"I really find fulfillment in therapy sessions - talking with people, listening to their concerns, and being there to support my clients. I love that I am able to help meet a growing need in my community."
Tell us a little about yourself. Where are you from and what do you do?
My name is Alyssa and I went to UNC - Chapel Hill for an undergraduate degree in Psychology and a master's degree in Social Work. I am a licensed clinical social worker working as an outpatient therapist in Raleigh, NC. I provide therapy for children and teens with mental health and behavioral concerns.
What does your typical day look like?
A therapist’s day can look very different. I have an office in a large community mental health agency where I see my clients, primarily children and teenagers. I am able to set my own schedule based on what is best for my clients so I usually come into the office around 11 am and have at least 4, hour-long therapy sessions.
On Mondays and Tuesdays, I do initial assessments with clients, which are an hour and half in length. During an initial assessment, we ask the client about their personal history, their family and relationships, and any traumas that they have had. We go over any current symptoms that they are experiencing and why they are coming in. I will then assign them a diagnosis and get them set up with a service. We type up a summary and a person-centered plan, which includes goals for therapy sessions and a crisis plan.
I usually have a few hours off throughout the day, although a lot of that time is spent doing paperwork. Over time, I have learned how to schedule clients and complete paperwork more efficiently. Sometimes, I will have 2 hours off in the middle of the day and will go out for lunch, and some days I don’t have time to eat lunch. My day varies depending on how many clients I have and with whom I meet.
Why do most of your clients come to you?
I usually have about 60 clients with my youngest client being 4 years old. With the younger kids, we are working on things like behavioral issues, ADHD, adjustment issues from the parent’s divorce or separation, and anxiety. The majority of my clients are teenagers coming in for anxiety and depression and have low self esteem. I use cognitive-behavioral therapy, so I teach them how to understand when they are thinking negatively about things and how to learn to think more positively about themselves. We see children, as opposed to adults, for a longer period of time because there is so much out of their control and things that they cannot change, like their family environment.
WHAT DOES AN INDIVIDUAL THERAPY SESSION LOOK LIKE?
Each session depends on the diagnosis. If the client is coming in for anxiety, for instance, it will look very different for a child with anger management issues. take into account the maturity level and interests of my client and decide which activities will encourage him/her to talk through things and be receptive to learning and practicing coping skills.
I can see in our online system when a client is here and checked-in. I will greet them at the front and take them back to my office. We focus on small, practical changes that they can make to better cope with what they are working through. My sessions can include talking about a specific problem, making lists of coping skills for anxiety, doing fun art therapy activities, playing Jenga or Checkers with therapeutic themes. For instance, if the child struggles with anxiety, we may practice taking deep breaths, or I will encourage my client to draw when he/she is scared. I would suggest to a child to talk positively to themselves or to go get a parent when they are feeling upset. I work with the parent as well and how they are responding to the child’s behavior. We will look at how to make behavior charts, reward systems, and appropriate consequences for addressing behavior.
How are your clients referred to you?
My clients are referred to me through doctors’ offices, pediatricians, school social workers, school counselors, and word of mouth. We also get referrals from Alliance, a managed care organization in charge of mental health practices in multiple counties. They work with Medicaid to see how many times people can be seen by a therapist. The majority of my clients utilize Medicaid.
Once we receive a referral to our agency, a licensed clinical social worker will complete an initial assessment and the client will be assigned a prognosis. They are then recommended for outpatient therapy or for some adults, in-home therapy sessions. We could refer them out for persistent mental illness, if needed. Our agency has psychiatric-mental health nurse practitioners in the office, and we may set the client up with an appointment to meet with them in addition to therapy with a licensed therapist like myself.
How many years of schooling did you have & what program did you go to?
I went to UNC - Chapel Hill for an undergraduate degree in Psychology. I stayed in Chapel Hill for UNC's School of Social Work, which is a 2-year master's program. Each year I spent half of my days taking courses and the other half at an internship learning about the job.
What I really like about social work is that if I decide that I want to do something other than therapy in the future, I have many more career options. With a masters in social work, you could end up working in a hospital setting, child welfare, non-profit, macro- social work, or direct practice. For instance, I am direct practice - working with individuals one-on-one. Whereas macro social work would include program management or non-profit work, not necessarily therapy.
When did you know this is what you wanted to do? Why did you want to pursue this career?
