Episode 39
In this student edition episode:
We’ll be answering the question “What’s it like to become a therapist?” This question gets asked often and we generally don’t have time to really give a true answer. Today I’ll be talking about the good, the neutral and the hard things about being a therapist. Tune in to this week’s Student Edition episode of All Things Substance.
Helpful Links
Free Treatment Tool https://betsybyler.com/treatment-tool/
Transcript
You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective. I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice. So join me each week as we talk about All Things Substance.
Welcome back to the All Things Substance podcast. This is episode 39.
Thanks for tuning into our very first student edition episode. The student edition of the All Things. Substance podcast is designed to answer common questions that students have about becoming a therapist and what it’s like to be one.
Today, we’re going to be answering the question “What’s it like to be a therapist?” As I thought about this, I was trying to figure out how I wanted to explain this. I went through different things in my head and it seemed like the best way was to start with the good things, talk about the neutral things that any job has and then the hard things.
When students ask me this question, they want to know if the job’s worth it. They want to know if I still would make the same choice that I made all those years ago. But they also want to know what downfalls there are and what the hard things are.
The answer to the first question is yeah, I would make this decision all over again. I’ve known what I wanted to do for a long time. That’s actually pretty rare. I don’t know that most people had an idea of the thing they were going to be when they were 16 years old and ended up becoming that thing and loving it. But I did, and I wouldn’t change that now. I don’t regret it and I still love my job.
Anyone you ask about what it’s like to be a therapist or whether it’s worth it is going to have a different opinion. Some people love their jobs. Some people don’t. I’ve seen people who have gone through their whole master’s program and come out the other side and decided “I don’t know that this is what I want to do.”
I know that most of you who are in the student position are hoping that that’s not you. The hard part is that you’re not going to really know. What I can do is tell you what it’s like for me and what I’ve noticed over the years and try to help you figure out for yourself if this is the path. So we’re going to start by talking about the good things about being a therapist.
I have to say the best part about being a therapist is that I get paid to talk to people all day. I remember when I was in grad school, one of my professors talked about having a fulfilling career.
And he said, you figure out what you love and then you find a way to make someone pay you for it. That sounds like a simple statement, but it’s actually pretty profound and was for me. As I thought about what I loved, what I would do if I never needed money ever again, well, I would still help people.
Before I became a therapist. I was in a volunteer position, working with teenagers. I spent probably 20 to 25 hours a week all through college, working with teenagers and being a mentor to them. I loved it. Being with my girls was incredibly fulfilling for me and I loved being a part of their lives.
Being a mentor is a little bit different because you have different access to their lives than you would as a therapist. As a therapist, I don’t go to basketball and softball and soccer and volleyball practice and games. I don’t hang out with them at a coffee shop. I don’t meet their families and hang out with them and their friends.
What I loved about it though, was that I was able to be an adult in this kid’s life that cared about them and wanted good things for them. I built relationships and gave them a reason to trust me. That was the feeling that I wanted. And if I didn’t need money, I would do that in some form. It’s just how I’m built.
When I thought about being a therapist, I did want to help people. As cliché as that sounds the” I want to help people”. It’s true. I really feel that I’m at my best when I’m in service to other people. I believe that for the majority of us, that is true also.
One of the things I’m good at is relationships. I’m good at building them and maintaining them. I’m a trustworthy person who can hold a secret and I try to be as nonjudgmental as I can. Yes. It’s true that friends would ask me for advice and that people would come to me. Probably many of you have that experience too. That doesn’t necessarily mean that we’re all meant to be therapists. We might just be really good listeners or we might have really sound advice.
The job of the therapist is basically: people come to us, we get them to tell us their deepest, darkest fears, and we try to make it so they don’t need us anymore. If you think about that, it’s kind of a weird job. The best part for me about being a therapist is that I get paid to talk to people; to help them and to be in a relationship with them. That for me feels like it’s not work.
Whenever I would be nervous about meeting a new client. I would just think to myself “this is just a person and you know how to be with people. Just do that”. The rest of it, the therapy part, the assessment, the treatment plan, all the things that will come later. I get to go to work every day and I get to be immersed in other people’s lives in a way that I can help them. I don’t have to make them do anything. I get to just be there and I love it.
I also love that I get to learn about how people function. That I get to figure out patterns in people’s lives. I’ve always loved strategy and figuring out puzzles and doing therapy is a lot of that. People come in and they sit down and they hand you the portion of their lives that they feel like they need to tell you about. Oftentimes it’s not even remotely the whole story. It’s not because anyone necessarily is holding things back, but they see their life from a particular view. And they’re coming to you because their life is not going the way they want it to. And so your job is to take all that information and sort it out.
