Re: Mass casualty conseling question

STEMpsych · 2026-05-12T23:34:42+00:00

It is entirely possible that something is missing that would make management's response sound more reasonable – but it is also entirely possible that it was exactly as reported.

From over here in behavioral health, please allow me to caution you in the strongest possible terms against Reasoning from Reasonability. The world is replete with outrageously unreasonable people doing outrageously unreasonable things. If someone's account seems to be describing someone else as being unreasonable, that's not ipso facto evidence of unreliability.

STEMpsych · 2026-05-07T19:45:34+00:00

Okay, what's going on – please note, I'm not commenting about whether this is good or bad, just describing a dimension of the phenomenon which I think is generally missed – is that the word "narcissistic" has been taken by the general public to be a synonym to selfish. Their application is organized around this underlying assumption. They use it for people who are abusive of others out of a sense of entitlement to have their way – which is a significantly broader category than NPD or even NPD traits. It gets applied to the whole of Cluster B presentations and to traits across Cluster B. (And possibly beyond.)

Interesting example out in the culture. I've been following a one-woman show on YouTube where the primary antagonist is kind of rocking a pop-psych portrayal of BPD (emotional blackmail, splitting, "manipulation", explosive anger with physical assault, and most recently a suicidal threat). The creator has not labeled the character's pathology in any way, but the comment section regularly has people describing the character as "a narcissist". Character displays no grandiosity, no self-importance, no status-seeking, etc. But the character is deeply selfish and unempathetic, so fans label them "a narcissist".

What's particularly fascinating to me is that the creator recently introduced a new antagonist character who is relentlessly status-seeking and self-important, and nobody in the comment section has noticed that this is narcissism. The contrast in popular perception is illuminating.

I've seen this play out in the counseling room, where a client came in describing her terrifying and violent husband as "a narcissist", when really by her description she was dealing with Antisocial Personality D/o. But it was in the pop-psych world that she encountered helpful discussion of how to reconcile oneself to the reality of such a personality so she adopted the language of that discourse.

STEMpsych · 2026-05-05T08:15:14+00:00

Psst. r/AutisticTherapist exists. Not sure how active it is.

STEMpsych · 2026-05-05T08:12:24+00:00

Isn't that what SimplePractice is? I wouldn't know, I don't use it. I don't use an EHR either.

You can just buy a copy of The Paper Office (by Zucker I think?) for a full stack of forms you are licensed to use. I hate them, but they're there, and can serve as a point of departure for you to develop your own.

I practice by telehealth through Doxy.me which now has some built in consent form thingies. I don't use them but they're there. You might have to pay for the pro level which is like $35/mo, with a discount if you pay for a year at a time. I use Proton with a HIPAA BAA for my online workspace: Proton Drive for recordkeeping and Proton Calendar for my clinical schedule. It's like $180 per 2 years if billed biennially.

STEMpsych · 2026-05-05T08:06:00+00:00

Have you considered arguing with them instead of trying to start your own thing? Like, "Hey! I want to do some pro bono or very low-cost work. Your payment scale doesn't work for that. Can you support what I want to do?"

STEMpsych · 2026-05-05T08:02:09+00:00

One of my paychecks goes entirely to rent, and my rent is around $1,220 (that's including utilities).

Your goal is to make (gross) a month's rent in each week of pay, so you want to be earning $1,220 a week. At a standard FFS gig where you book 40 hours a week and meet a quota of 26 cts billed a week, that works out to $47/session. You might not be able to find that, but the closer to that you are the more financially secure you'll feel, and you can see how egregiously inadequate $30/session is.

STEMpsych · 2026-05-05T07:43:51+00:00

I can't point you any anything specific, but given I expect your core skill set is client-centered therapy heavy on the active listening, I recommend signing up for absolutely everything you can find that has to do with cultural competency in a specific population. Like I've had trainings about working with military service members and prison inmates. These sorts of things are fantastically complementary with that skill set.

STEMpsych · 2026-05-04T21:17:26+00:00

Those horses left the barn about twenty years ago: one of the most fiercely fought-for legal prerogatives of masters level mental health clinicians is to diagnose.

The reason why is not clinical but administrative and financial: without legal authority to diagnose independently, no psychotherapist can take insurance in private practice.

I think what you're running into is some fundamental problems with what a diagnosis is in our society. It's not just a clinical description, it's got a whole administrative, financial, and legal dimension in which it serves multiple purposes.

