A Clarification for Therapy Consumers

Some problems that come up for people paying for therapy with health insurance

 Surprisingly sometimes clients in therapy are confused about who the insurance company is and who their therapist is...  Somehow the fact that they are 2 different entities escapes the understanding of the client.  When you pay for therapy with insurance (usually it is the bulk of the fee paid by the insurance and the patient pays a small co-payment), the insurance comes with you, not the therapist.  You are a subscriber to that insurance; your employer has made an agreement with them to pay a certain amount per employee every year to them and, in exchange, they will pay for a certain amount of therapy for any employee who chooses to use it.

 It has nothing to do with the therapist:  The therapist doesn't make their rules nor determine how they do business.  The therapist is independent.  They have created and built their practice; it belongs to them; it is an entity on it's own with nothing to do with your particular insurance company.  (In fact, sometimes some of us feel like the insurance companies have taken advantage of us by inserting themselves in between us and our patients)

Most insurance that therapy clients present with are called HMO's. This means that the company will only pay "providers" (this is what they call therapists) who are on their list.  To be on that list, a therapist agrees to their conditions, primarily to be paid at usually about half their normal rate.  For a new therapist, just building their practice, this is helpful to them as it brings patients to their practice.  For a seasoned, established therapist, they are doing you a favor to agree to deal with your insurance.  That's because for the therapist, it is extra paperwork, tracking, and phone calls-so, they do more work for less money.

The reason I am bringing this up is the occasional odd and unpleasant interactions I have had with some patients over insurance issues.  Somehow, they think I am responsible for what their insurance company does!  And the insurance companies, for their part, do seem to set it up that way, i.e. to make it look that way.  (They leave it to us to do their dirty work as you will see in the following 2 examples).
 
For example, recently one of the companies a few of my patients use, decided to raise the co-payment on some of their subscribers.  They didn't inform anyone---not me, not the patients.  It wasn't until I sent in my claims that I  saw this discrepancy.  Since I usually bill for a number of sessions at a time, usually about 6, there were some debts accumulated.  In this case, they had more than doubled the co-payment.  So, I had the unhappy task of telling my patients that they owed me money.  Some of them reacted angrily to me as if it were my doing.  One patient said:  "It sounds like the old 'bait and switch' to me."
Another time, the company decided that the patient had used enough of their benefit and, basically, didn't want to pay for anymore therapy for that patient.   When I told the patient, word for word, what the insurance representative had told me (basically that a limited number of sessions could be used going forward and that they had an end date), he thought that I was throwing him out of therapy.  I was able to straighten that out with him but, then, when I suggested that he could continue, paying himself for his sessions, he immediately and unequivocally refused.

Maybe you can see that these kinds of incidences can be hard on the therapist.  From our point of view, it is unfair.  Sometimes we feel devalued.  These examples I gave are but 2 of many things like this that happen.  So, I just thought that, for the sake of all of us---patients who want to use insurance to pay for the bulk of their therapy, and all therapists who agree to accept insurance---that I would try to clarify how this works.
Insurance is just an alternative method of payment but therapists are independent entities and are not the insurance company and have zero power over them.  (Most health insurers are for-profit businesses and so, naturally they have their eye on the bottom line; they are not helping professionals; they are in business to make a profit, not to help people.)
The therapists are just as subject to the whims of the insurance companies as the clients are.

Was this explanation useful to you?

Appearances Can Be Deceiving

It isn't often that anyone thinks about what it took for someone else to achieve what they have

Sometimes I get the impression, from clients or from others, that they think that becoming a therapist is easier than it actually is.   Once a client said to me:  "You must have an easy life!"  The opposite is the case; I've worked very hard, all my life.  The only help I had was from my Dad with paying for my college education, although I also worked part time and contributed that way myself. After that I did everything on my own steam! Clearly, I can't make that kind of response in a therapy session; I include here as an example of comments that have led me to this impression.

To become a licensed professional, the first requirement is a graduate degree.  So, first you must graduate from college, then apply and get accepted to a graduate school (no small task:  got to get good enough grades in college to be considered, usually have to go through an application interview and, depending on the institution, fulfill some other requirements), then follows anywhere from 1 to 3 additional years of education, including a practicum.  To graduate at my institution, there was a choice of a 4 hour comprehensive written exam and, once having passed that, a one-on-one interview with the dean or, writing a thesis (25% of graduate students finish the program and then cannot graduate; either they can't pass the exam or they can't finish their thesis).   The training is slightly different for each license but for my license, in addition to the master's degree, this is required:  3000 hours of supervised (unpaid) internship hours, and an oral and written exam from the state.  It's one thing to read through this but, just imagine doing it.  It takes fortitude! Once the license is awarded, it has to be renewed every 2 years.  To do this,  36 hours of continuing education must be completed by the therapist every time.

To be fair, we all don't know what is required for every profession.  Sometimes we assume that to do any particular job, it may take the same approximate qualifications as for whatever job we do ourselves does.   This is natural.  I know, for example, sort of what it takes to earn a medical license, but not exactly.  I do have a sense of how it is to do the work for a PhD, the next degree up from mine.  A high school graduate may not really have a sense of what has to go into graduating from college.  Most college graduates will probably have some appreciation for what graduate school entails.  And, of course each profession has other requirements, such as those I wrote about above, that will be unique.  Most people won't know about them.

We may also, on the other hand, give more credibility to a particular title than warranted.  Sometimes we make assumptions that a medical technician, because he has on a white coat, has more knowledge about medical matters than he really does.  So this can work the other way too.

