(p. 1) Introduction
Congratulations! The fact that you opened this book suggests you are considering becoming a mental health professional. (For simplicity, from here on I will use the term therapist to represent all mental health professionals including counselors, marital and family therapists, psychologists, psychiatric nurses, psychiatrists, and social workers). You are exploring a career that is extraordinarily meaningful and challenging. Where else can you find a career that will so fully engage both your heart and your mind? It is a career that offers rare opportunities to build trusting relationships with individuals from diverse backgrounds with the potential to help them profoundly transform their lives. Working as a therapist is a wonderful privilege but also a great responsibility. Therefore, it is critical that you have a good understanding of what the role entails, to determine if it is a good fit for you. This book is designed to help you make that decision and to prepare you to succeed.
Introduction to the Book’s Purpose and Content
You may feel called to be a therapist to help people, building on your strengths as a “wonderful listener” or “the person all my friends come to with their relationship problems.” You may be motivated by direct personal or family experience with mental health challenges, inspiring you to help others in the way you were helped. Or, alternatively, maybe you are determined to become a better therapist than the unhelpful therapist you encountered or to bring culturally sensitive mental healthcare to an underserved community. Perhaps you’ve been intrigued by the mind–body connection and want to delve deeper into how to optimize mental and physical wellness. Or you’ve grown increasingly concerned about the grip of addiction on so many and want to help ease this scourge. Maybe you’ve been inspired by scientific discoveries about the brain, and you want to learn how to make sure these discoveries can actually improve people’s lives and reduce suffering.
There are many powerful motivations for exploring this noble career path. But how do you know if your motivations could actually translate into a rewarding lifelong career? What are the surprising realities and challenges of being a therapist? What personal characteristics and strengths may be best suited for success in this career, and what weaknesses could interfere? What do you need to know about the business (p. 2) or legal aspects of mental healthcare or how diversity, equity, and inclusion ideals are prioritized in mental health? These important questions and more will be addressed.
You are exploring this career at an opportune time. Workforce demand is great, with job opportunities projected to increase into the future. Demand for mental healthcare was already high prior to the COVID-19 pandemic and social unrest related to racial injustices, but it is now even greater. Experts predict that the stresses and trauma associated with these events will result in elevated rates of a variety of mental health challenges for many years to come.1
If you are already convinced this is the best career path for you, there are still important decisions to be made regarding which particular occupation (often referred to as discipline) to choose. The disciplines that will be described in this book include, counseling, psychology, marital/couples and family therapy, social work, psychiatry, and psychiatric nursing. While there are similarities across these disciplines, there are also important distinctions in graduate school pathways and costs for master’s versus doctoral degrees, licensure or certification, practice specializations, and employment opportunities. The information in these pages will help you to determine which discipline and degree path might be the best fit for you.
This book will also expand your knowledge about what’s possible in this career, introducing you to a diverse array of exciting job opportunities. You’ll learn about the rewards and challenges of working with children, adolescents, families, or elderly adults; people who have experienced trauma or grief; those who feel hopeless, depressed, or anxious; couples who want to improve their relationships; individuals with severe mental illnesses; those with physical illnesses, eating disorders, or developmental disorders; military veterans and their families; and many others.
Learning more about possible career paths will help you find the best fit for your specific passions and strengths. Throughout this book, therapists who have pursued a variety of paths will offer advice intended to help you make important career decisions and prepare for success. They’ll share hard truths about the challenges and the rewards to make sure you have realistic expectations.
These pages are full of practical “how to” guidance for pursuing a mental health career, but the book raises bigger, thought-provoking questions too. These bigger questions include exploration into the art and science of how psychotherapy works. You may be exploring this career path because you believe you have the heart and soul of a healer. That is a great start, but to be an effective therapist you’ll need to fully integrate your compassionate healer identity with that of a scientist, critically reviewing research on the evidence for different practices. This book will challenge you to think about what it means to integrate the art and science of therapy—to use both your heart and mind—to offer the most effective help to those in your care.
You will also learn about future developments in mental healthcare, including how innovative technologies like mobile device apps, virtual reality, and artificial intelligence impact therapy so that you can be prepared for the future. As you read through this book, ask yourself if the dilemmas and questions that are raised are the kinds of things you want to spend your career grappling with. Do these challenges and (p. 3) opportunities make you more motivated to pursue the hard work of becoming a therapist? For me, and the dozens of therapists sharing their wisdom in these pages, the answer is a resounding “YES!” Where else can you find a career where you build such meaningful connections with others and utilize emerging science to help individuals and families reduce suffering and dramatically improve their lives?
