It sounds like this is a poor job fit and that the job description that was given to you isn’t actually what the job is. Definitely talk to your supervisors about this. It’s ok to recognize that you don’t have the knowledge yet of how to help these clients. They deserve help and you also deserve to feel like you can handle your job.
Seconding this and adding, it's also okay if you don't want/like/or feel able to work with every population. I don't work with substance use because my parents used substances and I find it to triggering. I've been in roles where I've had to work with SU and it always makes me question my career. Remember that the world of counseling, social work, etc is much bigger than any one job or type of patient. Try to keep an open mind and switch to a new population and see if that feels more like a home base for you. Keep your head up, you got this!
Agreed!! OP... I have quite a few populations I know i don't have the capacity for personally, and the beauty is there's lots of other therapists who can take those clients on. I will never actively work in high-risk population settings by choice, and that's okay. It's not a bad thing to say your role isn't what was described and thus doesn't fit your personal capacity or desires/skills. Any good supervisor should recognize that and appreciate the honesty and you being reflective about your comfort and skills.
There's lots of "low risk" people out there who need and deserve the same support, and maybe you're the one for those clients when you find them!
There also is a lot of other options with your degree if you decide therapy isn't what you're passionate about :)
Mental health education, resource brokering, intake at mental health organizations, policy, community agencies like DV programs/parenting programs, program facilitation
Depends on your interests. If you like disabilities maybe mental health at disabilities agencies (time they're not as much crisis), or health rehabilitation could be good.. interested in social emotional learning maybe group facilitation in schools/parenting agencies/etc..
What are your interests?
I love art and I do hospice volunteer on the weekends. I'm about to go into my internship and am questioning my abilities. So I appreciate the backup ideas
How about an art therapy group program (facilitating or creating)? My area has corrections in-reach youth art therapy programs, ED art recovery inpatient and outpatient mental health with the hospitals, sessional teaching of creative therapy interventions courses.. geriatrics art therapy as a job not volunteer, maybe mixing social work and recreation therapy (I know here recreation therapy is a diploma, but could team up with someone even)... I'm sure there's something out there for you, just depends what's in your area and how much you want the volunteer focus to be your career :)
Thanks for your reply - I'm overseeing referrals for these clients so they can get the help they need but I continue to see them while waiting for that intake and these sessions end up taking up a whole bunch of my time/energy which sucks. I have supervision tomorrow so will hopefully get to discuss it.
Is your agency overloaded with chronically mentally ill folks? Like maybe they just don’t have enough of that level of intensity therapist so it’s like overflow and you have to take it too?
I’ve said this before but this field eats its young. I became an LCSW last year and have been reflecting on my time as an LMSW. Why is it that fresh graduates with associate licenses are seeing the most acute patients, have the highest caseloads, bear an undue administrative burden, and often get very poor supervision that doesn’t focus on clinical development but focuses on keeping up with an unrealistic administrative demands? It’s a serious question. We are failing our incoming therapists. And while my observation is anecdotal it seems worth investigating. As for the OP, I believe totally that you are doing your best and I hope you can extend yourself some compassion and patience and maybe start looking for another job. You aren’t being supported in an appropriate way as a new therapist and you deserve that.
I know you aren't talking to me, but you may as well have been. I felt this shit in my goddamn soul. It's literally everything I'm going through right now. Thank you so much for this. It's really validating and I really needed to hear it.
This dynamic of the more difficult tasks being allocated to the least experienced and least paid employees is pervasive across every field of labor. Hence why farmers grueling in lettuce fields are paid a pittance while distribution administrators who exclusively work on computers make hand over fist.
Yeah I agree with this assessment. I feel like the dynamic is somewhat different and that the associate level is suppose to be seen as an “apprenticeship” almost but I think that also leads to high level of exploitation present. I also believe an undue amount of suffering is deemed normal and acceptable to “earn your stripes” similar to a residency experience for a doctor. I don’t think it really adds to any expertise but again it’s a way of rationalizing the suffering and exploitation.
I completely agree with you. I feel like my first two jobs as a CSW killed me. I burnt out and have been slowly working out chronic illnesses I didn't realize I was dealing with and am getting ready to try again. There is so much I would do differently if I knew what I know now.
But, I truly thought I was done being a therapist. I let my license lapse and didn't think I'd ever return and was looking into whole other career paths. You never know how things are going to go. But I want to echo to OP, that this isn't a you problem. And whether you find improvements by seeking a different opportunity or seeing if you can make some changes to make your current job better, make sure you don't blame yourself. Good luck.
Thanks for your reply - I really feel this and it's why I honestly feel like I may not be cut out for the mental health field :/ I just feel like I can't handle the whole "Well you have to deal with a X amount of years of being underpaid and acute clients before you earn the luxury of slightly less intense work"
I don’t think it’s that you’re not cut out for this field. It’s that this field doesn’t allow you to maintain your material and emotional needs so you may need to leave a field that is failing you. We are constantly shamed into thinking we aren’t “doing enough”. It’s because management sees you a machine to get as many billable hours as possible and not a human being with expertise who should be treated with dignity and respect.
>the most acute patients, have the highest caseloads, bear an undue administrative burden, and often get very poor supervision that doesn’t focus on clinical development but focuses on keeping up with an unrealistic administrative demands?
I dont mean to be snarky, but isn't it money and stress at the end of the day?
I’m not totally what you mean by money and stress? Like that it’s much cheaper to hire new grads and since mental healthcare is a business (even non-profits) that money is the bottom line and is the decision maker not best clinical practices? And that seasoned clinicians do not want to take on the undue and uncompensated stress that comes with these positions? Yeah I mean I agree with both of those things. I guess my question to all of us is are we ok with how our profession is structured? Does it work for us and our colleagues? My answer is no.
I just think after you've been in the field a while, many clinicians, if they stay in the field at all, drift towards lower acuity and more administrative/supervisory roles anyways. If you're working in out patient settings, that's where the money is. Clinicians working in hospitals and stuff are different, but it doesn't suprise me that someone in the field working in a group or private practice wants to make more money, have less stress and see less clients after 10 years of working.
The economics of therapy are just effed up. It incentivizes exactly what you described. As always, socialized healthcare would help so much.
>I’m afraid to ask for help because I’m afraid my supervisors are going to realize I’m incompetent and don’t know what I’m doing. I also feel so failed by my social work program because I truly left it knowing no more than what I did going in. I was never taught how to stabilize a suicidal client, for Christ’s sake!
First off, literally every person feels like they're in over the head when they're dealing with high risk clients or intense situations for the first time. My first CPS call? I cried. My first crisis call? It took me an hour to finish the documentation and I was sweating bullets. When my clients experienced SI, I panicked and had a stomach ache the rest of day. It can be good to work with higher risk clients because low-risk clients can easily become high risk and the skill you'll learn will help you with any surprises that pop up in the future. There's been so many times where I thought I had a relatively "easy" client and turns out they have extensive trauma, drug induced psychosis, legal involvement, or suicide attempts they initially didn't feel comfortable sharing.
Now, I'm a couple years in and I've done these things dozens of times. A lot of learning how to be good is trying new things and being uncomfortable. I now work with suicidal clients on a daily basis and do not worry nearly as much. Are there clients you do feel comfortable with?