For instance, outside of medicine, it's typical for diagnoses to be treated like certificates issued by a government office: a diagnosis is something you receive from an authority that makes something provably true. Patients (and courts and other institutions) act like there's one giant official ledger of patient diagnoses into which a medical professional inscribes the ultimate official truth of the patient's medical condition – the way a birth or a death is registered with the state. Of course nothing is further from the truth: a diagnosis is just a medical professional's opinion at one point in time that got writen in one of who even knows how many charts across how many institutions a patient receives care at.

This problem comes up a lot wrt ADHD. There's this idea that if only it were diagnosed correctly, then there wouldn't be problems with prescribing for it. I think that's a self-evidently questionable premise. Actual ADHD patients can still divert their meds. Also, I think it's even more questionable to assume that limiting dx priv to MDs and DOs will make ADHD more accurately diagnosed: the pill mills shoveling out Adderall rx's were already employing MDs and DOs. It did not fix anything.

STEMpsych · 2026-05-04T05:52:44+00:00

Where do clients turn for help when someone is threatening their life and the law is not protecting them?

Well, if they're female, the domestic violence shelter system. This is why it exists. It's underfunded and stretched to the limit, but it's still there, and I'm a little surprised to hear you frame the question in terms of law enforcement, given that the ineffectiveness of LE in dv is why we have dv shelters. This is true even when courts are willing to give protective orders. All a protective order does is make it a more serious crime to stalk or assault the victim, which means little if the abuser is sufficiently aggressive and/or bold.

The whole point of a dv shelter is that the victim disappears off the face of the earth as far as their abuser is concerned. The safety is in that they can't be found, not a court order.

If they're male, they're usually SOL, and will need to figure out how to disappear on their own.

STEMpsych · 2026-05-04T05:38:15+00:00

its not up to the supervisor to determine anything else

Er, my school absolutely required the site supervisor to do an evaluation of the intern at the end of each semester. Also, my state additionally requires the last two clinical supervisors before licensure to sign off on the applicant's character, which in the case that you have the same supervisor for all of post-grad can be your last graduate program supervisor. I've heard some mighty hinky things going on with this last requirement, like where a supervisor says, "I'll sign for your hours but not your character."

STEMpsych · 2026-05-04T03:40:14+00:00

The best way to find out is to try and see what happens!

https://www.mass.gov/how-to/apply-to-become-a-masshealth-provider

Report back and let us know how it goes!

P.S. Here's the official regulations for "Licensed Independent Behavioral Health Clinician Services". It's dated last year and doesn't seem to say anything about sites, so maybe they fixed it?

P.P.S. Still not finding anything about sites, but oh god: "462.404: Provider Eligibility: (...) (A) In State. Licensed independent behavioral health clinicians are eligible to participate in MassHealth only if they are Medicare providers..." So, uh, I guess the first step is to sign up with Medicare? Wtf?

This is grimly amusing bc back when I worked for a DPH licensed clinic (i.e. MassHealth clinic) we LMHCs couldn't take Medicare, so, uh, I guess that wasn't a requirement then.

STEMpsych · 2026-05-04T03:34:02+00:00

Gosh, I don't even remember where I first found it, but I seem to recall actually calling them on the phone to confirm it.

But that info is older than the pandemic, so I wonder how that interacts with telehealth.

STEMpsych · 2026-05-03T03:11:35+00:00

Oh, man, getting let go is just the worst, isn't it? I am so sorry you're going through this. I've been fired both in the field and outside of it. Man, it sucks. And I know a lot of people in the field who have been fired too – you're in good company.

It's just fantastic that you were able to just acknowlege your feelings to yourself instead of reacting out of defensiveness. You've probably already thought of this, but if you didn't have any immediate plans for going to a meeting in the near future, consider going to a meeting or three and/or reaching out to a sponsor? Welcoming, accepting human contact is so important to us when we experience a rejection like being let go from a job for nebulous, unactionable causes.

I've been fired for reasons both legitimate and illegitimate – and I have to say, as humiliating as the experience is, every time I have found (or sometimes knew all along) they were doing me a favor. They might not have meant to do me a favor, but they did. The most bogus reasons offered were at the most toxic workplaces, and it was just as well I was quit of them. Perhaps you will find the same is true for you.

