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Ask a Mental Health Therapist

Discussion in 'Off-Topic' started by CivCube, Aug 25, 2011.

  1. CivCube

    CivCube Resist.

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    I am a certified MSW clinical social worker. Although an MSW can work in many different fields, mental health therapy is one of the more common occupations. Currently I'm doing outpatient group therapy at the area's major nonprofit hospital--soon I will start individual therapy with clients.

    I will leave the rest to you if you're interested. Any questions?
     
  2. MjM

    MjM Chieftain

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  3. MobBoss

    MobBoss Off-Topic Overlord

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    How many hours was your internship and how long did it take to accomplish?
     
  4. SS-18 ICBM

    SS-18 ICBM Oscillator

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    What are some common misconceptions about mental illness and treatment you would like to dispel, if any?
     
  5. Perfection

    Perfection The Great Head.

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    What kind of mental health issues to you work with?
     
  6. downtown

    downtown Crafternoon Delight

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    What is your relationship with the insurance industry? Do you think paying for quality mental health care is a problem?
     
  7. CivCube

    CivCube Resist.

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    Social studies and anthropology were my favorite subjects in school. When I decided to go into social work, I realized in hindsight that I was getting paid to live a PBS show 24/7. It's incredibly satisfying to work with people and see them make progress, while still learning something new about the human condition every day. As dreary and unglamorous as the human services can be, I also enjoy working in a profession where I can see results and direct feedback from my work.

    512 hours. Half of those hours had to be in direct contact with clients (face-to-face, phone call, group). The process took about four months to finish. It was nice to go to work and still have enough time to drive a couple hours for night class.

    My LCSW (Licensed Clinical Social Worker) will come after about two years of supervised clinical practice. Having those initials would mean I would be able to take Medicare clients on an individual basis--a fairly useful trait for our agency, as the clientele continues to expand to all ages.

    Thankfully the original stigma of mental illness as strange and frightening is going away. The local hospital has seen a tremendous growth in use since it opened about six years ago. Some misconceptions continue to exist while new ones are born:

    "I will always have this condition.". I've seen many clients talk about "owning" their condition like a terminal illness in response to the public stigma that is still out there. While it's a good-natured idea, I disagree that it's constructive. With a problem as multifaceted as a mental condition, there are plenty of options and ways to improve one's quality of life. To assume that it's permanent is to do a disservice to oneself.

    All mental illnesses are physical and require medication. Plenty of therapists would disagree with me on this point. Clients with depression and bipolar disorder are often prescribed medications and have to go through a trial-and-error process of finding the right dosage. My opinion is that many medications could be replaced with better self-care in body and environment, and that includes constant physical exercise. The public still doesn't realize that mental illness, while often based in physical symptoms, is also based in a person's larger, holistic issues that impact every part of life. This is why in our outpatient program we go through many topics that are impacted by mental illness: codependency in relationships, emotional intensity, physical wellness, grief and loss, and similar topics are covered in addition to psychotherapy and cognitive behavioral techniques.

    Electroconvulsive therapy is still like in One Flew Over The ****oo's Nest. I got to watch an ECT session on the other side of the hospital here. It's certainly much more advanced than the 1970s. Clients go under, the specialists make sure they're secure, and a very small electrical surge is applied to the side of the head. The feet are held in place to make sure the clients don't hurt themselves. Within fifteen minutes the clients are awake. By the time they walk out, the process has taken less time than for a dental hygienist to clean your teeth. Many clients have reported feeling improved functioning and life satisfaction after an ECT. That said, it's still used as a last resort after talk therapy and medication.

    Borderline personality disorder is the most common diagnosis in my wing. We get a lot of women coming out of abusive relationships, so emotional intensity (another name for BPD) and codependency are very common issues we work with. A separate program that deals specifically with BPD has been successful in treating one out of three clients that we see. Anxiety (often social anxiety), bipolar disorder, PTSD, and depression are also common diagnoses. Sometimes a client will present with some mild psychotic tendencies. As I work in the partial outpatient side of the inpatient center, client will frequently be readmitted into residential treatment if their suicidal ideations become too severe.

