week 2

week 2 out of 3 weeks of intake assessment, apparently. she said she will work with me more likely than not. somewhat reassuring, i guess.

she said that she has a supervisor who is an analyst and that she talks to them about my case. i think that was meant to be reassuring. it is somewhat. i could tell she had being talking to someone:
- she asked about self-harm (yes, probably a good idea to assess risk with someone who mentions borderline personality)
- she gave me her card with the crisis number on back (yes, probably a good idea see above also cards can help with object constancy)
- she said it was amazing that i am doing my PhD given that i'd been basically independent from 14 (yup, emphasizing and encouraging strengths is a pretty good move, too)
sigh.
i guess its a good thing.

feeling... like i'm very much seeing a person in training. she doesn't have her repertoire of open questions and slightly more directive questions yet. still, some therapists never manage to sort that one out, so i suppose she is doing okay. she is fairly self-conscious about it in a way that most experienced therapists are not. even if experienced therapists don't manage to sort that one out they still develop this air of 'what is your problem' rather than 'how can i alter the way i'm asking'. i... wouldn't be terribly surprised if i'm only about the 1st or 2nd or possibly 3rd person who she has seen for therapy. really... it really is striking me like that. still... i suppose that is okay. it is mostly that i need someone to talk to for support and i'd rather a training p-doc than a training clinical psychologist or counselor so that is okay...

does feel like that, though. i guess thats okay, though. for now. glad i have p-doc back home...

Kim
I felt the same way with my T. When I first started seeing her, I felt like she was walking on egg shells. I wonder if some of them are just as nervous as us in the first few meetings.
Anyways, my previous T had been doing it for 15 years, which was strange to see her that way. We were sort of all over the place in the beginning trying things and moving on to others. I thought well maybe she had not deal much with people who were sxually abused.

You said something about working on a PhD, is it in psychology? If so, there could be some insecurity on her part to that as well. You know wanting to do or say the right thing. Just a thought. I would say give it a little more time to allow both of you to get more comfortable with each other and if you still feel that way, then go with your gut.

I am seeing a new one now, and she didn't seem the slightest bit nervous, yet, she has only been in practice for 3 years. Go figure lol

Hangingon

the T i saw before had over 20 years exp and it showed - I couldnt gloss over something that was worrying or upsetting me - he would notice and we would discuss it - my current T has less exp and yes it shows - I can go in wanting to discuss one thing and come out not having discussed it - my fault not hers - she somtimes forgets what we said I would do for homework if there is any - I guess its hard when you see a lot of patients to keep everything straight - P7

Yeah, it sounds like a good thing.

Which of course would make me suspicious or attempt to make it not such a good thing...

i feel ambivalent about experience. i think there are pros and cons and individual difference and fit and the like are more important at the end of the day. for instance, older clinicians can tend to go with the labeling 'heuristics' more than younger clinicians since they have more experience with people so labelled. that can lead to assumptions, generalizations, and stereotypes that aren't so helpful. but then younger clinicians can also tend to do this more than older clinicians since they just forked out for their copy of the DSM and they are so proud! and the experienced people can learn about all the funny borderline cases and the diversity of actual cases. so... i guess judgements and stereotyping isn't necessarily more of a feature of either younger or older clinicians it is more about individual difference.

i'm not too sure what to make of us... i guess she seems a bit awkward at times. mostly because she is trying to get the hang of the things she is supposed to be doing / getting through so it isn't terribly intuitive as yet. she kinda cracks me up. she will ask a very general question (as most therapists tend to do) and i make my usual move of asking them to clarify... and... she is the first person who will list about 4 or 5 aspects that she is wanting me to focus on (guess thats what she read in her textbook about what it is that she is trying to assess). i'm able to basically speak an essay addressing each of those aspects in turn (and link them up into a narrative) but i'm not sure how that strategy will work with the majority of clients... lol...

this is what makes me think that she hasn't had much actual patient contact... works ok with my very rationalist approach in general... but i've never experienced anything like it... she seems to like that i'm a student. genuinely (some cringe or start to feel insecure or whatever). but she seems cool with it (secure enough in herself, i guess). so that is fine. the crisis line... came from a stereotype about borderline self-harm and crisis to crisis to crisis.. she didn't pick up on that in our first meeting (and there is no reason why she should because that hasn't been an issue for me for about 4 or 5 years now). but the dx rang little warning bells in her supervisor (with the stereotype in hand) obviously...

