What I Learned During My First Year As A New Mental Health Therapist

Seeing as how June 3rd of 2020 marks my one-year anniversary of being a "real world" practicing clinician, aka an Associate Marriage and Family Therapist, I wanted to share some of the few experiences that meant a lot to me.

I hope these moments can either resonate with those who are already working in mental health, or those are interested in the field in general.

Here are 5 things I've learned during my first year as a new therapist.

1. You're never really ready for the "real world"

I'd say I was pretty fortunate with my graduate program seeing how we simultaneously went to class while working with actual clients in a training clinic. In addition, it's always nice to know a licensed supervisor was nearby to help me navigate through some tough stuff. Night by night, after my last class was complete I'd run upstairs to this wonderful local treasure to continue my training by working closely with great clients of Kern County, Ca.

Starting my early career as a marriage and family therapist trainee, I was introduced to a variety of problems to solve: I was completely blown away. After two years of this, plus rigorous coursework, working 4 jobs (don't do that by the way) and "life" hitting the fan, I got my piece of paper and went full speed into the "real world." I was ready! So I thought.

I did obtain my current career position months before I graduated thanks to how well connected my graduate program is to the community. And though my program did the best they could to prepare me, it's pretty common that a good chunk of therapists state they felt their program didn't prepare them enough. And they're right, but I think for different reasons.

In short, the reason I say you're never really ready for the "real world" is because of the many complexities it has to offer. Even if my graduate program was 4, 5 or even 6 years long, I still don't think I'd be as prepared for what the future brings (e.g., COVID-19, anyone?). Furthermore, I've worked with many clinicians over these past 3 years with combined experience of 80+ years and still, we come across unique scenarios that even surprise the most seasoned of therapists. Eventually, I just let go, and told myself:

As hard as you work, there is still much to learn. Take it easy on yourself and slow down.

This first realization was a hard pill to swallow because I wanted to be fully prepared for the "real world," hah whatever that means anymore. Believe it or not, the fact that you may be questioning your skill set, knowledge, competence or anything in-between gives me a hint that you care about the quality of care you offer. This could also mean that you're willing to work on it, gradually. What a wonderful thing to worry about, honestly. So, it's okay that you're not "fully ready" for the real world. Chances are, you're doing good enough right now.

Take it easy on yourself. Really, actually take it easy. Also, get yourself a good therapist for your own personal growth because they're totally necessary for the field we work in.

2. Learning insurance language/ note entry doesn't have to be so hard

Ever heard of S.O.A.P. notes? It stands for Subjective, Objective, Assessment and Plan. This was something I was not necessarily trained in before hopping into my first year of clinical work. I literally just Googled SOAP notes while writing this to make sure I've got the acronym correct. Seriously.

As you grow closer to your beginning stages of typing insurance notes, or any good note, maybe you're like me and searched all over the internet to figure out how to write a great note that is "billable" and "has medical necessity." Stuff like that.

From what I've gathered, most county, state, government or non-profit organizations take some sort of medical insurance to support those in mental health. Because of this, companies need to know that you're doing good treatment in order for reimbursement to apply. Makes sense. But what really goes into a good note? How do you know what shouldn't go into a good note? Will I get in trouble if I do this incorrectly?

As there are tons of available trainings: some of which are provided by your job, and others are extracurricular such as online programs; here's a simple method to the madness that helped me out. And after I reached this realization, my notes have been a smooth ride since.

Personally, I think I overstimulated myself during my training in trying to understand the insurance language for Medi-Cal (since I treat client's for mental health in California). What I learned in my training immediately left my mind after I went home because there's just TOO MUCH information to soak in a single week.

Don't get me wrong. There are plenty of mistakes you will make while learning this, but again, I made it so hard on myself. And yes, there are general rules that must apply and are very important to abide by; however, there's a personal rule that I use that for some reason get's me by pretty well:

Quality intervention begets quality responses, which in turn, can generate quality plans of action for awesome treatment.

Attempting to memorize every boundary and limitation with insurance language will overstimulate your mind leading to headaches, migraines and yes, even bad note entries. I'm very lucky that I have a supervisor who is super transparent about my note writing process, so if you're not experiencing this now, suggest this to you agency as soon as you can!

