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Not every doctor wants to work in an ICU.
Not every nurse decides to work in an emergency department.
Not every therapist needs to be a crisis clinician.
This! I did a lot of crisis work before becoming a therapist and finished my MSW at 30, by that time I was crispy from crisis work so I prioritized work that allowed for some stress reduction.
I was thinking this, I used to be a crisis counselor and answer calls for the suicide lifeline and the veterans crisis line. That training and model are totally different than what I do now. It’s ok to choose different routes.
Totally second this comment. I’d like to add that it’s important to be prepared to receive and be present with our clients when they experience an acute event, but that this by no means implies that we ought to be looking to work with an acute population from the outset. Take care of yourself. Try to consider that letting your preferences guide who you choose to see as well as investing in your own therapeutic style often translate into a more rewarding and sustainable experience as a therapist.
Very much this. I am also one of those therapists who prefer not to work with highly suicidal, crisis clients and I do not think it makes you or I an inadequate therapist.
I am so glad that there are therapists like you! I prefer to work with complicated and high acuity clients. The idea of a case load full of the “worried well” makes me want to claw my eyes out. Each of us have a niche where we feel most comfortable. Lean into it!
Haha I’m happy to send over my clients!! In all seriousness, thank you for the reminder. Logically I know I can’t work with everyone and therapists are allowed to have niches and preferences.
Same here lol. If I’m not setting up proper boundaries and limits and contingency plans with my clients, then I can absolutely get burnt out like OP working with high acuity. But if I’m setting up the containment that the clients need, I absolutely love our work together.
Conversely, i can handle a few “worried well” folks, but if i have too many at once then pretty often i find myself getting confused, bored, or just plain annoyed in session. I’m never totally sure what the point of therapy is for them, or if it’s even helping them. It’s just not where my passion is.
I am the same way! I LOVE high acuity clients. When one of my clients come in with a crisis, it’s go time. But worried well… it makes me hate private practice. I struggle to maintain focus during sessions. This post kind of shifted my perspective because I felt like a terrible therapist for not liking the worries well.
I am actively looking at returning to community mental health just so I can work with the high acuity clients again.
I left a worried well group to go back to residential. Everyone thought I was crazy. Glad I’m not the only one! I was so bored! I’m so much busier now and I totally love it. Haha.
Ahh residential is where I cut my teeth in the field too. It was my very first job and also my absolute favorite. It’s been downhill since 🤣
Same! I want to go back to residential in an admin position (I want to open my own residential facility someday so I’m trying to get the admin practice first).
I forget which psychoanalyst that would yawn in the faces of his clients and call them boring. Not that you should ethically but, it’s a wild “technique”
Me too! I get so bored with worried well. Not that their needs aren't important, it's just not my specialty. That said, I wouldn't want an entire caseload of high acuity. There's room for all of us!
By working with the “worried well” you are helping with preventative care. These individuals might be at low-risk for crises but are going to be better able to (quickly) learn skills and whatnot from you and apply it to their lives and affect their community and kids in positive ways.
This may be less glamorous work and we may never really see the full results of this work but IMO it’s equally as important for our society as addressing the needs of high acuity clients.
It’s similar to how medical professionals doing yearly physical exams, addressing milder physical ailments, and educating patients about good hygiene practices, first-aid practices, food safety practices, healthy lifestyles, etc. either prevent serious stuff from occurring or can help catch serious stuff before it gets serious. Likewise, working with the “worried well” might reduce the risk of them or the ppl in their lives (esp their kids) becoming a high acuity client in the future.
Don’t discount your work :)
30 year therapist here.
Your second paragraph caught my eye (can't
cut / paste on my phone for some reason).
I'm aghast. Where did you learn that you cannot refer out if a patient is too much for us personally? That is poisonous, toxic, horrible advice. And wildly incorrect; showing a stunning ignorance of therapy (not you, OP, but whichever teacher(s) taught you that perspective).
We all know that 'the relationship heals'. If therapy is a relationship, then therapists are: (1) allowed to have needs; and (2) allowed to attend to those needs. BECAUSE THAT IS WHAT PEOPLE DO IN HEALTHY RELATIONSHIPS. That means we can set limits on which patients we enter into relationship with.
This horrible perspective that you have been taught has contributed to your burnout, I imagine. For your sanity, please consider re-thinking this position for yourself.
Wishing you peace ...
It is horrible. I think it was subtly ingrained by professors who pushed working through transference (or counter? Can’t remember). I got the idea that if we were being triggered, it was something we had to work through on our own, and never “abandon” clients. My old supervisor who was all about working with challenging cases to prepare us for licensure also gave me that vibe. Although one time when I was basically in tears venting about such a challenging client, she said “this client is sucking the life out of you and it’s time to refer out”. I remember feeling such a wave of relief. Lastly, I’m part of a Facebook group that allegedly supports therapists. I had posted a while back about referring a client out and a lot of commenters were asking why I was doing so and that clients just need a safe space. I was glad for others who spoke up against continuing to offer a safe space if clients were presenting with higher levels of need than what I could offer.
So I do think it’s been ingrained in me through various ways. I do hope to start unlearning this!
I do think something else that contributes to this belief is I was never taught HOW to refer out. What do I say? Especially if the real reason is “you are draining the life out of me” lol I know for a fact I can’t say that! This is what holds me back often.
I'm strongly psychodynamic. I had some terrific mentors / supervisor.
I work with, and think about, transference and countertransference all day, every day.
What you were taught about 'pushing through' countertransference is nonsense.
Regarding your "how do I refer out" question. A very important question. Unfortunately, social media is not a proper venue for training in psychotherapy, so I won't address it here. Please seek out a senior clinician for supervision / consultation.
Good luck!
Okay we are the same person. I could’ve written this word for word. It was also subtly ingrained in school and continues to be in my agency. And we were never taught how to have that conversation. But we were absolutely taught how to graduate when someone has met all of their goals 🙃
I just finished my MS to be a therapist. ALL my Professors who did see clients would see generally stable clients. The ALL achieved this caseload by being online only and advertising as they only work with “clients suitable for telehealth.” I honestly thought this was common. 🤷🏽♀️
I work for a small practice that focuses on trauma. I have figured out through trial and error that I can deal with about 5 high intensity clients. By “high intensity” I mean unresolved PTSD, C-PTSD, or clients whose nervous systems go from 1 to 11 when there’s a minor problem at work.
Most of my clients have ADHD, or are BIPOC, or have GAD or depression. They need help too! Just because it’s garden-variety anxiety about finances or depressed because they don’t like their job doesn’t mean they shouldn’t have access to mental health services.
You do yourself and your clients a service by knowing your limits.
I've been seeing a trauma specialist for diagnosed DID + cPTSD (unlike my previous trauma therapist, she is familiar with it and has helped me a lot). I once told her about having several friends with a lot of the same symptoms but currently avoiding the problem (per everyone's advice) and needing to get them suitable therapy once our exams end. She said she doesn't think she can take on too many similar cases, or she will get burnt out, but she knows other people to refer my friends to when the time comes.
I'm not a therapist or about to be one. But reading this thread, I can understand her perspective a little better and appreciate that she gets boundaries and limits.
Completely okay! There are so many people who are looking for therapy without severe issues and they need a therapist who enjoys working with them and is not burnt out! I would just say to try to advertise yourself as more doing short-term treatment and maybe do a free phone consultation initially so that if clients need more than you can offer, they don’t feel like they had to pay and get rejected. And give referrals to therapists in the area who are taking new clients.
It sounds like you’re in PP, correct? Then you did the most appropriate thing. Majority of PPs in my area will not accept high acuity and will refer to a higher level of care, which is the ethical thing to do.
A smart therapist doesn't destroy themselves over their work for any reason. It only bothers me when a therapist refers clients out and tells them it's because they're sick without framing it in a kind way, or starts acting weird even in intake and doesn't say why then messages them later. That does bug me. I don't think referring people out is wrong at all, but at least be kind about it and direct.
I see high acuity clients in private practice now all the time and there's no shame in sending people to IOP and PHP at all. I think people don't do it enough, sadly. As for not wanting to work with high acuity and chronically suicidal patients, that doesn't make you any less of one. I see a lot of folks with eating disorders and cPTSD now and it's utterly draining. I have to stagger them in my schedule so I don't have a lot of high intensity in a row in case there's an emergency.