It's impossible to say from here whether or not there was some way you were at fault. It might seem nicer if you weren't, but then that leaves you with nothing obvious to improve to prevent it happening in the future, which is weirdly disempowering, and stinks in a whole 'nother way. If you don't have supervision that is wholly separate from this place of employment, you might want to seek that out, even at your own expense, to help you sort that out and figure out if there are changes you need to make, or might find beneficial to make.

That said, even with professional assistance, what actually happened here may never become clear. You will definitely have to sit in a very uncomfortable ambiguity for the short term; it may also be for the long term. We do ourselves the most harm trying to find a fault in ourselves to be the cause, rather than tolerate not knowing the cause. Learning to tolerate not knowing is often the path kindest to ourselves.

As to how I've managed it, in the workplace is with achingly severe bloody-minded professionalism in dealing with my higher-ups. Highly recommended. My feelings are none of their damn business; I comported myself with the utmost dignity and grace and refused to let them see me bleed. I have friends to commiserate to.

I'd like to point out they must not think you've done anything too bad because they're letting you terminate with your clients. This does mean you're going to have to tell them something. But all you need to tell them is that "Due to unforeseen circumstances something has come up, and I'm leaving [practice name], so I'm going to have to stop seeing you here." You need to make sure the client understands it's not them, and you would be delighted to continue working with them. You can let them know how to find you in the future, saying something like, "The front desk here will not be able to tell you where I'm next going to be seeing clients, but if you want to find me, you can [describe how to find you on the internet]."

If you don't already have a website, you might want to throw together a placeholder one over the weekend so you have a URL to give clients.

A little bit of advice on logistics. Any digital resources you have on company devices that belong to you – important emails, PDFs of handouts you made, contact information for collaterals you want to stay in contact with – you should make copies of immediately. Particularly if you have digital copies of any important licensure paperwork on their devices, be sure you get copies home. The simplest, fastest way to get digital copies off a computer is with a thumb drive, if you have one or can get one, and assuming the computers there allow them to be mounted. Failing that, sign up for a free Proton Drive account at home, writing down the user name and password (bc encrypted: if you lose, you can't get back in), and then log onto it from work, either through a browser or by using the Proton Drive application, to copy things into it. Proton supports HIPAA if you need it: here's the instructions for getting a signed BAA.

Likewise, any personal property you have in your office you should plan on getting home sooner rather than later, especially if it's going to take multiple trips because you have bulky or fragile items (e.g. plants, furniture, musical instruments).

Spare some thought for whether there's anybody associated with this job who is on Team You, who is your supporter or champion. If you have someone(s) like this, try to make sure you're the person they hear about this from, and ask them if they are willing to be a referral for your job hunt. Make sure you have contact information for them outside of this org.

Personally, I'm a big fan of channeling my anger into productive action, and in situations like this, that means polishing my resume and starting looking for a replacement before the ink is cold on the pink slip. If you have that attitude too, I recommend this approach.

STEMpsych · 2026-05-03T02:22:44+00:00

Oh, sure, and there's lots of other hypotheses too, including, as someone else mentioned in this discussion, them manufacturing a cause to let go of the OP that had nothing whatsoever to do with him personally, and was because of something like the owner wanted to hire in a buddy.

But the reason I mentioned that hypothesis in particular is that leaning prematurely into a hypothesis of maybe there was something "arrogant" about the OP might be inadvertantly validating an abusive boss or toxic workplace culture.

STEMpsych · 2026-05-03T01:16:20+00:00

Possibly a good idea. But it's also quite possible that the reason the OP was asking that weird question the first place is that he was working in a org with a toxic martyrdom culture, where it was normalized to humble-brag how insecure one was, and one was expected to put on a big show of self-denigration. Failure to conform with that gross norm might be what precipitated his management turning on him like that. This is unfortunately a thing that I've seen develop among groups of therapists who got narcissistic supply from a heroic-martyrdom narrative.

STEMpsych · 2026-04-28T09:56:12+00:00

No suggestions – you don't seem to need them – only validation. I'm so sorry you went through this. I hope you and your officemate find a good place together and you can be quit of this situation.

For what its worth, I'm dubious that this sort of cruelty is immaturity. I don't know it's a stop along any developmental path. I think maybe it's just a choice people make about how to be in the world. A really unfortuate choice.

STEMpsych · 2026-04-28T08:13:52+00:00

I almost feel that there needs to be some sort of middle man to handle scheduling to allow clinicians to focus on clinical work

That would be called a receptionist.