Throughout this book, I will urge you to ask yourself tough questions about how your personal experiences have inspired and prepared you for this career path. Since I am encouraging this self-reflection, it seems only fair for me to start by sharing some of my experiences in this introduction. By highlighting my own career decision points and their implications, I hope to help you anticipate the decisions you’ll face. I will also share lessons I’ve learned to give you my view of the rewards and challenges of this career. In subsequent chapters, dozens of other mental health professionals offer their advice and share lessons learned, so you’ll get valuable diverse perspectives.
Looking back, I cannot imagine having pursued any other career, but I did not always have this clarity. I spent my early college years without any certainty of my desired major, let alone my career aspirations. I explored many fields. I liked the arts and humanities, studying literature, philosophy, and other cultures in anthropology. I wanted to learn multiple languages to travel the world with great fluency until it became clear that I had no aptitude for languages (resulting in a useless jumble of unidentifiable babbling when I try to communicate in a foreign language).
I was also fascinated by science courses and even liked the challenging logic of math and statistics. I know I benefited from my explorations in all these fields, but it was also clear that I was not a natural expert in any one of them. Thankfully, I discovered psychology midway through college and gravitated to it immediately because it tapped into my analytic and scientific interests as well as my humanistic and cultural interests.
When I graduated from the University of California Berkeley with my major in psychology, I had no idea how to translate my passion for this academic field into a career. (Maybe you are feeling something similar now?) I did not know anyone who worked in the mental health field and had minimal knowledge of career options. Once again, I was juggling potentially contradictory interests. I loved the stimulating intellectual challenge of psychological research, but I was also drawn to the rewarding human connections in mental health practice.
Given that I was unprepared for graduate study, having no clarity about what I wanted to pursue, I sought practice experience and was hired as a mental health worker in a group home for young men diagnosed with autism and other severe mental illnesses. Our clients had spent most of their lives in a locked state psychiatric hospital. They were part of the national “deinstitutionalization” movement, resulting in closures of many psychiatric hospitals.2
(p. 4) This initiative to move individuals out of institutions into community settings was well intentioned. However, shifting individuals who had spent most of their lives in highly structured hospital settings into suburban homes staffed by people like me with only a textbook education in psychology presented many challenges.
My job in the group home was unquestionably the hardest job I’ve ever had. Our staff shifts were 48 hours long, and we were responsible for everything from basic daily needs (e.g., meals, dressing, bathing) to implementing detailed educational and behavioral interventions and supervising family visits and field trips. Most of the residents had difficulty communicating, and some expressed their frustration through physical aggression. Community outings were particularly fraught. Our residents were often uncomfortable in unfamiliar surroundings, and they would occasionally run away, become very agitated, or engage in socially inappropriate behaviors.
I vividly remember a community field trip when a client became overwhelmed in a grocery store, yelling and then knocking over a large display of glass jars. He quickly ran out of the store, and I had to follow him. With all sorts of potential disasters running through my mind and my heart racing, I knew I needed to stay in control despite the possible dangers. Fortunately, I caught up to him, and we sat together to calm down. It’s about 40 years later now, but I still have twinges of lingering anxiety when I hear “We’re going on a field trip.”
The group home job challenged me in every possible way. It was physically demanding; I sustained a few on-the-job injuries including a broken arm. And, of course, it was emotionally challenging as well. As I got to know our residents and their histories, which often included heartbreaking traumas and rejections, I was overwhelmed with sadness at times. Yet I was also profoundly inspired by our clients’ resilience and their pride in achieving their goals. The job was also intellectually challenging. I wanted to figure out why our residents behaved as they did and how I could apply what I had learned in textbooks to improve their daily lives.
Despite the challenges, and maybe partly because of them, I absolutely loved that job. I think I learned more there than I ever learned in a classroom or on any job since. The topics I’d studied in college classes came to life. For example, the public stigma about mental illness that I’d studied was on blatant display any time our clients ventured into the community—with people staring, shunning, and shaming. I felt it vicariously when people expressed frustration that we staff members were clearly inept because our clients were not “better controlled.”
Our clients came from diverse backgrounds and reinforced for me the powerful impact of race, ethnicity, and social class in shaping identity and others’ perceptions and biases. Family visits also provided a glimpse of the family systems dynamics I had read about. I saw the real toll severe mental illness had on loving family members who often felt helpless. I was also inspired by the resilience of family members who advocated so passionately for their loved ones after many years of frustrations.