For me, I think of it like a rope that’s been tied in a bunch of knots over and over and over, and it’s pretty tight. I have to figure out how to gently pull different strings and when to do it so that I can help them untie those knots and find a way to get free from the things that are holding them back.
I love being able to be different than the person expected. I present myself in therapy the exact same way you hear me here. I’m the same here as I am when I’m with my family, as I am when I’m with clients as I am, when I’m out in the community. I pride myself on being the same person.
Certainly there are different boundaries and I talk about different things, but ultimately what I’m looking for is a relationship with someone so that they know who I am and that they can trust my responses, knowing that I’m going to keep their information safe and that I am a safe person so that they can be vulnerable. It is a great honor for me to be able to do that with people.
I don’t know how many people I’ve seen over my career. In the early days, I used to pride myself on the fact that I could remember everyone I had ever worked with. That number has to be over a thousand by now. It’s been 18 years since I started being a therapist and I’ve worked in multiple places with multiple people and families. I can’t remember everyone anymore. There are times that I’ve read an assessment that I wrote and I recognize that it’s my writing style, but I don’t remember this at all. There are people of course, that I remember from many, many years ago. I wonder how they are and I’ll probably never know. While that’s hard, I still am grateful for the time that I was able to be in their lives.
I think about the therapist that got through to me when I was in high school named Betsy and she made an impact on my life. I don’t necessarily remember the thing she said to me. I remember how she treated me. I remember how I felt. Those are the things that I want for my clients.
Sometimes they remember the things I say. We joke about there being a little Betsy on their shoulder, sort of like in the old school cartoons where there’s an angel and a devil on their shoulder and they carry their little Betsy with them. And sometimes they hear me saying things that I’ve said in session and we joke about how sometimes that can be annoying and sometimes really helpful.
I love being able to be a person that while I’m not in their daily life, they get to carry my care and concern for them with them. I am there encouraging them to make good choices for themselves that are going to bring good and peaceful and happy things into their lives.
My job is not to show them the error of their ways. My job is not to convince them of a certain level of behavior or morality or anything like that. My job is to help reflect back to them the life that they would like and help them remove obstacles that are in the way.
Each person is a unique challenge. Their life is specifically different from other people. I may have seen hundreds and hundreds of teenagers. Their lives are very similar in certain ways, but each teenager I’ve seen has a unique perspective, a unique emotional makeup, a unique family, unique opinions, and all of it makes up who they are.
I especially love getting to see teenagers that hate everyone because typically they don’t hate me. It’s just something that I’m able to do. And it’s not because I have some specific technique. The only thing I can point to without asking all those kids why they trust me is that I’m not expecting them to be anyone other than who they are.
I don’t judge them for the choices they’ve made and I take them as they are. If they’re angry, they can be angry. They hate people. They can hate people. If they’re using lots of drugs, they can use them. Just not when they’re with me. I hold my own boundaries and they can choose whether they want to work with me or not.
Over the years, I would get people who were mandated to see me. That’s a hard situation for adults and for teenagers. It’s not my favorite, but a lot of times, if that’s the case, I try to talk with them about, well, if you have to see someone for therapy, you might as well get to choose who that is.
When you leave here I’d like you to think that that didn’t suck that bad. Because for me, that’s success. I figure that one day they may want to come back to therapy and I want them to remember that I’m there and that seeing me wasn’t that bad. What would it be like if they actually wanted to come in.
For the most part when people are mandated, I am able to get them past the point where they don’t really think about that. To the point where they would see me anyway, even if they didn’t have to. It doesn’t always work, but it generally does.
I think it’s been two kids that I’ve kicked out of my office in 18 years. That’s not to say that they haven’t been frustrating or there weren’t moments where I wanted to shake them or I wasn’t angry because absolutely I still have feelings. I still get annoyed when teenagers act like assholes.
It means that I just have to manage my own reaction. Two kids out of 18 years where I said,” ah, no, we’re done”. Really was about some sort of pretty massive disrespect to their caregiver or to me in one case I suppose.
For the most part, I’m able to roll with that. I don’t know who you each would want to see. You will find a specific type of client that you love and you’ll find specific types of clients that you cannot stand. And sometimes you know that instinctively, and sometimes you find out that you were wrong.
When I was going to grad school, I knew I wanted to work with teenagers and in my internship I made sure I was able to do that. And it confirmed what I knew to be true. That was, I love working with teenagers. I didn’t realize how much I would like working with other adults too, though.
