When I was a training therapist, I sat in supervision groups listening to more experienced clinicians discuss “trauma work” as if it were some distinct and almost secret modality. At the time, the term felt technical and gated, packaged as if a therapist graduates from doing “regular therapy” before being able to offer this "othered” serious kind of work.

But trauma doesn’t sit in this sealed box. It is not “underneath” other problems. Rather, it is ever-present in how someone sees themselves, how safe the world feels, how the body interprets and responds to stress, and which strategies are used to cope, avoid, or connect with others.

Therefore, even if you don’t realize it, you are doing trauma work with patients. So, you need to be deliberate with how you’re engaging in it.

Almost 15 years later, I will share what I now know: there is no particular, single thing called trauma work. Trauma work starts immediately. Trauma-focused care is a nuanced lens, rather than a separate category. It’s not “this is depression,” and “that is anxiety,” and trauma is in a deeper fold, just waiting to be processed.

And so this is what I’d like to share with clinicians who still feel mystified by the mysterious phrasing “trauma work.”

Building a Trauma-Focused Framework

This article, like all my articles and books, is intended to be foundational.

It is not rooted in one specific modality or population. I aim to “go broad” to encompass the main strokes. My readers work with all types of people and in all types of settings, and my hope is that there is something for everyone to glean.

That said, use your own discretion and consider that my reflections may not be indicative of your own clinical experiences or particular modes of treatment. Like all clinical suggestions, take what you need and feel free to reach out if something feels utterly off.

Understand That Trauma Work Starts From the Get-Go

Despite how trendy modalities want to package their training, there is not one specific moment where therapy suddenly shifts into “trauma work.”

All therapy is contextual; trauma work starts the first time we sit with someone. That’s because, from the onset, we, as therapists, are being evaluated. The trauma, therefore, speaks to us both verbally and non-verbally.

From the beginning, the patient is assessing: Is this person safe? Can I trust this person with my feelings or needs or longings? How do I balance the shame I feel with the desire to be witnessed and understood? What if I lean all the way in, and they abandon me?

For many people with trauma histories, safety has been deeply compromised. They are inherently hypervigilant about trusting others, and this apprehension unfolds into the treatment.

In other cases, there is such a frantic desire to experience relief that they want to share everything. That feels urgent and acute- the need to “release” feels omnipresent, both to them and to us.

And in some cases, it’s a combination of both: the longing to be seen and the terror of actually being seen.

And so, you are “doing” trauma work by modulating your own presence first. Do not overlook that the extraordinary gift of attunement itself can be a corrective emotional experience. Many patients can feel this as early as the first session, and they should certainly start feeling it within a few sessions.

Even if they don’t feel safe yet (and the safety often does take a good amount of time), there should be a developing felt sense within the patient’s inner monologue that sounds like: “Even if I’m afraid or insecure or feeling extremely discouraged sharing all my stuff, maybe this person can help me. Something about them feels somewhat trustworthy. They feel like they know what they’re doing. And even if I’m uncomfortable, it also feels okay (or even pretty good) talking to them.”

Trauma is Not Separate From Other Presenting Concerns

A common clinical error is assuming trauma exists in its own distinct category.

It doesn’t. A trauma-focused therapist operates under the framework that trauma fundamentally impacts how a person perceives themselves and the world around them.

Trauma can erode internal and external safety, making it hard to feel settled within one’s body and the rhythms of daily life. This lack of safety can lead to avoidance behaviors or the ongoing need to repeat the same behaviors, hoping for a different outcome.

Therapists can theorize that many compulsive tendencies are ways to manage trauma symptoms and maintain a sense of safety in the world. Therapists can also conceptualize that trauma exacerbates other symptoms, including anxiety and depression.

And so, despite how modern treatment plans are packaged, you do not treat one without the other. Neither the body nor the psyche knows “what is depression” versus “what is ADHD” versus “what is emotional neglect.”

The same is true for therapists. You can’t treat anything in isolation because all symptoms overlap and reinforce one another- that’s why changing one way of being can and does often impact the entire system.

Trauma Pacing Requires Striking the Right Balance

Pacing matters in all courses of psychotherapy. Move too quickly, and you risk overwhelming the person, pushing them into the dysregulation, shutdown, or damaging reeactments that often reinforce why they’re in therapy. But if you move too slowly, it feels like nothing is happening.

Both are problematic.

Therefore, the work lives in the tense space between:

Sitting with what feels painful right in the here and now.

Moving toward what has been avoided or what feels intolerable.

The gap between these two states can be quite long, and readiness is often built through ongoing safety and repetition. We strive to meet people where they are, but we hold onto hope regarding where they can be.

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Thank you for being here. If you’d like to support more of my writing, please consider upgrading to a paid subscription or purchasing one of my books.

If you don’t already follow me on Instagram, I facilitate a free Q&A for therapists every Wednesday. In my practice, I offer individual therapy and group therapy for therapists. If you’d like to learn more about me or my clinical offerings, please check out my website.

If you are new to my Substack, I create each of my posts from a place of experience, experience, and humility. While I have spent countless hours in a therapist’s chair and have published content extensively about this field, I wholeheartedly enjoy watching how new knowledge unfolds year after year. These insights emerge from that curious landing space.

With that, my suggestions should never be taken as strictly factual, and I do not prescribe them as the sole way to provide therapy. Our work is both nuanced and delicate and should be respected as such. Take what you need and feel free to share any feedback as you desire.

There is always another compelling must-do, must-have training.

Another Level I, Level II, Level III, another certification that requires another prerequisite course, which qualifies you for another advanced course, which eventually allows you to list more letters behind your name.

If the quest to accumulate more frameworks feels relentless, it’s because it is. And it’s quite unlikely that embracing this scattered approach toward practicing psychotherapy is making you any more effective. In fact, it’s likely exacerbating your stress and reinforcing imposter syndrome.

The Problem of Measuring Competence

In my article, The Psychotherapy Field is a Structural Mess, I dive into the many issues affecting how competence is measured in our profession.

Although we have clarified several common factors that coexist within skilled therapists, effectiveness, in many ways, still feels like an opaque measure. Unlike a surgeon who objectively removes a tumor or a mechanic who determines whether the engine starts, the confirmation that we are doing “good work” doesn’t necessarily show up as concrete data.

Progress is difficult to define. Better yet, what even is progress in the context of psychotherapy?

For example, if someone meets every treatment goal but still feels awful or stuck, did you do good work? If a patient gets angry at you for misunderstanding their experience, are you an ineffective therapist? How long can someone feel worse before a therapist agrees that treatment actually isn’t going well? What really is your role?

How much suffering is expected when someone is confronting trauma, grief, addiction, or attachment wounds? What exactly is our role in any of it?

There are no universally satisfying answers.

All this ambiguity can be challenging to reconcile. I find that new therapists are most susceptible to this existential pain, as they often absorb immense pressure to facilitate treatment according to plan and deliver specific results. But even us experienced therapists often find ourselves questioning: what really is our role here? Do I know enough to help this person? Am I missing something fundamental here? Am I too complacent? Is this level of anxiety (or lack thereof) normal?

And ample space for subjectivity just isn’t always welcome.

Patients in distress understandably want immediate relief. Parents want their child fixed. Partners want their marriage saved. Insurance companies want clear diagnoses, objectives, goals, and evidence-based interventions attached to those goals. Society at large increasingly prescribes “going to therapy” as though therapy itself is a standardized intervention capable of resolving nearly every form of human suffering.

We also want to do right by our patients.

We want them to thrive and leave therapy with a positive impression of what this work can offer them.

We definitely don’t want to cause harm, leading us to often ask ourselves, Am I really helping here? Could I be providing more? Doing more? Am I falling short?

I believe that it is within this fragile arena that we are most vulnerable to latching onto the belief that accumulating more theory or more interventions will translate to more competence.

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The Problem With Learning By Accumulation

First things first: training is essential.

Pursuing ongoing education and refining our skills are integral parts of maintaining an ethical practice. I don’t think many therapists would disagree with me on this claim.

I value my hunger for knowledge and have plenty of trainings under my professional belt. Each year, I read anywhere from 50 to 100 books related to the field. I attend ongoing consultation groups and meet with an individual supervisor myself. I have a personal therapist, and I like to think I’m invested in “doing my work.”

I am the first one to say that it is not enough to just arbitrarily ‘trust the process.’ You cannot trust a process if you don’t understand what the process is supposed to entail. As I often remind training therapists, it is quite possible to cook chicken every night for years without being skilled at cooking chicken.

Rote practice alone does not always translate to effectiveness. You can cook chicken every night for the rest of your life, and it doesn’t mean you should open a restaurant.

But instead of learning how to cook chicken well, many therapists decide they must learn how to cook chicken and bake apple pie and grill steak and make homemade pasta and perfect a soufflé at the same time. They choose to take introductory courses in six different cuisines, but they still don’t feel particularly confident with that chicken.

Now let’s see how this happens in our field.

We know that experience does not guarantee competence, but have we overcorrected by assuming that competence derives from accumulation? Accumulating more modalities, more frameworks, more interventions, more certifications?

The motive is good. There is always more to learn.

You study trauma and realize you need to learn more about dissociation. You learn about dissociation and realize you don’t know enough about the nervous system. You learn about the nervous system and realize you don’t know enough about attachment. But is it attachment? Or is it ADHD? OCD? PTSD? What about the bulimia? What about the impact of perimenopause? What about the influence of their culture? Their religion? And are you missing the mark if you don’t utilize Brainspotting? EMDR? IFS? NARM? ERP?

The problem is not that these areas are irrelevant. The problem is that they can all be perceived as highly relevant. Every lens offers a new way to understand the person sitting across from us.

But no one lens is the ‘perfect’ lens.

Because this can feel unsettling, we seek more training. The training exposes us to another enormous body of knowledge we have not mastered. We might leave knowing more, but we also become more aware of everything else we still don’t know. We’re often left with more insecurity, making another certification sound even more appealing.

The Certification Industrial Complex

Choosing a modality is hard. In some ways, it’s like choosing a profession. You have a sense of what you will enjoy, but you may not know how it really resonates with you until you’re in the weeds of it.

In graduate school, you should receive a foundational breadth of various theories. That doesn’t mean you feel competent. If you’re like many therapists, you enter the field feeling woefully unprepared and scattered. You’re given a high caseload with an hour of supervision and a prescription to just be curious!

To feel a little more secure in your work, you consider getting certified in something. As you start searching, you are bombarded with all kinds of tracks, classes, programs, mentorship opportunities, and fancy sets of acronyms available for purchase.

You choose one and get started. You’re so excited for what you will learn.

What often happens is you feel like you’ve now stepped into some dogmatic space where you are now privileged to learn the “secret way” for doing the “best kind of therapy” there is.

This therapy is the right therapy, which means all the other ways of practicing therapy are outdated, harmful, misattuned, simplistic, or otherwise unethical.

You have found the answer for working with couples or panic disorder or addiction, and everything else is missing something essential. And if you aren’t intervening from this framework, you may as well deem yourself incompetent and report yourself to the licensing board.

I am somewhat exaggerating, but only somewhat.

My observations come from what I have picked up throughout years of attending trainings myself. Just like when we get invested in any hobby, it’s easy to feel a bit frenzied in our quest to internalize the skills. But once we have to commit to the rote practice (which can often feel awkward and clumsy), it’s tempting to then abandon them for the next shiny, exciting hobby.

Integration and Consistency Over Accumulation

Therapists risk feeling profoundly fragmented when they collect trainings instead of integrating the knowledge they learn.

If you learn IFS, you will start looking for parts, but then, if you read a book about attachment, you will start conceptualizing your patients through the lens of attachment styles. Take an introductory somatic course, and you learn to track the body. Intersect that with psychodynamic work, and you might feel preoccupied with exploring transference. And once you learn ERP, you will certainly want to pay attention to themes of reassurance-seeking and the compulsions reinforcing anxiety.

I digress.

All of these things matter. We are always presented with infinite paths we can take with our patients.

But breadth is not the same as depth, and at some point, professional growth often requires slowing down the acquisition of new frameworks and spending considerably more time in the ones you already know.

What good is every tool if you don’t know which one to use or when to use it?

Patients can feel your fragmentation. If therapy feels like a sequence of techniques rather than a coherent process, they may struggle to understand what you’re actually doing together. The work always needs a consistent presence, even when you draw from multiple frameworks. Integration means the approaches inform one another instead of operating as totally separate clinical agendas.

The integrated therapist moves fluidly. They understand how separate interventions may connect to a larger clinical understanding. They have absorbed their training enough that their work doesn’t feel like ‘switching’ between totally different modalities or techniques.

Integrated therapists do not perform a series of interventions. Their entire being carries the intervening presence with openness and regulation. Their training feels so integrated that they do not visibly “put it on.”

If you are fortunate enough to know a therapist like this, you can sense their embodiment. They do not scramble to determine which technique belongs where. They feel grounded, although they are equally responsive to the person in front of them. They can tolerate not knowing exactly what to do next because they hold a greater understanding of what they are doing and who they are with that patient.

This fluency does take time, and it also takes the commitment to integration.

When Should You Get Certified Then?

Certifications can be immensely valuable, and specialized training augments our professionalism. Patients need therapists with knowledge and competence within their areas of concern.

So, when therapists are considering some kind of certification, I think one of the most helpful questions is: What problem am I hoping this certification will solve?

Ideally, your answer lands somewhere concrete.

Maybe you’re working with a population you do not adequately understand, or you feel like you’re flailing with treating certain symptoms. Maybe consultation has revealed a gap in your knowledge, or you have discovered a specific area you genuinely want to devote months or years to studying.

These answers have nothing to do with what other therapists are or aren’t doing. Just because everyone else is trained in a modality or you feel like it’s the “thing” patients want doesn’t actually mean it’s the right fit for you.

This field moves through trends quickly, and as therapists excitedly talk about an approach, it can feel like you’re behind on training. You might worry that you’re missing something if you do not speak the language everyone else is speaking.

There is so much marketing pressure driving these loud trends. And in recent times, as therapy has become so mainstream, many patients are requesting specific approaches directly.

It is completely understandable to want to remain relevant and responsive to these needs. We just have to be mindful about how we build our practices. Trends change, and perpetually pivoting to meet those trends risks you feeling scattered: you become familiar with hot approaches, but you are not grounded anywhere.

Real knowledge comes from actual integration, and actual integration requires ongoing consistency and deliberate practice. You have to really study something long enough to understand its nuts and bolts, and you have to engage in it long enough to internalize its clinical blueprint.

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What Actually Makes Therapists Better?

It is always beneficial to consider how to actively refine the work you already do with the knowledge you already have. Here are some of the gentle suggestions I often offer to my supervisees or within the workshops I facilitate:

Prioritize Direct Feedback

A patient’s perceptions around therapy should not be a mystery. If they are, you are potentially missing key information about the treatment. It is your responsibility to remain curious about how they experience the therapeutic process and how they experience you.

This is NOT about turning sessions into satisfaction surveys (*although I recognize insurance companies sometimes require this). Instead, feedback is woven naturally into the relationship, with patients being presented with ongoing opportunities to share their reactions about your work: What was it like when I said that? I noticed you got quieter after I responded. Did I miss something there? What do you imagine I’m thinking about you right now? Was there something you wanted from me that you didn’t get today?

You can pay attention to shifts in affect, withdrawal, compliance, irritation, idealization, avoidance, and what patients struggle to tell you directly. In depth-oriented work, you do not necessarily perceive feedback as confirmation that you are doing a “good job,” but you do contextualize it as important relational data. How patients respond to you and how safe they feel disagreeing with you offer information about how the treatment and relationship are unfolding for them.

Deliberate Practice and Dedicated Repetition

Deliberate practice entails identifying one specific skill and working on it repeatedly. For example, if you’re a new training therapist, you commit to ending every session on time. You prioritize strengthening this single part of therapy. In prioritizing this one skill, you will notice when you start wrapping up and what most interferes with ending. You will also notice whether your timing becomes more natural with practice.

Having such a narrow focus allows you to observe whether your skill is actually changing. It also gives you space to uncover what might be making improvement difficult.

Maybe, as you start practicing something, you discover that you lack a particular clinical skill, and that data points toward consultation or additional training. Again, you can cook chicken 10,000 times, but repetition alone does not tell you whether you’re cooking it well. First you learn to cook it reliably; then you refine timing, technique, seasoning, and eventually the more advanced skills that build upon the fundamentals.

Consultation and Supervision

These always matter because they allow you to work through blind spots and broaden your existing skills.

Through outside discussion, we consider formulations we may have overlooked and practice questioning assumptions we have started treating as fact. This allows us to examine how our own reactions influence the treatment.

Good consultation should not merely tell you which intervention to try next. It should consistently enhance your ability to think clinically across the board.

Immersion

As an athlete, I have always valued the benefit of structured training blocks. Dedicated blocks support us in concentrating our energy on developing something specific rather than vaguely trying to improve everything simultaneously.

I think therapists benefit from applying the same mentality.

Consider committing to immersion over sampling. Spend six months reading deeply about one area. Join a consultation group and bring cases through the same lens. Revisit the foundational texts. Practice the interventions repeatedly.

What I’m really saying is to give yourself enough time inside one body of knowledge to move beyond introductory understanding. You can always study something else later. But constantly switching subjects deprives you of the sustained attention that allows knowledge to consolidate into genuine integration.

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Thank you for being here. If you’d like to support more of my writing, please consider upgrading to a paid subscription or purchasing one of my books.

If you don’t already follow me on Instagram, I facilitate a free Q&A for therapists every Wednesday. In my practice, I offer individual therapy and group therapy for therapists. If you’d like to learn more about me or my clinical offerings, please check out my website.

If you are new to my Substack, I create each of my posts from a place of experience, experience, and humility. While I have spent countless hours in a therapist’s chair and have published content extensively about this field, I wholeheartedly enjoy watching how new knowledge unfolds year after year. These insights emerge from that curious landing space.

With that, my suggestions should never be taken as strictly factual, and I do not prescribe them as the sole way to provide therapy. Our work is both nuanced and delicate and should be respected as such. Take what you need and feel free to share any feedback as you desire.

Is this the right relationship?

Am I making a mistake?

What if I regret this?

What if my health gets worse?

What if I relapse?

What if something happens to my children? My parents? My dog? My home?

People bring these heavy questions into therapy every day. They want to absorb our perspective, our expertise, and maybe our explicit permission before they make a big decision. Under all this, they want absolute certainty.

As you keep pressing and exploring through the folds of therapy, you find these questions move into the more existential request of, tell me what happens next, and beneath that, tell me that I will be okay.

Although it is not always advertised this way, a great deal of therapy requires sitting with the vast unknown. We obviously cannot predict the future any better than our patients can. To make things even more complicated, we also cannot guarantee the objectivity of the past or even what’s fully happening in the present. Instead, we rely on our patients’ self-reported stories: how they experienced events, what they remember, what they have forgotten, what they choose to disclose, and the meanings they have assigned to what happened. We also rely on our own clinical intuition and subjective bias about what is occurring in the here and now.

There is so much we do not know, cannot know.

As our patients grapple with this uncertainty, we must embody our own capacity to tolerate it with them. This can be harder than it sounds, but it remains one of the most important pieces of our work.

Why We Desire Certainty

Certainty seduces us because it promises prevailing relief.

If I know this outcome will happen, I can prepare for it. I can rehearse it. I can find safety and regulation around it.

The illusion of certainty regulates the emotional anguish that lives within the ambiguous edges of not knowing. We assign certainty to a grandiose pedestal, as if just knowing the answer would allow us to relax into something that feels impossible to trust.

And so, we rely on brilliant strategies in an attempt to obtain certainty. These include habits like avoiding, researching, checking, seeking reassurance, ruminating, monitoring emotions, developing multiple contingency plans, and revisiting decisions that have already been made. Some of these strategies are unwanted. Others feel embedded within us; they are respected and validated, despite evoking immense distress.

All of these strategies offer brief hits of relief, reinforcing the need to continue doing them when uncertainty emerges. The more we continue engaging in these strategies, the more habituated we become to the security offered within these mental cycles. Amid them, we code uncertainty as a dangerous beast that must be tamed. Because we fear it, we want to eradicate it. Or, in the case of this work, patients sometimes want their therapists to eradicate it for them.

There is a great deal of suffering here.

This is because certainty, of course, is impossible. Few things in this life are guaranteed. And even though we intellectually know this, truly accepting the bounds of this unknown can, at times, feel impossible.

The Facades of Certainty

Although very little can ever be guaranteed, modern society now allows us to track every nuanced detail with meticulous rigor.

We can view our heart rates, screen time, basal temperatures, steps, spending patterns, investments, calories, menstrual cycles, weather patterns, and the quality of our sleep cycles. We can examine menus before choosing a restaurant and read countless Reddit threads comparing mattresses. When we are at the grocery store, we are seemingly presented with over 100 types of white bread, and I haven’t even mentioned the whole-wheat or gluten-free options.

And with the advancing speed of artificial intelligence, we can look up any symptom or question within seconds. We can ask the void what something means, what to say, what to do, and when to do it.

Some of this is useful. It is nice to be able to research various options and compare what might work best for us in a given situation.

But access to this endless stream of information risks even more disconnection from ourselves. If we default to continually seeking, checking, and reassuring that we made the right choice, we also default to outsourcing inner wisdom and intuition. As this pairing persists, we continue reinforcing the notion that more information will somehow lead us to the perfect conclusion.

It’s an illusion. In our efforts to find certainty, we are more seeking to remove the vulnerability of failing. And this is a risk that can never be fully removed.

The more we cling to find certainty, the more uncertain we feel.

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Building Inner Trust

If certainty says, I can relax once I know what happens, inner trust says, I can find the capacity to respond even though I cannot know what happens.

This sounds wonderful in theory. But for many people, this capacity feels inaccessible, and it’s why they’re in therapy. They do not trust their present or future selves to withstand the terrifying rejection, the heartbreak, the economic disaster, the devastating illness, the death of someone they love, the process of aging, the potential relapse, or whatever other possibility fuels their anxiety.

They imagine themselves being swallowed whole by the catastrophe.

When they are swallowed, they are damaged beyond repair. They are defenseless and unable to find their way back. Conversations around ‘tolerating uncertainty’ are too simplistic. They do not just fear what might happen. They fear complete wreckage, the kind that ravages one’s entire existence.

The desire for certainty creates bids for safety. If I can predict it, I can prevent it. If I make the perfect decision, I won’t be regretful, abandoned, hurt, defenseless, or unprotected. If I notice every possible warning sign, nothing will catch me off guard.

The bids are tantalizing, but they are impossible to fulfill.

Despite vigilance and the absolute best efforts, you cannot curate a life completely devoid of illness, betrayal, aging, relapse, death, or grief. Eventually, therapy has to help people develop a different relationship to their own vulnerability.

The Basement of Fear: “I Wouldn’t Survive It”

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Therapists are trained to understand love.

In our clinical work, we conceptualize patterns of connection and repair, explore remnants of relational trauma, speak about attachment, and aim to help people untangle the complicated ways they protect, love, abandon, and rediscover one another.

We talk about whom and how our patients love (and don’t love) all day.

Some of the stories around love are uplifting. Many are quite harrowing. All of them have relevance, teaching us about how our patients move through the world and what relationships mean to them.

And as therapists, we aim to be the regulated secure bases, exhibiting attunement and unconditional positive regard. After all, we know that the strength of the therapeutic alliance is an essential element of successful treatment.

We know all this. Yet, within our own work with patients, love remains one of the most taboo and uncomfortable words to say aloud.

