A few years back, I used to recommend that just about everyone get a therapist so they'd know you at baseline. Now, in light of the BetterHelpificaiton of the industry, I wonder if it's doing more harm than good on the whole.
My prior approach - telling everyone to have a therapist - was largely driven by my experience in Florida, where it appears involuntary psychiatric exams and commitments are performed at a rate FAR exceeding other states. https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900477 (Caveat: this may be due to Florida's superior record keeping, but the numbers are so high vis a vis every other state that I tend to doubt that explanation.)
The high rate of Baker Acts (or 5150s, sectioning, whatever it's called where you are) in Florida creates an environment in which people are afraid to talk to their own doctors or mental health professionals about depression and suicidal ideation. It's a real problem, especially among the student population.
I figured that if you could develop a long-term relationship with a therapist, you'd be more inclined to discuss potential suicide and self-harm topics without fear of being improperly Baker Acted. I no longer believe that, and I wonder if the proliferation of online therapists (and others who behave more like affirmation coaches) has actually increased the rates of involuntary psych holds. I don't like considering that we're disincentivizing people from reaching out for help.
That actually might be an interesting topic - navigating therapy and mental health treatment while harboring fear of being involuntarily held. Thanks as always for the great article!
Thank you for this! I have been wanting to discuss involuntary commitment but I haven’t figured out a way to approach it that’s practical. One consideration I was thinking about exploring is the ethics of involuntary treatment across types (Mental health; Substance use; Civil Commitment for “inability to care for self” and under Jimmy Ryce Act) but I didn’t know where the application would come in. Thanks for reading and supporting! <3
I love that this piece brings up discussing termination at the beginning of therapy. This is a GREAT point because therapy really isn't supposed to be forever. When I was in a really dangerous relationship with a therapist, there was no discussion of me ever terminating--it was a "therapy forever" situation and I think when you're a patient who is overly dependent on a therapist you may think "But I never want to leave my therapist! I want to see them forever!" When I moved on to a much healthier therapy relationship we discussed termination right up front and specifically that "therapy is not forever." Great points through this piece.
Thank you so much for your perspective! It’s hard to imagine when you’re in it that things that you enjoy about your therapeutic relationship (at the time) can still be inappropriate, unethical, or harmful long term. That’s why I want to help people be informed proactively. I’ve heard so many stories of people who go to lunch with their therapist or text every day and it’s hard to explain that even though it makes you feel good in the moment, it’s not okay. Thank you for reading, too!
It’s not okay at all but no one wants to hear that they’re being taken advantage of by someone they deeply trust and rely on. I didn’t want to hear how badly I was being treated either and it was way worse than lunch. :( Please keep spreading the word!
I agree with all the points in this article, but I question the duration section. Depending on the issue it can take a hell of a longtime to build up trust with a therapist. There’s also something disconcerting about needing to be ‘solution’ focused all the time, as if the therapy process is just about making a client ‘normal’ enough to go out into the world
That's a great point, Megan! I appreciate your perspective. The issue is more transparency around the timeframe for services. Additionally, although some therapeutic approaches are intended for self-actualization or discovery, many are indeed designed to be solution-focused to help clients overcome an issue that *they have identified* is causing them suffering—not necessarily anything to do with "abnormality." Although I recognize that many clinicians come from a paternalistic viewpoint and label what the client needs to resolve - which I strongly disagree with. Some of my other articles might clarify my disdain for diagnosis-focused treatment and labeling.
I also elaborated on this in a previous comment, "With psychodynamic psychotherapy, the length is often years upon years, yes. It is still important that the length expectations are discussed up front - however! A lot of people go in unfamiliar with modalities and end up implicitly agreeing to a decade-long service without realizing it. I could have been more clear that the length of time itself is not necessarily an issue as long as that is discussed up front, desired, and doesn’t impede the client financially. Additionally, it is still okay to recognize if you’re treading water or not progressing as you’d like - you can always pursue new modalities."
Does the bit about therapy length apply to psychodynamic psychotherapy? My impression is that in the modality of therapy I’m a patient in, it is normal and standard for therapy to go on for years upon years.