i am curious about what they say about me... i expect it is mostly technical detail stuff which isn't so terribly interesting to me.... definately those three things i listed in my initial post... i wonder what else? hrm...

i've worked with training people before... but... this person.. i'm pretty sure she hasn't seen anyone for therapy before. i think... i could well be... her first assignment. odd... still, i suppose someones gotta be...

i guess... i'm not here for long so any work that is done while i'm here will be of the brief supportive variety. so she doesn't really need to be especially skilled or practiced for that. so long as the fit is right. and i think the fit is okay. she said, too, about having a week off for christmas but that we would try and schedule a make up sometime in the new year week so we didn't miss two in a row (supervisor again, no doubt). its kinda interesting, actually... the analyticity of it all... guess she has her little manual in her back pocket about how to conduct an intake assessment and the like... and she is trying really hard... and after however many years of learning the facts learning the facts learning the facts there is a person.. kinda odd.. i have a lot of sympathy for that. it is kinda odd. so maybe this will work out okay... given that i have more sympathy for her position than many would and given that she just explains her position fairly honestly from her pov (which is kinda funny strange and haha at the same time) i think we will...

Kim the guinea pig?

aw. i don't feel like one, i guess... but i'll admit that i haven't seen someone so young / early into things before.

4th year. what does that mean? 4th year of psychiatry specialization or 4th year of med school? pretty sure she is a MDalready so that must mean 4th year of psychiatry specialization... i'm sure she is well practiced with the medication stuff... it is just therapy that is a bit of a novelty...

in fact... i said about having a reaction to prozac and she perked up a bit and was like 'what kind of reaction' so maybe she is more of a medicator... i was like 'hysterial reaction, most probably' and she still looked curious so i was like 'started shaking and fell over'. then she was unreadable... so who knows... maybe she thought i was messing with her or maybe that is the most prevalent side effect or who the **** knows...

i think i'm okay with it because i respect her knowledge base (not of therapy, admittedly, but more generally). many many many many years of cramming facts.. does something to ones brain that i like.. i'd have a much harder time seeing a counselor or clinical psychologist, as i said...

kim, you and T are still very new to one another, getting to know one another. that could account for some awkwardness maybe?

also, knowing you are there for a relatively short time, she may be trying to get a feel for how to make that limited time work well for you. have you talked about the fact that you will be there for only a certain amount of time? i assume you told her that but have you talked about it?

supportive therapy is good, no?

UGGHHHH
Kim that seems annoying! I'm glad you have far more patience than I do. When I'm stereotyped by "professionals", I tend to do bad things, like play with them for kicks, seeing how far I can take it. What good is having ADHD if I can't have fun with them?

My current T of two years now is far too good for that trick though.
Thankfully, I'm not stereotyped by my current T, and he's not condescending in any way. He's been in practice for over twenty years now, which does make a huge difference.

Also... if I sense "phony" (which is sorta what I read from your new T without knowing her), it will never work. My current T would never feed me a line of bull. I like being able to be straight and direct with my T, even challenging him if I feel he is misdirected or assuming something that isn't so. He doesn't get offended or feel that his professional status has been challenged either, which a newer and more insecure T might do.

You've been around the block a few times. I'm sure that you'll know right away if it's a bad deal with your new T.

aww... i don't think i'm conveying things very well...

i think she is trying. but i do get the distinct impression that this is new to her (how many assessments has she given vs how many assessments have i sat through?) i've been in the health system much longer than she has...

but... i think she is trying. and that is quite commendable. and she seems like a nice person (not judgmental - or not tooo judgmental etc) so personally i think we get on fine. insofar as i can figure her emotional leakage (every has that) i'm getting the impression that she has a sense of humor and that she gets mildly annoyed / pissed but it is understandable really and fairly benign. she just... doesn't know what to say much of the time. which is okay, i guess, i've had therapists with much more experience not know what to say. and i do think that she has her little handbook somewhere of what sorts of things she needs to assess for and that her supervisor is checking to make sure that she gets through them (it wouldn't do for her to have a list in front of her) and it isn't something that comes naturally to her yet.

