All About Therapy - Episode 8

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Episode Transcript

(00:12):
Hi, I'm Daniel Bartley along withMerrimar Weeks. Welcome to Psychobabbel Dashni.
Today we have a special guest ona therapist. Her name is Demitra,
and we're going to go through differentsteps on the process of getting therapy,
ending therapy, who should be intherapy and everything in between that. Yeah,

(00:36):
So before we start, we'd liketo put out a disclaimer that this
episode may be triggering for some people. It is in no way mentor place
professional mental health treatment or therapy.So we'd like to welcome Dimitra to the
podcast. Thanks for coming, Weappreciate it. Thank you for inviting me.

(00:57):
I'm happy to be here. Solet's start with just a basic question
like how do you know if you'resomeone who needs therapy. So therapy I
think can benefit anyone, and itcan be from anyone who may be feeling
overwhelmed with different areas of their life, whether it be school or work,
or family issues, relationship issues.And then anyone who is struggling with any

(01:21):
mental health issues, anxiety, depression, inappropriate anger, any kind of mental
health disorder or illness that is impairingtheir functioning their daily life. Okay,
So and then all Right, Idecide that I need therapy, and how
do I go about finding a therapist? Right, Danielle, Yes, and

(01:42):
well let's just start okay. Well, one of the main ways that you
can find a therapist is you cangoogle your local community mental health centers.
The other thing that you can dois ask your primary physician for a referral.
Or you can also call your insurancecompanies and ask to see, you

(02:02):
know, if they if they coverinsurance, and they can give you a
list of providers that are covered.The other thing also too, that I've
noticed is that some clients come fromword of mouth from family and friends if
they ask around the community. Allright, and what is so? What
is should a patient expect to occur? Like the first therapy session? What

(02:24):
happened? So that's a great question. The first thing that usually occurs in
the first session is usually the assessmentor the intake, And essentially what that
means is we cover the person's life'shistory in about fifty five minutes. Some
assessments can be longer than that,they can be two hours long, and

(02:44):
we cover essentially symptoms, why they'rethere, what is troubling them. We
cover family history such as drug andalcohol and mental health issues, child hood,
any trauma, any abuse, Sowe just kind of cover everything as
much as we can to get aclear picture of what is going on,
so we can then render a diagnosis, which is not a label, it's

(03:07):
just a starting point for treatment,and then we sort of set expectations about
what we expected therapy, and atthe end of the hour, we decide,
you know, with services to provideto them that would be beneficial,
whether it would be doing just therapy, whether it's referring them to med PSALM

(03:28):
for medications, or whether it's doingboth, or even if they need case
management as well. So therapists donot give them. We do not give
medications. We are not authorized becausetherapists do not go to medical school.
We simply open up the case,we diagnose and then we refer to whatever
appropriate services. And so if aclient needs medication, then we would do

(03:51):
the referral to a psychiatrist orner's practitionerand then the client would go and have
their own medical assessment with them,and then at that point, at that
assessment is when that particular nurse practitioneror a psychiatrist would decide whether medications would
be appropriate. Okay, so weget to our first session, right,

(04:12):
you give the patient a diagnosis,do you come up with some sort of
a plan like how you're going toproceed or did that happen in the second
session. So the first session isbasically a collaboration between the clinician and the
client about what services would be themost important and beneficial for them. So,
okay, so you want to dotherapy, great, let's set that

(04:33):
up. Typically some people can dotreatment plans the first time, but usually
the second time the client will cometo a session is when we review goals.
So between the first session and thesecond session is when the client really
needs to think about what they wantto get out of therapy, what are

(04:55):
their personal goals, and so theybring that information to the concision the review
with a clinician, and then weestablish a treatment plan. And what does
that mean? What is a treatmentplan? What does that tail? So
a treatment plan is usually a formthat we write down the client's goals and
they sign it and we sign it, and that's sort of like our little

(05:16):
contract. It's our guiding light ofwhat we are working on and what we
are focusing on. And that treatmentplan is usually good for a certain length
of time, but it can bechanged at any point. So if the
client wants to come back after amonth and want to add a goal or
take a goal out, we cancertainly do that. It's a very flexible
sort of thing. And what kindof goals do you mean? Like?

