#therapisting

I've been out of things for a couple of years now, which is why I'm willing to talk about it, and maybe the pandemic has helped things a little, but holy shit the counselling and psychotherapy field is not equipped to help its practitioners in the gig economy.

Of all my interests and talents, I pursued a degree in psychology because being a therapist is supposed to be a safe, stable, well-paid job. Every therapist I met who was registered before 2008 worked and lived under that assumption. And oh boy are all the fee structures--registration, supervision, continuing education, conferences--set up for that scenario.

After getting my Master's, I struggled like hell to get a job. It was especially bad because to get my license, I needed a supervisor to take me on. To take me on, most supervisors wanted me to already have a caseload and client base. To get a caseload and client base, I needed a job.

Friends: Every single job I heard back on wanted me to have my license before I could even land an interview.

Professors and career advisors and professional development specialists all advised me very earnestly to just keep cold-calling people on the supervision list, and it began to feel a lot like my parents' friends telling me to hit the bricks and hand out resumes. That's what worked for them, right?

If your main concern is that the therapist will voluntarily start telling people about The Old Guard and the fact that immortals exist, I think that could be fairly easily dealt with. 

I think a major question is whether you think the potential harm comes from the therapist themself, or whether the therapist is a weak point through which someone else could do harm. 

Basically put: If someone like Merrick wanted to find the Old Guard, and they suspected Booker had told that therapist information that could help someone find them, how would such a villain exploit this person to do it?

And then you can go through tactics: 

 Would they try to trick the therapist into believing this fell into an area where they had to disclose confidential information, like a police investigation or legal proceeding? Would they create an actual legal proceeding or police investigation to force the therapist to disclose this information? Would they punish the therapist legally for failure to comply? 

 Would they break into the therapist's archives to access session notes? Could the therapist enact extra security or write those notes in an oblique style to hinder this access? (I'm the child of locksmiths so I know that most security systems made have exploits to get around them--you just have to be willing to incur the necessary time, expense, and amount of damage to get into) 

 Would they surveil or bug the therapist's office to hear sessions as they happened? What amount of practical security, cyber security, and countersurveillance would make things safe? 

 Would they try to coerce the information out of the therapist using the threat of force against that person or someone they cared about? Are these considerations the therapist is prepared to anticipate and deal with? Will the therapist be asked to preserve confidentiality in all these circumstances (eg. if their child is being kidnapped and held for ransom, the ransom being information about the Old Guard, will they still keep Booker's secrets?) or is there a point at which it becomes permissible for them to give up some information?  How would Booker deal with those situations?

Maybe there are therapists who counsel people with incredibly high security clearances who can handle these issues--maybe their children are so well-protected they can't be kidnapped, maybe their archives are stored so securely they can't be broken into. Maybe they're watched by an external force to see if their bank accounts show large new bribes they can't account for, to make sure they're not selling client information. Copley would probably know how to find them. 

My current therapist is a psychiatrist who is working with me on meds and also with Cognitive Behavioural Therapy (CBT) talk therapy. I’m perfectly happy with him, but if he ever got hit by a bus or something (or simply retired at some point), I’d be in the market for a new therapist. So I ought to know the difference between clinical psychologists and counselling psychologists.

Thank you.

In practical terms, on the client end, there's very little difference. The real divisions you need to know are:

Psychiatrist: Someone who went to medical school and specialized in psychiatry; can diagnose and prescribe medication. Usually designated MD.

Psychologist/Therapist/Counsellor: Someone who has gone to graduate school and focused on psychology or clinical social work; can sometimes diagnose, but usually cannot prescribe medication.

Psychiatrists do sometimes do talk therapy! I had a psychiatrist like that once. He was great. Sadly, this is mostly going out of fashion. Because they have so much extra training, they get higher salaries; administrators who care about increasing efficiency and cutting costs will therefore change them from seeing a patient for an hour each, to seeing a patient for only 15 minutes to talk about medication, and shunt the clients to cheaper therapists for talk therapy.

Within the field of psychologists/therapists /counselors, there are approximately eleventy squillion different variations in education format, theoretical basis, research background, and bragging rights. That's where the Counselling vs Clinical division lives. However, all the fields have similar aims (helping people reduce distress and become more healthy) and similar approaches (sit in a room and talk) and they freely poach any techniques or knowledge from each other that seem useful, so there's very little intrinsic difference that you would see.

The one big difference you would see is if you needed a formal diagnosis, more than just the person who treats you going, "Yeah, looks like [fill in the blank]". This is usually only needed if you're applying to something specific, like government benefits or special education accommodations. Assessment psychologists/neuropsychologists mostly tend to focus only on assessment, which is a whole different field in itself. Because of their expertise, and that someone who provides psychotherapy with you might be somewhat biased with their own ideas of what your deal is, formal assessments are generally done by someone who is not your therapist.

Anyway. The big difference between counselling and clinical psychology is basically historical. Clinical psychologists historically descend from the workers in hospitals, asylums, and mental health clinics, who focused on people with acute mental illnesses. They worked closely with psychiatrists and emulated psychiatry's popular methods at the time (mostly Freudian psychoanalysis) and focused specifically on treating mental health as a disease. This has generally been seen as a relatively more factual and sciencey field, since it's where a lot of the research on abnormal psychology and how to treat it has happened.

