#lpcc

[thistherapylife]

“This is a PSA for your friends who are mental health therapists. We might not be ok. We aren't picking up new hobbies or cleaning our houses. We aren't organizing closets. We are losing sleep thinking about the massive toll this virus is taking on the mental health of the world. We're worried about our clients with whom we may be the only point of connecting during their week, and now we can't see them in person. We're holding the grief of High School Seniors who just lost all of their proms and graduations and regular schedules and routines. We're walking newly unemployed clients through rights and applications for assistance. We're working with other therapists who are navigating a completely bonkers system around rules and regulations. We're talking to clients about how to navigate technology in order to say hello, and in some cases, goodbye to aging parents and grandparents. We're navigating our own grief, our own disruptions, our own pain and if we're lucky and brave enough, letting it take up space just like we're making room for our clients. AND we're providing trauma counseling while staring all day into blue lights on computer screens that may be making us go blind. So if you know and love a therapist - say a little prayer. We're not in an ER or on the front lines of the virus, we're on the front lines fighting like hell for your lives and emotions and processes and sanity. And our own too. And we love you. And this is really really hard.” Bethany L Lynne

Literally all of this

[thistherapylife]

why do you hate home visits?

Because I have a disability and you never know what’s it’s going to be. I’ve done family therapy standing up for over an hour because there is no place to sit. Public housing isn’t accessible always and even with an elevator - it doesn’t usually work. Or normal apartments with a fuckton of stairs. Heating and cooling abilities are often, sadly, luxury items and in a lot of ways I face the same issues as elderly folks when it comes to temperature regulation. It’s physically difficult for me and I don’t ever want to have to have a health crisis in a client’s home. They also take so much time. If I had 10 clients, maybe I’d have time but I have closer to 17-8 for individual and another 15 for case management and I’m in a supervisory position - the time does not exist. That’s the personal but there are also general difficulties with home visits - I’ve seen légions of bugs. Even when folks are trying their best public housing is often neglected or have limited access to ways to take take of an issue that might be from the hoarder three flats down. The smells can be horrendous - I’m extremely sentitive to smell and even if the family doesn’t smoke weed someone in the building usually does. Or cat or dog urine. It’s also unpredictable- as much as you say that you need a confidential space - you can’t control that environment. So many half dressed relatives or caregivers. I went into a lot of homes at the start of my career and I just can’t do it anymore most of time. They can be super valuable and there are sessions will never forget.

[thistherapylife]

From Termination Challenges in Child Psychotherapy  by Eliana Gil PhD and David Crenshaw. 

What an amazing book for any clinician working with child or adolescent populations - It's a great resource and I wish I had at the start of my career.

[thistherapylife]

Finding a great therapist while working as a therapist is like:

[thistherapylife]

So I think it was you (I follow a couple therapy blogs) that mentioned they won't see any patients while they're in an altered state (non-prescribed drugs, alcohol, etc) for ethical reasons. Can you explain the reasons for that (is it, patients might not have their proper boundaries and do things they'll regret in session, or what?) and is there a hard line or a bit of a judgment call (if I fuck up and forget I have an appointment and have a beer before going, do they have to send me home)?

There was a delay in answering this because I had to pull out my law and ethics textbook and poll some of my therapist friends. Because this had been part of my licensing exam and I was looking for justification. See this is why I love getting these asks - it keeps me sharp. Not seeing intoxicated clients happens for a lot of reasons and I’ll go through them.

1) It’s a judgement call. Usually. If you are working for agency or a hospital (like me), then you may be bound by the rule of the agency or hospital. Because we work primarily with minors, we are not allowed to see intoxicated clients. Have I probably had a session with a kid who smokes weed before school when I’ve seen them at lunch? Yeah sure - but I’ve been seeing most of my caseload at the agency for a while so they will tell me even though they know I will stop the session. So because of where I work, I don’t have the wiggle room I have in private practice.

