Seattle Part 6: the HMO

October, 2014

On my first day, it took me nearly an hour to get to my new job, though it was only about 8 miles distance from my residence. I had to drive down a long, narrow, busy Seattle street through traffic and stoplights, then get on a congested freeway. Traffic moved very slowly across the lake, and there was no other way to get there.

I worked on the top floor of a medical clinic, the local face of a busy HMO (Health Maintenance Organization). The mental health clinic employed around ten therapists, and we were all kept significantly busy. Clients who held a particular insurance were given good rates to see a doctor or a counselor at the HMO, and they were charged a lot of out-of-pocket expenses to see anyone else, thus we always had a long list of people waiting to be seen by a provider. Someone might call in in some sort of crisis and then not be able to see a counselor for six weeks afterward, based on current openings.

I had worked at community health centers before, so I understood the medical model of therapy. I was a clinical social worker, or LCSW, meaning I could get higher than standard reimbursement rates through various insurances, including Medicare and Medicaid, and the company seemed happy to have me there. But this place worked at a much higher pace than anything I had ever experienced before.

First of all, consider therapy itself. A counseling session requires the therapist’s all. There can be no distractions, no phones or music or computers. It’s just the therapist and the patient. There can’t be errant thoughts, or outside stressors, or headaches, or upset stomachs, or sleepiness. The therapist can’t yawn, or stretch, or eat a snack. The client requires one hundred per cent of the therapist’s focus, as well as their clear memories of past therapy sessions, like names of loved ones and therapeutic goals. On top of that, therapists are often dealing with clients who have extreme trauma issues. They hear stories about combat, suicide, rape, abuse, grief, and pain. And when one client leaves, the next is generally waiting, and the therapist can’t still be thinking about the first or she won’t be able to focus on the second.

Doing three or four therapy sessions in a row requires a tremendous effort; doing seven or eight becomes downright exhausting if not impossible. The HMO required more. And doing that day after day, well, it’s not for the faint-hearted. In standard clinics, even busy ones, I became accustomed to doing four therapy sessions, having an hour lunch, then doing three more, with the last hour of the day being reserved for case and progress notes, treatment plans, and correspondence. It was already at a taxing schedule.

But at the HMO, the expectations were much higher. They had competitive wages (about 45 dollars per hour, consistently, on salary) and a great benefits package. But they had their therapists on a very rigid schedule, seeing a patient basically every forty minutes with no time for case notes built in.

A standard schedule might go like this, for one day:

8 am: ten minute staff check-in

8:15: first patient (let’s say an elderly woman with Alzheimer’s whose husband just died)

9: second patient (a teenage girl who recently attempted suicide)

9:45 third patient (a refugee worried about her loved ones in her home country)

10:30: fourth patient (a couple going through extreme marital issues)

11:15: fifth patient (a veteran struggling with PTSD issues)

12: thirty minutes for lunch

12:30: sixth patient (a single mother of four processing stress)

1:15: seventh patient (a woman with a new baby, struggling with postpartum)

2: eighth patient (a mother processing stress over her son coming out of the closet)

2:45: ninth patient (a man referred by his boss for losing his temper at work)

3:30: tenth patient (a ten-year old boy whose parents recently divorced)

4:15: eleventh patient (a woman with borderline personality disorder, recently out of the state hospital following a suicide attempt).

Then, after that, once your notes were finished, you could go home for the day. Every other week or so, there would be a staff meeting of some kind. And every second or third day, a client might cancel or not show up, giving a chance to catch up. But that many patients per day, every day, four days per week, generally meant between 36 and 45 people seen per week. Sessions had to be shorter and more goal-directed, and a failure to adhere to the schedule meant knocking multiple clients back. If a client came in in crisis, very little could be done to manage it without having to cancel another session afterwards completely, and openings after that became hard to find.

I came into the job with boundless enthusiasm. The team of people I worked with were amazing, funny, friendly, and supportive. The agency had great diversity representation, several gay therapists, and a good camaraderie. But as I finished my first week of work, beaten down, grey, and bitter, I began to realize how tired everyone was. It was like working in an emergency room, without breaks, day after day, every day. With an hour’s drive each way.

In Utah, my therapy work had almost exclusively been with LGBT people who were struggling to align their sexuality with their Mormonism. Here, I was seeing people from every walk of life, all struggling with their own sets of problems. The word Mormon wasn’t being brought up anymore, but there was constant depression, anxiety, trauma, grief, and emotional pain. And within two weeks, I found myself unable to offer my client’s my all any longer. Instead of being an incredible therapist, I was becoming a mediocre one, simply to survive the rigorous page.

And with the reality of the new job settling in, Seattle didn’t feel quite so magical. It felt wearying, and expensive. Some cracks in the foundation of my dream life began to show.

And every night, there was the phone call to my sons, who remained far away, and who I missed very, very much.

how to love your job


Don’t hate your job. You spend far too much time there to hate it.

One of the major reasons people seek me out for therapy is due to their job related stress. They hate their jobs, they don’t feel appreciated, they haven’t had a raise in three years, their co-workers don’t like them, they are bored.

The first thing I need to do with clients is help them determine where it is they are unhappy at work with.

I ask the client to rate their satisfaction level with work in four different categories, using a standard grading scale from A+ down to F-, and I ask them to keep their answers focused to today, right now, not how the job could be or how it used to be.

“The first category is Achievement,” I tell them. “A good grade in this category means that you have a manageable work load. You feel challenged, but not often overwhelmed. You are being stimulated without being bored. And you go home at the end of the day having enjoyed what you do, feeling like you are making a contribution.

“The second category is Work Environment. A good grade here means you enjoy your coworkers, have a good relationship with your boss, and that you do well with the politics of the place. This also includes the space you work in, the facility and office, the lighting and location.

“The third category is Sustainability. A good grade here means this is something you can see yourself doing long-term. You recognize that you are growing and changing over time, and your needs at work will do the same. You can grow and adapt within the position, and feel like you are contributing.

“And the final category is Compensation. A good grade here means that you receive a fair and competitive compensation, given your education level and skill level within your position and company; you are making a fair wage given what others in the field are making, and given your responsibilities. In addition, you have a fair benefits package.

“Now in accordance with all of this, of course, is balance with life and relationships, but we are focusing specifically on the job itself. I know attorneys who make an awesome wage, but they work 80 hours per week and burn out quickly. I know people who have created their own catering businesses and love what they do, but they are struggling financially and get bored working at home. I know people who love their job at the fast food counter and do great at it and love their coworkers, but they aren’t paid fairly and have no benefits.

“So look at your job and think about what is missing. If you have an A for compensation, but an F for work environment, that probably isn’t a sustainable job. If you have an A in everything but sustainability, and you know this job is temnporary, you have to find a way to make it work, to grow where you are and plan for what’s next.”

So as you look at your current job, what are your ratings? What is it you are happy with, and what is it you need to look at and problem-solve to get the higher satisfaction ratings you crave? Sometimes that means bold changes, or difficult conversations, or more patience, or further schooling and training.

I know people who stay in the same jobs that they hate for, literally, years or decades.

Don’t hate your job. You spend far too much time there to hate it.