With psychodynamic psychotherapy, the length is often years upon years, yes. It is still important that the length expectations are discussed up front - however! A lot of people go in unfamiliar with modalities and end up implicitly agreeing to a decade-long service without realizing it. I could have been more clear that the length of time itself is not necessarily an issue as long as that is discussed up front, desired, and doesn’t impede the client financially. Additionally, it is still okay to recognize if you’re treading water or not progressing as you’d like - you can always pursue new modalities.
About two years after my divorce, I suddenly started to feel intense, consuming anger toward my mother. It was dominating me, and so for the first time in my life, I decided I needed to go into therapy. I was 39. One of the first things the therapist said to me was - if I began to feel dissatisfied with therapy, or her, or that things were no longer working for me in therapy, that I needed to let her know. Sounded great, I didn’t think too much about it, we moved on. Therapy was great for the next two years. I felt it was really helping me. Until it wasn’t. I spent most of my time unloading a lot of feelings that I wasn’t able to share with anybody in my life. But then, I no longer felt that was productive. I felt I was treading water, not moving forward and wanted therapy to be more than what had become bitch sessions. I also noticed that she had begun to share some of her personal stuff with me and it began to feel like she liked me as a friend, which bugged me a little. So I told her that I didn’t feel therapy was working for me any more in it’s current pattern- exactly as she had told me to when we started out and periodically brought up over the course of the two years- using her own language to let her know. She went ballistic on me. Absolutely ballistic. She told me I was a horrible mother, a horrible teacher ( things I had shared I felt I was when I was at my most vulnerable) and that my struggles with my profession and my teen children’s issues were because I was a terrible person. She was vitriolic in her disdain. I was stunned. I walked out in the middle of her diatribe and never went back. When I took some time and space to reflect on what went to terribly wrong- still haven’t figured it out, I have basically concluded that she was mentally ill- I realized her increasing sharing of her own life and its similarities to mine, the way the sessions were beginning to feel like bitch sessions to a friend instead of therapy, the sense that I was getting nowhere were a clue. Also, I remembered early on that she told me she was treating one of my students. She never shared his name but the way she described him, I knew who he was. I felt unsettled by that at the time and should have left then. But she was my first therapist and I didn’t know much.
Wow, Ellie - what an intense experience! I’m impressed that you advocated for yourself and left therapy, as many find it hard, especially in similar circumstances. Even recognizing that it wasn’t working anymore is a big deal. I’m sorry that you had that experience, but it sounds similar to other experiences I’ve heard from people. It genuinely keeps me up at night, knowing how common these types of “professionals” are.
Everyone is susceptible to bias, as you note above. Sometimes clients need to be aware of the biases their providers have. This is especially important when the client has an extremely different background of life experiences than the provider, or if the client comes from a different culture.
Someome clients may need personal disclosure from providers, so they can understand the extent of bias they are working with.
Thank you for reading and sharing your perspective! That's a great point! I encourage clients to explore the alignment of their clinicians with their values, beliefs, and other cultural facets. It's important to note, too, that there are clinicians who can compartmentalize their beliefs on behalf of good practice with clients. For example, working with clients with a different religious background is often possible if the focus is on the client's goals and perspectives. Modality often impacts this, too. If you are pursuing long-term psychotherapy that is heavy in interpretation, or CBT which is often used in discrediting ways, then this is a major concern.
There are professional disclosures and mutuality disclosures that allow for rapport building without personal information. For example, "Clients in similar situations have found [technique] helpful." We make passive disclosures all of the time, like wearing wedding bands. A single disclosure is not a huge issue, but when disclosures are used from the clinician's perspective, they must be used intentionally and with great care for how they impact the working relationship. If a client requests a disclosure to match suitability, that is different, as you note!
It is rare to find a 100% match between client and clinician culturally. Which, we absolutely need to create more opportunities, as the mental health field (regardless of credentials) is close to 80% White women. Overall, though, the goal is to be neutral and not to impart values or views onto a client - ideally leaving room for the client's culture to motivate treatment. Now, that is often not the case. So, utilizing disclosures to mitigate potential harm is an interesting way to make something productive out of an imperfect system.