(05:36):
My goal is to feel better?So then we would ask what does what
would that look like? What doyou mean by feeling better? Does that
mean having less anxiety? Does thatmean working on your depression? Does that
mean learning how to how to helpyour self esteem? So we would go
over all of those specifics, andthe treatment plan needs to sort of be

(05:59):
a specific as possible and ideally measurable. So, Okay, you want to
work on anxiety, you want towork on reducing your anxiety attacks. What
would that look like? Do youwant to go from five panic attacks a
week to one? Do you wantto be able if you have low self
esteem? Do you want to beable to reduce any negative self statements from
if you're having twenty a day tofive a day. So it can be

(06:24):
as specific as we want it tobe. Yeah, And definitely in my
practice, whenever I set goals,because we as nurse practitioners will set goals
too, and I always make surethat you pend it that they're realistic goals,
Yeah, for sure, because ifyou set your goal so high and
then you don't achieve it, thendo you kind of backslide because you're disappointed

(06:45):
in yourself? Then, So wedefinitely have to do those measurable, realistic
goals absolutely, And I actually justhad a situation with that recently with a
client where we reviewed their treatment plan, because you really intrude those every once
in a while and make sure thatthey're still appropriate. And we had to
reduce the goal because the previous clinicianhad set it too high. With the

(07:08):
collaboration of the client obviously, butoftentimes I think we have to be careful
that we really listened to what theclient needs and wants, because we may
want to improve their symptoms by fiftypercent, but that may not be realistic
for the client. We may havestarted twenty five percent, and so we

(07:29):
had to reduce that those measurements forthat particular client so they felt more comfortable.
Right, So how I mean thismight be too in depth for a
twenty minute thirty minute podcast, butokay, let's say I am having you
know pan panic attacks, We andI want to reduce it the thought that's
our goal, right, So wheredo we the next session? What do

(07:51):
we do? How do I dothat? What? What are the steps
you take to help with So everysession is going to be different depending on
the clinician and how they do therapyessentially, and what their background is and
what their skill set is. Italso depends on the client, you know,

(08:13):
the level of readiness or motivation,their comfort level. You have to
build trust first, so if theclient does not trust you, they're not
really going to be very invested.So the first few sessions are really about
establishing rapport, building safety and trust, having very clear expectations and boundaries.

(08:33):
So the first session or two isreally about discussing, Okay, this is
what we expect from you as apatient, this is what you need to
expect from us as your therapist.These are our goals and this is what
this is our plan. So whatare some of those expectations, Like what
what do you expect as a therapist, and then what should the patient expect
as a patient from the therapist?You do over that a little bit,

(08:56):
we can't okay, So typically aska clinician. What I would like to
expect, or typically what most cliniciansexpect from a client is a motivation,
and that would mean you have towork towards your goals there. It is
not a place where you come andjust chit chat about nothing. You're working

(09:18):
towards some sort of action plan tofeel better. So I always look for
motivation and I look for engagement.So you have it's for me. It's
a collaborative effort, and it shouldbe a collaborate effort for really all clinicians.
So I think that the client needsto be invested. They need to

(09:41):
respect the rules of attendance. Theyneed to be engaging and ask questions.
They need to be willing to learn. I think that's important. And the
other thing too that I think isimportant that clients need to understand is that
we are not there to fix them. We are there to guide them in
how they fix themselves. We areguiding life for them. And I have

(10:05):
a lot of clients that come inand just sort of expect just to sit
there and for for us just todo everything for them. That's not how
that works. It's a team effort. I personally, I'm pretty strict with
attendance because A, if you don'tcome, you're you know, once we
get the ball rolling, it's goingto sort of stop that process, and

(10:26):
it's very easy for clients then tostop coming. So I think that having
that motivation from the client is imperative. Respect, mutual respect, and trust.
So respect my boundaries, respect myrules, respect my attendance policy,
and the advice versus well. Alsobe appropriate, you know, have social

(10:50):
appropriate etiquette. Therapy is a safeplace you can come and be how you
want to be and talk about whatyou want to talk and express yoursel of
how you want, but it stillhas to be within social norms and etiquette.
Like you can't come into the officeand you break my stuff kind of
a thing. If you're angry,that's okay, and men talk about that.
This is where you learn self expressionthat is structured and it's appropriate.

