Anyone else still get really nervous before a pt?

[Childdoconeday]

Long story short- I have for years wondered if this is the right field for me. I enjoy the work some days , but overall i don't find myself looking forward to work. Once i'm in session, I'm fine, but i don't look forward to work each day and i wouldn't say im particularly passionate about therapy.

I don't know why i shared that, i guess i just wanted to share some backstory before sharing this- I find myself feeling very anxious the day before my sessions or even right before most of my therapy sessions. Major imposter syndrome. Does anyone else still feel this way? Its been 4 years since graduation and i still feel this way. I should note that i work in a community mental health setting so i see a wide range of presenting issues.

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[erg923]

Are you “nervous” or just want don’t want to do it/be there. Sounds like the latter?

 

[Childdoconeday]

Are you “nervous” or just want don’t want to do it/be there. Sounds like the latter?

Hm... both. I feel "nervous" when I read the chart and the presenting issue seems complicated based on the notes provided by the intake line. But yes, i didn't think about it, I often feel like I don't want to be there and hope for a last minute cancellation. It's terrible, but it's the truth. I wonder if i'm the only one who feels this way as my coworkers and former grad school buddies seem to truly be passionate about work.

 

[summerbabe]

But yes, i didn't think about it, I often feel like I don't want to be there and hope for a last minute cancellation. It's terrible, but it's the truth.

It sounds less like 'Am I going to do a good job? What will the patient think of me? Can I help this person with difficult problems?' and more like 'Man, I wish I was somewhere else'.

It could be burnout, crappy work environment, mismatch between your interests/skills and job duties, poor fit with this profession or something else.

How did you generally feel during training/earlier in your career? Was there also 'anxiety'? If so, was it more performance/competence based or also dread-related? Did you aspire to work in CMH? Do you feel stuck (debt, sunk cost of a PhD/PsyD)?

One of my favorite teachers growing up worked decades as a DoJ lawyer, had some major life changes, realized he wasn't happy, and ended up teaching middle school history (and seemed pretty enthused to show up everyday). And I'm sure we all know people like that in our own lives.

 

[modestmousktr]

Hm... both. I feel "nervous" when I read the chart and the presenting issue seems complicated based on the notes provided by the intake line. But yes, i didn't think about it, I often feel like I don't want to be there and hope for a last minute cancellation. It's terrible, but it's the truth. I wonder if i'm the only one who feels this way as my coworkers and former grad school buddies seem to truly be passionate about work.

I was also sort of thinking this sounded a little more like dread than pre-session jitters. It sounds like you are post-doctoral, but I'm wondering if you're feeling a little burnt? Is this recent? I think it's certainly not unheard of, and a lot of people probably relate. I felt like this a lot in my second year of my Ph.D. program, and I think it was a sign of burn out. I dreaded sessions, always fantasized about calling in sick, prayed for cancellations, and just felt really overwhelmed by it all and tired all the time. I didn't have great sleep hygiene, time management, boundaries, a therapist, or self-care routines in place. I also was working in a clinic with mostly college students with mild depression/anxiety, when my population of interest is youth and adolescents with severe trauma.

Do you feel like your current self-care routines (PLEASE skills from DBT lol) are adequate? Especially given COVID, you might need to re-assess things that have even traditionally worked for you. Are you getting social support from meaningful relationships outside of work? I'm wondering if your passion for work could be ignited or re-ignited by taking care of that sort of stuff. And if all of that is gucci, then maybe it's the setting? Toxic work environment/upper management or maybe just clients you aren't clicking with? When was the last time you did feel passionate about it and what was different? I know you are post-grad, but do you have supervision or consultation at this CMHC that you can bring this up to?

Like other posters, I feel a little bit more like this is burn-out than something else, and I so wish for you that you'll find that passion for work, whether in or outside of the field, because I know how awful it feels to not look forward to sessions, and how rewarding and beautiful it is when everything finally "clicks".

 

[conky124]

Kinda sounds like you should be a researcher or should be doing a job that is less clinical. In my experience my colleagues and cohort mates who primarily want research careers have expressed this sentiment to me more than a few times. Personally, I cant help but get a little bummed from no shows even though they happen all the time.

 

[PsyDr]

Kinda sounds like you should be a researcher or should be doing a job that is less clinical. In my experience my colleagues and cohort mates who primarily want research careers have expressed this sentiment to me more than a few times. Personally, I cant help but get a little bummed from no shows even though they happen all the time.

WHAT?! Are you really recommending avoidance as an intervention for anxiety?!!!!