I never really saw myself working with adults or even older adults, but I have found that I really enjoy it. I’ve also found that I like working with adult men. I think guys have a unique need in therapy. I find that I’m able to meet that need. That I’m sensitive enough that they can talk about their feelings, but that I’m not so sensitive or seem so perfect that they don’t want to tell me ugly things about themselves.
I find it really rewarding when I’m able to work with a man who doesn’t trust people and who doesn’t really talk about feelings and get them to the place where they’re able to be their real selves with me. Have their masculinity intact and be able to be sensitive and talk about things that they feel without feeling like they have to hide. I take great satisfaction in that, and I love the guys I work with.
I didn’t think I’d want to work with little kids and I’m not wrong. I think little kids are darling. I just don’t want to work with them. Because it’s just not my forte. I’m far too sarcastic and dry in terms of sense of humor and I’m not a naturally playful person.
Now there are some people in my life who would probably disagree because I can be pretty playful. I do like talking to kids, but in terms of therapy, it’s just not my forte. Now I have seen little kids. I remember one of the last kids I saw. She was six when I saw her and I think she’s 16 now.
When I saw her, she would sit in a chair across from me and her feet would dangle because she was little. We’d sit at the skinny card table so that we could play games and she would swing her legs and kick me almost the entire time. And it wasn’t hard and she wasn’t doing it on purpose. She just was a kid who had ADHD and struggled with sitting still.
So one day I’m sitting in my office and I’m in between clients. And I heard some sort of banging on the glass outside of my door and right outside my door was the door to the lobby with a panel of glass on the side. And I heard this bang, bang, bang. And I was like, what is that? And so I pulled my schedule up to see who I was seeing and I was like, oh.
And so it continues and I have like 10 minutes before I need to go out there. And I walk out to the door and I see this little girl sitting on the floor and she’s bonking her head into the glass. And I opened the door and I said “you are not banging on my window”. And she was like “Ugh, I’m sorry, Betsy. When am I coming in?” And I’m like “just a few minutes”. And she’s like, “ugh, fine”.
So then a little bit later we’re playing go fish. Right? Girl has terrible sportsmanship had been kicked out of the Boys and Girls Club for getting in a fight. Nobody wanted to play with her because she just was a terrible loser and kind of vicious. And I know it sounds weird to say a six-year-old is kind of vicious, but she kinda was. She was this little waif of a girl. She was really thin and small and just looked like she would be no threat to anybody, but this girl had a vicious tongue.
So this day we’re playing Go Fish and she asked me if I had a card and I said, “I do, I would love to give you this card”. And she goes, “ugh, Betsy”. And it was just the cutest thing, but that’s not every kid that I meet that’s going to have that kind of a sense of humor or dry or sarcastic. She and I worked well because my style worked for her, but it’s just not me.
I have had therapists that worked for me, who I swear to God when kids saw them it was like they were a Disney princess. The kids loved them and just thought they were the prettiest and the sweetest and the most handsome people they had ever met in their lives. Those are the people who work with little kids. It doesn’t matter whether you look like a Disney prince or princess, it matters about the spirit that you have because kids see it.
The thing I found out about myself as a therapist is that I hate middle school. Hate it. Can’t stand working with middle school students. It is not their fault that being a middle schooler is like being a cretin, but I can’t do it.
Yes. I have skills. Yes. I could do it if necessary and have, but it is not my forte. And I find them way harder to deal with. I would far prefer a kindergartener to a seventh grader. This isn’t because middle school was particularly hard for me. It’s just, they’re hard to get to talk. Some days they’re going to be acting like they’re still in elementary school and other days they think they’re grown. So it’s just all over the place. I find that high school just works for me.
When you think about becoming a therapist and you think about the fact that you could get paid to talk to people all day long, I wonder who you’re thinking of. Are you thinking of kids? Are you thinking of adults? Are you thinking of specific issues that people are going to bring you? Those are the things that you want to be thinking of. If you never needed money ever again, what would you do with your time?
It’s a really important question. Because as we move forward, talking about this we’re going to be talking about the things that are neutral, not necessarily bad or good. They’re just part of a job and all jobs have these things. And then we’re going to talk about the things that are hard about being a therapist and those hard things might not be as many as all the good things, but they are really powerful and things that you’ll have to weigh in your own heart and mind to see if this is the career for you.
Before we move on to the more neutral things. I just want to address a couple things that I remember thinking, I remember thinking that I could go into private practice someday and work for myself. And that’s true. I don’t know that private practice is going to be for everyone, but it is an option.
