Meaning, I can take a few steps backwards in my recovery from depression and anxiety, but that doesn’t erase all the lessons, skills, and wisdom acquired in my past.

Those words are consoling to me the last three or so weeks as my boundaries crumble and I go back on promises I made myself not so long ago. I know that the footprints are going in the wrong direction, but I seem incapable of making myself turn around to walk toward healing. I’m afraid that I’ll lose it all — the knowledge, the insights, the discipline that I procured the last three or so years — as my strides reverse.

My therapist swears I won’t. And I’m holding her to her word.

Because you can’t unlearn something. It’s there, stuck in your neural passageways along with all the other gunk from your childhood. Recovery from depression–beginning the path to wholeness and happiness with the help of aids like cognitive-behavioral therapy, psychotherapy, drugs, Omega 3s, yoga, exercise, gratitude — is like learning to ride a bike or studying a foreign language.

You can store the bike in your garage for 10 years, or not utter “Gracias” to your Latin neighbors for decades, but the moment you’re ready to go, it comes back. With a little practice, of course.

I’m reassured by wise mentors in my life who have lived more years with depression and anxiety than I have, who agree that true recovery is based on progress, not perfection, and that growth almost always happens in uneven patterns with “muchos” messes. No neat freak need apply.

So even though we may feel like we’re spinning around in circles — lacking the gravity needed to pull us in a certain direction — even then we’re probably absorbing information, gaining knowledge, and educating ourselves in the subject of life so that, as T. S. Eliot so beautifully articulated:

“We shall not cease from exploration, and the end of all our exploring will be to arrive where we started and know the place for the first time.”

So we’re putting out a call for any and all psychotherapy stories — from therapists, psychologists, psychiatrists, counselors, clients and patients. If you have a story you want to tell and can do so in under 1,400 words, we’re interested.

We’re not looking (just) for salacious stories. We’re looking for stories that show the personal nature of therapy, and how it can help people.

Read on for details…

We are looking, first and foremost, for your psychotherapy story (or that of a loved one; or if you’re a professional, one involving your psychotherapy session with a client). We don’t want fictional stories. We also don’t want you to tell your story in public if you’re not ready to share it and have it be read by thousands of people.

We are also looking for submissions that meet our editorial guidelines. These include:

• Good English grammar.
• Simple formatting — no indenting, but please use paragraphs and spaces between your paragraphs.
• Spell-checking before you send.
• Make the details anonymous. We don’t want you to be too personal with your details, to ensure no one recognizes you (or your client) from the story.
• Taking 5 minutes to proof-read your submission before sending it to us, making sure it reads well and makes sense.

All entries will be published anonymously, unless you specify otherwise.

There may be a small stipend involved if your submission meets our editorial guidelines and is a story we end up publishing. If this is the case, we will contact you for your billing details. (We’re not guaranteeing any stipend or giving details about it, because we prefer people do this for sharing their story, not for the money.)

Submit Your Psychotherapy Story

Ready to go? So are we! So go ahead and send us your best story about psychotherapy to:

(We can take any format you care to send it in.)

The Fine Print:
Any submission to Psych Central grants us a royalty-free, perpetual, irrevocable, non-exclusive right and license to use, reproduce, modify, adapt, publish, translate and distribute such material (in whole or in part) worldwide and/or to incorporate it in other works in any form, media or technology now known or hereafter developed for the full term of any copyright that may exist in such material. Authors may retain their original copyrights if they so desire. Psych Central has the option, but not the obligation, to publish any material it receives at this email address.

I appreciated that even more when I went to see my most recent doctor. He was far more gruff, business-like, and running more than 20 minutes late for our appointment. He didn’t apologize for keeping me waiting, and while he listened to my family history with detached professionalism, he went through his canned speech about needing to exercise regularly and other kinds of things with the kind of empty delivery you find in a person who’s said the same thing so many times it has lost all meaning.

Doctors and therapists both can keep bad habits, and they are the kinds of things that turn patients off from them. Patients rarely feel it’s appropriate to address these bad habits directly with the doctor (especially if they intend to keep seeing them), so it was with some relief I came across Dr. Dominic Carone’s blog entry about the “10 ways doctors can lose their patients.”

Here are the first few to whet your appetite:

10. Not accepting lists of symptoms or timelines from patients. If you see patients, you know they range on a continuum from poor historians who have no idea why they are there to see you and those who arrive with carefully constructed histories that they are eager to give you as soon as you walk in. Just about the worst thing you can do when this happens is to tell the patient that you don’t want the list and do not even want to look at it. That connotes a dismissive attitude to the patient and it makes them feel like all of their work was for nothing – work that was done in the hopes it would help you figure out what was wrong. You may have very good reason at the time not to look at the list such as time pressure, but at least take the list and say you will later take a look at it. It will likely provide you some useful information.

9. Asking patients to choose what type of medication they want to take. When a patient has a medical condition in need of medical treatment, the physician is looked to provide their advice as to what medication to take. They don’t want to be given a list of three possible medications, told to research them at home, and come back with a decision. From a patient’s perspective, this is why the doctor went to medical school, not me.

8. Long wait times and no apology and/or rushing the patient once coming in. While no patients want to wait long, they will generally accept the wait time if they are pleased with the care you provide, or if it the initial visit, know that you have a good reputation. However, if the patient waits long and you then walk in and do not acknowledge the wait, explain why there was a wait, and apologize for the wait, it will significantly aggravate the patient. Rush the patient after a long wait and no apology and it will worsen the situation further.

7. Poor bedside manner. This is an easy one and has been addressed extensively by others, but don’t do things such as repeatedly looking at the clock, repeatedly interrupting patients, focusing more on you than the patient, talking rudely, making poor eye contact, etc. Follow the Golden Rule and you will easily establish rapport the majority of the time.

I’ve experienced each and every one of these with my regular physician, but I’ve also heard plenty of stories of people who’ve experienced these kinds of bad habits with their therapists and psychiatrists.

My biggest pet peeve is making an appointment for the morning, knowing that the chances of the doctor or therapist running behind is far less likely earlier in the day than later in the day. So when I arrived recently for an 11:00 am appointment, only to have to wait nearly 25 minutes before being asked to come into the exam room, I have to stop my face from turning into something out of a horror movie. If you’re running nearly a half hour behind with just 2 or 3 hours of your day behind you, that says something.

But the absolute worst thing about late professionals is their lack of awareness they are even running late, and the lack of any apology for doing so. I understand emergencies or a patient who needs a little extra time — that’s perfectly fine in my book. Simply offer a brief explanation to me when you come into the room, as well as a brief apology, and all is forgiven.

When a professional can’t even offer that, I do question whether this professional is the right one for me. Because basic manners and common decency are something all doctors and therapists should not only have, but practice daily. It demonstrates a lack of respect for your patient — you know, a fellow human being — when you treat them as just another cog in your daily assembly line of patients.

Nobody wants to be treated that way. So if you’re a doc or a therapist, and you recognize yourself in some of these bad habits, now’s a good time for a wake-up call. After all, it’s never too late to change.

