Tag Archives: Students Audience (Grad/post-grad)

Students Audience

How to land an internship you’re excited about in 48 hours or less

By Wesley Murph January 19, 2022

The accident happened on a sunny Saturday afternoon.

I was driving home from my internship site, where I had seen clients that morning, when I stopped at a red light. As I changed the radio station on my car’s stereo, I heard screeching tires and crunching metal.

Then, as if I were in a Steven Spielberg movie, a maroon-colored car launched over the back of my car. It landed on its side and skidded down the asphalt against oncoming traffic.

As I stared at the unfolding scene, something big plowed into the back of my car, pushing it into the car in front of me. Glass shards and taillight debris rained down inside of my car.

I glanced in the rearview mirror and saw green liquid spewing from the van that was now embedded in my car. I feared that my car would explode and that I would be burned inside. As quickly as I could, I opened the door on my car and stepped on to the slick pavement. I glanced around to make sure I wouldn’t be hit by an oncoming car and heard a woman screaming from behind the maroon car. I immediately dialed 911.

“There’s been a bad accident,” I said to the 911 operator. “I think people are hurt. Please send help quickly.”

Minutes later, several police cars arrived and began directing traffic. A firetruck and an ambulance arrived next. A first responder said the woman driving the maroon car was shaken up but was otherwise OK. Just to be safe, they were taking her to the hospital.

I sat down on the sidewalk, grateful that nobody was seriously hurt. But when I looked at my car, I knew it was totaled. I also knew I would have to find a new internship site because my site was 60 miles from my home and the majority of clients I saw were in-person.

A few days later, I emailed my internship coordinator at the graduate school I attended and told him what had happened. We met on a video call, and he said it might be three months before I was placed at a new site. “If that happens,” he said, “you may not graduate on time.”

My pulse quickened. I had been in graduate school for nearly two years, and I was six months away from graduating. I needed 150 additional direct client hours to walk with my peers, and there was no way I was going to wait three months to find a new internship site.

So, I put on my marketing hat with one goal in mind: to find a new internship site. I never imagined what would happen, but I am grateful to say that I received five internship offers in 48 hours.

I would like to share what I did so that others looking for an internship site can find one they are excited about. Or you might tweak my campaign to connect with potential supervisors and land a new job.

I can’t guarantee the results if you follow this campaign, of course. But I can say it will help you connect with counselors in your area. It will also strengthen your sense of confidence and freedom by giving you more control over your future.

Google search

The first thing you need to do is find clinical supervisors for whom you want to work.

I played around with keyword searches in Google until these searches brought me to a webpage containing nearly a hundred clinical supervisors in my area. The webpage had a picture of each supervisor, a paragraph about the supervisor, and the supervisor’s email address and phone number.

I carefully read each supervisor’s bio until I found 25 whom I wanted to contact. I then researched the various supervisors using Google to find out more about each person. I went to each supervisor’s website, if they had one, and read their “About Me” page. I wanted to make sure that I genuinely connected with each supervisor before reaching out to them in an email.

I recommend that you complete this step too. Research the clinical supervisors in your area until you have a list of folks you want to work for. Really get to know these people. What clinical theories do they practice? Have they published any studies? If so, what are the results of those studies? How did they get into counseling? Have they written any blog posts or been a guest on a podcast? If so, what did you learn from their post or podcast? Do a deep dive into these people so you can honestly say to yourself whether you would want to work with them or not.

Next, I encourage you to create an Excel or Google Sheets file to help you keep track of your campaign. I created a new Google Sheets file using these headings:

  • Full Name
  • Email
  • Phone
  • Specialty
  • When Contacted
  • Response
  • Result

I filled my Google Sheets file with the 25 clinical supervisors I liked and connected with the most. I then sent a sincere and personal email to each of these supervisors.

Cytonn Photography/Unsplash.com

Email marketing

Here is what I wrote in the email:

 

Subject Line: Clinical Supervision?

Hi (First Name of Supervisor),

 

My name is Wes.

I found your contact information online, and I connected with you because ________. I am reaching out with a question about clinical supervision.

I am completing my master’s degree in clinical mental health from Northwestern University. I am supposed to graduate in March 2022.

Last January, I started my clinical hours at an internship site in Salem, Oregon. I live in Portland, and in August I was involved in a car accident that totaled my car. I am unable to drive to Salem to complete my clinical hours and am looking for a new internship site closer to my home.

Do you know of a licensed mental health clinician in Portland who may be interested in letting me finish my clinical hours underneath their supervision?

If not, do you know someone I can contact who may know someone?

I appreciate you for taking time out of your schedule to read my email.

 

Very respectfully,

Wes

 

Notice how the first paragraph has a blank line. This is where you put the information you gathered from your research. The more specific you are, the better connection you are likely to make.

The third paragraph contains my story. It grabs my reader’s attention because it’s heart-wrenching. You may not have a story like mine. But that’s OK. You can tell your contact another powerful reason why you would like to work with them.

The results

I emailed 25 potential supervisors on a Thursday. I received 18 responses and scheduled video interviews with five of them. I interviewed with one supervisor that Thursday night, three on Friday and another one the following Monday. All five of these amazing supervisors graciously offered to take me on as their intern. Working for any of them would have been delightful, but I chose the one that aligned best with my goals.

I relayed this information to the placement team at my graduate school. A day later, the site at which I wanted to intern was approved.

I also responded to each supervisor who got back to me. I told them I was thankful that they took time out of their schedule to try to help me and that I hoped we would bump into each other at a professional conference in the future.

I made sure to sincerely thank the four sites that offered me an internship but which I politely declined. This is respectful and maintains the relationships I established with each of these generous supervisors.

I was amazed at the outpouring of support from the counseling community in my city. The counseling community in your area is likely just as supportive. All it takes is a sincere and genuine email to open a conversation with someone you admire and want to work for. Who knows what will happen? But this process gives you some control over your future instead of simply hoping that fate is on your side.

 

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Before he began a master’s degree program in mental health counseling, Wesley Murph owned two small businesses, including one that was featured on The Dog Whisperer with Cesar Millan. He currently helps couples communicate more effectively so that each person feels valued, heard and appreciated. He also works with men to resolve anger issues and relationship conflicts that are lowering their quality of life. You can find him at BuildingBetterMenPDX.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Four lessons in building therapeutic relationships

By Anne-Marie Burke November 9, 2021

Tell me if this resonates: You enter graduate school bright-eyed and bushy-tailed, fresh with hope and galvanized by various novel theories that promise to offer you some sliver of competence when you enter the counseling room in barely a year’s time. Like any counselor-in-training who takes seriously the ethical imperative to “do no harm,” you are practicing basic skills, reflecting on how developmental models and family systems reveal your own skeletons, and thinking to yourself, “Surely these heady ethics issues won’t come up in internship.” (They do — immediately.) 

But you are still stuck. There are nagging questions jangling in the back of your skull: “How in the world do I counsel someone? Where do I even begin? What do I do when I am totally lost in a session?” 

Seeking to know the future and set my expectations, I consulted with a diverse milieu of practitioners, doctoral students and professors. Nonetheless, satisfying answers eluded me. As my anxiety grew, I was forced to seek comfort in the cozy lap of our profession’s favorite platitude: Trust the process.

Having since finished practicum/internship, I can now appreciate the futility of trying to anticipate all that this defining year has in store for counselors-in-training. Although I cannot tell you what to expect, I can shed light on the complexity of your experience and encourage you to lean into the promise of the therapeutic alliance.

Counseling’s heartbeat

The importance of the therapeutic alliance for client change cannot be overstated. It is the heartbeat of each intervention, technique and theoretical approach in the counseling profession. Furthermore, scholarship abounds with evidence of its effectiveness in the field.  

