I caught my therapist in a lie; am I overreacting?
March 3, 2014 7:08 AM   Subscribe

I've been seeing my psychologist for about 18 months. Overall, she's great: upbeat, insightful and easy to talk to. But on a couple of occasions I've left therapy with a distinct feeling that she wasn't being entirely forthright with me, or like she actively tried to make me feel insecure during a session. Are these red flags real?

My psychologist, Lynn, is seeing me for depression, social anxiety, and sexual assault trauma. Lynn is about my age (late 20s), and we're both straight females with similar interests, so we quickly developed a good rapport. I was one of the first clients she started seeing after she left Metro Counseling Inc. and started her own small private office. I've seen a handful of therapists in the past decade or so, and I feel like she's quite the find overall; I'm very comfortable talking with her, and I feel like she has given me some very valuable tools to help me deal with my problems.

About 2 months in, Lynn and I both decided that it seemed like I might benefit from taking some kind of medication for my depression. She referred me to a psychiatrist named Dr. Alexander, and I signed consent forms so they could coordinate on my treatment. I saw Lynn weekly, and I've been seeing Dr. Alexander every two months or so. I like him quite a lot, too. I feel like he's a very compassionate person. The first time I met with him, he had me take a depression inventory and prescribed an antidepressant. He has tweaked my medication a couple of times since then (I now take a small amount of a benzo, as needed, for social anxiety) and I feel like the medicine does help somewhat. As far as I recall, he has never mentioned any other diagnoses to me.

A couple of weeks after my first visit with Dr. Alexander, I asked Lynn if the two of them had gotten a chance to talk about my treatment; She seemed kind of evasive/uncomfortable, and after a pause she said that, they had, and said "He and I agree that we're likely dealing with a personality disorder here". This surprised and me and made me feel bad, as I know personality disorders carry the stigma of only being "manageable" rather than "curable". I asked her which personality disorder she suspected, and she said something like "I don't think it's important for us to talk about that right now. Let's talk about what we should do to look forward this week." It's possible that she was trying to spare my feelings, but it struck me as odd that she wouldn't tell me specifics.

I didn't get a chance to talk about this with Dr. Alexander for a long time, as my sessions with him are very short and only focus on whether or not my medication seems to be helping. But recently, it occurred to me during a visit that I should ask him what my official diagnosis was, and if it had changed at all as a result to talking to Lynn about me. Again, he didn't mention anything about a personality disorder, just clinical depression and anxiety.

I can't shake the feeling that it's strange that Lynn's report of their conversations is so different from Dr. Alexander's report. Are psychologists and psychiatrists obligated to tell you the truth when you ask about your diagnosis? Is it possible that they felt like telling me my "real" diagnosis (the personality disorder) might set me back in my treatment?

There are a couple of other occasions where I felt like Lynn was evasive when I've asked questions about my treatment. Once, she had me fill out an end-of-the-year treatment evaluation where we both gave our assessment of how I was doing; One of the questions was "Rate your stability on a level of 1-10, 1 being completely unable to function and 10 being completely functional". Lynn said she'd rate me as a 5, which seemed really low to me, as I considered myself pretty stable even when I first started seeing her, and she and I have done a lot of hard work talking through my issues. When I asked why she picked a five, she said "It's the middle of the scale. It just means your not doing particularly well OR particularly badly. But I don't think we should focus on the number so much as the work you're doing."

TL;DR I feel like my therapist dodges the question when I ask for details about her plan for me, and where our therapy is going. MeFites who are work in mental health care, and MeFites who have experience with therapy, am I being paranoid about her vagueness, or does something seem slightly amiss?

I realize a lot of people's first reaction on a question like this will be "you don't trust your therapist, DTMFPsyD", but keep in mind that my difficulty trusting people is one of the major problems I sought therapy for. It's quite possible that I just pick things apart too much and I would find a reason to distrust other therapists.
posted by anonymous to Health & Fitness (44 answers total) 3 users marked this as a favorite
Not an answer: I suggest you contact the mods ASAP and remove the references to what appear to be real names of organizations and individuals.
posted by Tomorrowful at 7:11 AM on March 3, 2014 [33 favorites]

I would bring this up as an issue in your discussions with your talk-therapist.

"I'm really focusing on your thoughts about a "personality disorder." I spoke to MD about it and he said that he only thought depression and anxiety. So now I'm having an issue with trust because I feel that you portrayed this "personality disorder" as a joint diagnosis, and yet he's saying no. I trust you both and like you both, and this is really bothering me. In the past when I've asked point-blank, I feel like you're deflecting. Please, this is taking over too much of my waking thoughts. Just tell me what you're thinking, and then let's get back to work."
posted by Ruthless Bunny at 7:28 AM on March 3, 2014 [31 favorites]

We only have your side of the story and your evaluation that she was being evasive, (and your own evaluation of your stability) so its impossible to say, however, if she has recently started her own business, she may not want to lose you as a client - if you're doing really well, and your meds are stable, then she may feel that you'll want to reduce the frequency of your sessions.

