Rookie therapists, rookie family support

“Thank you for the opportunity to work with your son,” the therapist said at our last appointment.  “I’ve learned so much.”  He had been a good therapist but a very inexperienced one.  The old therapist had moved out of state and my son needed an appointment with no lag time, so we traded off waiting for someone experienced with having someone quickly.  I knew from the beginning that he was a rookie, but the advantages outweighed that, or so I thought.  He had grown in his understanding of us and the next person would reap that benefit.  Just not us.

My complicated son was a challenge to even the most experienced therapists.  His laundry list of diagnoses and symptoms didn’t fit neatly into any slot.  But inexperienced therapists mistook his anxiety for ADHD and his meltdowns for conduct he could be enticed to control with star charts.  Both were untrue. We had to wade through these tentative, by-the-book steps each time we had someone who was a rookie.

Complicated kids with significant mental health problems get matched to newbie therapists every day.  Veteran parents talk online or in support groups about ways to speed up their learning curve.  We share our hard won knowledge with them and try to temper their faith in the system with our practicality.  Sometimes it works.

The very best match is for a complicated child to see an experienced therapist.  That therapist draws on their book learning, just like rookies do, and knows when to throw some of it out the door.  They pull strongly on their own hard won knowledge and have a really good idea of when to stay the course or try something new.  They often see parents as allies, bolstering our belief in ourselves.  They get it.

Many years ago, I heard Robert Brooks, a child psychologist, speak about children and building resilience.  Although I was fascinated by the topic, what I still remember was that he said he should probably go back and apologize to the patients he treated early on in his career, which was an unexpected thing for a psychologist to say.  There was so much he didn’t know, he had realized.  He gave his then-best in those early days, but lacked the wisdom, experience and empathy he gained over time.  Those are precious components in the work of therapy, ingredients that are built steadily and slowly, which make an enormous difference.

Recently, I had a chance to co-author a chapter on family advocacy in a handbook for the American Psychological Association with Kathleen Ferreira.  We wrote about the work of family partners and family support specialists and how their impact is unparalleled.  We were enthusiastic about promoting the importance of family advocacy in a volume that will probably be used to educate new psychologists.  We paused midway through and talked about the mismatch we both see between complicated kids and inexperienced therapists.  “It happens with family advocates, too,” I said and we immediately saw the parallels and went on to toss that idea about several times.

Most professions recognize that the beginner, the one who has the initial required qualifications, still has a long way to go.  In sports and law enforcement, the newbies are called rookies.  Other professions, like social work, have different levels of licensure, which indicates both experience and education.  In other occupations, such as being an electrician or plumber, there are well-defined levels of expertise.  This is also true in professions as diverse as musicians and carpenters.  A light bulb went off for both of us and we decided to apply this to family advocates.

At the novice level, we wrote, there is a great deal of enthusiasm, but also “well meaning mistakes.”  Next, at the apprentice level, the family support person has greater skills and is beginning to understand how tough the system can be to navigate.  At this stage, people often realize that while they did everything right, they didn’t get the results they intended.  Third, at the journeyman level, the family advocate has more good days, better results, has seen more and is becoming adept.  Finally, at the master level, we wrote, the family support person or family advocate “does not guess, but rather knows what to do. The advocate has skills that often make the work look effortless to others, and that is reflected in the results.” This is the ladder to mastery – from novice to expert.

Family advocacy or family support work is still pretty new and we are all still trying to find ways to talk about it.  When my son was young and we were trying to educate a rookie therapist, I noticed that my fellow family support specialists were all over the map in terms of expertise.  Some had it all together with mountains of knowledge and skills.  They were comfortable helping families whose children had significant mental health needs navigate through special education, call their insurer or make their case to state agencies.  Others knew some of that, but not all.  Still others were rookies, enthusiastic, knowing their own experiences could help the families going down the same road.  But they had a lot to learn like any newbie does. When this work was new, we were quiet about our learning curve.  We were working toward acceptance, endorsement and validation of our work.  It was the right thing to focus on then.

