Dear Mental Health Treatment Community (Therapists, Counselors, Social Workers, Psychologists, Psychiatrists, Psychiatric APRNs, etc.):
Welcome to my soapbox. Today, I wanted to take the time to explore the 10 things I hate about our profession. This is a rant about all the crap that mental health treatment providers do that just, frankly, sucks, and shouldn’t be happening, but isn’t strictly unethical, just unappealing and disheartening to hear about again and again from clients in my therapy room, and from providers themselves.
Yeah, that’s right. I’m talking to you all. Listen up, we all have some explaining to do, and if this post makes you uncomfortable, so be it. (It makes me slightly uncomfortable writing it, so I know it’s something that needs to be said.) I’m not perfect at all of these either, but I do try to recognize them (or be open to feedback from colleagues and trusted people) in my practice, so I can continuously improve. Without further ado, here are the 10 things we need to shift in our profession:
Return freakin’ calls and emails from potential clients. Yes, even if you’re full. Yes, even if the client isn’t a good fit for your practice. Yes, even if you’re tired and the email seemed dumb, etc. People are desperate for help, and if their first ten attempts at reaching out to someone fall flat or garner no response, they lose steam and stop trying to get help. If we, as therapists, want a healthier society, then we need to support people’s efforts to create change in their lives by reciprocating their energy when they reach out.
Geez, tell clients their diagnoses, and show them their treatment plan, if they ask to see it. I’m always shocked when providers tell me that they don’t tell clients their diagnosis for fear of “it upsetting them.” Are we not in the business of helping upset people reset emotionally? Can we not handle pushback, criticism or genuine feedback from the very people who we are treating… in an area in which they are admittedly an expert—their own experiences, thoughts, body sensations, and perceptions? This is their health record, not yours, and they deserve to know what your clinical impressions of their symptoms are, and what direction their treatment is headed in.
Cease claiming to offer a 'safe space for individuals to delve into their emotions' on your listings and websites. It's cliché, insincere, and devalues the true essence of our work in therapy sessions. If you're not fostering a secure environment for individuals in therapy, then it's best to step away, and figure out what is not working. If you are indeed establishing an unsafe or harmful treatment setting, then it's time to exit the profession. Seriously.
Stop pretending therapeutic harm is rare. It's real, it happens, and clients are suffering because we, as a profession, bury our heads in the sand, and don't gatekeep effectively.
Therapeutic harm is a significant concern that cannot be downplayed or dismissed as an uncommon issue easily resolved by authorities. It is akin to soul murder, where individuals in need of support end up being harmed by those they trust. Recognizing the prevalence and impact of therapeutic harm is crucial, as many vulnerable clients may struggle to report such incidents, particularly in systems that are not easily navigable. (I mean, have you ever met a client, outside of the helping professions, that even knew about the fact that you can look up providers by their names online in order to make a report to their licensing board? I haven't met such a client with that kind of savvy.)
To address therapeutic harm effectively, it is essential to take the experiences of affected clients seriously, offer them support, and guide them towards appropriate resources if they choose to take action. Prioritizing belief in their narratives, validating their encounters, and ensuring access to necessary assistance are key steps in demonstrating genuine support for those impacted by therapeutic harm.
Identify biases and gaps in your knowledge and seek to remedy those you can (with biases, you are required to rectify this issue ethically, so get on it, as soon as you become aware of one), and refer out when you can’t fill the knowledge gap. There are tons of therapists out here, and someone out there is an expert in the thing you’re not. They will be a better fit for the client who needs that kind of help.
Get really good at apologizing. I apologize regularly in session. I want clients to understand that I know I’m not perfect, and witness what a genuine acknowledgement of remorse and repair looks like. This doesn’t mean I get it right every time, but I want to get it right most of the time.
