Clinical Patience

I had a teenage client I dreaded.

I want to be careful with that word, because it’s not the word you’d expect. He wasn’t difficult. He wasn’t resistant. He wasn’t one of the kids who makes you check the schedule twice and brace yourself. He was likeable. He was adjusting well. By any reasonable measure, he was doing fine.

And I dreaded our sessions anyway.

Not because anything was wrong. Because nothing was. We’d sit down and I’d find myself pulling teeth — not because he was shut down, but because there genuinely wasn’t much there. Whatever came up, he could already navigate it himself. He didn’t need me to get through his week. He was getting through his week. And I’d catch myself zoning out, watching the clock, going through the motions of a session that didn’t have a reason to exist anymore.

When I’m dreading something, or zoning out in session, that is very telling. My own dread is data. But I want to be careful about what kind of data it is, because this is exactly where a newer clinician can take the wrong thing from a blog like this.

Dread is real information. It is not a verdict. Dread can mean a client is genuinely done — and it can also mean countertransference, or avoidance of a client who is harder than you want to admit, or something about this person that is pulling on something in you. The dread tells you to look; it doesn’t tell you what you’ll find when you do. Figuring out which kind it is — that’s the work, and it happens in your own therapy, in supervision, in consultation. It took me years to get good at that sorting. I didn’t come into the field knowing how to do it, and I didn’t do it alone.

📚 This is Blog #32 in the New Clinician Survival Kit Series (Click to explore the series)

Weekly honest support for the struggles every clinician faces: “I hate group therapy.” “I can’t do this.” “My client hates me.” “I’m making it worse.” “I can’t say no.” “They’re going to report me.” “I’m too tired to care.” “What do I even say?” “I don’t know enough.” “They keep relapsing.” “Am I documenting wrong?” “My supervisor doesn’t get it.” “I can’t handle this caseload.” “Nobody told me about the paperwork.” “I don’t like my client.” “My client’s cute.” “My client likes me.” “I got a complaint.” “I want to quit.” “My coworker is terrible.” “The most underrated job in mental health.” “My client scares me.” “Fear of losing a client.” “Fear of what they show you.” “My client died.” “I’m worried my client is hopeless.” “I don’t practice what I preach.” “I freeze in crisis situations.” “My workplace is toxic.” “I don’t know how to specialize.” “My client isn’t getting better and I don’t know why.” “I’m tired of waiting.”

These aren’t signs you’re failing. They’re signs you’re human.

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There Are Two Ways Patience Runs Out

Here’s the thing nobody told me, and the thing I most want to tell you: “I’m tired of waiting” is not one experience. It’s two completely different ones, and they pull in opposite directions, and both of them will make you question whether you’re any good at this job.

The first kind is the teenage client. The client who’s essentially done. Who has met their goals, who isn’t presenting with anything beyond developmentally normal stuff, who could walk out the door today and be fine. And you’re sitting there, week after week, feeling less and less necessary, wondering what you’re even for.

The second kind is the opposite. The high-acuity client you’ve been seeing for months and months. The one who is very much not done. Where real progress has happened — meaningful progress — and yet significant behaviors are still causing real internal and external consequences, and somewhere in month eight you catch yourself thinking this shouldn’t still be happening.

When The Client Is Done But Won’t Leave

Let me describe what this actually feels like, because the textbook version — “client has met treatment goals, initiate discharge planning” — does not capture it.

It feels like dread before a session that has no reason to be dreaded. It feels like imposter syndrome while the session is happening, because you’re not doing much work — you’re not doing much work because you’re not really needed — so the hour goes slow, and the slowness makes you feel like you’re failing at something, even though nothing is failing. If that particular flavor of am I even doing anything is familiar to you, I wrote a whole post about where it comes from earlier in this series.

And then you go to write the note.

There’s always something to document, technically. But it’s vague. It’s generic. Instead of worked on X, Y, and Z, it’s maintained or strengthened or reinforced. And that note, sitting there looking thin on the page, mirrors exactly how the session felt in the room — like not much happened, because not much needed to.

Not Much There Is a Conclusion, and You Have to Earn It

But here’s where I have to be honest, and where I’d want a newer clinician to slow down: “not much there” is a conclusion, and you have to earn it. There are two very different reasons a session can feel empty. One is that the client genuinely has no more clinical work to do with you. The other is that the fires are out — the crisis, the acute symptoms, the structure-collapse — and what’s left is the slower, quieter, maintenance-phase work, and I am simply not as fluent in that phase.