But what is the therapeutic alliance? An agreed-upon definition is difficult to find, but two common threads are routinely mentioned:

  1. A mutual respect is present between the client and the counselor as they embark on the shared purpose of resolving the client’s issues.
  2. Once safety and trust have been established, honest disclosure from the client is required, alongside support and nonjudgmental feedback from the counselor. 

These key aspects of the therapeutic alliance have their own implications: How do we establish mutual respect? How can we ensure safety and trust? Instead, I have simplified the therapeutic alliance down to one thing: figuring out what the client needs from me in every moment. 

Branislav Nenin/Shutterstock.com

Despite initially feeling underqualified to counsel clients — some of whom were at their most vulnerable — I was not ill-equipped. Theories and hypotheses lit my path, while companions such as horizontal and vertical processing, reflecting and silence never failed to fuel my clients’ process of discovery. These tools, along with many others, emboldened me to take risks with clients that, in turn, spurred them to “try on” emotional intimacy with me.

But in the beginning, it was not pretty. Impatient with the skills I was learning, I lurched from one to the next, hoping something would stick. For example, when an open-ended question and simple reflection did not produce the kind of insight I intended, I would jump to psychoeducation or a more complex reflection rather than giving space to my client to process what I had said. Thanks to good feedback from my supervisor and group members, I gradually slowed the pace of sessions down considerably and challenged myself to “be” with my clients intentionally. As I became purposeful in my skills, particularly with reflections, rather than panicking from one to the next, my clients relaxed with me and also became purposeful in their responses. This had an opening effect that laid the groundwork for safety and trust. 

Still, I made mistakes. I went headlong into directions that clients did not buy, catapulted to interpretations that pushed them away and introduced concepts that they simply could not wrap their heads around (e.g., they have value as a person because they exist, not because of how they perform). In such moments, the therapeutic alliance can crack; it can even rupture if these moments are frequent. Even the smallest misstep can create a distance that did not exist before. Recognizing those mistakes and renewing my commitment to figuring out what the client needed from me in that moment put me back on course. 

Doing this often allowed many of my therapeutic relationships to flourish. Because of this, I found that I could also offer difficult feedback to my clients. I believe that clients show up in the therapy room similar to how they show up in everyday life. Knowing this, if they engage in a pattern of behavior with me that is detrimental to building relationships, I judiciously offer feedback regarding their impact on me. 

For example, one of my clients struggled with impulsivity during conflict. She needed to resolve issues on her terms, leaving little room for how her partner processed conflict. During a session, I noted her compulsion to speak over and over again about the conflict as if I were not even there. Because I trusted our relationship, I was able to say, “I know you care deeply about the people you love, and this conflict is wearing you thin, but as you talk about it, I feel an overwhelming need from you to repeatedly say everything you need to say rather than engage in a conversation, and this makes me feel distant from you. I wonder if others in your life feel this same disconnection when you are attempting to resolve a conflict?” 

Her normally tough exterior immediately crumbled, and she burst into tears. She responded, “I thought I was doing everything in my power to overcommunicate and show how much I care about this person, but I am definitely not doing that.” It was the therapeutic alliance that helped the client believe me because she knew I cared about her. This exchange and realization led the client to engage in productive interpersonal work from there on out.  

Navigating the frontier of uncertainty

Perhaps all this talk about therapeutic alliance comforts you. You are skilled at constantly navigating your clients’ specific sensitivities and acknowledging your own mistakes. I hope this brings you substantial peace of mind. But do not be deceived. There is something else bubbling underneath all of this, and it is magical.  

The great pleasure of the therapeutic alliance is not that you can control it. In fact, the opposite is true. You have no clue where it will take you. For instance, I recall a time when one of my clients was laughing about their dog’s odd name one moment, and the next they were divulging their mother’s rape and their subsequent childhood in victim protection. 

In every session, no matter how I prepared, I landed in uncharted territory. This uncharted territory is the fertile but painful frontier of uncertainty. In this frontier of uncertainty, I made it my singular responsibility to shepherd properly by modeling presence, authenticity, cognitive flexibility and emotional agility. As a practicum/internship student, I noticed four counterintuitive ways to navigate this frontier and build powerful therapeutic relationships. 

Lesson No. 1: Do not infantilize clients. I treat clients as the adults they are by going over my center’s attendance policy with them and charging them for no-shows and late cancellations. This can lead to some awkward conversations, and, candidly, it is tempting to not charge them. Yet when I do have these conversations, clients show up, work with me in advance to reschedule their appointments or tell me to charge them because they know the policy. 

In other words, they treat me as a human whom they can affect with their actions. It is an invitation for the client to meet me at a boundary, which, by nature, brings connection rather than pushing us away from each other. Resistance to paying indicates other boundary issues that are worth exploring together. 

Lesson No. 2: Allow clients to be the experts of their own lives. Remember the abrupt drop into uncharted territory that I mentioned earlier? Generally, a big dose of anxiety accompanies it. Here, instead of asking myself what is going on with the client right now, I quickly ask myself what is emerging inside of me at this very moment. A quick scan of my internal environment usually tells me that I am too preoccupied with looking incompetent or fearful of disappointing my clients. This makes me overly involved in my own need to find answers and not involved in my clients’ search for their answers. 

My goal is to help clients make meaning of their life, not ascribe my meaning to their life. Recognizing whose search I am in — mine or theirs — and then permitting myself to not know their answers generally allows me to enter back into the session and sync into their process. This takes us to places that my limited understanding never would have given us access to. 

Lesson No. 3: Allow clients to feel that they matter to us. One of the most effective ways I have done this is simply to ask my clients, “Are you getting what you need?” Better yet, I ask them to tell me what they got out of the session. This helps both of us know where we stand. 

We are taught in counseling skills classes to summarize a session. Doing so demonstrates that we have listened thoroughly and, more important, ensures that the client feels safe and seen. If I have not done this throughout the session, then asking the client to tell me what they got out of it at the end is not going to bring us closer. But if I have gone to great lengths to show that I have seen and heard the client throughout the session, then asking them to summarize is a good way to see where we are on the same page and where we are not. 

What stuck? What did not? We see what we are creating together, which further bonds two people. (Note: I am careful here to ensure that clients are not giving me answers for my own ego. When we have a strong bond with our clients, they might want to please us. Teaching them to discern their progress through what Carl Rogers called their own “intrinsic valuing system” rather than our “conditions of worth” is critical for their long-term success.).  

Lesson No. 4: Seek out exceptional supervision. My supervisor sharpened my attunement to the therapeutic alliance by leading me to the root of my countertransference. 

In a couple’s session, I was determined to amplify a boyfriend’s voice by redirecting to him each time that his girlfriend would cut in. It had begun sinking in that their relationship was in jeopardy, and, naturally, she was in a lot of pain. But instead of validating her pain, I stayed the course to see what was happening inside of the boyfriend. In a sense, I cut her off emotionally. 

This backfired in two ways. One, there was an insurmountable distance between the girlfriend and me for the rest of the session. And two, rather than continuing to express his own emotions and thoughts, including his desire to end the relationship, the boyfriend turned his attention to comforting and validating his girlfriend. She could not see his pain without her pain first being acknowledged, and he was in pain because he was causing her pain. And I missed it because I had my own agenda. How did this happen? 

Upon listening to the recording of the session, my supervisor nonjudgmentally asked me what my feelings were toward the girlfriend to have skipped such an important reflection. I answered that I had not wanted to allow her to monopolize the conversation in yet another session. But there was more to it below the surface. 

At the beginning of the session, the girlfriend had accused me of turning her boyfriend against her. This had caused a high amount of tension in me and a desire to defend myself, even though I knew her accusation was only a distraction from what was going on between her and her boyfriend. I knew it was much easier to blame me than for her to see the signs that had been present in their relationship for months. 

