Everyone who enters a graduate program in counseling daydreams at some point about his or her professional future. The ultimate goal for some is to start a private practice. For others it is to work in a certain setting or with clients who have specific issues or treatment needs. Many therapists also consider expanding their repertoires to include consulting, professional development or even college teaching. Graduate education seemingly can help counselors develop all of these competencies through course work, assistantships, service learning and internships.
Learning about therapeutic techniques and best practices in mental health is the gold standard in preparation for licensure. But being a clinical manager — someone who supervises counselors and other mental health professionals in a public or private mental health setting — requires a different skill set that is not readily addressed in most graduate counseling programs. Looking back, I wish that my course work and other educational experiences had prepared me to become a manager, leader, trainer, organizational development expert and advocate, in addition to becoming a counseling practitioner.
Most counselor education works to establish one’s identity as a counselor. This can be a double-edged sword. On one hand, attachment to this professional identity ensures integrity in one’s work as a clinician, identification with ethical codes and association with the larger body of professional counselors and healers. On the other hand, the idea that one is trained to provide therapy sometimes discourages the individual from considering other competencies and roles that counselors are often introduced to when entering the actual world of work. Granted, the therapeutic relationship is what we are best trained for and what most of us look forward to in our work. But our dedication to helping clients in their healing journeys also involves intensive documentation, billing, marketing for private practice, working within a larger system, sharing resources, and getting along with coworkers and support staff, among other things. In addition, the paycheck that accompanies therapeutic counseling work is sometimes insufficient to pay all the bills and student loans and meet all the other needs of the households we are trying to manage.
When I was in graduate school, I didn’t devote any thought to the possibility of entering the world of mental health leadership. My ultimate goal was to obtain my license and open a private practice. After achieving that goal, however, I realized I had additional hopes for my professional future that would not be met in the context of private practice. I became aware that opportunities for advancement existed in many mental health organizations. These opportunities were more profitable than doing therapy exclusively and were also very fulfilling, allowing me to shape my staff and help the populations we were serving in various ways.
Challenges in mental health management
The challenges are many when a counselor takes on the role of manager in a mental health setting. It is easy to feel unprepared for the bumps and bruises that take place while learning to lead others. What follows are some of the areas I have found particularly challenging as a manager working in mental health.
Managing employees
I don’t remember learning how to effectively manage employees in my graduate counseling program. It has been one of my biggest challenges. Sometimes we assume that simply having a supervisory title or being called “the boss” will speak for itself. This is referred to as legitimate power in the leadership literature.
Many counselor-managers also assume that because of their employees’ backgrounds as clinicians, these employees automatically will be cooperative, be willing to express concerns and contribute ideas to improve what is happening in the workplace. Unfortunately, employees do not manage themselves. Managers must sometimes intervene to ameliorate problems and streamline the organizational structures that are already in place. While paying attention to licensure standards, managers must also interpret organizational rules as well as the unspoken rules of engagement in the workplace. For example, some mental health organizations encourage clinical managers to take an authoritarian approach to leadership and not take “excuses” from clinicians who are unable to reach quotas for billable hours. In another mental health organization, however, the clinical manager facing this issue may be encouraged to conduct a focus group with his or her clinicians to find innovative solutions to increase client contact hours.
Teaching and leading
Little did I know when I began my management role in mental health that teaching and leading were synonymous. I learned that role modeling, reflection, experiential learning and goal-setting — the same techniques we use with clients — must also be used with employees, and that I was expected to understand and develop the talents of my employees. By the same token, I have also learned that I need to continually learn from my employees. They are the front-line service providers and possess valuable insights that can improve what we do as a cohesive unit. I have also learned to learn from my mistakes in the work setting through purposeful reflection and mentoring from my superiors.
Organizational culture
According to Edgar Schein, each organization has its own culture that includes artifacts, values and tacit assumptions. On the surface, symbols that represent the organization are visible and recognized by members of the organization, while at the deepest level, assumptions and beliefs exist that drive what is considered appropriate or taboo. When a counselor enters a management and leadership role, he or she must become familiar with the organization’s culture and learn to operate within that belief system. This often requires significant adjustment and change. A big part of any mental health organization’s culture is how clients and clinicians are treated, and the counselor-manager needs to be aware of this. Advocacy is one of the values imparted in counselor training, but it is not always easy to implement in the organizational setting.
Managed care, grant funding and budgeting
Funding sources often dictate the groups of clients the organization can serve and how treatment is planned, delivered and measured. With the push for integrated health care and evidence-based practices, counselors can be caught off guard when there is no option for them to provide their preferred treatment, when treatment modalities and number of sessions are dictated by the funding source, and when they are introduced to billing. The manager of these counselors needs to understand quality assurance and improvement, performance minimums and budgeting. In addition, the manager must coach employees in all of these areas.
Specialized programs with grant funding require the counselor-manager to understand all laws and rules relating to the funding source as well as internal organizational procedures. This can be overwhelming for a first-time leader who is unfamiliar with the organizational politics, financial reporting procedures or best practices in data collection and analysis.
Multicultural issues at all levels
Managers often face concerns in mental health organizations regarding who is being served, who is in charge and who should be hired. There is a need for diversity of all kinds in leadership, mental health administration and research. With a rapidly diversifying population, the United States is facing numerous challenges associated with a lack of ethnically and otherwise diverse leadership. If diversity is absent in mental health management and leadership, the beliefs and perspectives of those populations currently underutilizing mental health services (even with insurance) will not be acknowledged. I have committed to researching this issue as part of my efforts to advocate for mental health services that support everyone’s needs.
Torn loyalties
Last but not least, a paradox exists in being both a clinician and a manager in mental health settings. Sometimes your inner clinician knows a certain course of action would be best for the clients served by your staff members. But directives from higher-ups, organizational loyalty, staff concerns or any number of other things can interfere with your programmatic goals for the clients. The inner clinician aspires to be reasonable with a counselor-employee who is not making minimum contacts with clients. The hope is that if you approach the employee with your concerns, he or she will magically increase the number of billable hours, therefore improving performance from a business perspective. But the inner leader knows that the organization expects you to deliver a write-up and a warning about termination to the employee.
Future directions
It would be beneficial if graduate counseling programs offered mental health leadership courses to inform students about the full array of careers in mental health and the variety of leadership and administrative roles that exist in a variety of settings. More career education is also needed on how to advocate for the rights of clients and employees as well as legislation that supports mental health service funding.
Graduate students should be given the opportunity to seek electives or additional training in the areas of management/ leadership, organizational psychology, health care law and human resources. Aspiring professionals in graduate programs would also benefit from ample opportunities for research and shadowing to more accurately portray the realities of careers in mental health management and leadership. Learning opportunities that increase understanding of the management, business and legal aspects of mental health leadership would help prepare the newest generation of counselor-leaders, who are very much in demand in the world of mental health today.
Christie Melonson is a licensed professional counselor and consultant in San Antonio. In addition to being a manager with the Center for Health Care Services Head Start Mental Health Program, she has a small private practice and is a doctoral candidate in education at the University of the Incarnate Word. Contact her at melonson@student.uiwtx.edu.
Letters to the editor: ct@counseling.org