Perhaps because we therapists don't, in fact, wear a white coat, we are thought of as knowing less than we do.  We dress in professional style work clothes.  We are in an office with no special equipment.  In fact, most of us have an office that looks more like a living room.  They are designed to be comfortable and inviting, not intimidating.  But sometimes I wonder if these cues are misinterpreted---if some patients think that a session is just a visit almost like what one does with a friend.

Obviously , everyone is going to be different about the assumptions they make---about any of us in any job.  But, over the years, I have had enough comments and indicators to know that the level of training and expertise that I and my colleagues must have is often not understood by the very patients who seek our help.  Sometimes when we work with a patient, we seem to be simply engaging in a conversation, sometimes we sit in silence; these are times when it is easy to see how someone new to therapy, (or, even an on-going client), may have no idea what the therapist is thinking, much less what  has gone into putting that therapist in that position.

I don't mean to imply that I feel unappreciated. Not at all.  I feel very valued by my patients.  I have a unique relationship with each one.  Trust has developed.  They recognize the benefit of their therapy.  Nonetheless, I find that the other part, the huge amount of work and determination that goes into becoming a therapist and maintaining that license is  not always recognized.                                                           
We all know that we each have areas of more fragile self-esteem.  But, after all my training and experience, I do have a sense of self value in my work.  So, sometimes I have had the odd experience of being treated, by a patient, with less respect than I have for myself.

I have seen some therapists become irate at paraprofessionals and at practitioners whose title is "coach"(some certified, some not) because they see them wandering into counseling areas that really require the professional expertise of a licensed therapist.  Not only do they feel that it is an incursion but they also worry about the welfare of the clients.  However, despite some apparent lack of information on the part of consumers, most states do have a state board that licenses many professions and business people.  Those boards are in place to protect people.

Part of the reason I wrote this post is because you, the readers, have indicated that you want to know about the behind-the-scenes aspect of a therapist's practice.  I do have some readers who are studying to become therapists so they and, of course the other therapists who are also readers, know all about this.  But those readers who are in therapy themselves or considering therapy or are just interested in this subject may not know.

Was this information you found interesting?

Top Ten Therapist's Traits

Which characteristics make for a good therapist

 Many people have the idea that therapists are 'a breed apart'.  Usually I am writing to say that therapists are in fact just human, they are not perfect, that they experience the vicissitudes of life like everyone else.  Of course this is all true.
However, in my opinion, there are some qualities that an individual may have that make them more suited to this profession:
 
Focus.  The ability to focus, to block out extraneous sounds or sights or, at least to not be distracted by them is pretty basic and important.  Some people are quite distractable  and require a library-like environment as well as a mind that isn't preoccupied, to be able to maintain focus.
A therapist has to be capable of maintaining the focus despite what else may be happening in the waiting room, the hallway, on the street outside, or in their own mind.  
In addition, the therapist has to be able to track which means that, if there is an interruption, they should be able to return to the thread of the session.
Sometimes even the patient themselves produce a distraction; they suddenly exclaim that they remembered something they forgot earlier in the day, they failed to turn off their cell phone at the beginning of the session and it rings, or they begin bringing in related but off the course topics.  The therapist has to be able to field these interruptions and remain focused on the task at hand.
In addition, it takes a lot of ability to concentrate in order to clearly get what the patient is communicating.  The kind of listening required is not just to the topic but, also to nuances, tone of voice, attending to body language and trying to sense the unspoken parts.
 
Enjoying the unknown.  Therapy can be a mysterious process and so an individual who enjoys the intrigue of the unknown will be happier at work.  Sometimes a person comes in presenting a problem for therapy and it turns out that the real problem is something completely different.  A therapist who can be interested in following a sometimes winding road and enjoy the surprise, or surprises while proceeding, will do better.  The course of any therapy process is unpredictable; the therapist has to like following the signs along the way and let go of controlling the outcome.

Willing to take risks.  Again, the unknown plays a part.  When a new patient walks in the door, the therapist has no idea of who that is or what they are bringing to the table.  
Also, therapists sometimes pick up an unarticulated aspect of a problem being presented or an apparently out-of-awareness trait in the patient that is pertinent, and once having decided it will be useful, has to be willing to take the risk of communicating that to a patient who may be caught off guard.

Be an idea person.  Therapists need to have some skill in conceptualizing.  Idea people who have an imagination and who are prone to think inventively will make good therapists.  This usually arises from the intuitive function.  Therapists still need to have some practicality.  After all, some problems brought to treatment have practical aspects that need to be sorted out.  It can't all be about ideas and concepts but, the capacity to conceptualize and think creatively is valuable.  Many patients present an array of material and the therapist has to be able to take those disparate parts and feed them back to the client in a cohesive way---or, at least that ability will be very helpful.

Artist Unknown

 Finds other people interesting.  One who is interested in the variety that is represented by knowing a number of people well will find doing therapy ever challenging.  Not being bored by hearing another try to explain their point of view, wanting to know what is behind the public mask, and being really intrigued by that is a good characteristic for a therapist to have.  One cannot feign this interest; if attempted, not only will the client  sense it but, also the therapist will lose focus, concentration, and connection.  If the therapist is genuine about wanting to learn about the person before them, it will contribute to an involved, alive, productive dynamic between therapist and patient.

Have a compassionate nature.  Someone once told me, "You have a big heart".  Being able to offer true compassion can go a long way in the therapy relationship.  This characteristic is an asset for the therapist and the patient; compassion can be healing. 

Curiosity.  Having a curious nature will make a therapist feel and appear engaged.

Mental organizing.  An aptitude for mental organizing is an asset for a therapist.  By this I mean things like being able to prioritize, listening to a lot and finding the essence in the message, and scanning verbal material for signs.