Of course its also possible that you're paranoid and have an inflated sense of how well you're doing. We have no way to know for sure.

Regarding her evasiveness about the diagnosis and disagreement with the psychiatrist, it could be that she hadn't spoken to him yet and was winging it, or she had an had forgotten what was discussed/confused you with another patient. Its also possible that they were considering a personality disorder diagnosis initially but by the time you go around to asking the Psychiatrist they had changed their minds.

If you feel your therapist is avoiding answering direct questions about your diagnosis or treatment, you should call them on it, be politely persistent but don't accept more deflection as an answer.
posted by missmagenta at 7:33 AM on March 3, 2014 [2 favorites]

Personality disorders carry a lot of stigma among mental health providers, despite many being treatable with psychotherapy. I've definitely seen psychologists/iatrists downplay personality disorder diagnoses because they're worried about patients being offended and leaving therapy. Also, since there are no medications specifically indicated for personality disorders your psychiatrist could honestly say he's not treating you for that, just depression and anxiety (which could be related to a personality disorder.)
posted by arrmatie at 7:35 AM on March 3, 2014 [8 favorites]

I agree with Ruthless Bunny. If it's on your mind, talk about it. It's important that you address this concern, just as it's also important that you feel that you are getting a clear course of treatment.

I can think of many different scenarios in which the apparent discrepancy would be wholly innocent. Maybe they had floated the possibility to one another, but they had dropped the idea. Maybe the personality disorder diagnosis didn't affect the psychiatrist's course of action - the antidepressants and anti-anxiety medication would treat depression and anxiety, but they would also be orthogonal to the therapist's treatment for a personality disorder. Things like that.

I can also think of other scenarios in which your concerns would be more or less on the nose.

I couldn't possibly know for sure. It would only muddy the waters for me to speculate further.

That said, your "1-10" story does not read as evasion to me. Rating your perceived functionality from 1-10 is a purposefully vague game that is designed to spur reflection and discussion. Besides, for all you know, maybe the "game" was always to disagree with you about the rating, so that you would always be aware that you are a functional person making progress, but also that you have more to work on. Again, I wouldn't know, but there's nothing inherently wrong with being a bit gnomic about that kind of thing.

That said, you do have a need and a right to have a concrete understanding of what's going on.

Talk to your therapist about your concerns. Don't be accusatory. Just say that the apparent discrepancy has been gnawing at you, and that you need to feel secure about this issue.

Best of luck.
posted by Sticherbeast at 7:49 AM on March 3, 2014 [4 favorites]

Some otherwise good therapists get freaked out about the idea of telling a client they suspect a personality disorder, because they're worried clients will freak out or get angry. I don't think it's great to hold back a diagnosis for that reason, but it's not uncommon.

My larger concern would be whether the therapy is helping you overall. If it has been, then maybe you can bring up the issue with your therapist but default toward trusting her judgment. If it hasn't been, then maybe this is not the right therapist for you. It's not just about trusting your therapist -- many clients with anxiety or trauma find it very difficult to trust their therapist, often for totally valid burned-in-the-past-by-people-in-authority reasons -- but also about making tangible gains in your stability and functioning, even if those gains are small or slow.
posted by jaguar at 7:50 AM on March 3, 2014 [1 favorite]

I won't give a long answer because I think the other folks are giving good advice, but allow me to reassure you: you are not overreacting and your concern is valid. In your shoes I imagine I would have a similar reaction.
posted by zdravo at 7:51 AM on March 3, 2014 [3 favorites]

My inclination is to tell you that this sounds fishy as hell and you should DTMFA.

When someone is a proven liar, it's a little hard to go back and ask them to tell the truth, no?

She dropped a drama bomb on you with her "diagnosis" and that behavior alone is grounds for termination - holy moly! Even if you are the most unstable person Imaginable, you are paying for her expertise and honesty, yet you are getting neither expertise nor honesty.

It's OK if you discover you've put your trust in the wrong person and then discover you have made a mistake. You deserve MUCH better from your mental health care provider. Period.

Yes, it will be a very helpful exercise for your therapist if you confront her and persist in getting answers about your diagnosis and treatment. She has a lot to learn.

My advice? Put that energy into finding an adult professional practicing psychology who can actually help you.
posted by jbenben at 8:00 AM on March 3, 2014 [7 favorites]

I do not see a lie. Maybe you should think about why, given what you know, you felt that was the way to phrase your question.

Or, you could tell her you feel like her way of responding to that question was not the full truth or straightforward enough for your comfort.

If you continue to believe she lied to you, that will hurt you. How can therapy work if you feel unsafe?

One way or another, you need to resolve your distrust.
posted by Lesser Shrew at 8:04 AM on March 3, 2014 [5 favorites]

I don't think she lied about anything? Are you suggesting you think she's exaggerating your problems so you will pay her more/stay in therapy longer? I really doubt that; as you say, a personality disorder is not usually "treatable" (although perhaps you're thinking she wants you to stay a client for life to manage it?)