Can a therapist love a patient? Can a patient love a therapist? What makes the love real? And whether it is or isn’t real, how does treatment unfold ethically and sustainably, in a way that best supports a patient’s whole self?

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The Origins of Love in Psychotherapy

From the beginning of therapy, love has been understood as a core ingredient in healing. It was Sigmund Freud who wrote a letter to Carl Jung that “psychoanalysis is in essence a cure through love.”¹

Well over a century later- and despite a slew of criticism toward Freud’s work- ongoing research in attachment and developmental psychology continues to echo this foundational idea. As early as graduate school, clinicians are reminded that the quality of the therapeutic relationship is among the strongest predictors of successful treatment outcomes.²

But what makes some therapists consistently more effective at fostering these high-quality relationships than others? When I began synthesizing research for my second book, For the Love of Therapy, I delved into the data behind the concept of supershrinks. This endearing term describes how patients of the best therapists improve at least 50% more and drop out at least 50% less than patients of average therapists.³

In another post, I will distill the key ingredients of a supershrink. For now, it is enough to say: they know their baseline, they practice deliberately to improve their baseline, and they remain adamantly receptive to feedback at all stages of their career.

For the sake of this article, it’s important to focus on receptiveness. How we interpret and integrate feedback creates deep opportunities for attunement. When patients trust we can truly respond to their needs, therapy can deepen at a pace that feels simultaneously tolerable and transformative.

The Gift of Empathic Attunement

Virginia Satir said:

“I believe the greatest gift I can conceive of having from anyone is to be seen by them, heard by them, to be understood and touched by them. The greatest gift I can give is to see, hear, understand and to touch another person. When this is done I feel contact has been made.”

We know connection matters in every relationship. We also know relationships lacking genuine connection feel sterile and even hollow. This is true in psychotherapy, and it is true in all facets of life.

Feeling positively perceived creates the foundation for connection to flourish. The opposite is also true. When we sense someone might reject or dislike us, we employ numerous survival strategies to maintain a sense of safety. We lie, downplay, rationalize, withdraw, divert, dissociate, project, abandon others, and abandon ourselves.

Patients come to therapy with agonizing stories, with behaviors that feel destructive and thoughts that scare and depress them. They often initiate the process at a time of profound stuckness, wedged between knowing something needs to change and doubting or downplaying or fearing their inner capacity to make that change.

Regardless of the presenting concern, they look to us for answers and guidance. For validation and witnessing. For the blueprints to know how to move forward.

They gaze at us for the mirrors we hold and the frames we maintain. It is a breathtakingly vulnerable process that deserves the utmost respect.

And as they wade through their ambivalence around change, patients also often reveal their own attachment wounds. Through dialogue, both therapist and patient recognize how and when others did not meet their needs. We collaboratively develop language to understand the fears of rejection and the terror of abandonment. They begin to grieve what they did not receive just as deeply as they grieve what felt actively harmful.

Diana Fosha, founder of accelerated experiential dynamic psychotherapy (AEDP), where I have received extensive training, emphasizes that the core process of therapy lives within the capacity of undoing aloneness. The felt sense of being held in the mind and heart of the other supports inner resilience and allows previously unbearable emotions to be metabolized.⁴

To simplify, fewer interpersonal experiences in life feel more regulating than knowing your internal world matters to another person.

Love in therapy does not always need to come in the form of an explicit declaration. Instead, it embodies an orientation that lives through this empathic attunement.

If we travel back to Freud, to the origins of our profession, even he warned against approaching sessions with a rigid analytic mindset. Instead, he suggested that theoretical formulations and diagnostic frameworks be set aside long enough for einfuhlung, which may be most closely translated to empathic attunement, to guide a therapist’s work.⁵

His contemporary, Sándor Ferenczi, expanded the idea. In a renowned speech in 1920, Ferenczi noted how progress in therapy had less to do with the patient’s intellectual insight or how they retrieve memories. Instead, his method developed to the fullest when he recognized that genuine sincerity and empathic attunement were the essential ingredients to reach a traumatized individual.⁶

Relational presence was and is held as the key factor in psychotherapy. The well-known psychoanalyst Nancy McWilliams writes that analysis is a:

“mutually loving process in which the therapist’s subordinated subjectivity fosters an actualization of love along with an actualization of self in patients through a natural progression of desire, belief, and hope… I think the therapist’s love is experienced mainly in processing the repetitions. The client may feel hurt in ways excruciatingly like his or her childhood suffering, and yet the therapist, unlike the early love objects, tolerates the client’s pain, knows that the interaction feels horribly familiar, and by empathy and interpretation contributes to the client’s capacity to distinguish what has happened now from what has happened in the past.”

This exquisite explanation speaks to the depth that empathic attunement can offer. While our roles cannot be that of a rescuer or eraser, we accompany people as they sort through their suffering. We remain present as they revisit familiar wounds, and we consistently tolerate all the emotions that arise with that scaffolding.

Experiencing Love in Therapy

I stumbled upon love accidentally in my own psychotherapy.

Like many providers, I carry a textured life riddled with strife on my back and am no stranger to engaging in my own internal work. The many, many hours I have spent sitting on the couch myself have been instrumental in becoming a more integrated and regulated human- which supports me in life and in my professional role.

Therapists owe it to themselves and their patients to engage in such introspective, depth-oriented processes. After all, how can we lead someone into the raw places we are unwilling to travel to ourselves? If we cannot tolerate the complexity of someone sitting with us, we will struggle to tolerate the complexity of sitting with others.

Those familiar with practicing psychodynamically are aware of the currents of transference and countertransference that reveal themselves in treatment. This emergence is not not wrong or bad, but how we attach in therapy contains significant data about how we attach everywhere in life.

I have worked with different therapists over the years. Some felt more effective than others, but all experiences, even the negative ones, supported my growth.

Several years ago, sifting through new layers of trauma work, I found myself feeling especially tender toward my own therapist. As our relationship deepened, I began pairing her warm presence with immense comfort. By that point, I had received many important corrective emotional experiences, moments where I anticipated rejection and instead received curiosity or where I expected judgment and instead found compassion. This safety allowed me to work through tender material that had long remained guarded and avoided.

At one point, while expressing some glimmer of gratitude for the safety I felt, I said, “I love you. I love being with you,” and she responded, “I’m just taking that in, and I love you, too.”

I immediately protested: “You’re not allowed to say it back.”

And she asked, “Why not?”

Why not?

At the time, the answer felt so obvious that her question felt ridiculous. Therapists were expected not to say that. Those three words in that sequence crossed a line. It insinuated reaching some dangerous edge, blurring the boundary between professional care and personal attachment. You were allowed to say, “Thank you,” or “I have love for you.” You were definitely allowed to explore, “What does that love feel like?” or “When have you felt this way before?”

I don’t remember how I responded. I do know we have we spent many hours unpacking the concept of love and what it means within therapy, within life. We still explore this, as I continue to discover what love asks of me and within me. Love itself isn’t a conclusion or an arrival. It remains fluid, and the questions it evokes in therapy are ultimately the same questions it evokes everywhere else.

What does it mean to love and trust with such expansiveness it ignites your soul? What does it mean to trust despite fear, uncertainty, longing, and the risk of getting hurt? What does it mean to love someone who knows the parts of yourself that feel so damaged? What does it mean to receive care during a state of crisis or within the tight folds of hot shame? What is co-created within the nuanced context of therapeutic intimacy?

And what, if anything, makes those questions different from the ones we ask of love everywhere else?

And perhaps the deepest question for therapists and patients alike: What is it like to experience a love that is both safe and steadfast? One where the limits are unmistakably clear, but the warmth is never withheld. A love that does not rescue or possess or masquerade, but gently and consistently offers a coexistence of closeness with safety.

The Backlash Against Love

I have always felt love toward my own patients.

It is fierce and unquestionable, as real as the love I feel toward the many other people in my life. When I lead with love, which I consciously choose to do, the work feels soft and expansive.

My patients amaze me; I want them to feel embodied in their own inherent goodness. They carry so many unique strengths, and my hope is that they land in those strengths when they feel resourced and ready.

When I lead with love, the work is exquisite. Compassion comes easily. Patience comes easily. It also becomes easier to tolerate ambiguity and remain regulated during painful moments.

But love is not inherently ethical. In fact, fewer concepts in psychotherapy have the potential to become as misunderstood. That is why our profession remains so cautious around the language of love. Without oversight and protection, we can cause great harm.

Love and Unethical Actions

We are quick to conflate the feeling of love with behaviors that are clearly unethical, including harmful boundary violations, dual relationships, or fostering dependency for personal gratification. As a patient, I have been on the receiving end of these behaviors in my own therapy.

Unchecked affection feels good until it doesn’t.

As a supervisor, I have watched many well-intentioned therapists use love as a rationale for murky boundaries or choices that ultimately serve their needs more than their patients’. This is problematic, and the slope is as insidious as it is slippery.

Therapists need to be mindful of how they respond to love. If not, urges to comfort, rescue, or be the “only one” who truly understands the patient can damage the therapeutic process. Love then becomes about satisfying one’s own ego. Without reflection and thoughtfulness, the emergence of love can morph into the therapist meeting their own need to feel “good” or “needed.”

Love and Sex

Because these risks of therapeutic harm are real, the concept of love itself becomes suspect, and we warn therapists with guidelines that say, Check your countertransference! Don’t foster dependency! You should be working yourself out of a job!

Such cautions do serve an essential purpose, creating inherent guardrails protecting vulnerable people from harm. An overwhelming majority of patients seek care with histories of being abused or exploited by figures of authority. Many arrive wary, anticipating rejection and scanning for cues that pain will repeat itself. This vigilance has likely caused some suffering, but it has also helped them survive.

Respecting this dynamic matters.

The power differential in therapy cannot be overstated. No matter how much we dismantle our authoritative presence or emulate a sense of equality, therapists do hold tremendous power within the room. The person in power is always responsible for how they manage that power.

I cannot locate precise, recent statistics on therapists engaging in sexual behavior with patients. One dated study published in 1993 reports that between 1976 and 1986, approximately 45% of all malpractice insurance claims paid on behalf of clinicians resulted from therapist-patient sexual contact.⁷ Of course, it is imperative to mention that many cases remain unrepresented and undreported.

Sex with patients is always exploitative, so the ethical line must remain unequivocal. Even if feelings of love seem genuine, the therapist’s authority and inherent emotional influence erode the capacity for true consent.

Love and Longing

Love in therapy does not always feel warm or comforting.

Sometimes it feels disorienting and shameful, particularly when it shows up through erotic desire, maternal or paternal yearnings, or the global aches to be chosen, protected, rescued. Psychodynamic therapists understand these experiences as forms of transference, which speak to how the patient’s emotional history emerges directly within the therapeutic relationship.

These feelings can elicit many different types of reactions, including a deepening preoccupation with the therapist, replaying sessions or conversations, desiring more contact, jealousy of other patients or family members, uptick in certain behavioral responses. This can happen even (and often) if the patient never discloses them aloud. And if they do mention something, therapists often feel anxious about how to respond appropriately.

When such longings become visible, they often speak to unmet attachment needs that predate therapy and may continue to exist in the here and now. For many patients, therapy is the first experience of true emotional witnessing.

The therapist must balance the delicacy of holding such longing without extinguishing or indulging it. In other words, we engage these longings with respect, curiosity, and reflection. We do not “give in” to them inherently, nor do we shut them out. We slow the process and explore what the longings are asking for.

What does this experience represent? How did it originate? What emotional needs are being illuminated in this present moment? What grief exists in this space?

This scaffolding can be painful and exposing. Patients may feel confused, angry, humiliated, and vulnerable. Therapists need to be regulating; we must remain steady as patients navigate their attachment uncertainty.

If you rush to extinguish longing or distance yourself from it, you inadvertently teach that longing is dangerous. Steadiness, on the other hand, communicates that such feelings can exist and be spoken about.

Over time, steadiness becomes something the patient carries within themselves. It takes time, but the deeper work is not about eliminating attachment needs or convincing people they should no longer care so deeply. Instead, we aim to develop internal relationships that feel sturdy enough to hold such needs with more flexibility and self-compassion.

Longing is survivable, and it can exist with boundaries, uncertainty, and the ongoing movement of life. But this requires therapists to remain thoughtful rather than reactive and to mentalize rather than gratify or withdraw.

Love and Dependence

One of the more pressing concerns about love in therapy is that it inevitably cultivates dependency. The fear is that if someone feels deeply cared for, they will cling to the relationship. They will need the therapist too much. They will never get better.

This is a fear experienced by both patients and therapists alike.

In such an asymmetrical relationship, these fears require immense holding. We come in with our authority and expertise. We can exploit attachment even with the absolute best intentions.

Dependency emerges when we pair love with fractured treatment: inconsistent messaging, grandiose promises, subtle or obvious reinforcement of helplessness, and avoidance of the patient’s world outside of what may be happening in the here and now. Dependence occurs when we fail to support people in integrating what is felt in treatment to what can be felt in life.

This transition takes time, and the process can feel quite choppy. Amid attachment uncertainty, it is not uncommon for patients to compare other relationships to the therapeutic one. Patients may feel resentful that others do not listen to them the way their therapist does. They may feel icky around the concept of closeness and trusting another person with their secrets. All of this can amplify attachment concerns.

At this, we go back to the heart of corrective emotional experiences. Research in neuroplasticity shows that experiences of safety support the brain to rewire messages around attachment.⁸ When people are met with attunement and empathy, they can slowly internalize: I can be known and still be safe.

This template supports a desire to start meeting needs outside of therapy. Patients engage in real-world attachment, learning new ways to seek closeness and relate to others. It is rarely linear; it is more typical to oscillate between fear and courage or despair and hope.

Again, the therapist’s role is to maintain steadiness through these fluctuations. Our reflection and consistency continue to support the ambiguity experienced in life.

This is the essence of holding a patient instead of keeping them. To hold is to offer reliability and respect. You are available within your frame of treatment, but the relationship is always attuned to expanding the patient’s life to greater degrees.

Being kept happens when a therapist positions themselves as indispensable. This maintains unrealistic expectations of what you can provide, and this ultimately harms patients. In all cases, keeping a patient is about the therapist’s ego, not the patient’s growth.

What Are We Talking About When We Talk About Ethical Therapeutic Love?

Humans are wired for connection, primed for love. If therapists have the honor of leading with anything, we lead with the traits that emulate love: patience, unconditional positive regard, curiosity, compassion, and kindness. We lead with what we want the patient to internalize for themselves.

Thus, love in therapy must be approached with tremendous care. The power differential is real, and longings can feel dysregulating. If therapists lose sight of their role or attempt to meet their own emotional needs within the relationship, boundaries can be violated, and harm can take place.

Ethical love never binds two people together, and in therapy, it aims to strengthen the patient’s capacity to form secure relationships with themselves and others.

These risks are real, and it’s also important to note that the presence of love itself clarifies why we must take it so seriously. When we can hold it intentionally, we can offer the gift of therapeutic love.

From this framework, therapeutic love is both intentional and profoundly relational. Unlike other forms of love, it is meant to be adamantly consistent. Boundaries are never crossed because nothing is untamed or indulgent or reckless about it.

Because this love remains disciplined and mentalized, it allows us to offer the presence someone can rely on steadily over time. It is this presence that creates the conditions for feeling seen, understood, and held.

Therapeutic love, therefore, is an ethical, deeply human practice. It is the container through which we provide the corrective emotional experiences that give healing a heartbeat.

“It’s Not Love; You’re Just Paid to Care”

Money is deeply emotional, and the transactional nature of therapy poses numerous complications.

At some point in treatment, patients grapple with the reality that they are buying a therapist’s time. As this realization intensifies, it can spiral into fear or rage or disgust: If I am purchasing their time, I am purchasing their care. If I stop paying, I no longer receive their care.

This logic is straightforward. If an hour must be bought, the same must be true for that warmth, compassion, and co-regulation. If one does not buy the hour, these elements would not exist.

At this crux, the relationship can start feeling both artificial and fragile, as though the connection is only contingent on a financial agreement rather than something genuine between two people. Many therapists will respond with something like, You pay for my expertise- my care is free!

But it can sometimes be more useful to widen the lens, and I have explored this both with patients and supervisees. As we know, nearly every human relationship contains a transactional component. The only dynamic that does not require any form of reciprocity is that between the infant and caregiver. And while children certainly do not “owe” their parents anything, even young toddlers start attuning to their caregivers’ needs and preferences.

From an early age, we all learn the intricate tango of “take” and “give.” If I do this for you, you do that for me.

In this sense, therapy is not unique because of the transaction. Instead, the unique part is that the transactional element is explicit and concrete. Unlike other relationships, where expectations may feel more ephemeral, this one is clear.

If you pay me _ for the hour, I give you _.

This agreement does not manufacture care within the relationship; it just structures the containment in which care can occur. Payment ensures the therapist’s expertise, time, attention, and availability. It protects that specific hour and that special frame; both people know to show up consistently and engage in the meaningful work together.

The transaction safeguards the relationship. It clarifies the role and protects the emotional space where all parts and feelings are welcomed. Because the parameters are known, the patient does not have to earn the therapist’s presence through likability, emotional caretaking, or social reciprocity (although they may still try to engage with the therapist through those patterns).

Payment may secure the hour, but nobody can force a genuine relationship. That part depends on something beyond any transactional bounds: the therapist’s capacity to build authentic rapport and offer safety within the relationship.

If you cannot achieve that, treatment will not progress.

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“But They Don’t Really Know You”

Carl Rogers said:

“The therapist should be, within the confines of that relationship, a congruent, genuine, integrated person. It means that within the relationship he is freely and deeply himself, with his actual experience accurately represented by his awareness of himself. It is the opposite of presenting a façade, either knowingly or unknowingly. It is not necessary (nor is it possible) that the therapist be a paragon who exhibits this degree of integration, of wholeness, in every aspect of his life. It is sufficient that he is accurately himself in this hour of this relationship, that in this basic sense he is what he actually is, in this moment of time.”

His emphasis on authenticity spoke to how therapists can and do bring their true selves to work.

When I say I lead with love, I do not mean something sentimental or performative. It is not something I “turn on” when I come into the room, like a professional costume I put on for the sake of the hour.

Leading with love can guide how we sit with patients. When I meet with people, I am not coming in with just fragments of myself. I am me, even though parts of me are not necessary or appropriate to showcase.

I do not leave my humanity when the session begins. However, I am deeply mindful of which parts of my humanity benefit from being displayed and which ones do not. Because of this discernment, patients always receive access to my full presence with no distractions distorting our time or energy. Within their time, there is no competition- there is nothing else but them, me, and the time together.

This evokes the other common, legitimate critique of therapy: But you know them, and they don’t really know you.

And this is correct.

People see one side of us, and it’s not the full version. That’s a very good thing. Patients do not and should not have access to our entire lives. They lack the full scope of our history and relationships, the details of our struggles. They do not witness us taking out the trash or becoming impatient at the grocery store.

If they did, it would likely dilute the very conditions that make therapy therapeutic.

But they may indeed experience love even without knowing our fullest self.

And isn’t this true of all relationships? People speak fondly about loving a former kindergarten teacher, a hairdresser, a tattoo artist, or their child’s nanny. Although we (and they) know the distinct roles those individuals fulfilled, we do not discount this love. We do not say, but you didn’t know them.

It goes deeper: I loved my grandmother, who died when I was still a young child and remains forever held in the simple images only a little girl can carry. Did I know her full self? I did not, and I never will.

I loved the cluster of cells growing inside me long before those cells became my children. Did I know their identities, their quirks and beauty? Of course not. I know my children well now, but I also realize I can never know the vast constellation of their every thought and need.

I love my friends, even when I do not see all the deepest nuances of their internal worlds. Does that mean the love is less valid? Absolutely not.

I love my dog, who cannot communicate with me, cannot tell me what it is like to sit on my lap as I write these words in this moment. This love is as real as the love I share with people who can communicate with me directly.

And I love my own therapist, who offers a beautiful presence that may not match all of how she shows up in her personal life. I trust she loves me, even though I pay for the time that makes our relationship possible.

Love does not require total knowledge of another living being’s inner experience. Love is about someone meeting a core need and the meaningful connection associated with that need.

In this sense, leading with love is less about a fleeting feeling and more about embodying a full orientation. This love is steady and unwavering. It lives in the consistent capacity to remain wholly present with another person.

Ethical love is as gentle as it is disciplined, holding space without reservation or distraction. It truly is the pulse of therapy, transcending the mere offering of empathy or coping strategies. It creates a container where safety can be experienced and eventually reflected outward into the patient’s own life.

This is part of an ongoing series of reflections and realities of the field. I’ve made it free for public use. If you’d like to support more of my writing, please consider upgrading to a paid subscription or purchasing one of my books.

If you don’t already follow me on Instagram, I facilitate a free Q&A for therapists every Wednesday.

In my practice, I offer individual therapy and group therapy for therapists. If you’d like to learn more about me or my clinical offerings, please check out my website.

If you are new to my Substack, I create each of my posts from a place of experience and humility. While I have spent countless hours in a therapist’s chair and have published content extensively about this field, I wholeheartedly enjoy witnessing how new knowledge unfolds year after year. These insights emerge from that curious landing space.

With that, my suggestions should never be taken as strictly factual, and I do not prescribe them as the sole way to provide therapy. Our work is both nuanced and delicate and should be respected as such. Take what you need and feel free to share any feedback as you desire.

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Sources

1. https://pubmed.ncbi.nlm.nih.gov/24702217/

3. https://www.researchgate.net/profile/Scott-Miller-32/publication/266031113_Miller_SD_Hubble_MA_Duncan_BL_NovemberDecember_2007_Supershrinks_Learning_from_the_field’s_most_effective_practitioners_The_Psychotherapy_Networker_316_26-35_56/links/5651fdfb08ae1ef929754e02/Miller-SD-Hubble-MA-Duncan-BL-November-December-2007-Supershrinks-Learning-from-the-fields-most-effective-practitioners-The-Psychotherapy-Networker-316-26-35-56.pdf

4. https://aedpinstitute.org/about-aedp-psychotherapy/

5. https://pmc.ncbi.nlm.nih.gov/articles/PMC5976702/

6. https://pmc.ncbi.nlm.nih.gov/articles/PMC10204595/

7. https://lawecommons.luc.edu/cgi/viewcontent.cgi?referer=&httpsredir=1&article=1356&context=annals

8. https://www.researchgate.net/publication/261700116_Neuroplasticity_as_an_Explanation_for_the_Attachment_Process_in_the_Therapeutic_Relationship

Thank you for being here. If you’d like to support more of my writing, please consider upgrading to a paid subscription or purchasing one of my books. If you don’t already follow me on Instagram, I facilitate a free Q&A for therapists every Wednesday. If you’d like to learn more about me or my clinical offerings, please check out my website.

If you are new to my Substack, I create each of my posts from a place of experience, deep thoughtfulness, and humility. While I have spent countless hours in a therapist’s chair and have published extensive content about this field, I wholeheartedly enjoy watching how new knowledge unfolds year after year. These insights emerge from that curious landing space.

With that, my suggestions should never be taken as strictly factual, and I do not prescribe them as the sole way to provide therapy. Our work is both nuanced and delicate and should be respected as such. Take what you need and feel free to share any feedback as you desire.

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Fantasy is rarely an objective blueprint that predicts behavior. More often, as we explore fantasies, we see they represent powerfully symbolic solutions to emotional problems.

“I just want to run away.”

“I want to quit my job, throw my phone off a cliff, and live in the woods.”

“I wish my ex could experience even half the pain he put me through.”