Not only does my supervisor give me helpful feedback, but so do the people who literally do this stuff for a living. They are known as the Quality Improvement Division (QID). Every county has one regarding mental health, I think. And guess what?

You can call them and talk to a human. WHAT???

These great people have given me so many tips, tricks and templates of writing a good note that it's hard to find an excuse not develop into a good writer as a therapist. Yes, it took some time, but eventually I was able to generate a good, high quality note that was not only good enough to receive insurance reimbursement, but it was good enough for what I valued, too: quality client care.

Most agencies that work with QID services are looking for notes that showcase meaningful improvement. If that's not motivation enough then I don't know what else to tell you. With each note I write reminds me of the ongoing strength each one of my client's have, and how wonderful it is to be in a position to travel with them through rough terrain on a daily basis.

I'm considerably lucky to be in this position.

Writing notes for insurance is a newer language to learn, but we don't need to make it so dang hard. This is coming from a person who was not formally trained in notes per se, but I did receive fantastic training in my graduate program to understand the importance of the process of therapy. Without that, I don't know where I'd be as a therapist. Both come hand in hand.

So, write your notes. Fail fast, and learn from it. See what works for you and in support of your clients, and the team you work with. Rely on your supervisor and QID programs. Remember, quality intervention can create quality responses in clients. So, try to always work on your craft even if you've already graduated, or if you feel you've been providing mediocre therapy with bare minimum note entry, HELLO. It's never a bad choice to want to improve in this area, but with purpose and meaning as the motivating factors.

3. Talking taboo doesn't have to be a missed opportunity

Time and time again I have a new client that enters my office, we begin and good work is done, but then this comment occurs before they leave: "I'd like to talk a little more about _______." Which isn't a surprise to those seasoned in the game. More interestingly, that blank spot has been fulfilled with taboo topics more often than not. You know, the conversations people advise not to have during lunch at work:

Sex

Race

Culture

Politics

Religion

The very thing many people embrace about themselves, or are oblivious of other's experiences, are in these areas. And wow! People are just itching to find an outlet, somewhere, somehow. And it's happening, in therapy...A LOT...if you allow it.

You've seen what I'm talking about here. And I highly doubt you don't see it right now with how social media is stock full of outcries and responses of COVID-19, George Floyd or whatever may be coming next down the pipeline of unfortunate events.

People such as clients or even close friends want to have these conversations and tell me, "Jake, I just don't know how to start, and I get stuck." Taking a closer look at this phenomenon of being unsure how to approach these conversations tells me something huge that I think the younger me would have missed completely:

Most individuals would like to talk about these things, feel validated somehow, and may want guidance on how to approach future scenarios with friends, family, and others they'd like to keep in their lives for the long haul.

Which makes perfect sense to me. These conversations hit so close to home with what we value, what we believe, what we turn our eyes toward and what we turn our eyes away from. The results of how we conclude our day are endless by the decisions we make from start to finish. These taboo topics don't have to remain taboo. And they certainly don't have to remain in our minds only, because that's quite a lonely place to be. Even for a therapist.

We may or may not approve of what our co-worker, friend, family member or clients may be partaking in or believe in regarding some of the taboo categories, but it sure is a nice feeling when we can get some sort of validation for these topics when they do come up. Nor do we understand what someone from a particular race, culture, religion or anything remotely far from you experiences, or doesn't experience.

It's not so obvious to me how even I, in the position that I'm in, can conclude a person's experience unless I start asking the tough questions that they may or may not be ready to answer. But hey, the questions are now out there which hopefully tells people I'm here for you, and ready to have some rich conversation.

I'd even bet that two individuals who chime in agreement with some of the these topics still have slightly different versions of how they each experience it, or go about it. Which again, is fine. But what does this tell me as a clinician? Often, I try to share the following with my clients who are in the beginning steps of sifting through this heavy material and immediately ask for feedback:

In a city of 100 people, chances are there are 100 different perspective experiences that we can still learn from if we give it a chance.

More often than not, clients tell me they wholeheartedly agree with this for a major reason that seems to be repeating itself. They tell me that they had wished they were asked about their personal experiences by friends and family a long time ago in regards to these taboo topics. They tell me they'd rather be focused on as an individual who experiences these things, and not the other way around.