“Hey Mr. Agoraphob, if you get anxious when you leave the house, maybe you should just stay at home.”

@Childdoconeday get some therapy for the anxiety. Don’t avoid the anxiety provoking situations.

 

[conky124]

WHAT?! Are you really recommending avoidance as an intervention for anxiety?!!!!

“Hey Mr. Agoraphob, if you get anxious when you leave the house, maybe you should just stay at home.”

@Childdoconeday get some therapy for the anxiety. Don’t avoid the anxiety provoking situations.

Yessir, sometimes avoidance is a good thing.
Well it doesn't sound like it is all performance anxiety...and so far the self induced exposures aren't working The dread could be rooted in just not liking the work. I know its bad to say, but like cold feet before a wedding (a big indicator to call it off) I think impostor syndrome might be trying to tell us something and that it may be important to listen to it rather than ignore it. I notice I experience impostor syndrome in academic settings but never in clinical settings (maybe I should) and have realized that despite liking research a lot I hate graduate academic environments, but maybe I was just in bad ones.

 

[WisNeuro]

Yessir, sometimes avoidance is a good thing.
Well it doesn't sound like it is all performance anxiety...and so far the self induced exposures aren't working The dread could be rooted in just not liking the work. I know its bad to say, but like cold feet before a wedding (a big indicator to call it off) I think impostor syndrome might be trying to tell us something and that it may be important to listen to it rather than ignore it. I notice I experience impostor syndrome in academic settings but never in clinical settings (maybe I should) and have realized that despite liking research a lot I hate graduate academic environments, but maybe I was just in bad ones.

If everyone who got cold feet before a wedding called it off, we would have exceedingly few married people anywhere.

 

[erg923]

but like cold feet before a wedding (a big indicator to call it off)

That is completely wrong.

 

[conky124]

@erg923 @wiseneuro

completely wrong? My graduate prof (very well published) in child and family therapy taught us that it is a myth to think everyone gets cold feet and actually cold feet is an important indicator it won't work out. Just found this from a quick google search, lemme see if there is more


Lavner, J. A., Karney, B. R., & Bradbury, T. N. (2012). Do cold feet warn of trouble ahead? Premarital uncertainty and four-year marital outcomes. Journal of Family Psychology, 26(6), 1012–1017. https://doi.org/10.1037/a0029912

Are the doubts that people feel before marriage signs of impending difficulties or normative experiences that can be safely ignored? To test these opposing views, we asked 464 recently married spouses whether they had ever been uncertain about getting married and then compared 4-year divorce rates and marital satisfaction trajectories among those partners with and without premarital doubts. Doubts were reported by at least one partner in two thirds of couples. Women with premarital doubts had significantly higher 4-year divorce rates, even when controlling for concurrent marital satisfaction, the difficulty of their engagement, history of parental divorce, premarital cohabitation, and neuroticism. Among intact couples, men's and women's doubts predicted less satisfied marital trajectories. Premarital doubts appear to be common but not benign, suggesting that valid precursors of marital distress are evident during couples' engagements. (APA PsycInfo Database Record (c) 2016 APA, all rights reserved)

 

[conky124]

If everyone who got cold feet before a wedding called it off, we would have exceedingly few married people anywhere.

that is a myth I am told. looks like the study I posted above may be the only one investigating this topic empirically and it says otherwise. granted little literature on this topic but I'm seeing none supporting your notion. I also used to believe that as well, not so sure anymore

 

[cara susanna]

Thing is research jobs aren't easy to come by, and a lot of them still involve clinical care to some degree.

 

[Ollie123]

I still get intermittent jitters for intakes. We're not talking "Can't sleep the night before" level jitters. More the kind I probably wouldn't have even noticed before I started engaging with a mindfulness practice. Doesn't really impact anything in my day-to-day.

I'm not sure I would say I hope for no-shows or cancellations since it affects my metrics, but I'm certainly not disappointed when they happen. That's mostly because I have low clinical effort and am extremely overloaded at all times though - its not really "I don't want to see this patient" so much as "thank goodness I have an extra hour to work on the grant application."

All that said, there are absolutely certain days/times when I'm dreading clinical work for one reason or another. Its usually when I'm particularly burned out on work or stressed about something completely unrelated to work. I'm finding this happening slightly more since the pandemic started. Normally once I get into the swing its fine. I did cancel appointments one day back in May when I was pulling 80 hour weeks working on a grant application and just didn't feel like I could be effective as a clinician that day. In talking with colleagues, these sorts of things seem reasonably common (i.e. everyone indicated they had days like that now and then).

