pros/cons of being a therapist

July 18, 2006 4:41 PM

What might I hate about becoming a therapist?

Following up on shivohum’s earlier question about what to read, I’m looking for candid opinions about why NOT to become a therapist. Of course, I’d like perspectives about why it is a good idea, as well, but I need some reality. I have some loving people in my life who think this is a good idea, but who are not necessarily forthcoming about what will suck.

For reference, I have a Ph.D. in Neuroscience, and as a post-doc I’m finding that I hate research. I don’t like the competition, the extreme hours it takes to earn and retain grants, and the general lack of gentleness and care that people show for one another. I have enough intellectual curiosity to ask interesting questions and design experiments, but when it comes to doing the background reading, carrying out the experiments, and writing up the papers, I’m rapidly bored. I also hate managing multiple projects with multiple technicians—I lose track of details.

Therapy appeals because I am certain I will like a larger portion of my colleagues (my mom was a school social worker, so I know some of them), the process of my own therapy has fascinated me, and my usual topic of recreational conversation has to do with life issues and feelings, etc. I’m thinking MSW, since I already have the Ph.D, and this combo can lead to more career options than just therapy.

Practitioners, what do you love and hate about being a therapist?

posted by aimless to work & money (24 answers total)

My mom was an MSW therapist who retired, in part due to the changing insurance landscape. Some down sides:

- The hassles of dealing with insurance companies, as most insurance companies will only pay for brief therapy (6 sessions, as I recal) and having to try to give people enough support to figure out their problems on their own past that, even if it was something extremely serious. Unfortunately the people with bigger problems often did not have the funds to pay for continuing therapy. She also said that when she started in the 70s, 1 hour of therapy required 20 minutes of paperwork and that by the 90s, that had reversed. These two problems are what led her to retire in her late 40s.

- It was an additional challenge that she had kids... she had a policy of not seeing any person that lived in our town and especially not kids that went to our school. My freshman year of high school though, she was finishing up with a senior. the senior saw me smoking in the school parking lot and told my mom. WTF? this policy occasionally backfired. I did some sort of summer program every year when I was a kid. Inevitably, one of her patients would be there either as a kid or as a parent. And although my mom wouldn't approach them, they'd approach her and something ask about therapy-related stuff right then-and-there.

- Setting up private practice isn't easy.

- You did all that work for your PhD! Use it! Teach?
posted by k8t at 5:01 PM on July 18, 2006

My mom was a psychotherapist for years. What she found most tiresome, as the years went on, was spending so much her life in mono-directional relationships.

It's not like other work places where after working together you go get some beers. After work is done, you can be left with a lot negative stuff, despite your knowledge of transference and how to handle it.
posted by milarepa at 5:09 PM on July 18, 2006 [3 favorites]

I would imagine it's depressing to hear depressed people talk about how depressed they are.
posted by onepapertiger at 5:15 PM on July 18, 2006

My wife is a therapist (with a MSW) and while there are many things she likes about it- you asked why you might hate it.

- Insurance is a pain as noted above
- Shaking off bad stuff as noted above, definitely an issue.
- Also, social life is a major piece, therapy from the therapist's perspective can be a lonely profession. So you have to actively develop friendships with people who are *not* therapists if you want to talk about something unrelated.
- You also have to be accustomed to dealing with your clients at unexpected times, at night, on the weekends, etc.
- If you are going into business for yourself the whole billing process (insurance is part of this) is a major pain. You either have to hire someone who does the billing for you or be prepared to do it yourself. Taxes aren't much fun either, so if you're not well organized . . .
- And speaking from someone who is the spouse of a therapist, dealing with unbalanced people all day long will sometimes make you unbalanced- so make sure you have a good support system at home.
posted by jeremias at 5:26 PM on July 18, 2006

Don't forget the ethical dilemmas. That's a good thing to read up on. I took a class about ethical dilemmas and therapy and it really made me not want to be a therapist.
posted by amethysts at 5:27 PM on July 18, 2006 [1 favorite]

