Yesterday I decide that I feel bad about quitting the shrink all abruptly and in a rage. That I didn’t want to end like that, if just out of politeness. I really wanted to call and leave a message apologizing, and wishing him a happy holiday. I said that I was going to be the bigger man here, be the one to let my ego come down off the high horse first. Because, true, he shouldn’t have gotten sucked into the whole yelling and power struggle, but I participated too. I felt bad. I decided that, for the sake of my own dignity, that no matter what he said or did, that I wasn’t going to get into another knock-down-drag-out. I was going to be mature and in control, like my first therapist taught me.
Unfortunately, he answered the phone, despite my best attempts at timing to get voicemail.
“Hi, this is Sara. I just wanted to say that I’m sorry for losing my temper, and I didn’t want to end on that note. So…I’m sorry for anything I said or did that was inappropriate – ”
At this point he cut me off and said ominously, “Well, I’m sorry too that you’ve chosen to be like this and end things this way.”
My blood pressure immediately rose and all of a sudden I was almost ready for a fight again. I mean, even if I and my personality flaws are 90% at fault, there was at least some unprofessionalism on his part.
I took a deep, deep breath, and said, “Let’s not go into this again. I really just wanted to apologize for yelling, and wish you a happy holiday.”
He could hardly control his anger and snapped back at me, “Happy Holiday!” and hung up.
* * *
I promise, soon to get to the post on recurrent/long-standing mental illness and what the Buddha has to teach us. You know, something that might be of use to someone.
But since this is my journal, I can use it to think in writing. This incident raised so many questions for me.
Am I so crazy that I am imagining the anger/stubbornness/power struggles coming from him? Is that projection or some other psychological bullshit I am doing because I’m really as fucked up as he says?
Is there a legitimate therapeutic reason ever for being obscure or concealing the therapeutic mechanism? Is it ever right to say to a patient: I don’t think we can discuss your condition, how we are going to go about treating it? Is it ever ok to refuse to discuss the kind of therapy you do? Is it ok to say, “You just have to trust me” – and not at a given moment, but as a guiding policy? Especially when the patient is going through considerable distress as a result of the treatment? I mean, if I give a patient steroids for a serious disease, and they complain of side effects, I feel obligated to explain why I think that the benefit of the drug outweighs the side effects, what it is doing to them. Is psychiatry really so different?
Is it ever ok to refuse a patient their record, especially while refusing to give a reason? (Thanks to Jay for some perspective on this one.)
Is honesty on the part of the therapist always an important part of therapy? I mean, to me, it seems like that’s exactly what I’m paying for – someone else’s honest and trained opinion. But maybe I am understanding wrong – maybe I am supposed to just let him do whatever it is he is doing?
Is there a rule that therapists should never apologize? I mean, this whole thing would have been avoided (in retrospect), if he could have just said something like, “I’m sorry you feel hurt.” I wouldn’t even expect an apology for the content of what he said or anything – just some sort of acknowledgment that I was upset. Is there a rule in therapy that it undermines authority/transference/focus on the patient to apologize? I mean, my natural instinct in a similar situation with a patient – no matter how nuts they are – is always to say something like, “I’m sorry you’re so upset.” And when I’ve lost my temper or gotten annoyed with a patient, I always apologize – but maybe out of my own sense of guilt and remorse rather than concern for them?
The reaction I got was, “Why are you upset? There’s no reason for this to be upsetting to you. Why should this (being called both narcissistic and borderline in two sentences, one after the other) be a cause for concern?” This seemed so invalidating after I had said it was worrying to me to think that that might be the problem and asked what the treatment would be, what to do about it. I think I would have been ok if he had said something like, “Yeah, it’s hard to hear.” But a total failure to understand why I was upset – and then to tell me to “not be upset” was incredibly invalidating. It’s ok to tell a patient, I think, that their feelings are colored by their past experience or knowledge, that maybe they are taking offense or being hurt excessively – that, after all, might be part of what brings them to therapy. But to flat-out say that someone has “no right/reason to be upset” seems sort of anti-therapeutic to me – I mean, isn’t part of the idea of therapy recognizing and acknowledging feelings (even if one wishes to change them)?
