So, Now What?
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So, Now What?
09- The Surprising Reasons Why You Feel Dread When Looking At Your Schedule
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Therapists are taught to be able to "work with everyone that comes through the door."
This messaging is not only rigid, but harmful to your and potentially your client's wellbeing.
In this episode I share about my pitfalls with my previous experiences with how I mistakenly adopted this philosophy and how we can bring nuance into this conversation. I also share practical tips on how to work through creating a caseload that is more respectful to you and your nervous system.
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Hey, welcome to another episode of so Now what? So now you have a private practice. So now you've graduated grad school and you're finally ready to spread your wings and dive into something that you could only dream of, which is your private practice. Maybe you're transitioning out of some community mental health institution or a group practice and you're finally ready to land on your own two feet, ready to curate your own schedule, ready to curate your own caseload and maybe taking insurance, maybe not taking insurance.
Speaker 1:I want to talk about today, about the pitfalls of having a caseload that is under the messaging of you need to accept everyone that walks through your door. You need to be able to work with everyone. You need to be able to treat everyone that comes into your practice. That is something that is pretty controversial. I hear in grad school from my own experience as well as a lot of my colleagues experiences. They've said that their supervisors or instructors have told them you should be able to work with everyone that walks through the door, and I totally disagree with them. I think it's something to shoot for, that we really should be curious about who walks into our door and how to work with them. Maybe they have a wide range of presenting issues that they want to come to us with, and our internal yeses or nos show our biases, can show our fears, our biases can show our fears. And the idea is that when we're interns, we have this wealth of supervision and mentorship and a lot of people looking over our shoulders in both the best and worst ways, and this is a time where we should be able to take on any client. That is the messaging that a lot of us get in our different realms of practice and even after grad school is over, even after our internship is over, we get this huge guilty message from our culture that says if we can't work with people that walk through our door, if we can't work with certain people, specific people, we are selfish, we are not considerate, we are not open-minded enough and we should be able to endure any challenging client that comes through our door and that's just not something that I think is even ethical or is a best practice.
Speaker 1:I first want to talk about the reasoning behind some of these messages that we get the message of we should be able to accept anyone and everyone comes from, maybe a training program that wants to instill the value that therapy should be inclusive and if we're in these training programs, we do have access to privilege and we should share our privilege, especially share the experience of healing, with as many people as we can, and that means working with anyone that walks through our door. The second intention behind this message is to expose clinicians and training to a wide range of presenting concerns so that we could expand our toolkit, so we could expand our mindsets, so we could expand our comfortable zones that we're in and really push ourselves to learn new things and to work with people who are really different than us. I think this makes sense to me. It's really noble, but when we take it literally or we internalize it as an absolute rule absolute rule it can set us up for failure and also an unsustainable practice. And these are the dangers of working with that messaging around. I should work with everyone. First, it creates a sense of disconnect to our own set of boundaries and limits, so everyone comes to their own set of boundaries and limits, and that messaging causes us to suppress and ignore all our body signals that this isn't going to work out. And part of that is understandable, because part of our body signals are telling us oh my gosh, this is so challenging. Some of those messages are just telling me that I'm anxious and I should really work through that anxiety so I could grow in my practice. And sometimes, when I don't discern whether or not that's anxiety or that's just like a real danger, is that I end up in sticky situations that I regret later on because I should have listened to my intuition. And so there's a difference between ignoring perceived danger and ignoring real danger, and sometimes, when our clients are a real danger to us and we ignore signs early on, it can turn into a more serious issue, like our clients stalking us or a client being obsessed with us or a client actually posing a real danger to our physical safety. We're actually posing a real danger to our physical safety.
