The Long, Lonely Trek to Licensure

“All right, we’re all out of time for today. I look forward to seeing you two next week.” The smile I offer isn’t reciprocated. Neither partner says anything. He’s scowling, and she’s looking away, tears streaming down her face. He reaches out toward the screen, and it goes black.

I release a long, deep sigh, and a familiar acid seeps into my stomach. Rain slashes against the windowpane.

I slump into my bed, a few feet away from my makeshift telehealth station, and pull a pillow over my head. My session with my supervisor starts in half an hour.

A notification on my phone dings. I tap the screen and see a new email. It’s from a therapist I’d reached out to earlier this week, hoping he’d be able to help me with the sense of inadequacy that has hounded me since I started seeing clients almost a year ago.

Hi Ben, I’ve never seen this, but it looks like your copay would be more than my private pay rate. I have a sliding scale we can use, so sessions would be $85 each. If you’d still like to schedule, let me know.

Another notification pops up:

You’re late on your credit card payment. Click here to schedule a payment and avoid having your account closed.

My breathing speeds up. I think about the rest of the day: after my supervision session, I have a lunch break, then two more couples and an individual. I want to stay in bed and never get up; at the same time, I want to run and drive and never stop. The latter wins out.

I bolt up from bed and dash off an email to my administrative team to cancel my afternoon clients. I know I should contact my supervisor, too, but I don’t. As I rush out the door, I forget to grab a raincoat, and sheets of cold rain cut through my sweater. I clamber into my car and start driving.

Somehow, I make it to a nearby park. Enormous old evergreens dot the lawn, their blue-green needles standing out against a gray sky. I put the car in park and collapse onto the steering wheel. Tears stream down my face, rainwater pours down the windshield, and my body convulses as I sob.

I’m not okay.

A Silent Crisis

For most of us, becoming a therapist is a daunting task. Over the past several years, as I’ve shared my story online through social media, my newsletter, and my Becoming a Therapist podcast, I’ve heard from countless other beginning clinicians who are chronically self-doubting, financially strapped, and just plain worn down. Many of them had never shared their distress before. Some were quietly giving up on the field altogether.

A large survey conducted by Motivo, a virtual clinical supervision platform, found that only 43 percent of psychotherapists ever make it to licensure. From a pool of 150,000 clinicians entering practice between 2019 and 2021, nearly 80,000 encountered barriers that prevented them from getting licensed. That’s more than half! These obstacles remain in place as our country buckles under a severe mental health crisis and badly needs additional capable clinicians. Something needs to change.

A Case of Stage Fright

In graduate school, I was warned about the emotional demands of doing therapy and strongly encouraged to set up systems of self-care. I felt confident my existing systems—healthy and supportive relationships, evening runs, and a deeply rooted spirituality—would help me stay balanced. Nonetheless, soon after beginning to work with clients, something began eating at me.

After sessions, I’d return to my office and curl up on the brown leather couch where my clients had just sat. My fists would clench into tight balls. I wanted to disappear. Eventually, I learned that I was feeling shame.

It turned out that doing therapy wasn’t just a job to me; it was a stage. I felt as though each client was an auditorium full of discerning theatergoers, and that the outcome of each session reflected how well—or poorly—I’d performed.

I didn’t feel comfortable sharing my feelings with my fellow supervisees; it’s hard being the first one to admit you’re not okay. But I needed to connect with someone, badly. So I created a Twitter account (@BecomingaThera) and immediately searched “beginning therapists.”

Search results: 0.

What I did find, though, were big-name players on “therapist Twitter,” clinicians who were self-confidently sharing their perspectives on everything from the intricacies of theory to whether it’s ethical to eat in session (to my surprise, this was quite a heated debate). No one, though, seemed to be sharing the experience, and more specifically, the difficulty, of being a beginning therapist.

Part of me was disheartened, wondering if I was the only one. Another part of me saw a unique opportunity. Could I maybe start the conversation? Why not? So I created a blog.

I began to share how I struggled with anxiety and sometimes needed to cancel sessions because I couldn’t cope. I validated the financial burdens that novice therapists face and was honest about my own credit card debt. I owned my self-doubt and insecurities about being so new to the field.

Beginning therapists responded:

“Thank you so much for sharing. I thought it was just me.”

“I’ve been so scared to speak up in supervision and with my peers. I needed to hear this.”

“I feel so alone.”

Soon 10 followers became 100, and then 1,000, and now more than 6,000. I started a newsletter, and it’s attracted 1,500 subscribers. The numbers themselves aren’t astronomical, but from the start, the urgency of the responses was validation enough. It helped me see that I wasn’t the only one. It also meant this was a bigger problem than I’d originally imagined.