Read the full entry: 10 ways doctors can lose their patients

Most of us have been there at least once in our life: the awkward spot where you know a loved one has a mood disorder or drinking problem, but is too stubborn to admit it and to proud to get help. You might see the consequence his behavior is having on his children, his job, or his marriage, but he is blissfully blind or is in too much pain to see the truth.

What can you do, short of taking the person by his shoulders, shaking him, while screaming, “Wake the hell up and see what you are doing?!?”

It’s very complicated.

Because people are different.

Mood disorders vary.

And families are as unique as the illnesses themselves.

After doing a bit of research and consulting with a few mental health professionals, I have compiled this list of suggestions, to be read as merely that: suggestions.

1. Educate yourself.

The first responsible thing you can do is to educate yourself. Because you can’t really spot a type of disorder without knowing its symptoms. In guessing that a sister is depressed, you should know if there have been any significant changes in her diet, sleep, energy, and so forth. You can’t really assume your brother-in-law is bipolar based on Matt Damon’s performance as a pathological liar/bipolar freak in “The Informant!” or that a friend is obsessive-compulsive because her behavior resembles Jack Nicholson’s in “As Good As It Gets.”

Educating yourself is not only going to help you gather the facts that you need in order to know how sick your loved is, but it is going to help you feel more in control of the situation—so that you can guard yourself against the fruitcake that will be hurled at you come Christmas dinner. It won’t be a TOTAL surprise.

2. Gather the information.

Here comes the fun part. You get to pretend you are a detective for a month or so and gather any facts you can about the person without a) invading her privacy, or 2) bringing on an awkward confrontation. If you think she is depressed, ask about her diet. “Are you still eating Chipotle’s Burrito Bowl for lunch? No? Why not? Are you still playing tennis on Tuesday nights? Why have you stopped? What book are you reading for your book club? Have you hosted any of the meetings recently? It’s helpful to get together with any mutual friends and/or family members who would have additional information, so that together you can get a truer picture of what’s going on. The person may tell you something that contradicts your sister’s information, and the discrepancy can be even more significant than either of the answers. After studying the symptoms of the disorder that you think your loved one has, you will better know the information you need to find out.

3. Make a plan.

Here’s where it gets hard, because there is no right solution, and you can’t know the appropriate approach until it’s over. There is, of course, the intervention: when you gather together family and friends of the person and you all publicly confront the person with his behavior. Everyone either expresses a way that he/she has been affected, or reads a letter, or does something that ultimately communicates, “Dude. Uncool.” The intervention is the most extreme approach, and isn’t right for every situation. It can be when a person is in danger of either hurting himself or hurting someone else –by suicide, recklessness, or severe substance abuse. In some cases, police may even need to be called.

As much as we’d like to be able to force a sibling or friend or parent into treatment, we simply can’t. They have to meet strict criteria for being committed involuntarily to an inpatient hospitalization program. Someone has to prove that they are incapable of meeting their own basic survival needs (paying bills, proper hygiene, nutrition) or that they are a danger to themselves or others. States vary with regard to the criteria, but it is not easy to make the case because you have to bypass all those human rights and stuff that we have.

So, that leaves ….

4. State the facts.

You’ve studied up. You have the evidence. You know that she is depressed, but not so severely that she presents a risk to herself or to her family. And yet … the disorder is clearly wreaking havoc on her home life as well as her friendships and job. What do you do?

You start with the facts, and depending on how the conversation is going, you end with the facts. No one can dispute facts. They are what they are. They have no emotion or judgment or attitude attached to them. And they are especially heard when spoken from a person who has done her homework.

For example, when I was in that spot—being confronted by a friend about my severe depression six years ago—she simply listed a few things that I couldn’t deny: 1) there was food on my robe, 2) I couldn’t stop crying, 3) I had lost 15 pounds in two months, 4) I wasn’t speaking in coherent sentences, 5) she wasn’t the only one worried about me — there were at least three others.

My husband could have told me in vague language that he was worried about me, but I probably wouldn’t have listened because he wasn’t a doctor and he wasn’t laying down concrete evidence. I could hear what my friend was saying because I knew she had done her homework and was merely calling out the obvious, not making a general judgment of me.

Strangers’ responses to learning that I’m a therapist are varied, and it’s not uncommon for them to be loaded in some way or another. “You’re analyzing everything I say, aren’t you?” many people joke. “Mmhmm,” I’m tempted to respond, with a raised eyebrow and Mona Lisa grin. “Oh,” others murmur, before the conversation trails off into stilted silence and the person starts surreptitiously glancing over my shoulder for someone else to rescue them.

The wedding guest’s response to learning I’m a therapist was of the “Oh, that’s cool” variety. I didn’t think anything of it. Contrary to popular belief, I don’t really “analyze” anyone, let alone people I’ve just met.

Later in the evening, after a lovely dinner, people started migrating to the dance floor, and I followed. I love to dance at weddings and I can dance well enough. By which I mean I don’t call attention to myself with my awkward moves. Often.

As the strains of Hava Nagila faded and the music shifted to more contemporary dance fare, the wedding guest I had previously chatted with caught my eye and shouted above the DJ, “I can’t even imagine my therapist dancing!” Incredulity and an afternote of the freely flowing wine (we were in Sonoma, after all) rang through his comment.

I laughed and shouted back, “Yep, we’re people too!”

After the wedding, I smiled to myself again about the encounter. The wedding guest’s exclamation was a reminder that clients vary broadly in their views of my role as a therapist. Some, like the guest, seem prone to thinking of me existing solely within the confines of my office. Like the students who believe their teachers live at school, these clients keep me in a safe box. They don’t imagine me dancing at weddings, or in other “real life” activities because it doesn’t really occur to them to do so. Sometimes it’s easier to disclose vulnerable material to someone whom you imagine, consciously or not, is not quite real.

There are other clients who keep me boxed up, but for different reasons and in a different way. These clients view me as a professional with a capital P, much like they might view their dentist or accountant. In these clients’ minds, I am the keeper of important information about things like how to intervene during a panic attack or how to skillfully communicate with a partner. These clients want to talk about symptoms and solutions. They don’t care about my dance skills or lack thereof, or at least not any more than they care about whether their accountant plays baseball.

There are, however, some clients who are curious about who I am outside of the consulting room. They want to know more about me as a person, apart from who I am as a therapist. Of course these two things are inextricably intertwined, but not often in ways that are clear to clients when it comes to the specifics. These clients want to know if I’m married; they ask whether I have children; they’re curious about whether I like the outdoors or scrapbooking or cooking. Sometimes they want to know if I have struggled in ways similar to them. Probably most important to the therapeutic endeavor, they wonder about how I see them, what I think of them, whether I am judging them.

Like many therapists, I am eclectic in my approach. I believe strongly that therapy is not a one-size-fits-all process, and that I need to tailor not only my technique, but also the therapy relationship to each client based on his or her needs.

Multiple theories inform my practice, one of which is a relational, or interpersonal process approach. One of the philosophical underpinnings of this approach is that the therapeutic relationship is a real one, and that here-and-now interactions between therapist and client can serve as powerful tools for promoting insight and catalyzing change.

