Category: Blog

How Clinical Empathy Can Restore the Impact of Invalidating Medical Experiences

Posted on by Psychotherapy.net Team

I have a small antique sign that I bought long ago at a Goodwill store. Beside a whimsical illustration, it reads, “it’s nice to be important but it’s more important to be nice.” Medical doctors are important, there is no denying that. We rely on them to keep us healthy. But, at times, a purely clinical nature can cloud their ability to provide the empathy patients often require. Please understand that what you are about to read does not apply to every single doctor, specialist, and practitioner.

This is not intended to be an indictment of the medical profession or a blanket statement of its shortcomings. Rather, this is an examination of how, in my experience, medical practitioners can fall short of fully recognizing and understanding the connection between physical health and emotional health, and how mental health practitioners can support clients in the aftermath of what they experience as invalidation.  

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The Necessity of Clinical Empathy

Clinical empathy, more than anything, means remembering what it’s like not only to be a patient but also, to be a human. While this concept is drilled into those of us in fields like social work and psychology, perhaps a little further drilling is needed for some in the medical field. Years ago, I visited a cardiologist following a short hospital stay for what ended up being anxiety and panic. At the time, though, I was advised to follow up with a specialist to check on self-reported symptoms, including racing heartbeat and palpitations. At that visit, the cardiologist, becoming visibly frustrated with me, sighed and said brusquely, “look, I can’t tell you what every little sensation you’re feeling in your chest is.” I felt in that moment as if he saw me as a neurotic hypochondriac. In retrospect, I wasn’t being crazy; I was simply frightened and seeking answers. The doctor, though, had failed to recognize — or acknowledge — my fear, showed frustration rather than empathy, and left me feeling misunderstood and invalidated.

In his book, Clinical Empathy, David M. Berger writes that empathy is “the capacity to know emotionally what another is experiencing from within the frame of reference of that other person, the capacity to sample the feelings of another or to put oneself in another’s shoes.” I don’t think this doctor tried to do this; to be fair, many others I’ve seen have. 

Here is what that doctor could have discovered about my frame of reference: I’d been witness to a lot of illness in my family when I was growing up, I was prone to anxiety and struggled with panic attacks, I’d been a caregiver for my mother as she went through multiple bouts of cancer. Any or all this information might have helped this doctor decide to take a softer touch with me. And that empathic curiosity is all it would have taken for me to have felt validated rather than silly.

I will never forget a very different experience. A doctor told me something I will never, ever forget. But first, he allowed me to explain what I was feeling. He listened openly, non-judgmentally, and empathetically. He never once caused me to feel I was being silly or neurotic. In our field, we call it “holding space,” but we have a fancy name for everything. He listened —that’s the long and short of it. After he heard my story, my past experiences, and my worries, he left me with a thought that has sustained me and allowed me to heal from persistent health-related anxiety.

He said, “some of these sensations you’re feeling are your body remembering the pain from the past.” He understood. When the emotional imprints of the past manifested through frightening physical symptoms, I could remind myself that my body has a memory, just as my brain does. The same way an uncomfortable thought doesn’t mean something bad is happening, I could reassure myself that an uncomfortable physical sensation doesn’t mean something catastrophic is happening.

It was only then that I began to heal from my chronic somatization and worry. This individual, by the way, was not a therapist, counselor, psychologist, or mental health professional. He was, of all things, an oral surgeon. But, more importantly, he was a human being and he allowed himself to be vulnerable and it made all the difference.

This doctor modeled what we as therapists hope to do for our clients: first and foremost, he listened empathically, non-judgmentally, and compassionately. Next, he offered psychoeducation that helped me understand what I was experiencing, and lastly, he made sure I knew not only that he cared but also that he didn’t view me as a neurotic.

In another life, perhaps he had been a therapist. As an oral surgeon, his bedside manner, no doubt, served his patients very well. I was lucky to start working with a truly wonderful therapist following this experience, but my layman’s understanding of the importance of clinical empathy truly began with the oral surgeon. My therapist built on that initial foundation of understanding and empathy and, gradually, I healed and became less anxious about my health.

As a psychotherapist, my role is to help clients rebuild trust following invalidating parenting, abuse, or trauma. But I can also help clients rebuild trust and safety following experiences of clinical and medical invalidation. Just as I could not heal in an environment where I did not feel safe and accepted, neither could my own clients. I have the opportunity to do the honorable and important work of restoring safety for those whose sense of it has been shattered.

Even a brick at a time, I can help my clients build a fortress in which they feel validated. For me, it started with a medical practitioner who took the time to listen and understand. It continued with therapists and other medical professionals who have supported me and been understanding of my life experience. I now feel safe, supported, understood, and validated.  

***

Sometimes, my job is to help clients pick up and reorganize the remains of an invalidating and shattering experience and to reorganize them into a meaningful and restorative whole. What an honor that I can help clean up the mess that’s left from past invalidations and assaults on their sense of safety and well-being. My hope is that, as you read this, you consider expanding your own fortress-building and safety-expanding capacity with clients who have been subjected to traumas, both great and small, including medical invalidation.

Psychologists Struggle Too: How Shame Keeps Us Silent

Posted on by Psychotherapy.net Team

Nothing breeds shame more than silence. If something is not spoken about or represented in our systems (e.g., family, workplace, industry), it can be considered wrong. This is why I have devoted my life to speaking out about mental health and, more recently, done so on a public stage as a psychologist who has experienced mental illness. I want to demystify the experience of mental illness in mental health professionals so they don’t suffer in silence, because we are, like the rest of the population, only human. However, it hasn’t always been that way for me.

Back in the 80s and 90s, when I was growing up, there were no representations or discussions of mental health or mental illness within the systems I was exposed to. The only thing you did hear was people being locked up because they were “crazy” or hearing the message that “you are weak if you have a mental illness.” And no one was talking about looking after their mental health, only physical health.

Struggling with Depression

So, when I struggled with my own mental health and eventually experienced clinical depression in my early 20s, I had no idea what was going on, and I didn’t dare speak up for fear of being seen as “less than.” I only received help when my partner contacted my parents for help, as he didn’t know what to do. While I did recover, I did so mostly on my own. I didn’t talk about it to others. I held a lot of shame for being depressed for many years.

Fast forward to my early 40s, early 2021. The world has changed drastically with how mental health and illness are represented and discussed, and I have about 20 years of study and working in the mental health arena under my belt. I now know differently that mental health is essential to care for, and mental illness is not a sign of weakness.

But despite all this, I once again suffered mentally, that time with a combination of burnout, vicarious trauma, and compassion fatigue. You would think that I would have reached out and spoken about my struggles this time with all that I knew and had learnt from my previous experience, but I kept quiet. I didn’t dare say anything because, once again, I felt deeply ashamed.

I felt ashamed and suffered silently for a couple of reasons. First, I believed that psychologists shouldn’t get mentally ill. I thought that, as a psychologist, I should have known better. I should have been able to prevent it. I thought that it somehow meant that I was not a capable psychologist. The other reason that compounded the first was that there was no representation or discussion of psychologists becoming mentally ill or working while managing their mental health or mental illness.

None of my peers, mentors, or senior psychologists ever discussed it. It was all under the radar and not out there for all to see. Outside of encouraging us to care for ourselves and seek professional help when needed, no psychologist or mental health professional I came across in training spoke of their own experiences of mental health struggles. Most likely, they didn’t feel safe to do so because nobody did for them. It wasn’t normalised or validated enough to feel safe to talk about it.