(11:16):
Now as far as what clients shouldexpect, and this is this is a
little complicated because unfortunately, I've hada lot of clients come in and had
therapeutic relationships that were not appropriate.So A, you want to have a
clinician that respects your confidentiality. Byou want to have a clinician that is

(11:45):
providing a safe, trusting environment foryou that is non judgmental and non critical.
So if you have a clinician thatis making feel guilty or is pushing
you or trying to take to muchcontrol over the session, that's really not
appropriate either because it's a collaborative effort. They need to respect where you're at,

(12:07):
They need to respect your pace.What would taking too much control over
the session? What does that?What does that mean? I have no
idea what that book was, sothat would probably look like that. When
the therapist is trying to create goalsor override your goals to what they think
your goals should be, that isa no no. They can provide feedback

(12:31):
and suggestions, but ultimately the goalsare the clients and we have to respect
that even if we think they needto work on other things. If the
therapist is overriding the therapy session anddoing all the talking and is not doing
any kind of feedback, that's probablythem being a little bit too controlling.

(12:54):
Being flexible is a clinician is important. Flexibility of time, what it's ability
understanding of where the client is thatmentally and emotionally understanding that they need to
establish trust and rapport, which isessential for any therapeutic relationship. If you
do not have trust in your clinician, then you're probably not going to be

(13:16):
invested to work. What about theselike I know, I had some patients
and they had been in therapy withthe same therapists for I swear ten years.
What the fuck is that about?I mean, how can you for
ten years and there's no literally likethere was there was no change. Every
time I saw the patient, youknow, for medication management, they still

(13:39):
were talking about the same problems,but there had been no progress. So
when do you know? When doyou stop and say this isn't you know,
this isn't helping us? Do youmove on? Do you Is it
just some people are stuck in thisplace? What's that about? Well?
So I have clients that I haveI've seen for years, okay, but

(14:03):
I always go over with them theirprogress. We always check that if you're
going to stay with me for thatlong, we've got to make sure you're
still getting something out of it.Because people can get comfortable in therapy and
then it just becomes really not therapeuticafter a while. You're just social.
It is, and it should notbe a social visit. It is a

(14:24):
professional relationship. It is not afriendship. We are not your social network,
if you will, we are thereto help you learn tools so you
can go out into your life andbecome, you know, the best version
of your self and function. Sosometimes the clinician and the client will get
used to or get into this normalizedroutine and so years pass and they're just

(14:48):
comfortable and they leave it at that, which is not really appropriate. Now
there are some exceptions to that,okay, but in general, if the
client is not improving, then reallysomeone has to have a conversation and it
should be the clinician to address itand say, hey, you know,
we've worked together for so long,you haven't improved and so long, maybe

(15:09):
you need to see someone else.So, as a patient, should that
be a red flag for you thatyou've been with this therapist for two years
and things haven't changed and you don'tfeel any better? Is it in that
time to move on? Like?How do I know as a patient when
it's this isn't working it? Doyou know what I mean? When you're
stuck, When you're stuck and you'renot improving and you don't feel any better,

(15:33):
and you keep trying the same things. At that point, you're either
going to continue to do what you'redoing, which is going to have the
same results, or you're going tohave to try a different approach with somebody
else. And although that can beuncomfortable because clients can be used to us,
right, and that's understandable because alot of them don't have yeah,
and they always say I don't wantto tell my full past to somebody else.