I remember thinking that if I wanted to stay home with my kids, that I could work part-time or that I can even work out of my house. This was long before tele-health so working out of the house would have meant clients coming to the house. While I love my clients, I don’t want that to be the case.
It’s not because I’m scared of them. Although there have been people over the years that have been fairly dangerous as humans. It’s because I like my privacy and I want my outside world to be outside.
So while I thought things like job flexibility, working for myself were good reasons to become a therapist. They’re not the reasons that sustain you. The work itself has to be important. Yeah, there are lots of ways you can do therapy and lots of schedules that you can have in different places you can work, but what’s more important is that your answer to the question of what would you do if you didn’t need money?
That being a therapist fits in with that answer somehow. When it comes to the neutral everyday part of the job, I was thinking about what to tell you. Basically the parts of being a therapist that you aren’t really going to school to learn are about paperwork, productivity and billing.
A lot of people, I think going into the field think that billing and productivity aren’t really things that they have to think about. They have to think about paperwork, of course, but the other two, not so much. And I’m here to tell you it does matter. You do need to know, and you do have to care about those things.
When we talk about how to choose a program, I’ll talk to you more about billing and the money side of things, because the truth is if you can’t bill, you don’t work. In order to support our jobs we have to be able to bill either a private person, their commercial insurance, or their state insurance. That’s how the United States works. I don’t know about other countries. I do know that’s how it works here. It’s a reality of needing to pay for your job. Billing and productivity are your responsibility.
When you go to interviews, if you are just waxing poetic about how you want to help people, that’s only part of the job. And that’s only part of what the people who are in charge want you to know. A good supervisor will balance that. A good supervisor knows that billing is important because they have a budget to manage, but they also know that doing good work is the reason that we’re all there.
Part of your life as a therapist is going to be dealing with insurance and the number of clients you see in a day. We’ll take a 40 hour workweek. That does not mean 40 clients. Now there are probably some agencies that run their people into the ground who want you to book 38 to 40 clients a week. That isn’t possible in terms of any kind of healthy workplace. It’s also irresponsible and I would say unethical to try to see that many people a week.
There are probably therapists that do it, even in private practice who decided that that’s what they want to do. I don’t believe that is sustainable. There is a finite number of people that you can see in a given day and still have energy to be at your best. There’s a finite number of people you can keep in your head at any given time.
The majority of the people that you see. Yeah, you’re going to have notes on them, but their information is going to be in your head. You have to remember all sorts of details about them. You have to remember their situation, the things that they said to you before, who their kids are, who their family is, who their best friend is, what their pet’s name is. You have to remember all sorts of things.
If I mistake those things and say the wrong thing, clients notice, and they feel like you’re not listening. If you have a couple hundred people that you’ve seen in a month, there is no chance you’re going to remember that. The most open clients I ever had at a given time was 104. And I can tell you that’s too many.
Clients don’t come in for weekly therapy and then leave. Their schedule for how they come in is totally random and depends on them. Most of the time, people start with weekly therapy. At least that’s how I roll, but it goes biweekly and sometimes there’s more space in between visits and nobody’s even talked about it. It’s just how life worked out for the person.
There are people I haven’t seen in six months who show up in my schedule because when you’re in an agency, you typically aren’t running your own schedule. There’s usually a reception person who is going to be taking care of that for you and you’ll just see your schedule for the day and boop, there’s somebody you haven’t seen in a long time.
Certainly you can go back and check your notes, but there’s a relationship that’s still there. That person expects you to be able to pick up where you left off. The beauty of the work we do is that we can. We might not remember every detail, but we can remember enough to be able to step right back into that relationship with them.
So when we’re talking about a weekly schedule, there’s a thing called productivity. Now, in different agencies they call it different things, but it means the same thing, billable hours. You’re getting paid for your 40 hours a week. The money you’re bringing in for the agency is only when clients show up, that’s it. Some places might charge for missed appointments, but the majority of the people in my experience aren’t paying those things or they end up dropping off if they have those fees. You can’t bill missed appointment fees to anyone who has Medicaid or Medicare. That cuts out a lot of it.
So at the end of a given week, you have to have a certain number of clients that you’ve seen in order to support your job. It’s all going to depend on your agency, how many hours of supervision a week you need and paperwork time. I can tell you that the trend is that agencies don’t want to give you paperwork time cause they figure that you’ll have a cancel or no show and be able to do your paperwork. Sometimes that’s true.
