(This is an excerpt from a book I wrote on how to have career in the mental health field. I unpublished it because it would need to be revised to stay current.)
“And you may ask yourself—’Well…How did I get here?’ ”
It’s possible, even likely, to make some of the most important decisions you’ll ever make as a counselor, without being aware that you’ve made them. Subtle and unsubtle influences are everywhere. You may choose your training program, wisely, but the supervisors you’re saddled with during internships and early jobs is usually luck. Your early career colleagues might be conventional thinkers, brave explorers, or everything in-between. Geography, fashion, and time of entry into the field all play a part in the context of your chosen vocation. When I started, the field was dominated by men. Now, it’s dominated by women. When I started, psychodynamic approaches were just being challenged by humanistic and systemic styles. Now, humanistic and systematic ideas are part of the counseling dialect. Of all the professions, there are few that include more choice of approaches than in the counseling field. The following are some meta-decisions you’ll encounter:
Are your clients cases, or people with problems?
Seen your doctor lately? Chances are, not for long. A host of cheaper assistants (and the cheaper assistants have their own even cheaper assistants) take your pulse, blood pressure, blood, urine, and fluids you didn’t know you have. If you’re unlucky, they may even slip you something and harvest a kidney to help pay for their own health insurance. You may have the most personable doctor in the world, but in modern medicine, you’re more a computer readout than a person with dis-ease.
The mental health system has no equivalent to vitals and fluid tests, so (as I’ve stated to the point of weariness for readers) clinicians must fake it with the DSM. As everyone knows, we do that by counting behavioral symptoms, and if we reach the magic number within a DSM category, yay—reimbursement!
So your new client is now a collection of symptoms and a DSM number that resembles the balance in a counselor’s bank account. Counselors are conversant with the concept of historical baggage, for example, emotional baggage in the form of a difficult childhood, or the baggage of bad decisions that lead to sharing offspring with an ex. To that, the mental health system has added the baggage of casehood. (More on that: How to Suck as a Therapist.) Following their first recorded DSM diagnosis, clients don’t get to present themselves as who they are in the present. They are defined and labeled forever. We can claim that it’s for the client’s good, but the history of groups who have been defined and labeled by others is now widely accepted as a form of oppression. Continuing to regard your clients as just people with problems, especially when you’re overworked and underpaid, will be an ongoing challenge.
The second meta-decision you’ll make as a counselor is, *is the work of the client done primarily in your office, or out in the world? *
When I was training, there were two dominant categories of counseling: psychodynamic, which largely evolved during the first half of the 20th century, and systemic, which largely evolved during the second half of the 20th century. Practitioners of the former may differ in their theories of personality, and in their concepts of abnormal psychology and motivation, but mostly agree that the major work is done in the session, and that the important stuff happens between therapist and client. The focus is on insight and catharsis58. This category includes the original analytical therapies practiced by Freud, Jung, Adler, Horney, Sullivan, early hypnotherapy, and modern offshoots such as Fritz Perls’s Gestalt, and Carl Rogers’s person-centered. Practitioners of the latter believe that the major work is done in the context of the client’s everyday life. This category includes Ericksonian Hypnotherapy, strategic therapy, cognitive-behavioral, Rational-Emotive, Reality Therapy (mostly), and Neurolinguistic Programming (NLP).
While lots of counselors mix and match, when pushed, most will claim that one or the other is superficial. The adherents of the first group will contend that they’re working with the underlying cause of the problem but need to throw in some practical problem-solving stuff to keep the client interested. The adherents of the second group will contend that the talky insight stuff is necessary to develop rapport, so the client will cooperate with the behavioral homework.
My presumption is that therapy is about change. When clients come in, they want to change either a behavior, a pattern of interaction with a significant other (and sometimes with insignificant others), or their attitude towards or feelings about a current behavior or situation. So it’s always about change of some sort.
The first group believes that healing and behavioral change follow insight and analysis. The second group believes that behavioral change produces insight, but that insight may remain subconscious, which is just as well because behavioral change, not insight, is the goal.
In short, the decision of what kind of therapist you’ll be is determined by your theory of change: insight leads to behavioral change, or behavioral experiment (client homework) leads to behavioral change. Again, these two modes of counseling aren’t mutually exclusive, but which you favor will guide your thought process.
The third meta-decision you’ll make as a counselor is what will my specific approach be?
As I stated earlier, according to Wikipedia, there are over 200 known styles of psychotherapy. This ridiculous number owes less to novel ideas, and more to money and ego. Every time some college professor or random clinician comes up with a slight variant, it’s a whole new school of counseling. Soon, it’s offered as a continuing education class where, after the seminar, you can invest in three DVDs and a book for $195. That’s just the beginning. You can get certified by taking eight weeks of intensive training and supervision, for just $5995. When a counseling approach is not working for a clinician, rather than get better at that approach, clinicians often go shopping.59
I think novelty in counseling is a good thing. You can’t drag seminal thinkers, whole, into today’s context. First, we’d need to agree that all the questions of human behavior had been answered decades ago. Second, we’d have to regard culture and (by extension) cultural evolution, as irrelevant to psychological problems. I can’t imagine, were they alive today, that Freud, Jung, Adler, and Horney would have wanted their original theories poured into concrete. On the other hand, novelty should be in ideas, not marketing. And maybe we should be looking to venerable rather than drive-through sources for ideas. I’m interested in what the Dalai Lama has to say about contentment, but I draw the line at McDonald’s Double-Mindfulness burgers.