For some, the struggle has been intense and prolonged. One therapist sent me an email full of worry that his career might be cut short because of his depression. “The doubt I have in myself deepens the depression,” he wrote. “If a session doesn’t go so well, it’s hard not to take it personally. And then I feel like a fraud. I’m supposed to be the one with the answers for this kind of thing, right? If I can’t help myself, how can I help them?”

Of course, this therapist needed supervision, but what they craved most was connection with other clinicians who were coping with similar struggles. “Everyone in the cohort I graduated with seems to be doing great,” he continued. “We’d go to happy hour, and they’d gush over how well their clients were progressing and how energized they were by the work. I stopped going because I felt worse afterward.”

Burning Out

I totally got it. Three years ago, as I cried in my car at the park, I’d felt like the worst therapist in the world. I, too, had drifted from the group I’d graduated with. I doubted that any of them went around canceling their sessions because they felt emotionally overwhelmed. I was pretty sure that nobody was thinking about giving up on their career because of fear and anxiety. Everyone else looked like they were thriving, while I was burning out.

Unbeknownst to me, I had plenty of company. When the Motivo survey asked emerging therapists why they weren’t making it to licensure, one of the top responses was burnout. Burnout tends to be associated with emotional exhaustion, which even experienced therapists deal with, depending on their caseload, life circumstances, and self-care routines. What’s more common among newer clinicians, though, is the exhaustion that comes from feeling like an impostor. On top of a demanding caseload, most beginning therapists lack the confidence that comes from years of experience. They don’t yet know that if a session goes poorly, it doesn’t mean they’re a bad therapist. They’re terrified that someday soon, their clients, supervisors, and peers will see through their professional mask and expose them as a fraud.

Coming Clean

The evening of my meltdown, I drove myself home from the park, went to my laptop, and composed a brief email to my supervisor. Sorry for missing today. Can I call you?

As soon as I pressed send, my heart began to race. How would I even begin to explain why I’d no-showed?

Less than a minute later, his response came through.

Good to hear from you. I was a bit worried. Yes, of course. I have some time now. Give me a call.

My hands were clammy and shaky as I dialed his number. One ring. Two. A reckless thought flashed through my mind: Hang up. Just quit and be done with it.

“Hello?”

I couldn’t speak.

“Hello? Ben?”

“Oh, hi,” I croaked. “Sorry, I couldn’t hear you for a second.” Way to go, Ben. Start with a lie.

“So what’s up? Are you okay?”

“Um, uh . . . .” What will he think of me after this? “No,” I finally blurted. “No, I’m not okay.” Tears began to burn at the corners of my eyes.

“All right, what’s been going on?” He sounded genuinely curious.

I plunged in. I told him exactly what I’d been feeling that day, and the day before, and on most days for the past year. I told him how being a therapist felt like being onstage and how every day I felt like I wasn’t performing to audience standards. I told him how badly I wanted to quit, and how ashamed I felt about giving up because all my peers seemed to be doing just fine.

When at last I finished, there was a brief pause. “This is a lot, Ben,” he finally said. “No wonder you’re barely hanging on. Let’s figure out what you need.”

And just like that, I wasn’t alone anymore. There was still the daunting task of identifying exactly what needed fixing and how to go about making it happen. But I wasn’t holding it all on my own anymore. As my supervisor and I continued to talk, a new feeling began to well up ever so slightly. A feeling, I realized, that I’d been missing for quite some time.

It was hope.

Money Troubles

One of the practical steps my supervisor suggested was cutting back on my caseload. I took his advice. Emotionally, this was a huge relief; however, a smaller caseload meant I was making even less money than before. To make up for the shortfall, I began DoorDashing. I’d start the week seeing clients on Monday, Tuesday, and Wednesday. Then, on Thursday and Friday (and Saturday and Sunday if I was particularly cash-strapped), I’d deliver folks their favorite Chipotle or Noodles orders.

Sure, the occasional late order or particularly ornery customer put a damper on my mood, but unlike sitting across from a client for 50 minutes, I could just hop in my car and zip away. All in all, it was less taxing work.

Still, a smaller caseload had a big downside: it was going to take me a lot longer to get licensed. For many therapists, getting licensed correlates with a significant jump in pay. My hope of becoming financially comfortable was pushed out years into the future. I wondered if I’d ever get there.

In the Motivo survery, another top reason therapists gave for not making it to licensure was inadequate pay. Many therapists aren’t paid while they do their practicum. They may have to keep their full-time job to pay the rent and keep the lights on—which means they have to see clients in the evenings. That jam-packed schedule, in turn, leaves little room for rest and self-care.