“If I hadn’t torn my ACL, I would have gone pro.”

Almost everyone fantasizes.

People fantasize about moving somewhere remote where they can forage and grow their own food and live off the land. Others fantasize about sleeping with their neighbor despite being happily married. Some mentally rehearse meticulous revenge strategies against a childhood bully decades after the taunting ended. Patients with established sobriety imagine relapsing on a substance they have not touched in years.

People don’t really know what to do about their fantasies.

Some dismiss them as childish or silly or downright nonsensical. Many will conceal the contents of their fantasies because they feel too shameful to acknowledge. They sometimes hold prevailing fears that having fantasies means they inherently wish to act on them or that the thoughts reveal something disturbing about who they truly are.

Therapists can also become uneasy, particularly when fantasies involve themes around suicide, relapse, violence, or infidelity. The conversation may automatically shift toward assessing risk or discerning whether someone intends to act on what they’re imagining. Some take fantasy at face value, assuming the story represents an immediate intention rather than connecting it to other patterns within the context of one’s life.

In some cases, assessment matters, as certain fantasies may require careful evaluation. But, as therapists, we may spend a great deal of time exploring emotions, memories, beliefs, and relationships. Fantasy, however, often doesn’t receive the attention it deserves.

It’s a missed opportunity. I find that a person’s capacity to fantasize speaks to their capacity to mentally rehearse a myriad of life possibilities. It can also help them restore a temporary agency or regulate overwhelming emotions. Symbolically, fantasies allow people to experience needs that may not be met in the real world.

As therapists, we should all be considering: what fantasies does this person have? And what do those fantasies reveal about what this person may need more or less of in real life?

Fantasies Are Rarely About the Content

After many years of exploring fantasies with people, I have found that one of the most common themes is: people rarely want what the fantasy actually offers.

I’ll explain. The person fantasizing about running away doesn’t want to fully abandon their life. The person dreaming of fame may hate being the center of attention. The person fantasizing about having sex with their neighbor may have zero desire to betray their marriage.

Fantasy is symbolic. It translates emotional needs into vivid stories our minds can temporarily inhabit. The content within the narrative matters, but the needs underscoring the fantasies matter far more.

Because fantasy is rarely literal, the work is about naming the needs the fantasy attempts to satisfy.

What Different Fantasies Reveal

Each fantasy is extraordinarily personal. At the same time, they often cluster around recognizable emotional themes. As therapists, we can note how many fantasies revolve around similar longings for safety, freedom, recognition, justice, belonging, and relief.

My examples below are not exhaustive, and they are not mutually exclusive. Many fantasies evolve, overlap, shift, or expand throughout the course of therapy.

Fantasies of Escape

I find that fantasies to disappear often emerge during periods of chronic stress, intense caregiving, or prolonged burnout.

These patients may speak about the allure of leaving home and backpacking internationally. They might tell you they wish they could just throw their phone in a river. Often, in plain form, they will tell you, “I just want to be left alone.”

As you trace the contours of the fantasy, you often see that escape has little to do with isolation and more to do with desiring relief. This person may feel overwhelmed by responsibility and the daily intertia of “doing.” They fantasize about fewer demands and more spaciousness. There’s a longing for existing without constantly performing or producing or anticipating everyone else’s needs.

But tread curiously here: none of this means they want a different life.

In fact, many will insist they love their partners and children and careers and homes and communities. They are grateful for what they have. At the same time, they equally may feel overwhelmed by the maintenence required to sustain it all.

Escape fantasies can act as a form of a psychological vacation. The desire isn’t usually about abandoning one’s life. Instead, it’s about experiencing the capacity to slow down and be present within it.

And if they do want a different life?

Sometimes their fantasy is showing them that their current set-up isn’t working. The person dissatisfied with their relationship may actually need to leave. The person fantasizing about a career change may need to take that tremendous leap of faith.

Escape fantasies really can help us pinpoint something essential with our patient: Is this current life sustainable? And if it’s not, what will we do next?

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Disclaimer: This article discusses therapy harm. Therapy harm is a broad term that includes the experiences of mistreatment, retraumatization, and legal and ethical failures that can occur within mental health treatment.

If you have been harmed in therapy yourself, some parts of this essay may be activating. Please move through the content gently and take breaks as needed.

If you are a therapist, this is a conversation our profession cannot avoid or downplay. If we expect people to entrust us with their stories and needs, we have an enormous responsibility to continually examine the ways therapy can both help and harm. Looking honestly at our profession is a necessary act of ongoing accountability.

This is a challenging essay to write. It is challenging because I am listing more problems than solutions, and it is challenging because it confronts the many difficult realities within our field.

But I write it because, like many therapists, I have listened to many patients describe painful, devastating experiences in therapy.

I write it because I have a privilege in how my writing reaches an audience of therapists committed to practicing with integrity and clinical excellence.

I write it because I supervise therapists wrestling with the ethical complexities of this work, and I see how seriously they take the responsibility of caring for others.

I write it because I am aware of my own edges as a therapist and because I, too, grapple with the tides of hindsight showing me there were times I could have done more, done better, done differently.

I write it because I have experienced harm in therapy myself. I know what it is like to let myself be vulnerable and then feel disoriented and violated and question if I could trust another therapist again.

Therapy is often packaged as inherently beneficial, and we all want that to be the case.

We hear the feel-good, blanket statements like, Everyone should be in therapy! We know it is recommended as the answer to everything from parenting struggles to workplace burnout to poor body image. And on paper, the premise is beautifully straightforward: patients engage in a safe and supportive relationship with a trained professional who listens deeply and offers thoughtful interventions.

But.

It is not always so straightforward.

I am relatively confident nearly every therapist has encountered a patient who describes being hurt in therapy. It is not a matter of “if.” It is a matter of what and when.

We do not set out to cause harm. But even our best intentions do not offer immunity from mistakes or the unintended consequences of our work. In fact, sometimes it is the blind spots tangled within our best intentions that cause the most problems. Conversations about therapy harm are difficult because they reveal themselves within these layered labyrinths.

Not every painful therapeutic experience is automatically harmful. Not every harmful experience in therapy is abusive. One person may feel deeply wounded by an intervention that another person finds incredibly profound.

Sometimes an individual therapist causes harm. Sometimes the system employing the therapist or maintaining the treatment causes harm. Sometimes both coexist.

If we want to be ethical and effective, we hold all these possibilities.

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What Happens When Therapy Goes Wrong?

Let me start by clarifying what therapy harm means. The concept itself is layered, and understanding its depth requires us to honor multiple realities at once.

First, I find that it is helpful to distinguish between the following related concepts:

Therapy discomfort: This is the expected pain that often accompanies the tender work of dynamic psychotherapy. It is the splitting sadness of grieving a profound loss. It is the raw fear of being vulnerable with another person. It is that moment of coming into contact with anger after suppressing one’s voice for decades. Good therapy is hard, and this kind of discomfort is inherent in growth. It should feel purposeful. It should, at times, feel tough. But if the distress exceeds capacity or happens without adequate preparation or attunement, it can lead to a rupture.

Therapy rupture: Ruptures in therapy refer to moments of misunderstanding or disconnection. They can happen when a patient feels unseen, rejected, abandoned, disrespected, or alone. When the therapist thoughtfully repairs a rupture, it may evoke a positive corrective emotional experience. But unacknowledged or mishandled ruptures can contribute to therapy harm.

Therapy harm: Therapy harm refers to treatment experiences that contribute to significant patient suffering. The suffering type varies, but the impacts can be emotional, physical, sexual, logistical, or financial. At its core, therapy harm speaks to treatment leaving people worse off than before.

Some experiences of harm in therapy entail obvious legal or ethical violations. Other forms of harm, however, emerge within the vast gray territory of psychotherapy.

It is in this tender space that well-intentioned clinical decisions and genuine patient suffering occupy the same space. This is where a therapist’s best intentions can converge with their blind spots, and it is where they can deeply hurt the very people they seek to compassionately help.

Traversing The Ethically Gray Areas of Therapy

Some forms of therapy harm are relatively straightforward. There’s a neatness to how defined they are.

Do not breach confidentiality. Do not engage in sexual relations with patients. Do not commit insurance fraud. Do not hire a patient to work for you.

We know these obvious ones. It doesn’t mean harm doesn’t exist in these contexts. It does, and it way more than it ever should.

But much of “what goes wrong” in therapy lives within the blurred lines.

I illustrate some of these gray examples:

A patient with developmental trauma enters therapy eager to resolve their most harrowing symptoms, telling the therapist they are “ready to dive in.” The therapist, aiming to “meet them where they are,” begins trauma processing. But they have not fully established the patient’s sense of stability. As a result, that patient leaves sessions utterly overwhelmed and dysregulated. They terminate under the assumption that therapy is making them feel worse. They are angry that the therapist moved too fast, angry that the trauma now feels more alive than it ever did.

A patient living with a chronic illness is referred to therapy to cope with the emotional toll of their physical limitations. The therapist introduces a gratitude exercise to foster a gentler mind-body connection. But the patient feels dismissed. The pain seems unbearable, and applying gratitude to it feels like they’re being given a bandage to treat a heart attack. Therapy feels like just another space where someone is reframing their suffering, and the therapist feels like just another provider who can’t grasp the nature of living with chronic illness.

A school-based therapist must report suspected child abuse. The report is both ethically and legally necessary, but the patient experiences it as a profound betrayal of trust. They are terrified about their parents discovering what happened. They are terrified the abuse will escalate further. The therapist became another adult with power who made a decision about their life without their consent.

A patient with undiagnosed OCD is receiving treatment for a substance use disorder. They describe their fears of being a bad person, and the therapist responds by offering reassurance about their goodness. The patient is relieved, although the relief is temporary. Instead of learning to tolerate uncertainty, the patient becomes increasingly attached to this reassurance to feel safe. The therapist unknowingly reinforces this prevailing belief that they cannot trust themselves.

A patient with an exhaustive history of bullying talks to his therapist about getting written up at work. He connects it to his race, but the therapist tries to explore whether it could be due to any other factors. The question is meant to encourage a broader exploration of perspectives, but the patient feels minimized, and now the therapist has echoed a lifetime of discrimination.

A therapist must cancel several sessions due to a death in their family. One of their patients is also grieving a sudden death. They logically know the cancellations are necessary, but they feel frustrated by their therapist’s lack of availability. The therapist reinforces longstanding fears that others cannot be depended on.

A therapist shares a few posts about feeling burnt out on their professional social media page. A long-term patient sees it and feels both guilty and anxious that they are contributing to this problem. Because they fear they are being too sensitive, they do not divulge this private dilemma with their therapist, but they start withdrawing from the relationship. The therapist has now fractured a frame that felt predictable and safe.

I could go on. I am not teaching a laws and ethics course, and I am not here to nitpick every facet of human behavior, but each of these short vignettes illuminates the complexity of our work. Are these experiences indicative of therapy discomfort? Therapy rupture? Or therapy harm?

Who decides?

This is not an exam, and these are not multiple-choice questions. Ask ten therapists how they might respond to each vignette, and you would receive ten different answers.

So, rather than answering them definitively, I am trying to highlight one of the thornier paradoxes within our field: the greatest strength of psychotherapy is that it’s relational, and the greatest weakness of psychotherapy is that it’s relational.

Relationships cannot be neutral. They are shaped by so many factors: attachment, culture, power, expectation, timing, personality, and countless other life experiences. Every intervention is filtered through this lens, and no amount of training or good intention exempts us from bias or oversight.

So, what do we do with that?

Should therapists who harm patients no longer practice? Should patients accept the unfortunate consequences of imperfect relationships? Are patients too demanding of their providers? Are providers failing to give patients what they actually need? And what about all the therapists trying to do their absolute best in systems that seem to care very little about patient welfare?

Is there a need for justice, and what should that justice be, and who determines how that justice might be served?

These questions feel unsettling because psychotherapy itself invites us to hold two extraordinary tasks: we need to become deeply involved in another person’s inner world while accepting that our humanity can be both our greatest instrument and greatest detriment within that world.

When Treatment Itself is Harmful

Not all therapy-related harm originates from individual therapy. Sometimes the interventions and structural systems carry an immense potential to be traumatic.

Like all things, this is nuanced. One person’s perspective may differ entirely from someone else’s.

Take inpatient psychiatric hospitalization, which is controversial for many compelling reasons. Some people report these experiences as genuinely lifesaving. They will say that they needed stabilization and protection. It may even serve as a pivotal moment in their recovery process.

Others will tell an entirely different story, one that embodies dehumanization.

Hospitalization can be horrifying. They recall their stripped autonomy and being aggressively searched and restrained. They speak about being terrified in an unfamiliar environment filled with other people in crisis.

Both experiences are real. Life is not about the events that happen to us, but it is about how we react and contextualize and exist in reaction to what happens to us. This is true for harm within greater systems.

As therapists, this means knowing that the same interventions can be perceived in completely different ways. This is reflected across every system of care.

The ‘troubled teen industry’ has come under increasing scrutiny for practices that former residents cite as abusive. Many survivors have come out talking about being deeply traumatized, and their stories remind us that labeling something as ‘therapy’ or ‘treatment’ does not make it safe.

The same complexity presents itself within mandated reporting. We’re legally and ethically obligated to report abuse, even when doing so may jeopardize the relationship. Reporting can be beneficial, but it can also be incredibly damaging. We’ve all heard the stories of retaliation or an escalation of violence that patients feared all along.

I emphasize that this is what makes the power element of therapy so difficult.

Is a diagnosis ever just a diagnosis? Maybe, but a diagnosis can impact how someone understands themselves for the rest of their lives. It can also determine access to treatment, disability accommodations, insurance coverage, military service, and how all other healthcare providers perceive them.

Documentation, which is the bane of most therapists’ existence, becomes part of a legal record. It can be an administrative burden, and it can influence custody disputes, disability claims, criminal proceedings, and choices made by professionals who may never actually meet the patient themselves.

A recommendation based on a moment in time can determine whether someone is hospitalized, whether child protective services gets involved, whether they return to work, whether they remain in school, and whether they can live in housing with their pet. Did you give that recommendation enough thought? Enough reverence?

No matter our setting or our modality, we hold tremendous authority, and our interventions can influence the course of someone’s life. This is a delicate power to hold, and it means we must never lose sight of its weight and responsibility.

What Do Harmed Patients Need in Therapy?

When patients share about harm by a previous therapist, there’s often an instinct to determine what actually happened. Was the therapist unethical? Was it a poor fit? A projection? A misunderstanding around what therapy entails? Will that patient experience the same harm with you? This all crops up.

But it’s not your job to investigate. It’s your job to witness and connect.

People who have experienced harm in therapy often feel profoundly ambivalent about engaging in treatment again. They may want help while fearing it. They may closely monitor interactions, struggle to open up, anticipate that their concerns will be dismissed, or present as highly mistrusting.

Whether or not their previous therapist or treatment acted unethically is important. I am not disputing that.

But it’s more essential to understand the impact it had on your patient. What happened? What was missing? What did they actually need? What are they afraid could happen again?

They need to be heard.

At baseline, we must actively strive to understand a patient’s internal experience. We should be just as curious about therapy-related pain as we would be about any other pain.

What happened? How did they make sense of it then, and how do they make sense of it now? What did they need? How has it impacted the way they now approach relationships or trust or safety or treatment?

Just as we would listen carefully to any patient describing a painful life experience, we must listen when that experience occurred in therapy. When we listen, we do not listen as investigators, judges, or even defenders of the profession. We also do not listen to attach to any single outcome.

Amid this listening, we stay curious. We must communicate in our words and actions: “I believe this experience hurt you, and I want to understand how.”

They need welcoming space for ambivalence.

Many patients feel quite conflicted about returning to therapy. They might feel reluctant to share about harm in therapy with another therapist. Ambivalence is not the same as a lack of motivation, and it is not a pathological form of resistance.

It is important to understand that rebuilding trust takes time and corrective emotional experiences. You do not force this onto anyone, and you must be willing to step into the ambivalent arena with them.

Trust cannot be rushed. It develops through countless moments of attunement and safety. Your job is to offer those conditions as consistently as possible.

Take time to explore their engagement in therapy. What motivated them to try again? What fears do they have? What might happen if you act similarly (or differently) to their past provider? What is it like to be in this space with you right now?

They need transparency.

Hypervigilance about power makes complete sense after therapy harm. Therapy itself can be unnecessarily mystifying, and many patients become understandably cautious about the entire treatment process.

Our work should be explicit for all patients, and it’s especially important if trust within treatment has ever been eroded. It can be helpful to explain your clinical thinking and discuss the rationale behind certain interventions. It is also supportive to invite questions and acknowledge uncertainty. You want to model that you welcome disagreements and that you engage in therapy with patients rather than for patients.

Transparency does not eliminate the inherent power differential, and it’s equally important to name that as well. It can, however, hold us accountable to that power.

They need hope without vacant promises.

It can feel tempting to reassure patients with statements like, “I’m not like your last therapist,” or “I’ll always be here.”

But trust is not built through comparison, and it certainly cannot be built on promises you cannot guarantee. You hold no crystal balls to the future, and you also do not hold any perfectly-clear magnifying glasses to the past.

Rather than asking patients to trust you immediately, your task is more about creating the kind of therapeutic relationship in which it gradually becomes possible. You can be consistent without being unrealistic, and you can embody unconditional hope without embodying unconditional rescuing.

They need permission to criticize or reject therapy.

Some people believe that criticizing previous therapists makes them “difficult” or “treatment-resistant.” They might also worry about you becoming defensive or automatically siding with your profession.

Here, it is not your role to protect other therapists or defend the field. It is also not your job to rush to condemn another therapist with the patient. Neither tend to be helpful, as this is not about ‘taking sides.’

Instead, the role is to understand the patient’s internal experience. They are allowed to question therapy, and they are allowed to be wary. What hurt them? Was this pain similar to other pain they endured? What might they need from you to feel more comfortable in this process?

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What Does Ethical Practice Ask of Therapists?

If therapy can be harmful, and if mistakes are, to some extent, unavoidable, what does ethical practice ask of us? We cannot eliminate painful emotions. We cannot control how patients interpret our responses or experience the therapeutic process.

How do we minimize preventable harm while remaining accountable if harm occurs?

It is not straightforward.

We long for the binaries: ethical versus unethical, good therapist versus bad therapist. But no binary adequately captures the complexity where intention, perception, power, and context intersect.

This does not mean abandoning accountability or simply saying, therapy is an art! We must pursue this practice with humility, recognizing that harm can occur without malicious intent and that ethical practice requires us to tolerate complexity without losing the commitment to do our best.

The grays will always persist, but ethical practice asks us to:

Work within our scope of competence: I recognize that defining scope can be complicated, particularly for therapists working in under-resourced systems or being assigned to work with certain demographics. Competence is not the same as knowing everything. However, you want to recognize the limits of what you know. This is why ongoing consultation, supervision, referral, and continuing education are necessary.

Remain humble: Clinical judgment is not infallible. It doesn’t matter how long you have been practicing or how “skilled” you think you are. No theory or intervention is the “perfect” one. We must be willing to question our assumptions and revise our conceptualizations. Humility allows us to attune, and attunement allows us to stay connected with what’s actually happening.

Stay receptive to all feedback: The pipeline from therapy discomfort to therapy rupture to therapy harm can be slippier than therapists realize. Patients communicate dissatisfaction both directly and indirectly, and ethical practice asks us to notice those moments and make them more explicit. This allows opportunity for potential repair.

Work collaboratively: Clinical work should never be practiced in isolation. We are too prone to our own biases and countertransference. Consultation, supervision, and doing work in your own therapy allow you to challenge your assumptions and broaden your perspective.

Truly know your role: As a therapist, your job is to create safe containment for facilitating insight and supporting a greater psychological capacity. Ideally, this helps people make more informed, authentic choices in life. Therapy harm often comes from acting outside of this role. You can do “too much” by becoming overly directive, imposing your values, creating dependency, or stepping beyond your competence. You can also do “too little” if you avoid difficult conversations or fail to intervene when clinically appropriate.

Stay active and current: Ethical practice requires ongoing engagement with our evolving field. Ethical codes change, and nothing in this work is ever all that static. Remaining current honors the need for integrating new knowledge into longstanding clinical wisdom.

Remember you are the instrument, and you are the detriment: Therapists worry greatly about AI destroying the profession. The worst part about AI is that it strips the full essence of therapy. The best part about AI is that it eliminates human error. To end this essay, I focus on both. Good therapists honor the essence of relational complexity and emotional intimacy. At the same time, they also honor that human error cannot be understated. Although we can’t be perfect, we have to be paying attention to when and how we might get it wrong.

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This is part of an ongoing series of reflections and realities of the field. I’ve made it free for public use. If you’d like to support more of my writing, please consider upgrading to a paid subscription or purchasing one of my books. If you don’t already follow me on Instagram, I facilitate a free Q&A for therapists every Wednesday. If you’d like to learn more about me or my clinical offerings, please check out my website.

If you are new to my Substack, I create each of my posts from a place of experience and humility. While I have spent countless hours in a therapist’s chair and have published content extensively about this field, I wholeheartedly enjoy watching how new knowledge unfolds year after year. These insights emerge from that curious landing space.

With that, my suggestions should never be taken as strictly factual, and I do not prescribe them as the sole way to provide therapy. Our work is both nuanced and delicate and should be respected as such. Take what you need and feel free to share any feedback as you desire.

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“You need to do your own work.”

We hear this guidance in graduate school, and it is repeated throughout every point of our training. Few recommendations are as universal as this one, and for some very good reasons.

But what does it mean?

How do we define the work? And maybe more importantly, how do you know whether you’re genuinely working on yourself with intention and humility or just becoming fluent in talking about yourself?

To Do Your Work Means to Know Yourself

Who are you when you feel most ashamed? How do you respond to criticism when you emphatically disagree with it? How well can you tolerate praise? What kinds of relationships leave you feeling energized and passionate? Or drained and defeated? What stories do you tell yourself when life is utterly unmanageable? What emotions are hardest for you to tolerate? Where do you continue to find yourself stuck in life?

We are all so exquisitely human, and the more intimately we can explore our emotional landscapes, the less likely we are to confuse our unique experiences with our patients’ or unknowingly ask them to carry something that belongs to us. This is the heart of knowing your own edges. When is your humanness impacting your clinical capacity? And what do you do when that humanness is grating against you?

You can be the “wounded healer,” and therapists who know themselves well are not necessarily wiser or more emotionally regulated than everyone else. That said, they may be more apt to recognize when their inner world is getting activated in the therapeutic relationship.

Paradoxically, therapists who do not know themselves well often present as quite rigid and defensive. They might cling to diagnoses or interventions or manuals to maintain a sense of control or ego. They may mistake their certainty for competence or their personal values for objective truth.

Rather than asking, “What is happening inside of me right now?” they risk unconsciously concluding, “I know exactly what is happening with this patient right now.”

They will often struggle with boundaries, as boundaries can reflect what is unexamined. Some become overly guarded because they fear the inherent intimacy associated with therapy. Others are too loose or inconsistent because they worry about hurting the patient’s feelings. Neither is inherently a sign of poor ethics; however, these patterns can signify attempts to regulate your emotional comfort.

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Your Patients Walk Into Your Unexamined Places

Therapeutic relationships tug at the spaces within us that sometimes feel raw and unfinished. There’s the patient who reminds you of your youngest self, and there’s the one whose helplessness ignites your desire to rescue. There’s the person who irritates you with their frequent rescheduling, and the one who causes you to doubt your competence when they ask why you asked that question.