Those feel identical in the room. They are not the same thing. One means the client is ready to step down. The other means I need to get better at the part of the work that isn’t a fire. You cannot tell which one you’re looking at from the dread alone. You have to actually examine it — and that’s another place supervision or consultation earns its keep.

The Part That Isn’t About You At All

Here’s what I wish someone had told me early, because it would have saved me a lot of self-blame: a lot of the time, the client staying too long is not a clinical problem. It’s a systems problem.

In an ideal world, that teenage client steps down to something that actually fits what he needs in that moment. A mentor. A coach. A peer or social group. A lower-intensity support that isn’t clinical treatment, because he doesn’t need clinical treatment anymore — he needs connection and structure.

But especially in community mental health, those things often don’t exist. There’s no mentor available. There’s no coach. There’s no social group with an open spot. There isn’t a separate substance use provider, so you’re doing both the mental health work and the substance use work yourself. The middle of the system — the soft landing, the step-down, the lateral support — is missing. It’s clinical treatment or nothing. This isn’t a personal observation so much as a documented structural gap: the behavioral health system has never been built out enough to catch everyone it’s supposed to.

When Staying Is The Right Call

So sometimes the right clinical call is to keep the client in treatment a little longer. I want to be precise about that, because there is a version of “keeping a client longer” that is a problem — continuing to see and bill for a client who has genuinely met every goal and no longer needs care is not a kindness, it’s a compliance issue, and it’s not what I’m describing.

The client I’m describing still needs care. That part is real, and it’s documentable. What they don’t need is this specific service — outpatient counseling — when what would actually serve them is a program built around their goals: a mentorship, a structured skills or social program, a different level of care that simply doesn’t exist or isn’t accessible to them. Choosing to continue outpatient care as the best available option, and documenting it honestly as exactly that, isn’t padding. It’s a deliberate, defensible clinical decision made inside a system that didn’t hand you the right tool.

What That Actually Looks Like

So what does that actually look like in practice? Say a client’s acuity is genuinely low — relapse risk is low, the fires are out — but they’d still benefit from more social support than they have. On paper, you could justify a lower level of care. But that’s not the only thing the clinical picture justifies. You can also still name real, legitimate goals: strengthening social connection, building natural supports, increasing the kind of self-efficacy that makes someone less reliant on formal treatment over time. Both of those things are true at once, and good documentation can hold both.

If that client would genuinely do best in a mentorship program, or with a case manager, or in a career-focused program — refer them, every time. But when those don’t exist, or the waitlist is six months long, keeping them in outpatient group while you work those goals isn’t you failing to discharge. It’s you choosing the most useful container actually available and being honest, in the chart, about what you’re using it for. The work doesn’t disappear because the ideal setting does. It just has to be named accurately.

That’s not your failure. And it’s not really the client’s, either. It’s a field that has no aftercare layer for people who are mostly well but not quite ready to be without support entirely. When you feel that impatience, some of it probably isn’t impatience at all. It’s grief about that gap. And grief about a system with holes in it is not the same thing as being bad at your job, even though on a hard week it can be very hard to tell them apart.

The Waitlist In The Back Of Your Mind

There’s one more layer to this kind of impatience, and I want to name it honestly, because the noble version isn’t the true version.

The true version is anxiety.

I know there are people on my waitlist. I know our field is starved for access — that people need help and most of them never get the chance to sit in front of someone. That scarcity is real and measurable: roughly forty percent of the country lives in a designated mental health professional shortage area. I know that motivation is a moving target: someone who is ready and reachable today might not be ready next week, or next month, and the window closes.

So when I’m sitting in a session managing mild, maintenance-level concerns, that knowledge runs underneath the whole hour. Someone with active structure fires is waiting, and the window on their willingness might be closing while I hold a slot for someone who’s essentially fine.

That’s not me being noble about resource allocation. That’s anxiety. And it’s worth saying out loud, because if you feel it, you might be telling yourself you’re callous or burned out, when actually you’re carrying an accurate awareness of scarcity that the system has handed you and given you no good way to resolve.

But I want to be clear about what that anxiety does and doesn’t get to do. It does not get to push a client out the door. I have never discharged someone because a more acute person was waiting, and you shouldn’t either — triage is not a decision you make mid-session, weighing one client’s need against another’s. What the waitlist anxiety can do is make me avoid a conversation I should be having anyway.

