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Episode Description
It’s your third code of the day. You haven’t eaten. And your supervisor shrugs: “You signed up for this.”
Jill Barker spent eight years in crisis work in ERs and behavioral health hospitals before moving into private practice. She joins hosts Ashley Charbonneau and Morgen Villegas to talk about why therapists leave crisis work, and what keeps some of them going.
They get into back-to-back schedules, insurance limits, and what it feels like to physically restrain a client you came here to help. Jill also shares her fight with the LCSW exam and the social work board. Her take: good therapy is not measured by an exam.
If you’ve ever felt alone in a broken system, this one’s for you.
GUEST BIO:
Jill Barker, MSW, has spent most of her career where mental health care gets the most intense. She started in a 24/7 psychiatric and substance use treatment facility in New Jersey, then moved to emergency department crisis work. In 2020, she brought that work to Colorado, where she kept doing hospital-based crisis care.
After nearly eight years in crisis services, Jill moved into private practice, where she focused on trauma and trained in EMDR. Today, she’s back in direct patient care and getting ready to open her own practice. She’s passionate about making Colorado’s mental health system stronger and easier to access.
CHAPTERS
[0:00] Content Warning & Introduction
[3:40] Welcome & Meet the Guest
[6:22] What Makes a Good Therapist
[7:49] How Systems Impact Therapy
[13:17] Crisis Work & Physical Restraint
[15:56] Burnout & Finding Community
[18:25] Licensing Exams & Systemic Barriers
[25:54] Critiquing the Field & What's Next
Transcript
Content Warning & Introduction
Ashley C.: For today's episode, we will be talking about some potentially difficult topics as they relate to work in residential facilities and psychiatric hospitals. Before we jump into today's episode, I want to offer some context and set the stage for our conversation. In parts of today's episode, we will be talking about something that's often referred to as physical management, a hold, or putting hands on a client, or a restraint.
Depending on the setting, this can include physically restraining someone when there is an immediate risk of harm to themselves or others. If you've worked in a high-acuity environment such as a psychiatric hospital, a residential program, correctional facilities, or jails, this might be something you've witnessed or even participated in as part of your role.
If you work in private practice, outpatient mental health, medical social work, hospice, most school settings, community mental health, or many other areas of our profession, you may have never encountered this before. Hearing therapists talk about physically restraining a client may bring up some strong reactions, questions, or even discomfort.
If that's you, I want to invite you to notice those reactions rather than immediately judging them or even judging us. Ask yourself, "What is this bringing up for me? What assumptions am I making? What experience have shaped the way I think about this?" Our hope here, it's to have an honest conversation about a reality that exists in some corners of the mental health field, one that many of you will never experience, while others may encounter this regularly.
I also want to acknowledge something important. In a perfect world, none of this would be necessary. In a perfect world, every client would receive the support they needed long before reaching a point of crisis. Every environment would be adequately staffed, trauma-informed, and designed to prevent escalation.
Every setting would have the time, resources, and space to de-escalate situations without anyone ever needing to physically intervene. However, that is not the reality in which many of us live or work. Many of us work in settings where we are responsible not only for the emotional well-being of the clients that we serve, but also for the immediate physical safety of clients, staff, and others in the environment.
Sometimes those responsibilities intersect in incredibly difficult ways. I myself have explored a lot of the ethical dilemmas that go on when we are asked to put hands on our own client, for example. Today's conversation lives in that tension. It's not about minimizing the potential harm that can occur when physical intervention is used.
It's about acknowledging the complexity of these moments as well as the impact that this type of intervention has on both our clients and ourselves as humans and as helpers. Wherever you're listening from, I hope that you approach this episode mostly with curiosity. Even if your practice or job or role or career looks very different, I hope this conversation gives you a greater appreciation for the complexity of this work happening across different corners of our profession
Welcome & Meet the Guest
Morgen V.: Welcome back to The Art of Being a Therapist: The Space Between Training and Real Life. This is the podcast where we explore the human side of therapy, the stories and the questions that we don't always have easy answers to. I'm one of your hosts, Morgan, and you just heard from my co-host, Ashley. Today we are diving into that question almost everyone who's ever sat on a therapy couch has probably wondered about: what actually makes a good therapist?