Because our work is relational, we are stepping into vulnerable and exposing dynamics, allowing ourselves to be scrutinized, idealized, devalued, and, in the most tender moments, cracked open.

We move through this work evoked by countertransference, but failing to recognize what gets activated within us leads us to respond from our unresolved needs instead of thoughtful clinical intention.

“Doing your own work” means learning how to notice what is getting stirred within. The inability to recognize internal activation causes therapists to respond from unresolved needs instead of thoughtful clinical intention.

For example, you might reassure someone that “things will be okay” because you cannot tolerate anxiety well yourself. Or you will offer canned advice because it feels “more productive” than sitting with helplessness. You might rush people toward insight if sitting with ambiguity feels too uncomfortable. Or you may interpret someone’s anger as pathology because anger has always felt unsafe to you.

Your reactions are data. Data is different from directives.

Your Emotional Limits Might Become Your Patient’s Limits

Even if it is never explicitly named, patients attune to what emotions feel welcome in the room with you. If you tend to downplay anger, they might soften it in response. Or, if you present as overwhelmed by grief, the patient might inherently intellectualize sadness instead of fully experiencing it.

If you cannot tolerate uncertainty, you might find yourself trying to fill the space with intellect or explanations.

If dependency makes you uncomfortable, you may push toward independence before the patient feels secure enough to stand on their own. And if conflict feels threatening, important disagreements may never actually take place in your office.

How do you lead someone safely into a place you are unwilling to visit yourself? While you can’t travel everywhere because you don’t have every life experience, you do need to be willing to acknowledge those scary places within yourself that may feel defended or unfinished.

Insight Is Not the Same as Integration

Knowing yourself only places you on the highway. You can aimlessly drive forever, accumulating vast language for your patterns without ever changing your relationship to them.

Many therapists feel inundated with self-awareness. They can describe their childhood wounds or label their defense mechanisms. They speak with nuance about the current state of their nervous system. But fluency is not the same as transformation, and insight itself rarely changes patterns.

What good is having a diagnosis if you feel diminished or debilitated by it? Or how helpful it is to articulate your attachment style if you continue organizing your entire existence around it?

Insight puts a name to an experience, offers vocabulary for what can feel so painfully abstract. But there’s a profound suffering that comes when you feel consumed by self-awareness instead of fueled by it.

Right here, doing the work means practicing new ways of relating to your insight. Growth is not measured by what you cognitively understand. It is measured by what you can now tolerate or do differently. Insight is a stepping stone for understanding yourself, but integration changes how you live.

Doing the Work Does Not Mean Being Healed

“Doing your own work” cannot ever be synonymous with feeling fully cured or resolved. Patients do not benefit from therapists who never struggle. They benefit from skillful, compassionate providers who take care of themselves well. This is more about being emotionally honest than emotionally invincible.

All people grieve and become dysregulated and make mistakes. You will still experience fear, shame, loneliness, heartbreak, and uncertainty- these are the blueprints of what it means to have a pulse in this life. You can and should be impacted by the gravity of your internal and external world.

A strong therapist accepts that they will be affected by the tides of life. They do not suppress or deny this reality. Accepting your own growth does not exempt you from suffering. Every new stage of life asks something different of you, revealing strengths you may not have known you had alongside vulnerabilities you assumed you already resolved.

“Doing your own work,” in many ways, embraces this fresh vulnerability. You learn your own edges and build a greater capacity to tolerate them. You recognize that you never fully arrive as a flawless human. And, paradoxically, you relish in the knowing that there is so much you cannot know.

Healing is not measured by how little life impacts you; it is measured by how much capacity you have to stay in a relationship with yourself when it does.

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Read more

This is part of an ongoing series of reflections and realities of the field. I’ve made it free for public use. If you’d like to support more of my writing, please consider upgrading to a paid subscription or purchasing one of my books. If you don’t already follow me on Instagram, I facilitate a free Q&A for therapists every Wednesday. If you’d like to learn more about me or my clinical offerings, please check out my website.

If you are new to my Substack, I create each of my posts from a place of experience, experience, and humility. While I have spent countless hours in a therapist’s chair and have published content extensively about this field, I wholeheartedly enjoy watching how new knowledge unfolds year after year. These insights emerge from that curious landing space.

With that, my suggestions should never be taken as strictly factual, and I do not prescribe them as the sole way to provide therapy. Our work is both nuanced and delicate and should be respected as such. Take what you need and feel free to share any feedback as you desire.

Do therapists need side hustles?

The question is everywhere, and therapists are quick to chime in with their answers. Some clinicians argue we should stop glorifying entrepreneurship and simply return to doing therapy. Others believe multiple income streams have become a necessity rather than a luxury. Many argue that private practice is only truly sustainable if you have a partner with a stable income or family wealth.

What if everyone is asking the wrong question?

What if we’re not talking about side hustles, but we’re really exploring how therapists can build careers that allow them to protect both their financial well-being and clinical integrity?

I do not think therapists need side hustles. I do think therapists need a sense of stability.

Therein lies the chasm of tension.

Most of us entered this profession because we wanted to sit with people through some of the hardest moments of their lives. We imagined the therapy itself. We did not necessarily imagine how much time we would spend thinking about websites, marketing, taxes, referral networks, cancellation policies, electronic health records, and business strategy. Those working in agencies instead find themselves thinking about productivity requirements, documentation demands, insurance authorizations, and administrative expectations.

Therapy exists within systems, and those systems impact us all.

Over the past several years, in response to my writing and speaking, I’ve had the privilege of talking with many therapists around the world. My recent essays, The Private Practice Model is Hardly Sustainable and The Psychotherapy Field is a Structural Mess, sparked international conversations about the layered intersection of money, privilege, competence, and the structural realities of our profession. My article, Are We on the Cusp of a Therapist Exodus? speaks to the widening gap between how therapists wish to work and how they are expected to work.

It is true that we are speaking more openly about the parts of the uglier parts of the profession: financial stress, burnout, productivity standards, ethics of private practice, and the discernment between being a “good therapist” and being a “successful business owner.”

But therapists are still grappling with the same consistent questions:

How do I build a sustainable career?

Can I make private practice work?

How do I protect myself from burnout without compromising patient care?

How do I make a living without losing sight of my values or why I entered this profession?

Therapists are constantly trying to balance two competing needs. We want to be grounded and emotionally available for our patients. This is vital, as it represents the glue that makes a genuine presence possible. At the same time, we need enough stability to make that presence possible.

When things feel volatile, as they can in this field, the math gets blurry. If you see too many patients, you risk feeling resentful or exhausted, which can affect the quality of care. These effects become compounded if you do not feel competent or well-suited to work with all those patients. On the other end of the spectrum, if you do not see enough people, you risk feeling anxious and overly focused on your financial well-being. This, too, affects the quality of care.

So, is this about side hustles? Or is it about how therapists build and nurture careers that allow their clinical decisions to remain clinical?

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Side Hustling Isn’t New In This Field

Therapists were diversifying their professional roles long before social media, online courses, and the proliferation of “personal brands.” The theorists we admire weren’t simply meeting with patients all day.

They were busy disseminating knowledge: Freud lectured and published. Carl Rogers taught. Aaron Beck trained clinicians. Marsha Linehan developed workshops and her DBT certification programs. Nancy McWilliams writes, teaches, supervises, and consults. Diana Fosha, Pat Ogden, Sue Johnson-this list of pioneers goes on. We know these names because they shared their work beyond their therapy office walls.

Today, many professors teaching in graduate programs also hold multiple professional roles. They teach. But they also maintain private practices, supervise trainees, conduct research, consult, write, or provide continuing education.

This speaks to greater themes of how therapists contribute to the field. They:

• Maintain a clinical caseload.

• Teach in graduate programs.

• Provide clinical supervision.

• Consult with organizations, businesses, or other clinicians.

• Write books, journal articles, academic newsletters, or blogs.

• Present at conferences or lead workshops.

• Develop continuing education courses or training programs.

• Conduct research.

• Serve on advisory boards or professional organizations.

• Provide expert witness or forensic services.

• Create educational resources for clinicians or the general public.

• Offer intensives for patients.

• Facilitate retreats or other self-care pursuits for clinicians.

I am not even highlighting the many other income streams professionals rely on to pad their financial buffers. I know therapists who make and sell art, referee recreational sports, teach fitness classes, manage real estate, freelance in graphic design, and offer virtual assisting services- just to name a few options.

None of these multi-layered paths inherently indicates a problematic “hustle culture.” In fact, many therapists find that variance allows them to maintain professional sustainability. The ways they contribute to the profession have always been broader than the standard therapy hour.

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But What If You Just Want to Do Therapy?

That said, not all therapists seek to build out some multi-layered empire of a career. Many want to simply sit with patients. This reflects why many of us enter the profession in the first place. We fully see the world’s suffering, and in that, we want to help people reconnect with themselves. We aim to witness emotion and growth, and we value honoring complexity and depth.

Can that be enough?

Yes, of course. But it also helps to understand the realities that come with building a practice around therapy alone.

Private Practice Is More Than Clinical Work

Therapy may be your profession, but operating a practice also means running a business. The business exists whether or not you enjoy entrepreneurship.

Someone has to be a skilled therapist. They must be thoughtful in their practice, connected to the treatment, and attuned toward helping people achieve a sense of stability and wholeness that feels meaningful to them.

Someone also has to build the website, answer inquiries, return phone calls, complete documentation, manage billing, track expenses, pay taxes, review insurance claims, update informed consent forms, network with referral sources, market the practice, complete continuing education units, maintain licensure status, purchase liability insurance, vet electronic health record systems, and figure out what happens when you get sick or want to take a vacation.

In private practice, that “someone” is the same person. You. You, always you. You, even when you’re sick, you. You, whether you have 2 patients or 20 patients, you. You, whether or not you can pay your taxes this quarter, you. And if it’s not you, it’s you outsourcing and managing some other individual, company, or system.

But it’s you, and nobody will care about your business as much as you will.

Your clinical work happens in the session, but your private practice work lives within the margins and spaces between.

Every Therapy Practice Model Requires Tradeoffs

Each model asks something different of you.

The private cash-pay model can offer greater flexibility and lower caseloads if you charge a high enough rate. But obtaining patients requires diligent networking, strategic and effective marketing, and geographic or socioeconomic conditions that support these out-of-network fees.

Insurance panels generally provide more consistent streams of referrals. However, seeing patients in-network means accepting lower reimbursements and taking on more administrative work. There can also be a perceived sacrifice regarding how insurance may dictate clinical treatment.

Working for a group practice means your owner absorbs many overhead costs and provides both referrals and administrative support. But accepting this kind of hybrid position means accepting a percentage split, and you may not agree with all the policies or systems existing within their practice.

Many therapists work for agencies instead, and this is a perfectly suitable option for ensuring more stability and community. The tradeoff here generally means exchanging entrepreneurial responsibilities for organizational ones, including productivity requirements, administrative oversight, limited autonomy, and adhering to institutional policies that may not fit your preferred style of practice.

But it goes deeper than all of this.

What kind of therapist are you when referrals or salaries are down, and expenses are up? What defined or abstract parts of your practice suffer when your livelihood depends on your patients?

Can You Honor Ethics Above Economics?

Financial pressure in this field shows up in both dramatic and subtle ways. For therapists, one of the more concerning trends is how economic stress can change clinical incentives.

A few come to mind:

• An open hour represents lost income instead of an open stretch of time between sessions.

• A successful termination evokes more anxiety about filling the hour than joy in celebrating the patient’s growth.

• A therapist hesitates to refer someone to a clinician with more specialized expertise because it means sacrificing part of their livelihood.

• A therapist continues to accept new patients even after reaching emotional capacity because slowing down means risking financial stability.

• Vacation or illness signifies lost revenue instead of necessary time away.

• Every reschedule or cancellation carries emotional weight if it directly impacts income.

• Reducing session frequency becomes financially riskier than continuing at the current pace.

• Burnout represents a necessary force to push through instead of a signal indicating the need to slow down.

• An overly full caseload feels safer than an appropriately sustainable one.

These choices speak to a need to keep a business afloat, but when therapists are asking, what serves my practice instead of what services this patient, they enter an ethically complicated territory.

You’re Not Failing If It’s Not Feeling Sustainable

There is a longstanding trope that input directly correlates with output. The formula says that if you work harder and hustle more, success naturally follows.

Private practice doesn’t always work that way.

You can be an exceptional therapist and still struggle to build a sustainable business. This is because clinical skill is just one part of this colossal equation. Sustainability requires many variables: marketing, networking, financial planning, risk tolerance, and a willingness to operate without many of the safeguards traditional employment provides. None of those qualities necessarily highlight whether someone is a gifted clinician.

When I entered this profession, the messaging largely spoke to paying dues and earning stripes. You spent years “grinding” before slowly building a private practice through referrals and reputation. I am not saying this expectation was fair. I am saying there was a general understanding that the process took experience and time.

Today, the rhetoric has changed dramatically.

Now, therapists are flooded with flashy courses promising to “crack the code” and help them build six-figure practices for just $999 and a vial of their firstborn child’s blood. Now, you need a business coach. You need a niche and letters upon letters of certifications behind your name.

At the same time, you’re also reminded not to try “too hard.” Just be authentic. Just show up. As long as you are passionate, you can trust that the right patients will find you. Do not do anything that does not feel genuine or wholehearted.

Can’t we all see how these messages seem to directly contradict one another? You’re either one marketing strategy away from success, but success should be effortless if you’re aligned enough.

In daily life, neither reflects the reality most therapists experience.

Building a sustainable private practice often feels difficult because running a business is difficult. This has nothing to do with whether or not you are a “good” therapist, and struggling here does not mean you have failed. There is no gold medal in this space. There is only the ongoing work of aiming to sustainably care for others without sacrificing yourself or your livelihood in the process.

Beyond the Side Hustle Debate

Because I have a multi-layered career, I hold a unique privilege of experiencing this profession from several vantage points. I see an entire caseload of patients. I speak at conferences. I supervise training clinicians. I have published books and written for numerous organizations. I create educational content and run a therapist meme page with nearly 200,000 followers.

I enjoy this diversity, as it maintains a deep sense of vitality and connection to the profession. I value being able to support people in various ways and having a broader platform to share about some of the tender parts of this field. I also never want to fall into the abyss of equating patients to dollar signs.

At the same time, I know my solution is not the solution. It is a solution that works well for me. But I am aware that my professional life resembles exactly what critics of hustle culture push back against. I understand why, as not every therapist wants this kind of career, and I don’t think they should have to.

Instead of asking whether therapists should have side hustles, I think the more important question is: how do you ensure that your career allows your clinical decisions to remain clinical?

There is no standard blueprint, but it’s important to recognize if and when financial pressure is shaping clinical judgment. You can start by asking yourself:

• What emotions come up when a patient is ready to step down or terminate?

• How do I respond when my schedule isn’t full?

• Do I ever hesitate to make a referral because it affects my income?

• Have I built enough stability that I know if and when ethics might be competing with economics?

• Do I feel pressured to “make it” in private practice because I am equating that success with my worth as a therapist?

• If my practice no longer felt possible tomorrow, what would I want to do instead?

And most critically, “Am I making this decision because it serves my patient, or because it serves my practice?”

Most of us aren’t immune to financial pressure, but the goal is to build a career where money can sustain the work without directing it.

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If you’re a therapist in private practice, I’d love to hear your story.

I regularly have these conversations at conferences and across social media, but I’d love to hear from readers here as well, especially because so many people in this community are prospective therapists, graduate students, associates, or in the early stages of building their careers. Private practice can feel exciting, but it can also feel incredibly overwhelming.

How are you navigating these realities? Have you found ways to build financial sustainability while protecting your clinical integrity? Have you diversified your work or chosen to focus solely on therapy? What has worked for you, and what has surprised you along the way?

Please share your experience in the comments.

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This is a slightly updated revision to my original post that you can find here.

People generally enter therapy because something in their life isn’t working, and it is causing them distress. Remaining the same no longer feels sustainable. And in many cases, there is a persistent sense of stuckness that feels unbearable.

Even if the person does not know exactly how to move forward, they can often define what they want to change. For example, they want to feel less anxiety. They want to experience more satisfaction in their marriage. They want clarity about choosing a career path.

And yet, despite these stated desires for improvement, most people remain deeply ambivalent about change.

This is because change, even when desirable and attainable, entails upheaval. To consider change is to invite the harsh possibility of disruption, and that prospect can feel deeply disorienting. Familiar patterns offer predictability, organizing our identities and expectations about the world. We want to cling to those patterns, even if they also come with a steep cost.

All change means tolerating uncertainty, questioning long-held beliefs, experimenting with new behaviors, and often relinquishing coping strategies that once felt necessary for survival. It is not an easy task! These shifts can feel destabilizing, which is why stuckness often feels strangely preferable.

People claim they hate feeling stuck. And stuckness is absolutely distressing.

But people often hate absorbing the risk of failure or experiencing regression more than they hate being stuck. They hate accepting the possibility of regret and the vulnerability that comes with trying, slipping, and trying again. Trying is exposing. Trying is threatening. Although stuckness feels frustrating, it is predictable, and predictability feels safe.

Stuckness, frustrating as it may be, is at least predictable.

We can conceptualize that much of therapy exists within the scaffolding of tension between the desire for change and the instinct to maintain what feels safe.

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The existence of this tension shapes how people measure progress as treatment unfolds.

This tension is often what shapes how both patients and therapists measure progress. When we feel stuck (or regressed), it is natural to define success in extremes. People look to the best-case scenario, the idealized outcome. They want to be symptom-free; they want abstinence; they want to ‘reach the destination,’ whatever that destination might be.

How Do We Really Measure Progress in Therapy?

Standard treatment plans simplify progress, as do insurance companies and frustrated parents sending their young kids to therapy. Patients and therapists alike also buy into the desire for these easier forms of measurement.

The formula is straightforward: problematic behavior needs to be reduced or extinguished.

But therapy is rarely this linear.

The ambivalence and discomfort that tend to initially block change also teach us a significant lesson: meaningful progress is less about reaching peaks and more about stabilizing the base. It’s about learning how to tolerate the in-between and strengthen the capacity to weather inevitable fluctuations in progress.

So if progress isn’t linear, and if we can accept that it’s a constant state of fluctuations, how do we best measure growth and change?

First, we need to consider that when both patients and therapists conceptualize goals for therapy, we tend to instinctively focus on the best possible outcome. We co-create a future where symptoms are either tamed or eliminated, where life feels steady and enjoyable. We look toward the ceiling, holding onto hope for a brighter, bigger future.

The ceiling asks: How high can they jump? How well can they really perform? The floor asks: How well can they steady during everyday circumstances? What do they do just after their absolute worst day?

The Floor Vs the Ceiling

The ceiling: maximum performance and optimal peaks of growth

The floor: average performance over a duration of time

The ceiling asks: How far can we go? How fast can we move? How much progress can be made? What is the best and most optimal way of functioning?

The floor asks: How do we improve the average? How stable are we under ordinary circumstances? How do we manage the fluctuations? How well do you still perform on the worst day of your life?

While I have gleaned many invaluable insights through my trainings over the years, I do not credit this framework to our profession. Instead, it emerged for me when I returned to distance running after a decade-long hiatus from the sport.

I ran when I was younger, but stopped because I kept plateauing and injuring myself. All these setbacks stole the freedom and joy running offered. Athletes who resonate with this familiar pattern know this particular frustration.

In hindsight, my training was poor, and my strategy needed significant refinement. Instead of taking things slowly and steadily, I approached nearly every run with the mindset of focusing on how hard and fast I could move.

My body, as it does, protested.

When I resumed running years later, I encountered the 80/20 rule, a practice broadly followed by most elite athletes.¹ The concept is simple: 80% of training should occur at an easygoing, conversational pace, and 20% is done at higher intensity.

The 80% builds the base or floor, which supports one’s capacity for durability, endurance, resilience, strength, and steadiness under the majority of conditions. The strength of the base speaks to how you reliably perform on any ordinary day- whether your legs feel heavy, it’s too hot outside, or you didn’t sleep well the night before.

The remaining 20% of training focuses on the ceiling. These workouts push limits: tempo runs, interval workouts, hill repeats, race-pace efforts, and all-out runs. They improve speed and peak performance.

Ceiling work is important- especially if you want to compete- but too much of it is demanding and can result in serious overtraining, injuries, plateauing, or emotional burnout.

And so, this is why the most effective training programs emphasize building, maintaining, and sustaining the floor. Easy miles, slow runs, listening to the body, and consistently showing up- even if performance isn’t top-notch- to strengthen the aerobic system and raise the baseline.

The premise is straightforward: if you do nothing else but run three miles every single day for a year, there is a very good chance that you will run those miles faster and more efficiently over time. And if you toss in a few 5-7-10-mile runs, that 3-mile stretch will feel much easier.

The body adapts to what it does repeatedly, and endurance that initially feels difficult gradually becomes ordinary. The goal isn’t about running faster or further; it’s about making certain distances or speeds feel more manageable. As the floor rises, last year’s challenge becomes today’s baseline.

In other words, the goal isn’t only about raising the ceiling (speed, performance). It’s also about raising the floor. A higher floor means that, even on bad days, the baseline improves. The floor represents one’s capacity for durability, endurance, resilience, and capacity under any condition.

Psychotherapy can work similarly.

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“Never work harder than the patient.”

How many times have we heard this trite advice repeated in lectures, echoed in supervision? How often is it shared across glossy social media posts as though it is one of psychotherapy’s universal truths?

The intentions behind the sentiment, like most training intentions, are good. The phrase is meant to protect therapists from overfunctioning and burnout. It aims to remind us that we cannot rescue people from their distress or assume responsibility for choices that ultimately belong to them.

This wisdom is essential. It’s true that we can’t force insight or manufacture motivation. It’s true that we can’t force someone into changing. Assuming ownership of another person’s life can position us on the highway toward resentment, exhaustion, or both.

The problem with this advice is that many therapists hear it long before they can contextualize what the heart of therapy work actually is. They mistake effort for responsibility, and they begin using their patients’ apparent effort as an ongoing guage for their own engagement. If someone seems ambivalent or unmotivated or angry with treatment, they wonder if they should pull back as well.

It continues.

When a patient feels hopeless, as they often do, they begin wondering whether they should become less hopeful. When a patient feels stuck, as they also often do, they question whether continuing to think deeply about the case means they're overfunctioning.

In trying not to "work harder," they risk inadvertently withdrawing from the very qualities that make therapy so effective.

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The Cost of Emotional Restraint

In a society increasingly influenced by manualization and measurable outcomes, the desire for certainty has seeped into the scaffolding of therapy. Understandably, therapists search for rules that simplify their complicated work. New therapists, in particular, cling to certainty. They want to know where the lines are.

How much investment is too much?

When does caring become overinvolvement?

If I spend time thinking about a patient between sessions, have I already crossed a boundary?

Supervisors and professors often reach for concise and memorable phrases to offer reassurance. Don’t work harder than your patient is one of the most common. It is easy to remember, easy to repeat, and it sounds definitive.

But the phrase puts therapists in a precarious position. Instead of cultivating discernment, it instills a specific type of self-surveillance. I see many therapists wonder whether their investment or basic empathy has crossed some barrier instead of asking what the relationship actually needs.

Rather than asking, "What does this relationship need from me?" they begin asking, "Have I become too invested?" Some scrutinize their empathy more than their clinical judgment.

And what about the patients who stumble across this phrase?