Speaker 1:An ethical concern is that if we take people outside of our scope of expertise, we can potentially not be equipped to work with them and then cause further harm because we are taking in more than we can work with. That's beyond our scope, and an example of that is a clinician that is not trained to take on complex trauma works with someone with complex trauma and they can traumatize them even more, and this is something that we run into all the time, especially in my early days. I was working in a community mental health clinic and I remember working with a client that was way beyond my scope of expertise and I remember saying something that seemed good at the time. I said something like you should really internalize the message that you are a good person, that you didn't do harm to this other person that they were expressing, that they were worried about doing harm with. And I then realized later like years you know, much later that asking someone to repeat a mantra isn't going to be helpful. In fact it might actually exile different parts that are already here that are worried about them to begin with, and so I didn't realize until later on that this person had complex trauma, which I should have just seen it as a red flag to begin with. But I just said I should work with anyone and everyone that comes through my door. In fact, as an intern, I might need to because I might not have a choice, and this person ended up not coming back to see me again. I can't help but wonder, even to this day, how I must have possibly caused them more harm, and I won't ever know the answer to that. But I know from a personal example from that example that I was practicing outside of my scope and I didn't realize that, don't want that in the future for any of my future clients. Or especially, I wish that I could have had a different experience as an intern, with someone telling me it's okay to practice discernment on whether or not they're a good fit.
Speaker 1:Sometimes some progress stalls, some stagnation, and both parties could feel drained as a result of working with each other. And the last danger is that this I should work with everyone kind of mentality reinforces a sense of guilt and martyrdom. That's already in our therapeutic culture. Clinicians learn to equate with saying no, with selfishness or incompetence, and it keeps us locked in the cycle of overfunctioning and it depletes the energy that we need to do quality work. And that's really hard when it comes to, I think, our culture, where we're trained and conditioned to always say yes, to always be on top of things, to always let everyone in, when in fact, saying no is probably going to serve the client and you more.
Speaker 1:Ultimately, what I observed to be my result of accepting anyone into my practice in my early days was that for me, I was scattered in my level of expertise. I didn't zone in on my zone of genius and I didn't get training in what my clients who are great fit would have needed. Back then I could have gotten better training earlier because I would have recognized these are who I'm really well suited to work with and this is the approach or modality that I think would work best with them. This is the approach or modality that I think would work best with them. The other thing for me, the big impact, was that I was carrying a sense of dread or happiness before certain sessions and it bled into my personal life. I just could not have a great social life. My family life was suffering because I did not have energy to give to my family. I was conserving my energy for my clients and not really allowing my energy to be distributed in a way that would create self-care for me and, as a result, I had a huge caseload imbalance. I had a lot of misaligned clients and it overshadowed my joy and stuck the joy out of my practice in general and it was not sustainable. I was burning out faster. I was noticing clients were not. There was a turnover, a big turnover in my client load and I was not experiencing joy.
Speaker 1:How do we adjust your caseload in a way that's sustainable and ethical, and I want to share a little bit about my journey for that. For me, I think that our caseload really coincides with how well we market ourselves. The more. The better we market ourselves and the more specific we are in calling in our people, the more people will come that are a better fit. It requires your messaging to be pretty specific and it requires you to be okay with people repelling people who are not a good fit, and so sometimes my messaging will be offensive and will be pretty icky to people who are not supposed to work with me, and that's okay. I've accepted that and I've done a lot of work to accept that, because I am a big recovering people pleaser and marketing is healing for me because I have to practice being repulsive. I have to practice being potentially repulsive to people and not being pleasing to everyone, and my people pleaser parts really want everyone to like me and that's just not going to happen.
Speaker 1:Something that I have begun to work with in my marketing is and you'll see this up ahead is I take messaging that is generally accepted in our therapy culture and I challenge it, and it's things that I've always challenged, but I've challenged quietly and I've never been public about challenging them in public about challenging them. So for me, in my marketing I'm going to start presenting very controversial quote unquote controversial, it's not even really super controversial, but things that we just take for granted and take for truth and just are part of our status quo and our therapy culture and I challenge them. And for me, that is a practice to clarify my zone of genius, to bring in people that resonate with the message and to work with my people that I really want to work with. And that means that I'm going to share my creative work, my non-therapy work too, and my life outside of my practice, because that will ultimately resonate with other people who are as quirky as I am and weird as I am and will help me adjust my caseload so that I'm really working with people that really want to work with me and believe in me and I resonate with and that are ready on board with my style and my messaging.