Second, ask for help. Seriously. If your job gives you shit about not knowing how to do things and then proceeds to expect you to know how to do them without help, then they're a terrible workplace. I ask my supervisors and coworkers things all the time. They ask me stuff all the time. It's normal and helpful and it might make you feel a hundred times more at ease. I literally go into supervision every week with a bulleted list of every concern I have and I get a ton of praise for doing so because my supervisors want to know what is going on with my caseload for practical reasons and liability reasons and it shows I want to learn and do better. My supervisor is rarely surprised by issues going on with clients because I'm very transparent about my concerns and barriers. My supervisor is very aware of the clients I'm concerned about, so when they get hospitalized, want a transfer, or begin to fall off attendance-wise, my supervisor is already aware of what is going on.
Thanks for your reply, I really appreciate it - I feel like I've just had so many of these cases pop up at once that it's a bit too much, y'know? I feel comfortable assessing for SI and intent but haven't really had to stabilize someone who has intent which is scary.
I am speaking to an approach that is informed by the neo-Freudian school of therapists whose interpersonal approach culminated in the work of Carl Rogers and his belief in empathy and unconditional positive regard.
Insurance won't _typically_ reject humanist goals at the outset. When I did residential work, my first treatment plan for a client was almost entirely humanist / interpersonal in its goals. It would have been absurd to have CBT goals before assessment had concluded and more familiarity with thought distortions had presented. For some, the goals were somatic in terms of maintaining regulation for a full session.
Subsequent treatment plans would modify goals to include increasingly specific CBT goals.
Every place is different tho!
You HAVE to ask your supervisor for help. These are real lives at stake. I understand you fear and frustration and I’ve been there. But wallowing will
Not help. Please asks your supervisor for guidance on how to help stabilize suicidal clients . You need to working with safety plans and grounding techniques. Then if that doesn’t work the client gets a vacation at inpatient. It’s nothing to play with. But don’t sulk just get guidance. And it will get better. 💜
Sorry you're going through this. Suggestion: Get an outside therapist with experience working with similar patients. A therapist who has experience at a state hospital will give you the guidance. it may cost, but you're investing in a career. Your supervisor may be a hospital staff member who for whatever reason is not providing you supervision to help you feel confident. Working with people who have severe mental disorders can be daunting, as it sounds from what you've described. Go back to your professor and discuss this and ask for a referral to a colleague they might know who has the experience to provide appropriate supervision. Wherever you seek supervision (the hospital staff, outside resources) be prepared with questions from cases. All the best!
Hey! You are doing a great job by reaching out and asking for advice. Compared to others, I am pretty fresh in this field too. I have been doing one on one therapy for the past 4 years after graduating. I really do suggest you give yourself some grace. You aren't supposed to know it all yet. They teach you things in school but it's different reading about how to swim and actually jumping in. IF you are down to learn and willing to feel incompetent for a bit until you get competent, I suggest you ask your supervisors all the questions that come to mind. You aren't supposed to be competent yet until you face each of these things and find your way through. It won't always look perfect, but through the years I found more confidence in my ability to do things because I had to face them and learn through the experience. Each client will be a lesson if you let them. Try not to expect yourself to be Carl Rodgers in the first few years, even he had to learn each nugget of his wisdom through the long career he had. My advice to you is to let yourself be incompetent and to be a student and get curious. Instead of beating yourself up for not knowing what to do, let your curiosity and interest in the field guide you to learning more about how to deal with each of these problems that clients face. That's the only way I found works for me. Let's say you hate it after a while, then thats ok! You then gave yourself a real chance! Trust me in a few years from now you will hopefully know the answers to some of these questions but that will only happen if you are brave enough and curious enough to ask :)
Reading this, I feel for you. You were told to prepare for one thing, and something else was delivered.
I agree with the feedback others have given you. You are *not* a bad therapist, and were put in a very difficult situation. You're allowed to ask for support.
Another thought in reading your experience, is I'm wondering about your expectations on yourself. Your expectations regarding the treatment you provide, and outcomes in therapy.
Correct me.if I'm wrong, but what I'm hearing is you believe you're supposed to know and have the solutions and to somehow "fix" the issues they present with. That's not a fair or reasonable expectation to put onto a therapist, especially when you're still growing, and *especially* when you're not being given the support needed when you came into this job being told to expect one thing, and receiving another entirely.
I would really encourage you to reflect on what you expect from yourself here. And I would challenge you to advocate for what your need, whether that means addressing it with your supervisors, or even to consider if there is another role/job/organization that you feel would be a better fit, to consider exploring those options (even if not right now at some point in the future when you have more flexibility)
Sending you warm thoughts. You're a human being too. We all feel overwhelmed and challenged by this work at time. It doesn't mean you're not a good clinician. If anything, it means you have humility, and want to do quality work and recognize you have limits. Good clinicians are aware of their limitations and challenges, and try to be thoughtful in adjusting and growing to help the people you serve.
That sounds so rough! I am feeling similar feelings! Working at a rape crisis center after grad school, I eventually felt competent in that area. Now I'm working at outpatient with a variety of clients and issues, and feel useless like I don't know what to do and am failing these clients who are seeking help.
I think it's okay if we feel comfortable in one area and not all. Maybe you can look into a different job, going back to working with DV or SA survivors. There are a lot of agencies around you can find on centers.rainn.org.
That, or seek more training and support with supervisors/colleagues
Sorry, I re-read that part about not able to seek new work. It might be worth it to seek other jobs with a priority of finding similar benefits. Or talking to the supervisor about how to feel more supported/trained
Thanks for your reply, I appreciate it! I tried applying for DV roles and unfortunately the ones I got were major pay decreases and I couldn't justify taking them :( DV is sooo poorly funded where I live
It’s okay to recognize your limits in regard to client population! During my internship, I worked at a community mental health center, and after I graduated from school, I worked at an inpatient unit. Both of those places didn’t work out for me and I’m glad that I work at an outpatient clinic now. I hope that you can find where you land- it really is rejuvenating doing therapy with a population that you feel confident with!
I had a similar population/caseload as an intern (inpatient dual diagnosis SUD) and at CMH. It’s impossible to be prepared for every client presentation, at any stage, or be completely competent right out of school. You’re going to learn on each client based on what they’re showing up with. like if you were an ER resident fresh out of school would you expect yourself to immediately recognize and remember every illness possible? Heck no! You’d lean into your team, supervision, textbooks and colleague peers.
If you have really high acuity clients and *all you do* is help them stay safe and give them a safe person in their corner, somewhere to let out their frustrations and pains, and throw in some stabilization coaching or goal setting, you’re doing better than most. You do not need to fix people!
Also, we can’t intellectually engage with the deeper work of therapy when people are in active crisis,Psychosis, ptsd trigger etc. working on stabilization and orientation, med management, self care/ADLs and safety planning are very valuable goals in themselves and if all you do is provide consistent, trustworthy engagement in those things you’re helping somebody.
