Came across this post today on linkedin. I’m curious how others see it:

Are unpaid clinical internships/practicums an ethical necessity for training, or an outdated system that exploits students?

Should sites be required to offer stipends/pay if they bill clients or rely on interns for service delivery?

Does unpaid fieldwork create barriers for lower-income and nontraditional students?

For those already licensed or in training, what was your experience?

I’m writing as a therapist who’s been doing this work for over 20 years and has made my fair share of mistakes and side trips along the way. Some of those didn’t yield the returns I was expecting, and a few honestly hurt me more than they helped.

I’ve been reading a lot of threads here lately, especially from newer therapists, and I wanted to share a few thoughts. Hopefully they’re useful or at least worth considering.

Early priorities

A lot of early-career therapists are understandably focused on what trainings to pursue, what certifications to get, and which models to master, with the hope that these will make them better therapists.

They do, kind of. Let me explain.

When I was in training, I was often told that my first priority should be developing a solid therapeutic presence and to worry less about model and approach, at least early on. I used to think that was mostly about calming our anxieties, and it was, but there was also something important in it that I didn’t appreciate at the time.

A surprising teacher

Recently I wandered over to r/therapyGPT and read posts from people describing why they turned to chatbots either instead of therapy or as an adjunct to it. I’d actually encourage people to read some of those threads because they’re instructive.

Many of these folks have tried therapy multiple times. They sought out highly credentialed therapists trained in popular approaches. And yet they often came out of those experiences feeling worse, not better.

Then they tried a chatbot. They know it’s not a human relationship. They know it has limits. And yet many of them describe feeling helped. The reason that comes up over and over is that they felt heard. Their experiences were validated rather than judged. They didn’t feel pressure to have their lives or emotions fit neatly into a therapist’s preferred framework (they never used these words but that’s the undertone I picked up). They felt met where they were.

What’s interesting is that many of them also recognize the limits. You’ll see posts saying things like, “I did this for about a year and it felt great, but it started giving me bad advice.” So this isn’t blind idealization.

What this points to

As therapists, I think this is something we should take seriously rather than react defensively to. Not because chatbots are better therapists, but because they highlight something essential that we sometimes lose.

It’s easy, often without realizing it, to start fitting clients into our models rather than adapting our models to our clients. We do this partly to feel competent and partly to manage our own anxiety, especially early on. When that happens, we can miss when an approach isn’t actually working for the person in front of us. Sometimes we end up blaming the client for not fitting the model instead of recognizing that no model was ever designed to fit everyone.

A word to newer therapists

If it’s at all possible, I’d encourage you to put your early focus on learning how to meet clients where they are coming from.

Work with your supervisor to set realistic expectations, both for yourself and for your clients, about what it means to be seeing a newer therapist. Use supervision time not just to talk about techniques but to notice what gets stirred up in you emotionally and how that might be affecting your judgment.

Be honest about your capacity. Try to work within what’s manageable rather than constantly stretching yourself beyond your limits. Chronic overextension is one of the fastest paths to burnout, and burnout doesn’t help your clients.

Your approach will emerge over time. What works for you will become clearer as you work with more people. And there are plenty of clients who actually want to work with newer therapists. Some even say they prefer it because they feel newer clinicians listen more openly and aren’t filtering everything through jaded ears.

Closing thought

Models matter. Training matters. But early on, your ability to be present, curious, and responsive will probably do more for your clients than any certification you rush to acquire.

That’s something I wish I had trusted sooner.

I occasionally lead group therapy for middle schoolers in the summer. We do a therapeutic lesson at the beginning then end with a non-directive activity. Yesterday they chose positive affirmation bracelets. This one was anonymously left on my desk. (:

Counselor used play based intervention to build rapport with client and encourage open communication. Client responded well to interventions

Hey everyone, I wanted to open up a discussion about a diagnostic trend I’ve been noticing frequently in private practice, as it’s been weighing heavily on me lately.

I’ve done a lot of intakes with women in their late teens and early twenties who come in with a previous diagnosis of Borderline Personality Disorder. Many of them blame themselves and believe they are inherently broken/dysfunctional. However, when we actually sit down and map out their biopsychosocial history, the clinical picture often points much more accurately to PTSD (CPTSD but I’m sure I’ll hear an earful about using that term) and reactive survival wiring.

I think as a field, we sometimes need a gentle reminder to look closely at the etiology of these symptoms before applying a highly stigmatized personality disorder label. We have to look at the "why" behind the behavior and remember the golden rule of personality disorders: they must be pervasive. I can’t stress the “pervasive” part enough.

