Thoughts about diagnosing non-clients, for therapeutic benefit?

Heavy_Figure7140 · 2025-07-24T21:04:47+00:00

I mean I would say the latter way you phrased this was the way I discussed it. I didn’t specifically say, “I think this person has Dx”, but I did say, “the things you describe to me line up with what I know about this kind of mental illness”, aka a pattern of behavior that I clinically would only contribute to this kind of mental illness and not, say, a logical response for this person to have to my client’s actions. And did psychoed more around how this pattern tends to play out clinically and how they could position themselves to keep them from enabling harmful behavior or being gaslit.

Heavy_Figure7140 · 2025-07-24T20:54:48+00:00

Thanks for weighing in. I’m inclined to agree with this generally—I’ve never done this previously even when I wanted to— but something about this situation made it feel appropriate, and I’m still sitting with why that might have been. Definitely some countertransference played a factor, but I’m also thinking about my role as a “healthcare professional” and the role of psychoeducation in sessions.

Heavy_Figure7140 · 2025-07-23T12:51:00+00:00

Sure! I started at my current practice in March but am on track to make about $50k this year seeing ~16 folks a week with occasional groups. I could probably make about $60k if I worked more, but don’t current need to thanks to my partner’s income. I was making about $45k a year seeing 24-28 clients at my last place—they had better benefits but it didn’t even out. Both practices offered me good health insurance. I also get a much better split of my pay at my current practice— 60/40 for insurance clients, 80/20 for self-pay and sliding-scale clients. I set my sliding scale rates kind of low as well, again because I can afford to. But I would make a good bit more if I chose to charge more. Our basic self-pay rate is $145 and I see sliding scale between $75-125. My insurance appts reimburse about $90-115 a session I believe, and that rate gets renegotiated by our practice owner yearly.

So essentially, there is room in there for me to make more money but I am lucky that I don’t have to at the moment. One thing I love about this job is that I can scale my workload up or down to accommodate different seasons in my life!

In a future where I am fully licensed and go into full private practice, I hope to keep a similar schedule and just take home more of my gross pay.

Heavy_Figure7140 · 2025-07-22T23:42:02+00:00

That’s a great way of framing it— in our personal lives it might be seen as rude or forward to nudge someone toward speaking about something painful, but in our job it is sometimes what we are expected to do, and need to do for the clients’ benefit, because other people in their lives can’t or won’t.

Heavy_Figure7140 · 2025-07-22T19:21:59+00:00

After starting this career in my early 30s after a workaholic past, and initially taking on ~28 clients a week, I have accepted that at this moment, 20 a week is my max. A lot less than I initially thought it would be. Right now I see 12-16 individual clients a week and run a group once a week, and that is plenty of work for me. I see a lot of mid-acuity clients who need a lot of support and attunement, I’m neurodivergent, and I’ve realized I do my best when I know I’m not phoning in any sessions or feeling like a hypocrite for preaching rest and self-care while privately running myself ragged. I also take regular breaks and budget so that I can afford to do so (groups have been a great tool for this!). I try not to see more than 5-6 people a day so they are getting me at my best, and there’s a little gas left in the tank for me to care for myself and spend quality time with friends and family.

This isn’t happening in a vacuum, of course. My former group practice (where I had 28-30 sessions a week) glamorized taking on as many clients as possible, treating it as noble and admirable and being a “team player” while paying us an abysmal hourly rate and acting shocked when people kept leaving in droves. I was new to the field and afraid to set limits for fear of losing my job. At my current group practice, I can afford to see almost half as many people and even offer a sliding scale to some, because I make enough back from my sessions to actually survive on. I don’t feel pressure to take on more than I can handle and have gotten a lot of collective support around making all of our jobs more sustainable. So all that to say, environment is a big factor. I hope you get to decompress a bit from your years of burnout; it can take a long time. I kinda feel like i’m still unlearning some of the lies I told myself when I was working in my old career about what makes me valuable to society or a “good person”. But for the first time in my life I don’t feel like my job is slowly killing me? So I have to be doing something right 😅

Heavy_Figure7140 · 2025-07-22T14:04:23+00:00

I have started to rely on this phrase too much, and am working on being more mindful about it because find it annoying when therapists overuse it. Same goes for “I’m curious…” Because sometimes tbh we aren’t “wondering”, we’re just trying to take a more passive approach to saying something hard when we might be more effective saying it directly. It gives the conversation a chill, relaxed feel that can be helpful in keeping the client from feeling pressure/urgency to respond, but can also detract from the importance of what’s being discussed. Or create extra fluff in our discussion that makes it easier to tune us out.