Not just someone with a degree or training, but someone who truly helps people heal. We're excited to explore that with today's guest, Jill. She has worked across almost every corner of the mental health world, from psychiatric facilities to intensive therapy with child welfare clients and families, work in large systems, and outpatient therapy with weekly clients.
She's done therapy and de-escalation in crisis settings. She's done therapy in high acuity settings in hospitals. So today we're talking about what she's learned from all of that, what she thinks clients need, what therapists get wrong, what licensing exams mean, and how therapy changes across settings.
And of course, how systems impact all of that. Welcome.
Hi. Thanks for having me. Ashley just set this up, and I'm gonna start with a question. Your career path gives you such a unique lens 'cause you've worked in so many different environments. Would you be okay just walking us through that journey? Back east I worked in a behavioral health hospital doing crisis work, and I worked in the emergency room for a little bit before I moved.
Jill B.: I was able to transfer to a behavioral health hospital out here where I continued crisis work. After about eight years of crisis work, I decided to try private practice where I had a focus in trauma. I also received training in EMDR and I did private practice work for about two years. Then I switched over to a fully remote position where I wasn't doing as much patient facing, and now I'm back to doing some patient facing.
Ashley C.: I'm curious about expanding on some of the questions that we originally started with. Given all of the places that you've been and the perspective that you have, how have you landed on what makes a good therapist or how we provide good therapy? you've interacted in multiple complexities of mental health as well as the systemic piece, and then the licensure piece.
What Makes a Good Therapist
Jill B.: So I know that's kind of a broad question, so let me know if you need more specificity there. One thing is not being judgmental, just listening and holding space and offering support to a client. Ethics and following state guidelines is also very important. I think one thing I learned when I was doing trauma work is everyone moves at their own pace, so it's important to allow people to grow and meet them where they're at.
That's a little bit of my social work lens. I remember first starting trauma work and feeling like I wasn't doing enough to help people, but over time I realized that there's so much that goes into it. Building rapport, offering that safe space when people are ready, if they're looking to process, if they're looking to get to know you before they get into the trauma work.
Morgen V.: So I think that was something that I learned when I started private practice. How do you think systems influence that? How do you think systems influence our ability to meet clients where they're at? Depending on where you work, if you're working for a larger system, sometimes there's more pressure on the therapist to meet with so many patients a day.
How Systems Impact Therapy
Ashley C.: Sometimes they're making your schedule for you. How do systems impact or intersect or even prevent us from being able to do those things? Yeah, you said it, Morgan. Prevent. I didn't wanna lead Jill too much, but yes, I love that you just went for it. Yeah. So I would say one is a lot of places wanna make your schedule, right?
Jill B.: They want you to have so many slots to see so many people a day. Do we actually get a break to take care of ourselves in between clients, like a lunch break, going to the bathroom, drinking water, having 10 minutes in between just to reset for yourself before the next client so you can ensure that you are giving them your all and your best when you meet with them?
Some places are better than others, but some are very... They pressure you in the sense of you have to be seeing this many people, this many clients a week. Sometimes they don't let you choose what clientele you wanna work with. Sometimes they're just like, "We have a lot of kids, so you're gonna meet with a lot of kids," which I don't mind kids personally, but if that's not their population, it could be hard to navigate.
I think sometimes The systems really prevent us from doing the work, 'cause if you're scheduled back-to-back clients all day, what happens if someone needs a few extra minutes and your job is very pushy of, "No, that's the time they have, and then you gotta keep it moving"? I think that's a big part of it, the pressures they put on us, and it's all about how many people are you seeing a day, but also insurance.
It goes with systems that sometimes they dictate to therapists how you treat the patient, how often you can meet with them. They may deny a service. So those things affect patient care, and it's unfortunate, but I think a lot of people in our industry try to speak up and ask for supports even if your employer may not be willing to give them to you.