Ability to manage the self.  A therapist has to learn to be able to put their own personal concerns aside when they are in a session.  This is a skill that takes practice.  It helps with the first quality, the ability to focus.  
Things happen in life, to everybody, but when the therapist comes to a session with a patient, they need to be able to leave those things of theirs for later.  The more their own personal life is settled, the easier this will be.  This is why, as I've said before, we should all be willing to go to therapy ourselves.  But, if something difficult and unexpected does occur, the therapist has to be able to self-manage.  It just isn't fair to the patient to not be fully present.

Sense of humor.  I didn't count this on my official list because I don't think it is essential.  A therapist who is of a primarily serious nature could do just fine.  But, some patients like to joke around a little and sometimes humor is also good for the therapist's state of mind.  A little levity in a session is a good thing in my book.  Depending on the therapist's style, humor can add a little but it isn't a necessity.

Confidence.  I think this one will occur naturally if the therapist has the others on the list.  That list will contribute to successful therapy episodes and, thus, will contribute to the therapist's confidence.  A therapist who is a confident person will impart a sense of ease and encouragement to the patient.

This particular post just begs for input from other therapists.  Some of you may think other qualities are more important, some may think some of these are not of primary importance to an effectively functioning therapist, some may have additions to the list, some may heartily agree with my list.  Please comment.

All readers, please share your opinions and experiences. 

Your Request

 Response to Poll

There was a request from one of our readers re. the poll, expressing an interest in posts on several topics.  One was for posts about the patient-therapist relationship.  While I am holding that in mind for future writing, I just want to mention that many of the posts here do say a little about this; here are 2 examples.

 A Healing Relationship

  The Imperfect Therapist

For now, I will offer this:  My patients mean a lot to me.  I learn so much about their personal lives and their own interior experience in the course of therapy.  As I mentioned in one post, paying the level of attention that I do to a patient leads to involvement which leads to caring.  At the same time, I must maintain certain constraints.  A professional demeanor is expected and deserved by a client who comes for therapy.  The frame of the therapy provides a sense of safety and a certain predictability which allows the therapy patient to freely express themselves.  Do I think about them outside of the therapy sessions?  Of course!  Do I worry sometimes?  Yes.  Does their new learning, their insights, their making some movement toward resolution, their accessing a deeper understanding of their concerns  matter to me?  It does.  Am I happy when a client of mine reports an achievement?  I am.  If a client has to move away in the middle of treatment, do I miss them?  Yes, I do. 
 When they complete a satisfying therapy for themselves and conclude their treatment, however, I may feel a moment of sadness but mostly I am gratified; I am prepared for this and am working the whole time to help them feel more actualized in their own life and to take, eventually, a happy leave from me.  So I don't mourn a client leaving under this circumstance, I see it as a success.

I am one therapist.  This is how I feel.  Each therapist is different as discussed in the posts about selecting your therapist.  Some may feel as I do or, similarly.  Some may take a different view.  I know that some therapists read this blog---maybe they will comment on this part of being a therapist.

What else would you like to know when you wonder about the client therapy relationship?

The Therapy Relationship-Is It For Real?

The juxtaposition of the personal and the practical in the therapy relationship

Sometimes the practical aspects of therapy come up smack dab in conflict with the personal relationship between the therapist and the patient.  When this happens, it can be very hard on both.

Because this has occurred in my practice-sadly, a number of times-I try every way I can think of to derail it in advance.  So, for example, when a new patient begins I am quite careful to make clear the cancellation policy, the fee for extra paperwork, how the appointment time frame works and anything else I can think of that might trip us up!

Unfortunately, sometimes people agree at the outset and then either forget what the policy is or decide, when it actually comes up, that they have objections to it.  Several times this has happened with long-term patients, who occasionally 'no-show' an appointment and pay the fee, then suddenly decide on the next time that it happens, that they want to argue about it.  It surprises me when it occurs that way.

Then, they don't want to hear the explanation for the policy!   And, in fact, most private practice therapists have similar policies for the running of their practice and they really are reasonable.  But, if you don't know the why of it, they can seem unreasonable.  Indeed.

Having been on the other side of the fence (which as said before, all therapists should do from time-to-time), I know what it's like to suddenly be reminded that I had to pay for a session I didn't get!  In my case, I woke up with a cold, called as soon as I knew I wouldn't be able to make it, but, as my therapist said when I went in the next time:  "It wasn't 24 hours notice."  Yikes!  Well, of, course, I paid it without complaint since that was her policy and I had agreed to it.  This is many years later and here I am writing about it so it is obvious that this is a hard pill to swallow.

In this case, though, therapists are not like doctors who have people lined up in the waiting room to fill in if an appointment doesn't show up.  Even so, docs charge a standard fee for not cancelling the appointment.  We, however, dedicate a full hour for each person (not the usual 15 minutes that doctors allot), usually about 45-50 minutes for the session and a few minutes in between for notes, catching our breath and preparing for the next appointment.  Also, we prepared for the appointment that didn't come.  We paid the rent for that hour, the phone bill---well, anyway, you get the idea.  Basically, as a therapy patient in a private practice, you are the therapist's employer for each hour that you reserve.
(There is no invisible entity who pays your private practice therapist a salary.)

  

Another thing that can happen, in the case where a patient is using insurance to pay a portion of the therapy fee, is that the insurance changes.  Maybe the employer changed plans and the new insurance doesn't list the patient's therapist.  Collision! 

Most people, who have been used to paying a small co-payment for therapy are shocked when they are faced with paying the actual fee.  The collision is between the personal value both the therapist and the patient may have on the therapy relationship and having to pay out of pocket for that value.  

