Friday, August 07, 2009

"It is the Relationship That Heals"

If this is your psychiatrist or therapist run...

I am always struck by how much support I get in my comments and how many thoughtful people comment. This was going to be a response to the comments in my last post, but it has turned into its own post instead...

I love to hear from people who comment on a regular basis. I feel like over the years I have developed relationships/friendships with many of these people. I also feel really good when I hear from those who rarely or never write. It feels like the beginning of a mutual support system. I am glad my writing reaches out to people. I hope it continues to do so. Your comments often inspire this one, so comment away.

I write this blog, not just for myself, but also for others trying to work through and battle the same or similar issues and demons. People sometimes comment about how open I am. My original intent for my blog was to try really hard to make this as close to therapy as possible. I wanted to push myself to be open and as completely honest as I thought I needed to be for therapy to work for me.

I also planned to use it to prepare for my therapy sessions, to debrief after my sessions, and to push myself to become brave enough to talk about deeply personal, and often scary thoughts I have. In writing I hoped I am able to show others that therapy is a rewarding, and helpful process, even if it is sometimes really, really hard to fully participate in.

I was hoping that if others could be "insiders" in another person's therapy sessions, if they could see my process, my difficulties, my struggles, my successes, my cycling, my wingbat thoughts and ideas, my creativity, my attempts to get better, and even my failures: I was hoping others might take a chance with their therapist; try hard to open up in therapy, to go to therapy if they never have, to address there darkest secrets, to address any patient/therapist disconnects in therapy, and to find the therapist or psychiatrist that truly fits their needs.

Before I met Dr. X. I had already been to therapy numerous other times each with varying degrees of success, and sadly often failure. With most of the therapists I saw there was either a complete disconnect between myself and them, or if it worked I was in need of a longer course of therapy, and I believe medication which no therapist ever mentioned was available.

I now believe I needed to somehow muster up enough energy to be more of an advocate for myself...Though I know, when severely depressed that may not be possible. If I were to have a second chance to be start at 19 again, if I needed to see a new psychiatrist/therapist, I would approach it as a customer trying to find the best "product"/"service"/treatment for me.

I would be more assertive, have greater expectations, ask more questions and not settle for the first person who comes along. I would have looked for someone like Dr. X from the start. Of course, that is easier said than done.

Below are some of the things I would look for in a psychiatrist/therapist if I had to look again:

  1. When meeting a new psychiatrist or therapist, make a list of the types of behaviours that are important to you in someone you are seeking help from.
  2. Be open to new ideas and approaches.
  3. Ask them questions.
  4. Listen to how they answer your questions. Are they welcoming? Do they sound put off by your questions? Are they caring?, or pushy?, or short?
  5. Do they have time for you?
  6. Are they just medication oriented?
  7. or Do they provide therapy? (I find it really helpful to have a psychiatrist who does both).
  8. Do they LISTEN?
  9. What are there credentials?
  10. What kind of experience do they have treating people like you?
  11. What type of therapy do they practice? I find the less dogmatic about a particular therapy style the better....Use whatever works!
  12. How flexible are they?
  13. Do you feel comfortable around them?
  14. The last sentence...Do you feel comfortable around them? tricky, because many many times, probably during each of my sessions, there is some degree of feeling uncomfortable around Dr. X. Even 8 years into therapy I feel guilty, or ashamed, or afraid, or even angry at him periodically. The test of being comfortable lays in whether I can talk about my uncomfortableness...even if it takes a few sessions.

    If I feel he has said or done something I am uncomfortable with, and I can safely work through and see this as an opportunity to discover something about myself and others...then it is indeed a powerful and psychically "comfortable" relationship.

