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Professional Issues

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.

Pro bono counseling: How to make it work

By Bethany Bray March 24, 2021

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.”

This is an important tenet of the counseling profession, and one that pulls at counselors’ empathy and call to social justice. However, counseling clients for a reduced fee or for free – pro bono – in a private practice setting comes with some caveats.

John Duggan, senior manager of continuing and professional education at the American Counseling Association, stresses that private practitioners who have any kind of third-party contract, such as agreements to accept clients from an employee assistance program, Medicaid or elsewhere, must take positive steps to avoid risk if they charge anything other than the same rate for service for 100% of their caseload. This is due to several reasons:

  • Charging different rates for services reimbursed by federally funded programs opens the practitioner to risks of fraud accusations or investigations by the U.S. Centers for Medicare & Medicaid Services (CMS). In general, Medicaid and other third-party insurance plans prohibit practitioners from waiving copays.
  • Insurance companies may be unwilling to honor a fee schedule if a practitioner charges different fees for the same contracted service to different clients.
  • Offering remuneration to clients is unethical and potentially illegal (see Standard A.10.b. of the 2014 ACA Code of Ethics). While there are exceptions, waiving copays/fees and underbilling are potential HIPAA violations.

Lastly – and perhaps most importantly – Standard C.5. of the ethics code prohibits discrimination in professional counseling. Offering different fees to different clients could potentially make a counselor’s health care business vulnerable to accusations of discrimination or lawsuits, Duggan says.

The only private practice scenario that would be exempt from the above points is if a counselor does not have any existing third-party contracts and treats 100% self-pay clients, without insurance, he notes.

“It is ethically essential to prioritize our work that’s pro bono,” says Duggan, a licensed professional counselor and licensed clinical professional counselor. “However, the bottom line is that professional counselors who manage a health care business should also operate as ethical businesspeople. Always consider ethical, legal and compliance issues before reducing fees, copays/fees or underbilling.”

Duggan points out that there are many ways a counselor can do pro bono work that do not involve counseling clients on their practice caseload. Volunteer or reduced-fee work in the community – anything from public speaking or leading workshops to mental health response during disaster situations – can be a rewarding way for counselors to give back.

There are also organizations and agencies that facilitate the counseling of clients outside of a clinicians’ existing caseload. Duggan points to the Pro Bono Counseling Project (probonocounseling.org) as an example. The Maryland-based nonprofit pairs clients with limited incomes who are uninsured or underinsured with volunteer practitioners for free mental health care.

When it comes to navigating the nuances of pro bono work, Duggan suggests counselors refer to ACA’s numerous resources, most notably the 2014 ACA Code of Ethics (including standards C.1. and I.1.b.) and The Counselor and the Law: A Guide to Legal and Ethical Practice by Anne Marie “Nancy” Wheeler and Burt Bertram, particularly Chapter 3 (available at counseling.org/store). Practitioners may also want to consult an attorney for guidance.

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2014 ACA Code of Ethics, Standard C.6.e.

“Counselors make a reasonable effort to provide services to the public for which there is little or no financial return (e.g., speaking to groups, sharing professional information, offering reduced fees).”

  • See the full ACA Code of Ethics at counseling.org/ethics
  • ACA members who have further questions can schedule a practice or ethics consultation with ACA’s counseling specialists by emailing ethics@counseling.org. 

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Pro bono: Opportunities

  • Remain cognizant of the potential for exploitation of clients, attend to their vulnerabilities, and consider their best interests in all professional decisions.
  • Look for opportunities to serve your local community by providing some pro bono services that capitalize on your unique interests and skills (e.g., speaking, teaching, mentoring, leading support groups, volunteering at a local nonprofit clinic).
  • Remember: Pro bono services are subject to the same rigorous ethical standards as all other counseling services. Practitioners offering clinical mental health services must also remain compliant with state and federal laws.