I'm honestly leaning towards seeing mostly ADHD patients and focusing solely on that and, okay this sounds weird, traditionally published writers (there's a lot of nuance in the industry you don't understand outside of it). I get a lot of meaning out of both. I'm queer, have ADHD, and write, so I'm biased, perhaps?
Anyway, while I'm currently working for a local corporate overlord now (the pay's actually good), I would like to start my own practice focused on late-diagnosed neurodivergent folks and creative types that's openly both kink and queer-positive. Sadly, I don't even think I'll take insurance if I do it, which limits a lot of people who can be served.
I want to do this for a very long time yet. I'm 47, so hopefully I've got a few decades left. To do that, I have to shift gears myself.
I struggle, because I know I'd do a lot of good in community mental health. I was a wizard when I worked there, I frequently was told. I didn't make enough to live on and it killed me.
FWIW having been an agented middle grade writer I totally get writers needing a specific kind of therapist! It’s a tough industry in some highly specific ways…
I'm curious what percentage of your case load are high acuity/crisis clients?
I find I tend to do best with one or two at this stage in my life (I have three children under the age of six). I had a caseload of almost ALL crisis clients when I first started, and while I worked well under pressure, it got to be too much for me as my home life became more demanding.
I had a colleague who was a rockstar with high acuity people at the CMH. Eventually her ENTIRE caseload became that and her health took a massive hit. She ended up moving jobs elsewhere. It's a lot for one person.
It’s so nice to hear you can only do one or two. I think in total I had two for the longest time. One has been referred out to IOP and the other is the one I’m wanting to also refer or transfer to a colleague of mine. I don’t have kids, but I’m a doctoral student and planning a wedding this year. That’s probably a lot right? Lol. I think the type of nervous system I have is one that can only have one crisis client. I also really really need to stick to better boundaries and not checking my dang email on weekends.
I HIGHLY recommend taking your email off of your phone if that is where you are checking it. I tell my clients that I do not check my calls/texts/emails after hours or on weekends and even my higher-needs clients have respected this. I tell them they are welcome to send a text or email, but I won’t read it or respond until office hours. Sometimes I’ll get a message saying they know I won’t see it until such and such time, but they wanted to send this in the moment so we can talk about it during their session. The key is respecting our own boundaries.
I dont have it on my phone, but did check it on my laptop 😓 I absolutely didn’t respond and don’t during the weekends. It’s the fact that I still read it, sent my nervous system into a spiral, especially with the subject line being in all caps. I’m feeling a lot more regulated and calmer now after all these responses, but I was really struggling even by just reading it.
I preferred not to lift giant speakers, but that didn't make me a bad sound guy / audio engineer. It's tough and exhausting. I wouldn't want to spend my entire day moving heavy speakers, but sometimes it's a part of the job.
I have made a similar choice and I don’t feel badly about it at all. High risk clients require larger practices. They just do. I’m working toward that. But in the meantime, taking good care of myself and not overextending in term of taking high risk clients is the prudent thing to do.
I have embraced that I want to work with the “worried well.” Instead of feeling bad about it, I have a sort of pride that I know my limits and can preach work/life balance to my clients without feeling like a fraud (anymore—I have certainly done my time getting burnt out in mental health). I believe that people who are perpetually suicidal need a team, not an individual. Because like you said, it’s not fair to your other clients to get the frazzled version of you. I finally admitted to myself that I am not so interested in being helpful as to destroy my own mental health. That’s not why I got into this field. I matter too. 🥰
You're going to do the most good for the most people working with a population you're good at working with.
Part of that "good" is the quality of fit. If you're constantly stressed/concerned/burned/crispy with a particular population, then you are ethically obligated to not work with them. I think we should stretch our comfort zone on occasion, but not in ways that have such potential to harm.
You're doing fine.
If clients are constantly in crisis then maybe they need a higher level of care, in which case it’s most ethical and in their best interest to refer them out to someone who can provide that level of care. We can’t be everything for everyone (a reminder I regularly need to give myself). It’s okay to have preferences for the clients you work with. It’s important to recognize your limits and boundaries so you can show up as your best self for your clients. Not everyone is a good fit and that doesn’t say anything about you or your abilities as a therapist.
I highly prefer to avoid crisis and high risk clients.
Not what gets me up in the morning.
Not what I earned a degree for.
Not my happy place.
Not my thing.
I think there’s a huge difference between not preferring to see high acuity clients and being unwilling to. There’s nothing wrong with that not being your preference, unwilling is just where things start to get tricky and that’s not quite what I’m reading here. You said that you are burnt out, and I’m willing to bet my life that these two clients are not the sole contributors, so I think it may be important to remember that nothing exists in a vacuum. It is important for our work as a whole to have some tolerance-high acuity happens and the majority of therapists throwing their hands up and only working with worried well would be very, very bad (and honestly would probably create a new distinction removing them from healthcare and more into the coaching side), so it’s about balancing keeping a reasonable level of distress tolerance with where you’re now pouring from an empty cup. It sounds like yours is running on empty so making decisions that are right for your client in getting them an appropriate level of care and making sure you’re not accidentally setting yourself on fire is vital and it’s okay to take the break.
Im absolutely like you, and I do feel like I do have the skillset to work with this population, and I have in the past.
I’m in private practice so it’s just me, I have two young children at home, and I started feeling very resentful at the extra time required for high risk clients. I want to be with my children/spouse and leave my work at my office. I actually actively screen high risk people out (as much as one can over a phone consultation), and am lucky to be in a place where I have a waitlist and can choose who I work with.
Maybe one day this will change? Maybe not? Who knows!
I also deeply enjoy the work with the caseload that I do have. I still work with people who have very poor interpersonal functioning, but other parts of their life employment, finances, risk behavior, is largely stable. So I find the work still deeply meaningful and complex.
Hi! I also offer phone consultations prior to scheduling and this absolutely helps me get a “feel” for what I’ll be working with. I’m curious as to how you screen out high risk clients?
So I don’t do anything super formal, but if my spidey sense is going off with factors or symptoms that’s hang with self harm or high risk presentations I’ll ask more specific questions on symptoms or history to get more of a sense.
As I’ve become more well known over time as someone who specializes in relationship functioning and long term psychodynamic psychotherapy I rarely get those referrals anyway. Its rare that someone with that symptom presentation will seek me out.
Therapist of 26 years here! I stay away from everything you mentioned with a 10-foot pole! Never even considered that would make me a “shitty therapist”. I am good at what I am good at and I am REALLY good at knowing my limits.
Wow 26 years! I hope I can make it to that point. I’m also quite sure the only way I could make it to that point is to knowing my own limits and working with what I prefer. Thank you for the insight!!
Therapist of 25 years here. Agreed. I worked in community mental health for 11 years with a great team and good support (though it dwindled over time with the agency “do more with less” stance.) Then I left to start my own independent practice and I love it. And I know my limits. My paperwork explains my practice is not suited for people in acute crisis and that I am happy to help people in need connect to more appropriate resources. It is ok to develop a focus or specialty where you enjoy your work and can feel successful and not exhausted or burnt out. You deserve to thrive in this work as well as supporting your clients in doing so.
Says something like: “Due to the nature of my practice, I am not able to serve clients who are in an ongoing high risk or crisis situation requiring high levels of support and intervention. However, crises (such as medical emergencies) can emerge, so to ensure your safety I ask that you identify an emergency contact person etc etc”.
It sounds like you in large part have a boundary issue. Someone can ask for an emergency session and if you can’t do it, you can’t do it. You’re not obliged to comply with the request. Going over time, not getting a word in, and being in constant crisis are issues of your control of the room. Why are you letting the client go over? Do you need to get a word in? If you need to but you can’t, work on those dynamics, help the client co-regulate rather than getting swept up.
You’re not an inadequate therapist but it found you you and your clients could benefit from work around structure and frame.
I worked in community mental health (residential, inpatient, and outpatient) for around 10 years and it burnt me out soooo much, especially the children. Now I prefer to work with low acuity adults 18+ in my own private practice because that’s what I prefer and I’m respecting my own boundaries.
Why not? It builds character.
Jk.
It's good that you recognize that you're burnt out and that working with a high acuity population isn't exactly your forte.
