Please help me understand my therapist.
November 2, 2017 9:59 AM Subscribe
I've been working with a psychotherapist for about a year and a half and I'm feeling stuck. For the past two sessions we've been talking about the therapy, and I'm not feeling comfortable with his answers. I'd like help in evaluating them. More details below the fold.
My therapist is a psychiatrist who practices psychotherapy in addition to prescribing medications, though he's not willing to be my prescribing physician. The crux of the problem is that I'm not seeing him doing very much during our sessions. I spent several months recounting my difficult past. Since then, the sessions have been unstructured. For the most part I will vent about whatever recent event has sent me down the rabbit holes of my past. He'll ask occasional questions, but I'm not able to discern that there's a method to his questioning.
I decided to step away from what I have been doing in our sessions in order to evaluate what is going on. To that end, I have been asking big-picture questions. One that prompted an worrying answer "What is your treatment plan for me."
After a long pause, he said something to the effect that we'd keep doing what we have been doing until at some point he would fail me. My past has several chapters that involve people or institutions failing me in pretty significant ways. But there are several other issues I want to work on, including my dearth of friends, which I think has a lot more to do with me in some way than it does with the people I have met over the years without forming friendships. An attachment problem is lurking in there somewhere. I also feel inadequate because I have almost nothing to show for my working life in the way of accomplishments despite being educated in elite institutions from which many of my peers have gone on to significant careers.
So, I had been hoping for a bit more from him in the way of a treatment plan. I would have liked it if he had listed the issues we've been working on and given me a general sense of his game plan for each of them. I would have liked it because it would have made him an active participant in my therapy, someone with a plan and the means to execute it.
Thus, hearing that the plan was to keep doing what we've been doing until he fails me left me feeling like I was staring into the void. There's no apparent direction to the therapy and no indication that the therapist has specific plans to work on the issues I want to work on.
The next answer that disturbed me came when I asked whether he thought I needed to be in therapy. In classic therapist fashion, he answered my question with a question, to wit, Did I think I needed to be in therapy? I responded by saying it was not acceptable in this evaluation process for him to offer up a question in answer to my question; it was time for Q&A, not Q&Q. The closest he came to an answer was to say that not all patients are capable of realizing when they no longer need therapy, but he thought I would be.
I am not finding this useful. While I trust my therapist, I have a sense that he's being evasive and that we're playing a game of 20 questions in which I don't receive the answer I'm seeking unless I ask a perfectly targeted question. Any imprecision or ambiguity in the question is license to equivocate even though he very likely knows very well what it is I am after.
I also have a sneaking suspicion that he's not retained as much of my history and my problems as I think he should have given the amount of time we've spent on them. It could be that he really doesn't know me as well as he should.
I asked my therapist for a diagnosis or at least a summary of what he thinks my problems are. He sought cover in DMS-5, saying that I didn't have any obvious thinking disorders or cyclical mood swings. I already knew that; what I wanted to know what what my problems look like to him, and he didn't answer that.
Finally, my therapist has been cagey when it comes to explaining the intellectual and theoretical bases of his practice. Initially, he dismissed my question, saying something to the effect that our day-to-day work is more important than the theories behind it. Later, he did provide an explanation but not a label for his methods. Without that label (e.g., Freudian, Jungian, etc.) I'm not able to give you a useful summary of what he said.
I would like to hear from anyone who can contextualize the answers I've received to my fundamental questions. As far as I can tell, either there's no method to what he's doing, or there is and for some reason he's not willing to discuss it with me. Either way, I'm alarmed.
I get that having him fail me (which he's close to doing) might permit us to use the current failure as a model for examining past failures. The problem is that he'd be so implicated in the failure that it would be a conflict of interest for us to proceed. I'd need a qualified independent arbitrator who could ask both of us probing questions and issue findings, but that would be expensive, time consuming and ridiculous if it were even feasible.
If this were CBT work, I'm sure the therapist would have a playbook that we would be discussing. However, in my experience CBT does not deal with one's past, preferring instead to reprogram one's thinking about the present. That isn't something that will work for me. I need to excavate those rabbit holes, find out what's in them and why, and then find a way to fill them back in with sterile material so they won't become reinfected.
