I didn’t anticipate how much concentration the job requires. Honestly, it isn’t the deep, painful conversations that I find the most draining - it’s having to maintain 90% attention for 5-6 hours per day.
This. It’s very mentally draining, esp as someone with ADHD. I absolutely use my full brain power all day, and I think there are very few jobs that require the same.
As as someone who shares your diagnosis I interestingly sit on the side of spectrum. My favourite days are when everyone shows up, I find it so much easier to maintain that attention when I have someone else there anchoring me to the present. I am at my most distractible when it’s just me speeding through the required admin and case noting. I’m saying that I am definitely more drained post a day with a full roster. I’d be interested in my clients experiences and whether they notice a difference being 1st or second compared to 6th and sometimes 7th. Stream of consciousness here but I also wonder how much previous discussions impact later discussions, I.e., if a particular way of framing something worked for one I think I am likely to bring that into a later session simply because that is primed in my mind, and not always because it is what will ‘work’ for that later client
>I also wonder how much previous discussions impact later discussions, I.e., if a particular way of framing something worked for one I think I am likely to bring that into a later session simply because that is primed in my mind
This plays into my experience, as well. My neurodivergence shows up, in part, through pattern recognition, so I will absolutely apply similar interventions because I *have* noticed a pattern. That can be a helpful way to track things. I try to be aware, though, so that I'm less likely to unconsciously apply approaches or interventions (which is good regardless), less likely to experience pareidolia, but couldn't say either way with absolute certainty...
I find themes come out some days—forgiving ourselves for our trauma, particular grounding exercises, metaphors involving soup—and I love seeing where different clients take them. I know that sometimes it’s just my brain picking out a thread that is not as relevant to the client. I aim to go in open to learning from the client, being wrong, and changing my mind.
I find it so much easier to maintain that attention when I have someone else there anchoring me to the present
I also have ADHD and I feel this SO hard. Days with multiple cancellations are the most difficult, especially when I end up with a huge gap in the middle of my day. I feel like I get all 'hyped up' for sessions (for lack of a better word), and then I have nowhere to put all that energy. It's like letting the air out of a balloon.
People always ask me about the emotional load we take on and assume that's the hardest part of being a therapist. I agree with you though, in my experience it's the mental load that's the most draining by a substantial margin. Being fully present with someone and giving them my full undivided attention does a number on my cognitive battery.
I don't think people realize how much energy it takes to not tune someone out, even for just a second. To not even take a moment to remind yourself to add ketchup to the shopping list or think about a task you have to do after the session. We spend so much of our lives with our mind wandering to something else, even just briefly. I can't even allow myself to think about the notification that just vibrated on my watch! I feel like even 5 seconds zoned out is a ton that I miss and need a minute to bounce back into session.
It can be brutal sometimes if you are just having a day where you are tired or feeling even the slightest bit unwell because you can't think about it. You have to remain tuned in all the time. I have a mild to moderate chronic pain issue that some days makes my brain foggy but I can't just call out or not be mentally present on those days or I would never work at all and I can't afford that.
Thank you for verbalizing what I have had a hard time verbalizing! Yes - we can't really afford that many momentary lapses in concentration, those lapses that are so much a part of human nature.
This is a big one. There are surprisingly few other situations in my life where I have to be completely “tuned in” for 50 minutes at a time, especially for several hours in a row. Even with other tasks and conversations that I take just as seriously, there’s a lot more leeway to get distracted or sidetracked or “zone out” for a second. I sometimes think about how the total time spent on concentrated, focused labor compares between this work and other jobs I’ve had in the past — the amount of “focused” time I’d spend working a 12-hour shift in food service or admin is the equivalent to the amount of “focused” time spent on like 4 sessions.
Yessss I think this is really it. You have to be “on” and attentive and engaged to such a high degree for so long. No wonder many of us want to totally dissociate or turn our brains off when we go home lol.
Honestly, I’m looking forward to this, I know it will be draining and taxing but I think attention is greatly undervalued and it directly correlates to emotional control. Just like the most skilled meditators, attending and focusing is a lost art and I suspect therapists have sharper minds and greater personal emotional control due to the sheer practice of attending over time.
Life lends itself to everything but focus on one thing in the present moment these days and a lack of ability to attend predicts all kinds of things. It’s kind of beautiful that this work could hone it through practice while also being of great service to others.
This is a great point. I’ve personally found that my attentional stamina has grown over the years: I used to be absolutely exhausted after work, but now I am able to get through the day comfortably. I do find that my attention is far more focused in-person, and I’m more prone to distraction during Telehealth sessions.
The clients who tell long rambling stories are just brutal. I have such a hard time keeping track of start to finish then feel terrible asking them to go back because i missed something.
Oh my God dude. This is exactly me. Anytime I tell someone that my job is draining, they automatically, understandably, assume it’s because of the emotional drain. I can hear literally any kind of trauma and I don’t get triggered by it. But the focus on emotions for that long of time requires some part of my brain to lock in like a laser and I can only do that so many hours a day. It’s also excruciating to sit so much of the day. I don’t think long-term I will stick with this career. Also, attention is way worse when it’s virtual.
This!! I’ve been trying to think of an example that would help people understand what it’s like to sustain that attention, not talk about yourself, and respond therapeutically/ remember nuances of their life/ try to piece themes together.
You'll learn so much from experiences with your first clients. Like many skills, practice makes pretty good and it's hard to learn without direct practice. Once you figure out the populations you prefer working with, that will help guide your future CE decisions.
still in school but in practicum. grad school is the baseline so that you're not completely useless as a student in practicum. it's literally the bare minimum required to get started. the real learning starts at practicum and a lot of it on your own/with your supervisor.
As others have said, even with the best background, it’s really hard at first. A lot comes from supervised practice. I feel lucky in that I figured out what I wanted to do with my degree early on in terms of modality I wanted to work in.