Many already arrive in therapy convinced they are too much or not enough. Some carry profound shame about needing other people. As they explore what it means to take space, they also worry about exhausting or disappointing us. Moving through the minutes, they apologize for crying, for rambling, for “taking up too much time,” or for “messing up.” Many fear that if they don't improve quickly enough, their therapist will eventually become frustrated, lose interest, or give up on them altogether.

It can be so disorienting.

Now imagine you’re a patient encountering the message that your therapist should never work harder than you.

Imagine reading those words during the darkest season of your life, when you feel you’ve exhausted your options, and therapy is the last-ditch effort for stabilization. Imagine reading them while you’re regressing, relapsing, losing momentum, losing hope, and desperately needing one place where you don’t have to pretend you’re okay. Would you want your own therapist wondering whether they had become more invested in your wellness than you?

I’d argue you’d need to trust your therapist could continue holding hope without requiring you to hold it first. You’d need to believe their steadiness wasn't contingent upon your progress, that they could remain deeply invested in the work, even when you temporarily couldn't be.

Don’t work harder than your patients may be tossed around as basic guidance for therapists. But we have to remember who eventually hears these phrases.

Many people come to therapy having survived on scraps of conditional care. They’ve learned that love is earned and support eventually expires. Against that backdrop, “Don’t work harder than your patient” can reinforce some of the very relational fears our patients need the most support with.

How Are We Even Defining ‘Working Harder?’

The phrase don't work harder than your patient also exists on a flawed assumption: that therapy is a competition of effort and that both people in the room are engaged in the same kind of work.

They’re not.

What does it mean to work harder than the patient?

Are you doing “too much” if you read additional literature to support a specific case? What about if you think about a patient between sessions? Or hold hope when someone has none? What does it mean when you believe your patient can do something they cannot imagine themselves doing?

A severely depressed patient who manages to shower before an appointment may be exerting extraordinary effort even if they still feel suicidal or can only provide one-word answers in session. Someone else living with complex trauma who cries for the first time in years may have worked harder during those sixty minutes than a progress note can ever capture.

Meanwhile, you may spend hours reflecting on that same session, consulting with your supervisor, examining countertransference, and considering how best to approach the next meeting.

Who worked harder? What if it were you? What are we even asking?

The therapists’ work is not the patient’s work.

Depending on your therapeutic presence, your work is about listening, connecting, regulating, conceptualizing, educating, attuning, and guiding. These are the skills you are trained and paid to provide. The patient's work is about surviving, expressing, risking vulnerability, making meaning, tolerating emotion, and gradually building the capacity to live differently. But unlike you, they are neither hired nor paid for this work.

And so, the efforts cannot be measured in the same currency.

So, it’s not about whether you’re working hard. It’s really about knowing: what work is mine?

Therapists Are Supposed to Work Hard

I have sat with many supervisees who agonize over whether they care too much. They worry that thinking about a patient after a session or feeling deeply moved by someone’s story indicates poor boundaries or unhealthy overidentification. Many have internalized the belief that if they are investing more energy than their patients appear to be, they must be doing therapy incorrectly.

I tend to invite another perspective: great therapists put forth great effort into their work. Great therapists thoughtfully carry what belongs to them.

This is not because they feel responsible for their patients’ outcomes, but it’s because they recognize the inherent privilege and complexity of what has been entrusted to them.

We come into our sessions regulated so we can remain grounded while sitting with another person’s emotional complexity. We stay present enough to notice subtle shifts in facial expression, body language, affect, and content. We hold multiple hypotheses simultaneously without rushing toward certainty. We tolerate ambiguity and stay with powerful emotional responses without impulsively acting on them. We remember details from sessions months earlier because those details are meaningful. We continually ask ourselves what belongs to the patient, what belongs to us, and what belongs to the relationship itself.

Again, this is why we are hired to do this work. None of it has anything to do with mirroring a patient’s effort.

Some days, a patient arrives bright-eyed and brimming with insight and momentum. But other days, they might arrive in a state of collapse, feeling emotionally numb or convinced nothing will ever change.

Your effort cannot and should not fluctuate in proportion to theirs. It must stay steady enough that, over time, patients trust they never have to earn it.

One of the most crucial parts of therapy is a patient discovering that our care does not have to be earned through their progress or perfect engagement. Transformative therapy happens when we show up with thoughtful consistency for our patients, when we stay committed to working hard, even and especially when they cannot.

The Risk Isn’t About Working Too Hard

The phrase don’t work harder than your patient points toward an important truth, but it identifies the wrong problem. The real risk isn’t working too hard. The real risk is assuming responsibility for work that isn’t yours.

These are different concerns, and the distinction matters.

Psychotherapy welcomes the paradox that we must become invested without becoming possessive; we must hold hope without attaching to outcomes. We also must offer care and grace while knowing we may not receive that in return.

Some therapists find this tension hard to tolerate. You have to remain emotionally engaged without confusing such engagement for total responsibility.

If you don’t know what’s yours, you risk rescuing or overfunctioning. You also risk believing the fantasy that if you could only ask the right question or find the right intervention, you could change the patient in front of you.

If you don’t know what’s yours, a lack of change starts to feel personal. You might begin questioning your competence instead of respecting your role and your patient’s autonomy.

Therapy Is Not Symmetrical

The phrase, Don’t work harder than the patient also assumes that therapy must be built upon equal forms of effort.

But it isn’t.

Your work is rooted in your clinical training, emotional regulation, theoretical knowledge, ethical judgment, and carefully maintained therapeutic frame. You are responsible for noticing patterns that remain outside your patient’s awareness. You track processes and note significant details embedded within the content. You maintain boundaries. You create safe conditions for fuller emotional exploration to occur.

Your patient brings their histories, patterns, fears, defenses, longings, and willingness- even if tentative- into session.

Neither role is more important, and neither role is interchangeable.

People don’t come to therapy when everything is working well. They typically come because there are experiences they cannot yet tolerate alone, emotions they cannot yet regulate consistently, or painful patterns they cannot yet change.

We do not become responsible for how they live their lives, but we do aim to temporarily lend capacities they cannot reliably access on their own. We lend steadiness when they feel overwhelmed, and we lend curiosity when shame shuts things down. We lend hope when despair creates a blockage and slowness when things feel too fast, too loud, too much. As therapists, this is all baked into how we consistently offer much-needed corrective emotional experiences.

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Presence Is Not the Same as Responsibility

I speak a great deal about presence and all the moving parts that steady presence entails.

Some of the most meaningful moments in therapy occur precisely because the therapist remains present when the patient cannot yet do so for themselves.

We do this in many ways like:

• Staying emotionally available when they expect abandonment.

• Remaining curious when shame insists there is nothing left to understand.

• Holding their strengths when they can only see their failures.

• Tolerating uncertainty when they search for immediate answers.

• Regulating the pace when everything feels too overwhelming.

• Maintaining the frame when the world feels chaotic and unpredictable.

• Seeing wholeness when they only see symptoms or diagnoses.

• Welcoming emotions they have spent years suppressing.

• Trusting the process when they have lost faith in it.

• Bearing witness to pain that has never before been expressed.

• Offering compassion when their inner world feels dominated by criticism.

• Remaining patient while safety develops at its own perfect pace.

• Recalling the larger stories when they become consumed by the current chapter.

It is our patients’ work to decide how they wish to engage and which choices they make within and outside the therapy room.

The responsibilities are meant to be different. The goal is not about who works harder. Instead, the goal is to work wholeheartedly at the work that belongs to us, while trusting our patients to grow into the work that belongs to them.

Thank you for being here. If you’d like to support more of my writing, please consider upgrading to a paid subscription or purchasing one of my books. If you don’t already follow me on Instagram, I facilitate a free Q&A for therapists every Wednesday. If you’d like to learn more about me or my clinical offerings, including my therapy practice or supervision options, please check out my website.

If you are new to my Substack, I create each of my posts from a place of experience, experience, and humility. While I have spent countless hours in a therapist’s chair and have published content extensively about this field, I wholeheartedly enjoy watching how new knowledge unfolds year after year. These insights emerge from that curious landing space.

With that, my suggestions should never be taken as strictly factual, and I do not prescribe them as the sole way to provide therapy. Our work is both nuanced and delicate and should be respected as such. Take what you need and feel free to share any feedback as you desire.

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The wounded healer remains one of psychotherapy’s most enduring archetypes. At its core, the belief is that our own suffering does not disqualify us from helping others. In fact, when harnessed thoughtfully, the textures of our humanity can become some of our greatest clinical strengths.

Our lived experiences deepen empathy, cultivate compassion, and remind us that healing is rarely linear. They become sources of wisdom, offering hope that adversity can be transformed into something meaningful.

But every archetype has its limits.

What happens when your own anguish blocks the work instead of expanding it? What about when your lived experience stops informing your presence and starts competing for it? And how do you know the weight of your own needs or unresolved pain has become too heavy to consistently hold someone else’s?

These are uncomfortable questions without single-sentence answers. They challenge the comforting narrative that our own suffering inherently makes us better therapists. Sometimes it does. Sometimes it doesn’t. Like all clinical tools, our humanity must be examined before it can be automatically trusted. Otherwise, we risk our wounds narrowing our curiosity or interfering with the therapeutic process.

Wounded healers obviously belong in this profession. But there is a profound difference between being informed by your wounds and being led by them.

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Lived experience is a tool, not a clinical credential.

Nobody stumbles or stays in this profession by accident.

The motives that draw us toward this work often speak to something deeply personal. These include the many experiences that shaped you, relationships that changed you, complex questions you’ve spent years trying to answer, or wounds that undeniably showed you what true suffering feels like.

Your lived experience offers tremendous value, allowing for deeper empathy, broader compassion, and opportunities for relatability. It dismantles the divide of “them” (patient) to “you” (expert/professional). Without this divide, everyone is plainly, and exquisitely, human.

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On paper, choosing a therapeutic modality is supposed to be a straightforward, professional decision. The gist is that you train in something, you commit to it, you build a practice around it. CBT, psychodynamic, ACT, EMDR, somatic- pick your lane and start driving. The rest will unfold accordingly.

In reality, the vast majority of therapists don’t choose a modality decisively or actively. More often, they are introduced to a smattering of frameworks in graduate school, like customers grazing on Costco samples. As they move through their fieldwork, they are possibly influenced by a supervisor who happens to favor one orientation over another. Then, they’re left to largely figure out the rest on their own.

I often hear new therapists, in slightly embarrassed tones, admit they have no idea what their modality is yet, or that they’re still piecing together how all the interventions or presence are supposed to fit together. Years pass, and they still don’t feel confident that they know “how to be” or “what to do.”

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Why Choosing a Theory Is More Complicated Than It Seems

If you feel behind because you don’t have a clear theoretical orientation yet, you are not alone. Despite what many books and social media algorithms depict, many therapists feel confused and unsettled when it comes to this part of their work.

Developing a modality isn’t always as simple as just choosing a framework and practicing it. It involves integrating a way of thinking, being, and sitting, and it takes time and deliberate practice to build this competence.

That said, here are some of the barriers many therapists wrestle with:

You may only receive foundational classes in graduate school

Many graduate programs emphasize breadth over depth. What I mean is that they introduce you to various orientations, but they rarely offer enough sustained immersion in any single one to fully internalize its blueprint in practice.

This begins the gap that coincides with the many structural issues prevalent in our profession. You can understand a theory conceptually long before you can comfortably apply it in real time with real patients sitting across from you. Knowing what to do does not mean you actually do it.

So, by the time you graduate, you might be able to articulate the meat of the main modalities, but you have not developed a genuine felt sense of how they structure a session.

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There’s pressure to collect credentials as a proxy for legitimacy.

After graduation, many therapists start accumulating training and certifications like children collecting items on a scavenger hunt. This is out of the sense that obtaining “more” expertise makes things “more solid.”

Therapists want more letters after their name. More completed trainings. More frameworks they can confidently say they use. More offerings to provide.

It’s a way to function like professional reassurance. If you learn just enough modalities, you’ll feel legitimate in one of them.

In actual practice, however, the opposite effects tend to occur. Therapists often find that more exposure without integration simply leads to having more tools without a coherent way of arranging them. Instead of feeling more coherent, these therapists feel scattered in their thoughts and inconsistent in their practice.

There’s pressure to follow whatever is trending.

Modality popularity is a real thing in this profession, and it seems to evolve every few years.

At different times, certain approaches gain popularity and momentum. If the seemingly cool therapists are doing therapy one way, everyone wants to do it that way. And clinicians then feel this pressure to “get trained” or risk falling behind.

Over the years, I have seen this cycle in waves around cognitive-behavioral therapy, dialectic behavior therapy, acceptance and commitment therapy, eye movement desensitization and reprocessing, internal family systems, brainspotting, ketamine-assisted therapy, the Gottman method, emotionally focused therapy, somatic experiencing, emotional freedom technique- to name a few!

Amid this ABC soup, when one sequence of letters “rises,” another tends to “fall.” Suddenly, for example, you’re ostracized if you still practice CBT after everyone has embraced somatic work. Or you begin wondering whether you’re inferior to other clinicians who are all praising the life-changing benefits of EMDR.

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Please reference Part I here.

This is part of an ongoing series of reflections and realities of the field. I’ve made it free for public use. If you’d like to support more of my writing, please consider upgrading to a paid subscription or purchasing one of my books. If you don’t already follow me on Instagram, I facilitate a free Q&A for therapists every Wednesday. If you’d like to learn more about me or my clinical offerings, please check out my website.

If you are new to my Substack, I create each of my posts from a place of experience, experience, and humility. While I have spent countless hours in a therapist's chair and have published content extensively about this field, I wholeheartedly enjoy watching how new knowledge unfolds year after year. These insights emerge from that curious landing space.

With that, my suggestions should never be taken as strictly factual, and I do not prescribe them as the sole way to provide therapy. Our work is both nuanced and delicate and should be respected as such. Take what you need and feel free to share any feedback as you desire.

The Therapy Relationship

Presence precedes perfect interventions.

Therapy is not primarily a practice in applying technique. We do not “do therapy” as if it’s outside of us. It exists within you as a person, and we sit with and witness patients through our sustained practice of attention.

Your presence communicates warmth and connection, and people are exquisitely sensitive to this exchange. When you are fully present and engaged, even imperfect interventions land differently.

Of course, timely interventions matter and should not be discarded. Patients need to feel that therapy offers value and helps them make desired changes within themselves.

But when presence is missing, even well-formulated interventions can seem hollow or misattuned. So, we honor presence by remembering that it is a moment-to-moment discipline that asks us to return to the room and the emotional reality of people as they show up in the here and now. Presence is not an alternative to any technique; it simply creates and maintains the foundation where technique can be received.

Learn more about my PRESENCE model with 280+ applicable interventions here.

Patients constantly assess for safety.

Trust is not static, which means it does not arrive and stay in any fixed container. This is true for the therapeutic relationship, just as it is true for all relationships.

This kind of assessment is implicit, ongoing, and happening outside the realm of conscious awareness, with people asking, “Is it actually safe to be here?” The bid for trust starts before therapy even begins, and it pulses throughout care.

Your emotional state is folded into the clinical material. If you are dysregulated, you cannot regulate. If you are authoritative, you may receive compliance, but you’re unlikely to receive much connection.

The assessment for safety runs through all of treatment, although it’s more pronounced in some people than others. Safety threats typically become most activated during moments of shame or the fear of rupture. With that, we aim to continue reinforcing trust through countless interactions and moments of steadiness.

Rupture/repair can be one of the most impactful interventions you offer.

Most people have limited to no blueprint for healthy conflict resolution. Instead, they know dynamics full of explosiveness, defensiveness, blame, withdrawal, rejection, and abandonment. They bring the legacy of those dynamics into therapy, just as they bring them into all parts of life.

New therapists often fear ruptures because they worry it means they are “messing up” as a therapist or harming their patients. This concern makes sense; of course, we do not want to hurt the people in our care, and we should absolutely hold ourselves accountable for any wrongdoing we cause.

Repair work demonstrates that relationships can withstand tension without “something terrible happening.” This type of corrective emotional experience can be profound, as it offers something many people have never experienced before.

For more on why and how to provide corrective emotional experiences, please read here.

Trust is often earned through consistency, not expertise.

When I supervise new therapists, they often feel frantic and full of urgency to “gain more expertise.” I remember that surge of anxiety and desire to know as much as I possibly could. At the time, I equated having more expertise with having more mastery. But therapy does not inherently operate that way.

In practice, your clinical effectiveness tends to depend much less on total knowledge and more on the ability to stay engaged and receptive. Sometimes this feels counterintuitive in training environments that emphasize technique acquisition. It can also feel difficult when patients come to you “looking for all the answers.”

Over time, therapists realize that patient trust largely depends on whether you are perceived as emotionally reliable. Can you listen openly? Can you show up warmly and safely? Are you willing to experiment to determine what works best for the individual sitting across from you?

Expertise helps us formulate treatment and understand how to best intervene, but consistency is what allows people to risk becoming known in the first place.

Curiosity goes further than certainty.

Certainty can restrict exploration, and when therapists become too narrow-minded in how they formulate treatment, they may begin to see only what fits their hypothesis. This risks missing the lived complexity of the person in front of them.

Curiosity keeps your clinical space open, allowing for more revision and spontaneous discovery. It also highlights your humility, which many people experience as deeply regulating.

Curiosity isn’t a pure absence of clinical judgment. We do need to be tracking behaviors and conceptualizing various needs and responses. But we should hold those lightly enough to stay fluid and attuned.

Focus equally on how people feel with you, rather than what you say.

Patients can and do forget exact words, but they remember how they felt in the presence of a safe person. Furthermore, they also remember how they felt when things were unsafe. Every experience is held within the therapeutic frame in ways that shape treatment outcomes significantly.

Snappy one-liners make for good social media posts, but they are not the essence of meaningful therapy. Concise reflections do help synthesize experience, but they do not replace deeper exploration.

Good therapy balances both. We do want to offer thoughtful reflections, but we also want to be emotionally attuned in real time, tracking shifts and pacing ourselves accordingly.

Do people need to feel comfortable throughout therapy? No. In fact, meaningful therapy can and does feel uncomfortable. This is because being witnessed fully is raw. At the same time, patients desire that rawness, that contact with their emotional landscape with a trusted guide. They have been starving for it for many years.

Your capacity to stay regulated is a non-negotiable intervention.

Patients borrow regulation from their therapists, especially when their own internal systems are dysregulated.

While it’s not necessary to be perfectly calm at all times, you must be able to hold steadiness. If you are getting flooded or reactive, the focal point can get too blurred.

Patients constantly borrow nonverbal cues from you. They watch how you tolerate silence, and they track your ability to remain emotionally congruent when difficult emotions emerge. If they sense you are overwhelmed by their experience, they are more likely to feel overwhelmed by it, too.

Therapy is a collaborative conversation, not an academic performance.

It is easy to lose focus and assume that you need to perform correctly to do well with your patients. This can reinforce themes of self-monitoring or excessive reliance on external techniques at the expense of relational contact.

Performance pressure generally arises from internalized expectations about competence. You may feel you must say the right thing or demonstrate value in every moment. This mindset, however, can pull you away from what’s happening in the present moment. You’re more focused on self-evaluation rather than attunement.

Therapy should never feel stuffed with jargon. It is not about you showing off your knowledge or experience. It is about meeting someone where they are, with compassion and grace, with open arms and an open mind. Collaboratively and eagerly.

Clinical Wisdom

The presenting problem is not always the presenting problem.

Patients often bring their most visible layer of distress into therapy. They are depressed. They hate their boss. They feel directionless or anxious or disconnected from their husband.

But this “symptom” is not necessarily the core of their suffering. Visible symptoms can function as adaptations. Look further, and you will see that they resemble downstream effects of deeper emotional or developmental patterns. If you only stay at the level of the presenting complaint, you might miss the entire structure underneath it.

This is the heart of “process over content” work. You must pay attention to overarching themes. How does the presenting problem represent an entry point rather than the entire map? If this symptom is the tip of the iceberg, what else exists beneath that surface? And if you treat that presenting problem well enough for it to disappear, what else would remain?

This is not to dismiss the presenting problem. Those problems need processing and treatment. But as many therapists and patients will discover, only treating that specific issue rarely provides the sustainable relief people desire.

Insight often arrives long before action.

People often understand their patterns long before they can live differently.

They will tell you why they’re struggling and identify the origins of their behaviors. They might also share their love language, horoscope, attachment style, enneagram, and self-diagnosis to verify their pattern.

In modern society, information is not gatekept, and people have become highly oriented toward self-discovery. But this does not change the gap between knowing and doing, which is one of the most common spaces in therapy.

Insight does create possibility, but it rarely creates change by itself. That is the norm, not the exception.

However, therapists and patients both risk colluding with stuckness when they feel frustrated that self-awareness has not led to desired changes. You must keep in mind that this is the norm, not the exception.

For more on working with stuckness, please read here.

People grieve identities more than they realize they will.

Therapy work entails so much grief work, but even therapists tend to be surprised by how deeply people cling to past and current identities. Even if they start resenting that identity, letting it go often feels like an immense upheaval.

This is because identities are so much deeper than cognitive constructs. They uphold felt senses of meaning and orientation within the world. Even more limiting identities can provide comfort and structure.

When change begins, the grief can feel disproportionate to the “logic” of the situation. Letting go of an identity means letting go of a known way of being, even if that way of being no longer feels sustainable.

This grief is often unrecognized and unnamed, so working through that together can be one of the more influential pieces of therapy, as it allows people to understand they are making space for more integration. Grief gives language for the bridge between who someone was and who they wish to become.

Defensiveness protects what feels most vulnerable.

Many therapists misread defensiveness as a form of opposition or refusal. Clinically, it can be best interpreted as protection. It is a sign that something emotionally significant feels exposed.

This may mean that the therapeutic pace has intersected with some vulnerable core. The patient responds in ways that keep them safe: tightening, distancing, intellectualizing, downplaying, dissociating, and devaluing.

Consider that this is data, rather than an obstacle that needs to be removed. Defensiveness tells you where the work may be touching something relevant. Rather than trying to move past the defense, we want to understand what the defense is aiming to protect.

Sometimes you do work harder than your patients.

As early as graduate school, therapists are bombarded with the warning that they cannot work harder than their patients. It’s meant to be protective, as it highlights that you cannot change anyone who doesn’t want to be changed.

I invite you to consider something different. Sometimes there are moments where we offer containment in ways a patient cannot contain themselves. We hold onto hope when they cannot. We highlight that we will stay, even if they leave themselves.

This isn’t about who is working harder. There is no competition. We are hired to work hard, but the patient is always in the driver's seat of their lives. They have to go home to themselves and live within their own bodies. Rather, when we work hard, we commit to steadiness and showing people that we can tolerate all parts of them.

The deepest wounding lives in the gap between one’s expectations and one’s reality.

We all hold many different expectations about how life should be and how others should act. When reality doesn’t match these expectations, people feel disappointed, angry, depressed, betrayed, jealous, anxious, and more.

Therefore, you need to learn which expectations your patient has about themselves and others. Why do those expectations matter so much? Where did they come from? What if they could change or even let go of some of that expectation?

In many cases, therapy frequently involves bringing various implicit expectations into awareness. As you will see, people do not always realize the intensity behind the standards they hold.

But when you can examine those standards together, you offer some spaciousness for renegotiation. The visibility gives people more freedom to decide how they want to approach their expectations.

Sitting beside pain is different from trying to fix or erase pain.

Therapeutic presence often requires avoiding the impulse to resolve distress too quickly. Such desires to fix often speak to a therapist wanting to rescue or alleviate pain. Sitting with, on the other hand, implies a felt sense of contact, and this contact creates safe conditions for deeper emotional processing.