I processed the accusation as therapeutically as possible, trying to redirect her to the boyfriend’s wishes to end the relationship. But in truth, I was angry and caught off guard. I unconsciously cut myself off emotionally to her in order to align with him. This resulted in all of us being isolated from each other.

Surprise! They never came back. I failed. But in this failure, my supervisor helped me uncover an invaluable piece of guidance: I should not be afraid to ask myself what I am feeling toward a client. I find that my answers are often surprising and worthwhile. I must then assess honestly whether my feelings are affecting my desire to build a relationship with the client. Are these feelings hindering my ability to prioritize my client’s growth? This does not mean that I should just tell clients what they want to hear, but it does mean that I should guard against withholding empathy from them because of my own negative feelings.

The catalyst for change

Despite implementing good tools to enhance the therapeutic alliance, I have had several clients who simply did not want me to continue as their counselor. In some cases, it may have had absolutely nothing to do with me personally. It may have been that I reminded them of someone, that my age made them uncomfortable or any number of other reasons. One former client came to her second session only to tell me that she did not want to continue working with me and not to even bother giving her referrals. 

On the other hand, I witness so much change in other clients’ lives that I overflow with joy. I celebrate those moments and allow fulfillment to cascade through my body. Then, I stop and reflect. Coupled with those moments are the tentacles of hubris tempting me to believe that I am bigger than the therapeutic process. I am not. The therapeutic process — and my clients’ engagement in it — is the catalyst for change. It’s not about me. 

I stay bound to the therapeutic process with my clients and bound to my role in their process. I am not bigger than this process. This truth buffers me on the days (I think) I am totally ineffective and, conversely, humbles me on the days I want to take more credit than I deserve. Good news: This reality testing is also a good way to prevent burnout. 

As I write this, I find myself wishing desperately that I could tell all counselors-in-training what to expect, but I cannot. You will engage in dozens of new therapeutic relationships, all of which must be watered, pruned and loved differently. Those of us who have come before you are cheering you on. Keep doing your work, and trust that if you do, you will get more comfortable in not needing to know what to expect.

 

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Anne-Marie Burke graduated with a master’s degree from Georgia State University’s mental health counseling program. She is a clinical mental health counselor and national certified counselor practicing at Samaritan Counseling Center in Atlanta. Contact her at amburke@samaritanatlanta.org.

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Humility wins

By Ellie Rose September 15, 2021

Guess what? If you have ever been in or are currently in therapy yourself, Carl Rogers might not have been a good fit for you. Neither might have Bessel van der Kolk or Irvin Yalom.

The clout that some of these big names in therapy possess is generally well-earned. Who doesn’t appreciate the advances in thinking on things such as unconditional positive regard, trauma or transference that these experts have provided?

As counselor clinicians, we are fortunate to have a wealth of brilliant minds who have gone before us before we ever step foot in our first theories classroom. But it is OK that we are not them. Inside the walls of a therapy office, there is not a single human on this planet who is (or would have been) the best therapist for everyone.

One of the ways that I market myself as an associate-level clinician still working toward independent licensure is this: leaning into humility. Rather than feeling less than those who already have 20 years in the field, a doctorate-level education or an alphabet of special certifications, I focus on fully occupying my space in this little corner of the world where real and meaningful change can happen for my clients.

Humility is powerful. And accepting all that you are and all that you are not is far more of a strength than a deficit when it comes to attracting and retaining clients. Here are some tips to challenge your thinking on fully embracing what you bring to the therapy table:

1) Accept that you won’t be a good fit for everyone; you will be an excellent fit for some. My website FAQs include the question “Why should I pick you?” My answer leads off with “Maybe you shouldn’t …” before I expand on how important it is to find the right fit in therapy.

Do not be anxious about all the things you are not as a counselor; rather, stand tall in exactly what you are. Even if you are just an intern at the cheapest university in America and receive subpar supervision, you still bring an entire lifetime of experience to your clients. Your very person is a gift.

If you had an abusive childhood, bring it. If you face constant household moves from a military lifestyle, bring it. If you’re happily married or are in the middle of a high-conflict divorce, bring it. Are you a parent? An artist? Do you have attention-deficit disorder? Bring it. All the elements of your very person are tools. They are uniquely yours and uniquely perfect for certain clients.

2) Sell the confidence you have in the client, not yourself. During the first intake session, I am very open with clients that I am not necessarily everyone’s cup of tea. I give them permission to fire me. And I validate the challenge they currently face in going out on a limb with a new therapist. I let them know that I have myself had a string of therapists with whom I didn’t really connect before I finally found the right one.

I look them in the eye and say something like this: “If this doesn’t feel right here, or if you aren’t connecting with what’s happening in this room, by all means, let’s talk about it. I might not be the right person for you, but I trust that the right person is out there, and I will offer some names for you that might be a better fit for your needs.”

Clients have responded really well to this. Some tear up just at that moment of me recognizing how scary it is to start dissecting a lifetime of pain with a stranger. Others thank me for giving them permission to be direct. Candidly, there are very, very, very few clients who don’t come back. In being given the freedom to choose what is right for them, clients will typically stop wondering if you might just be a smarmy businessperson trying to make a buck off them.

Imagine going to a car dealership and, right off the bat, the salesperson indicates that they want you to get the most out of your car-buying experience. Then, they acknowledge that they might not have what’s right for you but will help you find the place that does. Wouldn’t that feel great and immediately earn your trust? When you meet with a professional who is willing to recommend that you take your business elsewhere if warranted, that can lead to a substantial leap in rapport building with that person. When you do this as a counselor, it demonstrates to the client that you are perfectly confident in what you do offer and aren’t desperate for their business. Note: Even if you are desperate for their business, the client won’t benefit at all by knowing that.

3) Consider risking your own time. I found the therapist I’m currently seeing after I had interviewed a few others and was feeling weary in the hunt. Someone recommended him to me, and he stood out to me initially for one reason: The first session was risk-free. No, I’m not talking about the industry standard “free 15-minute consultation”; I mean that he offered an entire session at his expense to see if it would be a good fit. The catch was that if clients wanted a second session, they would book it and then pay the fee for the first session as well as the second. If he was terrible, no loss to the client; they could walk away.

I was immediately struck by his boldness and figured he must feel confident about what he was offering, so I gave it a shot. It paid off. I scheduled a second session right away and gladly paid the cost of the first. That was nearly two years ago, and I still see him regularly to this day. It was a marketing technique that served as a really attractive selling point for me as a client. Some variation of this might work for you too.

4) Be comfortable saying, “I don’t know.” You don’t need to be an expert on everything to be a great counselor. You don’t even need to be an expert on anything specific to be a great counselor! While establishing a niche can be a smart career move and might be personally fulfilling to you, it’s also OK to be a general clinician who handles only things such as anxiety, depression and grief. Evidence has consistently shown that it is not the specialized skill that produces the highest rates of success; rather, it’s the therapeutic alliance … and this is something that exists far beyond textbooks and continuing education workshops.

If a client asks you a question that you don’t have the answer to, say so. Offer to find answers for them or with them. If a client wants a particular type of therapy that is not in your wheelhouse, say what you know and what you don’t, and let them know if you are (or aren’t) willing to learn about the type of therapy they are seeking. Most of all, if you are asked for a very specialized service such as eye movement desensitization and reprocessing or brainspotting and you aren’t trained in it, PLEASE don’t pretend that you are and go home to binge on YouTube videos in hopes of faking it. State clearly your scope of practice and stay within it — while constantly trying to improve on your own time.

acidmit/Shutterstock.com

As a consumer, I am deeply appreciative of those experts who admit the limitations of their knowledge and don’t pretend to have all the answers. This deepens my trust in them. My general physician does this, which is why I would endure scheduling inconveniences just to see him; his word is gold. When you are confident in what and who you are, there is no reason to feel threatened by what you don’t know.