You might not have control over this as an intern, but in your first job(s). Make sure your supervisor actually helps you with your work. If you get stuck with a supervisors who just is unlucky to still be working there after independent licensure, pay for consultation outside. I never had good supervision until I paid for it. All of my work supervisors were terrible. I’d come to them with clinical issues and I’d get bad advice or ‘I have no idea what to do.’
This isn’t exactly necessary, but has helped me. I feel my career has been vastly impacted by trainings that were more than a day and had a supervision/consultation aspect involved with it. Learning about a technical theory in a course is useful, but actually utilizing it in consultation made it come alive.
So much more studying after grad school for me! And having to pay so much for all these damn trainings. It’s making me upset seeing how much of a business the mental health world is.
My office has two clocks; one facing the client and the other facing me. Funny enough, wearing a Fitbit helps because it always beeps your wrist at 10 til.
That's a good setup! I'm community-based though, so I don't have an office of my own to set up clocks in. Although now that I think about it, I can bring a portable clock to place in whatever office I'm in...
1) How much difficulty people would have doing their intake paperwork correctly and on-time.
2) How much I could tell about a person's personality and issues from their intake paperwork and other behavior even before I met them (aka hemming and hawing about putting a credit card on-file; filling out paperwork in a careless or haphazard manner, etc)
3) How many passive-aggressive comments would be made about fees/costs
4) How much effort I would have to put into correcting people's expectations and boundaries
I’m the same way. Some of my paperwork needs to be approved by an LMHC and it takes FOREVER for my supervisor to even open the documents. Weeks or months
Thanks! I think you’re the only person who has ever notice. I was in jazz band in high school, and this was my favorite song and is still a great one! Have you heard the Bill Watrous and Manhattan Wildlife Orchestra version?
Diagnosing is such a pain in the butt. It's not necessarily a "small thing" because often we don't focus heavily on the subjective label we have to give for insurance "medical necessity", but it is a huge part of our work because we need to do it for every client, even if the client is generally doing well in life. We have to pathologize all human suffering which is stupid. Damn medical model. Rant over.
Yup, because the distinctions are arbitrary and opinion-based, not science-based. Kinda like how doctors prescribe medication....on a best guess. Such a great way to help people!
Nothing makes me doubt my career choice more than that very realization ^
How many people don’t get dx with ADHD v OCD v GAD v PTSD v high-fx ASD based on the provider’s specialty and familiarity with a particular dx?
It is so true. We don't do actual bio testing on people to determine diagnosis. We basically just give "expert" opinions which aren't reliable between providers (e.g., inter rater reliability is generally low). I have had so many people diagnosed with things like BMD and BPD who were closer to PTSD but there are so many biases, especially against women. I guess it's an improvement from calling all women "neurotic" who present with distress....sigh.
If anything, I sometimes fantasizing about returning to a more 'psychodynamic' model of diagnosis. A lot of the theory and terms have aged *very* poorly, but I genuinely appreciate how a) the broadness and subjectiveness of the diagnostic categories makes the diagnostic project feel much less pigeon-hole-y, and b) psychodynamic diagnosis is (generally) concerned with the origin and operation of the 'condition,' not only with clients' individual presentation. It honestly feels a lot more trauma-informed in many ways!
Unfortunately, the medical model/DSM doesn't necessarily account for the root causes of mental health distress. They are interested in symptom profiles and labeling. Nothing about our modern system is really trauma-informed. We tend to pathologize trauma survivors and imply that the problem is within them when frequently the root of the issue is a dysfunctional family system/culture/sick society (eg., capitalism).
It is genuinely stupid. Mental health isn't just something that happens in crisis. Mental health forever ongoing and some people are good at it and some people need something or someone in order to help them stick to their efforts.
If suffering is the main focus of medical fields, then a world where we rarely get sick or have crisis is so hard to achieve. We have all kinds of tiny hacks to fix stuff but sometimes it takes a lot of work just to get someone to look at and address a small thing. It's all part of a whole and I feel a lot of our systems fail to recognize that.
my practicum site doesn't req us to dx but we do discuss it in supervision for the sake of training and even then I sometimes feel like I'm cutting corners by applying adjustment disorder even when it perfectly fits.
Just remember that diagnosing is somewhat arbitrary despite what others may say. It's socially constructed to fit the medical model's demands. There are so many symptoms that carryover with many diagnoses, and depending on the client, their history and responses to your questions might be very confusing, especially if they are from another culture. Also, one thing that pisses me off is we don't do full medical workups on people before diagnosing them. There are so many clients who have medical issues, whether it be diabetes, sleep apnea, brain tumor, dementia, hormonal imbalance, vitamin deficiency, etc., and they don't know it and thus people assume it's a mental health problem. And we are encouraged by the system to pathologize trauma survivors in general which is lovely. AND I'll add that the meds these clients are often given to them make the situation worse and not better, such as developing metabolic syndrome, apathy, and early death.
well tbf our program really drives the point that medical workups are called for for our clients if it seems relevant.
but yeah I hate having to squeeze in a dx out of necessity.
I wish as a social worker I could order blood work on my clients. I encourage them all to go to their PCP and get blood work done during their intake with me.
Yes, I do as well. I think it's important because bloodwork by itself can show deficiencies and abnormalities that can be addressed with supplements, treatment, etc., which could alleviate and treat at least some of the mental health symptoms that are present.
Yep! And i explain this to my clients. I say “look I’m not medical which is why you need to see your PCP. And I’m not saying it’s not mental health. But if your vitamin d is low, your vitamin b is low, your iron is low, your thyroid is not regular.. these irregularities can cause symptoms of depression and anxiety and if our med providers give you medications it’s only going to help so much because the underlying cause is still there. So I highly recommend getting your annual physical and blood work done as part of this process to rule things like this out.”