The 5 out of 10 thing sounds extremely minor and unimportant; it doesn't matter which of you is right, and probably, if you want to settle your mind about it, I'd pick the number in-between 5 and whatever number you picked and just agree to go with that. It's possible she's right, it's possible you're right, it's likely you're both partially right; in any case it is NOT a big deal and I would immediately forget it. Probably she was not thinking about it much even at the time and somewhat arbitrarily picked a number.

The personality disorder thing is more serious, and unintentionally cruel IMO, because she's kind of dangling it over you and it's stressing you out, and that's not right. She needs to tell you what she's thinking. I would not assume your other doctor is truthful; possibly he forgot, the personality disorder thing is too speculative for him to consider it a "diagnosis" or he is not comfortable diagnosing it first. It's still possible they had a brief conversation. If they did, she should be able to tell you a few more details to set yor mind at ease.

And also, a personality disorder is not the end of the world, and therapists are not always right and do make mistakes like the rest of us, so keep that in mind.
posted by quincunx at 8:14 AM on March 3, 2014 [3 favorites]

Is insurance paying (partially or fully) for your therapy? If so, your therapist and the psychiatrist will report to the insurance company what you're being treated for via diagnosis codes. You may already have these on your insurance statements, and you can check to see if they jibe. If you don't have that information, you have every right to ask your therapist for the specific code for your diagnosis.

To me, from your story, it sounds like the psychiatrist is following a fairly normal course for treating clinical depression and anxiety. It also seems like a red flag that your therapist would be evasive about the diagnosis, and it would seem strange if you were being treated for different diagnoses from the two of them. I don't understand why other commenters don't see where you think the therapist is lying: if she says unequivocally that she and the psychiatrist have discussed your diagnosis and are in agreement when the information from your psychiatrist disputes that, it does indeed sound like it could be a lie.

I would continue to pursue the issue of your diagnosis with the therapist, and stick with her if she is able to clearly reveal a simple misunderstanding, or leave if she remains evasive.
posted by I EAT TAPAS at 8:22 AM on March 3, 2014 [2 favorites]

Your therapist does sound vague (what is a '5' really?) but that's ok, she's vague so that you fill in the details with your own interpretations and then you two can sort through your interpretations in order to understand you better. But what is happening is that your discomfort with her vaguery turns into "she's a liar!" And if she only rated you a 5 when you feel higher than a 5, that doesn't mean she's a liar it just means you two see things differently. So try to understand where she thinks you need to improve.

As for the diagnosis, for all you know, her & the Dr decided that she would be the one to handle the PD discussion, and that he would only treat what he can (anxiety/depression). Therefore he just kept quiet about it. Imagine if he told you - you might freak out in his office. How would he handle it? That's not his job. He's just the Rx guy.

Follow Ruthless Bunny's advice - bring it up straight and clear, and keep going until you get an answer that satisfies you. And be honest with yourself - if you are the reactionary, emotional sort then maybe your therapist is right to treat things with 'kid gloves' and only gently introduce you to what she thinks is really going on. Imagine if she bluntly dressed you up and down with what she thinks is wrong. It could be very destabilizing.
posted by St. Peepsburg at 8:27 AM on March 3, 2014 [3 favorites]

Your therapist sounds inexperienced. If you like her enough to accept the errors of judgement that result that's your decision. I probably wouldn't but its a personal choice.
posted by hazyjane at 8:32 AM on March 3, 2014 [4 favorites]

You should have signed some sort of Informed Consent form when you started treatment -- with both of these providers. (Hell, I signed one at the acupuncturist the other day.) Go to the records folks and ask to see a copy of your signed Informed Consent form; it should almost certainly specify that you have the right to review all details of your treatment plan, most likely including diagnoses and communication between clinicians.

From my point of view, it's impossible for you to know how to coordinate your own care if they are coordinating care without involving you. That seems ethically suspect.

I mean, I agree that giving you a particular diagnosis (particularly a potentially stigmatizing one) might lead you to pigeonhole yourself instead of focusing on the individual aspects that you would like to manage better. But your description of your therapist ("late 20s") makes me think that she is inexperienced and doesn't know how to manage these interactions in a way that is both respectful to you as a patient and professional to her fellow colleagues. That worries me a lot.
posted by Madamina at 8:34 AM on March 3, 2014 [7 favorites]

I want to clarify that part of dealing with trust issues which are the result of trauma, is knowing when (and how to gracefully) dump people you discover you've mistakenly trusted.

How hard is it to say, "I haven't had a chance to speak to him yet."??

You need to clarify with the psychiatrist, not the therapist. Either they've spoken at length, or they have not. Either he, a medical doctor, concurs with any diagnosis, or he does not.

Call the psychiatrist, not the therapist, first.

You pay for this treatment. You're not "damaged goods" unable to manage your own care. Your goals are the ONLY thing that matter here.

UPON EDIT: I think the "lie" is that the therapist did not liaison with the psychiatrist. Or perhaps she did, but she disagrees with his diagnosis?

I feel lucky I never had to parse this sort of behavior by a therapist back when I was in need.

I'm going to paraphrase....the statement that some therapists feel uncomfortable answering certain types of questions, as if the evasive behavior is somehow acceptable - I know that was conveyed with good intentions, but it inadvertently excuses unprofessional bad behavior.