That was then.  I’ve been the novice, apprentice, journeyman and master.  I’ve faked it, hoping no one saw my skill gaps and I’ve said, “Let’s figure it out together.”  Like that rookie therapist my son had, I’ve learned from every parent who was gracious enough to teach me what they knew.  In the end though, complicated kids and families do better when there is expertise.  Rookies, please learn quickly.

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6 thoughts on “Rookie therapists, rookie family support

  1. We’ve had many rookie therapists…. But what is most annoying is when they are also condescending to the parent and pretend they are the experts and know better – which is so completely NOT TRUE for our complicated kids. What I’ve learned is that it works best when the parent and the therapist can see themselves as a team and learn from each other.

  2. I agreed with you, Lisa. The Family Partner I was after six years was very different than the family partner I was year one. Rookies have to be willing to ask what they don’t know, for the sake of the parents they work with. And more experienced staff have to be patient and willing to provide guidance.

    I also saw so much variation in knowledge and skill levels from FPs, therapists, and every other member of teams. With my own complicated child, I had one in-home therapist write her whole evaluation on how much she thought I didn’t know. She seemed to be angry that I didn’t want her endless supply of brochures.

  3. My son had two novice Psychiatrists and more novice therapists too count. The last Psychiatrist changed all his diagnoses that we now have to wait to get them undone. He saw one novice therapist who suggested we buy two or three oranges and put them in the freezer so that when he had a psychotic episode he would remember to go get one and it would break the episode. I inquired why she would tell us to do it. I said if we freeze the oranges and he gets angry he might use them and now they are weapons. Her response was oh I didn’t think about that. My response was he won’t be back. Both Psychiatrists were fired after our PCP learned of how his sessions were going. Tired and trying to find help. He had a great therapist but because he has Medicare & MassHealth she does not take Medicare.

  4. Lisa, this is a great post and taps into a complex and widely shared experience, I think. The “rookie” mental healthcare specialist can range from kind and ineffectual, so that you (or I should speak for myself–I!) feel guilty about breaking off treatment, to condescending, to dangerously incompetent, as other commenters have noted. Like you,our super-complex son’s case was more than once foisted off on a newbie therapist/FP team because that’s who was available–and we were DESPERATE. That is generally a losing combination, even when the team in question are lovely people.

    I like the way you frame the stages of “apprenticeship” for Family Partners. It makes total sense that the learning curve resembles any other, and that empathy alone is not enough. If only it was!!

    I’m with you (as I think you know) on the point that the knowledge and lived experience we parents hold could and should be indispensable to our kids’ clinicians. I wish there was a greater emphasis on parent/clinician partnership in MH training programs–and in clinical practice.

    Glad you are writing about these issues!! Thank you for all you do.

  5. I have worked as a school based care coordinator and community healthworker for the past 5 years in the Gardner school district. It has been the most rewarding position I have had with its many challenges, too many to list. One being, finding the right therapist connect for students. With so many variables to consider: insurance, in school or office based, request for a male or female therapist, space w/i the school to hold therapy sessions, and tentatively extensive need due to a variety of traumas. If in school services are requested, a high percentage of our students carry a Mass health product and most agencies connect “rookie” therapists with the schools. Whatever, the reasoning is…lack of staff, turn over, licensing for new staff, etc; I typically find the agencies assign newly certified therapists to work with students carrying Mass health.
    My lived experience as a parent with a child who has anxiety and depression has afforded me the skill set to work with families in an empathetic and mindful manner. Understanding the importance of working to find a good therapeutic connection the first time around vs. need to “shop” services to find another. My child’s journey, although challenging and difficult has allowed me to assist parents/guardians I work with at a higher level of understanding to address the child/adolescent as a whole; an understanding I wouldn’t have otherwise.

    1. Part of the reason rookie therapists are assigned to MassHealth clients is because most private insurers require a license. If you are doing internship hours, without a license you tend to get the kids on MassHealth because the agency can bill for them and not provide direct oversight. With a kid on private insurance I would need a licensed clinician to come with me to open the case before I could start billing.

      I’ve been on the other side as a rookie therapist with a pretty complex kid, knowing a case was far beyond my current capability and not being able to get the support I needed, and was asking for, from my agency. I knew my limits and they kept insisting it was a great learning experience, which I strongly disagreed with. To me it was unethical and playing with fire.

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