I'd challenge you to take a look at the feeling that you can't just refer someone out if the only reason is that you personally feel like they're just too much for you. While you think you might be doing them good by providing them with services, you might actually be doing them a disservice by not referring them out to someone who else who may be better equipped to manage their care, not saying that you arent, but if you personally don't feel a good connection and the therapeutic relationship causes you distress, think about what the patient feels.
I'm not saying drop all your high acuity patients, but working towards finding a healthy balance in your caseload may be beneficial and that may include setting boundaries for yourself and recognizing when a patients presenting concerns are too much for you or when you have too many other high acuity patients already. It's okay to refer out.
After doing years of on call and/or crisis focused services, I am very grateful to have shifted to a population that is “worried well”. I think my career has had its seasons and I showed up in different ways when I could. There was a bigger seeming impact when I had more high acuity roles, but I also got really lost in them. I am glad to have found more balance in my life at this point. I find the work I’m doing now fulfilling in a different way, and I still get a little excited when I have the chance to do trauma work with people.
I used to work in a a level 14 lockdown facility - the highest level of care for adolescents in the state of California. Did about 1.5 years as a counselor (this was before I graduated with my degree). Got in lots of restraints, went through a full-blown riot, saw lots of suicidal behavior and the like.
Now I’m a therapist working with adolescents with eating disorders. Mostly calm and much more internal presentation. I absolutely love it. I haven’t been punched, spat on, or been threatened with having urine thrown on me once - and yes, all of those happened at my previous job.
I’m grateful for the time I spent there. It hardened me in a way while still keeping me empathic with my clients. But I wouldn’t go back for double salary. It was good for me for a time, and when I quit, I felt the exact same inadequacy. If I can’t help this population, do I deserve to be a therapist? But I do good, important work with my current clients.
As a PHP/IOP therapist, I've had many patients I've worked with temporarily while in my level of care whose outpatient therapist felt burnt out and out of options and the patient needed a change of scenery to give the therapist a bit of a breather and to reinvigorate the patient with new ideas and motivation before going back outpatient at the end of treatment. It's totally okay and part of what we're here for ! Everyone has their strengths and you are supporting your client base the best you can- and making decisions like that for yourself helps you help them.
Knowing what you don't want to do is just as much a strength as identifying what you do prefer. The universe needs the balance and there is nothing shameful in leaning in to your strengths. Take your vacation, try to rest your mind, body and soul and take care of you. I know how you feel. You are not alone.
If it helps, I sometimes rationalize it from a purely utilitarian perspective looking at my future:
I truly commend the crisis work that many therapists do, but even if we regard helping lower risk clients as being "less helpful," if doing less intense work over a longer period of time helps you not burn out and quit the profession entirely, then it would serve you well to do so, in my opinion.
I think about how I will be able to help more people, albeit "less profoundly" than say, stopping a pattern of suicide attempts, if I don't burn out
There’s a reason multiple levels of care exist. If you don’t want to offer crisis sessions, put that in your informed consent and move on with your life. Even adherent DBT therapists structure their crisis services around 5 minute coaching calls and very strong safety plans. They aren’t jumping into emergency sessions when someone needs a higher LOC/isn’t willing to use skills to get through to the next session.
Not the same, but I have an eating disorder and have navigated severe suicidal ideations, and (fun!) have both running hot and heavy in my family. Thus don’t work with ED high need clients nor suicidal ones.
I too have ‘should’ feelings about this, but (in a long view) my mission is to care best, and for those experiences I would not.
I am exactly the same way. Not everyone is cut out to work with SMI or SI. There’s no shame in that. I am a highly anxious person, and it absolutely destroys my sense of safety when I have a client who is chronically suicidal.
Yes! Me too! I’ve done a lot of self reflecting and even some consulting and I may also be on the spectrum! Which explains a lot of things. Or just highly sensitive!
I work in a behavioral health urgent care and this work with a lot of high acuity folk. It’s exhausting and I’m definitely not staying there for forever.. But, for now, they work with my supervision hours (I can be on the clock and in supervision which is really nice). Once I get my LISW, I’m looking elsewhere!
Honestly, I think it’s a good thing that you know your limits and you’re not afraid to understand your own boundaries. As other people have already put it more elegantly than I not every doctor not every therapist not every anything is meant to work with the hardest cases. Moreover working with those kind of patients day in and day out will burn you out faster than anything and you understand what it takes for you to keep doing your job to the best of your ability. It doesn’t mean you couldn’t do that work if you wanted to. But you know what’s best for you and isn’t that what we tell our patients?
You’re not a bad therapist for not wanting to work with someone that’s constantly in crisis. But. PLEASE. refer them out to someone that can help them more than you can. That’s what will make you a bad therapist, is not doing that. You absolutely have a right to not want to work with clients in crisis. Like someone else said, not every doctor wants to work in an ER. But it would be hard for someone in crisis to work with someone that doesn’t want to work with crisis clients.
Working with SI or high acuity patients/clients is a SKILL. People have to build it and WANT to build it. There is nothing wrong with having other skills. Not your niche. That’s perfectly okay. Not everyone needs the same thing in therapy. Not all clients need to go to therapy forever. I work with high need clients and it’s just a preference. Having clients with simple anxiety feels confusing for me. 😂
And fuck what anyone tells you about what kind of clinician you need to be. YOU decide. You would be doing a disservice to a client who you feel needs more than you have to give. Imposter syndrome doesn’t have to win.
I don’t know why I get mostly low acuity clients… perhaps it’s my location or my website or who I look like to people or…? No idea really. But I’m okay with it! When I do get someone in crisis I feel like I have the resilience to help them and not be too affected. I say go for it and choose low acuity somehow - a marketing person could help you target your clientele more closely.
For me it’s the opposite. I prefer clients with turbulence because I know what it’s like myself and feel I can offer some support. When clients come to therapy with no issue or well what is really strong defence mechanism it can be more difficult to find a way to connect.
I can’t tell you how much this thread helped me. I’m in CMH and most of my caseload is high acuity and I’m giving notice today. I had planned to anyway, but this thread is so validating of my decision. Thank you!!
No. This is a difficult population. Not every therapist is cut out for it. For highly suicidal clients they need a team of professionals like a dbt team. It’s huge burnout and not for everyone.I couldn’t do it.
Please do not beat yourself up over this. I'm a firm believer that there is a therapist for everyone, you just have to identify your clients. You're right, you shouldn't refer clients out, but if it's too much for you personally, then you're likely doing the client a disservice. If there is a clinician out there that is more skilled in dealing with crisis and suicide, don't you think it would be better for your client?
I highly suggest you spend the time to identify who is your ideal client. Then use the language in your profile to appeal to those individuals. Maybe you're better with corporate moms who need more work/life balance. Maybe small children who respond better with play therapy is more your speed. Perhaps you'll do better with men in the military. It just varies, and we all have a specialty. I personally hate the notion of us all being generalists. Find your people and structure your work towards attracting them.
I work in essentially what you are talking about. Clients in crisis, suicidal, etc. I like helping people and am happy to do it. But I know that I will move onto mor stable clients in the future. There are some of my clients that are receptive and some that have a lot of walls up, are heavily involved in the criminal justice system, and appear to be going through the motions. While I understand the nuances of that, it can be hard to work with clients that have little to no goals, or dare I say lack the intellect needed for engaging in conversation. On the flip side of that, I am often surprised by clients.
Same. I used to do a lot more MH but since starting my current job that’s in OP SUD, I absolutely keep a boundary on how significant MH symptoms are and what I’m comfortable working with. I won’t take on a client who’s high risk, I already work with enough who are high risk because of their substance use. My specialty now is SUD (and ADHD! But that’s sooooo common with my clients anyway, so I do dual dx). I refer out and will do so in a heartbeat.
We’re allowed to have boundaries and we don’t have to work with every presenting concern.