    It's a huge problem. Most of our clients have dysfunctional lifestyles because they come from very stressful backgrounds. This often means they are unable to pay for services and also do not qualify for reimbursement. The nonprofit hospital usually eats the expenses instead of letting the client go without treatment.

    Insurance also determines the kind of service we can provide. Our group sessions are always 45 minutes to an hour not because they've been effective for group work but because such time slots are prescribed by insurance companies. This makes it so that Client A can go to so many sessions in a month, while Client B can be restricted a certain number if he/she does not qualify for full reimbursement. This can happen halfway through treatment and pull the rug out from under the client, making things fairly frustrating for both us and the client.
     
  8. Perfection

    Perfection The Great Head.

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    How do you manage to provide therapy without becoming too emotionally invested in the outcomes of your patients? (Or do you think you've become too emotionally invested in the outcomes of your patients?)
     
  9. CivCube

    CivCube Resist.

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    It's a challenge that goes in two ways for me. One is definitely a skill I've had to learn over time and continue to hone with regards to how invested I am in clients while they're still in treatment. Becoming too invested in a client's issues has led to some burnout in the past. A professional demeanor and detachment are necessary when dealing with clients who may have manipulative tendencies. It's a tricky balance between being genuinely there for them and keeping those relational boundaries in place.

    No matter what, client resistance will happen either because the client doesn't want to be accountable for change or because the client still doesn't understand how his or her behavior affects the group. A lot of times when a new client joins the group, there's a shaky period where the client is learning how to put aside social strategies that haven't worked in the past. While that's going on, other clients may remain rigid in their personality disorders. This often leads to an atmosphere that can be uncomfortable if one doesn't emotionally detach. The best way to deal with problematic behavior is to set clear expectations at the start of every session and continue to act as an assertive facilitator.

    The other side of that is being invested in a client's outcomes once therapy has terminated. On that note, I'm always eager to see them succeed. Unfortunately, many clients continue to live in unsafe environments and become worse. It's not unheard of for clients to be readmitted over a decade. On the other hand, many clients do have improved quality of life after therapy, so it's a toss-up. I still have hope that maybe thirty years down the road, mental health services could engage the client outside the hospital and help change some things in the environment. Until then, I can only do what I can to push Sisyphus' stone up the hill. That's enough to satisfy me for now.
     
  10. Moss

    Moss CFC Scribe Retired Moderator

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    Kind of in-line with Perfection's question:

    How difficult is it to not "take your work home with you" ? Or haven't you found it too much of a problem?
     
  11. CivCube

    CivCube Resist.

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    I've learned that it's best to simply not worry about if I take my work home with me or not. As long as I'm doing the duties I was hired to do, I'm satisfied that I'm doing my job. It's still important to compartmentalize and keep some detachment from work while at home, but if negative thoughts about work do come up, I simply act as my own therapist and engage the present moment as more of a priority. Simple to say but it has taken time to do that successfully.

    As for how tense work may get, it depends on the day and the client. Sometimes a client just knows how to push the right buttons; likewise, a comment I make may set off exactly the wrong reactions. A group may turn out ineffective for the clients based on how they react to it.What I've found is that clients and emotional states will rotate rapidly in and out of group. What may be a problem today may evaporate tomorrow as clients progress in therapy. It's that kind of dynamic that is as refreshing and entertaining as it is sometimes draining.
     
  12. Perfection

    Perfection The Great Head.

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    How specific are your groups? (I.e. are the groups broadly focused like "the group of people who have some sort of problem" or narrowly broadly focused like "the compulsive collectible spoon shoplifter support group")?
     
  13. sanabas

    sanabas Psycho Bunny Hall of Fame Staff

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    Do you apply that to all conditions, including things like bipolar & schizophrenia, or only some of them, such as borderline & depression? Do you think the view that "I can reach a point where I no longer have this condition" is realistic or constructive for all conditions?

