How to respond to challenging questions from clients:

Q1: You are not a real doctor, are you?

A1: “Yes, I am. I have earned a doctorate, as indicated by the “D” in my PhD and it is in a learned or scholarly field of study as indicated by the “Ph” part of my PhD. “Philosophy” means the love of learning, the pursuit of knowledge and that is what I am equipped to do. That is why I am considered a real doctor.”
Optional additions: “PhDs started around the year 1500 with the Renaissance.” If the asker is Italian an aside on Bologna may be useful; if French, consider the University of Paris; if Catholic, explain how the universities grew around cathedrals; if Protestant, re-read your Max Weber, etc.

“In America, and only in America, are those with only an MD or DO routinely called ‘doctors.” They are properly called physicians. These degrees are for professional practice, not doing research or teaching in a university, as is a PhD. Medical schools go back only 
to 1910, the Flexner Report, blah, blah.”

For the anxious, consider adding: “Almost all MDs and PhDs are also state licensed to practice so we all met educational qualifications and are monitored by our respective boards.”

Q2: “Are you a psychiatrist?”

A2a: The answer I would like to give:

“No, I’m not. Do you think you need mind-altering drugs with severe or permanent side effects, hospitalization, especially against your will, or memory loss from electro-convulsive shock therapy.”

A2b: The answer I might give.

“In America we have no single profession dealing with psychological problems. We have several each with a different pattern of education and skills.

“For example, psychiatrists all went to college and a standardized medical school and then 3 years of residency training (unless they were trained in another country and took and exam here). They learned almost nothing about psychotherapy or development or psychopathology except diagnosing from the DSM. They have almost no research training and so cannot evaluate the usually shabby work of their colleagues.
“They can prescribe meds, and do they ever, for every human situation captured by the DSM. They usually prescribe a) whatever the drug rep who just brought bagels and doughnuts for the office is pushing this week, or b) the meds they learned about in training years ago, or c) whatever worked for the last patient they treated with your diagnosis (even though diagnoses have no relation to treatment), or d) whatever they want to try using any kind of rationale, because once on the market for one use, any drug can be prescribed for any condition (called “ off-label” prescribing).

“Psychologists, like myself, can’t prescribe meds (except in some special settings and some states). If you can really benefit from meds I will work with your PCP or other prescriber because after all they, not psychiatrists, write 85% of scripts for psych meds.

“Psychologists, also, blah blah blah.” Oh, alright, describe, as appropriate to you:

• Three or more years of professional school with many advanced level courses in personality, life-span development, child psychopathology, psychodynamics, assessment of intellect, personality and school issues, courses in statistics and research design, neuropsychology and brain-behavior relationships, social psychology and small group behavior, etc.
• Practica, traineeships, clinics, rotations, supervised hours, and a year-long approved internship, post-doc, etc..
• Two major research projects with data collection, literature reviews, data analysis, publication.
  Be aware that this stuff does not matter to the person in pain in your office. Instead prepare an “elevator speech” of less than 60 seconds explaining no more than 3 points.

Be ready to deal with local competitors such as social workers, CRNPs, APRNs, counselors, pastors/priests/rabbis/etc., healers, palm readers, public hypnotists, gurus of the month, and their relatives.

Q3: So you’re a psychologist. Will I have to lay on a couch? Can you read my mind? Will you always be analyzing everything I say? Will you hypnotize me?

A3: - “No, I am not a Classic Freudian Psychoanalyst. You also won’t have to come 4-5 times a week for 5 or more years.”

• “No, sorry. You will have to tell me what you are thinking and feeling.” Optional for marital therapists: point to sign on wall that reads, “If you loved me you would read my mind.”
• “I analyze or think about what you say only when I can use that understanding to help you. If we meet on the street or somewhere you are not paying me and so I am off duty; no analyzing.”
• “I will use that technique only when we both agree that it might be helpful to you.”

Q4: “Why do you charge so much?” or “Why is psychotherapy so expensive?”

A4a: “All services are expensive which take the time of a educated, experienced and skilled professional because you are buying that history as well as the face to face time.”

A4b: “When services are personalized to you they cost more. A lawyer applies the law to your specific circumstances, a dentist deals with your particular teeth, and no machine can replace a masseur.

“Generic services and products are cheaper but may not work or work best for you. For example, buying a bunch of appliances and cabinets may not really fit your kitchen space, your cooking and storage needs, the look you like, etc. Coffees especially blended to your tastes cost more than generic or brand names. School teachers offering standard teaching methods may not draw out the best in your child while a tutor or learning specialist could. Perhaps clothes off the rack fit you but alterations for your body by a skilled tailor will improve them.” [Notice the additional shift from just working to 
really working well?]