I learned a lot of essential lessons in this first mental health job that have been reinforced throughout my career and are reflected in core themes within this book. For one, I learned that empathy and compassion are essential in this work but that (p. 5) these must be balanced with disciplined respect for appropriate professional roles and boundaries. Compassion is a great motivator, but to help our clients most effectively, we sometimes need to keep our compassion in check and respond in more disciplined ways. For example, it would not be therapeutic to solve problems for our clients, even if our compassion motivates us to do so when clients are painfully frustrated. The role of a therapist is to help clients build insight and skills to solve problems, not to try to solve them ourselves.
My job also taught me the value of structure and the importance of communicating clearly about expectations and rules. Conversely, I also learned the need for flexibility and adaptation. I tend to be a planner, so being clear about structured plans comes naturally. This was a beneficial skill in a stressful and sometimes chaotic environment. However, planners like me often have difficulty adapting to a change in plans when things go awry. So I had to work on quickly regrouping and setting new plans when necessary (and it is often necessary). Being a good therapist relies on balancing the need for structure with the need for flexibility. The COVID pandemic reasserted the necessity of flexible adaptability for all of us.
My experiences in my first mental health job formed my initial beliefs about what makes mental healthcare work. I started out believing what many people likely assume, namely, that compassion, empathy, and authenticity are the most important ingredients of therapy. Over time, I came to realize that while these are necessary, they are not sufficient for effective practice. In other words, we cannot rely on compassion, empathy, and authenticity alone. Therapists need to build on this foundation with evidence-based strategies (practices supported by research) to help clients change. This is a theme I will return to throughout this book.
My job at the group home reinforced my commitment to a career in mental health. I still wasn’t exactly sure which path to take, but I recognized that I would need a graduate degree if I wanted a job that didn’t require 48-hour shifts. It took me a few more years to clarify my specific ambitions. First, I earned a master’s degree in developmental psychology, which facilitated gaining a fantastic job as a research assistant at Columbia University in New York. I learned about how to conduct rigorous and relevant research from extraordinary mentors, working on studies evaluating the effectiveness of adolescent suicide prevention programs.
This research job was eye-opening because it taught me how rewarding applied clinical research could be. Prior to that I had a limited understanding of research based on my college experience, which required that I track guppies (with different colored dots painted on them) swimming in a tank. It was messy work in a lonely dank basement lab. I didn’t fully understand the purpose of the study, but I knew I needed research experience, so I diligently tracked those colorful guppies night after night. I naively thought that an activity only counted as research if it were conducted in a laboratory and involved a highly controlled experimental design. It took me a few years to learn how misinformed I was, and I hope I can help you avoid the same misjudgment. Research experiences range from basic laboratory research to applied, community-based research. Gaining any kind of research experience is valuable, (p. 6) whether it is conducted in a basement lab or out in the community, so look for what is compelling to you.
After working with the amazing research team in New York for a few years, I finally had the clarity I’d been looking for and felt ready to take on doctoral studies in clinical psychology. I entered Yale University with a combination of pride and anxiety, wondering if I truly belonged there and thus experiencing the common “imposter syndrome” most of us feel at times.3 I was pleased to find that I could continue to learn about both research and clinical practice, given that I didn’t want to give up either. My classes were fascinating, the faculty members were leaders in their fields, and my fellow students were great. It was an amazing place to learn, full of both history and cutting-edge innovation. I still sometimes marvel at my luck in ending up there.
While my classes were often challenging (don’t get me started about advanced statistics and programming), the most nerve-wracking and exciting part of grad school was the addition of clinical practice training. There is nothing quite like facing your first client who is looking to you for relief and guidance. As I try to reassure my own students now, almost everyone feels slightly terrified and unprepared as a beginner.
It’s been a few decades, but I still remember very clearly when I first took the role as therapist. I say “took the role” because I didn’t yet feel qualified to call myself a real therapist. Mary, my first client, was a woman in her early 40s. (Note that all client names have been changed.) She had been separated from her husband and recently diagnosed with Stage 3 colon cancer. She had three elementary school–aged sons, and she was seeking therapy to cope with all these stressors. She also wanted help figuring out how to talk to her sons about her medical issues. A faculty member gave me this information right before I met Mary, and I remember thinking something like, “WHAT!!?? This woman deserves to see an expert. I am not prepared for this at all. What do I know about facing a life-threatening illness or marital separation or parenting!?”
With trepidation, I sat down with Mary, who, in my memory, was infinitely more calm and gracious than I. I’ll never forget when early in that first session she said to me, “Oh you must hear this all the time.” The irony almost made me laugh out loud. I thought to myself, “No, in fact, this is the first session I’ve ever had as a therapist, so I’ve never heard anything before, everything is new to me.” Fortunately, I didn’t say this because I had learned about the importance of boosting a client’s positive expectations for therapy. I didn’t want to undermine her hopeful expectations. Authenticity is valuable but should be balanced by the best interests of the client.