    Seems like you're buying into another misconception, that medication and better self-care are mostly an either-or scenario. Rather than replace helpful meds with better self-care, why not augment helpful meds with better self-care? Then you can try phasing out the meds later. For everyone, it's probably going to be useful to replace poor self-care with good self-care. For some, a medium-long term goal is probably replacing current meds with no meds. But good self-care is useful all by itself irrespective of meds, rather than a replacement for them.

    ****oo's nest was filmed in the 70s, but the ECT depicted in it is more like the 50s. And I'd still take some serious convincing to do it, having seen many people who have. Some found it really good, some not so much, and the side effects I've seen are very, very high on the list of stuff I never want to have.


    This happens now over here, no reason (other than funding) it couldn't happen there now too. In fact, I'm sure it does in some areas, because I've talked to people who have been involved in programs that visit people in their home. Easier to improve people's self-care if it's not always in a come & visit the hospital, clinical setting.

    You work for a privately-run hospital? How's it funded? What state or federal govt-run services do the clients who come to your hospital have potential access to?

    When you do group work, who else does it with you; nurses, doctor, psycholgist? What will be your focus with the clients when you start doing 1-1 stuff? Is your role to actually do things like CBT, or is it more to try and get the client doing things, help them deal with finding work, housing, etc, and hook them up with psychologist, dr, etc to work on the more treatment specific stuff?

    Have you had a client top themselves yet? How did you cope/how do you think you'll cope?
     
  14. Takhisis

    Takhisis is it fall yet

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    Why do you call them clients and not patients?
     
  15. Boundless

    Boundless Chieftain

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    Do you find it hard to separate between home and working life?
     
  16. Kan' Sharuminar

    Kan' Sharuminar Fluffy

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    What's the most rewarding experience you've had with your work?
     
  17. Quackers

    Quackers The Frog

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    If you have an entire day full of depressed patients - don't you go home feeling depressed yourself? In other words how do you keep yourself happy when your enviroment can be so miserable!
     
  18. CivCube

    CivCube Resist.

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    Some sessions such as Emotional Intensity will be more specific to women with BPD. Most of them have good diversity and can range from 18 years (the minimum age for our program) to over 80 years. Such heterogeneity creates a good environment for different opinions and feedback for everyone.

    Certainly not. Some conditions such as schizophrenia are developmentally based and are simply part of the person's make-up. If some conditions can't be "cured" or successfully coped, then it is a matter of learning to live as a person with that condition. Other conditions like depression, however, are often based in lifestyle and unsatisfactory functioning. What can be realistic and constructive for both, however, is to treat each client with the dignity he or she needs to help them live for themselves.

    I think medication is useful only when all other self-care strategies have been tried and don't work. For most of our clients, that's not the case--many are living with terrible sleeping schedules, eat improperly, and exercise very little if at all. That way when such strategies are tried (such as a client with bipolar who exercises constantly but can't ameliorate a manic episode), there's better information for the psychiatrists to decide how much medication to prescribe.

    Don't get me wrong, we're not jumping at the bit to taser your head at the first chance. It's always going to be a last resort simply because of that lack of certainty. That's why dosage is kept to a minimum and spaced out considerably--the doctors want to make sure that it's actually working.

    Our Family Wellness Program is the first of its kind to do just that. It's currently set up as a long-form study taking place over several years. Children who come from very unstable backgrounds are recommended by school nurses and social workers for assessment. From there a wide intervention on the family is implemented, from therapy with the child, therapy with the couple, and the family as a whole. Parenting classes are provided with supplemental education for the children. And there are periodic home visits from a specialized team. The early results say that it's working to some extent--the families with more consistent interventions have been shown to improve more.

    The hospital relies on a combination of insurance reimbursements and fundraising. The clients have access to any state-run services; in South Dakota, however, that doesn't mean very much. That's why it's often our job to help network them with services such as home weathering and emergency electricity.

