Wednesday, June 29, 2016

Finding a Good Therapist

I've been to a LOT of therapists in my life, more bad than good. The reason for the high number is that I went to the bad ones between one and three times each, and I stuck with the few good ones until either I moved or they did. It was my first truly good therapist who taught me what therapy can and should be, making me far pickier the next time around.

Aside from that, I realized through my own research that the root of my problem is childhood trauma, which no therapist had figured out before. Even my good therapist hadn't treated me for trauma, and that's what I needed. A simple cognitive behavioral approach wouldn't do. I saw five different lousy, no good therapists before finding the right one on the sixth try.

In my family, we tend to see situations like this as our own fault. The thinking goes: I saw 5 different therapists and hated them all. The common denominator is me. I am being too picky or doing something else wrong. But it turns out that wasn't the case. So, for anyone else seeking a good therapist, here's my take on what makes a bad or good one, based on this recent experience.

Bad guy #1, seen as part of a migraine work-up at a headache clinic: At this point, I had no idea that I even HAD any mental illness. It was also before my brother had been diagnosed with anxiety, before my brother died of a heroin overdose, and before I knew my brother was into anything more than pot. My family is what you call a "covert" narcissistic family. Our problems aren't obvious. We look good. No drunks, no violence, no incest, not even a divorce. The guy asked me a series of questions utterly irrelevant to me. Does anyone in my family have an alcohol problem? Nope. Drug problem? To this I replied, "No, just pot." He goes, "That's a drug. It's illegal." Yeah, well, we differ on that. I replied something about it not being a big deal, and he kept insisting that pot is the devil or something. Years later, I realized my poor brother was self-medicating in the only way a teenager with no mental health resources who is living under abusive parents knew how. He was crippled by anxiety, and he smoked pot. If he lived in a different state, he could have gotten a prescription.

The guy kept going on with the questions: Domestic violence? No. Incest? No. Anyone in prison? No. Divorced parents? No. No, no, and no. And none of these questions did anything other than make me feel like this guy was wasting my time, and that if I said anything he didn't like (i.e. pot isn't a big deal) he'd correct me and basically shout me down until I shut up. Also, none of them picked up on the fact that I actually DID suffer from a big problem.

Then he asked if I had any anxiety? Sure. What about? Well, my migraines. Anything else? No. Just my migraines. Trust me, if you get migraines every day from common environmental triggers like fluorescent lights and television, you'll have anxiety too. I had to watch out for TVs and computer screens in stores at the time, ATMs on the street, fluorescent lights. Just leaving my house was about as risky as crossing the street in the game Frogger, and I had to do that every single day. One wrong move and I'd have serious head pain for the rest of the day. Yes, I had anxiety about that. But no, nothing else I was aware of.

As I think back, I was actually being bullied at work at the time, although I had not recognized it as bullying yet. It was just a few months before the bully got me fired. So there was other stuff going on in my life. Big stuff. But this guy never found out.

Bad Therapist #2: At this point, I had gone to a good therapist once, for a few visits. It was still just for my migraines, but one day I told him about my family. For the first time in my entire life, somebody listened. He said it sounded like my mom was narcissistic. My parents were toxic. I had a right to reduce the amount of contact I had with them. It was SO comforting to hear that. But then I moved, and told myself that I was being a baby by going to therapy. I was a spoiled little rich girl who came from a great family and had no right to complain about it. Maybe a year later, I decided I'd give therapy another go. A friend told me about a low cost program, and I went to whoever they assigned me to. I poured my heart out to this woman about my family. I revealed a lot of anger at my mother, and fear for the health and well-being of my brother, who was still living at home and suffering a lot of abuse.

This therapist did not listen or validate my concerns at all. About my brother, she told me that that was his problem, not mine, and he was a grown up and it was his job to solve his own problems, not mine. Yeah, well now my brother's dead. So thanks. That was great advice. Aside from that, even if that had ultimately was correct advice for a therapist to give a patient, it was wrong to invalidate my feelings like she did.

She also invalidated my feelings about my mother. I told her how I felt, and she said, "So what I am hearing is that there are both bad and good things about your mother." No, I told her. I just told you bad things. She corrected me, "There are bad AND good things about your mother."

OK, so you know what? There are bad and good things about every person. Probably Hitler had some good traits and Mother Teresa had a few flaws. That doesn't make it OK not to listen to your patient and to completely invalidate them like that. To show a complete lack of empathy and to refuse to acknowledge that your patient is in pain.

I gave up on therapy.

Then my brother died. I realized it was time to get serious. I wasn't some spoiled brat with trivial problems who was complaining for no good reason. Now that there was a dead body involved, I had solid proof that my family was actually fucked up. I got lucky on this one. I found a great therapist and went to her for a while. Ultimately, she moved away and so did I.