There will be very few days in your career where every single client scheduled shows up. I have a pretty low cancel/no show rate. Always have. Part of that is because when I was in management, my schedule was limited and my clients knew that. If you have a tight schedule, people are less likely to cancel. If you have an open schedule, they’re more likely to cancel.
Here’s a for instance, I have a chiropractor who I love. It is also difficult to get in to see him. I have to plan about a week and a half in advance in order to get to see him for my 15 minute appointment. So if I have a choice and it could be canceling that appointment or not, I’m going to be really careful about that because I know that I can’t just be like see him tomorrow or in a few days. That’s a whole rearranging of my schedule in order to see him. It’s the same way with therapists.
So you take your 40 hour work week and you subtract things. You subtract a staff meeting, which lots of places have. You subtract supervision. If you have that, which I think you should. And then you subtract any paperwork time or travel time, depending on your job. And you’re left with a certain number of hours.
Some agencies won’t give you any paperwork time at all, trusting that you’re going to be working during your cancel or no show appointments. That works, but not having any paperwork time can feel really hard. It’s also just the reality.
A good agency will have a good balance and give you some time that you can plan on to do your paperwork. You may end up doing it at the end of the day, or you may be one of those people who is disciplined enough to do a 50 minute session and have that 10 minutes to do their note in between sessions. I’m not that disciplined and I suck at time management, so that’s never been my way.
So the number of hours you have left over in your schedule is probably, I don’t know, let’s go with 32. So out of 40 hours a week, you have 32 client hours available. It’s also kind of standard, at least where I live. The number of people that show up however, is going to be less than that. So in order to make a productivity expectation of say 25 to 27 clients who show up a week, you have to book more than that. If you have a 25% cancel no-show rate, then you need to be booking more clients in order to meet your target.
Productivity really matters. You will be responsible for these numbers and people will talk to you about it if you don’t meet them. If there aren’t enough clients in the area, then that isn’t your problem. But they’re going to want to know what you’re doing to follow up on people who don’t show up or generating new clients, those kinds of things.
It is a tough balance because you also need to be paying attention to your own self care and making sure you’re not getting burned out. But those productivity standards are set from somewhere above your pay grade. You typically aren’t going to have much say over them.
It might be tempting to try to go into private practice right away. But my encouragement for all of you is get that out of your head. Private practice right after grad school;. I do not believe is a good idea. There may be people who do it and are successful at it, but there’s a lot of reasons why I think that you shouldn’t do that. Not necessarily something we need to go into today, but there it is.
So we talked about billable hours and productivity. Billing of course has to do with those billable hours, but also making sure that you’re doing all of the prior authorizations and whatnot that come with that to make sure that the visits are covered. The agency you’re with will have a way to handle that. So they’ll teach you how to do that and so you don’t need to really worry about it, but it is your responsibility to pay attention to just telling you that now.
Trust me, if you’re interviewing the person in charge is going to want to know that you understand these realities and that you’re willing to do good work and take care of the productivity and billing side of things as well.
The other thing you need is you need your paperwork done. It is a necessary part of what we do. There are some people who have probably a little more respect for paperwork and would say that it’s an important part of treatment. I don’t have that view necessarily. I do think notes are important. I do think assessments are extremely important. Later on in the series, we’ll talk about differential diagnosis versus lazy diagnosing. But I think that the documentation is important but it’s also just part of the gig.
You’ll have to figure out for yourself a way to do it that is good enough. Not perfect, not amazing. Just good enough. For an assessment that’s a little different, I think assessments need to be excellent all the time. With paperwork, there are three main types of paperwork. There’s an assessment, the progress note and the treatment plan.
It is your responsibility to keep up on those things and make sure that they’re getting done on time. And that is not waiting weeks, not getting behind, making sure you’re on top of your notes. All of us get behind at one time or another. If you’re having trouble catching up, I would encourage you to talk to a colleague or your supervisor to just get some help because every one of us has struggled to figure out how to make this work. Especially if you don’t have a lot of paperwork time.
I can hear somebody wondering what about planning for sessions or what about doing research? That’s going to happen on your own time. You’re going to have to do that when you’ve done your paperwork and when everything else is done. There is no time set aside for those kinds of activities.
The last part that’s kind of frustrating about being a therapist, not bad, not good. Just a reality is that you have to kind of be a generalist. In the beginning of your career. You can’t typically pick and choose who you’re going to see. Now, if you’re in a specific setting, say an inpatient adolescent psych unit, you’re going to have a specific set of clients. And you’re going to know what they’re there for, because no one’s getting in a psych unit unless they’re a threat to themselves or others.