Source: John Duggan, senior manager of continuing and professional education at the American Counseling Association

  

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Read more

Counselors who enter private practice often find themselves confronting the push and pull between their desire to provide empathic, client-focused care and the need to turn a profit. Counseling Today will take an in-depth look at this topic in the magazine’s April cover article, “Finding balance in counseling private practice.”

 

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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.

Five regrets of the counselor

By Whitney Norris March 8, 2021

When I am supervising rookie counselors, one of my favorite discussions that often arises naturally concerns how unique the work of a therapist is. Yes, it is often incredibly tough work, but at the same time, we get an intimate, front-row seat to the experience of hope, pain, change and healing. (Along these lines, if you haven’t read Irvin Yalom’s The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients, I highly recommend it.) If we can truly be witnesses to this on the deepest level, there are so many incredible lessons that we are privileged to receive.

I recently came across an article about the book The Top Five Regrets of the Dying: A Life Transformed by the Dearly Departing, written by Bronnie Ware. After years of transformative work in palliative care, Ware summarized much of what she had learned from her work, first in a blog post and later in a 200-plus-page book. As I read, I found myself taking each of Ware’s lessons and adapting them to the unique work we do as counselors. I think that many counselors will be able to relate to these regrets and lessons.

1) “I wish I’d had the courage to live a life true to myself, not the life others expected of me.”

The work of Virginia Satir immediately came to mind when I read this one. It seems to me that perhaps a few too many of the pioneers and educators in our field want to, essentially, clinically clone themselves. Often, models come with a complete list of do’s and don’ts. I was even given an acronym in graduate school that taught me the exact way to sit during a counseling session. What I’ve always appreciated about Satir’s work is that she encouraged clinicians to be their own unique version of a great therapist.

When we’re new to the field, especially as interns, most of us do, in a sense, “try on” the techniques and styles of those we’re learning from. This, I think, is totally appropriate. Problems can arise, however, if we never grow out of that.

I’ll never forget the first time I was undoubtedly confronted by this “clinical differentiation” process. There was one specific professor in my graduate program whose therapeutic way of being I nearly idolized. I learned so much from him, and it so happened that much of our unique styles naturally overlapped. Then, one day, I was challenged to see some distinct ways in which they didn’t.

I had had a tough, conflict-ridden family session a few days previously, and we were watching the tape together in supervision. After talking through an overview, my supervisor told me he thought I should call and apologize to one of the family members for drawing the hard boundary that I had. After what felt like the longest eight seconds of my life, I swallowed hard and said, “But I’m not sorry.” I still felt I had done the right thing and could easily articulate why.

My supervisor paused thoughtfully and said, “Then you shouldn’t apologize.” And that was it.

He taught me an incredible lesson that day. We all need to be open and receptive to the information we can glean from what mentors, supervisors and others expect of us as counselors. And we need to be intentional about how and why we do what we do, whether that involves the companies we choose to work for, the clientele we choose to see, or the model and theories we posit. But we were never meant to do someone else’s therapy. We are meant to do only our own. To live the “therapy life,” we are meant to live uniquely.

2) “I wish I hadn’t worked so hard.”

The standpoint from which we view quotas and session numbers is greatly influenced by our training, workplace, financial situation, capacity, etc. With this lesson presented by Ware, I find myself wondering whether, at the end of my career or end of my life, I will be wishing I had worked more to see more clients or given more individual attention to each of the clients with whom I worked.

To put it more bluntly, if I have regrets here, will I regret quantity or quality? Will I wish I had worked with a smaller caseload in order to pursue more specialized training or to take more time to read books and research about the specific needs and patterns of the clients with whom I worked? Or will I look back and wonder why I didn’t work to see more clients in order to help more people? Will I wonder why I didn’t find a way to branch out on my own so that I could have more choices in how much I worked? Will I end up regretting that I didn’t follow what my mind and body were telling me about my capacity?

I don’t believe there are many rights or wrongs here. I believe our best bet is simply to make this choice more consciously. When I think ahead, I imagine myself wishing only that I had made my choices with more intention — made them on purpose instead of letting other factors, in a sense, choose a path for me.

3) “I wish I’d had the courage to express my feelings.”