OP, again, you are paying for a service. Just because you are seeking therapy, it does not mean you are too "broken" to distinguish professional treatment from shenanigans.

Your therapist is relatively new to the field and she has a lot to learn, apparently.

For sure I'm not saying you should never talk to this person about her mistakes, rather, her credibility is blown to the point that I have a hard time advising you that her answers to you wouldn't be more if her covering her ass at your expense. Proceed with caution.
posted by jbenben at 8:37 AM on March 3, 2014 [4 favorites]

Mod note: Comment removed; folks, this is not a place for arguing with each other.
posted by cortex (staff) at 8:58 AM on March 3, 2014

Why is a psychiatrist less qualified to treat certain disorders considering the psychiatrist has more schooling and a medical degree, where the therapist does not?

I missed that - I thought "Dr." meant medical doctor, not psychiatrist. My bad.
posted by St. Peepsburg at 9:00 AM on March 3, 2014 [1 favorite]

Mod note: This is a followup from the asker.
I haven't used the professionals' real names here, Lynn & Dr. Alexander are pseudonyms.

I am paying for both professionals out-of-pocket, as neither is on my insurance plan.
posted by cortex (staff) at 9:19 AM on March 3, 2014 [1 favorite]

Any medical professional that says "well the diagnosis doesn't matter, let's move on" is not a medical professional to me. No one in medicine should hide the truthful answers that you ask in your questions, especially if it's 'what is my diagnosis because the coordination of care seems to be lacking--the psychiatrist said it was different."

You don't have to stick with her. I understand about trust but to me, I wouldn't trust anyone dianosing me yet won't talk about the diagnosis. Screw her. Move on.
posted by stormpooper at 9:21 AM on March 3, 2014 [11 favorites]

I missed that - I thought "Dr." meant medical doctor, not psychiatrist. My bad.

Psychiatrists are medical doctors. That's why they can prescribe medications.
posted by BungaDunga at 10:08 AM on March 3, 2014 [11 favorites]

If I had been seeing a therapist for 18 months (paying out of pocket!) I would want some real, tangible, concrete results after all that time.

You mention that's she's given you valuable tools to help with your problems, but you also talk quite a bit about how compatible and upbeat and easy to talk to she is. She's not, or at least she shouldn't be, your surrogate friend. She's supposed to be a professional helping you sort your life out and improve it.

I think the evasiveness is annoying, but forgivable for someone who is delivering otherwise. The dishonesty might not be dishonesty, but just sloppy or confused communication between the 3 of you.

If she's helping you a lot, keep her around. You can still push for some clear answers on the things that are bugging you. If she's not (or not any more) guiding you to substantive improvements in your life, take your current annoyance as a cue to try someone else.
posted by mattu at 10:24 AM on March 3, 2014 [2 favorites]

Can you not just bring it up again in your next session, this time with very frank language? Specify that this has been weighing on you and you really want to take a moment to talk about it in a clear and up front way.

I think that by framing it as "So have you and Dr. So and So been conferring about my case?", it's easy for your psychologist to give you an answer to that which doesn't answer the question you really want the answer to. And it's also easy for her to see your follow-up questions about diagnoses and personality disorders as a digression from what she thought the conversation was about. This could be the case whether she's being deliberately evasive or not. She can't read your mind. She doesn't know that "Have you guys talked about my treatment?" is your way of asking her what your diagnosis is.

Just ask her what's up with the personality disorder diagnosis. In clear words that make it obvious that this is what you want to know.
posted by Sara C. at 10:35 AM on March 3, 2014

...asked her which personality disorder she suspected, and she said something like "I don't think it's important for us to talk about that right now. Let's talk about what we should do to look forward this week." It's possible that she was trying to spare my feelings, but it struck me as odd that she wouldn't tell me specifics.

You are assuming that they agreed on a determined disorder. It's entirely possible they discussed the possibility that because X and You weren't processing as expected the have a long range plan to look at other issues.

Just let her know you are stuck and have questions about that interaction.

With soft tissue injuries, it's very common to say try this for a certain amount to of time and if we don't see results, we'll need an MRI. They don't say we'll need an MRI to look for and rule out these specific things. Especially if they want a client that with anxiety to focus on what they can and should be doing short term.
posted by Lesser Shrew at 10:35 AM on March 3, 2014

[rearranged a bit on edit]

I'm not sure I agree with the majority on this. I can imagine situations where being labeled as "X" could send a person into a spiral of defeat, depression, and self-dislike, especially if she knew of other people with condition X who were, well, just awful to be around.

However, different people will express condition X differently, and it's possible that a few, many, or even the vast majority are reasonably pleasant and able to form good relationships. However, the few really bad people with X will be most memorable, and will mean that whenever people (you the patient, or the patient's friends and family) hear "X" they will instantly feel -- not think, but feel -- that having X means terrible things that are not true.

