The Perils of the Mental Health Professional

Between thirty to sixty percent of all mental health therapist leave their position within a year. I was one of those therapists on several occasions.

After spending about $100,000 to become a therapist, I realized that I could not handle the stress and overall working environment and demands that were placed on me. I knew I was always into research and would have preferred being a researcher over a clinician, but that is a dead area for job growth. For clinicians, the people therapists work with are vulnerable, yet often, especially with kids, the constant changing of therapists can have a negative impact on their treatment.

If you are thinking of becoming a social worker or any other kind of therapist, consider the challenges I note below.

Financial Burden

The same study above noted that financial stress is a leading cause of therapists leaving their jobs. Though pay has improved overall in the past few years, it’s still low for someone with a clinical graduate degree. On average, therapists will make between $50,000 to 60,000 per year.

For perspective, I can make that same amount driving school buses and cleaning them on the side. That, I found was much less stressful and more rewarding. One does not need a college degree to drive a school bus or truck, but many therapists are strapped with huge student loan debt because master’s programs do not often provide stipends or any other kind of aid but graduate loans.

In terms of how pay works, such can be broken down into salaried and contractual. Salaried therapists are given regular pay but are often exempt from overtime pay. Though it’s nice to have a steady income, caseloads are way too high. Most agencies want a full-time clinician to carry between 30-40 cases per week. Others can push it to sixty.

It is an impossible caseload because therapy takes planning and time. Sessions generally run 45 minutes to an hour. Seeing over 5 clients per day, some with severe mental illness takes a major toll on a clinician. To add to the problem, many of these salaried positions require that the clinician meet a billable benchmark every week.

However, often, clinicians do not control who gets sent to them, but if they fail to meet billables, they are held accountable. That would be like punishing a school bus driver if they picked up 25 kids instead of 30. They have no control over who rides and who does not ride the bus.

It also pushes those in such agencies to commit possible Medicaid fraud because if a therapist doesn’t meet billables for a week, they can then try to have more sessions with the same client every week. They may try to clinically justify two sessions per week, but such is a grey area. In my professional opinion, many for-profit and not-for-profit agencies that operate in Maryland are in close danger of committing Medicaid fraud.

For those working part-time or contractual, they only make money if a client shows up. Most clients in need use Medicaid. Many clients are no-shows, so the clinician does not get paid for the session if the client cancels. I have had six clients in a day. Only one showed. Because the agency I worked for was private, I was paid only $25 for that session. I made $25 for an entire day. These positions do not offer any security or benefits. It takes time to have a steady caseload, but, often, a therapist cannot wait six months to get a decent paycheck. They leave.

Overall, therapists still get paid poorly, and though in demand, the nature of billing and insurance makes many employers more predatory to the clients and their clinicians.

Unrealistic Continuing Education Requirements

In my profession, I am required to have 40 total hours of continuing education credits every two years to keep my license. As a longtime teacher, I know that these courses are largely useless because what can one learn in one to three hours that stays with them? Often, we have to pay hundreds of dollars and take anything we can get so that we can renew. We are busy!

In other cases, there are well-known training in trauma and other areas that sound intense and worthwhile, but these cost over $3,000 and span days. Therapist don’t have the time, money, or support from their employers to pay that. One of the reasons I left social work and will not renew my license is that I cannot get my continuing education credits done in time. It would cost me hundreds of dollars.

I don’t have the money or the time. I work three jobs because a social work salary is not self-sustaining in the State of Maryland. To add to this misery, the Maryland Board of Social Workers wants all clinicians to get fingerprinted every two years. This adds more unnecessary costs to overburdened therapists. We can have background checks without fingerprints since many agencies fingerprint us.

From a more realistic position, I worked in child exploitation prevention. The vast majority of those with child sex offenses are either first-time offenders or they have gotten away with the offenses over time. Fingerprinting is little more than a false sense of security that bills the clinician. Then we have to pay over $200 every two years to renew a license that is good in only ONE STATE, further limiting the clinician and the service we could otherwise provide people during this mental health crisis.

Continuing education has become a way for more experienced clinicians to make money at the cost of their junior clinicians. Clinicians certainly need continuing education. And some of these courses are good, but overall, therapists are too overburdened and stressed to focus on the training they need and feel passionate about. We have to take whatever is there.

Paperwork, Paperwork, Paperwork, and that Darn Medical Model

Sorry insurance companies, but the medical model does not work for therapy. The insurance companies will point to their poorly written and manipulated “white papers” to say some short-term interventions work. Yes, that is true. The placebo effect is very effective.

But such focus also simplifies the complexity and messiness that is being human. A well-renowned trauma therapist and teacher from Maryland tells her clinicians that the only way to make progress with a client with complex trauma is to work with them for five years. I have no reason to doubt her, but she can do so because she bills privately and her clients are wealthy enough to pay out of pocket. They don’t have Medicaid or an insurance company where we must diagnose a person in an hour. Diagnoses are complex and can change over time, and some mimic others.

