[Disclaimer: I have used aliases to protect the confidentiality and identity of clients or patients. No other names have been changed.]

While I was working at Duplin-Sampson County Mental Health Center in Clinton, North Carolina, I had a number of different responsibilities. I was hired as a Social Worker III. That was my title. I worked as a therapist/psychotherapist and I had to do intake assessments, as well as maintain a caseload of some fifty or so clients who came for therapy and medication monitoring.

I was frustrated that they didn't let us do therapy with clients without being interrupted. Other mental health clinics in North Carolina manage this but they couldn't figure this out. I would be meeting with someone and the receptionist(s) would get mad if I did not pick up the phone if I was in session with a client.

Sometimes I would pick up on the second call and they (one young woman was the most irritating) would ask me why I didn't answer, and I'd say "I was working with a client - we are doing therapy. I was distracted."

"Well, she has to see the doctor and he's ready."

I would think, and sometimes say, "I'm not ready" or "we aren't ready." I would then say "she's a real bitch!"

I didn't like the psychiatrists and some of the staff. It didn't seem that they respected the clients. I worked side by side with other therapists/social workers, mental health nurses, and case managers.

At least at this job, I was more than a case manager as I had been in my previous job that lasted all of one month. You don't have to have a Master's in Social Work to be a case manager. Plus, I was at home with Lynn every day.

The case managers would bring clients to the clinic for the day treatment program or for sessions with me. So, that was cool.

I was meeting with a Licensed Clinical Social Worker (LCSW) and finishing up my requirements for becoming an LCSW myself - I was still provisional.

I remember being in a staffing meeting when a psychiatrist remarked that he works with "chronic crazies all day." It infuriated me. Plus, why did he think that he was free to speak like this in the clinic? Was this okay here? Did people have such little respect for clients with mental illness?

It's a good thing I was going to get all the hours I needed for my LCSW before leaving. I had in mind working in private practice once I was licensed. Can you blame me?

I reasoned that I could still work with vulnerable people who didn't have lots of money. I had been told that there are ways to be accommodating to people with a limited income when you work in private practice. For one, you can work pro-bono – for free – if people can't afford to pay or if they cannot afford the flat rate.

Anyway, one of my duties was to visit the local hospital to do evaluations at the local hospital to determine if someone required psychiatric hospitalization, such as was the case when suicide was involved.

I would make an assessment as to what happened... how did they end up at the hospital? What method was used to end their lives if that was the case? Did they still have access to that weapon or method of suicide?

Most of the time they were indeed suicidal, and I had to go to the magistrate to request involuntary commitment orders. They would then be taken to the clinic (sometimes) to get the doctor (psychiatrist) to sign the order for commitment.

I was never over-ruled in my assessment. I mention that because not everything I observed and concluded about the treatment of a client was something that the psychiatrists and I saw eye to eye on.

Interestingly, some of these people who were committed to an inpatient hospital (I had to find a placement also) were my clients or I would offer to work with them. Here, I was sending them to a psychiatric hospital against their will for a commitment and they are happy to work with me when they get back!

I say all this to illustrate why I wanted to go into private practice. Not only would I have more control of how things are run but I knew that when it came to working directly with clients, I NEVER had any problems.

I did work with clients with psychotic disorders like schizophrenia and many people at the clinic seemed to see very little value in psychotherapy treatment for schizophrenia. So much revolved around the psychiatrists and they seemed to control the decisions about the treatment of mental illness or psychiatric disorders in the area for those who could not afford to go elsewhere.

Culturally, the area is rather rural. Pig farms were very common around the area and this created a stench, to be honest. There were a lot of trailer parks. Pockets of Spanish-speaking communities dotted the countryside, and my knowledge of Spanish was useful.

The population was over 50% white and just over 25% African American, but that being said, the ratio of clients at the clinic was about 50-50 White and Black. That reflects the role income plays in access to mental health services or being exposed to the mental health system.

The attitudes of the staff to the extent that they were somewhat disrespectful of clients and the therapy process had more to do with the attitudes toward mental illness than racism.

Towns were small. People knew one another.

For example, there had been a violent murder in one of the nearby towns which made all the newspapers. The murder and trial had been a few years ago, but the sister of the murderer was still hiding her face in public. She was my client and she had come into the clinic wearing a scarf.

The things I was learning also seemed to be met with superstition among the religious folks of the area. I was studying clinical hypnosis and I remember one client saying she was afraid that the trance state might make her vulnerable to the Devil or Satan. That was the first time I had heard something like that.

Some of the delusions that people had were obviously religious. That should come as no surprise in a rural county.

I was curious and confused a bit at times by the nature of different hallucinations that I heard described. I met with people who described hearing voices, seeing things, and tactile hallucinations. When I say I was confused, I mean I had an open mind, but I could not readily understand what a particular experience was like. So, I listened to the descriptions of various experiences being described by clients.

I wasn't judgmental or anything, but I sometimes didn't want to just take the word of the psychiatrist regarding a diagnosis and the proposed remedy.

Take for example a client who had primarily tactile hallucinations of crawling sensations on her skin and possible delusions about an unknown disease. The doctor saw her for fifteen minutes and maintained her on Zyprexa. The side effects of this anti-psychotic were not as serious as those of older anti-psychotic medications like Haldol, but it was still a major tranquilizer.

There have been some mental health professionals who have said that only psychiatrists can diagnose mental illness or psychiatric disorders. I question that. I mean, the doctors were not doing medical tests when I brought the clients in front of them, and they processed clients every fifteen minutes.

