“What You’ve Always Wanted to Know About Being a Great Therapist: But Were Afraid to Ask” (the most common concerns that smart, budding therapists secretly ponder about)

There are many careers outside of the mental health field that rigorously questions the student in the process of planning to pursue a career. I think that potential mental health clinician should be under the same scrutiny. A good supervisor will encourage their interns to reveal intimate and personal information about themselves in an effort to sculpt a conscientious clinician.  Interns become obsessed with knowing their own motives for every word they utter. The exercise of knowing what is driving conscious and unconscious intent is the common protocol on becoming a therapist, and continues to flow like an artery throughout even the most seasoned clinician’s career. As time goes on, even the most passionate, loving and well-intended budding young therapist will discover over the course of their training that there is much more to them than pure intent of altruism in their work. Only the greatest of therapists will brave bringing to consciousness their shadow qualities of selfish motive and hostile intent.  Only the greatest therapists honestly disclose when these shadow qualities unconsciously rear their ugly heads and get expressed during the hours they are attempting to do the most good.

The nerve wracking feeling that you as a clinician is being put in the position of authority on how to help a person wend their way to happiness, while you yourself are still trying to answer that question for yourself makes it hard not to feel like a fraud, a hypocrite, an imposter.  And what about having a client referred to you that is actually in better shape than you yourself might be? This is why it is essential to stay close to smart supervisors, good professional community connection, and plenty of self-acceptance.

Whether your wounds and injuries were incurred within your family of origin or just with people in general life, it is unavoidable for one’s own history not to color and shape the therapeutic process with each and every client that comes into your practice.  This process can be fraught with the possibility being an agent for good, or a change agent for unconsciously imposed self-serving motives.  Because of this well-known fact, the path to actualizing one’s skills requires a rigorous self-questioning, abundant humility, a robust ego, and a fairly strong ability to remain flexible and open each step of the way.

The process of becoming a seasoned and masterful therapist takes many years of experience to accomplish. There are many paradigms to study, and because many roads lead to Mecca, each person has to find the lens that works best for them to approach their clients with.  The following 16 questions are some of most common ones that interns and young licensed therapists ask themselves. No need to feel self-conscious, ashamed, or fearful to ask. You are not alone!

1.  I wonder how the theories I study and my experience with clients will mesh with each other. I wonder how much that it is ultimately going to influence what I specialize in, and which theorists I will want to follow.

That is what makes the process of becoming a seasoned therapist so much fun!  We are studying an art, not a science, and just when you think you have your finger on the pulse of the healing strategy or paradigm that is “right”, someone else comes along with a bigger and better strategy or paradigm that you must now study if you want to consider yourself cutting edge, competent and secure as a clinician.

2. What is the best way to go about learning about all the psychological approaches that are out there?

We are living in a day and age where technology is churning out more information than that average person can possibly take in and also expect to live a balanced life.  There is no way to be an expert at every paradigm and model of psychology except to accept that you are committed to being a life long learner.  A hundred years ago the only psychological model there was to approach being a therapist with was the Freudian model.  Psychology has grown into a vast body of knowledge since the time of Freud, and that can both be mind boggling and exciting at the same time.

3. I love working with children, but I have a hard time managing my frustration toward their parents at the same time.  I made three CPS calls last week and the injustice of it all wears on me.

You are talking about the common problem of having a big heart and the burn out that comes from the pain of seeing that world is not full of people who should be having children of their own, as well as parents who are in desperate need of being taught good parenting skills.  If you don’t have children of your own, you need to be aware that parenting is one of the hardest jobs a person could ever have, and that you chose to be in a career that can be traumatizing to the clinician as well.  No one who cares about people, and especially helpless and innocent people like children, is defenseless to burn out and depression from seeing abuse and injustice inflicted.  It is important to stay close to supervision with someone who can help you help the family, as well as having a strong shoulder for you to cry on.

4.   I wonder about how I am going to make a living out of this work. Things like: How will I market myself?  What demand is out there that makes me marketable as a therapist? How I can be a really good therapist and still support family and myself?

