I had a 30 min exploratory meeting with a rep from Rula who told me they would pay me $70 a 60 min session for CO. It took everything in my soul to not spit out my water and end the meeting right there.

Meanwhile, I’m working on getting credentialed with Medicaid myself & they pay at least $100 for a session. Fuck the health tech companies, grab a few good insurance panels, your drink of choice, and spend 6-8 hours getting your stuff together and you can do it yourself.

The only outright benefit is if you’re looking to get initially credentialed fast the companies are great for that, and I’d still encourage you to submit your own apps while working for the companies.

Not everyone needs therapy.

I can’t fix normal. Some things just have to be endured.

I recently changed jobs and as I work with a more diverse population, I am beginning to see I have a penchant for certain client populations, some that aren’t my cup of tea, and some I’m indifferent about. As I learn this about myself, I’m questioning if this is “normal” and sometimes if it’s ethical (for me, and for our field).
I’ve seen therapists say they prefer to work with a particular population. Examples: women going through divorce, kids who have experienced trauma, teens, PTSD, people impacted negatively by religious institutions, first-generation immigrants, veterans, etc.
What I don’t see, and this is the part I’d like to discuss, is therapists who don’t like working with a particular group. I’ve seen a lot of “That’s outside of my scope, so I refer out” which I understand, and makes sense to me. But what if it is in scope and one does have the credentials and skills, but you just really don’t like working with a particular subset? It doesn’t trigger any personal trauma. There’s no personal experience contributing to countertransference. What if you just really dislike working with men, or teenagers, or depression, or intellectual disabilities, or pregnant women, or criminal offenders, or anxiety, or SUD, or (fill in the blank)?
Is that an ethical gray area? If you refuse to take that subset as clients, is it discriminatory? Does it mean you need to learn/grow more, be more accepting/empathetic, have better UPR? Does it mean you’re just human? If it is veering toward unethical, how do you know? How do you bring this up in supervision, or with peers without sounding like a bigot or way too picky? Should you overcome it and accept those clients anyway? If so, do you just tolerate it as one of the cons of the job? If you do that and get too many of that type of client, how do you still love your job and flourish and feel fulfillment in your chosen career path? Am I overanalyzing? (Probably.)
I hope I worded that OK and it didn’t come across as offensive, ignorant, or judgy or anything. I would just really like to engage in some discussion on this topic, because I don’t see it come up and I’m feeling a bit alone thinking through this by myself. I still work with all the clients that come my way, treat them the best I can, and don’t have any big feelings surfacing. It's more the realization of "I simply don’t enjoy working with this population.” I’m not really struggling. It’s just not part of my day I look forward to, and I just want to question this and learn more from others in my field who might have felt this way on their professional journey.
This is on my agenda for supervision, I’d just like to see some straight talk (especially from more seasoned therapists and/or others who have switched from a specialized population to a more diverse one), learn a bit more, and organize my thoughts a little bit before I bring it up in the limited time space for supervision.
TIA for any discussion, feedback, or experiences! (I wasn't sure whether to flair this as "discussion" or "support." It could be both I guess.)

TL;DR - How do you navigate client populations you prefer not to work with?

I have been supervising an MHC-LP weekly for about 5 months. I thought everything was going fine and that they were benefitting from our time together and the resources I provided. I enjoyed it and I sincerely thought they did too! I was wrong. They had reported at least two crises of confidence. The first was at the beginning when their caseload rapidly increased and they felt overwhelmed, so we strategized that they would ask the practice owner to limit their caseload. The second was about a month ago when they started feeling that they "didn't know what they were doing" in couples work and "didn't think this was the right career" for them. At that session, we discussed clinician self care and training options. They also reported that they were headed out on vacation, so we discussed how maybe that was warranted.

The next session (or the next-next session) after their break, they reported they were experiencing anxiety in supervision. I asked if there was anything I could do to address it - change my working style or format? I worked with them to find a solution and we decided to amend the format to give them a greater sense of ownership over the process (they specifically said that me asking questions "made them go blank") and agreed to limit the supervision time to allow them to self regulate before and after. I also reiterated the need for self care. We had one more session after this, in which we discussed a complex case in which they again felt out of their depth. I also normalized this experience and provided resources/guidance/advice.

