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Episode Description
Imagine learning a new language during the worst week of your life. Holds. Intakes. Utilization review. For therapists, it’s everyday talk. For clients in crisis, it’s a maze.
In this episode of The Art of Being a Therapist, hosts Ashley Charbonneau and Morgen Villegas go inside three mental health systems: psychiatric hospitals, community mental health centers, and jails. Both are social workers who have worked in these settings. They share what these places look like from the client’s chair.
You’ll hear:
What really happens during a psych hospital stay (it’s not eight hours of therapy a day)
What “didn’t follow up” often hides
How 90-client caseloads and turnover affect the therapy relationship
What mental health care looks like behind jail walls
Small ways to give clients back some control
These systems can save lives. They can also wear down everyone inside them. Both are true.
Content warning: This episode discusses suicide and mental health crises. If you are struggling, call or text 988 to reach the Suicide and Crisis Lifeline. If you are in immediate danger, call 911.
CHAPTERS
[0:00] Content Warning and Intro
[0:36] Welcome and Three Systems
[2:31] Psychiatric Hospitalization
[6:56] The Intake Experience
[9:27] Autonomy and Trauma in Hospitalization
[11:44] What Happens in Psychiatric Hospitals
[16:46] Discharge Planning
[18:10] Community Mental Health
[31:35] Jail System
[39:31] Practical Takeaways and Closing
Transcript
Content Warning and Intro
Morgen V.: Triggering content warning: This episode includes discussion of suicide, mental health crises, and other potentially distressing topics. Please take care of yourself while listening. If you are experiencing suicidal thoughts or a mental health crisis, call or text nine eight eight to reach the Suicide and Crisis Lifeline.
If you are in immediate danger, call nine one one or go to your nearest emergency room
Ashley C.: Let me know when you're ready
Morgen V.: Okay, I'm so ready. I'm excited, and I'm scared and excited.
Ashley C.: Okay.
Welcome and Three Systems
Ashley C.: Welcome back to The Art of Being a Therapist, the space between training and real life. I'm Ashley.
Morgen V.: And I'm Morgan.
Today it is the two of us. We're gonna do something a little different. We're gonna talk about three systems that many therapists work in or have worked in or refer clients to.
So these three systems are psychiatric hospitals Community mental health and jails. So many people don't know what it means to work in those systems or even be a client in those systems, and so today we're gonna spend some time diving into that.
Ashley C.: As professionals, especially as social workers, I think Morgan and I are pretty fluent in systems, especially what happens within those systems.
So for example, we know what an intake is, what a treatment plan is, what a psychiatric eval is. We know what level of care means. We know what it means when someone says they're going to staff a case, make a referral, consult with utilization review, or put someone on a hold. That language is part of our everyday jargon, and so it's quite normal to us, and we say it quickly without even thinking about it sometimes, even though the people we might be talking to might never have heard some of those terms.
Morgen V.: Imagine if you're interacting in any of those places that we just named, or really any aspect of mental health, and you don't know that language. And just imagine you're learning it during one of the effing hardest moments of your life, okay? And that's the lens we wanna use today. We're not saying that every psychiatric hospital looks the same or every community mental health center operates in the same way or every jail experience is the same.
There definitely are differences based on geography and demographics and resources, obviously funding and policies. We're really wanting to, I think, elicit curiosity from our audience today and really speak to some of the experiences that we have had and the perspectives that we share or don't, Ashley.
but
what does it actually look like? What does it feel like?
Psychiatric Hospitalization
Morgen V.: So let's start with psychiatric hospitalization.
Ashley C.: Let's imagine someone is experiencing a mental health crisis, and I wanna break down that term just a little bit before we get into the setting. So when we talk about mental health crisis, usually we're talking about someone being suicidal or they want to hurt or kill themselves, homicidal or they want to hurt or kill somebody else, or some psychosis, meaning they are experiencing some delusions or fixed beliefs that are not true or hallucinations such as hearing voices or seeing things, some perceptual disturbance.
There is also a term called grave disability, and when someone is placed on a mental health hold, for example, a mental health hold is literally a form that places someone on a hold and takes away their rights, and at that point they have to be hospitalized and be prevented from leaving whatever facility they're at.
