An open letter to my students VII: becoming a therapist- the first few years

After taking a PRN job with a local hospital I had to stop by the HR office to sign some paperwork and get my orientation dates. As I sat in the HR rep’s office signing my life away I decided to ask, “hey, so I’m getting my PhD in about a month. What’s the bump for having a PhD?” “Bump?” “Yeah. Like pay increase.” “You mean like money? There’s no bump.” “No bump?”

Me questioning the meaning of life“Well, you know, we can’t bill on a degree.” A little bit of me died that day. Of course not, I thought because, you know, cash rules everything around me.

I’ve had several students ask me, “should I go on and get a PhD?” When I ask “why do you want one?” I never get a straight answer. My impression is they like the idea of having a PhD, as though it’s some sort of life power up. I think what they are really looking for is a boost for their self esteem. I’m sure if I knew them better that would make perfect sense given their background. However there are cheaper and less painful ways to boost your self esteem, like eating ice cream or doing elicit drugs.

Bring!

For others, myself included, the desire for a PhD is fueled by a drive to be a better clinician. I don’t know of many people (any?) who come out of their masters program feeling like they know how to do therapy. I think this is because programs often confuse theory with practice. The clearest example of this is the work of John Gottman, the king of marital therapy research. In his Sound House Relationship Model he states that healthy couples have a 5:1 positive to negative comment ratio. If a couple could be that positive would they need therapy? How does knowing this ratio help a client change? This is theory, not practice.

A lot of this confusion is because schools have to teach according to credentialing standards. Credentialing standards are heavily political. Hence many of the things taught are taught because of who’s in power. As someone who’s obsessed with practicality I think this leads to the awkward fact that a masters degree is mostly to learn to few basics and qualify you to take the licensure exam.

“In theory, there is no difference between practice and theory. In practice, there is.”-Yogi Berra

After you get your degree licensure is your next step. Licensure is what the state gives you so you can practice, which is why it’s often tied to billing. Licensure is decided state by state. This means that the state determines which classes you need in order to take the licensure exam, so make sure your degree classes match your state licensure requirements. Licensed therapists frequently have to take random classes in order to continue practicing when they change states. The state also sets how many hours you need before you can become licensed and therefore these requirements vary from state to state. The rule of thumb is 3000 hours which takes about three years to gain. Also states tend to be pretty weird about moving licensing between states, so, for instance, when I move out of state I’ll probably have to go back under supervision in order to earn a new license.

If masters degrees are for learning theoretical basics and credentialing for licensure test, and licensure is for practicing and billing what are PhDs for?

Research and teaching.

PhD’s are for learning how to do research and to acquire the credentials to teach. They aren’t for clinical skills. Most PhD’s I know at teaching colleges make around 50,000 a year. If you want be in academia with a research university, you’ll make a little more (70,000+), but it’s a publish or perish environment. I remember shuddering when I heard that being a professor at a research university was like being a grad student because you’re always writing papers. I thought right then “never again. Not for me.” One piece of useful advice I got when I started applying at different schools was, “never pay for a PhD.” PhD programs oftentimes have Graduate or Teaching Assistantships which cover tuition and provide a small stipend. While they don’t give you a lot of financial wiggle room they do relieve the astronomical cost of paying out of pocket.

If masters degrees are for learning a few theoretical basics and credentialing, licensing is for getting paid, and PhDs are for research and teaching, how do I learn to become a better clinician?

My experience has been that clinical skills are learned from multiday trainings or certifications, which focus on the therapeutic relationship and use role plays. The important thing about these longer trainings is the ability to practice microskills and get feedback from someone who’s further along in that skill than you are. The key is deliberate practice and feedback. I cannot tell you which trainings to go to. Some, like Scott Miller, say that CEU training has no effect on clinical skill. I still believe EFT is a step above other therapies. But a huge part of the EFT certification process is (drum roll) deliberate practice, feedback, and a community which sustains practice through the hard times.

So here’s a quick recap: Masters Degree = Basic theory and Credentialing for licensure Licensure = Ability to Bill PhD = Research and Teaching Certification (deliberate practice + feedback) = Therapeutic skill