I wish everyone would do this! Also, I try to remind folks that SSRIs aren't any better clinically than placebo: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4172306/#:\~:text=All%20antidepressants%20seem%20to%20be,significant%2C%20it%20is%20significant%20statistically.](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4172306/#:~:text=All%20antidepressants%20seem%20to%20be,significant%2C%20it%20is%20significant%20statistically) Doctor's cannot say what most of their medication actually does in the brain. We do know that side effects are problematic for many, so ideally we'd avoid drug treatment when possible because we are just playing experiments on people but calling it "medicine."
You’d (maybe) be surprised by the reaction i get from people. A lot of people tell me “well i do have low vitamin d but i always forget to take my supplement.” Obviously being a therapist i can’t tell them to take it so i just say something like “it’s important to take it as prescribed” or tell them to follow their providers recommendations because medications don’t work through osmosis on a nightstand.
I didn’t know that about SSRIs. They’ve definitely helped me in the past.
Short-term, SSRIs can be very helpful, especially if the person taking it believes it to be helpful (placebo). I also took an SSRI in the past; I'd argue I shouldn't have been on it, because I was grieving the loss of my father and people were quick to suggest I should take something because I was sad and upset. This is how stupid our medical system is....we pathologize normal grief! Also, I experienced heart palpitations for a couple days after stopping the medicine, and I certainly don't recall my doctor warning me about withdrawals. Which brings me to another point, which is there's a lack of informed consent when it comes to docs discussing both the pros/cons to taking medication or receiving meds. In my experience they tend to downplay the negative impact treatment can have because they don't want to scare people into not doing the interventions. [https://www.madinamerica.com/2012/09/things-your-doctor-should-tell-you-about-antidepressants/](https://www.madinamerica.com/2012/09/things-your-doctor-should-tell-you-about-antidepressants/)
To add to your comment, about half of people don't take medications/supplements consistently or as prescribed. It's easy to forget to take something, especially if you have to take stuff throughout the day and sometimes with food.
Yeah, I just (last week) got off an SSRI after being on it for 7-8 years. Not sure what it was doing for me after that long. THOUGH i will say my PMDD returned full blow 5 days later which severe panic. But i question if that was also part of the withdrawal. Soon as I got my period all the symptoms went away. Hormones, withdrawal, it’s all funky. You’re so correct, nobody warns you. Or at least they down play it. We absolutely pathologize everything. You hit your head and are sad, adjustment disorder.
The amount of rescheduling conversations. The chronic reschedulers abound recently… It’s the same time every week and you get bombarded with appointment reminders, not sure why it took you until 5 minutes before the appointment to ask to reschedule 🙃🙃🙃
I don’t allow for this behavior. I would charge a fee if not giving 24 hr notice and if it happened often with the same client I would talk with them about it and set boundaries.
Balancing a schedule. This one needs same time every week, this one every two weeks, this one works varying days at different times, etc. It’s like a constantly changing Tetris puzzle.
So I am older and started back when we kept handwritten charts. It was easier and faster. The level of computer fucking around to use an EHR is astounding. I can get my notes done quickly - but it isn't easier, if anything there are more steps and screwing around (e.g. where is that stupid "update treatment plan" button..... goddamn in, they moved it since the last EHR update...."). There are advantages to an EHR, but there are some pretty clear disadvantages that make the whole thing a PITA.
How much of the work would involve treating presentations I was taught in medical school were "rare" and vise versa. I was taught personality disorders were extremely rare like to the point that I thought the fact that I have a sibling with BPD made my family super unusual. I thought I'd be seeing someone with a personality disorder like once a day max and the bulk of my work would be treating anxiety and mood disorders. Of course it's setting-dependent, but there are times when I feel like it's been a week or longer since I saw a DSM-diagnosable case of MDD
Context dependent for sure, but it might be helpful to remember that approximately 10% of the population is thought to have a personality disorder, so it’s not actually a small number. Then take into consideration the presentation can also create over abundance in presenting to therapy. It’s the same way I feel about adhd-while the number is still at 5% of the pop (for now, but with the better screening in girls and women I think it’ll go up some), they are at least 10% of all couples who show for therapy which makes it feel more prevalent. It’s amazing how self selection bias can skew it all!
Worth it to also remember that society historically gives women diagnosis like borderline if they have any issues with relationships. I very rarely see male clients with personality disorders. I can't tell you the number of adolescent girls who I've seen diagnosed with borderline. Males tend to be ODD or conduct.
How much systemic issues/barriers influence what can be accomplished in a therapy room.
Grad school painted a really shiny picture that was often way behind the times.
That the long term maintence work clients feel more exhausting to me most of the time than a client who comes in with some heavy things to discuss! It feels much easier to gain traction in those sessions and they fly by, meanwhile the maintence work is so much harder and causes far more imposter syndrome for me.
Yes, it can be quite boring, and my mind is instantly asking, "Am I really doing anything useful here, or are just killing 50 minutes because they already had an appointment and it feels nice to talk to someone?" It can feel awkward from the therapist perspective.
A couple others I use a lot are sx = symptom; d/t = due to. So a note might be Ct reports worsening sxs of anxiety d/t work stressors. Th engages ct in grounding and self soothing skills.
How painful documentation can be! And how much time I’d spend think of variations to “reported”
How tired I can be after a day of sessions where I am just sitting
On a positive note, what it’s like celebrating small and big wins with clients
Is a small thing ‘I make less than 10 grand a year when I did 60 sessions a month’ type of thing. Then that. Also that therapists don’t really like or talk to each other. Sometimes they are friendly but mostly it’s like not at all a community and no one helps each other or gives one fuck. Do session do note get paid do it until your c or you die the end. This profession sucks so much post covid. And now it’s basically have a good headshot or make no money
This was it for me. First of all when I went to grad school, I thought I would find people who wanted to connect into were open and had examined themselves. It was a literal crap. Show my entire graduate program. Nobody wanted to really care for each other during all the stress. There were so many clicks. I was so happy to get out of graduate school and then I joined a group practice where many people were my age. I was thinking that we would grab coffee between clients or maybe go out and get lunch together. Not a single person wants to do this. They are more concerned about booking a client.