(15:56):
I hear that all the time exactly, especially when they're not improving in
therapy, right. But then that'swhen you have the honest conversation about it.
If you let's remember your goals.Why are you really here. It's
not for you to be comfortable,it's for you to get better, and
sometimes that means challenging yourself and tryingnew things, and you do it gently

(16:17):
and you you know the their currentclinician can collaborate with the new clinician,
I mean the lid and sign arelease so the records can go to the
new clinicians. So there are waysto go about that that makes it easier
for the client's transition. So whatare some of the benefits of therapy that
that people should go well, thebenefits can be many. Like I said

(16:44):
before, if you are struggling inany way, if you are distressed with
your life and life is hard,you know for all of us, you
can just go and talk to someoneand figure out some tools and learn about
yourself, learn about your emotions andhow to process them and what to do
about them. You can learn whathealthy relationships are versus and healthy relationships.

(17:06):
It helps you to look at inappropriateor maladaptive patterns that you may have as
far as your belief systems, yourbehaviors, and how do those benefit you.
What can you do to change thosethat may benefit you even more So,
you're basically describing CBP right, cognitivebehavior therapy. That is one form
of therapy, yeah, which isI think the most popular form of therapy,

(17:30):
But there are many different forms oftherapy. So depending on what the
client's needs are. So if aclient has trauma, for example, you
know you might want to seek outa trauma therapist. If you have sexual
abuse issues, you may want tofind a clinician that has is more trained
with sexual trauma. So it reallythe benefits can be many. If you're

(17:57):
having a lot of mental health issues, they can be from mild to moderate
to severe with anxiety, depression,mood swings. If you're having swiss atality,
if you are just struggling really badly, nothing is working, go to
a clinician, you know, talkto somebody, learn about what's going on.
Because these are disorders and illnesses thatcan be worked on and people don't

(18:22):
have to suffer. So what aresome red flags that you as a patient
might look for and look for thatyou should do leary out your clinician.
Okay, so the first one wouldprobably be any kind of poor boundaries by
the clinician. So the clinician needsto have very appropriate ethical and moral boundaries.

(18:47):
So they cannot be, for example, be sexual in any manner with
you. They cannot be asking youto go out to dinner, to go
and have coffee. They should notbe acting like you're a friend, any
inappropriate requests or offers. Poor communication. Your clinicians should be able to communicate
effectively. They should have good problemconflict resolution skills, assertiveness skills. Your

(19:14):
clinician should not be critical or judgmental. They should not be placing their own
values or belief systems upon your lifestyle. That's a no note this is not
about the clinician. It is aboutthe client and their lifestyle. If you
have a clinician making the session aboutthem, that is probably the biggest one

(19:37):
that I have seen. And evenwith some seasoned clients that have come to
me from other clinicians, they didnot realize that the session was inappropriate because
their clinician kept talking about themselves andtheir problems. That is a no no
runlike health that happens. Yeah,I know it happens all the time because

(19:59):
patients will come me and say,oh, they just talked about themselves.
And when my daughter was sixteen,shouldn't for so sorry, she went to
a clinician and she talked about herselfand her kids all the time. And
then the one session, Zoe toldme that she braided this lady's hair because

(20:19):
she asked her to, and Iwas pissed. Well, yeah, I
was like, what in the fuck? Like, You're not there to braid
anybody's hair, right, that's right, that's very inappropriate, inappropriate request.
Yes, okay, definitely what aboutthis? Is this a red flag or
not? I had a patient thatI saw and then the therapist in the

(20:41):
office saw and her main she hada lot of issues. What are the
main issues? Was that her alcoholichusband? Yeah, he was abuse so
blah blah blah. Anyway, andthe therapist said, you know, after
like a year, if you don'tleave him, I'm in a subte because
that's the name. I No,that is not appropriate. Now, the

(21:07):
clinician does have the right to terminateunder certain circumstances if the client is not
working hard enough or you know,there's there are issues that arise. That's
those situations are different. But youcan't black and mail a client that if
they don't do what you want themto do, that you're going to terminate,
because the client might not be writing. Especially if you're dealing with abuse.

