[Disclaimer: I have used aliases to protect the confidentiality and identity of clients or patients. No other names have been changed.]

I now had a growing client base and an office of my own. I was accepting insurance payments and/or checks for services.

I now had a growing client base and an office of my own. I was accepting insurance payments and/or checks for services.

I was set up to be able to bill Blue Cross/Blue Shield among others... and Medicare. Clinical Social Workers can't bill Medicaid in North Carolina for some reason. We can bill Medicare, though.

I was trying to find out if a colleague in the field, named Mary Ellen, who was working with some individuals who had schizophrenia, could find out if some of them wanted a therapy group. She was a volunteer/intern and through her contacts, she had been given the opportunity to work with a few clients in the community.

They were staying at a nursing home not far away. I decided to offer the conference room as a meeting place for a support group for people with schizophrenia. Mary Ellen and I decided that there was a need for a support group that would be of interest to the people she was serving.

She started bringing her clients to my office building. Depending on how many people showed up we would either use my office or the conference room.

This was a great learning experience for me. I really wanted to offer something for people who were battling such a debilitating and disturbing form of mental illness. It was sad that these individuals ranging in age from the late 20s to the 50s were all staying in a nursing home.

I suppose that is better than being homeless. But usually, you think of nursing homes as being there for the elderly who cannot care for themselves.

I had asked if any of them wanted to meet with me one-on-one for therapy. I was sensitive to the fact that some people might see this as a way for me to pad my income to enrich myself, especially if I met them at their residence, the nursing home.

These individuals had Medicare and I could bill Medicare. While it's true that this would increase my income and bring in money for me that doesn't mean I wasn't genuinely interested in helping them. They wanted to have someone listen to them and to try and understand what they were experiencing.

They had a doctor that they were seeing. I knew that much and that they weren't seeing a therapist, though they had someone at the clinic who could provide psychotherapy if the staff person was so inclined to do so.

It had been my observation that some people in my profession thought that the only remedy for schizophrenia was medication. I had noticed this when I was working at Sampson County Mental Health Center. I also remembered that when I was working there some of my clients, if not most of them, if asked, or if it was offered wanted to meet with me for psychotherapy.

In my heart, I knew that I was trying to offer something good for people who might benefit from talking to someone who is grounded in reality but also very empathetic.

In addition to just listening and trying to understand their experiences, I used a few psychological techniques to help them build their self-esteem. I also talked about some skills that would be useful in communicating and coping.

This wasn't something that went on for a long time but I did have a chance to work with some clients for a few weeks.

I did have a client named was Anne Marie who had anorexia which was particularly challenging because starvation can cause a variety of serious physical problems. There are also serious challenges in getting accurate information about binging and purging.

It would become clear over time that a medical doctor needed to be the one who is primarily in charge of the care of someone with this serious problem. The empathy and rapport that I had developed with Anne Marie were great, but I still had concerns.

What seemed like a great challenge for me became something that was more serious and needed to be overseen by someone with an MD after their name, with admitting privileges at a hospital.

Anne Marie had returned from college for health reasons and was living with her parents. We were able to have some family sessions as well. I felt it was important to find out about her health when I listened to the concerns that her parents had expressed.

Anne Marie's parents became increasingly concerned that I wasn't doing enough and that her physical health was in danger. I was not in a position to assess her physical health. I didn't know why or how I was being expected to act as a central contact person for all of Anne Marie's physical health and well-being. That was something that I had to make clear.

I had taken some training on the treatment of eating disorders, but it could not cover the physical/medical issues.

The last thing I wanted was to be responsible for someone's medical care or assessing a person's physical health. So, I explained this in-depth.

I didn't want Anne Marie to feel like I was abandoning her or not on her side. I just needed to be sure that there was someone else that she was seeing for those issues related to her physical health. I couldn't be the one that asked if she had kept an appointment with her doctor or the one that weighed her and took other vital signs.

Like so many others with eating disorders, Anne Marie had symptoms of Borderline Personality Disorder (BPD). There is a sense that you are walking on eggshells with a person who has BPD, where you are challenged repeatedly to demonstrate that you care about your client.

Sometimes a person with BPD will cycle between idealizing someone like a therapist to hating them. In other words, we are talking about intense and unstable interpersonal relationships... chronic feelings of emptiness. Another symptom that is readily obvious as overlapping with anorexia nervosa is changing perceptions of self-identity and self-perception.

For a person with anorexia, they might see themselves as overweight even when others see them as emaciated - grossly underweight. The feeling of food in them can trigger feelings of anxiety and lead to purging to vomit the food out of their stomachs after they eat.