The therapy relationship becomes an experimental forum in which I can provide interpersonal feedback to clients, they can process their role in the dyad, and they can test out new ways of relating. Some clients struggle with eye contact. We talk about why. Other clients are hesitant to disagree with me. We discuss what it is like to feel the need to continually acquiesce to others. On the flip side, other clients seem primed for an argument and take issue with just about everything I say. I share my experience of what it is like to be on the receiving end of their unrelenting criticism. And so on.

Over time, clients begin to view their interpersonal ways of being from a new perspective. They translate an increased awareness of thoughts and feelings about how they are in relationships, and new interpersonal behaviors into relationships outside of therapy.

Regardless of how clients initially perceive my role as a therapist, I am bound to reflect out loud at some point about the here-and-now dynamic playing out between us. Whether or not they want to know about my dance skills, clients hopefully learn that they can count on me for honest, genuine feedback about how I (as a therapist and a person) experience them. If they want to continue believing that I sleep on the couch in my office, that’s fine, so long as they take what they have learned in therapy with them into the world at large.

The world is full of them. How hard it is for us, non-idiots, to put up with them. But to get our jobs done, our kids fed, and our pets groomed, we must deal with them.

Idiots come in many shapes, forms, and types, but the ones that frustrate me the most are those who don’t believe in any form of mental illness. These creatures maintain that all mood disorders are cute, creative stories crafted by persons who enjoy obsessing, ruminating, and crying their eyes out… a wealthy bunch who can’t think of anything better to do than come up with a make-believe tale about a few neurons wandering around the limbic system afraid to ask for directions, just like Moses.

We must tune out the idiots to achieve any kind of sanity or serenity. But how? Here are four ways that have worked for me.

1. Expect nothing.

If you expect your cousin to understand your bipolar disorder, then you are going to be disappointed when your cousin doesn’t understand your bipolar disorder. But if you sit down to lunch with her fully expecting her to space out on 90 percent of the conversation, you won’t walk away from the table bummed out that she didn’t inquire about your manic cycle. Or know that it doesn’t have anything to do with a washing machine. I think Sylvia Plath was referring to idiots when she said, “If you expect nothing from anybody, you’re never disappointed.” That goes for parents, in-laws, siblings, pets, spouses, children, and ministers.

2. Don’t offer information.

I don’t do this one well. I tend to spill my guts to whoever is seated next to me — which is why I have made so many friends on flights between Maryland and Ohio. The conversation doesn’t always go well, though, especially if I’m talking to an adamant anti-medication person who believes all psychiatrists are agents of the devil, involved in a racket with Big Pharma, reaching into the pockets of innocent people everywhere, and spilling poison into the bloodstreams of children. Obviously, that dude is not going to approve of my I-would-be-a-gonner-without-meds tale. He could very well give me the old furrowed brow to express utter disapproval.

At this point, most folks would change gears and go back to talking about the weather or the turbulence ahead. On a bad day, however, I keep going full stream ahead and absorb this guy’s opinion, tossing it around in my head. Before the flight is over, I am back to feeling like a pathetic loser who is addicted to antidepressants and at the mercy of an evil empire.

When this happens in a dialogue with a close idiot in my life, I take the disapproval very personally and I start to dislike myself. No one, however, can disapprove of you, or furrow the brow, if he has no information to analyze or shred. So if you stop giving the idiot material to bash, he will have to find something else to grate—hopefully, a person, place, or thing that has nothing to do with you or your life.

3. Try some visualization.

This technique helps me with the idiots I have to see on a regular basis. Visualization essentially gives you some much-needed boundaries to protect yourself from the cannon that could be fired at the next family function. You have to experiment to find the right kind of visualization for you. For example, you could visualize yourself in a bubble, where absolutely nothing can hurt you. It resembles a mother’s womb — a place many of us would like to revisit. Or you can envision the idiot in a bubble. Whatever she tries to launch at you isn’t able to penetrate the protective force.

My recent visualization is to imagine that the deemed idiot is made of stone. Why? Because I am continually frustrated that she doesn’t respond with more compassion. Visualizing her as a statue of ivory stone reminds me to keep my expectations in check and that she can’t take away my self-esteem or self-worth just by her cold, stoic way of being.

4. Don’t take it personally.

I really hate it when people say this to me. However, I read chapter three of Don Miguel Ruiz’s classic, The Four Agreements on my way to see an idiot the other day, and his words helped me build a layer of protection around myself so that I left her house feeling less disappointed and hurt than I usually do. Ruiz explains that we can become immune to hurt and rejection. For real. He writes:

There is a huge amount of freedom that comes to you when you take nothing personally. You become immune to black magicians, and no spell can affect you regardless of how strong it may be. The whole world can gossip about you, and if you don’t take it personally you are immune. Someone can intentionally send emotional poison, and if you don’t take it personally, you will not eat it. When you don’t take the emotional poison, it becomes even worse in the sender, but not in you… As you make a habit of not taking anything personally, you won’t need to place your trust in what others do or say. You will only need to trust yourself to make responsible choices. You are never responsible for the actions of others; you are only responsible for you. When you truly understand this, and refuse to take things personally, you can hardly be hurt by the careless comments or actions of others.

There you have it! The Idiot’s Guide to Dealing With Idiots!

So when jobs surface in her company, or if she hears of an opening in her field, she only shares the information with non-friends. It’s just too messy, she explained to me the other day.

Having experienced a situation not too long ago that became just that — messy — I can understand her logic and applaud her for sticking by that rule. I am now much more careful about sharing work opportunities with close friends… in order to protect myself.

Should the same rule apply to therapy?

I never thought so. I mean, my psychiatrist told me the other day that I am her third biggest source of referrals, after a local cardiologist and a gynecologist. I don’t hesitate to share the numbers of both my therapist and my psychiatrist because, frankly, there are so many bad ones in Annapolis that I would feel guilty putting my friends into their dangerous hands.

However, in the last month, I’ve heard from two people who regret sharing their therapist with a friend. The first is frustrated because she can no longer get into see her therapist. The head doctor is now too busy with all the referrals. My friend has lost her preferred hour, so she’s had to rearrange her schedule around the therapy visits of her friends.

Annoying.

The other woman started to have friendship issues with the woman whom she referred to her therapist. So when she would discuss the friendship frustrations in therapy, the therapist no longer was able to see the situation objectively. When the therapist “took the other woman’s side,” according to my friend, she ended up so hurt that she quit therapy. She recently explained this in an email:

When we are in therapy, all parts of our lives come up. When something between you and the person you referred happens, and it will, you are backed in a corner you can never escape. The best of friends have arguments or differences and usually work them out between themselves. However, when you put a third party into the mix, especially a therapist who is seeing both people, it is always going to be the elephant in the room and there is no way that cannot affect your therapist relationship.

I can see her point. I remember when my mom and I shared a therapist, and I was doing a lot of inner-child work, exploring the pain of some of childhood memories. In some ways, it was helpful for my therapist to know my mom in that she benefitted from a bit of context with which to assess the situation. However, there came a point when both of us were subconsciously fishing for information on the other. The therapist was placed in an awkward spot. My mom eventually moved on to another therapist, so the situation resolved itself. But it could have exploded into a bloody mess.