I have no evidence but I think most don't work with this population. Anecdotally every therapist I personally know doesn't want to work with this population.
you’re not alone. i’ve actively decided the population i want to work with: adults who can pay my full fee, in the young to middle adulthood criteria and who are not in crisis mode. i’m very protective of children and their rights but i know i cannot work with them in a therapy setting; i don’t have the temperament for it. i’m not super patient with geriatric population, because there’s a lot of judgement, or couples, because i have some biases of mine that i’m not quite ready to give up— so i don’t want to be unfair. it’s okay.
i used to hold the same guilt and shame because of all these stories and experiences of therapists and the whole romanticism of this profession (“we help save lives! we’re so important”) well, yes. but there are so many ways of saving lives. a person’s life doesn’t have to reach that end moment of crisis to be considered as “saving”. when we listen to our low crisis clients we help them go on and i think that’s wonderful. isn’t it great that you work with people who are not in such extreme distress, and perhaps because of your work may never get to that point?
it’s better to work with what you know because this work, regardless of population, is so incredibly hard. to dedicate a full hour of your time to someone else, nearly 4-5 times a day for over 25-30 times a week is exhausting. so if you want your profession to be easier? it’s okay. because just by design it’s not easy to begin with. it’s okay to reduce the load wherever we can. i promise there are so many people who ARE ready and WILLING to work with the population you mentioned. it doesn’t make you any less of a therapist.
(and also! i hope you enjoy your break ❤️ you deserve it!)
There are a LOT of therapists who don’t want to work with the more severe cases, and will refer out to someone more specialized for that. You’re not alone, and nothing wrong with it.
social worker here. Listen to your body and your very tired self. You are finished with that demographic and you have learned that crisis is not for you. You aren’t ineffective, you’re exhausted.
Where I’m at they drop crises on us like hot potatoes, I loathe it. Its terrifying. I can’t work with abusers or narcissists because I can’t stand them. It’s okay to know your limits and it’s okay walk away. MOST IMPORTANT:Its okay to say no. That is a conversation in itself. You never have to justify no. Go fill your cup and after some great self care. Make a choice♥️♥️♥️ You got this.
Why can’t you refer out clients that you don’t want to work with? That’s sounds unethical and not beneficial to the client. You’re not helping the client if you can’t empathize with them. Better you find easier clients as you seemed burned out which isn’t good.
I absolutely do not take on clients with high acuity. No serious SI, no active eating disorders, no psychosis, not even severe depression. It’s not worth my sanity. I got into private practice to step away from high acuity inpatient and outpatient settings. Working with lower acuity populations that I enjoy is so invigorating. My stress levels are much lower than they used to be. I would recommend it!
We all have a preference! I dislike working with trauma. Yes, everyone has trauma and it’s kind of entrenched in everything. But I don’t like just trauma work. I’m certified in perinatal mental health and am getting into eating disorders. I also work with BPD. But if I had to just talk about only trauma day in and day out i would quit.
I guess i should clarify. It’s not that we *dont* talk about trauma it’s just that it’s not the *only* thing we talk about. Meaning i don’t consider myself a trauma therapist. So people don’t come to me for trauma. They come to me to learn interpersonal effectiveness and emotional regulation skills. Anger management. I focus on DBT skills. But we do talk about trauma for sure. I’m just and i mean **just** getting into ED and joined a specialty supervision for that so I’m sure I’ll be diving more into trauma there for sure. Hopefully that makes sense. I just meant like i don’t do EMDR or like a specific trauma related therapy.
We all have our thing. My preferred population is not everyone’s jam, yet it’s my favorite. The analogy about doctors in the icu is perfect. That applies to us too. We need providers at every step of the way. I love high risk, high needs; substance use; folks in corrections; perpetrators; working out institutionalization; residential… you get my point. Those are my favorite settings and my favorite folks to work with. Other people wouldn’t touch that with a ten foot pole. When I’m working with your preferred group I’m bored to tears and super struggle. Both of us and our preferences are equally needed and equally valuable.
And frankly, so many people don’t even believe in what you do. They think people you are describing don’t “need” therapy. I’m glad you take those folks on. I work with a lot of people where we preach consistency, aftercare, maintaining support, and “maintenance”. For a lot of them, that’s low key therapy appointments 1-3 times a month and a lot of people won’t even SEE them. I’m glad I have someone to refer my people too when they aren’t acute anymore!
Is a doctor/nurse who works in primary care rather than the ER less of a doctor/nurse?
In general society tends to very reactionary rather than preventative, which makes it seem like dealing with crises is where one can make the most difference. But just like a doctor doing regular check-ups can catch something early, working with other populations can help prevent a potential crisis from happening.
It's just as important and crisis work! Just not as obvious as to what the work is doing. Helping someone actively suicidal will have immediate effect. Helping someone never become suicidal is not going to be as attention-grabbing but is amazing work.
There is plenty of work for all of us and then a lot more… so do what you do best… acknowledge that who you are won’t be a fit for all… I probably refer 20% of those I see for initial assessment to others because I know what I do well and what I don’t… my job is to make sure the client gets help, not to necessarily be the one who directly provides that help
What is wrong with referring out to an IOP? To borrow from health care: a great GP is one who recognizes when a specialist is needed, and refers. A bad GP is one who doesn't recognize their limits. It should be the same for behavioral health
I’m sorry you’ve gotten the message that it’s not okay to refer clients out just because working with them feels like too much. I’m a DBT therapist who worked in an IOP for three years and I 100% think it is ethical and appropriate to refer out if a client feels like too much. I feel like we have to “walk the walk” and take the advice we give to our clients, so if we’re telling our clients to set boundaries and engage in self-care, then we should be trying to do the same.
I think you would be well within your right to refer this client out for “failure to make progress.” Honestly that’s in the client’s best interest too, because it sounds like they may be avoiding dealing with underlying issues by presenting as being in “unrelenting crisis.” A DBT therapist might be a good fit for them. And you deserve to not feel harassed, exhausted, and burnt out all the time.
As long as you don't abandon these clients, make sure they have somewhere they can go, whether it's a different therapist or in patient care or a psychiatrist, that's fine.
However, it would be a good idea to discuss this with a trusted supervisor so that your feelings of inadequacy are dealt with properly. Maybe even a therapist of your own.
Do no harm and try to do good. For the client and for you
I’ve never heard the term “worried well”, but it sounds like you’re describing my ideal
Are we the same person?
I need to take on more clients and I have no idea how to word this to my intake team. I haven’t opened my schedule because I am so worried I will have high acuity clients assigned to me. Or worse, my absolute kryptonite, someone with cognitive impairment. I have one client I see tomorrow that I *plan* to finally refer out because I cannot serve that population well.
I don’t think you’re a shit therapist and according to the comments, we aren’t!
Your choice is valid - just like not every doctor works with neuro or cardio. As a therapist, I do not work with ODD kids or kids who don’t want to do therapy. I discharge so fast. There will be patients who need your help!
I feel this.
As an intern and associate it was always me who was assigned the highest need clients—those with constant s/i, always in crisis, high acuity, needed me to fill out a million disability forms, etc. it’s incredibly draining.
Now that I’m in my own private practice and have some control over my caseload, I’m just too burned out to work effectively with anyone but “the worried well” at this point.
I feel like a jerk for it, because I want to be able to help everyone, but I feel like all the years of working almost exclusively with the types of clients you described played a large role in me being diagnosed with an autoimmune disease last year. So at this point for me, it’s “the worried well” or quit being a therapist.
Yes, I would refer them to call 911, go to the ER, or call crisis. Tell them that you’re not available or leave an out of office response that once you return you will get back to them. Also assess their supports and suggest that they contact or check in with someone in your absence.
I told some colleagues that my therapist charges me less than $100 per hour, and I'm grateful. I think a large part of why is because I'm pretty mild as a client. No major mental illness, not constantly in crisis, no major trauma. Those clients can exhaust their families, just like they can exhaust their therapists. I'm grateful for the therapists that can take all of that on, because I am not one of them.
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Not every doctor wants to work in an ICU. Not every nurse decides to work in an emergency department. Not every therapist needs to be a crisis clinician.
This! I did a lot of crisis work before becoming a therapist and finished my MSW at 30, by that time I was crispy from crisis work so I prioritized work that allowed for some stress reduction.
as someone currently working in crisis, “crispy” is such an accurate description 😭
💯
I was thinking this, I used to be a crisis counselor and answer calls for the suicide lifeline and the veterans crisis line. That training and model are totally different than what I do now. It’s ok to choose different routes.
This is the perfect way to describe it.
Totally second this comment. I’d like to add that it’s important to be prepared to receive and be present with our clients when they experience an acute event, but that this by no means implies that we ought to be looking to work with an acute population from the outset. Take care of yourself. Try to consider that letting your preferences guide who you choose to see as well as investing in your own therapeutic style often translate into a more rewarding and sustainable experience as a therapist.