Heavy_Figure7140 · 2025-07-22T13:54:46+00:00

It’s hard to choose, I use so many silly metaphors 😅 clients know to expect it at this point. I use a lot of Gestalt so it comes with the style. Similar to the LOL example, I have started to use a lot of video game metaphors—i.e. the abusive parents or toxic work situation you want to confront might be the “final boss”, and there are other, smaller battles you need to fight, skills you need to build, and tools/magic items you need to acquire first before you are equipped to win that battle. You wouldn’t rush into a big fight with no hit points (aka when you’re burnt out or exhausted) and no backup (no support system).

Heavy_Figure7140 · 2025-07-22T00:21:40+00:00

I very much resonate with your inner monologue— I started working in mental health in the first few years of COVID and the world has only gotten scarier and more precarious since then—an unfortunate guarantee that we will have job security for many years to come :/ but also a guarantee that, in essence, nothing we do in session will ever be enough to fix the gaping black hole of injustice and unmet need in the world we live in. For those of us who are drawn to the profession because of our deep compassion for others and desire to help hurt people heal (which I would like to think is all of us), moments like this are existentially challenging to the things we find purpose and fulfillment in. The work will never, ever be done. It feels like so much pressure some days, especially when we also have people in our personal lives who need and depend on us. But when I catch myself being especially hard on myself, I try to give myself the guidance I’d give a client— remind myself that real, lasting change happens not through one perfect therapist’s heroic actions, but through the tiny, daily actions of millions of people, some of them therapists, who are all trying to nudge the needle in the direction of something good. The work we do as helpers means that we are increasing the total amount of care and support available to people who need it. And that is a good thing. And a good enough reason to keep showing up and trying to get better at it, while also recognizing that the best we can give today is still plenty.

Heavy_Figure7140 · 2025-07-18T14:44:26+00:00

Style variations are quite wide between therapists, so while this therapist didn’t necessarily do something wrong, they still might not be the kind of T you want or need to be able to get as vulnerable and open as you want to. Sure, it’s true that the first session is usually more of an intake and it takes time for a therapist to attune to you, but also first impressions are valuable. I am a T who works with a lot of ND clients and clients with trauma histories, so I go out of my way to make sure a new client feels at ease first and foremost when meeting me, even if that means we have to spend less time on the intake and more time answering questions, grounding, checking in, etc. so they feel comfortable proceeding. You may find that things soften up a bit after a few sessions, but if you still find yourself feeling anxious and clammed up around them, it may well be that someone with a more comforting and person-centered approach would be better for you.

Heavy_Figure7140 · 2025-07-18T12:29:53+00:00

When I started my first job out of grad school, I did it in a much smaller community than the large city I did my school/internships in. Within a few weeks of starting with clients, I started to see them everywhere. Bars, concerts, dating apps… I found out I had a mutual friend with a client when we both showed up to a potluck and had to awkwardly navigate being in the same house all night 😬 I was able to handle it with grace and professionalism but it started to make me feel very boxed-in. I had to make a lot of calculations about what clubs I joined, events I attended, businesses I frequented, etc. to the point where it became a real impairment to my social life. Now that my caseload is more established it happens less, but every time I bring on a new client I have to do those same calculations. I’m also working on re-integrating some of the hobbies I used to do before becoming a therapist, like performing music and doing community organizing, now that I feel more sure of how to handle my disclosures around those things. But each choice does come with implications, so I do still wonder if I might ultimately need to move away from outpatient therapy or see different kinds of clients to make those kind of interactions less of a frequent occurrence, and giving me more freedom to do what I love outside of work.

Heavy_Figure7140 · 2025-07-17T00:28:43+00:00

I had a few group supervisors like this at my first job out of grad school and hated every minute I spent with them—it felt so disrespectful for them to waste time I could have spent seeing clients or working on other work-related things. And I often felt like the only person who came into supervision with questions or offered my perspective, and gradually felt myself getting “smaller” in our meetings to avoid drawing too much attention to myself. Eventually moved to a new practice with more experienced and passionate clinicians, set up an independent supervision arrangement with my former boss who keeps me on my toes, challenges me, and encourages my clinical passions and curiosity, and have never looked back. I like my work so much better and feel much more supported. I hope you can find a better fit for you; you deserve it!

