The Transition: Finding and Keeping a New Therapist

A few weeks ago, my therapist of many years retired from direct therapy and moved into a managerial role. That means that a few weeks ago, I not only lost a serious piece of my support system, a repository of a great deal of knowledge about my mental health and history, and someone who knew my coping techniques inside and out, but also someone that I would consider a friend or at the very least an ally.

I’d spent more time with Rebekah than I have with many people I today consider my friends. An hour once a week for over 4 years is a lot of time to invest in a relationship with someone. Add in the fact that those hours are times of serious emotional work, when you show your therapist a lot of vulnerabilities and work through the harder parts of your life, and this is someone that you have to trust in a serious way, not only to be good at their job but also to handle you and your feelings gently and respectfully. You have to learn that this is someone you can feel safe and comfortable with, maybe someone you can even enjoy your time with.

When most relationships end, it’s understood to be a time for some grieving, for some element of hurt and sadness. For some reason the therapist/patient relationship is still viewed pretty strictly in business terms, that they are providing a service and you are paying them. That’s strictly true, but it’s also true that there are many service providers that get close to their clients: massage therapists, manicurists, hair stylists…all sorts of people that you see on a regular basis will come to know you over time, and many people see those relationships as important in and of themselves, beyond the service that gets provided.

While finding a therapist that is a good fit for you is hard in any circumstance, it gets significantly harder when you’re comparing them to your old one, the one you liked so much, your friend. Trying to start fresh after having built up a level of understanding and history with someone is incredibly difficult.

Here’s what I’m telling myself:

This is hard. It gets to feel weird and uncomfortable. If the new therapist keeps feeling weird and uncomfortable in a month or two months, this might not be the right fit.

Finding a new therapist is a challenge no matter what, but finding one to fill the shoes of someone you thought was just about perfect is even harder.

No one has failed if you decide this isn’t right for you and move to a different person. No one will ever replace the therapist you liked so much. If you’re lucky you’ll get a new friend. If not, you got someone awesome to help you through some of the hardest times you’ve had so far.

It’s certainly weird to feel as if I need to grieve for the ending of a patient/provider relationship, but I do feel that way. I miss someone who knew me so well, someone I trusted. I suppose what I’m trying to say is that the nature of the relationship between therapist and patient is a unique one. It would be nice to have an open discussion about the rules of the unique relationship.

Frustrations with the DSM

I live in a very psych oriented world. I work for a nonprofit that provides services to kids with autism and developmental disabilities and general mental health problems. I spent at least five hours a week in therapy. I talk a lot about mental health, I care a lot about mental health, and a few of my friends and I just started throwing around the idea of creating a skepticism and psychology conference (SO EXCITED). So I’m thinking (as per usual) about mental health.

One of the talks at SkepTech (by the fabulous Stephanie Zvan) was about psychometrics, which is “The science of measuring mental capacities and processes.” She talked a fair amount about how we often define certain disorders based on our stereotypes: we view autism as a boy’s disorder, so the diagnostic criteria are slanted towards how autism presents in boys. I think this is a very important thing to address (especially in terms of race. UGH), and I think the place to start is with the DSM (the psychology diagnostic manual). The DSM is very much a quantitative measure. For eating disorders for example, it lists particular weights, numbers of binges and purges per week, and length of the persistence of the disorder as diagnostic criteria. In many ways, these concrete diagnostic tools are incredibly helpful: they allow insurance to see who to treat or not and they allow clinicians to have something more solid than personal judgment to use in their diagnoses. That’s important. We do need some element of consistency, we need some science in our diagnostic tools.

The problem shows up in the fact that many of these diagnoses are written around what is considered the typical case and doesn’t necessarily allow for any variation. It also doesn’t address the fact that many people have lots of symptoms that don’t quite fit into a neat diagnostic category. In many ways it’s far too rigid. Diagnoses that involve NOS (not otherwise specified) often aren’t covered by insurance, aren’t included in research, and aren’t afforded as much respect as serious problems by clinicians or the individuals diagnosed.

This is a really big deal because it limits who can access mental health care based upon demographic or personal variation. Males with depression generally exhibit it in very different ways from females, and they are not diagnosed as often because they aren’t viewed as the typical depression sufferers. People of color are not diagnosed with eating disorders nearly as often as white girls (particularly teens).

So how can we both create helpful categories AND capture the wild diversity of mental illness? How can we approach mental illness not as a checklist of symptoms that we address and move the individual back to the neurotypical end of the spectrum? First and foremost, insurance needs to NOT be tied to strict diagnosis. That is not fair to individuals who might need preventative therapy or interventions, or those who want to catch a disorder before it becomes so serious that it interferes with their life. It is also not fair to those individuals who have a serious mental illness that is wreaking havoc on them, but who don’t fall neatly into a category. But it’s also unfair to those who DO fall into the category, because it might ignore any other symptoms or problems that could be contributing to their diagnosis. OF COURSE labeling some patterns and similarities can be helpful because it allows us to conduct research and to develop treatments that work for people with similar issues. But these labels should not be considered so strict, should not be the only guide we have in treatment, should not have such harsh boundaries, and should allow more movement between diagnoses. They should be guidelines (the code is more like guidelines than actual rules).

There should also simply be more cross-cultural research. Right now we have very Western-centric views of psychology as well as very white, male views of psychology (thanks Freud). We need to focus on evidence based treatments, and we also need to simply be willing to have MANY types of treatment available for people who are exhibiting different symptoms because of their demographic. We need to have psychologists who are social justice aware: personally I think that sociology, women’s studies, and race studies classes should be required of every psychology major. It is SO important to improve our mental healthcare system, and the first place we need to turn is how we determine who needs mental healthcare.

If we’re being honest? EVERYONE. Mental healthcare isn’t about turning people into the neurotypical. It is about improving functioning. Everyone could use a mental health checkup, just like they have a physical health checkup to make sure they’re functioning like they should and to catch any worries or glitches before they turn into something serious. We need a paradigm shift that no longer sees diagnoses as identifying problematic difference to seeing diagnoses as identifying problems with functioning that require help.

NOTE: they are trying to adjust some of these problems in the latest update of the DSM, the DSM-V which is coming out in May.