for instance... i'm used to as soon as i say the words 'borderline personality disorder' therapists - no matter whether they are half asleep or staring off in space or doing compassionate and empathetic face - raise their eyebrows a little and now they have about four questions that take priority on the question agenda:
- self harm
- crisis management
- manipulativeness (setting boundaries for phone calls and out of session contact and the like)
- making clear about when t is going to be unavailable (holidays)
she didn't do that. how refreshing. she must have made a note but i could tell from what she said next time that her note said `BPD' because her comment revealed that she needed me to clarify whether i'd said `borderline personality disorder' or `bi-polar'. lol. that is hilarious. no stigma from her :-) i bet her supervisor gave her a bit of a talking to... and i bet they figured it out from my emails / phone calls :-/

it is ok. i'm probably a reasonable first case load... no crisis anymore and (so long as i click which i think i am) fairly tolerant of such things as therapist going AWOL for months etc etc etc. the supportive thing is basically what i need from her right now (only going to be around for another 6 months and she knows that).

i'm not playing with her or anything like that... it is just kinda amusing to me because i guess i know more about the mechanics of the process than the average client so i can see more of what is going on with the mechanics of the process. is is one of the things she needs to learn, though. i'd be happy if i come out of the relationship feeling like i've been heard and understood and that she genuinely likes me despite my rants... and if she comes out of this process thinking that therapy can be just as useful as medication and that being a good therapist is a worthwhile thing to do that is as much of an art and science as being a good medicator...

Kim, I'm just wondering if you ever feel as though you are doing her a 'service' for her own growing experience? Just being that she is not experienced in counseling... and also because some of us just "get" the process regardless of the personal differences/style with various therapists. I'm wondering how you feel about that.

I guess I think that therapy (ideally) should be a transforming experience for both the therapist and the client. Otherwise... It becomes this rather unsavory thing of paying for a service. So... I don't feel that that is especially different in our interaction... Though maybe I'm focusing on that a little cause we can only really do the brief supportive thing.

Kim, I'm curious about how you got a pdoc for therapy? I think of pdocs as someone you go to for meds or perhaps meds+therapy. Did you call names out of the MD section of the phone book and say "I'm looking for a pdoc for therapy," and see who was interested? It seems unusual to me and I wonder how easy it would be to find that. Where I live, pdocs are a lot more expensive than therapists, and not necessarily better at therapy than therapists, so the big cost is a deterrent from seeing the pdoc just for therapy. I guess it is heartening to me to learn that pdocs even receive training in therapy in their residencies. But it's also kind of scary that this pdoc you are seeing is in her 4th year of residency and yet you may be her very first therapy client!

Do you call her "Dr."? I would think that typical of a doctor/patient relationship. But yet you're getting therapy from her, so maybe you don't call her "Dr."

Once apon a time there was a neurologist. The neurologist became interested in cases of paralysis (hence anxiety, depression, and trauma) and developed a talking cure. The neurologists name was Freud.

In the beginning one needed to be an MD before one was permitted to apply to a psychoanalytic institute in order to train in how to give the talking cure.

Psychiatry eventually came to develop a symbiotic (or perhaps mutually parasitic) relationship with pharma. Psychoanalysis came under pressure from the rise of biological (read pharmaceutical) psychiatry on the one hand and from the rise of cognitive behavior therapy (with its efficacy studies) on the other. Psychoanalysis was in danger of being phased out (not many candidates) and so the training institutes opened their doors to related fields such as education, psychology, and social work.

Through all this upheaval... There are clear demarkation lines between individual psychiatrists - and indeed medical schools - who value therapy and those who do not. The latter advertise as being 'biologically' or 'empirically' focused since they tend to not want to advertise their reliance on pharma and pharma trials. The former... Advertise as being more 'pluralistic' or something like that - but given the extreme position of the alternative it is always harder to know whether they mean that therapy is tolerated, tolerated for some conditions, or positively valued.

I prefer to see p-docs for therapy. Has to do with academic focus and theoretical orientation (much more psychoanalytic / psychodynamic orientation from the p-docs who deliver therapy than from the majority of clinical psychologists / counselors who deliver therapy). I tend to click better with someone who has spent so many years of total immersion in a scientific world view. I find I'm much less likely to get weird comments about crystal healing or higher powers or (by my lights) inappropriate self disclosures. Professionalism... Scientific world view... Just my experience... Probably better demographic for me, too (more likely to be older guys than younger females).

Yep, more expensive... Sometimes able to bill it as a 'medical consult' (covered) rather than 'therapy visit' (not covered). (This might not apply to the US). Otherwise... I've mostly seen them in the public service in New Zealand (so I didn't pay them anyways). My p-doc in Australia... Was very generous with offering me an affordable sliding scale... Here... I contacted a person from the psychoanalytic training institute asking whether I could see a candidate for sliding scale... He said I might try x (x was unable to offer me a sliding scale I could afford - this was a clinical psychologist). Then he said I might try seeing a senior resident from the hospital clinic. So... That is what I'm doing, apparently. I qualify for charity care here (seeing as I'm well below the poverty threshold) even though my health insurance explicitly excludes psychiatry / neurology.

