You can learn a lot about people (and therapists) based on what organizations they belong to. Now during the time of COVID 19 pandemic, I have some time to reevaluate, why I belong to a particular organizations. I ask myself: am I getting my money’s worth? Does this membership help me become a better therapist? Are there other benefits?
Here is my attempt to answer why I joined this organization and what I need from its members.
This year, I will have circled the sun 66 times. I have been a licensed therapist since 2010 and opened my private practice 4 years before that. I have two master’s degrees. The first degree is in Public Administration. It served me well during a quarter century of developing health care policy and setting payment rates for two different state agencies.
Before that I was a Registered Nurse (oncology, and when I first started personal therapy), before that I was a member the United Auto Workers, Aerospace division as a utility worker, before that food service worker at $1.35 an hour, and before that I was a lost soul who didn’t do well in school or social situations.
Nixon’s escalation in Viet Nam and Cambodia bombing was tearing this country apart, while Timothy Leary, the High Priest of LSD was called the most dangerous man in America. The movie “Refer Madness” was my parent’s mantra and party entertainment with my friends. I just couldn’t make sense of the world and there was no one was there to help. Four Dead In O-H-I-O.
Time passed. Got married, had a baby, drove a minivan, my father died. I earned a second Masters in Counseling that qualified me to take a licensing test and now I am legally able to see clients as a therapist and bill insurance companies. A good therapist follows the law, don’t they?
Every work day I receive numerous learning opportunities. These arrive via: email, US Postal mail, FAX, or a recommendation from a colleague about a new book, a free eBook, a workbook, stress reducing coloring book, blog, YouTube video, Netflix series or movie, Pod cast, LISTSERV, and on-line training. Am I a misinformed therapist if I am not up to speed on the latest video? The latest blog? The latest lingo? Remember in person training? (meeting new people was part of the experience).
I am sure that these authors, bloggers, trainers, directors, actors, Pod casters, and Zoom hosts mean well and probably have a worthwhile message. I cannot possibly learn it all. If I could, would I remember in the moment what that grain of insight and compassion is needed? Maybe, maybe not.
To prepare for my work day, I start by pulling charts for established clients. I’m old school, I keep hard copy notes (try and hack that!). Most days the pile of charts is about 4 or 5 inches high. It reminds me of some research I once read that showed the best predictor of readmission to a psych hospital is the weight of the chart: the more the client’s chart weighed, the higher probability of readmission. What does this say about me if my clients have thick charts?
My client’s lives are not simple nor straight forward. It seems regardless of what I list on my Professional Disclosure, website, tell the insurer, or discuss with the client before scheduling an intake, I often end up in territories for which I have no or limited experience.
A few clinical examples.
A client tells me during a pre-intake interview that they have communication issues at home and at work. Seems straight forward, until during the 2nd or 3rd session when I suspect they are in an abusive relationship or religious cult and can’t get out. They self-identify as gay and BIPOC. I identify as hetero, white, and male. What do I say or not to say?
Another client tells me they have PTSD from their childhood. Between sessions they decide to move forward with bottom surgery by saying “hey, can you complete these forms..? “ I have had no clinical or legal training on what it means to put my signature on these forms. Should I refer the client, which could further contribute to their isolation? Put their PTSD treatment on hold, while I educate myself? Do I sign to forms (as other therapists do)? If I don’t sign the form will the client walk?
Another client comes in for sex and porn addiction. As it turns out they are highly dissociative and different parts have different acting out behaviors. Do I prioritize treatment for addiction? For dissociation? For developmental trauma and an attachment disorder? Where do I start? How do I coach the client to have a conversation with their partner?
Or the client who called me in crisis after their partner discovered the extent of their sexual acting out. The partner indicated some of the websites visited should be “illegal.” Turns out the client’s hypersexual behavior was part of the bipolar mania. Now the client was experiencing severe bipolar depression and was prescribed a “new” bipolar antidepressant. Based on a blog they follow, they ask about the appropriateness of the medication. I am not a prescriber, and the client has major trust issues. Can I help them navigate the Bermuda Triangle of getting conflicting information from the prescriber, the blog, and myself?
One client self-referred based on recommendations from their recovery support group. They state I am the only one they trust, yet I am unqualified to treat their presenting complaint. I worry about self-harming behaviors if I don’t continue to treat them. I worry about them because I care about them. Maybe we’ll just sit and talk and hope for the best. She asks if we can chant.
Then there is the business side of the business we are in.
Sometimes I hear: oh you lost your job and your insurance?, oh, you were paying out of pocket and now you can no longer afford my rates (partly because of your spending/gambling addiction)? Do I have to forgo income to be a therapist? Would I expect my own therapist to work for free?
Sometimes I have to say: “your last check to me want not honored by the bank”, or “you are apparently no longer covered by that insurance,” or “to continue as my client, you need to pay for session(s) for which you no called, no showed.” By seeking payment, is my middle class privilege showing up? Does it matter that the client told me they “lost high six figures” at the casino. Maybe they are being evicted.
Our profession is all about ethics, and ethical questions are everywhere. Do I terminate treatment for payment issues, when my clients ask for help? What are the ethical and legal considerations when I try to balance compassion with good business boundaries for myself?
All of this reminds me of a few guide posts that have served me well.
So to answer the question, what do I need from the members of this organization:
I visited Sigmund Freud’s London office (now a museum). One of the displays contained Anna Freud’s typewriter. In that typewriter was a letter to “John” (I’ve got the photo). Here is the content of that letter, it seems to be consistent with my thoughts.
"Dear John ..., You asked me what I consider essential personal qualities in a future psychoanalyst. The answer is comparatively simple. If you want to be a real psychoanalyst you have to have a great love of the truth, scientific truth as well as personal truth, and you have to place this appreciation of truth higher than any discomfort at meeting unpleasant facts, whether they belong to the world outside or to your own inner person.
Further, I think that a psychoanalyst should have... interests... beyond the limits of the medical field... in facts that belong to sociology, religion, literature, [and] history,... [otherwise] his outlook on... his patient will remain too narrow. This point contains... the necessary preparations beyond the requirements made on candidates of psychoanalysis in the institutes. You ought to be a great reader and become acquainted with the literature of many countries and cultures. In the great literary figures you will find people who know at least as much of human nature as the psychiatrists and psychologists try to do.
Does that answer your question?"
From a letter written by Anna Freud in. Kohut, Heinz (1968). "Heinz Kohut: The evaluation of applicants for psychoanalytic training". The International Journal of Psycho-Analysis And Bulletin of the International Psycho-Analytical Association
I would add to Anna’s list; the need for flexibility, resilience, acceptance, and comfort with not knowing.
Having said that, my question to Anna is: how do I follow your advice, while trying to make a living and cultivating self-compassion? Can you help me?
Can the members of this organization help me? If yes, I’m all in.