5. How can I help others with their problems when I haven’t sorted out my own stuff yet?

Every therapist has blind spots to helping others with problems that they themselves have not figured out how to deal with.  It is really essential that you know what your scope of treatment is, which population you feel comfortable being able to connect with, and accept that as long as you are one step ahead of the patient there are plenty of people left to help.  As long as you are staying on a path to continue to be introspective, open to knowing yourself, and working on your “own stuff”, that’s the most you can expect from yourself and any budding therapist you know.

6. Do I have to be perfect to be a therapist?

If you had to be perfect to be a therapist there would be no therapists.  Just as there are no perfect people in the world, and therapists are people, you can stop holding that expectation right now.

7. How can I ethically charge people in crisis/conflict for my services?  Especially considering the population I work with?

You can ethically charge people for your services because clients are paying for your time and your expertise on how they can organize themselves around whatever crisis they are struggling with, as well as giving them self-care tools to prevent future crisis.  If the population you are working with cannot afford your private practice prices they need to find a mental health clinic that is affordable for them. If it goes against your own moral values to charge someone in crisis, or from a low-income population, you may want to stick with working on salary at a mental health clinic.  It is important for clinicians to seriously weigh these things out so that there isn’t a vulnerability to harming oneself by under earning to save the world.

A compromise between working for a clinic and being in private practice is to always hold spaces for low fee/no fee clients. Doing that assuages some of the guilt you might feel for being a Capitalist in a Capitalist country.

8. How do you know when you are establishing rapport?

I was taught from the beginning that I don’t have to mind read where I stand with a client, I can just ask them.  You are free to ask your client if they are enjoying the therapy, or if they feel they are being helped, or if there is a way that they feel you are missing the picture on them?  I don’t believe in wondering that kind of thing to myself, and I call it a “reality check”.  In thirty years of working with patients I have never lost rapport from checking to see if I have rapport.

9. Do you accept gifts?

It depends on the client and it depends on the gift.  I think that refusing to take a gift that is not ridiculously extravagant is hurtful to your relationship with the client.  People give each other gifts all the time; it is a sign of sentiment and appreciation.  If you have problems with receiving gifts you need to work that out with your own therapist and not take it out on a loving, generous client who is expressing appreciation of the relationship.  Obviously if the gift giving has no understandable framework around it, such as a Christmas gift, and the client does it to buy power, favor or position, than you’re talking about a therapeutic

10. How do you terminate a client?

If you are working closely with your clients then termination should end naturally.  As you track the process of goals being met that the client and you have defined together, once those goals are met it should be obvious that you have done your job.  Short term clients who come in with short term goals and only short term goals are easier to terminate because it is more obvious when the goal has been met.  Goals that are defined by reaching internal states of self confidence, self love, well-being, etc., need to have concretely defined external results that the client can point their finger at that represents those internal states.

11. What is the best way to build a practice?

The best way to build a practice is to be open to telling anyone and everyone what you do and carry cards with your name and number at all times.  Be willing to take low fee clients, lecture on a subject that pertains to the kinds of clients you want to have in your practice.  For example, if you love working with children, go to schools and offer your services to lecture to parents on parenting.  There are many, many places you can give small talks, recreation centers, senior citizen homes, schools, Temples, Churches, etc.  Stay humble, hunker down, and get your name out there.  As a seasoned clinicians I am always looking for new interns that charge lower fees to refer clients to.

12. What do you do if a client is asking you things that you don’t have the answers to?

There’s nothing worse than a therapist that bullshits.  If you don’t know the answer to a question, or you hit a place where you are unable to guide your client, say so.  Just say, “I’m not exactly sure what to say at this moment, but I’m going to think long and hard about it before our next session, believe me.”  Then you run back to supervision and work it out there so that you have something to say when you go back the next week.  Your client will not only appreciate you not trying to pull the wool over their eyes, you will be modeling humility for them as well.  Saying, “I don’t know the answer to that question” doesn’t make you an incompetent therapist, trying to pretend you know when you don’t, does.