 

[conky124]

Thing is research jobs aren't easy to come by, and a lot of them still involve clinical care to some degree.

True, but there are plenty of other options.

 

[WisNeuro]

that is a myth I am told. looks like the study I posted above may be the only one investigating this topic empirically and it says otherwise. granted little literature on this topic but I'm seeing none supporting your notion. I also used to believe that as well, not so sure anymore

More than 50% of men in research indicate "cold feet" prior to marriage. Their feelings on this are not very predictive of divorce as women's feelings are. Otherwise that study says that 2/3rd of at least one person in a dyad reported those feelings. So, that'd be saying that 2/3rds of weddings should be canceled. Couple this with a declining divorce rate, and you'd have a LOT of otherwise happy couples who would have called it off.

 

[conky124]

More than 50% of men in research indicate "cold feet" prior to marriage. Their feelings on this are not very predictive of divorce as women's feelings are. So, that'd be saying at least 50% of weddings should be canceled. Couple this with a declining divorce rate, and you'd have a LOT of otherwise happy couples who would have called it off.

Just because it is common among 50% of men doesn't mean it should be ignored. The myth is that everyone gets cold feet and that it doesn't predict divorce or marital satisfaction when the evidence suggests it does.

The paper says that women with premarital doubts are 2.5x more likely to have divorce compared to women without.

Also I was never saying that all weddings should be called off from cold feet, not sure why you are saying that.

 

[WisNeuro]

Just because it is common among 50% of men doesn't mean it should be ignored. The myth is that everyone gets cold feet and that it doesn't predict divorce or marital satisfaction when the evidence suggests it does.

The paper says that women with premarital doubts are 2.5x more likely to have divorce compared to women without.

Also I was never saying that all weddings should be called off from cold feet, not sure why you are saying that.

Ypu said it was a "big" indicator to call it off, when, in fact it is a very poor indicator in most cases. I.e., men had the higher rates of the cold feet feelings, and in men, it is very poor indicator or 4-year divorce rates.

 

[conky124]

Ypu said it was a "big" indicator to call it off, when, in fact it is a very poor indicator in most cases. I.e., men had the higher rates of the cold feet feelings, and in men, it is very poor indicator or 4-year divorce rates.

So now you are making the argument that it is a poor indicator of marital satisfaction? Does that mean you are acknowledging that "everyone gets cold feet and its ok to ignore it all together" was a myth?? I mean if you are trying to start another debate about how good of an indicator it is then at least compare it to other indicators (like infidelity, also common among men) and back it up with evidence. Ideally with evidence from within the past two decades would be ideal. Don't want you to dig up one of your dusty old articles like last time

 

[WisNeuro]

So now you are making the argument that it is a poor indicator of marital satisfaction? Does that mean you are acknowledging that "everyone gets cold feet and its ok to ignore it all together" was a myth?? I mean if you are trying to start another debate about how good of an indicator it is then at least compare it to other indicators (like infidelity, also common among men) and back it up with evidence. Ideally with evidence from within the past two decades would be ideal. Don't want you to dig up one of your dusty old articles like last time

If you look back to my comment, it was regarding the incredibly common feeling of cold feet. Which, by teh study that you posted, is about 66% of people in that situation. That is what I would consider very common. Please show me where I said that it was meaningless. And, your study still indicates that it is a poor indicator in most people. Your evidence if anything just supports the ideas that I have expressed.

 

[conky124]

If you look back to my comment, it was regarding the incredibly common feeling of cold feet. Which, by teh study that you posted, is about 66% of people in that situation. That is what I would consider very common. Please show me where I said that it was meaningless. And, your study still indicates that it is a poor indicator in most people. Your evidence if anything just supports the ideas that I have expressed.

you know what, you have been exactly right all along. You win! A+

 

[WisNeuro]

you know what, you have been exactly right all along. You win! A+

I know. But always good to be acknowledged.

 

[AcronymAllergy]

Mod Note: Let's try to steer back to the original topic, please. If folks want to have a separate discussion RE: the cold feet/marriage topic, I'll gladly break that out into a separate thread.

To the OP: I sometimes get a little anxious before the occasional appointment, but with you, it sounds like it's occurring much more frequently. It certainly could be burnout, but I wonder, given that it's been occurring for years; has it gotten better after you've taken time off or worse after frustrating systemic issues (e.g., changes in management or clinical expectations)?

