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.

Some Of My Frustrations With The Mental Health System And How It Fails Those It’s Supposed To Help

DGStory92211editAfter the tragedy at Sandy Hook Elementary School, there was a lot of talk about our broken mental health system. As a mental health counselor, I have worked in the mental health system since 2006 and could go on and on about why I think the mental health system fails many of those who need it the most.

It basically boils down to politics and money.

When I worked at the psychiatric hospital, I would see severely mentally ill people come in, but because they had no insurance, they were generally released back onto the streets within 24 hours without any medication or follow up appointments. At the same time, patients with insurance, regardless of the severity of their mental state at the time, were almost always hospitalized for at least 72 hours and released with medication, prescriptions, and/or follow up appointments.

Needless to say, the patients without insurance returned on a regular basis, to the point that I got to know them all pretty personally and could even predict when they would return. These clients were considered indigent clients or “regulars” as some of the hospital staff would call them.

They never got better, not necessarily because they didn’t want to, but many of them never really got the chance to get better.

Sure, many of them were homeless, some of them drug and alcohol abusers, and some even used the hospital like a hotel knowing that if they said the right words they would at least have a place to stay for several hours, but the large majority of them never really got the chance to get the help they needed because they didn’t have the money or insurance.

So, they would be back out on the street, most harmless, some committing petty crimes and a few were pretty scary as far as what they were capable of doing to an innocent person unaware that this person was in the midst of a psychological breakdown.

It was sad and frustrating which is one reason I left the psychiatric hospital and started working with juveniles, but even now I see how the system fails many people.

Now things are much more billing and money driven. They don’t care much about clients, giving quality therapy, making sure that counselors are well trained and given opportunities to stay well-trained and updated. All they care about is how many clients you can see and bill for in a day.

We are given three times as many clients as we can properly manage and give quality therapy to, but agencies don’t care about that because they are under pressure and in competition with other agencies and what’s called a “Managing Entity” that holds all the funds given to mental health and substance abuse facilities and can decide which facilities get and lose funding.

It’s frustrating and sometimes makes me want to quit my job because I can’t effectively do my job to the standard I feel like I’m obligated to by my own ethics and the ethics of the American Counseling Association.

On top of all that, my frustrations with the mental health system include a time when I had to have a young woman hospitalized after she had growing paranoia, anxiety and delusions that she was being controlled by other people who were raping her and turning her into a dog. She even crawled around on all fours and urinated on her mom’s carpet.

She was released from the hospital without any diagnosis and was only given a prescription for anxiety. This did not stop or even decrease her paranoia and delusions and I had to have her hospitalized again when her paranoia was so bad she started having thoughts of killing herself.

The reason I had her sent to the mental hospital the first time was because they had the resources and staff needed to truly help her better than I did working out of a school based program. Yet, they basically put a patch on a wound and sent her on her way.

In another situation I had a client stab himself in the neck during an argument with his girlfriend. Sure, this was impulsive and maybe he didn’t need to be hospitalized for an extended amount of time or given medication, but he didn’t even spend the night in the mental hospital before they released him without a diagnoses or any follow up.

If this same guy decides next time to stab his girlfriend in the neck, she may try to sue the hospital, or if she dies, her family may want to try to sue the hospital and everyone will be talking about how the mental health system failed her.

This reminds me of another aspect of working in the mental health hospital.

Almost twice weekly we would get handfuls of inmates being released from jail, inmates the jail didn’t feel were mentally stable enough to be released back onto the streets. Most of these inmates didn’t have any insurance so we would take them in and release them in the morning.

How scary and sad is that? The jail didn’t feel safe letting this inmates free to roam the streets, but they couldn’t legal hold them beyond their sentences, so they entrusted the psychiatric hospital to stabilize these inmates before releasing them, and all we did the majority of the time was give them a place to sleep and then let them out the next day.

In defense of the psychiatric hospital, a lot of it came down to funding and unfortunately, not much funding is given for those without insurance. We would have what were called indigent beds, beds paid for by the state for those without insurance, but there weren’t many and they didn’t pay as much as insurance beds did.

I believe most of the people who work in the mental health field, those who haven’t been tainted or sold their soul so that they can become program managers, directors and supervisors who are more concerned about funding and stats than actually quality of care, really do love and care so much for those who suffer from a mental illness that we go far and beyond what is expected of us and definitely far and beyond what we are paid to do.

Places I’ve worked typically don’t pay their therapists/counselors what they deserve. Those who are licensed could make more as program directors or supervisors who don’t see clients. Positions that once required masters degrees are starting to only require bachelors degrees so that agencies can lower the salary, which usually lowers the education, experience and dedication of those being hired for a lesser salary.

Quality of patient care is sure to suffer.

The mental health system is so broken and so politically and funding driven, that if things don’t change drastically and soon, I can only see much darker days ahead for all of us.

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.