The medical model has us do treatment plans that are artificial. “We will teach the client three skills that they will master in two weeks.” No, we won’t. Such can break the continuity of care. The kid instead wants to talk to you because her dad just punched her in the face and she does not want you to call Child Protective Services. You have to, though you know it may do more harm than good. CPS was called three times before. She calls them “dumb CPS.”

I’ve seldom seen a clinician keep to a treatment plan because insurance companies want “measurable results” but not everything is easily measurable. How does one measure the impact of a grown man’s fist hitting the face of a nine-year-old? How does one measure the impact of CPS leaving the child in the same situation over and over again?

In many respects, domestic violence has the worst effect on kids putting them in imminent danger. Yet, they are seldom removed from homes where one parent is beating up the other parent or even a child.

If I am a medical doctor, things are usually very measurable. My client has bad LDL. I prescribe exercise, but know my client is too lazy to do it. To my surprise, he became an Olympian at 53, but while such is impressive, his LDL was not impressive and remained high, so I prescribed Crestor. His LDL is now down to normal results (there is no such thing as normal, by the way). You see, it’s measurable.

But Bipolar Disorder is not measurable, neither is Pedophilic Disorder, Obsessive Compulsive Disorder, or the ever-so-popular Narcissistic Personality Disorder.  Every treatment may or may not work, but we know that suicidal ideation is always a factor. Yet there is no way to measure or know that a client will kill themselves or others. If you work with kids long enough, you will lose one to suicide.

I cannot say, I will shame an adult’s sexuality for three weeks, and by the fourth week, he will have a socially acceptable sexuality.  No, he won’t, but he may tell me he does at his peril. The medical model is a hoax in mental health, and insurance companies are in direct conflict with mental health best practices when it comes to client care.

So much of the paperwork we have to do is unnecessary. Thank lawyers, where liability means more than client care. Money is the god here, nothing else.

We have to do multiple consent forms, an intake, scales every few weeks, a treatment plan, a treatment plan report, certifying for billing, notes and case notes, and a heck of a lot more. Then add the constant meetings that interfere with client care, the continuing education and licensing requirements, and little to no funding for these requirements, and it’s no wonder so many people leave. I have barely touched on clients yet.

We still have to see and speak to 30 or more clients every week. No, this is not psychiatry, where they meet with a client for 15 minutes, order a blood test, and maintain or adjust meds. The medical model may have some relevance there. They are medical doctors after all.

But we are listening and supporting our clients through some of the most challenging aspects of their lives. I’ve worked on some of the most horrific cases imaginable. Oddly enough, that did not affect me as much as a supervisor who said, “At the end of the day, no one cares about the kids” we treat.

It’s about billables, even for the not-for-profit. It’s how our society is structured. People are meant to be used and thrown away, and we wonder why we have a kids’ mental health crisis, high suicidal ideation rates, and teens shooting up our schools. They do because we value money over people and the community.

Kids are not the problem; rather, they are a reflection of what’s wrong with adults and overall society. In this case, societal norms are mental illnesses.

When I went into social work, I wanted to work with men who struggled with their sexuality and with those with child sex offenses. I could handle that work and had some influence, however modest. I was just reminded of this a few weeks ago when two clinicians contacted me out of the blue to thank me.

Yet, in my line of work, I was constantly threatened and put down by fellow social workers because my focus was unacceptable. They told me, in their opinion, I was a man and should talk about that. Opinions are not facts, nor are they science.

Given all of this, I decided to give up being a social worker. The profession has become laden with paperwork, and micromanagement, along with a flawed pitbull advocate mentality that only one opinion matters. If that collective opinion does not match science, then the science must be wrong. That is where we are. Respect for human beings is no place to be found.

I would think very carefully before getting into the mental health profession. It seems that all the money floats to the top shareholders, and there is nothing left for anyone else. There is no sign that such will change anytime soon.

I am now on a quest to simply be proud of the job I do while serving my community. That is enough for me, even if I have to give up my car and walk to work. Still, I think I had a lot to offer the profession in terms of focus areas on paraphilia and male sexual struggles, but our culture does not allow any research or discussion on uncomfortable topics. If research is done, it is often saturated with politics. It turns out that human sexuality is off-limits in the United States. Few will fund such research unless it upholds present opinions.

We still live in a country where one cannot put up a sign that reads “Sex Therapy” without being called out for making children “promiscuous.” Hotels cannot advertise “Human sexuality training” because people will all freak out. Yet, every place we look, we see nothing but violence and degrading language used toward others who simply have different feelings and experiences than we do.

I’ve realized that we are facing a kind of broken that I simply cannot fix. Broken is profitable, so those in power will continue to foster hatred and division for personal profit. This is unfortunately mirrored in the mental health profession.