Posted on 12 Comments

What No One Tells You About Being a Therapist

A therapist’s office is intended to be a safe, warm space that allows for others to express and process patterns of thoughts, feelings, and behaviors. It’s a place where people go to feel better. As a helping professional, I have the privilege of being part of the personal development and growth of my clients. I am deeply passionate about what I do, and I’ll be the first one to admit that I still get goosebumps whenever a client experiences an “Aha” moment. That being said, the mental health profession is not one without challenges.

According to the Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services (DBHIDS), it’s estimated that about 22% of adults in the city are diagnosed with Depressive Disorder, 16% of adult Philadelphians experience frequent mental stress, and 13.8% of teens experience suicidal ideation.

To paint a clearer picture, these statistics mean that in Philadelphia 1 in 5 adults are diagnosed with depressive disorder, and 1 in 7 high school students have reported seriously considering suicide. These startling numbers are not counting the undiagnosed or unreported cases. These rates have remained consistent within recent years, with the exception of a wild increase of opioid-related deaths and ER visits for drug overdoses. With the growing severity of the opioid epidemic in the United States, an already overwhelmed system seemingly only has so much wiggle room before it breaks.

Community Behavioral Health (CBH) is a non-profit corporation contracted by the City of Philadelphia to provide mental health and substance use services to Medicaid recipients in Philadelphia County. There are about 144 Community Behavioral Health organizations in Philadelphia, and I have worked for and with many of them. Although I love the work that I do with clients, working in community agencies has created an entirely new perspective on how therapists and participants are treated among the Community Behavioral Health system….. and I think we all deserve better.

I remember learning about proper ethics and counseling techniques in my graduate program, bright eyed as I geared myself up for a future as a helper. Looking back, it seems so naive for me to have thought that it would be easy. Admittedly, I often wish I could go back to school and pay closer attention to discussions on how to avoid burnout, but sometimes it seems that in the community behavioral health field, burnout is inevitable. Although it would not have changed my choice of profession, I wish I had been more prepared for the community mental health world.

Here’s what I wish I had known:

  1. There are not enough mental health therapists in the community behavioral health system. It seems as though a major theme within the therapist community is the feeling of being overwhelmed by a bogged down system. Community Behavioral Health has an incredible amount of participants in need of mental health care and not enough wo/manpower to provide the quality of care necessary to treat severe mental health symptoms. This means that the large number of participants receiving services are divided among the limited mental health professionals that exist, meaning higher burnout rates for therapists.
  2. There is a major focus on productivity. Full time therapists are given a certain number of clinical hours that they must provide per month, typically called productivity. For example, in my organization, the month of October held 160.63 available treatment hours. I need to achieve 66% of that, meaning I needed to provide at least 106 hours of therapy to meet productivity expectations. If I don’t, I risk being written up. So when we get into the nitty-gritty of things, my work performance is not determined by the quality of therapy I provide, but by the quantity of services I provide. Where I try to validate myself, it is sometimes hard to focus on my successes with clients when I am consistently reminded of “my numbers.” It also makes it more difficult to be understanding when clients cancel, which is often framed as one less hour toward productivity.
  3. Many organizations are turning to fee-for-service. Fee-for-service is pretty self-explanatory. In fee-for-service positions, therapists only get paid for the sessions they complete. This means that if a client does not show up, the therapist will either not get paid, or will get paid a small percentage of what they would have received. Oh, and fee-for-service therapists don’t get paid for the paperwork or outreach they do…. and let me tell you, in this field there is always a lot of paperwork and outreach to do.
  4. Community behavioral health is behind. Think about all of the ethical guidelines, evidence-based practices, and sensitivity training we learned about in school. Now, try to imagine trying to implement those practices in an organization that always seems 20 years behind the present status quo. This isn’t necessarily community behavioral health’s fault. It simply takes time to roll out new methods given the amount of education and training they require.
  5. Sometimes people don’t listen. I feel like I can talk about ethical treatment and appropriate care until I’m blue in the face, and it still doesn’t feel like I am heard. I often find myself thinking of therapists as the nurses of the mental health field– we have an incredible amount of knowledge, have spent years studying the subject, and care deeply about making sure our clients are receiving proper care… and it still feels like we are spinning our wheels just to be heard and respected.

And finally, none of this would matter if we didn’t care. Professionals typically don’t join the mental health field if they don’t care about the well being of others. This makes it even more frustrating when we can see that the overall focus is not on the quality of care we provide, but instead, on the success of the business. Although I can recognize that the business aspect is important, it just does not feel right to put the needs of the business before the needs of people. Helpers feel passionately about the injustices within social systems, because we care about the outcomes of the people we work with. It can be incredibly frustrating to see the above factors as barriers to doing what we love most– helping people.

12 thoughts on “What No One Tells You About Being a Therapist

  1. Love this! Informative. My son has ADHD and ODD with anger explosive disorder and bi polar depression it’s a huge challenge everyday

  2. Thank you for sharing a side most of us don’t think about. Would these things improve, at least in your life, if you joined or went into private practice for yourself?

    1. I do think there is a significant difference, but I love working with underprivileged populations and the clientele in community behavior health agencies. I just wish the agencies weren’t so complicated! I’m more so hoping to advocate for a better system so the therapists and clients get the best care they can.

  3. Yeah all this folk psychology and academic studies are pretty much just showing how big of a problem mental illness is. It’s not getting better. Depression, also, especially, leads to drug use, bipolar 2 is the most depressive mental illness to exist which a manic episodes for BP2’s is about 3 days of…..terrible, debilitating, violently sick invoking thoughts that make a mere “episode” traumatic…..the thoughts. I’ve been diagnosed with ADHD, Bipolar 2, PTSD, and epilepsy. I’m also a recovering heroin addict of 9 years. I started using to stop my half week long bouts of absolute despair.

    Patients need to be given journals to write in. They need to be read. Documentation/observation of the subject while in the throes of their shit. These are moon rocks.

  4. My mother is a therapist and shes a revolutionary in what is needed of a new spectrum. And you’ll be told all that is to be of the truth including the shit of being a therapist. Just need to ask. What’s a “they” I want to meet these theys. They are so relied on and believed and blamed for not telling what is accessible knowledge from a googling or book. Not to hate. Im very happy to read this. As one of the sick. But also as one of the never that’s gotten as far successfully in treatment which invokes serious survivors guilt, I’m starting to get a little irritated with the abundance of jargon. Fuck therapists, fuck spectators, fuck the “normal way”. Its time to take the lowest common denominator and comply. The patient is the authority. Not the problem. Not the cause.

    1. Thank you for being honest and true with your experiences in therapy. I agree! Change and progress can be so slow, and changes definitely need to be made by both therapists and the system to better help people. I hope others read your story and are inspired to advocate! ❤️

  5. I worked in Community Mental Health several different agencies for about 20 years and can’t disagree with any of this.

    1. It’s such frustrating work, but also the most rewarding!

  6. Reblogged this on cabbagesandkings524 and commented:
    Nope, they don’t tell you this going in.

  7. Thank you for the insight, I have been thinking of becoming a therapist, myself. I enjoy helping people. This was really helpful. Thanks again. 🙂

  8. So informative and needed in a world where there is so much need and mental health challenges are on the rise. Many hands are tied on what can be done and its challenging for everyone to deal with on so many levels. Great post!

  9. My siblings are social workers and therapists, and they echo your thoughts constantly, so thank you for sharing! You’re totally right that knowing these things beforehand would be more helpful as well, they seem particularly difficult to deal with if you learn then on the job.

Leave a Reply