My therapist is a psychiatrist who practices psychotherapy in addition to prescribing medications, though he's not willing to be my prescribing physician. The crux of the problem is that I'm not seeing him doing very much during our sessions. I spent several months recounting my difficult past. Since then, the sessions have been unstructured. For the most part I will vent about whatever recent event has sent me down the rabbit holes of my past. He'll ask occasional questions, but I'm not able to discern that there's a method to his questioning.
I decided to step away from what I have been doing in our sessions in order to evaluate what is going on. To that end, I have been asking big-picture questions. One that prompted an worrying answer "What is your treatment plan for me."
After a long pause, he said something to the effect that we'd keep doing what we have been doing until at some point he would fail me. My past has several chapters that involve people or institutions failing me in pretty significant ways. But there are several other issues I want to work on, including my dearth of friends, which I think has a lot more to do with me in some way than it does with the people I have met over the years without forming friendships. An attachment problem is lurking in there somewhere. I also feel inadequate because I have almost nothing to show for my working life in the way of accomplishments despite being educated in elite institutions from which many of my peers have gone on to significant careers.
So, I had been hoping for a bit more from him in the way of a treatment plan. I would have liked it if he had listed the issues we've been working on and given me a general sense of his game plan for each of them. I would have liked it because it would have made him an active participant in my therapy, someone with a plan and the means to execute it.
Thus, hearing that the plan was to keep doing what we've been doing until he fails me left me feeling like I was staring into the void. There's no apparent direction to the therapy and no indication that the therapist has specific plans to work on the issues I want to work on.
The next answer that disturbed me came when I asked whether he thought I needed to be in therapy. In classic therapist fashion, he answered my question with a question, to wit, Did I think I needed to be in therapy? I responded by saying it was not acceptable in this evaluation process for him to offer up a question in answer to my question; it was time for Q&A, not Q&Q. The closest he came to an answer was to say that not all patients are capable of realizing when they no longer need therapy, but he thought I would be.
I am not finding this useful. While I trust my therapist, I have a sense that he's being evasive and that we're playing a game of 20 questions in which I don't receive the answer I'm seeking unless I ask a perfectly targeted question. Any imprecision or ambiguity in the question is license to equivocate even though he very likely knows very well what it is I am after.
I also have a sneaking suspicion that he's not retained as much of my history and my problems as I think he should have given the amount of time we've spent on them. It could be that he really doesn't know me as well as he should.
I asked my therapist for a diagnosis or at least a summary of what he thinks my problems are. He sought cover in DMS-5, saying that I didn't have any obvious thinking disorders or cyclical mood swings. I already knew that; what I wanted to know what what my problems look like to him, and he didn't answer that.
Finally, my therapist has been cagey when it comes to explaining the intellectual and theoretical bases of his practice. Initially, he dismissed my question, saying something to the effect that our day-to-day work is more important than the theories behind it. Later, he did provide an explanation but not a label for his methods. Without that label (e.g., Freudian, Jungian, etc.) I'm not able to give you a useful summary of what he said.
I would like to hear from anyone who can contextualize the answers I've received to my fundamental questions. As far as I can tell, either there's no method to what he's doing, or there is and for some reason he's not willing to discuss it with me. Either way, I'm alarmed.
I get that having him fail me (which he's close to doing) might permit us to use the current failure as a model for examining past failures. The problem is that he'd be so implicated in the failure that it would be a conflict of interest for us to proceed. I'd need a qualified independent arbitrator who could ask both of us probing questions and issue findings, but that would be expensive, time consuming and ridiculous if it were even feasible.
If this were CBT work, I'm sure the therapist would have a playbook that we would be discussing. However, in my experience CBT does not deal with one's past, preferring instead to reprogram one's thinking about the present. That isn't something that will work for me. I need to excavate those rabbit holes, find out what's in them and why, and then find a way to fill them back in with sterile material so they won't become reinfected.
