Six Things Therapists Don’t Want You to Know

Woman-with-finger-over-li-007As therapists, we want you to open up to us. To trust us enough to tell us things you may have never told anyone else. We want you to explore your deepest, darkest places and deal with things you may not even be aware that you were dealing with or avoiding. However, as therapist, there are some things that we keep from you and here is what I consider to be the top five.

1. “Sometimes You Bore Me.”

As therapists, we get paid to listen to other peoples problems and that may seem like an easy task, but it’s not. Sitting and listening to someone talk for 50 minutes can be mentally and emotionally draining, especially when the person talking is going on and on about something that is irrelevant to why they are actually in therapy. Sometimes it is hard to shut out our own internal chatter and (I feel guilty to admit this) it’s easy to start daydreaming or letting your mind wander instead of being attentive and present.

When I find this happening, it’s usually a clear sign to me that I need to redirect the client, or that whatever I am doing isn’t working and I need to try a different approach. Some clients however simply aren’t that interesting.

I remember running into a fellow therapist at the coffee machine saying she needed some extra caffeine because her next client was “a snoozer”. Fortunately, this is a rarity and not the norm, but if your therapist looks bored, it’s a good chance he or she is and it could be a clue to both of you that you aren’t really working on the real problem at hand, but dancing around it.

2. “You’re All Better, But I Want You To Keep Coming Back Because I Need Your Money.”

Therapist in private practice depend on their clients to make a living so, sometimes, even when therapy should come to an end, after the problems have been resolved, a therapist will keep rescheduling you to come back, even if you run out of things to talk about. They don’t want to let you go or to discharge you because that is taking money out of their pocket, so they will continue rescheduling you to come back as long as you or your insurance company continues to pay them.

Speaking of which, most insurance companies will only pay for a certain number of sessions so a therapist may want you to keep coming back until you’ve used up all your sessions and then, rather you are better or not, they may stop seeing you. That is unless of course you have the money to pay out of pocket, which can be costly. Most therapist charge anywhere from $75 to $200 an hour.

If you feel like your work is done with the therapist, but they continue rescheduling you to come back, it’s okay to bring this up to the therapist, to stop going to see the therapist or to get another one if you feel like your therapist is using you. A good therapist doesn’t want their client in therapy longer than necessary, even if discharging that client is going to take some money out of their pocket.

3. “Your Secrets Are Safe With Me… Sort Of.”

As therapist, we want you to feel safe talking to us and tell you that everything is confidential and we like to think that it is, but there are somethings that may not be confidential such as when someone talks about killing themselves, someone else, abuse, neglect, etc. Also, courts can demand to see our records in the event of a court case such as an employment dispute or divorce proceedings. As therapists, we generally fight to keep our records private and only release what we absolute must, but while we promise confidentiality, there are exceptions.

Also, therapist often consult with other therapists, but usually we keep names and irrelevant details out of the discussion. It’s not uncommon for therapists to discuss patients with friends and family even, but in those cases names and details are always kept out because violating confidentiality is against the law and a therapist can be sued if it’s proven that he or she violated their clients confidentiality.

4.  ” I May Need More Help Than You Do.”

Therapists are human. Sometimes therapists have problems consciously and unconsciously that they may not be able to deal with on their own, yet they still show up to the office everyday to help others. This isn’t necessarily a bad thing, but it can be. If your therapist is not in the right frame of mind and doesn’t know how to let his or her own problems go once face to face with a client, a litany of problems can occur.

Therapists aren’t supposed to give advice, but often we do and if your therapist is going through their own life situations, they may give you some very bad advice, not be present or make some very unhealthy decisions.

I’ve heard stories of therapists crying and confiding in their patients as if their patients were there own personal therapists, leaving the patient confused. I’ve also heard of therapist who were so cold and bitter while going through a divorce that they couldn’t be objective and empathetic when listening to their patients talk about their own relationships.

I’ve also known enough therapists who went into counseling and psychology (probably unconsciously) to help themselves and ended up being therapists who were just as neurotic, unstable and mentally unhealthy as many of the patients they were supposed to be helping.

This is where issues come into play like the therapist who slept with his or her patient, or had some other unhealthy, inappropriate dual relationship with a patient like having a patient temporarily live with them or being overly and unprofessionally involved with a client.

It is often advised that therapists have their own supervisors or therapists to talk to so that they can keep their personal and professional lives separate. Fortunately, most of the people I knew would make bad therapist ended up going into other fields.

5. “You Will Get A Diagnosis Rather You Deserve One Or Not”

Unfortunately, in this day and age of managed healthcare, everyone that has insurance has to get a diagnosis in order for the therapist to get paid. Sometimes this is easy because the patient obviously fits a certain diagnosis like depression or anxiety, but sometimes it’s not so obvious.

For example, when a patient is just dealing with typical life stressors that don’t meet criteria for a mental health diagnosis, the therapist will have to make a diagnosis fit if he or she wants to get paid.