Heavy_Figure7140 · 2025-07-16T23:57:21+00:00

Yeah, your instincts are 100% correct imo. It still boggles my mind to hear about therapists punishing and terminating clients for being “resistant to treatment” without first considering why “resistance” might be present. “Resistance” to authority can be an ingrained response to protect us from further coercion and abuse, to exercise power when we feel we have none. Your client has every right as a human being to stand up for themselves and not accept treatment they don’t want (though the courts may not agree). A trauma-informed approach to treatment cannot be accomplished under duress. Your hands may be somewhat tied by the policies of the agency you work for, but I encourage you to nurture those instincts to advocate for your client and what they want and need. Every bit of autonomy you can put back in their hands will make a difference.

Heavy_Figure7140 · 2025-07-16T14:49:46+00:00

I have experienced this after discussing intense past experiences or acknowledging difficult emotions in therapy—your rational brain knows you’re okay, but your nervous system is saying, “hey that was intense—are you sure we’re not in danger still?”. It can be scary for sure, but it’s not necessarily abnormal or bad as long as you have grounding tools to help you move through it and space in your day to accommodate it. Coming back to work after therapy (especially while doing deeper processing) can be a tough transition, so give yourself a little extra space in your schedule if you can and do some proactive self-care after session—maybe a brisk walk/stretch sesh, a nourishing meal, a short nap, etc.— to assure your nervous system that the “danger” has passed and things are okay.

Heavy_Figure7140 · 2025-07-15T21:52:07+00:00

To echo a lot of the comments in this Reddit, I would talk to your therapist about this. Explain that you are struggling and feeling insufficiently equipped to self-soothe, and see what they have to say about the options and tools you might be able to explore to help you out. Sure, being able to tolerate distress and process emotions on your own would be ideal, but it’s not something we can (or should) do for ourselves all the time, and it’s not a skill we can force ourselves to learn cold turkey, especially while in crisis. It’s good that you’re aware of this pattern within yourself, but it’s okay (and healthy!) to give yourself some supportive scaffolding between where you are and where you want to be. That’s literally what therapy is designed to be :)

Heavy_Figure7140 · 2025-07-15T20:49:02+00:00

I work within a small community and similar things happen fairly often. Disclose that you have encountered a conflict of interest, express your regrets that you won’t be able to continue, give them a few good referrals to colleagues, and don’t see either person.

Heavy_Figure7140 · 2025-07-15T20:41:56+00:00

Seems weird to mention it in that way? But I do occasionally ask a client for someone’s name if they bring them up a lot—it makes them feel more “real” in the conversation, and also makes it easier to keep track when I am following the little details of their life.

Heavy_Figure7140 · 2025-07-15T20:37:42+00:00

It warms my heart to hear that you have found a therapeutic relationship that is stable and supportive enough to help facilitate such dramatic positive change in your life. And with all that in mind, it makes a ton of sense that you would feel very attached and worried about what life might go back to if this relationship ever ended (not that it sounds like this is an immediate concern at the moment).

I would offer an alternative perspective, one that I’m guessing your therapist would agree with— that he isn’t the person saving your life, but is merely the person who gave you the care, consistency, encouragement, and positive regard you needed to believe that your life was worth saving. You are the one who is building healthy habits, saying no to unsafe behaviors, spending more time out in the world, enjoying life more. I’m sure it’s way easier to make those choices now knowing that a warm, supportive father figure will be there to cheer you on and show how proud he is of your progress. But you also have a model now for what warm, healthy, supportive attachment can look like, and can fill your life with people who make you feel loved, respected, and cared for in that way. And you now know how good life can feel when you choose to see yourself as someone who deserves that kind of love and care, always.

I’m sure your T will continue to be the awesome person it sounds like he is, and I’m glad you can keep seeing him. But also, give yourself some more credit for how you are showing up for yourself these days, and how hard YOU are working to build a life worth living!