    Nurses do run groups, although the hospital is starting to shift to credentialed therapists. When I do 1:1 therapy, it will be a combination of interventions along what you describe. CBT will be often used to frame challenges like finding work and housing; the main emphasis will be on the client's immediate functioning in dysfunctional thinking and relationships. In both group and some 1:1 sessions I've also used interpersonal process theory to help keep the clients' attention on what is happening in the room--that is, how their dysfunctional thoughts and behavior play out in real-time and affect the quality of discussion.

    Psychiatrists and psychologists often come downstairs to do 1:1 sessions and check up on how the medication is working.

    There's no simple panacea when either client or staff dies. I haven't seen a client complete suicide yet, but it's happened in the program before. On the staff side, however, there have been quite a few tragedies in recent months. Another therapist was killed in a car accident, followed by another death elsewhere in the hospital.

    Both "patient" and "client" are used interchangeably throughout the hospital, depending on the level of care. In our outpatient setting, the clients are voluntarily using our groups and classes, so we prefer a term that's more encompassing of life problems. It's also a social worker thing--we just like language that's not overtly medical in tone.

    At times, yes. Mental health extends to everyone, including therapists. Any personal issues I think about can always be thought through with the material we use for discussion, which can blur the lines.

    It's always rewarding to directly engage individuals and hear honest, genuine self-disclosure. I find it fun to be able to help guide someone at their level and slowly help them work their way through a mental labyrinth. When I'm able to give hope to people is when I think I have the greatest reward.

    One rewarding experience was with a younger depressed client who was still mulling over what she could do for herself. After a couple sessions, we were able to work out goals that she wanted to do. Suddenly, this bright, happy look of relief came over her face. Maybe for the first time in a long time, she felt that someone on her side.

    Another time was with an elderly woman with some dementia. In group, she remained very quiet while others gave their disclosures and stories. Once she was able to share something, though, she became very serene. After group, she told me in a very little voice that she was glad she was heard. Maybe for someone her age, it's more therapeutic to be able to have someone be there with her. Later in therapy she was more engaged by the group and actively listened.

    It helps to work with a staff that has a good sense of humor. We frequently give each other a hard time about stupid stuff, so that help to keep the drama down. Even so, the group energy can rapidly fluctuate between sad and quiet to manic and frustrated, often between sessions. I try to stay as detached as I can while remaining genuine with clients, but it's also important for me to keep track of what stimulation is still lingering from a particularly difficult session. Eating a good amount of food between sessions and getting into a good workout after work can help.

    Because clients can fluctuate so much in mood, however, it's somewhat easier to take outbursts in stride. If they're not in a good place to talk well now, something can change tomorrow, or concurrent therapy can help calm them down. When the whole point of your job is help decrease stress, that helps somewhat. ;) Nonetheless, there are frequent "bad days", but the first step is to simply accept them as part of the job.
     
  19. Mathilda

    Mathilda Queen

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    How do you encourage a depressed person to do that?
     
  20. CivCube

    CivCube Resist.

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    With our four-week program's structure, we have plenty of time and material to help clients realize alternative coping strategies for themselves. For a depressed person, this may mean thinking about how to best formulate goals and daily objectives that better activate serotonin alongside their existing prescriptions.

    Before that happens, they really have to start thinking about their problems in complete context. We assign an extensive autobiography assignment that requires clients to think about their life history and family environment. Other classes and groups bring up topics that they may not have considered in much personal detail before. On that foundation we're able to get the ball rolling. The clients are better able to acknowledge their problems in specific detail so that they can respond with the skills they learn in sessions.

    But it's still not easy. Many clients still harbor some resistance or uncertainty toward change well after discharge. We do what we can to address that resistance in group (sort of the whole point), but there will often be a lot of work left to be done for the client. That client may either return to inpatient side, continue in outpatient therapy at our other location, or continue on with life with the skills we've tried to educate them on.
     

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