn to another specialist (if necessary, I can recommend colleagues who, in my opinion, have more opportunities to work with this particular person ).* Special thanks a lot for this article written by Polina Gaverdovskaya, for pushing me to write this text about clients and client cases, with whom I am more involved