We didn't have another session after that. An hour and a half before our next scheduled supervision, the practice owner emails me to say they requested a switch and my supervision would no longer be needed. The practice owner requested a meeting and prior to that meeting I put together a summary doc of my supervision notes for whomever the next supervisor would be. During this meeting, the practice owner was very supportive and friendly. They told me that the supervisee told them that I was "steamrolling" them and that there was a "modality mismatch" and that I "misinterpreted their anxiety." Also, that "my approach was overly manualized." I shared with the practice owner that I understood that that was their experience, but that I didn't quite understand the "modality mismatch" because they are practicing CBT, DBT, and EFT, all of which I'm trained but not certified in, and that we don't use manuals. I also said that my style is direct and assertive and I could see how that might come off as steamrolling, especially with someone junior who's concerned about their competence. I asked how long they had been feeling this way because it seemed to me maybe like a few weeks - since their crisis about a month ago - but the practice owner didn't know. I felt blindsided and confused, but resigned that this was their choice and it's a learning opportunity for me.

After the call, I reached out to ask about process for updating the supervision docs with the state. The practice owner says that there's an issue with the gap in supervision while they reassign so could I sign off on the hours in the interim. I'm not meeting with the supervisee, no longer have chart access to their notes, and I believe the practice owner will be supervising in the interim. I don't feel comfortable with this. Aside from the ego blow - someone I thought I was helping has declared me profoundly unhelpful - and the loss of income (I was paid well for the supervision), it feels like an ethics violation for me to sign off on hours I'm not meeting with the supervisee. Also, it feels like something the practice should have addressed this with the supervisee when they requested the switch as part of properly managing a transition to a new supervisor. Of course I plan to sign off on all hours I met with the supervisee but not beyond my termination. Am I overthinking this?

That's it, the title. Just wanted to throw some positivity on the feed.

I heard a quote a few years back from a chef, it said, "Some days, this is just a job; other days, it is not." And that exactly captures my feelings towards this career. I am privileged to have these relationships with people I otherwise never would've met. Despite the hard parts, I am grateful to be in the chair across from whoever wanders into the office.

I work on an inpatient psychiatric unit in the midwest. I have a coworker who was recently hired about 1 month ago. He is trans and expresses himself through his clothing choices/ nails etc. Anyways, we have some kids (between the ages of 7-10) on the unit who have had some questions and have said things along the lines of "Are you a boy or a girl?" "Why do you have girl nails"
During these interactions, I've witnessed my coworker respond pretty intensely and say things like "I'm obviously a boy, are you dumb" or " Isn't it obvious?" or turn to me and say "Why would they say that??"

I can't speak for his lived experiences as a trans man and I get that being questioned about your identity is hurtful. I also think there's a boundary/ level of what's appropriate esp when working with young kids/ kids who are currently hospitalized bc of their mental health.

I'm not sure how to address the gender question's concern directly either bc I don't want to be offensive or come across as insensitive. I've had other conversations with him about his clinical judgement that he has not taken well.

has anyone had a client who does show up to the office right after that 15 minute grace period?

i once had a client tell me they weren’t sure if they’d make it before 5:15 and i let them know that i’d have to mark it as a late cancel if not, and then at like 5:17 i went to the receptionist to let them know i was heading out for the day and i saw the client come in right then 😵‍💫 so then i felt a little awkward and was like ugh am i really gonna be that person and tell them sorry no session (which how would you even approach that face to face), and i went ahead and had the session even though i was ready to go home lol

what do you do in that situation?

The new Elizabeth Holmes film is clinically fascinating and I’d love to hear different perspectives on the film. I kept thinking, is this dissociation? Or is this an incredible liar? Or is it - most likely - both at the same time? It was difficult to keep my therapist cap off when the dynamics and presentations were so intriguing. All takes welcome!

Headway is updating their provider agreements, and requiring that providers sign off by 11/17. They only let you review one document at a time, so I have only been able to review the first one so far without signing it.

There are some significant updates on the agreement that you are going to want to be aware of.

