I was recently talking with a therapist buddy about applied RPGs, and I started talking about the work I do with in-home services. He said, "God, I wish I could do that, how do you get into that?"
So, today, I'm going to talk a bit about my day job. It's still a little relevant to the applied RPG stuff, as I have used gaming quite frequently, but I also just want to talk about the nature of the work as a whole for people looking at getting into it.
I work for a WISe agency, which is what it's called in Washington, but in most other parts of the country they use other terms like Wraparound, etc. What it comes down to is that we provide intense in-home mental health supports for families frequently entering crisis to reduce the amount of police/emergency calls and hospitalizations. It's similar to the mental health crisis response stuff people have been talking a lot about (CAHOOTS), but more pre-emptive- we have supports in the home when crises are likely to happen so we can either deescalate them, assess for triggers, or provide therapeutic supports to the family to address stressors. We also have a crisis service where we do respond to crisis, but it's only with youth at this time.
It's very hard, emotionally draining, and occasionally high risk work. But it's also incredibly rewarding to see a family go from being absolutely miserable and in crisis constantly to thriving and able to manage crises as they arise.
There's three roles, generally- a clinician, who is a therapist who handles the mental health side of things, a care coordinator (this is what I am), who is more of a case manager, and a peer counselor, who works with the youth or parent to help bridge the gap between them and the therapist and ensure their voice is heard. We provide in home services several times a week at whatever hours are convenient for the family. For me, this usually means I'm working evenings, and during the school year my typical day starts around 1 or 2pm and ends around 9pm, but I know other people who work much more scattered hours.
I think the most important thing is for people looking to get into this work is to have realistic expectations, as the burnout rate is very high. I've been doing it for about two years (for this stint), but before that I did a five year run before college debt forced me out. However, while I was taking a break to do tech work and pay off student debt, I thought about it constantly, as it's incredibly rewarding.
As such, here's the most important things to understand about this work, both pros and cons.
-You are working where the action is happening. I can't stress how much of a difference this makes, being able to see the behaviors happening in real time. I've sat in on intakes where parents and youth will report specific things, but actually witnessing their in home interaction, it's completely different. This ability to see the behaviors in real time allows for a lot more accurate and swift assessment. I absolutely love this aspect of the work.
-It feels good. You are helping families in dire need, often times struggling with poverty and any number of other stressors. Watching a family go from feeling helpless to deal with their youth's struggles to feeling confident as a family that they can take on anything is one of the best feelings in the world.
-You're doing good. A lot of the mental health offerings for low income families are not great, and lot of these families are at their last straw after having been failed by various agencies and organizations for years. Being able to really help them when they have been struggling gives you a sense of making the world a better place.
-You're reaching diverse clients, and there's diverse staff. There's been this sort of assumption that therapy is only for rich white people, but that's not who we work with. We work with people of all different ethnicities, sexual orientations, religions, and walks of life. Furthermore, our staff is very diverse, which is amazing. Still female dominated like most mental health, but it's great to see so much overall diversity in our ranks. On top of that, there's a lot of educational diversity, ranging from people with advanced graduate degrees working in the more clinical roles to people with their GED working as peer counselors. I think it's critically important to allow people from all levels of educational attainment to be able to work in mental health, and this allows it.
-You get to have a flexible schedule, to a degree. I personally like working swing shifts, and that fits in with a lot of the work I do. I also tend to front load my sessions Monday through Thursday, so I can take Friday as a slow day to work on paperwork.
-You can get creative. I've done interventions with youth that use collaborative writing, Dungeons and Dragons, Minecraft, and any number of geeky passions, and using these tools to help families is an absolute blast. I've also been able to train other staff on how to use Minecraft to help build rapport with kids and help them with emotional expression and frustration tolerance. Just awesome stuff.
-You learn how to deescalate situations. This is a really cool ability that I've gleaned, the ability to calm situations down and help people in crisis self regulate. Being really good at this is something that is useful all throughout life, and I wish more people (especially in emergency response) had the same training that I got.
-You're on your feet a lot. I think one of the reasons I stayed in shape during quarantine was I was still working out in the field, as even during lockdown, we had crisis responder status. Having to stay active with kids (and often doing sessions outside to lower COVID risk) had me walking a lot, and I personally really enjoy that.
Now for the cons.
-The pay is not great. In comparison to being a private therapist or working in the private sector, the pay is significantly lower. However, with the amount of driving that is involved, mileage can actually make the pay quite good, but this is ultimately dependent on how far out your clients live.
-Your schedule can be absolute chaos. A lot of these families are dealing with a lot of poverty and other life stressors, and that can cause them to be difficult to reach, needing to reschedule constantly, or only available at weird times. This can be a good thing, sometimes, but it can also be very hard on your social life when you're busy most evenings.
-On call is difficult. You can get calls from clients in crisis at any time, and this often means that you will need to step away from dinner, hanging out with friends, spending quality time with loved ones, or sleep to help them through it. I've had clients reach out to me in crisis at around 6am, and as late as 1am. It's not fun. On top of that, there's weekend on call rotations, which I really struggle with, as I'm one of those people who, if I am on call, I literally can not relax at all.
-There's risk. Aside from the driving, there's also all manner of other risks, ranging from environmental risks (going into homes with black mold and insect infestations) to risks of physical violence. I try to be very upfront about this with people, as many of my co-workers have been assaulted at some point, sometimes seriously, and a few have been seriously injured. I have been punched, shoved, and had hard things thrown at me. I have heard therapists tell me that it's not appropriate to talk about the violent aspect of this job as that conflates mental health with violence, but it's a reality that we face. When working in homes with clients who have physical escalations, you do what you can to deescalate, but sometimes mistakes happen, and things get out of control and you can't get out of there in time. I think one of the biggest reasons I have been as lucky as I am is that I can move quickly to get out of range, and I would want anyone looking at this work to be able to do the same.
-On that note, trauma. This job can be very traumatic. You can develop secondary trauma from just hearing about the experiences your client's have lived through, or you can develop it from dealing with the escalations first hand. When I did this job the first time around, I had a client run to a garage while escalated, then when I went to keep eyes on him, he grabbed a staple gun and pressed it at my chest and pulled the trigger. Thankfully it wasn't loaded, but in the moment I thought it was a nailgun. That left a significant mark on me. I've had several other instances where I've been in really hard situations where I can feel my mind begin to develop some very bad thoughts about what happened, and have had to take steps to mitigate them. You absolutely have to take care of your mind.
-You get this sort of weird disrespect from other therapists sometimes. I don't know what this is about, but I've gotten crap from other therapists who are very quick to state that what we're doing is not valid. Our medicaid billing begs to differ. However, most therapists are appreciative and have a lot of respect for the work we do.
-Driving can be exhausting. The amount of driving I do is extensive, and due to the nature of our area and the sprawl, I may spend 5 hours in my car on a busy day, often times trapped in traffic in the boonies, surrounded by trucks with racist bumperstickers. That part of driving sucks. However, the extensive driving also means I subsist off gas station food a lot, but as someone who actually likes gas station food, this is not a bad thing.
So there you have it. This is a very difficult job, but it is also incredibly rewarding. I do want to see more people getting into this line of work, as we are frequently overwhelmed and have very high turnover, but I also want to be realistic about the type of work it is.
The way I've conceptualized it is, I'm a Paladin. Any other job, I'm just some type of commoner, but this is a Paladin job. You're on a dangerous mission to face darkness and pull people away from the brink, but you're also doing the will of a larger good. The analogy even works when thinking about the amount of emotional plate mail I have to put on before some sessions.
And it feels good to be a Paladin.