Many therapists believe that an effective session relieves someone of their emotional activation. The patient leaves feeling better. But this is not always true. We do not control “how long” it takes for activation to change or wane. We only control our presence when the activation is there.

And so, while grounding and stability are necessary, our job is not about making people feel total relief by the end of each hour. Sometimes, it is more important for us to help them feel more fully while knowing they do not have to feel it alone.

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The stories people tell themselves are often more painful than the events themselves.

Over time, people develop rich internal stories that amplify shame, helplessness, self-blame, and rage beyond what the original events alone might dictate. These stories influence how current and future experiences are interpreted.

Therapy often involves gently revisiting these narratives. You should not replace them or force reframes. That is not your job, as your role isn’t about convincing people that their interpretations are “wrong.” There is no right or wrong here.

However, we do want to support patients in loosening their certainty and opening space for alternative meanings. As people develop greater flexibility in the stories they tell themselves, this can lead to more flexibility in daily life.

Self-of-Therapist

You will never feel completely prepared.

There is no point in a therapist’s development where uncertainty fully disappears. Even decades into practice, new situations emerge that cannot be anticipated or rehearsed. All people bring unique configurations into the room.

Therapy is not a closed system where mastery eliminates ambiguity. We remain as ready as possible. However, “being prepared” eventually transitions away from knowing “what to do” to trusting your capacity for “how to be” with whatever unfolds.

Every mistake is an opportunity for deeper reflection.

Mistakes are unavoidable. They happen all the time, and they do not necessarily disappear with more competence or experience.

Just like in any relationship, it’s not so much about if you make mistakes, but how you respond to those mistakes. Can you model humility and hold yourself accountable? At the same time, can you offer yourself a sense of grace and compassion, the way you probably would for anyone else?

Your own therapy teaches you what textbooks and training cannot.

Effective therapists are committed to ongoing knowledge and growth, both personally and professionally. They stay connected to training and supervision because there is always so much to learn. Clinical competence requires continual attention, and we all must commit to being lifelong students.

But along with ongoing education, nothing can replicate the lived experience of sitting on the couch yourself. Your work in personal therapy provides the context for understanding what it feels like to trust someone with your inner world. It reminds you what vulnerability feels like, how difficult it can be to articulate painful experiences, and how presence (or the absence of good presence) influences treatment.

With that, your own therapy exposes you to your own wounds. Many clinicians find that some of their most durable insights come from what it feels like to be on the receiving end of the therapeutic relationship.

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The best therapists remain humble enough to change their minds.

Nobody fits neatly into a single formulation. This is why having rigid adherence to theory or intervention can constrict the creative curiosity all good therapists must maintain.

This is not to say you should not build competence within specific frameworks. You absolutely should, as doing so allows you to feel more grounded and cohesive in how you practice. Without having the blueprints, you risk feeling scattered.

But theories are guides, rather than absolute rules. Your task is to hold both structure and openness simultaneously. Respect your models and tend to them well, but do not let them confine you or the people you work with.

It is common (and okay) to feel guilty about how your actions impact patients.

When I facilitate Q&As each week, I always receive some variant of the question: How do I not feel so guilty for taking time off? Is it bad that I feel guilty for needing to terminate with this person? I don’t know how to deal with my guilt around boundaries.

These questions and pleas arise from the tension existing between professional responsibility and human limitation. Of course, therapists want to be reliable sources of support. However, you have finite capacity and personal needs that do not always follow a predictable schedule.

To all of these questions and concerns, I gently note that the guilt makes sense. We enter this profession because we care about humanity and want to support people through some of their most vulnerable seasons of life. We do not want to add stress to whatever may already be stressful. However, this can all be true, and our circumstances can still change, or we must engage in some decision that we know could anger or upset our patients.

You are not outside the relational systems you participate in. Just like your patients, you are subject to the edges of being human: illness, life transitions, ethical boundaries, insurance constraints, and agency policies that sometimes require difficult decisions.

Your guilt does not inherently mean something is wrong. Caring about your impact speaks to your capacity for empathy and moral awareness.

Your own wounds will inevitably show up in the room.

No therapist enters any session as a blank slate. You come in with your history and values and needs and unresolved pain. You cannot eliminate these influences, and you can and should be aware of them.

The good news is that these wounds can deepen your empathy and allow you to sit with experiences that might otherwise feel foreign or frightening. They add texture to what you offer. Other times, they become blind spots, as they make certain stories feel especially activating, even if you can’t understand why. They can also make you more susceptible to over-identification and acting out of a place of pure countertransference.

This is why we do not work in isolation. We stay connected to mentorship, supervision, consultation, and our own recovery processes. Self-awareness is a constant unfolding and a perpetual ethical responsibility.

You will have seasons of doubting your competence and effectiveness.

Every experienced therapist I have ever connected with agrees with this sentiment. Sometimes we move through stretches of time where we struggle with the existential nature of therapy.

Therapy requires continuous engagement with suffering and uncertainty. Of course, this can lead to periods of questioning the meaning or efficacy of the work.

While uncomfortable, periods of doubt encourage reflection, continued learning, consultation, and slowing down. When you can tolerate the experience for what it is, you might be able to notice what needs more attention or care. Attending to those needs can deepen your clinical maturity.

With that, over time, you learn that confidence and doubt are not inherent opposites. Instead, they often act as alternating states within a complex developmental process.

The Work of Therapy

Feeling integrated is one of the most important markers of any treatment progress.

Integration is often a more meaningful indicator of change than symptom reduction alone. It refers to a person’s capacity to hold different parts of themselves without avoidance or fragmentation. When someone feels more internally coherent, they are less vulnerable to extreme shifts in identity or affect.

This does not mean behaving “well” all the time. Symptom-free is rarely the appropriate goal in any treatment episode. Ideally, we want our patients' internal words to feel more interconnected and less split. This means welcoming the fact that a spectrum of emotions can coexist. Over time, this creates a sturdier foundation for stable decision-making and relational engagement.

You can often recognize integration by tracking increased nuance. Nuance means people tolerate contradiction more easily and recover from emotional activation more quickly. They also experience less pressure to define themselves within “good” or “bad” parts.

Therapy often slows people down before it moves them forward.

Although it can feel paradoxical, therapy often requires slowing people down to create more space for emotional experience. This is often challenging for therapists and patients who are conditioned to cope through urgency or themes of over-functioning.

By slowing down, you help people notice what feels arbitrary or automatic. You get them in touch with their emotions, bodily sensations, assumptions, and needs in real time.

None of this is passive work. You’re creating enough space to pause and observe their internal experience without moving straight to action.

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We aim to help people stop abandoning themselves.

A great deal of suffering comes via self-abandonment. Self-abandonment comes in many forms, including when people dismiss their needs, neglect their well-being, reinforce shame spirals, override their emotional cues, or maintain a consistent incongruence between their values and actions.

As you map out a patient’s pain, you will often see that some of their deepest aches live in the times they abandoned themselves. This can be surprising, as we often assume that the greatest hurt is caused by others. And while that hurt is real and devastating, it gets more compounded by moments of internal disconnection.

Therapy often involves helping people recognize the abandonment in real time. Reconnection to self becomes its own measurement of change. When people learn to stay with their internal experience rather than automatically orphan or leave it, you can see that new responses become more accessible.

Progress is often measured by flexibility, not perfection.

Perfection is unattainable. This is why I often speak about raising the floor rather than only keeping eyes on the ceiling.

The truth is that people move in and out of different flows with their various recovery processes. There will always be hard seasons. Flexibility reflects one’s capacity to respond differently depending on context and internal state.

This flexibility helps people tolerate distress, and holding such adaptability is often a better marker of emotional well-being. than the full absence of symptoms. In therapy, we support patients in increasing their tolerance and expanding their behavioral options when adversity arises. From this framework, growth is ongoing and dynamic rather than any fixed endpoint.

You don't need to have all the answers.

It is tempting for therapists to believe they need the right insights or reflections to offer effective work. However, not having answers can often create more space for meaning-making. This allows curiosity to remain active rather than shutting off exploration prematurely.

Therapy cannot be about providing solutions as quickly as possible. We want to create conditions where new understandings can emerge.

I promise that, while knowledge matters, your patients do not need you to know every answer. But they do need you to be open to exploration and co-created discovery. They also need to know you’re willing to learn with them.

All change asks people to tolerate uncertainty.

Even if the change is small, and even if it’s greatly desired, all change holds the mirror to uncertainty. And as Virginia Satir once said, “People prefer the certainty of misery to the misery of certainty.”

Remember that change evokes existential exposure. You’re asking someone to step into a state that has not existed or been internalized. This can inherently feel so threatening.

People wrap themselves around what feels familiar and known. Those patterns may be painful, but they still maintain some sense of coherence. Letting go feels disorienting, and this is why change is often negotiated at levels that don’t feel fully rational.

Some of the hardest work is people coming to terms with learning that life cannot be controlled.

Many people still hold onto hope that they can control the external world. This is often true in relational settings where such bargaining can feel quite relentless. If they “just do X,” the other person will “do Y.” And so, they may keep doing X, only to feel enraged that "Y” does not happen.

Efforts to control represent attempts to reduce uncertainty and protect against anticipated pain. People build various coping strategies under the assumption that if certain conditions are managed well enough, outcomes can be guaranteed.

Nobody controls the future. Nobody controls how their boss responds, if their child gets sick, or what the weather will be tomorrow. Letting go of this control is deeply emotional, and it can feel like a tremendous free-fall.

However, we aim to help people redirect their energy away from controlling what cannot be controlled. At the same time, we also strive to support people in exercising agency in the many places where agency exists.

The opposite of shame is not confidence; it is safe connection.

Shame convinces people they must hide parts of themselves to earn or maintain worthiness. Because of this, many patients enter therapy expecting that if you truly knew them, you would reject them. In response to this terrifying fear, they act in ways that conceal and omit the parts of themselves that feel most fragile.

Healing rarely occurs because someone suddenly feels confident. More often, it happens when someone discovers they can reveal the parts of themselves they believed were once unacceptable and remain connected. You offering a safe relationship targets shame in ways that self-esteem exercises alone cannot.

This is why the relationship matters so much. Before someone can fully reconnect with themselves, they often benefit from the felt sense of another person staying with the parts that often feel intolerable.

For more on how we can work with shame, please read this article here.

Systems, Families, and Relationships

Changing one behavior in one person changes the entire system.

All individuals participate in larger relational systems that constantly adapt to one another. If one person starts behaving differently, everyone else is impacted, whether they recognize it or not.

This is one reason why change often triggers conflict rather than relief. When one member disrupts the equilibrium, the system will work hard to restore its previous balance.

Every relationship has a homeostasis it tries to maintain.

Relationships settle into predictable dynamics over time, and these dynamics influence how conflicts are managed and how people settle into various roles. This is why calling a relationship “dysfunctional” is shortsighted. Even some of the more disturbing dynamics can become stable due to their familiarity.

Understanding relational homeostasis helps therapists conceptualize why change often feels systemically difficult. Growth creates temporary instability before new patterns have time to develop.

The goal cannot be about determining who is “right.”

It is common for patients to seek validation that someone else in their life is the problem. Many therapists feel pulled to offer that validation because they want patients to feel believed and understood. Emotional witnessing is essential, but prematurely deciding who is “right” narrows the work.

And while we often encounter situations that involve abuse or exploitation, we also must understand that relational dynamics have various interactional patterns worth examining.

This is especially true when working with families or couples. Focusing on “who is right” prevents exploration of what is actually happening between people. Instead, we want to explore, What function does that person’s behavior serve? How does one person’s response influence the other person’s response? What is keeping this cycle in motion?

To be clear, none of this excuses harmful behavior. But we want to widen the lens enough to understand the full relational system rather than jumping to all-or-nothing verdicts.

You are never just treating the individual sitting in front of you.

Regardless of why they are in treatment, people always carry a longstanding history of influence into the room. They come to therapy with their family messages, cultural identity, community standards, intimate relationships, past therapy experiences, and broader social systems, none of which develop in a vacuum.

Even in individual therapy, we can observe these various systems. They show up in attachment patterns and behaviors, and they emerge between you and the patient together.

Remembering this will always help broaden your perspective. It grounds you in continuing to ask, “What influences impacted this person? Where did those messages come from? Who reinforced that belief or downplayed that need?”

Nobody fights about the dishes. They fight about what the dishes represent.

All content is symbolic, and conflicts are not about surface-level issues. Beneath disagreements about chores, communication, finances, schedules, and emotions are deeper questions about respect, responsibility, emotional connection, and safety.

Therapy helps people move beneath the content of various arguments and toward the meaning each person has attached to it. This is where meaningful resolution can emerge.

If you only focus on the literal topic of an argument, you’re caught in the same cycle as your patients. You’re sticking to facts or timelines or competing versions of events. These details, even if they matter, do not explain why the conflict carries so much emotional weight. Instead, you must be willing to consider, What does this conflict mean to each person?

In the event of the dishes, one person may perceive the dishes as proof that they carry the full mental load of the household. But the other may experience the argument as confirmation that nothing they do is ever enough.

The dishes are the content where fears and expectations are revealed. Our task as therapists is to help people translate their content into process.

“Behavior problems” are often connection problems.

Whether you work with children, couples, or families, those “unwanted” behaviors often communicate needs that lack language or regulation. An individual withdrawing or becoming aggressive is often a reaction to disconnection rather than pure disobedience.

This does not mean we do not address behavior, and it does not negate the need for boundaries or accountability. But instead of solely focusing on extinguishing behaviors, we also want to consider what needs those behaviors are attempting to communicate.

If you become preoccupied with stopping a behavior as quickly as possible, you might overlook the conditions that generated it (or continue to generate it). Behaviors rarely show up in isolation. And while addressing one behavior may come with temporary compliance, it often does not resolve the underlying need.

What is the behavior accomplishing? And what would become more difficult if the behavior disappeared tomorrow?

For more on unwanted behaviors, please read this article here.

Roles are adaptive before they become limiting.

All roles emerge because they help systems function under various circumstances. They are creative and resilient, offering a sense of purpose within a relational context.

However, some roles become rigid and persist long after the environment has changed. Over time, it feels exhausting to be the perpetual caretaker. Similarly, the scapegoat may feel frustrated that nobody can see beyond the identity that might have been assigned to them as a child. The role starts defining the person rather than simply describing a function they once served.

Therapy helps people understand how these roles emerged and why they may have been adaptive. They always develop for reasons that make sense. And as people step out of those familiar roles, the entire system generally reacts.

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Addiction is everywhere.

I don’t need to harp on the harrowing statistics. Most of us know the devastating toll and the harmful impact that comes with stigma and misunderstanding. This is why I want to emphasize that clinicians must build competence in conceptualizing and navigating addiction.

Because even if you do not specialize in addiction, it will seep into your practice. And even if your current patients are not struggling with addiction, there’s a good chance someone they love is. There’s also a good chance some of your patients are struggling without fully telling you.

Before opening my own practice, I spent several years working across the full continuum of addiction and eating disorder care, ranging from medical detox to long-term outpatient treatment. During this time, I helped build a trauma-informed track, and I also created several group curricula. I sat with countless people and listened to their stories and held their needs.

The work of addiction can be arduous; the narratives are heartbreaking, individuals and their family members often lose hope, and clinicians often feel like their efforts carry little weight against the fierce nature of cravings and compulsion.

As a therapist, I work with many people struggling with different types of addictions in my current practice. As a consultant, I regularly consult with treatment centers and nonprofits, training their staff and hosting comprehensive workshops on how to better support and intervene with patients.

Addiction work is everywhere. It is inescapable and essential for therapists to understand.

The “system” has many flaws, some of which I will address in this essay, but I have also witnessed how thoughtful treatment can help people change the trajectory of their lives. This continues to give me a surplus of hope.

The content of every addiction story is unique, as are the recovery methods, but many common factors often intersect. With that, I remain steadfast in my ability to honor deep attachment and resilience in my clinical presence.

Here is what I wish to share with any clinician seeking to deepen their understanding of this complex phenomenon.

Current Deficits in Addiction-Based Treatment

For the sake of this article, I am broadly defining addiction as the compulsive and chronic engagement in a particular stimulus despite harmful consequences. The “stimulus” is whatever the “drug of choice” or “concerning behavioral pattern” is.

Clinicians sometimes argue over semantics and content, trying to assess whether an addiction to shopping is as significant as, say, an addiction to cocaine, but I anchor on the following questions:

Is it causing a great deal of internal and/or external distress? Does the individual need more of the substance or behavior to achieve the desired effect? Are they able to stop or reduce use? Are they hiding, lying, or otherwise engaging in risky behaviors to maintain the status quo?

If so, regardless of “what it is,” we are in the realm of addiction, and that realm certainly exists on a vast spectrum.

Both public and private treatment facilities have their fair share of deficits. While this is not a comprehensive overview, I will list some of them below.

Lack of comprehensive treatment: Many treatment programs only focus on stabilizing addiction without considering other co-occurring mental or physical health symptoms. This is not inherently “bad,” and sometimes it’s the necessary hierarchy, especially in more acute cases. However, the risk of relapse is often heightened when other conditions are not contextualized into care.

Short treatment duration that fails to implement sufficient aftercare: Most treatment episodes are dictated solely by insurance constraints. If you’re “lucky,” the patient may receive upwards of 30-90 days of monitored care. However, this is never a guarantee, and all clinicians working in treatment know the perils of patients discharging prematurely because they no longer receive sufficient authorization. Furthermore, even long-term care without adequate aftercare is often a recipe for struggle. Many people can cobble together enough resourcing to maintain a recovery under supervision; however, once back in the real world, the struggle can feel unmanageable.

Perpetual stigmas against medication-assisted treatment or harm reduction models: While this has changed in some areas, there still tends to be a strong preference toward abstinence-based treatment. Abstinence is an excellent and necessary choice for many individuals. However, failing to consider the merits of other methods is both shortsighted and potentially life-threatening.

Accessibility problems: Not everyone can afford treatment. Some people can afford treatment, but cannot balance the other logistical concerns associated with losing employment or securing childcare. This creates ongoing barriers for both patients and clinicians alike.

Treatments that focus heavily on “tough love” and “accountability: Most people with addiction have enough internalized shame to fill a stadium. They do not need another person to “call out their bullshit.” Such treatment frameworks can be retraumatizing, as they may reinforce that the individual is inherently damaged and broken. It is also often condescending to assume people do not recognize the consequences of their behavior. Many do. Many deeply need witnessing, containment, curiosity, hope, and attunement.

Why Attachment Always Matters

John Bowlby once kindly said, “We’re only as needy as our unmet needs.”

Attachment theory is dense, but the simple, overarching takeaway is that early relationships shape how we define ourselves, regulate emotions, and connect with others throughout our lives. Attachment is not “fixed,” but people default into certain modes when threatened.

When I talk about attachment, I talk about two main fears associated with attachment. They are the fear of being abandoned and the fear of abandoning oneself. Both show up intensely with addiction.

Attachment deficits in childhood may coincide with hypervigilance and internalized beliefs around the ideas that:

• People are largely unsafe and will ultimately cause harm.

• It is safer to figure out things alone.

• Love and care are conditional and can be quickly or unexpectedly taken away.

• Certain emotions or needs are either “too big” or “completely wrong.”

• Worth is connected to something external, such as appearance, performance, or compliance.

• Even a good connection is unpredictable and can’t really be trusted.

It is a misconception that attachment theory is solely about how one attaches to others. It’s also about attachment to self, which is a major premise of internal working models. Many patients seeking therapy for addiction have attachment wounding, even if this wounding is not within their conscious awareness.

Addiction as the Secure Base

People indeed build a dependence on their substance, and they also develop an attachment to it. The substance or behavior (and all the rituals surrounding it) gradually fulfill many of the functions that secure relationships also provide.

For example, the cycle offers comfort, predictability, relief, and it tends to ask for very little vulnerability in return. And unlike people, the substance does not disappoint or reject. It does not abandon or leave.

The addiction can become a pseudo-secure base because it provides:

• Predictable pleasure and comfort whenever distress emerges

• Immediate emotional regulation

• Escape from uncomfortable emotions, such as shame, loneliness, grief, or fear

• Relief from unmet attachment needs

• A sense of control that relationships cannot guarantee

• Sense of shielding from vulnerability and intimacy

This is why any recovery often feels far more emotionally complicated than simply “giving something bad up.” From an attachment-based framework, many people truly feel they are losing a core part of themselves. They may also be losing the most predictable relationship they’ve ever had.

And so, separating from the addiction, even slightly, often triggers:

• Grief and loss

• Intense emotional dysregulation

• Heightened shame

• Fear of being alone with themselves

• Fear of intimacy and connection

• Increased vulnerability to relapse

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Therapist Vs Addiction for Secure Base

In an attachment-oriented psychotherapy, our aim is to generate with the patient a new relationship that is more attuned, inclusive, and collaborative than those that originally shaped him- David Wallin

In our work, we want to help patients gradually transfer some reliance on the addiction to other sources of regulation and connection. Therapy does not replace the addiction, and therapists do not become primary attachment figures indefinitely.

But the therapeutic relationship represents a flexible, secure base where the patient can begin exploring recovery. By offering attunement and safety, we aim to provide an alternative experience to the shame and self-abandonment that fuels addiction.

The goal is not to convince someone to change or “recover.” The goal is to promote enough safety to hold patients as they reexamine their relationships to their addiction.

We aim to do this with three goals in mind:

Goal 1: Create safety through connection

By and large, we want to elicit safety by offering a secure base within the co-created therapist-patient dynamic. Many people entering recovery have never experienced a relationship that feels consistently safe. Instead, they have learned to expect criticism, disappointment, abandonment, or judgment. We aim to meet them with steadiness over punishment. We can hold their attachment complexity without flinching.

Goal 2: Support emotional regulation

Addiction often functions as an external regulator that becomes reinforced and preferred over the years. This is why even slightly removing a substance or behavior feels like an upheaval. People see how their numbed emotions tend to emerge with a vengeance. As therapists, we model our own regulation and help patients slowly build the capacity to tolerate this distress in real time.

Goal 3: Cultivate corrective emotional experiences

Many patients expect therapists to react the same way important people in their lives have reacted. For example, they anticipate rejection after relapse or withdrawal when they become emotionally activated. But when you respond differently, you offer a new relational experience that can disrupt long-standing assumptions about themselves and others.

Attachment Issues that Arise in Addiction Work

Some of the main attachment issues prevalent in addiction work include:

Emotional Regulation Difficulties

• Struggling to tolerate distress without external soothing

• Difficulty self-soothing between sessions

• Emotional flooding during early recovery

• Downplaying discomfort associated with vulnerability

• Using intellectualization, minimization, or avoidance to escape affect

Attachment and Trust Difficulties

• Fear of depending on the therapist or any healthcare provider

• Fear of being abandoned

• Hypervigilance to rejection

• Difficulty believing any care is authentically genuine

• Heightened desires for reassurance or comfort

• Patterns of lying about or downplaying addictive behaviors

Self-Worth Difficulties

• Shame-based identity

• Belief they are broken or defective

• Difficulty accepting compassion

• Worth tied to external factors, like appearance or performance

How Do You “Do” Attachment-Based Care?

When I train and supervise therapists, I am almost always asked, “Okay, so what do I actually do?”

Like most things in therapy, the answer is both simpler and more complex than any essay can provide. Attachment-based work is less about mastering specific interventions and more about embodying a steady presence. All my principles largely derive from my CHAIR framework and PRESENCE model, both of which emphasize how transformation can occur within a co-created relationship.