I remember the first time I worked with someone who had a chronic medical condition. She was nervous upon intake and asked what kind of experience I had in this particular area. I told her plainly that I knew nothing more than a couple of paragraphs out of my textbook regarding her condition but that I was honored to give her space to process her own pain and deepen my learning alongside her. During the same intake, I tried to defer by offering to find her names of people with special training in that area if she preferred someone with more experience. She declined, saying that she had a good feeling about me, and we worked through several fulfilling months together. This type of scenario has repeated many times in my young career, but I add the following caveat: There are certain situations or disorders that I insist on referring out because it would be detrimental to the client not to have the right kind of training for their needs in those cases. This brings me to my final point.

5) Never stop learning. Mandated continuing education credits are just the bare minimum. Competent professional therapists immerse themselves in the worlds of counseling, psychology and the human condition. This doesn’t mean reading every new self-help book that gets cranked out, but it does mean being diligent about exposing yourself to books, media, people and experiences that will not only deepen your skill set as a clinician but also deepen your own authenticity. This is especially relevant when you are dealing with couples, families and other unique populations.

Our world has been changing fast. Mental health therapists don’t need to know it all or specialize in everything. That would be an impossible feat. But we do need to constantly be updating our own knowledge and beliefs and fully developing our personhood to humbly bring best practices into the presence of our clients.

 

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Ellie Rose is a licensed mental health counselor associate, national certified counselor and private practice business owner in Vancouver, Washington. She works with individuals, couples and families through a therapeutic lens that encourages her clients to lean into reality, find meaning, and develop skills in handling the onslaught of life’s challenges. She is also a mother, reader, writer and speaker who can be contacted at ellie@ellierosetherapy.com or found on Instagram: @ellie.rose.therapy.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Starting a counseling career in the time of COVID-19

By Lindsey Phillips March 30, 2021

Many counselors can easily distinguish between what their professional career looked like before the coronavirus pandemic started and what it resembles now. But for most new professionals, counseling in a pandemic is all they have known. COVID-19 has shaped almost every encounter they have had with clients and colleagues alike. And the careers that have greeted them upon graduation have looked dramatically different than the ones they prepared for in school.

Hannah McGrath, a recent graduate from the Master of Divinity/Master of Arts in counseling dual degree program at Wake Forest University in North Carolina, always wanted to be a counselor. But as she acknowledges, “This [experience] is not how I thought things would go after I spent four years in graduate school.”

In March 2020, McGrath returned from spring break to discover that she would have to finish her counseling internship virtually. Many of McGrath’s clients, who were university students, had gone home for spring break and did not return to campus because of the pandemic. Some of them were out of state, which meant she was unable to provide counseling to them. Professors and supervisors scrambled to make sure she had the documentation she needed to do telebehavioral health and to help her find clients so that she could complete her internship hours in time.

It’s difficult to anticipate the long-term implications of beginning a counseling career in the time of COVID-19, but McGrath and four other new professionals agreed to shed light on the ways the pandemic has shaped them — and their future outlook on the profession — thus far.

Rethinking a counseling career

Kathryn Beskrowni, a provisionally licensed professional counselor, had concerns about starting her new counseling career even before the pandemic reached the United States. In January 2020, she had just finished her internship at Terrace House, a group practice located in St. Louis. She was apprehensive about leaving a steady job as a learning and development manager at College Bound St. Louis, a nonprofit that empowers students from economically disadvantaged backgrounds to achieve undergraduate degrees, to become a counselor clinician — a career she knew would depend heavily on building a suitable caseload.

Before graduating, Beskrowni, an American Counseling Association member who specializes in relational issues and life transitions, applied to a few jobs in private practices, hospitals and other mental health organizations. After not hearing back from anyone for over a month and a half, her career anxieties only solidified. “I had a two-month period where I didn’t know what I wanted to do,” Beskrowni recalls. “I had to emotionally prepare for this new life I was stepping into.”

She decided to reach out to her former intern supervisor, Christina Thaier, a licensed professional counselor (LPC) and the founder and director of Terrace House. Together, they discussed Beskrowni’s future as a counselor. Through their conversations, Beskrowni realized that one of her biggest hesitations revolved around the limiting feeling of only doing therapy.

Fortunately, Thaier worked with her to create a position that addressed all of Beskrowni’s goals and concerns and would allow for her to grow professionally. So, Beskrowni joined the team at Terrace House both as a therapist and assistant director of community relations (a role in which she helps to oversee and recruit counseling interns).

A few weeks later, COVID-19 made its way to the United States, and all the uncertainty surrounding the pandemic heightened Beskrowni’s career anxieties and concerns about financial stability yet again. Ultimately, she decided to keep her job at College Bound St. Louis, which provided steady pay and hours, while also transitioning into her new role as a professional counselor.

For about six months, she juggled both jobs, switching back and forth between her two work laptops — a privilege she had because of the ability to work from home during the pandemic. “It took me a really long time to feel safe and comfortable enough to fully commit to the unpredictability of a counseling career, so I held on to [the nonprofit job] for longer than I needed,” Beskrowni says. But she’s happy that she finally did become a counselor, and she’s excited about the future direction of her career.

Readjusting career plans

Before the pandemic, Darius Green, a recent graduate of James Madison University’s counselor education doctoral program, planned to find a full-time position in counselor education. He was willing and able to move anywhere. But the pandemic changed things. He wasn’t sure how much the pandemic would affect college enrollment and university faculty hiring, and he was anxious about the job search process and his own financial stability. “I worried if I would be able to find a job in counselor education, and if I did find one, I worried about the risk of that position being eliminated,” he says.

Green, an ACA member whose research interests include wellness, diversity, social justice and counselor education, did apply to some counselor educator positions, and he even scheduled a few interviews. But he ultimately decided not to pursue that career path because he didn’t feel prepared for the several hours of virtual interviews and teacher demonstrations, and given the uncertainty surrounding the pandemic, his willingness to pick up and move just anywhere had dissolved.

“Originally, I felt willing to move just about anywhere to get my foot in the door, but the pandemic shifted my priorities and values,” Green says. “My top priority wasn’t having a job in counselor education [anymore]. My top priority was having a job with benefits and a stable income.”

In part for that reason, he decided to continue working as the assistant coordinator of the James Madison University (JMU) PASS Program, which supports student learning and success in challenging courses at the school. Although he applies some of his counseling skills to this position, the job itself isn’t counseling focused. So, he also works part time as a counselor at the ARROW Project, a community mental health organization in Staunton, Virginia.

Even this part-time position came with new challenges. “I was nervous because I hadn’t been trained to do telebehavioral health,” Green says. “I’m fairly tech savvy, but [with telebehavioral health], there’s just a lot more to think about.”

The pandemic caused Green to readjust his career plans, but it also gave him the opportunity to work from home. This has allowed him to balance his full-time job at JMU and his role as a counselor at ARROW, which otherwise would have involved a 20-minute commute.

Green isn’t sure if a career in higher education is sustainable or obtainable right now, so he wants to keep his options open by working toward his counseling licensure. He also knows his experience as a counselor clinician will strengthen his curriculum vitae if he does decide to pursue jobs in counselor education down the road.

Growing pains

Rachel Wyrick, a master’s student in the counseling program at the University of Missouri-St. Louis (UMSL), was looking for an internship position right when the pandemic hit the United States. Wyrick wasn’t sure if they would be able to find placement with so many agencies focusing on switching their practice to telebehavioral health. After a few weeks of silence, Wyrick finally got the email they had been hoping for: Terrace House offered Wyrick a position as a counseling intern.

Wyrick had felt like they were hitting their counseling stride during their practicum a couple of months before the COVID-19 pandemic. Wyrick had become more comfortable with clients, and Wyrick’s initial nervousness was slowly waning. But when everything went virtual, Wyrick’s anxiety shot back up. In many ways, Wyrick felt like they had to start over by learning how to do therapy using telebehavioral health — something that was not on their radar before the pandemic.