On an up-note, if you want to have kids, it is a great schedule! My mom was able to just ease off her clients as she was pregnant, refer some to others, then take 3 years off. Then when my sister and I were 3, she went back to work 2 1/2 days a week, then went to full days (10-3pm) when were were in elementary school, then went until 5 or 6pm 2 night a week, and we went to day care those afternoons and summers, then back to a full schedule when we were old enough.
posted by k8t at 5:47 PM on July 18, 2006 [1 favorite]

Another down side, your friends and family will see you as a person to come to when they have problems. Extensively.
posted by k8t at 5:47 PM on July 18, 2006

I think a lot of the things that are frustrating about nursing are similar to the things that would be frustrating about being a therapist. These include:

1. Watching people make the same mistakes over and over and over again. For example: I'll be helping a patient deliver her third baby soon; she has sickle-cell anemia (so her life expectancy isn't great) and the father(s) of these babies are nowhere to be found. We talked extensively after her second child was born about birth control, finances, and the fact that she makes crappy choices regarding the men with whom she associates. The result? Not a thing changed. Baby #3 is on the way. I suspect Baby #4 won't be far behind.

2. Watching people try to take advantage of you / the system / each other. If there is a loophole, there is someone willing to exploit it. If there is a way in which someone can get something for free, someone will try. Not everyone, obviously; the advantage-seekers are certainly in the minority, but the ones that exist are infuriating in their manipulativeness.

3. Speaking of the system, working within it is incredibly frustrating. To explain in any detail would take hours; let's just say it sometimes seemed designed specifically to hinder any real progress or healing.

The bottom line is that a lot of times, trying to help people just doesn't work, because getting people to change their behavior is extraordinarily difficult. You have to be willing to keep trying even though you know the odds are against them, and you, and you have to be willing to play Sisyphus a lot in the hope that sometimes the rock will stay at the top of the hill.

All that said, there is a tremendous amount to love about being in human services. All the times you can help someone be the person they should be, stand up for themselves, treat themselves with respect, demand respectful treatment from others, take steps to make themselves healthier, overcome obstacles, make good choices... There are no words for how full my heart is with these things. Even on the most frustrating days, I love my job beyond measure. You might love to be a therapist, too, if you feel yourself called to help others.
posted by jesourie at 6:13 PM on July 18, 2006 [6 favorites]

Let's see, I got an MSW ten years ago because my "recreational conversation [had] to do with life issues and feelings," and an MSW seemed the quickest path to legit. credentials to practice. I hedged my bets by focusing on administrative social work -- with plans of doing management if I couldn't stand therapy, or vice versa.

Well, for me social work wasn't a great fit. Found I had little in common w/my peers in grad. school and although I enjoyed practicing therapy, I can't imagine doing it day in and day out. I found it a little mind numbing after awhile. But that's just me. The novelty/curiousity wears off if you're seeing more than 3-4 clients a day. I guess if I mixed it up w/some group work, administrative, etc., it might be okay. Overall however, in the U.S., I found social work to be painfully hierarchical. I think it's because of insurance pressures, the lack of decent paying positions, etc. -- makes all the licensed MSW's fight tooth and nail for every shred of dignity, salary, and status.

Soon after grad. school I decided to follow my passion for technology and entrepreneurism and headed to Silicon Valley. Never looked back, but imagine someday, if I ever retire, I might resurrect that MSW and do a little therapy practice on the side.

Obviously no two people are alike. Good news is there are plenty of ways to get a taste of doing therapy -- beginning w/working suicide lines as a volunteer, or other lay therapist volunteer positions.
posted by pallen123 at 6:56 PM on July 18, 2006

I'm a social work psychotherapist.