Morgen V.: Systems almost pressuring us to be unethical sometimes, right? If we don't have capacity and we're exhausted, if we're not at our best, that is not good patient or client care. Pushing us towards a certain population even if we don't have the interest or even the training or the specialty supervision for that, that's not good client care either.
I would blame myself for not being able to do the things in the quote-unquote right way, and ultimately I couldn't do it. I couldn't sustain a practice in community mental health because it did feel unethical and it didn't feel right. I just couldn't do it. I'm curious if there's other stories with that or other observations of how that has unfolded for you in your life now that you can look back in retrospect in some of those environments, right?
Jill B.: Yeah. I would say that no matter what area you're working within our industry, whether it's behavioral health or something else, I think a big part of success is having a good manager or supervisor, someone who is pushing you to be your best, but not pushing you in the wrong direction, right? "Oh, hey, you've been working really hard today.
Maybe you should go step out," or, "That last client, you did such great work, but it was heavy. Why don't you go take a walk or take a break?" I've had some really great supervisors in the past, especially in crisis work. I remember being in a code once, and my supervisor at the time was like, "Hey, that seemed really heavy.
Go step outside for a few minutes." And I know it's something that sounds so small, but in the moment it really does make a difference, and I think that's how I lasted so long in crisis work was the people that you're surrounded with. I worked with a lot of incredible people who I really felt had my back because most behavioral health hospitals don't have security, so it's you and your coworkers are The security.
So I think that's really important to have, and then I've also experienced it on the other side where you have a boss who just wants to make your life a living hell and it doesn't matter what you do. Everything you do is wrong. One of my first bosses told me one week my assessments were awful and I needed to shadow someone, and then a week or two later it was, "Oh wow, Jill's seeing the most patients every day."
Morgen V.: And I remember having good coworkers who were supporting me and my one coworker saying, "Wow, our boss just really hates you and I don't know why." It's just important to have that support because you really do need it. I wanna go back for a second for our listeners who may not know what a code is. Jill and I both worked in settings where we, the therapist, the social worker, has to go and put hands on a client to physically manage them or restrain them because of a crisis situation.
Crisis Work & Physical Restraint
Morgen V.: And that is probably a whole nother podcast episode. Very traumatic for everyone involved. We as helpers don't naturally lean towards putting hands on other people, and when we have to, it's difficult to wrap your mind around. I wanna highlight what Jill said. Sometimes it is code after code after code or you have a supervisor who's like, "Well, that's just normal.
Jill B.: You signed up for this." I think you nailed it. I would just like to add that it's a last resort if they're a danger to themselves or others. If they're disruptive in some way, the first step is we wanna try and do verbal deescalation, but sometimes we may have to go hands-on, and it's the least restrictive, for CPI for example, they always say it's the least restrictive restraining technique.
Morgen V.: Yeah, and by least restrictive can also consider putting a client behind a locked door and not letting them out. In the types of settings Jill and I have worked in, we don't have weapons, whereas in some places like prisons there is security who have weapons. I've only gone hands-on probably once or twice with a client in my whole career, but- It's so hard to describe unless you have to do it.
The impact on you, on your sense of morals, on your sense of "I'm a social worker." This clarity here around having a good supervisor who would be able to say, "Go take a break. Go re-regulate your own nervous system. Work through whatever traumatic kind of body response you might have had in that moment," versus a different kind of supervisor who's like, "This is just part of the thing and this is what we do, and move on to the next crisis," right?
Ashley C.: I'm holding all of this in my own nervous system right now, and it's feeling really activating. It's hard to reconcile the requirements versus their own expectation or our own hopes for this career, right? That's how they get burnt out the fastest, and that is painful for so many of us to carry. You're telling me I'm a great clinician, and you are crushing me with my schedule, and I don't have a voice and I don't have choice Jill, I don't wanna speak for you, but I think you and I have had similar experiences where I have felt alone because of situations Jill described for people who have never worked in a 24/7 facility where you are trained in some of those techniques.