These kinds of emotional reactions are often so strong that it's very difficult to get beyond them and proceed reasonably. Even if it's true that a person with X can lead a happy life and be wonderful friend and comfort to others, the strong initial emotional response may make it very difficult (or even, if the information is received at the wrong time, impossible) to get beyond that emotional response.

In addition, all labels are imprecise, and carry a lot of baggage. Maybe your therapist believes that you don't need to deal with the baggage right now, or that whatever label she and the doctor talked about might partially or technically apply, but not fit you 100%. Yes, having a name for an array of uncomfortable symptoms can be useful in certain situations -- a lot of situations, maybe -- and may be a comfort, but that's because it simplifies things.

There are lots of reasons to avoid labeling people, especially ourselves. Sometimes labels can be helpful, but we have to be careful of them. Having a label will make your mind work a certain way, will let you simplify your thinking, but that may not be the best thing here. I can tell you you're more complex, more human, than label X, but that would never be able to undo what happens when you start labeling yourself.

OK, so whether all of this is true for you in this particular circumstance isn't something I know. In your shoes, I'd be quite upset; I'm not a trusting person and you'd better believe I'd demand complete transparency from a therapist. I'm just trying to help you understand a possible reason why her evasiveness may be well-intentioned.
posted by amtho at 10:40 AM on March 3, 2014

Regardless of the dx. If the treatment strategies help... it is working. If it isn't helping it's time to find someone else regardless of the dx.

In regards to goals for therapy she may purposefully be avoiding the question of 'what goals do you have for me' because therapy is 100% about your goals.So redirecting that is pretty normal.

As for the scale thing I'd just let that go. There are many reasons you can have different perceptions and that is okay.

As for trying to figure out what she means about the personality disorder all you can do is ask and explain the discrepancies that you have found. Let her explain. Be adamant that this is really bothering you.
posted by AlexiaSky at 10:51 AM on March 3, 2014

Something happened to me that was similar to the 5 out of 10 thing. I directly addressed it with my therapist, and I had to really insist that she tell me what the point of that was. I kept rephrasing her answers back at her "so what you're saying is..." until I understood that she was doing two things: trying to point out that even when I'm stable, there is a whole universe of better-than-stable that I could be reaching toward; and trying to poke at my perfectionist tendencies / needing to think of myself as above-average.

Anything your therapist does that gets on your nerves should be good fodder for therapy, if you can address it directly, I think.
posted by Bentobox Humperdinck at 10:57 AM on March 3, 2014 [4 favorites]

My first thought was that Lynn must be relatively inexperienced. I think the most important thing here is that you don't trust Lynn. In your position, I think my best option would be to tell her, "Here are some things that are confusing me and making me wary," and talk about it. But I don't know if I'd be able to do that because it's very hard, especially because anxiety is a big problem for me. The lack of trust isn't your fault; it's a primary job of a therapist to establish and build trust with you. I have a really good therapist now who would thank me for bringing it up, and talk about it without defensiveness; I've had one in the past who would take it as criticism and not use it as an occasion for strengthening the relationship.

I suggest that you make a longer appointment with the psychiatrist to talk about some of this. The purpose would be to help you feel like you're a partner in your treatment. Also, if you don't want to continue with Lynne, you can ask Dr. A for names of therapists who have more experience.
posted by wryly at 10:59 AM on March 3, 2014 [4 favorites]

Whether and how much a mental health professional should share with you about their treatment plan and diagnoses (firm and tentative) is a really complicated question. There are practical implications for treatment as well as ethical concerns.

Say she considered a diagnosis for a few sessions, but discarded it as unlikely after consulting with another professional, the Psychiatrist, who has more experience. In that case, telling you that she considered it might have a serious negative impact on your well-being, if the diagnosis is stigmatized or has a poor treatment prognosis. In this case, even letting it slip at all was the mistake.

That is just one scenario, though, and obviously we can't know what's going on.

I don't see anything obviously horrific, so perhaps the best thing to do here is talk to her more about this in a straightforward way.

Borderline Personality Disorder is quite treatable, by the way. Reading about it on the internet paints a grim picture, but that's not the reality.
posted by the young rope-rider at 11:19 AM on March 3, 2014 [1 favorite]

I would suggest having an open-ended discussion with your therapist using Ruthless Bunny's script. (If that feels too stressful or challenging, you can write it out, let her read it, and then discuss with her.)

I would also suggest seeking a therapist with more years of experience under her belt. I made the mistake of spending years in therapy with a newly-minted therapist, and she made a lot of missteps on my dime. Including similar crossed-wires re: conferring with my psychiatrists, and having conflicting diagnoses. It undermined my trust, and made me feel like I had to spend waaay too much mental energy second-guessing her.

Since you are paying out of pocket -- you have options for treatment other than this therapist. Why not look around and see if you can find someone else who is both simpatico AND super-experienced?

It's not just a dollars-and-cents loss here, in terms of the money you are spending. You can't put a price on the opportunity cost of squandering your precious months/years on someone who simply isn't at the top of her game quite yet. With a better therapist, you will make better, deeper progress, at a faster rate.

