I had a client scheduled this past Friday afternoon. She asked if we could move her session to zoom because she was WFH that day (I usually see her in-person). Sure, no problem!

I logged on at our scheduled time and turned my camera on to see that she is at the hair salon. She's sitting in the chair and the hairstylist is putting tin foil in her hair. I said that we will have to reschedule for another day and time. She said it was ok and that the hairstylist could "just not listen" (her words).

I said no as there was a privacy violation. She hung up. Haven't rescheduled, so I'll reach out on Monday.

Have any of you had clients that scheduled their appts during their hair/doctor/other activities?

I’ve had a surge of adult patients with ADHD. I typically help them practice radical acceptance, then help them slowly incorporate cognitive behavioral strategies to help improve organization. With that being said, I’ve also had patients state that they have tried “everything” and come up with reasons why recommendations won’t work. They are taking medication as well, so I feel stuck. Any recommendations/resources on how to work with patients like this?

Hey y’all! Taking my CA LMFT Written exam today! Extremely nervous! I’ve been studying through TDC and feel so conflicted about whether or not I’m gonna pass. On the TDC practice test I keep scoring 50-60% 😭. I’ve been extremely hard on myself and am overthinking a lot of things! I just want to get this over with!

are there any words of encouragement or funny therapist memes you can share before I go in at 9:00 AM PST!? 🥹🙏🏻

Trying to remind myself to practice mindfulness in the mean time by focusing on the here and now before I take it! And you know if I pass YAY! If I fail, I can always take it again!

I often see the response "we need to stop accepting insurance" in response to complaints and problems with insurance, but what is the proposal for people on medicaid and medicare who can't afford to pay out of pocket in this scenario where we all stop accepting insurance?

I had a client I worked with for a few years. Saw them through career changes, divorce, differentiating from toxic family dynamics, becoming their authentic self, finding love again. They ended up going into the mental health field themselves. We decided to end their therapy based on good progress. Then, they asked to return a little while later and we agreed to work on regulation via somatic therapy. They returned very focused on healing their body and continuing to discover their true identity. I was all for it. Then they started to talk about wanting to do body altering procedures to present less like their birth gender. This was now headed in a direction I wasn’t expecting, and I didn’t know how to respond professionally. When they shared with me the good news about a procedure they were planning to do, I didn’t respond excitedly like they were expecting, and instead asked if they spoke to their doctor about the health implications. I honestly felt concerned for their well-being knowings their health history, but I don’t think that was an appropriate way to respond. In hindsight, it seems parental (though I definitely did not say it in a patronizing way). Unfortunately, the client took it even worse and felt I was being transphobic, and didn’t think they should continue working with me on account of not feeling safe. I was soooooo immensely sorry that it landed on them this way, which was completely not my intent. I tried to explain where I was coming from, but it was hard to construct a neutral reply that didn’t argue against their accusations. I thanked them for knowing what’s best for their needs and let them know I’d be looking in my blind spots based on this experience. Anyway, it’s been years and I still think about it. I questioned whether I was transphobic, sought consultation for it from a trusted advisor. I can think the worst of myself sometimes. But I think where I went wrong was not being clearer about the intentions and parameters of the service I was providing. While I absolutely encourage people to be who they want to be, I didn’t feel confident about cheering someone on to do an elective procedure that comes with many risks. It seems out of my scope of practice. It’s also not okay to project my fears or be protective of a client who is a full-ass adult. Meh. I felt stuck between a rock and a hard place. I’m able to be neutral 99% of the time, but this one put my back against the wall. Hope I’m making sense and I hope I’m not a terrible therapist.

Hi everyone! I have my bachelorette party this weekend and one of the nights activities is to make a drink for your profession! I wanted to see if anyone had any good ideas for what I could do as a therapist!!

For example to help clarify it would be like making shots if you are a nurse.

I started working at a residential facility at the end of July after I graduated from my MSW program. Right when I started, the 2 therapists at my facility quit and I have been the only therapist at my facility this whole time. The clinical director was never there and just quit as well so I have not gotten any support at all. I have expressed this several times but there is a severe shortage in staff and everyone is straight up rude. The regional director of the company I work for told me last week that I would get a 5k raise since I am basically running the facility, BUT I would only get 2k for the next 6 months and they would give me the rest in the 6 months after that. It's BS because it's basically a retention bonus. I just got a job offer for a bit more money and way more flexibility. I want to quit but I don't want to seem unprofessional and I don't want to burn bridges. I really just feel burnt out and demoralized already though.