Counselling psychology, meanwhile, descends historically from pastors and school counsellors—people in churches or schools with "normal populations" who were the obvious go-to people for those in emotional distress or uncertainty about their lives. Counselling focused on training people who needed the skills to help somebody grieving the loss of a loved one, or who needed to figure out what they wanted to do with their lives. It has generally thus been seen as a fuzzier, less rigorous field, and less prestigious. It's also closely entangled with Social Work, which grew out of many of the same settings and focused on helping ease the lives of people affected by society's many ills.

But they were all of them decieved, for another Ring was made—

Counselling as a field got significantly transformed by Carl Rogers, who used scientific research to see what kinds of therapy approaches helped people—and to the shock and horror of many many people, the warm and gentle approaches used in Counselling and Social Work turned out to work better than Freudian impassivity—even in Clinical populations!

Because see, the division between these fields was based on a misapprehension. A hundred years ago, or even fifty, we thought that these fields focused on significantly different groups, and it turns out that's not really true. Freudian psychotherapy in its failure state was all about impersonal disconnection, pointing out the flaws and foibles of somebody's psyche and expecting them to fix it. Using Rogers' method of treating mentally ill people like human beings, looking them face-to-face and believing in their ability to better themselves as people, actually worked! Amazing!

And also, a lot of people with mental illnesses are really good at masking, compensating, and functioning as normal enough to avoid general detection and referral to medical treatment. Anyone dealing with the "general population" is inevitably going to deal with people with profound levels of depression, anxiety, psychosis, addiction, and every other mental disorder under the sun.

Therefore, anybody practicing in either field had to learn about both, because each required the skills the other had. These days, the difference is generally more about who your grad school was founded by fifty or a hundred years ago than your training recently. Counsellors get hired by mental hospitals, and clinical psychologists work in schools.

The differences still linger in little ways, like how in the Canadian Psychological Association, there are different "sections" that each organize their own newsletters and social media groups and parties during conferences. They discuss new research and issues relating to their areas of practice. Most people belong to three or four each, since they overlap—there's Counseling and Clinical, sure, but also Black Psychology, History and Philosophy, Psychology in the Military, and so on.

So I am mostly being petty and flippant when I say I'm glad not to be on the Clinical listserv, where there is, I imagine, a "Jordan Petetson is Making us Look Bad" Quarantine Thread, which will be locked after 9000 replies with no resolution in sight.

Anyway, that's all inside baseball and not useful to you. Onto the useful stuff.

Full disclosure: What I'm about to say may be unconsciously biased by my perspective, despite my efforts not to be so, because my Master's degree in Counseling means I have significantly less professional prestige than psychologists with doctorates, especially in Clinical Psychology. However, I earnestly believe that I am paying attention to the science and speaking the truth here.

All the best evidence states that what level of education someone has, what school they learned it in, and what therapeutic technique they are applying are not good predictors for whether therapy with them will help you.

And yet, therapy undeniably does work. It's just that, for all our trying, we still struggle to put our fingers on precisely what the difference is.

You are actually in the best position to predict success, because the best metric we can find is whether you, personally, feel that your counsellor is listening to you, understands and cares about you, and is helping you reach your goals. That's literally the most important thing. Does this counsellor seem like someone you could work with?

"That is a very good point and I am probably going to go cry about it later."

Random thing, you mentioned bpd I heard in my abnormal psychology class that a lot of therapists won't treat someone diagnosed with bpd??? It was the teacher who is a grad student studying to be a therapist who said it. And like. I don't understand. They sound like a very in need population who was often abused and there's a whole huge book of treatment resources written by someone with bpd. I've heard they're "hard to treat" and talked about like they're hopeless. but like why be a mental health professional if you don't like mentally ill/different people?

This is also the same professor who insisted trauma is only the few things listed under dsm ptsd definition as traumatic events.. like she said parents getting divorced isn't a traumatic event because you aren't physically in danger... that class really scared me about the mental health field because of all the awful people in it aspiring to be therapists including the teacher.

Sorry for all the asks I love the work you do on this blog

Ahahaha, what IS it about undergrad abnormal psych professors? Mine said he wouldn't touch clinical practice with a ten-foot pole, and told a story about how once a student told him she had schizophrenia, and he knew that she was lying because obviously nobody with schizophrenia could actually manage to attend university.

(It's seriously untrue. I've had both friends and clients with psychotic disorders who succeeded in university. He was being an ableist bastard. Like, I know psych students can tend to over-identify with a disorder they're studying without actually having it, but that doesn't mean no psych student is ever entirely correct about their deal.)

Okay so, BPD. The thing about BPD is that it requires a special skillset that does not come standard in most clinical training. If a therapist who doesn't have that skillset tries to treat someone with BPD, the therapy will not be very effective and the process will be very frustrating for both them and their client. To be very frank, it's just as true that ordinary therapists are bad at treating BPD and don't like feeling stupid, as it is that people with BPD are hard to treat.

