Bipolar 2 From Inside and Out

Posts tagged ‘therapists’

When Couples Therapy Works

Couples counseling is never easy. It’s hard enough to have one person discussing their problems with a therapist, much less two. Two opinions. Two versions of reality. Two sets of problems. Two emotional whirlpools. Two perspectives. Two of everything.

And one therapist. One person trying to understand the dynamics. One person listening to two stories. One person trying to help two individuals and to help a couple.

It’s a wonder it ever works.

But it can. It does. Not always, but sometimes.

My husband and I have been to couples counseling three different times. Two of them helped. One didn’t.

One was a long-term round of therapy when we were much younger, trying to work out some of the typical problems that young couples face. We weren’t fighting, but we didn’t know how to live and work together well.

Our therapist was an older lady, very dignified and comforting. A good listener, she gave us as long as we needed to talk before she did. It was a productive relationship and helped a lot.

The second time didn’t go so well. It was short-term therapy, under the auspices of an Employee Assistance Program, so we had six weeks to work things out.

Except it didn’t work. The therapist took sides, and sided with my husband. She ignored my bipolar disorder (or depression, as it was diagnosed at the time) and suddenly, he was the sane one and I was damaged. She expected me to accommodate him. After every session, I felt shredded. I didn’t make it through the six weeks. At some point before that, I refused to go.

The third time was after we had a major blow-up, one that threatened to ruin us. My therapist recommended a counselor who could work with both of us. We had opposing views that were incompatible. There was bitterness and anger on both sides. The therapist gave us a safe space to say what we needed to, question each other’s perceptions, and work out a way to go on from there. Mostly, she listened. After only a few sessions, we achieved a detente and were calm enough to continue without outside help.

Three examples—uniquely ours and not representative of anyone else’s experience. Three dynamics. Three outcomes.

What made them different? Two were safe spaces for both of us, and one wasn’t, for me at least. One was long-term and might have been even longer if the therapist hadn’t retired. One was short-term and even shorter because I couldn’t continue with the process. One was positively episodic, three sessions only.

Of course, I don’t know what couples therapy is like from the therapist’s side. From my own perspective, it seemed that the process only worked when there was space—space in time, as long or as short as needed, neither cut off artificially or drawn out more than necessary. And when there was someone who listened to both of us. Comfortable physical spaces, too, not impersonal offices but welcoming rooms that looked like someone could relax in them.

Two people with multiple problems. Two processes that worked for both of us and one that didn’t.

I can’t pontificate about the process. All I can say is that couples therapy can work, and does work, and did work for us—at least two times out of three. What made the difference? I think it was the ability of the therapists to step back, listen to both of us, and not tell us what to do. They talked too, of course. They recommended books for us to read. They suggested new ways to think about things and talk about them. They absorbed the bad feelings in the air and didn’t deny them. But in their presence, it was possible to think, to listen, and to talk. To disagree, to argue, to come back together. To heal and discover. To grow.

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Mental Health

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Breach of Confidentiality

One of the things that people who see a therapist dread is a breach of confidentiality. Fortunately, it almost never happens. Therapists have client-therapist confidentiality that forbids it. It’s like the seal of the confessional for priests.

There’s an exception, however, and that’s the Tarasoff warning. Here’s how it came to be.

Way back in 1969, a young woman named Tatiana Tarasoff, a student at the University of California, Berkeley, was murdered. The killer was Prosenjit Poddar, also a student at the university. They knew each other and had gone on several dates. Unfortunately, as happens way too often, the couple had differing opinions on where the relationship should go.

Poddar became obsessed with Tarasoff. She was no longer interested. So he began stalking her. He had an emotional crisis and began seeing a therapist at the university medical center.

So far, it’s a pretty typical story of a relationship, a breakup, and an extreme emotional reaction. However, it soon became much more than that.