I was doing OK (or so I thought) until I went to grad school and shit hit the fan. Also, I had health insurance through the school and access to mental health services. Thus began my run of shitty therapists.

Bad Therapist #3: I pour my heart out to her. She replies, "So what do you want me to do?" Then, before we wrap up, she asks if I have an alcohol problem (no) or a drug problem (no) or if I'm about to commit suicide (no). I understand the liability issue for therapists that requires them to figure out quickly if their new patient is about to off themselves before their next session, but it came off as the most tone-deaf thing ever. It felt like she did not listen to a single thing I said. She lacked empathy. The right response to a patient explaining how much pain they are in is NOT "So what do you want me to do?"

It was around this point that I realized my root problem was trauma. I found the HMO's system of scheduling therapy really upsetting, because you call them to say you want therapy and then they have someone call you back to schedule it. Supposedly, the scheduler who calls has some special mental health skills to match you with a suitable therapist but in reality they don't. They just have the magic power to look at a calendar and say things like, "Well if you're free on Tuesdays then I can fit you in with Sven." And I'm not going to see someone named Sven. I want a female therapist. But, moreover, I'd like to find someone who will be a good fit in more ways than just availability on Tuesdays. The other thing is that you can't predict when they will call you back, so they call and catch you while riding the bus, or while in class, or at other inopportune times.

After trying Bad Therapist #3 with this HMO and then refusing to see Sven, I waited a while. After I figured out the issue was trauma, and further figured out I probably need EMDR, I decided to take matters into my own hands. I looked at the bios of the mental health staff on the HMO's webpage and picked out two women who deal with trauma. Then I called. They suggested one over the other, and made an appointment. The first available timeslot was two months away. So I waited. Then I saw her.

Bad Therapist #4: I actually like this woman. She was nice. Almost too nice. Sugary sweet, and constantly complimenting me in a way that made me not really believe any of the compliments. It's just weird to meet someone and after getting to know you for five minutes they've established that you're a fantastic, funny, likable, witty, smart, etc etc etc person. They barely know you! But at least she listened. She agreed with me that the problem was trauma. She agreed about EMDR. But she didn't know how to do EMDR. We had to refer me to someone who did. Which led to...

Bad Therapist #5: I took one look at this woman and thought to myself, "We're not talking about my sex life." I immediately did not trust her. Later I realized what it was. She reminded me of Dolores Umbridge from Harry Potter. She gave no eye contact and explained that she had to write everything I said down in order to remember it and that was why she gave me no eye contact. Still. It felt like she wasn't listening. When I began to tell her about my problems, she started insisting that I ought to use some special software that adjusts your computer's light to help you sleep better. She got really pushy about it, too. I realized before my second visit that I just did not trust her and was really bothered by the lack of eye contact. When I called to cancel, she got even worse. She called back while I was in a crowded, noisy coffee shop and couldn't really talk. She asked why I was canceling, and I gave her a short, polite explanation, that I did not think I could build a trusting therapeutic relationship with her. She challenged that. OK, lady, you just PROVED I can't build a trusting relationship with you. That's you not listening and validating my feelings, right there. I said I had to go. She wouldn't stop talking. I hung up.

Bad Therapist #6: This one was also awful. The first day I went to see her, she said she was diagnosing me with anxiety and depression. I'd told her I suffered from anxiety, but not depression. I've since started suffering from it but I had not really at that time. So I said, "I suffer from depression?" She said, "Well, they often go together." I said, "I'm not opposed to the diagnosis, but I wasn't aware that I was suffering from depression. How do you know?" She said, "Well, maybe we can assess it later. I'll just put anxiety for now." Yeah. Way to go. Diagnose me with something before actually examining me for it.

She was going to do EMDR. She said we were going to start by teaching me tools to handle any difficult emotions that would come up. She wanted me to envision a box with a lid where I could put difficult emotions if they came up in class or something, and then I could take them out of the box and deal with them later. "That sounds awful," I thought. I hate visualization stuff like that. I didn't think it would work for me, either. But, as luck would have it, I'm AMAZING at suppressing emotions. I don't even need her stupid box. So I said, "I don't want to." She replied sharply, "You have to."

I have to? Yeah, we're done. Wrong answer. The right answer would be something that implies that she's listening to me and validating me, such as "Can you tell me why you don't want to?" Maybe she'd learn something important about me that way that could help her in treating me. Maybe I have a concern about it that she could talk me through, and then I'd be willing to do her dumb box exercise later.