(And training to deal with people with BPD clinically is often not included in grad school education. DBT training is expensive and they won't accept you unless you have an adequate clinical placement.)

Also, part of dealing with BPD in particular is... people with BPD often have trouble seeing authority figures with anything more nuanced than "adoration and compliance" or "fear and loathing". As a therapist, you're signing up as an authority figure. Part of the work means letting your client express all their feelings about you, and helping them work to something more nuanced and sustainable, like, "I am furious and enraged that I'm in pain and I wish my therapist could take that pain away, but I realize that's not within her power. I have to admit that she's not being an evil villain here, so I can feel my resentment but let it go."

Which can be stressful to deal with, as a therapist. You have to live with a lot of hurt and anger and rage headed your way, and keep your perspective. Be empathetic without getting carried away in those emotions. You have to be able to face that pain and say, "I can't take that away. I can only help you learn to bear it."

Basically everyone I know in grad school had a nervous breakdown somewhere along the line because we go to therapist school because we're smart and capable and feel good about helping people, so when we encounter a person we can't help, or are put in situations where we have to stop helping, we tend to have existential crises and end up sobbing in the student lounge about What Am I Even Good For Now. I was lucky because I had a version of that breakdown before I entered grad school, and my therapist warned me to get a new shrink when I moved for my Master's, "Because if you don't need one at the beginning, you'll definitely need one by the end." So I was more equipped to help classmates for whom this was a wholly new experience.

In my opinion, the healthy way to approach the problem of A Person You're Not Good At Helping is to practice humility, set reasonable boundaries, recognize the limits of your competence, and see where you can learn and grow. But many therapists and helping professionals use what I consider to be an unhealthy approach, labelling such clients as "defensive" and "resistant" and "hard to treat" and blaming them for the difficulty.

Which like, I get that "practicing humility" is like "doing exercise", sometimes you're tired and cranky and don't want to go for a run. Sometimes you just want to blame the other person for not accepting your magnanimous help.

Anyway, within the field of mental health psychotherapy, complex trauma is a unique sub-speciality that many therapists don't want to touch at all. I had many classmates say, "Woof, you're into complex trauma? You must be so tough, I could never." 🙄

(Technically I have the ethical obligation to represent my profession in the best possible light to encourage public confidence in the field of psychotherapy. But I think it's not undermining the profession to admit what everyone already knows, which is that some therapists are oblivious assholes who do bad work. I've seen it, I've met them, I want them to piss off forever. Jordan Peterson is a blight to our names and Phil McGraw can go choke.)

So people who are on your wavelength about BPD and trauma and What Therapists Are For are out there. They're just a little rarer than the usual run of therapists. For what it's worth, I've found they cluster more in areas like complex trauma, DBT, Narrative Therapy, and the Hearing Voices Movement. Next year (knock on wood) I'l be going to a conference on the treatment of complex trauma with a friend, and this sounds weird given that it's a weekend all about child maltreatment, but I expect it to be a blast, because I'll get to be among My People, talking about the work that fills our souls.

I really wish that as an undergrad, I'd spent more time hanging out with Social Work students, and going to conferences and trainings. Those are where I met some of the coolest people I really clicked with. And in grad school, I had the extreme pleasure of meeting other people who were a lot like me. Those friendships were especially rewarding because as skilled helpers, we ended up playing a game of Needs Chicken, where each tries hide their own needs and caretake for the other, which finally ended up in a standoff where we had to agree to put down our caretaking skills and just be honest about what we wanted, even if that felt new and scary and raw.

Yeeeeah. I’ve mentioned working with a lot of young Christian adults lately? And honestly, fandom’s purity culture is still only a pale echo of what churches teach all the time. Forget qualifiers like “deviant”--they’re teaching all the incredibly vulnerable children in their care that thinking about sex AT ALL under ANY CIRCUMSTANCES is a TERRIBLE HORRIBLE NO GOOD VERY BAD SIN.

Pastors will fend off suggestions that we, uh... educate them about sex in any way, shape, or form, since that makes them less vulnerable to sexual abuse and exploitation, by saying, “You might as well give them instructions on how to rob a bank!”

Like, my dudes and ma’ams... that would only be an apt comparison if you raised your children with the belief that their highest happiness in life was one day finding the perfect bank to rob and committing the perfect heist.

be gay do crime

In a system where marriage is set up as the highest goal of most people’s lives, teenagers are VERY ANXIOUS about learning how to succeed at it, and so many churches and parents feed them absolute HORSESHIT instead of concepts like... “If you’re not enjoying the sex you’re having you should probably talk to someone about it” and “It’s not your partner’s job to make you feel happy at all times and it’s a bad idea to get mad at them for failing to do this.”

And meanwhile we have so many fucking stories about people who did EVERYTHING RIGHT in this system and got absolutely robbed of any sort of healthy sexual relationship. I’m seriously not kidding when I say this is a system that routinely produces adults who are like, “I’m so ashamed... sometimes when I’m driving or working or whatever... I get aroused at the thought of tenderly making love to my husband/wife... I’ve asked God to take away these terrible feelings but I’m afraid I’m just tainted forever... My spouse would be so disgusted with me if he/she found out.”