Written by: Victoria Steel; Bachelors Degree in Psychology, Masters Degree in Counseling Psychology, LPC.
As a crisis therapist I see people at their worst, and daily I hear stories of how the system has failed people. Promises that were not kept, mental health that was misdiagnosed, insurance companies refusing to pay, and individuals and families that are at the end of their rope. I think overall (because there are always those therapists that shouldn’t be therapists) many of us in the mental health field just want to help. The sad truth is the tools we are given to do that are sadly lacking. I am regularly put in a position where I can’t help a client the way they need either because insurance won’t pay, or because the right kind of help will be entirely too expensive for the client. Some clients need access to medication much faster than anyone can provide (the average wait to see a psychiatrist in the state of Colorado is 3 months). Some clients have been misdiagnosed and over-medicated. Some clients have been getting their mental health medication from a Primary care Physician who is severely under-qualified to prescribe mental health medication. The mental health centers , who overall are more equipped to treat a variety of mental health disorders, are so overwhelmed we are only seeing clients every 3 weeks or so. Conversely, private therapists who have more availability (can see clients weekly), don’t have the resources that a mental health center does. Consequently, this causes a lack of appropriate care all around.
Similarly, there are mental health centers out there that will only serve people in their ‘catchment’ area, meaning you can only receive services if you live in the right county. This is even more limiting because mental health centers offer the greatest amount and variety of mental health services, and they are refusing services to some. Likewise, it can take several weeks or more for an appointment to set up services through a mental health center, and once you are signed up for services it can take several more weeks before you see a therapist. This is because mental health centers are severely understaffed. There are several reasons for this, the greatest of which being funding. Often mental health centers are required by the state to provide certain services, and they are not given enough money to do so. For example, in the state of CO mental health centers are required to provide crisis services 24/7/365. However the funding they get from the state only covers about 60% of the cost to provide that kind of service, leaving the mental health center to come up with the rest. As a result mental health centers end up spending their Medicaid/Medicare funds to cover the services they are required to have but not compensated for, which leaves less money to hire more therapist (or pay the therapists they do employ better.) It is much more lucrative to be a private practice therapist; however most private therapists will only work with privately insured clients, which leaves a lack of therapists and a lack of options for the lower income majority.
Then, when you really get down to being able to help each individual to the best of your ability the system consistently gets in the way. As mentioned before there is a severe lack of psychiatrists in Colorado, and as of January of 2019 there are .9 people available for each mental health position available in this state. Also, many of the ‘basic need’ resources tend to fall under the mental health umbrella because state programs are also severely understaffed/underfunded. This puts therapists in the position of case manager often helping clients with housing resources, food resources, legal resources, school resources as well as many other resources that are severely lacking. Consequently, the more case management a therapist does, the less actual therapy they are doing. So one would think the solution might be to stop doing the case management piece. However, this is a double edged sword, because in all fairness; can a person without housing really spend much energy focusing on their mental health?
On a different note, as in any field, there are those people in the mental and physical health fields that, while mostly good intended, are not educated enough in certain areas, and attempt to help clients who they are unequipped to help. I can’t tell you how often I have to find a quick appointment with a psychiatrist for a client who’s PCP has attempted and failed to medicate them properly (often times a ‘quick’ appointment means a matter of weeks instead of months.) I am also, unfortunately, often put in a position where I have to question the treatment a client is receiving. Clients with severe trauma are often misdiagnosed as being schizophrenic or bipolar, when in reality severe trauma rewires the brain. So while the symptoms they are experiencing may mimic a severe mood or psychotic disorder, what is actually happening is PTSD. I have had to tell clients to find a new therapist because the therapist they chose is clearly unqualified to treat their trauma. I have seen clients who are being re-traumatized because a young, inexperienced or untrained therapist is attempting to treat severe trauma. I have seen clients whose therapist isn’t even treating their trauma, who instead are being treated for psychosis, or severe depression; and taking medications that are sedating the symptoms instead of treating the underlying issue. Treating trauma successfully is done with only a few specific therapies. Without training in those therapeutic approaches, any work a therapist does with a client can make things worse, and at best, will be unsuccessful.
Why is there this lack of knowledge surrounding this issue? Because masters counseling programs continue to under emphasize the roll that trauma can play. Recent studies have found that close to 2/3 of people hospitalized for schizophrenia in their early 20’s no longer have symptoms of schizophrenia 20 years later. Why, because these people successfully dealt with their trauma, they never had schizophrenia to begin with. Studies have also shown just how prolific childhood trauma is, with upwards of 2/3 of the population having experienced a form of interpersonal trauma or type II trauma (abuse, neglect or sexual abuse). This number doesn’t include those who have experienced some sort of type I trauma (such as a natural disaster, car accident, or mass shooting). The numbers tell us that 1 in every 5 people has experienced sexual abuse and 1 in every 4 has experienced physical abuse. I remember reading these numbers in a book during my master’s program, but no one bothered to show me the significance of this, until I worked for a mental health center. Mental health centers overall are becoming more aware of the significance trauma plays in every choice we make as clinicians, from dealing with our own trauma successfully to making appropriate and empathetic treatment decisions with and for our clients. However, clinicians that never work for a larger organization that mandates this kind of training for all their staff are most likely severely lacking in this kind of knowledge.
As a final thought, I have also seen clients who have been given false diagnoses so that a doctor can prescribe a certain medication. While this seems unethical, there are several medications out there that can help clients with specific symptoms, however are considered ‘off label’ for use with certain diagnoses. This is significant because insurance companies can refuse to pay for medications that are prescribed ‘off label.’ In the mental health field this is most often seen with clients who have a PTSD or trauma related diagnosis. There are very few medications approved to ‘treat’ PTSD, this is because people with PTSD experience a large array of symptoms, from general depression/anxiety symptoms, to mania, delusions, hallucinations, and disassociation. This means that while each person with depression might receive the same or similar medications, someone with PTSD (if necessary and desired by the client) is medicated based on the symptoms having the most significant negative impact. Another big difference is, for a person is being treated for something like Bipolar, medication will be most effective long term. However, when the root of symptomology is trauma medication tends to change as symptoms do, and while medication can be helpful for some, it is not always effective or helpful for everyone.
In closing, while the flaws in the system are all too obvious sometimes, the majority of those working within the system came into the field because we want to help people. We didn’t do it to fix the flaws in the system, we didn’t do it to heal society at a whole, we enter this field to help people. And the majority of us work our butts off daily, often giving more than we have to do so. There are times my clients get more of my time than my children, times when I use the last of my emotional energy at work and my family is left with an empty shell when I get home. There are times when I can’t do anything but work within the system I’m given which may mean making a impossible choice, and I often feel stuck. So, do I get a mother the help she so desperately needs even if that means her children end up in foster care? Do I place a client who is struggling financially on a 72 hour hold because they are suicidal, even though the ambulance and hospital bill will ultimately cause more stress; and if I don’t how do I go about keeping them safe? Do I report a therapist who made a bad clinical choice, or do I let it go this time realizing we are all human and we all make mistakes. And once I manage (with the help of my amazing supportive team) to make the impossible choice, who holds the doctors, the hospitals, and insurance companies accountable when they ignore my recommendations? When they release a client who has made threats against themselves and their family. When they discharge a client with severe medical issues and has a fever to the street because they are homeless and don’t have insurance? When they refuse to pay for the right kind of treatment because the doctor who works at the insurance company, without ever laying eyes on the client, has decided that the clients symptoms are the result of drug abuse, or a medical condition (even if there is no evidence to support this.)
Edited & Reviewed by: Manda Jones
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