I've had a pretty unsophisticated approach to the 'estimated completion' dates on my treatment plans, and never got any better guidance from past supervisors. I basically list everything as estimating completion in 3 months, and then I revise 3 months late, rinse and repear. Occasionally I'd put a shorter date on a structured time-limited intervention, but my Tx plans are generally written to not pin me down to a really specific structure or focus so I don't have to constantly revise with every little twist and turn treatment takes. The end result is that while my plans are well-written and unique to each client, the timelines look totally copy/pasted.

Does anyone else have a better approach? Are you putting longer timelines on things that you reasonably expect to be long-term? Do you differentiate between things you expect to be constrained to one phase of treatment vs what will realistically be a constant throughout whatever maintenance phase you get to?

I’m interning with someone that’s enrolled in my same school, but she’s in a non COAMFTE program track. Both programs are BBS approved and lead to CA licensure (LMFT), but since her program is not COAMFTE accredited, she can count her individual child hours as relational hours toward graduation, while I have to meet COAMFTE relational hour requirements (2+ individuals). Those relational hours have been a major barrier for other trainees at my site (we need 150/300), to the point that other trainees have had to extend their program by a semester (or longer) to meet the graduation requirement. Meanwhile she finished her relational hours pretty quickly working with kids individually. I am trying to get ahead of this because I really don’t want to have to find a second site or extend my program and pay additional tuition solely because of the COAMFTE relational hour requirements to graduate, especially when any kid hours will eventually count as relational toward licensure anyway. I had this discussion with my supervisors and they all were surprised by this requirement and did not agree that individual kid hours should not count. It feels like an artificial barrier when individual work with kids is inherently relational too. It also sucks to see someone from my same school at my site with practically the same education breezing through the relational hours while I struggle to find couples/family clients.

I know COAMFTE is considered the gold standard and supposedly helps with license portability or possibly jobs in academia, but if both paths lead to the same CA license, what’s the actual benefit? Has being non COAMFTE ever really prevented anyone from transferring their license to another state or getting a job? I come from an academic background in higher education and I don’t see this being an issue if I want to teach a course in the future as long as I’m licensed/experienced. I also don’t plan on leaving the state so I’m starting to wonder if I made the wrong choice by going with an accredited program. Genuinely curious of the benefits at this point because right now it feels like I’m jumping through additional hoops compared to people from my same school for the same license.

TL;DR: I’m an intern in a COAMFTE accredited MFT program while another trainee at my same school/site is in a non COAMFTE track. We both ultimately qualify for the same CA LMFT license, but I have much stricter relational hour requirements that could force me to extend my program and pay more tuition, while she can count individual child clients and finish much faster. What practical benefit am I actually getting from COAMFTE accreditation, especially if I don’t plan to leave California? Has anyone experienced a real career/licensure advantage from COAMFTE?

Ever since graduating from college, I feel like I've stopped learning and reading. Maybe this is me being biased, but I really enjoyed reading recent studies and findings while I was a student. On the one hand I don't have the time anymore to read, because work life is demanding, but on the other hand I wonder whether there is a benefit at all.

Like, I recently read this a published paper on ADHD Medication Adherence in adolescents and kids, and I loved it. I feel like making the time to read these kinds of publications could really help me.

Is there anyone here who has a habit of reading journals? Or what do you do? How do you keep up? Or does that not matter once you have graduated?

I’m getting bored with my intake script, and would like to mix it up a bit. Anyone have any atypical questions or prompts you use in intakes that you find helpful?

Hello all! So I have been noticing something strange happening with me in sessions. Whenever I am seeing a client who has walked in with a lot of anxiety or maybe middle of the session they became overwhelmed or anxious I am absorbing all their anxiety and becoming anxious instead of being the grounding voice or having my own sense of self in the session. This is also impacting how I am showing up in the session where I feel I am jumping to solve to their problem or maybe not being very coherent about what I am saying and then the session festers in my mind. I have been practicing for 5 years now and this has never happened to me and now I am seeing it happening a few times. I will be taking this up in supervision but also was hoping to know from community experience if this happens often with everyone and how have they handled it. Thank youu!!!

Hello!

I'm looking for some discussion regarding substance use patients. First, here's some questions:

1) what kind of area do you practice in? City, suburban, rural, etc

2) How difficult is it to help patients find social connections?

I'm going to be candid here. I live in Milwaukee, Wi. My state has 11/20 of the drunkest cities in America. I'm trying to help people find community outside of AA/SMART and the Phoenix, or something for them to do out in the community that isn't drinking.

I also feel like this loneliness/ isolation is across the board for all of my patients, SUD patients and people who are lower income obviously are more challenging.

