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.

The DSM-V: Coming Soon, Criticisms, Flaws and All

DSM-5_3DThe long awaited and controversial Diagnostic and Statistical Manual of Mental Disorders, version five (DSM-V) is slated to come out toward the end of this month.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is considered the bible of psychiatry. It is the guide we use in the mental health field to help us diagnose clients and this May, the newest version of the DSM, version five, is slated to be released, but not without much controversy.

The DSM is considered a research standard worldwide, yet, outside of the United States it is rarely used. Still, what is in the DSM is of international concern because trends in diagnosing in the United States (i.e., attention deficit disorder, autism) tend to spread worldwide especially in many European countries, China, Japan and Brazil.

Much of the criticism about the DSM comes from both the way illnesses are categorized and the ever expanding criteria for mental illness that basically makes everyday life issues a diagnosis.

Other  criticisms include weak scientific support and poor reliability in some of the DSM-V field trials, which leave some to believe that it will lose its role as the international standard for research journals.

One of the real dangers if the DSM-V is really that severely flawed is that all of the mental health field will also become tainted, with people not trusting those who are trusted to test, diagnose and help people in need.

With the DSM-V, we also put ourselves at more risk of mis-diagnosing, over-diagnosing and over-medicating individuals.

Some say that the changes to disorders such as Generalized Anxiety Disorder can include almost everyone, as well as a proposed new diagnoses called Somatic Symptom Disorder which will be diagnosed to any patient who has “excessive and disproportionate thoughts, feelings and behaviors” in relationship to an illness, which includes chronic pain and cancer. How much worry constitutes “excessive” worrying. Who wouldn’t be worried when they are dealing with a painful, chronic, potentially debilitating or life threatening illness?

Some believe that much of the flaws in the DSM period are because disorders are placed in discrete categories such as Bipolar Disorder and Schizophrenia, instead of “dimensionality” in which mental illnesses may overlap and people may be placed on one of several spectra such as the proposed Autistic Spectrum Disorders.

Most clients I see have a combination of symptoms, some which do not meet complete criteria for one specific diagnosis, but can meet several others and present differently at different periods, which is why I may see a client who has received three different diagnosis over the same number of years.

However, most in the mental health field prefer for mental disorders to continue to be categories as they already are which is one reason dimensionality won’t likely be introduced into the DSM anytime soon even in the face of growing evidence that disorders are more fluid and less rigid than previously thought.

It would take more research and funding into dimensionality for it to truly be accepted, but much of that research and funding is already put into confirming the categorization of mental disorders the way they already are.

Basically, people don’t really want change. Much of the mental health field, drug and insurance companies, like the rigidity of the DSM even though it is clear that it is failing many people.

Even patient groups and charities prefer the rigidity of the DSM because it highlights their disorder and keeps it visible. They do not want to see schizophrenia or bipolar disorder re-labeled into a spectrum just as Aspergers Disorder is slated to be dissolved into the autistic spectrum disorders.

On top of that health-insurance in the United States pay for treatment based on current DSM diagnosis. As a matter of fact, that is one of the most frustrating things about dealing with insurances.

In order to get paid for my services, they want a diagnosis almost immediately, usually after the first session or two of me meeting a client. Sometimes a DSM diagnosis is obvious, other times it is not and more time with the client is needed, but insurance companies won’t pay for that unless you diagnose them with something first. Insurance companies are probably the last ones who want to see the DSM categories dissolved.

According to Dr. Allen Francis, former chair of the DSM IV task force, the ten worse changes to the DSM-V are:

1) Disruptive Mood Dysregulation Disorder: DSM 5 will turn temper tantrums into a mental disorder- a puzzling decision based on the work of only one research group. We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children. During the past two decades, child psychiatry has already provoked three fads- a tripling of Attention Deficit Disorder, a more than twenty-times increase in Autistic Disorder, and a forty-times increase in childhood Bipolar Disorder. The field should have felt chastened by this sorry track record and should engage itself now in the crucial task of educating practitioners and the public about the difficulty of accurately diagnosing children and the risks of over- medicating them. DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.

2) Normal grief will become Major Depressive Disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life.

3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder, creating a huge false positive population of people who are not at special risk for dementia. Since there is no effective treatment for this ‘condition’ (or for dementia), the label provides absolutely no benefit (while creating great anxiety) even for those at true risk for later developing dementia. It is a dead loss for the many who will be mislabeled.

4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.

5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called Binge Eating Disorder.

6) The changes in the DSM 5 definition of Autism will result in lowered rates- 10% according to estimates by the DSM 5 work group, perhaps 50% according to outside research groups. This reduction can be seen as beneficial in the sense that the diagnosis of Autism will be more accurate and specific- but advocates understandably fear a disruption in needed school services. Here the DSM 5 problem is not so much a bad decision, but the misleading promises that it will have no impact on rates of disorder or of service delivery. School services should be tied more to educational need, less to a controversial psychiatric diagnosis created for clinical (not educational) purposes and whose rate is so sensitive to small changes in definition and assessment.

7) First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.

8) DSM 5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot. Watch out for careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets.

9) DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life. Small changes in definition can create millions of anxious new ‘patients’ and expand the already widespread practice of inappropriately prescribing addicting anti-anxiety medications.

10) DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.

DSM 5 has dropped its pretension to being a paradigm shift in psychiatric diagnosis and instead (in a dramatic 180 degree turn) now makes the equally misleading claim that it is a conservative document that will have minimal impact on the rates of psychiatric diagnosis and in the consequent provision of inappropriate treatment. This is an untenable claim that DSM 5 cannot possibly support because, for completely unfathomable reasons, it never took the simple and inexpensive step of actually studying the impact of DSM on rates in real world settings.

Even with much of it’s flaws and criticisms, the DSM-V is likely to be the best guide for diagnosing mental disorders that we have had thus far. We can only hope that with further research and funding, the next revision of the DSM will be better and more forward thinking.