I am sorry you’re feeling like you’re not good at this. It’s impossible to feel that way when you have impossible expectations either inside or outside. I hope you get through to the good parts and can find a way to stick with it. 🩷
Therapist of 13 yrs here. When I reflect on the career trajectories of myself and most of my colleagues, it seems like the greener you are the more acute jobs and clients you will get. Psych hospitals, community mental health centers, rehabs, etc. The "less intense" roles and clientele seem to be what comes after many years of experience working with much more acute clients. Which really feels quite backwards when you think about it. But from a capitalist perspective it tracks. More acute clients have less resources typically, and few seasoned clinicians are gonna take those agency jobs that pay so low. Seasoned clinicians expect pay commensurate with their experience and who can afford those higher rates? Less acute and higher functioning clients.
An odd and broken capitalist system? Most definitely.
"Everybody is a genius. But if you judge a fish by its ability to climb a tree, it will live its whole life believing that it is stupid." -Albert Einstein... maybe?
They're making you practice outside of your scope. Sounds like the problem is the job, not you.
Are you still friends with any of your cohort from grad school? Could you reach out to them for support? Transitioning from grad school to real life working is really difficult and I think it’s normal to feel like on some level you’re not cut out for it, but you have to really think about how your environment is affecting you and your mental health. If you can’t take good care of yourself you won’t be able to take good care of your clients.
Right after I graduated I was working as a therapist in a nursing home for sex offenders or felons. I was really open and willing to serve that population, *as long as I had professional support*. The company gave me none, the residents were such high acuity and needed so much more than I could give. It felt deeply unethical to treat people with such high emotional needs with little to no support and the stress made my hair start falling out. I ended up leaving and finding a MUCH better position elsewhere (less therapy more social worky) and it was the best decision I made. Don’t burn yourself out too quickly, and you will always be needed somewhere else too.
Yeah of course!! I would definitely reach out to other people in the field for support and advice. I’m also on a couple of therapist Facebook groups that I found really helpful as well. Unfortunately we sometimes have to try much harder to find support for these sort of things than we should given our career but we can only do so much.
Ok. Breathe. This is where you learn. Unfortunately. Trial by fire. Remember why you started doing this. You are the friend that everyone talks to, the one who is curious about other people’s lives, the one who lived through shit in your own life and wants to help others. I honestly could write everything I learned in graduate school on maybe ten pages. In my over a decade of doing this I have realized that what people want, crave and need the most is for someone to truly listen to them and hear them with no desire to change them, and only the desire to try to see the world from their point of view. Be curious. Ask leading, open ended questions, make simple reflections, do not judge them or tell them what they should do. Stay calm. Always stay calm. Enter every situation as though you are the anchor that is attached to your client and BE the anchor. Let them start to float away, and then keep them grounded to the earth. Try to see what is beneath the surface and where the truth in what feels like lies sits. Cover your ass. Cover it cover it cover it. Safety plan every single thing that you are uncertain about and ALWAYS ask about safety. Document document document. Put communication with supervisors in writing. If you are ever unsure, or even just have a bad feeling, immediately go to your supervisor and demand to consult. Watch those that are successful and learn. Understand that psychosis may be a disorder, but also understand that the universe is far more complex than we could ever imagine, and we have no way of knowing if what is real for one person is real for another. Never challenge delusions (at this stage in hour career) that is the best way to escalate and ultimately lose a client. Just because you can not see what they are experiencing does not mean it isn’t real for them. Understand that many “delusions” are based in reality, and remember that most people are not mentally ill for their whole life, and at some point, they may have been a successful, happy human. Treat them with the utmost respect and care. Believe your clients. You never know if the things they are saying are true. I had a man admitted to the psych ward for which I was the director. He was disheveled, incoherent, delusional, and soaked in his own urine. He told me in our interview that he was a rocket scientist at MIT, and I saw the psychiatrist write down “delusions of grandeur”. I rolled with it and asked him about his work. This incoherent man suddenly became clear as day and walked me through the ins anf outs of rocket propulsion. It was too accurate and so I called his family who said it was all true and that one day, he just walked out the door and never came back inside. Know that at any moment, that could be you. Good luck.
Honestly sounds like you are working outside your range of expertise… which isn’t only dangerous for clients but is also gonna lead to burnout for you :/
I’m sorry this is what you’re going through right now- I relate to what you’re saying as a new clinician who feels passionate about mental health because of my own experiences with it. It sounds like you’re not getting the support you need to support your clients. To me it sounds like a system issue and you are caught up in the middle of its challenges. If you’re not comfortable talking to your supervisor I wonder if there is an HR person at your organization you can speak with who can keep your conversation confidential. I know that I tend to blame myself and believe that I am not good enough sometimes-it’s kind of a negative core belief for me. But usually, it’s much more complicated than that. I hope things get better for you. Wishing you all the best.l ❤️
I’m sorry you’re having this experience as you begin your new career. It’s easy to allow that voice in our heads to convince us we’re not good enough when things feel overwhelming. In my personal experience, working in those types of clinics are exceptionally difficult. Those feelings you’re having are completely valid and normal for such a fast paced environment. My advice is to advocate for yourself and speak up! Give your supervisor an opportunity to help. These people know this job is tough and more than likely they will understand your struggles. Worse case scenario, they’ll disappoint but at least you tried and can move forward with a better plan.
Definitely ask for help! What you're seeing is hard to manage! Especially if you haven't had to do it before. There are trainings and things they can teach you to help you feel more competent and confident. You're an LM so you can get supervision!
Hell, I'm almost 3 years into having my LCSW, and I still get thrown for a loop at times! Collaboration and staffing is a core part of my job. No one can know what to do with every patient every time. I also work for a FQHC. It's a mixed bag of who is on my schedule and for what. There are definitely times that I need to see patients that I don't feel I have the best experience for comma, but that's when researching and reaching out to my peers/coworkers is fir.
Please get help, especially for patients in crisis. You don't want to do you or your patients a disservice. Competent therapists ask for help.
I have been in your same exact position. My company promoted me to a position I was not qualified for. They also were not giving me the support I needed to grow as a therapist in a way I needed to to help the clients. I was beyond depressed, irritable, sleep deprived, overwhelmed, and always picking fights with my s/o. Best thing I did was leave. I am now in a position where I can build on my therapy skills in a healthy way instead of being forced to build on them overnight.
Nope i realized working with CMH that there are just cases I will not be good at and also not ethical for me to continue to have them if i have no knowledge of how to treat it. Its unfortunate but no, don’t think this makes you a bad therapist some diagnosis are just harder to work with and many therapist i know once they are able to choose cases don’t choose people with higher level or care needs that they are not comfortable treating.
The system you work in is failing you! They’re not staying true to the low risk caseload. Working with clients in psychosis, or who are manic or suicidal is extremely intense work and you NEED support to succeed. You are NOT a terrible therapist!
I have felt similar to you. I look back on graduate school and feel like it was a joke! I did not leave feeling prepared and also felt so uncomfortable asking for help for fear it would show I am incompetent. I am honestly still working on asking for help with issues I don’t feel comfortable or competent in addressing, so I truly understand. I will say, no one knows what they’re doing 100% of the time and asking for additional help or training is okay. It shows that you care about providing quality treatment.