Katie Holmes = Evidenced Based Practice
Years ago, Tom Cruise was jumping up and down on Oprah’s couch, demonstrating his feelings toward (then) fiancé, Katie Holmes. Cruise could just as well have been illustrating how health insurance companies feel about evidenced-based practice (EBP). As much as I criticize insurance companies, I don’t blame them for not wanting to pay endlessly for vaguely defined goals. Unfortunately, the evidence on insurance companies’ heartthrob, EBP, has much in common with the elusive weapons of mass destruction: the evidence has more to do with how badly you want the evidence to be there than what’s manifest (Evidenced-Based Practice). Regardless of how shaky the grounds are for EBP in the mental health field, insurance companies will use it; there’s nothing better to go on, and EBP research aligns better with short-term concrete approaches than indefinite-length counseling.60
Above, I mentioned that when one’s counseling approach is not working well, counselors go shopping. There are several reasons why your approach isn’t working for you:
(1) You may have chosen a style that does not fit your personality. I have been heavily influenced by the famous hypnotherapist, Milton Erickson, but I had to come to terms with not having a proactive style. I could make use of his insights, and learn to use language with more precision, but I was not going to use hypnotic inductions.
After taking part in a cognitive-behavioral therapy research setting (as a facilitator), and reading a couple of books on the approach, I realized that it did not matter how useful CBT could be, I could not bear to practice it. There are several other approaches that were not a good fit for me, for example, Gestalt, person-centered, and psychodynamic. I leave those styles to other practitioners.
(2) You may not have sufficient training in the style you have chosen.When I chose to be a brief strategic counselor, most experienced clinicians were using a psychodynamic approach. You could fit all the experienced brief strategic counselors in a mini-van. You could carry all the relevant books61 without using a backpack. I had to train myself, by reading the handful of available books, attending a few workshops and conferences, but mostly using trial and error. And I had to walk through 10 feet of snow…
Getting better at your primary approach will usually provide more help than adding a bunch of styles. Today, most counselors, novice or experienced, can get advanced personal training, watch DVDs and Webinars, and download ebooks on their Kindles, phones, and tablets.
(3) You may not be cut out to be a counselor. People who have hobbies often believe that turning their avocation into a vocation is ideal. Then they learn that the business of photography, jewelry design, or gardening is not the same as the art and craft. Likewise, with the counseling business. Being the primary confidant of your friends is not the same as working in the mental health system.
How will you know that you’re destined to be a counselor? Here’s one way: if you read this whole guide, and you’re still enthusiastic about being or becoming a counselor, then nothing you’ve read here will discourage you.
How to Have a Career
The counseling field is often both a difficult professional environment and a competitive business environment. That doesn’t even take into consideration the challenge of becoming a competent clinician. If you work in an agency, you will find that your bosses aren’t the compassionate bunch you’d expect with trained counselors. As in most professions, your superiors may have gotten to their positions by being good at office politics, rather than being good at clinical work, or good at leadership.
Occasionally, people land in great organizations. If that happens early in your career, you might expect that will be the norm. While I encourage people to be adventurous, if you find a decent-paying job in a comfortable organization, don’t assume you’ll find another situation that matches it, let alone exceeds it.
Before you commit to a counseling career, look at the statistics on the average and mean incomes for the mental health professions. You need either a carefully crafted business plan or a willingness to sacrifice riches (that is, being able to pay your bills) for the love of the work. Even if the former is true, that you think you can make big money, I hope that anyone who doesn’t have a passion for counseling goes into something else. Working 40 hours a week at something you don’t find interesting and enjoyable (not every moment, to be sure) is miserable. And anyone who can make lots of money from counseling will make even more in the marketing field.
A satisfying and possibly lucrative career
Pick some counselors’ web sites at random. They list 20 to 30 problems they treat. They will provide a safe space to take you on a journey to find your authentic self. By implication, their primary approach is insight-oriented talk therapy, with no theory that would explain how it will help you. But in case you are too anxious or depressed for that insight-oriented journey, they keep cognitive-behavioral therapy in their back pocket, right next to their iPhone.
Luckily for both counselors and clients, many people just need someone to listen. They don’t need meds, dramatic breakthroughs, or a U-Haul load of insight. They just need someone to stop texting and listen. You could be that person. Unfortunately, so can dozens of other counselors in your area. It might be a good idea to find a way to stand above the crowd of counselors.
Be the proctologist of counselors: The easiest way to stand out is to specialize in something, preferably something that most counselors prefer to stay away from. Most counselors don’t like to deal with boys in their teens (especially if they get in trouble with the law), personality disorders, significant sexual problems, life-threatening eating disorders, or domestic violence. If you want to carve out a career in private practice, invest in advanced training to deal with one of the icky categories. Get great at it, and once you do, it will be far more satisfying than icky. You’ll get plenty of referrals, and eventually have opportunities to mentor, teach, and consult.
Complement a group practice: If you have a specialty, become the go-to person in a group practice. If you are the expert in what no one else wants to do, or what no one else does well, you will be sought.
There are counselors who make money. If you don’t follow the crowd, or take the easy path, you can be one of them.
Institutions usually start with the interest of the customers, but over time segue to serve the providers, or worse, the monied interests. If you work in the mental health system, find a way to make it work for you and your clients.
When my daughter started her master’s program in education, I suggested that she would not learn much in class, that her learning opportunities would come from doing research and writing a thesis. I was advising her that the program would be what she’d make of it. I also have a young friend who recently became a public school teacher. And another friend who just started a second career, as an MFT. What these roles have in common is that they will all take place in institutions that have survived well past their pull dates. And in all these cases, when their institution doesn’t support it, they will have to make it work for themselves and for their clients or students. They’re all confident, emotionally strong people. I have faith, a belief they’ll do well and make their little part of a deficient system, better.
I hope anyone who’s choosing the counseling profession goes into it with their eyes wide open, with the confidence to make the system work for them and for their clients.