What do you think?
Should you share your therapist with a friend?
If you have already, what happened as a result?

One of these bad habits is especially frustrating to clients — a therapist’s constant yawns during session. People often read into a yawn far more than what is usually meant — or not meant — by the behavior.

Part of the problem is yawning itself — we don’t really know why people yawn in the first place. So a person often will assume the worst — “I’m boring him with what I’m talking about.”

But that’s often not the case.

The only thing we know for certain about why humans yawn is that there are a lot of theories. The most popular theory is that we yawn when we’re bored or tired. This theory suggests that when we’re bored or tired, we tend not to breathe as deeply as we do when we’re thinking or engaged with an activity or conversation. Therefore our brains are becoming oxygen-deprived. The theory is that the act of yawning increases oxygen in the blood, which in turn increases oxygen to the brain.

Another set of theories focuses on the impact of yawning behavior on our lungs. One idea is that yawning helps keeps our lungs lubricated with an oil-like substance called surfactant. Another lung-focused theory is that yawning stretches our lungs, which is like flexing a muscle. You don’t do it very often, but it feels good when you do.

One of the more popular theories is that there is some important social component to yawning. Guggisberg and colleagues (2011) noted, “The only specific effect of yawning that could be demonstrated so far is its contagiousness in humans, some non-human primates, and possibly dogs, whereas all studies investigating physiological consequences of yawns were unable to observe specific yawn-induced effects in the individual of any species.” In other words, none of the physiological reasons for yawning really pan out when looked at by researchers.

Yet other researchers suggest there is an evolutionary reason for yawning — one that is no longer serving its evolutionary purpose. Whatever that purpose may have been.

Yawns are, however, socially contagious, and we still don’t quite understand why that is.

If you come away from this entry scratching your head about the purpose and meaning of yawns, you’re not alone. As you can tell by this cursory look at the research, we are basically still in the dark about why they occur in the first place, what purpose they serve, and why they can be socially contagious.

Psychotherapy and Yawning

This suggests two things about yawning in psychotherapy. The first is that we shouldn’t be too hard on a therapist who has a yawning fit while in session. There’s no hard evidence yawning is directly related to boredom or our mind’s focus. We all have certainly observed a correlation there, but our self-observation is often unreliable.

Second, although we don’t know why people yawn or what purpose yawning serves, a therapist should always be at their professional best when seeing clients. That means coping well with stress, dealing with counter-transference and practice issues as they arise, and maintaining a healthy lifestyle. This latter point means eating right, getting some regular exercise and getting a regular 7 to 8 hours of sleep every night.

If a therapist is doing all of these things, and still gets an attack of “the yawns” while in session, give them a break the first few times it happens. But if it seems to happen every time you’re in session, consider changing appointment times. There are certain times throughout the day that a person can become more tired than usual, such as first thing in the morning, late afternoon (often after 4:00 pm), and right after lunch (early afternoon).

If that doesn’t seem to impact the amount they yawn, consider talking to the therapist directly about this behavior. While it may seem petty to some, or not really relevant to the reason a person is in therapy, it can negatively impact the therapeutic relationship in subtle (and not so subtle) ways. It’s best to bring it out into the open and talk about it.

Yawning is rarely something most of us have much control over. Keep that in mind before you read into your therapist’s yawns, and understand that he or she likely doesn’t find you boring — they just can’t help themselves sometimes.

Reference

Guggisberg AG, Mathis J, Schnider A, Hess CW. (2011). Why do we yawn? The importance of evidence for specific yawn-induced effects. Neurosci Biobehav Rev., 35, 1302-4.

The article essentially made the case that if fewer men go into counseling professions, then fewer men may want to attend because they feel more comfortable talking about certain topics with other men. Dr. Grohol wrote a fabulous piece on this blog yesterday making the counter-point that there is no research evidence to support that view. While I also understand this to be true, I still have some concerns about the trend.

For me, the most important thing is that unique concerns related to male psychology and the lives of men will be devalued. Each time I teach a class on the psychology of men, there is almost instantaneous push-back and reactivity. The arguments are generally that “all psychology is the psychology of men”, that most of the theorists in the textbooks are males, and that focusing uniquely on the psychological experience of male counseling clients (gender role issues, fragile nature of masculinity, power/sex dynamics, aggression, incorporating emotions into male identity, boyhood and socialization trauma, homophobia, etc) is not a credible topic and may even aid maintenance of a perceived patriarchal structure in the profession. I often make a statement up front that there is usually minimal compassion for the male experience, or interest in male psychology, and the level of agreement from the students is striking to me.

The ironic part is that in my training to be a psychologist, I became very skilled at working with female clients. Most of those accessing services were female, all of my supervisors and professors (with two exceptions) were female, and I got specialized coursework on the psychology of women. Not once was there even a 10 minute part of a lecture on the psychology of men. Sadly (but in hindsight not surprisingly), despite being male, when male clients came to my office, I felt lost amidst a complex picture of gender role expectations and pressures, internal conflicts, and distaste for the type of feeling based interventions that I was trained to do. In short, it was a mess, and later in my training I became compelled to be a voice for the importance of understanding male psychology.

Another important aspect of male therapists is in modeling alternate ways of being for both male and female clients. The experience of a client working with a male therapist who is healthy, attuned to his feelings, attentive, well-boundaried, and compassionate can be enriching by itself. I often hear my clients tell me that I am the only man they have ever met who is comfortable with emotions or who can communicate differences in non-aggressive way. For my female clients, the only man who they have had deep discussions and a connection with that doesn’t include a sexual motive. For adolescent males, I’m the one that models a healthy and mature way to be a man in contrast to what is seen on TV, or valued by an equally confused peer group or by a distant father. These things have intrinsic value above and beyond the content of the counseling sessions, and opportunities for these experiences are becoming more scarce.

Ultimately, the concern with these changes in the field is that the male psychological experience will be further devalued and ultimately obscured, and that this is what will cause fewer men to attend counseling sessions. There will also be fewer opportunities for people to develop healthy therapeutic relationships with men, and the unique benefits that come from them. Unfortunately there is no data on this stuff yet, but the writing is on the wall.

_{Will Meek, PhD is a licensed psychologist in the state of Washington where he provides counseling for adults, couples, and teens. He writes regularly on his blog: The Vancouver Counselor. He also writes about male psychology at Psychology of Men.}

What we are doing, I have discovered from years of theoretical research and clinical observation, is looking for someone who has the predominant character traits of the people who raised us. Our old brain, trapped in the eternal now and having only a dim awareness of the outside world, is trying to re-create the environment of childhood. And the reason the old brain is trying to resurrect the past is not a matter of habit or blind compulsion but of a compelling need to heal old childhood wounds.

Some of you undoubtedly are thinking: “Oh puh-leaze, move on from the naval-gazing-it’s-my-mommy’s-fault theory.”