Wyrick specializes in relationship issues, trauma, posttraumatic stress disorder and LGBTQ+ populations. Because Wyrick works with clients experiencing trauma and uses somatic therapies, Wyrick had reservations about how effective telebehavioral health would be. But Wyrick embraced the change and discovered they can still build a strong rapport with clients virtually. In fact, in many ways, Wyrick finds it more intimate. Because they are sitting face to face with clients, Wyrick can easily read the microexpressions on the client’s face via screen.

“And for my style of counseling, it actually really suits me and the populations that I serve,” says Wyrick, who was named UMSL’s clinical mental health master’s student of the year this past December. It can be comforting to clients to be in their own space and to see their counselor as a “real” person in their own space, Wyrick explains. Wyrick notes that when clients ask about Wyrick’s plants or artwork in the background, it often seems to jump-start a stronger connection.

Wyrick still oscillates between weeks of feeling connected to clients and weeks of feeling unsure and inadequate. “Will it always feel this way, or is this a normal part of the process of growing as a professional?” Wyrick wonders. Wyrick hasn’t had much practical experience outside of the pandemic, so it’s hard for the counselor-in-training to know what might be unique to the pandemic and what is simply typical growing pains.    

Difficulty finding a job

After moving to New York, McGrath noticed there were more jobs for social workers than for counselors. That’s when she learned that some states privilege different mental health workers. Social workers have a longer history in New York than do licensed professional counselors and, in turn, more job options. Many of the types of jobs McGrath had assumed would be open to her — such as being a counselor in a hospital — were not.

McGrath applied to every counseling job she could find, but many of the places didn’t respond or told her they were hiring only fully licensed counselors. “I felt like I had no job options,” she says. The fact that New York City had to shut down because of the pandemic didn’t help, she points out. Nothing was business as usual.

Finally, in June, she found a job working with a foster care agency as a mental health counselor-limited permit.

Looking back, McGrath realizes the pandemic heightened her anxiety around her job search. She felt a sense of panic and urgency to find a job. If she could do it all over again, she says, she would slow down and take her time during the process.

During graduate school, a visiting speaker told McGrath, “Your first job doesn’t have to be a perfect job, but it can be the perfect teacher.” She is taking that advice to heart as she continues navigating her counseling career during an uncertain and challenging time.

Building a caseload

After graduating with a master’s in counseling from the University of Mary Hardin-Baylor in spring 2020, Mika Smith-Tjahja, now an LPC associate at Firefly Therapy Austin in Texas, put a lot of pressure on herself to instantly build up her caseload. “I was hard on myself at first,” she recalls. “I had high expectations about getting a certain number of clients each week.” When that didn’t happen, she felt discouraged.

At the beginning of the pandemic, Smith-Tjahja was averaging one to three clients a week for about two months. Her supervisor reminded her that it takes a while to find clientele, so she trusted the process. Smith-Tjahja’s caseload has since doubled, but it is still below the number of clients she would like to average per week. She recently accepted a second counseling job at Connected Heart Therapy in Austin and hopes this will build her client base even more.

Smith-Tjahja, who specializes in anxiety, depression and trauma, wonders how much the pandemic has affected her ability to build a caseload. A few referrals have told her they prefer to wait until in-person therapy resumes, so she knows that it’s a factor.

Smith-Tjahja has started thinking outside the box to find people who need help right now. She joined a Facebook group for mental health professionals in Austin to share and request referrals. She has found the group to be a great resource both for referrals and networking.

She has also suggested to her supervisor the idea of creating a low-fee closed counseling group for individuals who are interested in therapy but can’t afford the higher fees. The group would benefit the community while simultaneously teaching Smith-Tjahja more about the community’s counseling needs and informing others that she is available and eager to help, she explains. Smith-Tjahja is also interested in doing pro bono work in the future, once she feels more settled in her role as a professional counselor.

Finding support amid the isolation

Smith-Tjahja says her biggest challenge throughout the pandemic has been the isolation, especially in terms of not being able to interact in person with colleagues. She imagined trading her graduate school cohort for colleagues in an office or hospital. Instead, she works from home, alone. Because that feeling of community isn’t there anymore, she created her own virtual community — a support group for LPC associates like herself. When she reached out on social media to find others to join her group, she was surprised by the response: More than 50 people joined. They meet once a month, and they recently invited a certified public accountant to present on how to manage taxes for one’s private practice.

She also reached out to her former cohort and formed a peer support group. In their last meeting, they all echoed Smith-Tjahja’s sense of isolation and agreed that they needed this group because they had missed the sense of community it offers.

McGrath acknowledges that it can be challenging to feel connected to other mental health professionals right now. She communicates with her colleagues through emails and phone calls. Sometimes, she says, when she doesn’t get a reply within a couple of days, she wonders if her colleagues are busy, if they are ignoring her or if they think she is a bad therapist.

Wyrick likewise admits that it’s easy to fall into self-doubt, especially when everyone is isolated from each other. The Terrace House internship program tries to address this by pairing new professionals with other new professionals who are a few months or years further along in their careers. Wyrick has benefited during their internship at the Terrace House from having a mentor. Wyrick has had virtual coffee dates with their mentor, which provided a semblance of an in-office interaction.

Supervision is also critical. “It’s hard to know where you stand as a new professional right now,” Wyrick says. “Having a well-seasoned professional reflect back what they see — whether it be strengths or growing edges — is really helpful.”

“Normally we’d have these [professional] experiences with peers and be able to compare … and all develop together,” Wyrick continues. “Without that, our supervisors are our main source of reflection and validation … of how hard this experience has been and the strength that we’ve shown.”

Green encourages counselors to remember that not everyone comes from a privileged background and has the same opportunities and resources. Therefore, it is important for established counselors to reach out and support new professionals, especially as they try to find their footing in the midst of an ongoing pandemic, he says.

Professional connections provide not only career opportunities but also emotional and social support, notes Green, a member of both the Association for Humanistic Counseling and Counselors for Social Justice, which are divisions of ACA. People are less inclined to reach out virtually, so it can be isolating at times, he points out. He had several mentors schedule virtual meetings in the fall, but those meetings have slowly decreased in the succeeding months. Green tries to lead by example, taking the time to message his colleagues as well as other new professionals.

After the pandemic, McGrath looks forward to meeting her colleagues in person and building work relationships that will help her grow professionally. She says she wishes she could just pop into a colleague’s office right now and ask a question or chat about how their week is going. But until that is possible, she advises her fellow new professionals to make efforts to connect with other mental health professionals in whatever way they can.

Establishing work boundaries

Working from home has caused the boundary between work and personal life to become blurred for many new (and seasoned) professionals. As McGrath points out, it’s often difficult for counselors to have set work hours when they are seeing clients six days a week. “The longer the pandemic has gone on, the harder it’s been to keep those boundaries,” she adds.

“Establishing work boundaries is already a struggle for new professionals,” Wyrick says. The pandemic only adds to this problem. Wyrick’s workspace is in the bedroom, which means they can answer emails at all times of the day. It’s also tempting to take on clients outside of scheduled work hours, Wyrick points out. Wyrick often thinks, “What’s one more hour?”

Wyrick has had to create a routine because their partner is a professor who is working from home as well. When Wyrick is working, they shut the door and turn on a white-noise machine. This signals Wyrick’s partner not to interrupt.

Green says the amount of email he receives seems to have increased during the pandemic. It often overwhelms him, he confesses, and he spends a substantial amount of time sorting and prioritizing these messages. Smith-Tjahja also finds herself checking her email constantly because she is trying to build up her clientele right now. She says she hopes to establish a better schedule for checking and responding to emails after she has more clients.