Is any problem always the patient’s pathology?
And most importantly: Why do I keep seeking validation and understanding in a place where I so obviously am not going to get it? Why am I seemingly endlessly attracted to going back to someone who repeatedly hurts me, hoping for a different outcome the next time? What buttons is he pushing in me, or what screwed up need do I have that I keep running right back in for another round?
* * *
I’d like anyone, but especially therapists working in various schools, to respond to any question that catches your eye.
Anyway, if anything, that phone conversation should have cemented my position. From time to time, the situation catches me and I feel kind of bad. Not abandoned or whatever – I mean, I know if I’d just give in and stroke his ego a little, I’d be welcomed back and “forgiven.” It’s not like he’s kicking me out. I am, as he said, “choosing to end this way.” I think the choice is being made rationally, for sound reasons. I mean, I have to trust my own intuition and logic – it’s the only source I have. The real question is why I’ve been ignoring the signs for so long.
But still, I think it’s ok to feel a little sad. After all, even if he never did offer me much in the way of comfort, even if I’ve gone downhill under his care and felt worse for it…it still is, as Tony White would put it, an attachment, even if not the healthiest one in the world. I did like the guy as a person, if not as a therapist. And we’ve known each other a long time. And he did try to help me. Maybe I’m just unhelpable or unreasonable. So I think it’s ok to feel kind of bad, knowing that in the long run I’ll be better off. And I think I really do need to examine why, after so long and so much of my gut and brain telling me otherwise, I kept being pulled back.
Is a big part of it hope and regression? That he promised that, as deeply flawed as I am, that there was hope of a “cure” if I’d just keep coming and talking to him? (A lot of my frustration that brought up the conflict was that this therapy seemed to be going nowhere – that it was just like chitchat…with no change in anything.)
* * *
About the comment on the last post about the colors and design of the blog being dark and depressing, well, true. But I rarely see them anyway – I just see the compose window and get the comments by email. I almost never look at the finished blog, so I forget the dark colors and photograph. I feel sort of like I do want to leave it, just because this is the place I can let the darkness out, my place to be the goth teenager I secretly always wanted to be. My other blog, the one about my real life and not my mental patient life looks nothing like this at all. Though it is a good point. I do take a lot of these kind of suggestions in real life – exposing myself to sun, to sunny people, exercising, keeping the Dali posters off my walls in favor of something warmer – definitely a good point.
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My Sad Alter-Ego 
Um… just ditch the fucking idiot if he yelled at you. That’s just weird and seriously unprofessional and there’s no way I’d be paying for someone to yell at me… I can do that myself.
In my opinion the professional relationship between you and the psychologist has broken down with some anger from both sides it would seem. All I can say is that you learn from this experience and maybe with your next psychologist, you could try a more docile approach of accepting the role of patient rather than medical colleague as the psychologists you see might want to come to a significant diagnosis before explaining it to you. What they have written in their notes maybe early assumptions or guesses about your condition and by you seeing them it could be detrimental to your wellbeing. All I’m really saying is that to begin with give the new psychologist your trust (I know that can be difficult) and let him puzzle out your condition rather than you trying to figure it out with him. If after some time you feel that he isn’t helping you then you could ask him to explain what process he is using with you and to try your approach of him diagnosing the condition with you.
Either way the psychologist you have been seeing shouldn’t have gotten so emotionally involved and should have realised that he could have helped you by being more frank and open about the conclusions he was coming to.
I hope you feel a bit better soon.
Dom
He is in the wrong here. It is not “all in your head.”
>>Am I so crazy that I am imagining the anger/stubbornness/power struggles coming from him? <>Is that projection or some other psychological bullshit I am doing because I’m really as fucked up as he says?<>Is there a legitimate therapeutic reason ever for being obscure or concealing the therapeutic mechanism? <>Is it ever ok to refuse a patient their record, especially while refusing to give a reason?<< NO. At least not in the US.