I may have uttered similar opinions had I not fallen into this trap so many times in my adult life, even as a happily married woman. What I failed to recognize until recently is that a healthy marriage doesn’t protect you from attempts to fill in the deep hole left from the earlier years. If you don’t do it in your primary romantic relationship, you get the job done via friendships and family relationships. Try as you may to recover from your past and move on, but I agree with Hendrix that you will always subconsciously seek to heal those wounds by trying to recreate a similar situation and forcing it to be different.

The trick is disassociating the situation from the brain phenomenon.

It’s not about the person, place, or thing you are fixated on. It’s not about the friend who is emotionally unavailable. It’s not about the relative who will never remember your birthday. Or the co-worker who is smarter (or so he thinks) than you. It’s merely the low brain recognizing a possibility to have some fun, a potential sandbox to build the sandcastle of your youth so that this time it can stand forever.

There is relief, I think, in knowing that there are patterns of thought that are so intense and ingrained in us that we may not even be conscious of what’s going on until we reach an “ouch” point, at which point we say, “What in the world? Where did this come from?”

I liken it to being brought up eating fruit loops.

Let’s say your mom fed you fruit loops for breakfast every day from the time you were one. With skim milk. Just kidding. You really didn’t know anything different—that there was healthier stuff in the supermarket. Then, one day, your grandma comes to stay with you and makes you a bowl of Kashi whole grain cereal. It tastes awful. You take one bite and push it away.

“It’s good for you,” your grandmother says. “It will make you big and strong.”

“I don’t care,” you tell her. “I prefer to be small and fat and eat my fruit loops.”

It’s what you know. It’s comfortable. It’s familiar. Damn it. You just want your fruit loops.

But if you want a healthy relationship … in all forms (friendships, marriage, sibling bonds), you must train yourself to like the whole grain cereal. Even though your body genuinely craves the sugary, processed, colorful stuff, you must keep on eating the Kashi, trusting that one day you will crave the Kashi like you do the fruit loops.

Yesterday I was interviewed by a website on depression. One of the questions was this:

Sometimes people with depression feel so awful that they don’t want to do anything. Yet, when they get themselves to do something (take a walk, speak with a friend, etc.), they often feel better. Can you offer any suggestions as to how someone can take some positive actions when they are feeling really down?

I responded:

That’s really hard. I’ve been there, and I know how hard it is. I guess I know from patterns in my past that if I go through the motions, eventually one day I will realize I’m walking without thinking so hard about putting one leg in front of another. I guess you just have to trust that you won’t always feel miserable, but the steps to get there require your doing something that feels so counterintuitive. You have to steer right to go left, in other words. So if you can just say to yourself, “This feels like the worst possible thing I could do right now … but I’m going to try to do it anyway in the hopes that it will, one day, make me feel better.” You put a penny away every day in the hopes that one day you will be able to buy a small treasure with your coins.

It’s the same thing with your marriage or friendships or any relationship. In the beginning, and at times throughout the relationship, you have to steer right to go left. It’s not supposed to feel natural. Not to a person who grew up without the emotional nurturing that is supposed to take place during the early years. It feels foreign, scary, and just too stable!

“I don’t know how I managed to marry someone as grounded, compassionate, and wise as Eric,” I told my therapist the other day. “He certainly doesn’t fit the profile of anyone I dated before him. He is the only person with whom I’ve felt peace.”

“He is your angel,” she said.

He is my Kashi.

So I pursue the fruit loops in friendships that can’t sustain me, in less-than-healthy family relationships, in every possibility I have to cling as though my life depended on it to a person, place, or thing that is emotionally unavailable. And the more unavailable, the tighter I cling, so that subconsciously I can transform those days of abandonment to unconditional love, a kind of emotional nurturing that I so crave.

But the good news is that I’m catching myself sooner in the process than I used to, so it doesn’t hurt as bad when I finally realize what I’m doing. I’m investing less and less of myself into building the sandcastle of my youth because I know that it’s only a matter of time before the waves or the wind destroy it. I can’t heal it by revisiting it. Not by making a friendship into something that it can’t be. Or giving a relative a birthday calendar that he can hang on his wall. The only way healing happens is by doing the counterintuitive thing and eating the wholegrain cereal.

Because, grandma was right. It will make you big and strong.

Image by http://nutritiouslife12.wordpress.com

I have learned to slow myself down, detach myself from the process, and be absolutely truthful while remaining as unprovoked as possible. Otherwise it is an exhausting exercise.

One question did get me going, though. It revolved around whether or not a person can change and what causes a person in therapy to improve or not improve.

The conversation below is a dramatic re-enactment of real events…

Lawyer: Under what circumstances does a person in therapy not get well?

Me: Are you assuming the therapist is perfect? Because one reason a person does not improve may be the skills, knowledge and training limitations of the therapist.

Lawyer: Assume the therapist is perfect.

Me: So the lack of improvement is totally the responsibility of the patient?

Note to reader: This is rarely the case. Therapy by definition involves a minimum of two people who are human. In which case perfection is impossible. But we are in a court of law where reality seems always to be in question so…

Lawyer: Yes. Would level of intelligence be a reason?

Me: No. People with very high intelligence can be resistant to treatment, just as less intelligent people can.

Lawyer: Could the presence of a diagnosed mental illness or personality disorder be a reason?

Me: The presence of a mental illness diagnosis or personality disorder alone is not a reason for lack of improvement in therapy.

Lawyer: Then what would be a reason?

Me: There could be many reasons but underlying them is often anxiety. ‘What will happen to me if I change?’ Fear, basically.

At this point the lawyer switched to a completely different topic. My answers probably weren’t suitable to his argument so he gave up on me. Fine, but these questions kept echoing in my head.

Any therapist worth their salt will admit that they have had patients who seem to stay stuck for session after session. Maybe you have been in therapy and wondered if anything is really getting any better after making a big investment of time and money. What could be the reasons for lack of improvement?

Questions for Therapists About Lack of Progress in Therapy

Therapists learn about treatment resistance clients in the cradle of graduate school. Hitting a wall in therapy is not a reason to panic. In fact it could be an opportunity to step back and reassess. From the therapist’s point of view:

1. If someone is not showing improvement after a reasonable amount of time we may ask ourselves, are we the right therapist for this patient? Occasionally our patient would be better served with a specialist, sometimes in addition to, or in lieu of our own work. The patient may need supplementary professional help, for example a psychiatrist if medication might help.

2. Have we, with the patient, identified clear goals that give us a way of measuring improvement? Do we need to redefine or recalibrate our goals to be more achievable? We may decide to target specific behaviors, or identify mini-goals as appropriate steps toward the bigger one or stepping back or sideways to step ahead.

3. Are our interventions accessible to the patient? In other words, are we giving our patient tools within their reach? Tools they can use? Sometimes this takes thinking creatively, stepping out of the usual cookie-cutter solution.

4. Is it possible there is something about the patient we don’t like and therefore we are ineffective because we are holding ourselves back? This type of counter-transference can lead to therapist resistance if unchecked. It is an important part of our job to be aware of this and act accordingly.