A4c: What you don’t want to say:“We charge a lot because we can.” This is a competitive and capitalist society. We base our prices on competition. We compare ourselves with other professions. But selectively. Licensed plumbers and electricians? Not nurses certainly. Be careful with this because the patient might see the converse. Some of our competitors get much less and so should we. Even worse, if we are truly worth only $40/hour in this system, shouldn’t we return all the payments we received above that level for all those years past?

“We believe that we deserve a good return on our investment (years and costs of extensive education, significant lost opportunity costs)” even if we never use any of it on you. We base our prices on input, on our costs to deliver the services, not on output such as their value or benefits to the client or society.

We believe that we deserved what we got years ago (adjusted now for inflation and even more for our added years of experience), even if we got it by luck (the nature of the reimbursement system in the 70’s when we got included under health insurance), and we want it all back. Screw the market.

Q5: How can you respect yourself for making money off the misery of the weak and sick?

A5a: “I didn’t make them sick.”

A5b: “I didn’t take a vow of poverty, only of service.”

A5c: “That’s why we need national health insurance/healthcare.”

A5d: “We can make them stronger and healthier with our specialized knowledge and it cost us a lot to acquire that. We have earned the right to a decent livelihood.”

Q6: Why should I pay you when there are lots of free ways to change?

A6a: “Come back when you have tried them or listen to my reasoning. When tying to change, buying books, reading newspaper columns, listening to talk radio, asking the advice of friends, consulting non-psychologist professionals, etc. does cost less than face-to-face 
therapy but these are not likely to work because:

1. They don’t do all the investigating of your situation, history, maintaining factors, figuring out why what you have tried didn’t work, what keeps you from changing, how to work around the unchangeable, etc.

2. No one  is there to work with you, using scientifically 
supported methods to use effective ways to improve your situation.

3. When such advice does not work, there is no one to ask to find or invent other ways that will work. We are more than one-trick ponies applying a one-size-fits-all treatment.

4. We will not be friends so there are no other considerations to affect by what we do. Only in therapy can we:

• return to a topic as many times, for as long as necessary, and from every angle to fix it.
• stick with every problem until it is solved and re-fix it if it comes back.
• address every cause and maintainer and every effect of the change.
• deal with every aspect of your life that is affected. We need not keep anything secret of off the table.

5. I will not rush you because we meet by the hour and no one is waiting on me. I am here for you and you alone.”

A6b: “You will owe me money but nothing else.”

Q7: “Why should I see you instead of a psychiatrist, social worker, priest, counselor, life coach,” and then “... or a CAC for my alcohol problems?”

A7a: No empirically supported reason (Darn it.)

A7b: “We know more ways to create change. We are not one-trick ponies  like they are.” [Best be sure this is true, you true believers.]

Q8: “Why does therapy take so long?”

Non-answer 1: We are fond of saying something like, “Well you didn’t get into this pickle overnight, did you?” but to fully agree with this requires the client to understand developmental patterns, stressors/diatheses theory, and to take responsibility for their contributions to their suffering. How many new clients have these  understandings?

Non-answer 2: But perhaps they did get it suddenly. For example, phobias acquired after a single overwhelming crisis, depressions due to deaths/surprise divorces/criminal convictions or other legal actions
A8a: “Ma’am, I am plumb out of magic bullets. You watch too much Dr. Phil and listen to the radio shrinks. Even Dr. Phil always follows up with therapy.”

A8b: “Just because it simple doesn’t mean it is easy.” Albert Ellis

A8c: “It is hard to unlearn behaviors, change habitual responses, and substitute better behaviors. It take lots of practice and effort and so it takes time.”

Q9: How do I know this will work? Why can’t I have a guarantee if you are really competent?

Yes, I know life is often unfair, reality is probabilistic,, methods are not perfect, etc. But what answer can you give someone who does not understand Heisenberg, complexity such as systems theory, and our work’s dependent nature?

Q10: Changing is too hard.

A10a: “Compared to what?”

A10b: “Someone famous said: Everybody wants to be happy; no one wants  to change.”

Q11: I am too old/too set in my ways to change.

A: If you avoid cliches about old dogs, what do you say?

Q12: Why should I come for treatment when it is (his, her, society’s, my employer’s, genetics, my mother’s, my father’s) fault that I am suffering?

A12: Family therapist’s answer: “Bring them in.”

A: What do you say?

Q13: I am not unhappy. I am not breaking the law. I am not hurting myself. I don’t have a problem. He/she/they/the darn judge does.

A: What do you say?

Two points about all the above. First, even what might appear to be hostile questions can be made into opportunities to educate and build rapport and positive expectations. Second, please send me responses you have used and your ideas so we can explore and continue this necessary discussion.

Ed can be reached at edzucker@mac.com.