Tale #2: A Diagnosis by any other name....

That diagnosis you have is probably crap.

Now before you go blasting me with hate and sending dirty vibes my way a la Ben Folds style hear me out.

Do I believe mental illness is real? Yes.

Do I believe such things as depression, anxiety, and even schizophrenia affect all different types of people?  Of course.

Do I believe mental health is serious business and should be treated as such?  You bet your bippy I do!

Do I believe the majority of Americans have a remedial understanding and skewed perception of such mental health issues? ABSO to the LUTELY!

The thing of it is, according to the National Institute of Mental Health only 2.6% of the American population suffer from Bi-polar Disorder.  And apparently…..they all live in Southern Illinois because nearly every family I come in contact with has a grandmother, uncle, and third cousin twice removed who is Bi-Polar. [Dismount soap box]

There are many things I will tell you as your therapist but your diagnosis is not one of them.  Unless you ask me out right, I don’t disclose that information to you. (Please don’t question my ethics. Nowhere in the counselor’s instruction manual does it say I must inform clients of their diagnosis.) There is a reason I don’t tell a client what I have diagnosed them with. And that reason is that a diagnosis can become a crutch.  I have literally had people say to me such things like, “You know I can’t get a job because I’m bi-polar!”  And after I pick my jaw up off the floor, I climb back on my soap box and insist, uh…I mean encourage them to find ways to cope with the symptoms that come with Bi-polar, instead of choosing to use it as an excuse for giving up on all social responsibilities. It seems too often people pass on educating themselves on the signs and triggers and accepting the responsibility that life will need to be managed differently and opt to travel the low road.   Of course, it should go without saying that some don’t just take the high road when coping with mental illness but they go all Bear Grylls on Mount Everest when it comes to surviving.  I can hear some of your grumbles now.  But Jessica, you are thinking, my mother’s brother-in-law’s step-cousin is bi-polar and there is no way on God’s green Earth she could ever function on her own in the real world. Maybe that is true.  But I have hope that every person in this world has the capability of being a happy, healthy individual.  If I didn’t have that hope, I wouldn’t do what I do, day in and day out. 

The truth is I struggle with diagnosing. If there was a TV show called Man vs. Mental Illness then I would probably crash and burn and be left behind to be eaten by gigantic alligators.  It’s messy and unclear and quit often questionable and I don’t like it.  And I’m going to let you in on a few well hidden secrets your therapist may not tell you about diagnosing.  

1.   A while back a concerned mother asked to talk to me about her son’s diagnosis given to him by a hospital.  She told me that in the past he has been diagnosed with ADD, ADHD, ODD, Mood Disorder NOS, and now he is Bi-polar and she wanted to know which one was right.    This mother felt that it depended on the day of the week as to which diagnosis her son had.  Unfortunately, she is right. When I meet a person for the first time I do a Mental Health Assessment.  It is an eleven page series of questions of everything from social history to education to presenting problems.  I have to base my diagnosis on the behavior and information given to me that very day.  If a child is released from the hospital with a diagnosis of ADHD but I don’t see or the family doesn’t report the symptoms of ADHD that day, technically, I can’t give that diagnosis as well. Even though it is possible for a person to have more than one diagnosis at a time I still can’t give it if I can’t prove it based on the information gathered that day.  The problem then, is that diagnosing is subjective and the DSM acknowledges this. In the limitations section it notes, “The specific diagnostic criteria included in DSM-IV are meant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a cookbook fashion.” This to me is a recipe for inconsistency.  (Pun acknowledged and intended.)

2.   Inconsistency aside, diagnosing is also a lot of pressure.  If the above quote is true, then my clinical judgment serves as the catalyst for an appropriate diagnosis.  Do you want to know how many classes I took in graduate school that taught me how to diagnosis someone correctly?  Zero.  I can remember touching the DSM three times in my two and half years in grad school. The closest I came to an actual lesson on how to use it was in my Abnormal Psychology class when one portion of one class period was spent reviewing a case study and “familiarizing” ourselves with the “Bible of counseling.” It wasn’t until after my internship with the place I work now that I even felt competent enough to own the DSM let alone exercise my “clinical judgment” when using it and even still some days I question my proficiency on the subject matter. I hate knowing that the four digit code I write on a piece of paper is going to be hovering around in the counseling atmosphere for the rest of that kid’s life. Once I place my qualified mental health professional signature on that line, that diagnosis is there to stay.  It’s the proverbial tattoo of mental health.

