Though most therapists believe they know themselves, self-knowledge never reaches 100%. This is true of the human condition in full. The admonition to “know thyself” means that looking inside is a lifelong enterprise.

Consider a counselor on the rise. He chooses to move from the university to the role of employee at a hospital and then to solo practice as his own boss.

Patients from his previous workplace often follow him to his new office, but he requires an ongoing flow of additional clients.

These referrals come from an MD or fellow counselor he knows or a recommendation from a person who profited from consulting him. His name might also appear on the list of an insurance company for whom he is a “preferred provider.”

Solo practitioners often make this jump in their 30s. Virtually all took on patients during training and supervision before finishing graduate school.

Someone will be his first patient, just as someone must be a surgeon’s first try. They learn from instructors who learned from another who learned from someone else. Everyone involved rationalizes the necessity of becoming skillful in this manner.

There is no other way to become competent than to enter the playing field of life lacking expertise. The soul who agrees to be seen by the relative newbie typically cannot afford a more seasoned advisor with a track record of excellence.

Psychologists, social workers, and physicians who work as employees typically receive referrals from organizations that compensate them. They are paid a portion of the fee, with the rest going to their employer. All that changes when opening a new practice.

Except for the independently wealthy, everyone knows they are taking a financial risk when making this professional leap. Some don’t succeed and must return to dependency elsewhere to maintain an adequate wage.

Imagine a prospective patient contacts a professional who needs new clients to sustain his unsteady business. The latter must ask himself, “Am I experienced enough to help?”

This is the same question all professionals reckon with, but the decision is less fraught when the practice is full.

The range of problems causing people to seek consultation is wide. A second question arises: “Am I skilled enough to achieve success with this particular problem and a client with his background?” The temptation is to say yes; sometimes, business considerations might tip the balance.

Since one doesn’t know if the practitioner asks this of himself, the patient should. “How many people with my problem have you treated?” Forthright answers can be expected.

In solo practice, one sets one’s own fee for service, with exceptions. The therapist can decide on any amount, though insurance companies limit what they will remunerate based on a schedule of “reasonable and customary” charges. They also make decisions based on their own business incentives. There is no single, agreed-upon list of acceptable fees.

Some individuals belong to Preferred Provider Organizations (PPOs). The helping professional might also accept the fees Medicare allows.

The National Center for Health Statistics describes a PPO as “A type of medical plan in which coverage is provided to participants through a network of selected health care providers, such as hospitals and physicians. Enrollees may seek care outside the network but pay a greater percentage of the cost of coverage than within the network.”

Joining such networks (including Medicare) reduces the amount the patients must pay out-of-pocket and tends to expand the number of referrals a healthcare professional receives.

Once again, it is possible to rationalize the amount of money charged to those in distress. Therapists must decide on the number of clients (if any) from whom they will accept discounted fees. Counselors may also take on patients without insurance and charge them on a “sliding scale.” That phrase refers to lowering fees based on the patient’s economic circumstances.

Those who endure financial calamities have been known to promise to pay their bill over a long period.

Not all practitioners will treat persons who are unable to pay anything. Sigmund Freud, the father of psychoanalysis, discouraged it.

Beyond his need to make a living, the psychoanalyst reasoned that payment for treatment reinforced the value and importance of the doctor’s time and the seriousness with which the sessions should be taken. Money is not a small reality in human lives, and understanding the part it plays for someone seeking help is significant.

In all of this, rationalization by the counselor can come into play. I have known “providers” who believed their work was a “calling” and required them to assist those struggling to get by. A few other helping professionals of my acquaintance seemed to have forgotten why they got into the profession in the first place: to serve.

Physicians and the rest of the helping community want to think well of themselves, just as everyone does. One feature of their career is improving the lives of those seeking assistance. In some cases, the result is easy to evaluate.

If you tell your ophthalmologist that you see more clearly and are amazed at how much more color there is in the world following your cataract surgery, he will have strong reason to believe he made a difference. Vision tests can also affirm a change in visual clarity.

If the psychotherapy patient says his life has improved, describes significant behavioral changes, and the psychologist’s observations and personality tests support this — then the doctor has evidence of the value of his work, as well.

However, it must be admitted that the therapeutic community does not have precise measures for every possible change the patient seeks. The counselor also knows that the passage of time can heal on occasion, leaving unanswered the question of time’s role in the process.

Should treatment fail, both medical and psychotherapeutic professionals may rationalize that misfortune. In some instances, they are right to do so, but not in each case.

Think of a surgeon who enters the operating room doubtful of his skills. Everyone wants him to be sure, confident, and decisive despite a history that might include rationalized errors. If he were traumatized by every imperfection in his work, the world would have no surgeons.

None of this is to minimize what helping professionals accomplish. Their talent can be life-changing in the best sense.

As a retired clinical psychologist, I do not write any of this as a disinterested, omniscient man speaking from a mountaintop. I live with a selection of the same psychological defenses characteristic of all humankind.

Neither the patient nor the doctor enters the consulting room without rationalizations that allow all men and women to manage their way through what we call life.

Therapists understand the phrase “wounded healer.” The expression refers to emotional and moral injuries, personal losses, and places people have lost their way. They try to minimize the detrimental influence of those wounds on others, in and out of the office.

The majority of helping professionals know the finger points at them in terms of responsibility. They have been given the gift of trust from those who count on them for comfort and assistance.

Therapist or not, we must all be on watch, asking ourselves if our words, deeds, and beliefs are too self-serving.

How much do we need to check? 

Again and again and again.

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The top photo is Three Girls Annoyed by Some Screams. It is the work of Basile Morin. The following painting is The Psychiatrist, a 1919 artwork by Kurt Schwitters. Finally, Psychotherapy Icon by Luis Prado. All of these are sourced from Wikimedia Commons.