The reality of training to be a mental health professional is that the only way to truly develop competence is to actually see patients. Though I was tempted to try to hide in case studies and role plays forever, focusing only on what I would do so as to never risk messing up, I discovered quickly that this was not an option. As an MSW (Master of Social Work) student in New York City, my peers and I were thrown into the city’s highest need, lowest resource communities a mere two weeks into our educational experience. Armed with little more than naive optimism, I set out to learn how to be a clinical social worker.
How was it determined which people would be the victims of my well-intentioned but clumsy first efforts at conducting therapy sessions? The anxious aspect of my personality hoped it would only be those with relatively straightforward problems with clear solutions so that the potential havoc I could wreak would be minimized. Alas, the realities of the city in which I live and the system within which I work would allow no such thing to happen.
In my experience, NYC is a city where the extremes of wealth and poverty coexist, but do not comingle. The way I see it, there are two siloed mental health systems here: one that serves the rich and one that serves everybody else. For those with money, the options are limitless. Therapists and psychiatrists who do not take insurance abound in this city, some charging upward of $500 for a 15 to 45-minute single session. Excellent at what they do I’m sure, but entirely inaccessible for most. On the other end of the spectrum lies the public mental health system, a constellation of public hospitals and community-based clinics scattered throughout the city. It is in these places where those who cannot pay as much are seen. This includes individuals whose mental health difficulties are often caused or compounded by a multitude of psychosocial stressors.
Though these two systems aim to provide similar types of services, the scales are heavily weighted against one. The public mental health system is understaffed and overburdened, and as such it is in its settings that social work interns like myself often find themselves. In my case, it was an outpatient mental health clinic in Manhattan’s East Village that served as my own personal psychotherapy training ground.
My eight months at this clinic were a sort of mental and emotional bootcamp in which I was asked to do things I had never done before on a daily basis. When I arrived I had never conducted a therapy session in my life. About a month later I had a full caseload of individuals, couples, and families to manage, and was considered the primary therapist for every one of them. These were not the uncomplicated cases of my dreams. While I thought my superiors would hand-select relatively straightforward cases, the reality was far from this. . Rather, I saw a broad swath of mental health diagnoses, including depression, anxiety, bipolar, and schizoaffective disorders, that were inextricably interwoven with homelessness, unemployment, financial instability, immigration-related concerns, legal issues, and trauma.
Therapy is not an experience for the faint of heart. It demands brutal honesty and total vulnerability. Therapists pry into the most intimate aspects of their patients’ lives, not to be nosey, but rather because it is the only way for us to understand how we can help. The single most fitting word I can think of to describe my patients is brave. It takes a tremendous amount of courage for an individual to open up in therapy, and I am consistently humbled by the willingness with which my patients engage this task. But therapy is a transaction - in exchange for their honesty and openness, patients engaging in therapy have the right to expect that they will be greeted with expertise and knowledge of how to help them work through their problems. But what happens when this expertise is absent?
Graduate school taught me a lot of things, but one thing it did not teach me was how to do my job. I caught on quickly that my classes aimed to broaden my knowledge base and teach me a way of conceptualizing the problems I encountered in a manner consistent with the dictates of my discipline. They did not, however, teach me much in the way of how to concretely intervene in my client’s lives in order to facilitate positive growth and change. This is not meant to be a criticism of my graduate education. I fully recognize that only so much can be imparted in two years, and that the priority is to build a strong foundation that can be furthered through post-graduate employment experience.
But the fact remains that the crux of my job as a therapist is to help people produce the changes they wish to see in their lives. And when I began my internship at that outpatient mental health clinic, I had very little idea of how to actually go about doing that. Because of this I often couldn’t help but think of my patients as casualties of my own inexperience, and be bothered by the feeling that they deserved better than what I could offer. Further, because of the nature of the mental health system, the people with whom I worked were often high-need and low-functioning. Namely, they were individuals and families who could have benefited greatly from the care of an experienced, specialized mental health professional, yet who found that kind of professional unreachable due to financial and practical constraints. In short, I, or a similarly inexperienced therapist in training, was their only option.
I once read an article about starting therapy and was struck by the suggestions that it contained. Though I agreed with every one of them, I couldn’t help but notice what a privileged perspective it reflected. It essentially encouraged readers to shop around for a therapist until the person found a good fit for the individual’s personality and goals. This is absolutely the ideal situation, but one that is unattainable for many. The individuals and families who visited the clinic in which I worked were not given a choice as to which therapist they would see. They were assigned a therapist based on whoever had availability in their schedule. If it happened that the patient did not like that therapist or their style, there was very little, and oftentimes no, flexibility for a change to be made. And so it goes that in so many cases the individuals with the greatest needs end up matched to the therapists who are least equipped to meet them.
I worked my way through that internship hoping that what I lacked in experience I made up for in kindness and presence with my patients. I rationalized that any interaction with a caring person who has the desire to help is therapeutic, and that the only way I could be more helpful to future patients was to invest in my present patients, learning from them and from my mistakes. I still believe these things to be true, but continue to be troubled by the ethics of providing “therapy” when the only thing that qualifies you to do so is your participation in a graduate program. We have to learn somehow, but is it really right to keep patients with entrenched difficulties that impede their ability to live meaningful lives in therapy that may be unproductive, ineffective, or aimless simply for our learning purposes?
The pattern I often see is therapists working in community-based, public mental health care at the beginning of their careers when energy and zeal are high and the need to accumulate clinical hours for licensure purposes is paramount. But working within this disorganized and fragmented system that so often fails to meet the needs of its consumers is frustrating, discouraging, and ultimately exhausting. To avoid total burn out, many practitioners transition into private practice once they have acquired the necessary expertise to do so. Yet the clientele that fills the caseload of a private practitioner tends to look quite different from that which predominates at a public hospital or community health clinic, often higher functioning, better educated, and with greater access to resources. And that is how the cycle perpetuates, how the people with the highest needs find themselves working with the mental health professionals who have the least experience to draw upon in order to meet them.
Though now a full-fledged, licensed mental health professional, I still consider myself an inexperienced therapist, and I continue to come up against this dilemma in my practice. I frequently encounter cases that are unlike anything I have worked with before, and feel a bit lost as I attempt to put together a treatment plan that I can only hope will work. I dream of a world in which the public mental health system is more functional such that a greater number of skillful, accomplished professionals are incentivized to continue to work within it. Until that time, I will work to make my peace with the fact that sometimes, for any number of reasons, I am all that people have. And though it may be imperfect, I am optimistic that the something we burgeoning therapists can offer in terms of mental health support is a whole lot better than nothing.