    The question I try to ask myself when this happens is whether these feelings are coming from me and my mood or experiences, or whether the psychiatrist or therapist is doing or saying something, that promotes my feeling ashamed, afraid, intimidated etc

    I "understand" (in my rational mind) Dr X. is NEVER judgemental, or angry, or pushy, or authoritative, or any other way that might increase or promote my feeling bad in therapy. That does not mean I do not ever feel these things. Who I am, what I have experienced etc. impact my reactions towards all my relationships' experiences and interactions

    Some Psychiatrists/Therapists (like some people of every persuasion or occupation) are pushy, or arrogant, or sure whatever they say is right, and the patient knows nothing about helping themselves. They tell the patient to just do whatever they tell them to do etc. This is the kind of therapy/doctor, that I always found did not work for me. For me a good therapist and/or psychiatrist forms a partnership with their patient, values their patients ideas and lets the patient know they are valued

    Some of my readers have expressed difficulties, or difficult relationships with, with their psychiatrists and/or therapists. I believe it is important to delving into into why I might feel that way. What kinds of behaviours, exchanges, actions, thoughts are taking place both in and out of therapy that are leading to your feeling a disconnect?

    In his book, "Love's Executioner" and in his novels and psychotherapy textbooks, Psychiatrist Irvin Yalom writes and expands upon the idea that, "it is the relationship [between patient & psychiatrist or therapist] that heals". My experiences in therapy with Dr. X have reinforced and proven this to be the case for me.

    I try to remember therapy is sometimes difficult. During some phases it can see impossible a lot of the time. As people with depression, or other mental illnesses, (really as people even with no mental illness)... as people period, we may have difficulties with some relationships in the first place; maybe that is even why we are in therapy.

    If I find something happening in my sessions that disturbs or perturbs me I always ask myself is the difficulty in therapy the therapist, or have I not opened up and taken the chances I need to take in therapy.

    • Is it my issue clouding the session,
    • Are my symptoms such that they are affecting my judgement (not always easy to know)
    • or is the therapist doing something hurtful that negatively impacts my ability to open up?
    • Is my therapist a good therapist?
    • Did they just make a mistake,
    • or is their attitude always this way?
    • Is it my approach to therapy?
    • or is it the therapists approach that is making it not work?

    The most important thing I can do as a patient is talk to my psychiatrist or therapist if I am feeling uncomfortable, or hurt, or diminished or disconnected in any way. I may not have the courage to bring it up while it is happening, or even during the next session, but if something about my therapy is festering inside me...I always bring it up.

    Everytime I have brought difficulties up he is completely open to discussing what went on. He apologizes if a mistake was made on his part, or we discuss my reaction if we discover my perception might be coloured by other things. He accepts and encourages my feedback no matter what. This is part of what makes our relationship so important and the bond so strong.

    I guess what I am trying to say here is that the first therapist you see, even the fifth and sixth therapist you see, may not be right for you . Don't give up because your therapy does not seem to be working for you.

    Therapy, and good relationships in therapy, is/are hard work. If the relationship between you and your psychiatrist or therapist does not seem to have a positive impact on you maybe try approaching your therapy a different way, or try a different kind of therapy, tell your therapist how you feel. If it still is not working perhaps trying a different therapist or psychiatrist would be the positive change you need.


    EJ said...
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    EJ said...
    This comment has been removed by the author.
    EJ said...

    (Sorry Aqua...I am a bit scared of posting the below comment, because I don't want to say anything that would upset you or make you feel that your privacy has been invaded in some way. But I have been thinking about this, and I don't think that you will...)

    I am pretty sure that I see Dr. X too (if his first name starts with G., then he is my psychiatrist as well). He is the most amazing doctor that I have ever met.

    I only know that we see the same psychiatrist because he has a very distinctive style, and also because of the health problems that he has that you have discussed in your blog. I want to make sure that you know that I don't know this for any unusual reasons, if you know what I mean...

    Dr. X is the first psychiatrist that I ever had (I first saw him 10 years ago when I was in university and he was a resident), and I am so grateful that THIS is the first person I met for this.

    IT is really hard to find good therapy! And it is especially hard when you don't feel well. I don't think that I could put in the effort necessary to find the right therapist.