As part of managing your care, I agree with others here that you should have another convo with your psychiatrist as well. It's fine to let him know what your therapist said. Push for the truth...it is more than OK to do so.
posted by nacho fries at 11:21 AM on March 3, 2014

Well, you're pretty clearly not done with treatment in general (characterizing what your therapist said as a "lie" reveals some problematically black and white thinking IMO), but maybe you should be done with this particular therapist. If you don't trust her and insist on making it about who is right and who is wrong, you will have a very hard time making progress.
posted by wierdo at 1:05 PM on March 3, 2014

There is nothing paranoid about wanting to know what your therapist is thinking about you, and about your treatment, and finding it weird that something is being kept from you. You have a right to know what others ( your therapist and your doctor) are thinking about, and it would make sense to me not only to wonder whether something is being kept from you, but angry that something is being kept from you. Their thinking is absolutely relevant to your treatment and you deserve to know EVERYTHING. What disorder they think you have, all the reasons why they are thinking that, etc. In others words, you deserve to be spoken to and treated as an equal in your treatment. Unfortunately, however, I think your experience must be the way they do it 99% of the time. The doctors are the "experts", and you have no need to know about their thoughts, and even if you did you would not understand them since you are not schooled in psychiatry or psychology, and obviously know nothing about yourself, they do. I'd say ask her and your psychiatrist what the diagnosis is, even if it's a tentative one, and ask anything else about possible diagnoses, or their thinking along any lines, and don't be ashamed to do so. You deserve to know what they think about you, as well as how their thoughts change along the course of treatment, and you deserve to give your input on what YOU think about it too.
posted by Blitz at 1:11 PM on March 3, 2014 [1 favorite]

You said you've seen a handful of therapists. If you have a history of changing therapists over trust issues, that might be why you're not sure whether you should continue with her. Some of the personality disorders can lead to feeling the urge to leave when difficult emotional work comes up, seeking a "fresh start" even though it's more of a step back. It's an act of protection from fear of how painful the work is getting, and it is really hard to work around with people who are choosing to come to therapy, not forced to. Lynn's soft-pedaling reminds me of that - reaching out to patients who are trying to justify their refusal to engage without recognising that it is their own fears. You might ask her bluntly if you think that's what's going on.

There are batteries of tests that can be given to diagnose personality disorders clinically. I have a family member who is getting that done on top of an extended therapy history so that the psych team seeing them can decide what particular flavour of personality disorder is happening to decide on treatment plans. This is after the common treatment methods and meds have not worked, and my outsider understanding from the staff's explanations is that most of the time, the actual specific diagnosis is not critical if the patient is responding well to therapy. They only go into a formal diagnosis if they need it for billing or because the therapies aren't working.
posted by viggorlijah at 6:50 PM on March 3, 2014 [1 favorite]

I'd be a bit taken aback by Lynn's evasiveness too, if I were in your shoes. That would be the start of me looking for a new therapist and possibly seeking out mental health testing and being told what the results were.

I also want to chime in to say that personality disorders are treatable, not merely manageable. So take heart, if that is indeed what you have. The stigma isn't as bad as it used to be and there are many innovative therapies out there.
posted by xenophile at 6:52 PM on March 3, 2014 [1 favorite]

She blundered and made (I think) a bad decision in leaving a person with anxiety dangling about a possible personality disorder diagnosis. Inexperienced. Talk to the psychiatrist, since you trust him.

My understanding is that ratings used to assess progress are just that, and not some complicated exercise. I think she has assessed you as functioning at '5'. It sounds like she might be conservative (in rating and maybe other ways). You don't agree, though. I think it's not an insignificant discrepancy that should be talked about . No one I have had therapy with has ever brushed a question or concern under the rug, rather the opposite has happened.

My experience with therapists - cbt practicing psychologists, rogerian social workers, one pdoc - has never involved benign deception (to my knowledge, that is) - always, results of any formal assessments have been openly discussed, and the goals and method s of therapy were always transparent; further, I felt I was an active participant in deciding what mattered. The (I would suggest) authoritarian dynamic (at least in these examples) you describe is something I've read about as the kind of thing that *used to* happen and it's not one I personally would be comfortable with. That said I can only speak about my experience of therapy for moderate anxiety and depression.

Definitely address these issues, first with the one you trust, I think.

Also personality disorders - bpd especially - are, as has been said, contested constructs, not easy to define or assess - there's room for disagreement in there, and a second opinion if you want one.
posted by cotton dress sock at 6:54 PM on March 3, 2014

Also as a point of reference I have always been informed about what kinds of discussions might be had about me, and with whom, and my consent to this was always sought.
posted by cotton dress sock at 7:01 PM on March 3, 2014

OK, so for what it's worth, I am a doctor (but not a psychiatrist and not even close to being a psychiatrist) and here were my thoughts upon reading your story:

- You do not have conclusive evidence that a lie has been told, you assume the therapist was lying because she has mentioned a personality disorder and the psychiatrist has not. But this could be an issue on the psychiatrist's end, rather than Lynn's. He might have forgotten or made a mistake. You need more information, and you should ask about it directly instead of trying to make a general query and hoping the specific information comes out. Ask your psychiatrist: "did I ever carry a diagnosis of a personality disorder?" - personality disorders in psychiatry are diagnosed under axis II, he would have to note in your chart if there were any diagnoses under axis II because this is pretty much how every patient note in psychiatry ends. Of interest to you, they also make a "global assessment of functioning" or GAF. It's on a scale of 1-100. More on that later.