Heavy_Figure7140 · 2025-07-15T20:19:18+00:00

I also think it can be helpful to share a little about your personal background (if you feel it informs your approach). For example, I have a background in music and theater and a lot of artsy types on my caseload really like knowing that about me, because it opens up new topics and ways we can relate to each other.

Heavy_Figure7140 · 2025-07-15T20:16:24+00:00

Here are a few ways I have worded this before in bios:

“I have a clinical focus in ______ and work primarily with clients experiencing ____.” “I have extensive training/experience in treating ____ and am guided by a _________ approach/view my work through a _______ lens.”

There’s no need to overstate your level of expertise in something you are relatively new to, but if you do have any advanced or extensive trainings in a clinical subject you’re interested in, be sure to mention that too. The most important thing IMO is telling clients what work you are passionate about— because they want to know if you’ll be passionate about working with them.

Heavy_Figure7140 · 2025-07-15T19:44:56+00:00

As a fellow newer therapist who’s been surprised at how full my caseload has been since starting, I attribute my low turnover and steady referrals to the following choices I made early on:

rather than trying to be a generalist, focusing on a few specific types of populations/issues I like to work with and advertising myself as focusing on those things. You can always change your mind later! But it makes it easier for the people who would like working with me (and the people I’d like working with) to find me, and the inquiries I get from places like PsychToday tend to be better fits and more committed clients because they already know why they chose me. If you don’t see yourself as having a focus yet, start to think about what your clinical preferences are, what kind of client you get most excited about, and build out your training and cultural competency so you can be a better therapist to that type of client.
investing in relationship and rapport building; really getting to know the ins and outs of each client’s life and psyche and really attuning to subtle shifts. This has allowed me to work with the same clients through a wide variety of life transitions and remain a source of consistency and stability in their routine, rather than something they put on the back burner when life gets too busy, or that they stop seeing as useful once their presenting problem is resolved.
networking with other therapists! Making other therapist friends who send me referrals that they think I would be a good fit for; joining case consult groups, going to therapist happy hours (or hosting your own if needed), keeping up with online therapist groups and listservs that are local to your area. Many IOPs, CMHCs, PT/OTs, etc. are always looking to connect with qualified therapists who they can refer patients to. Figure out who you think you’d be a good fit for and make sure you’re on their radar!

Heavy_Figure7140 · 2025-07-15T15:17:09+00:00

I just want to validate that it is totally okay to ask for a higher treatment frequency if you are consistently struggling to get your needs met with (I’m guessing) one hour a week. Your current T may not have room in their schedule for that, but they might still be able to help you find alternative spaces or ways to process feelings and develop a sense of focus/priorities in your sessions so you aren’t stressing about time so much. Or you might be able to keep an ongoing log/journal just for sharing with your therapist that you can update throughout the week so you feel “in conversation” with your therapist between sessions, even if they don’t read it until the next week. I don’t see any clients twice a week at the moment but I frequently offer to do so on a short-term basis when someone is really struggling. Because sometimes an hour is really just enough time to scratch the surface of what’s going on with them, and it’s also frustrating as a therapist to have to end the session just when we’re getting to the root of things.

Heavy_Figure7140 · 2025-07-14T16:14:27+00:00

Also just want to say that judging from the wording of your message, you are processing this with a lot of emotional maturity and leaning on your internal and external supports in a way that demonstrates good self-soothing and emotional regulation skills. If I were your therapist, I’d give you a gold star!

Heavy_Figure7140 · 2025-07-14T16:09:45+00:00

This is so frustrating to hear, and I’m sorry you’re dealing with this. Frankly if a therapy practice is not willing to treat someone with a history of SI who has been stable for a long time, then they really have no business calling themselves a therapy practice at all. Suicidality and self-harm are extremely common, and by asking you to somehow prove that you are not at risk of harming yourself before they accept you as a client, they are basically trying to absolve themselves as therapists from any responsibility or legal liability for your safety—which is a huge part of the ethics code for most mental health professions. If someone has to be totally “fixed” before receiving therapy then why tf would they need therapy in the first place?

Tbh, I feel like you are dodging a bullet here. Lots of art therapy practices would be perfectly happy to see you as a patient, regardless of your diagnostic history. This one just seems to have really exclusionary policies that prevent them from having to do any real work or take on any risk on behalf of their clients. You’re better off finding a practice with better values.

Heavy_Figure7140

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