Oh, I totally fucked up that response. Sorry.
In short: you may be crazy 🙂 but he’s off the beam. He’s behaving in an inappropriate, unprofessional manner. Most, if not all, of the anger and power play is coming from him. And NO, it is never OK to refuse to give a patient her record, at least not in the US.
Here either – they can, in extreme cases, go to an ethics board and state a case not to, if, for example, some patient would jump off a building if they told them they had cancer…but in this situation, what can I do? I can send a lawyer letter, but I don’t think I really want to go down that road. And somehow, I suspect I wouldn’t get much other than a brief note out of that either.
I just can’t figure out why all of this situation has me so upset. Or what keeps attracting me to go back. All day (I’m post-call) I keep wondering if really what he says is right. If I am doing borderliny shit, like trying to make him upset because I am.
Dom – this guy is a psychiatrist. And I thought I was almost overly trusting of him…like at the very beginning, I asked about his approach and got a wiffling answer, even before this breakdown or any other…and I didn’t insist on a clear answer…I should have been tipped off then…there were lots of warning signs, but he was always nice to me…though it often felt like every kind of relationship I’ve been in where I know I shouldn’t go in in the first place, but it has some uncontrollable attraction.
Hi Amy – thanks for the support.
I have read most of your posts over an extended period time, and being a psychiatrist, have been reluctant to comment. You seem to bite (it’s a joke). As physicians we are, first & foremost, scientists: we make observations & decisions based on available data. And not only that, we will do it all over again (and sometimes again & again) to be sure. When I write, I am scrupulous in distinguishing conjecture, speculation, opinion, and “anecdote” from science. You are not.
Secondly, I learned a long time ago that accepting one side of any patient’s and/or clinician’s “report” is foolish, if not dangerous. Asking lay-people & “clinicians” to comment on your subjective report is patently unfair. Imagine – theoretically – your therapist presenting YOU to colleagues & they responding, “Why do you tolerate her? Fire her! She’s disrespectful, resistant, and help-rejecting.” In my estimation – -theoretically – as unfair as the former.
As to the issue of withholding psychiatric records (and I’m in the US), clinical notes are contemporaneous records of contemporaneous events by one clinician. It is illegal in the US to “change” a clinical note entry (and I believe highly unethical even if it were legal), but I frequently submit myself & my accompanying notes to a treatment team, to a supervisor, or to a colleague(s) and frequently change my opinion of what contemporaneously occurred. I have, I am, and I fully expect to be wrong now and in the future. Therefore, of what benefit – and that is precisely & ultimately the primary criterion of any practicing physician – would my notes be to you? I suspect – theoretically – that open-ended access to clinical notes would divert the therapeutic process to the notes, rather than the patient-physician relationship.
I have no problem telling a patient what I believe a diagnosis to be, of what the accepted clinical standard for treatment consists, whether I feel competent to provide that clinical standard, & how I plan to proceed. I both respect and reserve the right to terminate pursuant to mutually agreed-upon goals. A patient I diagnosed with BPD said, “And just WHAT do you plan to do?” I said, “contain you.”
Finally, I would refer you to the literature regarding long-term outcomes of therapy with Borderline Personality Disorder (which I might suggest could have been the place to start). I, for one, am especially encouraged by the data, and never a patient’s disdain for any given diagnosis.
For the record, my diploma says “Cum Laude,” and while I believe my frenetic personality is best suited for the ED, I love what I do.
Foofoo, thanks for your comment. It was interesting. I also sort of wish he had gotten some kind of outside advice on how to handle things, to present to colleagues, etc. I think he is sort of biased right now. I also wonder many times why he hasn’t fired me; in fact, I find it somewhat suspect that he has always encouraged me to stay. I, in fact, would be happy to get rid of a patient like me. My gut feeling is that crazy chicks are his thing – he has sort of a savior complex. Doesn’t want to “give up on me” or anything. I think that by far the most responsible thing would have been for HIM to long ago have raised the issues I raised now and the lack of efficacy of his treatment.
