What’s Really Wrong With Me?

WWWM

For the past decade I have been conducting psychological testing for various reasons. Sometimes a person wants to know if they have ADHD or a learning disorder. Sometimes we are looking at career options and want to determine if college is a good choice, or maybe if a specific job fits their knowledge, skills, and abilities (KSA’s). Maybe it’s about a legal matter and making recommendations that are useful to an attorney or a probation department. Most often what I do is a diagnostic study to understand whatever is happening and make appropriate treatment recommendations. It’s the answer to the “what’s really wrong with me and what can I do about it” question.

In the course of hundreds of evaluations, something I’ve noticed is a lack of consistency and sometimes an outright lack of agreement among clinicians. Just this month I was beginning a therapy relationship with someone who disclosed every diagnosis along the Autism spectrum. Last month a client presented with “bipolar, major depression, anxiety, ADHD, PTSD, ADD, generalized anxiety, panic attacks, learning disorder.” What a laundry list! How is it possible for one person to have so many labels? How can one person run the gamut of an entire spectrum like Autism or psychosis? It’s more common than you think, and here are a few reasons why.

Point in Timesign
Any psychological evaluation represents a brief moment in time. Hopefully an evaluator thoroughly reviews your history, including medical and mental health records and prior evaluations. That’s certainly a best practice. It does give us more information (data points) to consider for diagnostic purposes. But even then, your evaluation a single slice in time of what that clinician observed or recorded (testing) on a specific day. Having a bad day? Testing might underestimate your best abilities. Forget your medication? Your mood might be a little more off kilter than usual. Or paying attention might be pretty hard. Leave your glasses at home? Probably going to make it hard to complete testing with speed and accuracy. Or the biggie…did you hold back some information? Sharing all the details is important for an accurate diagnosis.

Even if everything goes just as it should, it’s still entirely possible that a diagnosis can be right in that moment but not really accurate for your daily functioning. Or it might be accurate for problems lasting a few weeks or a few months, but not forever.

bullseyeMoving Targets
Another consideration is that diagnoses can be “moving targets.” There is a lot of overlap in symptoms for various disorders. For example, problems with attention and concretion can be related to ADHD, depression, psychosis, intellectual disability, learning disability, dementia….and on and on. Having mood swings? Could be a bipolar disorder, but it also could be a normal variation of depression or even personality traits. Behavior problems? Might be ADHD, depression, anxiety, Autism Spectrum Disorder, psychosis, personality-related, or a bona fide conduct disorder. See how easily this can all be confused? Yes, we get lots of training in diagnostics (psychopathology), but it takes good rapport and good investigative skills to understand what’s really going on.

This is never more true than with children and adolescents. Symptoms can look very different in young folks. Depression in a teenager often includes irritability, hostility, and acting out. Which can look like an oppositional defiant disorder. Some behaviors could be the result of medications affecting the developing brain. And, quite often, children and teens simply cannot verbalize what is going on the same way you and I can. They try, but they themselves might not understand it in order to explain it coherently.

Treatment = Change (hopefully)
Another consideration is that appropriate treatment really should change diagnostic labels over time. If you are taking medication and engaging in weekly therapy, your depression should get better and eventually that label should go away. Or perhaps your Major Depressive Disorder transitions to a Depressive Disorder NOS and then to nothing at all. ADHD frequently abates over time as the adolescent brain develops into adulthood. But not always, and more and more adults are given a label that traditionally had to be first diagnosed in children.improving together

The biggie here is Autism Spectrum Disorder. With appropriate and consistent treatment (social skills training, therapy, and possibly medication), it is very common for the more severe symptoms related to communication and social interaction to greatly improve to the point it really can be hard to see that a label is appropriate. The same is true for learning disorders. The schools refer to this as “response to intervention” and is now formally measured for those receiving special education services.

Arriving at the right diagnosis can sometimes be pretty straightforward. Other times it feels like I am a detective solving a mystery. The end result will depend on the available information, how willing people are to be open and honest, and the skills of the clinician. It is vitally important that you feel comfortable with the person evaluating you. You are far more likely to be open and honest if you feel safe and secure.

Feel free to contact my office if you keep asking “what’s wrong with me” and it seems like nobody can understand you.

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The First Session.

How to begin.

Therapy 1The questions I am most often asked by friends, family, potential clients, and even strangers at parties are “What is therapy like? What happens?” Some people who have never sat on the couch genuinely wonder what goes on behind that closed door. Others use this is as a way to tease out my particular therapeutic style. Most often, though, it is a question about what happens in the first session with any therapist. I certainly understand the question.