Burnout & Finding Community
Ashley C.: I just remember going home and you're like, "Who do I even talk to about this?" And then you find someone like you, Morgan, or like you, Jill, and you're like, "Okay, I have a community. I need to keep building my community. I can do this. If I don't wanna do this exactly, I can see a way out." Other people have forged a path outside of these high acuity settings.
Morgen V.: Jill, I think another thing you and I have had in common is we started in systems, left a system, went back to a system, left a system, went back to a system, then private practice. I think it's hard too, 'cause depending on what kind of system you're in, it really just makes or breaks you. And I think a lot of it comes down to the burnout, being overworked, asking for things and not getting them, if there's a safety component, those basic needs that we require to be in this profession and be able to do our best work every day.
It's hard when we don't have them. It doesn't create a sustainable career. What I'm hearing you say is that when you have people that have your back or providing emotional and some physical security, that's what creates a sustainability, right? That's the pocket of resistance against insurance or some of these systems.
It's the sticking togetherness. It's the camaraderie. It's finding people that have similar values that do create a shift, that do create that counter-energy to what you're describing in the system, where you can be effective and you can have movement and momentum with folks. And I think it's really important that, going back to what Ashley said, like feeling alone, that resonates with me a lot.
I can relate to it in a lot of different ways. Sometimes this industry can be lonely. I even felt lonely when I first went into private practice 'cause I just went from a shared office and being ready for my next crisis to being like, "Okay, I'm sitting in a quiet office. What do I do with myself? Just wait for my next client?"
It's a very different feeling when you come from such a high-intensity place of work. But I think your coworkers really make the experience, and I think that's why even in a lot of failed systems so many people stay because they have that camaraderie- ... with each other, even if they don't have it with management.
Licensing Exams & Systemic Barriers
Ashley C.: Yeah, I agree. I want to talk about a topic that, Jill, I know is really important to you and has really impacted you. But Jill, I'd love to hear your experience or beliefs about licensing exams because that's another system that really impacts all of us regardless if you're a social worker, a professional counselor, a marriage and family therapist, or a psychologist across states.
Jill B.: That is something that all of us have had to go through. Yeah. It's something that is very important to me, and I've been battling it for quite some time. For those that don't know, for social work, every state has different requirements. I went to school in New Jersey and then moved shortly after to Colorado.
I didn't do enough research on my own to find out what Colorado needed and how to navigate DORA's licensing board. That was a struggle. Since then, I've been navigating issues in regards to our clinical exam for social work. I've sat before and I've been very close, and I have had special accommodations to help support me with testing, and the social work board makes it challenging for people in our industry to get those accommodations.
I recently had to redo it and they changed the process a little bit. LCSW exam is changing in August, so the board's hope is that it will be better for people to sit for the exam, and they're switching up content a little bit. I think that a lot of it is my own struggle. I think overall it is demoralizing to have a nurse practitioner, a therapist sign off on your accommodations, and then you have to fill out a whole testimony for yourself to the board as to what ADHD is and why I need these accommodations.
I understand paperwork is involved regardless, but I think Our board can be more accommodating with people's needs, and if they need additional testing arrangements. I read a lot online how we're having a lot of shortages between social work, healthcare in general, other clinical professions, and it's the constant question I'm asking myself, like, why is it so difficult?
Morgen V.: Why do they make it so much harder? I wanna know that, too. ASWB, if you're listening, y'all need to do better. Do better. Do better. There's gotta be some reciprocity, like in exchange for year over year in the profession, to maybe waive the exam requirement or something like that. I just feel like that is absolutely not the essence and spirit of social work, right?
Where we are supposed to be thinking about meeting people where they are. So what you're naming is like a reflection of a system that is not conducive to providing good social work or therapy. When you're in a program, they really push that your board is, "Go to your board," or, "They support you."
Jill B.: Maybe someone has a different experience, but I feel like every time I've tried to reach out to them, they need something else or it's not enough. So my hope is that if anyone's listening, you're not going through it alone, and we will get through it together. And I'll take it one step further. Good therapy is not measured by an exam.