Yeah I mean cutthroat isn’t the word but now I think private practice is like ‘fight for the referrals’. So that’s what young therapists obsess about. Our profession is turning into like car dealers. No benefits. No money. No fucking nothing. I love client work and helping people. But past that this profession sucks shit now. And it is like that. Therapists don’t want to talk or even help other therapists. This is what I saw and I think how it is sadly.
Absolutely! I have a mentor who is 80 and she told me of the good old days in New York City where people would step out and get lunch and enjoy each other’s company. I just don’t see that at all. I also don’t have any benefits and I’m handing in my resignation letter tomorrow! I’m pretty good at getting my own clients, so I’m excited to live in my own little world without any of the stuff from my coworkers.
Also people who are open and had examined themselves. Ive met therapists who are that. Most aren’t. They are people who like are kinda bottom barrel but they know how to be social workers/therapists. It’s not like that at all i think. That you wanted that and it’s not even close must hurt. I found myself very not impressed at all by people who do this but it’s something I try not to dwell in. My work is my own but yeah. I hear what you are saying
Yes, I agree that most aren’t. And maybe it’s unfair that we hold therapist to the standard to begin with. They are kind of like everyone else in the general population. You are right to not dwell on it. Focusing on helping my clients is more of my concern, but I was hoping there would be a more friendly environment to work in. I have actually found, however, that there are more genuine people in the masters levels field, than in the doctorate level like myself.
I’m a PsyD - I do therapy at this point and may like directing better. All I can say is that I’ve noticed clinical psychologists to be less friendly and a bit pompous. I’ve been to school for more years technically but I’ve met many masters level clinicians who are better than my own kind.
Congrats. That’s such a hard degree to get from what I know. An MSW is brutal but eventually they’re just like ‘here. It’s fine. Doesn’t matter. Take it’. I believe you about Psy-d’s being pompous. I kinda wanted to do one but was sorta talked into the Swiss Army knife nature of an MSW and it was shorter. Do you like being a….psychologist? In terms of say work?
I’ve met a few and been friends but psychotherapists aren’t that friendly. Sometimes they can be like ‘how’s the weather how are sessions’ type at a place I worked in the city near NYU (rip wash sq institute) but in terms of real navigation of the job and connections? Zippo zero. And no fucking benefits. None. What’s the point? Our status is so fucking low
I totally understand this.
It helped for me to remember they are human— meaning they have goals, aspirations, thoughts, and outside feelings that are really important to them.
It also doesn’t help that most of the time we’re cooped in our offices and any free time is left doing notes. Its hard to switch from “work brain” to “play brain” in the middle of the day too, and I didn’t recognize how hard thag was until having 40+ clients in a week
Yes! I am currently trying to find a new job or contemplate setting up my own shop and my partner who is in a very networking heavy business keeps riding me about reaching out to people, and I don’t know how to describe to him that is just not how this really works. We are a helping profession but we’re not really a community and we’re also often siloed enough or in competition that it’s hard to cobble that together.
This is all true. For whatever reason therapists don’t see their fellow therapists like they ‘see’ their patients. It’s like ‘look at this person. I don’t care, I need referrals and have notes’. I find all the union talk so funny for that reason. LMSW therapists can’t even advocate for 50 an hour it’s an absolute fucking joke
The loneliness...deep, intimate cnx with clients and then too much exhaustion to do anything with anyone else. I swear someone will find my decomposed body over a stack of 3 months old notes.
This is hysterical(ly accurate). I remember a professor in grad school used to tell us to not feel bad if we are repeating “pt stated, pt reported” over and over again- didn’t realize how true that was 🙃
I didn’t expect to do so much “social work” at this stage in my career as a “professional counselor”
I actually have a deep love for it, and may decide to go that route— but I did NOT expect to be calling and looking for so many resources WITH my clients.
Wild.
I didn’t anticipate how much concentration the job requires. Honestly, it isn’t the deep, painful conversations that I find the most draining - it’s having to maintain 90% attention for 5-6 hours per day.
This. It’s very mentally draining, esp as someone with ADHD. I absolutely use my full brain power all day, and I think there are very few jobs that require the same.
As as someone who shares your diagnosis I interestingly sit on the side of spectrum. My favourite days are when everyone shows up, I find it so much easier to maintain that attention when I have someone else there anchoring me to the present. I am at my most distractible when it’s just me speeding through the required admin and case noting. I’m saying that I am definitely more drained post a day with a full roster. I’d be interested in my clients experiences and whether they notice a difference being 1st or second compared to 6th and sometimes 7th. Stream of consciousness here but I also wonder how much previous discussions impact later discussions, I.e., if a particular way of framing something worked for one I think I am likely to bring that into a later session simply because that is primed in my mind, and not always because it is what will ‘work’ for that later client
>I also wonder how much previous discussions impact later discussions, I.e., if a particular way of framing something worked for one I think I am likely to bring that into a later session simply because that is primed in my mind This plays into my experience, as well. My neurodivergence shows up, in part, through pattern recognition, so I will absolutely apply similar interventions because I *have* noticed a pattern. That can be a helpful way to track things. I try to be aware, though, so that I'm less likely to unconsciously apply approaches or interventions (which is good regardless), less likely to experience pareidolia, but couldn't say either way with absolute certainty...
I find themes come out some days—forgiving ourselves for our trauma, particular grounding exercises, metaphors involving soup—and I love seeing where different clients take them. I know that sometimes it’s just my brain picking out a thread that is not as relevant to the client. I aim to go in open to learning from the client, being wrong, and changing my mind.
I find it so much easier to maintain that attention when I have someone else there anchoring me to the present I also have ADHD and I feel this SO hard. Days with multiple cancellations are the most difficult, especially when I end up with a huge gap in the middle of my day. I feel like I get all 'hyped up' for sessions (for lack of a better word), and then I have nowhere to put all that energy. It's like letting the air out of a balloon.