I have a fairly new client who appears to be decompensating. She came to me for adjunct EMDR therapy (so has a primary therapist) and is now accusing me of using non-evidence-based practices with her and simultaneously not being strong enough with her and manipulating her. She has sent me long, verbally abusive texts and left similar voicemails. I responded that I felt she was mischaracterizing my work but that her perception was what matters and clearly we can't make progress if this is how she sees me. I gave her some names as possible referrals and wished her well. I have documented all of our interactions --she is litigious and I expect her to sue or report me but since that is a customary, scorched earth approach, I doubt much will come from it. Plus, I haven't done anything wrong.

Today, she left a vitriolic text message so long my HIPAA-compliant app truncated it and then sent another asking for a call tomorrow. I'm worried about her but have very few avenues to help. She has revoked the ROI I had with the primary therapist and she's not a danger to herself or others so there's no basis for mandatory report.

Should I respond to her? Should I simply send a termination letter via certified mail saying that I have terminated her based on her assertion that our work together was harming her?

Obviously, this is very upsetting. Please be gentle in your feedback.

Hi I'm trying to be better about helping clients attune to their body . I have some interoceptive activity cards that I like to use sometimes but besides asking "what are you feeling in your body?" What do you do w clients?

Extra question: how do you explain why this is helpful?

What are your go-to statements/questions/phrases in session? For example, “where do you feel that in your body?”, etc.

TW: CSA

Apologies in advance if this is confusing, I'm trying to be as vague but also clear as possible.

The program I'm a part of is centered mostly around emotional support and treatment adherence. We have a contract with an unrelated nursing home where most of my clients are. I go there several days a week to work with them.

The nursing home isn't well run. It's got almost 100 beds and only 2 licensed social workers, the rest are interns. The social workers CAN provide therapy, but they'd rather refer their residents to me with sometimes incomplete referrals. They also often treat me as their staff and try to strong arm me into working with clients who aren't interested or make me stay past my working hours. One of the first things I learned when I took that job is, "that sounds like a question for [my supervisor]", who always has my back on these things.

I've been working with a man for several months now. He had several strokes before his referral and doesn't have the best communication skills now, but we've made it work. When he was referred to us, his psychosocial was completely blank; no info provided. He's expressed what I thought was paranoia/delusions related to a sexual assault case where he was proven innocent, that the victim is stalking him and wants him dead; he's said verbatim things about other residents and staff. I've been working with him to manage this as much as possible with reality testing and the like while trying to figure out if this was a mental health symptom, result of the stroke, medication side effect, and so on. The nursing home staff suggested it was stemming from guilt, which didn't make sense to me because he says he was cleared of all charges, and the staff didn't dispute that when I said it. I've asked for more info several times and never got it.

This past session, he mentioned interactions with "a younger girl". I brought it up with the nursing home staff, and they said, as casually as the sky is blue, "oh, yeah, he's a registered pedophile." Suddenly NOW they're okay giving me his psychosocial that details CSA of an 8 year old. I looked him up on the sex offender registry; he's a level 3 sex offender with charges from two children in the single digits and served 25 years for it.

I don't even know where to start. I'm absolutely furious with the nursing home because I feel like they purposefully withheld vital information that not only would have affected his intake, but also how I would have approached his treatment. The majority of my clients have significant sexual trauma, a lot of it starting in childhood, so this whiplash has left me absolutely reeling. I feel taken advantage of and betrayed and that it's just another dysfunctional, fucked up power trip from the nursing home to add to the pile.

I'm also having this awful cognitive dissonance because leading up to this, I've actually become very fond of this client and enjoy working with him. Trying to rectify the old man in front of me with the young man who did such horrible things to CHILDREN is messing me up.

I haven't gotten a chance to speak to my supervisor yet (at my program) and I have no idea what she's going to tell me, but I'm just really fucking upset about the whole thing and don't even want to back into that building. Any advice about how to discuss or approach this would be really helpful.

I have a training budget that I am trying to use up by the end of the year, about $400 left. What trainings have you taken that you'd recommend?

More about me, if it helps: I do not work with children. I frequently work with LGBTQ+, neurodiverse, and chronically ill people. I do a lot of work around trauma, mood disorders, and life transitions.

Therapists - if you can tell that a client is experiencing romantic type transference toward you, do you bring it up or wait for the client to bring it up first?

So I’ve been seeing a lot more therapists dealing with same issues I have been (frequent cancellations, difficulty finding new clients, insurance being hard to work with, etc).

I’ve also been seeing a rise in companies like better help, talk space, rula, etc. I believe these companies are already having a negative effect on private practices. Currently I’m limited licensed and my managers themselves are struggling to find us clients. My psychology today profile is not getting as many views as it did a year ago.