Speaking Out and Sharing Humanness

I only started speaking out about my mental health struggles as a psychologist when I began seeing a supervisor who could provide an environment where I felt safe to disclose my struggles. She was different from other supervisors I had. She was interested in my experiences and what was going on for me in the context of my work. She helped me to recognise my mental illness and take the necessary steps to recovery. She never made me feel like I was “less than,” nor did the psychologist I eventually saw for therapy.

More importantly, they both shared their humanness with me, their struggles, enough to help me debunk my belief that psychologists should be able to prevent their own mental illnesses. These experiences gave me the courage to share mine more with others, and as I did, I discovered that many psychologists and other professionals were also struggling with their mental health and changing how they worked to care for their mental health. It helped me drop the shame I had held for being a psychologist with mental illness.

Having had such a powerful experience of having my mental illness normalised by other people in my field, it became a passion of mine to pay it forward; to continue to change the culture of mental health professionals to one where we can talk freely about our mental health and what we need to take care of it; to recognise mental illness and support each other through it. I now share my mental illness story wide and far through various mediums, writing blog articles, appearing on podcasts, producing a lived-experience podcast, publishing my memoir, and providing therapy to fellow clinicians and others from different professions suffering from burnout.

I still fear sharing my story with fellow psychologists. I know this comes from being someone out on the fringe of my profession speaking out about this, but more robust than my fear is my compassion to help fellow mental health professionals drop any shame with struggling mentally. I can do that by sharing my mental illness experiences and mental health struggles. I don’t want another fellow psychologist or anyone to suffer in silence. We are only human.

Virtual Treatment of Eating Disorders and the Importance of Human Connection

Posted on by Psychotherapy.net Team

Be the person you needed when you were younger

-Ayesha Siddiqi

The Virtual World

I could never comprehend the idea of virtual eating disorder treatment. It would be so easy for clients to hide their food or engage in disordered behaviors behind a screen. How could I really connect? Especially with my young clients, I imagine them secretly watching Netflix behind the computer screen while I try and explore their deepest fears.

Cut to Covid! The world shut down, and my ideas on virtual treatment shifted as this became the new reality for all therapists. I have always worked with eating-disordered clients in one way or another since before I even completed graduate school. After working with eating disorders in community mental health, I started to burn out with the lack of support and knowledge in the field. As a recovered clinician, eating disorders are my passion and the reason I became a therapist. This is the population I want to work with, but this is also the most complex population which requires a complete treatment team and effective provider collaboration.

For my professional sanity — and to continue this career without burning out — I needed to shift gears and investigate a more supportive environment in which to treat eating disorders. The thing is: I live in a place where you must travel at least an hour to get to any eating disorder treatment center, which would mean I would have to travel at least an hour to work at one. While I was offered a position at one of these centers, I saw myself continuing the burn out with the commute and two young children at home.

As fate would have it, the treatment center connected me with their virtual eating disorder partial hospitalization program, which, as it just so happened, was hiring. I was still very hesitant but wanted to keep my mind open. I’d been through many treatment centers as a young teen — I know ALL the tricks. How could I help anyone, virtually? It was during my interview process that I came to the realization that there are many places where treatment is unavailable. What if this is the only treatment available to some individuals due to lack of transportation, living distances, or family circumstances? Would it have helped me as a teen if it were my only option? I must give this a shot. I must explore how I can best support this population virtually, because this is the only thing available to some individuals.

So, I made my decision to hop on the virtual train. It took some adjusting, soundproofing, and office plants to make the switch manageable — at least on my end.

The Young Anorexic Client

The sound machine is roaring.

Two boxes appear on my screen.

One screen showing my face, the other showing that of a new, adolescent client.

She is starting our program today after being discharged from a residential treatment center. I am meeting with her to introduce myself and complete a risk assessment. She admits that she is not thrilled to be on virtual, but that there are no other options near her. Her parents and treatment team are forcing her to complete this program. She admits to knowing that she needs it, and she is a minor, so her parents have leverage. She presents guarded, as teens usually do, waiting to see if I pass the obligatory therapist “vibe check.” I appreciate the honesty but notice the apathy in her voice. This is going to be a difficult client to connect with. I must learn how to connect with her.

Finding Connection

If I’ve learned anything about the virtual world, it is the importance of finding the ability to connect. Yes, it is more difficult virtually than when you are in person, but still doable. In fact, some people open up more through a virtual encounter because they feel safety in distance. New research has shown that the brain neuropathways activate more with in-person interactions. Which means I have to be more creative about forging a meaningful connection. (1)

Because the individual on the other side of the screen can’t get a sense of my “vibe,” and because a digital image of myself elicits different responses from neuropathways, I must rely on building rapport quickly.

I’ve learned the hard way, through moments of uncomfortable silence, that this sometimes requires talking about random teen trivia to get young clients to feel safe with me. My clients are experts in their life. I am merely a guest. The more my clients let me into their world, the more I can show them tools that will appropriately work for them. I have to meet my clients where they are at.

I find the best way to build trust is to find out their interests and build on that. That doesn’t mean I just pretend that I want to know about their interests. I mean taking the time to learn about them and ask deep questions. This helps me understand my clients and what treatment approach works best for them. My job is not to heal my clients. My job is to help them learn the tools to heal themselves.

Only with trust can a client effectively “buy-in” to what I am talking about regarding treatment. Why would anyone talk to me if I don’t feel safe? Building connections and creating a therapeutic alliance is about helping clients understand that you are a safe person.

Young teens are my favorite clients to work with. The most important part of effectively working with teens is to teach them to build connections that are stronger and safer than their eating disorder. The first safe connection might be with their therapist. The eating disorder is my client’s safest and most secure relationship. Which is why it is so difficult to recover from — it works.

The eating disorder becomes an entity of its own that protects the clients from trauma, rejection, fear, and most importantly has the capacity to numb. For clients with significant trauma or poor attachments, the predictability of this disorder is comforting. Ironically, it is providing them a mental refuge while slowly killing them. Accepting and understanding that the eating disorder has served a function for my clients is the most important starting point towards genuine connection. The eating disorder is my client’s biggest and most secure connection.

The Young Adolescent Client

The session starts the same.

Two screens.

Sound machine whirring.

I will call this client Abby.

Abby is hunched down on the floor with her laptop facing her. She is anxious and having difficulty sitting still as evidenced by a bouncing leg. This is not her first time in treatment. She has already told me she does not prefer virtual but has no other options at this time. By this point in our sessions together, we have discussed the usual eating disorder behaviors and worked on increasing Abby’s ability to talk back to the eating disorder voice. The ability to assist her in calling out the eating disorder is crucial. That means knowing how the eating disorder talks. Hint: it’s sneaky and insidious.

Since working together, what stands out about Abby is her increasing discomfort with the present moment. It is more than the eating disorder; I know the look of unresolved trauma. Abby is living in fight or flight. Her eating disorder being taken from her is forcing her to confront difficult traumatic experiences.

Abby started Cognitive Processing Therapy while in residential care but stopped it when the therapist realized she was not benefiting from the therapeutic intervention. So, what can I do here now virtually?

New research has shown that treating PTSD and the eating disorder at the same time yields better results for both. (2, 3) This is contrary to what was first taught to professionals about only treating one at a time.

I worked with Abby for some time, but Abby’s mother’s insurance eventually changed, and her parents no longer wanted her to participate in our program for understandable financial reasons (This is another aspect of eating disorder treatment that is complicated).