It's tough.  I've been on both sides of that dilemma.  Once I saw a Dad and son who had left the son's therapist for this very reason and were shopping for a new therapist.  The boy was very unhappy at the prospect of losing his therapist; I tried to encourage the Dad to return to her.  But, the Dad was adamant, refusing to even consider paying for the sessions.  (In this case, it's always worthwhile to attempt to negotiate with the therapist.  You may be able to agree to a reduced fee.  It would still be more than you are used to paying but may be worth it to maintain an established therapy relationship.) 

In another instance, it happened in my own practice where the insured had a job change which came with a different plan on which I was not listed.  It is such a conflict when this occurs because everyone wants to continue the way it was; yet, changes have to be made and sometimes, unfortunately, the therapy relationship ends up getting lost.

I don't have a sliding fee scale but some private practice therapists do-especially in the beginning of building their reputation.  What if two neighbors in the same community have different fees?  They compare notes.  Next comes an objection to why their fee isn't as low as their neighbor's.

These are of 3 examples of many.  So, you can see that thorny issues can come up about money and therapy.

The feelings that sometimes emerge in these situations can be quite profound.  This is why I do my best to get all the business aspects to therapy out on the table at the beginning before any personal feelings between the patient and therapist have developed.  On the patient's part, it usually has to do with feeling uncared for.  In the example with the neighbor, the patient might think, Doesn't my therapist care as much about me as about that other client...  Or, if the patient doesn't really think it through, when they have to pay for a missed appointment, they may feel that the therapist is being unfair to them and must not really care.  

Of course, the therapist can have similar feelings come up.  Doesn't this person have any value on our relationship?  Don't they realize I am a person too?  Do they think so little of what they are receiving in therapy?  Therapists may have thoughts like that when patients start wrangling with them about money.

When a long-standing patient quits over a money disagreement, it is very hard for the therapist:  They are involved, invested in the issues they are working on together with the patient; they have a personal connection to the individual, they've been putting out their best effort-isn't the patient aware of that...? These might be some feelings that will emerge for the therapist in this situation. 

It's tricky territory and has lots of potential for misunderstandings and hurt feelings.  As a patient, what you can do, instead of refusing to listen to your therapist when they offer to explain the rationale behind a practice policy, is listen and try to understand it.  (There is a lot of work and activity that goes on in a therapy practice that is invisible to the patient)  
If you do have to part ways  due to financial constraints, be clear with your therapist about whatever your feelings are-maybe that you feel a great loss in leaving but that it is financially impossible to continue, or whatever your feelings are.  
When you cut a therapist off abruptly (without that kind of discussion) due to dissatisfaction with financial matters, it leaves a therapist stunned and sad.  They have been sincerely devoted to trying to help you sort out whatever you were bringing to therapy and suddenly they seem to be treated as if they can be easily replaced.  Disposable.  Some therapists burn out and quit the field.  It's often thought that this is due to an overload of dealing with heavy problems.  I think it may more likely be-at least for private practice therapists, who don't usually have support staff-dealing with the sense of being unappreciated when these money struggles come up.
One of my colleagues who is also a long-term friend was expressing something like this to me the other day.  She was talking about "...what has happened to our field"  and saying she could imagine closing her practice because of being so disillusioned.  That would be a great loss as she is a seasoned, conscientious, bright therapist.
 

On the patient's side, you may wonder, when money matters come up, "...does my therapist really care about me?"  I say, the therapy relationship-as different as it is from all other relationships in life-is for real.  I do care about my patients and I think most therapists do.  Maybe a way to think about it, as the patient, is that you are paying for their training and experience--------and think of that part as separate from the genuine caring relationship that usually develops.

Comments?  Any ideas about traversing these treacherous waters?  Have you had experiences with this dilemma?

Defensiveness

A tip about dealing with it and an introduction to a new series

The other day, I told my doctor about my acupuncturist and brought him some written materials she has about her work.  Here was his initial response: "She isn't an MD.  To be frank, she just doesn't have the training.  I only work with MDs."  

I said nothing in response to this but just waited as he read over the materials.  Then he said:  "Can I keep these?"  Sometimes a person will have an initially defensive response to any sort of communication.  Some even do this as a habit.  The tip is that when this happens, just wait.  I think that people who do this are trying to give themselves time to make a choice.  They are protecting their sphere of influence so that they can decide if they want to be influenced.  If, when you get this resistance, you immediately jump in and try to persuade the person who is in the self-protective mode, you are going to engender an even more defensive reaction.

In therapy, the therapist often tries to help the patient to lower their defenses in the session.  This is to allow for opening up.  Eventually, some patients begin to cooperate with this effort themselves, noticing when they have a defensive reaction and trying to deactivate it or, at least, saying out loud that they feel defensive.  The therapy can then proceed to examine why the topic caused this guardedness or the need to feel protected.

Defense mechanisms is a clinical term and concept; therapists use a defensive functioning scale and identify defense levels in a patient they are working with.  But, speaking for myself here, I don't consider them to be an all bad thing.  Actually, defenses are mostly what is commonly referred to as coping mechanisms.  They are useful and necessary.  In fact, if a client does achieve a deep opening in a session, I will consider it important to help them resurrect their defenses before they leave the office.  I don't want people leaving a therapy session raw and exposed, if possible. 

 Lowering of defenses is for certain situations:  The therapy office, an intimate relationship, and introspection.  

Sometimes therapists have to also consider the larger effect:  The therapy process, overall, tends to help people develop more self-acceptance, more self-knowledge, and therefore, more openness in general.  So, a therapist might consider that if the therapy is removing or modifying one defense, there may be some method of dealing with difficulties with others or with oneself, that should be put in place of it.  