Assess for neurodivergence prior to slapping a big label like Bipolar Disorder or Borderline Personality Disorder on there. This doesn’t mean you need to operate outside your scope, so put down your damn pitchforks, psychologists. Nobody out here is suggesting that I, an LCSW, should be doing a ton of testing that I’m not trained in. What I am saying is this: Be curious about the possibility of neurodivergence first as an explanation (either full or partial) for the symptoms a client is experiencing. "As per the survey taken by the National Depressive and Manic-Depressive Association (DMDA), 69 percent of patients with bipolar disorder are misdiagnosed initially and more than one-third remained misdiagnosed for 10 years or more (1). Similarly, a survey done in Europe on 1000 people with bipolar disorder found a mean time of 5.7 years from the initial misdiagnosis to the correct diagnosis (2,) while another study reported that on average patients remain misdiagnosed for 7.5 years.(3) And quit assuming because a client annoys you that they have a personality disorder. Your annoyance probably has more to do with counter-transference, your nervous system dysregulation, and your own lack of differentiation of self, than your client's personality. Plus, when we think about ourselves in the room first (a.k.a., figuring out what is being stirred in us), we become better clinicians, who are better able to regulate our clients and teach them new ways of getting their needs met. It's strengths-based to 'check yourself before you wreck yourself' (clinically).
Adopt the golden rule when working with other providers. Think to yourself, "Is this the way I want to be treated by another professional in my field?" It is okay to disagree with other providers. It's okay to see a case differently. It is even okay to correct another provider's behavior, if you believe it to be unethical. Here's the key though: you can speak to that person privately first. Get clarification. Make sure you have a clear understanding of the situation prior to judgement. After all, isn't that what you'd want in return, if your places were reversed?
Get consultation when you really need it. And pay for it. Your colleagues’ time and expertise isn’t free. Sure, if you’re at lunch with someone and want to explore a simple clinical question with your friend, that’s fine. I don't mind when my friends or office mates wanna bat around ideas. However, if you want clinical consultation on a complicated case, lots of information about business or marketing techniques, or you're asking about a treatment modality that is specialized, like EMDR, Brainspotting, IFS, etc., pay an expert. Get some expert clinical consultation that is good, and good consultation usually isn’t free.
This one is specific to people in middle management, upper management and the C-suites at agencies, group practices and non-profits. If you haven’t seen a client in 5+ years, haven’t attended a therapy specific training in the last three years, and/or receive six-figure bonuses while your clinicians on the ground have to receive food stamps to make ends meet, then you don’t get to play dumb when your burnout rates are high, when clinicians are leaving in droves, or act like you would know exactly what to do clinically in a difficult, multi-layered case. When young clinicians come to me asking if what their COO or upper manager is asking for is ethical, and it's not, I am appalled. And guess what? Those COOs and managers get to do what they want. They've earned their stripes and they don't get replaced at agencies. They, like fat on a soup, rise to the top of the boiling pot. Don’t assume years in the field equals clinical expertise or knowledge on how to build a thriving, supportive agency environment.
There it is, folks! The spicy list of the 10 things I hate about our profession. Again, I want to reiterate, I've done many of these things before in my own practice. I've made mistakes, but as the great Maya Angelou said, "Do the best you can until you know better. Then when you know better, do better." Here’s the thing: we have to be able to have these types of conversations in order to move forward collectively towards a future where mental health treatment is accessible, safe, effective and collaborative. And this future is possible. If we all pitch in.
What do you think? Did I miss anything on this list? Are any of the points particularly powerful or thought-provoking for you? Let me know in the comments below!
Take exquisite care of yourselves,
Megan
Citations
Lish JD, Dime-Meenan S, Whybrow PC, et al. The National Depressive and Manic-Depressive Association (DMDA) survey of bipolar members. J Affect Disord. 1994;31:281–94.
Morselli PL, Elgie R. GAMIAN Europe. GAMIANEurope/ BEAM survey I—global analysis of a patient questionnaire circulated to 3450 members of 12 European advocacy groups operating in the field of mood disorders. Bipolar Disord. 2003;5:265–78.
Ghaemi SN, Sachs GS, Chiou AM, et al. Is bipolar disorder still underdiagnosed? Are antidepressants overutilized? J Affect Disord. 1999;52:135–44
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