Normalizing vs. Pathologizing

I'm having a sort of rupture with my T right now, and I was thinking of how her approach to me differs from my marriage counselor's. And I realized that part of it was that he tends to normalize things I'm feeling/thinking, while she tends to pathologize them, to say that they're something I need to fix/change, that they're part of my mental illness. It's not quite as black and white as I'm making it sound here though. But I'm curious as to how other people's T's approach it.

For example, the desire for reassurance. T would say that I shouldn't seek reassurance so much, that I should just be able to reassure myself. Like my need for reassurance is a sign of my depression, anxiety, and/or OCD.

Whereas MC would say it's totally normal/natural to want reassurance, like it's a basic human desire. But that there are times when there's no way to know how things will turn out, so reassurance might not work then. So I need to learn to live with that anxiety.

I respond much better to MC's approach. I already feel like I'm screwed up, so to hear that something is just another sign of my mental illness and that I shouldn't want/need it just makes me feel worse. To hear that something is a completely normal desire, that makes me feel much better. It's validating. Yes, I need to learn to live without frequent reassurance, but knowing it's a natural human desire makes me feel less like there's something wrong with me, less like I should be suppressing my emotions, less like I'm broken.

So just wondering how your T's approach stuff like that and how you respond. (I could give more/better examples, this one is just particularly fresh).

Sounds like you can see the reasoning for both views. Perhaps think of it more as them balancing each other out. It doesn't have to be either/or, black/white. It can very well be that gray area in between (which you seem to already realize) that you can have needs for reassurance AND also work on finding ways to reach some of that reassurance on your own.

I wouldn't like your therapist's approach at all. Mine is more like your MC. She does not label or pathologize or talk in terms of fixing. If I ask for reassurances, I don't even think it's framed as asking for reassurance. Then again, I don't tend to ask for things that would make me feel better. I did ask her to say Yes indeed, once. And she did. I don't see any value at all in questioning why someone needs something that feels supportive or is helpful.

Are you finding any benefits to seeing this therapist? It could it be that no one compares to your MC, so if you have seen some good things from your therapist, maybe just focus on that area (or areas) to work with her on.

Mine is more like your MC as well.. Making me feel reassured , that may feel a little of something , and that is normal, like you said your MC says.. everyone does that a little... will say something like "but you don't do that to the extreme, if you were extreme on that to one end , then maybe it would be pathological".. I would internalize your MC thoughts and what he is telling you, seems alot better. That would be hard, definately... Wish you the best!! Lonesome , it seems from several posts I've seen, you are really perceptive and smart about alot!

Sounds like your MC has a Humanistic approach. I like that better too.

My T is humanistic and believes that everyone has needs and that they are OK, normal, important, helpful etc etc and she tries to meet me with these needs. Actually, it is a far less dirty word than it ever used to be and that is s big step in itself. If she was like your T then I would probably still have a fear of the word. I like the suggestions that maybe no one will compare to your MC and also that maybe they can both be good for you in their own way. It does sound tough though and I am glad you have your MC to support you in this Lonesome. Hugs to you while you work through this with your T.

My T would never say, I 'shouldnt'. Run

I have to say I do prefer your MC’s approach - precisely for the reason you mention. I’d feel bad enough and wouldn’t need ‘reminders’ re how weird I am or what’s wrong with me.

I guess it might work for some and some clients might prefer her (imo) tough-ish love. Whereas MC seems more into gentleness, validation, reassurance and.. normalisation. Wanna lend me your MC for a wee bit?

My T's approach is more like your MC's, and I prefer that.

In my most recent session I was very upset after receiving some bad news, and T reassured me that everything I was feeling was normal under the circumstances. It made me feel a little better, just to know I was normal!

A good t is sensitive and caring and reflects on what you say; validates ALL of your feelings.

This is a lot like the difference between the first T I had, and the second. The pathologising really didn't help me.

Perhaps it's just a different approach but I sometimes feel that some people like to tell others there is something seriously wrong with them. It just makes some people feel better about themselves, more knowledgable, more intact, perceptive and healthier themselves. I get the feeling if they are not talking directly to patients they are probably psychopathologizing anyone and everyone behind their backs.