5. Are we being patient enough? If most resistance to improvement comes from fear, what can we do to address the fear?

In my training, many years ago, I complained to my supervisor that I didn’t understand why a patient kept coming to see me week after week with no visible improvement. Being a great supervisor, she said to me, “Who makes you the judge? Your patient does not wish to fire you. She is getting something out of therapy. Be patient. Listen.”

Months later my patient revealed childhood sexual and physical abuse that she could not reveal until she was good and ready.

Why Patients Don’t Get Better

Usually the goal in therapy is some kind of change. To achieve this goal, both parties need to be truthful. What things may make a person in therapy afraid of revealing the truth and afraid of change?

1. Fear of judgment. If I could have a nickle for every time a patient prefaced a sentence with some variation of, “You will think this is awful…” I’d be on a beach in Maui right now. If you can identify with this, you may have held onto this awful thing for ages so it takes up an extraordinary amount of space in your brain and has probably bored a hole in your self-worth.

The therapist has a different perspective. He/she is trained to be non-judgmental. He/she has probably heard a ton of stuff much worse than whatever it is you think will horrify them. Even so, it is human to want others to think the best of us. It takes a lot of trust to tell the truth to your therapist. It takes faith to believe that the awful thing you are about to reveal will be treated with kindness. Yet to get unstuck that is precisely what is needed.

2. Fear of rejection. Underneath the fear of being judged is fear of rejection; a primal fear. That’s why shunning is such a devastating punishment. You may be wondering, ‘If I get better, will my family who is so used to my problems, still have a place for me? Will they still love me?’

3. Fear of assuming greater responsibility. Sometimes if we stay childlike we are rewarded by people taking care of us. It can be very uncomfortable to give up the sense of protection that staying dependent on others can give. The rewards of being an emotionally healthy well-integrated person are rich and complex, but not always obvious. It takes risk and belief in ourselves to take up the reins of adulthood.

4. Fear of success. What if you get better and you no longer have a reason to see your therapist? Fear that if you change too much your life may become unrecognizable could be a factor in being stuck in therapy. People can get used to failing. It can become their comfort zone. In that case, the lack of discomfort actually feels uncomfortable. Or, said another way, happiness just feels weird.

5. Fear of intimacy. Sharing our truth to another who respects it, “gets” it and reflects it back in kind, is the essence of intimacy. If we get close to people, if we reveal ourselves to another, we become vulnerable and that is scary.

Fundamentally we are talking about fear of pain and like every living being on the planet, we humans are hard-wired to resist pain by either running away from it or fighting it, tooth and nail. Why should therapy be any different?

We therapists need your feedback to work effectively for you. If you like your therapist and still feel stuck, try to get through the fear enough to bring up your feelings of stuck-ness so that you and your therapist can work on it together. You do not have to have the reasons for being stuck figured out. It is enough just to say, “I feel stuck. Could we please look at that?”

It takes a skilled, compassionate therapist and a motivated, brave patient to give the therapy process a chance.

What are some of the reasons you’ve found therapy seems not to be working? What have you or your therapist done to try and help move your psychotherapy forward?

Ms. Hyde is an attorney and comes to SAMHSA with more than 30 years experience in management and consulting for public healthcare and human services agencies. She has served as a state mental health director, state human services director, city housing and human services director, as well as CEO of a private non-profit managed behavioral healthcare firm. You can learn more about Ms. Hyde here.

Dr. John Grohol: So I wanted to understand a little bit better how the Voice Awards originated. What was the motivation behind coming up with this novel sort of way of recognizing both consumers and Hollywood contributions to mental health and substance abuse issues?

Pamela Hyde:  Well, let me start by just saying SAMHSA’s role in the federal government is to be the voice for people with mental health and substance abuse service needs and for people who might be at risk of those needs. So that means that part of our job is to try to educate the public and to try to provide information, provide materials, and just get the right information out.

So, as a part of that effort over the last many years, I think there’s been a variety of ways of trying to do that, and there’s no question that the entertainment industry has a profound impact on people’s understanding and perceptions of lots of things.

Dr. Grohol: Sure.

Pamela:  And in this case when there are misperceptions that are commonly held and are reinforced through media by having inaccurate or misunderstandings about people with behavioral health needs, that a problem. So I think that… Mark can obviously speak to this better than I, because he was here was here when it started, and I think partly it was his idea to start. But the concept of using that power of message to have a positive message about people with mental health and addictions is just an awesome way to try to get the public to understand and accept people better.

Dr. Grohol:Do you think it’s had a sort of reinforcing effect by having this awards ceremony take place that we’re now perhaps encouraging more story lines that explore mental health issues then maybe we would have seen 10‑15 years ago in TV or movies?

Pamela:  Well, I think it’s definitely possible and probable that we are impacting the positive way they’re doing that. When you get rewarded for something, and you see other people getting rewarded for something, even though this is an industry that gets awards a lot, I think this is kind of a unique one. And I think to the extent that people see that people are watching, and that people care about how people are being portrayed, and the fullness of their humanity and just the illness that may be taking them for a ride at the moment, then I think that is definitely reinforcing for story lines and others.

I think especially true right now, frankly, when there’s a lot of discussion about military families and their issues in dealing with things like PTSD and substance abuse and other things like that.

I think people are sensitive to it right now, and I think the industry is wanting to portray some of those issues. And I think they want to portray people in a positive way and help support our military families in their struggles as they return.

Dr. Grohol:Where did the idea for honoring the military come from for this year’s theme?

Pamela:  That’s a great question. Actually SAMHSA been going through a process where we’ve been identifying strategic initiatives, and we decided that military families was an important strategic initiative this year. We have eight of them, and that’s one of them. And part of the reason for that is that they have increased risk for substance abuse, for mental health issues, for prevention issues. Children of military families sometimes have harder times in school because of the separation of the parents or separation from parents.

There’s evidence that army wives, for example, just a study done on that group, had a more difficult time with depression and some other issues like that.

So, there are unique things about being in the military, whether it is separations, or whether it is moving a lot, or whether it is just the pressure on people, or literally being in combat. Those things have special behavioral health needs, and that are being recognized.

I think we’re also seeing a growth in things like suicide among active military individuals. We’re seeing huge numbers of homeless individuals who are veterans.

And I think all of those things right now, the whole United States ‑ the public, Congress, the president, everybody ‑ is just saying, “This is just not OK when we have so many people out there fighting or being on call for our country. They need to be treated in a way that is appropriate.”

The other reason, frankly, is just there’s so many of them. We’ve been in war for a lot longer than we ever have. We have National Guard people who’ve been going, being deployed in numbers that they never have. We have reservists and veterans in huge numbers.

You put all that together, and we’ve got tens of millions of Americans who have served or serving, and we just need to recognize their needs. And then you add all that to their families, the numbers of their families, and there are a lot of people. So that’s a special interest of ours at this point.

Dr. Grohol:Besides proper funding, what do you see as some of the biggest challenges facing mental healthcare in America today?

Pamela:  Well, I think there are several things. One is I think the attitudes that people have and the misperceptions that people have. We have some sayings or some messages that we really try to get across, one of which is that “behavioral health is part of health,” so trying to get people to understand that you’re mental health and your emotional health is just as important as your physical health. So that’s one issue. There’s more and more mental health and behavioral health and addiction treatment that’s going on in primary care settings as well.

