Finding Your Way As a New Clinician

“Can you tell me the three most important things I should try to remember when I start working with my clients next week?”

This is a text from my friend Kim, who’s on the brink of her second career. I know her as a fellow writer, but now she’s a graduate student in counseling and starting her first outpatient practicum.

“Sure,” I text. “But I’m going into session. I’ll get back to you.”

Ever since I started teaching graduate students how to be a therapist almost 20 years ago, I’ve loved practical inquiries like Kim’s. Most students experience their graduate training as a firehose of academic information, often abstractly worded with generous amounts of jargon. But when they sit down with an actual client, they feel unprepared to enter into the profound and sometimes frightening uncertainty of each session.

I get it. Thirty-four years ago, when I first became a therapist with a full-time caseload, at the age of 25, I lived in a constant state of foreboding. Sunday evenings were the worst: I’d look at my schedule for the week, see specific clients’ names, and start to dread their arrival. What did I really know about doing therapy with them? With anyone? In addition to heart-racing worry, I spent considerable energy trying to hide my anxiety from colleagues and supervisors, who I’m convinced, in retrospect, likely saw it anyway.

And I was physically sick. During my first six years in the field, I had a series of untreatable gut problems called by various unattractive names: irritable or leaky bowel, acid reflux, celiac, ulcerative colitis, to name a few. So many diagnoses, so few solutions. I consulted medical doctors and GI specialists, naturopaths and herbalists and acupuncturists, but no one in the early days—this was before any books or talk about vicarious trauma—made the connection between my gut pain and the overwhelm of being new to clinical work. I was doing a great job camouflaging my distress.

The beauty of being a therapist, which you can’t possibly grasp at the start of your career, is that you’ll have lifelong community—deep, beautiful friendships—with others who’ve answered the same calling. What other professional degree requires face-to-face, intimate conversations where one person talks about matters of the heart and the other practices listening closely, with no agenda beyond acknowledging? I want to go out on a limb here and make a bold declaration: Therapists make the finest friends. They know themselves. They’re unafraid of risk and challenging truths. They embrace change because they fearlessly live in it with their clients, day in and day out. And they navigate relationships with intention and awareness. They’re excellent resources for complicated questions.

I had recently had conversations with two friends, both seasoned therapists, both colleagues who work with therapists at the beginning of the journey, where we tackled a similar question: What do you wish you could’ve told your younger self as you started down the path of becoming a therapist? Their words were on my mind as I considered what to say to Kim.

Tori Lopez, a licensed clinical social worker, gives me her answer when we meet up for drinks at The Sports Bra, a women’s sports bar in Portland, Oregon. Tori and I have known each other for 15 years. We cofacilitate workshops on navigating work stress for professionals in health and human services fields. She now has a private practice and does a fair amount of clinical supervision, but for many years, she worked in nonprofit settings where she was often the only person of color.

Tori identifies as Latina, multiracial, and gender nonconforming. “When you have marginalized identities, that little voice of internalized oppression can be pretty loud,” she says. “The dominant narrative in my brain was: What would a white, cis, male, hetero clinician think about what I said to my client? The self-questioning can feel crippling.”

What would she tell her younger therapist self?

“Your lived experience counts,” she says. “It’s what makes you a really fucking good therapist. Book stuff is great, but at the end of the day it’s about building relationship and moving at the speed of trust. Use your own story to build connection and safety. With my BIPOC clients, they don’t have to explain the impacts of oppression or wonder if I understand. There’s an unspoken you get it. That particular use of self is something our white-centered field won’t necessarily encourage us to do.”

“It’s so intimidating in the beginning,” another friend, Kate Davis, also a licensed clinical social worker, tells me a few days later. “Sometimes my clients seemed more together than I felt inside.” Kate and I met when we taught clinical practice in the same graduate school. She has a soft spot in her heart for new therapists and offers continuing education for them on how to navigate common early challenges. We’re drinking coffee at Crema, one of Portland’s finest pastry shops, on a summer afternoon.

In addition to being a respected therapist, Kate identifies as a person with complex PTSD and neurodivergence. “Fat and feral,” she adds, smiling. “I saw that phrase on a baseball cap.” When she was growing up, Kate’s family struggled with poverty. She used welfare tokens for school lunches and knew what to say when the landlord told her that her mom owed back rent.

Kate and I bond over our shared love of Kay Redfield Jamison’s An Unquiet Mind, published when we were both first starting our careers. I recall Jamison’s reckoning as a prominent psychologist living with bipolar disorder: “One is what one is, and the dishonesty of hiding behind a degree, or a title, or any collection of words, is still exactly that: dishonest.”

But Kate’s thinking about self-disclosure as a therapist with mental health challenges has evolved since then. “Take your time deciding whether you want to be entirely ‘out’ as a person with mental health labels,” she says. “There are great liberatory reasons to do so: destigmatization, role-modeling, decentralizing power, and redefining what a therapist looks like. But not every client wants to know their therapist is neurodivergent or living with other labels. If they’re living with the same diagnoses you are, they may be terrified every day and assume you are too. Or they may believe that ‘crazy’ people can’t be good therapists.”