I think therapy is great. It's a proven, effective way to help people get better from mental problems. It's great to help people for a living, to know that in the majority of cases what you do matters and does help. I also think the human mind is fascinating and endlessly complicated and is a joy to study all the time. It's a strange profession for a lot of reasons, though, and I'll try to explain some of them.

To start with some of your stated pros: the biggest misconception I see is the one having to do with your potential associates. Social work school is, for many reasons, an intellectually draining place. The level of intellectual rigor and curiosity was quite low at my school, and I went to the best clinical social work school in the country. Stories from other programs, particularly ones not focussed on clinical work, have made me almost weep. It can also be a very lonely profession. In private practice it's just you in an office, no colleagues. Even in agency settings there can be a lot of alone time depending on patient load and the number of people you work with. For instance, I'm the only therapist at the medical clinic where I work, and medical personnel, while very caring, have a completely different attitude toward patients.

You don't mention your gender in your profile, but it's kind of lonely to be a man in social work. I'm very comfortable, in many ways more comfortable, around women, and still with only 10% of my grad school class male, and now working in a clinic where I'm the only man, I sometimes look around and wish it were a bit more balanced.

Insurance can be tough, and many people find it better to have both an agency job and a private practice in order to secure benefits, so many therapists I know work longer hours than they might have started out thinking they would.

There's also, frankly, a battle going on for the soul of mental health treatment. It's been going on for quite a while, and there are many gray areas where there's common ground, but there's an awful lot of emphasis put on the assumption of physical causes for mental disorders, even in the face of shaky evidence. Part of this comes from pharma funded studies of medication efficacy, part of it comes from pressure withing medicine toward psychiatry, part of it comes from capitulation on the part of social workers and other therapists. It can be frustrating to fight for a central rather than an adjunct position in mental health treatment, in large as well as small ways. It can be tiring to have people suggest in various ways that at best psychotherapy operates at the level of amelioration. This is one of the reasons that I always start comments here about therapy by pointing out that it's safe and proven effective, because it is, but many people seem to think that it's somehow less than biological treatment despite the evidence which argues convincingly to the contrary. (Which is certainly not meant to suggest that all treatment is the same for all conditions.)

But the biggest con is probably contained in Jacques Lacan's admonition that "the analyst holds his place in horror." Not only is the place of witness horrific, not only do therapists have to contain, in some sense, the very real and immediate pain of their patients, but the more subtle horror of the effacement that good therapists have to practice in order to be available for their patient's use can be quite disturbing. The first time a patient accuses you of nefarious aims, and your possible responses are constrained by the therapeutic relationship, its a pip.

The ethical dilemmas are not really hard to manage.

All of that said, I'm glad I'm a therapist. I don't think I'd have quite the temperment to only see patients of the rest of my career, but that seems to not be much of a problem. You've got a PhD, so with an MSW you could do therapy and teach either psych or SW. It's a fascinating profession and I really believe in it. If the research about effectiveness weren't so unequivocal it would be a more difficult undertaking, but as it is I feel great about being a therapist. The things I mentioned are challenges, not reasons not to become a therapist.

My email is in my profile, and I'd be happy to talk more about this if you want.
posted by OmieWise at 6:57 PM on July 18, 2006 [12 favorites]

I should have said that while nurses are trained to communicate therapeutically with patients, we are not therapists, nor are we trained to be. All other things being equal, therapists are infinitely more qualified than nurses to, well, be therapists.

I do think there's a lot of overlap between the experiences of people practicing in the two disciplines, though; I've heard many of the social workers with whom I work express similar frustrations to the ones I encounter as a nurse, and that was the point of my comment.
posted by jesourie at 7:09 PM on July 18, 2006

There are many customers who turn to a therapist because everyday social contacts have gotten tired of hearing them complain.

Do you want to be the only sympathetic person that someone can complain to? I know you are supposed to focus away from listening to complaints and toward some sort of treatment, but many customers want to pay for sympathy.
posted by MonkeySaltedNuts at 8:32 PM on July 18, 2006

I think it also depends on whether you're working with chronic patients (long-term disorders) vs temporarily ill patients.
posted by IndigoRain at 8:39 PM on July 18, 2006

Can (former) patients weigh in?