Abby will need long term therapeutic intervention for her complex trauma and the increasing severity of the eating disorder. Her motivation for recovery continues to wax and wane.

Let me explain what we were able to do virtually and how.

My work with Abby explored relationship patterns, boundaries, and the impact her trauma has had on her eating disorder relapse and recovery process. Abby learned evidence based therapeutic interventions to effectively talk back to cognitive distortions and her eating disorder voice.

And while all of this work was pivotal, I want to emphasize what got us there…

Soccer!

I know you are thinking. What is she talking about?

Hear me out. Gaining trust from my adolescent clients must come first.

The connection I made with Abby was as simple as soccer. Soccer was Abby’s motivation for recovery, soccer made her feel confident and alive. Soccer activated neuropathways in Abby that allowed her to feel seen by me.

All of the in-depth work that needed to be done started and ended with soccer. Ultimately all of the work that was done on a virtual platform started and ended with my ability to see my client and connect. In the end, my initial reluctance about working virtually with eating-disordered teens was largely unfounded. I would likely have encountered similar challenges had I worked face-to-face with Abby. It was the connection that built the bridge and soccer that reinforced it.

References

(1) Neuroscience News. (2023). Zoom conversations vs in-person: Brain activity tells a different tale. Neuroscience News, 27 Oct.

(2) Perlman, M. D. (2023). Concurrent treatment of eating disorders and PTSD leads to long-term recovery.” Psychiatric Times, Times, 17 Oct.

(3) Brewerton, Timothy. D. (2007). Eating disorders, trauma, and comorbidity: Focus on PTSD. The Journal of Treatment & Prevention. 15(4). 285-304.

Psychotherapists Are the Luckiest People on Earth

Posted on by Psychotherapy.net Team

An almost completely neglected topic in psychotherapy is how much patients teach their therapists — not only to become better therapists, but also to become better people. Many of the best hours of my life have been spent doing psychotherapy, and many of my favorite people were the patients I did it with. Early in my career, I realized that I was a better person when doing psychotherapy than in my other relationships — much more empathic; much less selfish. Gradually, my work with patients helped smooth the rough spots in my personality, making me a better husband, father, grandfather, teacher, and friend. This piece is a small thank you for the great debt I owe my patients. I could not be more grateful and will now enumerate some of the many gifts I’ve received from my clinical work over the years.

Ten Ways Patients Make Us Better People

  1. Close Relationships: Our ability to engage in close relationships derives from inborn mammalian nature interacting with early nurture — but later life experiences play a big role in enhancing or reducing our comfort with intimacy. The essence of psychotherapy is forming a therapeutic alliance, which often turns out to be therapeutic for both partners — teaching each how to become more comfortable getting closer to people.
  2. Empathy: The ability to understand what other people feel and to see life through their eyes is also partly inborn, partly nurtured — but no profession other than psychotherapy requires and enhances it so much. Empathy muscles grow with exercise — every session is an opportunity to build and stretch our capacity to feel and express empathy.
  3. Courage Under Fire: My patients have all had much more difficult lives than my relatively easy one. And almost uniformly, they have, more or less, lived with the hand they were dealt with a courage and grit I am not sure I could have managed. I will never complain about the challenges and disappointments in my life because I have witnessed the grace shown by my patients in facing much more difficult lives.
  4. Emotional Honesty: Most people lie only rarely, but few people are emotionally honest most of the time, with themselves or others. It requires too much work and isn’t really necessary in everyday life. But psychotherapy is different — patients have to feel, think, and do things with a degree of honesty not normally required of them — and their honesty rubs off on us.
  5. Resilience: One of my patients described his life as “knocked down eight times, get up nine times.” Patients get knocked down over and over again — not only by the expectable exigencies of their external lives, but also by the internal problems that are the focus of treatment. I have been amazed and inspired by how often patients get up that ninth time — how seemingly insuperable problems and hopeless situations turn out just fine because they have the guts to keep trying and never give up hope.
  6. Good Minutes: Psychotherapy isn’t always complicated — for many patients, the goal is to maximize good minutes each day and enhance the appreciation of life’s little pleasures. This has certainly rubbed off on me.
  7. Unselfishness: A basic precept guiding the therapist’s behavior is to always put the patient’s interests first and to never be selfish or exploitative in even the most subtle ways. This also rubbed off, if to a lesser degree, in my therapy relationships.
  8. Humility: Working with patients taught me that what I don’t know about life and people is a lot, and that I often do and say dumb things. I also learned that patients could readily forgive and forget my errors of the mind but had trouble forgiving and forgetting my errors of the heart.
  9. Acceptance: Sounds corny but doing psychotherapy with patients teaches you the wisdom to know what to try to change and what to accept — in them and in yourself.
  10. Gratitude: I have had my share of failure as a psychotherapist — people who left treatment with the accurate feeling that I hadn’t helped them. But patients who did well were often very generous in their gratitude in a way that taught me to be openly grateful to them and to other people in my life.  

Magic Moments in Psychotherapy

Psychotherapists are the luckiest people on earth because our profession allows us to participate in so many deeply meaningful relationships — hour after hour, each and every workday. Certainly, this makes for a demanding career, but a richly rewarding one. And psychotherapy done well never gets routine or dull. You always have to be alert to the possibility that a “magic moment” will occur — an opportunity for you to make a big difference in your patients’ lives or for them to make a big difference in yours. Patients are not your friends but may sometimes be, in a way, closer — when you are both changed through the special intimacy of the therapeutic relationship. Our patients can be our best teachers. Mine certainly have! Questions for Thought and Discussion What are your impressions of the author’s premise? Who among your own patients/clients has taught you important lessons? Might you ever express gratitude directly to a patient for a lesson taught?

Beyond Neurosis: The Case for A Humanistic Approach to Illness Anxiety

Posted on by Psychotherapy.net Team

Not Just a Page in a Manual

In my client, Colin, I saw myself. He was, as I had once been, fixated on his physical well-being to the point that his hypervigilant behaviors had taken over and begun to negatively impact his daily life. He had put college on hold in his senior year and moved back home. He was consistently wracked with worry about his physical health even though he had no documented health problems. In session, Colin would constantly check his body, running his fingers along his neck to investigate for lumps or placing his hand across his chest to ensure that his heart wasn’t palpitating. He would often express the feeling that he was doomed to become horribly, catastrophically ill. He lived in constant discomfort and suffered persistent feelings of worry. I had been there myself.

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By the age of 30, I had visited numerous emergency rooms complaining of vague discomforts: heart palpitations, lightheadedness, shortness of breath, headaches, bladder pain. I’d be discharged each time with a clean bill of health, but I wouldn’t quite believe it. Often, I’d seek further care, visit other doctors and specialists, and ruminate and fixate on an impending health disaster that was surely just around the corner. I just couldn’t seem to accept that I was healthy; it was too risky. If I let my guard down, then the worst would happen.

It took a while, but I recovered. Therapy helped. So did a low dose of Prozac. I still got anxious about my health, but not to the extent that I constantly sought out care and lost myself in anxious rumination. But what about Colin? What would help him? When I began to think about what had helped me, I was surprised at how simple it sounded. I had found a therapist who didn’t make me feel crazy, irrational, or neurotic. He listened to me and never judged, even when I rattled off vague physical symptoms and the anxious conclusions I would draw from them, even when I told him I had scheduled yet another doctor’s appointment. He stayed with me.

