...well, I kinda have a bit of everything, doc.
October 8, 2012 8:41 AM   Subscribe

Which issues do I bring up in a first session with a new therapist? Snowstorm inside.

I have a first appointment with a psychotherapist in 3 days, which is good. I also have a long list of (not neccessarily connected) issues and no idea what to bring up in a first session, which is bad. I need some help to set priorities, if that is even possible. (I was sent away by a therapist a decade ago as "hopeless case" and do not care to repeat the experience.) Part of the problem is that I do not experience all of my issues as issues, yet they may be factors playing into the things I do consider as issues. I don't know if it would help to bring those non-issues up or if it would derail from the actual reasons I made the appointment for.

Issue: Strongly suspected ADD, no H, self-medicating with caffeine from age 15 on (33 now). I have such a high tolerance by now, it's not working anymore. I'm just holding a level, but the attention span gets shorter and shorter. I can't focus on anything, not even things I like and want to do. I got through school with okay-but-not-great grades and the help of a damn lot of Red Bull. Since graduation, I went from odd job to odd job. This is the reason I made an appointment.

Issue: Likely related, I have and never had any structure in my life whatsoever. I sleep and get up at random times, my mind is all over the place and I forget to do basic things. It takes me 1 - 2 hours on average to fall asleep because the inner monologue doesn't ever stop. Obviously, this doesn't work well with school or work and in the past, my go-to solution was "more caffeine" if I have to get up at a certain time. I was given pretty much every available sleeping pill in my youth and none of them changed a thing. Some had no effect at all, some made me tired, but still unable to fall asleep if there were important matters (such as googling what my favorite food is called in other languages) to take care of.

Non-Issue, but likely connected: Strongly suspected Schizoid Personality Disorder ("suspected" around age 19 by neurologists and a PCP who was also a psychotherapist, but it's no official diagnosis). It's not that I dislike people. I just can't be around them. If I am, it's dead certain I'll end up with a burn out diagnosis after a few weeks - I had enough of those in the years I tried to pretend to be "normal" and have "normal" jobs. I do not feel lonely or sad or that something is "wrong" with me, however, this is a big issue with my career options. I feel it is perfectly possible for me to pursue a degree once I get the ADD under control, but the job service is hellbound to not support any kind of class I can take from home and instead tries to send me back to highly social jobs such as call centers.
Therefore, this is only a "practical" issue - a diagnosis would make it a lot easier for me to get the degree I want (which would give me options to work from home/in an enviroment with little social contact). I appear to be a "text book case", including the "unlikely to seek therapy on their own" part. If it wasn't for the ADD - which does interfere with my otherwise working coping mechanisms - I would never consider seeing a therapist about just this. It somehow feels wrong to bring up an issue that doesn't feel like a problem to me, at least not a problem a therapist can "cure".

Issue: I'm transwhatever. I see my physical body as little more than an inconvenience and I have accepted long ago that I will never "pass" as anything but my birth sex. I do not want to the opposite sex either. In a perfect world, I would not have a sex at all, just a blank body. I find both sets of genitals weird. I know that it is not possible to physically transit to "whatever/none" because such surgeries aren't legal, so it might be pointless to discuss this matter with a therapist who can't change it anyway. A part of me wants to try though, in hope to get my name legally changed to something gender neutral, if nothing else. Besides the "whatever" part - text book case of trans.

Issue: Mild social anxiety. It's not being nervous about social situations - in fact, I was a good speaker in school and never had any trouble to talk to strangers. I don't worry about standing out or making a bad impression because I genuinely give a shit what people think. What does give me panic attacks - freezing in shock, "playing dead" behavior - is the door bell and to a lesser degree the phone ringing. I guess on some level it's simply being easily startled, on another level being unprepared for an encounter and having no time to put on my "mask of sanity". (Social situations are mentally draining for me and I need time to prepare - mainly to make myself clear, which then makes people go away sooner and I can mind my own business again.) This wasn't nearly as bad before my attention span went down to the point where it interferes with my life.

Tl;dr: My first experience with a psychologist was him telling me I have "too many symptoms" and am "a hopeless case" and sending me away with some sleeping pills. Don't care to repeat that experience, so which issues do I bring up in a first session with a new therapist?
The options are: ADD, completely unstructured life, Schizoid Personality Disorder, being transwhatever, social anxiety.
posted by anonymous to Health & Fitness (12 answers total) 2 users marked this as a favorite
Print this question up and bring it with you to your first session. It sounds like you have things to discuss, but are unsure of what the priorities are. That's part of what you and a therapist will work on together.
posted by xingcat at 8:50 AM on October 8, 2012 [1 favorite]

Don't overthink your first session; definitely let the therapist know why you were unhappy with your previous therapist. It will be an information gathering appointment that first time anyway, so chances are you will be able to summarize the areas of your life you want to address more in-depth in the future. If all goes well (i.e. if you think this person is a good match for you), you will have subsequent sessions to dig into the topics you've told us about.