Yeah, this is a bad-fit therapist. It's entirely possible this model works for some people, but it isn't working for you, and now that you've realized it, finding someone new would be a good next step.
posted by restless_nomad at 10:05 AM on November 2, 2017 [5 favorites]
posted by restless_nomad at 10:05 AM on November 2, 2017 [5 favorites]
Best answer: Some therapists don't say much, and many give indirect or vague answers to the kinds of questions you're asking. I'm not maligning them -- but it's not what you need. Trust is super-important in a therapy relationship, but it's not everything. I think you might want to ask yourself if you're benefiting from therapy, not whether you need it. It sounds like you're not getting much out of it. (I do think it's weird that this MD Psychiatrist has you go to someone else for medications.)
Finding a new therapist can feel like a very big deal, especially if you've had bad experiences in the past. The last time I had to do it, I told myself that I could shop around, that I wasn't making a momentous decision but just making phone calls and seeing how people sounded. I decided to tell prospective therapists that anxiety was making the process hard for me, to see how they responded. And I concentrated on the fact that I wasn't making a momentous, lasting decision if I actually met with a therapist. If you dread looking for someone new, see if you can name some of the problems it's bringing up and accommodate them.
I really think it's good that you had that conversation, especially because it's hard to do and you handled it by honoring what you needed, instead of accepting what was given. I sincerely wish you well.
posted by wryly at 10:28 AM on November 2, 2017 [2 favorites]
Finding a new therapist can feel like a very big deal, especially if you've had bad experiences in the past. The last time I had to do it, I told myself that I could shop around, that I wasn't making a momentous decision but just making phone calls and seeing how people sounded. I decided to tell prospective therapists that anxiety was making the process hard for me, to see how they responded. And I concentrated on the fact that I wasn't making a momentous, lasting decision if I actually met with a therapist. If you dread looking for someone new, see if you can name some of the problems it's bringing up and accommodate them.
I really think it's good that you had that conversation, especially because it's hard to do and you handled it by honoring what you needed, instead of accepting what was given. I sincerely wish you well.
posted by wryly at 10:28 AM on November 2, 2017 [2 favorites]
Best answer: So you're looking for more analytic/psychodynamic therapy (CBT, as you note, is focused on the present and on function more than content) but the things that anger you are pretty standard in analytic therapy. There is theory behind it, but if it's not working for you, it's not working for you. You're not going to find a lot of therapists who want to explore the rabbit holes with you who are also always willing to give you a neat, self-contained answer.
As far as methodology, it isn't really that discrete. Unless you go to a vanishing breed of psychoanalysts, most people aren't strict disciples of a particular school. FWIW, and I always trot this out, efficacy in therapy has been shown to be more about a good relationship with the therapist (which seems not to be there) than therapeutic orientation. I mean, not to sound like your therapist, but what would it do for you to know that he is a Winnicottian?
posted by Smearcase at 10:37 AM on November 2, 2017 [5 favorites]
As far as methodology, it isn't really that discrete. Unless you go to a vanishing breed of psychoanalysts, most people aren't strict disciples of a particular school. FWIW, and I always trot this out, efficacy in therapy has been shown to be more about a good relationship with the therapist (which seems not to be there) than therapeutic orientation. I mean, not to sound like your therapist, but what would it do for you to know that he is a Winnicottian?
posted by Smearcase at 10:37 AM on November 2, 2017 [5 favorites]
Best answer: Agree with Smearcase that your therapist's answers/avoidance of answering is not out of the range of what psychoanalysis looks like, although it also sounds like he has been rather passive/complacent as a therapist and not "pushing" you so to say, if you feel like you've learnt nothing much after 1.5 years.
However, if you find the opacity and neutrality of psychoanalysis frustrating, analytically-inspired approaches with more transparency and collaboration like schema therapy, cognitive analytic therapy, or attachment-based therapy may be better fits for you.
posted by monocot at 11:13 AM on November 2, 2017 [1 favorite]
However, if you find the opacity and neutrality of psychoanalysis frustrating, analytically-inspired approaches with more transparency and collaboration like schema therapy, cognitive analytic therapy, or attachment-based therapy may be better fits for you.
posted by monocot at 11:13 AM on November 2, 2017 [1 favorite]
Best answer: Life's too short for bad therapy. Find one that fits you and don't be afraid of shopping around.