I sat with some of these lessons longer than others in applying them to our work as counselors. After I read this one though, the application came to mind immediately.

While writing this article, I’ve also been reading through Louis Cozolino’s The Making of a Therapist: A Practical Guide for the Inner Journey. There have been many aspects of his candidness in writing to counselors-in-training that I have appreciated. This has stuck out the most to me in his many pleas to approach the work with humility — to admit when we’re in over our heads or when we need help. What I most appreciate is how Cozolino points out, much like Jeffrey Kottler does in his writings about counselor development (especially in On Being a Therapist), that this never ends. We never hit a stride where we no longer have questions, insecurities and specific struggles with clients.

Beyond that, most excellent therapists I know have at some point even questioned whether they should or want to be doing this work. Those of us who work through that well don’t keep it to ourselves. Doubts aren’t built for that kind of response. The path of least resistance is to talk through them with courage or, as Brené Brown would say (in Rising Strong), “rumble” with all that being a therapist does and will continue to bring up in us. I think the bravest among us have come to realize that there’s no shame in that.

As I said earlier, this work is tough — beautiful and tough. To not expect it to be accompanied by a somewhat constant dose of vulnerability can set us up for burnout and, eventually, at the end of the road, perhaps regret.

4) “I wish I had stayed in touch with my friends.”

In my mind, this one piggybacks off of No. 3. I have little doubt that when I look back at the end of my career, I will perhaps be even more grateful than I am now for the colleagues who made themselves available to process through these courageous conversations about the difficult and emotional work that crossed our paths.

One of the dangers of the field shifting more toward private practice than larger agency work is how easily this can lead to a sense of isolation before we see it coming. Even when we work with people we enjoy in these settings, we’re often just “ships passing in the night” during the last five minutes of the hour. Experts in interpersonal neurobiology are speaking more to the importance of the co-regulatory processes in therapy (see The Heart of Trauma: Healing the Embodied Brain in the Context of Relationships by Bonnie Badenoch). We will be best served to keep this in mind beyond just our one-on-one work with clients. I believe that getting support from colleagues is not just important, but actually essential, to doing good work.

In The Making of a Therapist, Cozolino spoke to some of his pushback on this need and his own reconciliation of it over time: “Put a group of us together in a facility designed to help clients and you find that at least half of our time and attention is dedicated to taking care of each other. For years, I found this confusing and demoralizing, and I wondered why we couldn’t put our own problems aside and just do our jobs? After much reflection, I realized that this attitude doesn’t work. Everyone in mental health, clients and caretakers alike, needs help, support and healing. Trying to help clients without helping the helpers ultimately fails.”

5) “I wish that I had let myself be happier.”

Lately, I’ve been finding myself wanting to abandon the term “self-care” because it’s so overused and, I think for the most part, misunderstood. The last point I want to make here really goes beyond the term anyway.

There’s no way around the frequent intensity of our work and the unique stressors found in such close and intentional proximity to pain and suffering. Sure, there are tangible things we can do about that, as I’ve mentioned earlier (and as Emily Nagoski and Amelia Nagoski expertly highlight in their book Burnout: The Secret to Unlocking the Stress Cycle). But we also can’t escape the reality that, as counselors, we don’t have the luxury of not taking care of ourselves. We can’t do the work we do, at least not for very long, unless we tend to ourselves.

I tell students in my practicum classes that if you’re not willing to make attending to your own physical and mental well-being a distinct aspect of your job day to day, then you need to find another career. We have to take care of ourselves like it’s our job. Because it is. That’s how we let ourselves be happier, among other things. Suffering as a badge of honor and martyrdom has no place in this profession. It certainly doesn’t make us more effective as counselors, and it definitely doesn’t make us healthier, more loving people outside of the office.

The following quote from Brianna Wiest, from a blog post she wrote for Thought Catalog, comes to mind so often for me that I think people are tired of hearing me say it: “Self-care is often a very unbeautiful thing. … True self-care is not salt baths and chocolate cake, it is making the choice to build a life you don’t need to regularly escape from.”

