Gary Bloom

March 29, 2021

Game of Thorns

(This is an excerpt from a book I wrote on how to have career in the mental health field. I unpublished it because it would need to be revised to stay current.)

“When I spoke to Stanford professor Bob Sutton, he told me his #1 piece of advice to students was this: ‘When you take a job take a long look at the people you’re going to be working with—because the odds are you’re going to become like them, they are not going to become like you.’”
—Adam Rifkin

When I began my outpatient work, my inclination, my training, and clinical tradition aligned: I started sessions by listening to the reasons my clients came to see me. As private pay for private practice and government grants for community clinics gave way to managed care, initial sessions became more about recording stuff on an intake form and coming up with a diagnosis for insurance reimbursement. Have you ever gone to the emergency room for a painful but not life-threatening injury or illness? You know how unnerving it can be: hurt and scared, you’re flooded with admittance and insurance forms. Counseling clients coming to initial sessions with emotional pain: hurt and scared, they’re flooded with admittance and insurance forms, and then, rather than discuss that emotional pain with their counselor, they must answer a heap of questions relevant to only the intake form. No wonder that the most common number of sessions clients attend is a big, fat, one.

You may believe that it is simple to separate how clinical work is reimbursed (for a psychiatric diagnosis), and how you think about client problems. It’s harder than you think. Novices at clinics or hospitals, spending their time around psychiatrists and veteran counselors, get colonized quickly. Hear diagnostic jargon and DSM codes, daily, and you’ll soon conclude that to be respected as a grownup clinician, you better use those terms. But if you succumb, you’ll never see your clients as humans again. From then on, they’re cases—people not with emotions, personal histories, and lives like your own, but clients with diagnoses, with medical charts as evidence. 

Follow the Money

Working in the mental health system is like watching your favorite television show; you hate Comcast but put up with it because you love Game of Thrones. Here’s what you’ll put up with to earn a living: (1) As a counselor, you must keep detailed medical records to satisfy state requirements, and scramble to comply with state and federal statutes covering privacy and security of medical records. (2) There are no healthcare professionals with grad degrees who make as little as the average masters-level clinician. (3) While doctors can afford a staff to assist with records and billing, therapists in private practice usually do all that on their own. (4) Psychiatrists always get to play on their home court by using the disease model for insurance payments; marriage and family therapists, primarily trained in interpersonal conflicts models, and social workers, primarily trained in social justice models, must always be the visiting team. (5) Those boring Using the DSM classes you took in grad school will turn out to be important classes. 

Insurance reimbursement started on a high note, but evolved into a Faustian bargain. In the 70s, state legislatures started passing laws that gave masters-level clinicians insurance parity, meaning that they became full-fledged mental health professionals. The intended consequence is that all covered mental health professionals had to use the DSM to provide a medically recognized mental illness diagnosis. Over time, the criteria for reimbursement became increasingly oriented towards the disease model. The designation, adjustment reaction,the non-mental illness diagnosis, was no longer acceptable. The unintended consequence is that all mental health professionals became psychiatry and Big Pharma’s bitches. 

Just because the distribution of that money is, ahem, less than equal, doesn’t mean that some players in the Mental Health System (MHS) aren’t doing well. For counselors, social workers, and even most psychologists, the money distribution looks like hungry baby birds waiting for a piece of worm. For psychiatrists and pharmaceutical corporations, the money distribution looks like pigs at the trough.

Psychiatrists have always made good money—they’re doctors. But the increased partnership with the pharmaceutical industry has allowed them to dominate the mental health industry in a new manner. When they were the only clinicians that could take insurance for psychotherapy, they dominated the 50-minute hour approach. But the release of the chronically mentally ill into communities increased the demand to subject them to chemical restraint. That demand could come indirectly from the involved family or directly from the legal system or from clients themselves. Fewer and fewer psychiatrists engaged in talk therapy. Insurance companies preferred to pay them for 15 minutes of medication review once a month, and psychiatrists found four sessions an hour to be more lucrative than one. 

Your First Professional Position

If you’re just entering the counseling profession with your newly minted master’s degree, you’re likely to start with a low-status, low-paid position. After job-hunting for a while, more than likely, you’ll not only settle for one of those jobs, you’ll be thrilled to get one. If you’ve paid tuition for a couple of years, and had an unpaid internship, making even a low salary will look comparatively good.

Along with coming to terms that receiving some money to work is better than paying money to work (during grad school), what else is good about low-paying jobs in counseling? There are several benefits:
  • The more areas in the system in which you work, the more you’ll know the systemic issues your client may encounter. For example, if you get a client whose parental competence is being challenged or overseen by Child Protective Services, experience working for a similar agency will give you additional insight into how to assist them. If you get a client who’s been involuntarily admitted to a psychiatric inpatient ward, and you’ve worked inpatient or crisis, you’ll have additional insight into how to assist them.
  • You’ll know more about various client issues than those who have dealt with only the worried well, or psychiatrists who see clients for a 15-minute med review once a month. Those in entry-level positions usually get experience with a wide spectrum of clientele, usually far wider than those in higher-level positions. You’ll learn more about issues that bring people to counselors.
  • The variety of clients can help you choose your career direction.Working with a variety of clients, and their issues, can help you choose a career path that in the long run will be more useful than an initial high salary.

The Paradox of Mental Health Treatment Goals

“When the going gets weird, the weird turn pro.”
—Hunter S. Thompson 

Medicine may be difficult, but some aspects are refreshingly straightforward. For example, a patient comes to a physician because she has an infection, with a resulting high fever. Physician treats patient with antibiotics. Patient’s infection goes away, and the case is considered successfully treated.

Contrast with a counseling client. If you work at agencies that make most of their income from managed care, their profit will increase if sessions are strung out to get the maximum in insurance benefits. Ditto for you if you work in private practice. On the other hand, if you work at an agency where the service is primarily pre-paid, such as a health maintenance organization, you serve the agency best by getting your clientele moving on successfully with their lives in as few sessions as possible. When clinicians move from a setting that rewards long-term, “in-depth” therapy to one that rewards brief therapy, or vice versa, it takes some skillful mental gymnastics to rationalize that the approach you’re currently using is the clinically superior one.