Sometimes therapist will go for a “soft” diagnosis, like adjustment disorders, but some insurance companies won’t even pay for a “soft” diagnosis, so an adjustment disorder with depressed mood may be unnecessarily upgraded to major depressive disorder, single episode.  Your therapist may never tell you that you have been diagnosed, but you have been and at some point, if you care, you should ask what your diagnosis is.

A major part of my job is to diagnosis clients and everyone that enters my door leaves with a diagnosis if they didn’t have one already. I am always surprised at the number of patients who are referred to me with a current diagnosis, but when I ask them if they’ve been diagnosed with anything they either say “no” or “I don’t know”. These people are walking around with a diagnosis and don’t even know it.

6. “This May Hurt”

Most therapists won’t tell you up front that therapy can be emotionally and mentally painful. Most of the time we go to therapy because we are dealing with or avoiding some type of mental pain and we as therapist want to help you find it, confront it and deal with it. It can be pain that you know, like a recent divorce, or pain that you didn’t even realize was there, like how much you miss your dad that abandoned you when you were 3 and you haven’t thought of in over 10 years.

You may also come to some conclusions while you are in therapy, conclusions that may be difficult like ending a relationship, telling your mother how you really feel about the way she raised you or learning to say no to people you’ve always said yes to. A good therapist will be there with you and walk you through that pain, but most won’t tell you upfront how much this may hurt, otherwise, you might not go through with it.

Most therapists are good people who are in this field for the right reasons, not for the money (which isn’t great in the first place, but can be made), the power (some therapist like having a “God Complex”) or any other selfish reasons. Still, like in every profession there are good therapist and bad therapist and knowing how to identify a bad therapist can not only save you time and money, it may keep you from coming out of therapy worst off than you started.

STDs and Pregnancy Scares: My Week In Review

immigration.istock-e1335353696609Last week was a super busy and crazy week. It seemed like I couldn’t get a handle on anything. On top of the many clients I already see, the referrals were pouring in and I only got a chance to meet with a couple of those, the most serious ones, two girls who had attempted suicide recently and had been hospitalized.

I met with both of them once and just kind of introduced myself, explained what counseling was and wasn’t since neither one of them had ever been in counseling before, and then started trying to build rapport with them. Both are very damaged young ladies, but I think we all are to some extent. They both, just from their presence, scream some type of past history of abuse to me, and one is living with a parent with a severe mental illness and drug addiction, so you can imagine the affects that will have on a teenager.

Besides that I had two clients that thought they might be pregnant. One is 17 and one is 16 and the sad thing is, as much as they say they don’t want to be pregnant, I think they really do want to be pregnant because neither one of them are doing anything to prevent becoming pregnant. If they aren’t pregnant, then it’s probably only a short matter of time before they will be.

Neither of them are mentally mature enough to be mothers, despite their biological maturation. One is really naive and I am sure she thinks that being pregnant will make the boy she’s sleeping with (who is not her boyfriend) commit to her. The other has severe low-self esteem and is very emotionally unstable, she says she is ready to be a mother, but mentally she acts about two years below her chronological age.

Talking to these young ladies, it’s clear that neither one of them have any idea of the dedication and sacrifice that goes into being a parent, but they don’t see a baby as a responsibility, but as a solution to one problem or another.

Still on the topic of teenage sex, another female client came to me crying because she thinks she may have a sexually transmitted disease. I referred her to the school nurse and then to a community clinic since she doesn’t want her mother to know.

This girl is very sexually active and at 16, claims she has had about 20 sexual partners. She doesn’t open up much, but I am working on helping her build her self-esteem and I am almost 100% sure that there is a history of sexual abuse, but she hasn’t disclosed that as of yet. She talks a lot about her mother, whom I haven’t met yet, but from what the she says, her mother seems to be just as promiscuous and I am sure that affects this client’s behavior and relationships with males.

We did talk about her father whom she felt abandoned her when she was young and I think that explains at least in part why she is always trying to be with one guy or several. That on top of her mother’s influences on her and her low self-esteem (she once told me that the only thing she likes about herself was her hair), all contribute to her risky sexual behavior.

She’s supposed to go to the clinic this week so hopefully she’ll find out that everything is okay or at least is treatable.

And then on Friday, while I was facilitating a group, I looked up and saw two female sheriff detectives standing at my door. I was immediately dismayed because I had no idea what they wanted to talk to me about. Ends up, one of my clients reported being sexually abused and the detectives were there to ask me what I knew about it.

It initially felt a little intimidating, like an interrogation because none of the answers I gave them seemed to be concise enough, and they kept pushing, but I was treading on giving them information I knew I legally and ethically should give them while also respecting my clients confidentiality by not giving them information unrelated/unnecessary to  their investigation.

In the end I think I did both well, but it was definitely an experience. It was my first time ever having to deal with detectives in that manner although I make suspected abuse and neglect calls to child services all the time.

That was a rather stressful way to end the week on top of everything else, but I left work on Friday and ran four miles with one a friend which was a great way to distress while venting. Taking care of yourself physically, mentally and spiritually is a must in the helping professions or you’ll succumb to burnout and compassion fatigue, places I know all too well and try to prevent with every fiber of my being through self-care, which is sometimes easier said then done.