So I keep the two separate. The thing that makes me raise termination is never the waitlist. It’s the clinical picture: the client has moved toward their goals, and the work has gone stale or stuck. That — not the people behind them — is the reason the conversation is warranted.

The Question You Have to Ask Before You Act

So when you feel ready to move a client toward discharge and they’re not — before you do anything — you have to interrogate the impatience. Because it can mean two very different things, and they require different responses.

One possibility: the impatience is accurate. The client genuinely has no more structure fires. The real work ahead of them is maintenance — and maintenance is theirs to do, not yours to supervise. You’ve done your part. The impatience is data telling you it’s time, and the discomfort of the termination conversation is the work, not a reason to avoid it.

The other possibility is the one I named earlier — that what you’re reading as “they’re done” is actually “I struggle once the fires are out.” That doesn’t make you a bad clinician. It makes you someone with more reps in crisis work than in maintenance work, which is extremely common, especially early on and especially if most of your caseload runs acute.

But it means you can’t fully trust the impatience until you’ve separated they’re ready to go from I’m less sure of myself in this phase. The research on termination treats appropriate, well-timed ending as a clinical skill in its own right — not a gut call, and not an afterthought. The literature on premature termination is worth knowing precisely because getting the timing wrong, in either direction, has real consequences for the client.

Both can be true at once. Usually some of both is. The point is not to act on the feeling until you’ve sorted out which part is which — and if you’re newer, that sorting is not something you’re expected to do alone in your own head. That’s what supervision is for, and it’s a completely legitimate thing to bring to it.

The Other Kind: When You’ve Been Patient For Too Long

Now the opposite client.

I want to be clear about something first: I’m actually very patient. I can sit with a client and work through ambivalence — that’s not where I struggle. Ambivalence doesn’t wear me down. Sitting in the not-yet of someone’s change process is something I can do, and do well.

What wears on me is time. When we’ve been meeting for months and months, and there’s been progress — real progress, the kind I’d point to and defend — but significant behaviors are still there, still causing internal and external consequences, something starts to erode. The thought creeps in: this shouldn’t still be happening.

And here’s the specific trap of the long haul, the part that doesn’t get talked about: the longer you work with someone, the more you get to know them. You get comfortable. And as you get comfortable, your boundaries get a little softer without your noticing. You become more invested, more familiar — and that’s when I catch myself on the soapbox.

I’ve actually said it out loud, to clients, more than once: I’m sorry, I feel like I’m preaching. Because I can feel it happening. And I can see it land on them — that look in their eyes when they shift from receiving help to enduring a lecture. The slight tune-out. The flicker of being judged or taught instead of validated. They don’t always say anything. But the look is unmistakable, and it tells me I’ve drifted from doing therapy into doing instruction, and instruction is not what they came for.

That softening, and the work of catching it, is its own ongoing project — I’ve written separately about how hard boundaries actually are to hold, and the long-term client is exactly where they slip.

That’s the moment I start to wonder if I’m the wrong fit. Even though I know — logically, clearly — that it might be the client’s ambivalence holding things back, not my competence.

Imposter Syndrome Leaks In Even When You’re Doing It Right

Here’s something I’ve noticed in my own work that I think is worth naming plainly: I get more imposter syndrome in maintenance than I do in a crisis.

That probably sounds backwards. But most of my clients, most of the time, are not in a maintenance stage of change — they’re earlier, messier, more acute. So when a client does reach the slower, steadier phase, it’s less familiar terrain for me, and that’s exactly when the second-guessing shows up. Are we still doing real work? Would someone else have moved them further by now? Is my patience actually skill, or is it just me not being sure what the next move is?

That’s the stage where I find myself reaching out — to a peer, to consultation — asking some version of am I missing something, or is this just what this phase looks like. When I was earlier in my career and not yet fully licensed, that’s squarely what I brought to supervision. The questions didn’t stop when the license came through; the place I take them changed.

This is part of why the research on how change actually happens matters. Change in therapy is frequently nonlinear — slow stretches, plateaus, sudden shifts, periods that look stalled from the inside but aren’t. If your internal benchmark is steady visible movement every week, a normal maintenance phase will read as failure when it’s nothing of the kind.

The thing that keeps me steady through that is not reassurance. It’s a practice. I deliberately anchor to the small steps. The slightly more honest disclosure. The trigger they can now name that they couldn’t see six months ago. The slightly longer stretch. The fact that they’re still coming.

I don’t do that because it’s a nice thing to tell myself. I do it because it’s the only thing that keeps the long game survivable.