If you want to learn more about my PRESENCE model, I recommend reading my article listing 280+ interventions here.

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I first spoke about burnout at a large virtual conference in 2020, at the height of the pandemic, when therapists were unexpectedly and frantically converting curated offices into telehealth squares on a screen. At the time, mental health was trending, and everyone, it seemed, was either becoming a therapist or entering therapy.

Six years later, the burnout conversation feels both saturated and diluted. Burnout is now a staple of professional discourse. You can’t escape it, as it’s seemingly plastered within every crevice of therapy conversation.

Burnout is still as real as ever, but the term itself now feels more like a lazy cop-out. Burnout serves as this all-encompassing, convenient container for the nuanced experiences that show up in this work. But when I talk about the term exodus, I’m not talking about therapists just being tired or overworked. I’m not talking about anything that a weekend getaway or professional training fixes, either.

By using the term exodus, I’m talking about both the implicit and explicit ways therapists redefine their careers in light of the profession's inherent limitations. I’m also naming the reorganization and reconfiguration I see happening all around me, from therapists quitting jobs without a clear plan for what comes next to transitioning into roles that have nothing to do with direct care. And I’m also speaking to how many passionate, skilled clinicians are leaving the field altogether.

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Why Burnout Doesn’t Fully Capture the Picture

Burnout describes a state of depletion. When a therapist is burned out, they feel emotionally exhausted by their work. Their effectiveness declines, and they may experience a sense of detachment or resentment toward their clinical duties.

For a long time, burnout was framed as an individual problem (and in some circles, it still is). The solutions are not gatekept: seek supervision, get your own therapy, reduce your caseload, take breaks, practice self-care.

This isn’t an article about burnout. You’ve read those articles. You’ve probably tried many of those solutions. They help, but they don’t always resolve the distress within.

Burnout can describe the effect, but it doesn’t always define the source. It may also label what feels depleted, but it fails to capture why the depletion occurs and keeps re-merging across various stages of the career.

Language, of course, is complicated. Burnout is not the same as compassion fatigue, and resentment is not the same as moral injury, and exhaustion is not always the same as disillusionment. They can, however, all blur, overlap, and even reinforce one another in ways that sometimes feel difficult to discern.

For the sake of this article, however, I am focused specifically on naming the exodus that’s happening within us and around us. I am referring to the ways clinicians are questioning and reorganizing their working identities in response to the current limits of this profession.

This includes those who are leaving clinical work entirely. It also includes those who are staying, but changing how they stay. And finally, it includes those who remain relatively steady in their work, but are aware of how unstable the broader field around them feels.

In other words, maybe you’re struggling to reconcile what it means to be a therapist right now. And if you’re not, there’s a good chance you’re surrounded by dozens of colleagues who are.

The System Most Therapists Work Within

As both an author and speaker, I have spent years detailing the reality of modern therapy in the United States. It is a nuanced role. I love being a therapist. I am deeply gratified by my work and wholeheartedly connected to the practice I have built. My career offers tremendous meaning to my life.

It feels important to name this. I know that my critiquing the field for being a structural mess can seem like I’m rejecting the work itself. In reality, the opposite is true.

It is because I love this work that I have often felt the need to illustrate the structural labyrinth shaped by productivity metrics, insurance jurisdiction, documentation requirements, time constraints, and high-volume caseloads. I have worked and supervised within this infrastructure.

The majority of therapists feel they must shove complex clinical work into acceptable boxes, leading them to:

• rely on diagnoses over thoughtful narratives

• time-limited sessions instead of spacious, open-ended work

• productivity targets over intentional clinical pacing

• accepting “what’s assigned” over ensuring competence

Furthermore, the vast majority of therapists work in roles with duties outside of therapy itself. Most clinicians working in agency settings feel the strain of improvising other responsibilities. I’m talking about things like case management, crisis support, care coordination, wraparound services, and other demands that extend far beyond clinical connection. Here, your role feels less defined and more subjective, causing both emotional and ethical concerns.

Even in private practice, which is often advertised as freedom, the cost of autonomy must be examined. As I outlined here, therapists working for themselves pay the price of financial precarity and the ongoing responsibility of sustaining a successful clinical practice and effective business simultaneously.

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The Work Does Not Match the Training

We know that modern graduate programs vary in type and intensity. That said, most of them overlook preparing students for handling the nuances of current work settings. As a result, therapists complete school, often with 4.0 GPAs and high expectations, but no real concept of how to manage a high caseload, adapt to short treatment timelines, stay “productive,” and conceptualize appropriate care.

Burnout tends to happen fast, but it’s not just about being overextended. Instead, new therapists with the least amount of training are given complex, acute cases with little support and guidance. They’re also responsible for negotiating all the compromises between wanting to provide high-quality treatment in a system that cares more about profits and metrics.

And so we have a contentious dilemma that often includes therapists:

• ending treatment earlier than feels clinically appropriate due to insurance limits or agency expectations

• shortening sessions to meet scheduling or productivity requirements

• taking on more clients than feels emotionally or clinically sustainable to maintain financial stability or caseload targets

• spending significant unpaid time on documentation, treatment plans, chart updates, and administrative tasks

• adjusting clinical approaches to fit “evidence-based” or manualized models that may not fully match the presenting complexity of the client

• deferring clinical intuition in favor of compliance-driven documentation standards

• carrying cases with acuity levels that exceed what their training or supervision structures adequately support

• learning on the job in real time, often without sufficient containment for the emotional weight of that learning

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Why a Therapist Exodus?

We all know that the landscape of this profession has changed dramatically over the past decade. Even within the past 3-4 years, I have witnessed significant movement, particularly around early-career attrition.

Many now feel this profession’s trajectory feels far more fragmented than linear. The viable pathways seem less predictable, and the endpoints also appear less stable.

Pay-to-Play Graduate Programs

Public counseling programs are capacity-limited and geographically constrained. When I was applying to graduate schools, most cohorts only had between 20 and 40 slots open per year. The application process was lengthy and included letters of recommendation, personal statements, GRE scores, and interviews. The programs required students to attend their own therapy for a designated number of sessions each semester.

Private institutions, on the other hand, often operate on a different logic. Many have multiple rolling start dates and more flexible admissions criteria. The emphasis is often less on selectivity and more on accessibility and even scalability.

I’m not saying one path is better than another. In public programs, the ‘scarcity effect’ creates its own level of competition and rigidity. But in private programs, accessibility often intersects with tuition revenue.

The profession, in some ways, feels both harder and easier to enter. The barrier to entry is easy, but long-term sustainability seems harder.

Nowadays, potential therapists can enter the profession on a whim, but the entry comes at a high financial cost- often upwards of six figures of student loan debt. Because of this tremendous investment, there is an urgency to stabilize quickly after graduation. Unfortunately, most therapists quickly realize that the financial outlook does not match any of the weight of their debt burden.

And so, early-career therapists step into roles that are both emotionally demanding and financially bleak. This was true back when I started as well. But for many clinicians today, the mismatch feels even more compressed and less forgiving. It appears to now directly shape the attitude of one’s career and whether they remain in the field altogether.

Compensation Concerns

Across the U.S, insurance reimbursement for outpatient therapy has remained relatively stagnant. This holds even as the costs of living, inflation, and general overhead costs have increased.

Clinicians and agencies accepting insurance must often compensate for this margin through higher caseload volume. Over time, this structural math creates ongoing limitations. You need more patients to maintain income, more documentation to justify care, and less time to actually provide it. It feels like a lose-lose for everyone.

This reality can lead to all kinds of strain, logistically, emotionally, and financially.

Logistically, schedules often feel fuller, both with needing to see more patients and complete more administrative tasks. Emotionally, there’s the ongoing tug between what a therapist believes treatment should look like compared to what they can realistically offer within time and reimbursement constraints. And financially, many clinicians must continually reconsider their workload just to remain afloat. Instead of being able to grow or deepen their clinical work, they need to prioritize paying their bills.

Clinical Disillusionment

Financial strain is one piece of the exodus puzzle. But another pressing concern is the ongoing mismatch between how clinicians wish to practice therapy versus how they are expected to practice it. This is one of the issues I see come up again and again.

Here’s how it begins: most therapists enter the field with some clinical blueprints grounded in attunement and relational care. They envision time and spaciousness with their patients. There’s room to conceptualize and explore and follow the pace of the people in front of them. There is often an authentic excitement about helping people and changing their lives.

The real world, as it does, can feel quite jarring. Many clinicians quickly encounter the harsh “grind” of working in systems that value output over depth. These environments hinge on whatever can be tracked, billed, documented, measured, and audited. Because of this, therapists are asked to conform. They need to synthesize a complex human experience, for instance, into a few sessions to maximize efficiency. They consult with a supervisor who focuses far more on how they documented a safety plan rather than exploring whether that intervention was even clinically appropriate.

I have witnessed countless clinicians grappling with this painful dissonance. Nobody, it seems, cares about their conceptualization. Nobody cares if they want to provide depth-oriented, relational care.

Instead, it’s: how many hours did you bill? Have you updated that treatment plan? Is the authorization approved? Are you meeting your productivity requirements?

Of course, documentation and accountability matter. All systems require structure, and patient care requires oversight. And the metrics are sometimes easier to measure than the relationship, so the metrics become the focus.

But the framework can feel punitive, causing many therapists to become jaded and hopeless about their roles. I find that there’s so much grief in this space.

When I say grief, I talk about the turmoil associated with discharging a patient before they seem ready because insurance is no longer authorizing treatment. I name the frustration of needing to adapt to manualized models that may not fully fit the patient's here-and-now presentation. I see the helplessness of watching a waitlist grow while knowing you cannot reasonably take on more patients. I observe the exhaustion of trying to provide thoughtful care while constantly racing against productivity expectations and administrative demands.

These dilemmas do not inherently come with perfect answers. Therapists, after all, are balancing accessibility versus sustainability, thoroughness versus efficiency, and individualized care versus standardized requirements. It is a puzzle with many missing pieces.

And so, I want to say this: most therapists aren’t actually rejecting the exquisite work of therapy. They are, however, rejecting the harsh conditions under which therapy is expected to take place. They are rejecting caseload sizes that leave no room for nuance or thoughtful pacing, and they are rejecting productivity models that define “good, meaningful treatment” in billed hours rather than depth of engagement.

I will also say this: while egregious situations certainly happen, there is rarely a single breaking point. More often, the exodus emerges from the gradual accumulation of disappointments and constraints that erode one's felt experience of being a therapist.

Increasingly Unsustainable Systems

Over the past decade, we’ve all heard that the demand for mental health treatment is on the rise. We’ve all heard there is a shortage of mental health professionals.

But is this true?

It’s complicated. Access gaps are real across public systems. Waitlists are long, and community clinics are absorbing a dramatic strain. But many clinicians working in these settings report extremely high caseloads and very limited support.

We’ve moved away from the trope of “paying your dues” in under-resourced or exploitative settings. But what have we replaced it with? In many cases, clinicians are still entering environments with high acuity and volume. But they may have even less mentorship or long-term professional scaffolding than their predecessors.

I also challenge the concept of “shortage.” If you look at the system as a whole, you can see the uneven distribution of therapists. Many are working within those settings. But many others are quitting their jobs, leaving insurance panels, shifting into part-time private pay, or exiting direct care altogether.

In other words, it’s hard to pinpoint if there are “not enough therapists.” Instead, I think it’s far more accurate to say that the existing workforce is increasingly fragmented. Therapists feel pulled by uneven settings with different levels of sustainability and compensation.

Demand for therapists is one thing, but the capacity to sustainably meet that alleged demand is another. How long can one remain in a high-intensity system? How long can one stomach the uncertainty of private practice? Is it true that there aren’t enough therapists? Or is this conversation really about how long therapists can hold steady amid so many undefined conditions?

Saturation Within Private Practice

For years, private practice functioned as the “exit ramp” for more mid-level clinicians. When I entered the field, I didn’t even know you could work for yourself until you were fully licensed! Like most of my colleagues, I followed the sequence of accumulating hours in various agencies until I seemingly and slowly “graduated” into private practice.

This sequence is no longer the only path, as private practice is now a starting point for many new therapists. Agency work, which once felt like more of a foundational training ground, is now often perceived as overly demanding and under-resourced.

All settings have their advantages and drawbacks. But for the sake of this section, it’s important to note that the saturation of private practice is also affecting the broader exodus in various ways.

This is because success within a private-pay framework tends to be concentrated in higher-income populations. Therapists practicing in these settings can generally offer more clinical autonomy and manage a smaller caseload. But they are structurally dependent on a market of individuals who can afford out-of-pocket fees or high out-of-network costs. Growth within this model is not passive; viability generally requires strong skills rooted in entrepreneurship and networking.

Insurance-based private practice can feel like a better alternative for those who don’t want to continuously market themselves or rely on referral-building strategies. But as overhead costs rise and reimbursement rates stagnate, this can become harder to sustain without increasing patient volume.

And so, private practice is not just the automatic alternative to system-based care. Instead, I have often perceived it as its own divided landscape. On one side, there is sustainability (private pay) at the expense of accessibility (fewer patients can afford it). On the other hand, there is accessibility (more patients can afford it) at the expense of sustainability (you may need to juggle a higher caseload than you want).

Striking a balance between the two is difficult. And both sides absorb tremendous judgment.

What Happens Next?

While hope is one of the best currencies a therapist can offer, I am also a realist in all my affairs, as I believe that’s equally an important part of attunement.

While I don’t hold a crystal ball into the future of psychotherapy, here’s what I envision happening:

Acceleration of hybrid and side-gig-based careers: Instead of a single, stable “therapist job,” I envision more clinicians continuing to build multifaceted income streams. This diversification can be a safeguard against burnout, but it also represents an ongoing societal response to financial anxiety. We are seeing this shift in many industries, and remote work continues to make it even more accessible.

Further stratification of private practice: I imagine private practice will continue to divide into its two distinct tracks: private pay and insurance-dependent. While many may try to balance honoring both options, I think the middle space may continue to shrink. Those succeeding in private practice will continue to be able to charge high rates, but those who do not “find their footing” within their businesses may continue to struggle to secure “their place” in the field. With that, I do believe many therapists will actually leave private practice to secure more stable employment.

Growing issues with accessibility and workplace shortages: If more therapists leave insurance panels or agency-based work or the field altogether, accessibility will continue to remain a problem. Waitlists may remain long in public community health, while private-pay therapy becomes more concentrated among those who can afford it. As workplace instability persists, organizations may find themselves struggling to recruit and retain qualified clinicians. The pressure to “keep positions filled” will outweigh the ability to be selective in choosing the right candidates. Workplaces will be more reliant on whoever is “willing to stay” and “put up with the conditions” rather than whoever is best positioned to do the work well. This, of course, affects everyone, including the patients themselves.

Increased normalization of early-career pivoting or exits: I predict more clinicians will leave direct therapy roles earlier in their careers or pivot into adjacent roles sooner than previous generations. If attrition remains a problem, I imagine the profession will become more polarized between those who find their “place” in the field and those who stumble or leave early.

Expansion of non-therapy substitutes for care: More people may turn to therapy alternatives, including coaching, peer support groups, and AI tools to supplement or replace mental health treatment. Over time, the concept of “traditional therapy” may change altogether and become just one option in a wider and less regulated network of emotional support.

Where Do We Go?

Despite my concerns about the future of this profession, I do not write any of this from a place of complete cynicism.

As I always say, I genuinely love my work and believe deeply in its value. I continue to see extraordinary therapists enter this field, and I remain convinced that meaningful, life-changing care happens in therapy sessions worldwide.

But just as we often encourage our patients to hold multiple truths, we must do the same. We can acknowledge some of the ongoing tension within the profession without abandoning hope for its future. In fact, I would argue that these kinds of honest conversations are a prerequisite for meaningful change.

The therapist exodus is not just about good therapists leaving the field. It’s also about how many providers are simply searching for ways to build their careers in ways that feel clinically meaningful and personally sustainable.

The future of therapy will continue to evolve. I have written about this evolution for years and spoken about it in countless presentations. Change is inevitable in all facets of life. The structures of care will transition, and the business of therapy will shift. The pathways into the profession will adjust based on market demand and other emerging trends.

The need for therapy is likely to persist. But we need to create conditions that allow therapists to persist with it. Because if the profession continues to lose thoughtful, invested clinicians faster than it can retain them, the consequences will be dire and dilute the field altogether.

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In recent years, therapy has become intensely body-based.

Everywhere you look, you’re bombarded with somatic awareness and nervous system regulation and how trauma is stored in the body. I’d argue that this movement was propelled by Bessel van der Kolk's influential 2014 book, The Body Keeps the Score, which fundamentally impacted how many clinicians conceptualize trauma and healing.

In many ways, as a long-time trauma therapist, I think this unfolding has been important. For generations, psychotherapy largely favored cognition: analyzing thoughts, interpreting narratives, challenging distortions, searching deeper and deeper for more insight. The body remained a ghostly afterthought.

Maybe the pendulum needed to swing. The mind and body, after all, reinforce one another. They are not competing systems, and I do not believe they should be treated as opposing forces within some therapeutic culture war.

As the once-elusive concept of “trauma work” has expanded, it has interwoven many essential concepts rooted in neuroscience, including hyperarousal, dissociation, fight-flight-freeze reactions, and nervous system functioning. If trauma work is central, the body becomes harder to ignore.

But everything in life is a trade-off, and therapy is no exception.

“What do you notice in your body?” has basically replaced the cliched adage “How does that make you feel?”

The question can be useful. But have we become so enthralled by embodiment that we’ve unintentionally put it on some risky pedestal?

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The Body Is Not Equally Accessible to Everyone

Therapy trends can unintentionally universalize experience.

But in real life, as most of us know, people vary tremendously in how they access their own bodies.

Yes, some individuals naturally notice subtle physiological internal states. They can identify tension in their shoulders or constriction in their throats. Their observations feel both intuitive and immediate.

But others cannot. In fact, most don’t know what’s happening within their bodies at all. People often arrive to therapy after living their entire lives moving through their days via intellect, creativity, spirituality, action, humor, and observation. Their internal words are often rich, even if their bodies remain comparatively opaque.

Sometimes interpreting or even talking about the body may not be as accessible to:

People with trauma histories with dissociation or chronic shutdown states: For some individuals, limited bodily awareness is survival. They learned to endure overwhelming experiences by not feeling the body and “moving through” as best they could.

People with chronic hypervigilance or anxiety disorders: Some people are not disconnected from the body at all. In fact, they often feel exquisitely attuned to every micro-sensation. But rather than feeling connected or embodied, they resonate more with a loud internal noise that never shuts off.

Neurodivergent people: Neurodivergence can impact interoception, and internal states may be noticed too late, too intensely, or sometimes without clear differentiation. Cognitive mapping or relying on external cues sometimes feels more reliable than pure body tracking.

People with alexithymia or limited emotional labeling: Some people experience strong affect, but they have difficulty translating their internal states into language. Naming what’s happening in the body can feel either elusive or downright impossible.

People with chronic illness or pain conditions: If bodily sensations are painful or overwhelming, turning attention inward can increase a state of distress rather than reduce it. Here, the body feels frightening and difficult to manage rather than informative.

People with eating disorders: Those with eating disorders focus their attention toward weight, shape, hunger, fullness, and perceived body “wrongness.” They are aware of their bodies, but this awareness is filtered through protection and self-monitoring rather than felt experience.

People who were never taught or modeled body awareness: Last but absolutely not least, most people were never taught this concept. Even if somatic awareness may feel “obvious” within therapy culture, the practice of turning inward in this particular way is generally unfamiliar.

Is Body Work Always Necessary?

I have spent many years working with trauma, addiction, and eating disorders at all levels of care, both as a therapist and supervisor. I have sat with countless people whose relationships with their own bodies feel utterly fractured.

Building a relationship with one’s body absolutely has its merit. The body is the home, and it’s the only home nobody but ourselves lives in. We thrive when we know when to push and when to rest. We benefit from learning how to let sensations rise and fall without immediately reacting to them. It can be important to cultivate an inward curiosity, especially when we want to feel more connected to ourselves.

In my work, I absolutely see how body-based interventions can help people interrupt relapse trajectories by creating pauses before certain unwanted behaviors. I see how it supports others in recognizing when they are moving toward dissociation, panic, or explosive anger. There is real clinical value in checking in with the body as an early warning system. And many build more positive relationships with their bodies, reinforcing their desires to nurture and care well for themselves. All of this is so important. I would never devalue that.

But the body is not the only doorway into the self.

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Any experienced therapist knows that insight does not naturally lead to change. Naming patterns is important and can help people find language for their suffering, but self-awareness does not automatically reorganize how one copes in everyday life.

Yet, we often romanticize breakthrough moments in psychotherapy. The breakthroughs look like someone crying for the first time in years or ending an unhappy relationship or changing their career or stopping drinking altogether.

The breakthroughs matter, but the grit of therapy tends to look a bit less cinematic. In many sessions, therapy looks like sitting with someone as they touch some of the same difficult edges over and over and over again. It looks like circling the same tender issue from many different angles. And it definitely looks like a patient insisting they want to change, they must change, while continuing to preserve whatever feels most familiar.

Ambivalence is a Form of Safety

Ambivalence is not lazy, and it is also not irrational. We can conceptualize that ambivalence is often exquisitely organized. This is especially true for patients with higher levels of self-awareness. These are the ones who come to sessions with statements like:

• “I know I self-sabotage.”

• “I know this relationship/job/situation is bad, but I can’t leave.”

• I know this behavior/pattern/coping strategy is hurting me.”

• I know I should speak up / leave / do something different.”

The clinical temptation is to orient toward movement, toward change. We want to sync the insight with the paired behavior. But we must remember that awareness and action are not inherently existing within the same systems.

Ambivalence honors what might be lost and what could get hurt. For example, leaving an unhappy relationship means risking losing a sense of stability. Changing careers means potentially failing or exposing oneself to financial vulnerability. Setting boundaries can threaten attachment.

Even the best healing feels terrifying when someone has maintained an identity around surviving pain.

Stuckness deserves reverence because even the most unwanted behavior represents a sophisticated solution. People rarely surrender their survival strategies simply because they are intellectually aware of them.

Ambivalence represents someone trying to negotiate between two competing truths. These truths are:

• I cannot keep living like this.

• I do not feel safe enough to live differently.

And Ambivalance is Also Highly Shame-Based

The back-and-forth that comes with ambivalence creates immense internal conflict because patients genuinely do want to change. They are not lying to us, but they worry they come across that way. They are not trying to be defiant or difficult, but they may be labeled in such a way.

In reality, they feel exhausted by their own repetitions. They are frustrated by the gap between what they intellectually understand and what they can emotionally tolerate.

This is why therapists must understand that insight can sometimes intensify shame. When someone feels self-aware, they tend to witness their own self-paralysis. They start tracking all the ways they “should” be different while simultaneously remaining frozen.

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There is a strange and often unspoken fantasy associated with private practice that many therapists aspire to actualize. While it is rarely stated directly, I see it existing within every fold of psychotherapy entrepreneurship.

The trope is:

• You become your own boss.

• You set your own hours.

• You curate a beautiful office.

• You charge a sustainable fee.

• You escape burnout.

• You work with your ideal patients.

On paper, this feels both reasonable and meaningful. Who doesn’t want autonomy and freedom as a therapist, especially when you have felt the tremendous weight of institutional pressures within the workplace?

It seems like a dream.

Until you start crunching numbers.

Because beneath the aesthetics of private practice, we see that many therapists are struggling to make the math work. This is increasingly true in cash-pay settings, which are often romanticized as the gold standard of ethical and sustainable care.