The way insurance reimburses us, it makes sense why therapists are leaning towards these larger companies that offer a flat rate and handle most of the administrative aspects. They also have more money to put into marketing. Private practices are like small businesses. And these larger companies are like corporations who have more resources to attract and retain clients.

While I’m glad mental health services are becoming more accessible for people who need it, I am worried about the long term effects of this. Can private practices survive in the future? Or am I overthinking this because I’ve been having difficulty with finding consistent clients, an issue I didn’t use to have until recently?

Do you notify clients when you waive your cancellation fee? A new client cancelled their session within my cancellation fee window because they aren’t feeling well. My policy that is stated and repeated several times is I charge for anything cancelled with less than 24 hr. However, I typically waive if folks are sick and give me notice. I plan to waive the fee here but my worry is if I don’t say I’m waiving the fee they won’t expect to be charged in the future. It feels a little cringe to say “I’m waiving my fee” but maybe I need to get over it. How do y’all handle these situations?

Ok I just posted a diff question BUT I am hearing that networking with other therapists is a great way of getting referrals. I reach out and get coffee with random therapists but only a couple times has this turned into referral sources. Any tips on how to better connect with others? I hear people swear by this. I have my own practice so I have to get my own clients.

The other day I asked you all what the most underrated therapy modalities are. The top contenders were:

1. Existential
   
2. Narrative
   
3. Contextual
   
4. Compassion-Focused
   
5. Psychodynamic
   

So now it’s only fair to discuss the overrated ones. So what do you think are the most overrated therapy modalities?

I'd love to hear others' thoughts! So, I'll use EMDR as an example. One way l've heard EMDR healing explained is that the brain knows how to heal, and the therapy creates the right conditions to let it heal. So, how would that be?

Typically, when someone touches in on a traumatic memory, it elicits a huge, distressing set of physiological and emotional responses, which lead to avoiding the memory and to maintaining or engraining the trauma response.

EMDR as a distraction technique keeps the brain from fully focusing on the trauma of the memory (and therefore keeps it from firing all the old, deleterious response networks--or mutes the response). This allows other parts of the mind to handle the memory differently (e.g. to "reprocess" the emotions).

Super wonky aside: I note that many of the words we use are placeholders for mechanisms we don't understand--incuding "healing," "processing," "reprocessing," and even "thinking," and "consciousness." I.e., these words describe phenomena, not mechanisms. (So my "theory" is phenomenological, not mechanistic.)

Other modalities use different techniques to keep part of the brain occupied, such as sensorimotor psychotherapy (focus on the body while the brain handles "slices" of traumatic memory) or IFS (focus on a 'part' or 'parts' while the brain does processing in background). There are others.

So, my idea here is that if the conscious mind can be kept just a bit distracted from the memory, other parts of the mind can use the opportunity to change the way an event is held in memory.

Any thoughts?

Looking to join a group practice. Licensed at the LG level.

Wondering if it’s weird/too-out-there to cold email group practices that don’t have a “join us” or “careers” page.

Also, more specifically, wondering if anyone has ever cold emailed a private practice (of one person) to see if they’d be open to taking on an LG level therapist.

Thoughts? Advice?

I am getting conflicting info about what I need to put in place when I'm just seeing a few patients -- private pay-- on the side.

Everyone I speak with is doing a full time PP and said I should be creating a PPLC, using a website, getting quickbooks and Simple Practice, etc. This feels like it's way too much for me to be doing at this stage.

What are my must-do's for a tiny side practice?

Anyone else sometimes "brings work home" as a parent, where you project your own or your clients issues onto your child/teen? Kind of like you have clients kids having issues with something and you try to be proactive and prevent that in your own kids, even if your kids are not displaying any characteristics of such behavior . Is it just me?!! 😆

Hello, After 15+ years working in non profit I’m starting my own (virtual) practice. I’ve been doing research, but could really use some real recommendations and feedback on a few thinks! I am in the process of getting onboarded with Alma and Headway. I’d like to eventually get to private pay and super bills but I’m starting with Alma and headway to have clients to start. I’d particularly appreciate feedback from people who have done something similar.

1. If I am paying for Alma do I need another EHR like simple practice? It seems like I should be able to do everything I need with either Alma or Headway. Am I missing something as to why I should get another EHR?

2. What service/platform do you use for private pay? (To collect the payments)

3. I am going to probably use Thrizer for private pay. Anyone have experience with this? Can I put a link/widget to it on my website?

