Wednesday, October 6, 2010

The Dilemmas of Therapy



I’ve been seeing a psychologist for the last few months. This is a kind of miracle – I stopped seeing my last therapist in 2003 – but it’s more low-key than it sounds. Anyway, something that happened last week made me think of the differences between different kinds of mental health professionals, and the way these differences have played out in terms of my own experiences and the various life stages at which I’ve seen therapists.

My therapist is a registered, or counselling, psychologist. This means she’s a full member of the Australian Psychological Society and is entitled to practise as a psychologist, but she doesn’t have a Masters degree in psychology or, I assume, the extent of supervised clinical experience with the mentally ill that a Masters would entail. This is the first time I’ve seen any kind of psychologist for any length of time. Previously, in my early to late thirties, I saw two psychiatrists consecutively over a period of about nine years.

She’s good at what she does, and has a talent for ‘reading’ people, which I think makes up for her presumed relative lack of clinical experience. But I sometimes feel as if I know the ‘rules’ of therapy better than she does; and the arrangement as a whole, with her modus operandi as part of it, is very different from the therapeutic relationships I’ve had in the past.

For example, my psychologist is never on time, and she never apologises for being late. Sometimes the lateness is a piddling few minutes but it’s usually more. Once she was almost fifteen minutes late and appeared at the door of the dollhouse-sized waiting room with nary a ‘sorry’.

As someone chronically deprived of my mother’s attention, this presses all my buttons. What’s most fascinating about it is not that as a patient my reactions to such a situation might be overblown – that would be expected. It’s that these reactions aren’t – can’t be – a key part of the therapeutic relationship. They can’t be examined and their underlying dynamics unearthed.

Such a situation simply wouldn’t have occurred with my previous therapists – for one, if a rare example of extreme lateness had occurred they would have apologised; for another, they would probably have raised for discussion in the consulting room the feelings that such an episode would have aroused in me.

Inevitably the therapeutic relationship, as it applies to my psychologist and me, does have some degree of the type of parent–child dynamic that occurred with the two psychiatrists – I feel needy before I see her, relieved when I can sit opposite in the tiny, untidy room and pour out my fears and triumphs. But this dynamic is underlying rather than dominant, and it’s not being used as part of the therapeutic process.

This is not just because of her perceived lack of qualifications, of course. It’s also partly due to the fact that I don’t, consciously at least, want to put her in that position – how many parent figures can you have throughout your life (an infinite number, it seems, as I still treat people in authority as parent figures); partly that my therapist is either about my age or slightly younger (it’s hard to tell – she’s very good looking, and probably botoxes); partly due to my lowered expectations as a result of my excessive aloneness in the last few years; and partly because of the way the Medicare (national insurance scheme) operates – the rebate is limited for psychological help compared with psychiatry, a maximum of 12 visits a year or 18 if the GP approves, so the sessions are widely spaced (once every two or three weeks) and they’re very practically oriented.

My psychologist and I mainly talk about strategies, tactics and techniques in relation to examples I bring up of problematic episodes that have already occurred or potential scenarios I’d like to venture into. We’ve looked at the past, but mainly in terms of how it affects my perceptions of others and of relationships today.

My therapist was chosen for me by my GP and I listened to my gut feeling in deciding to see her, and then to stick with her. I had to rely on my gut feeling because I was desperate to see someone at the time, and I knew that if I checked on her credentials before my first appointment and she wasn’t sufficiently qualified my head would say all sorts of judgmental things about her.

And my gut feeling was on the money. The fact that she wasn’t a clinical psychologist initially quietly horrified me (‘But I’m sick! I have about five different mental illnesses all blended together in an indivisible whole – how can she possibly help me?’). She does, however, have a human resources background, which was perfect for the issues I was grappling with at the time. She continues to be great at putting my many work issues into perspective.

So the current situation has both advantages and disadvantages. Because of her not being a clinical psychologist, as well as all the other reasons outlined above, I still feel as if I’m essentially on my own.

In some ways this is good for someone like me, who was never parented properly and has spent their lives searching for the perfect parent. In the past I relied on my psyches to be excessively parental, and while I was seeing them, I didn’t ever really take full responsibility for seeking sustainable adult relationships.

This had serious and long-term implications for my emotional development. Neither of my previous psyches fully realised the extent to which I needed to be ordered around when it came to relationships. There was one crucial point in my life when I needed to be told very firmly to have sex with the first realistic contender that came my way, to be set sexual ‘homework’ if you like. But the extent of that need simply wasn’t evident to my therapist at the time, and I didn’t have the maturity or self-awareness to articulate it.

Realising the limitations of my psychologist’s skills (and she is skilled in many ways) puts the responsibility onto me for my own recovery. And I’m hardly a rank beginner. I have a friend with OCD who has been practising exposure for so many years now he’s virtually an expert, and we have regular debriefings about it. I’ve also done plenty of my own reading as well as attended a social phobia group that included CBT and exposure.

Yes, my social phobia is complex and difficult, as it’s combined with a compulsion to display my symptoms to particular people and an underlying terror of making meaningful connections with others. My therapist works with me on exposure, but because of the nature of my problem, I have to tailor the program in conjunction with her. It would be wonderful if my therapist could tailor a program exactly to suit me. But exposure is exposure. I know enough now to tailor my own program with her help – she is my back-up.

And I have another weapon in my armory, a weapon that only I can wield – meditation. I finally have the self-love to use it regularly, and it’s beginning to show subtle but noticeable results.

Those are the advantages of not being able to completely turn my therapist into a parent figure. There is also a major disadvantage.

Because I can’t go through the ‘transference’ (when the patient falls in love with the therapist as an all-powerful parent figure) it means that I don’t feel emotionally ‘held’ during the session. And this means that the scary feelings that come up for me whenever I am in close contact with a person for any period of time can’t be taken out and looked at honestly.