I just felt it was valid to really listen to people to understand their experiences. Was the medication making their life better? That's what I wondered.

My attitude toward at least one doctor was somewhat cautious if not suspicious - the doctor who referred to clients as "chronic crazies" and one of his colleagues.

One day, I took a particular client of mine to see the psychiatrist. My client was complaining about the side effects of the medication. The doctor acted like he was ignoring him! And he held up the microphone to the dictation machine and dictated notes while speaking to the client.

He was referred to a day treatment program, I went and looked for him. Technically I wasn't supposed to meet with him for treatment at this time, but he was on my caseload. He was still my client. I told him that he has a right to refuse to take medications and to put that in writing.

That got me in some trouble. I was told that I should address it with the team!

Another client had schizophrenia and the general sense I got was that psychotherapy for this condition isn't a high priority. This young woman wanted therapy with me. So, I just added it to the treatment plan. If that is what the client wanted, why not.

Luckily, they didn't go out of their way to over-rule the preferences I made for how I would provide treatment if there was time.

By adding therapy to her treatment plan, that also obligated the case management team to bring her into the clinic because my client didn't have her own transportation. The case managers were good about that and didn't complain.

These are just prototypical examples of my experiences.

I started seeing one client who had some unusual symptoms. Her name was Nancy. She had come in dealing with depression and panic attacks. Those were her diagnoses.

Nancy was 27 when I started meeting with her.

She began to describe some dissociative symptoms that one might find if a person has experienced something traumatic.

I would listen to her and ask her to clarify what she meant.

I had a few structured interview techniques that I was using to explore these experiences.

I would ask very open-ended questions like "Can you tell me what that is like?" I wanted to be sure that nothing I might feel about her experiences influenced her responses or my exploration.

Also, the interview questions that I was using as a guideline were very subjective. Asking "what's that like?" can help to increase our understanding of what life is like for a person. I use the word "our" understanding to indicate that both I and the client are working together to understand what is happening.

I asked about traumatic experiences as well, such as sexual assault. She mentioned an event in which she had been sexually assaulted a couple of years ago.

I did try to broach the topic that something more might be going on than Major Depression and Panic Disorder. The doctor hardly seemed to be listening. Nancy was right there, and I was alternating my gaze between her and the doctor.

He just asked more questions about her medications.

After meeting with the doctor, she said to me, "I was telling you that the medications are not helping with my problems."

"I know and I wish I could do something about that," I told Nancy. "I can't advise you about medications."

"He wasn't even paying attention," she said.

"I know but I am, right?" I asked.

"Yes, I appreciate that you believe me," she said.

"Do you mean some people don't believe you?" I asked.

"Well, my boyfriend doesn't understand things and before you, I stopped coming to the clinic," she said.

"What's not to believe?" I asked.

"I don't know," she answered.

I had used a popular interview schedule that had some questions that were medical and thus outside my area of expertise but the information I gathered would be helpful.

We ruled out substance abuse or use.

It was somewhat amazing how competent and disciplined Nancy seemed. Her job and career did not indicate college plans, not yet. That's unfortunate that she had not considered this because she seemed bright and intelligent.

We discussed her experiences of child abuse and trauma. This is where it got very disturbing. It's also amazing what she remembered. I tried to keep this clinical and to avoid pulling her into any of the memories at this time. So, we moved along in a matter-of-fact manner.

The abuse in her childhood was both physical and sexual. It was rather disturbing what had been done to her by men and women. She confirmed that she had been forced to have sex with people of different sexes, ages, and even with animals as a way to make her feel shame or as a form of punishment.

Obviously, this was all very disturbing.

She admitted and described things in such a matter-of fact-way that made her seem so believable. It wasn't like she stopped and said "no way, that's really disturbing."

She would pause when I asked a question, then say "yes" or "no" to various questions. I tried not to use any suggestive phrasing or to indicate approval or disapproval for any of her answers.

Sometimes people can over-represent their problems or symptoms as a cry for help or indicate a need for help - perhaps even to indicate that one deserves the more intensive treatment that is available.

She would provide details after she answered "yes" to a question as she recalled examples of an event or an experience. She actually didn't seem overly eager to participate all the time in therapy. So, it didn't seem like she was going out of her way to gain my sympathy.

This interview was done outside the clinic. We went outside because it seemed more accommodating to her. Her mood and interest changed at times.

She was vaguely aware of hearing voices and a feeling that she was different at different times. Her experience of amnesia suggested a dissociative disorder.

There was so much more to explore. I did present my findings with the doctor at our next session and suggested that there might be more to explore.

At some point, when speaking to me alone, the doctor indicated that he thought I was suggesting that she had Dissociative Identity Disorder and that he didn't believe in that disorder. That is a condition in which people have different personalities.

I indicated that it is too early to tell but it was frustrating and confusing that any diagnostic disorder was "not believable."

Unfortunately, my experiences at Sampson County Mental Health were ending. I was asked to resign. The chance to work more with Nancy was interrupted shortly after I had made such progress and had helped her to gain some insights and to feel like someone was listening to her.

There were a number of reasons for my departure including going outside the traditional structure of the clinical staff, being behind on paperwork/charting, and a few minor issues that reflected my unique values that may have been out of step with this clinic.

I had gained the clinical supervision hours to qualify for the certification as a Licensed Clinical Social Worker and that meant I could go into private practice.

During the next section of this book, I will discuss my experiences in private practice. This was the height of my success and where I had been going with my career for as long. I had accomplished so much over the past fourteen years. So many accomplishments.

accomplishments.