The most concerning sections, at least to me, are:

-II.E Provider Content. Provider may provide their name, biographic information, likeness, voice, image, photographic portraits, videos, recordings, pictures or other content (the “Provider Content”) to Practice for Practice’s use on the Provider Technology Platform and/or the Headway Marketplace. Provider hereby grants Practice, its affiliates, successors, and assigns, the perpetual, worldwide, royalty-free, and irrevocable right to use, record, reproduce, distribute, display, disclose, license to others, publish, republish, perform, and create derivative works from the Provider Content in any and all media now known or hereafter developed, in perpetuity, in whole or in part, in composite or distorted character or form, without restriction as to changes and alterations. This includes, but is not limited to, the right to use the Provider’s name, likeness, image, voice, and any materials (e.g., video footage, photographs, audio, recordings) captured or provided by the Provider for the Provider Technology Platform and/or the Headway Marketplace. Provider acknowledges that they shall not be entitled to any additional compensation or royalties for the use of their Provider Content. Provider hereby waives any right to inspect or approve the finished product, the use of their Provider Content, or any materials in which the Provider’s Content may appear. Provider releases Practice and its agents, employees, affiliates, successors, and assigns from any and all claims, liabilities, or damages arising out of the use of Provider Content, including but not limited to defamation, invasion of privacy, or infringement of rights of publicity, and from any liability by virtue of the exercise of any grants and authorizations hereunder, any blurring, distortion, optical illusion or use in composite form, whether intentional or otherwise, that may occur.

Summary of that - Your name, photo, voice and video can be used perpetually, sublicensed, and altered “in composite or distorted character,” with a release of claims. It survives termination (section IX.F). You also warrant you own the rights (section IV.A.12), which matters if your photo came from a photographer.

-X. INDEMNIFICATION
A. Provider shall indemnify and hold Practice, its officers, directors, employees and
agents, harmless from and against any and all actions, claims, demands and liabilities, and
against all loss, damage, costs and expenses, including reasonable attorneys’ fees, arising directly or indirectly out of Provider’s negligence, willful misconduct, breach of this Agreement, or violation of applicable law.

Summary of that - Indemnification in the prior agreement was two-way. Each side indemnified the other. This changes indemnification to one-way. Which means that if the practice (Headway) engages in some sort of misconduct, it is not agreeing to withhold responsibility from the provider. That seems like a weird change, and I don't have a good explanation for it.

There are other changes as well, accommodating for the shift to the importance of the provider portal.

I know that a lot people will respond to this with "get off the platforms". And fair enough - that's a legitimate response. But for those who are either still planning to be on them, or who are in the slow exit process, these are things you need to be aware of. I would love to get more clarity from Headway before the required signature date.

Soooo I’m sure we’ve all had an embarrassing moment, right?? Right??

I don’t have any in person clients right now, just telehealth. I also never have water nearby me and just go from session to session no issue.

It was not a particularly bad day, about 5 or 6 scheduled that day. My second to last session was going great. Then all of a sudden I start coughing… violently… couldn’t catch my breath. It was like something was sucking the air out of my lungs. I apologized to the client and for some reason I had my water bottle nearby so I paused to drink it.

Problem solved? Right? Nope. I temporarily lost my voice. And then I started coughing again! I was so confused and my client was just staring at me. My voice didn’t fully come back for the next 30 minutes. I kept coughing and drinking water to help. At the end I felt so embarrassed. This has never happened before! Thankfully my client was understanding but… what was that? My voice was super shaky and almost gone.

The only other embarrassing thing that’s happened was my contact literally falling out of my eye during session and I had to excuse myself to use the restroom to put a new one in (telehealth as well).

Welp. From now on I have my water bottle nearby in case I cough for no reason and lose my voice 😅

Today was a hard therapist day for me. Just really trauma heavy. I can only think of one other case so far in my career that hit me this hard.

Give me your best feel good movie I can watch right now to either cry or laugh, idc.

Hi all,

Happy OCD awareness week! I have seen so many awesome posts online spreading psychoed on OCD and importantly, showcasing ERP, the gold standard tool to treat OCD. Please feel free to check out the IOCDF for great resources and newly published data on OCD/ERP. Next week there are still some openings for their 3 day advanced symposium on OCD comorbid autism/ADHD as well.

As a person with OCD and an ERP therapist, I felt inspired by all the posts I’ve seen online of people with OCD and separately, ERP therapists, documenting some of their most radical, “silly”, or shocking exposures they’ve participated in or conducted. I figured therapists with OCD and/or ERP therapists could share in that and leave our own sentiments here on our ERP highlights (without divulging PHI).

As a child during my own ERP some of the most memorable things I had to do: hold a bag of walnuts (I’m allergic), walk past a construction site and take deep breaths (I thought I’d die from inhaling the chemicals), and going for walks without my EpiPen (I thought a walnut would fall from the sky and kill me).