Wyrick says working from home has taught them a lot about their personal work patterns and values. Before the pandemic, Wyrick took pride in always being plugged in, but now they realize that mindset is not in line with their values.

“At the beginning of this [pandemic], we had no idea how long it was going to be, and the optimists of us thought it was going to be a short time. So, that allowed things to be a little chaotic and wild at first,” Wyrick says. “I was thinking very much in emergency ‘go’ mode, but now I’m trying to be very mindful about creating habits that are going to be sustainable over time.”

Finding opportunity in the chaos

Smith-Tjahja experienced several significant events in her life during 2020, but they looked different because of the pandemic. She graduated with a master’s in counseling, but the ceremony was virtual. She got married, but it was not the ceremony she had hoped for. She and her husband bought their first house, but her parents weren’t able to go look at houses with her. Smith-Tjahja feels happiness for these milestones but also a simultaneous sense of grief because these events didn’t follow the traditional route she had expected.

But the pandemic also opened up new career possibilities for her. A year ago, Smith-Tjahja assumed she would probably work in a hospital until she was licensed. Working in a private practice was a distant dream, but that dream became a reality this fall. After getting her provisional counseling license, she reached out to a counselor she had kept in touch with throughout her graduate program to see if the counselor needed any help at her private practice, Firefly Therapy Austin. The counselor offered her a job.

During quarantine, Smith-Tjahja also decided to get trained in eye-movement desensitization and reprocessing (EMDR). She could easily take the classes from her home and didn’t have to spend money on travel, food or a hotel. This training has opened up another career opportunity. She reached out to another counselor who just started Connected Heart Therapy, a private practice offering EMDR to the Austin community. They offered Smith-Tjahja a job as a part-time counselor, which will allow her to continue her EMDR training.

Wyrick describes their initiation into professional counseling as a trial by fire. Although it wasn’t the start to Wyrick’s career that they had hoped for, it has given Wyrick confidence in their ability to rise to the challenge and their capacity for growth. Wyrick hopes the experience of practicing during a pandemic will encourage and allow new and seasoned counseling professionals alike to rethink the ways that they do therapy and how they can best serve their clients.

The uncertainty that the pandemic generated and the sudden shift to telebehavioral health muted some of the traditional milestones for emerging counselors, including graduating and starting a counseling career, Beskrowni points out. She hopes that other new counseling professionals will still take the time to celebrate their accomplishments and find a sense of freedom in their evolving possibilities.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Finding balance in counseling private practice

By Bethany Bray March 25, 2021

Managing a counseling practice takes strength of both heart and mind. To succeed, private practitioners must find balance between two roles: that of the caring, empathic and client-focused clinician and that of the shrewd business owner, which necessarily involves charging fees and making money.

Most people who enter the counseling profession do so first and foremost because they feel called to help others. At the same time, many counselors harbor dreams of one day owning their own practice, and that involves handling tasks that sometimes go against the grain of their helping instincts. Charging fees to clients who skip appointments or following up about nonpayment or a declined credit card can feel unnatural to counselor clinicians, especially after they’ve spent multiple sessions listening to the person talk about the painful life challenges they are facing.

“This is a tough area to navigate for many therapists, myself included,” says Dawn Altman, a licensed professional counselor (LPC) with a practice in Bryn Mawr, Pennsylvania. “It has been my experience that the most difficult area to navigate is my own money mindset and feelings of worthiness. … Most therapists come to this field with a sheer desire to help people work through emotional difficulties and live a more enlivened life. It feels somehow ‘sticky’ to ask for money for supporting someone who is struggling. The lines become blurred between what comes naturally to most of us — helping others — and requiring payment for our services.”

Money, money, money

One major aspect of maintaining balance between the heart and mind aspects of private practice involves setting — and enforcing — rates and fees.

When she first started her practice, Altman set her fees low because she doubted her own value. “Looking back, what came up for me was what is known as impostor syndrome — that internal experience of believing that you are not as competent as others perceive you to be. This is true of so many women in particular,” Altman says. “I had to get really deep with myself and ask myself, ‘Do you fear success as a business owner more than you want it?’ The answer was, of course, no, so I had to just rip the Band-Aid off and feel the fear and bill [clients] anyway.”

Now, after years in practice, Altman has found that her caseload feels balanced when she reserves three slots in her schedule for clients who pay on a sliding scale. If a potential client requests to pay on a sliding scale and those three slots are already filled, Altman has a list of practitioners to whom she can refer the client so they are not left without options. “I find that this system works for me because I can still provide a service to those who may not be able to afford my normal fee, but I don’t get resentful that I am working for pennies,” says Altman, a member of the American Counseling Association.

Norm Dasenbrook, a licensed clinical professional counselor (LCPC) with a practice in Rockford, Illinois, believes that counselors’ ethical mandate to keep up with self-care includes financial self-care. It’s not greedy to charge what you’re worth; it’s necessary, he says.

“If I’m thinking about how I’m going to pay the rent for my office when I’ve got a client in front of me, that’s not the best care,” says Dasenbrook, who also runs a consulting company that offers trainings and workshops on managing a therapy practice. “Charging what you’re worth is the best care for clients because you’re not thinking about that stuff when a client is in front of you. We [counselors] work hard and should get paid for that.”

Dasenbrook advises that private practitioners who are starting out should ask local colleagues about their rates to find the “community standard.” From there, they should decide on comparable rates and fees and stick to them. Private practitioners should also keep in mind that most clients are not going to shop around and choose a therapist based only on their hourly rate, he says. Rather, that decision revolves around many factors, from a practitioner’s area of expertise to their reputation.

From Dasenbrook’s perspective, the business and empathic sides of private practice are not mutually exclusive. Practitioners can find ways to accommodate clients with empathy while still getting paid, he says. For instance, with clients who are having financial difficulties, Dasenbrook will work out a payment plan allowing them to pay in small installments, or he will offer them half-hour sessions for a lesser fee. In other cases, he will refer clients to local charities or agencies that offer free or reduced-price therapy. These measures all ensure that clients are treated with care and continue to get the help they need, which is empathic, Dasenbrook says.

“To me, [the caring and business sides of counseling] go together. You’re providing a service and collecting a fee. There’s nothing mutually exclusive in there. You can do both with empathy,” says Dasenbrook, who has provided private practice consultations at the ACA Conference & Expo in years past.

Counselors in private practice who struggle with the idea of charging fees should look at how other service professions approach it, Dasenbrook says. He points out that plumbers and car mechanics don’t feel guilty about charging what a service is worth, and he stresses that counselors shouldn’t either.

“Don’t lowball your fees,” he urges counselors in private practice. “Think of other professions. A cardiologist that’s just out of school charges the same as one who has been working in the field for 10 years.”

Bethany Lato, an ACA member with two office locations in the Milwaukee area, also finds that the empathic and business sides of practice management can be interwoven through intentionality and commitment to purpose.

“One way I [incorporate empathy] is by maintaining a clear vision, purpose and foundation for what my business is and who it is for,” Lato says. “When focusing on tasks such as finances, sales and marketing, web presence and long-term business planning, I tend to wear more of the entrepreneurial hat. I think about it from the business perspective: What makes the most financial and business sense in order to achieve that mission?

“From there, I circle back around to empathy: How is this serving my clients and the people that I hope to reach? Am I making sure that I am taking care of my needs while also providing care to others? By beginning my work and concluding my work from a place of empathy, I aim to find that balance and never get too caught up in the business side or in simply making money. Sometimes this comes naturally, and other times it takes a conscious effort to maintain focus on the true mission and what feels truly aligned for myself and the clients I work with.”

Caseload questions

Determining caseload size and finding the “right” number of clients to see per day in private practice is an individualized decision. Counselors must charge high enough rates and take on enough clients to make money and stay solvent, yet still keep their caseloads and daily schedules from becoming so packed that they can’t give clients (or themselves) the time and attention they need.