(21:30):
There are so many multi level factorsthere. You can't just do that
with somebody. And you can't givethat with any relationship. I mean,
patients come to me all the timeand you know, say that they're you
know, in an abusive relationship.And never do I want say you have
to leave them. You know,I don't know their situation, I don't

(21:51):
know their finances, where they willgo, you know, how they will
cope with it. I guide them, you know, and give them the
positive and I'm not a therapist,but do you know what I mean?
I couldn't ever imagine that. Well, we do not tell clients what to
do. We guide them to thepoint where they decide what is best for

(22:12):
them and we just review options.Yeah, because if not, then they're
coming back on you know what Imean, on you in a sense like
if some do you know what Imean? Well? And ultimately too,
if we keep making the decisions onthem, it doesn't empower the client.
And part of therapy is teaching clientsto learn their own power again, so

(22:34):
it has to be their decision,it does. You might say that again,
say that again, Yes, that'ssport. I think people need to
understand. It is to empower.It is to empower the client because a
lot of these clients have had alot of helplessness and like control in their
life and people have abused them andcontrolled them, and so the therapy session

(22:56):
is to help them regain that poweragain so they can make their establish a
life that they want that makes themhappy and improves their quality of life.
It's about them finding themselves. Ilove that. It's yes. Okay,
So the other red Flax look atis if your client, if your clinician

(23:17):
is not listening to you. Ifthey're distracted, if they're picking up the
phone all the time, they're checkingtheir texts, you know they're they're fiddling
with stuffing their nails. Her therapistswould file and paint her nails through sessions.
What more than oh my, I'veheard of some pretty doozy stories.

(23:45):
Uh, there was a long timeago a clinician that was going through family
albums during the session. People,please, if this ever happens to you,
run for the hills. It shouldnot be happening. The session is
about the client, so please doNow. Having said this, I will

(24:07):
say at times it is appropriate thatif a clinician is expecting the call because
there's an emergency going at home orwhatever, but you warn your client.
You let them know, hey,I've had that and you know we're human
too, but let them know.So no excessive self disclosure. That's another
one. They do not. Likewe're kind of touched on this, Like

(24:30):
they cannot be talking about their livesto you. They cannot be talking about
their problems. Now, having saidthat, there are times or some self
disclosure is appropriate only if it tiesinto the goal and helps the client.
It tea teaches them something or connectswith the client. But this is the
exception, not the rule. Itshould not be happening at every session,

(24:52):
and it should not be happening formost of the session. Okay. The
other thing is if the therapist isnot working hard enough. If you're going
in and you're talking about recipes andcats and the weather, Okay, this
is not okay. Some chit chatis all right. Sometimes it is okay

(25:15):
to sometimes have an easier session soyou don't work deeply into goals, especially
if the client is getting burned out. This is where flexibility comes in.
However, if most of your sessionsare about nothing and you have goals to
work on depression or anxiety, that'sa problem. So someone is avoiding and
it could be the client and itcould be the clinician. It could be

(25:37):
both, or it could be thatthe clinician does not have the skill set
so they're not really addressing dealing witha problem. That is a red flack.
Okay, So inappropriate reacting to theclient setting boundaries if the client is
communicating to the clinician that, hey, you know, I need to work

(26:00):
on this a little bit more,or if they have an issue with something
that the therapist said, or ifthey even want to switch therapists. If
your clinician becomes angry at you andreactive, but that's a red flag,
get the heck out of there.That should not be happening whatsoever. And
if your clinician is acting like afriend, absolutely not. Yes, there

(26:25):
is an intimate relationship between a clinicianand a client because it's a vulnerable place
to be where the client opens up. However, we are not friends.
We are a professional to you.Do we care about our clients. Absolutely.
In another time and place, couldwe be friends with some of our
clients, maybe, sure, Butonce you are a therapist, you are

(26:51):
a therapist for that person. Thatdoes not change. That depends. Yes,
for most most of the time,some words are different. But usually
if therapy terminates, usually they say, for at least in some of the
states, that you have to waitat least five years to have another kind

(27:11):
of a relationship with a client.Oh really, it's like a little legit
law. Yeah, I think it'sa five years at least to be able
to m Yes, I didn't knowthat. I wonder if we've learned so
much. Okay, so how haveyou covered everything that you wanted to cover?
Pretty much? There's something else youwant to go over, because I

