Nobody in social work school teaches you how to do short-term work in chaotic environments.
They teach you how to terminate a relationship with clients at the end of the 8 sessions you planned or when they’re “graduating” from therapy, but not when any session could be your last, when she could be shipped off to state prison any week now, when his brother could bail him out any day now.
They teach you how to structure a 50-minute hour but not a stolen 12 minutes when nobody is using the caseworker’s office. In the lectures on confidentiality they don’t tell you how to speak in code so your client will know you’re asking if his antipsychotic medication is working but his cellmate won’t understand.
There are books and seminars on treating PTSD symptoms, first establishing a therapeutic relationship, working on coping and safety skills, and only then processing traumatic memories. But they don’t tell you how to handle someone whose PTSD is eating them alive and who will only be at your facility for two more weeks, when you only have time for two sessions because there are 73 other people on your caseload.
There are whole theories about whether you offer a crying client a tissue from the box on your desk or wait to see if they take one. There is no theory about the most sanitary way to carry tissues in your clipboard to the corner of the TV room where you will end up meeting, or whether to help your weeping client wipe their face when their hands are shackled behind their back.
And that’s okay. I understand they can’t cover every possibility and some things you just have to learn on the fly. But there’s an implication from all the classes and books that after you do your time in the trenches you will eventually be an outpatient psychotherapist, with an office and a desk with tissues on it and one of those white noise machines outside the door. And I dream about it—what art to have on the walls, how to arrange the chairs. I dream of working in a place where I can eat lunch with metal cutlery, where I can wear scarves because the dress code doesn’t forbid things the clients can use to choke you. I dream of the therapy I could do with a 50-minute hour every week for years.
But there are a lot of clients who will never make it to that Zenlike office. They’re not in outpatient therapy because they’re busy getting high, or they’re hospitalized, or they’re incarcerated, or they have no insurance, or they have no bus fare, or they didn’t know therapy was a thing.
And if hospitals and jails are places people only work while they’re fresh out of school and waiting to get to private practice, the neediest clients will get the least experienced clinicians every time. That’s not fair to them.
When I have a client who really needs good ongoing therapy, I wish I could be sure they get it. I explain how it’s supposed to work, and when they leave I make sure they have appointments. But I know they probably won’t make it there, because their lives are too chaotic. And they will eventually wind up meeting with someone in the corner of an emergency department or a shelter or a psych ward or a holding cell. I hope the staff there are really good at what they do.