 At the same time, I like to teach people that some of the darkest parts of life can be faced with consciousness and without devastation.  

Some people do come to therapy hoping to be able to enjoy a change in their life without opening up, without self revelation and without having to go through much of a process of learning to trust the therapist.  This approach will impede any real insight or true internal shifts.  It will still allow for problem solving, venting, and a lightweight therapeutic effect, however.  So this is a more guarded, defensive posture which will preclude profound change but can still be one way to use the therapy resource.  Related post:  http://therapiststhoughts.blogspot.com/2012/06/attachment-and-transformation-in.html
Here is a post, written earlier that talks about defenses in a different way: http://therapiststhoughts.blogspot.com/2011/04/self-esteem.html

"Defense mechanisms (or coping styles) are automatic psychological processes that protect the individual against anxiety and from awareness of internal or external dangers or stressors.  Individuals are often unaware of these processes as they operate.  Defense mechanisms mediate the individual's reaction to emotional conflicts and to...stressors".  American Psychiatric Association

My intention is to write more about specific defense mechanisms.  Are you interested in this topic?

Family Therapist

How can therapy help

 One of the best recommendations for the process of psychotherapy I've seen:  

"Life is not what it's supposed to be. It's what it is. The way you cope with it is what makes the difference. "
Virginia Satir

I attended a seminar once, a long time ago, where Virgina Satir presented.  I think I was still a student then.  She had a few of us on stage to demonstrate her ideas about how things happen in families.  What a privilege!  I'll never forget her warmth, intelligence, confidence, and generous nature. 

The Best You

Is therapy for problem-solving only?

This post is prompted by a reader's comment.  This person was looking for two things from their therapist that the therapist did not want to offer.  One was reassurance that the relationship was fine and in good condition and the other request was that the therapist, in addition to pointing out problems, highlight for her some of her positive attributes.

When I conduct therapy, I go into it looking for the positive characteristics in the patient; that belies an assumption that there, of course, would be some good qualities in nearly anyone.  And I do enter each new relationship with that assumption.

First off though, we want an honest relationship and a true process.  So, here I am not talking about social niceties.  I am not talking about flattery.  Unless it's sincere, I don't mean just throwing in a compliment here and there for good measure.  

What I mean is looking for that individual's real assets and sometimes speaking about them.  I think that honing in on a patient's strengths and bolstering those positive traits should always be a part of therapy.  The purpose of therapy, in my book, is for you to become the best you possible.

But, not all therapists agree with this and so, once again, I remind you that if you want a solution-focused therapist or, on the other hand, if you want one who will try to include all parts of your character and personhood, you must search until you find the right match.  As you can see, if you are looking for one of those styles and you land up with a therapist of the other style, it's going to be a rocky road.

In this case, the client who wrote in also asked for some reassurance from the therapist, specifically about the therapy relationship.  Personally, I oftentimes ask clients to tell me if there is a certain way that they want me to work with them, if they have been in therapy before and have found things that are helpful to tell me about that, as well as to say if something isn't working and to express their wishes.  I expect our therapy  to be a collaborative effort and process.  I also ask, periodically, for feedback on how the therapy is going in the patient's view and often do a year-end review.  All therapists are not going to be of this mind-set.

When you read the post, Making Mistakes, you saw a list of some of the helpful things that therapists have to offer in their skill set.  That list is mostly about problem-solving and promoting growth which is, perhaps, the arena in which the reader's therapist most liked to work.  Indeed, this is the majority of what we do.  People usually come to us with a problem.  Or, sometimes they are having trouble with their own inner life, or their personal functioning.  So, indeed, therapy is not just about ego-boosting.  But, at the same time, I don't think people come to a therapist to be only told what's wrong with them.  It's best to have some balance.

Seems to me if you want a balanced outcome, there ought to be some balance in the process.  If the focus is only and always about problems and what's wrong, the implication (subtle message) is that the client is just a bundle of problems with no good side.
(One little caveat; it must be mentioned that each case is different, i.e. in one case lots of positive feedback and encouragement might be just what's needed and, in another, it might be the worst thing for the client.  Therapists have to make these determinations.  This post is about the development of the therapeutic alliance and collaborating on creating a working style.)  
Nonetheless, if a patient asks the therapist for something, it seems the least the therapist could do is explore with the client what that request means to them, what it's about. 

In addition, generally, I think that courtesy, respect, and a little encouragement on the part of the therapist can go a long way toward providing a welcoming, accepting situation in which the client can openly
share and explore their personal issues.
 

Sometimes I write about the work of other theorists. Sometimes I do synopses of research I hear presentations on or from seminars I attend.  But, usually when I write here, it is my opinion I am expressing and this post would be an example of that.

Other therapists, please weigh in.

It would be great to hear other ideas about this, whether you have an opposing point of view or are in agreement.

Comments on this topic are welcome.

Making Mistakes

Sometimes the professionals we rely on don't get it right

Have you ever had a physician make a mistake with you?  I have.  It isn't something you forget or get over easily. 
One example that happened to me is that I was diagnosed with a malignant melanoma and urgently pushed into outpatient surgery.  A lot of tissue was removed and it was not only a physical ordeal but also emotionally, a frightening thing to go through.  But, I trusted the doctor and went rushing forward.  Later I found out from a specialist in these type of skin cancers, at Stanford in San Francisco, that I had been misdiagnosed (did you know that slides of these medical events are kept?) and I actually had something harmless called a spindle cell spitz nevus which is supposedly often mistaken for a melanoma.  To finish this story, I later had a scar revision done by a plastic surgeon-also, not fun- but something far in the past for me now from which I am fully recovered.  The point is, the doctor I relied on made a mistake.