The second message we have is that “prevention works.” The science is clearer, but I think people are not quite as aware of that. They know a little bit more about what it takes to prevent diabetes and to prevent heart disease and things like that. They don’t know so much about what does it take to prevent mental illness or prevent an addiction. So getting that word out is really important, because that’s a barrier.

Another of our messages is that “treatment works.” There’s a number of folks who don’t understand that either. Or people, because of the discrimination or the social exclusion of people with addiction and mental health issues, are afraid to come forward and say, “I need help.” So it’s really important for us to help people understand that if they go seek help, it really works.

And then the final one is that “people recover.” And that’s also a barrier is when people see or the public see people with mental health issues or addictions as just somebody who really can’t really be helped, or “Isn’t it sad?” or they see just the illness and not the whole person and not the person who can be and is in recovery, and the strength that it takes to get there. That’s a barrier.

So, all of those messages for us are really to try to overcome some of those messages and help people understand how important it is.

Dr. Grohol: Do you think there’s anything more specific to helping soldiers returning from war and soldiers in the military to seek out treatment because stigma being such a large issue and the negative reinforcement that they get from fear of it hurting their advancements within their career in the military?

Pamela:  I think there has been some of that, and I’m sure it still exists, but that kind of concern exists in the civilian population, too — not wanting to step forward for those reasons.

Dr. Grohol: Sure.

Pamela:  I have to say the Department of Defense, the Secretary of the Army, a lot of the military leaders right now. The head of the Joint Chiefs of Staff, they’re all coming out publicly in the press and other ways and saying, “You know, it takes a real warrior to come forward, a real strong and courageous person to come forward and say, ‘I need some help.’” So, they’re working really hard at getting it more possible and easier for people in the military to seek help and making it clear that that’s not going to impact your career in the military. I think there’s still a lot of concern that it might.

So part of what we’re also working on with the National Guard, the Veteran’s Administration, and others is to make sure the civilian service delivery system understands military culture and military constraints and concerns. So that when people don’t want to go to the military‑provided healthcare, they can go to the civilian healthcare and get some help, either them or their family members.

Dr. Grohol: How closely does SAMHSA work with other government agencies that are also involved in mental health, like the NIMH, and how do you see the roles being different or differentiated?

Pamela:  We work extremely well and a lot with other federal agencies. We’re very clear that we can’t do it all. We’re the federal voice on behavioral health and substance abuse, and that is our role. But we’re a pretty small agency, relatively speaking, so we’re very active with CMS and the Medicaid program, because it provides a lot of funding for people who are low income and need the services that we are concerned about.

We’re doing a lot of work with CDC on prevention efforts in mental health and substance abuse and suicide and other kinds of issues. We’re doing a significant amount of work with military organizations I already told you about.

Tom Insel and I from NIMH just had a meeting not too long ago. We’re really talking about ways that we can collaborate on things. They clearly have the agenda and the responsibility for research, and we have the responsibility for service delivery and practice improvements.

And so we’re working to think about how we can be a better partner in disseminating what they may learn, and how we can also identify things that need to be researched ‑ So a lot of good conversations going on.

We also work really closely with the administration of children and families around emotional health development and early intervention and then some of the trauma and issues that happen for kids who are taken out of the home for various and sundry reasons.

We work a lot with the Department of Justice around things like drug courts, juvenile justice issues, and all the behavioral health issues associated with that ‑ really high numbers of kids in those systems who have substance abuse and mental health issues. So I could go on.

We just have tons of federal partners. And we consider that a major part of our responsibility is to be in other systems and in other agencies working with them to support their efforts.

Dr. Grohol:One last question: What do you see as the most important or exciting advancement in mental health in the past decade ‑ mental health treatment or care?

Pamela:  Well, two come to mind — I don’t know why, but they do. One of which is really more than 10 years, and that is really the consumer movement. I mean that is …and it’s not just the people in recovery. It’s not just in the last 10 years, but people being able to raise their voices and say, “Hey, I’m a human being, and I have family. I have pets. I like to work on the computer. I like to garden. I’m just a human being. And I have an illness, or I have a condition that is not unlike other health conditions.

So that consumer movement and that voice and advocacy is really important. People in recovery from substance abuse, their voices are just incredibly, incredibly important.

And the more that people come forward ‑ you probably know this about any group that’s sort of excluded from the norm ‑ the more you get to know them, the more you know somebody like that, the more it’s going to be an acceptable thing to do.

The other one that comes to mind, and I’m not even sure this is the last 10 years either, but this idea of what we call SBIRT, so it’s “Screening, Brief Intervention, Referral to Treatment Approach.” It started out…the evidence is really mostly around alcohol.

But the idea is to try to do that before people get all the way to addiction. The idea is to identify people who are problem drinkers, for example. And help them understand they’re problem drinkers, because a lot of times they don’t realize they’re drinking too much, and being able to do brief interventions that are proven that can actually to prevent a person moving all the way into alcoholism.

There are some similar but not completely full‑blown yet issues for screening and brief interventions around depression and things of that nature. There’s a lot of work going on around adolescent substance abuse and screening for alcohol abuse.

So, there’s a lot of work going in the institutes, not just NIMH, but also NIDA, and NIAAA, around those issues. I think those are pretty amazing things that are evolving, and I hope we can put into practice. And there’s a lot of work that still needs to happen about that. So those are a couple.

The other one that comes to my mind is what we understand about emotional health development and the prevention of mental health and substance abuse issues. So the IOM put out a report in 2009, which just… it’s just opened all kinds of doors around understanding that you can in fact prevent a lot of these things.

50 percent of adult mental health issues start before the age of 14. And about three‑quarters of them start before the age of 25. That tells you you’ve got to do something very early with the kids in building the emotional health and then giving them the skills to get past some of those issues they may face as they go into adolescence and beyond. So those are three big ones that come to my mind.

Dr. Grohol: Thank you very much for your time today, Administrator Hyde.

Pamela:  My pleasure. Thank you.

Visit the SAMHSA website to learn more about the agency.

Me? I would like one of those.

So I made one. In book form.

You see, I am an obsessive-compulsive woman who has recorded, in her journals, 12 years of therapy sessions, 21 years of twelve-step support-group jargon, nice get-a-hold-of-yourself tips from hospital inpatient psych programs, and oodles of insights from her wise friends and mentors. I then asked readers on a few different websites — The Huffington Post, Beliefnet.com, and Psych Central — to tell me the most significant lesson or mental health tool that they learned in therapy. I plucked the gems and added those to my pile of darlings. Then I stared at them. I dreamed about them. I obsessed about them. And ultimately I organized them into a handsome, compact volume of pointers that I could carry around without drawing too much attention to myself.

Of course there was also the hope of getting a little return on my mental-health investment of $40,000. Therapy is not free, you know. And those hospital inpatient psych programs really empty your wallet.