But grave disability means that the person is essentially disabled and cannot take care of themselves because of some mental health crisis. Anecdotally, I would say most of us when we're talking about a mental health crisis are referring to suicidal ideation with a plan, with a way to act out that plan, and with the intent to act out that plan.
And this is very nuanced. Because someone is suicidal, that does not mean necessarily that they are in crisis or a risk to themselves. There are clients who experience what we call baseline suicidality or passive suicidality. So maybe they want to die or imagine not waking up or wish they weren't here, but there is no plan to hurt or kill themselves That legally does not meet the threshold of putting someone on a mental health hold.
To put someone on a mental health hold, there has to be a plan, so what are they gonna do, when are they gonna do it, means, or how are they gonna do it, and intent, they have the motivation to carry it out. And this is not always clear-cut. So say someone is having a mental health crisis, what happens next?
The answer depends so much on where the person lives and what's happening clinically. But let's say this person ends up being evaluated for psychiatric hospitalization. Someone gets to that point a lot of different ways. Sometimes people voluntarily want to, quote-unquote, "check themselves in." Maybe someone they love was very concerned about them and said, "We have to go to the emergency room or the crisis center."
Maybe someone else called 911 and police and fire or EMS responded, and they were transported via ambulance. And truly, a lot of people don't want to be hospitalized, even in the midst of a mental health crisis. There's a lot of fear of being taken away from your daily life and being told you can't leave somewhere for 72 hours or three days.
And just remembering there's a lot of different ways of arriving at the exact same place, and then you get to usually an emergency room or crisis and then to an emergency room and then to a psychiatric facility. But if there's no beds available at the ER or at a psychiatric facility, clients are sitting somewhere, usually in the ER, and a lot of ERs don't have specialty teams to help someone through a mental health crisis.
Morgen V.: Yeah. So you're definitely not arriving on your best day.
Ashley C.: And imagine being overwhelmed, scared, depressed, manic, psychotic- traumatized, maybe intoxicated or withdrawing from substances, and usually it's a combination of those things on top of whatever mental health crisis is occurring. And now you're in an unfamiliar environment.
The Intake Experience
Ashley C.: People are asking you very personal questions. When did you last think about killing yourself? Do you have a plan? Are you hearing voices? What medications do you take? Have you ever attempted suicide? What substances do you use? What weapons do you have in your home? These questions make sense clinically, and they are important, and we have to ask them.
In a lot of circumstances, I would say, we need the answers. But I think we also forget how rushed we often are when we ask these, how impersonal the questions seem.
Morgen V.: Absolutely. And sometimes you have to-- you can imagine, again, coming into this space as a client, and you have to answer these questions, not just to one person, but to multiple people.
And Ashley, I think you were gonna speak more.
Ashley C.: Yeah. So you are probably telling your story to someone during an intake, then to a nurse, then to a physician or a prescriber, maybe then a social worker. Maybe someone comes in for a second assessment, and you're probably thinking, "I've already answered this question five, six, seven times."
When you ask someone the same question over and over, of course, there's gonna be some emotional response to that, whether it's agitation or numb or, "I can't do this anymore." And from our perspective as staff, we're probably thinking, "Oh, we need to do an assessment. It's required." But then when we put ourself in someone else's shoes, they're probably exhausted from everything that they've been experiencing, let alone either frustrated or not sure why they're answering these questions.
And I'm a social worker. Morgan's a social worker. We all have different roles on an interdisciplinary team, and that refers to a team of professionals with different areas of expertise. In a hospital, it's usually a social worker, a nurse, a prescriber, mental health techs, and those are the ones on the milieu or on the floor doing basic checks, managing the unit, man- watching for behavior concerns.
And we're all responsible for different pieces of an initial evaluation. And the client might be thinking, "How many strangers," literally people they have not met, "do I have to tell the worst thing that's ever happened to me?" And that's happening alongside all of these staff members' perspectives.
Autonomy and Trauma in Hospitalization
Ashley C.: And then there's autonomy.
So depending on the setting and circumstances, usually people in a psychiatric hospital have much less control over really ordinary things. So hospitals usually take away your belongings. They usually make you change into either scrubs or a gown, so you don't have your clothes. Even when you do get back your clothes, there's laces and strings in a sweatshirt that are usually missing because of safety concerns.