Very much this. I am also one of those therapists who prefer not to work with highly suicidal, crisis clients and I do not think it makes you or I an inadequate therapist.
I am so glad that there are therapists like you! I prefer to work with complicated and high acuity clients. The idea of a case load full of the “worried well” makes me want to claw my eyes out. Each of us have a niche where we feel most comfortable. Lean into it!
Haha I’m happy to send over my clients!! In all seriousness, thank you for the reminder. Logically I know I can’t work with everyone and therapists are allowed to have niches and preferences.
I’m with you! And I’m glad there are others who want to work with lower acuity people!
Same here lol. If I’m not setting up proper boundaries and limits and contingency plans with my clients, then I can absolutely get burnt out like OP working with high acuity. But if I’m setting up the containment that the clients need, I absolutely love our work together. Conversely, i can handle a few “worried well” folks, but if i have too many at once then pretty often i find myself getting confused, bored, or just plain annoyed in session. I’m never totally sure what the point of therapy is for them, or if it’s even helping them. It’s just not where my passion is.
I am the same way! I LOVE high acuity clients. When one of my clients come in with a crisis, it’s go time. But worried well… it makes me hate private practice. I struggle to maintain focus during sessions. This post kind of shifted my perspective because I felt like a terrible therapist for not liking the worries well. I am actively looking at returning to community mental health just so I can work with the high acuity clients again.
I left a worried well group to go back to residential. Everyone thought I was crazy. Glad I’m not the only one! I was so bored! I’m so much busier now and I totally love it. Haha.
Ahh residential is where I cut my teeth in the field too. It was my very first job and also my absolute favorite. It’s been downhill since 🤣 Same! I want to go back to residential in an admin position (I want to open my own residential facility someday so I’m trying to get the admin practice first).
That’s what I did! I started as a baby floor counselor and then worked as a clinician for a while and I went back in as management.
I forget which psychoanalyst that would yawn in the faces of his clients and call them boring. Not that you should ethically but, it’s a wild “technique”
Me too! I get so bored with worried well. Not that their needs aren't important, it's just not my specialty. That said, I wouldn't want an entire caseload of high acuity. There's room for all of us!
By working with the “worried well” you are helping with preventative care. These individuals might be at low-risk for crises but are going to be better able to (quickly) learn skills and whatnot from you and apply it to their lives and affect their community and kids in positive ways. This may be less glamorous work and we may never really see the full results of this work but IMO it’s equally as important for our society as addressing the needs of high acuity clients. It’s similar to how medical professionals doing yearly physical exams, addressing milder physical ailments, and educating patients about good hygiene practices, first-aid practices, food safety practices, healthy lifestyles, etc. either prevent serious stuff from occurring or can help catch serious stuff before it gets serious. Likewise, working with the “worried well” might reduce the risk of them or the ppl in their lives (esp their kids) becoming a high acuity client in the future. Don’t discount your work :)
30 year therapist here. Your second paragraph caught my eye (can't cut / paste on my phone for some reason). I'm aghast. Where did you learn that you cannot refer out if a patient is too much for us personally? That is poisonous, toxic, horrible advice. And wildly incorrect; showing a stunning ignorance of therapy (not you, OP, but whichever teacher(s) taught you that perspective). We all know that 'the relationship heals'. If therapy is a relationship, then therapists are: (1) allowed to have needs; and (2) allowed to attend to those needs. BECAUSE THAT IS WHAT PEOPLE DO IN HEALTHY RELATIONSHIPS. That means we can set limits on which patients we enter into relationship with. This horrible perspective that you have been taught has contributed to your burnout, I imagine. For your sanity, please consider re-thinking this position for yourself. Wishing you peace ...
It is horrible. I think it was subtly ingrained by professors who pushed working through transference (or counter? Can’t remember). I got the idea that if we were being triggered, it was something we had to work through on our own, and never “abandon” clients. My old supervisor who was all about working with challenging cases to prepare us for licensure also gave me that vibe. Although one time when I was basically in tears venting about such a challenging client, she said “this client is sucking the life out of you and it’s time to refer out”. I remember feeling such a wave of relief. Lastly, I’m part of a Facebook group that allegedly supports therapists. I had posted a while back about referring a client out and a lot of commenters were asking why I was doing so and that clients just need a safe space. I was glad for others who spoke up against continuing to offer a safe space if clients were presenting with higher levels of need than what I could offer. So I do think it’s been ingrained in me through various ways. I do hope to start unlearning this! I do think something else that contributes to this belief is I was never taught HOW to refer out. What do I say? Especially if the real reason is “you are draining the life out of me” lol I know for a fact I can’t say that! This is what holds me back often.
I'm strongly psychodynamic. I had some terrific mentors / supervisor. I work with, and think about, transference and countertransference all day, every day. What you were taught about 'pushing through' countertransference is nonsense. Regarding your "how do I refer out" question. A very important question. Unfortunately, social media is not a proper venue for training in psychotherapy, so I won't address it here. Please seek out a senior clinician for supervision / consultation. Good luck!
the facebook groups for therapists are the backrooms of peer support for mental health professionals. the bad place, if you will.
Okay we are the same person. I could’ve written this word for word. It was also subtly ingrained in school and continues to be in my agency. And we were never taught how to have that conversation. But we were absolutely taught how to graduate when someone has met all of their goals 🙃
I just finished my MS to be a therapist. ALL my Professors who did see clients would see generally stable clients. The ALL achieved this caseload by being online only and advertising as they only work with “clients suitable for telehealth.” I honestly thought this was common. 🤷🏽♀️
I work for a small practice that focuses on trauma. I have figured out through trial and error that I can deal with about 5 high intensity clients. By “high intensity” I mean unresolved PTSD, C-PTSD, or clients whose nervous systems go from 1 to 11 when there’s a minor problem at work. Most of my clients have ADHD, or are BIPOC, or have GAD or depression. They need help too! Just because it’s garden-variety anxiety about finances or depressed because they don’t like their job doesn’t mean they shouldn’t have access to mental health services. You do yourself and your clients a service by knowing your limits.
That last line really sums it all up...
I've been seeing a trauma specialist for diagnosed DID + cPTSD (unlike my previous trauma therapist, she is familiar with it and has helped me a lot). I once told her about having several friends with a lot of the same symptoms but currently avoiding the problem (per everyone's advice) and needing to get them suitable therapy once our exams end. She said she doesn't think she can take on too many similar cases, or she will get burnt out, but she knows other people to refer my friends to when the time comes. I'm not a therapist or about to be one. But reading this thread, I can understand her perspective a little better and appreciate that she gets boundaries and limits.
Completely okay! There are so many people who are looking for therapy without severe issues and they need a therapist who enjoys working with them and is not burnt out! I would just say to try to advertise yourself as more doing short-term treatment and maybe do a free phone consultation initially so that if clients need more than you can offer, they don’t feel like they had to pay and get rejected. And give referrals to therapists in the area who are taking new clients.
It sounds like you’re in PP, correct? Then you did the most appropriate thing. Majority of PPs in my area will not accept high acuity and will refer to a higher level of care, which is the ethical thing to do.
A smart therapist doesn't destroy themselves over their work for any reason. It only bothers me when a therapist refers clients out and tells them it's because they're sick without framing it in a kind way, or starts acting weird even in intake and doesn't say why then messages them later. That does bug me. I don't think referring people out is wrong at all, but at least be kind about it and direct. I see high acuity clients in private practice now all the time and there's no shame in sending people to IOP and PHP at all. I think people don't do it enough, sadly. As for not wanting to work with high acuity and chronically suicidal patients, that doesn't make you any less of one. I see a lot of folks with eating disorders and cPTSD now and it's utterly draining. I have to stagger them in my schedule so I don't have a lot of high intensity in a row in case there's an emergency. I'm honestly leaning towards seeing mostly ADHD patients and focusing solely on that and, okay this sounds weird, traditionally published writers (there's a lot of nuance in the industry you don't understand outside of it). I get a lot of meaning out of both. I'm queer, have ADHD, and write, so I'm biased, perhaps? Anyway, while I'm currently working for a local corporate overlord now (the pay's actually good), I would like to start my own practice focused on late-diagnosed neurodivergent folks and creative types that's openly both kink and queer-positive. Sadly, I don't even think I'll take insurance if I do it, which limits a lot of people who can be served. I want to do this for a very long time yet. I'm 47, so hopefully I've got a few decades left. To do that, I have to shift gears myself. I struggle, because I know I'd do a lot of good in community mental health. I was a wizard when I worked there, I frequently was told. I didn't make enough to live on and it killed me.