One day, Poddar admitted to his therapist that he wanted to kill Tarasoff. (He didn’t refer to her by name, but her identity was clear). The therapist said that, if Poddar kept issuing death threats, he would have to be hospitalized. Poddar stopped coming to therapy.

The therapist was left with a dilemma as to what he should do next.

The therapist and his supervisor decided to write a letter to campus police regarding the death threats. The police interviewed Poddar in the room he shared with Tarasoff’s brother. When Poddar denied everything and said he would stay away from Tatiana, the investigation was halted. The supervisor instructed the therapist to destroy all his case notes.

Of course, Poddar continued stalking Tarasoff and confronted her. When she tried to run away, he stabbed her with the knife he was carrying, killing her. He was arrested, tried, and convicted of first-degree murder (though he had tried to plea-bargain down to manslaughter). He served five years and was deported to his native India.

Tarasoff’s parents sued the university and the therapists on the grounds that they should have warned their daughter about the death threats. The therapists countered with the client-therapist confidentiality argument and won. Later, however, the case was retried and this time, in 1976, the Tarasoffs prevailed.

Since then, over half of US states have enacted “Tarasoff laws.” Others leave the decision up to the therapist. And Maine, North Carolina, North Dakota, and Nevada have specifically ruled that Tarasoff laws don’t apply there. The laws are still controversial. For one thing, the university therapists did call the campus police. For another, it leaves the burden of deciding whether a threat is credible solely on the therapist. And it left it up to the therapist whether to breach confidentiality. And there have been debates on whether Tarasoff warnings should be given regarding threats of physical violence that fall short of murder.

So, what’s a therapist to do? Warn clients that if they make threats, they’ll be reported? That can have the effect of causing the client to leave therapy. Guess—and it really is a guess—whether a threat is real or perhaps a fantasy? Err on the side of caution? Give priority to the confidentiality requirement? Risk a malpractice lawsuit brought by the client if the therapist does report the potential threat? A wrongful death suit for not acting in time?

Which prevails: the duty to warn a potential victim or the duty to preserve confidentiality? And is it a duty to warn or a duty to protect? (These distinctions have been made in some places.) We’ve become used to the phrase “harm to self or others” when it comes to involuntary treatment. But this question goes further. What does a therapist owe to a specific individual who may be killed? Sectioning the client? Reporting the threat to the police? Directly warning the potential victim?

It’s an awful lot to place on the shoulders of a therapist: determine the reality of a threat, make a prediction about future violent behavior, and determine an appropriate response. Weighing patient confidentiality and harm or death to another is a huge burden. But in the interests of there never being another Tarasoff-style murder, I’m coming down on the side of the duty to warn.

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Baby Steps Toward Healing

Once I attended a weekend photography workshop. One of my photos received praise as being innovative and interesting, one based on a technique I had seen a friend use. The rest of my photos missed the mark. I was frustrated by my lack of progress. The instructor reassured me, advising me that I should take (or was taking) “baby steps.” That photo provided a brief glimpse of what I could do if I kept at it.

My therapist has also reminded me of this numerous times. And she’s been right. Almost all the progress I’ve made in dealing with being bipolar has been gradual and incremental.

The baby steps process was long and arduous, lasting for years. The first step was taking Prozac, which helped me for a while, then didn’t. Most of the progress I’ve made with medication has been in tiny, discrete steps. My prescribing psychiatrists have never done anything quickly, which is in one way a blessing and in another a torment. They would try me on one drug, then wait to see the results, then try a different dose or a different drug altogether. Lather, rinse, repeat until progress at last occurred.

Progress in therapy has likewise been gradual over the years. First there were therapists who diagnosed me with depression, which was certainly true, though not the whole picture. And they helped, or at least a number of them did over the years. I learned a lot about depression in general and how it applied to me in particular. I also learned about relationships, and those insights helped my marriage.

Finally, I was given an accurate diagnosis of bipolar disorder 2 with anxiety. That was where the steps toward reaching some resolution regarding my medication really started. That was also when I started working with the therapist who reminded me about baby steps.