It’s a balance that varies for each private practitioner and one that must often be determined through experience. Kristy Crump, an LCPC in Bel Air, Maryland, continued to work three days per week in an agency setting as she began her private practice in 2014. Within a year, she was fully booked and able to leave the agency, transitioning into private practice full time.

Finding the right balance was a matter of trial and error, she says. “You have to evaluate how you feel at the end of the day, at the end of the week. I was seeing 10 or 12 clients in a day and would be exhausted and struggling to keep up. It just took time to learn what’s right,” Crump says. “Now, my balance is six [clients per day]. I have some colleagues who say, ‘Four is plenty for me,’ and others who say they can do 10. You have to figure out [a schedule] where you still feel like yourself at the end of the day.”

Dasenbrook recommends that private practitioners start with an end goal in mind when determining their optimum caseload. Do they want to maintain a second source of income, such as teaching or consulting, while operating a private practice? How many vacation days do they want to take each year? Do they want to ease into semiretirement in a few years? Once private practitioners determine their long-term goals, they can work back from there to figure out how many clients they will need to see to meet (or to leave time for) those goals, Dasenbrook says.

Developing a reliable list of referral sources is also an important part of managing caseloads as a private practitioner, Altman notes. Over the years, she has discovered that she operates best when seeing fewer than 20 clients per week. This helps her maintain balance with other facets of her life, including time spent with family and her identity as a “lifelong student.”

“I quickly found out that seeing over 20 [clients] per week does not work for me. I feel pulled in too many directions, and my family life suffers, as does my own physical and emotional well-being,” Altman says. “I am very intentional about the type of client that I want to see, and while it is hard to turn people away, I now have a waiting list for those who want to wait specifically for me, and I have a list of five or six trusted therapists in the community to whom I refer when I cannot accommodate the client. … This alone has made a huge difference to me in my work-life balance because I enjoy each of my clients, and I am not burned out at the end of each week.”

Out of whack

Bryan G. Stare, an LPC and counselor educator who has experience working in private practice, is a critic of what they call the capitalist U.S. health care industry. Many of the decisions counselors who own private practices must wrestle with — whether to see fewer clients, whether to waive fees, whether to do pro bono work — have an effect on the bottom line of their business. This is an issue that often contradicts the counseling profession’s commitment to pursue social justice, Stare says.

“You’re put in a difficult position in private practice. You’ve paid a lot of money for this education, whether it’s a master’s or a Ph.D. To live comfortably, there’s often pressure to charge more for your services. But many of us have entered this profession because of a call to help or for social justice. … It does create some strife there,” says Stare, an assistant professor and director of the clinical mental health counseling program at the University of North Carolina at Charlotte. “We need to take care of ourselves and our business to take the best care of our clients. If I’m not doing that, I’m not able to create a safe space to care for my clients. If I’m spread too thin, I won’t be able to provide ethical and competent care to clients. [But] the system isn’t designed for that; it’s a profit-driven system designed to garner corporate wealth and leave people suffering.”

Navigating this balance requires that private practitioners keep consistent tabs on how they’re feeling about their workload. Only counselors themselves can recognize when their balance is out of whack and they’re spending too much time either on business tasks or client care.

For Crump, it comes down to how she feels at the end of the workday. If she’s irritable or exhausted, it means she needs to reassess her workload. “If I’m not at 100%, I’m not helping [clients] much,” she says.

Crump acknowledges this balance got thrown off when the COVID-19 pandemic caused her to shift all of her client sessions to a virtual platform. Crump specializes in anxiety disorders, and she says some of her clients became needier amid the stressors of the pandemic. In conducting sessions and other aspects of her practice from home, the boundary line between when she was working and when she was “off” began to blur. Crump says she had to check herself and take a step back to regain her balance.

“Of course I want to take crisis calls, but I would soon find myself three sessions over my limit [for the day]. It’s a struggle because you do have that control. You can say yes. I don’t have a front desk that will say, ‘Sorry, she’s booked for today,’” Crump notes.

Stare, an ACA member who counsels a small caseload of clients in addition to teaching and research work, agrees that emotions are a barometer. Private practitioners should recognize signs of burnout and regularly process their own feelings. Stare’s support circle consists of trusted friends, colleagues and mentors with whom Stare can consult.

Multiple private practitioners interviewed for this article say their bodies give them clues — such as feeling tired, worn out or achy — that indicate their professional balance is out of alignment.

“We teach our clients to do this, and we have to listen to our own body and our own needs too, and nurture ourselves as we tell our clients to do,” Crump says. “We have to take steps back and reflect. It gets very stressful. Some days are really hard. I’m a full advocate that every therapist should have a therapist — they can help keep you in check too.”

Lato notes that somatic cues tell her not only when her workload is imbalanced but also when things are going well. When her work is in balance, “I find myself genuinely excited about my business and my practice, rejuvenated by my sessions with clients, and with vivid dreams and visions of what the business can be in the future,” Lato says. “It is that vision that often gets me through the difficult, out-of-balance times as well. I spend a lot of time journaling, meditating and vision boarding around the future of the business and my practice, and find it is always important to know where you are heading. With this clear vision and direction, it becomes easier to recognize when things are out of balance.”

Put it in writing

The counselors interviewed for this article agreed that one of the best ways private practitioners can minimize the need to have difficult conversations with clients about payment is to offer clear, thorough communication about fees and expectations before any counseling takes place.

Crump provides a full explanation of her policies in the informed consent that clients sign at intake, but she also talks the policies through with each new client before they begin counseling work. “It took me a while to get a flow to be able to speak about that to clients,” admits Crump, an ACA member. “It’s hard to say, ‘Hi, hello, I have a cancellation policy.’ … [But] if you are genuine, you’ll get that in return. When I let [clients] know my boundaries and no-show fees, I’m being honest. I explain that it’s ‘housekeeping.’ It’s important to talk about it, get it out of the way and separate sessions into counseling and noncounseling work.”

Enforcing professional boundaries, such as imposing cancellation fees on a client who repeatedly no-shows, also models healthy behavior for clients, Crump adds. “I’m teaching boundaries to all of my clients, so I want to make sure I have boundaries myself,” she says. “I make sure to set boundaries with clients from day one. I’m direct, and if I answer a crisis call in the evening, I talk about how this won’t become a regular thing.”

Yet Crump acknowledges that she still finds it hard to charge fees, even after years in private practice. It presses on her empathic reflex, she says, because she doesn’t want to discourage people from seeking counseling.

“I hate having the conversation to this day,” she says. “It’s hard because we’re in a helping role. We’re here to help, and it doesn’t feel congruent with what we’re taught. You’re imposing a boundary on them, but unfortunately, that’s part of the business. There’s no one to enforce that but me. It’s easier [when] you talk about it upfront, instead of waiting until it happens and then springing a fee on them. It’s a necessary evil that you have to do. At the end of the day, you’re running a business, and you have to pay bills yourself.”

Crump and the other private practitioners interviewed for this article say that before enforcing a cancellation fee, they usually extend a one-time grace period for clients who miss an appointment. They also make exceptions for late or lesser payments from existing clients facing hardships such as an unexpected job loss. However, they agree that charging fees to clients who are chronically late with payments or repeatedly miss appointments is a necessity.

“I will usually say to the client, in writing, ‘Twenty-four hours’ [cancellation] notice affords me the opportunity to offer your appointment time to a client who may be on a waiting list or who needs an urgent appointment. I hope you understand that I must charge you for missed appointments,’” Altman says. “Being upfront about fees and payment options is crucial in setting up a good relationship with the client and [establishes] the clear boundary that therapy is a valuable service for which payment is expected.”

Enforcing fees not only helps to ensure that a private practitioner’s finances stay in the black. It also sends a message that counseling requires commitment and intentionality from both parties — counselor and client.