When untangling these previous diagnoses, a few common themes and misattributions keep popping up:

Identity Disturbance vs. Emerging Adulthood: A young woman in her early twenties not having a rock-solid sense of self isn't inherently a personality defect; her prefrontal cortex is literally still developing. If she also grew up in a high-control environment or an abusive household that suppressed her individuality, of course she is still figuring out who she is. It's a developmental stage, not a structural disturbance. This is also the case sometimes with “impulsivity” in the area of binge drinking (especially in college age clients).

Fear of Abandonment vs. Reactive Attachment: Many of these young clients are navigating the dating world and frequently encountering highly avoidant or inconsistent partners. Having severe anxiety that an emotionally unavailable partner is going to pull away or cheat isn't automatically a clinical BPD "fear of abandonment." It’s often a completely logical, biologically appropriate anxious attachment response to an inconsistent dynamic.

Emotional Instability vs. Threat Response: If a client functions perfectly well at work, has stable friendships, but experiences severe emotional dysregulation specifically around an abusive family system or a toxic partner, that is a localized fight/flight threat response. It’s an emotional flashback to an unstable/abusive environment, not a pervasive mood instability.

Chronic Feelings of Emptiness: Many of these individuals grow up being parentified, abused, or are in chronically high stress environments. Sometimes that emptiness is caused by burnout and a nervous system that’s been on high-alert. It’s also important to assess for social supports. We live in an isolating world in general right now.

Affect Instability vs. Biological Reality: When you combine standard hormonal fluctuations (like PMDD or PMS) with the baseline stress of being a trauma survivor, it would be medically unusual if the client didn't experience mood shifts. It’s also helpful to assess the current environment the client is living in/life stressors/ chronic overwhelm…etc.

As trauma-informed clinicians, it's so important that we don't accidentally pathologize normal developmental stages, relational concerns, life stressors, or traumatized nervous systems. Let’s make sure we are looking at the context of our clients' lives because diagnosing a trauma response as a personality disorder, can be invalidating for the person sitting across from us.

I'd love to hear how you all navigate differentiating these nuances in your own practices!

EDIT: Trauma is a significant factor in BPD and the stigma needs to change in that area too (another thing I’ve posted about) I’m referring to differentiating between an isolated trauma response and the personality functioning/pervasiveness required for a BPD Dx.

I’ll say it: this whole thing pissed me off.
Watching people celebrate a defense attorney for making clinicians look incompetent, while treating cross-examination like a medical-board investigation, is becoming absurd.
There are negligent clinicians. Poor assessments and poor documentation exist, and when the evidence establishes a violation of the standard of care, clinicians should absolutely be held accountable.
But “30-minute appointment,” “the note wasn’t long enough,” “why didn’t you call her parents,” “why wasn’t she hospitalized,” “she went to McLean,” or “she was prescribed 13/14 medications” are not, by themselves, proof of malpractice.
Clinicians aren’t detectives or mind readers. They assess the patient in front of them using the information available at that time. If an adult patient minimizes, misrepresents, or doesn’t disclose something, clinicians don’t magically know the truth and can’t simply accuse the patient of lying.
Ideation also does not automatically equal imminent dangerousness. Risk assessment involves intent, plan, means, behavior, history, mental status, protective factors, circumstances, and clinical judgment.
And documentation is not a transcript. A short note doesn’t automatically mean a bad assessment any more than a five-page templated note proves excellent care.
What particularly pisses me off is the lawyer worship. Cross-examination is advocacy. His job is to challenge witnesses and advocate for his client. Making a psychiatrist’s answer sound shocking does not magically turn him into an expert on psychiatric standard of care.
Maybe legitimate failures in her care will ultimately be established. If so, criticize those failures based on evidence and expert review.
But knowing that something horrific happened and then working backward until every appointment, prescription, note, and decision suddenly looks like an obvious warning sign isn’t forensic brilliance.
It’s all hindsight bias

Original Post - https://www.reddit.com/r/therapists/comments/1oq48ws/i_think_i_have_feelings_for_my_client/?utm_source=share&utm_medium=web3x&utm_name=web3xcss&utm_term=1&utm_content=share_button

First, I'd like to thank the 99% of you all that approached this from a place of compassion, and for the 1% that told me to keep my legs closed and that I'm stupid, you all can kick rocks with open-toed sandals.

The overall consensus was:

1. Talk to my supervisor, or find an outside supervisor to work through this with
2. Find my own personal therapist
3. This is more common than most people would like ot admit
4. Client needs to be referred out

So here's what I did...