But with Colin, I blundered. I told myself just listening wouldn’t pass muster, wouldn’t be intervention enough. So, I went clinical instead of human. I forgot what had helped me. I thought it would be helpful to show Colin the DSM criteria for Illness Anxiety Disorder. My thought was that he would read it and realize that he was being anxious and irrational in his worry and fixation about his physical health. I probably don’t need to tell you that this approach backfired. Though he never said it outright, Colin, I have no doubt, felt pathologized, invalidated, and judged. Therapy didn’t seem to be progressing, and Colin’s anxiety wasn’t getting any better. If I was truly going to help him, I had to pivot, and fast.

Moving to Where There is No Sky

At that time in my career, I was reading a lot of classic psychology texts and one that consistently resonated with me was Man’s Search for Himself, by Rollo May. In this book, May describes a young girl coming home from school after there had been a drill for students to hide from a nuclear attack. Once home, the young girl asks her mother, “can’t we move somewhere where there is no sky?” Eureeka. Colin and I both, while in an anxious state, desired to be somewhere where nothing bad could happen. If there was no sky, there could be no bomb. If there is no stone left unturned, there can be no surprises. So, if we check enough, if we fixate and protect enough, nothing bad can happen.

Call it “hypervigilance” or “neurosis” or “hypochondria” — whatever unhelpful psychological designation you wish to give it — it comes down to one thing: an anxiety-based behavioral response. When I would visit ER after ER, I was seeking a safe place where nothing threatening could happen. When Colin checked and rechecked his body for changes and symptoms, he was seeking a stasis where nothing bad could happen. When he returned home despite excelling as a college student, he was seeking a safe, nonthreatening space.

The little girl in Rollo May’s book is, to a greater or lesser degree, and in one form or another, all of us. When we are threatened, we seek safety. This response is human, though primitive; it is not, however, neurotic or maladaptive or irrational. Once I realized that Colin and I were no different than May’s young girl, my clinical mind softened, therapy began to expand, and change started to occur.   

Putting the Manual in the Drawer

I put my DSM in the drawer and began to talk to Colin about anxiety as a general concept. I reached for any metaphor I could find: “anxiety is like a smoke detector that goes off at the slightest wisp of smoke;” “anxiety is like a home alarm system that gets tripped when a strong gust of wind blows.” I wanted Colin to understand anxiety at its core. The therapist I mentioned earlier had done the same for me; I recall him explaining the “mammalian brain” and the concepts of “fight, flight, and freeze.” The more he educated me on what anxiety is and why it happens, the more in control I began to feel. Gradually, I became an expert on my own unique presentation of anxiety. And from there, I began to learn how to manage it.

I wanted Colin to experience this sense of knowledge and power in the face of his debilitating worry. If he could understand anxiety, he might feel less threatened by it. But beyond education, this required normalization. If Colin viewed himself as part of esoteric group of neurotics, he would assuredly continue to feel isolated with his fear. If, on the contrary, he felt a sense of commonality, he might be more willing to step out of his rigid fixation. So, we talked about physical health and how scary it is. We talked about it as you and a friend might talk about the weather or the football game. I left diagnostic language and pathology out of it and just talked with him about something we all have in common.

Then Colin said, “now that I think about it, this all started after the thing at the airport.” A few months before, at an airport, while preparing to fly home from college for a break, Colin had become dizzy. He didn’t quite faint, but he thought he might. His brain went into overdrive, telling him he was having a heart attack or a seizure or something catastrophic. Though he flew home, he shared that it was after this incident that his health-related anxiety had really begun to escalate. Anxiety had caused him to put his life on hold. He was looking to move somewhere with no sky. Colin’s newfound understanding of anxiety had allowed him to draw an important connection that he felt safe enough to share and that, ultimately, would help him begin letting go of his catastrophic worry. It wasn’t clinical language that allowed for this; nor was it diagnostic criteria — it was talking, sitting together, creating safe space.

Now we really had something to build on: there had been a stimulus, then a belief, then a behavioral response. Incredible things happen when we just listen, and Colin’s disclosure provided an opportunity. So, we kept talking. We talked about how things happen that scare us, how we have a cognitive response to these things then a behavioral response. I was careful never to call into question or to judge his response, but rather to help him understand the chain. It was making sense. I can’t say exactly that there was a breakthrough (this is, often, a myth of psychotherapy, as true breakthroughs are almost never moments of dramatic and triumphant epiphany), but it wasn’t long after that Colin started to come to therapy less often, began to report feeling less anxious, and began planning his return to college.  

More Than an F-Code

Nobody ever asked me for Colin’s diagnosis. He never asked me either and I owe him a great debt of gratitude for staying with me despite my wrongheaded decision to show him the DSM criteria. He gave me a chance to change course, for which I am eternally grateful. Colin was my on-the-job training in humanistic psychotherapy. Sure, I’ve read Irvin Yalom and Carl Rogers, but nothing can supplant real-life practice. Colin was pivotal in my recognition of the importance of humanizing rather than pathologizing. In retrospect, he was more important than any course I’ve taken, book I’ve read, or theory I’ve learned. He didn’t feel safe in his body but, over time, he felt safe in therapy, and that allowed his sense of safety to expand outward and to begin combatting his sense of worry. I realize now that my own therapy had afforded me the same opportunity. Once I felt accepted and safe, I was free to begin questioning my anxious thoughts and conclusions.

So, sure — on paper or to insurance companies, Colin might be the posterchild for Illness Anxiety Disorder (F45.21), but in a human sense, he is much more than an F-code. Because of a frightening stimulus, his unique form of anxiety attached itself to his physical health. Anxiety attaches itself to something for everyone — what it suctions itself to merely depends on our unique experiences. So, what does this make Colin, really? Is he neurotic or a hypochondriac? Or, simply, did he, like any human, become frightened by something frightening and want to protect against it? In protecting against the threat, he utilized specific behaviors in order to remain safe. These behaviors, no doubt, worked for a while, then they didn’t. I had done the same. You have done the same. If we humanize the experience, we allow for coping and healing. If we pathologize it, we impede coping and healing.

When we descend from our clinical and diagnostic “high horse,” we truly become Rogerian and “meet our clients where they are.” When I was seeking emergency care for a perceived illness, I was not an exotic specimen to be viewed through a clinical microscope. I already felt different and alien; the last thing I needed was confirmation of that belief. I needed to be understood, accepted, and humanized, not studied as though I was a fascinating case in the annals of abnormal psychology. Colin and I have this in common: when we felt we were being viewed through a clinical lens, we personalized our diagnosis and become resigned to it as an immutable fact. When we felt accepted and seen through a human lens, we became able to view our anxiety as a cloud in the sky rather than as the sky itself.

Questions for Thought and Discussion

  • What are your personal and clinical impressions about the author’s client, Colin?
  • Have you encountered clients with health anxiety in your own practice?
  • How does your own treatment approach with these clients differ from the author’s?
  • What might you have done differently with Colin?   

A Week with Virginia Satir: The Gift

Posted on by Psychotherapy.net Team

I don’t know about you, but what really tightens my jaw is all this necessity of “proving yourself” with an evidence-based approach. What ever happened to “genuine,” or “being yourself,” as practiced by Carl Rogers or my role model, Virginia Satir?

As a lowly undergrad with an associate degree in human services, my best friend, a psychiatric nurse, and I had the opportunity to attend a weeklong training conference with Virginia Satir and Jane Loevinger as presenters. What a thrill to see them in action!

