Your Letters

I've told people who email me and ask for help with personal issues that I can't do this online. There are many reasons, but the most important reason is that. . .

I'm petrified that I'll make a mistake.

We're close, there's no question, and bloggers and blog-readers are a community and a close one at that, loving even. But there's no way to do a real evaluation from a letter, even from a blog (although they're revealing, no question!)

But here's the deal.

When a person contracts for therapy we sit down in a room, eyeball to eyeball, depending upon the capacity for eye contact, and I listen for about 45 minutes or an hour, depending upon what we've agreed upon from the start. Then I listen for another 45 minutes to an hour on another day, giving both of us time to think, and then maybe yet another 45 minutes, and then another.

So it's a lot of active listening, basically, all the while watching your body, your face, your dress, and all that listening and watching shapes a comprehensive extended socio-family-medical-sexual history.

Then we probably will add other people in the flesh to the mix, other important players in the system. The first person to have made contact is considered the "identified patient" in the system, usually.

Eventually, sometimes sooner than later, I'll make several psychological assessments, perhaps with the help of another clinician or medical doctor's input, also systemic, and add a few numbers maybe to a person's medical history via this lugubrious process we call diagnosis.

It takes more than a DSM IV, not to make a big deal about it. But assessment is half the battle..

And then there are HIPPA (government privacy) laws to contend with, confidentiality and privacy are critical, so how do we address that on the blogosphere. Even if someone broke into my building, picked the double locks on my doors, somehow cracked the ones on the cold steel filing cabinets, nobody could read my handwriting. But you can all read my Ariel, or whatever font this turns into when it's published.

This is my long way of telling you that using this space, this blog, to advise people about their personal problems just can't happen. You wouldn't want it, really; it's not what you want, a half-baked consultation.

I'll support you, even try to give you chizuk* (strength) but will surely recommend that you get real therapy when you write to me. Everyone needs it, if only to deal with somebody else. We humans are impossible.

But I'm thinking it is possible to answer generic questions here. It's risky because context is missing. So much context is missing when you ask me questions by email. And if you provided it, if you wrote me pages upon pages of detail to fill in the context, would I read it? Would I listen? Would you keep on working after work?

Probably not.

I'm sorry. Don't hate me.

But lets give a few questions a whirl. We'll do it right now. See how it goes. You add the context, color the meanings in your comments, and I can spin them back. An intellectual exercise, for teaching purposes, not therapy.

We'll consider two of them here, then in the post below this, you'll have a little more to chew on. I guess I can't let go of that topic of shame. Not just yet.

But let's start with an easy one.

Recently a reader asked:
How do you handle it when you have to cancel an appointment?
I say that I'm sorry, but I have a conflict and have to reschedule. Rarely do I specify what that conflict is, unless there might be some lesson in that, some therapeutic import. An example might be My family (parents/kid) needs me. Family is important, you know, sometimes more important than anything else, even work.

If I haven't given the patient 24 hours notice, then the next visit is discounted somehow. We figure this out. And sure, we talk about it if necessary. For about three minutes.

When a patient cancels on me, I don't want to hear more than that they were sick or had to go to a funeral or someone else was sick, and when can we reschedule? Unless it's face to face, during a visit. That's your time.

That was easy. Let's kick it up. A commonly asked question:
What should I look for when I shop for a therapist?
This is tricky and the answer depends upon what you need, obviously. But if I personally were looking for a therapist I would ask:
Will you be consulting with my primary care doctor?
I want a Yes. Or if the identified patient is a child,
Will you be talking to my kid's teacher?
Or, also, and
Do you also treat other members of the family? Do you think you'll want to do any family therapy?

How do you deal with my confidentiality if you do?

Did you get some family systems training in graduate school?
There's more to look for in a therapist than that, but those are some of the issues that surely matter. They're an indication of how a therapist thinks (and you're asking me).

Other therapists might say that warmth, humor, compassion, and the capacity for a therapeutic relationship exceed all. And they may be right.

But I'd look for someone who thinks big, too, who uses my world, not just his or her brain.


*Chizuk, chee, hard "ch" rhymes with "me"-zook, rhymes with book; this word chizuk means strength


Unknown said…
Thank you for your description of doing an initial evaluation. It is indeed a complex process that includes things we can describe to the patient and things that we may not be able to describe, the feelings and intangible impressions about the person and their world. And it can change over time as the doctor learns more about the patient and their world.
porcini66 said…
I can't say that I blame you! Holy COW! Answering questions on the net would only open you up to sooo much more than you likely want to deal with.

And, ah, last time I checked, blogs were as much for the writer as for the reader. I feel very grateful that folks take time out of their lives to blog. It gives me perspectives, it gives me insight, sometimes it even gives me wisdom. But do I EXPECT them to write so that I may have those things. Nope, not at all. I take what you and others offer me gratefully and with respect. I can see the temptation to ask you things - I have wanted to more than once - but deserve to have this space, in my opinion.

Thank you for writing.
therapydoc said…
I feel like this. Everyone, seriously, it's okay to ask questions. (not so clear, was I?) Maybe what you're interested in will grab me and it might be something I've wanted to write about for a long time.

It's the pressure I can't take.

Syd said…
I would think that offering any kind of therapy on line would be potentially dangerous. With my sponsees in Al-Anon, I keep my boundaries clear about therapy: That I am not one and that being a sponsor is about being a guide to the steps, nothing else.
Anonymous said…
you should tell the people -print out what article you would like help on and take it to your therpist and say I want help/to work on etc this topic/problem issue in article -my brother/sister does/doesnt this...
Leora said…
What should I look for when I shop for a therapist?
Just want to add:
A therapist can have a wallful of all the "correct" degrees and training and still not be right for you.

I was seeing one psychiatrist for a while, and every time I came home, my husband told me I was in a bad mood. Eventually, I switched. It could be partly she was trying to do my therapist's job, and she wasn't a very good therapist. So she gave advice that got me angry and depressed. With the two therapists (one a psychologist, the other an MSW) that I've had long-term I really connect well.
therapydoc said…
Right Leora. I always tell people to keep shopping til they get it right. They'll know. Thanks for the reminder.

And Syd, great parallel.

Tiger, so right, things change. Just when you think you know what's going on. . .

And Anon, Great idea!
Anonymous said…
We are what we repeatedly do. Excellence, then, is not an act but a habit.
Excellent post, excellent points. As you say, context is everything. A thorough assessment is key.
April_optimist said…
Well of course you can't do therapy over the internet! I can't imagine interacting with someone in an important way, especially if I don't know them personally, unless it's face to face. There's just too much that goes unsaid in the words and voice and so much information in the body language. And when you're dealing with vulnerable people....well of course you feel a responsibility to not risk doing harm.
Rebecca said…

In April,

Come he will,

In May,

Sing all day,

In June,

Change his tune,

In July,

Prepare to fly,

In August,

Go he must!
~by maple story accounts
Anonymous said…
how do i know i have the wrong therapist?

i'm totally trusting
therapydoc said…
Anon, one way is to discuss your doubts with your therapist.

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