- My impression of what happened with "Lynn" - she might have not known how to navigate this interaction, which might be a reflection of inexperience as others have mentioned and not of any plan to deceive you. I'm not really sure what her motivation would be to lie to you about having a personality disorder, but the possibilities (just toying with your emotions as part of a cruel game, etc) really don't seem likely of someone you describe as a warm and empathetic person. I'm not a therapist nor do I work with therapists, but I wonder if she wasn't sure if she was supposed to mention the personality disorder to you because it could undermine your relationship with your psychiatrist if he had not talked to you about it first, and then she regretted saying it and so got evasive because she could see she had distressed you? Maybe she was hoping Dr. Alexander had mentioned it and only realized he hadn't when she saw your reaction? I don't know, I'd just ask her straight up about it.

As for the 5 on the scale of 1 to 10 thing, if she wasn't lifting it directly from your GAF, maybe it was just her honest assessment of your functioning, and not an attempt to make you feel insecure? I guess the real question is, what are the things that were going on that were keeping you from being fully functional at that time? If you asked her what she thought was impairing your functioning or in what ways she saw you as being not fully functional and she could not answer that question, that would be concerning. As for the fact that you disagreed, that's tough for me to judge as some people have pretty low standards for functionality - I can't tell if you think that as long as you're getting out of bed in the morning, eating 3 meals a day and holding down a job, that you're fully functional, or what. If you want to know how the GAF is scored, see here.

"51 - 60 Moderate symptoms (e.g., flat affect and circumlocutory speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers)." Could this apply to how you were functioning at that time?
posted by treehorn+bunny at 10:14 PM on March 3, 2014 [7 favorites]

The question of whether or not to share diagnoses of personality disorders with patients, and if so how, and if not how, or various half-forthcoming compromises, is a topic of significant debate withing psychiatric communities for exactly the kinds of reasons you've mentioned. Regardless of the various professionally valid camps a therapist might fall into it is still a pretty difficult and tricky thing to navigate, and it sounds like your caregiver just flubbed it one way or another. If nothing else they've clearly given you a significant amount of stress to no clinical benefit and no increase in your agency over your treatment process.

treehorn+bunny's advice here is excellent as always, I would encourage you to share with Lynn how this has brought up issues of your trust in your treatment process and discuss with her how you can both expect to move forward in that context.
posted by Blasdelb at 5:20 AM on March 4, 2014

Now that viggorlijah has mentioned it, I'm going to say my first though on reading your question was that you are looking for an out.

I'm just a random Internet person who doesn't know your life and I may be totally off base.

Still stand by my advice to try and sort it using direct language with your therapist.
posted by Lesser Shrew at 6:54 AM on March 4, 2014

Leave this therapist now.

Look, there may be debate within the psychiatric communities about whether or not to share diagnoses of personality disorders with patients, but you don't have to give a damn about that. The idea that doctors who you are paying money can keep your diagnosis secret for purposes of their own is absolute bullshit, and it one hundred percent can screw you over.

Whether your therapist tells you about personality disorder diagnoses or not, they still exist in the system. They exist in that therapist's notes, and potentially on what she bills the insurance company. If you don't know about it, you can't challenge it if you think it is inaccurate - which means that diagnosis can ride for years, unchallenged. And a diagnosis that has existed for years - even if incorrect - can be extremely difficult to challenge.

I have friends who have been directly screwed over by this sort of thing. Combat veterans who sought treatment for their PTSD were sometimes "diagnosed" with personality disorders instead. Personality disorders are not a disability, while PTSD is. Often when they went to apply for disability, they were told "Actually, you don't have a disability, your doctor's notes show you have had a personality disorder for years." This is a real thing that happens to real people.

You don't have to put up with this. You deserve a therapist you can trust, especially if you have trust issues. The very, very last thing you need is a therapist who thinks she can lie to you, even if "for your own good."
posted by corb at 8:26 AM on March 4, 2014 [5 favorites]

She sounds inexperienced at best and unprofessional at worst. The fact that she decided to steer you away from the conversation by saying "I don't think it's important to talk about right now..." is so rule breaky according to the fundamental epistemological stance of the kind of therapies I have experience with. But then, the therapists I have the most respect for are the ones who do not write a diagnosis in the record without first talking to the client...and who are willing to write "adjustment disorder" for insurance purposes if the insurance company insists on a dx. (These therapists will also often ask you to co-author your case notes -- which can be very therapeutic, by the way!)

The correct response to your follow up questions would be something along the lines of "what would that dx mean to you? From my perspective, that diagnosis would open up a whole range of possible treatments (that are only available if you have dx...."