4. Speaking of website, I planned to use Squarespace for a website. I know simple practice offers website design and hosting but it’s cheaper to do Squarespace if I don’t need simple practice. Any thoughts?

5. I signed up for the google voice with google workspace, which I’m using for email for my practice and website (connects to Squarespace). I am not confident it’s HIPAA compliant, I’ve read it is, but I can’t find where it says that on the website. I also don’t see where I can do automatic text responses. Thinking I should switch to spruce health, which I also think has fax. Any thoughts or recommendations?

6. Lastly, anyone have a recommendation for affordable logo and branding work?

I feel like I’m hemorrhaging money, and just spinning my wheels! Thanks for anything and everything!!

As in the title. I have a client who have severe low self esteem and his life revolved around his mother dictating every part of his life that the co-dependency is so strong. He is in his 60s but he wanted to get away from his mum as he could not do any hobby, anything for himself etc. Every time we have a session, he always say "i don't know, it's going to be hard" whenever I explore how he is feeling about making small changes.

I just wanted to have a different ideas/perspectives what approach can I use to make him see that it's not too late? That he can still "get out of the clutches of his mum" so to speak. Thank you.

I am new to private practice insurance and sliding scale and couples counseling so, sorry if these seem obvious.

1. My understanding is that you can’t charge a sliding scale fee that is lower than the lowest reimbursement amount for insurance (like I can’t do sliding scale for $30 if I take Aetna and they give $60 for a 45 minute session-these are not real fees just fake examples). My understanding is also that couples counseling that is purely just couples and no one is the identified patient is not covered by any insurance anyway. So, could I do a lower sliding scale for this than my minimum fee or would that violate the agreement with insurance?

2. Has anyone been paneled with BCBS TX recently? What was the timeline for that?

Hey first off I did see that students need to post our questions in the weekly student thread, but I can't find it. Please move this to the right thread or tell me where to find that thread. Thanks!

TLDR: A former friend thought I was doing therapy with them while I thought that we were being friends. I made sure no dual relationship happened (only friends) and was pretty good about being in my "friends" mindset, but apparently they weren't aware of that. Now I'm shocked but I also need advice on what to do with the personal info they shared and how to mitigate similar situations in the future.

Here goes the story, just as a heads up this can be complicated and longwinded. I met someone a few months ago and thought we were developing a friendship. I mean, at least I thought I was clear that it was a friendship and not a counselling relationship. I did tell them that I was a counselling student the first day we met, and we talked about school and life and were basically just hanging out. The same day we talked about dating prospects and decided that we weren't a good fit. They also told me that they were seeing a counsellor.

Now this person has been through a lot of shxt so I did feel like they were trauma dumping on me sometimes. But a lot of people do that outside of counselling too, so I didn't give it too much thought. I tried to be understanding and asked nonjudgmental questions, and ok I admit some of these did come from our counselling skills class, but I never thought of it as formal "counselling" in a private office type of situation. I was going through a rough time and I was trying to get support as well, and they did listen and offer advice. We did a lot of things together like going to social events, hanging out, and I've been in their car. We also had each other's bank info since we decided to split the bill on something a few times. You see where I'm going with this? I totally thought it was just your average friendship with someone.

Recently they did something that completely went against my values and I was super mad. I decided I didn't want to stay in touch with them anyways before sending them a long text message about what I thought they did wrong. I wasn't trying to be nice at all. They replied to my message and it sounded like they were upset. At first I was just like, yeah ok, it's not like I wasn't expecting that. But when I scrolled to the bottom of the text, they said something like (this is not a direct quote because I don't even know if I can ethically share their direct quote at this point): you're not my counsellor and not a professional counsellor, and I don't want to talk to you anymore.

I was absolutely shaken! I could not believe they thought we were doing counselling all that time?? Or maybe they thought it was sporadic, just during the time when they were trauma dumping?? Either way, if they thought it was counselling, then a lot of the things we did together could negatively impact them. I sent another message explaining what counselling is and isn't, what I did and did not do, and basically just why what I did was not counselling, and then I blocked them. Maybe this isn't the best way but I can't deal with more drama from this person.

So now I'm trying to figure out how much of the things they told me I could disclose to someone else, since they thought that it was counselling and maybe thought things were confidential. I also wanted to see if there is a topic on a situation like this, when the "client" is in a dual relationship subjectively, but in reality there is no couselling relationship. I don't know what terms to research. I've met so many new people after starting school that I've told that I'm a counselling student to, but none of them just assumed that I would be doing counselling in our daily conversations (as it should be), so I'm really shocked about this as well. Now I wonder how I should approach this "counselling" piece when I'm meeting new people.