As a field, we are inundated with messaging around ‘abundant mindsets’ and ‘charging your worth,’ while simultaneously navigating student loan debt, inconsistent referrals, health insurance costs, taxes, consultation fees, retirement concerns, and- more recently- the expanding influence of venture capital within mental health infrastructure.

And in practice, you must face constant layering of conflicting messages:

Pay your dues, but don’t stay underpaid too long; build experience, but don’t overextend yourself; be fully present with complex clinical material, but also maintain boundaries and practice self-care and limit how many patients you can realistically see; develop a niche, but remain flexible enough to meet market demand; avoid burnout, but grow a caseload large enough to be financially viable; prioritize clinical excellence, while also becoming visible enough to sustain referrals in our branded economy.

What are we possibly supposed to internalize? It seems that no matter what path you choose, you are maybe doing something right, but you are definitely doing something wrong.

Has Social Media Sold Therapists a Lie?

I believe it absolutely has.

I say this as someone who’s had a full private practice for about a decade. I say this as someone who also openly criticizes the narratives circulating in our field. I say this as someone who has never concealed that I absolutely rely on other income streams to sustain my work and life outside of direct clinical practice.

In recent years, social media has sold private practice as a form of liberation: there is the aesthetic office, the depiction of slow mornings, the “I only work three days a week and never miss a middle-of-the-day school assembly with my child” narrative, and the glossy stories about charging premium fees while being deeply aligned and fulfilled.

What a compelling image. Is it true? More importantly, is it sustainable?

That full fee? What about office rent, electronic health records, credit card processing fees, consultation, licensing fees, continuing education fees, taxes, marketing, website maintenance, health insurance, retirement, unpaid cancellations, and unpaid administrative labor?

And what if nobody in your market can actually pay that fee?

And if you lower it, can you sustain seeing 30 or 40 patients without significant consequences?

If you can’t work at that volume, how else do you intend to stay financially afloat? If you are not independently wealthy or subsidized by some other income, what is holding your model together?

This is what the social media narrative conceals. “Freedom” is a conditional form of stability that depends on invisible labor and uneven privilege. It also typically costs some set of financial realities that are rarely shown within the curated version of this profession.

And if you can’t do it on your own?

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Should You Pay Your Dues Before Going Out On Your Own?

This conversation has become increasingly polarized.

I entered this field when clinicians were expected to spend years working within agencies before starting their own practice. The ‘grind years’ were meant to toughen my skin, harden my soul. And indeed, it was where I received a breadth of clinical exposure and matured as a new therapist.

Critics argue that these systems can be exploitative and underpaid. They can burn out therapists before they even become licensed.

Both perspectives contain truth. Agency work offered benefits and financial stability at a time when that was non-negotiable for me. It exposed me to the invaluable merits of high-acuity cases and interdisciplinary collaboration. Nothing prepared me better for crisis management. Because I entered the field at a young age, it was during this time that I developed immense resilience.

At the same time, I had high caseloads and very low pay. I worked three jobs for several years. Supervision was insufficient at best. I watched many colleagues harden, but they also sacrificed their hearts and lost their spirits.

I am not convinced I could have survived private practice early on. I did not have any financial security blankets or family wealth to ease the instability. I met my husband during graduate school, and we were two emerging therapists trying to build a life while carrying our own uncertainties about this career’s sustainability. We both worked relentlessly, taking on extra roles and spending years stabilizing financially.

Did I pay my dues?

Possibly. I know I survived systems that placed extraordinary demands on me. I know I learned meaningful interventions and sat with many amazing people.

I also know that I, like many new therapists, was responsible for working with some of the most challenging cases with the least oversight and experience. This reality is rarely discussed honestly enough within this field. New clinicians carry enormous clinical responsibility with very little mentorship.

This is what complicates the “pay your dues” conversation. As we talk about the structural problems in the work, we also have to confront the fact that we implicitly ask some of the least experienced clinicians to treat society’s most vulnerable patients.

What About Group Practices?

Group practices are sold as the middle ground between agency work and solo private practice.

In theory, they offer a supportive, collaborative environment for clinicians. This promise is certainly appealing. Less isolation, built-in referrals, administrative support, consultation opportunities, and some messaging around protection from the volatility of independent practice.

But I often observe a reality where both the owner and the therapists resent one another.

The owner does not feel respected or appreciated for the behind-the-scenes business management. After all, they are paying for office space, payroll, marketing, credentialing, software systems, liability coverage, staffing issues, and the endless invisible labor required to keep a business functioning. They hire and mentor clinicians, only for some therapists to eventually leave with much of their caseload, which they are fully entitled to do because nobody “owns” patients.

The therapists resent the financial split. Of course, they do not like handing over 30, 40, 50, 60% of their earnings. They look at their caseload and feel emotionally activated by how little of that money actually reaches them directly. And if referrals slow or supervision feels inconsistent or lacking, they rightfully feel deceived.

What About the Big Platforms?

The surge of large therapy platforms brings another layer of complexity into this conversation.

Many of these companies seem appealing, especially to newer therapists seeking referrals and billing infrastructure. They offer a promising solution instead of needing to build your entire practice from scratch. This appeal makes sense. You create your profile, determine your availability, and theoretically gain access to a steady stream of referrals without needing to market yourself independently.

Yet, the platforms are profit-driven businesses. They are venture-capital-backed businesses operating within systems that prioritize scalability and bottom lines. I am not suggesting that it is bad. Had they been around when I first started my work, I likely would have joined them. I am saying it is risky and that therapists should not confuse accessibility with long-term protection.

These companies exist within a broader scope of startup culture and rapid expansion models. As we know, when mental health care becomes integrated into large-scale corporate infrastructure, expectations become blurry.

They have also become highly competitive; on a platform, it almost feels impossible to stand out. You’re a searchable thumbnail next to hundreds of other clinicians offering similar language around treating anxiety or relationship issues. Your visibility is algorithmic, your bio must communicate expertise, and your marketability must be captured within a few paragraphs.

Here, you are a therapist. But you are also a member of a marketplace where your discoverability determines your career survival.

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What About ‘Becoming a Brand?’

This is another rapid evolution within modern psychotherapy. Under the ‘branding’ framework, you are expected to become this visible personality, and many therapists resonate with feeling pressured to:

• build a niche

• create consistent, engaging content

• master SEO

• network locally

• make and sell courses

• film psychoeducational videos

• cultivate parasocial trust

• remain ethical, regulated, and clinically grounded throughout all of it

This is a whole labyrinth of labor on top of the labor associated with actual therapy.

I write this as someone who relates to ‘becoming a brand.’ I am a therapist, but I am also a well-known author, speaker, and ‘meme maker.’ My multifaceted presence has created tremendous opportunities for my practice and career at large. I am highly aware that this is a privilege that has created leverage that did not exist when I began. I am also aware that it offers uneven advantages that are difficult to replicate from scratch.

I also have inside knowledge of branding and marketing because, to make extra money in my early years, I built a writing business. I helped therapists create websites and online content. I learned how to please search engines through technical nuances like keyword strategy and audience targeting.

Now the field is entering a new phase again. This one is shaped by AI-generated content and even faster cycles of online attention.

I am not dismissing the benefit of branding.

However, I am also critical. Therapists are now existing within a profession where visibility itself increasingly functions as currency.

One’s clinical skill or depth of training does not reliably determine one's success. Instead, there’s an emphasis on other factors like aesthetic coherence, posting consistency, and satisfying the always-hungry algorithm.

Some of the most visible therapists are not necessarily representative of our field as a whole. However, they are becoming the default image of what therapy “is.”

This coexists with more tension. What if you don’t want to become a brand? What if you want to only sit with patients, think deeply, and engage in meaningful but private labor? Can you survive? Can you make it in a field that now feels more contingent on the ability to be found in the first place?

The Profession Has Always Depended on Financial Privilege or ‘Side Hustles’

I openly have several income streams, as does my husband, who is also an experienced therapist. Both of us started with essentially nothing. We worked and worked and worked. Amid my practice, I built a writing business, social media page, wrote two books, and created training programs. He directed, supervised, and moved into management.

We love our clinical work. We also cared about our financial sustainability.

Are we unique? I’m not sure. Even the master theorists seem to have a similar way of doing business.

After all, what do Freud, Jung, and Rogers have in common? They were all writing, teaching, developing theories, and building parallel intellectual or institutional projects alongside their clinical work—in other words, multiple income streams.

How did the theorists even become theorists? In a sense, they were side hustling long before the term existed.

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Translate that into the present moment. The pattern of “building things on the side” has just become modernized, although it now looks like therapists running courses, selling CEUs, managing podcasts, producing reels, or writing on Substack.

The reality is that “being a therapist” often does not fully cover the conditions required to stay a therapist.

Unfortunately, this is rarely named directly within our training. You may be taught clinical knowledge, but you are not given much direction on how to build a sustainable economic life.

Instead, the implicit message seems to be that if you are good enough, the system will take care of you.

But what actually happens is that many therapists are patching it altogether.

I’ll share some examples: one therapist picks up weekend supervision groups because their caseload alone does not cover rent. Another starts seeing clients on multiple platforms, accepting lower rates in exchange for more volume. Another optimizes an Instagram page because they realize their educational content generates more financial stability than clinical hours ever did. Another relies on a partner’s income to make private practice possible. Many just accumulate debt and shame while still trying to hold loving space for their patients.

What Happens When Therapists Have Privilege?

Stratification persists. I’ll explain it simply.

Some therapists can afford to stay purely clinical, and some cannot.

The former often have access to support systems, such as family wealth, dual-income households, and early financial stability. They can afford those multi-year certifications or private supervision. They can meet with a good private therapist weekly. They can attend expensive intensives or spend months in lower caseload phases to “focus on development,” allowing them to absorb slow seasons without panic. They can leave underpaying positions without having to immediately replace that income stream. They have room for recalibration, room for experimentation.

I now have this privilege. It offers so many advantages. For example, I can give back by devoting a portion of my practice to sliding scale and pay-what-you-can fees. If someone terminates abruptly or one of my children gets sick and I must cancel sessions, I am no longer anxious about whether I can replace the lost income that day.

Meanwhile, other therapists exist under different constraints. They calculate whether their cancellation policy will alienate patients they cannot afford to lose. They decline trainings they want to attend because the cost competes with groceries or loan repayments. They build their competence in fragments, between sessions or in the margins of overextended weeks.

I lived in that reality for years. I could not initially afford the training I wanted, so I borrowed books from the library to deepen my clinical skills. I could not pay for weekly consultation groups, so I relied on informal peer conversations until I found a supervisor generous enough to offer supervision at a very affordable rate.

This all speaks to developmental stratification. Different speeds of training, different depths of specialization, different access to reflective space, and ultimately, different trajectories of clinical identity formation.

The latter are far more likely to move into hybrid identities where their clinical care is just a piece of their broader economic strategy.

Neither is right nor wrong. The world has never been fair. This is not a conversation about that.

But side hustling is structural, and failing to talk about the nuances of such entrepreneurship is a disservice to the many therapists who wish to succeed in private practice.

We Need More Honest Conversations about Money

Here’s what I don’t think we need.

We don’t need more rhetoric about abundance. We also don’t need to shame therapists for their fees. And we certainly should not pretend private practice is either effortlessly freeing.

Instead, we need to be more transparent that:

• many therapists are financially struggling

• talking about economics often feels precarious

• emotional exhaustion impacts earning capacity

• many therapists are subsidized by other sources

• many therapists feel stuck between ethics and financial survival

We must confront these contradictions. If we want deeply skilled and emotionally-present clinicians, we cannot deny that these conditions are often in direct tension with the economic realities of the profession itself.

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In most professions, we can accurately and precisely measure competence. The pilot flies the plane from destination A to destination B, the surgeon completes the procedure, the plumber fixes the clogged drain, the chef prepares the steak, and the professional basketball player scores X amount of points.

We all know that psychotherapy feels more abstract and inherently harder to measure. This makes sense. Human behavior is deeply complex and layered. We do not want to minimize the spectacular uniqueness each person possesses.

And yet.

We expect therapists to develop mastery within a system that cannot even agree on what mastery looks like.

Instead, therapists are routinely recommended to trust themselves before they have any meaningful way to evaluate themselves accurately. They are given enormous emotional responsibility with surprisingly minimal observation, inconsistent standards, contradictory supervision, and almost no universally agreed-upon definition of what “good therapy” actually entails.

When they feel overwhelmed, as many do, they are slapped with imposter syndrome and told to work on it in therapy, in supervision, and to “trust the process.”

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The Field Cannot Agree on What Therapy Is (And What It Isn’t)

What are therapists actually supposed to do with patients? What is your main role?

The answer depends entirely on whom you ask.

I might emphasize relational depth and attachment. Another may insist on behavioral interventions and direct symptom reduction. Someone else may encourage body-based tracking or nervous system regulation, while their colleague focuses on cognitive restructuring. The graduate school professor may be teaching about the benefits of decolonizing all conventional methods.

Even our definitions of mental illness continue to expand and evolve. The DSM once contained just over one hundred diagnoses. The current version contains nearly three hundred. Meanwhile, therapy itself has become a frontline recommendation for almost every form of human suffering: grief, burnout, relational dissatisfaction, loneliness, career confusion, low self-esteem, existential dread, family estrangement, trauma, anxiety, depression, and countless other experiences that often blur the line between pathology and being human.

I am not criticizing this expansion, nor am I against people seeking therapy for such tender concerns.

But the broader this field becomes, the more challenging it feels to define what treatment is actually intended to accomplish. In some ways, we have democratized therapy faster than we have operationalized it. Subsequently, it is the therapists who must wrestle with that ambiguity while the patient arrives expecting expertise, clarity, relief, and, of course, transformation.

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Therapists Are Asked to Trust Themselves Before They Know How

Over the years, I have had the privilege of working with many, many therapist patients and supervisees with varying degrees of experience. They differ in type and need, but almost all will resonate with a deep desire to help people and be “a good clinician.”

They study theories. They memorize legal and ethical codes. They learn about various presenting concerns, ranging from relational trauma to ADHD to eating disorders to problematic gambling to suicidality. They learn theories and try them on, although they often work with supervisors who practice differently. They patch together podcasts and books and trainings, trying to hold onto substance and guidance wherever they can find it.

The real work is always messier, vaguer, harder to calculate, concretize, metabolize, and define. The real work captures the essence of humanity, but this essence does not fit within straight lines, nor does it always adhere to one particular protocol.

The real work is a patient dissociating halfway through the session. It is someone vaguely hinting at suicidality. It is the couple erupting into conflict and telling you that you are a waste of money. It is the patient asking, “What would you do if you were in my situation?” It is sitting with someone who only answers in one-word responses, and it is feeling such a strong rapport with a patient, only for them to disappear on you without warning.

To soothe the rough edges, we throw therapists a series of familiar platitudes.

Trust the process.
Just be present.
You’ll find your style.
Therapy is an art.
The relationship heals.

All of these statements are wholly true. They contain deep wisdom, and they speak to what it means to hold steady amid uncertainty.

But they don’t answer: What if I genuinely don’t know what I’m doing?

Therapy Has a Strange and Nonexistent Apprenticeship Problem

I have spoken about this phenomenon at length in my books and in various trainings. We are vastly underresourced with very little opportunity to actually observe direct therapy.

Think about nearly any other skilled profession.

Surgeons observe many surgeries before performing them. Electricians shadow experienced electricians. Barbers cut hair under direct supervision. Pilots train extensively in simulators alongside instructors.

And throughout this process? The novices receive direct feedback and ongoing coaching. They can review their own work and grow accordingly.

But therapists? Not so much.

Many clinicians spend far more time doing therapy than watching therapy. You have spent hundreds or thousands of hours sitting with patients. How many times have you observed another clinician sit with one of theirs?

Therein comes the argument around confidentiality. And yes, patients deserve the utmost privacy and protection. Psychotherapy should not be performative. But it creates this strange personal dilemma.

Many therapists are only ever meaningfully observing treatment in three contexts:

• at the trainee level where novices largely watch other novices via videos or two-way mirrors

• inside their own personal therapy

• through television or other video portrayals

And these are all optional. I know many therapists who have never been in their own therapy and have never watched another therapist in practice.

This is unusual, and I will also make the claim that this is dangerous. In so many other professions, novices spend years observing highly-skilled practitioners working in real time before being expected to independently perform. In psychotherapy, however, clinicians enter the field having rarely witnessed seasoned therapists navigate treatment in actual sessions.

This means that a staggering amount of therapeutic work occurs privately, behind closed doors, with minimal direct observation and highly subjective feedback.

Supervision and consultation are important, but they are limited, and they often depend on retrospective storytelling:

“This is what the patient said.”
“This is how I responded.”
“This is what I think happened.”

But therapy is not merely content exchange. So much of the exquisite work exists in timing, pacing, tone, rupture, nonverbal communication, emotional regulation, transference, silence, tension, and relational field dynamics that are difficult to articulate after the fact.

But we routinely expect therapists to develop mastery under these conditions.

Imagine if surgeons primarily learned surgery by later describing surgeries to supervisors from memory.

We Have Not Clearly Defined Competence

I consider this to be one of the most destabilizing realities in the profession.

We are told it over and over. Therapists are ethically required to practice within their scope of competence.

But what exactly is competence?

When do you officially become competent enough to treat trauma? Eating disorders? Personality disorders? Complex grief? Dissociation? Couples work?

After one training? Ten trainings? Supervision? Consultation? Certification? Personal experience? Reading enough books? Seeing enough patients with that presenting concern?

The field does not offer universally agreed-upon answers. In fact, the field becomes wildly opinionated and even defensive when trying to refine this term.

So, because competence remains this somewhat elusive term, many therapists are often left privately scrambling and constructing their own standards while simultaneously fearing they may be harming people.

This creates an almost impossible psychological bind: You are responsible for helping vulnerable people, but you may never feel fully certain you know how.

What We Call “Imposter Syndrome” May Sometimes Be Structural Distress

Of course, sometimes insecurity reflects perfectionism or a critical self-perception. But we must be mindful of overpathologizing this experience.

The truth is that many therapists feel insecure due to carrying enormous responsibility with inadequate support, contradictory guidance, high caseloads, and limited feedback systems. This transcends self-esteem, runs deeper than the answers of “go to therapy” or “practice self-compassion,” and speaks more to the impact of structural strain.

Therapists must manage numerous competing demands. They often work in agencies where productivity matters more than effectiveness. They hold immense responsibility while barely being compensated enough to cover rent, licensing fees, continuing education, consultation, and student loan debt. They spend a great deal of time conceptualizing what a patient might need, all while knowing there is no definitive answer proving they chose correctly.

Yes, therapists must focus on strengthening their internal locus of control with this work. That is essential for staying empowered. That is critical for growth.

But we cannot simply individualize distress without considering the environment that may be producing it. Structural ambiguity can be a catalyst for therapist inadequacy, and that alone needs more conversation.

The Profession Romanticizes Ambiguity

Psychotherapy often prides itself on being fluid, intuitive, relational, and deeply human. I embrace these qualities and embody them fully in my practice.

Presence matters, but a relationship alone does not answer every clinical question. While the depth of connection also matters, it is not the same thing as having clinical clarity. In this work, we are all simultaneously striving to:

• offer emotional safety

• accurately assess risk

• navigate ethical concerns

• monitor affect and shifts in real time

• regulate our own presence and reactions

• maintain appropriate documentation

• satisfy insurance or other administrative demands

• honor professional growth and ongoing training

Of course, so many therapists feel overwhelmed. Of course, so many therapists worry they are not doing enough.

But this introduces the next dilemma:

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Therapists Want Standards and Fear Standards

One fascinating paradox I have noted is that therapists often both crave and detest structure. There is a desire for clearer training and specific guidance coupled with reactivity toward rigidity, protocols, and anything that seemingly reduces human complexity into simple definitions.

Can we truly hold both?

Because therapy is subjective, and human beings are not algorithms or sums of diagnoses. There will never be one universally correct intervention for every person in every moment.

I emphasize that acknowledging complexity must coexist with ongoing efforts for more clarity. The field needs honesty and transparent conversations about how:

• little observation many therapists receive

• vague competence can be

• emotionally isolating the work sometimes feels

• financially exploitative some systems are

• contradictory treatment expectations can become

• exhausting it is to carry profound responsibility inside a profession that still lacks many cohesive structures

Psychotherapy is still a relatively young profession that sometimes masquerades as fully formed. This is unfair to everyone. I do not believe it’s a matter of therapists just needing more resilience or confidence. While inner work always has its virtues, we also must own and name this field’s current limitations.

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In therapy, the presence of shame rarely arrives like other emotions. It does not announce itself cleanly, the way anger might flare or grief may suffocate. When shame is in the room, it’s both adhesive and insidious, seemingly reorganizing the patient and the room before it is brought into conscious awareness.

We describe shame as a feeling. I have always believed that feeling is too small a word. I think of shame as an orienting principle that profoundly shapes one’s perception, memory, values, self-image, and relations to others. Shame decides what gets spoken and what remains hidden, and it also edits stories in real time.

And so, as therapists, how do we identify and tend to shame? And how do we support people as they are slowly disentangling from something that feels like the essence of who they are?

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The Clinginess of Shame

In therapy, shame feels sticky because it attaches to one’s overarching identity rather than a cluster of behaviors. When shame is high, there is no real distance between oneself and one’s actions. In this fusion, the internalization often sounds like: This is who I am, and it’s really, really bad.

The ‘stickiness’ often transcends language. To really feel shame is to feel exposed in a way that threatens internal safety and external belonging. So, here, shame activates the primal ache: If this part of me is seen, I will be left, rejected, abandoned, or harmed. I cannot survive that.

And because we are wired for self-preservation, the mind aims to fuse with shame. Patients enter therapy believing they are the problem, convinced they are wrong, bad, weird, unlovable, or impossible to understand. Paradoxically, it is within this fusion that they feel the most control. If I am the problem, the narrative is contained. If I can anticipate rejection before it happens, I can brace for pain before it arrives.

While this may feel limiting, it also feels safer than the abyss of uncertainty.

Shame as Unspeakable

One of the harder tasks of therapy is that shame is highly durable, outlasting insight and often remaining intact even in the presence of attunement and care.

At the same time, people rarely name it directly. Instead, patients circle it, in forms like:

• minimizing or quickly dismissing what was just said

• losing specificity at key moments in a story

• speaking in abstract language instead of staying in the present experience

• breaking eye contact or not making any eye contact

• laughing at something that doesn’t feel humorous

• changing topics abruptly

• slowing down or speeding up the voice suddenly

• over-explaining or over-justifying to make sense of behavior

• preemptively self-criticizing (“this sounds so dumb, but…”)

• checking for your reassurance

• going blank or foggy (dissociation)

Since shame rarely announces itself directly, we need to hold that these responses are simply protective containers. They function to stay near the shame-based experience that often feels too exposing to enter fully.

The clinical task is never to bypass these moments. There is no need to prematurely strip people of the protections keeping them safe. Instead, as therapists, we want to notice when they happen and gently make efforts to slow them down.

Vulnerability Is Not Always Liberating

Brené Brown famously said, “Vulnerability is our most accurate measure of courage.”

It’s a virtuous quote that travels well and looks good on social media posts, but it’s not always the antidote to shame. For many people, vulnerability is dysregulating and a significant catalyst for entering a state of full shutdown or fragmentation.

And so, when that’s the case, instead of focusing on, How do I help this person become more vulnerable, we may need to first start with, What is this person’s capacity to tolerate being known?

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