One example.  But these things have happened to me more than once.  And to people I know.  I know one person, for example, who had the opposite happen-a cancer that the doctor didn't think was anything.  Sadly, it was ignored and grew and now he is in big trouble.  So, back to our "imperfect therapists" (http://therapiststhoughts.blogspot.com/2011/05/imperfect-therapist.html).  If doctors, the professionals who, at least in this country, are elevated almost to royalty, can make mistakes, so can therapists.  And we do.

So, the point is, as the psychotherapy patient, don't be afraid to say, "I don't think so", or "that doesn't seem quite right," or-after true consideration-"I just don't think that fits me."  A solid therapist should be able to take that correction and keep moving along with you.

~You are the final authority in your therapy.  

You must look within to discover whether or not an intervention, a piece of feedback, a direction, resonates with you---or not.  

Ultimately, only you can know.~

On the other hand, in giving you this advice I have to warn against the other side where you are too guarded and skeptical in your therapy.  That will work against you.

•  Your therapist may, indeed, be able to point out a blind spot.  And, if you are open, you should  be able to acknowledge it, once it's highlighted.  
• Your therapist may be able to foresee trouble in a direction you are moving in, in your life, and you would be wise to consider the possibility when it's presented.  
• Your therapist may have a clearer view of the larger picture, which you hadn't realized due to being immersed in it, and that is beneficial to you.  
• By listening carefully and remembering salient points, a therapist may be able to draw together 2 disparate pieces of your communication and present a hypothesis; this can be enlightening for you.  
• A therapist, by attending, may be able to point out a contradiction; this may serve to illuminate a new perspective for you.

There's a lot a therapist can offer, due to training, due to experience, and due to the fact that when you are there, they put other concerns aside and focus entirely on you.

Nonetheless, they can occasionally be wrong, or slightly off.  (Remember the recent Fallen Angels post---no body's perfect).
http://therapiststhoughts.blogspot.com/2012/07/fallen-angels.html

Even the most splendid, lovely, accomplished, that you adore, therapist, cannot be flawless.

But!  What I have found---and, this is difficult to explain but it is a real experience,--- is, that if I stay open (as a patient) in a session, consider everything that comes up, whatever and all that is offered, I usually find something in it.  Weird, but true.  So, in my own sessions, I do correct sometimes but, mostly I just try to stay in the flow.

Food for thought I hope.

What comes up for you in reading this?

Caught My Eye

A brief quote that reflects part of my intention here

 

Lynn Fishman R.N. via Twitter 

   If your actions inspire others 2 dream more, learn more, do more & become more, you are a leader. ~ John Quincy Adams 

This quote from Lynn caught my eye because it is exactly what I hope to do here, on this blog. 

Have I done that?

Search Keywords/It Takes Two to Tango

A seeker who made me think

 

 "Taking care of your therapist" is the phrase that appeared on the search keyword list that Google provides for me.  And, oddly, it was there more than one day.

Usually I don't do anything about these search words as I can't know what they mean.  That's why I am always encouraging you to comment  on the blog---because I do want to know what is on your mind.

This cryptic phrase stuck with me for some reason.  It made me think.  Usually, of course, we all naturally view the psychotherapy relationship as pretty much one-sided.  A person who seeks out a therapist is not looking for someone to take care of; they are hoping to find help for themselves.  And, yet, as I continued my work with my patients and this mysterious shred of a sentence stayed with me, I began to notice something.

While the lion's share of the attention in a session is going from me to my patient, there is, in fact, an exchange.  It isn't even or equal and it shouldn't be.  But, it is definitely there.
And, I have been noticing that there is a real range:  There are people who pay attention, consistently, and with great consideration to how they treat the therapist-----all through many versions of everything in between-----to people who will rip off their own therapist.
 

This last, every time it happens, utterly amazes me.  It just knocks my socks off!  How can a person  finagle a way to not pay either their fee or their insurance co-payment to someone who has given them their compassion, their attention, and their best thinking?  Never ceases to amaze me.

When this happens, it feels de-valuing to the therapist.
Yet, while therapy is on-going, many therapy patients, if not most, can hardly get out the door.  Some are still talking, in the doorway.  They find it very difficult to end the session.  Why is that?  That's because therapy is therapeutic.  It feels good.  It is nourishing to the soul.  To have an intelligent, thoughtful, kind listener is enough to be hooked.  But therapy gives that and a lot more.  It's hard to leave when receiving that kind of attention.  I still don't know how to reconcile this oft-repeated occurrence-of not wanting therapy to end, with the one of cheating or defrauding the therapist.

The last time I was in therapy, I did everything I could to support the relationship with my therapist and to treat him with regard:

This includes simple things like making it to all my appointments, getting there on time, being ready with the payment-whether it is cash or a check and quickly giving it to him at the very beginning of the session, preparing for my session personally, i.e., thinking beforehand about what I wanted to focus on, never bringing my cell phone into the room, staying involved, open, and personally engaged throughout the session, not bugging him too often with in between-session phone calls, listening when he had something to say (not interrupting or cutting him off), occasionally thanking him, not taking it for granted if he did something extra such as get me a referral or talk to my doctor, and giving him specific feedback if he did or said something that had been particularly helpful to me.  If I brought up something or someone we hadn't talked about much or, for a long time, I would cue him in with something like, "My cousin, Ellen, the one I spent a lot of time with growing up..." in case he didn't immediately remember.  Usually he did, but, I just felt it was considerate not to expect him to recall every single little reference I had ever made.  One time, I paid with cash because I forgot my checkbook.  He was so pleased!  Said:  "That almost never happens!"  So, just note that some therapists in private practice find it helpful to be paid in cash.  The point is, just a little attention on the patient's part, can make a big difference.

