I started seeing my first community mental health clients three years ago. On the day that I met my first clients at my internship, I was immediately aware that no part of my graduate education (or my life) prepared me to work with clients this unwell. My fellow interns were similarly shocked. My internship was an exercise in endurance. I survived, but the way I survived cost me something. Despite the fact that several prior generations of therapist have made this journey, I struggled to find resources to help me make sense of what I was seeing and experiencing. Is it this severe everywhere? When will I start to feel like I know what I’m doing? Wait, what am I doing? How can my clients get better? Is “better” even the right word? I feel like I am going crazy… is this normal? I resolved that if I ever found my way through, I would try to describe and normalize the early difficulties of doing this work for those who start this journey behind me. I’m far enough in to have learned some things. There are some short-cuts. There are many, many, hazards. These are a few of the things I wish someone had told me before I started this journey. It might have shortened some of my suffering and meandering. I might have felt less alone.
- Your community mental health clients are much, much, more unwell than you thought possible. It’s difficult to describe the enormity and depth of the Grand Canyon. Even when you see it directly, it confounds your senses. In community mental health, most of your clients will be more unhealthy than you can wrap your mind around. It may feel as though you are standing on the edge of a vast canyon and your job is to help fill it. You don’t even have a shovel yet. Every bit of energy that your client has was spent coming to see you today for help. He is looking at you for help. Real help. There may come a time when you look at your caseload and feel the awful responsibility of it. That responsibility is real. These are your clients. You may feel very small in comparison to it. It’s okay. That feeling is horrible, scary, and normal. In time, you start to adjust to it.
- You learn to do this work at the expense of your clients. There is something deeply unfair about that to your early clients. There is no other way to do it. You can make amends to the cosmos by doing the best that you can each day. Then, work to do better.
- This is intimate work and the worst of it requires that you sit in close proximity to pain. There is something horrible about sitting in a tiny room for an hour only three feet away from someone in horrible pain. At first, you are likely to feel pulled around the room by your close contact with clients. You may feel the need to dig your heels into the carpet to avoid being pulled into someone’s black hole. Over time, this gets better. Soon, you will start to feel the pull of your own gravity and this makes it easier to sit in your chair. But for a while… for a long while… sitting that close to someone in pain is going to really, really, suck. Hang in there. It’s not just you that goes through this… and it does get better.
- Shortcut: Invite feedback from clients frequently. If you are lucky, they will tell how you can better help them. Ask permission before giving feedback, advice, or redirecting therapy.
- Shortcut: If you want to work to change thoughts, work with the body first. Work to name emotions. Deep breathing, etc. It’s easy to overestimate the emotional awareness of clients. The degree to which your clients occupy their bodies will vary drastically.
- What you do with your own emotional responses to your clients makes all the difference. The awfulness of client issues will cause you to feel very strong things. You are allowed to feel whatever you feel. It is important that you identify and process these emotions. You may have a strong impulse to blame your clients for the emotions that they evoke in you. It is critical that you become aware of this if it happens to you. Otherwise, you will not survive your internship with your empathy intact… which is one of the main goals. The seeds of burnout are planted here and nothing makes them grow faster than blaming clients for your own distress. So, tend your own garden and own your own emotions.
- Caution: Don’t rush toward trauma. Some of your largest early mistakes are likely to be asking a client to do trauma work before you and the client are ready.
- It’s all trauma. Almost everything that you will see is caused by trauma or is related to trauma. This can be a terrible realization that sneaks up on you. You may be aware that you will see a lot of clients that have had horrible things happen to them. You may be aware that you are seeing some of the most unwell people in your county. What you may not realize, until it gets close enough to terrify you, is that God-awful trauma happens all over and all the time. You know that it exists, but you don’t fully realize how ubiquitous it is until you spend a few months listening. You find out that trauma is about your culture too. You may have clients abused by fathers who were local politicians and lived in nice houses. You may have clients whose sexual abusers were therapists. You may have clients who are eight-years-old who have been molested and you may have clients who were sexually abused when Lyndon Johnson was in the White House. Working in a community mental health setting makes it harder for you to do what everyone else does to cope with a reality this horrible–pretend it isn’t real. You can’t. This isn’t a once-a-year television reminder that monsters are real. Your clients swim in it. You swim in it. You begin to see it for the massive, global, and long-standing public health crisis that it is. You may start to imagine the sheer number of abusers. Millions and millions of them. You may struggle to make sense of it. You may feel it gnawing on whatever remains of your hope, faith, or optimism. Try to process it the best that you can by talking to the most empathetic therapists that you know. You are unlikely to be able to have productive conversations about this with a non-therapist.
- Shortcut: When you don’t know what to do, listen and validate the client’s experience. Even when you do know what to do, listen and validate the client’s experience. Also, it’s your job to make sure that each session stays on track. That balance between listening and directing is an art.
- There may be a lot of misinformation from people who are supposed to help guide you. Many training supervisors are severely impaired. It is possible that most or all of the senior therapists at your organization are severely burned out. They may be lost themselves and don’t realize it. Don’t listen to anything they tell you. You will know them by the way that they speak about their clients. They may use DSM diagnoses instead of pronouns. Some may literally use curse words instead of pronouns. Most of their advice is about what you can’t do to assist your clients. They may focus exclusively on a tiny sliver of a client’s presenting issues and completely dismiss everything else. They frequently make the case that you should discharge clients that are difficult for you, instead of helping you to process that difficulty. They talk frequently about retirement. They are frequently nostalgic for a more “moral” time. They aren’t glad to see you when you have questions. I have come to believe that burnout is infectious and zombie therapists often run the show. Don’t let them near you. Find other helpers who still have a soul and listen carefully to them.
- In community mental health, you will have a lot of turn-over. It is possible that most of your clients during your internship will not get “better.” Some of your clients will get worse. Some may die or kill people. All will withhold things from you. Many will lie directly to you. All of this is normal and only a small portion of it may be about you. All of this for a long while will feel horrible, unfair, and deeply personal. This is very difficult work. On any day, do the best that you can. Resolve to do better.
- You will make a lot of mistakes. The best therapists are aware of their mistakes, own them, and learn a lot from them. Keep a close eye on the tendency to blame clients for your mistakes.
- If you are a therapist, you can’t get away from anything. Nothing. Whatever it is that you are sensitive about, the universe will bring that issue to you over and over. Clowns freak you out? You’ll have every squishy-red-nose depressed and socially anxious clown within 40 miles sitting in your office, back-to-back. You’ll have the feeling that the universe is on to you and is screwing with you… on purpose. Because of this, you must do your own work and get your own therapy. You need to do this pretty quickly, too. The universe isn’t good at sending you this message subtly. Even when you are in therapy for your clown issue (or whatever it is), they keep showing up faster than you are able to resolve this issue.
- You are doing incredibly important work in the world. Know that the difficult parts of it pierce and the good parts of it may bounce off like Nerf arrows. It is like this for everyone. It’s an art to know when to shield up and when to open up.
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