So basically, I think that secure people, and secure professionals, are less likely to do this.

Interestingly my first T also liked to personalise everything. I was always meant to say 'I' and 'people in general' or 'others' were not allowed to be part of the discussion. I think this CAN be helpful IF a person is trying to avoid their own stuff, but I don't think its always helpful. Second T would OFTEN respond to me with a generalisation. For instance, I went to a social event that I found difficult:

Me: so I sat there trying to get into a different mental state so that I didn't feel upset. And it was just like I was 12 years old again, trying the same things -

T2: When people are stressed they do return to earlier coping methods.

I have never seen a therapist who pathologizes a patient's expressed needs. I rarely ask for reassurance, and when I do I don't want "there there," more like I'm on the right path to improving my life. But I get that when I ask for it.

You've been seeing this woman for years, right?

My t says he is not negative because it just doesnt work.

I think it is subtle and T is trying for changing actions, not feeling. Your T does not say the desire for reassurance is abnormal, just the constant seeking for reassurance (which never seems to reassure?), that behavior. You don't have to change or suppress your emotions, they are valuable guides to what is happening with you and help you know yourself better and how to respond to issues with yourself or others. "Ah, I'm anxious and searching for reassurance; let's look at what I'm anxious about" and focusing on the actual issue making you anxious and how to resolve that issue, instead of trying to tell yourself you "should not be" anxious or seeing reassurance is the object I think. Focusing on the need for reassurance is secondary to the actual problem, what is making you anxious? You cannot control or change how you feel, only how you act and respond and positive actions and responses will create positive feelings.

In general, I would find your T's approach weird -- if I was considering sticking with the T, I would ask her to as to how exactly being told that it's a sign of 'illness' is supposed to help in dealing with the said illness? Like how is being told that your wanting reassurance is a sign of OCD actually supposed to help you deal with OCD (assuming that's what she's working towards in your therapy)?

I may be approaching this in a rather cold fashion but for stuff like this, I've found that moving the conversation away from an exclusive focus on feelings (E.g. "I felt hurt that you said that" etc) to really getting at the purpose of why the T is doing / saying what they're doing / saying can really help. It can lead to an interesting conversation and / or (as in my case recently) a potential mea culpa on the T's part.

Thanks for your response. Agreed that it doesn't have to be either/or. MC does also try to make sure I'm not just using reassurance as a "crutch"--like I'm not talking to him instead of talking to my husband (talking to both is OK). As he said the other day, using parenting as an example, at some point, you have to take the training wheels off.

Thanks for your response. Part of what's frustrating to me is that most of my e-mails to her are not sent for the purpose of reassurance--often I'm just telling her an insight I had while driving home, letting her know what happened in an MC appointment, etc. (If I want straight-up reassurance, I'm more likely to reach out to MC.) Yes, there was something a month or two ago where I was a bit upset she didn't respond because I was really stressing out about something, but that e-mail was different from the usual ones. And there was a period maybe 6 months ago where I was going through a crisis and texted and called her a few times, but she's said that it made sense for me to reach out a lot to her and MC then, so I know she's not talking about that.

When I first started seeing this T 4.5 years ago, it was mostly for anxiety/panic disorder, and while that's still a problem, our therapy evolved into addressing a lot of other stuff, both in the past and the present. I feel like maybe she was helping more when we were addressing a specific thing? So maybe I should consider talking to her about just focusing on a certain area.

Thanks for your post (and the compliment!). I am definitely working on internalizing some of what MC has said to me. I'm seeing it as, I missed out on getting some of these messages during childhood, so I'm getting them now. But it takes some time for me to accept them and start applying them to myself.

And I think my T actually thinks I'm *too* perceptive...like picking up on little cues from people's body language, etc.

Thanks, Waterbear (for the post and the hugs). You seem like you have a really good T. When I talked to MC on the phone the other day (after my T appointment), he said I kept treating "reassurance" like it was a dirty word, but he didn't think it was. I'm pretty sure at some point he told me it was OK to have needs, too.

Thanks! MC actually calls me out sometimes when I say "should" because he says there "Shouldn't be shoulds." Like if I say, "I should be doing x" or "I shouldn't be feeling y." While T--and my mom (hence the negative maternal transference for T)--are more into the "shoulds."