Speaker 1:One of the ways that I do that is that I, when I get consultations coming in, I mentally and I can do this like literally I could lay it out, but I mentally start assessing whether or not they're a good fit and I could tell within the first few minutes whether or not they're a good fit For me. It's easy to see if I could jive with people, if the rapport is there, if I could banter with folks and they're like feeling it or not. And I start putting people in buckets and they're not an evaluation of their character or their humanity, their assessment of our fit, not of their character, not their worth, but it's truly based on fit and that fit has different levels of evaluation. The first bucket is like the green light bucket. It's wow. They are so aligned. They have read through a lot of my Instagram or a lot of my website and they really resonate with my material and they want to work with me and there's good banter and they know my style, they know my therapeutic style, so there's like a lot of resonance with it. They might not be familiar with it but they're curious about it and they're open to learning.
Speaker 1:In that bucket people are also for me second time or third time therapy goers and they just want to get deeper in their work and they're ready to do some deeper digging. For me, they're not people who are super intellectual, they're people who are like intuitive feelers and they are usually people of color and they're really like maybe progressive in their politics and they have some of the similar values that I do around racism, sexism, homophobia, and they're pretty like inclusive minded, where they're thinking about different issues around the world, like climate change and the multiple genocides that are happening, and they're sometimes a part of those movements. Those people are a great fit for me and they're my people. They're people that I would be friends with and people that share. They could tolerate my quirks. I really like to RV and I really like to talk about RVs, but I don't necessarily need to bring it up in session. But they're like because I work in my RV, my Greenlight clients really love to talk about RV stuff or are interested in hearing about our mutual interests, shared interests around camping, around nature. They bring out my best work. There are people who are like I'm excited to work with and who we have great banter with back and forth or great social chemistry. Again, they don't need to take all those boxes, but there's like enough there where I'm looking forward to working with them.
Speaker 1:In my yellow bucket, which is the middle bucket, I can work with them, but there are limits and conditions. We might not have similar shared experiences. But there are folks that are very open-minded and may or may not have. So if I make an observation about them or if I share empathetic comments, what I notice is that they might not be able to receive it very easily, but they're open to talking about not being able to receive it very easily. So in this bucket I find that these are my yellow clients. Like I can work with them and I can do a lot of good work, but there's some limits and conditions. Maybe our social banter isn't great or maybe there isn't a lot of shared interest, but there's a shared enthusiasm about working on certain topics or working on certain themes that they want to process.
Speaker 1:My last bucket is my red bucket. My red bucket is folks that are really challenging, that are really like hard for me to sustain. I can work with them, but it takes a lot of energy for me to go into sessions with them. It takes some preparation. It takes me getting a lot of supervision and therapy to work with them, because a lot of personal feelings are brought up, or impatience or frustration, and a lot of stepness around our work happens, and so sometimes in this bucket this for me it's clients that are big on intellectualization. They really need to make meaning out of everything they need to like they cope with using their intellectualizing or thinking brain and they express a lot of thoughts and are not in touch with their feelings, which is actually the majority of how my clients operate, because a lot of folks who come into therapy are not in touch with their feelings.
Speaker 1:But there's a resistance in this red bucket to exploring feelings. There's a real big rigidity with staying in the thoughts realm and the thinking realm and so folks that are staying and are more rigid in the thought realm and are not open to talking about how hard it is to talk about their feelings, I would categorize for me in the red bucket, and this isn't always the case. There's flexibility in this because sometimes I have really good banter with folks in the red bucket and that can change. So it depends on how might I get vibes from them in our first consult session and it's hard to describe and break it down, but it really comes down to vibes. For me In our first consult session I could tell right away whether or not we're going to click and usually, because I am a really friendly person, I could almost click with everyone.