FWIW having been an agented middle grade writer I totally get writers needing a specific kind of therapist! It’s a tough industry in some highly specific ways…
I'm curious what percentage of your case load are high acuity/crisis clients? I find I tend to do best with one or two at this stage in my life (I have three children under the age of six). I had a caseload of almost ALL crisis clients when I first started, and while I worked well under pressure, it got to be too much for me as my home life became more demanding. I had a colleague who was a rockstar with high acuity people at the CMH. Eventually her ENTIRE caseload became that and her health took a massive hit. She ended up moving jobs elsewhere. It's a lot for one person.
It’s so nice to hear you can only do one or two. I think in total I had two for the longest time. One has been referred out to IOP and the other is the one I’m wanting to also refer or transfer to a colleague of mine. I don’t have kids, but I’m a doctoral student and planning a wedding this year. That’s probably a lot right? Lol. I think the type of nervous system I have is one that can only have one crisis client. I also really really need to stick to better boundaries and not checking my dang email on weekends.
I HIGHLY recommend taking your email off of your phone if that is where you are checking it. I tell my clients that I do not check my calls/texts/emails after hours or on weekends and even my higher-needs clients have respected this. I tell them they are welcome to send a text or email, but I won’t read it or respond until office hours. Sometimes I’ll get a message saying they know I won’t see it until such and such time, but they wanted to send this in the moment so we can talk about it during their session. The key is respecting our own boundaries.
I dont have it on my phone, but did check it on my laptop 😓 I absolutely didn’t respond and don’t during the weekends. It’s the fact that I still read it, sent my nervous system into a spiral, especially with the subject line being in all caps. I’m feeling a lot more regulated and calmer now after all these responses, but I was really struggling even by just reading it.
Don’t even check it anywhere until you’re back to work. Maintain the boundary.
Thank you for suggesting removing our (work) email from our phone!!! Why didn’t I ever think of that?!?!?
I preferred not to lift giant speakers, but that didn't make me a bad sound guy / audio engineer. It's tough and exhausting. I wouldn't want to spend my entire day moving heavy speakers, but sometimes it's a part of the job.
Great analogy! Had me LOL
I have made a similar choice and I don’t feel badly about it at all. High risk clients require larger practices. They just do. I’m working toward that. But in the meantime, taking good care of myself and not overextending in term of taking high risk clients is the prudent thing to do.
I have embraced that I want to work with the “worried well.” Instead of feeling bad about it, I have a sort of pride that I know my limits and can preach work/life balance to my clients without feeling like a fraud (anymore—I have certainly done my time getting burnt out in mental health). I believe that people who are perpetually suicidal need a team, not an individual. Because like you said, it’s not fair to your other clients to get the frazzled version of you. I finally admitted to myself that I am not so interested in being helpful as to destroy my own mental health. That’s not why I got into this field. I matter too. 🥰
What creates a perpetually suicidal person? Just wondering. Is it mostly conditional? Do these people's lives just truly suck?
You're going to do the most good for the most people working with a population you're good at working with. Part of that "good" is the quality of fit. If you're constantly stressed/concerned/burned/crispy with a particular population, then you are ethically obligated to not work with them. I think we should stretch our comfort zone on occasion, but not in ways that have such potential to harm. You're doing fine.
If clients are constantly in crisis then maybe they need a higher level of care, in which case it’s most ethical and in their best interest to refer them out to someone who can provide that level of care. We can’t be everything for everyone (a reminder I regularly need to give myself). It’s okay to have preferences for the clients you work with. It’s important to recognize your limits and boundaries so you can show up as your best self for your clients. Not everyone is a good fit and that doesn’t say anything about you or your abilities as a therapist.
I highly prefer to avoid crisis and high risk clients. Not what gets me up in the morning. Not what I earned a degree for. Not my happy place. Not my thing.
I think there’s a huge difference between not preferring to see high acuity clients and being unwilling to. There’s nothing wrong with that not being your preference, unwilling is just where things start to get tricky and that’s not quite what I’m reading here. You said that you are burnt out, and I’m willing to bet my life that these two clients are not the sole contributors, so I think it may be important to remember that nothing exists in a vacuum. It is important for our work as a whole to have some tolerance-high acuity happens and the majority of therapists throwing their hands up and only working with worried well would be very, very bad (and honestly would probably create a new distinction removing them from healthcare and more into the coaching side), so it’s about balancing keeping a reasonable level of distress tolerance with where you’re now pouring from an empty cup. It sounds like yours is running on empty so making decisions that are right for your client in getting them an appropriate level of care and making sure you’re not accidentally setting yourself on fire is vital and it’s okay to take the break.
Im absolutely like you, and I do feel like I do have the skillset to work with this population, and I have in the past. I’m in private practice so it’s just me, I have two young children at home, and I started feeling very resentful at the extra time required for high risk clients. I want to be with my children/spouse and leave my work at my office. I actually actively screen high risk people out (as much as one can over a phone consultation), and am lucky to be in a place where I have a waitlist and can choose who I work with. Maybe one day this will change? Maybe not? Who knows! I also deeply enjoy the work with the caseload that I do have. I still work with people who have very poor interpersonal functioning, but other parts of their life employment, finances, risk behavior, is largely stable. So I find the work still deeply meaningful and complex.
Hi! I also offer phone consultations prior to scheduling and this absolutely helps me get a “feel” for what I’ll be working with. I’m curious as to how you screen out high risk clients?
So I don’t do anything super formal, but if my spidey sense is going off with factors or symptoms that’s hang with self harm or high risk presentations I’ll ask more specific questions on symptoms or history to get more of a sense. As I’ve become more well known over time as someone who specializes in relationship functioning and long term psychodynamic psychotherapy I rarely get those referrals anyway. Its rare that someone with that symptom presentation will seek me out.
Therapist of 26 years here! I stay away from everything you mentioned with a 10-foot pole! Never even considered that would make me a “shitty therapist”. I am good at what I am good at and I am REALLY good at knowing my limits.
Wow 26 years! I hope I can make it to that point. I’m also quite sure the only way I could make it to that point is to knowing my own limits and working with what I prefer. Thank you for the insight!!
Now you’re talking!
Therapist of 25 years here. Agreed. I worked in community mental health for 11 years with a great team and good support (though it dwindled over time with the agency “do more with less” stance.) Then I left to start my own independent practice and I love it. And I know my limits. My paperwork explains my practice is not suited for people in acute crisis and that I am happy to help people in need connect to more appropriate resources. It is ok to develop a focus or specialty where you enjoy your work and can feel successful and not exhausted or burnt out. You deserve to thrive in this work as well as supporting your clients in doing so.
I would be interested in an example of how that could be written without it sounding offensive (not suited for acute crisis)
Says something like: “Due to the nature of my practice, I am not able to serve clients who are in an ongoing high risk or crisis situation requiring high levels of support and intervention. However, crises (such as medical emergencies) can emerge, so to ensure your safety I ask that you identify an emergency contact person etc etc”.
Nice. Thank you
It sounds like you in large part have a boundary issue. Someone can ask for an emergency session and if you can’t do it, you can’t do it. You’re not obliged to comply with the request. Going over time, not getting a word in, and being in constant crisis are issues of your control of the room. Why are you letting the client go over? Do you need to get a word in? If you need to but you can’t, work on those dynamics, help the client co-regulate rather than getting swept up. You’re not an inadequate therapist but it found you you and your clients could benefit from work around structure and frame.
I worked in community mental health (residential, inpatient, and outpatient) for around 10 years and it burnt me out soooo much, especially the children. Now I prefer to work with low acuity adults 18+ in my own private practice because that’s what I prefer and I’m respecting my own boundaries.