“At the end of the day, if I don’t set a boundary, I may not be acting therapeutically,” Stare observes. “If we’re not meeting regularly or semiregularly, depending on [a client’s] presenting concern, we’re not going to make therapeutic gains. Ethically, I can’t provide services that aren’t going to help.”

Dasenbrook urges private practitioners to spend time crafting thorough informed consent documents. Including details such as the hourly fee for services provided outside of counseling sessions (e.g., letter writing, filing court documents) ensures that clients are fully informed prior to being charged, he says.

Language centered on client consent, privacy laws and other practice issues varies from state to state, so private practitioners should seek training and consult with local colleagues and their state counseling associations when creating informed consent documents. “These are the people who are going to know the funky laws” in your state, Dasenbrook asserts.

The language in informed consent documents needs to be thorough and firm yet welcoming and calming, Dasenbrook adds. Clients filling out these forms are seeking therapy, so they may not be in their best mental state, he points out. They shouldn’t be made to feel as if they’re doing something akin to signing the seemingly endless number of pages involved in buying a home. Breaking informed consent into sections — treatment of minors, telebehavioral health, fee schedules, privacy laws/release of client information, etc. — makes things easier for clients to digest and allows counselors to remove sections that do not apply to particular clients. Per the 2014 ACA Code of Ethics, practitioners must include information about alternative/continuing service options should the counselor experience an emergency or pass away.

Ultimately, the time spent creating thorough informed consent documents should mean fewer confrontations with clients regarding fees and other policies down the line. “The business piece [of private practice] should be all taken care of in your informed consent,” Dasenbrook says. “It should be communicated upfront, before we even say, ‘What brings you here today?’

“Put it in writing, and get it all out ahead of time. … You want to take the money piece out of it [counseling] as best you can, and that’s why [I do it] all upfront.”

Getting down to business

The professionals interviewed for this article shared the following tips and insights on blending counselors’ caring instincts with the business side of running a private practice.

>> Maintain separate spaces: Stare uses an existential humanistic approach that recognizes the importance of feelings of place. With that in mind, Stare recommends asking for and accepting client payments in a space that is separate from the counseling room. If possible, keep a credit card machine or other payment mechanisms in another room and walk there with the client to take payment. Not sitting in the same chair and in the same room where therapy takes place to accept payment helps separate the two concepts for counselor and client alike, Stare says.

>> Pay first, talk second: Crump recommends taking payment from clients at the start of a session, before any counseling takes place. Crump didn’t always follow this process but eventually adopted the approach to avoid the awkwardness of having to transition from discussion of heavy, therapeutic topics to request for payment.

Keeping a client’s credit card number on file for automatic charging can also be beneficial if practitioners find it a good fit. Dasenbrook notes that private practitioners now have many convenient payment options, including apps such as Venmo and PayPal, compared with when he started in the profession three decades ago.

>> Stay on top of housekeeping: Tackling those unappealing tasks right away can be a benefit to private practitioners and their clients. For instance, Dasenbrook says, if a client’s credit card is declined, call them right away; don’t put it off or even wait until they come in for their next session. Addressing it immediately gets the issue resolved and is more likely to result in payment.

Similarly, Crump stresses the importance of filing insurance claims and paperwork as soon as possible after client treatment. This is especially important with new clients, to find out whether the private practitioner’s services are covered or whether the client has a deductible to meet. The sooner a practice owner knows there is a gap in a client’s insurance coverage, the sooner payment arrangements can be made, especially while the session is still fresh in the client’s memory. “Even though those case notes take longer, it’s worth it [to file right away],” Crump says.

Altman notes that a tough-love approach is sometimes necessary when tackling tasks that might go against a counselor’s empathic nature. “I used to offer monthly bills, which the client could then submit for reimbursement. However,” she says, “I found that several clients would simply ‘forget’ to pay. Their bills were racking up, and I was feeling resentful over both not being paid and the time it was taking me to have to rebill every few weeks.

“One client in particular would not pay me in a timely manner, and his bill would go unpaid for several weeks. I sent multiple reminders via email that he did not respond to. When the bill was a month overdue, I emailed him the bill one final time and told him that I was unable to provide the Zoom link for our next session until he had cleared up his account. He paid the bill immediately, and at our next session, I began with [talking about] the issue of payment. We agreed that moving forward, he would simply pay weekly, which he has done since that time.”

>> Play by the rules: Crump recommends that practice owners determine their “hard and fast” rules and endeavor to stick by them. For Crump, this includes taking Friday and Sunday off each week. She blocks those days off on her client schedule. In addition, although she doesn’t mind working in the evenings on occasion, she will build time into her schedule on a subsequent morning or afternoon to catch up on administrative tasks.

Another rule Crump has established for herself is never to send a client to collections for nonpayment. “I don’t see the need to cause unnecessary harm to those [clients]. If they could pay, they probably would have. It just doesn’t feel right,” Crump says. “Also, it [collections] is just one more thing to learn how to do and keep up with.”

>> Don’t do it all: One good way private practitioners can keep from becoming overwhelmed is to wield technology to their advantage, Dasenbrook says. This includes building a practice website with client intake and screening forms that ask for a person’s home address, insurance details, emergency contacts and other basic information. This negates counselors having to spend time asking for and transcribing this information in person or over the phone.

Dasenbrook also recommends that practice owners consider using software or hiring a professional to handle administrative tasks that they dislike or struggle doing themselves. That’s what Dasenbrook does with billing. “If there are tasks that you don’t like, then hire it [out],” he says. “You can try and do it yourself at first to learn and save money, but ultimately it makes sense to hire out if it causes a headache and takes too much time. Once your practice grows, start farming some of that stuff out.”

>> Seek and value supervision: “The No. 1 tip I would offer is to spend the money for high-quality supervision,” Altman says. “I had an incredibly gifted supervisor whom I worked with when I began, and it made a huge difference in the amount of time that I had to spend ‘winging it.’ Most of our supervision hours were spent on case discussion, but sometimes we talked [about] the business of private practice. It was enormously helpful to me as a business owner. Peer supervision is another great way to connect with others to share tips and insights and to just have a sounding board for cases or for life as a therapist in private practice.”

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Necessary skills

Private practice management demands a wide variety of skills, from overseeing scheduling and billing to determining one’s caseload size and handling client referrals. A successful private practitioner must also hone a number of skills beyond the nuts-and-bolts tasks of managing a practice, says Norm Dasenbrook, a licensed clinical professional counselor with a practice in Rockford, Illinois.

Dasenbrook considers the following qualities “musts” for private practitioners:

  • Clinical competency and excellence
  • Healthy self-esteem, self-awareness and the ability to set boundaries: This involves knowing what you’re good at and what you’re not, Dasenbrook advises.
  • The ability to know when you’re over your head professionally: This involves realizing when a client’s needs go beyond your skills and that you should seek consultation. Dasenbrook has been a counselor for three decades and still runs into issues for which he seeks consultation from peers. “It happens to everybody — when you’re sitting in session and you have no idea [how to help a client]. We’ve all been there. I’ve been there many times,” he says.
  • A business mindset and inclination for bookkeeping, scheduling, keeping medical records and other administrative tasks
  • Being comfortable with taking risks: “Sometimes we fail, but we keep on going,” Dasenbrook says. “You need to see yourself as an entrepreneur. Some things won’t work out, but you learn from it and move on.”

What skills would you add to this list? Post your thoughts in the comment section of this article, below.

 

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Action steps to learn more

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Pro bono: Yea or nay?

The 2014 ACA Code of Ethics encourages counselors to “contribute to society by devoting a portion of their professional activity to services for which there is little or no financial return.”

What role does pro bono work play for private practitioners who are trying to balance their empathy with the financial side of running a business?

Explore this topic further in an online companion piece to this cover story, “Pro bono counseling: How to make it work.”

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.