Therapists in a Fishbowl

The Challenges of Small-Town Practice

Magazine Issue
July/August 2019
A goldfish in a bowl

Q: I worked for many years in a major city, where my personal and professional lives rarely intersected. Now, I live in a tiny rural town, where I can’t avoid running into clients. How do I regain my personal privacy?

A: If by personal privacy, you mean the luxury of living your life without scrutiny by clients, the bad news is it’s not possible. That fantasy disregards an undeniable fact of small-town life: a therapist is a celebrity, a person of interest, to be watched and talked about. But the good news is there’s no bottom to the growth opportunities. I say that without irony after 25 years of rural life.

In parallel process to client transference in session, what I call social transference occurs out in the community. A therapist’s place in small-town culture is freighted with a wide variety of opinions and expectations, most of which, as in treatment, are independent of our personal selves. As with a client in session, managing these various responses starts with good manners: I’m an ambassador for our work and expect myself to be unfailingly polite and, if possible, kind.

However, that’s only the surface, for underneath swim all the management challenges of living in a fishbowl. In the past, the more vulnerable I felt, for whatever reason, the more overwhelming my longing became for the privacy I enjoyed in the city. Eventually, I asked myself: Is this wish for an anonymous personal life an avoidance? Am I hiding myself from others? From myself? If so, does it serve me, or my clients?

As a first strategy to “protect my privacy,” I tried hiding. But that’s impossible in a town with only two grocery stores, one mall, one congregation of each major religious denomination, and one public elementary, middle, and high school. Even if you don’t know it, you’ll have contact with people in your client’s life, be it a friend, relative, or coworker. In a small town, wherever people gather, they’ll talk about other people, especially those who contribute significantly to their lives. It doesn’t matter if you feel you’re nothing special. Get over it. You are special. Any healer is.

It’s best to accept and embrace this, rather than avoid it. Socially isolating ourselves leads inevitably to unhealthy restriction of personal pursuits and to professional burnout. After a few years of constricting my life to avoid possible reactions from clients, I had to ask myself: What’s the big deal if a client sees I have potato chips in my shopping cart? That I like polka-dot T-shirts? That I’m the worst student in the dance class? That my kid can be an obnoxious brat? I concluded it’s not, if I released myself from the outdated conventions of social propriety embedded in our training—training usually based on an urban setting.

What are those? As healers, we shouldn’t eat junk: no chips for us. We should wear neutral clothing: nothing should attract attention to us. Our children should be models of mental and physical health; after all, we know what we’re doing. Maintaining these illusions may be possible in a large city, but they’re far too brittle for small-town life. When I run into clients at the grocery store, they always glance into my cart. When I get called to the school by a teacher because my son is misbehaving, I have to remind myself that getting defensive doesn’t do me or our work justice.

Our personal limitations largely determine our professional effectiveness. Not wanting to confront them is human, and we therapists are no different. That’s why living in a small town is so great. Where else would I be forced to give up my obsessive standard of personal perfection? Living exposed for the flawed mortal I am yields infinite opportunities for growth. Again, I say that without irony.

Not Either/Or but Both

How do you remain an ambassador for the work while also being your own person, without inhibiting yourself with others’ (and possibly your own) unreasonable social expectations? Rather than trying to navigate each situation individually, I prefer to operate from one overarching premise: in session, I’m a therapist first, an individual second; out in the world, I’m an individual first, a therapist second. I’m a therapist to help people recover from, let go of, and come to terms with whatever it is that holds them back and causes them suffering. That applies to me too—no double standard.

However, I don’t ever forget I’m a therapist. Even when making an ass of myself in a dance class, I remember the responsibility my community role carries. So when the woman next to me in class loses her balance, stepping hard on my foot, I want to curse her, but instead I hop up and down, Ow. Ow. Ow. I’m entitled to express my pain and get sympathy. Anything angrier, though, would be at least impolite, at worst damaging (to both of us).

It doesn’t hurt my professional credibility for a client to witness me miss the beat, misstep, or get turned around. Just as I’m heartened to see the teacher (who embodies the phrase “poetry in motion”) wobble, clients like to see evidence that I’m human too. They like to see I haven’t arrived at some enviable end point of perfection. They like to see that my journey, like theirs, goes on. And on.

On a good day, it’s an opportunity to model self-loving behavior, like laughing when I turn left instead of right. On a bad day, when I have two left feet, it’s a reality check for the client: I too have to work for every gain.

With all this in mind, here are a few of the challenges I’ve navigated over the years.

Being held by the client to an unreasonable standard of personal competence. Denise, married, in her 50s, asks me, with clear disgust, how I can “let” my husband use his car as combination garbage can/laundry hamper/storage unit. (My husband, also a psychiatrist, and I are in practice together.) Of course, Denise, along with everybody else, knows my car and his too. We’re especially interesting because we’re married. (“Do you analyze each other?” “No, it’s too much work.” When my son’s friends ask him what it’s like to have two psychiatrists for parents, he shrugs, “They’re just parents.”)

Denise is perfectionistic, obsessional, and rigid. She gets upset with equal intensity over her husband’s habit of returning the ice tray empty to the freezer and the current administration’s policy of separating immigrant toddlers from their parents at the border. She’s just given me a teaching moment.

“It’s not my car, Denise. If he wants to ride around in a trash pit, what do I care?”

“It’s gross!” she says. “You should make him clean it up.”

She’s given me so many things to choose from in terms of my response, starting with her implicit two-pronged criticism: I’m not meeting good-wife standards; therefore, I must not be a good therapist either. Instead, I choose to address the interpersonal point, which may be of use to her. “You can’t make anybody do anything, Denise. Besides, I want to stay married,” I say.