But in most other places where we’re talking about outpatient therapy you’re going to be getting a huge variety of people. And you likely won’t have much say over who shows up in your schedule.
If you’re not familiar with how this goes in an agency, there are people assigned to register new clients. A person calls the agency and says they want to be seen. The agency side usually has a clerical person assigned to this task. It’s not a therapist.
This person is trained to take the information and set them up with someone. It’s not a really long and in-depth thing that they’re asking these clients, what do you want to be seen for? I’m depressed. Okay. Tell me about your insurance. Let’s talk about schedule and they get the person in there.
Your first contact is when you see this new name in your schedule. You open that up and you find out how old they are, what their registered gender is. If you get paperwork, you might see the word depression, or you might see nothing. The majority of the time over my career, I have not known why people were showing up to see me until I met them and brought them in my office.
It could be any number of things. Sometimes people even get in that I’m not the right person or they thought I was going to prescribe medication or they’re looking for psych testing or whatever the case may be. Because of that, we have to be able to work with all types of people.
Now, certainly I will refer out. If a child shows up in my schedule and that’s not who I see. I’ll contact the intake department and say, what’s up with us. If there’s a reason why the person has to see me, then I’ll see them and then decide who they’re going to see after me, or they’re going to move the person. Just depends on how things roll. But we don’t say I’m going to work with kids who have trauma between 13 and 18.
You can tell them that’s who you like best; you can ask for those clients and specialize there. But if you’re in an agency, you’re going to see a lot of people outside of those parameters. It’s not necessarily good or bad and you get good at that skill, but it is a reality. If you don’t know that it’s coming, that can be a huge shock. And so I’m just telling you, now you could wind up with a 60 year old who has depression and a 10 year old who’s refusing to go to school. Maybe your specialty is somewhere in between.
It is just going to depend on the agency, but more times than not if you’re working for a company and not yourself, you’re not going to have as much control over who you see. As you grow in your career and get better at certain things, your schedule does tend to kind of filter out people who aren’t in your specialty areas, but that takes time.
And so for those of you who are thinking about being a therapist, this is just how it’s going to be, and you’ll be alright. We all go through it and we all manage it. It just can be really scary when you weren’t expecting that to happen.
So now we get to the hard part. There are lots of things in a career of a therapist that can be hard. Sometimes people really struggle with the whole productivity and billable hours thing, and they find that to be one of the hardest things. It sorta depends on your agency and how they present it and how they manage it. For me, that’s a neutral thing and just a reality, the hard things are other things.
By far, the hardest part is death by suicide. The reality is that we are volunteering to see people who may not want to live. We can feel incredibly responsible for their lives. And in a way, we are responsible. We’re not responsible for their choices, but we are responsible for assessing them and judging risk. And that is fucking scary. It gets better and you get better at it, but you’re never immune. The chances that you will have a client that kills themselves at some point in your career is really high.
This won’t be because you suck at your job. This won’t be your fault. It just is a reality. People have suicidal thoughts all the time. Suicidal thoughts are not deviant. They are normal. As humans the only way we know how to make something stop is by ending our life and so it’s normal to think about it. What’s not typical is making a plan, starting to make gestures in that direction.
I knew that this was a reality for me as I went through my career. I’ve known it because they told us in grad school. I remember in grad school talking about the fact that we would likely have a client kill themselves during our career. It is as awful as you imagine and something that you have to move forward from if you’re going to keep going in your career. You can’t live your entire career being afraid that everyone’s going to die.
You need good supervision. You need good colleagues. You need good self-care. Because it happens. I had a client kill themselves in 2009. I had seen him the day before he killed himself and he looked better than I’d ever seen him. I think it was because he had decided. I think he had decided that he didn’t want to do this anymore. He didn’t want me to know. Didn’t want me to feel bad, but he had already known that day that he was going to do this.
I remember getting the call about it and I was in shock and panicked and just devastated. One of my first thoughts was,” oh my God, what did I miss? What did I do wrong?” And I went through my notes. It was so overwhelming.
I remember calling my supervisor and he said, Betsy, there are powerful forces at work inside of people. Pushing them in a direction and we are but one person. It doesn’t mean we shouldn’t try. That doesn’t mean our jobs aren’t important. It’s just the reality. In that young man, he had powerful things pushing him. He had been diagnosed with schizophrenia, was on significant medication. I think he realized that this medication and all of its nasty side effects was going to be his life. And he just couldn’t.