Picture it. Jonesboro, Arkansas. 1998. A young man goes to a therapist’s office for the first time. There was nothing that drove me to therapy. I was not depressed. I was not anxious. There had been no breakup. Work was good. School was good. I went to the therapist because it seemed like I should. Most of my friends were in therapy. Everyone had an “analyst” even if they had nothing to analyze. And then we analyzed that! Seemed very Woody Allen-esque to me.

I showed up for my first session and the therapist matter-of-factly asked what was wrong. When I explained that there was nothing wrong and I was perfectly happy, he had the unmitigated gall to accuse me of masking symptoms and living in a state of denial. Well now we had something to discuss! And we did. For three weeks. And I got bored. And then he got bored. We ran out of things to talk about. And I found other ways to spend money and be entertained.

I’m not sure if that was how my introduction to therapy was supposed to unfold. From what I hear from friends and colleagues, there is no one single way for a therapist and client to first connect. That’s certainly been my experience. In the last decade of working in mental health in various office, jail, and correctional facility settings, I have never found one sure-fire way to begin a therapeutic journey.

It’s perfectly normal and natural to feel nervous about your first counseling session, or your first session with a new therapist. I understand it takes a lot of courage to share your feelings and experiences with someone you just met. Our first interaction is really about establishing an initial connection. You deciding if I’m a good fit for you, and me deciding if I can help you. We work together to identify and understand your concerns and develop a plan to make changes in your life. This process usually takes several sessions. I think of it as the “getting to know each other” stage of our new relationship. This is a collaborative process, but ultimately you are in the driver’s seat.

Switchback at the base of Cape Smokey, Cabot Trail, Cape Breton, Nova Scotia.See, that doesn’t sound at all scary, does it? In my mind, therapy is a purposeful conversation between two people where one of those people happens to be in need of some assistance and guidance and the other one has some training to be helpful. We talk. A lot. We both talk. And I listen. A lot. We discuss. We explore. We. Both of us talking together. It’s a collaboration. And from my experience, if you’re able to talk to a friend then you’re pretty well able to talk to a therapist.

I know what you’re thinking….”does that mean you’re a paid friend?” Absolutely not! I am a paid professional who is good at relating to people and getting them to open up about what’s working and not working, and then helping them find better ways to problem solve and be happy. It sometimes seems like a friendship because there is genuine caring and a certain amount of back-and-forth in my conversational approach. But I am not a paid friend. I am a therapist and my job is to help you live your healthiest and happiest life.

But stop and consider this. If it often seems so friendly, doesn’t that mean it’s not really that scary? I sure hope so. I like to think I’m the least scary person on the planet. I take great pride in making people comfortable so we can effectively problem solve. I try really hard to lessen any anxious discomfort and allow you to focus on what’s happening. Does that mean it’s all laughter and giggles? No chance! There are tears sometimes. Every now and then you might even make realizations you didn’t want and consider throwing a brick through my window in the wee hours of the morning. I just ask you show up at the next appointment so we can talk about it and keep moving forward. And maybe that you wrap that brick in a reminder slip so I know who to bill. Just kidding. Sort of.

If you really want to get a feel for what that first session will be like, ask to talk to therapist for a few minutes over the phone. Most therapists are frequently quite busy and booked much of the day, but there are opportunities to return a five-minute phone call. Given that therapy is not inexpensive and requires some commitment, it only makes sense to me that you might want to chat me up for a few minutes before making an appointment. It’s similar to the “free consultations” offered by a lot of professionals, just briefer. Though it would be unreasonable to expect more than five or ten minutes, it’s a sensible request and one that I always honor.

From there the journey is something we navigate together. There is no one right way or one right path for all clients. See what happens. Take the chance. I don’t know the statistics on people dying from anxiety or fright in a therapist’s office but I’m pretty sure those are some low odds.

Happy SandSo back to the original question. When I went to therapy “for real,” the first session was nerve wracking. For all of about ten minutes. I didn’t know what to expect. It was a woman. And a very young one. Fresh out of school, in fact. But I went because someone I trusted recommended her. The interaction was professional, but friendly. She asked me so many questions I thought she was ghost writing my autobiography. We talked. We laughed. I cried. She comforted. I felt like she understood me. It still wasn’t that easy for me to open up, but once I did my life got a lot better. I returned. There was a lot of back-and-forth as I thought through issues and she made poignant observations and helpful suggestions. And from time to time I still check in as needed. Yes, therapists sometimes sit on the couch as well, but that’s a whole other blog entry. If you’re in pain or confused about life or want things to be different, go that first session. Walk through the door. Take that first step on a journey of enlightenment and improvement. It can be so worthwhile.