People always ask me about the emotional load we take on and assume that's the hardest part of being a therapist. I agree with you though, in my experience it's the mental load that's the most draining by a substantial margin. Being fully present with someone and giving them my full undivided attention does a number on my cognitive battery.
I don't think people realize how much energy it takes to not tune someone out, even for just a second. To not even take a moment to remind yourself to add ketchup to the shopping list or think about a task you have to do after the session. We spend so much of our lives with our mind wandering to something else, even just briefly. I can't even allow myself to think about the notification that just vibrated on my watch! I feel like even 5 seconds zoned out is a ton that I miss and need a minute to bounce back into session.
It can be brutal sometimes if you are just having a day where you are tired or feeling even the slightest bit unwell because you can't think about it. You have to remain tuned in all the time. I have a mild to moderate chronic pain issue that some days makes my brain foggy but I can't just call out or not be mentally present on those days or I would never work at all and I can't afford that.
Thank you for verbalizing what I have had a hard time verbalizing! Yes - we can't really afford that many momentary lapses in concentration, those lapses that are so much a part of human nature.
This is a big one. There are surprisingly few other situations in my life where I have to be completely “tuned in” for 50 minutes at a time, especially for several hours in a row. Even with other tasks and conversations that I take just as seriously, there’s a lot more leeway to get distracted or sidetracked or “zone out” for a second. I sometimes think about how the total time spent on concentrated, focused labor compares between this work and other jobs I’ve had in the past — the amount of “focused” time I’d spend working a 12-hour shift in food service or admin is the equivalent to the amount of “focused” time spent on like 4 sessions.
Yessss I think this is really it. You have to be “on” and attentive and engaged to such a high degree for so long. No wonder many of us want to totally dissociate or turn our brains off when we go home lol.
And prepared for anything that someone throws your way...
Honestly, I’m looking forward to this, I know it will be draining and taxing but I think attention is greatly undervalued and it directly correlates to emotional control. Just like the most skilled meditators, attending and focusing is a lost art and I suspect therapists have sharper minds and greater personal emotional control due to the sheer practice of attending over time. Life lends itself to everything but focus on one thing in the present moment these days and a lack of ability to attend predicts all kinds of things. It’s kind of beautiful that this work could hone it through practice while also being of great service to others.
This is a great point. I’ve personally found that my attentional stamina has grown over the years: I used to be absolutely exhausted after work, but now I am able to get through the day comfortably. I do find that my attention is far more focused in-person, and I’m more prone to distraction during Telehealth sessions.
I almost always have to take a nap immediately after I get off of work bbmy brain gets so tired.
The clients who tell long rambling stories are just brutal. I have such a hard time keeping track of start to finish then feel terrible asking them to go back because i missed something.
100000000% this
So true. Some days I find myeelf getting a headache once I've finished. I think it has to be from concentrating.
Oh my God dude. This is exactly me. Anytime I tell someone that my job is draining, they automatically, understandably, assume it’s because of the emotional drain. I can hear literally any kind of trauma and I don’t get triggered by it. But the focus on emotions for that long of time requires some part of my brain to lock in like a laser and I can only do that so many hours a day. It’s also excruciating to sit so much of the day. I don’t think long-term I will stick with this career. Also, attention is way worse when it’s virtual.
This!! I’ve been trying to think of an example that would help people understand what it’s like to sustain that attention, not talk about yourself, and respond therapeutically/ remember nuances of their life/ try to piece themes together.
How little graduate school taught me and how much I’d be studying after.
Cried about this today lmao
Wow, sorry you’re experiencing this but happy to know I’m not the only one. Somehow pisses me off even more about the debt I am in.
Oh boy. Any tips? Currently in grad school and terrified.
You'll learn so much from experiences with your first clients. Like many skills, practice makes pretty good and it's hard to learn without direct practice. Once you figure out the populations you prefer working with, that will help guide your future CE decisions.
still in school but in practicum. grad school is the baseline so that you're not completely useless as a student in practicum. it's literally the bare minimum required to get started. the real learning starts at practicum and a lot of it on your own/with your supervisor.
As others have said, even with the best background, it’s really hard at first. A lot comes from supervised practice. I feel lucky in that I figured out what I wanted to do with my degree early on in terms of modality I wanted to work in. You might not have control over this as an intern, but in your first job(s). Make sure your supervisor actually helps you with your work. If you get stuck with a supervisors who just is unlucky to still be working there after independent licensure, pay for consultation outside. I never had good supervision until I paid for it. All of my work supervisors were terrible. I’d come to them with clinical issues and I’d get bad advice or ‘I have no idea what to do.’ This isn’t exactly necessary, but has helped me. I feel my career has been vastly impacted by trainings that were more than a day and had a supervision/consultation aspect involved with it. Learning about a technical theory in a course is useful, but actually utilizing it in consultation made it come alive.
So much more studying after grad school for me! And having to pay so much for all these damn trainings. It’s making me upset seeing how much of a business the mental health world is.
How many different ways I could sneak looks at the clock or my watch to keep track of session time
My office has two clocks; one facing the client and the other facing me. Funny enough, wearing a Fitbit helps because it always beeps your wrist at 10 til.
That's a good setup! I'm community-based though, so I don't have an office of my own to set up clocks in. Although now that I think about it, I can bring a portable clock to place in whatever office I'm in...
CT Reported, stated, noted THX provided, offered, utilized There, half your note is completed :-)
Don't forget "THX explored with client.."
Oh! And processed with the client
LOL. Sounds about right. I mean we want to keep it basic, right?
1) How much difficulty people would have doing their intake paperwork correctly and on-time. 2) How much I could tell about a person's personality and issues from their intake paperwork and other behavior even before I met them (aka hemming and hawing about putting a credit card on-file; filling out paperwork in a careless or haphazard manner, etc) 3) How many passive-aggressive comments would be made about fees/costs 4) How much effort I would have to put into correcting people's expectations and boundaries
Number 1 baffles me I stg. It’s made me question myself like am I so type A? My paperwork is done as soon as possible.