Oh, I suppose they could if I insisted, but it would all be terribly awkward. I like my psyche and she says amazing things at just the right time, but she’s not really ‘mine’ – and to talk about some of the feelings that come up for me in relation to her (as opposed to the outside world – I can talk about that, no problem) would be more than my fragile self-image could cope with.

I think I’m a bit frightened that if I reveal those feelings, she won’t be on my side any more. And that inability feeds on itself – if I can’t articulate those feelings then I may start to display them through my panic symptoms in the consulting room, and that would be extremely embarassing. And my fear is that I’d then be on my own again, just as I was before I started seeing her. This is not a positive therapeutic situation!

My current way of dealing with this problem is to see the sessions themselves as part of my exposure therapy. It’s difficult for me to sit in the same room with just one other person for an hour. The session becomes part of my (self-administered) treatment, with the psychologist as unknowing resource.

Of course, this may not work indefinitely. My symptoms are already clamouring for attention in the consulting room and there may come a time when I can no longer manage them adequately without acknowledging them. I guess that will be a time of reckoning: the time either to seek another therapist or to attempt to turn the therapeutic relationship into something more challenging for both of us.

6 comments:

  1. Hello Catherine,

    I wish you progress with your therapy.

    Although I'll never stop hoping for some sort of rewarding parent/child relationship with my parents, and some sort of admittance from them that they contributed to my stuffed-up mental condition, I've done a lot of inner work (alone and unspoken) towards forgiving them. I do believe that they probably did the best that they knew how at the time, or at least, the best that they were capable of. They might have known there were better ways to parent, but may well not have been personally capable of implementing such methods. I don't know, and never will. I beat myself up less about it now than I have in the past, and I have benefited. I do believe that my soul chose my body to live in, and therefore my family situation is teaching me lessons that I need to learn. I don't fit into my family, but since I have begun a journey of spiritual development, people have begun to appear in my life with whom I do fit. But that's just part of my story - I hope you don't mind my contribution.

    Kind regards,
    Gaye

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  2. Hi Gaye,

    I always value your contributions - it's great to hear another perspective on the issue of parents and families!

    I believe pretty much the same thing about choosing my family. I don't understand the concept of karma, particularly when it comes to animal suffering, but I've felt its workings so strongly in my life that I can't help but think it's the most likely scenario.

    I'm also struggling at the moment with letting go of my family, and realising on a deeper level that they can't give me the support I need. I'm starting to reach out a bit to the wider world - it's such a slow process for me because it's so damn scary, but there's no alternative!

    Cheers

    Catherine

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  3. Hello again Catherine,

    you're right, there is no alternative for people like you and people like me - we have to reach out to the world out there, and it's scary. Obviously it's scarier for you than me, as you are unfortunately suffering more and in different ways than I am. But it's also obvious that you have the courage and desire to take small steps towards learning how to relate to the world we live in - you should be proud of your desire and achievements.

    I've found that since I started on the path to recovery, I'm gradually becoming acquainted with the true me that has been hiding and compromising for all of 50 years because of social conditioning and fear from within. I have been so wounded that I didn't think there was any hope of getting past the wounds, but I have found the inner strength to try, and I'm amazed at the progress I've made. I still shrivel up in a corner, and I still fall flat on my face, and I still shiver in my boots with fear, but I have the confidence to get up again now, to get out of that corner.

    No one in my family understands me, or shows any inclination to wish to understand me. It's hard, and still overwhelms me at times, but now that I've learned to be true to myself and accept the person that I am, I'm finding that like-minded people are attracted to me - we are just finding each other out of the blue - totally unexpectedly. They are only very few, and we are only passing on our journeys and may not meet again, but we are giving something positive and rewarding to each other as we meet and share along the way. I have to be aware enough to recognise these people, and I have to be brave enough to take advantage of opportunities. These chance meetings with like-minded people are enriching my life and I know I am enriching theirs, and then in turn I am sharing this richness with others in my life. They will be sharing the richness with others in their lives, and so the ripple effect widens. We are all connected.

    Cheers,
    Gaye

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  4. Hi Gaye,

    thanks for sharing your experience on this. I think that once you're committed to growing in the way you describe, even the setbacks become part of the process (and progress!) but it's hard to see at the time - one of the hardest things for me to do is to 'mother' myself after a perceived 'stuff-up'!

    I heard someone say about recovery from anxiety that it's about attitude - and I try to think about that when I have to do something really 'scary' - if I'm positive about it, then others will be more accepting of me.

    Like you I feel as if in some ways I'm coming into the world for the first time. Although I was in some ways more 'out there' at earlier times in my life, I was always hiding myself from others, and hiding my feelings from myself. Sometimes I feel very raw, but you've reminded me how important it is to stay open and positive, despite the feelings of unworthiness that resurface!

    Cheers
    Catherine

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  5. Meditation! Great, great stuff, I agree.

    I don't have a 'parent' feeling for my tdoc at all. I do feel some distance, but after two years, we've worked to establish a lot of trust. I feel like I can demonstrate any symptom, and it will be accepted. I hope you can work through all this rough stuff in the front. Good for you to get back into the therapy, even though it is always difficult, even after all this time. Good stuff, though, I'd be even more nutso without it, if here at all.
    Adventures in Anxiety Land

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  6. Hi Blue Morpho,

    Thanks for commenting. You've made me think that it might be better to bring this stuff up in the session anyway, not just to diffuse tension but as part of the therapy. Perhaps it could be a way of developing more trust with my therapist - testing the waters a bit.

    You're right about the difference therapy can make - it's been a long and difficult winter, and sometimes just knowing that a session was coming up kept me hanging in there!

    Cheers
    Catherine

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