They lock your belongings up, including your phone. So someone else is also deciding when meals happen, where you sleep. You might have a roommate you've never met. You might have to sleep with the door open so that staff can check on you every 5 or 15 minutes, and remembering that these facilities control most aspects of your schedule, so when meds are offered, when groups happen, like I said, when meals happen, when you can use the phone, when visitors can come, even when you can go outside or if you can go outside at all, whether a door is locked, and ultimately when you can leave
Morgen V.: It's just a system that seems like it doesn't meet the need of someone who might be suffering internally with wanting to die and then being locked up and having kind of a punitive response, which I'm sure we'll talk about either in this episode or a future one. Some of these rules exist for obviously really legitimate safety reasons.
A procedure can be clinically necessary or legally required or just intended to keep someone safe, but it can still feel really scary, humiliating, and confusing and really disempowering. So now just imagine being someone with a trauma history. People are telling you where you can go, what you can have, when you can leave, potentially entering your space, checking on you repeatedly, really watching you closely 'cause they're concerned about your safety.
The intent is, I understand, is protection, right? But your nervous system, it might experience something truly different. And so that, it, that raises the question, just, further questions for us as therapists. How do we preserve someone's dignity when their autonomy might be limited? Of course, we want safety.
Of course, we want people to be able to seek support and help. But at the same time, understanding that dignity is also as important.
What Happens in Psychiatric Hospitals
Ashley C.: I also think people picture psychiatric hospitalization as eight hours of therapy every day, this deep dive into a therapeutic journey, and no, that is generally not what happens during psychiatric hospitalizations.
There's often groups, but I'm just remembering as a social worker on a unit, you're assigned to a group depending on the day, depending on the time, and you get the room assigned, and then you have to gather everyone who's on the unit, so anywhere between, I would say, 5 and 20-ish patients. And if groups are an hour, gathering them to a room can take quite a bit of time, and then you're trying to facilitate a group with patients who don't know each other often.
And so that's not the patient's fault, and that's not the worker's fault, but those are very difficult groups to run, and those are very difficult circumstances under which to have a successful group, I would say. So there's groups, there's medication management. There might be individual meetings with a social worker or a therapist or a nurse, but those people aren't doing therapy.
They are sessions or meetings, sure, but those meetings look an initial intake, calling family to confirm safety once they have a plan to return home, going over some skill or doing a suicide assessment or discharge planning. And you're not gonna sit down for an hour every day and process trauma. There generally isn't ongoing individual therapy in the way that you would think about outpatient therapy.
That's not the purpose of a psychiatric hospital. The purpose of a psychiatric hospital is responding to an acute crisis and stabilization. So this is anecdotally, I should've done a little bit of research, but anecdotally, the average length of stay at a psychiatric hospital is 3 to 10 days. So either when that mental health hold expires at, right at that 72-hour mark, someone either has to sign themselves in or the psychiatrist has to petition the court for an additional certification to hold that person for longer.
And a lot of hospitals might have an adolescent unit, an adult unit, maybe a detox or substance-related unit, maybe a unit for people experiencing psychosis, but there aren't specialties within all of those units. As a patient, you're not getting matched with someone who specializes in your specific type of trauma or grief or OCD, postpartum mental health, eating disorders, or whatever else might be going on.
You might be the only patient on the unit experiencing the diagnosis you identify with, and there might not be a psychiatrist or anyone else on your team who has ever seen what you're experiencing. I used to see 7 to 12 patients a day. A day. Like Morgan and I talk about what is good therapy, that is not good work, and just sets us up, and therefore the patients up, for failure.
The focus is we need to prevent this person from killing themselves. We need to stabilize this person. We need to get someone through mania. We need to address withdrawal from substances, or we need to start or adjust medication. And again, this is a matter of a few days, and that's it. And we're often purposefully not digging deeply into trauma during those few days, because if someone is already not stable or is just approaching stability, opening up their entire trauma history is usually clinically inappropriate and might destabilize them further.
And it's not really trauma informed. We don't wanna re-traumatize someone by asking them to do a deep dive into the root cause of their mental health if we are not sure about the care that they will be receiving in 3 to 10 days, for example. And stabilization doesn't fix the circumstances that led to the crisis most of the time.