13. What if you have inappropriate feelings during the session toward your client?

I’m not sure if there is such a thing as “inappropriate feelings” toward a client.  You are in a relationship with your client, and having relationships with people bring up feelings.  Hopefully you are engaged enough with who you work with to have feelings come up toward them.  You just have to trust that you can control both sexual impulses and hostile impulses.  If you can’t trust that, than neither you nor your client are safe together.  From my experience over the years I know that therapists generally don’t like talking about sexual feelings, crushes, and obsession or hostile impulses, rejecting and abandoning impulses toward their clients.  Unfortunately, these are the hazards of the job.  If you want to be a clinician that doesn’t struggle with these hazards you can count on being benign at best, or just plain ineffective. You may go through noticing many different feelings during the course of treatment with your clients, but the thing that is most important is not that you have those feelings but how you handle them.  Our first commitment is our advocacy for our clients, and not doing any harm to them.  If you notice that you are feeling extreme feelings of either hate or love toward any client it is something that you should bring to your supervisor.  You should never feel afraid to tell your supervisor about any feelings you may be having toward a client, they are there to help you either work those through or finesse them effectively in the therapy room with the client. If you have the feeling that your supervisor has learned to handle this kind of issue themselves, talk to someone else whose work you respect in the field.  It’s never one stop shopping with supervision, again, supervisors are also people and they aren’t perfect either. It is important to remember that any feeling that you are feeling toward your client is probably indicative of how people in the real world feel toward your client.  You can use that visceral experience to their benefit as long as you know that you are not acting those feelings out on the client.  Depending on which paradigm you work from your supervisor will help you express your feelings through the vernacular of that paradigm.

14. How does email fit into your practice?

Email can be a great resource for you and your clients or incredibly dangerous.  You have to be prepared for nosy spouses, friends and other family members snooping online into your clients email and that will censor what you way. Write only what you would be willing for the world to see.  No one is invulnerable to being misunderstood through email exchange.  You can’t read tone of voice, either yours or your client’s, and unless you have established strong rapport in the therapy room where you can risk being misunderstood by email you need to keep it short and sweet. Out of respect for the seriousness of my relationship to my client,  I ALWAYS attach the following with every email sent to a client, although that does not protect me in any way.

This message (including any attachments) contains confidential information

intended for a specific individual and purpose, and is protected by law.  If

you are not the intended recipient, please delete the message.  Any

disclosure, copying, or distribution of this message, or the taking of any

action based on it, is strictly prohibited.

16. I have clients that start to get frustrated with therapy because they have the fantasy that coming in for therapy will guarantee them that they will get what they want.  I want to be able to keep my clients, but I also don’t want to misrepresent what therapy can, or cannot do for them.

Every client holds a secret wish that coming to therapy will solve all of his or her problems.  This is where the clinician must be very clear to disarm this type of unrealistic thinking, and be able to tolerate being perceived as a withholding mother, or less competent, or whatever negative way the client has to think before they get on board with reality.

I have found one universal type of client who comes in to my practice thinking that the magic of our conversations is going to give them what they want.  It is the woman over 35 who is single, works at a high powered job that has brought out expression of strong characteristics of aggression and domninance in her, in a city where younger and more feminine women abound and they come to therapy hoping they will leave therapy with a boyfriend. The only problem with coming to therapy to deal with the frustrations of being single is that whatever you discover about what your part is in that being that way still does not guarantee that you will meet someone that you want to be involved with, or that someone will come along, or that you won’t remain single and frustrated. This is a hard, cold reality that takes a lot of courage to be up front about with a lonely, anxious, person in this position, but every intern should be encouraged to finesse certain realities into the therapy room without completely dashing the hopes and dreams of the client.

I have learned over time that many people come into therapy in the hopes that putting time and money into getting what they want to get will get them that.  That is an untruth.  Outside of a robust internal relationship with themselves and hopefully others, or ways of coping, rather than just surviving, around being thwarted getting what they want to get, clients cannot be guaranteed any more than that through psychotherapy.

That said, and with that understanding, I am, of course, still willing to have these kinds of client come in for therapy.  If the client and I can go deeper into both understanding things about that may be interfering with having a relationship become long term, or finding new and better ways to cope in the meantime, than the hour will have the purpose that therapy is to be used for.