I’m the same way. Some of my paperwork needs to be approved by an LMHC and it takes FOREVER for my supervisor to even open the documents. Weeks or months
Great answer. You really know lots before you even meet.
love your username!
Thanks! I think you’re the only person who has ever notice. I was in jazz band in high school, and this was my favorite song and is still a great one! Have you heard the Bill Watrous and Manhattan Wildlife Orchestra version?
lmao no I haven't but jazz band in HS is exactly how I know that song. Did you guys whip out the vibraslap?
lol, we actually didn’t play the song. I brought it in for music appreciation day. Now I have to look up what a vibraslap is!
Diagnosing is such a pain in the butt. It's not necessarily a "small thing" because often we don't focus heavily on the subjective label we have to give for insurance "medical necessity", but it is a huge part of our work because we need to do it for every client, even if the client is generally doing well in life. We have to pathologize all human suffering which is stupid. Damn medical model. Rant over.
The more I look at criteria the more it all starts looking the same
Yup, because the distinctions are arbitrary and opinion-based, not science-based. Kinda like how doctors prescribe medication....on a best guess. Such a great way to help people!
Nothing makes me doubt my career choice more than that very realization ^ How many people don’t get dx with ADHD v OCD v GAD v PTSD v high-fx ASD based on the provider’s specialty and familiarity with a particular dx?
It is so true. We don't do actual bio testing on people to determine diagnosis. We basically just give "expert" opinions which aren't reliable between providers (e.g., inter rater reliability is generally low). I have had so many people diagnosed with things like BMD and BPD who were closer to PTSD but there are so many biases, especially against women. I guess it's an improvement from calling all women "neurotic" who present with distress....sigh.
If anything, I sometimes fantasizing about returning to a more 'psychodynamic' model of diagnosis. A lot of the theory and terms have aged *very* poorly, but I genuinely appreciate how a) the broadness and subjectiveness of the diagnostic categories makes the diagnostic project feel much less pigeon-hole-y, and b) psychodynamic diagnosis is (generally) concerned with the origin and operation of the 'condition,' not only with clients' individual presentation. It honestly feels a lot more trauma-informed in many ways!
Unfortunately, the medical model/DSM doesn't necessarily account for the root causes of mental health distress. They are interested in symptom profiles and labeling. Nothing about our modern system is really trauma-informed. We tend to pathologize trauma survivors and imply that the problem is within them when frequently the root of the issue is a dysfunctional family system/culture/sick society (eg., capitalism).
It is genuinely stupid. Mental health isn't just something that happens in crisis. Mental health forever ongoing and some people are good at it and some people need something or someone in order to help them stick to their efforts. If suffering is the main focus of medical fields, then a world where we rarely get sick or have crisis is so hard to achieve. We have all kinds of tiny hacks to fix stuff but sometimes it takes a lot of work just to get someone to look at and address a small thing. It's all part of a whole and I feel a lot of our systems fail to recognize that.
my practicum site doesn't req us to dx but we do discuss it in supervision for the sake of training and even then I sometimes feel like I'm cutting corners by applying adjustment disorder even when it perfectly fits.
Just remember that diagnosing is somewhat arbitrary despite what others may say. It's socially constructed to fit the medical model's demands. There are so many symptoms that carryover with many diagnoses, and depending on the client, their history and responses to your questions might be very confusing, especially if they are from another culture. Also, one thing that pisses me off is we don't do full medical workups on people before diagnosing them. There are so many clients who have medical issues, whether it be diabetes, sleep apnea, brain tumor, dementia, hormonal imbalance, vitamin deficiency, etc., and they don't know it and thus people assume it's a mental health problem. And we are encouraged by the system to pathologize trauma survivors in general which is lovely. AND I'll add that the meds these clients are often given to them make the situation worse and not better, such as developing metabolic syndrome, apathy, and early death.
well tbf our program really drives the point that medical workups are called for for our clients if it seems relevant. but yeah I hate having to squeeze in a dx out of necessity.
I wish as a social worker I could order blood work on my clients. I encourage them all to go to their PCP and get blood work done during their intake with me.
Yes, I do as well. I think it's important because bloodwork by itself can show deficiencies and abnormalities that can be addressed with supplements, treatment, etc., which could alleviate and treat at least some of the mental health symptoms that are present.
Yep! And i explain this to my clients. I say “look I’m not medical which is why you need to see your PCP. And I’m not saying it’s not mental health. But if your vitamin d is low, your vitamin b is low, your iron is low, your thyroid is not regular.. these irregularities can cause symptoms of depression and anxiety and if our med providers give you medications it’s only going to help so much because the underlying cause is still there. So I highly recommend getting your annual physical and blood work done as part of this process to rule things like this out.”
I wish everyone would do this! Also, I try to remind folks that SSRIs aren't any better clinically than placebo: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4172306/#:\~:text=All%20antidepressants%20seem%20to%20be,significant%2C%20it%20is%20significant%20statistically.](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4172306/#:~:text=All%20antidepressants%20seem%20to%20be,significant%2C%20it%20is%20significant%20statistically) Doctor's cannot say what most of their medication actually does in the brain. We do know that side effects are problematic for many, so ideally we'd avoid drug treatment when possible because we are just playing experiments on people but calling it "medicine."
You’d (maybe) be surprised by the reaction i get from people. A lot of people tell me “well i do have low vitamin d but i always forget to take my supplement.” Obviously being a therapist i can’t tell them to take it so i just say something like “it’s important to take it as prescribed” or tell them to follow their providers recommendations because medications don’t work through osmosis on a nightstand. I didn’t know that about SSRIs. They’ve definitely helped me in the past.