So think about a person and their environment. Stabilization doesn't fix poverty, domestic violence. It doesn't create housing. It doesn't fix a toxic workplace. It doesn't cure trauma. It doesn't create childcare. It doesn't repair an abusive relationship. It doesn't all of a sudden provide supports for the person.
It doesn't erase grief. And people are usually going back to some sort of chaotic environment that they came from. So they're going back to general instability. And again, this is, a blanket statement, and it is not true for every patient, but they're going back to stressors most of the time. And at the hospital, staff is usually saying, "Okay, you're stable enough.
Here's your discharge plan
Discharge Planning
Ashley C.: And even discharge planning can be messy. I've seen discharges happen because the utilization review team, or UR, has told the clinical team that insurance is no longer authorizing continued hospitalization. And for people outside the system, UR is basically the process where the hospital and the insurer are looking at whether somebody continues to meet criteria for that level of care and whether insurance is going to keep paying for it.
I've also seen adolescents not get discharged because their parents refuse to pick them up or because there isn't an available parent or legal guardian. I've seen people medically transferred back to an emergency department because their physical health concerns suddenly outweigh psychiatric concerns.
And discharge planning rarely means we found the perfect specialty provider for you and you have an appointment tomorrow. That never, ever happens. Usually it's, "Go back to your regular prescriber, here's a referral but there's a long wait list," or, "Go to your local community mental health center," or, "Sorry, we couldn't get you an appointment with anyone, but if you experience another crisis, go to your local emergency room."
And then someone is back in this cycle of mental health crisis and being discharged, mental health crisis and being discharged, and we call that rapid hospitalization.
Community Mental Health
Ashley C.: And that leads us directly into the next system we wanna talk about, community mental health.
Morgen V.: So this is a system that I think we talk about quite frequently.
Just refer back to community mental health. They can just go to the community mental health center. Have them contact their local CMHC. We just use that language so casually, but I don't really know if we ever stop to think about what we're actually asking someone to do and what that really looks like.
Ashley C.: Or what community mental health is trying to do. In many places, community mental health is the safety net. It's where people can access care who might not have the resources or insurance to go somewhere else. Community mental health centers can provide incredibly important services ranging from therapy, psychiatry, case management, crisis services, substance use treatment groups, peer support, maybe sometimes employment services, sometimes a day treatment program, sometimes a crisis stabilization unit, sometimes services for children or families or housing.
And like Morgan said earlier, the clinicians who work there are doing really important work, and the system is trying to meet an enormous level of need with no money. Not no money, but limited resources.
Morgen V.: Oh, I could go on a whole tangent about that if you really look at the CEO salaries versus the therapist salaries, but that could be another episode.
Yes. Just like the really bad, the poorly distributed amount between therapists and the leadership. But anyway. So yeah, so- Anyway. Thank you. Yeah, I just am recalling those days of making just absolutely laughable amount of money when I first graduated from my, with my master's. And those systems just have so much need with such limited resources.
Let's again put ourselves in the position of a client. You're, you just left a hospital. You're given your discharge paperwork. Someone tells you to contact your local community h- community mental health center. You might call, you might email, but you might be told there's a wait list. You might be told that there's walk-in hours that you could go to try to do an intake appointment.
You might be told that you have to come in during a specific window and just wait. So you have to get yourself there. You might be able to drive. Maybe you can't. Maybe you have to take a bus. You might have kids and you might be able to take them and, or you might have to take them with you. You likely have a job that doesn't offer paid time off to be able to do this.
You might have a boss that's already upset that you've missed work due to hospitalization. You might still be in some kind of mental health situation. It might not be at a crisis level, but there could still be severe depression, severe stress reactions. There just could be a lot where it might feel like making a phone call or sending an email just feels really impossible.
Maybe you don't even have a working phone. There's just so many different factors here that could get in the way of being able to connect to this, this service, and there also could be that you don't understand the paperwork. We are throwing out so many terms today, and I'm just becoming really acutely aware again of the language, and when you're not in the system, when you're not, when you don't work in it and you're a client, it can just feel extremely overwhelming.
And so none of these things are necessarily visible to a clinician who might just see on their paperwork, "Client just didn't follow up." There could be just so many multiple layers.
Ashley C.: We as professionals often use words to describe clients or patients that carry negative connotations, so non-compliance, refused, not engaged, unwilling.
