Once I had an office of my own, the question changed.
For years, I had been asking whether I could become a therapist. Now people were arriving at my office expecting me to be one.
Some found me through professional directories, my website, the telephone book, insurance listings, or referrals from other clinicians. Others came because someone who had already worked with me recommended me.
My practice grew faster than I expected.
The hypnotherapist who had warned me that Wilmington was saturated with therapists had not meant to discourage me. He was describing the market as he understood it. But people were coming, and they were returning after the first session.
I did not have to persuade them that I could listen.
They experienced it.
Beyond medication
At Duplin–Sampson, I had encountered the assumption that psychotherapy offered little to people diagnosed with schizophrenia. Treatment often revolved around medication, brief appointments with a psychiatrist, and case management.
Medication could be important. It might reduce voices, delusions, agitation, and other disabling symptoms. But medication could not listen to someone describe what it was like to hear voices. It could not address loneliness, shame, trauma, family conflict, or the experience of being treated as though a diagnosis had replaced one’s humanity.
A colleague named Mary Ellen worked with several adults diagnosed with schizophrenia who were living in a nursing home.
They were not all elderly. Some were young or middle-aged adults whose psychiatric difficulties had left them with few other housing options.
We discussed whether they might want a support group.
My office building had a conference room, so I offered it as a meeting place. Depending upon attendance, we met there or in my office.
The group did not become a permanent program, but for a while it gave several people something rarely offered to them: a room where their thoughts were not treated solely as symptoms to suppress.
I listened to descriptions of voices and unusual beliefs without pretending that I shared those perceptions. Empathy did not require me to confirm that every frightening belief was objectively true. It required me to recognize that the fear, confusion, and isolation were real.
We talked about relationships, communication, self-esteem, and coping with experiences other people found difficult to understand.
Some participants wanted individual sessions too.
I was aware that Medicare could reimburse me for the work. Receiving payment did not negate genuine care. Therapists need to earn a living, and these clients were asking for a service they valued.
The ethical question was not whether money changed hands.
It was whether the person sitting across from me was being helped, respected, and given a meaningful choice.
They wanted someone to listen.
I had created a practice partly because I believed they deserved that opportunity.
Knowing the limits of empathy
One young woman—whom I will call Anne Marie—came to me with anorexia.
I had received training in eating disorders, and we developed a strong therapeutic relationship. Her parents were increasingly worried about her declining physical health. They wanted reassurance and action, and gradually I felt that they were looking to me as the primary person responsible for determining whether she was safe.
I could provide psychotherapy. I could explore body image, fear, control, family relationships, and the emotions associated with eating.
I could not determine whether starvation was compromising her heart, electrolyte levels, or other bodily systems.
Anorexia was not solely a psychological problem. It could become a medical emergency.
I met with Anne Marie and her family and explained my concern directly.
“I’m not a medical doctor,” I told them. “I don’t want anything to happen to Anne Marie. I couldn’t live with that.”
I was not rejecting her or withdrawing all care. She could, should, and would continue attending the eating-disorders group I conducted. The group allowed me to help with the psychological and relational dimensions of the disorder without leaving her family with the impression that I was medically monitoring her condition.
What I could not safely continue was serving as her individual therapist and the family’s primary point of contact. A physician needed to remain centrally involved and responsible for assessing the physical danger.
Making that distinction was difficult. I did not want Anne Marie to experience it as abandonment.
But empathy did not qualify me to practice medicine, and a strong therapeutic relationship could not replace medical monitoring.
Recognizing the limits of what I could provide was not a failure of care.
It was part of providing care responsibly.
Different people, different needs
Private practice allowed me to adapt therapy to the individual.
There was no receptionist interrupting because a psychiatrist was ready. If someone reached an important point near the end of a session, the time belonged to us.
Some clients wanted practical strategies for anxiety or depression. Others wanted to understand how earlier experiences continued shaping their relationships. Some needed help regulating panic before they could approach anything deeper.
I used cognitive methods, relaxation, guided imagery, hypnosis, psychodynamic ideas, and person-centered principles. No single theory could explain every human problem, and no technique was appropriate for everyone.
The relationship surrounding the technique mattered most.
A guided exercise would accomplish little if the client did not trust the person offering it. Interpretation without empathy could become another form of judgment. Even a useful insight had limited value if someone did not feel safe enough to receive it.
Therapy was not something I performed upon another person.
It was work we entered together.
Continuing to learn
My MSW had not completed my education. It allowed me to continue learning responsibly.
Books accumulated beside the bed and throughout the house. I read about trauma, anxiety, hypnosis, couples therapy, family systems, psychosis, eating disorders, and the conditions appearing in my practice.
I attended continuing-education programs and remained involved with the local Society for Clinical Social Work. Colleagues discussed difficult cases, ethical questions, boundaries, and the realities of maintaining a practice.
At times, I helped organize workshops so that other clinicians could continue developing their skills and satisfy their professional requirements.
When someone asked me to explain a social-work concept or help make difficult material understandable, I experienced it as an honor.
Teaching required more than remembering information. It meant another person believed I understood the subject well enough to make it accessible.
Knowledge had become something I could give.
Work for people who could not always pay
As the practice grew, I offered some sessions without charge or at reduced rates.
I could not work for free all the time. The office had rent. There were taxes, insurance, professional expenses, and the ordinary costs of the life Lynn and I shared.
But I had not entered social work only to serve people with excellent insurance or enough money to pay the full fee.
Private practice gave me some control over that decision. I could reserve space for someone whose financial circumstances might otherwise keep them outside the door.
It did not feel like charity bestowed from above. It preserved continuity between the graduate student who had designed the street sheet and the clinician I had become.
In 1995, I had tried to make resources easier to locate for people who were homeless and overwhelmed.
Now I could make some therapy available within the practice I controlled.
I did not yet know that the street sheet would someday be handed back to me.
During these years, I knew myself as the person creating something useful for others.
Evidence
My success was not best measured by the number of diagnoses I could treat or techniques I could name.
It appeared in smaller evidence.
A client returned.
Someone disclosed an experience she had been afraid to tell.
A person diagnosed with schizophrenia asked for another session because being heard mattered.
A colleague trusted me with a referral.
Someone asked me to teach what I knew.
My schedule filled.
These were forms of recognition.
My family had often treated my abilities as uncertain or conditional. Engineering interviews required me to sell a professional identity that never fully fit. In social work, people experienced what I could do directly.
They did not need me to persuade them that I could listen.
They felt listened to.
At the end of the day, I returned home to Lynn.
Sometimes she was reading. Sometimes she had been writing or working with pottery. Sometimes we talked about Word Salad, the practice, money, books, future plans, or nothing consequential at all.
The work mattered deeply to me.
It was not the whole of me.
The office was where I helped people find safety, language, and understanding.
Home was where I did not have to be the therapist.
There, I was Lynn’s partner.
And the life waiting for me after the final appointment was part of what allowed me to open the door for the next person.