Last week, out of the blue, my Linkedin Profile started sending me messages from therapists and other professionals congratulating me on my six-year anniversary working at HOPE Psychotherapy of Houston, first as an Intern, then later with my own practice. I had forgotten about it and was surprised to find I have been a licensed therapist for now over six years. I started thinking about how these past six years have been, and what I have learned. I realize I did not understand what it took to be a therapist, and how to navigate the profession. I write these thoughts to help other therapists, especially new ones, to understand some of what I went through, to be better prepared.
I Was Not Ready
Six years ago I had just got my LPC-Intern License, allowing me to practice (with supervision). Before this, the only therapy I had done was at my practicum in graduate school. I did not have much real world experience providing therapy and did not understand the therapeutic landscape. In graduate school therapy was discussed as something provided in offices, mostly to Clients who wanted help. I did not realize most therapy, especially for Interns, is conducted in Partial Hospitalization programs and Psychiatric hospitals. Most Clients in these programs are severe long-term Clients who have already had years of group therapy. Most go from one program to another and rarely improve to the point of independence. Most of my Clients had Schizophrenia, Bipolar Disorder or Major Depression.
While I had knowledge of therapies, conditions, and treatments, I did not know how to apply them. I knew what CBT was, and knew how to apply it on a limited basis, but did not know how to integrate it into a Client’s life. I did not know how to build the trust needed for therapy to work. Part of the problem is the way our educational system works. Most of our learning is in a classroom. While my school did a good job giving me knowledge, I did not have much real world experience to draw on. One semester of real world experience is not enough time to prepare. I believe I did a good job overall, but as with anything, I made many mistakes at the beginning.
Employment as a Therapist Intern
While in graduate school, I did not realize how difficult it would be to find employment as a therapist. I did not expect it to be easy, as most professions are difficult at the beginning. I did not realize most therapists work 2-3 jobs to survive. As a profession, therapists on average make very low money. Most struggle to make $40,000 a year. Consider it takes at least six years in school, with a cost often over $100,000, to realize most therapists will always be in debt. I did not enter into the profession to be rich. I wanted to help people, people who have had addictions, as I once had. Many therapists have problems balancing their professional and personal lives, especially if they struggle to survive.
I accepted this soon after I started working in partial hospitalization programs. I realized I would need to work full time at a program or hospital, and part time for myself. I worked in different partial hospitalization programs providing group therapy. I have also worked in a couple of outpatient centers. As an intern, you will be most likely providing group therapy as most places will not hire Interns for individual therapy. Hospitals and treatment centers often employ Interns as they are cheaper to employ than fully licensed therapists. If you are a therapist intern, you will most likely begin your career in a hospital or a treatment center.
The Realities of Private Practice
I knew from day one I wanted to be in private practice. I have always wanted to work for myself, and a private practice allows this. I began to build my private practice as an Intern under Supervision. While I was not independent, and not private, I started to market and built a name for myself. I have found as a therapist you need to have a grasp of marketing and business. Unfortunately, you will not learn this in graduate school.
Without marketing, you will not have a private practice. You need to become an expert in marketing and view it as a job. Some weeks I spend 20+ hours marketing for my practice. This includes speaking engagements, social media, writing, blogging, and meeting therapists, and doctors. You cannot be afraid to go out and make yourself known. As with any good marketing strategy, you will need patience. It will take years to market yourself, and it will never end. You will need to market as long as you have your practice, of you will eventually run out of Clients.
To be in private practice, you will need to have specialties. The more difficult and severe the specialty, the better. Depression, for example, is not a good specialty, as most therapists treat it. Suicide, however, would be a good specialty, as most therapists do not specialize it, and do not want to. A good specialty is one most therapists will not treat, making you stand out. My specialties are Internet Addiction and Autism Spectrum Disorder (Asperger’s). Most therapists do not treat these conditions, especially Internet Addiction, meaning I will stand out.
There is a good chance even with a private practice; you will need other employment. Caseloads come and go with changes in the economy, and at times, you will need a stable income. This is a reality you will most likely have to accept. Most therapists do not work 40 hours a week, most work 60+.
The Importance of Ethics
If you are a therapist, then you have heard of HIPAA. Did you know therapists in private practice need to be as HIPAA compliant as a hospital? Most therapists do not know this as of 2016 and are not HIPAA compliant. If you take insurance of any kind or have in the past, you need to be HIPAA compliant and can be sued if you are not. As I graduated in 2009, this is not something I learned in graduate school. I am not sure if graduate schools even inform students of this fact. It took me six months to become HIPAA compliant, as well as one can be as there is no 100% compliance.
If you are a therapist, do you know your ethical codes? Do you review them line by line when revisions occur? Do you know most of their by heart? If not, you most likely are doing something unethical and do not even know it. It does not matter if you work for an organization or have your own practice, you need to know your codes. Being a Supervisor I go through the ethical codes line by line to my Interns, so they know them. I will make sure my Interns are prepared so that they can provide the best therapy possible for the protection of them and their Clients.
If you are a therapist, do you have malpractice insurance? You better, even if you work for an organization. If something happens and you are sued, your organization will not protect you, but will most likely blame you. I have known many therapists who work in organizations who did not have malpractice insurance, thinking the company would protect them. You need to protect yourself and be ready for anything, and malpractice insurance provides this protection.
So, how does a therapist prevent burnout after working two jobs just to survive to repay those student loans? The best advice I can give is to not take your work home with you. I do not mean the physical work, but the mental and emotional work. Do not stress on Sunday if your Clients are doing their homework and if they will be OK. As a therapist, you are responsible for the therapy you provide, and the protection of your Client’s rights. It is not your responsibility for your Client to change. I have seen many therapists worry and feel if the Client does not change, they are to blame. If you are putting more work into the therapy then your Client, then therapy is not working. When I am not working, I am not thinking about my Clients. I am thinking about me and my life.
Also, you need at least one day per week where you do no work. Sunday is a good day for this, as most places are closed, and most go to church or consider it a day of rest. Working seven days a week is not sustainable. I have done this and regretted it, as I was not focused and mentally tired, which impacted my work. If you do not take care of yourself, you will not be able to help anyone else.
Last but not least, you need boundaries. You need them with your clients and your co-workers. At times, you will not be able to do something. Do not feel guilty and put yourself in a bad position. You need to be assertive and stand up for yourself and your needs. Sometimes this means you will need to tell your boss, or your Clients, you cannot do something. We are not machines and saying no at times will go a long way toward preventing burnout.
I feel I enjoyed my first six years as a therapist, all though they were difficult. I learned much about myself and the profession. I learned I have what it takes to be a good therapist, and do an excellent job building trust with my Clients. I have more learning to do and wish to expand on my understand of addictions and Asperger’s Disorder. My next six years will be great, but I will need to work hard to see my goals realized. If you are a therapist, what are your thoughts, or if you are a Client, what do you want to see in a therapist? Let me know!
Photo Credit: FreeImages.com/John Apostolopoulos
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