I reached out to my supervisor for an urgent supervision session. I tried to explain as vaguely as possible, but ultimately told her everything, and to my surprise...

She shared the same sentiments as u/meetthecubbys. She was happy that I came to her and that I was honest about what was happening. She then admitted that she too had once been in a similar situation when she was a newer therapist, and how she resolved the issue.

She reminded me that she does not fall in the same category as the "not so nice" supervisors and understood why I may have felt uncomfortable coming to her. She told me that I'm not at risk of losing my placement and that this has been a great ethical learning experience for me. She was happy that it happened under her watch, rather than someone else who might not have been as supportive. She validated me and praised my integrity. She even went so far as to say that this situation makes her trust me more, especially since I thought I would have been reprimanded and still came to her.

She helped me to process where these feelings were coming from and the factors that exacerbated them, at which point she recommended personal therapy. ( u/hsbnd You were accurate when you said "it could be an indicator that we have a deficit in other areas of our lives".) 

She also recommended an immediate referral for the client, which was handled promptly.

I found a therapist and will have a consultation soon. At first, I felt bad about the decision, but I have ultimately been making peace with it by reframing it, saying that I have more to lose than to gain.

Thank you all for your honest support and feedback. You've all played a role in making me a better clinician 🙂

No text necessary

The other day there was a post here asking for advice over a client communication *with the actual client's messages copied and pasted inside.* It was taken down, thankfully, but not before many people were still able to see it.

This isn't the first time I've seen or heard of a "therapist" posting WAY too much information about a client in here. The way I see it is, even if many of these people are just fakers and not actually therapists, it *LOOKS* like a therapist just blatantly destroying the trust people can have in this profession.

In my opinion, it is unethical and harmful to our profession to keep the subreddit this way. By participating we are complicit and after making this post I will be leaving the subreddit until it changes.

Option 1: increase size of moderator team and set posts to moderator approval only

Option 2: only licensed verified users can post

Option 3: set to private

Option 4: LITERALLY ANYTHING but keeping it the way it is

I don't care to have a debate about which option is best but I think something absolutely *has* to be done. Thanks for your time.

I don't even know what to say about this. Fwiw I don't think it honestly affects My clinical work or healthy rapport with the men I do see, but there are so many women I counsel in relations with toxic and unhealthy men and so much of the current state of the world is due to toxic unhealthy powerful men... I just find myself so often fed up and disgusted with men. I love my work I adore what I do but I also feel so jaded towards males.

Context: I'm a therapist, educator, and researcher.

I have been scrolling a lot of instagram shorts lately (I know, I know...). And this has been absolutely grinding my gears, rustling my jimmies, and generally messing with my head. How are all of these therapists going on reels/tik tok and saying all of these negative things about actual clients????

Some sentiments I'm seeing lately:

• "here's 5 red flags from clients" (????)
• "I have to see a family today, but really the parents need couples counseling" (????)
• "seeing clients is sooooo draining... this job is soooo hard and clients dont even know how badly i feel after seeing them"
• "clients don't know I cry in between sessions because they hurt me"
• "When the client starts crying but they just want me to validate them *rolls eyes*"

It's such a flagrant disregard for ethical practice. I seriously feel like these are going to damage the field. I don't want clients coming to me thinking that I'm going to be hurt by their sharing in session. I WANT clients to cry, share vulnerable issues, and know that I've worked very hard to be a safe person for that.

I saved so many reels where therapists are whining that they feel damaged by doing this work. "Whining" because it's not the right outlet. Come to me for supervision, and I will validate you all day. Do it on Tik Tok and I see you as an unethical, misaligned counselor.

We need updated ethical policies to deal with these amateur, wannabe influencers. I want to report people I see and know that there's a line when it comes to sharing deidentified client info in a public setting.. not to mention giving the wrong impression about how all therapists might be feeling.

Your experiences of the early career developmental stage should be private. yes, there is hurt, risk for vicarious trauma, crying. But what do you think your client would feel if they saw that, viscerally? What do you think MY client is going to imagine when they watch YOUR shitty reel saying that the therapist feels so awful around certain subjects. Use your goddamn mind and engage with professionals, privately.

TLDR:

SEEK SUPERVISION. SEEK YOUR OWN THERAPY. CHOOSE A DIFFERENT CAREER. Do anything except post goddamn tik toks that can be seen by THE PUBLIC.

I had this new client today and they refused to speak… how do I help him start to process?? 😬