But aside from being able to pay for more therapy, my sincere intention with The Pocket Therapist is merely to pass along what I’ve learned in my sessions. Because, who knows, some of the cognitive exercises and calming techniques, could help you too. At the very least, after reviewing a few of my therapy breakthroughs, you will know that your distorted thoughts are hardly unique and that you have a friendly companion on the sometimes frustrating and tiring road to wellness.

Dana Scarton over at The Washington Post has the insightful article addressing this issue by talking to a number of therapists across the country. These therapists have had to deal with their own challenges with social networking sites and “researching” people online once it was brought into psychotherapy by a client or a client’s actions.

Professional associations haven’t addressed this kind of technology in their ethical guidelines, but common sense rules the day. As I just gave a presentation to therapists on this very topic, here’s the upshot of what I had to say about this from a professional’s point of view …

• Feel free to be on social network like Facebook or Twitter. But do not “friend” your clients and do not allow your clients to “friend” you. Become intimately familiar with the privacy controls on these networks and ensure that the general public cannot see personal details of your life you would prefer to share only with your immediate friends and family.
• Develop a social media policy. Years ago, I was recommending that therapists develop and share with their patients an email policy. But now you need a more inclusive policy that covers social networking, emails, and even doctor rating sites. Dr. Keely Kolmes has an excellent one here. Share it with your patients and ensure they understand its highlights in session.
• Anything that is publicly available online is food for thought. While I don’t encourage therapists to investigate and research their clients, if a client has a public blog or journal, the client should be aware that their therapist may be reading it. If a client wants the therapist to read it, I think that’s fine, but clients should know that therapists generally don’t have so much spare time that they spend all of it looking for and reading patients’ blogs, tweets or what-not.
• Setting and maintaining clear boundaries is always the hallmark of a professional therapeutic relationship. Let such boundaries always guide your decision making with any new online tool or technology.
• Share your decisions with your patients up-front. Nothing causes more trouble that having to make up policy after something unintentional has happened. Setting clear policy, sharing that policy, and ensuring your patients understand your policies is always the way to go. Even if you don’t use or intend to use any of these tools, you should nonetheless have a social media policy that states as much.

And here’s why you need to do it sooner rather than later, especially if you work with younger, more technologically-engaged clients:

[Psychologist Stephanie] Smith also has a Facebook account for her personal life. After teenage patients discovered that account and sent her “friend” requests, Smith enacted a policy forbidding past or current clients from engaging her online. She informs new clients of the policy and obligates them to comply.

This is the type of problem that UMass’s Benjamin wants to avoid. “To me, it’s a much bigger issue than bumping into a patient in a restaurant,” he says. “You’re putting out there, ‘Hey, these are my contacts.’ And someone then wants to enter your social circle. It puts you in a position where you must take a stand.”

Here’s the reason I have no problem with therapists being on Facebook or what-not, as long as they understand and set their privacy settings appropriately. Therapists are human beings too, and we’ve long since come from the psychoanalysis days of psychotherapy when therapists were supposed to be these blank slates that had no personal life, no personality, and could share zero details of their lives. While it’s not appropriate for therapists to go to the other extreme, it’s a therapist’s humanity that makes the therapeutic relationship work. (If we didn’t need human therapists, a computer could well be programmed to do all the work of a therapist.)

The key is that when clients and therapists interact online, it’s done in a manner that doesn’t create new boundary issues or problems with the therapeutic relationship itself. This is done by therapists understanding the options they have available to them, thinking about them mindfully and with some deliberation about the choices they are making, drawing up a social media policy, and then ensuring their clients read and understand the policy in the next session.

Read the full article: Google and Facebook raise new issues for therapists and their clients.

If psychology wants to remain a science based upon the understanding of human behavior — both normal and abnormal — and helping those with the “abnormal” components, it would do well to avoid going down the road of prescription privileges. But perhaps it’s already too late.

We first noted this disturbing trend in 2006, how they were shot down 9 out of 9 times trying to gain prescription privileges in 2007, and why prescription privileges for psychologists will eventually drive psychiatrists out of a job. We also noted that one of the programs setup to help psychologists get prescription training wasn’t a “college” at all.

The fundamental problem with psychologists gaining prescription privileges is the inevitable decline over time in the use of psychotherapy by those same psychologists. This is precisely what happened to psychiatry — they went from the psychotherapy providers of choice, to the medication prescribers of choice. Now it’s hard to find a psychiatrist that even offers psychotherapy.

Psychologists claim that they are somehow “different,” and that their training makes it less likely they would simply go to an all-prescription practice over time. But those claims ring hollow to me.

By switching to a heavily prescription-based practice, a psychologist will be able to nearly double their salary. Can you imagine any other field where you can double your salary with an additional 2 years’ worth of training? Are proponents actually suggesting that money has little or no significant impact in helping a person make career decisions? (We only have a few decades’ worth of research to demonstrate how money does indeed influence our decision-making process.)

My good colleague Dr. Carlat has the first salvo — in anticipation of his upcoming book (which is a must-read when it’s published in May) — on his blog, Psychologists Prescribing: The Best Thing That Can Happen to Psychiatry. His argument in a nutshell:

[P]sychiatrists are not [yet] losing business [in the 3 states where psychologists can prescribe]. But as more and more states approve prescribing psychologists, this will probably change. I predict that patients will vote with their feet and preferentially see prescribing psychologists once they realize that such practitioners provide one-stop shopping—meds and therapy combined.

And herein lies the great opportunity for psychiatry. As psychologists gradually become serious competitors for our patients, we will have to re-evaluate how we practice and how we are trained. We will have to take a close look at our catastrophically inefficient medical school-based curriculum. We will have to decide which medical courses are truly necessary and which are not.

So what evidence does Dr. Carlat have that psychologists will continue to offer both psychotherapy and medications? Sure, the initial psychologists will stick close to home — psychotherapy — and use medications as a sometimes-adjunct to help therapy get its kickstart. That makes sense, as they’re likely to be a little older and well-established in the field.

But as more and more psychologists gain prescribing privileges, what’s to stop the profession from following in psychiatry’s footsteps? Why wouldn’t a large group of clinical psychologists — perhaps even a majority in a few decades’ time — just turn to the same “dark side” psychiatrists have turned to … What’s to stop them from going to the 3 or 4 medication check-in appointments per hour that most psychiatrists do?

I suspect proponents of psychologist prescription privileges believe that because of psychologists’ fundamental, significant training in psychological methods and behaviors, this makes them less likely to be influenced by pharma’s siren call. But without specific data one way or another, I’d defer to the evidence that we already have:

• Psychiatry went from primarily doing psychotherapy to primarily prescribing medications in the course of a few decades.
• A significant body of research demonstrates the influence of money on human decision-making
• Psychologists have not demonstrated why or how they would forgo the influence of money and follow psychiatry into the same pharma-focused model of treatment (psychotherapy is hard; medication is easier and people prefer ‘easy’)

For these reasons, psychologists shouldn’t prescribe — it’s likely to dilute psychology’s focus and function. They should remain the primary psychotherapy experts that their four years of didactic training — mixed in with direct clinical experience during most of that time plus the additional year of internship — have provided. To gain prescription privileges is to open the door to losing that expert position in the future.