During my senior year of college, we had a class with speakers from different graduate programs and career fields, including the UNC School of Social Work. I didn’t know what I wanted to do when I graduated from college and I didn’t think I wanted to be a therapist when I was in undergrad. I didn’t know what it would really be like to do therapy. I was very indecisive at the time on a career path, but one thing was for certain: I felt led to work with underprivileged people and wanted to utilize my Spanish major by serving a Hispanic or immigrant population. I chose Social Work because it has a heavy focus on addressing social justice and serving the oppressed and underserved. I also liked how I would have a degree that gave me liberty to go into different types of work and professions.
During my first year of graduate school, I did case management within a program focused on child welfare. I found out through that internship that case management was not right for me. My advisor encouraged me to try child therapy so I focused on that for the following internship. During my second year of the Social Work program, I realized through my internship at an outpatient therapy practice that I really loved working one-on-one. I didn’t really know whether or not I would like therapy until I experienced it. I was lucky to have different opportunities through multiple internships.
What are the requirements for a license to practice?
To get an associate license to do therapy, you need to complete an application, which includes recommendations. You can then start working as an associate therapist with a supervisor who you talk with on a daily basis. In North Carolina, in order to get full licensure, you have to take an exam and pass it within two years of obtaining an associate license. In other states, you may have to pass the exam first before you start practicing. Someone with a full license has about 3,000 hours of clinical direct practice and 100 hours of direct supervision. For every 30 hours I have with clients, I have to have 1 hour of supervision. It averages about 40 hours a week for two years.
What aspects of your job do you like/dislike?
The volume of paperwork following each session is definitely the most challenging. We have a 24 hour time limit on documenting notes and entering assessments into the electronic medical record system. If I have back-to-back clients, then I may have to come in early or finish at home in order to have all documentation done. However, I love getting to talk to people one-on-one. I really find fulfillment in the therapy sessions - talking with people, listening to their concerns, and being there to support my clients. I love that I am able to help meet a growing need in my community.
What are some challenges that you face as a therapist?
One aspect specific to my location and practice is that most of my clients are on Medicaid or are uninsured. Transportation issues and last minute cancellations are common. I work with a lot of Hispanic families and some therapy sessions are done entirely in Spanish. I love that I can utilize my Spanish speaking skills, however, I also see undocumented children, which brings about more challenges in providing the care that is needed. The first several sessions are spent gaining rapport, building a relationship, gaining trust, and getting to know each other. Alliance, the program that works with Medicaid and direct practices like ourselves, allocates sessions for uninsured clients, usually 8 per year. If more sessions aren’t approved, then it can be difficult to provide the care that is needed. For instance, I do have one client who is undocumented with a lot of trauma. This client needs more than 8 therapy sessions. As a therapist, I am hesitant to touch on some issues because I want to be able to complete the treatment.
What is the biggest misconception people have about what you do?
Some people have an idea of a person lying on a couch talking about their problems. This misconception probably comes from what people have seen in movies. Though I do have a couch in my office, therapy can be a lot more interactive. Because I work with kids and teens, I do a variety of different activities, games, worksheets, and talk therapy with my clients.
Another misconception is that you have to be good at giving advice or always know what to say. I soon realized that my training program prepared me to do the job. Through my training in school, my internship, and the supervision that I received, I learned how to understand different mental illnesses and how to address different issues that come up in therapy. In my opinion, to be a good therapist, you need to be empathetic, good at listening, and interested in helping people that are hurting. As far as knowing what to say and do in session, you will receive the necessary training to prepare you for that.
What would you tell someone who wanted to pursue your career?
If you think you want to be a therapist, research what type of specific graduate programs you are interested in. To be a therapist in NC, you can go to graduate school for social work (LCSW), licensed professional counseling (LPC), or licensed marriage and family counseling (LMFT). Each program provides different training is geared toward a specific population seeking counsel.
Another thing to consider is the setting in which you will practice. With intensive in-home therapy, you work with clients with more intense issues and provide therapy in their home. There are certainly challenges in providing care in the home, but it also gives you insight into why the client deals with an issue and it may help in providing practical solutions. I had the opportunity to gain experience in in -home therapy during graduates school. I am grateful for that it allowed me to see that side of social work, that experience was beneficial in getting my current job.
What are your long term goals?
I am still figuring that out! I would like to gain more knowledge and training in trauma and work with children who are either in foster care or in Child Protective Services. Whether I stay in an agency like the one I currently work in or start a private practice is something I will decide in the future. I think many have the goal to be in private practice because, with social work, we are trained for community work and the population can be challenging. It makes sense why many therapists want to pursue clients with private insurance because they are invested in the outcome. However, there is a lot of fulfillment in providing care for a population that has many needs.