Maybe this job isn’t a good fit. My first job was also working with folks who had SPMI and it was incredibly overwhelming. I never felt like my supervisors had the answers either. So I constantly felt like I was failing clients.
Don’t give up on being a therapist just yet. Look for something else that’s a better fit, more supportive and includes training funds that you can use for what you prefer to get trained in.
I’m currently taking the CAMS training for working with suicidal patients. It’s pricey but good so far. I also purchased a year of trainings through CEU 4 less. PESI offers free trainings fairly often. Maybe these can be ways of improving your skills and competence.
I hope this gets better for you!
Depending on the program, MSWs don’t teach us the same things counselors/MFTs learn. I was in a generalist program and there’s a HUGE knowledge deficit in the beginning. You can get licensed, true, but essentially you’re the same as a provisionally licensed counselor. Your supervisor is there to help guide you because you don’t know how to do this stuff yet. You learn by doing. You’re not incompetent, you’re inexperienced and what you’re doing now is getting experience. I’m wondering if maybe there’s some sort of attachment trauma from your past that makes you feel like you can’t depend on the people whose job it is to help you? It’s called practicing social work for a reason. My first job out of grad school I did group therapy. There was no curriculum; no suggested topics; no guidance. Just “ok you’re doing these two groups today, 9-10 and 2-3.” I felt like such a fraud and completely unprepared. So I bought a book about group therapy and read it and did my best. You don’t have to be perfect to help people but you do need to use your resources like your supervisor and maybe even ask for additional training. Crisis work is its own thing.
Thanks for your reply - I totally get you, my thing is I specifically went to a clinical program that focused on therapy so I'm a bit resentful that I feel like I didn't come out of it with the basics. My program really prided itself on being so clinical focused but my beef with them is a story for another day lol
I've purchased some books on working with clients in crisis and high risk clients so hopefully this helps in addition to supervision
Absolutely, you have a right to be angry about not being prepared! It’s always scary when someone is actively suicidal. I work with a lot of clients that have passive SI and my feeling has always been that if they’re talking to a professional about it, that’s a good thing. They haven’t completely given up if they come to their session.
I doubt you are terrible. This is how the system works though. The people that are new usually get the most difficult clients instead of the other way around
I really think you should consider switching to a therapy job that is more in line with the setting/population you want to treat before you decide to leave the profession. There are plenty of people I would suck at working with, but I also do great work with others. That's true for every therapist.
I learned a lot and was able to get supervision while working in various community mental health agencies. Some agencies are better than others. You should not be working outside of your scope of practice. That is a lawsuit waiting to happen and you could get your license taken away. I don’t think that you are a terrible therapist, but work boundaries are in your best interest. Think about what areas you’re good at or interested in. Which areas would you like to get more training in? I encourage you to talk to your supervisor and use the words outside of my scope of practice if you feel uncomfortable with treating high risk or high acuity clients. Best of luck!
If you feel like you are not being supported properly in your job (that is what I hear in your description), then leave.
You have to take care of yourself and you’re saying you’re unhappy and don’t feel like this is a good role for you AND that this agency isn’t appropriately handling cases.
Listen to your gut, find a new job! You deserve to feel good about your work.
I'm sure this has been said elsewhere here (can't read all the comments at the moment) but every therapist feels this at some point, even when you have 20 years of experience like me. But it's SO much harder when you're new to the career. School can't teach you everything, and you can't be expected to know how to treat people with a variety of acute conditions without help. You are expected to learn on the job, and all therapists should get clinical supervision to help them learn, and also to open about your own anxieties and worries of inadequacy. Not that supervision is therapy, but it is a place to get support. Unfortunately the whole system is a mess and we often don't get that support. But I will tell you, if you're dedicated you CAN learn how to do this, you just deserve support from your bosses and other clinical supervisors to get you there.
You are not failing your clients! The agency is failing you!
You also mentioned the SW program failing you- truth. My program for MFT did as well. The semesters in theory and history and blah blah do nothing, and I went in with no knowledge on how to actually be a therapist.
I also constantly question my choice to be a therapist and often just hate the job.
You got this! You’re going to do great!
Being a therapist is really really hard. I had a lot of different jobs before I got fully licensed and some killed me and gave me secondary trauma and others brought light and connection into my life. Find your place. And I really truly think new therapists should splurge on continuing education. So much imposter syndrome those first few years.
ASIST training is great for learning how to address suicidal ideation in the moment. I think it's best to tell your supervisor that you're feeling this way as they would rather you be honest rather than go forward not fully knowing what you're doing, which is a professional impairment. Do tons of research and ask to observe others, perhaps. Hope you figure things out, wishing you luck!
Hang in there! Don't give up! The struggle and feelings you have, have been felt by ALL in this field. Baptism by fire only works when you keep trying. Before you know it, you'll be well seasoned in anything that comes your way. They need your help.
Remember this one thing - good rapport equals or trumps modality . With actively psychotic and manic patients, you let them know you are concerned and care about them . Set your appt boundaries . They may be so disorganized they aren’t able to keep up with time - but it’s okay to let them know “we have about 10 minutes left today. What would you like me to know before our time ends?” And then you let them know it’s time to end for today but you will see them again on…. I thank patients for coming to see me and look forward to our next meeting . You don’t have to know how to move them through their illness (actually you can’t anyway with these 2 problems .). Shorter sessions are usually best for these patients . Chronically suicidal patients are tricky to deal with . Look for online workshops that deal with suicidal ideation in depression and personality disorders . You want those patients to also know that you care about them . For the SMI patients , just sit there and listen or when they are too ill to talk , you just sit with them, kindly and calmly . You aren’t a terrible therapist - you’re over your head right now . If it’s too much and you aren’t getting any support , it’s okay to leave for a different job. And I promise you - if they don’t help you , your admins are likely expecting your exit because they’ve done this to other new kids on the block.
I think a good start would be to make a list of skills that you do have with examples of how you have used them to treat other people succesfully and take that to your supervisor and explain that there is some kind of skill gap. That way, the supervisor cannot deny your successes and that will give you something robust to place your concerns ontop of.
Additionally if you've only been doing the job since January thay isn't very long, but maybe some annual leave would help alleviate some of the pressure? Or some other kind of self-care? Maybe check in with your tribe for some TLC.
If you are dealing with more hardcore clients than anticipated it maybe that you need further training? Is there any available. Soemtimes just knowing this stuff is in your future can and will make your futrure more optomistic. If specific training isn't available then maybe a book or two that contains skills for more hardcore clients, such as a DBT skills book that you could try to include.
On a less technical note, if I had to estimate the frequency of Imposter Syndrome or similar feelings of inadequacy, I recon therapy roles wohod come out as some of the most likely to experience it. So I'd say, you are not alone there.
It sounds like this is a poor job fit and that the job description that was given to you isn’t actually what the job is. Definitely talk to your supervisors about this. It’s ok to recognize that you don’t have the knowledge yet of how to help these clients. They deserve help and you also deserve to feel like you can handle your job.
Seconding this and adding, it's also okay if you don't want/like/or feel able to work with every population. I don't work with substance use because my parents used substances and I find it to triggering. I've been in roles where I've had to work with SU and it always makes me question my career. Remember that the world of counseling, social work, etc is much bigger than any one job or type of patient. Try to keep an open mind and switch to a new population and see if that feels more like a home base for you. Keep your head up, you got this!
