Finding Meaningful Work After Graduation?

[ITALA]

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I am in my second semester of MHC program. I had my shadowing experience at the local mental health agency, and I am finishing up second Theories class. I just learned about Reality and Solution-based therapies, and was told these are the primary theories I will be using if I accept agency position after graduation. I am frankly terrified, as I do not believe these therapies could even be called that. Applying these theories, to me, is similar to applying bandaids to open wounds. I can not imagine that working at the agancy, using these theories could ever lead to feeling like you have made any difference in clients (who are for the most part severely mentally ill) lives. Has anyone else felt this way after doing their practicum/internship or have you been able to find more meaningful employment?

Thanks in advance for your answers.

 

[Quichita19]

Hey Itala,
I am coming to the end of my year long internship at a community mental health agency. I have similar views to you regarding short-term and/or behavioral therapy. However, over the last year my perspective has changed and I see that these orientations have their benefits. 1) we will only be working with these folks for a year, and given that we are just beginning in the field and it will take a while to establish rapport and also our therapeutic style and confidence, short-term therapy is the only feasible option at this point. 2) Many of these clients have a limited ability for insight and very poor coping skills. In my experience, much of my work with clients has been focused on building up their distress tolerance and ability to regulate emotions, and overall building up their personal confidence and ability to trust and respect their intuition and feelings, and then be confident enought to communicate that to others and be able to maintain appropriate boundaries (DBT is wonderful for this!). Also, you really can't get to the "meat" of clients' issues until solid coping mechanisms are in place. Although, yes, this is putting a proverbial band aid over the wound, this is making a HUGE difference in a lot of these clients' lives, which is what I'm there for : ) But, also you can take hope because although much of our work is with behavioral/short-term theoretical orientations at this point, I also come from an eclectic perspective, and I find myself mixing in psychodynamic, humanistic, Gestalt, etc therapies as well. Also, you might find you have a passion for this population, or you may not, which is also fine. After you graduate, you can choose to work in an agency with a higher functioning population and eventually you can always go into private practice🙂 I hope this helps, and remember hang in there!! Not to scare you, but for me, my first few months at my internship site were very difficult and draining. But, just remember a lot of intense feelings and countertransference (as long as it is recognized and dealt with) are normal and it will pass. Also, make sure you take good care of yourself and engage in plenty of self care!!

 

[ITALA]

Hey Itala,
I am coming to the end of my year long internship at a community mental health agency. I have similar views to you regarding short-term and/or behavioral therapy. However...

Dear Quichita,

Thank you so much for your reply. This is exactly what I needed to hear. Everyone I asked so far looked at me like "What? You do not want to help the poor and the disabled? What kind of person are you?" In fact, I would love nothing better than to be in the position to help in an agency setting, but I want to make sure that what I do is really helping. Hearing that you found your experience to be rewarding is very encouraging. I also get a lot of "Oh, just do not worry too much about things in advance", and I just can not help wanting to know the direction I am moving in, because a few people I know who completed MHC/MSW initially wanting to become psychotherapists, are now doing something completely different - one is a supervisor at the sheriff's office, one works in policy making field, and the other one started her own restaurant. Counseling did not work out for them at all. I just don't want to end up in their shoes. That is why I am looking to find meaningful employment to an extent that it is possible. 🙂

 

[apumic]

I find it interesting you question short-term therapies. What do you propose instead in these settings? At the agency where I work and with the population with whom I work, repeatedly pushing back to their childhood abuse and essentially asking them to relive those experiences has often been attempted before and sometimes is what got the kid to us in the first place! There's a reason these "short-term" therapies have been so successful and, while insurance certainly plays a part, much has to do with research showing little effect of certain long-term psychotherapies.
I find it interesting that you present such goals as emotion regulation to be "superficial," when, in fact, they are often the underlying problem. Sure, the person's abuse may have made these responses adaptive, but that does not necessarily mean digging up an old skeleton is going to be the best way of fixing the problems the skeleton caused in the first place.

 

[Quichita19]

I find it interesting you question short-term therapies. What do you propose instead in these settings? At the agency where I work and with the population with whom I work, repeatedly pushing back to their childhood abuse and essentially asking them to relive those experiences has often been attempted before and sometimes is what got the kid to us in the first place! There's a reason these "short-term" therapies have been so successful and, while insurance certainly plays a part, much has to do with research showing little effect of certain long-term psychotherapies.
I find it interesting that you present such goals as emotion regulation to be "superficial," when, in fact, they are often the underlying problem. Sure, the person's abuse may have made these responses adaptive, but that does not necessarily mean digging up an old skeleton is going to be the best way of fixing the problems the skeleton caused in the first place.

