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High Stakes Clients

babyI recently got a new client–a very young mom with an addiction and domestic violence history, trying her best to stay away from her abuser and to stay clean, bouncing a four-month-old baby on her knee.

She belongs to a class of clients that I’m calling “high stakes”, because when they show up in my office, I feel intense empathy, sympathy, and a desire to make it all turn out all right.  I looked at her thin shoulders and that baby she’s holding, and thought, “I really have to pull this off, for her and her daughter.”

But does that pressure actually make for good therapy, or do the reverse?

Countertransference is the strong reaction a therapist has to a client, and it can help guide the work or undermine it.  For example, often a strongly negative reaction can indicate that a personality disorder is present in the client, and that influences the type of treatment that’s appropriate.

Sometimes, the strong reaction is about the therapist’s own past issues that are not fully resolved (even if the therapist had believed that they were.)  Countertransference is always worth examining, so that it doesn’t get in the way of treatment.  Also, it can highlight an aspect of personal growth that the therapist needs to attend to.

For me, working with high stakes clients evokes complicated feelings.  I find that I look forward to the sessions because it’s energizing to feel like you’re doing something that really matters.

But there’s also a bit of trepidation because I fear missteps more.  I’m afraid to fail, when it seems like there’s so much on the line.  I feel like they need me more than other clients, and that’s both exhilarating and, at times, overwhelming.

Now, I should mention that it’s also satisfying to work with clients whose lives are more stable, and to help clients resolve more short-term problems.  I know therapists whose caseloads are primarily comprised of high stakes clients (which can include those with severe trauma histories, personality disorders, suicidal gestures and intent), and I don’t think I would have it in me to do that work exclusively.

But I’m grateful to have the opportunity to pepper my caseload with high stakes clients.  There’s a special connection you feel when you are working hard to see the best in someone, and to help them see that in themselves.  Because often what distinguishes a high stakes client is that they haven’t had people in their lives who really believe in them.

It’s a delicate balance, though: trying to help people see themselves in a better light and visualize a more hopeful future, without putting yourself in the role of savior.  That’s where I find I have to be most mindful.

If I start to believe too much in my own power to heal, if I start to take on full responsibility for my client’s well-being, the client might not do the work he or she needs to do; they become dependent and reliant on me.  I can fall into the trap of working harder than the client.

The key is becoming a collaborator with your client.  That means never infantilizing the client, but instead, being partners in healing.

Mother and baby image available from Shutterstock.

High Stakes Clients

Holly Brown, LMFT

Holly Brown is a marriage and family therapist in the San Francisco Bay area. She has a private practice in Alameda ( ). She is also a novelist ( Her latest is HOW FAR SHE'S COME, a workplace thriller which received a starred review from Publisher's Weekly: "This provocative tale will resonate with many in the era of the #MeToo movement."

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APA Reference
Brown, H. (2013). High Stakes Clients. Psych Central. Retrieved on May 30, 2020, from


Last updated: 7 Aug 2013
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