A few years back, I used to recommend that just about everyone get a therapist so they'd know you at baseline. Now, in light of the BetterHelpificaiton of the industry, I wonder if it's doing more harm than good on the whole.
My prior approach - telling everyone to have a therapist - was largely driven by my experience in Florida, where it appears involuntary psychiatric exams and commitments are performed at a rate FAR exceeding other states. https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900477 (Caveat: this may be due to Florida's superior record keeping, but the numbers are so high vis a vis every other state that I tend to doubt that explanation.)
The high rate of Baker Acts (or 5150s, sectioning, whatever it's called where you are) in Florida creates an environment in which people are afraid to talk to their own doctors or mental health professionals about depression and suicidal ideation. It's a real problem, especially among the student population.
I figured that if you could develop a long-term relationship with a therapist, you'd be more inclined to discuss potential suicide and self-harm topics without fear of being improperly Baker Acted. I no longer believe that, and I wonder if the proliferation of online therapists (and others who behave more like affirmation coaches) has actually increased the rates of involuntary psych holds. I don't like considering that we're disincentivizing people from reaching out for help.
That actually might be an interesting topic - navigating therapy and mental health treatment while harboring fear of being involuntarily held. Thanks as always for the great article!
Thank you for this! I have been wanting to discuss involuntary commitment but I haven’t figured out a way to approach it that’s practical. One consideration I was thinking about exploring is the ethics of involuntary treatment across types (Mental health; Substance use; Civil Commitment for “inability to care for self” and under Jimmy Ryce Act) but I didn’t know where the application would come in. Thanks for reading and supporting! <3
I love that this piece brings up discussing termination at the beginning of therapy. This is a GREAT point because therapy really isn't supposed to be forever. When I was in a really dangerous relationship with a therapist, there was no discussion of me ever terminating--it was a "therapy forever" situation and I think when you're a patient who is overly dependent on a therapist you may think "But I never want to leave my therapist! I want to see them forever!" When I moved on to a much healthier therapy relationship we discussed termination right up front and specifically that "therapy is not forever." Great points through this piece.
Thank you so much for your perspective! It’s hard to imagine when you’re in it that things that you enjoy about your therapeutic relationship (at the time) can still be inappropriate, unethical, or harmful long term. That’s why I want to help people be informed proactively. I’ve heard so many stories of people who go to lunch with their therapist or text every day and it’s hard to explain that even though it makes you feel good in the moment, it’s not okay. Thank you for reading, too!
It’s not okay at all but no one wants to hear that they’re being taken advantage of by someone they deeply trust and rely on. I didn’t want to hear how badly I was being treated either and it was way worse than lunch. :( Please keep spreading the word!
Like I mentioned, we need both perspectives! You’re doing a really brave and important thing sharing your story.
Thank you.
I agree with all the points in this article, but I question the duration section. Depending on the issue it can take a hell of a longtime to build up trust with a therapist. There’s also something disconcerting about needing to be ‘solution’ focused all the time, as if the therapy process is just about making a client ‘normal’ enough to go out into the world
That's a great point, Megan! I appreciate your perspective. The issue is more transparency around the timeframe for services. Additionally, although some therapeutic approaches are intended for self-actualization or discovery, many are indeed designed to be solution-focused to help clients overcome an issue that *they have identified* is causing them suffering—not necessarily anything to do with "abnormality." Although I recognize that many clinicians come from a paternalistic viewpoint and label what the client needs to resolve - which I strongly disagree with. Some of my other articles might clarify my disdain for diagnosis-focused treatment and labeling.
I also elaborated on this in a previous comment, "With psychodynamic psychotherapy, the length is often years upon years, yes. It is still important that the length expectations are discussed up front - however! A lot of people go in unfamiliar with modalities and end up implicitly agreeing to a decade-long service without realizing it. I could have been more clear that the length of time itself is not necessarily an issue as long as that is discussed up front, desired, and doesn’t impede the client financially. Additionally, it is still okay to recognize if you’re treading water or not progressing as you’d like - you can always pursue new modalities."
Does the bit about therapy length apply to psychodynamic psychotherapy? My impression is that in the modality of therapy I’m a patient in, it is normal and standard for therapy to go on for years upon years.