Some of these things are simple courtesy, a few are coming from a deeper level.  But, it all added up to treating him with regard.  Of course, as a therapist myself, I know what it takes to do what he does.  I don't expect every patient who goes to a therapist to know how they (the therapist) got to that position nor what it takes to stay there.  (And, in fact, I do realize that what takes tremendous effort can, in an experienced person, look quite easy).

But I would hope that, over time, the patient would take in the wonderful combination of caring and thinking that a therapist offers to them.  And yet, it just doesn't always happen.  For some, either it goes unrecognized or unappreciated.

Of course, at the clinical level, it tells the therapist something about the patient's own self care, about how they've been treated previously, and also how they currently function in their relationships with others in their outside life.  Behavior is information. But, for the purposes of this post, I'll not stray off into that kind of analysis and just stick with the therapist-patient relationship.

Some of the things that happen are not quite, but are almost, shocking.  When a long-term client leaves the therapist in the lurch, owing money by tricky means like no-showing the last appointment and not paying for it or not having the co-pay the last few visits, promising to mail it and then becoming unavailable without having settled the account as promised, writing a check on a closed account, and so on, it simply leaves the therapist with a sinking heart.

I used to try and try to get the payment and then, ultimately, after a ridiculous number of attempts, would turn the account over to Collections.  I haven't done that lately as, for me, no matter what the client has done to me, I just can't muddy up the helping relationship with something so punishing.  The intention of therapy is to shine light into the darkness of life, not to add bitter experiences.  So, I absorb the loss.

On the other end of the spectrum, are people who are always responsible for their part, live up to any agreements they've made with the therapist, are considerate of the therapist's time, and pay regularly:
They are generally courteous and show that they are aware that the therapist is a person too.  There is rarely a patient who doesn't miss some appointments (although some never do, without a proper cancellation) but the people at this end of the spectrum always pay for my time.
I've had some who voluntarily gave me a raise (raised their own fee)-yes, believe it or not-and people who have paid, not only the fee for a missed appointment but offered to pay extra for making me sit there and wait not knowing what had happened.  Usually this comes with a sincere apology.  

It is clear, this group has a value for the therapy process and respect for their therapist.  They leave no doubt.

~The world has become a harsher place in recent years.  But the holding experience of a good therapy relationship is a respite from that competitive, confusing world outside.  The therapy office itself can become a container (a confidential container, with boundaries) for your dreams, hopes, fears, worries, wishes and secrets.  It does seem, like the search keyword the writer wrote, to some degree meant, it is fitting to take good care of your therapy and your therapist.~

A good therapy relationship is key to a productive therapy experience.   Most therapists will try to meet you more than half-way.  But, they can't do it all for you.  
Your contribution will be key to the best experience and outcome for you. 

"Psychotherapy is a two-way street:  Both the patient and the therapist must take responsibility for their part in creating the healing relationship." Quoting myself from the post, A Two Way Street

The more that you honor your therapy relationship, the more fruitful your therapy will be.

Pleas write in the comment section about how you feel about how you treat your therapist.

The Imperfect Therapist, Part III

Clients assessing the therapist

                                              Sculpture by Christine Kaiser

  Sometimes a therapist may look more flawed than they are.  
People come to therapy with certain expectations---sometimes they are happily surprised, sometimes they may feel they are not getting what they were looking for.

In this last case, we therapists sometimes receive criticism.  It has happened to me a few times.  When it is warranted, I am fine with it.  When it  isn't, I find it really hard to take.  But, the therapy session isn't the place for the therapist to become defensive...!  So, I feel it is actually much easier to take a deserved criticism as feedback and an opportunity to improve than it is to try to redeem yourself when a patient has complained inappropriately.  How do you stick up for yourself?  Difficult to do.

One time I got told that I didn't give enough direction and that I was more of a "listener type".  Actually, as therapists go, I am probably on the more talkative end of the spectrum (you may have figured that out if you've looked through this blog at all---lots of posts in a shorter time than most...!)
I am not one of those, "uh-huh, yes, ummm", silent type therapists (and I have also received compliments on that from other patients).  I am more of an engaged in an exchange type of therapist than most.   So, this felt quite unjust.
 I do listen though.  I have to know what the actual problem is and that takes some attention and time.  As a matter of fact, I often have to restrain myself because it is so tempting to tell people what to do which is not our job.
I do give suggestions however.  And, this comment seemed particularly undeserved as it was a case wherein I had made more suggestions than usual and really tried to work out a plan of action with the patient, only to have it ignored.
(Have you ever noticed how sometimes a person does something themselves and then blames another?  Very common.)

Of course, most people don't necessarily understand how therapy works, even some who have partaken of it for a long time.  When I go to therapy myself, I am not only working on myself or my own issues but, I am taking full advantage of the process.  Of course, that's because I know what it is.  
It would be a benefit to patients or potential patients to learn about how therapy actually works and why it helps, what a therapist's role is, and how the patient can make the most of their experience!      (Here is a post on that topic:  http://therapiststhoughts.blogspot.com/2011/12/biggest-bang-for-your-buck.html)
I don't believe in keeping therapy a mystery or a secret---that's one reason I do this blog---the more you can understand how the process works, the better position you are in to take the full benefit.  Here is another post on how you can best benefit from your therapy process:  http://therapiststhoughts.blogspot.com/2010/04/your-side-of-street.html 
Some people are more difficult to help than others:   

• Some come to therapy---a place, by definition, for change---very resistant to change.  
• Some present themselves to a therapist for help with a thorny problem and then withhold some of the pertinent information, leaving the therapy process handicapped.  
• Some repeat the same problem over and over but never apply in their life what insight or decision was arrived at in any of the sessions.  
• Some want things to be different in their lives but are interested only in 'tea and sympathy'.  
• Some would like it very much if others in their life would change but refuse to try anything differently themselves (even how they think about something).  
• There are patients who lie to their therapists sometimes which, of course, makes it impossibly difficult to help appropriately. 
• I have even had someone say, at the end of a session, wherein we developed a detailed plan about how to deal with a difficult family member, "Oh, I just wish she'd just stop causing problems."  It was clear to me at that point that none of the planning we had done was going to be applied.