I really hope to only be met with compassion and support here. I've seen conversations go off the rails with some people feeling that "tough love" and similar tactics will work. That is not welcome here.

I do a lot of crisis work, and a few days ago a client almost certainly completed in the middle of a virtual session. It was awful and painful, and I do not know the outcome yet, because I haven't been back to work since. The reason for that is my sibling attempted just a few days later. While they are physically recovering, I am becoming increasingly aware that the people around them have been unsafe. Their words, actions, and inaction almost certainly led to this. My sibling lives very far away and I am truly unable to be there with them physically. My sibling is disabled due to a severe and rare chronic health condition.

I have been told by my parent and the partners parent that the partners mental health is poor and they may be verbally abusing my sibling. The partner's parent lives with them and also expressed that they feel my sibling has a right to choose to end their life and has many reasons to have considered doing so, although they would never directly help. The parent stated that they knew my sibling was considering this, and when. They did not get help. My parent has a history of treating my sibling like a financial burden and I am concerned that there was either coercion or at least prior knowledge that this might happen on that end too. My sibling struggles to care for their own needs, and has never been connected to the appropriate resources in their area. I have offered but my ability to support is limited because they only share limited information with me and I live in a different state with different laws, resources, etc.

I am currently making as many calls as I can to advocate for them as they heal in the hospital so that they do not go back to this unsafe situation. However, I'm being blocked because I wasn't allowed access to speak with the care team since my parent has their own issues, including being controlling, secretive, and shutting down rather than dealing with the situation at hand. I have missed work for several days. While I'm being told that they understand, I am worried. I am worried I'll be seen or treated as unreliable. I am worried that, if I disclose any of what is going on, they'll trust me less because I have a lot on my plate already. I am upset because I want to be at work supporting other people. I am heartbroken and scared because the professionals that could save my siblings life aren't hearing me and getting the information needed to keep them safe.

I have my own therapist who I have seen twice this week. I'm on meds and see a psychiatrist to manage my own mental health. I have friends who I have told all of this to who are supporting and guiding me. I have even reached out to a hotline for immediate support. I'm also contacting the hospital on my siblings behalf and leaving messages for several departments. I called adult protective services. I don't know what else I can do but it is tearing me apart and I just don't know how I am going to be able to continue as a clinician after this. I don't know how soon to return to work because the whole situation is at a standstill.

I am not sure exactly what I need. Maybe this situation is so outrageous that no one else here can give me any input. I don't know how to pick myself back up and go to work. I am poor and can't afford significant time off. I also just want to get back to doing this work. I don't know how long is reasonable to stay away, and how to move through this situation with appropriate boundaries being both a loved one and a mental health professional. I don't know. I don't know.

I was previously seeing a client pro bono while I was an intern. I was charging $35 for my other clients. I just became an LCSWA and I’m slowlyyyyy building my caseload. I have a couple clients because I’m still waiting for insurance credentialing.

I told the client that some of the fees were going to change once I was licensed and that I would be getting credentialed with their insurance. However, the client said their out of pocket fee for insurance is $90, which they said they can’t afford.

The LMFTA at my practice charges $25 reduced fee. So, I went along with that. Technically, because of overhead fees and taxes, I’m making $15 for that client’s session.

The client is also an evening spot, which I know is a popular time.

The practice I’m at charges $250 a session self pay but some of the LCSW’s charge $150 a session. My supervisor said the lowest she’s gone is $75.

I’m conflicted. I enjoy working with this client, but less than $25 an hour…sucks. She just signed the document about the $25 fee.

It’s something I’ve been thinking about a lot and I’m not sure if I made the right decision. Is it too late to ask her what she can realistically afford and change it? Would that be unethical?

I am treating a male adult. He was in a relationship with someone quite abusive and decided to leave her. (The breakup never quite happened) Soon after, he started having panic attacks and became depressed. He was overwhelmed with feelings of guilt.

He is now exhibiting symptoms of psychosis. He is absolutely sure of his false beliefs and can not talk about anything else. I am at a loss. I'm not sure what's the point of our sessions anymore.

I am strongly suggesting psychiatric treatment and medication, but he strongly refuses. He is convinced he is right and the rest of the world is wrong. His family is involved as well, but no one can reach him.