A Retreat for Connecting and Growing

The setting was September at Starved Rock State Park near Oglesby, Illinois — a magnificent Indian summer. The trees were brilliant shades of orange, reds, and yellows. The sun was hot with temperatures in the 80s every day. The park followed the river, and waterfalls and hiking trails were explored when we were not in session. Home was The Lodge.

There were exactly 102 participants divided into 34 triads (Satir said everything happened in triads), 17 families during the day for breakout practice sessions, and a large group (33) for the evening session, which we kept for the entire week. During the day, we would break into our triads or families to practice what was taught in the lecture. In the evening, the three large groups were left to come up with their own agenda. Virginia and Jane disappeared, emotionally exhausted, I presumed.

I remember that first evening sitting in this large circle of fellow attendees with either their arms or legs crossed. I knew enough about nonverbal body language to understand defensiveness and vulnerability. We waited for someone to assume the role of leader and take control. Someone suggested we go around the circle introducing ourselves. Out came the titles; psychiatrists, psychologists, social workers. I am sure they were not particularly impressed when I identified myself by name since I had only an associate degree in human relations. I certainly was intimidated! I wondered why I was there!

There were many things to like about Virginia Satir. One was her simplicity. You can read and appreciate her books, Making Contact, People Making, and Conjoint Family Therapy, Satir: Step by Step without a college education. You can share and teach it to common, ordinary everyday people.

Other qualities I valued in Satir were her compassion, genuineness, and effective use of self. She did not shy away from physical contact. She used touch. Participants at all her seminars would approach her during break to shake her hand or receive a hug, trying to capture some of her healing energy.

We knew she was an only child and her parents met over a pickle barrel, that she shied away from the color lavender, and had a down to earth sense of humor. My friend and I took up a collection from the group and bought her a lavender shirt. I will never forget the IIIFFI club. (If It Isn’t Fun, F— It club!)

Our lecture on this day was on being an effective therapist. Her basic message was that to be an effective therapist you must see, hear, and feel at the client’s level. When I returned from break, I discovered “my practice family” had volunteered or been chosen to be the demonstration family for a role play. We stayed in our designated area and the rest of the group gathered around us. Virginia asked for a volunteer to work with this family.

Something happened to me within the context of my family. Emotionally, I was overpowered by the pain I felt. It became more than a role play. I let whatever I thought or felt fly. The Family made short order of several different therapists, who could not penetrate the wall of anger and pain. At first, I felt the anger of the observers because I would not cooperate or allow the therapist to work nicely with my family. I then felt them drawing in closer and closer, hanging on to my words and emotions. I could feel them all and I didn’t care.

When we took a break at lunch time and the others left, I looked at Virginia and with tears running down my face, I said, “I don’t think I can take much more of this.”

She looked at me with a little smile at the corner of her mouth and a twinkle in her eye and said, “Feeling something, are you?” I went to my room, emotionally drained and physically exhausted. When we gathered again after lunch, we were outdoors in the warm sunshine. I had stabilized emotionally. The family was seated in a circle once again. Virginia asked the group what they would like to do with this family, and they said, “We would like to see you work with this family.” And so, she did. One by one she went around the circle. She took their hand and spoke to them in a soft and gentle manner, touching them with her words.

I was going to be the last one she would speak to. I had been really disruptive. I wondered what she would have to say to me. When she got to me, she paused, and taking my hand said, “In order to be an effective therapist, you must see, hear, and feel at the client’s level. When I meet someone as beautiful as you, I just want to give them a hug. May I?”

This great lady who everyone wanted to hug, was asking to hug me. I stood up not to take but to receive a priceless gift! She touched me. I never planned to enter, let alone complete my career as a child and family therapist, but I did!

I understand why I have such an intense dislike for the phrase “evidence based.” I do not fit in that box. I do not enter a therapy session with a brain-based approach in mind. I enter with my heart. Satir’s gifts, her use of self, of touch, and her message of simplicity, are part of me. I can hold a client’s anger. She validated me, a lowly undergrad in a sea of professionals. To this day, the words, “see, hear, and feel at the client’s level,” ring in my heart!

Working Effectively and Developmentally with Traumatized Adolescents in the Juvenile Justice System

Posted on by Psychotherapy.net Team

Would you ever want to go back to adolescence? I cringe at the thought. What a torturous time of peer pressure, identity development, and naivete about one’s own mortality. I’m sure there are a few folks out there who would happily re-experience this time in their lives, but my gut tells me it would be a small group. When I reflect on this time in my own development and then consider my experiences working with incarcerated youth, I can’t help but feel immense empathy for what they are going through, knowing they now have this experience of incarceration to contend with that will further impact everything from their self-image and their behavior to their comportment in the world. When you further consider the diagnoses that start to present themselves as these youth ages, it can become gut-wrenching to imagine how they are going to navigate life after incarceration.

Longing for While Sabotaging Connection

In my work with Zed (fictional name), I’ve seen an adolescent who so desperately wants connection, but is so afraid it won’t last that he rapidly and abusively sabotages his positive relationships. He is profoundly adept at putting on a tough face and acting as if he does not feel lonely, sad, and hurt when this transpires, and he ultimately carries the belief that people always leave, so it is better to strike before being struck. This belief has become a self-fulfilling prophecy of sorts and is heavily characterologically entwined with every facet of his being.

When Zed was younger, he ended up in the foster care system while his parents were struggling with addiction, and inevitably found himself in and out of the juvenile correctional system, transient, and in group home settings. Zed is not without insight — in fact, he frequently states, “I was acting up in those placements; I wanted to be back with my parents.” It’s important to verbalize that although it is true that he may have exhibited self-sabotaging behaviors, Zed’s presentation is directly entangled with the broken attachment and trauma that he experienced, culminating in a recent diagnosis of Borderline Personality Disorder (BPD). This diagnosis has somewhat shocked Zed and he has been persistently reluctant to accept it, and understandably so. As a teenager whose brain is still developing, the idea that your behavior is being pathologized rather than viewed as a response to injustice would be immensely overwhelming. In a session, I once offered Zed the adage, “Hurt people, hurt people.” The idea behind sharing this was to hopefully leave him with a mental nugget to come back to and ponder. However, the response I got from Zed that day was that it’s justifiable for hurt people to hurt people, particularly if it’s someone who has hurt them already. I could feel Zed’s desire for others to feel his pain — it was practically streaming from him, along with the deep injustice he felt he had experienced and the unfairness of it all to such a young person. My inner dialog was saying, “Wow, this person has experienced so much emotional pain, it is practically blinding him and those around him.”

As someone working closely with someone with BPD, it is easy to imagine how other staff members who perhaps do not have much in the way of mental health training could become easily overwhelmed, frustrated, or fearful when working with a teen like him. When Zed perceives injustice, judgement, or simply does not receive the information he would like, he can escalate and become both physically and verbally aggressive. However, the reframe of this, which I have found myself discussing with other staff members, is that he is screaming out to be held, if not literally — which may indeed be true — but figuratively. I’ve found that in instances like this, boundaries are the equivalent of being held, along with unconditional positive regard. When a resident with BPD is actively upset, they are banking on (somewhat unconsciously) the self-fulfilling prophecy of, “I am too much for others. People will always leave me,” becoming fulfilled.

What to do in moments like these, when it would otherwise be so easy to punish and control, is critical not only for their treatment, but as potential lessons of life they can take forward with them. For example, I’ve found that self-injury is often utilized as a method of power and control by someone who is diagnosed with BPD, which in turn, can make clinicians and staff fearful. They then might inadvertently reinforce the self-injurious behavior by acquiescing to what the patient demands just so the self-abusive behavior will cease. This is immensely harmful in the long-term, as the patient will utilize this strategy consistently if it proves fruitful.