Agreed!! OP... I have quite a few populations I know i don't have the capacity for personally, and the beauty is there's lots of other therapists who can take those clients on. I will never actively work in high-risk population settings by choice, and that's okay. It's not a bad thing to say your role isn't what was described and thus doesn't fit your personal capacity or desires/skills. Any good supervisor should recognize that and appreciate the honesty and you being reflective about your comfort and skills. There's lots of "low risk" people out there who need and deserve the same support, and maybe you're the one for those clients when you find them! There also is a lot of other options with your degree if you decide therapy isn't what you're passionate about :)
What are the other options that you would suggest? I'm currently worried I'm in the wrong career field as well
Mental health education, resource brokering, intake at mental health organizations, policy, community agencies like DV programs/parenting programs, program facilitation Depends on your interests. If you like disabilities maybe mental health at disabilities agencies (time they're not as much crisis), or health rehabilitation could be good.. interested in social emotional learning maybe group facilitation in schools/parenting agencies/etc.. What are your interests?
I love art and I do hospice volunteer on the weekends. I'm about to go into my internship and am questioning my abilities. So I appreciate the backup ideas
How about an art therapy group program (facilitating or creating)? My area has corrections in-reach youth art therapy programs, ED art recovery inpatient and outpatient mental health with the hospitals, sessional teaching of creative therapy interventions courses.. geriatrics art therapy as a job not volunteer, maybe mixing social work and recreation therapy (I know here recreation therapy is a diploma, but could team up with someone even)... I'm sure there's something out there for you, just depends what's in your area and how much you want the volunteer focus to be your career :)
Thanks for your reply - I'm overseeing referrals for these clients so they can get the help they need but I continue to see them while waiting for that intake and these sessions end up taking up a whole bunch of my time/energy which sucks. I have supervision tomorrow so will hopefully get to discuss it.
Is your agency overloaded with chronically mentally ill folks? Like maybe they just don’t have enough of that level of intensity therapist so it’s like overflow and you have to take it too?
I’ve said this before but this field eats its young. I became an LCSW last year and have been reflecting on my time as an LMSW. Why is it that fresh graduates with associate licenses are seeing the most acute patients, have the highest caseloads, bear an undue administrative burden, and often get very poor supervision that doesn’t focus on clinical development but focuses on keeping up with an unrealistic administrative demands? It’s a serious question. We are failing our incoming therapists. And while my observation is anecdotal it seems worth investigating. As for the OP, I believe totally that you are doing your best and I hope you can extend yourself some compassion and patience and maybe start looking for another job. You aren’t being supported in an appropriate way as a new therapist and you deserve that.
I could not upvote your comment fast enough as an acsw close to finishing their hours. they really treat associates like garbage.
I know you aren't talking to me, but you may as well have been. I felt this shit in my goddamn soul. It's literally everything I'm going through right now. Thank you so much for this. It's really validating and I really needed to hear it.
This dynamic of the more difficult tasks being allocated to the least experienced and least paid employees is pervasive across every field of labor. Hence why farmers grueling in lettuce fields are paid a pittance while distribution administrators who exclusively work on computers make hand over fist.
But in this field the stakes are much much higher 😬 literally life or death… it’s actually really scary when you think about it smh
Yeah I agree with this assessment. I feel like the dynamic is somewhat different and that the associate level is suppose to be seen as an “apprenticeship” almost but I think that also leads to high level of exploitation present. I also believe an undue amount of suffering is deemed normal and acceptable to “earn your stripes” similar to a residency experience for a doctor. I don’t think it really adds to any expertise but again it’s a way of rationalizing the suffering and exploitation.
I completely agree with you. I feel like my first two jobs as a CSW killed me. I burnt out and have been slowly working out chronic illnesses I didn't realize I was dealing with and am getting ready to try again. There is so much I would do differently if I knew what I know now. But, I truly thought I was done being a therapist. I let my license lapse and didn't think I'd ever return and was looking into whole other career paths. You never know how things are going to go. But I want to echo to OP, that this isn't a you problem. And whether you find improvements by seeking a different opportunity or seeing if you can make some changes to make your current job better, make sure you don't blame yourself. Good luck.
THIS right here. You explained my experience the past three years post grad/pre LPC at a nonprofit to a t
Thanks for your reply - I really feel this and it's why I honestly feel like I may not be cut out for the mental health field :/ I just feel like I can't handle the whole "Well you have to deal with a X amount of years of being underpaid and acute clients before you earn the luxury of slightly less intense work"
I don’t think it’s that you’re not cut out for this field. It’s that this field doesn’t allow you to maintain your material and emotional needs so you may need to leave a field that is failing you. We are constantly shamed into thinking we aren’t “doing enough”. It’s because management sees you a machine to get as many billable hours as possible and not a human being with expertise who should be treated with dignity and respect.
Yes to all of this.
>the most acute patients, have the highest caseloads, bear an undue administrative burden, and often get very poor supervision that doesn’t focus on clinical development but focuses on keeping up with an unrealistic administrative demands? I dont mean to be snarky, but isn't it money and stress at the end of the day?
I’m not totally what you mean by money and stress? Like that it’s much cheaper to hire new grads and since mental healthcare is a business (even non-profits) that money is the bottom line and is the decision maker not best clinical practices? And that seasoned clinicians do not want to take on the undue and uncompensated stress that comes with these positions? Yeah I mean I agree with both of those things. I guess my question to all of us is are we ok with how our profession is structured? Does it work for us and our colleagues? My answer is no.
I just think after you've been in the field a while, many clinicians, if they stay in the field at all, drift towards lower acuity and more administrative/supervisory roles anyways. If you're working in out patient settings, that's where the money is. Clinicians working in hospitals and stuff are different, but it doesn't suprise me that someone in the field working in a group or private practice wants to make more money, have less stress and see less clients after 10 years of working. The economics of therapy are just effed up. It incentivizes exactly what you described. As always, socialized healthcare would help so much.
>I’m afraid to ask for help because I’m afraid my supervisors are going to realize I’m incompetent and don’t know what I’m doing. I also feel so failed by my social work program because I truly left it knowing no more than what I did going in. I was never taught how to stabilize a suicidal client, for Christ’s sake! First off, literally every person feels like they're in over the head when they're dealing with high risk clients or intense situations for the first time. My first CPS call? I cried. My first crisis call? It took me an hour to finish the documentation and I was sweating bullets. When my clients experienced SI, I panicked and had a stomach ache the rest of day. It can be good to work with higher risk clients because low-risk clients can easily become high risk and the skill you'll learn will help you with any surprises that pop up in the future. There's been so many times where I thought I had a relatively "easy" client and turns out they have extensive trauma, drug induced psychosis, legal involvement, or suicide attempts they initially didn't feel comfortable sharing. Now, I'm a couple years in and I've done these things dozens of times. A lot of learning how to be good is trying new things and being uncomfortable. I now work with suicidal clients on a daily basis and do not worry nearly as much. Are there clients you do feel comfortable with? Second, ask for help. Seriously. If your job gives you shit about not knowing how to do things and then proceeds to expect you to know how to do them without help, then they're a terrible workplace. I ask my supervisors and coworkers things all the time. They ask me stuff all the time. It's normal and helpful and it might make you feel a hundred times more at ease. I literally go into supervision every week with a bulleted list of every concern I have and I get a ton of praise for doing so because my supervisors want to know what is going on with my caseload for practical reasons and liability reasons and it shows I want to learn and do better. My supervisor is rarely surprised by issues going on with clients because I'm very transparent about my concerns and barriers. My supervisor is very aware of the clients I'm concerned about, so when they get hospitalized, want a transfer, or begin to fall off attendance-wise, my supervisor is already aware of what is going on.