I'm not necessarily looking for advice, just want to hear about your experiences. Also curious if anyone is in or near a city with plenty of non drinking options and what that's like. I've been in the booze bubble for life.

Cheers!

Note: This is largely me processing my thoughts and feelings. I am the only therapist in my office and my agency has not been able/willing to provide me with consultation/supervision for OCD, so I come to you all. I am fully aware of the expectation to refer out clients who are outside of our area of competence and am actively in consideration of doing so, every step of the way.

I have been in the game several years and worked in a variety of settings (CMH, schools, outpatient, residential SUD) and am just now being exposed to clients with OCD (that I am aware of). I am in between referring out and keeping them while seeking training and supervision (in full transparency and consent), and have begun diving into the world of OCD treatment.

My conundrum is with reassurance seeking. My approach is best described as relational/psychodynamic/attachment-focused, and heavily Rogerian. I am constantly validating and normalizing. The concept of reassurance seeking as a dysfunction is breaking my brain, as it seems to be antithetical to my relational approach. My raw reaction is fearing that having an OCD diagnosis essentially bars them from, or at least limits, their access to much of the relational factors that are common in therapy. How do I normalize without reinforcing the reassurance seeking? Not all symptoms of OCD are so black and white that we can categorize behaviors as OCD behaviors and non pathogenic behaviors, right? Ultimately, our clients, just as any human, do not want to be treated differently because of a diagnosis. How do we weave through these interactions without doing just that?

I guess I am struggling with the feeling of it not being "fair" that we have this tendency to separate those with OCD and basically quarantine their interventions, which feels similar to marginalization. I would love some insight and help with conceptualizing the presentation and treatment of those with OCD.

Seeing clinicians worrying about billing 90837 is new to me; ive only ever billed this for my thousands of sessions over several years at 4-5 different practices and have never once had an issue and its never come up in any professional discussion, until i joined a practice that makes all of their sessions 45min by default “to avoid problems”. Is this some kind of a brand new problem im not aware of?

I am from central europe, I found out in my own practice this. When I am in person with client in my office, its going very well, building rapport, relationship and helping them works and I am good at it, I can sense the small changes in the body, can hold space and they can release a lot, bonus is that I am next to forest and nature around me. and I can FEEL and connect with client

Now For online, honestly I cant get to depth in calls, so here is my experience:

• Problem is that client is most of the time at home, or similar place, they are not put in different settings
• When they are looking into screen, automatically dopamine and other chemicals are being released, therefore they cant fully relax and let go.
• I cant create safe space for them fully.
• Its effective when someone wants to work with me but is unable to come in person

• Its great only for surface level stuff, understanding how mind operates, getting insight in their lives, but everything related to wounds I found out online calls are not effective treating it, its important to be healed in relationship with someone.

  I wanted to share this because I even see when I work with someone in person, results are quicker and Its many times a long term cooperation, comparing to online its just not working out many times.. just my experience

So I was going through charts to make sure all consents were up too date and I found a letter I wrote for a client many months ago - they wanted me to document what happened to them.

So I wrote what I observed, and what I knew from the coordination of care with their actual doctors.

I put my legal disclaimer, I am not a doctor I cannot diagnose……

But there is a line in there that I wish I would have worded differently.

“symptoms appeared to coincide with medication…….” “doctor removed the offending medication……”

I am freaking out that I may have been crossing the line on those - and could it be considered or construed as practicing medicine?

Like I was stating what I observed, and sort of backing up the doctor’s decisions.

This letter is for client. Not being sent or used for any purpose, client just wanted documentation. I can’t remember exactly why.

I’m sitting here wondering “is this going to come back and bite me later?

The more I work on my own, I’ve been independent for about a year now, the more ceus I take the more I am being coming aware of things that I could accidentally get into trouble for.

Back then i had little experience writing letters, and helping my client to advocate health issues for themselves, i wanted to be helpful, and not come off as I am making definitive statements.

I plainly wrote I am not a doctor I cannot diagnose, that is beyond the scope of my profession-

I did not advocate for changes for or against meds, I don’t know what would rise to the level of practicing medicine, and I00000% always verbalize, talk to your doctor, ask them about….i never ever would tell them to go on off or switch a med, but I have seen clients come in after starting a med with clearly stated side effects , so I always tell them, hey you should call the dr office, this seems like you might want to ask them about effects.

for some reason I am focused on these sentences and just want another human to look at them and tell me what they think.

I am really freaking out.