I’m grateful that I didn’t get blamed for his death. Not because I did anything wrong, because honestly I didn’t miss anything. But because when our loved ones die, we’re not totally rational. His family easily could have decided that I missed something or was at fault. And it was hard to come back from. And I was super hypervigilant about any kind of talk about death or suicide or deep depression or anything. And I recovered, I had good colleagues. I had a good supervisor and I was able to move forward.
Knowing that one of your clients could kill themselves and knowing that we see a ton of people who are suicidal throughout our career, that is hard. I still choose to do what I do, even though there is that risk. Just because I’ve had one client doesn’t mean I’ve met my quota somehow. It’s possible it could happen again. I do what I can in my power to make sure I am judging risk appropriately and the rest of it is up to the client.
I think the second hardest thing I think about being a therapist is the amount of shit that you hear from people’s lives. Average people, non therapist people don’t really want to know the horrors of people’s lives. They don’t want to know all of the nasty shit that happens to people. They kind of know about it from hearing stories, reading them, et cetera. Over an 18 year career the things that were shocking to me in the beginning probably don’t register anymore.
It’s not that everybody I see has a terrible like lifetime movie story. You got to think about over the years, the number of people that you will see who have trauma, who have been treated poorly, who have been abused, who have hopeless situations, who don’t have the ability to get out of them who are just broken from all of the things that they have been subjected to. That adds up.
It is why you will find that you are most comfortable around other therapists after a while. Because when you’re talking about, I don’t know, incest the other therapists aren’t going to bat an eye. Whereas if you start talking about something like incest around normal people, you’re going to get a face and they are not going to be ready for that. We live in that space.
We are a safe place for people to bring all of the terrible things and lay them out for us. It can be heavy. This is a huge thing for you to determine if you can handle. You don’t have to be able to handle it today, as you’re choosing about going to school, or even if you are in grad school right now. You can learn how to keep your boundaries so that you’re not overly involved or overly, emotionally invested, and you get a little desensitized to things.
I treat primarily trauma. The number of people who have been through a traumatic experience is incredibly high. I have tons of that and I remember stories, tons of them. Even if you listen to other trauma therapists, even some of the famous ones, they have had the exact same experience. They are no more well equipped than I am to hear those stories. We just hear them and we figure out how to set them aside so they don’t take over.
Every once in a while you’re going to have one pop-up that’s going to get to you. That you’re going to be thinking about when you go home, that might even give you a nightmare. I find that it is the price I pay for being able to work with people and be there for them. Not everybody is built to do this, and only you can decide if you are or aren’t. If you’re listening to what I’m saying and you’re like, “oh fuck”, you should probably think about that.
If you’re listening to what I’m saying and thinking, “oh, okay. I, I can do that”. You’ll be alright. Every one of us in the field knows how to deal with these things. Some are better than others. But having colleagues around you, having good supervision, those are huge things.
We’ll talk about supervision in a different podcast because I am passionate about supervision and I have extremely strong opinions about what it should be and what it shouldn’t be. So we’ll cover that later, but in dealing with all of this heavy work, it takes a balance and it’s better for you to start out that way in your career then get burned out and have to deal with it later.
The last hard thing I want to cover today is about resources. When we meet with people, one of the things we hear is where they need help. They need different resources. They need to be connected to those resources. What would be helpful typically isn’t going to be available. So for instance, someone you’re seeing might need different housing. They might need to get out of their current living situation. But subsidized housing lists, at least in my experience, are about two years long. And so that’s not happening any time soon.
Maybe they need medication, but they don’t have insurance. That’s difficult. There are ways to get around it, but it’s complicated and typically these people aren’t functioning at their highest and it’s hard for them to do certain things.
Maybe they need a case manager, someone to do all that footwork. Well, some places that’s available and other places it’s not. I live on the border of two states and in one state case management is crazy available. There are so many case managers it’s mind boggling to me. On my side of that border, though, it is scarce. You don’t get a case manager unless you are severely persistently mentally ill. And that’s a small subset of the population of people seeking services.
There are times that you want someone to go to the hospital and the hospital won’t admit them because they’re full and this person isn’t really that dangerous to themselves. Or you want someone to go to treatment for drugs and alcohol and their insurance doesn’t cover it, or it’s not available, or they don’t have transportation.
When you’re the therapist and you know your client needs a thing and it doesn’t exist or isn’t available to them for some reason, it is super hard. Because we are trained to do the therapy work that’s our wheelhouse, but we end up being so much more. You will have to do case management in your therapy sessions. Insurance companies won’t love it. which is why it’s just part of what you do during your therapy session.