This is definitely a question of therapeutic orientation. You make a good point that short-term therapies have their merit, especially in agency settings, where clinicians don't have the time to work with clients that would make psychodyanmic therapies and "digging up old wounds" unethical. However, I'm a die-hard believer that just because you can teach someone how to deal better with intense emotions and dysfunctional coping mechanisms, doesn't mean that the underlying feelings of worthlessness, ineffectiveness, (or whatever they may be as there is a whole plethora) have been resolved and won't continue to plague that person. I think it is absolutely essential to bring the unconscious into consciosness in order to resolve it, otherwise these patterns will continue to repeat themselves in the person's lives through their relationships in an attempt to resolve these deep feelings of inadequacy. I think this is the main reason why so many clients in community mental health settings are stuck in that perpetual door where they continue to cycle through interns for years with very little progress. It's sad to me that this population is put with interns when they really need clinicians with long-term experience to help them resolve their underlying issues. This is what I meant by putting a band aid over the wound.
While the concept of the way you think influences the way you act is absolutely true, and can definitely produce huge growth in client's lives. They learn how to value themselves, think differently, and regulate their emotions, which is very important. I also challenge your idea of emotional regulation being the underlying problem. I believe that the past traumas and/or abuse are the actual underlying problem that are at the root of inability to regulate the emotions because they are like triggers being constantly pushed and sending the person into an "uncontrollable rage" until they can be brought out into the person's conscious, talked about, and resolved. I agree with you that the emotional regulation piece is absolutely crucial in getting the person to the point that they can handle the trauma and still function in their everyday life. But, that skeleton is most definitely still in the closet and is the proverbial calm beneath the storm. Just because you aren't talking about it in therapy doesn't mean it isn't still there causing problems in the person's life.

 

[Therapist4Chnge]

(This is an abbreviated response, and I'll come back later and expound a bit more.)

Often the presenting problem is the smoke and not the fire. Many people come through the doors of a CMHC because they are having struggles in their day to day lives, and they would like to reduce/eliminate these problems. While many short-term therapies can be very effective for a host of issues, they also have their share of weaknesses. One of the biggest weaknesses I've found with short-term approaches (even time-limited dynamic work) is that it often doesn't allow for the time and space to fully get to the root cause, and thus limiting what you can work on during the therapy.

Another major hurdle is the limitation of some orientations to disregard/downplay some of the more deeply rooted issues, and instead focus on surface level treatment of symptoms. While symptom reduction is an important aspect of therapy (particularly when a presenting problem focuses on the Sxs), failure to treat the cause of the symptoms does very little for the person in the long term. It has been my experience that unless a person can dig deeper, they most likely are going to re-experience many of the same hurdles because they have not learned how to navigate these experiences.

There is definitely a place for short-term work, manualized treatments, skills-focused training, etc.....but sometimes people do it at the detriment of doing the longer-term work. We are raised in a society that values instant gratification, though this often leaves us half-healed and wholey wanting.

More on this later.....

 

[ITALA]

This is definitely a question of therapeutic orientation. You make a good point that short-term therapies have their merit, especially in agency settings, where clinicians don't have the time to work with clients that would make psychodyanmic therapies and "digging up old wounds" unethical. However, I'm a die-hard believer that just because you can teach someone how to deal better with intense emotions and dysfunctional coping mechanisms, doesn't mean that the underlying feelings of worthlessness, ineffectiveness, (or whatever they may be as there is a whole plethora) have been resolved and won't continue to plague that person. I think it is absolutely essential to bring the unconscious into consciosness in order to resolve it, otherwise these patterns will continue to repeat themselves in the person's lives through their relationships in an attempt to resolve these deep feelings of inadequacy. I think this is the main reason why so many clients in community mental health settings are stuck in that perpetual door where they continue to cycle through interns for years with very little progress. It's sad to me that this population is put with interns when they really need clinicians with long-term experience to help them resolve their underlying issues. This is what I meant by putting a band aid over the wound.
While the concept of the way you think influences the way you act is absolutely true, and can definitely produce huge growth in client's lives. They learn how to value themselves, think differently, and regulate their emotions, which is very important. I also challenge your idea of emotional regulation being the underlying problem. I believe that the past traumas and/or abuse are the actual underlying problem that are at the root of inability to regulate the emotions because they are like triggers being constantly pushed and sending the person into an "uncontrollable rage" until they can be brought out into the person's conscious, talked about, and resolved. I agree with you that the emotional regulation piece is absolutely crucial in getting the person to the point that they can handle the trauma and still function in their everyday life. But, that skeleton is most definitely still in the closet and is the proverbial calm beneath the storm. Just because you aren't talking about it in therapy doesn't mean it isn't still there causing problems in the person's life.

This is wonderful to know that there are like-minded people out there. I agree with every word.

 

[ITALA]

We are raised in a society that values instant gratification, though this often leaves us half-healed and wholey wanting.

More on this later.....

My fear is that maybe the confines of agency structure and insurance reimbursements are the ones causing the employees there to revert to short term therapies. It is as if wealthy paying clients get the "real deal" therapies, and the severely ill who have no resources, get the "band aids"...

 

[Therapist4Chnge]

My fear is that maybe the confines of agency structure and insurance reimbursements are the ones causing the employees there to revert to short term therapies. It is as if wealthy paying clients get the "real deal" therapies, and the severely ill who have no resources, get the "band aids"...

Managed care definitely has a large influence over the services being provided. The "haves" definitely have an advantage over the "have nots", though there are still amazing therapists that work with regular folks.

There are CMHCs that offer longer-term therapy (traditionally dynamic) for patients who want longer-term therapy options, though the caveat is usually it is with a more "green" therapist collecting hours. I know our local clinic offers this option, which coupled with a sliding scale makes it accessible to most/all people.

 

[ITALA]

There are CMHCs that offer longer-term therapy (traditionally dynamic) for patients who want longer-term therapy options, though the caveat is usually it is with a more "green" therapist collecting hours. I know our local clinic offers this option, which coupled with a sliding scale makes it accessible to most/all people.

Interesting, so far my agency exposure has been limited. I will continue looking for different options.🙂