It might be helpful to sit down and truly think about what you do and don't enjoy about your job. Are there specific types of patients you enjoy seeing and whose appointments you aren't anxious before vs. types of patients you really, really dread? Are there things you're doing outside of sessions that you like? Do you find your mind drifting to thoughts of, "I wish I just X or Y at work every day," or anything like that?

I certainly have had my share of burnout in the past. But when it's come on, I still enjoyed the general idea of my work, and have daydreamed about ideal settings in which I'd be less frustrated and stressed. If you ultimately determine it's the work itself you're dreading, it might be time for a change (either of scenery or occupation).

 

[erg923]

Mod Note: Let's try to steer back to the original topic, please. If folks want to have a separate discussion RE: the cold feet/marriage topic, I'll gladly break that out into a separate thread.

To the OP: I sometimes get a little anxious before the occasional appointment, but with you, it sounds like it's occurring much more frequently. It certainly could be burnout, but I wonder, given that it's been occurring for years; has it gotten better after you've taken time off or worse after frustrating systemic issues (e.g., changes in management or clinical expectations)?

It might be helpful to sit down and truly think about what you do and don't enjoy about your job. Are there specific types of patients you enjoy seeing and whose appointments you aren't anxious before vs. types of patients you really, really dread? Are there things you're doing outside of sessions that you like? Do you find your mind drifting to thoughts of, "I wish I just X or Y at work every day," or anything like that?

I certainly have had my share of burnout in the past. But when it's come on, I still enjoyed the general idea of my work, and have daydreamed about ideal settings in which I'd be less frustrated and stressed. If you ultimately determine it's the work itself you're dreading, it might be time for a change (either of scenery or occupation).

At the tail end of my staff psychologist job at the VA, I was quite happy with no-shows sans a couple "favorite patients." I mean, it's their dime not mine, right? Although, it was the VA, so that reasoning is only somewhat applicable.

In retrospect, what it really meant is that I didn't want to be there/do that. For some it might just be an issue of "pleasure and mastery." I mean, you DO work in CMH? You are probably paid garbage and have a clientele that you can't help no matter what you do? Many may just be coming for "medication management" and engaging in psychotherapy/counseling is required to maintain it? "Medication management" is a ridiculous term, by the way.

For others, it might be even more than that (such as...I really don't like clinical work at all anymore). Only you can tell us which it is.

 

[Sanman]

Anxiety prior to a session? This only really happens to me when I am dealing with cases that are outside my normal wheelhouse (geriatrics stuff) had some PTSD and OCD that had me going back to the books and planning my interventions more carefully. Advanced dementia with crazy behavioral concerns and agitation? No problem, I can deal with that on the fly. I certainly do have individual cases that I slightly dread, but this is mostly due to clients that I am stuck with and will not do their part in treatment and are often low SES (missing repeated appts, no interest in treatment or change, in one case drug use that was later discovered).

 

[ExecutiveDysfunction]

I’m a fairly anxious person and I definitely have some pre-session jitters pretty often. Not to mention some physiological anxiety symptoms, for instance my cheat/stomach always gets a little sweaty (but not close to the degree that I’m like dripping sweat or anything.

If you’re anxious, you’re anxious. It’s just important to work on that and manage it the best you can. But as others have said, burnout is a different beast.

 

[deleted343839]

I should note that i work in a community mental health setting so i see a wide range of presenting issues.

Once i'm in session, I'm fine, but i don't look forward to work each day and i wouldn't say im particularly passionate about therapy.

Have you considered looking for work in a setting where you can develop more of a specialized or focused practice? Working in a specialty, and dividing my time between direct service and other activities, is how I tolerate my job. I do enjoy the occasional clinical challenge and even cases outside my main specialty, but I wouldn't call myself a generalist at heart.

The only patients I get nervous about are the folks whose recent medical records are filled with demanding/complaining/threatening messages to multiple providers. After a decade of practice I know this is irrational on my part. Usually it all works out okay, sometimes better than okay, and I've never had a board complaint or other serious issue.

 

[foreverbull]

Lots of good ideas here, and I'd also add: social anxiety could be part of it, perhaps? Folks who have social anxiety are more likely to feel pre-session jitters when there is lengthy, intimate social interaction and expectations in place for performance (including being paid, potential to look incompetent, etc.). Some folks have it but it wanes over time and exposure, but for some folks on the more extreme end, it may not go away, just slightly decline but come right back for difficult issues, meeting someone for the first time, or working with someone when you feel "stuck," etc. If there is more pressure with the interactions, they'll be even more draining and energy-depleting.