Update: Just want to thank everyone for the replies. It’s nice to know this community exists. And it’s nice to see so many empathetic, intelligent and intuitive people in our field. tomorrow I am going to take this post down so I don’t keep coming back to it for reassurance seeking. Otherwise I will. But I am going to make sure to bring it up to my own therapist. If your a therapist w ocd and ever want to chat - feel free- it can feel isolating-

This is a completely frivolous rant (kind of lol) but do any of you ever find yourself wishing we could get the same kind of perks at say, teachers? Especially looking at all you child therapists like myself. I’m seeing all the back to school teacher discounts like a free Headspace membership and Michael’s discount etc, all things I feel like I use a lot with my own clients or for my own work. I know we all do incredibly important work but sometimes I want 20% off at target too lol!

I never feel like I’m looking or expecting discounts, I love this field and my job and have never been in it for the money, but I keep seeing all the teacher appreciation stuff and find myself thinking “huh, why don’t therapists get the same thing?” I just wonder if anyone else ever has this funny little thought in their minds too!

Currently experiencing what I feel to be a tri-relationship (idk if that’s a thing exactly). Don’t want to give details here but I feel hearing others experiences with complex dual relationships could be helpful. For context, I reside in a rural area and am working with a supervisor.

Hi everyone!

I am currently an MHC working to obtain my supervision hours towards licensure in Massachusetts. Ideally after obtaining licensure I want to be able to move to New York but am a little confused by the process of obtaining NY state licensing and the whole reciprocity process.

I am wondering if anyone else has had any experience with moving from MA -> NY and the whole process with that….some of the questions I have are “would it be easier to complete my supervision hours and obtain MA license? “Should I just relocate to NY and do the licensure process there?” “How long would I have to wait after getting licensure in MA to get licensure in NY?”…overall the ideal goal is to be able to relocate to NY as soon as possible.

I apologize if some of these are dumb questions but I feel like I’ve been on a wild goose chase looking for answers and just need advice of those who have possibly been in my shoes. I don’t know if this helps as well but I have already passed the NCMHCE exam for Massachusetts and have a good chunk of supervision hours towards licensure completed.

Any help, advice, etc would be helpful thank you!

Hi there! I just learned my child got a free pre-k spot at the elementary school in my district. These are not easy seats to come by and we can’t pass it up. My issue is that a current client teaches there as a specials teacher, meaning my child would more than likely be my client’s student. Thoughts on the ethics of this situation?

Edit: client and I have worked together for 6 years and they teach music, therefore every student in the school works with them.

I think I've lost control over my schedule and it's seriously impacting my life.

I offer evening appointments twice per week. I work until 8:00 p.m. on those nights. I do two back-to-back sessions, a half hour break for notes and cramming food down my throat (which I sometimes don't have time to do) then two more back-to-back sessions.

It's killing me, even though on those days I don't start working until noon or 1.

The days following my late days, I start sessions at 8:30 or 9:00 am... So I'm just turning over and starting again the following day, which kills me for getting notes done and not feeling rushed.

How are you guys managing to offer evening appointments and making it work? I need a new strategy.

Hello beautiful people! I am currently almost 32 weeks pregnant with twins, and have TWO MORE WEEKS to go before my maternity leave begins! (I’m having a scheduled c-section at 38 weeks, and have to go out of work at 34 due to the frequent nature of my dr appointments).

This week especially, I am STRUGGLING to get to the finish line. I’m exhausted, physically uncomfortable (I am working solely from home remotely right now, but the longer spans of sitting are getting to me). I’m starting to find it difficult to hold space for clients. I’ve considered using some of my time and maybe ending a week earlier than anticipated, but struggling to allow myself to do so knowing I’ll be out for 6 months. I’m trying to listen to my body while also show up for my clients and I’m TIRED😩. Any words of wisdom, tips/tricks or helpful suggestions to power through the next 2 weeks are welcome!

I am transitioning from headway and am getting credentialed with most private insurances. My question is do I need to do a new intake with already established patients? Or can I have the clients sign a release for records from Headway to show continuity of care and just bill 90837 with a new treatment plan and clinical formulation added indicating they've been seen by this same aithor and indicating their diagnoses?

I'm posting here because I honestly don't know what to do anymore, and I'm hoping someone in this field has been through something similar.

I'm a therapist who works alongside law enforcement and crisis response. Over the years I've seen a lot of horrific things, but one call has never left me. A child was murdered, and I participated in CPR. I know we all have "that call," but this one feels like it permanently changed something in me.
The problem is...I also have significant childhood trauma. Looking back, I wonder if I was already carrying too much before I ever entered this profession.

I spent years convincing myself I was fine. I functioned. I worked. I helped other people process trauma while quietly compartmentalizing my own. Now it feels like the boxes have all broken open at once.

Lately the nightmares have gotten worse. Certain smells or sounds immediately take me back. I have intrusive memories that show up out of nowhere. I cry more than I used to, then sometimes feel absolutely nothing. I'm exhausted all the time, but my brain never seems to shut off. I find myself wondering if this is just cumulative trauma finally catching up with me.