I did five years of weekly therapy for depression and anxiety. One of the things that I really liked about my therapist was her obvious (and I felt sincere, or she was a great actor, which in the context probably doesn't make much difference) enthusiasm for the possibility of engaging me in a process that could actually improve my quality of life. I can see where that could be a strong selling point, if the possibility of helping people really lights your fire.

On the other hand, I often thought she had a difficult and strange job. It was clear she put a lot of thought into when to let me talk, when to redirect, when to call me on bullshit, when to let me vent. I think for a lot of people there is no neutrality in their internal dialog - it is all noisy, fucked up adversarial crosstalk. Thus a lot of the role I saw for my therapist was listening to the various sides weigh in without becoming partisan to a particular voice, thus providing something I had a real hard time coming up with - objectivity. On the other hand, I've known several people who seemed to wind up with "activist" shrinks who very early on adopted some kind of program for their clients betterment - without exception these were bad relationships that didn't last and didn't help. So from my bias anyway the ability to maintain neutrality would be a necessary personality trait.

The final thing I'd say is, will you be able to deal with a significant percentage of hard cases and perhaps even lost causes? We joke about the therapy nation, everybody's been through counselling, but in reality people are still very gunshy about mental health care and I suspect on the balance most people evade therapy until their lives basically become unmanageable. Regularly seeing people who are unlikely to improve much or ever really be happy strikes me as a tough, tough career.
posted by nanojath at 9:22 PM on July 18, 2006

My job is slightly different than therapy but I thought I'd chime in. Sometimes, after 8-10 hours of engaging people, establishing rapport and making conversation empathetically, I don't have much energy to engage the other people in my own life. My emotional exhaustion tends to cause me to withdraw from others. That's probably a personality thing that's unique to only certain types of people.
posted by Slarty Bartfast at 10:06 PM on July 18, 2006

I worked for a therapist (MSW) in private practice while in school, and I can tell you frankly that s/he was reimbursed by insurance companies an average of $60 per one-hour session. So, assuming s/he saw 8 patients a day (though 6 was more common), 5 days a week, that's $9600 a month, from which had to come rent for the office, phone service, malpractice insurance, and assorted membership fees.

There was high turnover because many people stop coming once their insurance-allocated visits run out; an average of 2 new patients started every week. And at least 2 patients per week would cancel appointments due to difficulties that would come up in their lives. The therapist was constantly looking for new places to list the practice in order to generate a steady stream of patients, and would hold free divorce/stress support groups in order to generate interest/awareness of the practice. This therapist got many referrals from medical doctors and cultivated relationships with them so that they would recommend this practice above all others. We did mass-mailings to doctors (complete with follow-up phone calls and meetings when possible), and at the point I finished the job, the therapist was considering courting patients NOT affiliated with insurance companies so as to be able to charge more per hour.

I don't know if those are "cons" per se, but for me it was a turnoff once I saw how much this therapist had to hustle in order to have a practice that sustained itself.
posted by xo at 10:33 PM on July 18, 2006 [1 favorite]

The only therapist I've known personally got out of therapy a few years before I met him. He said that he started out liking the work, but over the years the strain and despair of dealing with the hopelessly damaged really got to him. Like jesourie said, watching folks make the same mistakes over and over again can be a real drag.

Maybe he wasn't a very good therapist, I don't know. But he wound up driving trucks and quite enjoying the quiet hours on the road.
posted by EatTheWeak at 2:12 AM on July 19, 2006 [2 favorites]

You have a Ph.D. in neuroscience; presumably you did some research on the mammalian nervous system. I think nowhere is the disconnect between hard science and the clinic as apparent as it is in mental health work; if you are approaching this under the misguided assumption that your neuroscience degree or training will be of any use to you at all, well, that's a handicap to overcome.