2) It is unethical to do therapy with someone who can’t consent, barring emergency, lifesaving treatment. So if you show up to therapy off your tits drunk or high as a kite - you aren’t really consenting to therapy because you aren’t able to consent period. Just before we have gotten informed consent in prior sessions - it’s not consent forever. One of my therapist friends who I think is a total baller said, “A lot of therapy is about intention and accountability. I think if someone is so intoxicated they can’t be intentional or accountable - or they’re avoiding those two things through their intoxication - that’s a problem. Even if it helps with disclosure, that disclosure needs to be intentional and accountable, or you have little basis to move forward.” And I 100% agree. She summed up my thoughts pretty perfectly. Disclosure that you can only share when you are really drunk means that the therapist needs to work on the safety of the room and relationship and have patience. 

3) It can be physical safety concern if you are visibly intoxicated. What is this person like when they are drunk? Are they going to get angry and put themselves or me in danger? Another colleague spoke about a client who would consistently attempt to run through traffic when intoxicated. So that’s dangerous. Are you so drunk you are going to lose consciousness? Throw up and choke? Will we have to call 911 because you’ve stripped to your undies and are throwing chairs in the lobby? All of those actions have consequences that could take weeks or months to sort out. You are just unpredictable when you are intoxicated and your reaction may change. It’s also a physical safety concern for us. Clients experience maternal/paternal transference as well as erotic transference. With erotic transference, alcohol may lower a client’s inhibitions and they may try to touch/kiss/etc (a colleague I trust had this happen to him - he was an agency in a group office setting so he was able to get out but it effectively ended the therapy between the two. The client was enraged that he refused her sexual overtures and he was worried about being sued.) Each therapist has their own history and aggressive or sexualized behavior may not bother them. But it would bother some of us.   

4) Substances can make you more emotionally volatile too. Reactions can be bigger and more intense which if you are dealing with someone who is suicidal or at risk in other ways is a problem. If you are in a group setting, you could be triggering other clients struggling with either sobriety or recovery from trauma inflicted by another while drunk. 

5) Seeing intoxicated clients is an enormous liability issue. Therapy on the therapist’s side isn’t just about the relationship with client and all that good stuff - it’s also about managing risk. You want to protect yourself in your records and because of the issues mentioned above you could be putting your license at risk. If they can’t remember the session and are assault after session, that puts in you a bad position. And like I love my clients but I need my license to make a living and still owe a fuckton of loans so I’m not going to risk it.

6) In some states, if you are too intoxicated to drive but have driven to therapy, your therapist may be required to report you the police if you are planning to get back into your car (due to credible harm to other). I am really uncomfortable with this but that’s the state law where I live and I think it’s kinda gross. I would rather lyft/taxi the client home and pro-rate the fee to them. 

Lastly - The consensus from people I know who work in recovery, addiction or chronically homeless population is in favor of seeing people when they are intoxicated provided they are with it enough to understand what’s going on. In some programs and community mental health settings, refusing to work with intoxicated people would have resulted in many people not being served. Another friend stated that “Also, everyone is stoned CONSTANTLY in post-2015 Washington. So there’s that too.” Which should also be considered.

I’m not touching on deliberate, planned intoxication - because that is something very different. There is some great PTSD trials right now regarding a day long therapy with a client who takes drugs (I want to say it was ecstasy) in your presence and then you go at the hard stuff. 

TLDR; if you have a beer before therapy, it’ll probably be fine as long as your therapist/agency doesn’t have a 24 hours prior sobriety clause in the informed consent. If you are worried, find out where your therapist stands. Talk about it. 

[thistherapylife]

Are you a therapist in a school setting? If so is that any different from something like a private practice? How?

I’ve done therapy in a residential setting, in a school setting and some in private practice. Right now, I’m primarily in a school setting. It’s very different than private practice. Private practice - it’s all on you administratively. You are marketing yourself to get referrals, billing insurance if you take it, finding, renting and maintaining your own space, your own health insurance etc. It also means that most of the time, you set your own schedule, which days you work and the times, how many clients you see. Clients also come to you. You still have to write some notes but from my experience - private practice folks vary *widely* in how extensive they are. Cost can be issue (i.e. if you think a client needs supplemental sessions or more than once a week, that’s coming out of the client’s pocket or you are justifying that to the insurance panel). When a client misses sessions, man it’s a thing you have to deal with. Depending on your policy, you have to charge them because that is time reserved for them. Income can be decent if you are seeing a fair number of clients.