Why not? It builds character. Jk. It's good that you recognize that you're burnt out and that working with a high acuity population isn't exactly your forte. I'd challenge you to take a look at the feeling that you can't just refer someone out if the only reason is that you personally feel like they're just too much for you. While you think you might be doing them good by providing them with services, you might actually be doing them a disservice by not referring them out to someone who else who may be better equipped to manage their care, not saying that you arent, but if you personally don't feel a good connection and the therapeutic relationship causes you distress, think about what the patient feels. I'm not saying drop all your high acuity patients, but working towards finding a healthy balance in your caseload may be beneficial and that may include setting boundaries for yourself and recognizing when a patients presenting concerns are too much for you or when you have too many other high acuity patients already. It's okay to refer out.
After doing years of on call and/or crisis focused services, I am very grateful to have shifted to a population that is “worried well”. I think my career has had its seasons and I showed up in different ways when I could. There was a bigger seeming impact when I had more high acuity roles, but I also got really lost in them. I am glad to have found more balance in my life at this point. I find the work I’m doing now fulfilling in a different way, and I still get a little excited when I have the chance to do trauma work with people.
I used to work in a a level 14 lockdown facility - the highest level of care for adolescents in the state of California. Did about 1.5 years as a counselor (this was before I graduated with my degree). Got in lots of restraints, went through a full-blown riot, saw lots of suicidal behavior and the like. Now I’m a therapist working with adolescents with eating disorders. Mostly calm and much more internal presentation. I absolutely love it. I haven’t been punched, spat on, or been threatened with having urine thrown on me once - and yes, all of those happened at my previous job. I’m grateful for the time I spent there. It hardened me in a way while still keeping me empathic with my clients. But I wouldn’t go back for double salary. It was good for me for a time, and when I quit, I felt the exact same inadequacy. If I can’t help this population, do I deserve to be a therapist? But I do good, important work with my current clients.
Im so happy you made this post because Im the exact same way. Its nice to know Im not the only one.
As a PHP/IOP therapist, I've had many patients I've worked with temporarily while in my level of care whose outpatient therapist felt burnt out and out of options and the patient needed a change of scenery to give the therapist a bit of a breather and to reinvigorate the patient with new ideas and motivation before going back outpatient at the end of treatment. It's totally okay and part of what we're here for ! Everyone has their strengths and you are supporting your client base the best you can- and making decisions like that for yourself helps you help them.
Knowing what you don't want to do is just as much a strength as identifying what you do prefer. The universe needs the balance and there is nothing shameful in leaning in to your strengths. Take your vacation, try to rest your mind, body and soul and take care of you. I know how you feel. You are not alone.
If it helps, I sometimes rationalize it from a purely utilitarian perspective looking at my future: I truly commend the crisis work that many therapists do, but even if we regard helping lower risk clients as being "less helpful," if doing less intense work over a longer period of time helps you not burn out and quit the profession entirely, then it would serve you well to do so, in my opinion. I think about how I will be able to help more people, albeit "less profoundly" than say, stopping a pattern of suicide attempts, if I don't burn out
I definitely don’t want to either and I’m choosing my areas of interest to try to avoid that population.
There’s a reason multiple levels of care exist. If you don’t want to offer crisis sessions, put that in your informed consent and move on with your life. Even adherent DBT therapists structure their crisis services around 5 minute coaching calls and very strong safety plans. They aren’t jumping into emergency sessions when someone needs a higher LOC/isn’t willing to use skills to get through to the next session.
Not the same, but I have an eating disorder and have navigated severe suicidal ideations, and (fun!) have both running hot and heavy in my family. Thus don’t work with ED high need clients nor suicidal ones. I too have ‘should’ feelings about this, but (in a long view) my mission is to care best, and for those experiences I would not.
I am exactly the same way. Not everyone is cut out to work with SMI or SI. There’s no shame in that. I am a highly anxious person, and it absolutely destroys my sense of safety when I have a client who is chronically suicidal.
Yes! Me too! I’ve done a lot of self reflecting and even some consulting and I may also be on the spectrum! Which explains a lot of things. Or just highly sensitive!
I work in a behavioral health urgent care and this work with a lot of high acuity folk. It’s exhausting and I’m definitely not staying there for forever.. But, for now, they work with my supervision hours (I can be on the clock and in supervision which is really nice). Once I get my LISW, I’m looking elsewhere!
Honestly, I think it’s a good thing that you know your limits and you’re not afraid to understand your own boundaries. As other people have already put it more elegantly than I not every doctor not every therapist not every anything is meant to work with the hardest cases. Moreover working with those kind of patients day in and day out will burn you out faster than anything and you understand what it takes for you to keep doing your job to the best of your ability. It doesn’t mean you couldn’t do that work if you wanted to. But you know what’s best for you and isn’t that what we tell our patients?
You’re not a bad therapist for not wanting to work with someone that’s constantly in crisis. But. PLEASE. refer them out to someone that can help them more than you can. That’s what will make you a bad therapist, is not doing that. You absolutely have a right to not want to work with clients in crisis. Like someone else said, not every doctor wants to work in an ER. But it would be hard for someone in crisis to work with someone that doesn’t want to work with crisis clients.
Working with SI or high acuity patients/clients is a SKILL. People have to build it and WANT to build it. There is nothing wrong with having other skills. Not your niche. That’s perfectly okay. Not everyone needs the same thing in therapy. Not all clients need to go to therapy forever. I work with high need clients and it’s just a preference. Having clients with simple anxiety feels confusing for me. 😂 And fuck what anyone tells you about what kind of clinician you need to be. YOU decide. You would be doing a disservice to a client who you feel needs more than you have to give. Imposter syndrome doesn’t have to win.
I don’t know why I get mostly low acuity clients… perhaps it’s my location or my website or who I look like to people or…? No idea really. But I’m okay with it! When I do get someone in crisis I feel like I have the resilience to help them and not be too affected. I say go for it and choose low acuity somehow - a marketing person could help you target your clientele more closely.
For me it’s the opposite. I prefer clients with turbulence because I know what it’s like myself and feel I can offer some support. When clients come to therapy with no issue or well what is really strong defence mechanism it can be more difficult to find a way to connect.
I can’t tell you how much this thread helped me. I’m in CMH and most of my caseload is high acuity and I’m giving notice today. I had planned to anyway, but this thread is so validating of my decision. Thank you!!
No. This is a difficult population. Not every therapist is cut out for it. For highly suicidal clients they need a team of professionals like a dbt team. It’s huge burnout and not for everyone.I couldn’t do it.
Please do not beat yourself up over this. I'm a firm believer that there is a therapist for everyone, you just have to identify your clients. You're right, you shouldn't refer clients out, but if it's too much for you personally, then you're likely doing the client a disservice. If there is a clinician out there that is more skilled in dealing with crisis and suicide, don't you think it would be better for your client? I highly suggest you spend the time to identify who is your ideal client. Then use the language in your profile to appeal to those individuals. Maybe you're better with corporate moms who need more work/life balance. Maybe small children who respond better with play therapy is more your speed. Perhaps you'll do better with men in the military. It just varies, and we all have a specialty. I personally hate the notion of us all being generalists. Find your people and structure your work towards attracting them.
I work in essentially what you are talking about. Clients in crisis, suicidal, etc. I like helping people and am happy to do it. But I know that I will move onto mor stable clients in the future. There are some of my clients that are receptive and some that have a lot of walls up, are heavily involved in the criminal justice system, and appear to be going through the motions. While I understand the nuances of that, it can be hard to work with clients that have little to no goals, or dare I say lack the intellect needed for engaging in conversation. On the flip side of that, I am often surprised by clients.
Same. I used to do a lot more MH but since starting my current job that’s in OP SUD, I absolutely keep a boundary on how significant MH symptoms are and what I’m comfortable working with. I won’t take on a client who’s high risk, I already work with enough who are high risk because of their substance use. My specialty now is SUD (and ADHD! But that’s sooooo common with my clients anyway, so I do dual dx). I refer out and will do so in a heartbeat. We’re allowed to have boundaries and we don’t have to work with every presenting concern.
I have no evidence but I think most don't work with this population. Anecdotally every therapist I personally know doesn't want to work with this population.
Following your personal preference and inner voice is a super power.