Kate stresses the importance of finding colleagues with solid ethics and similar experiences to help new therapists find their way. “Know your own mental health patterns and have a plan for how you’ll support yourself, including taking rest when you need it,” she says. “Make sure your clients know you have your own professional support. If your clients seem to worry about you a lot, explore that, and make sure you tell them, ‘I have people I lean on for help.’”

Kate shares with me about her early days in community mental health. “I learned that you’ll have clients who will hate you,” she says. “But don’t let that make you quit. Consider what you’ve done in the relationship and what you might do differently. Talk to a supervisor and colleagues. But don’t quit because someone got pissed at you.” As a counterbalance, she adds, “You’ll also fall in love with your clients, not in a creepy, countertransference way, but through witnessing their unfolding and changing, the healing you help make possible. It’s undeniably holy. I’m an atheist, and it’s holy.”

Can you tell me the three most important things I should try to remember when I start working with my clients? Kim’s text weighs on me between sessions, and I wish I could come up with something as brilliant as Kate and Tori’s wisdom. Two hours later, I text back: Go to the bathroom first. Be human. Read your notes.

Go to the bathroom first. When I went through graduate school, no one told me how important it is to go to the bathroom before a session, but it’s a solid piece of advice. You should also eat, stretch, and drink lots of water. If possible, exercise regularly and eat well to boost your endurance. I was many years into the profession before I realized that doing therapy is physical work. In listening closely to the client’s story—both the actual words and the unspoken meanings—we need our bodies to feel alongside them, to tune in accurately to our gut responses, felt intuitions, and empathic resonances. We can’t tap this visceral resource if there are other distractions in our bodies.

Be human. With emerging therapists struggling with imposter syndrome, I often share this well-known passage from the mid-century psychologist Carl Rogers (language adapted by me to be more gender-inclusive):

Before every session, I take a moment to remember my humanity. There is no experience that this person has that I cannot share with them, no fear that I cannot understand, no suffering that I cannot care about, because I too am human. No matter how deep their wounds, they do not need to be ashamed in front of me. I too am vulnerable. And because of this, I am enough. Whatever their story, they no longer need to be alone with it. This is what will allow their healing to begin.

Three simple Rogerian guideposts: You are human. You are vulnerable. You are enough.

It’s not that scientific knowledge and expertise and diagnosis and best-practices-informed interventions aren’t important. But they’re the backstage props to be brought to the stage judiciously, when the client is ready. Presenting a smart persona doesn’t matter to suffering clients. As another colleague, Suze Gadol- Anderson, reminded me: “When someone succeeds, it’s not because of us. If someone is struggling, it’s not because of us. Check your ego.”

Read your notes. Your role is to help your client create a coherent, compassionate narrative of who they are and the life experiences that have shaped them. What happened the last time you met with this client? What piqued your curiosity about them and the challenges they’re facing? What were the questions you didn’t get to ask? Most importantly, what are the themes at the heart of their struggle? Considering our role in co-constructing our clients’ narratives and how notetaking supports that, I’m reminded of a much-loved poem by William Stafford, called “The Way It Is.”

There’s a thread you follow. It goes among things that change. But it doesn’t change. People wonder about what you are pursuing. You have to explain about the thread. But it is hard for others to see. While you hold it you can’t get lost. Tragedies happen; people get hurt or die; and you suffer and get old. Nothing you do can stop time’s unfolding. You don’t ever let go of the thread.

One of my duties with my clients is to find the thread, articulate it, and hold on to it, as if we’re both travelers in the same mythical labyrinth. Often clients come to us with fragmented, jumbled, shame-saturated narratives of what happened to them, and we help them find the coherent story under the confusion, by listening closely, following our curiosity, asking about missing pieces, sharing our gut responses, and trying to resolve our own confusions about what’s going on. You don’t ever let go of the thread.

In a similar vein, in her memoir, Poet Warrior, Native American writer Joy Harjo reflects on her own experience of healing. Her catalogue of transformation sounds as if she too is answering Kim’s question, but from a different wisdom tradition:

At some point we have to understand that we do not need to carry a story that is unbearable. We can observe the story, which is mental; feel the story, which is physical; let the story go, which is emotional; then forgive the story, which is spiritual, after which we use the materials of it to build a house of knowledge.

Five simple stars we might follow alongside our clients on the path toward healing: observe, feel, let it go, forgive, build.

There was so much more I could’ve texted Kim when I thought about it, but in the beginning stages of your career, what you need are simple tips you can hold in your mind when you might otherwise succumb to panic. “Good luck!” I wrote, along with the words every new therapist needs to hear in abundance, words I’d wanted to hear myself, once upon a time, but hadn’t been brave enough to ask my supervisors for directly: “You’re going to be terrific at this work!”

Illustration by Jorm Sangsorn