I received my first lesson in the potential hazards of caring too deeply for a patient in the fall of 2006 during my social work internship at a psychiatric hospital in Queens, New York. I walked into Ward Six at 8 am for my 7-hour shift. I was carrying coffee and staving off a yawn – until I saw that in addition to the contingent of doctors and nurses milling about, two burly security guards were struggling to strap a straight-jacket on a toothpick-thin 18-year-old male who bucked against them with the hysterical strength of a mother lifting a car off her child. Scrambled eggs were splattered on the faded gray wall – remnants of the breakfast the patient had hurled against it while shouting indecipherable phrases at someone who clearly existed only in his mind.

My knees buckled along with my heart when I recognized the hallucinating patient as the polite, soft-spoken college freshman who’d been brought in by his shell-shocked parents a day earlier. Hiro* tearfully admitted he’d swallowed a handful of sleeping pills after failing his physics midterm. “I couldn’t live with the shame,” he kept repeating, as I fought an urge to hug his slim frame.

After the guards successfully medicated Hiro and led him away, I, too, felt narcotized. I’d just witnessed someone having his first psychotic break. My vocal chords worked enough to rasp to my supervisor, “How do you do it? How can you just go about your day?”

“Because we have to,” was the answer I’ve never forgotten. While seemingly simple and apt advice, it’s not always easy to follow. It certainly wasn’t when it came to Hiro.

The Therapist-Client Empathy Quagmire

We are drawn to this profession from a desire to help people who are struggling. “Empathy” is a word mentors burn into our brains as an essential quality for a mental health care clinician to possess.

In A Working Alliance Based Model of Supervision, psychologist Edwin S. Bordin wrote that the glue to a working therapeutic alliance is composed of three factors:

  1. collaboratively agreeing on therapeutic goals
  2. tasks to move the patient toward achieving those goals, and, arguably the most important variable,
  3. the formation of an emotional bond.

The latter is impossible to achieve without truly feeling something for the person who is entrusting us with his or her psyche. Our job as therapists, however, is to monitor that bond and any feelings we develop so that we remain objective enough to conduct proficient therapy.

The paradox of our profession is the necessity to care about the people we work with – but to not care too much.

Some Boundaries Should Be Judgment-Driven

Obviously, there are clear external boundaries to follow when embarking on a therapeutic relationship, number one being to never engage in physical intimacy with a patient. Another is to avoid dual relationships that might be harmful to your patient, such as letting a client do some bookkeeping or other work for you in exchange for a lesser fee. (I’ve gotten that offer a few times!)

Other boundaries are less clear-cut, but rather, judgment driven. For instance, I was touched that my longtime psychotherapist accepted my invitation to attend the signing for my first published book. Irina had a true insider’s view on how much the achievement meant to me. After my reading, Irina did not approach me for a tete a tete, which felt appropriate. How would I have introduced her to family and friends? When seeing each other in public – whether expectedly or unexpectedly – it is the therapist’s job to protect a client’s privacy.

At our next session, Irina mentioned she had gained a more nuanced perspective of my mother now that she’d seen the elder Amatenstein up close and personal. I responded, “That’s great,” asked for a few impressions of my parent, and our work continued.

(See also, why therapists need their own therapists.)

What Playing Favorites with Clients Looks Like

Patients often ask if I have “favorite” clients. A truthful answer would likely be “yes.” Whether the cause is countertransference or an undefinable je ne sais quoi – meaning there could be a friendship if the circumstances were different – certain clients have the potential to invade a clinician’s thoughts more than is healthy.

Our “over-caring” for clients, however, can lead to impulsive and potentially harmful actions in the therapeutic setting. If unchecked, this extreme empathy might lead to a breach of the APA’s guidelines on healthy psychologist-client boundaries.

That is why it is essential to monitor yourself using the guidelines below. If you answer yes to one or more of these bulleted points, you need to step back from the cliff’s edge:

  • Thinking a lot about a particular patient between sessions, perhaps even losing sleep over the client
  • Extending therapy times without charging a fee, except in times of crisis
  • Getting involved in lengthy text exchanges (brief texts about practical matters are fine – such as to change or confirm an appointment time)
  • Lending money and/or providing complimentary ongoing sessions to a client enduring tough financial times
  • Noticing that your emotional stake in the client renders you incapable of providing impartial feedback or guidance
  • Contacting your patient between sessions to ask about the outcome of a particular event that was discussed at the last session
  • Sessions feel more like catching up with a friend than conducting therapy
  • Socializing with your patient.

When Therapists Over-Step: Case Examples

Rachel Thanders, LCSW,* a psychotherapist in private practice, worked with Diana* for two years on her depression and commitment issues. Thanders shared with me that, over time, Diana became increasingly adept at handling her emotional issues sans intervention. The 50-minute sessions rarely moved the needle forward and Diana was increasingly ready to move into the therapy termination phase.

Thanders knew well that when a client-therapist relationship hit a roadblock or felt mired in quicksand, it was time to bring up the lack of real content as food for discussion. She had done this with many clients – but not with Diana. A case conference with her supervisor led Thanders to realize that she was holding onto Diana because “I’ll miss her when she stops coming in.”

It is often hardest to maintain emotional distance when the client is a child. Casey Ferri, a doctoral student in a school-community psychology program who interns at clinics specializing in family therapy, therapeutic visitation, therapy, and evaluations following child abuse and neglect wrote to me, “Often my goal through the court is to reunite a family, which at times, in my opinion, is more detrimental for the child. It is very hard to not become overly involved in the child’s emotions. At times, worrying about a child after hours is inevitable.”

Ferri shared the story of a caseworker so attached to what she believed was the best outcome for a foster child – not reunification! – that it became impossible for her to distinguish “the small positive steps” the parents were making to be granted custody of their son. This caseworker’s biases colored her recommendations to her supervisors who ended up making their own assessments and removed her from the case. The child was eventually returned to the parents and is doing well.

Re-Balancing the Provider-Client Relationship

Clients entrust us with their psyches, which is a sacred gift. We are in the room (even when it’s a virtual one) in service of them – not as their savior, bestie, or surrogate parent. Here, a few recommendations to avoid over-connecting:

  • When your heart is pierced by a client, be mindful of your impulses. Try not to leap into action without careful thought and checking in with a supervisor and/or peers and colleagues. Case consultation groups can be particularly helpful in this way. (See also, Regretting the Client that Got Away – A Tale of Premature Termination.)
  • Check in with your emotions often: Am I caring too much? What is in the best interests of my client?
  • If you feel you are emotionally bound to the client, act accordingly – this may mean talking to your patient about a transfer to a therapist better suited to handling the case at this time.
  • The more balanced your life, the less you will look to clients to fill the void. The better you practice self-care, the better job you will do for your caseload.

A Final Therapist’s Confession

From time to time, I still think about Hiro, the young adult I witnessed in the throes of his first psychotic break. As a social work intern, my job included daily sessions with Hiro, conducting family meetings, and, once he was stable, coordinating his discharge plan.

A few months after his release, I called Hiro, who was back at college, on anti-psychotics and depression meds and in regular psychotherapy. He was glad to hear from me, thanked me for my help, and said he was adjusting to his situation as best as possible.

Was my call going too far? Maybe, and it’s something I would not do now as a “seasoned” mental health practitioner. Yet, I believe my five-minute check-in with Hiro was not over-involvement but more like my therapist Irina’s attendance at my book signing: acknowledgment that he mattered.

At times, being a therapist is akin to balancing on an emotional seesaw – if we lean too far in either direction, we will be in danger of falling.

 

*Names and identifying details have been altered.

 

Last Updated: Jun 16, 2021