Morgen V.: That exam is so arbitrary. I can remember some of the questions being there's three possible choices, and I could not narrow it down, and I ended up picking whichever one, because it's based on your own objective view and your own worldview. Yeah. That's one of the conversations I'm having with students, with supervisees, with colleagues, with people who have been in this field much longer than I am.
Ashley C.: Make it make sense, right? You're telling me to speak out. You're telling me to fight for equality, to fight for equity, and then one of the biggest things that governs our field is unfair and not equal and impacts different people of different identities in different ways. And I think that is one of the hardest parts, is make it make sense.
Morgen V.: We're social workers and this is how our field is governed? What? What blows my mind is that they say the longer you're out of school, the harder it is to pass the exam, which I also think is interesting because- Wouldn't it be like, "Oh, I have this many years in the industry, I know these ethical dilemmas."
Jill B.: So some of it to me is unrealistic scenarios or I get tripped up because I'm like, "Wait, I wouldn't do that in my actual career." Yeah. In a real-life work situation, I'm not doing that. So I find it very interesting. When I'm doing practice questions, I have to forget what I've learned in the actual industry and focus more on this is how the test wants me to answer.
Morgen V.: Yeah. I have that conversation with supervisees all the time because in Colorado you can't take it until you have your supervised hours completed or close to completion, and I think that's the case in a lot of other states. And so that's minimum of two years post-grad, and the conversation I have with supervisees is, "I know you're a good therapist.
I know that you're doing a good job. I don't have any doubt about your ability to practice without supervision or to move towards full licensure. This test is about relearning how to take a test." And Jill, if evidence shows that the longer we're away from school, the harder it is for us to take a test, why are we set up that way?
Ashley C.: Why is our field set up that way? And it's not about knowledge, it's about how do you take a test, how do you read those questions. Morgan, you said you couldn't pare down three answers, and that's what test-taking is, right? It's not about the content or the lived experience or the knowledge, it's about how can I beat this test question?
Morgen V.: That's so true. I feel like that's naming of another kind of crisis in our field, right? The gatekeeping and the incongruence between the academic stuff that we learn in school versus what it's actually like on the ground, right? The theoretical framework versus what it is that we actually do.
Ashley C.: So these are all things that we grapple with, and the more that we can have these meaningful conversations with each other is what creates that sustainability and that, quote-unquote, good therapy, I think. I think you're speaking to what we've talked about today, and Jill's experience really helped frame this conversation around how do systems prevent good therapy.
Critiquing the Field & What's Next
Jill B.: Yeah. And I think a year ago I was really scared to critique our field, and I'm not going after our field. I'm a social worker through and through. But I think fear keeps us in our place. That's how systems thrive sometimes, and it takes strength and openness to have conversations like we did today around insurance and hospitals and harmful bosses, harmful practices with patients.
The field as a whole being governed the way it is also very painful and feels like a betrayal. I'm in a pivotal moment. I'm thinking about going back into private practice work and opening up my own practice, and I have a few other ideas in mind. I'm really looking to spread my wings and flourish as a soon-to-be LCSW.
I should be fully licensed in the next few months, and I'm hoping this new journey opens up a few more doors for me. I think a lot of our listeners, it really resonates with them around systems and private practice. I think a lot of us have a similar journey to you, Jill. And that's why I wanted to share my story.
I think it's important to understand that everyone's on their own journey and we all move at our different pace, and I just hope that I reach someone who's going through similar things and know that you can do this. Yeah. We got it. Don't let the system or anyone else get you down. I love that. Love that.
I'm just gonna take that in for myself today. Thank you. Yeah. Thank you. Thank you guys so much for this opportunity. I loved being a part of this and I'm excited to hear the rest of the podcasts. Thank you for being here today on The Art of Being a Therapist. If this conversation resonated with you, subscribe, leave a review, or share this episode.
Morgen V.: And as always, remember, good therapy isn't about perfection, it's about presence. We'll see you next time on The Art of Being a Therapist.