Thinking about the end of life while still somewhere in the middle of it can bring incredibly valuable insight — into our priorities, how we spend our time, our expectations, our habits and even our worldview. I think it is really important to ask ourselves whether our perspectives and patterns are forging paths of regret or paths of health and healing. Then, with appreciation for whatever arrives with this exploration, we have the opportunity to cultivate a courageous, balanced, emotionally honest, collaborative and happier work life that we can look back on with pride and immense gratitude.

 

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Whitney Norris is a licensed professional counselor and supervisor who co-founded and works as a trauma specialist at Little Rock Counseling & Wellness in Little Rock, Arkansas. She is currently pursuing her doctorate in clinical and translational sciences, with plans to study childhood adversity and prevention through the lens of public health and policy. Contact
her via whitneynorris.com.

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.

Using the ‘tap in dedication’ technique

By Nicholas Salazar January 13, 2021

Emma quickly checks her watch as she turns her key in the lock. It’s 9:57 p.m. She sighs as she pushes open the door and quickly moves to her room to drop off her bags before heading to the kitchen to make dinner, her second meal of the day since leaving at 6 that morning. She fills up a pot and turns on the stove, dropping in some noodles before opening her laptop to check emails and begin working on her course readings. It’s 10:03 p.m.

Emma’s eyes glaze over as she skims through the endless screens of text, and her head nods until she is awoken by a text from her boss: “Hey Emma, I just had someone call off. Can you open tomorrow morning?”

Emma immediately replies, “Sure thing, see you tomorrow!”

She glances at the time on her phone — 11:13 p.m. She panics and runs to the stove to turn it off. Greeted by a pot devoid of water, she throws away the burnt noodles and closes her laptop. She has finished only one of her five readings, but she needs to be up early tomorrow morning for work. She has six hours of classes after that and internship the following day.

It’s 11:30 p.m. Emma lies in bed with closed eyes and an empty stomach. Her mind races thinking about the different clients she has been working with and how they are holding up. She considers which clients might have which urges — and what she could do to help them, if anything. She thinks about the classes that she didn’t complete readings for and wonders whether she can get by without doing the readings. She thinks about herself as a counselor and questions whether she can ever be successful if she is already struggling.

It’s 12:25 a.m. Emma is asleep, but she will wake up in three hours to get ready to do this all over again.

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As a second-year graduate student who is also working on-site at a residential treatment program, I have discovered it can be difficult to not let every piece of life bunch together and form one massive challenge. It seems that everything of which I am a part is geared toward becoming a mental health counselor. It can be hard to engage in clinical experiences and separate the emotional intensity I experience on-site from my schoolwork, personal life and all other aspects of life.

In our field, being emotionally present and available and working through the sensitive topics of other people’s lives is our daily bread. But being able to stay engaged with a client can be a challenge, especially when you are burned out from the day before, or the events of that morning, or the previous client — not to mention school, work and other life tasks. Taking time to check in with yourself, support yourself and separate one facet of life from another is a skill I have found to be useful when applied in a genuine and purposeful manner.

Overview

“Tap in dedication” is a technique adapted from theater creators when dealing with highly intimate work on stage. It has been used for scenes ranging from a staged slap to simulated intercourse, and the intended purpose is to allow the actors an opportunity to establish their readiness to engage in sensitive and potentially harmful work.

My experience with this technique stemmed from my theater work during my undergraduate studies under the direction of Carin Silkaitis and Gaby Labotka, the latter being a certified intimacy director with Intimacy Directors and Coordinators. They introduced the technique of “tapping in” to those of us in the show, focusing on respect, safety and well-being for ourselves and for those with whom we were working. We used this technique regularly during scenes of overt sexuality, abuse, trauma and death.

We would physically tap each other’s hands, like a “high-ten,” as a way to say to one another, “I am ready to engage in this work with you.” When work on that scene or sequence had been completed, we would perform this action again to provide a physical symbol that communicated, “We did the work, and now we are stepping outside of it to be ourselves.”