If that means you’re helping them make a phone call, that’s what you do. If that means that in between clients, you’re making a phone call, that’s what you do. We end up having to become more than just therapists. If you want to do just therapy, then you’re going to need to see people who are basically pretty functional and have minor problems. And if that’s your gig, all right.
For the rest of us though, that’s not really how it’s going to go. It doesn’t happen all the time that you run into all these roadblocks, but it does happen and it is hard. There are times where I have felt like, “oh my God, if this kid just had one stable adult outside of me, they would be able to do so much more”. Or “if I could just get this person into their own apartment or if they were just able to get a job, but there’s no jobs to be had right now”, or whatever the case may be.
Perhaps you’re going to live in a place where there are abundant resources. I got to tell you right now that it better be a blue state because they are going to have expanded Medicaid and a lot more resources than a red state. It’s just how it is. What is right and what is available are not the same thing.
I don’t know how many of you have been scared off from listening to this and I hope not. For those of you who really have a passion to do this work, it will be okay. You will figure it out. The case management, the billing, the productivity, the seeing all sorts of different people with different problems. It does shake out and you get good at it.
I liken it to learning how to drive. In the beginning of learning, how to drive the lines on the road are super important. They feel really narrow and you’re trying to stay in between them all the time. As you learn to drive though, the lines aren’t something you pay attention to. They’re just there in the peripheral vision because you’re paying attention to other things. You’re watching behind you. You’re watching to your left to your right. You’re watching your speed. You’re paying attention to the direction you’re going and where you need to turn. You’re thinking about other things. It’s nothing like when you first started driving.
Being a therapist is the same way. We learn how to do all these things. In the beginning. It is really overwhelming. The goal with this podcast series is to just give you an idea of what it’s going to be like and some advice along the way. It is going to be okay though and this job is fucking awesome. There is nothing else I would do with my life than this. I love being able to help people.
I love what I do. That doesn’t mean that it isn’t hard. That doesn’t mean that I don’t struggle sometimes, that doesn’t mean that things don’t get to me. Even 18 years doing this, things still get to me. There’s still some kid that I want to adopt. I wouldn’t do it of course, but that doesn’t mean I don’t want to. Being honest about those feelings, being honest about being human, that’s what’s going to keep you okay.
So I don’t want you to feel like I’m saying that the bad does not weigh the good, because it does the rest of it though, is your responsibility to build your career the way you need it to go. And it’s not necessarily about which jobs you take. Yes. That does matter and you do need to pay attention to what kinds of agencies you’re in. But at the same time, a lot of that work is going to be what you do on the side .
I have one last piece of advice. If you are not in therapy and have not done your own work, you need to get on that. The majority of you are going into this field because you want to help people and you have some experiences. You either have personal experiences or someone near you has had difficult experiences as well.
You need to do your own work. You have no business being a therapist if you have not worked on your own shit. It doesn’t matter that you feel like you’re pressed for time. Doesn’t matter if you feel like it’s going to be too expensive. This is the career you’re choosing and your stuff, your own history will come up.
It will get triggered all over the place and your responsibility is to manage your own shit. I also wonder how do you know what it’s like to be a client if you’ve never been one? Make time, figure out how to get into therapy and make it a priority. If you truly don’t have any issues that you need to work on, then you and the therapist will figure that out and it’ll be a short course.
I have been in therapy at different times in my career, just because that’s what I needed. There is no shame in it and it is good for you to take care of your own mental health. It is imperative to your health as a therapist, even your effectiveness as a therapist, to be aware of your own stuff and to take care of it.
When you’re thinking about whether or not you want to become a therapist and you’re wondering what it’s like. It’s wonderful. It’s rewarding. It’s hard. It’s tedious. It’s disappointing. It’s maddening and it’s amazing. I truly love my work. I truly care about my people and I want to provide them with the best me that I can.
Next month the topic we’re going to cover is “how do you choose a graduate program and a path to take?” We’ll talk about social work versus psychology versus marriage and family therapy. Does it matter what school I go to? Do I pick one that’s online or do I pick one that meets in person? Does that really matter? So we’re going to talk about all of that in the next student edition episode coming out in August.
Next week on the podcast, we’re going to be covering one of the biggest drugs in the United States. Methamphetamine. The discussion about meth is going to take at least two episodes because there is so much to cover. And I really want to give you good information and help people understand why someone would use meth to begin with.
I hope you’ll join me for that podcast until then have a great week.
Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist friends and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know. Just send a message to podcast@betsybyler.com. I’ll see you on next week’s podcast. And until then have a great week.
This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, clinical or any other professional information.