I don’t expect anyone here to answer my questions – they are just discussion points, and a list of questions running through my mind.
I’m not talking about open-ended access to the notes; in fact, I have refrained from ever mentioning them previously out of respect for him and understanding that he needs to be able to write whatever without thinking, “What will she think?” However, when any medical treatment goes as badly as this one, I do believe that full access is the best way for both the patient and the team to understand what happened and make their peace with it. The same would go for a botched surgery. The sad thing is the adversarial system, with lawyers and money coloring things – it would be much better for everyone to just be able to understand that shit happens and to apologize. I just want to know what went wrong, since apparently neither of us is able to explain it. I want to know what he was thinking so that I can examine myself and see if there is any truth to it.
Furthermore, I don’t actually dislike psychiatrists – I think they are doing some of the most important and thankless work in medicine. They have the potential to help more than anyone. II wish I were good enough to do it. That said, there are a lot of hang-overs from less-than-enlightened times.
I am also familiar with the literature about long-term therapy in BPD – the dynamic approach is not very successful. Some others are. Success, anyway, means getting people to more or less where I am anyway. And in my case, I have clear evidence of it making me worse – provoking in me thoughts and concerns and doubts and behaviors that did not exist before. I have learned an important lesson in how our expectations of patients shape their behavior. I’ve never had this kind of interpersonal trouble with anyone – but the moment I am treated like this, all kinds of shit starts flying back – the rage etc.
And lastly, this whole blog, narcissistic as all blogs are, is my account of being on the other side of the couch, treatment table, what have you. And things look VERY different from this side.
I can relate a lot to using the blog to express hidden parts. I have my superficial blog as well. I doubt anyone would think to associate one with the other.
Sara, I am sorry, I just read foofoo5’s comment and i just can not help saying this: well, i have been a schizo since my mid teenage years and being around many (and yeah i mean many) of his colleagues, i can say shrinks are… well, tolerable? yeah but likable? naaaah…
p.s. in contrast to Sara, i am extremely unfamiliar with the literature of any sort!
love you Sara.
Milo
I never comment on blogs but have been following you for a while. What’s prompting me to respond is foofoo’s comment, which seems defensive to me, and may I say, not all psychiatrists follow your diligent procedure. I am also coming from the other side of the couch. I’ve been to several shrinks, and one has REALLY helped me (actually she was a PhD) and the rest have NOT. Maybe because they’re male? I don’t know. Foofoo, you make me very angry. Maybe it’s misplaced anger for Sara’s psychiatrist, because I really wish you, Sara, had dumped him so long ago. He was really fucking with your head, intentionally or not. For whatever it’s worth, I think these are the important questions from your post:
“And most importantly: Why do I keep seeking validation and understanding in a place where I so obviously am not going to get it? Why am I seemingly endlessly attracted to going back to someone who repeatedly hurts me, hoping for a different outcome the next time? What buttons is he pushing in me, or what screwed up need do I have that I keep running right back in for another round?”
I hope you are feeling better than you were when you said you didn’t think you’d ever see another Passover. I will stop rambling now, but I wish you only the best. You have lurkers rooting for you.
Check out Trauma and Recovery by Judith Herman… it’s a good read and very interesting, if a bit outdated.
Hello Sara:
I am not a physician (I am an attorney). However, I have been in therapy for various issues for numerous years. I have had 4 bad, 2 mediocre and 1 spectacular therapist (the psychiatrists were all bad). The one spectacular therapist saved and changed my life. I had almost given up on therapy when I found her, accidentally.
With this in mind, I can tell you unequivocally that any therapist who is abusive is not a good one. If you are lucky like I have been and find a good fit, I believe the help of a therapist is miraculous. You will know when you find it. Having suffered with so many jerk psychs (one who was “famous” and then actually was arrested during my treatment period), I see the difference. Please do yourself a favor and get away from any “helping” professional who makes you feel badly about yourself. It doesn’t have to be that way.