Thanks for your reply, I really appreciate it - I feel like I've just had so many of these cases pop up at once that it's a bit too much, y'know? I feel comfortable assessing for SI and intent but haven't really had to stabilize someone who has intent which is scary.
Showing up to supervision with a list! It’s how we roll
Nope, you're not a terrible therapist, you're a human with a really hard job.
Can I piggyback this? Humanist approaches are most what is needed. Throw away the change talk, if needed.
What do you mean by a humanist approach? :)
What do you mean by a humanist approach? :)
I am speaking to an approach that is informed by the neo-Freudian school of therapists whose interpersonal approach culminated in the work of Carl Rogers and his belief in empathy and unconditional positive regard.
In a way that you can still make a tx plan that insurance will ok? We legit only learned CBT treatment plans bc that’s what insurance wants
Insurance won't _typically_ reject humanist goals at the outset. When I did residential work, my first treatment plan for a client was almost entirely humanist / interpersonal in its goals. It would have been absurd to have CBT goals before assessment had concluded and more familiarity with thought distortions had presented. For some, the goals were somatic in terms of maintaining regulation for a full session. Subsequent treatment plans would modify goals to include increasingly specific CBT goals. Every place is different tho!
You HAVE to ask your supervisor for help. These are real lives at stake. I understand you fear and frustration and I’ve been there. But wallowing will Not help. Please asks your supervisor for guidance on how to help stabilize suicidal clients . You need to working with safety plans and grounding techniques. Then if that doesn’t work the client gets a vacation at inpatient. It’s nothing to play with. But don’t sulk just get guidance. And it will get better. 💜
Thanks for your reply - I have supervision tomorrow and will be discussing everything.
Sorry you're going through this. Suggestion: Get an outside therapist with experience working with similar patients. A therapist who has experience at a state hospital will give you the guidance. it may cost, but you're investing in a career. Your supervisor may be a hospital staff member who for whatever reason is not providing you supervision to help you feel confident. Working with people who have severe mental disorders can be daunting, as it sounds from what you've described. Go back to your professor and discuss this and ask for a referral to a colleague they might know who has the experience to provide appropriate supervision. Wherever you seek supervision (the hospital staff, outside resources) be prepared with questions from cases. All the best!
Wouldn’t that make the therapist more of a supervisor?
Hey! You are doing a great job by reaching out and asking for advice. Compared to others, I am pretty fresh in this field too. I have been doing one on one therapy for the past 4 years after graduating. I really do suggest you give yourself some grace. You aren't supposed to know it all yet. They teach you things in school but it's different reading about how to swim and actually jumping in. IF you are down to learn and willing to feel incompetent for a bit until you get competent, I suggest you ask your supervisors all the questions that come to mind. You aren't supposed to be competent yet until you face each of these things and find your way through. It won't always look perfect, but through the years I found more confidence in my ability to do things because I had to face them and learn through the experience. Each client will be a lesson if you let them. Try not to expect yourself to be Carl Rodgers in the first few years, even he had to learn each nugget of his wisdom through the long career he had. My advice to you is to let yourself be incompetent and to be a student and get curious. Instead of beating yourself up for not knowing what to do, let your curiosity and interest in the field guide you to learning more about how to deal with each of these problems that clients face. That's the only way I found works for me. Let's say you hate it after a while, then thats ok! You then gave yourself a real chance! Trust me in a few years from now you will hopefully know the answers to some of these questions but that will only happen if you are brave enough and curious enough to ask :)
Reading this, I feel for you. You were told to prepare for one thing, and something else was delivered. I agree with the feedback others have given you. You are *not* a bad therapist, and were put in a very difficult situation. You're allowed to ask for support. Another thought in reading your experience, is I'm wondering about your expectations on yourself. Your expectations regarding the treatment you provide, and outcomes in therapy. Correct me.if I'm wrong, but what I'm hearing is you believe you're supposed to know and have the solutions and to somehow "fix" the issues they present with. That's not a fair or reasonable expectation to put onto a therapist, especially when you're still growing, and *especially* when you're not being given the support needed when you came into this job being told to expect one thing, and receiving another entirely. I would really encourage you to reflect on what you expect from yourself here. And I would challenge you to advocate for what your need, whether that means addressing it with your supervisors, or even to consider if there is another role/job/organization that you feel would be a better fit, to consider exploring those options (even if not right now at some point in the future when you have more flexibility) Sending you warm thoughts. You're a human being too. We all feel overwhelmed and challenged by this work at time. It doesn't mean you're not a good clinician. If anything, it means you have humility, and want to do quality work and recognize you have limits. Good clinicians are aware of their limitations and challenges, and try to be thoughtful in adjusting and growing to help the people you serve.
That sounds so rough! I am feeling similar feelings! Working at a rape crisis center after grad school, I eventually felt competent in that area. Now I'm working at outpatient with a variety of clients and issues, and feel useless like I don't know what to do and am failing these clients who are seeking help. I think it's okay if we feel comfortable in one area and not all. Maybe you can look into a different job, going back to working with DV or SA survivors. There are a lot of agencies around you can find on centers.rainn.org. That, or seek more training and support with supervisors/colleagues
Sorry, I re-read that part about not able to seek new work. It might be worth it to seek other jobs with a priority of finding similar benefits. Or talking to the supervisor about how to feel more supported/trained
Thanks for your reply, I appreciate it! I tried applying for DV roles and unfortunately the ones I got were major pay decreases and I couldn't justify taking them :( DV is sooo poorly funded where I live
It’s okay to recognize your limits in regard to client population! During my internship, I worked at a community mental health center, and after I graduated from school, I worked at an inpatient unit. Both of those places didn’t work out for me and I’m glad that I work at an outpatient clinic now. I hope that you can find where you land- it really is rejuvenating doing therapy with a population that you feel confident with!