    I think that maybe part of the problem is that some psychiatrists see it as their job to primarily diagnose and recommend treatment, not usually to provide long-term therapy.

    I guess what I mean is that it is considered "wrong" sometimes as a patient to want to push a certain say no to short-term CBT, for example, which is what most psychiatrists I have met would recommend for me.

    I am back in BC again and I am seeing Dr. X again. I am really glad that he was willing to see me again. I am conscious all of the time of how lucky I am to have him.

    I understand what you are saying in this post, and I agree with it in many ways, but one thing that has always struck me is how the process of seeking care...especially when you are not not only stressful, but I do think that sometimes it can make the problem worse.

    If I could not see Dr. X. I very literally do not know what I would do. I am sure that there are other good psychiatrists out there, but they are very hard to find. The other thing that I find difficult is that (in my experience) you can't just interview a psychiatrist in order to find a good fit!-- you end up having to undergo a history in which THEY ask the questions initially, and I think.....Before I tell another person about this, can I be sure first that I trust you and am comfortable working with you?

    I worry all of the time that I have a personality disorder diagnosis. I know that these are real diagnoses, and they are extremely debilitating, but this is one diagnosis that I am terrified to have. Dr. X. tells me all of the time that I do not have this, yet I am ALWAYS conscious that many elements of my history (the chronicity, the one hospitalization that I have had etc) look like this. This is specifically what scares me the most about being honest when seeking out care. If I had a "clean" history, and things were straightforward, I would not worry about this. But my history is not really straightforward, and it is hard to explain in a 50 minute consult. I would only ever be able to be honest with someone who I felt would really LISTEN to me, and not jump to any diagnosis about me. I am terrified of having this diagnosis in my chart. This is what in the past has prevented me from seeking out care.

    I think that in some interactions with psychiatrists there can be a kind of projective identification that takes place, in which certain diagnoses ARE made...if you know what I mean. I have always been terrified of assessment. It does not always seem benign. Sometimes I think that this will hurt me, and I worry about what my medical chart looks like..

    I want to tell you again how helpful I always find your blog. Sometimes I do that with your blog. Sometimes I read your posts and I feel like you have just said exactly what I have been thinking or experiencing....

    I'm sorry for the long post....Thank you for being patient!

    Rach said...

    Amazing, amazing, AMAZING post. I could not have said any of this better myself.

    IN fact, I think I shall link to this post!

    Be well... stay in touch

    Aqua said...

    Hi Rach,
    Thank you. Link away.

    Hi EJ,
    Wow! Your comment is amazing. I'm certainwe both see Dr. X. I am glad to hear you have that opportunity too.

    Everything you say in your comment is really important, dead on for me and I think probably many others.

    The one thing I forgot to suggest is "try out" a therapist or pdoc to see if they are a good fit.

    I don't know what I would do if Dr. X. had not come along. I too was too sick at the time to ask questions like I suggest. I feel confident I could do so now (as long as my mood was not in a downward spiral).

    I too have asked Dr. X many times if I have BPD, because of the reasons you list and my suicidal ideation and what I see as a labile mood. He says no to me too.

    I too am terrified of this label, that fear itself is enogh to suggest that mental health professionals need to let go of their biases and preconceived ideas about bpd. I feel afraid because of what I read in journals, on medical sites and blogs, and what I hear in other places I have sought treatment (day programs, art programs etc.)

    I don't feel fear because of the patients with bpd I know, or have followed online,'s the judgement and criticalness I have encountered from various mental health professionls. Which is weird given I suspect no one with bpd asks for it or "makes it happen" anymore than we ask for our mental illnesses.

    I pray I never have to find or see another psychiatrist because ours is such a perfect fit for me.

    I'm glad to hear you are in great hands.

    EJ said...

    Hi Aqua,

    I will post this, then stop!, because I don't want to monopolize the comments here!