If I measure my worth by whether the significant behaviors have fully resolved, I will burn out, and I’ll burn out specifically on the clients who need a long runway — which is exactly the wrong group to lose patience with. I made this same argument about relapse, and it holds here too: anchoring to small steps isn’t a platitude. It’s a survival mechanism for the part of this work that takes years.

What I Want You To Take From This

If you’re newer to this, here’s what I most want you to hear.

You are going to feel impatient with clients. Both kinds. It doesn’t mean you’ve lost your compassion or picked the wrong field — it’s just information, and it’s usually accurate about something. The problem isn’t the feeling. It’s acting on the feeling before you’ve done the work of figuring out what it’s actually about.

When you’re impatient with a client who seems done: ask whether they’re genuinely finished or whether the right next resource just doesn’t exist. Ask whether you’re reading their readiness or your own discomfort with maintenance-phase work. Ask whether the waitlist anxiety is quietly distorting your clinical judgment. Then act on what you find — including, sometimes, having the discharge conversation you’ve been avoiding, because the discomfort of that conversation is the work.

When you’re impatient with a client who’s been with you a long time: check your boundaries first. Notice if you’ve drifted onto the soapbox. Notice the look in their eyes. And then remember you are one person, that real change is theirs to carry, and that the small steps you’re tempted to dismiss are the actual evidence that this is working.

And for all of it — don’t do the sorting alone. The whole move of this blog is figure out what the impatience is actually telling you before you act on it. That figuring-out is not a solo task. It wasn’t for me. It happens in supervision when you’re newer, in consultation and peer conversation later, in your own therapy throughout. The fact that you can’t immediately tell impatience from countertransference from a real clinical signal doesn’t mean you’re behind. Nobody can do that sorting alone at the start. You learn the difference by talking it through, over and over, until one day you notice you can mostly tell — and even then, not always.

I’m tired of waiting is a real feeling. It’s worth listening to. It is just rarely telling you the simple thing it seems to be telling you.

Impatience doesn’t mean you’re a bad clinician. Most of the time it just means something needs your attention — a conversation you’ve been putting off, a boundary that’s quietly slipped, or a phase of the work you haven’t gotten fluent in yet. Figuring out which one it is takes longer than the feeling does. That’s the part of the job nobody really warns you about.

This is post #32 in the New Clinician Survival Kit Series — a collection of honest, non-cheerful blogs about the parts of this work that don’t show up in grad school. If you’ve been feeling something and can’t quite name it, this series is probably where you’ll find the words.

Until Next Week | The Underrated Superhero

📖 External Resources & Research

• 🔗 Premature Termination in Psychotherapy: Strategies for Engaging Clients and Improving Outcomes — Swift & Greenberg, APA — Evidence-based examination of why and when clients terminate before meaningful progress, drawing on a meta-analysis of 669 studies, with practical strategies that frame appropriate, well-timed termination as a clinical skill in its own right rather than a gut call
• 🔗 Filling the Gaps in the Behavioral Health Workforce — Bipartisan Policy Center — Policy analysis documenting the structural shortage of behavioral health providers and the absence of a built-out continuum of care, including the finding that fewer than half of adults with mental health conditions and the large majority of people with substance use disorders go without treatment
• 🔗 State of the Behavioral Health Workforce, 2025 — HRSA — Federal workforce data establishing that roughly 40% of the U.S. population — about 137 million people — lives in a designated Mental Health Professional Shortage Area, with projected shortages across addiction counselors, mental health counselors, and other core disciplines
• 🔗 Change Is Not Always Linear: The Study of Nonlinear and Discontinuous Patterns of Change in Psychotherapy — Hayes et al., Clinical Psychology Review — Peer-reviewed review challenging the assumption that therapeutic change is steady and linear, documenting plateaus, sudden gains, and stalled-looking stretches as expected patterns — useful context for reading a slow maintenance phase as normal rather than as failure

📌 From This Series

• 🔗 Blog #10: “They Keep Relapsing” — The argument for anchoring to small steps instead of measuring yourself by full resolution — the same survival logic that keeps the long-haul client from wearing you down
• 🔗 Blog #2: “I Can’t Do This” — The new-clinician imposter syndrome that shows up not just when you’re overwhelmed, but in the quiet, low-demand sessions where you can’t tell whether you’re doing anything at all
• 🔗 Blog #5: “I Can’t Say No” — Why boundaries are hardest to hold with the clients you’ve known longest — the slow softening that leads straight to the soapbox