She said that her supervisor was an analyst. Not sure whether she is serious (hence might be interested in getting into that herself) or whether she is yanking my chain figuring I don't know the difference between analyst or joe blows counseling clinic...

she is calling me miss lastname or possibly ms lastname (accent is a little tricky).
i need her to stop doing that because back home people only do that when the implication is that you are being a 'right miss' (ie acting like a 2 year old throwing a tantrum).
i think she means it polite, though.
i say i have an appointment to see... well... first time i asked for first name last name. second time i asked for dr. last name. i had to say it twice both times but not sure if that is a function of both of those being novel or the accent being novel. i'll tell her to call me firstname at some point and ask what i should call her, i guess. i would expect that first name would be fine...

If your insurance is US-based, with the new parity for mental health coverage soon to be in effect, that may change.

You are not back home. It has no such implications here!

groan. yeah, i think i've offended a couple people by expressing a reaction to their calling me 'ms' (students, most notably). i'm used to students calling me by my first name (here most stick to 'professor' or probably 'ms' for TA's i'm now realizing). oopsie...

i can't figure out the mental health parity thing...

is it... 'comperable treatment for comperable conditions' or something like that? how do you compare HIV with schizophrenia? depression with cancer? what is the relevant measure of comparison? fatality? i don't understand...

is excluding mental health conditions allowable so long as 'comperable' non-mental health conditions are similarly excluded? are SSRi's more like plastic surgery or diabetes medication? neurology is excluded already... if neurological conditions are thought to be 'comparable' to mental health conditions my policy has treatment parity already: namely, BOTH are comperably excluded...

Hmmmm, your questions seem to be making the parity thing more complicated than my insurance makes it. I think it's just a certain number of visits a year. So if you could go see the doctor once a week for physical complaints, you could now go that often for mental health complaints. My insurance used to provide partial coverage for 20 visits per year to a therapist, but when parity hit, they raised that to 50. (Of course, they won't reimburse a penny of MY therapist's fees, but that's a different story--not all therapists are created equal in their book.)

> ... So if you could go see the doctor once a week for physical complaints, you could now go that often for mental health complaints.

Nice :-)

> My insurance used to provide partial coverage for 20 visits per year to a therapist, but when parity hit, they raised that to 50.

Even nicer :-)

That really is terrific :-)

Because of where I'm situated in life... It was basically a matter of selecting between $300-$900 health insurance (for 12 months) which fulfilled my visa requirements or... about $300 per month for a 'decent' policy. (the latter being well out of my price range).

Visa requirements are mostly about expatriation of remains and hospital coverage in the case of emergency (so being hit by a bus is the thought and substantial exclusionary criteria on neurology / psychiatry / dermatology / optometry / dentistry / reproductive issues / pre-existing conditions etc etc etc). I went with the best one of those I could find (I have pre-existings that haven't required treatment in the last 6 months that are covered - important for me because if i damage my feet / legs there is a risk I could never walk again). Worst case: I'm landed with $1,000 in hospital bills for coverage up to $100,000 PER CONDITION. And... Only $160 surcharge (across the board rather than per condition - which of course makes a substantive difference) before I only have a 20% co-pay (and I pay a max of $1,000 across the board rather than per condition). But... Emergency services really...

$300 per month... Not affordable for me. That seemed to be the 'entry level' insurance option that included mental health care and neurology and stuff. Out of my bracket. Have to say kinda impressed with the 'charity care' in this state (though not terribly fond of the name).

I don't expect treatment parity will alter policies like mine (that have major exclusion criteria built in)... But I'm really glad to hear that it is making a more straight-forward difference to the health insurance of (at least some) people here. That is good. I guess I was worrying it would result in no practical changes, really... Nice to hear otherwise.

Well, yeah, in theory, it's good, but it has no practical benefit for me, since my insurance won't cover my therapist for even 1 visit. So that benefit sure looks good on paper, but that's about it for me. I'm sorry about your insurance situation. It's hard being an expatriate. I'm glad you are finding some low cost services in the state you are living in.

"Experienced" vs. "new" T: maybe a new one, compared to an old one, may not "know" so many things that are actually completely false... and thus be more inclined to actually listen to you...

One may hope...