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!