Adapting this technique for counselors to use is a nice fit because of the themes of respect, safety and well-being — something that we helping professionals are adept at offering to clients but may not always apply to ourselves. In the counseling profession, it is important to find ways to respect ourselves and our work because if we do not, it can become all too easy to face burnout, experience vicarious traumatization or even fail to respect our clients.

I coupled the technique I learned in theater with aspects of dialectical behavior therapy to allow helping professionals to engage in mindful participation in their careers while providing them the time to check in with themselves before and after a day’s work. In the case of a particularly difficult session, counselors can also use this technique quickly between clients. Depending on site regulations, it may even be used with some clients.

The goal of the technique as I describe it here is to provide a way for counselors, counselors-in-training and other helping professionals to deal with sensitive subjects, to be present and engaged for the difficult work they take part in daily, and to be able to “leave work at the door” when they reach the end of the workday. It can be detrimental for helpers to bring troubling work home with them because it can impede their self-care and have a negative effect on the relationships they have outside of work. Ideally, using this technique will make it easier for clinicians to allow themselves to be engaged fully in their work life while helping them to separate this time from their personal life.

The technique

Practice self-care: Begin by entering or coming to the place where work will be done for the day. Next, take a moment for yourself by performing some action that is soothing and regulating for you. This could be making a cup of coffee or tea, enjoying a snack, reading a few pages of the newspaper, doing a crossword puzzle — anything you find that helps you feel relaxed or calmed. If this is a technique that you would like to use several times per day, between sessions or simply as it feels necessary, an activity that takes less time may serve you better.

Engage in mindfulness: Once you complete your self-care activity, it can be helpful to become grounded in your work environment. For example, take a few minutes to use a “five senses” grounding technique: Identify five things that can be seen, four that can be heard, three that can be touched, two that can be smelled and one that can be tasted.

Skills for distress tolerance can also be beneficial. An example is radical acceptance — taking time to accept one thing that you cannot change about how your day may go, while acknowledging that you can affect your own presence in the day. A technique such as one-mindfulness could be used to promote purposeful attention by focusing on one thing and allowing yourself to see, hear and appreciate it, whether it is physical, emotional or something else (e.g., a plant, a feeling, a thought). Any activity that helps you feel mentally at ease and instills feelings of calm and preparedness can be used for this activity.

An important consideration is to decide where and when you will engage in this process daily. For example, will you do it before you leave home? In the car or on the bus while traveling to work? Once you arrive at your office? From my experience of using similar techniques in theater, once the actions have been set, it is helpful to always do them the same way or as close to the same way as possible to preserve the integrity of the actions and process.

With practice, you will likely be able to engage in your self-care and mindfulness processes anywhere, although a change in environment or process initially could make it difficult to establish and maintain the mindfulness you hope to achieve. If you are in a position where you must travel regularly for your sessions, it can be helpful to have one specific action that you engage in prior to each session. It can also be useful to practice that action several times in settings that are calming before engaging in the activity in a more fluid and potentially stimulating environment.

Literally tap in: After you complete your grounding activity, you will literally tap in. This means to physically tap your hands on a surface or object. Your physical tap in signifies that you are mentally, emotionally and spiritually ready to be 1) devoted and engaged in the activities that follow in an effortful and conscientious manner, 2) fully present in your interactions and 3) aware of the effect that your effort and presence can have on clients and others.

Your physical tap in action serves to signify that your day has begun, and you will give conscious attention to all that occurs from that moment forward. Importantly, tapping in marks the time that is about others (rather than about one’s self), while the preceding actions were exclusively for the individual performing them (i.e., you). This can allow you to engage and deal with more demanding emotions and experiences by allowing you to acknowledge that this time is about being wholly devoted to another, just as the actions before were devoted to taking care of yourself. And in essence, you are taking care of yourself while caring for others because you have intentionally prepared yourself for your service.