But see, most treatments -- especially therapeutic approaches-- are available for trying out whether or not you have an official diagnosis. That may not be true in terms if meds. But meds aren't what she has to offer.

And there are no "secret diagnoses" with therapists -- it's called HIPAA.

What it actually sounds like to me is that she forgot to speak with the psychiatrist, but didn't want to look like she dropped the ball on the follow up. So she made something up about what they talked about, that may in fact be a hunch of hers that may not be borne out when she actually talks to the psychiatrist.

I wouldn't call her a liar, exactly ...although there was probably a white lie in there somewhere. It's not personal, she's not playing mind games with you. She's just not being professional, and she's trying to save face, navigating her way out of being embarrassed by her mistakes -- "saving face" is not the skill I want my therapist practicing my session. Humility, a quick apology "I'm sorry I haven't had a chance to talk to the psychiatrist yet" - that's what I'd be looking for. Not a suggestion of a diagnosis that she's not actually willing to discuss.
posted by vitabellosi at 9:07 AM on March 4, 2014 [6 favorites]

This would make me more cautious and less productive, which would mean the relationship with this therapist has become functionally incompetent and can't be relied upon for my ongoing care. I'm not sure if that's the case for you, just what it would mean for me.

To be very clear, since I don't want to contaminate the trust issue thing:
• I don't see a lie present about whether or not she discussed your treatment with Dr. Alexander.
• I don't actually see a problem with putting you at 5 vs., say, 8 - our perceptions of coping and thriving can be very different from those who aren't in the day-to-day with us.
• I also don't see a huge problem with just the surface issue of not being given the details of a specific diagnosis, within certain boundaries - the therapist who saved my life demurred from offering a specific diagnosis in my first year with her, because she felt that even as Dr. of psychology, she needed time to see my full coping cycle on top of recovery and further challenges and didn't want me bogged down with labels while I was processing some really heavy realities that I'd be navigating for the rest of my life.

BUT. You've been seeing this doc for 18mos, you're getting different answers between her and the psychiatrist, and corb is totally right about the misuse of personality disorders vs. other diagnoses and the impact thereof, and that is what makes me nervous and would make me feel less confident in the overall therapeutic effect of the relationship.

In my particular case, I was given a disability code as part of my regular evaluation, and it was my right as a patient to know that code and what it meant for me and the impact on my life and livelihood. If I were you, I'd ask for this directly, be honest with her about the effect of her tactics (whatever the reason, it's not productive for you and she needs that information to correct course or otherwise identify that this doesn't work for all patients), and then look for a new talk doc.

As hard as all of that may be, I believe it will be worthwhile in the long run to you.
posted by batmonkey at 2:28 PM on March 4, 2014 [1 favorite]

There is lots of variability about this based on where you are, but in California, at least, your treatment records belong to you. You can request them and they should be given to you.

There are exceptions made (in California at least) if a therapist has a concern that reading the records themselves could cause the client harm - in these cases, the therapist is able to write a summary and give that to the client instead of the actual records.

Apart from statutes, you deserve an honest answer about your diagnosis. You are in charge of your care and if you want to know the diagnosis, the therapist should tell you. Not only that, the therapist should explain her basis for giving you the diagnosis. I have sat with clients with the DSM and showed them the criteria and went through them one by one to explain why I chose a particular diagnosis.

Having said that, I want to point out that this kind of being flustered by client questions is totally normal in the development of therapists. New therapists are used to asking the questions and are uncomfortable with being asked. So she's deflecting, trying to return to the familiar ground of "being the therapist" - let's get back to work!

You can be patient with her if you feel that she's mostly being helpful in other areas. Or you can make this a breaking point. It's really up to you. However, I find there can be a great deal of growth for both parties when rough points like this can be worked through.

If you decide that you really want to know about this, calmly steer her back to your question. Tell her there is no work "to go back to" - this *is* the work at this point. Tell her that you can see she's anxious and deflecting, but that you want her to respect your request, and that you have a right to know her treatment plan (which includes diagnosis), to have it explained to you, and to agree it.
posted by jasper411 at 4:09 PM on March 4, 2014 [3 favorites]

Shouldn't they keep a PD diagnosis to themselves? Aren't they just basic categories and lists of behaviors that are somewhat debatable? I would think that yes, reveling a diagnosis like this might hurt therapy. I would think that even if a diagnosis is made it's best to just focus on the issues that may result from a PD and not label a patient.
posted by Che boludo! at 11:10 AM on March 5, 2014

Does sound fishy. My usual rule-of-thumb for these situations where something seems quite "off" but nothing can be conclusively proven, is that if there are three of these fishy incidents then I'm likely correct in my assumptions. We're all trying to discern the difference between instinct and irrational suspicion. Whenever I'm unsure if it's one or the other, I feel if there's only one seemingly strange situation then it's likely that it's a coincidence and the situation's fine. If there's three, then that's too many to discount. But it seems like not only are there somewhat suspicious evasions and diagnoses, you caught her in a direct lie. In addition to all the other fishy situations! When this happens, it's more than normal to feel like there's something sketchy afoot.
posted by tenlives at 4:19 PM on March 19, 2014

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