 In a school setting, most of the time you aren’t dealing with most of the stuff above. You are an employee for a district or an agency. They do the business taxes, the health insurance, the physical space stuff. When you are seeing clients in school, you get a lot more flexibility - especially if you are at placement all week. Client absent? No worries. Try and catch the client tomorrow. Major dissociation in session? Again no worries. The client just stays through the next period. Something major just happen? Cool, twice a week this week. And your clients have to be at school so it’s easy to find them, even if they are choosing not to come to session. It’s not my therapy and it doesn’t affect my livelihood if they don’t show. I can be way more patient with school based than in private practice because I get paid whether or not they come. It gives slow to warm clients more flexibility - I have no problem holding a slot for them and them not taking it because I do have the flexibility. I can fill that time a lot of ways - including seeing other clients because of the environment. It can also be really fucking frustrating to deal with everything not client related. It’s formal assessments and treatment plans every 6 to 12 months for every client. It’s not being able to control your caseload. I’m not good with psychotic disorders. But I’m expected to take what come down the line. They also control my caseload. I can (and do) push back against this aggressively but unless I can make an ethical argument or my individual supervisor backs me up I don’t have a lot of choice. Medi-Cal or district note writing can die in the fire. Having to get notes in within 24, 48, or 72 hours is a exercise in both futility and aggravation. (My notes? Basically only on time if I’m writing about a no show. If I have to choose between clinical care and paperwork - clients come first and I can’t maintain 10-12 hour days.). I also have to step carefully around teachers and school staff as well as all the office drama. To me, it’s worth it because I do get to do such cool work and get this much flexibility. But most agency therapists eventually get burnt out and leave or just make the choice to leave because the pay isn’t very good, you are expected to work long hours, to meet impossible productivity requirement and you are often dealing with intense trauma. And all of that is happening in addition to the systemic racism and oppression inherent in the systems that you and your client are trying to navigate. And most of the time the district doesn’t want to hear, “Hey this long term teacher is a racist asshat who is using racial slurs in class” especially if they are teaching the difficult to fill classes (like special education). I wish that I could say I have done this. I'm done it multiple times. I mean I do it. Everytime. It’s important that my clients know that I believe them and will fight with them and for them. But I know it will cause me a mountain of shit. I know it and do it anyway. But some people can’t.  And that’s okay because hopefully they’ll move onto something that suits them better. For me, this is worth it and I love, love my job. 

{Sidebar to the therapists and social workers reading this: We are going to real for a second. if you are a therapist in a school, public health or a community setting and you are feeling like, “Fuck me. I can’t do this work anymore” - get out. Secondary trauma is a serious occupational hazard. Take care of yourself. Try a new job in the same setting if you think it’s the agency. Try a new job is a different type of therapy. You have to make the best choice for you and your family. You won’t be helping anyone if you are burnt out. You’ll miss stuff and beat yourself up. You have to put your oxygen mask on first. Anyone who judges you for knowing your limits is fucking jerk and should be mentally classed as such. Love to all y’all}

Got a little windy there but I hope that explain it.

[thistherapylife]

Hey, I'm a psychology student and they told us at school that we need to start going to therapy (which is good since it gives me an excuse to go cause I actually need it) but I absolutely cannot afford it right now so I'm wondering if there's anything I can do until I can afford therapy?

Have you ever been? I couldn’t afford therapy while I was in graduate school most of the time but I had been through a *ton* of therapy in my life so it kinda held me over til I could. It is important. Until I went back, I had forgotten some of the visceral, physical feelings of being in the room with a therapist and it’s definitely made my therapy as therapist better. Until you can, try and make sure that you are connected to your supports, get some sleep, move, eat. Ask your professors for suggestions. Get together with your classmates and have a beer, a meal or coffee. Find the local intern/trainee support group (often run by the therapist group in the area) - they are often once a month and free. 

That being said, when you have a little bit of breathing room, many therapists have sliding scale or very low cost therapy slots for therapists in training. We’ve been there. I’d look into low to no cost counseling programs that use interns. (Like here or here). I’d also look into http://openpathcollective.org/ - you can find people in your area for 30-50 dollars a session. It’s great if you can find someone who works for you and most of us working in non-profits have used it at one point.

[unofficialchronicle]

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