3.   But I think the hardest concept I have to reconcile is the fact that ultimately, the only reason I must give a diagnosis is so we can get paid.  [insert not so surprised gasp here]  Truth is I cannot bill Medicaid (or most insurance companies for that matter) for therapy until a diagnosis is given.  And to take it one step further, my treatment plan goals then have to be directly related to the diagnosis.  Since when did helping people have to become so procedural and financially motivated?

Remember that episode of Arrested Development when Gob is kicked out of the Magician’s Alliance for accidently revealing how a trick was done.  Well, right now a feel like I’m two seconds away from being blacklisted and becoming the afternoon entertainment at Chuck E. Cheese.  But joking aside, my list of apprehensions with diagnosing could go on for pages and pages. I think my trepidations, however could be summed up in one sentence.  The deeper I get into counseling the bigger my fear gets that I will ultimately begin to see people as a classification of disorders instead of seeing their story for what it really is: Life.

Bloggers note: My apologies for the repetitive references to Man vs. Wild. I finally got around to watching the episode with my celebrity crush Jake Gyllenhaal and it’s been on my mind grapes all day.  

Tale #1: "If you don't have anything nice to say..."

Recently, a coworker and I found ourselves sitting in a therapy session with a mother, her fiancé, and her young son.  For nearly thirty minutes the mother went on quite the enthusiastic tirade about all of the horrible, evil, and awful acts her son had committed within the last couple years of his life.  I watched her son sit next to her, with his eyes fixated on her and mouth gaping wide open.  Not once did he defend himself or give any inclination that what his mother was saying was not true.  Even when I questioned him about the things he had done, he admitted to most of them.  For half an hour she referred to him only by his first name as if he were not present in the room let alone just sitting a few inches away from her.  Not once did she make eye contact or physical contact of any sort with him, nor he with her.  For a solid 1800 seconds she spewed out one negative comment after another intertwined with stories of how her other children do not behave in the same manner as him and how they “just aren’t any trouble” compared to this young boy.  It wasn’t until the words “spawn of Satan” slipped from her lips that my coworker quickly interrupted and asked the boy if he would like to go into the hallway and play with the other children. Immediately, I was ashamed of myself for not asking him to leave sooner or better yet, for not asking this mother to watch what she was saying.  Individual therapy is difficult enough but throw two or more people into a session and a strange phenomenon can occur.  It’s the ol’ squeaky wheel/greased dilemma.  The person who directs the therapy onto themselves becomes the target and everyone else is left to fend for themselves. In the midst of providing ‘empathetic listening and support’ to the mother I failed to do something so extremely vital.  I failed to be an advocate for this little boy. 

The good news is that I’m not one to make a mistake and fail to learn from it.  I’m always looking for ways to be better at what I do. In graduate school one particular professor made it a requirement in every one of her classes for us to practice counseling on a real person.  After each session we had to write these five page critiques of ourselves, answering a set of questions she had given us.  One of the questions was always “What were your strengths and weaknesses?”  I hate the word weakness and even worse, I hate thinking that I have them let alone admitting them on paper, leaving undeniable proof.  During my marriage and family counseling class we had to give a presentation on the sessions we had with our “clients.”  When my turn came I told the class I didn’t like thinking about myself in terms of strengths and weaknesses but rather in terms of strengths and ways to improve.  To the untrained ear, saying “ways to improve” instead of “weaknesses” may seem like the equivalent to saying “let’s give them all trophies just for playing.”  But in the counseling world we call it “reframing.” My point is that when I can clearly see that I’m doing something that is not beneficial then I need to figure out a way to make it so.