(27:33):
think I think that's pretty much mostof it. You basically just want a
therapist that is empathetic and emotionally attunedto you. And how do you know
when therapy ens? Like, isthat a decision you've come to with the
therapist? Is it when you've reachedyour goals? I assume it's when you've
reached your goals most of the time. But why usually states that they're sort

(27:57):
of you know, they're doing okayand they are feeling better. Sometimes the
clinician has to push a little bitbecause clients, again, they normalize the
situation. They don't want to change. So it's appropriate for the therapist to
sort of have a conversation, Hey, you know, you've mete your goals,
you're doing well, Like it's okayto start tapering off therapy. Do

(28:21):
you have anything No, I wasjust going to say, as a provider,
it's really important that we discuss theclients with the therapist, you know,
have a rapport so that we're onthe same base what we're working on.
As I'm prescribing medicine, as theyare getting therapy. It's just so
important and I do that. Imean, I've talked to my therapists,

(28:45):
my case workers daily, you know, about the clients and stuff like that.
I just wanted to emphasize how importantit is and read the note.
Yes, I read. So inmy practice, the therapist always opens and
I don't see the patient when theyfirst come in. The therapist always opens
them and then they'll refirmed to me, like you said, as a PsychEval

(29:07):
and I there's not one time thatI don't read the note beforehand. I
always read the notes beforehand to seewhat, you know, everything that's going
on surprising, like sometimes I wouldfind that, well, hell, I
didn't know that, but yeah,tell oftentimes they tell you the correctship and

(29:27):
they'll even like say like that they'redoing drugs, but whenever they get in
with me, they deny it,and I'm like, you know what I
mean, And it's in the therapynotes and just a lot of stuff because
things change, you know, theytheir story can often change too, with
one person versus the other, justbecause of you know, what we do

(29:51):
in services. Why so, justjust want to reiterate how important it is
to you know, we're a wholeteam and we shill always be working together,
right, So I think that,yeah, as a patient, you
should also expect that a lot ofthe same boundaries and issues with your prescriber,
even your psychiatrist, nur's practitioner,as you would with your therapists,

(30:14):
same red flags and everything. That'sright. The other thing that I wanted
to stress as well for the clientis clients have the right to request a
different provider, whether it's therapist ornurse practitioner. You are not stuck with
whoever you get. So if you'renot comfortable, you have the right as

(30:36):
the patient to say I would liketo see someone else. Yeah, I'm
not feel guilty about it. Well, and what I found crazy is that
a place I worked at previously,patients could say that, but the provider
had to agree to it, andif they said no, you either had
to stay with them or leave.And we had a position I work with
which oftentimes would not give up thepatient, but the patient had to either

(30:57):
stay with that psychiatrists or go toanother factor. I don't agree with that
at all. No, No,I feel that, and I don't think
that I don't need Also, Idon't think that the patient should have to
ask their therapists to change because thatbecomes an uncomfortable situation they want to do
And just so, I just willI mean, I'll generally send a little

(31:21):
thing to the therapist and then refermto somebody else. But the whole thing
is is that we've talked in previousepisodes about and you have the vibe with
the person in a sense, likeyou know, to be able to work
on your goals because there are there'ssuch such different therapists and providers like they
their techniques are different, and ifyou're not getting anything out of it,

(31:45):
why should you have to stay withthat person? Yes, again, sometimes
it's just as simple as like Danielsaid, Yeah, I just don't I
just don't like it for whatever reason, know what I mean? Correct Or
they talk I hear, I don'tneed any more reason than that. I
Yeah, you're going to build restand how are you going to do your
goals? You're going to go inthere pissed off like that you don't like

(32:06):
this person, and you'll never workon yourself. Correct And studies have shown
that the therapeutic relationship, the rapportthat you have between client and clinician is
probably the most important element of therapybecause if you do not trust or you're
not comfortable with a person that you'reopening yourself up to and being vulnerable with,

(32:29):
how are you going to be motivatedto work? Absolutely well, Thank
you so much to nature. Weappreciate you coming on. I hope that
this all this information helps people outthere. I think there's a lot of
good information. Yeah, it's somuch good information. So until next time,
right, you are not alone.We're here. Take care. Thank

(32:50):
you do. Tak cat Ja donta