Nonetheless, we therapists in such situations usually keep trying, every week, to think creatively about the patient's problem, to come up with a new angle of approach, and to maintain our compassion for the person before us.

You can imagine how hard it would be to take criticism in one of these scenarios...!

Lest I end this view on one of the challenges of being in the therapist role on a sour note, I will share with you a wonderful bit of an assessment I received today from a young client of mine---a cute teenager:  She said:  "I like it that this is like a conversation and I am not feeling like I am getting the 3rd degree!  I like having a regular weekly meeting even though I don't always have a crisis, it's nice to know this is here for me in case I do.  I'm glad we can laugh together sometimes.  I feel like you really care."
That little girl made my day! 

Please share your feelings in a comment below or in the reaction boxes.  

(This is Part III of the series, The Imperfect Therapist, which has continued to attract many readers; the second post in the series is here: 
  http://therapiststhoughts.blogspot.com/2012/03/look-before-you-leapthe-imperfect.html)

Celebration!!! Three Years.

 This is the blog anniversary

 The 1st post was written on Friday, June 26, 2009

 What am I doing here?  I am trying to provide a useful service.  During the time since I achieved my license and have been in practice, I have seen hundreds of people.  They have shared with me---they've shared their shame, their joy, their struggle, their wishes, their disappointments, their accomplishments, their love, their pain, their ideas; in short, they've shared with me their inner lives.  

I sure hope I have learned something from this.  And that learning is what I hope to impart to you.  If you have never seen the inside of a therapy office, I think that this blog will give you a small taste of what that may be like.  

If you have been in therapy or are currently engaged in that process, this blog should work for you as a stimulating adjunct to your own therapy effort.  If psychology is an interest of yours, the latest information from the researchers in the field is here.  If you'd enjoy a peek into what occurs between me and my patients, there's a bit of that here.  If you want to know what it's like to be a therapist, that has now been incorporated into the blog.   At first, my aim was to provide growth-provoking material in written form.  But, as I've gone along, it's become abundantly clear that you, my readers, actually want to know about me, or, people like me.  Now I have a label, "About therapists" so you can find out something about us.

I am also hoping to provide a place you can trust.  I try my best, in my profession, to function with integrity.  Naturally, everything I write here cannot be perfectly correct.  On the other hand, I didn't begin this blog until I had a whole lot of experience under my belt.  I have an intrinsic interest in my field so, even if I weren't required to complete continuing education, I would be attending seminars and reading about psychology anyway.  I know what is in my heart.  And my wish  to offer something here that will be helpful to some of you out there in the world, is real.  So, I hope that when you are perusing these posts and wandering around in the blog that you feel, confident and comfortable.

If you are curious, if you have a drive to understand, if you are seeking inspiration, you will be able to find resources for those quests here.

I am on a mission (and I don't mean to sound overly dramatic but that is how I feel) to add something good into the mix that is our human world.  At the same time, it also makes me happy to create the blog:  I feel inspired myself, I utilize my creative energy, and I am giving out all that I have.  I don't want to stop until I am on empty!

It seems like there does need to be some sort of change though, in how the blog is done.  As I've said before, I work many hours every week on it.  I rarely miss a day, believe it or not-yes-I work here every day.

I have to find a way to support this.  I've asked for your suggestions (Post, titled, Call For Participation addressed that problem) but I didn't get any.  My best that I can come up with is to place a Donation Button on the blog.  If you feel you received some value from visiting here, you may wish to help me to continue to offer my particular brand of encouragement for self-actualization and living life to the fullest.
 I want to continue to give you what you want (and, please, if there are topics you want me to address, ask me for it in one of the comment sections!) and, at the same time, I want to take care of myself.

Don't get me wrong, it is, as a matter of fact, a magnificent feeling, to altruistically give whatever you may have to offer, freely to the whole world.  It's wonderful.   (Bless the internet)

But! as one of my patients so wisely once said:  "If you don't deal with reality, it will deal with you."

***Primarily, though, this is time to celebrate---3 years of writing about us, people, fascinating creatures that we are---344 posts and counting!***

Again I invite you to join my blog as a Follower; it would mean a lot to me.  Write what you think, how you feel, what your questions are, in the comment boxes.  Talk to me.  Express yourself to the other interesting people who read this blog.

Celebrate!  Dance!  Listen to the music!  I am celebrating my accomplishment and I celebrate you in your personal quest!

"There are many times in our life when we may feel as small as a butterfly, and when we think that the things we can do have as little effect as the fluttering of a butterfly’s wings.  We think that in our own little space allotted to us, in the small roles given us to play, we make almost no difference in the lives of those around us.

Little however do we know that what we do may truly result to a big difference later on, creating waves of change that wouldn’t have happened had we not taken the initiative to do our part.

Let us remember the Butterfly Effect.  For who knows?  Your little deeds may just yield a tornado of blessings to countless others around you, even to those whom you haven’t even met."

I will be looking for your comments.