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What's In a Therapy Session?


Photo Credit @madgescottstudio


      I get no respect, said Jackie Mason the comedian.  That's how I feel.  Oh mom's in the basement working with clients. What an easy gig!!  Just chat with people on the phone or zoom or in person, like a friend!  Well that's your first mistake.  A friend told me she wanted to become a psychotherapist - how hard is that?  Hang a shingle!  A lot of not-that-smart people seem to do it...  Let me be the first to tell you, it's not easy.  So if you're looking for easy, you can stop here.

As I type this I'm juggling more than 40 people on my caseload, their LIVES in the balance. 


Just let that sink in.  


I used to work at iVillage, a startup for women in the heyday of the Internet boom around 1999-2001.  Now that was easy. They would call me in the middle of the night to fix a typo!  Now I get calls on Yom Kippur; people wanting to throw themselves into a pond. People are suffering - no doubt about that.  To become a Licensed Clinical Social Worker you have to put in YEARS of training and practice and continuing education, all at your own expense, and then you can get paid less than a secretary to manage it, with no benefits.  Until the pandemic we were literally the lowest (wo)man on the totem pole of meaningful jobs that you're supposed to be thrilled just to do.  In those years of school and work, you must be client-facing for thousands of hours, under direct supervision.  You must study not only psychopathology, but practice issues, community issues and global issues.  You must write papers, a thesis, that asks you to engage in not only measurable and evidence-based research but also keep the balls in the air, control your personal transference and dig deep inside for insight into your own reactions. No problem!  Again, if you still want to become a therapist, keep reading.

I love what I do and I'm called to it.  However, I do not wish to do it all day and night.  


A typical intake session gathers and identifies relevant background information and present-day stressors and supports. People ask, if I had a prior therapist, how can I start all over?  In my opinion your story will emerge regardless of how much or little you tell me. I will ascertain the patterns in whatever you choose to start with.  Then comes the meat and potatoes - why do you feel the way you do, and what can we do about it?  Benefits of medicines and therapies can offer a reasonably quick recovery for some.  Harder problems require longer, slower efforts.  


Some people ask - please give me a diagnosis, I need a diagnosis.  Why?  Why do you? Am I BPD they ask, without even knowing what that means?  Or ADHD?  Or Bi-polar? Thirty years ago that wasn't important to me at all.  I thought I knew better.  Then I finally noticed there are indeed symptoms that match up quite well - this could be helpful.  Now I'm back to not caring - diagnosis is too reductionist.  Holistic is my path now.  OCD is not the same as cleaning the kitchen.  And a mood disorder is not the same as having a bad mood.  People get caught up without examining the distinctions.  And yes, if you drink too much coffee you will feel more anxious.


In one session I hear a lot of self-blame, guilt, and loss of time and dates of things.  That tells me we might be dealing with PTSD.  In the next session I hear a lot of black and white, all or nothing thinking, a typical hallmark of young adults.  That tells me to introduce CBT, where we modify the thinker's thoughts, make them more equanimous, (In the Buddhist tradition, the term “equanimity” (upeksha in Sanskrit, upekkha in Pali) is a complex construct that has been given multiple definitions along the development of Buddhist thought. At its heart is the word for 'eye' and 'see', with a prefix suggesting 'gazing upon' or observing without interference).  I explain the concepts as I go.  This could make the recipient think that I don't have an agenda, or I'm not writing things down? But rest assured I do!  One of the things I do best is an initial assessment.  I'm good at it because for YEARS I've been practicing and studying the difference between normal teen behavior and alarming teen behavior.  I guess you could even say I'm an expert at the age of 60 yrs.


In the next session I hear and see a lot of tension, stress and loss.  I'm thinking sleeplessness, self-care and grief.  Anxiety. Failure to launch.  Languishing, isolation and fear.  This is the pandemic now talking.  Did you have this before?  What were the antecedents, even though there may NOT be a one-to-one correlate to what happened before.  So keeping an even cadence, co-regulating with my client, whist my dog is barking and the doorbell is ringing and kids are arriving home from after-school activities, no matter,  I am with my client, in the present moment, making judgment calls.  I realize I need to introduce DBT in the next session.  I record a process note, do the billing, get a glass of water and lean into the next appointment.  This repeats about 10 times a day. Then a patient wants paperwork for FMLA because her dog died.  I do it without charging for my time.  


Did I forget anything?  Oh yeah.  I have to check in with the parents, write and email, and organize my schedule.  By the time it's 8pm I'm toast.  Since Game of Thrones ended I have no escape.  The days drone on.  I love my work but I have no benefits.  No work, no pay.  Too much work, too bad.  No health insurance - so be it.  We say we're in a mental health crisis.  No one can seem to find an affordable psychiatrist.  I have to go to my yoga class now.  The system cannot hold. Oh, and I need to order a workbook on OCD for my next patient, while I practice my own EFT (tapping) technique.  The weekend arrives and I am completely shot.  I wonder why?

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