Alice Gives Career Advice for the Mental Health Care Professional

[CN: mental illness, self-injury, sexual violence.]

It’s been almost a quarter-century since I first began seeking out professional help to correct the undefined something that was going terribly wrong inside my head. During those 24 years of searching-but-rarely-finding, I have worked with 9 therapists, social workers, and psychologists; consulted with over 12 psychiatrists and psychiatrists-in-training; and been prescribed more pills, poppers, and potions than I have fingers and toes (or maybe brain cells) with which to count.

I submit to you: this qualifies me as having a certain expertise. 

Mostly it’s expertise in how to go slowly mad. But — work with what ya got, right?

Everything that follows draws from my own experiences (some of which has also occurred to friends and acquaintances). Consider it all contraindicated! Though, I suppose, one could follow the advice as written. Maybe you like to live on the edge.

You’ll certainly find greater madness out there.


Initial Diagnosis


Assume every client is depressed, until proven otherwise.

If, at some later point in time, your client starts describing symptoms not consistent with depression, criticize her choice of language and chastise her for disrespecting your profession.


Once you’ve reduced a client to sobs through a lengthy interrogation about her family of origin, conclude with: “You have not said anything that proves to me your father would not love and support you, no matter what you do.” Let her know that your diagnosis will be based in part on the irrational anger she displays towards her father.

Feel confirmed in your assessment when the client now begins displaying an irrational anger towards you. 


When informing a new client you think she has been misdiagnosed by previous psychiatrists, lean back in your chair, grin broadly, and say: “Guess what my diagnosis of you is!”

If the client reacts to the new diagnosis by saying nervously, “That sounds like a death sentence,” tell her it’s actually quite treatable now — then dismiss her with a xeroxed newspaper article on the mood-enhancing benefits of exercise and no recommendation for a follow-up appointment.


Interpersonal Skills

Respond with a spit-take upon learning that a client does not come from a broken home: “Wait! Your parents are still married?? TO EACH OTHER??!


Refuse to answer point-blank questions.

For instance, if a client asks, “When you say that you think I had a ‘big breakthrough’ today, what are you referring to? What is it you think just happened?” — reply only: “Well, what do YOU think just happened?”

For best results, ensure the client never figures out what you are talking about.


Attempt to build rapport by repeatedly saying things like: “You’re someone I’d love to hang out with, if you weren’t a client.” Or “we’d be great friends, if we had just met somewhere and you were not my client.” Or “you’re just like people I’m friends with, except we can’t be because you’re a client.”

Never ask the client for her own thoughts or feelings about this hypothetical friendship.


Cut a scheduled appointment short because you decide the client needs to go to a nearby psychiatric hospital for immediate evaluation — and then don’t alert the clinic that you’re sending her over (or why), despite promising to do so.

Remember: The possibility of getting committed becomes extra-exciting when no one (including the client!) understands what she is being evaluated for.


Take on the role of a punitive parent: “I am terminating my services with you because you need to learn that actions have consequences.”

Bonus points! if the action in question is self-injury, and the client’s sole expressed reason for seeking therapy at this time is: “I can’t stop cutting.”




Minimize a client’s own assessment of her self-injuring. Correct her on language you don’t agree with: “I thought you said you had ‘cuts.’ Those are just scratches.”

Do not worry about the client escalating the severity of cutting shortly after you refer to her injuries as scratches. Chances are, she won’t feel safe talking to you again and will thus become some other medical professional’s problem.


When a patient comes to the ER for stitches on a self-inflicted injury that is not life-threatening — and that she assures you did not result from a suicide attempt — have a cheery intern call her at home a week later to ask if she is willing to participate in a research study on people who have attempted suicide and survived.

Be certain you do not have the client’s permission to share her medical records before giving them to the cheery intern.




Refuse to believe a client’s stated sexual orientation. Reject the term(s) she uses to describe her orientation. Insist that the client still needs to “come out” as something else.

Remember: Just because the client doesn’t have a problem with her own sexuality, doesn’t mean you can’t make it a problem for her!

[tl; dr Be shocked to learn bisexuals exist.]


During your first meeting, insist the client must have been sexually abused as a child. If she tells you she wasn’t, suggest that “maybe [she] just doesn’t remember” being abused. But be clear: you’re absolutely sure abuse happened.