He is not a threat to himself or others at this point, but I don't know how ethical it is for me to continue seeing him. We have reached an impass, and I don't think talk therapy alone can heal him.

Any advice would be appreciated.

Hi everyone- taking recommendations for the above.
After just a few months in the vc companies, I’m
trying to get things settled up to move away entirely. Taking any feedback too! This process is daunting

I need to either leave the field or drastically cut back on my hours. I understand that we see a post asking for other options in the field at least once a month but here it is again! I want something remote, part time, and away from clients. I’d do data entry for Pete’s sake if it paid me decent. Looking for suggestions either in the therapy field or outside of the field that are remote, flexible on hours, and pay at least $60/hour 😬😬

Thanks!

I am a 28 year veteran therapist in PA . I am tired of the grind of PP. anyone work for a company they love? Any suggestions. I can do anything at this point I just don’t want to run a business.

Hello! Student counsellor in Scotland here. I am just wondering if any people who work in the area could recommend me some placement suggestions for my 100 hours. I am very interested in working with people who are at the end of life / entering hospice, people with bereavment and loss (inc child or pregnancy) anything to do with end of life in any capacity. This is my calling because my background is working in palliative care and it was the most wonderful job, but I am changing career to therapy now after many years of social care and casework.

Do you know of any charities or organisations who take students, even for just a limited amount of hours?

I'm able to drive so anywhere in the central belt is easy for me to reach and I'd consider going further afield as well.

What I can't do- working directly with children, working online for the entire placement.

Thank you in advance for any ideas.

I’m a primarily ACT therapist, but I really appreciate the use of the here-and-now and relational work like that used in gestalt therapy, psychodynamic, or Yalom’s existential therapy, and I’m trying to learn and integrate it more into my work with my clients.

Some questions or interventions I currently use are:

• How is it like to share that with me?

• Sharing my own feelings (with careful consideration) about how I experience the client or the session

• How is it like to hear that? (in regard to what I just said)

• Use immediacy to explore the client’s experience with the therapeutic relationship

I had a session today where the client and I had a very open conversation about our therapeutic relationship, and the client expressed a desire for us to focus more on this type of relational work.

But, I need more ideas and questions I can use, so if you do relational work, regardless of the orientation, could you please share some ideas or questions you use? Any advice is appreciated.

Has anyone successfully billed G codes, for example, G47 for unspecified insomnia, along with a 90791? I truly could not support any other diagnosis in the entire book and had to go with that but wonder if it will be denied.

Maybe this is coming off the back of some harder sessions today; but lately I have been really struck with uncertainty around my performance as a therapist.

For context I am about 3 years post grad with an MSW, and just over a year of being fully licensed with my LCSW. I spent the first three years in an OP psychiatric hospital setting and recently transitioned to a group practice. About half of my clients made the move with me from the hospital setting to my current practice.

I have always felt a sense of imposter syndrome through my graduate program, yet when I would express this I was universally met with “you’re doubting your capabilities” and people reassuring me that I have a “natural presence” and way with joining people. Some weeks I will have sessions that feel productive, and a part of me starts to feel like a good and decently competent therapist.

Then I have a session like I did today, with a longer term client processing a breakup and subsequent abandonment trauma, feeling in such distress and repeating over and over how they don’t know what to do or how to be. As much as I can offer tools to down regulate intense emotions, validation, and positive regard in the session - I still walk away feeling like I am missing something and not being a good therapist. I think in those moments I feel overwhelmed by a sense of helplessness, or that I should know what to do and I don’t.

Is this imposter syndrome? How do you know you are actually cut out to be a therapist? What if I am genuinely not good at this role, but because my supervisors and peers are so validating I wouldn’t be told if I was not fit for this?

Is this par for the course?

I work for a cmh agency. A large one. There is this culture of never referring people out. We primarily see people with Medicaid or no insurance so referrals usually aren't possible. But let's say you have a Spanish speaking client who has commercial insurance. 5 mins on psychology today yields 5 therapists including 2 in easy driving distance that speak Spanish and take the insurance and they all also do telehealth. My boss looks at me like I'm crazy when I object to doing therapy thru the translator service. Or someone in one of our clinics gets commercial insurance and that clinic doesn't have anyone paneled with it. They transfer the client to another one of our clinics, even if it's an hour away instead of providing local referrals that take their insurance. Am I crazy in thinking that appropriate referrals should include people local to you or that speak your language?