When therapists do start getting paid, they typically have to make the difficult choice between working for a large agency or a private practice. An agency often provides a modest but steady salary, supervision, health insurance, liability insurance, and sometimes even free training. However, it usually comes with a daunting caseload of 34 to 40 clients a week. A group private practice, by contrast, may come with a smaller caseload of clients who can usually pay more, but there’s often minimal supervision, no health benefits, no training, and no guarantee of success in marketing your services. In essence, beginning therapists can take the safer financial road of large-agency work but risk burning out more quickly, or take the riskier financial road of private practice with less institutional support but the possibility (no guarantee) of higher pay. Regardless of the road taken, most clinicians have to spend years navigating the licensure process before income and caseload can become reasonably balanced.

About six months after I began writing and connecting with beginning therapists online, I offered to meet one-on-one with those who were truly struggling. In responding to their stories, I usually said something simple like, “I’ve been there, too,” or some version of what my supervisor had said to me: “Let’s figure out what you need.” I wanted to grant these novice clinicians even a little bit of the hope I myself had struggled to find.

I found that some therapists were well aware they needed help but couldn’t get it. One beginner told me, “My supervisor is suggesting I get additional supervision because my caseload is growing, but I can’t afford that. I can’t even afford to get my own therapy.” I heard this from many new therapists. I find it sad—maddening, really—that people who daily offer support and healing to others can’t get it for themselves.

This beginner also said he was considering finding a full-time job outside the field while chipping away at his hours to licensure in the evenings. But when he took the risk of sharing this idea with colleagues, they reacted with disdain, saying he’d never make it to licensure if he was “giving up already.”

I was shocked and troubled. This novice clinician was just looking for permission to do what he needed to make it through.

The Way Forward

Beginning therapists are burning out, racking up debt, and giving up on the field altogether. It shouldn’t be this way—and it can’t be if we want to sustain the field. As a first step, more experienced therapists need to actively help their newer colleagues open up about the issues they’re struggling with. We need supervisors to start conversations with supervisees about what it’s like to doubt yourself, feel overwhelmed by your caseload, and struggle with your own mental health issues. We need agencies to take a hard look into how their caseload expectations are crushing those just starting out, contributing to burnout—and in too many cases, quitting the field altogether.

We also need to problem-solve the financial rock-and-a-hard-place that novice therapists endure. Whether this looks like lobbying for larger payouts from insurance companies or advocating for paid practicum placements, we need to speak up for more financial support for emerging therapists.

I’m no expert on the most effective or realistic strategies for change. What I’m convinced of is that we have to start talking as a field about how we’re going to support the next generation of therapists—or there will be no robust next generation. We need to offer a resounding message of encouragement for those entering the field, a message that we’ve been there too, and we’ll do our best to make sure they make it not just to licensure, but to decades of rewarding work after that.

We need to give emerging therapists hope.

Enough is Really Enough

Just a few months ago, I polled my newsletter subscribers on what they’ve most connected with in my writing. A reader replied, “I’ve just needed reassurance that it’s okay for things to not go so well and to know that, in the end, I’m going to be okay.” Many others echoed that response.

Who doesn’t need that kind of reassurance? I know I still do, to this day, whether that’s due to my own history of insecurity, my penchant for comparing myself to my peers, or my financial worries. Yet something has also shifted for me.

Take a recent, dreary-looking Monday. I’m driving into the office when a familiar sense of anxiety begins to tunnel its way into my chest. It’s going to be a long day, with seven clients scheduled. Low clouds cover the early-morning sky. After a few minutes, the anxiety intensifies. I turn down my morning playlist and take a deep breath. As I breathe in, I murmur to myself, I am safe and loved and steadfast. Breathing out, I think, I am enough.

The clouds show signs of breaking as I drive into the parking lot. The anxiety is still there, but it’s at bay now.

I unlock the door with my key card and say good morning to my office neighbor. We commiserate about how tired we are. “Why do we take appointments at 8 a.m.?” she asks with a sardonic grin.

I settle into my morning ritual of sipping green tea, glancing at charts, and scribbling a few gratitudes in my journal. My 8 a.m. client is someone I’ve seen for years now. I feel proud of the progress he’s made, yet 10 minutes before he arrives my stomach still twists.

I don’t want to run, though. I fully anticipate showing up for supervision at 11 a.m. I’m anxious, but I’m also okay.

Breathe in: I am safe and loved and steadfast.

Breathe out: I am enough.

As I open my door to retrieve my client from the waiting room, a ray of morning light breaks through the clouds and dapples my office floor. For a moment, I stop and think back to that teary, rainy day when I collapsed on the steering wheel. A quiet compassion for that younger therapist wells up in my chest.

I smile at my client. “Good morning,” I say, and I mean it.

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