I wanted to do the EMDR though, so I did what I did as a child when my parents wanted me to do something I didn't want to do: I lied about it. Oh, yeah, sure I did that box thing. Yeah, super helpful. Mmm hmm. If you feel you can only deal with a therapist by lying to them, that's a bad thing.

The next time I saw her, she wanted me to brainstorm 10 traumatic events from my life to use in EMDR. For each one, she wanted me to come up with some sort of visual for it. I'm not really a very visual person. I relate for more to touch and even smell. And several of my traumatic events happened over the phone. It's also reasonably likely I had my eyes closed and even covered with an eye mask, which I do a lot when I have a migraine. So our conversation went something like this:

Her: And what did you see when that happened?
Me: I dunno. I was in my bedroom. It was over the phone.
Her: But you have to pick something.
Me: My bedroom.
Her: No, something specific.
Me: I dunno. I mean, there were the walls, the window, my four poster bed I had at the time...
Her: OK, the window.

I didn't really trust that this was a good way to go about picking something. She just picked that. How can you know if it is true or not? Shouldn't that come from me?

The third and last time I saw her was an even bigger mess. The idea was for me to tell her about a place that I found very relaxing. She'd write it down word for word and then I'd lay back and close my eyes, and she'd read it back to me. I'd get really relaxed and then, once I was relaxed, she'd lead me through the eye movements you do in EMDR. There were many problems with this. One is that I didn't find the idea of imagining myself being somewhere else very relaxing at all. Second, how the heck do I get relaxed with this lady I can't stand in the room? I decided to play along. I told her about a beautiful lake in the Sierras. Then I said I didn't want her reading it to me. It bothered me. I can't get relaxed with her talking. She said that experts developed this and we had to do it just like they instructed.

Finally, she relented. OK, I could just shut my eyes and she wouldn't talk. I tried that and realized it wouldn't work. How can I relax with this woman sitting there doing nothing? So I said, fine, read it to me. She said no, not if you don't want to. It took some convincing to get her to read it.

I shut my eyes like I was supposed to, and she read it back to me. Her voice bugged me. The way she altered my words bugged me. And it distracted me from actually imagining that lake. But if I really wanted to get relaxed, I think something like a mindfulness meditation would do the trick far better anyway. I decided to lie again. I'd just say I did it. I'd do her bullshit eye movement stuff, in order to get to the real deal EMDR. Then I got scared. EMDR and the eye movements changes real things in your brain. What if being furious and upset as I was and then doing those eye movements would screw up my brain?

I told her that I felt angry and I wasn't relaxed. She decided to use the rest of the session to give me a questionnaire to find out if I am... I dunno. A difficult person or something. Right, you're being a bad therapist, I'm responding to that, and I'm difficult. Uh-huh.

Bad Therapist #7: This was far less awful or dramatic. A friend recommended a good therapist, and that therapist had no availability. She recommended someone else. I don't like filling out intake paperwork, so I typed up a document with all the info they always ask, like who is your family of origin, who do you live with now, etc, and sent it to her. It included that I'm suffering from depression and I'm working on my PhD.

She started out by saying that it looked to her like I said a lot of bad things about my life, but I have a lot of positives too. I mean, a PhD! Well, for one thing, I don't have it yet. I'm pretty far from actually having it. And grad school is notoriously miserable for everyone (me included). But I decided to play ball. She asked why I feel so bad if I'm getting a PhD. I said that it's not very fulfilling the way friends or loving relationships are. A PhD does not give you a sense of love and belonging, which is what all humans need. But besides that, there's a lot of uncertainty between now and actually getting an academic position after graduating, and it's all really difficult. It's hard to find funding, and you might not get a grant at all. It's hard to find an academic job, and you might only get one in a place you don't want to live.

She kept insisting that my life is great because of my PhD that I don't even have yet. In other words, she was NOT LISTENING. Nor was she empathizing, or providing me with "unconditional positive regard" or validating me, and therapists are supposed to do those things.

This occurred several other times, on other topics. Generally, she'd relent after a while. I'd insist to her that I'm actually telling the truth about whatever it was (i.e. PhDs not being a cure for mental health problems) and she'd ultimately be like, "OK." But I don't want to have to prove to my therapist that I'm telling the truth. I want them to believe me the first time. If they don't understand, they can ask questions.

The other thing she did that stuck out was asking if I have any siblings. I was pretty rude about that. "A dead brother," I replied. "Oh right," she said. She forgot. I'm sorry but that's a big thing to forget. Yes, people forget. It's a common thing that normal, imperfect humans do. But a therapist just meeting a patient should really hone in on the big deal details of the patient's life that will be important in understanding and treating the patient. My brother's death and my lack of family (since he was my only sibling) are HUGE for me. I did not write that much on the document I sent her ahead of time - just about a page or so of stuff - but I wrote a paragraph of key details about my brother's death and the family's reaction to it. It should have been at the front of her mind.