Thankfully (and somewhat miraculously from my perspective), Mary returned each week for our sessions. She was very open from the start, sharing her profound fears as well as the everyday stress of her life, including details of her medical procedures and her sons’ reactions. Empathizing with her was not difficult; managing the intensity of my concern for her and her family was. I found that my own anxiety and lack of confidence subsided (slightly) as I worried less about myself and focused more on how I could help her and her sons. Fortunately, for both our sakes, I had expert faculty supervision and was able to employ useful strategies to address the challenges (p. 7) she raised. At the conclusion of our 6 months of work together, she expressed sincere gratitude and was able to identify the ways in which therapy had helped her to cope with extremely challenging circumstances. She presented me with a small gift meaningfully selected to represent my last name, and I must admit that I still cherish it. I remain deeply grateful to her for teaching me more than she will ever know.
I completed my doctoral studies at age 32. If you are reading this at around age 20, perhaps this is discouraging, but don’t despair. I took a somewhat meandering route. Those who are more certain of their career aspirations can find a shorter route. Pursuing a master’s degree as opposed to a doctoral degree will also be more efficient and can offer many of the same career opportunities. However, if you are older, there is no reason for you to despair either. Many people are entering this career path in their 30s, 40s, and beyond. In fact, about 40% of those earning a doctorate in psychology are over age 35, and that number has been rising.4
I often speak with students who are in a hurry to finish their education. I absolutely understand the wish to finish school as soon as possible to start one’s professional career and begin earning a commensurate salary. However, I’ve seen this impatience backfire when students find that the path they pursued quickly is not a good fit for their career aspirations.
The sidetracks I took were well worth it. The mental health worker job in the group home and the research job in New York taught me so much and were absolutely instrumental in clarifying my career choices, not to mention meeting amazing friends and mentors. One thing I’ve learned is that it is foolhardy to assume that our personal or professional paths will progress in a perfect linear direction. Perhaps we learn the most through the unexpected detours, roundabouts, or U-turns.
Upon graduating with my PhD, I needed to make a choice between a career of primarily clinical practice and an academic career emphasizing teaching and research. I don’t believe there is any way to pursue both with equal emphasis. I chose the academic career path and have never regretted it. While research, teaching, and academic leadership have been my primary responsibilities, as a licensed psychologist I find many opportunities to remain clinically active. For example, most of my teaching is direct clinical supervision of trainees working in community settings. I also conduct applied research in partnership with other therapists.
I’ve been very lucky to work as a professor for almost 30 years. I get to talk with enthusiastic students and colleagues about issues that fascinate me. I am paid to read and write about topics that I like to read and write about for personal interest. I watch how students develop into expert professionals and benefit from what they teach me. There are few better feelings than knowing that you have been a positive influence on someone’s personal and professional development. Some of the quotes in this book come from professionals I worked with as students. Just reading their eloquent and insightful comments fills me with pride.
My academic career has been somewhat unusual in that I’ve had the opportunity to teach students from multiple disciplines, including counseling, marital and family therapy, psychology, and psychiatry. It’s more common for professors to work (p. 8) exclusively within their own discipline. Having worked across disciplines, I can tell you that there are actually more similarities than there are differences. However, the differences in emphasis are important to recognize so that you can find the best fit for your interests (as detailed in Chapter 4).
In addition to working across disciplines, I’ve worked in different settings, including a school of medicine in a large public research university, a nonprofit children’s hospital, and a private school of education and leadership. Each of these environments had very different cultures and pursued different priorities. I believe my diverse experiences across disciplines and work settings provide valuable perspective on a wide range of potential career paths, as I’ll share throughout this book.
I was motivated to write this book because of countless discussions over decades with students who are looking for clarity about how to choose a specific mental health career path and how to be successful in that career. My goals are to clarify some of the confusion about the varied graduate program and career options and to provide the best preparation for success in whichever path you choose in this amazing field.
1. Swartz, H. A. (2020). The role of psychotherapy during the COVID-19 pandemic. American Journal of Psychotherapy, 73(2), 41–42. https://doi.org/10.1176/appi.psychotherapy.20200015
2. Yohanna, D. (2013). Deinstitutionalization of people with mental illness: Causes and consequences. AMA Journal of Ethics: Virtual Mentor, 15(10), 886–891. https://doi.org/10.1001/virtualmentor.2013.15.10.mhst1-1310