Also, psychiatrists are not really that qualified to do one on one long term therapy. Unless he has another degree or other training in counselling/therapy, he's not a therapist. Psychiatrists like to paint themselves as a holistic solution to mental health, but they are only truly trained to deal with the physiology of mental health and medication/treatment plans. The education they get on counselling is much less than if they had a degree in psychology or even a certificate in social work. I know this because I have a friend currently specialising in psychiatry and it's not what they expected, it's a field of medicine, not of psychology, really.
I'm not surprised he's not able to adapt or create a therapy approach to help you, as this really isn't the main part of his job.
You already know what you want to address in therapy, and a good therapist would have figured out how to help you with that by now. CBT- centric therapists/counsellors may be more up you alley, as well as psychodynamic.
Also, I've found that for me to find a good counsellor, I had to kind of let go of the idea that the first appointment was anything other than me getting a feel for THEM as a person. You really need someone who validates you, believes in you as a human being, and is able to make you feel comfortable. Don't settle for any less. Therapy is hard, but you shouldn't be weary of the ACTUAL THERAPIST. Seriously.
posted by InkDrinker at 12:29 PM on November 2, 2017 [4 favorites]
Also, psychiatrists are not really that qualified to do one on one long term therapy. Unless he has another degree or other training in counselling/therapy, he's not a therapist. Psychiatrists like to paint themselves as a holistic solution to mental health, but they are only truly trained to deal with the physiology of mental health and medication/treatment plans. The education they get on counselling is much less than if they had a degree in psychology or even a certificate in social work. I know this because I have a friend currently specialising in psychiatry and it's not what they expected, it's a field of medicine, not of psychology, really.
I'm not surprised he's not able to adapt or create a therapy approach to help you, as this really isn't the main part of his job.
You already know what you want to address in therapy, and a good therapist would have figured out how to help you with that by now. CBT- centric therapists/counsellors may be more up you alley, as well as psychodynamic.
Also, I've found that for me to find a good counsellor, I had to kind of let go of the idea that the first appointment was anything other than me getting a feel for THEM as a person. You really need someone who validates you, believes in you as a human being, and is able to make you feel comfortable. Don't settle for any less. Therapy is hard, but you shouldn't be weary of the ACTUAL THERAPIST. Seriously.
posted by InkDrinker at 12:29 PM on November 2, 2017 [4 favorites]
You have a right to good customer service. That's a hard thing to get in therapy, since there's a clinical, creative, and personal aspect to whether you and your shrink fit. I went through four therapists - very frustrating and expensive - until I found the right one, who I have now been seeing over twenty years. If you need help, it is worth the search - and I want to say that by asking the questions you asked, you are putting yourself in good stead for whatever future (and with whomever) your therapy will lead you to.
posted by soulbarn at 1:55 PM on November 2, 2017 [1 favorite]
posted by soulbarn at 1:55 PM on November 2, 2017 [1 favorite]
I'm going through the exact same thing right now, even similar conversations. I don't think I'm going back. I found someone else who is more of a 'life coach' type person, because even though I have the same or similar rabbit-holes, I need to also improve the day to day WITH A PLAN. The vague, evasive, "I'm doing you a favor by listening to you even though you are paying me, and my obligation is to provide you with nothing but 50 minutes of my time" no longer works for me, even though my therapist was actually a very very nice guy. Just not particularly effective for me.
posted by bquarters at 5:17 PM on November 2, 2017
posted by bquarters at 5:17 PM on November 2, 2017
The thing is that every therapist, indeed every person, will fail you at some point in some way. This could be your opportunity to talk about how that feels, what your secret thoughts are, what your reactions are and why and what else you could do when someone fails to be who need them to be. That could be a fruitful line of conversation and thought.
posted by SyraCarol at 6:44 PM on November 2, 2017 [2 favorites]
posted by SyraCarol at 6:44 PM on November 2, 2017 [2 favorites]
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