And as Morgan said, that word does not nearly describe the layers that make up a whole person and the circumstances that they are living in, especially at the time of increased mental health symptoms
Morgen V.: Absolutely. And I'm just naming for myself, like having a caseload, and this was already a decade ago, but I had a caseload of 90 clients.
And so it's just, it's likely hard, I'm just imagining just as a clinician who has that many folks on their caseload to really even be intentional about that. Again, the systemic pieces might not allow space for nuance. So this is where I really want us to slow down. So again, around that language piece, we're saying a client didn't follow through.
It doesn't really say why. If a client's really severely depressed, making six phone calls, didn't have transportation, needs to attend an appointment across town in an unfamiliar space, it's not necessarily about motivation. There could be, again, like that piece around work or not being able to pay a bill or having kids.
Just a lot of different barriers. There could be a tendency within the system to medicalize or pathologize or even label what is actually a systemic issue
Ashley C.: And let's say you make it to your appointment at the community mental health center. There's another intake, more questions, tell us your history, tell us your symptoms, tell us your medication, tell us your drug and alcohol history, tell us about your trauma, tell us about housing, relationships, whether you're safe.
And clinically, we do need all of that information because we are trying to conceptualize what a case might look and how to help someone. From the client's perspective, it's another system asking them to narrate their entire life to a stranger.
Morgen V.: Another thing to name is that the intake appointment can typically be with someone who's not gonna be your therapist.
So you're narrating your entire life history to someone that won't even be someone that you're gonna work with. And then they essentially will assign that, they, what they call it, like assigning the case to an outpatient therapist after that initial appointment. So that's part of the reality of what it's to be interfacing with community mental health.
Clinicians, again, are in these settings carrying these, these enormous caseloads. And it brings us to that question that I think we're hearing a lot right now, especially in the news, why doesn't the therapist just do more? The therapist might already be doing a lot. They could be seeing clients back to back.
They could be res- responding to different crises in between clients. They're documenting, they're doing treatment plans, they're trying to coordinate with hospitals. They're trying to coordinate with different providers, and they're likely calling child protection in between sessions. They're very likely talking to insurance companies, trying to find different resources such as housing, helping with benefits, trying to figure out substance use treatment.
They're likely answering emails, returning calls. And when a clinician is then expected to walk into the next session to be fully emotionally present with another human, it's extremely difficult, right, because of that juggling right outside the session. And I can just speak a- again from experience, it was seeing clients back to back in the morning and then spending my entire lunch hour calling to manage crises or to manage resources or to send emails, and then it was seeing another three or four clients in the afternoon, and that's every single day, five days a week, and without a lunch.
And that's just an untenable kind of thing with therapy
Ashley C.: And that is so hard. Just looking back at my past self 10 years ago, same as you, Morgan, I can't believe I had the energy to do that. And that is, what you listed is not including potential hours to do a treatment plan or discharge summaries, et cetera.
That's not including however many voicemails we have. That's not including maybe staff meetings or supervision. And we just spoke with another guest of how, about how when you walk into work and you have 40 voicemails and 40 emails, either you don't get back to people, which truly I understand. If there's no time, you can't create time to do that.
Or you are pushing back client work to do all of the non-client work. And like you said, that is so hard, and this is why turnover is really high in these settings. And so let's imagine you're the client. You h- maybe finally trust a therapist enough to tell them a lot about your trauma history, and then they leave.
Now you get another therapist, and you tell the whole story. That therapist leaves six months later, and then you get another one. That therapist leaves three months later. We talk about therapeutic relationships as if they exist outside of the system they're happening within, but they don't. If someone has had four therapists in two years because of staff turnover, that is a huge part of their experience of therapy.
And we talk about the therapeutic relationship being the agent of change. What if there is no relationship because of all that turnover?
Morgen V.: Oh, it's such a real situation and problem. My heart just breaks really for that experience of having to terminate with folks when I was in community mental health.
Sometimes clinicians just don't have the ability to provide the treatment that they know would be most helpful. Likely clients would benefit from weekly therapy if that could be offered, but it is mo- more likely that it could be offered every other week or even every three weeks. And I've heard from colleagues that it's right now, I think, every four to six weeks depending on level of need.
