So you're about to see your first patient...

A letter to myself from 1 year ago, who is just starting their PsyD program

First off, congratulations on making it to the starting line. As we both know, even getting here was a journey in and of itself. One year in, I’m happy to report that we made the right choice. This field is incredible. And constantly surprising. And it’s looking like the infinite game we were hoping for. Enjoy, and stop and smell the roses from time to time.

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Be an empathetic nonjudgmental presence.

This is the absolute best piece of 80/20 advice in the field, and it’s something I remind myself of before every session now. The biggest predictor of positive change in therapy is the therapeutic alliance. Be an empathetic nonjudgmental presence. You’re going to be thrown into clinical work, and it’s going to be terrifying. (Not if but) when you find yourself worrying about what to say or what to do in session to help your patients, come back to this and you’ll make it through.

Everything else here is just a little something extra in comparison, really.

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Much of the program and the work will be what you expected, so there’s not too much to say on this. As you know: what you put into this program is what you get out of it. And you’re no doubt going to put in the work, introspect, do the readings, go to personal therapy, etc. I’d say this pays off! (Personal therapy in particular is, like, +50% better now, in my opinion.)

Other parts of this work will take you by complete surprise. Most of these are of the happy variety, and all of these should be experienced firsthand. It’s like you’re watching a flower bud begin to bloom, and the first layer splays out to reveal… an onion? But the onion is actually really nice too, and super interesting.

You are the tool. You are the instrument through which the therapy is conducted. So not only does this mean examining and working on yourself, but this also means that sharing about what is going on within you is a key part of learning. What are you feeling? What thoughts are coming up, no matter how trivial they might seem? What does this remind you of? The hard part for us will be not filtering.

Be open and honest in supervision. All you really have to work with is what’s in your head and what you’re feeling. So the more you disclose, the more material you have to work with and learn from. Like setting out Lego pieces to build with.

Seek consultation more than you think you need. I’ve never regretted asking for a consult, and I wish I consulted more in the first half of the year. When you’re open and honest and you allow whatever comes up, consulting can lead to random surprises and breakthroughs. This might sound like some bullsh*t, but trust me. Just go consult with Nina once and you’ll see.

Cultural considerations are essential. This one is tricky because the topic is so charged, so my best advice might be to try to tune out all of the noise and engage with the topic at face value as best as you can. Good diagnosis precedes effective treatment, and this piece is a critical component to good diagnosis. Also I’m excited for how obsessed you’re going to be with The Mental Pain of Minorities by Salman Akhtar (2014).

This work is surprisingly tiring, especially in the first 4 months. Be kind to yourself, and remember to take care of yourself.

You will be holding onto A LOT. This is one thing that was definitely not talked about enough, in my opinion. You will be holding onto stuff that is from your patients. That stuff will impact your life outside of the therapy room – your thoughts, your emotions, your struggles. Your own personal therapy. Your down time. AND this is expected. AND it will continue to happen for the rest of your career (though supposedly your capacity will increase with training and experience). When upper years start to annoy you because they keep bringing up Hate in the Counter-Transference by Winnicott (1994), this is part of what they’re talking about. And you’ll eventually understand, and start bringing up that paper to others too.

Now for some miscellaneous advanced items.

After becoming familiar with prioritizing being an empathetic nonjudgmental presence, one thing that may come up next is our desire for a clear understanding of everything at all times. There will be times with patients where you feel like something doesn’t make sense, or you have a sense that the moment is significant but you don’t know why. Your immediate response in the room will be to try to map everything out in search of a clear answer, with the hopes of providing an interpretation that captures exactly what’s happening. However, this is actually not your job. Your job is to put the patient in a position to explore the thing that doesn’t make sense (so they can develop their own understanding of it). And this is freeing.

Lastly, this work has a surprising amount in common with creative work. They say that most of the therapy work happens outside of the room. For the therapist, it is, of course, important to build an understanding of the theory and the technical details, plan interventions, etc. AND deepening your understanding of your patients will not be achieved through grinding this alone. Like with writing, going on walks is part of the work.

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Most of the above are things to look forward to. Some are things that will really challenge you. And all of these things in conjunction create this experience that I can only describe as amplifying the richness of the experience that is life. It’s incredible. And you’ll make it through it.