None of these things alone were big enough to stop seeing her over. But all of them together were. So I did.

I ended up going to Psychology Today to find the good therapist who I just met. Here are the good things she did.

First, she invited me to an initial FREE visit to see if we would be compatible. WOW. I had to pay $75 for the privilege of having my time wasted by the last therapist.

Second, she sent over an online form with just a few questions. What are my problems? What are my goals for therapy? Do I use alcohol? How much? Do I use drugs? (no) Do I want to harm others? (no) Do I have suicidal thoughts? (no) Great. We got that stuff out of the way before the visit. It's also notable the way she just asked if I use alcohol and how much, and if I use drugs and I presume there would be questions about what and how much if I had said yes. A friend who is a therapist himself said that this is the right way to ask a patient these questions. It normalizes the behaviors instead of stigmatizing them. A patient with a drinking or drug problem might be willing to fill out a form that asks "Do you use alcohol? How much?" but could be more likely to answer "No" if asked instead if they have an alcohol PROBLEM.

Then, I met her. I sent over the same write-up that I sent the previous therapist. She remembered even minor details on there, like my ex-boyfriend's name, and that I have an aunt I like a lot. WOW. I didn't expect that!

And, she listened to me. She validated me. She was great. Here's one exchange that shows how great she is:

Me: Going to school gives me a lot of anxiety.

Her: What about it makes you anxious?

Me: Well, first there's getting there on time. You can't be even a little bit late, and there might be traffic or it can take a while to find parking.

Her: Does it arriving places on time always give you anxiety?

Me: Yes.

Her: Did it give you anxiety to get here on time today?

Me: Yes.

[OMG she was reading my mind!!! You should have seen me trying to get to this appointment on time. I set 2 alarms the night before, then overslept them both, left late, raced down the freeway, hit construction that brought traffic to a halt, and pulled into the parking space 1 min before I was supposed to be there, and then the credit card reader on the meter was slow. YES, I was freaking out!!!]

Me: And then, you have to eat before you go to school, or bring food, because there's no healthy food around there, and what's there costs money. And it's a half-mile walk from the parking garage to my building, and that bothers me.

Her: What bothers you about it?

Me: I feel trapped. I can't escape easily. And I feel exposed. Vulnerable. It's dangerous.

Her: OK. [She rephrases what I just said, proving she understand and was listening.]

WOW!!! Think about all of the other things she could have done. She could have told me it's nuts to feel that way about school. And it IS nuts. That's why I'm in therapy. She could have peppered me with questions about other options, like whether I could park closer to the classroom. She could have tried to fix me, by making suggestions, like telling me to leave my home earlier so that I'm not rushing around the parking garage freaking out that there aren't any spots before class. BUT SHE DIDN'T.

And you know what? Had she done that, she would have really freaked me out. Because that's how the very person who traumatized me in the first place would have reacted. I would have been completely triggered by such a response.

The way she DID respond was incredibly healing. She listened to me. She believed me. She HEARD me. I didn't have to prove to her why I have a right to feel the way I do about going to school. She just accepted it.

Both she and I know that this is not a healthy way to feel about school. We both know it's nuts to be this freaked out about minor every day things, like arriving places on time or finding parking or walking a half a mile. At some point, something about me needs to change so that I can attend school without as much anxiety. But we're not going to get there today. It won't be a simple straightforward fix, like telling me I'm feeling the wrong feelings. Retraumatizing the patient isn't the answer. And she gets that. Hallelujah.

The real issues at play here are the ones underlying these interactions. This therapist is telling me, by listening to me, that I'm worthy of being heard. That I have a right to my feelings. I don't have to convince her that my truth is my truth. She believes it. She's showing me that I'm important enough not only to listen to but to remember what I tell her. She's also showing me that I can trust her. And she won't trigger my trauma with her response to what I tell her.

The other therapists, on the other hand, conveyed the opposite message. I'm not worth listening to. I'm not important enough to remember what I say. My feelings aren't valid. I can't trust them. In one case, I could only deal with a therapist by lying to her.

This is big for all patients going to therapy. Many patients doubt their own self-worth and their own right to be heard by others. Many patients have had people around them prove that people cannot be trusted, and that if you are vulnerable in front of another person, you will be hurt. For a patient to open up to a therapist, and for a patient to heal, they need to learn that they ARE worthy of being heard, and that people CAN be trusted. Some people can be trusted, anyway. They need to learn how to trust, and also how to figure out who to trust. That's what my new therapist is doing for me, that the others did not.

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