And that is assessed through the lens of how much suicidal ideation is a client experiencing, and that will likely determine how frequently they can be seen. And so if someone's not experiencing SI, then that would be, like, a lower priority client. And that's not a lens of prevention. Or
Ashley C.: treatment.
Morgen V.: Or treatment. Or
Ashley C.: treatment.
Morgen V.: Exactly. And so again, there's that limitation, and it's just really heartbreaking. As we continue to speak about this, there's just a lot here. And so again, therapy isn't providing housing. It's not providing childcare. It's not providing money. It doesn't create money. It can create spaciousness for people to be able to figure out what they need to be able to seek these resources.
It can maybe create some healing, but it just doesn't seem a very sustainable experience
Ashley C.: And oftentimes both us and the client are asked to solve problems that are not fundamentally mental health problems. Someone is anxious because they're about to be evicted. I can't prevent an eviction. I can't find new housing most of the time, and neither can the client.
Someone is depressed because they are isolated and living in poverty. I can't fix poverty. Someone can't regulate because they're living with an abusive partner. There's a lot of dynamics that play into why someone stays with an abusive partner, and that is long-term therapeutic work that oftentimes cannot be addressed in every other week or once a month therapy.
And a lot of times we're told, "Oh, just teach coping skills." That's not enough for a lot of nervous systems that have developed in trauma or in unsafe environments. That is not enough for someone who needs medication and doesn't have access. That is not enough for someone who needs a more robust substance use or trauma program.
A lot of colleagues we know, we try to advocate, we try to do research, we try to case manage, and we just don't have time and we don't have the power to influence systems in a way that would alleviate, frankly, a lot of mental health symptoms
Morgen V.: Oh, absolutely. Honestly, Ashley, we are describing, I think, one day in the life of a community mental health therapist of, like, all of the different nuances, and this is j- I'm just speaking about one day.
And I'm getting so activated talking about it because I'm just remembering what it feels like to have to figure out all of these different things with the 90 people on my caseload, and just feeling so powerless. And so yeah, you're mentioning coping strategies and kind of band-aiding people's experiences, and it's just not, it j- it just doesn't really get to the root of what's happening.
So something that community mental health can teach clinicians really quickly is you can't conceptualize a person out of their environment. Can't talk about someone's anxiety without talking about whether they have housing. You can't always talk about someone's depression without talking about whether they're isolated or if they can even afford food, or what if they have some vitamin deficiency?
What if they can't access medical care? So it's just, there, there's just so many different factors here. It's not just about someone sitting down in your chair and talking to you about something.
Ashley C.: And I'll acknowledge that for some people, community mental health is life-changing, both on the clinician side and the client side.
For clients, maybe it's where they finally get help, finally get medication. Someone helps them apply for benefits. A case manager helps them navigate housing or job stuff. And for a lot of clinicians, there's a lot that goes into working at a community mental health center. I've never worked in a community mental health center, but I worked in a hospital and in a jail.
That's where I learned crisis management. That's where I learned I have to understand the needs of my community and the resources available in my community in order to be a good therapist.
Morgen V.: Absolutely. Yes. So yeah, more than one thing is true with this. Ashley, oh my goodness. The system, yes, the community mental health system can provide essential and meaningful life-saving care.
We get that. We truly do, and I did witness that. I will say sometimes. But the same system can be chronically underfunded, overburdened, bureaucratic, difficult to navigate, and absolutely exhausting for clinicians and clients to be in. Those two truths don't cancel each other out. So now we're gonna shift our conversation here.
Jail System
Morgen V.: There are people whose mental health needs intersect with another system entirely, which brings us to jail.
Ashley C.: I'll be really careful about generalizing because facilities differ, experiences differ. Incarceration itself involves much bigger conversations around race, poverty, disabilities, substance use, mental health, public policy, power, and the criminal legal system that we can't possibly cover in part of one podcast episode.
But we're asking the same question that we've asked about psychiatric hospitals and community mental health. What might this environment feel from the perspective of the person inside it? So let's start with an intake. In this environment, someone has just experienced an arrest, which could go a myriad of ways.
The person might be intoxicated, they might be withdrawing, they might be terrified, they might be angry, confused, they might be injured, and they might have a plethora of mental health concerns going on. And while that's happening, the person is probably thinking about a million other things. Where are my kids?