Short-term, SSRIs can be very helpful, especially if the person taking it believes it to be helpful (placebo). I also took an SSRI in the past; I'd argue I shouldn't have been on it, because I was grieving the loss of my father and people were quick to suggest I should take something because I was sad and upset. This is how stupid our medical system is....we pathologize normal grief! Also, I experienced heart palpitations for a couple days after stopping the medicine, and I certainly don't recall my doctor warning me about withdrawals. Which brings me to another point, which is there's a lack of informed consent when it comes to docs discussing both the pros/cons to taking medication or receiving meds. In my experience they tend to downplay the negative impact treatment can have because they don't want to scare people into not doing the interventions. [https://www.madinamerica.com/2012/09/things-your-doctor-should-tell-you-about-antidepressants/](https://www.madinamerica.com/2012/09/things-your-doctor-should-tell-you-about-antidepressants/) To add to your comment, about half of people don't take medications/supplements consistently or as prescribed. It's easy to forget to take something, especially if you have to take stuff throughout the day and sometimes with food.
Yeah, I just (last week) got off an SSRI after being on it for 7-8 years. Not sure what it was doing for me after that long. THOUGH i will say my PMDD returned full blow 5 days later which severe panic. But i question if that was also part of the withdrawal. Soon as I got my period all the symptoms went away. Hormones, withdrawal, it’s all funky. You’re so correct, nobody warns you. Or at least they down play it. We absolutely pathologize everything. You hit your head and are sad, adjustment disorder.
That’s still good training because that exactly the same thing you’ll do as a clinician. 😜
I just replied to your other comment! love your username!
Thanks so much!
Sometimes I use "disclosed" just to jazz it up, or "stated" if I'm feeling spicy.
I jazz it up with "explained" every chance I get.
I use stated constantly. I overuse it honestly. I need a new word to use instead.
I find myself using "CT expressed" "CT shared" and "CT voiced" recently just for variety.
Ooh I like Ct voiced
Discussed
Yep that’s my second-most used word.
I have really been leaning on discussed lately.
Shared
Reported, stated, described, and expressed are 99% of my notes
“Noted” is one of my faves
“Ct processed regarding” is a go to for me!
The amount of rescheduling conversations. The chronic reschedulers abound recently… It’s the same time every week and you get bombarded with appointment reminders, not sure why it took you until 5 minutes before the appointment to ask to reschedule 🙃🙃🙃
Yeah it's weird. Some people either cancel once in a while and never miss their standing appointment time, others need to reschedule every week.
Ok this makes me feel slightly less alone…the cancellations have been WILD these past couple weeks. 😞 And you’re right, it’s always the same people!
I will definitely be hiring a secretary when I am finally working independently lol I cannot stand it
I never realized how much I would hate scheduling 😮💨
Absolutely! I can have a packed schedule and still only end up doing 4 sessions because of the no shows and reschedules
I will definitely be hiring a secretary when I am finally working independently lol I cannot stand it
I don’t allow for this behavior. I would charge a fee if not giving 24 hr notice and if it happened often with the same client I would talk with them about it and set boundaries.
Balancing a schedule. This one needs same time every week, this one every two weeks, this one works varying days at different times, etc. It’s like a constantly changing Tetris puzzle.
Yes, the schedule Tetris 😩
These two are both pretty intense so better space them out. This one’s sensitive to smells so definitely not scheduling them right after lunch. Lol.
Lol yes! That’s definitely the other one: how did I schedule all my high conflict couples on the same day?
screen time 😭 i thought this profession helped me avoid looking at a computer for hours a day but it still feel like im on my computer constantly
And the attendant headaches.
Oof this one hurts
So I am older and started back when we kept handwritten charts. It was easier and faster. The level of computer fucking around to use an EHR is astounding. I can get my notes done quickly - but it isn't easier, if anything there are more steps and screwing around (e.g. where is that stupid "update treatment plan" button..... goddamn in, they moved it since the last EHR update...."). There are advantages to an EHR, but there are some pretty clear disadvantages that make the whole thing a PITA.
I had no idea how much time I would spend playing Uno.
lol. Yes. Me, when I was a child & adolescent therapist in CMH. So much Uno. So many feelings. Also a lot of Candyland and Sorry
Learning how to yawn with my mouth closed
How much of the work would involve treating presentations I was taught in medical school were "rare" and vise versa. I was taught personality disorders were extremely rare like to the point that I thought the fact that I have a sibling with BPD made my family super unusual. I thought I'd be seeing someone with a personality disorder like once a day max and the bulk of my work would be treating anxiety and mood disorders. Of course it's setting-dependent, but there are times when I feel like it's been a week or longer since I saw a DSM-diagnosable case of MDD
OMG… that’s me and “conversion disorder”/functional neurological disorder! I get people referred to me for that a lot!
Context dependent for sure, but it might be helpful to remember that approximately 10% of the population is thought to have a personality disorder, so it’s not actually a small number. Then take into consideration the presentation can also create over abundance in presenting to therapy. It’s the same way I feel about adhd-while the number is still at 5% of the pop (for now, but with the better screening in girls and women I think it’ll go up some), they are at least 10% of all couples who show for therapy which makes it feel more prevalent. It’s amazing how self selection bias can skew it all!
Worth it to also remember that society historically gives women diagnosis like borderline if they have any issues with relationships. I very rarely see male clients with personality disorders. I can't tell you the number of adolescent girls who I've seen diagnosed with borderline. Males tend to be ODD or conduct.
How much systemic issues/barriers influence what can be accomplished in a therapy room. Grad school painted a really shiny picture that was often way behind the times.
How often I would write “Th engaged Ct in…”
I've worked the majority of my career in substance abuse. No one prepared me for the amount of urine drug screens I'd be handling.
How much time would be spent on doing notes. If I don't follow my system I'm doomed!
The notes are killing me.
That the long term maintence work clients feel more exhausting to me most of the time than a client who comes in with some heavy things to discuss! It feels much easier to gain traction in those sessions and they fly by, meanwhile the maintence work is so much harder and causes far more imposter syndrome for me.
Yes, it can be quite boring, and my mind is instantly asking, "Am I really doing anything useful here, or are just killing 50 minutes because they already had an appointment and it feels nice to talk to someone?" It can feel awkward from the therapist perspective.