    Re: BPD: I agree with your comments completely. I once had a job working in mental health, plus I once did a clinical rotation in school in any case, on both occasions it really really really upset me to hear the things that people would say about Axis II disorders. My biggest fear is that people will hate me, or that I "defective" or otherwise unloveable or exhausting etc, and it is hard for me not to feel that many clinicians use these diagnoses in a pejorative mean those things. (I remember once reading a textbook that was supposed to be funny, it was a "field guide to personality disorders", and it was hear all of the time about stigma and mental illness, but the stigma for those conditions is very real, ESPECIALLY among many psychiatrists. I don't want to be a patient anyone dislikes or hates).

    But: I agree with you, that my worry about this has very little to do with patients who have these diagnoses. BPD seems to me just as biological as depression, I have met (and liked) many patients with BPD. My concern is that for ME the diagnosis would be made because a therapist did not like me or found me frustrating...I think that if Dr. X gave me a BPD diagnosis I would be OK with it, because I would know that his motivation would be to HELP me. (I am not opposed to any diagnosis if the motivation for giving it is to help!).

    Aqua said...

    Hi EJ,
    Please don't worry about commenting. You have so much to say an it is so interesting. Comment away, because part of why I post is to hear from others and not feel so alone in all this. You help me, and I am sure others, by commenting.

    I too know first hand what it is to hear derisive comments, or tones in people's voices when they mention Axis II diagnosises. At the art clubhouse I belong to the head person has made it clear she believes I have BPD...she has pretty much told me I'm not depressed...what the hell does she know? Does she sit inside my head?

    Also, when in the hospital for another illness (hepatitis) a person was brought in, obviously very very psychotic. At the nursing station the nurses (and drs) made fun of her all night. It made me cry to hear how judgemental and mean...and so completely oblivious to so many people's "reality" they were. I wanted to stand up and scream.

    Even my GP has suggested I have BPD..and am therefore incureable/unhelpable. I get so angry with how little even professional people understand about those of us with BPD, MDD, BP etc.(basically all mental illnesses, and also how thoughtless and judgemental the very people who are s/b treating us are.

    Handsome B. Wonderful said...

    Oh man, I've had that therapist in the cartoon before. Except mine was a woman. Ugh--glad I didn't stick with her very long.

    EJ said...

    I have told Dr. X., I have always felt really awkward, that I don't fit in anywhere...and part of me was relieved when I entered the "mental health" system, because I's a place where I can belong! But I often end up thinking-- Depression isn't a club that I can belong to, either! I don't know, I find it so hard to relate to so many stories of depression. (I also told him, I am even screwing up DEPRESSION! How can this be?).

    This is why it makes me mad when other people pass judgment on what depression looks like. It is a very alienating experience to feel so horrible, and to know that it still does not look "right". I always wish that I could experience "depression" the way it's presented in textbooks...then I'd have a club that I could belong to!

    Sometimes it seems to me that you have to "earn" a depression diagnosis (which I guess you do, in a way), but it makes me angry that this is yet another thing for me to do badly at. I don't understand why some people who work in mental health (e.g., the woman at the clubhouse) are sometimes judgmental about this.

    P.S. I am a bit worried about my posts, because I am worried that my writing is a bit compulsive right now...sometimes I have a real push to write write write until this all makes sense... I am just worried that I do not have much of a filter right now.

    I have a blog, that I initially just started as a place for me to (try) to collect my thoughts, structure my thoughts, think this is private right now, but I will add your email address to it if you want.

    Aqua said...

    Hi EJ,
    I would love to read your blog. My email address is:

    Please try to keep writing even if you think it is compulsive (I don't see that, it seems to me you have lots of really interesting, and really valid points to make and information to share.

    I know what you mean may have noticed my posts in the past few days getting longer, and longer, and longer...I see this as a compulsive thing too...but also I see it everytime my mood starts to shift upward...especially if I was just severely, severely depressed.

    If you want to, e-mail me too. I want to e-mail you, but I have some kind of strange phobia about contacting people...oth by phone and by e-mail. If you e-mail me, I will return your message.