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.

Digging up the Roots of Depression

Anyone can experience sadness, grief, and despair (assuming one has the emotional capacity), but not everyone will experience depression. Depression is characterized by loss of interest, lack of pleasure, changes in appetite or sleep, irritability, low energy, decreased mood, among other symptoms that can have a severe impact on daily life. Try to picture being a slug with no hope and no desire to do anything- that’s depression. It’s like trying to run against the current… while underwater… and someone forgot to give you a scuba tank so you could breathe. Depression is as abundant as the common cold, and it is one of the most common mental disorders in the United States. Although previously believed to stem from chemical imbalance, we now know that root of depression lies among a variety of risk factors, including physiological, environmental, emotional, and situational circumstances.

Physiological factors may include genetics, diet, hormonal imbalances, or chronic illness. Both of my parents were diagnosed with clinical depression at some point in their lives. In my own case, an extensive family history of depression put me more at risk for developing depression myself (I like to call it The Double Whammy). So, while this encouraged me to learn some skills early to manage depression, I didn’t quite understand what it would actually feel like to be- in the words of a client- “cuckoo-nuts,” until it got severe enough that I couldn’t work through it on my own. In some cases, poor diet or hormonal imbalances can relate to decreased energy or mood, influencing depressive symptoms. In my case, this was a chicken-or-the-egg scenario. I’d feel depressed and lose my appetite, have candy or chips or nothing for dinner, and then feel MORE depressed because I was eating like garbage. Often, individuals with chronic illnesses, sleep disorders, or other health concerns experience depressive symptoms, as well, particularly if these conditions cause challenges completing daily tasks and living a fulfilling life.

Depressive symptoms may also be affected by environmental factors. For example, if someone lives in a stressful or chaotic environment, that person may be more likely to experience depression. My own depressive symptoms heightened after moving to the suburbs. Living in a house that I could not afford, working two jobs, and living far from my friends created financial stress, lack of self care, and isolation. I found myself hiding in my room with debilitating anxiety at the thought of coming out of my cave and engaging with my manipulative roommate and her bro-in-denial boyfriend- which often meant navigating my way through stale marijuana smoke and Patron. And don’t get me wrong, I am far from prude, but this wasn’t the lifestyle I wanted or expected when I moved. My inability to cope with feeling stuck in an unhappy and unfulfilling environment was a major factor in my depression spiraling. Additionally, environmental factors may affect those living in a setting with increased violence, domestic disturbance, or crime.

Individuals who experience low self esteem, pessimism, or have a history of physical or emotional trauma may be more susceptible to symptoms of depression. This can be more apparent in people who lack coping skills or positive outlets for emotions. I used to have a saying: “Turn your sadness into anger, and lock it up in a box.” Now, picture me screaming this from the tallest rooftop: THIS WAS NOT HELPFUL. It took a LONG time to realize that feelings are normal and okay, and pretending it does not exist does not mean a feeling goes away. It just means that it’ll eventually come up more bubbly and more aggressive than before, like an exploding pressure cooker, or manifest in symptoms of depression or anxiety. And so, my new saying is: “Listen to yourself.” We experience emotions for a reason, and, whether they are accurate or not, they all deserve to be respected and acknowledged.

Last, but certainly not least, feeling sad is not the same as experiencing depression. Let me say it again: feeling sad is not the same as experiencing depression. However, if you are a human you have probably encountered a situation that has caused you intense grief- and if you haven’t, give me some of those unicorn-and-rainbow sunglasses you’re wearing. Life transitions can be complex. Death of a loved one, issues in work or school, relationship problems, financial issues, moving- these are all situations that can cause one to feel stressed, overwhelmed, distraught. These are some of the situations that I deem the “Big Bad Sad-Makers.” Major life changes can affect daily routine, cause anxiety, and manifest symptoms of depression. If emotions that come from these situations cause disruption in your ability to engage in daily life, it’s something to look at more closely.

While these are common roots of depression, they are surely not the only ones, and many individuals experience more than one of these risk factors for depression. Take me for example- all four of these things joined up to make me a tiny burrito of sadness! From the time I was in college, factors have been coming in and out of my life to cause disruptions in mood, and the one thing that encouraged me most in dealing with my depression was learning about my depression. Everyone has a different experience with mental health, and if I can offer you one piece of advice in tackling your own mental health concern, it is to learn about it. It’s like Voldemort- Harry had to learn about Voldemort’s history, strengths, and weaknesses before he could defeat him. Yes, I just turned Mental Health into a Harry Potter reference… and I think it’s my proudest moment of the day.

Thanks to @depression-patriciajordan.com for inspiring me to write this. It’s not a simple answer, but it’s an answer none-the-less.

101 Coping Skills for Depression

  1. Identify potential triggers
  2. Identify your emotions
  3. Take a walk
  4. Call a friend
  5. Practice deep breathing
  6. Meditate for 5-10 minutes
  7. Draw a cartoon
  8. Write 5 things you love about yourself
  9. Stretch for 10 minutes
  10. Go for a run
  11. Play with a pet
  12. Make a playlist of feel good songs
  13. Listen to your feel good songs
  14. Dance
  15. Paint a representation of your emotions
  16. Make a collage using old magazines
  17. Practice handstands
  18. Do 10 push ups
  19. Go for a bike ride
  20. Clean your apartment
  21. Take a shower
  22. Put on your favorite outfit
  23. Style your hair
  24. Read a book
  25. Take a drive
  26. Take photographs
  27. Stay hydrated
  28. Go window shopping
  29. Socialize with someone
  30. Avoid judging your emotions
  31. Create a simple to do list and complete at least 3 things
  32. Cook a healthy meal
  33. Practice yoga poses
  34. Make jewelry
  35. Look at your rock collection
  36. Paint your nails
  37. Put on a face mask
  38. Play with makeup
  39. Video chat a loved one
  40. Free write in a journal
  41. Let yourself cry
  42. Go somewhere very public
  43. Bake
  44. Drink tea or hot chocolate
  45. Look up recipes
  46. Rearrange your apartment
  47. Watch stand up comedy
  48. Practice positive self talk
  49. Use a stress ball
  50. Make slime
  51. Go for a hike
  52. Sit under a tree and read
  53. Spend time in nature
  54. Sit by a river and listen to the water
  55. Read poetry
  56. Look at art
  57. Put a puzzle together
  58. Water your plants
  59. Write a poem
  60. Play ukulele
  61. Make a list of long term goals
  62. Watch America’s Funniest Home Videos
  63. Identify 10 positive thoughts
  64. Write a gratitude list
  65. Read inspirational quotes
  66. Write a song
  67. Get enough sleep
  68. Use essential oils
  69. Take a bubble bath
  70. Plan an activity
  71. Look outside mindfully
  72. Go outside
  73. Crochet a scarf
  74. Listen to a podcast
  75. Play a board game with a friend
  76. Plan outfits for the week
  77. Sing
  78. Practice visualization
  79. Watch a movie
  80. Meal prep
  81. Challenge any negative thinking
  82. Color a picture
  83. Get a massage
  84. Get your nails done
  85. Make worry stones
  86. Go rock picking
  87. Use progressive muscle relaxation
  88. Engage in problem solving
  89. Watch videos of funny children
  90. Write a letter to yourself
  91. Play a sport
  92. Make extra time for yourself
  93. Use lavender room spray
  94. Identify your strengths
  95. Do a body scan
  96. Look at old pictures
  97. Learn a new craft
  98. Spend time with a family member
  99. Volunteer
  100. Light a candle
  101. Explore somewhere you’ve never been