This post will expose a piece of the truth behind mental health from my perspective. It started as a post about being in a giving profession and how difficult it can be as…well, a human being. I was going to discuss the fact that 2 out of the 5 days I left the office, I would get into my car and cry.

I would cry mostly because of the stories I heard and the emotions I attended to all day.

Some of the stories are hard to hear and others are almost disgusting to hear.

Stories about the messy stuff in life like divorce, and custody battles, physical abuse and sexual assault.

Stories about teachers who have incredibly limited resources who call me asking if there is anything else I can do to help a child who cannot seem to stay in the classroom.

Stories about foster care workers who have 7 children in their home and have not received the financial support needed.

These are the stories of people’s very real lives and my emotions are always torn at the end of a therapy day. I feel a strange combination of incredible sadness and heart break along with a selfish gratitude

that I came home to a loving household when I was little with a healthy meal on the table and parents who could help me do my homework. Grateful that I currently have an extraordinary husband who understands, supports, and encourages me daily; grateful that everyday he wakes up and makes the choice to be with me just as I do with him. Being a therapist has made me inordinately aware of the choices we have in this world.
I think instead, I want to discuss the other reason why I cried.

I felt like I could not do therapy the way therapy is intended to be done.

Here is the outline of a “typical” day as an outpatient therapist where I worked:
9:00 am- first session
9:45 am- second session
10:30 am- third session
11:15 am- fourth session
12:00 pm- fifth session
12:45 pm- sixth session
…I think you can see the pattern.
There were a few clinicians who were able to maintain that pattern all the way to the last session of the day at 6:30 to 7:15 pm.

I was not one of those therapists.

On the days where I worked early, my last session ended around 4:15/5:00. The emotional drain I experienced by giving my all to each of “my” kids was too much for me to go the whole day.

Okay, so what’s the big deal? I got paid only when a client showed up for a full session. Working with a marginalized population made the no show rate around 70% due to various issues like transportation, mental health of the parent, involvement with DHS (Department of Human Services/CYS Children Youth Services), etc. So, with the no show rate so high and the fact that the only chance a therapist gets to get paid (through a fee for service model) is if a family shows up, most therapists took on up to 40 clients.


Now scroll back up to the list of stories that I shared and times that by 40. On rare occasions when everyone would show up in one day, you are going back to back with sessions; I take a child out to the waiting room and bring another one back.

I learned to hold my pee and essentially not eat anything during the day. The only times I could eat were when I would ask my client permission to eat a snack while they worked on the art project of the day to prevent myself from passing out.

40 clients also comes with 40 progress notes, or notes that get written after every session. Our notes are due within 3 days of the session. In addition, each of the 40 clients requires a treatment plan that needs to be updated every 120 days as well as consents for treatment to be updated yearly and a trauma assessment to be completed with each treatment plan.

Photo courtesy of keyword.

Most clinicians, including myself, kept a detailed spreadsheet of when things were due for each client and would highlight when treatment plans needed to be renewed. What if they did not get done? The person at the agency whose job it is to do quality assurance would email you and your supervisor to get it done immediately. Treatment plans and progress notes are necessary tools for the insurance company to see that we are doing the work they are “paying” us to do.

Another big aspect that insurance companies look for during their audits are memo’s to chart. These must include notes of our attempts to reach out to the supports around the families. It is a part of a family therapist’s job to touch base with school, DHS, foster care providers, and any other organization that comes in contact with the family. Most of the phone calls I have during my day are with school counselors or teachers as that is where a child spends most of their day. On average, I received about 4 phone calls a day.  There is rarely time during the day to answer calls, so when you are able to answer the calls, you have to push back your sessions.  Time to do notes?  I ended up doing my notes when I finally got home or if someone did not show up for session.

Now here is the question I am pretty sure you have on your mind: did you get paid for that? The answer is no.

Obviously, I am a therapist and I am in an underpaid career. Yes, I took this job knowing it was fee-for-service. I, by no means expect to make a ton of money or even a good amount of money. The point is more that I am the one in the room doing the work. I have been clinically trained to hear stories, interpret the stories, manage the emotions in the room, create ideal patterns of the way things can go better, etc. Paperwork is a part of any job, but for this job it is purely so that the insurance company can rest assured that I am doing my job. The treatment plan serves as a guide for me to follow the model I have engrained in my head. It is a 7 page collection of papers that is by no means a reflection of what I do everyday. No insurance person has ever stepped foot into my therapy room.

The truth? I love what I do.

I have not been given the opportunity to do what I can do.

I am capable of providing a very high level of therapy to families and to some, I was able to do so. I still know deep down that I am drowning by the other forces involved and am not giving my 100%. How could I? Have you ever held your pee for 5 hours straight?

Unfortunately, nonprofits are not all not for the profits.

It is time that light is shed on the idea that insurance paid therapy is burning out the good clinicians because they want to do their job and also live up to the expectations of the insurance companies as well as the management of the nonprofit.

What is all this for? I am in this industry to provide top level care to ANYONE who may need it regardless of their socio-economic status. I believe that regardless of your status in life you deserve the best level of care available. I know that I can make a dent in making this system better and it starts with exposing the truth.

Therapy at agencies does not exist in a bubble and is sadly riddled with hierarchical and structural issues involving personal wealth and gain by those at the top.  The only way to end it is to expose the system for what it is.  It is broken.

Spread the word