Mental Health Professionals Also Need Support
Sometimes, the hardest part is not knowing the outcomes. And sometimes, the hardest part is knowing what the outcome is and knowing it's not what you wanted for the client. – Judy
*Names have been changed to protect anonymity
In 2016, over 260,000 people in the United States were employed as substance abuse, behavioral disorder and mental health counselors, with about 5,000 of those in the state of Ohio, according to the Bureau of Labor Statistics.
BLS estimates also show the field is expected to grow by 23 percent between 2016 and 2026, outpacing the 7 percent average growth rate for all other occupations.
The National Institute of Mental Health reports in 2017, 19.8 million people received mental health services in the U.S.
All of these figures add up to a growing sector of the economy based upon the emotional labor of caring for those in mental crises.
One therapist who has worked at agencies in and around Geauga County over the last decade agreed to speak to the Geauga County Maple Leaf about the complex nature of their work.
‘We’re Still Regular People’
Judy* has experience with several different populations ranging from early childhood intervention to work with adults.
The vast majority she has treated for post-traumatic stress disorder, even if that was not their primary diagnosis or what initially brought them to treatment.
Clients suffering with PTSD are often being treated for a substance use disorder, Judy said.
“Many of my clients over the years are women and girls who are survivors of child sexual abuse who also are addicted to heroin or opioids,” she said, adding sexual abuse is much more common than the public realizes.
The most difficult part of her job can be the guilt that comes after a tragic event involving a client, she said.
“Some people don’t know this and I don’t want to scare them away from the profession, but I also want to emphasize that we (mental health professionals) have to be aware when we’re suffering trauma,” Judy said. “People going into the profession have to be aware when we are impacted by traumatic events – past and current – when working. We learn about compassion fatigue and burnout in graduate school, but it looks very different for each of us. We each have to be aware of what our own boundaries are.”
A mental health crisis has been noted amongst first responders, with the May 2018 Supplemental Research Bulletin of the federal Substance Abuse and Mental Health Services Administration dedicated to mental health and substance use in that group.
“It is estimated that 30 percent of first responders develop behavioral health conditions including, but not limited to, depression and post-traumatic stress disorder, as compared with 20 percent in the general population,” the bulletin said. “In a study about suicidality, firefighters were reported to have higher attempt and ideation rates than the general population. In law enforcement, the estimates suggest between 125 and 300 police officers (die by) suicide every year.”
For Judy, it’s important for the public to recognize that while much media coverage is dedicated to the opioid crisis, or concerns over suicide among first responders, mental health professionals also need to create a work culture that addresses their trauma.
“The people that work to try to prevent school shootings and the people who try to prevent suicides, and the people who are first responders are often therapists, counselors, social workers,” she said. “So creating (a trauma-informed) culture within an agency — particularly when we work with addicts, with crises in the community, anybody who’s experienced any kind of trauma — is important.”
Judy’s experience in Northeast Ohio showed her competent, trauma-informed culture is prevalent in area agencies.
“A lot of other places around the country could really take a cue from the resources and how (Northeast Ohio) agencies are run,” she said, adding she has worked at the best agencies, in terms of providing appropriate support to therapists, in Northeast Ohio and Geauga County.
But that type of support is not available across the country, she said.
“People that are right on the front lines immediately following an event, or during an event, or trying to prevent it, (the agency) needs to be very clear that they are hiring supervisors that know how to supervise people in those environments,” Judy. “And have consistent trainings yearly for their staff to watch for their own signs of burnout.”
‘Burnout’ and ‘Compassion Fatigue’
A 2018 literature review in the “Journal of Clinical Psychology” found over half of sampled psychotherapists reported moderate to high levels of burnout.
Being a younger age, having less work experience and being over-involved in client problems were the most common personal risk factors for moderate to high levels of stress and burnout among psychotherapists.
In Judy’s experience, burnout is less likely to happen in work settings with healthy boundaries.
“The culture of where you work really sets the tone of where the boundaries are with a client in a lot of ways,” she said.
A healthy workplace is one “where you are able to work effectively without too rigid or too loose of boundaries — either with your time, what you’re supposed to do with clients or the physical space of where you’re meeting them.”
Judy said mental health professionals are trained on burnout and compassion fatigue, which are different, but include a condition in which the professional begins to share trauma symptoms with clients.
Compassion fatigue can mirror PTSD, she explained, and comes from over-empathizing with clients or long-term exposure to knowing about or actively participating in traumatic events as they happen.
Some mental health professionals she knows have taken leaves of absence at times to address their own emotional wellbeing. Agencies also may offer Employee Assistance Programs for counseling and often make crisis counselors available to staff after an unexpected client crisis.
Judy highlighted a paradox of modern mental healthcare — while the public in general is more informed about how important it is to get help for one’s mental health, that awareness begs the question, who counsels the counselors?
“We all learn how to set boundaries for ourselves so that we may take care of others,” she said. “Like physicians, our first rule is to do no harm. This means making our own healing and ongoing journey, with ourselves, with our clients and as a profession, a top priority.”
Some ways in which mental health professionals insulate themselves against burnout and compassion fatigue involve knowing their professional limits.
Mental health professionals, Judy explained, are trained and licensed within a scope of practice that keeps them within their professional comfort zone.
“If I have documented experience and that’s where my training is, that’s my scope of practice and I use specific counseling (methods) for those populations,” she said. “Some people are able to work providing end-of-life or hospice care, some in prison populations, some (work with) addiction, some (work with) child sexual abuse. We all have an array of different skills.”
Even an independently-licensed professional, or one who is designated as a supervisor, will still have other professionals at their level they can reach out to confidentially to get feedback on an issue with a client while maintaining the integrity of the relationship to the client, she explained.
An ethically sound counselor will know what their limits are, but even so, most clients present with issues that are out of the counselor’s control, Judy said.
“We can’t control things like (a client’s) housing, whether or not they’re going to go out and still use (drugs), whether they get their kids back, whether or not there are other systems in place that can intervene the way they should for the best outcomes,” she said.
‘Sometimes We Need Help, Too’
For Judy, the most difficult part of her work is when things do not go as planned with a client.
Most mental health professionals have, at minimum, a master’s degree, as well as a license that must be renewed every two years, Judy said.
They must prove they are ethical and responsible, and that they are using evidence-based practices in their counseling profession — meaning, the types of intervention they use must be proven effective and not to cause harm.
But that does not mean they are always prepared for what a client brings into the clinical setting.
“Sometimes, the hardest part is not knowing the outcomes,” she said. “And sometimes, the hardest part is knowing what the outcome is and knowing it’s not what you wanted for the client.”
Asked whether counselors are stronger than normal people, she replied, “No, not at all.”
“We’re not there to problem solve or to give advice to change you,” Judy explained. “A good therapist will meet you where you’re at and that will be totally okay. You guide us. You tell us what you need. We have a specific set of skills … (but) ultimately, your autonomy is the most important thing.”
Most mental health professionals are also mandated reporters, meaning they carry the responsibility of notifying law enforcement of a client expressing credible intent to harm themselves or others, she said.
But, if the goal is to destigmatize mental healthcare, it has to be okay for mental health professionals to say, “sometimes we need help, too,” Judy said.
“We deal with a lot of stuff and we need to make sure that we’re creating a culture where it’s okay to acknowledge that and process through it to continue to provide care that is always in the best interest of the client, always,” she said.