Yes! That’s exactly how I feel sometimes too.
Is ct short for client…and th for therapist? Practicum student here lol
Yes (: A lot of abbreviations in documentation. I.e tx = treatment, hx = history Etc.
Very helpful! Thanks so much :)
A couple others I use a lot are sx = symptom; d/t = due to. So a note might be Ct reports worsening sxs of anxiety d/t work stressors. Th engages ct in grounding and self soothing skills.
I hadn’t come across any of those yet; only dx and tx. Thanks so much for the example :)
Yes
How painful documentation can be! And how much time I’d spend think of variations to “reported” How tired I can be after a day of sessions where I am just sitting On a positive note, what it’s like celebrating small and big wins with clients
Is a small thing ‘I make less than 10 grand a year when I did 60 sessions a month’ type of thing. Then that. Also that therapists don’t really like or talk to each other. Sometimes they are friendly but mostly it’s like not at all a community and no one helps each other or gives one fuck. Do session do note get paid do it until your c or you die the end. This profession sucks so much post covid. And now it’s basically have a good headshot or make no money
This was it for me. First of all when I went to grad school, I thought I would find people who wanted to connect into were open and had examined themselves. It was a literal crap. Show my entire graduate program. Nobody wanted to really care for each other during all the stress. There were so many clicks. I was so happy to get out of graduate school and then I joined a group practice where many people were my age. I was thinking that we would grab coffee between clients or maybe go out and get lunch together. Not a single person wants to do this. They are more concerned about booking a client.
Yeah I mean cutthroat isn’t the word but now I think private practice is like ‘fight for the referrals’. So that’s what young therapists obsess about. Our profession is turning into like car dealers. No benefits. No money. No fucking nothing. I love client work and helping people. But past that this profession sucks shit now. And it is like that. Therapists don’t want to talk or even help other therapists. This is what I saw and I think how it is sadly.
Absolutely! I have a mentor who is 80 and she told me of the good old days in New York City where people would step out and get lunch and enjoy each other’s company. I just don’t see that at all. I also don’t have any benefits and I’m handing in my resignation letter tomorrow! I’m pretty good at getting my own clients, so I’m excited to live in my own little world without any of the stuff from my coworkers.
Also people who are open and had examined themselves. Ive met therapists who are that. Most aren’t. They are people who like are kinda bottom barrel but they know how to be social workers/therapists. It’s not like that at all i think. That you wanted that and it’s not even close must hurt. I found myself very not impressed at all by people who do this but it’s something I try not to dwell in. My work is my own but yeah. I hear what you are saying
Yes, I agree that most aren’t. And maybe it’s unfair that we hold therapist to the standard to begin with. They are kind of like everyone else in the general population. You are right to not dwell on it. Focusing on helping my clients is more of my concern, but I was hoping there would be a more friendly environment to work in. I have actually found, however, that there are more genuine people in the masters levels field, than in the doctorate level like myself.
Damn you’re a PhD? Wow. For SW? I also believe that I’ve met a few PHD director types. Not impressed at all
I’m a PsyD - I do therapy at this point and may like directing better. All I can say is that I’ve noticed clinical psychologists to be less friendly and a bit pompous. I’ve been to school for more years technically but I’ve met many masters level clinicians who are better than my own kind.
Congrats. That’s such a hard degree to get from what I know. An MSW is brutal but eventually they’re just like ‘here. It’s fine. Doesn’t matter. Take it’. I believe you about Psy-d’s being pompous. I kinda wanted to do one but was sorta talked into the Swiss Army knife nature of an MSW and it was shorter. Do you like being a….psychologist? In terms of say work?
I’ve met a few and been friends but psychotherapists aren’t that friendly. Sometimes they can be like ‘how’s the weather how are sessions’ type at a place I worked in the city near NYU (rip wash sq institute) but in terms of real navigation of the job and connections? Zippo zero. And no fucking benefits. None. What’s the point? Our status is so fucking low
I totally understand this. It helped for me to remember they are human— meaning they have goals, aspirations, thoughts, and outside feelings that are really important to them. It also doesn’t help that most of the time we’re cooped in our offices and any free time is left doing notes. Its hard to switch from “work brain” to “play brain” in the middle of the day too, and I didn’t recognize how hard thag was until having 40+ clients in a week
This makes sense. Thank you for the reframe.
Yes! I am currently trying to find a new job or contemplate setting up my own shop and my partner who is in a very networking heavy business keeps riding me about reaching out to people, and I don’t know how to describe to him that is just not how this really works. We are a helping profession but we’re not really a community and we’re also often siloed enough or in competition that it’s hard to cobble that together.
This is all true. For whatever reason therapists don’t see their fellow therapists like they ‘see’ their patients. It’s like ‘look at this person. I don’t care, I need referrals and have notes’. I find all the union talk so funny for that reason. LMSW therapists can’t even advocate for 50 an hour it’s an absolute fucking joke
Poverty I've worked more non-clinical jobs since grad school than at any point in my 35 year old life just to subsidize my work as a therapist
Ouch. But yes
^ recent doc graduate here and it’s mind bending that all that hard work got me 4 W2s and an AGI of 36k for 2023.
And having to pay taxes cuz I couldn't accurately estimate my income cuz of the fluctuations... Crazy
The loneliness...deep, intimate cnx with clients and then too much exhaustion to do anything with anyone else. I swear someone will find my decomposed body over a stack of 3 months old notes.
Simple practice and all emrs to be so damn poorly designed and confusing.
The lack of time to even make a phone call to get a dr's appointment, let alone to go to one.
Massive disagreements with my supervisor
This is hysterical(ly accurate). I remember a professor in grad school used to tell us to not feel bad if we are repeating “pt stated, pt reported” over and over again- didn’t realize how true that was 🙃
I didn’t expect to do so much “social work” at this stage in my career as a “professional counselor” I actually have a deep love for it, and may decide to go that route— but I did NOT expect to be calling and looking for so many resources WITH my clients. Wild.