Beginning Counselor, Therapist Journal

The Journey Of Becoming A Clinician

What does it take to be a mental health clinician? Generally, whether a physician, or mental health professional “a clinician is a health care professional that works as a primary care giver of a patient in a hospital, skilled nursing facility, clinic, or patient’s home. A clinician diagnoses and treats patients.” Once you enter the mental health field you are always striving to be the best mental health clinician that you can be; fostering your own internal clinician.

However, where does that fit in the context of the workplace? Are there some positions that make you more of a clinician than others? In the mental health field there are a variety of jobs (and each one having it’s own level of clinical thinking) but after a review one finds that the following progression occurs in a mental health career:

  1. Intern – Shadowing, assisting, and developing clinical knowledge and skills within the context of a secondary education institution. Goal of this type of position to be a sponge for information, interventions, and theory to be implemented as able.
  2. Counselor – A term used more and more (within the mental health field) to describe entry level positions at residential facilities, group homes, Medicaid based agencies, etc. that do not require a state license to practice. More often than not this requires direct care such as supervising clients, following individual service plans, and assisting with daily living activities. Starting to develop and utilize your own clinical mind more so than your supervisor’s.
  3. Resident in Counseling (Optional) – After completion of the educational requirements and gaining initial experience a residency is entered into in order to gain licensure. Utilizing counselor positions to continue developing, refining, and practicing clinical thinking and intervention.
  4. Clinician – A term and position that describes an individual who utilizes clinical knowledge, and skill to design, implement, and evaluate therapeutic interventions. Typically, this includes assessment, diagnosis, conducting therapy sessions, and supervising entry-level workers. Preference is for these individuals to hold a state license but can be held by individuals who are in their residency.
  5. Therapist – A term used most often for individuals who provide therapy in the context of outpatient clinics, private practice, individual/group/family sessions in a high level of care (residential/inpatient) that require a state license in order to practice; occasional exceptions made for residents.

Life is full of challenges, surprises, and in some cases things that feel like miracles. Looking back on how my career in the mental health field has started I can only feel amazed and generally positive. My journey started with a small rural university in Upstate New York called Alfred University. While at Alfred University (AU) I completed my Bachelors in Clinical/Counseling Psychology with minors in Music and Theatre. There is never a dull moment in Alfred – all you need to do is wander around a bit to find a social justice campaign, students having a blast with Nerf guns or medieval gear, participating in a 5k run around campus, and more.

While at AU I conducted a research study focusing on whether there are trigger words that cause communication struggles in cross gendered friendships. The results of that study showed that when giving others criticism the shorter the statement the more profound of an affect it has on the other person. While it was a general study to set up the structure for a future study focusing more on the question of “Do trigger words exist?” it helped me establish my understanding and familiarity with human behavior and my desire to provide direct clinical care for them.

That desire led me to my graduate program for a Masters in Science in Education with a Certificate in Advanced Study in Mental Health Counseling at AU. The university still held it’s undergraduate charm but at the same time took on the stress and challenges that come with graduate level coursework. I was challenged in what I believed my way of interacting with others meant, what I thought about myself, and most importantly how I would be able to help clients in the future. Through a lot of self-reflection and memorizing the most recent research on developmental psychology, abnormal psychology, counseling theory, counseling techniques, and psychological assessments I was able to gain enough knowledge and experience to graduate and even earn certification as a National Certified Counselor (NCC).

A majority of my clinical experience leading up until this point had been in a halfway house, intensive outpatient substance abuse clinic, a campus outpatient clinic, and a community based program called Multi-Systemic Therapy. Utilizing my skills developed over summers working at a summer camp near Syracuse, NY I developed my counseling style integrating various theories, practices, and interventions as I started my first post graduate employment at Blackwater Outdoor Experiences. Blackwater Outdoor Experiences provided me with a look at what it means to provide direct clinical care for a client 24/7 for 22 days in the wilderness while also learning what it means to work as part of a multi-disciplinary treatment team to ensure the clients are receiving the best clinical and medical care possible. It was in this position that I also took on the task of becoming a resident in counseling in an effort to become a Licensed Professional Counselor (LPC).

Through the Blackwater Outdoor Experiences treatment team, the clinical director Margie Crow, LCSW, and my licensure supervisor Anthony Lea, LPC I was able to start recognizing even more concretely how theories and academics of counseling were implemented into direct clinical work. Most importantly I gained the knowledge of what it means to assess an individual’s capability to participate in activities of daily living, communicate with others, effectively manage their medication, and the different levels of support that exist for individuals struggling with mental health disorders.