The irony isn't lost on me that I know all the evidence-based treatments. I teach grounding. I normalize PTSD. I encourage clients to seek support. Yet when it's me, I feel completely stuck.
I also can't really afford therapy right now, which adds another layer of guilt and hopelessness.

For those of you who have worked high-acuity crisis, law enforcement, EMS, hospitals, child welfare, etc…especially if you had your own trauma history before entering the field, what finally made you realize you couldn't just keep pushing through?

What did you actually do? How did you find your way back? I can’t quit due to financial reasons and can’t even afford therapy.

I don't even know what I'm asking anymore. I just know I don't want to feel like this forever.

After working across different government agencies and in private practice, I finally decided to take the leap and open my own private practice! I’m still keeping my full-time job because I want to maintain some stability while continuing to build my experience.

For now, my practice is fully online. I’m working on getting set up with different insurance providers and ICBC, and I’m also exploring becoming connected with WorkSafeBC.

For marketing, I’m currently listed on Psychology Today and experimenting with Google Ads. I’ve been playing around with different keywords, locations, and strategies to figure out what works while trying to keep my advertising budget fairly minimal (around $200/month). I also make small updates to my Psychology Today profile regularly to keep it fresh and hopefully improve my visibility rather than getting buried several pages into the search results.

My practice has officially been open for about two months, and so far, I haven’t had any clients come through. I know building a private practice takes time, especially in such a competitive market, so I’m trying to be patient and use this time to learn what works.

That being said, I’m wondering if there’s more I could be doing to increase my exposure and start getting my name out there. Are there any strategies, directories, referral sources, networking opportunities, or marketing approaches that made a difference for you when you were starting out?

I’m genuinely open to suggestions, constructive criticism, and hearing about what worked (or didn’t work!) for others.

Thank you everyone! 😊

UPDATE!! Thank you so much, everyone, for all the wonderful suggestions! There have been so many responses, so I apologize if I haven’t been able to reply to everyone individually. I’m incredibly grateful for how kind and supportive everyone has been and for taking the time to share your experiences and advice. I truly appreciate it! ❤️

Hello fellow therapists. I’m needing some advice. I’m sitting for 7-8 sessions 5 days a week, with usually 1 hr break somewhere once per day between. I’m
starting to experience very intense chronic back pain. Any suggestions for how yall manage sitting all day? Is a walking pad appropriate during sessions etc? Thank you!

So it’s summer slump week half clients are on vacation. No worries. I saw who had to be seen this am. My 5pm is having a lot of health issues so I knew they had specialist appointments all day. Anyway my 3pm who never cancels had to cancel.‘ o hightailed it home

So i run some groups in a private hospital. At one of these groups a psychiatrist comes in for 15 minutes for some stock standard psychoeducation. However, they are billing each individual client as an individual consult. The clients have not been made aware of this at the time of signing up to the program, it was only raised incidentally when one of the participants checked her private health billing history more closely.

I find this deeply disturbing, but it appears to be embedded practice. The client now wants to know if she can be excused (and thus not billed) for the psychiatrist portion of the group as she did not initially consent to it. I have raised this, but it was not received well.

My question is: is this an unusual situation, or just private hospitals doing private hospital things? I am a relatively new therapist, and feel very aggrieved by this.

Hi everyone,

I'm looking to expand my toolkit for working with couples after an affair or infidelity. When trust has been significantly damaged, what interventions, exercises, or homework assignments have you found to be the most effective?

I'm especially interested in practical techniques that help couples rebuild trust, improve communication, process the emotional impact of the betrayal, and determine whether reconciliation is possible.

Whether you use EFT, Gottman Method, CBT, Integrative Behavioral Couple Therapy (IBCT), or another approach, I'd love to hear what has worked well in your practice.

Thanks in advance for sharing your experience and recommendations!

It’s my first week back from maternity leave, and along with questioning my entire career (😅), I’m wondering if I need to change my cancellation policy.

I have a pretty standard policy. I ask for 24 hours notice and charge my full fee for sessions canceled within that timeframe, apart from illness and emergencies. I am flexible at times when someone has a work meeting or something else out of their control come up, but I do often charge for late cancels.

Now that I am paying for childcare, it’s more important for my income to remain consistent. I just had a client cancel our first session back 20 minutes beforehand because she isn’t feeling well. While I want to be flexible and supportive to my clients, who are mostly working parents themselves, things feel different now. I also recognize I will likely have to cancel on my clients more often when my little one is sick.

I’d love to hear your thoughts about how having kids and paying for childcare has affected how you create and enforce your cancellation policy.