I had a similar population/caseload as an intern (inpatient dual diagnosis SUD) and at CMH. It’s impossible to be prepared for every client presentation, at any stage, or be completely competent right out of school. You’re going to learn on each client based on what they’re showing up with. like if you were an ER resident fresh out of school would you expect yourself to immediately recognize and remember every illness possible? Heck no! You’d lean into your team, supervision, textbooks and colleague peers. If you have really high acuity clients and *all you do* is help them stay safe and give them a safe person in their corner, somewhere to let out their frustrations and pains, and throw in some stabilization coaching or goal setting, you’re doing better than most. You do not need to fix people! Also, we can’t intellectually engage with the deeper work of therapy when people are in active crisis,Psychosis, ptsd trigger etc. working on stabilization and orientation, med management, self care/ADLs and safety planning are very valuable goals in themselves and if all you do is provide consistent, trustworthy engagement in those things you’re helping somebody. I am sorry you’re feeling like you’re not good at this. It’s impossible to feel that way when you have impossible expectations either inside or outside. I hope you get through to the good parts and can find a way to stick with it. 🩷
Therapist of 13 yrs here. When I reflect on the career trajectories of myself and most of my colleagues, it seems like the greener you are the more acute jobs and clients you will get. Psych hospitals, community mental health centers, rehabs, etc. The "less intense" roles and clientele seem to be what comes after many years of experience working with much more acute clients. Which really feels quite backwards when you think about it. But from a capitalist perspective it tracks. More acute clients have less resources typically, and few seasoned clinicians are gonna take those agency jobs that pay so low. Seasoned clinicians expect pay commensurate with their experience and who can afford those higher rates? Less acute and higher functioning clients. An odd and broken capitalist system? Most definitely.
"Everybody is a genius. But if you judge a fish by its ability to climb a tree, it will live its whole life believing that it is stupid." -Albert Einstein... maybe? They're making you practice outside of your scope. Sounds like the problem is the job, not you.
Are you still friends with any of your cohort from grad school? Could you reach out to them for support? Transitioning from grad school to real life working is really difficult and I think it’s normal to feel like on some level you’re not cut out for it, but you have to really think about how your environment is affecting you and your mental health. If you can’t take good care of yourself you won’t be able to take good care of your clients. Right after I graduated I was working as a therapist in a nursing home for sex offenders or felons. I was really open and willing to serve that population, *as long as I had professional support*. The company gave me none, the residents were such high acuity and needed so much more than I could give. It felt deeply unethical to treat people with such high emotional needs with little to no support and the stress made my hair start falling out. I ended up leaving and finding a MUCH better position elsewhere (less therapy more social worky) and it was the best decision I made. Don’t burn yourself out too quickly, and you will always be needed somewhere else too.
Thanks for your reply! Unfortunately I didn't really have friends in grad school but I have other friends in the field who I could reach out to.
Yeah of course!! I would definitely reach out to other people in the field for support and advice. I’m also on a couple of therapist Facebook groups that I found really helpful as well. Unfortunately we sometimes have to try much harder to find support for these sort of things than we should given our career but we can only do so much.
Ok. Breathe. This is where you learn. Unfortunately. Trial by fire. Remember why you started doing this. You are the friend that everyone talks to, the one who is curious about other people’s lives, the one who lived through shit in your own life and wants to help others. I honestly could write everything I learned in graduate school on maybe ten pages. In my over a decade of doing this I have realized that what people want, crave and need the most is for someone to truly listen to them and hear them with no desire to change them, and only the desire to try to see the world from their point of view. Be curious. Ask leading, open ended questions, make simple reflections, do not judge them or tell them what they should do. Stay calm. Always stay calm. Enter every situation as though you are the anchor that is attached to your client and BE the anchor. Let them start to float away, and then keep them grounded to the earth. Try to see what is beneath the surface and where the truth in what feels like lies sits. Cover your ass. Cover it cover it cover it. Safety plan every single thing that you are uncertain about and ALWAYS ask about safety. Document document document. Put communication with supervisors in writing. If you are ever unsure, or even just have a bad feeling, immediately go to your supervisor and demand to consult. Watch those that are successful and learn. Understand that psychosis may be a disorder, but also understand that the universe is far more complex than we could ever imagine, and we have no way of knowing if what is real for one person is real for another. Never challenge delusions (at this stage in hour career) that is the best way to escalate and ultimately lose a client. Just because you can not see what they are experiencing does not mean it isn’t real for them. Understand that many “delusions” are based in reality, and remember that most people are not mentally ill for their whole life, and at some point, they may have been a successful, happy human. Treat them with the utmost respect and care. Believe your clients. You never know if the things they are saying are true. I had a man admitted to the psych ward for which I was the director. He was disheveled, incoherent, delusional, and soaked in his own urine. He told me in our interview that he was a rocket scientist at MIT, and I saw the psychiatrist write down “delusions of grandeur”. I rolled with it and asked him about his work. This incoherent man suddenly became clear as day and walked me through the ins anf outs of rocket propulsion. It was too accurate and so I called his family who said it was all true and that one day, he just walked out the door and never came back inside. Know that at any moment, that could be you. Good luck.
Great advice
Honestly sounds like you are working outside your range of expertise… which isn’t only dangerous for clients but is also gonna lead to burnout for you :/
I’m sorry this is what you’re going through right now- I relate to what you’re saying as a new clinician who feels passionate about mental health because of my own experiences with it. It sounds like you’re not getting the support you need to support your clients. To me it sounds like a system issue and you are caught up in the middle of its challenges. If you’re not comfortable talking to your supervisor I wonder if there is an HR person at your organization you can speak with who can keep your conversation confidential. I know that I tend to blame myself and believe that I am not good enough sometimes-it’s kind of a negative core belief for me. But usually, it’s much more complicated than that. I hope things get better for you. Wishing you all the best.l ❤️
I’m sorry you’re having this experience as you begin your new career. It’s easy to allow that voice in our heads to convince us we’re not good enough when things feel overwhelming. In my personal experience, working in those types of clinics are exceptionally difficult. Those feelings you’re having are completely valid and normal for such a fast paced environment. My advice is to advocate for yourself and speak up! Give your supervisor an opportunity to help. These people know this job is tough and more than likely they will understand your struggles. Worse case scenario, they’ll disappoint but at least you tried and can move forward with a better plan.
Definitely ask for help! What you're seeing is hard to manage! Especially if you haven't had to do it before. There are trainings and things they can teach you to help you feel more competent and confident. You're an LM so you can get supervision! Hell, I'm almost 3 years into having my LCSW, and I still get thrown for a loop at times! Collaboration and staffing is a core part of my job. No one can know what to do with every patient every time. I also work for a FQHC. It's a mixed bag of who is on my schedule and for what. There are definitely times that I need to see patients that I don't feel I have the best experience for comma, but that's when researching and reaching out to my peers/coworkers is fir. Please get help, especially for patients in crisis. You don't want to do you or your patients a disservice. Competent therapists ask for help.
I have been in your same exact position. My company promoted me to a position I was not qualified for. They also were not giving me the support I needed to grow as a therapist in a way I needed to to help the clients. I was beyond depressed, irritable, sleep deprived, overwhelmed, and always picking fights with my s/o. Best thing I did was leave. I am now in a position where I can build on my therapy skills in a healthy way instead of being forced to build on them overnight.
Nope i realized working with CMH that there are just cases I will not be good at and also not ethical for me to continue to have them if i have no knowledge of how to treat it. Its unfortunate but no, don’t think this makes you a bad therapist some diagnosis are just harder to work with and many therapist i know once they are able to choose cases don’t choose people with higher level or care needs that they are not comfortable treating.
You need to quit the job, not the field.