When experiencing periods of time where Zed has actively engaged in self-injurious behavior, I approach him with one goal in mind: safety. It is during these periods of crisis when I remind him that I will only be able to do in-depth work with him when he can maintain safety for himself and others. Without this basic element of safety, there is no foundation, and nothing can effectively be accomplished. When I am successful in helping all of those working with Zed in this regard, it becomes much more likely that he will return to a place of equilibrium and avoid harmful behaviors.

Perhaps the biggest challenge I’ve experienced while working with Zed, is maintaining my sense of the “long-game.” Solution focused remedies won’t propel us there, but consistent unconditional positive regard, setting of boundaries, and supporting the therapeutic alliance will. While the gains often feel minimal and fleeting, consistency and determination go a long way in equipping teens like Zed with the tools for a more successful life outside of institutional walls. The most important thing I can do with teens like Zed is to remind myself and others around, that diagnosis is NOT all that these clients are. It is simply a marker and reminder that they have experienced significant and sustained trauma and potentially disrupted attachment, and they can be helped.

***
If we tell people there is no hope that they can grow through a diagnosis, we are neglecting to give them all the tools in the toolbox. And as carriers of the toolbox, it is our job to provide those we treat with the proper tools for the task at hand.

Questions for Thought and Discussion

  • What are your impressions of Zed and how this therapist addressed his therapeutic needs?
  • How does your work with clients diagnosed with BPD differ from hers?
  • What might you have done differently with Zed?

Effective Family Therapy Using Football Metaphors

Posted on by Psychotherapy.net Team

Joshua, age 8, was referred for treatment for anger management and aggressive behavior occurring in the home. After the development of a therapeutic rapport between Joshua’s mother and myself, she began to discuss problems she was experiencing with all three of her boys. She described it as “boys will be boys” behavior which consisted of hitting, pushing, kicking, disrespecting each other with name calling, ignoring personal space, taking personal property, and progressive physical contact (rough-housing) until someone was hurt or crying.

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This was an otherwise solid, stable, two-parent family with no apparent deep-seated issues. Basic needs were met comfortably. The family had a shared interest — they were united in their love for football! All three boys played in leagues. Dad was a football coach, and mom was a football mother. During football season, league play and NFL on TV dominated their lives.     

Shifting Therapy to a Focus on the Family

When working therapeutically with children, I have always considered it important to know their interests, because it can be both a bridge to the therapeutic relationship and serve as a tool to help the child buy into the treatment process. After meeting with Joshua’s mother individually, we shifted the focus from an individual treatment focus to a family focus.

With both parents onboard, Joshua’s mother and I designed “Life is Like a Football Game,” a behavior modification program for decreasing unnecessary and inappropriate verbal and physical contact.

Amid laughter, Joshua’s mother and I translated the boys’ inappropriate behavior into metaphor using football terminology, and then built the behavior modification program and incentives. We then scheduled a family meeting to discuss implementing the Game. Family members were asked to wear caps and jerseys supporting their favorite football team.

In the family meeting, the “warm-up” conversation focused on the teams they represented and the teams they liked to watch. Staying in the metaphor of football, we discussed rules, breaking rules, and consequences for breaking rules. We talked about players who broke the rules and did not demonstrate respect for the game, the coaches, the referees, and the consequences of those behaviors leading to sitting the bench or losing the game.

The conversation was shifted into behaviors occurring in the home and Joshua’s presenting issue was reframed as a family one. It was the team that was struggling, rather than Joshua, and Joshua needed the support of his team, and they needed his. The boys were told we would use football language to work on the game. The parents were introduced as coaches and referees (complete with whistles). The boys each received a handout of the rules, penalties, points sheet, and award levels. We read the rules and penalties, and discussed “The Plan.” The following Saturday was set as “Game Day.” The family enthusiastically left the session and looked forward to Game Day.   

Family Therapy as a Game of Football

The Rules of the Game
  • Game Day will begin on Saturday at 8:00 AM each week.
  • Each player will start the day with 35 Player Points.
  • Each penalty will cost the player 7 points from his individual score.
  • If a player loses all his points for the day, he will be placed in the locker room (mentally) for the remainder of the day and out of that day’s game.
  • The coaches will total each player’s points on Friday evening at 9:00 PM. Awards will be determined at that time.
  • Awards may be accumulated. Points will begin again on Saturday morning.
Football Terms

Timeout: The intentional use of separation between players to regain control and respect for the rules of the game. A referee, coach, or player may call timeout. If the referee calls timeout, he/she may designate where the players receive the timeout. If player calls timeout, he may designate where he wants to take the timeout and the other players must find neutral zones not in the same room. Time outs will be 5 to 10 minutes in length and determined by who calls the timeout.

Instant Replay: Infractions may be available by cell phone. Players beware; you are being watched!
Penalty: A consequence for demonstrating a lack of respect towards a player, coach, referee, or the rules of the game. The following are penalties you will be called for:

  • Illegal Motion: The use of facial expressions, hands, finger, arms, legs, feet, or any body part to accidentally/purposely annoy or irritate another player, which communicates a lack of personal respect.
  • Illegal Blocking: The intentional use of any part of your body to stop the forward progress of another family member who is making movement to a determined destination such as the refrigerator, the XBox, their bedroom or any other room in the house, or the community environment.
  • Pass Interference: The intentional physical or verbal interference of a player in the discussion between a referee/coach and another player.
  • Holding: The intentional physical use of restraint by one player of another when there is no play activity involved.
  • Unsportsmanlike Conduct: A verbal and/or physical demonstration of behavior by a player in the home, school, or community that demonstrates a lack of respect for the property, personal, and physical boundaries of another player, referee, or coach, or carries a threat for potential harm or safety to the player, another player, referee, or coach.
  • Roughing the Passer/Roughing the Kicker: The deliberate physical striking, hitting, or wrestling of one player towards another player after the play has been completed or whistled dead by the referee.
  • Intentional Grounding: The deliberate throwing or hurling of any object not meant to be thrown (toys, XBox controllers, shoes, balls outside of a game context) by a player to another player as an expression of anger, frustration, or retaliation.
  • Ineligible Receiver/Illegal Possession: The taking or receiving of the property of another player without the permission of the player.
  • Delay of Game: Plays called by the referee or coach will be completed within 90 seconds “It’s time to go…Put the XBox away, etc.…” or the player involved will receive a penalty.   
Tiers of Privileges Awards 
  • Lombardi Trophy AFC 85-105 Points: monetary $6, batting cages, movie theater movie with parent or a friend, Cocoa Keys outing/Magic Waters, Rockford Aviators Game, Volcano Falls, anything in the Hallas or Heisman Trophy
  • Hallas Trophy NFC 64-84 Points: $4 award recognition, 30 minutes uninterrupted XBox time, may choose a fast-food restaurant (individual meal with parent), have a friend overnight, have a pizza delivered at home, game time with a family member, fishing time with Dad, 2 hours YMCA time, anything in Heisman Trophy
  • Heisman Individual Trophy 49-63 Points: $2 weekly award recognition, movie or game rental, pick a favorite meal, food, or dessert for a family home meal, trip to the $1 store, shopping with mom, tennis time (60 minutes per award), quality time with a parent of choice  

Family Response to Therapeutic Intervention

There were multiple factors that contributed to the success of the intervention. A critical factor was two stable parents in a stable marriage providing a stable home environment and consistent use of “The Plan.” The intervention occurred in the home where the problem was occurring which made it more naturalistic — home team advantage, so to speak. The family knew and loved football, so it was not difficult for the coaches/referees or players to understand, competitive spirit, the rules, the penalties, and the consequences. The behavior modification plan was built on a positive platform to encourage competition and success. Even the child doing the poorest was still a winner. Hidden in the incentive rewards system was a lot of parent quality time!