Although I had made steps toward healing in the past, I had taken a deep and protracted plunge into depression before I started going to her. Several years of it had left me immobilized, despairing. At my lowest point, I described myself as “pathetic.” There were going to be a lot of baby steps needed to get me out of that miserable place.

So we went to work. I liked the kind of therapy she practiced – non-directional, non-judgmental. (I had had problems with therapists who weren’t like that in the past. Needless to say, I made no progress with them. In fact, I even took steps backward.) There was a long way to go.

Dr. B. frequently reminded me of the importance of baby steps and, eventually, how far those steps had taken me. I learned coping mechanisms. I learned new ways of thinking. I learned to accept myself with the reality of my bipolar disorder, but without the constant misery. And, by the time my proper medications had kicked in, we were making some even bigger steps. But all my progress was built on a foundation of many, many baby steps along the way.

I think all therapy consists of a lot of little steps. I don’t know anyone who has had a great revelation that instantly moved them further along with their healing. I only got glimpses of what my situation could be like if I persisted. And along the way, I regressed at times, needing to re-learn the lessons I had been exposed to and re-taking the steps I had already accomplished. Progress is like that – two steps forward and one step back – especially with a disorder as cyclical as bipolar.

Anyway, I still go to therapy and still take baby steps toward whatever my future holds. I realize it will take a long time – probably the rest of my life – but I’m dedicated to the process.

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Mental Health

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Naming Names

A lot of us I know write about our bipolar disorder or other mental conditions, whether it’s in a letter, journal, blog, or elsewhere. One of the problems that comes up is how to refer to other people who have affected your story or been involved in your life.

When I blog, for example, I try to disguise – at least thinly – the person (other than me) I’m writing about. For family members, I usually leave it at “my sister,” “my mother,” “my aunt,” “my cousin,” etc. Admittedly that’s not much of a disguise, as I’m estranged from my sister (which is a story I’m not likely to tell) and my parents have both passed away. But I have only one sibling and two parents, which makes their identities easy enough to guess, if you know my family at all.

My husband I refer to as Dan, having gotten his permission and never using his last name, which is different from mine. And my doctors I simply call Dr. G and Dr. B, or “my psychiatrist” and “my therapist.”

For friends or others who have affected my life, I invent pseudonyms, usually beginning with the same letter of the alphabet – Brandon for Bob, Joan for Julie, and the like, or a descriptive phrase – my friend the artist, my friend the writer, the rotten-ex-boyfriend-who-almost-ruined-my-life (I assure you he would be unable to recognize himself from that, even if he read my blog, which I’m sure he doesn’t). Some of these people are vital to my past, my present, and my stories, but I don’t feel I have the right to divulge their names.

If I write about these people in my other blog, the non-bipolar one (butidigress.blog), I might – and sometimes do – call my friends by their first names: Peggy the artist, Michael the writer, or sometimes leave them anonymous. In those blogs, I mention them with no pejoratives attached, or I use pseudonyms if I do.

When you’re writing in a letter or a journal which someone else might read (journals are not as sacrosanct as you might think or wish), it’s hard to avoid naming names. Once I was writing in my journal and a nearby person happened to glance over my shoulder and see what I was writing. Or you might let your therapist read a few pages of your journal to explain a situation that you were reacting to in the past. That’s safe, though. Your therapist is your therapist and not allowed to discuss your case with anyone you know.

Letters, however, are dangerous. First, there’s the kind that your therapist has you write to a person who hurt you, for example, as an exercise on how to express your feelings. Never send these letters. Even if you want to tell the person exactly how you really feel or felt, your raw, uncensored emotions and view of events are more likely to do harm than good. Especially if you’ve been in an abusive relationship or have been gaslighted, never reach out. It gives the person another way to be involved with your life, which is what you don’t want.