For sessions in general: just bring in whatever is on your mind that day. Everything is connected anyway, and a good therapist will help you find out what those connections are and why they are there. Best wishes!
posted by retrofitted at 8:54 AM on October 8, 2012

First of all, the "therapist" who sent you away is an awful therapist and you should forget everything he/she ever said. If any other provider pulls that shit on you, report them to the appropriate licensing board.

Secondly, you're not a hopeless case. You're capable of outlining your problems and wondering how best to tackle them. That's not hopeless.

Thirdly, I would say that in your first session with your new therapist, raise your concerns about not knowing where to start. He/she might be able to help you with that right off the bat. Otherwise, try devoting some thought to what bothers you the most. Do you want someone to help you implement some structure in your life? Do you want to tackle the social anxiety first, so you can function better in the world? Do you want to tackle the ADD so you can settle down and work on the other things? Don't feel you have to fix everything in one session. That's not how it works. It's a process. One thing at a time.

Best of luck to you.
posted by scratch at 8:54 AM on October 8, 2012 [4 favorites]

I'm not normally a fan of the "print this out and show it to the relevant other party" advice. But in this case, because the other person is a professional, trained therapist, I'd say that your best bet is to print this out and bring it to the therapist. You've done a really good job here of articulating all of the symptoms you're experiencing, how they affect your life, and their level of importance to you. You've also laid out why you have anxiety about bringing them all up, as well as a past experience (the other therapist declaring you hopeless) that colors your view of therapy. I think this is a great overview and will provide a lot of useful information to your new therapist.

I would also say, as a slight aside, that it may be unhelpful to diagnose yourself (even where the diagnoses have been "suspected" by professionals). It seems as though you have, on some level, bought into the idea that things are hopeless (e.g., "just can't be around [people]," "it might be pointless to discuss this matter"). I really hope that your new therapist is better than your old one, who sounds like a useless jerk to me. Because you are not hopeless, and there are treatments and therapies and ways of changing your thinking that can make your problems a lot easier to deal with and alleviate a lot of the suffering you feel. Even if you do, for example, have schizoid personality disorder (and I'm not saying you do, and your past doctors didn't either), that doesn't mean that you need to settle into a life without relationships in it; it would mean that you can work hard to enrich your life, both socially and otherwise, if that's what you choose to do. By labeling yourself and putting yourself into boxes, you're cutting off some of those avenues for building a more satisfying life, and I would encourage you not to do that to yourself.
posted by decathecting at 8:58 AM on October 8, 2012

it sounds like you are overthinking this by a couple orders of magnitude. i don't think you should bring any issues at all to your first meeting. just go in and have a chat, tell the person a little bit about your daily life, and maybe something about your history/story. your self-diagnoses are going to be much less helpful than just talking about how you feel and what you actually do from day to day, and by much less helpful i mean almost entirely unhelpful.
posted by facetious at 9:05 AM on October 8, 2012 [2 favorites]

You seem very clear about your problems and goals. During any interview with a therapist, these things should be covered:

1. This is my experience with therapy.
2. These are my problems as I perceive them.
3. These are my goals.
4. What are your thoughts on possible therapeutic avenues for me?

Based on what you've said, I'd recommend seeing a psychiatrist in addition to a therapist. Psychiatrists don't really want to talk to you--they just want to diagnose and dispense meds. After one or two sessions, your checkups with them generally amount to 15 minute medication reviews.

I'll echo what decathecting wrote: even if you do have schizoid personality disorder, there's certainly no reason you can't do some sort of CBT to help you manage anxiety related to social situations. Even if having fuzzy buddies isn't a goal of yours, a therapist might be able to guide you in enriching your life in general and finding some positive aspects of social interaction, even without emotionally intimate relationships. This might help you with your career goals.

I have a problem that not many therapists want to deal with and have been turned down on a number of occasions; an initial therapy session is a mutual interview. Some therapists just don't like to treat certain problems. This doesn't mean that you shouldn't keep trying to find one that works for you, even if you have some bad experiences or are turned down.
posted by xyzzy at 9:14 AM on October 8, 2012

Yeah, don't diagnose yourself. Don't overthink it. Just go in and chat, see if you can work with the person.