So much depends upon the trust and rapport built in at the beginning.

Or perhaps I’m just thinking of a red wheelbarrow…


If a client expresses shame around a sexual event severe enough to make you ask, “Were you raped?”, and her response is “I consented to everything that happened to me” — take this statement at face value.

Make no attempt to clarify what “I consented” meant to her in this situation.




Use scare tactics to prevent a client from questioning the efficacy of a drug:

Client: “I’ve been on this med for over six months, and — as I’ve told you before — I can’t tell that it’s making any difference at all.”

Doctor: “But think how much worse you might be if you were not taking it!”


Prescribe a potentially lifelong course of antipsychotics following a single quasi-psychotic episode. Do not be deterred by the fact that this episode was precipitated by a difficult topic coming up in therapy for the first time, and without adequate time to discuss.

Both therapist and psychiatrist should make a point of NOT following up on said topic later, especially if the client’s only psychotic symptom consisted of a voice in her head saying, “I’ll kill you before I let you ever talk about [redacted] again.”

Clearly: let that sleeping dog lie.


If a client strongly values her identity as a writer and tells you that, since starting a new medication, she can no longer write — that she does not recognize the only “voice” now in her head as her own — assure her this is great news! It means the drugs are working…

And that’s what really matters.

That’s all that really matters.

Got any horror stories of your own? An “I CANNOT BELIEVE THAT JUST HAPPENED” moment you’d care to share? Please comment below!

Mi schadenfreude es su schadenfreude.

Or something…  

Image sources: Far Side: Just plain nuts; Paulus: How embarassing; New Yorker, BEK: Wearing a beret?; Peanuts: The Doctor Is In; New Yorker, Leo Cullum: Mint?

29 thoughts on “Alice Gives Career Advice for the Mental Health Care Professional

  1. Apologies for all the scare quotes, I can’t seem to stop my sarcasm when retelling these moments.
    When I told my therapist about questioning my romantic orientation and possible identifying as aromantic, she “reassured” me that this was because of my depression (or her viewing all mental illness as depression as you mentioned) and that I would get better (alloromantic) through recovery. She reassured me that I would still experience her definition of real love, even as I was trying to come to grips with the idea that I may find love in areas other than romantic relationships.
    When my parents wanted me on anti-depressants, we went to my general physician who told me that I didn’t seem “that bad,” but she would put me on meds since I insisted. Bear in mind, I never wanted to be on meds and proceeded to only pretend to take them for the next couple years. At least, I felt entirely invalidated and she felt she’d helped someone get what they wanted, right?
    And finally, I was in group therapy designed for teen girls and one of them came out as a trans man to us. Our therapist refused to gender him correctly or respect his identity. When I confronted her about this one-on-one, she was dismissive of my concerns. He left group shortly after and I had no way to keep in touch or find out how he’s doing now.
    It’s interesting to recover these memories as I don’t often think or talk about them. Writing them down is likely a good idea…
    I really appreciate your blog and writings, thank you for being so open and thoughtful. It’s helping me with those things as well.


    1. Hi Riley,
      I am sorry to hear about your experiences of feeling invalidated by people you relied on to help you. Adolescence is tough enough without being treated like you are not capable of knowing your own self. I hope that today you are surrounded by people who see you and appreciate you for all that you are.
      Thank you for sharing — and I’m glad that you found my words helpful.
      ❤ alice


  2. And make sure that you HUG the client, especially if said client expresses her hesitation for a hug from a man she’s only seen ONCE, for TWENTY MINUTES.
    Yeah. Last time I saw him….
    The next one was a woman who was absolutely amazing, and helped me dig down to the real problems. She didn’t FIX them, but she helped me identify them and taught me the steps to fix them. Not that they are all fixed, but at least I’ve made some serious progress in the last 25 years.

    Liked by 1 person

    1. Gah! Boundaries, Mr. Therapist. BOUNDARIES!!

      Glad you kept trying — and that the next one worked out well! (I’m not sure we ever get “all fixed,” per se; so “serious progress” is seriously awesome. Good on you!)


  3. so much AUGH at every turn. SO much.

    YES rapport. YES reflecting language, YES boundaries, YES HIPAA, YES awareness of the power differential.


    (how is this is even still a thing i don’t even!)