Then there’s the possibility that whoever you wrote about accidentally reads the letter or journal. This can ruin whatever chance you might have had to repair the relationship (if that’s what you really want to do). Tear letters up, delete them, put them in a file called Never Send if you feel you must keep them to remind yourself of how you felt back then. But don’t send them or show them to anyone other than your therapist. (And keep in mind that your letters can be found accidentally, or after your death.)

I have known a couple, one of whom wrote to the other to present an ultimatum, and it didn’t work. The oblivious partner simply ignored it, which you’ll understand also caused great pain. It was a significant factor in breaking up their marriage. They were both, by profession, supposed to be good with words, but in this case, neither writing the letter nor reading it succeeded.

I suppose it’s time to resurrect that old adage, “Sticks and stones may break my bones, but words will never hurt me.” When used to “encourage” children who have been bullied, it is a lie. But keep in mind that your words can definitely hurt someone else – or yourself – too. Try not to do that.

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When Your Therapist Tells You What to Do

The classic examples of non-directive therapists are Sigmund Freud and his disciples, who legendarily sat at the head of their couches and made comments like, “Hmm,” “Tell me about your dreams,” and “How do you feel about your mother?”

Freudian psychiatry is, thankfully, now out of vogue. But there are still therapists who believe that their job is to listen, not to instruct.

On the other hand, there are more directive therapists who assign homework. This can be anything from “Listen to this podcast on mindfulness” to “Write a letter to your ex telling him/her what you truly feel.” They probably won’t tell you to kick the bum to the curb, but if you decide to do so they’ll help you prepare for it.

But, although I am far from a Freudian and shy away from those who are (not many these days), I prefer non-directive therapists. I am not averse to doing a little homework or having a therapist ask me in a session to vocalize what I would like to tell a person or even to write a list of the coping mechanisms I’ve developed. My preferred dynamic, however, is to give-and-take with the therapist and then go home to contemplate what was said and how I feel about it.

I have had therapists who have given me homework and I can’t say they were wrong to do so. Sometimes writing something down or throwing teacups against the basement wall (or whatever helps you get your anger out) is a good thing.

My most recent therapist was a combination of the two. She mostly listened while I rambled on about what was happening in my life or what had happened in my past. Then she suggested ways that I could think about the events or pointed out coping mechanisms that I had developed or suggested ways I could put those coping mechanisms to use.

All in all, I felt that our sessions were mostly non-directive. She did suggest that I listen to a podcast on mindfulness, but she never quizzed me on whether I did and only listened when I told her what I got from it. She never told me that I should delve deeper into mindfulness or listen to more podcasts. She left that up to me, if I thought it might be helpful.

I understand that some therapists, particularly those that work in community mental health facilities, are required to file treatment plans and I can see where giving homework can flesh one out more than “talk about feelings.”

Perhaps there is something I’m missing. Perhaps at different stages of therapy, directive psychological interaction is more beneficial. Perhaps my particular problems lend themselves more to non-directive therapy. Perhaps I just have an aversion to being told what to do, especially where it concerns my memories and my feelings.

Of course, everyone has the option not to do the homework. This can be seen as resisting treatment, or disagreeing with the treatment approach, or simply lacking the wherewithal to carry it out. Sometimes it may be more helpful when the therapist sacrifices part of the session to doing the assignment there instead of leaving it to be done at home. In this case, the therapist is being really directive, though of course the client always has the choice not to do the assignment. It’s much harder, though, when the therapist is sitting there waiting for you to make a list of your dreams, your feelings, or your interactions with your mother, or to bash an empty chair with a pool noodle.

What it comes down to, basically, is therapeutic philosophy and therapeutic style. And a client is not bound to pursue whatever style of therapy that is favored. Although it is sometimes difficult to realize, a client has the option to request or to seek a therapist whose therapeutic style matches what the client feels is most helpful.

Remember, your therapist works for you, not the other way around. If you need a more or less directive therapist, it is your right to seek one out. Therapy has been known to stall and a different approach or philosophy may be just what you need.

 

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