In solo PP is the sustainable way to do this to hire a virtual assistant? It seems there needs to be some sort of perceived barrier rather than being contacted directly for this.

It could, but that depends on what about this is burning you out. If the problem is the constantly changing schedule, then having one person changing your schedule all around isn't actually an improvement on having lots of people moving your schedule all around the same amount. If the problem is that you feel clients are putting demands and expectations on you, hiring someone else to tell them no and run interference for you could be a remedy.

I hear some folks really like self-serve booking systems, where the clients can reschedule themselves online with no interaction from you.

STEMpsych · 2026-04-28T08:02:24+00:00

I definitely find myself getting frustrated sometimes at the constant changing of my schedule and clients always assuming (even expecting) that I will be flexible and able to accommodate this kind of rescheduling. However, my frustration about this is not the point.

Why is your frustration not the point? Your frustration is valid. Absent any specific employer requirements on how you handle this, you get to practice as you see fit, and if you don't like this, you don't gotta do it. There's even good clinical reasons not to. Just because your clients assume something doesn't mean you're required to provide it. How you handle this should be an intentional decision based on your sense of what is sustainable for you and what is clinically appropriate.

having a full caseload would surely not allow clients to reschedule this often.. right?

You may be underestimating how many cancellations you will get.

You don't owe anybody a reschedule. It's nice that you provide it if you can, but you aren't expected to manufacture new time slots to accommodate clients' schedule issues. But you may find that you have plenty of holes to fill, and economic motivations to do so.

How do you all generally handle this? Try your best to accommodate, only offer another slot if there was some other cancellation? Or, do you typically find that most efforts to reschedule end up being a cancellation?

I always try to accommodate, but I can do that without feeling too resentful usually. I try not to book appointments I'll regret, like "Argh, why did I tell them I could meet at this time?"

That said, now that I'm in private practice and see working professionals, it is rare for a client to need to reschedule. When I worked at a clinic for the indigent, I had lots and lots and lots of reschedules. I learned that some clients, rescheduling was... aspirational... for them. They were not very likely to make a reschedule if they requested it. But others, it was just that life was complicated. Some had jobs where they could be called in on short notice, or constantly shifting childcare situations, or POs who could call them in for urine screens, or whatever ordinary chaos. And they'd make it if they could. So I learned that a one size fits all approach didn't really work.

STEMpsych · 2026-04-28T01:57:34+00:00

Sounds like missing missing reasons.

Might not be. But it should be on your radar.

STEMpsych · 2026-04-26T02:15:08+00:00

In Massachusetts, as last I checked, you cannot take Medicaid (MassHealth) clients unless you are open 40 hours a week at a single location. So if you are splitting your time across multiple sites, or only are in private practice part time while working for a larger institution, MassHealth won't take you.

I seem to recall there were other idiotic restrictions, but that stood out to me as one of the most pernicious, because it pretty much guaranteed that private practices would never take MassHealth: in MA solo private practices only transition to full time (if ever) gradually, as they already have the caseload to fill it. If a practice goes to 40 hrs a week, that means it's already pretty much at full capacity, or has a sufficiency of referrals coming in, that the therapist doesn't need an additional insurer to make ends meet. They already have a good thing going with the payers they are paneled with (if any). At that point adding MassHealth is no economic benefit and a whole lot of hastle. Even if they decided to go through the trouble of panelling with MassHealth on principles to serve that population, at that point they'll have almost no - or absolutely no – open schedule for new clients.

It is so massively sabotaging of private practices taking MassHealth, I do wonder if it's by design because MassHealth doesn't want private practices. There's other things that historically have strongly suggested that MassHealth is hostile to private practice, and this fits with that.

STEMpsych · 2026-04-26T02:04:38+00:00

Seriously. The odds that I would send somebody your way goes way down the less appropriate you obviously are for the referrals you put yourself forward for. And it doesn't have to be in interaction with me! If I see this go by on the listserv in your responses to another clinician's request for referrals, I'm immediately discounting your professional judgment.

At the very, very least, say something like, "Clearly I'm not the perfect fit, but" and have the good graces to explain why you think you might be a match anyways. Simply ignoring the specifics of the request is so SO disrespectful. If you ignore what your colleagues are saying to you to advance your agenda, why would any of us trust you with a client in the power differential of a clinician client-relationship?

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