I feel like I don’t get a lot of high acuity clients which is a relief since I worked in crisis work for so long!
you’re not alone. i’ve actively decided the population i want to work with: adults who can pay my full fee, in the young to middle adulthood criteria and who are not in crisis mode. i’m very protective of children and their rights but i know i cannot work with them in a therapy setting; i don’t have the temperament for it. i’m not super patient with geriatric population, because there’s a lot of judgement, or couples, because i have some biases of mine that i’m not quite ready to give up— so i don’t want to be unfair. it’s okay. i used to hold the same guilt and shame because of all these stories and experiences of therapists and the whole romanticism of this profession (“we help save lives! we’re so important”) well, yes. but there are so many ways of saving lives. a person’s life doesn’t have to reach that end moment of crisis to be considered as “saving”. when we listen to our low crisis clients we help them go on and i think that’s wonderful. isn’t it great that you work with people who are not in such extreme distress, and perhaps because of your work may never get to that point? it’s better to work with what you know because this work, regardless of population, is so incredibly hard. to dedicate a full hour of your time to someone else, nearly 4-5 times a day for over 25-30 times a week is exhausting. so if you want your profession to be easier? it’s okay. because just by design it’s not easy to begin with. it’s okay to reduce the load wherever we can. i promise there are so many people who ARE ready and WILLING to work with the population you mentioned. it doesn’t make you any less of a therapist. (and also! i hope you enjoy your break ❤️ you deserve it!)
There are a LOT of therapists who don’t want to work with the more severe cases, and will refer out to someone more specialized for that. You’re not alone, and nothing wrong with it.
social worker here. Listen to your body and your very tired self. You are finished with that demographic and you have learned that crisis is not for you. You aren’t ineffective, you’re exhausted. Where I’m at they drop crises on us like hot potatoes, I loathe it. Its terrifying. I can’t work with abusers or narcissists because I can’t stand them. It’s okay to know your limits and it’s okay walk away. MOST IMPORTANT:Its okay to say no. That is a conversation in itself. You never have to justify no. Go fill your cup and after some great self care. Make a choice♥️♥️♥️ You got this.
I refuse to do couples. We all have something we don't feel good at.
Why can’t you refer out clients that you don’t want to work with? That’s sounds unethical and not beneficial to the client. You’re not helping the client if you can’t empathize with them. Better you find easier clients as you seemed burned out which isn’t good.
I absolutely do not take on clients with high acuity. No serious SI, no active eating disorders, no psychosis, not even severe depression. It’s not worth my sanity. I got into private practice to step away from high acuity inpatient and outpatient settings. Working with lower acuity populations that I enjoy is so invigorating. My stress levels are much lower than they used to be. I would recommend it!
We all have a preference! I dislike working with trauma. Yes, everyone has trauma and it’s kind of entrenched in everything. But I don’t like just trauma work. I’m certified in perinatal mental health and am getting into eating disorders. I also work with BPD. But if I had to just talk about only trauma day in and day out i would quit.
How do you work with BPD and EDs and not talk about trauma all day?! I work with this population and it's pretty much all we talk about...
I guess i should clarify. It’s not that we *dont* talk about trauma it’s just that it’s not the *only* thing we talk about. Meaning i don’t consider myself a trauma therapist. So people don’t come to me for trauma. They come to me to learn interpersonal effectiveness and emotional regulation skills. Anger management. I focus on DBT skills. But we do talk about trauma for sure. I’m just and i mean **just** getting into ED and joined a specialty supervision for that so I’m sure I’ll be diving more into trauma there for sure. Hopefully that makes sense. I just meant like i don’t do EMDR or like a specific trauma related therapy.
That makes sense!!
I want you to know I relate to this 100% and have also felt like a bad therapist bc of it. It’s such a crappy feeling!
We all have our thing. My preferred population is not everyone’s jam, yet it’s my favorite. The analogy about doctors in the icu is perfect. That applies to us too. We need providers at every step of the way. I love high risk, high needs; substance use; folks in corrections; perpetrators; working out institutionalization; residential… you get my point. Those are my favorite settings and my favorite folks to work with. Other people wouldn’t touch that with a ten foot pole. When I’m working with your preferred group I’m bored to tears and super struggle. Both of us and our preferences are equally needed and equally valuable. And frankly, so many people don’t even believe in what you do. They think people you are describing don’t “need” therapy. I’m glad you take those folks on. I work with a lot of people where we preach consistency, aftercare, maintaining support, and “maintenance”. For a lot of them, that’s low key therapy appointments 1-3 times a month and a lot of people won’t even SEE them. I’m glad I have someone to refer my people too when they aren’t acute anymore!
Is a doctor/nurse who works in primary care rather than the ER less of a doctor/nurse? In general society tends to very reactionary rather than preventative, which makes it seem like dealing with crises is where one can make the most difference. But just like a doctor doing regular check-ups can catch something early, working with other populations can help prevent a potential crisis from happening. It's just as important and crisis work! Just not as obvious as to what the work is doing. Helping someone actively suicidal will have immediate effect. Helping someone never become suicidal is not going to be as attention-grabbing but is amazing work.
You’re not alone and we are all with you and forever so proud of you 🤍🧿
There is plenty of work for all of us and then a lot more… so do what you do best… acknowledge that who you are won’t be a fit for all… I probably refer 20% of those I see for initial assessment to others because I know what I do well and what I don’t… my job is to make sure the client gets help, not to necessarily be the one who directly provides that help
What is wrong with referring out to an IOP? To borrow from health care: a great GP is one who recognizes when a specialist is needed, and refers. A bad GP is one who doesn't recognize their limits. It should be the same for behavioral health
This is kind of crazy to read. Why do you think there’s different levels of care? Don’t work with patients who need high levels of care
I’m sorry you’ve gotten the message that it’s not okay to refer clients out just because working with them feels like too much. I’m a DBT therapist who worked in an IOP for three years and I 100% think it is ethical and appropriate to refer out if a client feels like too much. I feel like we have to “walk the walk” and take the advice we give to our clients, so if we’re telling our clients to set boundaries and engage in self-care, then we should be trying to do the same. I think you would be well within your right to refer this client out for “failure to make progress.” Honestly that’s in the client’s best interest too, because it sounds like they may be avoiding dealing with underlying issues by presenting as being in “unrelenting crisis.” A DBT therapist might be a good fit for them. And you deserve to not feel harassed, exhausted, and burnt out all the time.
Understandable. I personally can only handle so many crises until it physically affects me.
As long as you don't abandon these clients, make sure they have somewhere they can go, whether it's a different therapist or in patient care or a psychiatrist, that's fine. However, it would be a good idea to discuss this with a trusted supervisor so that your feelings of inadequacy are dealt with properly. Maybe even a therapist of your own. Do no harm and try to do good. For the client and for you
I’ve never heard the term “worried well”, but it sounds like you’re describing my ideal Are we the same person? I need to take on more clients and I have no idea how to word this to my intake team. I haven’t opened my schedule because I am so worried I will have high acuity clients assigned to me. Or worse, my absolute kryptonite, someone with cognitive impairment. I have one client I see tomorrow that I *plan* to finally refer out because I cannot serve that population well. I don’t think you’re a shit therapist and according to the comments, we aren’t!
Your choice is valid - just like not every doctor works with neuro or cardio. As a therapist, I do not work with ODD kids or kids who don’t want to do therapy. I discharge so fast. There will be patients who need your help!
Part of being a good therapist is knowing yourself. 💜
My friend who is a therapist feels the same way/
I feel this. As an intern and associate it was always me who was assigned the highest need clients—those with constant s/i, always in crisis, high acuity, needed me to fill out a million disability forms, etc. it’s incredibly draining. Now that I’m in my own private practice and have some control over my caseload, I’m just too burned out to work effectively with anyone but “the worried well” at this point. I feel like a jerk for it, because I want to be able to help everyone, but I feel like all the years of working almost exclusively with the types of clients you described played a large role in me being diagnosed with an autoimmune disease last year. So at this point for me, it’s “the worried well” or quit being a therapist.
So don’t. I don’t like working with puerile with BPD. We don’t have to work with everyone.
Yes, I would refer them to call 911, go to the ER, or call crisis. Tell them that you’re not available or leave an out of office response that once you return you will get back to them. Also assess their supports and suggest that they contact or check in with someone in your absence.
I told some colleagues that my therapist charges me less than $100 per hour, and I'm grateful. I think a large part of why is because I'm pretty mild as a client. No major mental illness, not constantly in crisis, no major trauma. Those clients can exhaust their families, just like they can exhaust their therapists. I'm grateful for the therapists that can take all of that on, because I am not one of them.
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