Compassion Fatique

As a therapist there have been several times in my career when I have felt the classic symptoms of what is known as compassion fatigue, also known as secondary traumatic stress disorder.

Compassion fatigue is the gradual decrease in compassion one feels for others over time. It is common not only in people who have been affected by trauma, but also in those who work directly with people who have been affected by trauma including those working in helping professions such as doctors, nurses, counselors, and welfare workers. Compassion fatigue is also common amongst lawyers and there is growing concern that the general population is often subjected to compassion fatigue due to the media’s constant coverage of disasters, violence and suffering.

Compassion fatigue can also been seen in charitable given. Such as if there is a major earth quake today the number of people giving charity may decrease as people grow frustrated with the way donations are handled or with the sheer size of the tragedy.  

Signs and symptoms

People suffering from compassion fatigue often feel hopeless, anhedonia (have a decrease in experiencing pleasure), negative attitude, and ongoing stress and anxiety.  In some cases compassion fatigue can be so bad that it’s effects can be similar to post traumatic stress disorder, which is why it’s often called secondary traumatic stress disorder: the person experiencing secondary traumatic stress disorder may experience fear, anxiety, nightmares and avoidant behaviors after hearing about a traumatic event from a client/patient as if he or she had experienced the event themselves.

The person experiencing compassion fatigue can show decrease in productivity, self-esteem, feelings of incompetence, self-doubt, difficulty focusing and other signs that often resemble depression. These can effect both the persons personal and professional life.

Personal Experience

Usually I feel compassion fatigue after many months of intense, often frustrating therapeutic work, no vacation, and little to no outlet to express my feelings and thoughts about my work or even about my personal life. What happens is that I find myself becoming easily irritated, frustrated and aggravated. I tend to have less energy and patience overall, especially when it comes to dealing with difficult clients. All of this makes it hard to really be present during sessions and when I get home I find myself wanting to be left alone with my pessimistic thoughts about myself, my work and the world at large.

A good therapist recognizes these signs and symptoms and knows when to take a break before compassion fatigue starts to impact them, their clients and those around them negatively.  It is important for all of us to recognize when we are suffering from compassion fatigue so that we can start taking care of our self. Taking a break, a vacation, talking to someone or just disconnecting from the world for a while may be needed (i.e. if someone is suffering secondary traumatic stress disorder after watching hours and hours of footage of a terrorist tragedy on CNN).

We must all learn when we need to take a break and how to practice self-care, a discussion for another post. As for me, I’m taking on a lighter case load which is typical for me during the summer, and I am also taking a vacation in July as well as trying to get back to some of the things that make me feel at peace with myself such as reading, writing and drawing. I know that once I have taken care of myself, I will be better capable of helping others learn to also take care of themselves.

The Symbiotic Relationship of Counseling and Unconditional Positive Regard

As another school year ends I look back at all the clients I’ve worked with during the school year and a good majority have made major changes. I’ve seen teens who could barely stay in school for a month because of getting suspended, end up having zero discipline issues for the last five months or more. I’ve seen kids with alcohol and marijuana problems minimize and some totally quit using and even more importantly I’ve seen kids I thought would take years to make positive gains make dramatic changes over a few months. 

I give all my clients surveys before discharging them so that they can voice how I have helped them or didn’t help them so that I could better myself in the future and this year I became emotional as I read over some of their responses. Some kids wrote things such as

  • “You helped me have a better relationship with my mother”
  • “You helped me realize that killing myself isn’t the answer”
  • “You helped me learn to love myself”
  • “You helped me learn how to get along with my baby’s father and take better care of my baby”
  • “I’ve learned to control my anger and how to express my emotions”
  • “You helped me learn how to get along with my baby’s mother and get more into my son’s life”
  • “You helped me realize how valuable my life is and how stupid and irresponsible ending it would be”
  • “I don’t smoke or drink any more and started liking myself”

 

This comments really touched me and made me feel blessed to have had such an impact on these kids and they have had major impacts on me as well. I’ve learned just as much about them about patience and the importance of bringing the family into counseling whenever possible and appropriate. I look back and try to reflect on all the things and activities I’ve done with these kids and while I’ve used a lot of counseling techniques, I think the one thing that made the biggest impact is the unconditional positive regard I’ve showed these kids. Unconditional positive regard is accepting someone as they are and not judging them and I showed these kids throughout the year that I liked and accepting them despite anything they did or said. Sure they often did things I didn’t approve of, but I always let them know that it was the act that I disapproved of and not them. A lot of these kids have never had anyone they could just talk to who accepted and didn’t judge them and I think building on that relationship overtime had the greatest impact.

A lot of times I hear interns and new counselors saying that they are afraid that they are afraid that they won’t always know what to say and I always tell them that it’s okay, sometimes I don’t know what to say and so I say nothing, I just listen and show unconditional positive regard and empathy instead of not being present in the situation because I am busy searching for the right thing to say when there likely isn’t. In a good counseling relationship it is symbiotic. I learn from them and they learn from me and that is one of the things I love best about being a counselor. I learn from even the most difficult of clients and hopefully they learn from me as well.