Literally tap out: After your sessions, work or treatments are completed (or between sessions if content was particularly difficult), it is time to tap out — literally — just like you tapped in. This is a physical action in which you physically tap the same surface or object you used to tap in. It is important to use the same object every time if possible to symbolize the ending of the specific dedication to your work.

This tap out provides a physical action to close out of what has been occurring during your workday and allows you to engage with the nonwork you again. Additionally, this action signals that the feelings and emotions that may have come up during your work are meant to be kept in that specific time; they are not necessarily meant to exist beyond the scope of that session or that day.

Enjoy your post-tap-out activities: At this point, it is time to go about the doings of your personal life and nonwork time. This means to do anything you would normally do after work — exercising, playing with your children, grocery shopping, attending to your home, spending time with friends and so on — without interruption from what occurred during your work time.

Additionally, some people find it incredibly helpful to engage in some kind of self-care at the end of the day, similar to what they did at the beginning of the day. This might involve watching a specific show, enjoying some ice cream, doing another crossword puzzle — anything that can help you to decompress and relax. This activity can be done at any time but may be more useful to do soon after tapping out so that it can serve as a nice, calming cap to your workday.

Technique considerations

This technique was adapted from a theater practice used in scenes in which violence or intimacy was approximated that could cause effects similar to reliving traumas or increase actors’ emotional discomfort. It is important to recognize when something goes beyond the scope of dedication to work. It is up to counselors to use their best judgment to determine when an event may need further intervention to protect their well-being. Some subjects may be difficult to “leave at work,” and if this circumstance arises, it may be wise to seek support. If a counselor has a troubling response to a client’s trauma, it may be useful to discuss this in the clinician’s own therapy sessions or to process it with trusted colleagues or supervisors so as not to shoulder the burden alone.

Using this technique can take up a fair amount of time depending on the self-care actions the counselor chooses to use. Given that reality, it can be useful to find a quick-and-easy action, or to incorporate parts of the technique into one’s daily routine so that it does not become a burden to the user. However, taking the time needed to prepare for one’s day is imperative to staving off burnout and to increasing wellness.

Although this technique is not intended as a catch-all for reducing stress, it may prove useful in helping to establish firmer boundaries between personal life and work life, which is a common stressor among counselors. The goal is not to fix every stressor that clinicians may experience, but rather to provide an opportunity for clinicians to have a solidified and intentional process of entering and exiting their daily work in a demanding field.

In the event that a counselor must travel between environments during the workday, it may help to tap in and tap out before and after each client and to use travel time for a bit more mindfulness. Especially because of the variety of possibilities, such as traffic or accidents, that can occur when traveling between places, practicing mindfulness during the journey may be helpful in terms of keeping travel stress separate from your work. Additionally, using this technique can allow helpers to reduce personal stressors that often are carried over into work with clients, thus enabling a fruitful and intentional work experience.

Suffice it to say there are many situations that may not benefit from the ability to tap in and tap out. Using this technique ultimately comes down to each person’s discretion. It is simply meant to give them increased autonomy in how they choose to handle their time in a helping profession.

Getting started

Ask yourself the following questions to get started with the tap in dedication technique:

  • What would it be like for you to intentionally tap in to your workday and tap out of it? Do you have any hesitations? What can you do to resolve those hesitations?
  • What self-care routines would you like to use to start your day? Which ones are you doing already?
  • Mindfulness is an integral part of preparing to tap in. What mindfulness practices do you have established on which you can draw? If you do not participate in mindfulness, do you have other religious or spiritual practices that you might use (e.g., prayers, religious texts, songs)?
  • Where will you tap in at the beginning of your work and tap out at the end?
  • What does it mean to you to practice your work in a conscious way?
  • What practices do you want to establish if your work life enters your personal life after you have tapped out?
  • What resources do you possess to process particularly difficult clinical workdays? Jot them down and use your list when you need it.

 

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Nicholas Salazar is a second-year master’s student at Marquette University in the Department of Counselor Education and Counseling Psychology. He works part time and is an intern at Rogers Behavioral Health in Oconomowoc, Wisconsin. Contact him at nicholas.salazar@marquette.edu.

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

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