It's also worth noting that the theme of "I want to connect" comes up way more than it should in my short time practicing. So then, what's the fix to all of this? How can conversations start? People are disconnected regarding tough topics. Well, there's endless answers, but it definitely could begin in the special four walls we call therapy.

And as a therapist, I'm definitely not in a position to project what people should be thinking, feeling or doing. That's just not in my job description, nor is it ethical.

However...

When these special topics do come up, consider that a potential rite of passage that your client is trying to check-in with you. These topics don't just jump on board for fun, because like I stated earlier, I'm noticing a trend of people saying what they'd really like to talk about toward the end of our discussion. And there I am, sitting with missed opportunity of something that could really lead to fantastic growth.

Believe it not, when these topics come up again and I take the bait and go with it, I cannot explain how breathtaking these dialogues can turn into. If you're a therapist, consider yourself very lucky, at least that's how I see it. I have the opportunity to almost live through 10,000 lives by standing next to good people as they try to navigate through some of the hardest, yet most meaningful experiences.

4. Approach challenges as often as you can

Gosh. Living through challenges is hard. And hard is such a weak word. That's just me talking, not my clients. But whenever I think about challenges that happen while practicing my craft, I always seem to picture one of my earliest experiences of sitting in a room with someone while their parent was in the waiting room. Shoutout to parents who get their teens involved in therapy.

This parent, man. They wanted the world for their teen, but their teen was also having a lot of other pressures placed on them which caused some imbalances at home, and for very good reason. Then the phone call happened, which many readers will resonate with because they remember their first, too:

I can't believe what's going on with my teen. What in the hell did you do to them to make them this way at home? You're the worst therapist I've ever worked with and my teen will never work with you again! You're done!

Even on my best days, this challenging moment pops into my mind. It's a special moment, but it used to set me back, far back. I questioned myself. In that very moment, I wanted to pull back and recluse into my hole and step away from therapy. That didn't last very long.

Now, I use it consistently as a reminder of the pain in that parent's voice. They had so much heart and wanted the best for this teen, and I don't blame them for struggling while entrusting a stranger like me who was only a few days new to their training clinic. Was it a fair comment by the parent? Doesn't really matter to me anymore.

I remember the pain I had in my stomach after we ended that conversation over the phone. I was sick because I had thought I did something terrible. This was the challenge. This was the moment where I had to make a rational decision after some self-validation.I remember leaving my office, went walking down the hall in defeat, and yelled:

This is going to make me a better therapist!

Yes! I did yelp this in an empty hallway. I checked first to make sure it was empty in fear of embarrassing, but anyway. In that moment, I made a quick decision to begin to embrace the harder moments. These challenging experiences that therapists have with clients, parents, caretakers and what have you, will take us past our limitation for that particular moment.

That's called growth in my book.

And during my first short year in the "real world" I've had to step up many times. If you're interested in reading a little more about one of the first crises I was involved in, check this out.

I know that I will be hit with newer challenges weekly where I work. This process is expanding my breadth of knowledge of local resources, clinical work, linkages, high risk situations and much, much more. I cannot be more thankful.

As often as us therapists give quotes to our client's to use as systems to develop insight about whatever it is they are currently struggling through, let me share with you one of my favorites:

No?tree, it is said, can grow to heaven unless its roots reach down to hell.

-Carl Jung

By far, this quote knocks out other quotes I used to share because it loaded with the ideas. Challenges will happen, and those same challenges can take us to the very place we don't want to go to most of the time, and they also take us to where we do want to go as well, all at the same time. Tongue twister I know. Read that twice. Upward mobility is a struggle worth getting to.

When our clients, and ourselves, reach a moment of limitation it can be hard to sit with. Nobody, in their right mind enjoys the fact that as human beings, we're simply limited in a ton of areas. The good thing is that limitations that occur during your clinical career, or anything you're striving for gives you a few choices:

1. I can stop right here, right now. And quit.
2. I can stop right here, right now. And think.
3. I can stop right here, right now. And think. And act.