Following my departure from Blackwater Outdoor Experiences I started to learn about the Medicaid based programs which include therapeutic day treatment (TDT), intensive in home (IIH), and mental health skill building (MHSB). These Medicaid funded programs allow for intensive mental health counseling programming to assist children under the age of 21 (for TDT, and IIH) and supportive skill development for those over the age of 18(for MHSB). I learned that such programming is extensive, and provided by Bachelors (entry level) providers who are being supervised by an individual with a Masters in a Social Science field. I grew in my knowledge and experience with clients who are experiencing mental health disorders that have more devastating symptoms that the more common generalized anxiety disorder, major depressive disorder, etc. After some time of providing this level of care as a counselor I was lucky enough to get my newest job.

I now serve as a Clinician at Brothers Keeper, Inc. (BK) in Chester, VA. In this position I am responsible for conducting psychological assessments and typing up clinical reports to send to Medicaid insurance companies, clinically supervising two counties of the BK Therapeutic Day Treatment program, review clinical notes and services plans, conduct a staffing/training once a month with each county, and provide counseling for an IIH client. At this new level of responsibility there are challenges of incorporating clinical knowledge into learning experiences for entry level staff but also utilizing your clinical knowledge to produce countless clinical arguments to the Medicaid insurance companies.

Throughout all of these experiences I have found myself critiquing my interventions, being challenged to revisit diagnoses, treatment strategies, and the basic questions used to assess an individual’s clinical situation. What I’ve found, is that at each level and position your internal clinician grows and becomes more confident so that you are able to provide the best care and make the best decisions for your clients. Through this continual growth you develop the following skills and more:

  • Develop a safe and empathic relationship/environment
  • Reflect thoughts, feelings, and meanings
  • Question and assess what is typical versus atypical
  • Provide multiple perspectives to a single situation
  • Consider the drivers of a client’s behaviors based on their history, behavioral presentation, and observation
  • Determine a client’s struggles and validate their experiences
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Beginning Counselor, Reflections & Updates, Therapist Journal

Understanding The Complications Of Clinical Work

Throughout my bachelor’s in clinical and counseling psychology and even more so in my graduate program for mental health counseling it seemed that the Diagnostic and Statistical Manual of Mental Disorders (DSM) was the end all and be all when it comes to diagnoses. I am now in the process of going for licensure in the Commonwealth of Virginia. I have started my 3, 400 hour residency under the licensure supervision of Anthony Lea, LPC. In our supervision meetings we have started to go back through the DSM starting with the introduction into the manual (that I never recalled reading or discussing in my graduate program).

What lesson have I pulled out from this process so far? There is a section in the very first few paragraphs that calls clinicians to remember that the DSM is not a comprehensive dictionary of disorders. In the “Use of the Manual” section  it highlights that “The symptoms contained in the respective diagnostic criteria sets do not constitute comprehensive definitions of underlying disorders, which encompass cognitive, emotional, behavioral, and physiological processes that are far more complex than can be described in these brief summaries. Rather, they are intended to summarize characteristic syndromes of signs and symptoms that point to an underlying disorder with a characteristic developmental history, biological and environmental risk factors, neuropsychological and physiological correlates, and typical clinical course.”

The key word that stood out to me was to “summarize” and prior to that “do not constitute comprehensive definitions” meaning that there is information and disorders beyond the DSM that a clinician will encounter in practice. I personally found this to be a revelation because over the course of my first year at Blackwater Outdoor Experiences we have worked with individuals who have had mental health disorder symptomatology that has not fallen directly under the diagnostic criteria of the DSM such as Nonverbal Learning Disability, and Processing Disorder. These two disorders specifically have affected a good portion of the clients I have been working with; there have been significant differences in their neuropsychological abilities that have caused them to struggle in academic, social, vocational, and familial settings. In most cases it was these neurodevelopmental or neurocognitive disorders specifically that were significant underlying factors for the development of the clients’ social anxiety, depression, low self-esteem, and substance use disorder.

Needless to say; my job just started feeling a lot more technical.

One could say that reality set in. At the same time I believe that the processes that I learned as a graduate student and now as a clinician in the field have allowed me to gain a better understanding of exactly how to parse through the information my clients present in order to help identify effectively what is the underlying struggle for them. I invite my clients on a journey with me on a therapeutic investigation to gather the clinical evidence we need to correctly identify these underlying struggles. Human behavior comes in a variety of personalities, emotions, actions, communication styles, and coping skills. The challenge as a clinician is to be able to understand that variety and recognize when an individual is dealing with a regular life stressor, trauma, or have a mental disorder.

How do you figure that out? That’s a topic for another day.