Grrr. Your therapist makes me so angry.
Blessings and light to you, Sara.
Thank you so much for the words of hope. Tonight I am meeting with someone new who I saw once. For some stupid reason, I still feel attached to the jerk. I guess that’s something for therapy ha ha. After this guy, my thoughts were that whatever I need isn’t to be found in the world of psychology. But I did have a good therapist before years ago and she was tremendously helpful, mostly in practical stuff…not deep psychological stuff. I guess I should keep trying. I’m still in training though, so money is a huge issue too.
Thanks, and best of luck on your way too.
That therapist is an asshat and you are better off without him.
As far as being gothic, it has no expiration date on it. I’m 40 and still goth and will go to my grave this way (hopefully not any time soon. lol)
I have never had luck with therapists. 😦 I’m treated for depression by my family doctor. She’s actually doing a competent job with it. I take Lexapro.
I totally agree. My family doc is doing at least as good a job…and a lot cheaper. And therapy seems like bullshit to me too. At least a lot of it.
And I also have been a lot better off without him – will update when I get a minute.
I totally agree. My family doc is doing at least as good a job…and a lot cheaper. And therapy seems like bullshit to me too. At least a lot of it.
And I also have been a lot better off without him – will update when I get a minute.
Thanks for writing.
Sara, why so adamant about having a psychiatrist? You are a doctor. You must understand that life is hard sometimes, and other times it is great. I am not being sarcastic when I write this. My observation is that you are generally bored (even though your job may be demanding that doesn’t eliminate boredom). It reads as if you crave attention from a psychiatrist and especially ones who add drama to your life. Now, I can understand the boredom and craving drama completely. I do think it may be that simple. Seems like you would do well if given the right combo of medication and possible stuck with your current psychiatrist. My suggestion to you is two: 1. Why not print out your entire “blog” start to finish and have him read it. He will then understand much more about you and be able to help you without making it a guessing game for him. And if not, or in conjunction with, since you are a doctor, I believe you may make a good psychiatrist. Have you ever considered changing specialties? With your experiences with psychiatrists and what you consider wrong and right with treatment of patients under their care, it would give you an advantage in becoming a psychiatrist of being on “both sides of the couch”. Also, nothing wrong with a dark side and thoughts. Why stress yourself trying to juggle two sides of yourself; the “sunny” one everyone sees and the “real” side of you that you perceive as “dark”. Just be yourself consistently. Any good reason why you shouldn’t? No one else makes an effort to change themselves. Also, it’s not necessarily BETTER to by a sunny, happy, happy one (kindof annoying actually). What is so horrible in your life? And, stop having 2 sides. Try the secret dark side as your consistent self, people will like you better. Much more interesting than the cookie-cutter “sunny” personality that is a dime a dozen. Thanks.
Hi Grace,
Thank you for this very insightful comment. Actually, I guess I need to put up an update post. You are right – I do not need a psychiatrist, except that I do because my regular doc is not comfortable prescribing the kinds of meds I need.
Since then, I found a different psychiatrist, and after a few more med attempts, landed on one that works, and I haven’t been back to see him since. The difference was immediate, the guy was … not great, but PROFESSIONAL. No mind fucks. I don’t really understand what exactly happened with the one before, I think in retrospect a lot of the drama and trouble was not my fault. Now that I am reasonably well medicated, the need for “help” and drama is gone and…life just goes on. It’s so strange, all the crazy just falls away.
As for him reading anything – any time I gave him a piece of this blog to read or anything like that, he never read it, which was hard, it was something incredibly personal to me and just brushed off by him. Also, English is not his preferred reading language.
Anyway – I’m glad I’m out of that mess. As for stimulants – I asked him once about something like that during the bad depression and he said no way, I went into manic rages on Edronax even…so something like that was just too scary. Effexor made me crazy, so I don’t think Pristiq would be a good idea. Cymbalta was horrible for me.
Thanks for stopping by.