There are plenty of times throughout the day where I feel I don't have the energy to complete certain tasks: go on a home visit, checking with and in-patient hospital client, performing 4 back to backs, yet I still do. Yes, we each have job descriptions that describe our routine, but trust me when I say that these typical descriptions you see on most resumes and CVs don't come anywhere close to the real challenges you will face.

And you will face them and conquer, as long as you truly utilize your supervision time, check in with colleagues often, and continue to take good care of yourself. Every muscle going through growth needs it's ongoing rest time.

Challenge yourself as often as you can because this will make future challenges a little more doable. And this will also make you a little more stronger each day.

5. Go with your gut, or something like that

They say therapists have this sixth sense such as performing educated guesses, hunches or gut feelings. Sounds like some wise Yoda stuff.

“Go with your gut” has been something many of my mentors have shared with me while working with my clients. It’s absolutely terrifying at first because the thought of “I don’t want to break them” occupies the mind, and legitimate fear always seems to kick in at the worse time.

But, here’s something I learned:

Clients are way more resilient than I used to give them credit for.

After a year of working with some of the most sensitive, and at risk populations, I still vote for this going with your gut approach. This process has taken me places that my older style just didn’t get to. And it breaks my heart to say this, but I think many of my previous clients were generally ready in moving forward, yet perhaps I was the obstacle.

And if you’re still wondering what this "gut feeling stuff" means or looks like, here’s what I’ve gathered from it:

“Going with your gut is your genuine way of showcasing to your client that you’ve paid well enough attention that you’re able to make well connected reflections or decisions that resonate well enough with your client in a special needed moment in order to move forward.”

I think saying all of that is well worth the run-on sentence. And one of the best things about going with your gut is that it either pans out pretty good, or it doesn’t. That’s it. Either way, the follow up should probably be: consult, consult, consult. Every. Single. Time.

I’ve quickly learned to rely heavily on my intervention specialists, therapists, psychiatrists, nurses and my supervisor when it comes to consulting. Collectively, loads of different perspectives of analysis come flooding my way.?I feel the love and support with my team, and it all came from going with my gut.

Here's the best part. When it's all said and done, I just follow up with my client and own whether or not this was a good gut feeling or say, “Well, we don’t ever have to do that intervention again. What’s next?”?Sometimes, the consulting doesn't even happen. Why? I have very bold clients who will immediately tell me, "Yeah, Jake, that ain't something that works well with me, next."

Permission to come aboard...denied! But that's okay. You're still getting good feedback in real time. That's what matters with gut feelings. My clients are pretty gracious with this type of process because I simply own the mistake, and chances are they appreciate the ongoing attempts, because that's what therapy is sometimes:

Trial and error is necessary for good therapy to happen.

And going with your gut is another way of saying trial and error. My clients have even shared with me that because of the level of transparency I show them in my process to provide better therapy, they are more willing to better their own quality of life.

How mind-blowing is that?

And it all began with just trying to go with my gut, or something like that, then I will keep doing it to the best of my ability. With safety of my client in mind. With my client's best interest in mind, and so much more.

The more we attempt to reach out to our client by giving certain reflections of feelings or meaning, the more chances we have at connecting with something. It's a gamble, that's for sure. But it's less of a gamble when you harness the power of taking a genuine stab at something, consult, take the feedback and own whether it works or not.

My gut tells me you'll find your way.

Wrapping it up

As bad as I wanted to continue writing this post, I gave myself a limit:

1. I wanted to pump out this post at least by my annual date. Check!
2. I also started writing this on June 1st because I'm a great procrastinator. Double check!

There are dozens of other learning curves that happened during my first year out in the real world for my associateship as mental health therapist. But if there's something I can leave you with it's this:

If you're a therapist, or planning on being one, give it your absolute all and take care good care of yourself. Quality care for clients is super important to me and I hope it is for you, too.

It never hurts to ask yourself if you gave today all of you. If you did, great. If you didn't, well that's up for you to decide where you'd like to go from here. No pressure ;)

I'm definitely in your corner to support you regardless how you may have answered that question. The person I was 5+ years ago would have easily said "NOPE." But where I am in life right now, I still try to give it my all (with the energy I do have) because I'd like to see what can happen in treatment with clients, and in my own life with every little step I take going uphill.

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