With psychodynamic psychotherapy, the length is often years upon years, yes. It is still important that the length expectations are discussed up front - however! A lot of people go in unfamiliar with modalities and end up implicitly agreeing to a decade-long service without realizing it. I could have been more clear that the length of time itself is not necessarily an issue as long as that is discussed up front, desired, and doesn’t impede the client financially. Additionally, it is still okay to recognize if you’re treading water or not progressing as you’d like - you can always pursue new modalities.
About two years after my divorce, I suddenly started to feel intense, consuming anger toward my mother. It was dominating me, and so for the first time in my life, I decided I needed to go into therapy. I was 39. One of the first things the therapist said to me was - if I began to feel dissatisfied with therapy, or her, or that things were no longer working for me in therapy, that I needed to let her know. Sounded great, I didn’t think too much about it, we moved on. Therapy was great for the next two years. I felt it was really helping me. Until it wasn’t. I spent most of my time unloading a lot of feelings that I wasn’t able to share with anybody in my life. But then, I no longer felt that was productive. I felt I was treading water, not moving forward and wanted therapy to be more than what had become bitch sessions. I also noticed that she had begun to share some of her personal stuff with me and it began to feel like she liked me as a friend, which bugged me a little. So I told her that I didn’t feel therapy was working for me any more in it’s current pattern- exactly as she had told me to when we started out and periodically brought up over the course of the two years- using her own language to let her know. She went ballistic on me. Absolutely ballistic. She told me I was a horrible mother, a horrible teacher ( things I had shared I felt I was when I was at my most vulnerable) and that my struggles with my profession and my teen children’s issues were because I was a terrible person. She was vitriolic in her disdain. I was stunned. I walked out in the middle of her diatribe and never went back. When I took some time and space to reflect on what went to terribly wrong- still haven’t figured it out, I have basically concluded that she was mentally ill- I realized her increasing sharing of her own life and its similarities to mine, the way the sessions were beginning to feel like bitch sessions to a friend instead of therapy, the sense that I was getting nowhere were a clue. Also, I remembered early on that she told me she was treating one of my students. She never shared his name but the way she described him, I knew who he was. I felt unsettled by that at the time and should have left then. But she was my first therapist and I didn’t know much.
Wow, Ellie - what an intense experience! I’m impressed that you advocated for yourself and left therapy, as many find it hard, especially in similar circumstances. Even recognizing that it wasn’t working anymore is a big deal. I’m sorry that you had that experience, but it sounds similar to other experiences I’ve heard from people. It genuinely keeps me up at night, knowing how common these types of “professionals” are.
This is a great list!
Thank you for sharing.
The only point I question is personal disclosure.
Everyone is susceptible to bias, as you note above. Sometimes clients need to be aware of the biases their providers have. This is especially important when the client has an extremely different background of life experiences than the provider, or if the client comes from a different culture.
Someome clients may need personal disclosure from providers, so they can understand the extent of bias they are working with.
Thank you for reading and sharing your perspective! That's a great point! I encourage clients to explore the alignment of their clinicians with their values, beliefs, and other cultural facets. It's important to note, too, that there are clinicians who can compartmentalize their beliefs on behalf of good practice with clients. For example, working with clients with a different religious background is often possible if the focus is on the client's goals and perspectives. Modality often impacts this, too. If you are pursuing long-term psychotherapy that is heavy in interpretation, or CBT which is often used in discrediting ways, then this is a major concern.
There are professional disclosures and mutuality disclosures that allow for rapport building without personal information. For example, "Clients in similar situations have found [technique] helpful." We make passive disclosures all of the time, like wearing wedding bands. A single disclosure is not a huge issue, but when disclosures are used from the clinician's perspective, they must be used intentionally and with great care for how they impact the working relationship. If a client requests a disclosure to match suitability, that is different, as you note!
It is rare to find a 100% match between client and clinician culturally. Which, we absolutely need to create more opportunities, as the mental health field (regardless of credentials) is close to 80% White women. Overall, though, the goal is to be neutral and not to impart values or views onto a client - ideally leaving room for the client's culture to motivate treatment. Now, that is often not the case. So, utilizing disclosures to mitigate potential harm is an interesting way to make something productive out of an imperfect system.