She raises her eyebrows, Whaaat?

“I have to pick my battles, Denise. That one isn’t worth it. The fact that his car is a wastebasket doesn’t affect me. If I had to share the car with him, that would be something else. But I don’t.” From there, it was simple to segue into her inability to triage her arguments with her own husband.

To say hello or not to say hello: that is the question. I follow the client’s lead. Even if I involuntarily smile or make eye contact when I turn into a grocery aisle and find myself face to face with a client, should the client not acknowledge me, I walk on by, no hard feelings. If the client nods but keeps going, I do the same. If the client speaks, I respond in kind unless he or she becomes indiscrete by, say, revealing the nature of our relationship within earshot of others or material that should be discussed only in session. In that case, I pleasantly but firmly stop the person. “I’m sorry to interrupt, but I have to run,” I say, starting to walk. “Nice seeing you!”

Hurt feelings. “You drove right by without returning my wave,” said Jane, a rejection-sensitive, long-time client. Obviously, I hadn’t seen her or I would’ve waved back. Social manners dictate one should always acknowledge being acknowledged. What’s relevant to her treatment is her assumption that I’ve chosen to ignore her—evident from the hurt tone in her voice, which I’ll address in a minute. First things first, though. “I’m sorry,” I said, meaning it. “I didn’t see you. When I’m driving, I’m generally on a mission and preoccupied.”

“You did have that look,” she said, letting me off the rudeness hook.

“Isn’t it interesting that you’d assume I’d deliberately ignore you?” I asked. “What’s that about, do you think?” With that, we started working, as she did see how automatic her reaction was.

Personal integrity vs. social conformity. When a client is a toxic leader of a group you’re a member of, maintaining personal integrity while remaining part of the group is the ultimate small-town challenge. After more than a decade of peripheral participation in our less-than-80-families house of worship, I reluctantly agreed to join the membership committee. Dysfunctional family dynamics understates the bullying, backstabbing, rumor-mongering, and hypocrisy I witnessed from the inside.

One of the worst perpetrators was Julie, the vice president of the board and my former client, who’d been in treatment for years for PTSD secondary to the physical and verbal abuse her husband had been dishing out. When I joined the membership committee, 10 years had passed since she’d left treatment, and she’d flipped from victim to perpetrator.

Two years into my three-year tenure, having failed to get traction with behind-the-scenes diplomacy, I asked for a public forum to hold the board accountable for their lack of transparency making decisions that negatively affected the congregation. Julie, along with some others, needed to be called out. But she was a former client. Did I have the right to put myself first? Ultimately, I decided that, yes, I did. I was a congregant; she was my leader. In that context, it was her obligation to take care of me, not the other way around. Technically, there was no conflict of interest, since she hadn’t been a client for years.

I had some hope that I might prevail in my request (many agreed with me that it was necessary, I was well-liked and had gravitas as mental health professional), but I knew I might not and took the risk with eyes wide open. My husband backed me. It did not go well. The board aggressively shut down dialogue during that meeting, with Julie being the most virulent. The machine won, and we left the congregation. I was disappointed but not surprised.

My worry that I’d be pilloried for calling out a former client (well-known, given she’d sung my praises at the time) proved unfounded. Instead, I was pilloried for stating the emperor wore no clothes. Fair enough.

Did this cost me referrals? Possibly. According to wisdom popularized by Lincoln, “You can fool all the people some of the time, you can fool some of the people all the time, but you can’t fool all the people all the time.” Although dissatisfied customers aren’t a great source of referrals, it took me years to get past my insecurities to see that. A competent clinician has nothing to fear, and I stand on my integrity.

Did it cost me socially? Not really. I’m introverted, need a great deal of solitude, and am happiest socializing in small, intimate groups. Once out of the group, I realized how much energy it had cost me to stay in—energy I now had for myself.

Friend vs. client; tenant vs. client. Given the smallness of our town, and the limited number of clinicians, it’s happened that friends and friendly associates have asked to become clients. With clients, I take on a professional responsibility for their well-being, putting their needs first and mine second. If I accept a friend as a client, we’ll never again be equals, fumbling our way through life, laughing, and helping each other. I don’t have that many friends—real friends—and I like to keep them. Therefore, I don’t take friends as clients.

A friendly associate requires a judgment call. How friendly? Is there a strong possibility that the relationship could evolve into friendship? If yes, I don’t take them on as clients. If I can tell that’s not going to happen, I might.

My husband and I own the building that houses our office, two other small offices, and two residential apartments. We don’t rent to clients, for the same reason we don’t take friends as clients. Tenants and their rents exist to help us cover our mortgage and taxes, which support us and the practice financially. If we rent to a client, then our professional responsibility to them takes precedence over our needs as landlords. Imagine trying to evict a client for nonpayment of rent. It doesn’t bear thinking about.

These are just a few of the challenges I’ve encountered. You’re sure to have your own. To keep your bearings, remember: First, be unfailingly polite. Second, when a conflict arises with a client out in the community, maintaining personal and professional integrity requires a solution that takes care of both of you, not one or the other.

The struggle to meet these two demands has forced me to grow into my self, own my role and authority, and address the vulnerabilities that limit my professional and personal choices. I’m a better therapist and happier human being for it. Given the incredible need for services in the boonies, that’s a win-win.


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photo: iStock/tanuha2001

Daniela Gitlin

Daniela Gitlin, MD, is rural psychiatrist in private practice in upstate New York. Her clinical memoir Practice, Practice, Practice: This Psychiatrist’s Life was selected a Finalist by the 2021 International Book Awards. Her second book, Doorknob Moments: Why Clients Drop Shockers on Their Way Out the Door and Why You Want Them To will be published by WW Norton in 2024. Learn more at