I would occasionally touch base with the mother, who indicated she and her husband were all initially very busy calling the infractions to drive home the seriousness of the issue. Eventually, the parents were able to put down their whistles and use verbal reinforcement. Over the course of time and with consistent repetition, the boys began to call infractions on each other — self refereeing. Problematic behaviors did decrease. The parents and the boys were able to apply this coded language when they were out in the community to literally “head things off at the pass!”

My total involvement with this family was less than 3 months! This family was able to take the sport they loved and apply it to their relationships with each other in the football game of Life.  

Questions for Thought and Discussion

What were your impressions of this therapist’s intervention?

In what ways have you integrated creative interventions in your practice with children and families?

What did you see as the benefits and possible limitations of this particular approach? 

Ethical & Legal Considerations in Using ChatGPT as an Aid for Clinical Diagnosis

Posted on by Psychotherapy.net Team

As psychologists, our mission often treads a tightrope of diagnostic precision and ethical consideration. The emergence of artificial intelligence (AI), particularly language models like ChatGPT, introduces an exciting yet complex layer to this balancing act. Such innovations have been lauded for their diagnostic acumen but also raise questions about legal implications and ethical stewardship. For this reason, I think it is important to explore the current state of AI applications in behavioral health, focusing on ChatGPT’s diagnostic capabilities as an aid to rendering a clinical diagnosis. In doing so, I hope to engage you in a thoughtful discourse about the ethical and legal dimensions of embracing AI in psychological practice.

Recent Literature on ChatGPT and Diagnostic Accuracy

A foundational study led by Mass General Brigham revealed that ChatGPT displayed a diagnostic accuracy of 72% across multiple medical specialties, even likening its performance to that of recent medical school graduates. Similarly, researchers at Queen Mary Hospital’s Division of Geriatrics investigated the efficacy of Generative Pre-trained Transformer 4 (GPT-4) in diagnosing older patients, citing an accuracy of 66.7% for primary diagnoses. These findings signify the AI’s prowess but also underscore the necessity for additional benchmarking and regulatory oversight.

In the context of behavioral health, Hilty and colleagues employed natural language processing to quantify linguistic features associated with mental and neurocognitive disorders. They advocated for using large datasets to enhance diagnostic objectivity, a mission that aligns well with the capabilities of ChatGPT. Salih Tutun and their colleagues discussed ethical frameworks that must be established to guide AI’s role in mental health, emphasizing the need for innovative yet ethically responsible diagnostic tools developed in line with guidelines for integrating ethical approaches to designing AI.

A Foray into ChatGPT’s Diagnostic Utility in Behavioral Health

To demonstrate AI’s capacity to enrich clinical thinking, I asked ChatGPT-4 to generate potential Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnoses based on a specific behavior pattern. The result is offered below.

Prompt #1: What are possible DSM diagnoses for someone who is easily wounded, drinks alcohol to the point of being unable to show up for work, gets angry quickly, has poor boundaries, is marginally employed, is in debt, and is unsuccessful in romantic relationships?

The 1st ChatGPT Response

The following response (in italics) was obtained verbatim. As you read the response, consider whether it would be helpful, legal, and ethical for you to be able to enter a behavioral prompt (question posed to ChatGPT) to get this type of response:

It appears that the individual in question may be exhibiting several symptoms that could potentially align with various Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses. It’s important to note that making an accurate diagnosis requires a comprehensive assessment by a qualified mental health professional. However, based on the information provided, several potential DSM diagnoses could be considered:

Intermittent Explosive Disorder (IED). Intermittent Explosive Disorder involves recurrent outbursts of anger that are disproportionate to the situation and often result in aggressive behavior or destruction of property. Individuals with IED struggle to control their anger impulses, and this may negatively impact their relationships and work life.

Borderline Personality Disorder (BPD). BPD is characterized by emotional dysregulation, unstable relationships, poor self-image, and impulsive behaviors. Individuals with BPD may experience intense anger and have difficulty managing their emotions. Poor boundaries and struggles in romantic relationships align with BPD features.

Alcohol Use Disorder (AUD). Excessive alcohol consumption, to the point of impairing daily functioning and causing absence from work, could indicate an Alcohol Use Disorder. This diagnosis would be based on criteria such as loss of control over drinking, unsuccessful attempts to cut down, and continued use despite negative consequences.

Depressive Disorder. The individual’s difficulty in managing anger, poor boundaries, and struggles in relationships could be associated with a Depressive Disorder. Depression can manifest as irritability and impaired social functioning, impacting both work and personal life.

Generalized Anxiety Disorder (GAD). Poor boundaries, being easily wounded, and difficulties in relationships might also be indicative of Generalized Anxiety Disorder. Chronic worry, heightened sensitivity to criticism, and interpersonal difficulties can be features of GAD.

Unspecified Personality Disorder. The individual’s challenges in maintaining boundaries, unstable relationships, and difficulties in employment could suggest the presence of a personality disorder that does not neatly fit within one specific category.

It’s crucial to emphasize that these are preliminary considerations and not a substitute for professional evaluation. A comprehensive assessment by a licensed mental health practitioner is essential for accurate diagnosis and appropriate treatment. The provided descriptions should not replace personalized clinical advice, and any diagnostic conclusions should be made by a qualified professional after a thorough evaluation.

Prompt #2: Which characteristics would need to be evaluated to make a differential diagnosis between the above possible diagnoses?

The 2nd ChatGPT Response
To differentiate between the potential diagnoses mentioned earlier (Intermittent Explosive Disorder, Borderline Personality Disorder, Alcohol Use Disorder, Depressive Disorder, Generalized Anxiety Disorder, and Unspecified Personality Disorder), a thorough assessment of various characteristics and factors is essential. It’s important to consider a combination of clinical interviews, self-report assessments, collateral information from family or close contacts, and possibly psychological testing. Here are some key characteristics that need to be evaluated to make a more accurate differential diagnosis:

Frequency and Intensity of Anger Episodes. For Intermittent Explosive Disorder, the frequency, intensity, and context of anger outbursts need to be evaluated. Determining whether the anger reactions are disproportionate and recurrent is crucial.

Emotional Instability and Impulsivity. Borderline Personality Disorder is characterized by emotional instability, impulsive behaviors, and unstable relationships. Assessing the pattern of emotional shifts, impulsive actions, and unstable sense of self is important. Alcohol Consumption Patterns. For Alcohol Use Disorder, an assessment of the individual’s alcohol consumption patterns, including frequency, quantity, and impact on functioning, is necessary. Evaluation of withdrawal symptoms, unsuccessful attempts to quit, and continued use despite negative consequences is important.

Presence of Depressive Symptoms. Depressive Disorder involves a range of symptoms beyond irritability, such as low mood, changes in appetite, sleep disturbances, and feelings of worthlessness. A thorough assessment of depressive symptoms is needed to consider this diagnosis.