Speaker 1:But if I really need to be honest with myself, I have these buckets and I really try to maximize and put as many people as I can in the green bucket in my caseload, because that helps me to operate with the best version of myself and it helps me be excited for my work and be transparent and be vulnerable and practice from a place of ease For my red bucket people. I can accept actually a pretty good number of them, but it's only if I'm in a season where there's nothing that's going on in my life, so I'm not having babies, not raising little ones. I'm like not in the toddler phase even. I'm like in a phase where my kids are a little older and I don't have a lot of big crises going on, like my personal life is actually doing pretty well, it's pretty sustainable, my marriage is going well, I'm getting a lot of support, I have a lot of child care. It's only when things are really good that I feel like I can accept a larger number of people on my red bucket.
Speaker 1:But if my personal life is not going so great, my green bucket needs to be maximized and I can't take any red clients Also. Green, yellow and red can also depend on my fees, determine how much support I can pay for outside of my therapy too. So if I have a lot of green clients but all of them are sliding scale, it is not considered green for me because it's not sustainable. Even though my banter is good with them, even though my social rapport is good with them, and even though they're my ideal clients, if they're not paying full fees, I actually don't consider them my green client because or close to my full fee, I should say they're not my green clients because I have expenses that I need to meet outside of my therapy practice and in my therapy practice to just meet the bare minimum. And I'm not looking to meet the bare minimum. I'm looking to have some savings, some vacation time to retire, to have retirement funds, to support my kids in their extracurriculars, to have therapy myself and to have consultation groups and to have time for rest and restoration, to have hobbies. All of that costs money. So if I don't have enough green clients who are paying close to my full rate, I can't energetically show up for everyone, even if everyone is aligned with me. So that's something that I keep in mind and have in terms of categorization and adjustment in my caseload depending on my season.
Speaker 1:Another practice that I do is I practice transparent referrals. I've gotten really good at saying no, that I can't work with you, and it's not a no, that is oh, no, I can't work with you, period, but it's. I want to make sure you get the best support possible and I believe another clinician can work better with you and has more expertise and can serve you better. So I've gotten really good with saying no and I've worked with setting caseload intentions and not just limits. My intention is different from my limits, because my limits ask me how many clients can I squeeze in? How many clients can I work with without burning out? Instead, my intention is sustainability and thriving. So my question that I ask myself in my setting my intentions are what kind of people is the universe bringing me that would sustain me and create a mutual, thriving relationship?
Speaker 1:It's not just about the numbers, but it's about the emotional load, and something that I do is I look at my caseload and I create a caseload audit every three to six months around. What clients light me up? What clients cause me to feel really heavy? What patterns do I notice? What adjustments do I need to make for more balance. Client relationships aren't meant to last forever and I have to be honest with myself about doing regular check-ins to see if progress is being made, if there's a treatment plan with a clear goal, if there's like a good fit even in the middle or towards the end, and there are scripts that I use and things that I stay in the moment to transition people out in a way that's respectful.
Speaker 1:One of the next things that I like to practice is to also see my clients for who they are and not for their potential.
Speaker 1:So whenever I look at my case consults, my new case consultations that I don't think of how they could potentially be in the green bucket, but if they are in the yellow bucket, to really be honest about it right now and to assume that they'll stay in the yellow bucket indefinitely, because if I start thinking about how they could potentially be three, six months from now, the pitfall there is that I will always be pulling them out of their situation versus being with them and sitting with them in the darkness, without an agenda, without attachment to outcome.
Speaker 1:So that is something that I also do in order to really have a sustainable perspective on my caseload is how the perspective of seeing every no that you give out is an opportunity to protect your future most aligned clients. Every no that you give gives you space and opportunity to have more yeses later on to your green people and to give yourself permission to say no to protect your energy and your integrity and, ultimately, your potential client's healing. So I hope this is helpful and I hope that you can take some action steps to categorize your client without, of course, judgments or evaluations based on their self-worth, but purely based on fit, and, to be honest with yourself, to ask yourself how you can curate your client load so that you have people that fit your practice in a way that's mutually respectful. I hope to see you next time and I will look forward to seeing you soon. Bye.