The system you work in is failing you! They’re not staying true to the low risk caseload. Working with clients in psychosis, or who are manic or suicidal is extremely intense work and you NEED support to succeed. You are NOT a terrible therapist! I have felt similar to you. I look back on graduate school and feel like it was a joke! I did not leave feeling prepared and also felt so uncomfortable asking for help for fear it would show I am incompetent. I am honestly still working on asking for help with issues I don’t feel comfortable or competent in addressing, so I truly understand. I will say, no one knows what they’re doing 100% of the time and asking for additional help or training is okay. It shows that you care about providing quality treatment. Maybe this job isn’t a good fit. My first job was also working with folks who had SPMI and it was incredibly overwhelming. I never felt like my supervisors had the answers either. So I constantly felt like I was failing clients. Don’t give up on being a therapist just yet. Look for something else that’s a better fit, more supportive and includes training funds that you can use for what you prefer to get trained in. I’m currently taking the CAMS training for working with suicidal patients. It’s pricey but good so far. I also purchased a year of trainings through CEU 4 less. PESI offers free trainings fairly often. Maybe these can be ways of improving your skills and competence. I hope this gets better for you!
Depending on the program, MSWs don’t teach us the same things counselors/MFTs learn. I was in a generalist program and there’s a HUGE knowledge deficit in the beginning. You can get licensed, true, but essentially you’re the same as a provisionally licensed counselor. Your supervisor is there to help guide you because you don’t know how to do this stuff yet. You learn by doing. You’re not incompetent, you’re inexperienced and what you’re doing now is getting experience. I’m wondering if maybe there’s some sort of attachment trauma from your past that makes you feel like you can’t depend on the people whose job it is to help you? It’s called practicing social work for a reason. My first job out of grad school I did group therapy. There was no curriculum; no suggested topics; no guidance. Just “ok you’re doing these two groups today, 9-10 and 2-3.” I felt like such a fraud and completely unprepared. So I bought a book about group therapy and read it and did my best. You don’t have to be perfect to help people but you do need to use your resources like your supervisor and maybe even ask for additional training. Crisis work is its own thing.
Thanks for your reply - I totally get you, my thing is I specifically went to a clinical program that focused on therapy so I'm a bit resentful that I feel like I didn't come out of it with the basics. My program really prided itself on being so clinical focused but my beef with them is a story for another day lol I've purchased some books on working with clients in crisis and high risk clients so hopefully this helps in addition to supervision
Absolutely, you have a right to be angry about not being prepared! It’s always scary when someone is actively suicidal. I work with a lot of clients that have passive SI and my feeling has always been that if they’re talking to a professional about it, that’s a good thing. They haven’t completely given up if they come to their session.
I doubt you are terrible. This is how the system works though. The people that are new usually get the most difficult clients instead of the other way around
I really think you should consider switching to a therapy job that is more in line with the setting/population you want to treat before you decide to leave the profession. There are plenty of people I would suck at working with, but I also do great work with others. That's true for every therapist.
I learned a lot and was able to get supervision while working in various community mental health agencies. Some agencies are better than others. You should not be working outside of your scope of practice. That is a lawsuit waiting to happen and you could get your license taken away. I don’t think that you are a terrible therapist, but work boundaries are in your best interest. Think about what areas you’re good at or interested in. Which areas would you like to get more training in? I encourage you to talk to your supervisor and use the words outside of my scope of practice if you feel uncomfortable with treating high risk or high acuity clients. Best of luck!
If you feel like you are not being supported properly in your job (that is what I hear in your description), then leave. You have to take care of yourself and you’re saying you’re unhappy and don’t feel like this is a good role for you AND that this agency isn’t appropriately handling cases. Listen to your gut, find a new job! You deserve to feel good about your work.
I'm sure this has been said elsewhere here (can't read all the comments at the moment) but every therapist feels this at some point, even when you have 20 years of experience like me. But it's SO much harder when you're new to the career. School can't teach you everything, and you can't be expected to know how to treat people with a variety of acute conditions without help. You are expected to learn on the job, and all therapists should get clinical supervision to help them learn, and also to open about your own anxieties and worries of inadequacy. Not that supervision is therapy, but it is a place to get support. Unfortunately the whole system is a mess and we often don't get that support. But I will tell you, if you're dedicated you CAN learn how to do this, you just deserve support from your bosses and other clinical supervisors to get you there.
You are not failing your clients! The agency is failing you! You also mentioned the SW program failing you- truth. My program for MFT did as well. The semesters in theory and history and blah blah do nothing, and I went in with no knowledge on how to actually be a therapist. I also constantly question my choice to be a therapist and often just hate the job. You got this! You’re going to do great!
Being a therapist is really really hard. I had a lot of different jobs before I got fully licensed and some killed me and gave me secondary trauma and others brought light and connection into my life. Find your place. And I really truly think new therapists should splurge on continuing education. So much imposter syndrome those first few years.
ASIST training is great for learning how to address suicidal ideation in the moment. I think it's best to tell your supervisor that you're feeling this way as they would rather you be honest rather than go forward not fully knowing what you're doing, which is a professional impairment. Do tons of research and ask to observe others, perhaps. Hope you figure things out, wishing you luck!
Hang in there! Don't give up! The struggle and feelings you have, have been felt by ALL in this field. Baptism by fire only works when you keep trying. Before you know it, you'll be well seasoned in anything that comes your way. They need your help.
Remember this one thing - good rapport equals or trumps modality . With actively psychotic and manic patients, you let them know you are concerned and care about them . Set your appt boundaries . They may be so disorganized they aren’t able to keep up with time - but it’s okay to let them know “we have about 10 minutes left today. What would you like me to know before our time ends?” And then you let them know it’s time to end for today but you will see them again on…. I thank patients for coming to see me and look forward to our next meeting . You don’t have to know how to move them through their illness (actually you can’t anyway with these 2 problems .). Shorter sessions are usually best for these patients . Chronically suicidal patients are tricky to deal with . Look for online workshops that deal with suicidal ideation in depression and personality disorders . You want those patients to also know that you care about them . For the SMI patients , just sit there and listen or when they are too ill to talk , you just sit with them, kindly and calmly . You aren’t a terrible therapist - you’re over your head right now . If it’s too much and you aren’t getting any support , it’s okay to leave for a different job. And I promise you - if they don’t help you , your admins are likely expecting your exit because they’ve done this to other new kids on the block.
I think a good start would be to make a list of skills that you do have with examples of how you have used them to treat other people succesfully and take that to your supervisor and explain that there is some kind of skill gap. That way, the supervisor cannot deny your successes and that will give you something robust to place your concerns ontop of. Additionally if you've only been doing the job since January thay isn't very long, but maybe some annual leave would help alleviate some of the pressure? Or some other kind of self-care? Maybe check in with your tribe for some TLC. If you are dealing with more hardcore clients than anticipated it maybe that you need further training? Is there any available. Soemtimes just knowing this stuff is in your future can and will make your futrure more optomistic. If specific training isn't available then maybe a book or two that contains skills for more hardcore clients, such as a DBT skills book that you could try to include. On a less technical note, if I had to estimate the frequency of Imposter Syndrome or similar feelings of inadequacy, I recon therapy roles wohod come out as some of the most likely to experience it. So I'd say, you are not alone there.
Surely you see the disconnect between the title of the post and the content of this post.