An Open Letter to My Students V: Most of You Won’t Do Therapy, but You Can Still Be Therapeutic

I was out with a few colleagues the other day. We went to lunch and as I was chowing down on my southern relish sandwich listening to the two of them talk about work, one of them, who just became a professor said, “We tell students they’ll get out and have this ‘skill,’ as though they’re going to go out and hang their own shingle. Really most of them will have to go out and get a J-O-B.” I stopped mid bite, bits of sandwich hanging out of my mouth.

That captured exactly how I felt for a long time. I remember when I graduated. Diploma in hand I was ready to start making those big counselor bucks. Surely all I had to do was walk into an interview and say, “I’m here! I have a MASTERS degree!” and they’d pay me what I’m worth. Right?

Not exactly. It’s not that getting a job was hard. Getting a job was easy. The problem was that my training was in how to do therapy, and the jobs, well they didn’t quite have therapy in mind. Over the past few years I’ve had a series of “therapy” jobs and it seems to me that these jobs have fallen into three basic types: Social Worker, Agent of Social Control, and Camp Counselor.

Social worker is what I did until really recently, (as in I still work there but I turned in my 30 day notice). At least every other weekend you could find me on the Behavioral Health Unit of the local hospital doing bio-psycho-socials and conducting a group or two. The majority of jobs like this entail making sure people have the resources they need. It’s a lot of phone calls and paperwork. It can feel … well its not always the most engaging work.

I worked with people who made the job enjoyable, but the work itself was not fulfilling. When I was in my PhD program my dream was not to set up after care appointments for 7.5 hours a day.

Agents of social control sounds like something from the matrix because, well, that’s exactly what the Wachowskis had in mind. I did this kind of work a few years ago when my job was working as an in- home therapist. My job was to use my therapy skills to keep kids out of trouble, so I was a “kind” alternative to a probation officer. Trouble was most of the time the kid’s behavior was a normal reaction to insane circumstances. In-home therapy is really hard because you have little control over the context, and the stakes are very high for you, as the therapist to bill, which requires seeing the family face to face. One of the things that bothered me the most about in-home therapy was feeling pushed by my agency to do therapy with people for whom therapy wasn’t a priority. I’d drive by houses and people wouldn’t be home. I’d call phones and people wouldn’t answer. When I finally did get a hold of the family I’d learn that they moved to a whole new school. Strangely, the pressure wasn’t to help these families change. Most of my referral sources were too tied up trying to survive the politics of their own agencies to question who effective therapy was. As long as they could check the box saying they had enrolled the kid in therapy they were happy.

“Camp counselor” is what I’m doing now. I run groups for elderly persons who have been referred to therapy by their doctor or nursing home. Most of the time I wonder if they really need counseling or just friends. When I first took this job I didn’t know that when an elderly person goes into a Medicaid-funded-nursing home the government takes away everything they own in order to pay for the patients stay. It’s been really sad to see how we take away everything our elderly have worked for their entire life, their homes, their cars, etc, and send them to live in dorms where they don’t know anyone. In that situation it makes sense to me why so many of them suffer from anxiety and depression. But, instead of changing the system, they get sent to people like me for group therapy because hospitals can bill for psychotherapy groups and nursing facilities want the grumpy elderly out of their hair. Add to this the open secret that many of our elderly are overly medicated which often leads to their psychiatric symptoms (more on this later), and you have a system incentivized to support itself. This is the fate of all of those hoping social security will take care of them upon retirement.

If you don’t find yourself as a Social Worker, Agent of Social Control, or Camp Counselor you can still find yourself hoodwinked into not doing therapy. Your agency will send you patients with autism, who’ve had a stroke, or who have some sort of developmental delay, and because insurance will reimburse for providing “psychotherapy” for this population you’ll get tied into providing them with therapy. Problem is psychotherapy isn’t what they need. They need something like ABA, which is a behavior modification therapy. Or they need an occupational therapist to help them redesign their lives so they can function in society with appropriate modifications. Both OT and ABA are needed. Neither are psychotherapy. But congratulations- you’ve now been exposed to how insurance dictates treatment. More on that later.

However, you are being trained to be a therapist. Part of the skill of therapy is to be able to provide therapy to people despite the context. By following the fundamentals and avoiding some of the bigger mistakes you will give many clients an experience they have never had and be a fighting force against shame.