    Liked by 3 people

    1. True! And Philly has a great one.

      I currently have two fantastic professionals (a woman and a man) I work with, for individual and group therapy. Not sure I’d still be alive without their assistance over the past few years? While I do make oblique references to each of them on the blog occasionally — not in THIS post, obviously! — I haven’t yet dedicated any space to discussing either of them at length. Mostly because: 1) those relationships are part of my daily life in ways that are still ongoing/unfolding, and 2) they each read this blog from time to time, and that could get…awkward. 🙂

      [Hey, M and C! *waves* If you’re reading this now, lemme just say “thanks for everything!”]


  4. I am very fortunate to have had some excellent therapists, people (primarily women, but I’m prepared to believe I wouldn’t have trusted many men to help me at the time) who knew when to give me a swift kick in the behind and when to be that soft place to land. They are out there.

    That being said – here’s the one I’ve never told anybody but my husband.

    At 14, I revealed to my psychiatrist (male) and social worker (female) that my long-estranged, recently reappeared father was showing me porn. They told my mother (who had left him 12 years earlier because he was so abusive she was afraid he would kill us all) to tell him not to do that anymore. Right before she dropped me off at his house for an unsupervised overnight home visit.

    I never bothered to tell them that he was teaching his suicidal daughter how to hang herself with shoelaces. I didn’t figure they would care.

    If you haven’t found a good therapist, I URGE you to keep looking.

    Liked by 2 people

    1. There’s a line from a book by my favorite author (Lois McMaster Bujold) that has always stuck with me, and which I thought of again while reading your comment. [From memory, so I’m probably garbling a bit]:

      “She took in his story like some fragile, spiked gift: too painful to hold, too precious to put down.”

      Thank you for the gift of this story.


  5. I guess I’ve been lucky in the therapists I have. The first negative experience that came to mind was a misheard word that led to a rather inexplicable argument. This occurred around 2000 or 2001. To paraphrase, in dramatic form:

    Therapist: “So you’re married?”
    Me: “No.”
    Therapist: “You said you were married.”
    Me: “No I didn’t.”
    Therapist: “I’m pretty sure you did.”
    Me: “I am positive I did not. I know for a fact that I am not married.”
    Therapist: “Just a moment ago, you said you were having trouble with your wife.”
    Me: “No, I said I’m having trouble with my LIFE.”
    Therapist: “……. Oh.”

    Liked by 2 people

        1. I hear ya! It shuts down all discourse and turns “I am repeating myself BECAUSE YOU ARE NOT LISTENING” into “Methinks the lady doth protest too much” faster than I can think to 2.

          I’m pretty sure the paperwork the cheery intern received (srsly, I could almost HEAR her ponytail over the phone!) included the notation: “Denies suicidal ideation.”

          Liked by 1 person

  6. I don’t have anything nearly as horrific as what you went through. It feels trivial compared to your plight. But it does seem odd to me, looking back to when I was in 2nd grade, that my teacher recommended I be put in Special Ed, because I was a “tomboy” and didn’t “act like a young lady”. Thinking about it 30 years later, I wonder if it was homophobia on her part.

    Liked by 1 person

    1. WOW. Special ed for “inappropriate gender expression in an 8yo” is, um…hard-core. Glad (or i’m assuming?) someone stood up for you against that recommendation!


      1. Unfortunately, my parents being German immigrants, they trusted that she must know what she’s doing, since she was “professional teacher”, and followed her instructions. It took 4 years of gradual “mainstreaming” to get back to the general school population.

        (It didn’t stop me from being a lesbian, although I am more assexual.)

        Liked by 1 person

        1. Oof. Sorry about that. The SPED years, I mean. Not the Love that Dare Not Speak Its Name (except now it seems to get spoken all the goshdarn time).

          When I was in 2nd grade, my teacher referred me to get tested for special education, too. But the counselor Mr. Morley (who was awesome!) determined that I did not have a learning disability — I was just bored out of my gourd in her class.


    1. Thanks for the support, m’dear! And most of the greatest hits did come from interactions with men! 🙂 But not all. And I’m sure many of these people were well-intentioned, just out of their depth.

      Realizing that hasn’t made me less angry, unfortunately. Just sad on top of the angry. But using our blogs for the occasional nasty griping isn’t the end of the world, right? 😉


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