Put another way, you're discarding the last 5-8 years of your career and starting fresh. Does that appeal to you?

There's also a choice most therapists make, and that's between public service and money work. To make money as a therapist, you have to build a network that will funnel to you patients with resources: either good insurance or lots of money. Here's a clue: if patients have managed to hang onto their wealth or their job with benefits, they are in the main not going to be the kind of severely mentally ill people who are the neediest of your skills. Money therapists spend a lot of time listening to the carping of the "worried well."

Public health therapists, like those who work in public hospitals, on the other hand, are the janitors of humanity. It's all fine and good to say you want to help the homeless, louse-ridden dregs of humanity, the ones you can smell coming before you can see them; but our society (USA) isn't willing to equip you with the tools you need to effect meaningful gains. There is a high rate of burnout in even the best-intentioned people in this field.

If you're the kind of person who gets enough of a kick out of "the data" to earn a Ph.D. in neuroscience, by the way, I'm assuming you have a certain kind of personality. Here are some of the things that will certainly irritate that kind of person:

-There is nothing duller than a dull mentally ill person, chained in isolatory, overintellectualized bonds of his own making.

-There is nothing more hateful than the bizarre behavior of a borderline-personality person, especially if you're trying to establish a therapeutic alliance with them.

-There is nothing more frustrating than being able, over months and visits, to a) be able to apprehend the problems in someone's life; b) devise a clear path to freeing them of those problems, and c) come up against the fact that deep down they really don't want to change. It can feel like a colossal waste of your time.

That said, if you're called, it's worth doing, despite all of the above.
posted by ikkyu2 at 2:38 AM on July 19, 2006 [2 favorites]

Speaking as someone who is self-employed but not a therapist, taxes become more manageable when you make it a habit to keep all tax related documents in one place. For me, an accordian folder works fine.

Label the outside, e.g., 2006 taxes. No matter how busy you are, no matter how distracted, put the documents in the folder and they'll be there for you when you need them.

I suggest a separate bank account for your business. It's not necessary but it makes life easier.

When you're in a service related profession, the business aspects can be difficult. You need to be paid and your clients may not be able to pay you.

You need to be very clear in your own mind what you will do if you get into that situation, and if you can't handle it, you need to pass on the client rather than start a relationship that will turn into frustration for both of you.

Before you start your own business, ask yourself, "can I operate this like a business?" If not, it's a charity.
posted by Ilaine at 3:53 AM on July 19, 2006 [1 favorite]

I've done volunteer work at a suicide/crisis hotline, and that erased any faint notion of doing therapy work that I might have harbored, not because of the listening-to-people-complain or the not-being-able-to-help issues, but by virtue of giving me a peek at what people thought about their therapist and/or expected of the therapeutic relationship.

A lot of the callers used the hotline because their therapist was unavailable (in some cases because the therapist had had to set boundaries and tell the person they could only call him X times per day). The animosity, anger, hostility, and resentment some callers felt towards their therapist -- with whom they usually had long pasts and presumably long futures -- made me grateful that I did NOT have to be the therapist. These feelings were often a result or a part of the caller's mental illness, of course, but that intellectual understanding would not necessarily make it any easier to assimilate such a viscerally disturbing situation.
posted by tentacle at 5:14 AM on July 19, 2006

My mom has been an MSW/LCSW for many years. There are lots of things that stress her out about it. The obvious things, I think, are the sadness and frustration that comes with dealing with people when they're at their worst and during the worst times in their lives. Hard not to take it home. When my mom was working with troubled teens during my own teen years, I think it made it hard for her to trust me and my sister. Also she would sometimes get threats from clients or their family members, making her really scared for herself and the rest of the family.

The other big thing is that if you're working within any sort of system or program or god forbid the government, you may not be free to practice the kind of therapy that you feel is most appropriate. There are all the usual office politics and power trips, but it's worse because it's people's real lives they're messing with. There will be things beyond your control that will affect the progress and well-being of your clients.