My solution was that every time I was forced to listen to a parent carry on about how horrible their child had behaved (and it happens almost daily) I would do two things. 

1.    I would listen patiently and not interrupt.

2.    When they were finished, with their child present, I would pause for a moment and then I would ask them what they thought their child’s strengths were. (I should also mention that I am a bit dramatic and I pretend the sad music from Full House plays in my head while the parent starts to speak…you know, the instrumental music that plays when Danny and Stephanie reconcile their relationship after he tells her she can’t get her ears pierced and she disobeys him by letting Kimmie pierce them.)

But instead of getting a steady flow of warm fuzzies about how awesome their kid is at throwing a football or how they like to help out with their little brother I’m often met with nothing but silence. Cold, dead, cricket’s chirping in the background silence. It is most certainly nice to have discovered a sure fire way to shut up a disgruntled parent but I never thought I would have encountered so many parents who didn’t have one single nice thing to say about their child. They sputter out words in incoherent sentences. They fumble with their hands and nervously avoid eye contact. Not moments ago, when discussing the bad, they barely paused to take a breath and now when faced with such a simple question they appear to have forgotten how to speak English. Of course, I never let the questioned go unanswered.  Some require more clarification: “What exactly do you mean by strengths?” Some require time to think: “Well, let me see, I know she has things she is good at, I just a need a moment.” And then a few require me to refrain from busting their knee caps:  [sarcastic laugh] “I can’t think of any…I guess he’s good at being brat.”

Eventually though, they all get there.  I don’t let them finagle their way out of it like I sometimes do when I ask them about their history of drug use.

I guess it just bothers me that I even have to ask in the first place…….

A Therapist's Tale

I recently completed my first year as a therapist with a crisis intervention program that works primarily with suicidal and homicidal youth.  Technically, it’s been a year and half but I don’t really count the six months I spent being called “the intern” instead of by my real name.  Completing a full year really means very little except that at my agency I got a whopping 2% raise.  And that itself means very little because I’m pretty for sure the state of Illinois has actually found a way to give me a pay increase and decrease at the same time. So, I suppose this is the part where I make the obligatory “I’m not in it for the money” statement. This, in fact, is a lie. Truth is I’m into any (legal) job with a pay check.  If I weren’t, then I wouldn’t have every other Friday circled on my calendar.  So, I guess a more appropriate statement would be, “I’m not in it for a lot of money.”  Honestly, most days I like my job and enjoy what I do. Not that there aren’t days that I want to toss my DSM IV TR in the trash and walk out the door never to have to provide empathetic listening and support to another living soul again.  But, I like seeing families restored and mended.  I love seeing children succeed and doing something they once thought was impossible.  I enjoy equipping and teaching and guiding and challenging and all of the other therapist-y things I get to do…..except for the paperwork….

So, then what’s with the blog you may ask.  If every day I get to dish out my opinion and suggestions to families who need it why do I suddenly feel the need to provide counsel to the rest of the world?  Well, before you go telling me not to pull that counseling crap on you, know that this isn’t your therapy session.  It’s mine.  This is my way to process what’s happening in the imperfect, messy world we live in, acknowledge my imperfections and mistakes, and focus on becoming the person God created me to be.  And if in the process you read this blog and it leads you to becoming a better person as well and we both maximize our potential and influence on this planet then so be it. 

So, since this is my own personal therapy session, I have to establish appropriate boundaries for those who may be reading. (Which, for now, will probably only be my mom.)

1.    These posts are my opinion.  You are absolutely more than welcome to disagree but you are not more than welcome to be mean, rude, or belittling. 

2.    Sense of humor is required.  One of my favorite bloggers, Jonathon Acuff, once made a comment of something to the effect of how sarcasm on the internet has a 2:1 ratio.  For every two people that get it, there is always one who misses the joke.  Don’t be that one.

3.    Personal responsibility must be accepted by all.  Choose your feelings, words, and thoughts.

So…without further ado.  Here is A Therapist’s Tale.