IANAD, but.... along with therapy, it sounds like you need to see a medical professional of some type. I hope someone who knows more about this type of thing pops into this thread to give you some direction, because even though IANAD,I could see most or all of your issues being caused by a physical condition.

The way you've laid this all out is very cogent and you owe it to yourself to have a medical doctor evaluate your symptoms/issues in addition to seeking therapy.
posted by jbenben at 9:50 AM on October 8, 2012

Two things strike me (a therapist, but not yours) reading your question. The first is the need to somehow communicate vast amounts of information both to us and at the first session, and the second is "Social situations are mentally draining for me and I need time to prepare - mainly to make myself clear, which then makes people go away sooner and I can mind my own business again."

What you need is a therapist who will form a new kind of relationship with you; one in which being understood is the norm. And of course, that will also require that you believe that such a relationship is possible. From my perspective, that's the most important thing you need to work toward, the contents of what you want to communicate being secondary.
posted by Obscure Reference at 9:51 AM on October 8, 2012

I wrote about my first therapy session in an earlier question about finding a therapist, which you can read here (skip down until the --- separator).
posted by french films about trains at 3:53 PM on October 8, 2012

If I were you, I'd address most of these points in the first session - just get them on the table as stuff you want to work on "at some stage". Make it clear to the therapist that the top priority is to... establish priorities. I.e. you don't know exactly where to start, and that's something s/he can help you figure out.

If you want an outsider's view on how to summarise your list above a little more succinctly, I'd say something like this:

- suspected ADD. (Bringing that up should mean the therapist asks you why it is suspected, which can lead you to talk about all the stuff in your second "issue" point too.)

- difficulty interacting with people at work, leading to burn-out in social jobs. (This might be addressed by talking about ways to make interactions easier for you, and/or talking about other possible jobs and career paths. I think that's pretty clearly related to the social anxiety thing, so you don't need to make it a separate point unless you feel it's really different.)

- gender identity. (You might decide this is something you don't want/need to bring up with the therapist. I get the sense that you are not conflicted or confused about this: you know what your identity is. And depending on where you live, you probably don't need to go through any complicated process involving therapists in order to change your name to whatever you damn well like. So if you want a gender neutral name - go ahead and change it. There's probably some form you have to fill out and a small fee, and then the cost of changing all your legal documents like driver's licence, passport, etc.)
posted by lollusc at 6:47 PM on October 8, 2012

Talk about whatever prompted you to make the appointment in the first place. From there, it should lead to other issues.
posted by JohnnyGunn at 11:43 PM on October 8, 2012

IANAD but I know quite a bit about ADHD. (Some family members have major ADHD issues.)

You did a fine job laying out the issues here. As others have said, you can present them to the psychotherapist the same way.

A rule of thumb in psychiatry is to treat the problems which are the most distressing or life-threatening first. You have made it clear here that the attention and people problems are your biggest issues. These issues are keeping you from holding onto a job and taking care of yourself. It's understandable that these issues are your highest priority right now. You also have insomnia and anxiety. Finally, you have gender issues, but for now these are on the back burner.

Psychotherapists can be extremely helpful (they've helped me a lot), but if you suspect you have ADHD (which is the formal name, even if you aren't hyperactive) you should see a psychiatrist and get yourself diagnosed and treated. Don't go to a PCP and don't go to a neurologist. Psychiatrists have the expertise you need.

Medication is not effective for everyone with ADHD, but if it works for you, it will kick in immediately, and it will change your life. It won't fix everything because there are lots of skills the rest of us learned growing up that you were too unfocused or impatient to learn. You have a lot of catching up to do, and the psychotherapist can help you with this. But it will be much easier if you are taking medication.

About your problems dealing with other people--it is increasingly being recognized that many people with ADHD (not all people with ADHD, but a significant subset) have such problems. So maybe you have another disorder causing these problems, or maybe it's part of the ADHD. Also, insomnia and anxiety are extremely common in people with ADHD.

Actually, now that I think about it, many people with ADHD have depression, and many depressed people have a hard time being around other people. Maybe that's what is going on. Your psychiatrist, when you find one, and your psychotherapist can help you sort this out.

Here's a book recommendation, although if you have ADHD you'll probably have a hard time focusing on it: Attention Deficit Disorder: The Unfocused Mind in Children and Adults by Thomas E. Brown. I've read a lot of books on ADHD and IMHO this one is the best. Read it or skim it and see if you recognize yourself in it.

Most adults who try medication for their ADHD wish they had tried it sooner. Please, please, please, get treatment. Once the ADHD is treated, it will be a lot easier to deal with the other issues in your life. Good luck.
posted by islandeady at 1:41 AM on October 9, 2012

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