Thanks for your response. I tend to think of T as more "tough love," too (or the bad cop to MC's good cop). She's said before that some other T's in the practice have issues with some of her methods, but she's also regarded as a great T. Not that MC doesn't ever question or push me--he certainly does some of that, too. But more of a gentle push.

And sure on that last part, as long as you don't borrow him on a Monday

I do not find their attempts at normalizing useful at all. To me I don't look to them to decide what is normal or not and my problem is not one of being concerned about me being normal. If I finally tell the woman something and she responds that it is normal - I just feel dismissed and like an idiot for bothering to tell her anything at all and letting her talk. I usually feel mostly like an idiot for allowing her to talk when I know she is awful at it.

Thanks for the response. Yes, it definitely helps to feel like we're normal! Especially if at some point in life we got messages that we weren't (or at least that our reactions to things weren't).

Thanks, SnowQueen! Interesting to see the differences between your two T's--glad you have the second one now.

For me, I wonder if it's partly that MC has experienced some mental illness (he's mentioned an anxiety disorder at least--not sure about other stuff) of his own and has also gone through a fair amount of therapy, so he has more of a sense what it feels like to be on the client/patient side. While I don't get the sense (she's much less open about herself) that T has dealt with much personally. I mean, not that her life has always been perfect, but no glaring mental illnesses. Plus she's just different personality-wise (MC is more similar to me). So she may have learned that continuing to reassure a client isn't good, but she hasn't felt that same need for reassurance that I have. So she doesn't understand as well why I can't just be like, "OK, I'm all good now!"

Yes, I'm overgeneralizing--I'm sure there are plenty of T's who haven't had MI themselves but are extremely caring, understanding, and sensitive to their clients. And plenty of T's who have had mental illness who are...not so sensitive (at least based on what I've read on here!) I'm just going by my experience.

Thanks for your response, ATAT. Yes, I've been seeing her for over 4 years. A bit of background: Wasn't super connected to her at first, but she seemed to be helping some. Then there was a period from maybe the middle of last year to the beginning of this year where I felt really connected to her. And it also seemed like she had come to really care deeply about me, like her eyes would well up with tears sometimes when I was talking (which hadn't happened in the past--only since like a year ago). But then the past few months, it feels like she's really pulled back again.

Earlier this year, she suggested hospitalization for me, which upset me, mainly because of how she presented it: "Would hospitalization really be so bad?" When I've told her multiple times I have a phobia of hospitals, plus I had freaked out months before when p-doc had just suggested a day program (not even inpatient). Plus she acted kinda weird that whole session. Next session, we talked about it, and she actually admitted (which was unusual for her--she doesn't tend to admit mistakes/apologize/say she might have been wrong, unlike MC) that she thought she might have gotten too close to me and lost her objectivity. And was concerned she wasn't providing the help I needed. We talked and hugged (which she rarely does with me, but will hug other clients--she said she didn't hug me because I had a bit of maternal transference).

Things got a bit better there, then at one point a few months ago, I told her I loved her, but knew the therapeutic relationship was unusual and unlike other relationships, so I knew she couldn't reciprocate. She agreed with that, and then added "Not that I don't love you, too." Which surprised me. It really feels like she's pulled back a lot since then, doesn't seem affected by what I'm saying so much, seems almost tired of me. I brought that up in our session this week, about how it felt like she'd pulled back a bunch since admitting the love thing, so maybe she felt she'd said and/or felt too much. And she was like, "You're making an awful lot of leaps there." Which felt very invalidating.

So I partly wonder if some of this is a transference/countertransference thing, especially because she's my mom's age (and has kids my age). I have/had positive paternal and a bit of erotic transference for MC, which he knows about and has worked with me to deal with (I suspect there's a bit of paternal countertransference on his part, too, but I won't get into all that now since this is more about T). He's said that transference in therapy can be beneficial in that it can uncover lingering stuff from childhood (or other times in the past). And you can sort of replay past situations, but work through them and have a different outcome--which is part of why he's encouraging me to try working things out with T.

OK, kinda rambling at this point, so will stop!