Who's picking them up from school? Do I get a phone call? Am I going to lose my job? Is someone feeding my dog? Does my partner know where I am? What happens to my meds? Who's gonna take me to court? Am I gonna lose my housing? And the jail system probably doesn't care about all of those questions, but what's on the forefront of the, the client's mind is so important to understand.
Morgen V.: Oh my gosh, absolutely. If you're a parent and you don't know where your kid is, you're probably really not interested in answering someone's psychosocial assessment questions until you know your kid is safe. So you really need to understand some of the context behind that. And now you're in an environment where you have very little or even
Ashley C.: no control.
Some clients have done this before. Maybe they've been to jail, that exact jail, they know what to expect, or maybe this is completely new. Some people, there's even relief. That doesn't mean jail is therapeutic or helpful, but it might mean, I now have a roof over my head and I know where my next meal is coming from.
When I worked in a jail setting, we had clients all the time who said, "I have three hots and a cot," meaning they have three meals a day and a place to sleep, and looking at basic needs, and sometimes jail provides that to people. So not making assumptions that this is a very simple experience or that everyone has the same experience.
For some people, there is a lot of different emotions happening at the same time. This environment is chaotic and unsafe, and I have a roof over my head. There might be fear and relief at the same time. Which really should tell us something about the systems outside of jail.
Morgen V.: It's if someone is, if incarceration is the first time someone's had a predictable meal, yikes.
That's absolutely a systems issue that did not start at the jail door
Ashley C.: And I could go on and on about that, but for the sake of this episode, I'll keep it focused to mental health treatment inside jails, which is extremely limiting. I would say most facilities don't have a full-time staff member who provides mental health services.
Some might have more robust programming than others, especially mental health courts or jurisdictions with mental health courts, but access to individual therapy and a psychiatrist is usually minimal or nonexistent. And I mention psychiatry because medication access changes drastically when someone is arrested.
Someone might be taking a prescribed medication in the community that is not available on the facility's formulary. There can be delays while medications are verified or restarted. Sometimes jails will blanket say, "We do not prescribe that here." That is common, at least in our area, for ADHD medications.
Most facilities will not prescribe a stimulant. And so imagine you've been taking a medication for years, and all of a sudden you are ripped off of that with no titration. And mental health monitoring happens largely through correctional staff rather than through mental health professionals as well.
Morgen V.: Okay. So it's, this is absolutely demonstrating to us that this is very different than a typical therapeutic environment. So just imagine trying to tell someone, "It's totally safe to be vulnerable here." Really, is it? Maybe in the room with a therapist it is, but then the client still has to leave the room and go back to the jail environment.
They're, like, maybe experiencing some kind of medication situation. They might be feeling really guarded around engaging in therapy. They may not be talking about certain things and could be really protective. The hypervigilance could make complete sense around that in that kind of environment.
Ashley C.: And I appreciate what you said about not even being safe to be vulnerable, and I'll just give an example of my office.
My office, when I worked in a jail, had a window for safety reasons so staff could look in and see what was going on. But imagine that someone can watch you, and sometimes even has to do checks while you're doing therapy with your therapist. And now imagine that your therapist's office is on the same floor and in the same area as 10 of the clients' bedrooms, and the milieu or the common area is in front of your therapist's office.
So I frequently had 10 or 15 b- adolescent boys watching TV in front of my office while I was trying to do therapy with someone in my office
Morgen V.: I'm just feeling so many things right now. I will continue, though, to engage in this discussion. This might be really hard for some listeners to hear about, and it, we're sharing this for a reason. There are just so many layers of power. Therapy is happening in an institution that already controls so much of someone's life.
And I wanna remind you, we're talking about jail. We're not talking about the psych hospital, but they sound somewhat interchangeable at times. Even if you are the nicest therapist in the world, you represent something. You have keys. You can leave. The client cannot. You have access to information or resources that they might not have.
There's just so many different factors here. There's reporting responsibilities. There's obviously limits to confidentiality. We just cannot pretend that these differences disappear just because there's a warmth or because we're a therapist. We have to really remember all of the other pieces that are at play
Ashley C.: And I think acknowledging that There's so many inequalities here, especially in the legal system. Nothing is fair. And we have to subscribe to policies and procedures that are often in conflict with our licensing boards or with our ethical standards. And for us, that is really challenging, and from the client's perspective, that can seem very chaotic.