And as others have pointed out, having a private practice is very difficult to pull off financially for an MSW.

OmieWise's comment is also completely consistent with what I've seen my mom go through over the years.
posted by lampoil at 6:29 AM on July 19, 2006

My mother, too, an MSW, private practice. I know that she was about ready to leave the profession altogether after 20+ years, because of the insurance issues mentioned above. Not how much she was reimbursed, but because of the TOTAL NIGHTMARE to get the reimbursement. It's a lot worse than you imagine.

What solved it for her was finally paying an admin to take care of the billing for her. This is absurd given the income and what it costs to get that done ... but ... it allowed her to enjoy what she's doing again. It's cut into her income substantially, or on the other hand, it's made the income possible, depending on how you think about it.

Don't take the bureaucracy lightly: think about applying for six grants a day, each one for like, $50. From insurance companies with foreign call centers.

On the other hand, my mother has always loved her job and has made some concrete changes in people's lives. That's worth a lot.
posted by cloudscratcher at 7:15 AM on July 19, 2006 [1 favorite]

I'm distressed to see how many negative responses there are in this thread, mine also, of course. I really like being a therapist. I consider it important, even crucial, work which is both helpful and frequently wanted. Patients are often profoundly grateful for the services I provide, and even when they aren't, the interactions between us have often been profound.

Um, that said, I thought of three further clarifications to my above remarks:

1) Most therapists I know who are intellectually engaged are doing something outside the consulting room to find that engagement. Belonging to a psychoanalytic institute, writing, teaching...these are necessary pursuits for people who seek intellectual gratification because the therapuetic interview, even when one rigorously seeks to formulate an understanding of one's patients, is very insular.

2) It's one thing to have reciprocal conversations with friends and family about feelings and life issues, and quite another to have those conversations in therapy. Good therapists really are at the service of their patients, and so the kinds of conversations that develop are by nature one sided and pretty constrained. There's a saying in therapy that every interpretation is hostile, and while one may not intellectually believe that, it's pretty clear after working for a little while that whatever you say as a therapist has more weight than such a comment would to a friend. It's kind of like the five pounds heavier everyone looks on TV.

3) ikkyu2's comment, as always, great, reminds me to mention that most therapy is the process of clarifying the patient's desire for therapy. In other words, an awful lot of people aren't customers for change, they're kind of window shoppers. Change comes quickly when people really want it, but I have patients on my caseload that I've seen for literally years where the only conversations we have are essentially about whether or not they have a desire to change. This is fine with me, but can be very frustrating, particularly if one's theoretical orientation views this process as less than therapeutic.
posted by OmieWise at 9:00 AM on July 19, 2006 [2 favorites]

I appreciate all these thoughtful comments. I asked for negative answers, because people are generally more inclined to encourage than discourage, in my experience.

I, personally, hope to teach a little, but I do not want to be a full time professor at, say, a liberal arts college. I'm not crazy about preparing lectures and making 30-100 people listen to me and discuss five days a week. But I do hope that with my background, I'll have some opportunities to teach. I gave a lecture about what neuroscientists know about eating and addictions to a bunch of school counselors and social workers during my last year of grad school, and had a wonderful time. They were so much more interested than the average college student in a neuro course.

I'm picturing a career that will change as I need it to. Early on, I'd like the flexibility to ease back on my hours to have a family. In research, this would essentially take me out of the competetive field at the time when I need to be most active. Later in my life, I hope that I'll be able to do some therapy, some teaching, and some administration--who knows where I'll head? But I get the sense that just two more years of school will give me a trade that will prepare me for far more jobs than I feel prepared for now.

Really, your comments are exactly what I needed to hear. I'm not discouraged, but feel better informed. Thank you!
posted by aimless at 9:17 AM on July 19, 2006 [1 favorite]