But if it has changed in such a way as to become MORE draining over time and not less, I'd say burnout is a major contender for the feelings you are having. I'd suggest reflecting on what might be creating burnout in your life; you might be finding that clinical work just isn't for you anymore, or the population you work with, site or type of job, etc. or it may just be other things getting in the way of clinical work that make your current job feel less enjoyable and more draining (many people struggling with the pandemic-related issues right now, not just clients!). I hope it becomes clear to you one way or another!

 

[Childdoconeday]

Thank you all for your responses, I read each one and I appreciate the support and the thought provoking questions. I also feel validated and appreciate how overall positive the responses have been. Thank you. I do think there is some element of social anxiety , but also recognize that i have felt this way for a long, long time. The only time i did not feel this way was when i worked with a specialized population for my internship. I think what is kicking my butt is the range of issues i need to see. i often also find myself feeling not interested in working with certain presenting issues. I need to initiate therapy for myself haha but I also think i do need to focus on developing a specialized practice (like MamaPhd) brought up. Anyways, lots to think about , but this has been extremely helpful and thought provoking. To any individuals considering psych grad school, please take your time with making this decision and don't feel rushed or pressured like i was into applying to grad schools. It's really hard to be 10 years in and not sure this is the path i am meant to be on.

 

[summerbabe]

It's really hard to be 10 years in and not sure this is the path i am meant to be on.

That definitely sucks and I feel for ya. But hopefully this can be the opportunity to regather, reevaluate, and set some new plans in motion to make the next 10 years a whole lot better. Good luck!

 

[Sanman]

Thank you all for your responses, I read each one and I appreciate the support and the thought provoking questions. I also feel validated and appreciate how overall positive the responses have been. Thank you. I do think there is some element of social anxiety , but also recognize that i have felt this way for a long, long time. The only time i did not feel this way was when i worked with a specialized population for my internship. I think what is kicking my butt is the range of issues i need to see. i often also find myself feeling not interested in working with certain presenting issues. I need to initiate therapy for myself haha but I also think i do need to focus on developing a specialized practice (like MamaPhd) brought up. Anyways, lots to think about , but this has been extremely helpful and thought provoking. To any individuals considering psych grad school, please take your time with making this decision and don't feel rushed or pressured like i was into applying to grad schools. It's really hard to be 10 years in and not sure this is the path i am meant to be on.

It sounds more like you are developing rather than struggling and that the position you have now is not a great fit for you rather than the career as a whole. I would take some time and reflect on what you liked about internship and what you like about your current position.

I would also learn to accept that you are not going to be an expert on everything. Learning your limitations is an important part of growing in this profession. When I first started, I felt the pressure to provide gold standard treatments to all of my patients regardless of the issues being presented. Now, I recognize that I am often an imperfect solution to a larger problem and have learned to set goals I can achieve. As long as you can be honest with yourself and your patient, it takes a lot of pressure off.

 

[Laradd]

I know you guys can slay it!

 

[mypointlesspov]

There are definitely times when I feel nervous before a client. Typically these are clients that have more... demanding parents though. I just started postdoc and have seen three clients so far over telehealth; I felt nervous before all of them, but I was also being observed which hasn't happened in months. Once I got into the swing of things I felt a lot better.

 

[Indiana_Jane]

Thank you all for your responses, I read each one and I appreciate the support and the thought provoking questions. I also feel validated and appreciate how overall positive the responses have been. Thank you. I do think there is some element of social anxiety , but also recognize that i have felt this way for a long, long time. The only time i did not feel this way was when i worked with a specialized population for my internship. I think what is kicking my butt is the range of issues i need to see. i often also find myself feeling not interested in working with certain presenting issues. I need to initiate therapy for myself haha but I also think i do need to focus on developing a specialized practice (like MamaPhd) brought up. Anyways, lots to think about , but this has been extremely helpful and thought provoking. To any individuals considering psych grad school, please take your time with making this decision and don't feel rushed or pressured like i was into applying to grad schools. It's really hard to be 10 years in and not sure this is the path i am meant to be on.

I am applying to internship this year, but I feel the same about the breadth. When I worked in an integrated-behavioral health setting, I noticed increased stress and burnout due to the sheer number of people I was seeing and the range of presenting problems. Seeing 13 patients a day with a mix of complaints was challenging and exhausting. Now that I am in a specialized practicum in my area of interest - I feel energized and motivated.