Obviously, this is very dangerous.

I ended up transitioning to offering mainly group therapy for those who had anorexia. Bulimia was a disorder I felt comfortable treating. With Bulimia people have body image issues and they might binge and purge but they maintain a normal healthy weight.

A couple of other girls/young women found me listed on the web, in the yellow pages, or through word of mouth.

Out of this arrangement, I picked up a client who had been diagnosed with Bulimia. Her name was Jennifer.

Jennifer's condition did not require the attention of a medical doctor as would be the case with Anne Marie who had anorexia.

Jennifer didn't have this problem. She did put a tremendous amount of focus on her appearance and her sense of feminine beauty. Sadly, this need can make a person feel like their worth is tied to their body image.

It was hard not to recognize the focus that she put on her body. She had undergone breast enhancement surgery. It would be naïve for us to avoid discussing details like this. These issues were precisely the kind of things that a person with bulimia needs to discuss with their therapist.

Obviously, a healthy male therapist has to be aware of his reactions when he is meeting with an extremely attractive woman, which did describe Jennifer. A male therapist who acts like he doesn't recognize things like this is lying or he is gay.

Our natural human reaction does NOT mean we are going to cheat on our wives, nor does it mean that we are objectifying a woman! Human evolution has programmed us to react in certain ways.

The point is that we were going to explore these issues in therapy - issues related to her sense of worth as a person as well as her as a woman. While it's true that professional boundaries were going to be maintained, it is valid to explore transference and countertransference issues.

I had studied psychodynamic and psychoanalytic theories, concepts, and ideas. Jennifer was interested in gaining some insights into herself and so this seemed like a good framework for some of our discussions.

We brought out into the open the thoughts she might have about the reactions she might want from men/guys in her life including her therapist. How did it make her feel that she was noticed in this way, based on her attractiveness?

Her understanding of these ideas grew over time. She talked about her experiences growing up. She was open to exploring dreams and their possible interpretations. She was intrigued by the ideas of Carl Jung, a contemporary of Sigmund Freud.

Any approach that was aimed at insight and seeking to make connections between events in her life up until now was valuable for her to explore, she indicated. With the insights, she felt she was improving, and the binging and purging was happening less frequently. I thought that knowing why this was happening was less important than her interest in discussing seemingly unconnected events in her life.

She did want to discuss the fact that she had agreed to be photographed nude by a friend of her boyfriend. I wondered when she told me this if she felt that she was seeking to see how I would react to her discussion of this fact. Did she want me to react with interest or excitement?

I asked her, "do you want to show me this?" I was curious as to her reaction.

"I don't know," she said.

I was concerned that she might feel like I was expecting her to show me the photograph(s).

Now, I am supposed to lie to you and tell you that I didn't want to see the photographs. Right! A beautiful woman is sitting in front of you, and she brings up the topic of being photographed nude and you want me to tell you that I didn't for a second want to see the photographs?

At the time, I was still very young and naïve. So, I felt guilty and discussed this with Marjorie who I was seeing for psychoanalysis. She wasn't young and naïve. She was about 70.

She said, "Of course, you wanted to see the photographs."

I said, "but I didn't think that she was more beautiful than Lynn."

"That's okay, it would be worse if you were dishonest with yourself," she said, adding "then you might fall victim to temptation."

I settled back down into the couch – remember I was lying on a couch when I saw Marjorie. I said, "yeah, I wasn't tempted to do anything."

Anyway, getting back to therapy with Jennifer...

Jennifer said that she also was having some problems with a situation with her boyfriend. The way he spoke to her during foreplay seemed to be degrading to her.

That incident with her boyfriend inspired her to ask if I could see them both for couples counseling. Indeed, I had studied this, and I described some tools that I could bring to the sessions that might be helpful in achieving certain goals for both her and her boyfriend.

We agreed that he could meet with me alone as well - before or after we met for couples counseling.

This went on for a while. It was very rewarding for me because she was paying out of her pocket for my services, as opposed to having insurance that would cover the cost of therapy. If either one of them or both had been dissatisfied with my competency, they would not keep coming and paying for ongoing therapy or treatment.

I only saw her boyfriend about three times alone and that was on the same days when we had couples counseling. I did continue to see Jennifer alone. We would examine her interests, desires, and expectations for her future, for her career, and what increased her sense of self-esteem and her feelings of self-worth.

It was great to see how empathy and respect for her had paid off with positive results as per her feedback. Again, she was paying by check out of her pocket and so if things were not working out for her, she had many other therapists she could consult in the area.