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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.

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The Power of Breath

There are several actions that occur in our body without clear direction and effort from our brain. A heart beat, for example, is a powerful and- barring any serious health issues- automatic rhythm that plays a vital role in keeping our bodies alive. My brain always visualizes Osmosis Jones running around inside my body to ensure that every task is being completed without my having to consciously perform them. It makes things, like breathing, seem effortless.

Although we may be accustomed to the effortlessness of breathing, how often do we truly take a moment to mindfully connect with our breath? In meditation, attention to the breath is a method of becoming fully present. By changing breathing pattern, we can produce different states of mind, such as increasing overall energy and relaxing the body and mind. The endorphins released by the body during deep breathing also serve as a natural mood boost. These effects make deep breathing a widely used coping mechanism in managing symptoms of various mental health diagnoses.

Deep breathing does more than influence our emotional state; it can impact our physical health, as well. If you are someone who has a regular exercise/cardio routine established, you have probably realized the importance of having a close relationship with the breath. In distance running, I have learned that the more I pay attention to my breath, the more in tune I am with the rest of my body. Promoting slow, deep breaths can assist in keeping a safe pace to prevent our heart rates from climbing to dangerous BPM’s. Additionally, attention to breath can increase control and power behind movements in strength training.

As stated earlier, through deep breathing our body releases endorphins, which act as a natural pain reliever. By increasing our oxygen flow, we are also improving digestion and detoxifying our bodies through both releasing carbon dioxide and speeding up the lymphatic system. So, next time you meditate, you can visualize the release of toxins along with that negative energy that spews out with every exhale. So whether you’re stressed, overwhelmed, in physical or emotional pain, or experience a variety of physical health concerns, controlled breathing can be a step to a greater overall sense of well being.


Here are a few simple breathing exercises to get you started:

Box Breathing

This breathing technique can act as a powerful stress reliever while heightening performance and concentration.

Begin in a comfortable position. Breathe in through your nose for a count of 4 seconds. Hold your breath for a count of 4 seconds. Exhale through your mouth for a count of 4 seconds. Repeat cycle as many times as needed.

Bellows Breathing

This is a rapid breathing technique aimed toward increasing energy and alertness.

Begin in a comfortable position. Inhale and exhale rapidly through your nose while keeping your mouth shut. Breaths should be as short as possible, but equal in duration. The diaphragm should move quickly. Do this for a cycle of 15 seconds, gradually increasing time with each practice. Breath normally after each cycle.

4:7:8 Breathing

This breathing technique promotes peace and tranquility. This exercise can also be used to more easily fall asleep. It may cause one to feel slightly lightheaded.

Begin in a comfortable position, keeping your back straight. With your mouth closed, quietly inhale through your nose for a count of 4. Hold your breath for a count of 7. Exhale through your mouth, making a whooshing sound, to the count of 8. Complete cycle 3-4 times, gradually increasing the amount of cycles with continued practice.


As always, Wellness Warriors, feel free to provide feedback and share your experiences if you choose to practice these skills. My hope is that these breathing techniques empower you to love and care for your breath while harnessing the art of controlled breathing. Until next time!

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What Is Depression?

Depression is as prevalent as the common cold. The Anxiety and Depression Association of America estimates that 264 million people around the world live with depression. Most people experience sadness, loneliness, or fear. These feelings are a normal part of life. However, depression involves clinical levels of low mood that impacts a persona’s ability to function within their daily lives.

Clinical depression is characterized by the following symptoms: persistent depressed mood, diminished pleasure or interest in activities, decrease or increase of appetite, insomnia or hypersomnia, psychomotor agitation or slowing, fatigue or loss of energy, feelings of worthlessness or guilt, diminished ability to focus or think, indecisiveness, and recurrent thoughts of death or recurrent suicidal ideation. The Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5)’s diagnostic criteria states that 5 or more of the above symptoms must be present within the same 2 week period.

How Is Depression Different From Sadness?

Most people experience intense sadness or grief. These feelings can impact a person’s ability to function, and they can also exist for at least 2 weeks. However, when we experience something difficult, sadness and grief are natural reactions. Sadness and grief share some characteristics with depression, but they are temporary and typically fade with time. Usually, sadness or grief involve moments of relief and have no significant impact in thought processes or behaviors.

Sadness is simply one symptom of depression. The DSM-5 indicates, “Responses to a significant loss (e.g. bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered.”

Who Is At Risk For Depression?

Mental illness does not discriminate. Anyone can experience symptoms of depression at some point in their lives. However, there are some factors that put others at more risk of depression than others. Biochemistry is a well-known factor in determining whether or not someone will experience depression. Individuals with depression often experience a deficit in certain neurotransmitters in the brain. This explains the effectiveness of medications that help to balance chemicals in the brain.

Although it is commonly believed that depression is the result of a chemical imbalance, the condition is much more complex. Genetics can also play a role, meaning that individuals with a family history of depression are more likely to experience depression. Research shows that there is also a connection between personality and depression. Studies show that difficulty coping with stress, limited engagement in community and environment, and limited insight may increase risk of depression. Environmental factors, including exposure to community violence, traumatic experiences, or limited access to resources, can also be predictors of depression.

When Should Someone Get Help?

Sometimes the line between between depression and sadness is clear, but sometimes it is not. For example, you may feel nervous while giving a presentation, but that doesn’t necessarily indicate a mental health disorder. However, becoming so overwhelmed with nervousness that you cannot follow through with the presentation may indicate a need for help.

If symptoms interfere with your ability to function within your daily life, it may be time to seek help. Challenges maintaining relationships, engaging in social settings, or performing in work and school can indicate a mental health disorder. Mental health disorders can also be responsible for changes in personality, energy level, and mood. Typically, symptoms that last 2 weeks or longer should be evaluated by a professional to determine the appropriate care. However, these are not the only situations during which to seek help. Anyone can get help at any time. If you feel the desire for therapeutic support, explore it regardless of how your situation compares to others!

How Is Depression Treated?

There are many types of treatments for depression. Just as depression looks different for everyone, depression treatments may have different effects for each individual. The most effective treatment method for depression is a combination of psychotherapy and medication. Some common forms of psychotherapy that are effective in treating depression include cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), or psychodynamic therapy. One might also seek support groups, group therapies, or community engagement programs for added support.

Research shows that the relationship between the clinician and client is the most effective tool in treating mental health disorders. That being said, it is important to have an open mind and to remember that effective therapy requires the ability to trust the clinician. If you seek support and find limited connection with the clinician, don’t be afraid to explore other options. Read about alternative treatments here!

How Can Someone Find Help?

Especially during times of high need, finding help can unfortunately require time and patience. Psychology Today has a great Find a Therapist tool, where you can limit search based on insurance, areas of practice, or location. Most insurance plans also have a website where you may consult your provider directory. This is a good way to ensure that a clinician accepts your insurance. It is a good idea to look more closely at your insurance plan to determine if your plan limits the amount of sessions you can attend.

To find help, it can be helpful to ask someone your trust. A referral from a friend, colleague, or medical professional is a good way to find a clinician who may be a good fit for you. Additionally, online resources, such as Anxiety and Depression Association of America, are a helpful way to navigate the mental healthcare system. It can also be a good resource to learn more about types of depression treatments to determine the modality that may be most helpful. Make sure you check out this page with information on support groups and additional resources for navigating the mental health system during a pandemic!