Tyra and I both hear a lot of horror stories. It goes with the territory. Therapy is hard work, and community mental health work is especially challenging. Clients may have severe mental health problems, other major health concerns, substance use struggles, inconsistent employment or housing, and a wide variety of other social and environmental problems — all overlapping. The therapists doing their best to help clients in these settings are themselves often overworked and underpaid. Many are in the early stages of their careers, making it more difficult to know what’s normal in that kind of work setting. How can you tell when a work environment in community mental health is need of fixing? How can you tell when it’s better to just leave?
Tough does not equal toxic
The fact that working in community mental health is hard shouldn’t surprise anyone. When you sign up for this kind of job, you know you’re signing up to work hard with people in very difficult circumstances. That’s the job.
Supervisors and administrators have to walk a difficult line. For their clinics to run, they need therapists to get through their own personal discomfort with clients who can sometimes be genuinely frightening. But they also don’t want to force therapists into situations that are truly dangerous or likely to be traumatic. Many supervisors and directors balance these extremely well. They show support and trust in their therapists, and protect them from a great deal of potential risk. They also challenge therapists who are skilled but scared to call upon their training — and their bravery. If you have supervisors or other administrators in your setting who do this well, tell them.
Ed. note: This post can also be seen at EarlyCareerClinician.com as part of a content exchange for this post and the one running Wednesday. Check out Tyra’s blog and services for early career therapists.
But there are times when community mental health workplaces aren’t just tough, they’re toxic. Power hierarchies fail. Policies may be implemented without realizing their effects. Key people leave. Difficult caseloads can be manageable with strong supervision and support; difficult caseloads without support can leave even the best therapists riddled with anxiety. In more extreme cases, therapists can feel they are being punished for raising legitimate concerns about clients or about their own experience.
Such workplaces need repair, and quickly. If you’re a therapist in such a setting, you have meaningful choices to make. First, though, you need to assess your own reactions.
If you talk with veterans of community mental health work, they’ll be able to give you some perspective on what kinds of stresses you should expect, versus those that should be more troubling. You can then reflect on how much of your concern is truly with the workplace, how much of it is your own, and how much of it is inherent to the work. Concerns about community mental health work are usually combinations of all three, so this is a matter of portioning out how much rightly belongs to each piece.
Work from within
It may be stating the obvious, but if you are in a work environment that you believe has become toxic or threatening, the ideal solution (for both staff and clients) is to work from within the workplace to fix it.
To do this, first spend some time on your own getting specific about your concerns. It may be helpful to do this in writing, and to edit until you feel good about the language. You want to be as clear as possible about (1) the name of your specific concern; (2) the events or other evidence supporting that this is an issue; (3) the impact of this issue on you, colleagues, clients, other staff or any combination thereof (do be cautious here not to speak on behalf of others who can or should speak for themselves); (4) what you see as possible specific solutions; and (5) what specific work you are willing to do in order to make those solutions happen, if the clinic agrees with your concern.
Once you have your concerns clear, arrange a time to meet with the person in your clinic in the best position to fix them. If that’s an administrator, you may want to go to a supervisor first, and then ask to meet with your supervisor and the administrator together.
Of course, supervisors and administrators may not react well when you first raise an issue, no matter how skillfully you do it. They’re allowed to have bad days. It’s also true that they are probably overworked and underpaid. And they may believe that they have little power to change the situation. Assume that they have good intentions, and that they are as invested as you are in creating a workplace that works well for everyone. You are, after all, on the same team. If they agree that there is a problem but don’t think your solutions are realistic, brainstorm with them other possibilities. If one interaction with them goes poorly, or even if two or three do, that may not mean anything. Rely on the overall body of experience you have had with them, and give them some time to digest what you presented.
Understand your limits
There are a lot of possible outcomes when you try to resolve a problem from within a workplace, and most of them are ultimately good. Your superiors might agree with your sense of the problem, implement some agreed-upon fixes, and improve the working environment. You’ll still have stressful and difficult work, but it should be a qualitatively different experience.
It’s also possible that attempted solutions will not work. Interestingly, even in these situations, I’ve heard from clinicians who quite happily stayed. They said that the support they felt from supervisors and administrators in simply acknowledging and trying to fix the problem was enough. It changed their relationship with the workplace going forward. Even those who leave after such efforts tend to describe the experience as positive.
It’s also possible that supervisors and administrators will disagree with you, either about the nature of the problem or about what solutions are worth pursuing. You of course don’t have to leave such a setting, but you should do some cold math at that point about exactly what you are willing to tolerate, and for how long. Many prelicensed therapists simply choose to keep their heads down and drop the issue in order to keep gaining experience hours for licensure. Knowing that your situation is temporary, and a means to an end, can make it easier to tolerate.
I of course can’t tell you what your personal limits should be. Some therapists endure clients who threaten them, supervisors who berate them or sexually harass them, or situations where the lack of pay is blatantly illegal. Others leave. Either choice is defensible. For the sake of those who follow you, though, even if you decide to stay in such an extreme situation, I hope you take steps to address it after you’re safely out. Formal complaints do work.
If you’re in a community mental health agency that is doing well, make a point of thanking those people who create such a good environment. The work is not easy, and we all have our limits. I spent about five years working in various community mental health agencies. It was incredibly difficult, incredibly valuable experience. And I’m glad it’s over.