If they don't know why their therapist is doing something, it can be very difficult to trust but also reduce anxiety in a system that already has so much control over you
Morgen V.: Yep. So true. And so it's like, can you stay aware of what these environments feel to the human being experiencing them? That's the art.
Not just knowing what the policies say, not just knowing what our boards or our ethics say, not just being aware of the interventions, but just really understanding and holding these different realities all at the same time, this dialectic experience.
Practical Takeaways and Closing
Morgen V.: So let's shift this a little bit and make this practical.
If you're listening and thinking, "Okay, I can't redesign an entire mental health system tomorrow," neither can we, even if we want to. Even if we really want to, and trust me, we do. But there's things that we can do differently inside these systems that we're already in. If you haven't had to experience any of these systems as a worker, a client, or even as a client's loved one, there are things that you can advocate for if you do come into contact with one of them.
One of the biggest things is simply explaining what's happening. As social workers specifically, we really need to challenge ourselves not to assume people understand our language. So that's one. Just tell people what's happening and why. If you say, "We're gonna staff your case," explain what that means.
Explain what that language implies. If you say, "We're waiting on a UR," tell them what the UR is. If you're completing a safety assessment, explain why you're asking the questions. If someone can't leave, explain what determines when that changes. Give context to things. Information can essentially become a, a compassionate act and return a little bit of control to
Ashley C.: someone who might not have as much.
And if you're the client or the loved one, we know it can be incredibly hard to speak up when you're overwhelmed. But to the extent that you're able, ask questions. What does that mean? Who makes that decision? What happens next? When will I know? Who can I talk to? Can you please explain that again? You are allowed to not understand the system, and you are allowed to ask somebody to slow down, and I hope you do feel empowered to ask questions so you understand the system in which you are being treated.
Morgen V.: Yes, absolutely. And maybe we can't offer choices because of different rules within the jail. There's policies and laws and there's safety requirements, but there could be other types of choices that we could offer. Would you rather meet an hour after lunch? I'm even thinking of in the IFS way, does that part wanna speak or does that part wanna take us?
Does that part want to continue to be quiet? So just offering little tiny choices where in the greater picture, that loss of control has taken over.
Ashley C.: And we also need to acknowledge repetition. If we're asking someone to tell a painful story for the fourth time, name that. Say, "I know you've already told several people this.
I know it might be frustrating that I'm asking again. I read what I could before coming in so you don't have to repeat everything." And that little bit of acknowledgement might make a huge difference because it lets somebody know that you're aware of what the system is asking them to do.
Morgen V.: Yes, absolutely.
And in my ISS lens, that guarded nature or someone who is being really protective, that could be a part of them that's really developed to be able to keep them safe.
Ashley C.: And maybe the biggest one that we all need to stay curious about is power, especially those of us who work in a system where we have authority and the client does not.
We can be kind, we can be compassionate, we can be excellent therapists, we can genuinely care about somebody, and we still have power. Pretending that power isn't there doesn't make the relationship more equal.
Morgen V.: Oh, yeah. Just really being super thoughtful about how we use that power.
Ashley C.: We have to understand the limitations and the histories of systems without using those limitations as an excuse to stop seeing the person in front of us.
Morgen V.: Goosebumps. Okay, so we're about to close now. This has been like a lightning fast episode today, but we really wanted to come on here to share our experiences and our perspective. What we really hope is it's also educational. Many of us who work in this field never work inside one of these systems, but many people listening may never be clients either.
But these systems do exist. They shape people's lives. They shape our clients' lives. They shape, I think, a lot of the narrative that we're living in right now. And so if we're gonna refer people into them or we're gonna talk about them or critique them or advocate within them, we really should know what they actually look like.
Ashley C.: I agree. And we spend years learning how to look at clients, how to assess them, how to diagnose, how to conceptualize, how to treat, and we also need to regularly ask, what does the system look like?
Morgen V.: And just continuing to remember, what does therapy feel from the other chair ac- across from us? Where do our policies, procedures, rules, language, ethics, and good intentions actually land for a person receiving them?
Ashley C.: Thanks for listening and hanging out with us today, everyone. We'll see you next time. On The Art of Being a Therapist.