Excessive Worry and Anxiety. In Generalized Anxiety Disorder, persistent and excessive worry about a variety of topics is a hallmark. Evaluating the extent of worry, physical symptoms of anxiety, and impact on daily life is crucial.

Impaired Interpersonal Functioning and Boundaries. Assessing the individual’s ability to establish and maintain healthy boundaries, as well as the quality of their relationships, can help differentiate between various disorders. An examination of interpersonal dynamics is particularly relevant for personality disorders.

Duration and Chronicity. Evaluating the duration and chronicity of symptoms is important. Some disorders, like personality disorders, involve longstanding patterns of behavior, while others might have more episodic presentations.

Family and Developmental History. Gathering information about the individual’s developmental history, family dynamics, early life experiences, and any history of trauma or adverse events can provide insights into potential underlying factors.

Response to Treatment. Observing how the individual responds to interventions, therapy, or medication can help in refining the diagnosis over time. Different disorders may respond differently to specific treatments.

Rule Out Medical and Substance-Related Factors. It’s important to acknowledge that medical and physical factors can indeed contribute to or mimic psychological symptoms. When evaluating an individual with behavioral and emotional concerns, considering potential medical conditions is a crucial aspect of a comprehensive assessment.

Need for Medical Evaluation. Given the individual’s symptoms, it’s advisable to conduct a thorough medical evaluation to rule out any underlying medical conditions that could be contributing to the symptoms. Medical conditions such as hormonal imbalances, thyroid issues, neurological disorders, or even medication side effects can impact mood and behavior.

In a comprehensive assessment, both psychological and medical factors should be taken into account. If an individual is experiencing significant psychological distress, it’s recommended to consult both a mental health professional and a medical doctor to ensure a comprehensive understanding of the situation and to consider all potential contributing factors. Remember that an accurate diagnosis often requires a multidimensional approach, and it’s not uncommon for individuals to have overlapping symptoms or co-occurring disorders. A licensed mental health professional with experience in assessment and diagnosis should guide the process, integrating various sources of information to arrive at the most appropriate diagnosis.

Ethical and Legal Caveats in Using ChatGPT

This demonstration is but one of many examples where ChatGPT can be used to broaden the clinician’s thinking about possible diagnoses to consider, as well as different avenues to explore to gather additional relevant information.

Despite its promise, ChatGPT is not without challenges. The AI model can inadvertently exhibit social prejudice and toxicity, thereby warranting rigorous oversight from clinicians. Furthermore, the legal ambiguities surrounding liability remain unresolved, especially when ChatGPT diagnoses are used as standalone evaluations. Multicultural and diversity issues, and protected health information were intentionally excluded from this demonstration.

ChatGPT and similar AI models serve best as adjuncts rather than replacements for human expertise. The current state of these tools does not support their verbatim use in clinical settings. If you’re contemplating the incorporation of ChatGPT into your practice, seek advice from your malpractice carrier’s attorney, your state or national psychological association’s legal office, or the APA Division 5, the Division of Psychometrics and Quantitative Psychology. If these groups don’t offer anything yet, get involved and start something as part of their group. Depending on your circumstance, independent legal counsel may also be advisable.

Telehealth.org also offers Continuing Medical Education (CME) and Continuing Education (CE) courses to guide you in this evolving terrain. Ensuring responsible utilization of ChatGPT in psychological diagnostics requires a confluence of caution, human judgment, and robust regulatory frameworks. As we step into the future of AI-augmented healthcare, let us tread with both anticipation and due diligence.

Disclaimer: This article is written for educational purposes only and should not be construed as legal or clinical advice. The information contained in this article was sourced from a telehealth.org blogpost titled, ChatGPT Diagnosis: Walking the Tightrope of Legality and Ethics found here and is re-printed with the author’s permission.

The Challenges and Rewards of Therapeutic Work with Brain-Injured Clients

Posted on by Psychotherapy.net Team

Over the course of my career, I have worked with many people who sustained brain injuries. In the 1980s, I worked in a brain injury rehab program set in a nursing home, then in private practice during the 1990s. For many years since, I have been an employed psychotherapist in nursing homes.

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In my experience, those who have acquired a head injury typically display irritability and quick flashes of verbal anger — aspects of “organic personality change.” The individual may be more impulsive, acting prior to thinking about likely consequences, might show less awareness of social boundaries, and have problems with short term memory. Sharing some of their stories will offer you a glimpse into some of the challenges and opportunities I’ve experienced in working with these clients.

Case Illustrations of Clinical Work with Brain-Injured Clients

Douglas

One of the clients I met while working at an in-patient brain injury rehab program was Douglas, who was in his early twenties, and was injured riding his motorcycle while intoxicated. Anger management was a focus of therapy; he often expressed anger over being injured, and at his father for bringing him to the rehab program. One additional task of therapy was to assist him in formulating a new sense of personal identity — as he was not who he had been, and not yet who he was becoming, but was feeling lost and overwhelmed somewhere in the middle. Another goal was to strengthen his motivation to maintain sobriety in the future.

During a psychotherapy session one day he unexpectedly said, “Getting a brain injury was probably the best thing that could have happened to me.”

“Tell me why you say that, Douglas,” I asked.

“Because otherwise I don’t think there was any way I could have stopped drinking.” But that attitude and outcome are not achieved by all people.

Brandt

During the time I was working in private practice, I also provided psychotherapy and consultation with a statewide head injury program in Massachusetts. That was where I met Brandt, who had an alcohol use disorder, and, over time, had acquired three different brain injuries because he was not able to stop drinking.

Brandt had his first head injury on a construction job site when he was under the influence of alcohol. To others in his life, Brandt appeared to have a friendly and outgoing personality. Yet the overly friendly, and often tactless and joking manner he displayed represented “changes of personality” associated with frontal lobe executive dyscontrol due to his first brain injury — when a piece of work equipment struck him in the forehead.

Because of his frontal lobe dysfunctions, Brandt found it difficult to anticipate or perceive likely consequences of his actions, and he might brush off or disregard cautions and advice offered to him by me or others in his life.

His second injury occurred when he had been drinking one night with friends. They ran out of beer, and Brandt jumped into his Volkswagen Beetle and sped off to buy more. He drove too fast around a curve in the road, the car rolled over and he was ejected from the car. He landed unconscious on the ground in the dark.

Brandt awakened and lifted his head, and immediately in front of his face was a gravestone. He had landed in a graveyard! How could there have been a more pointed and dramatic message about where his drinking would lead him? Nonetheless, he continued drinking until he had a third brain injury that resulted in significant disability, and he was moved into a group home for daily care.

Mrs. Kelly

During the period when I worked in private practice and was offering head-injury-related consultations, I went to Chicago for a co-presentation at a brain injury conference. I spoke about brain injury from a professional point of view, and the co-presenter, Mrs. Kelly, talked about the personal experience of living with a brain injury. Driving home one day, Mrs. Kelly had been struck and injured by a drunk driver.

During our presentation, Mrs. Kelly spoke of the life losses and challenges that had resulted from her injury including relearning to walk, talk, conduct daily tasks, the gains that resulted from her rehab, and from the continuing support of her husband, who had accompanied her to Chicago who was always in her company.

I spoke of the common goals and aims of brain injury rehab, and about the work of individual therapy, group therapy, and family or marital therapy following a brain injury. During our talk, we also shared a particularly poignant background to our shared experiences, because Mrs. Kelly had earlier been one of my teachers in high school. Using her characteristic humor, Mrs. Kelly once said to me, “I used to get mad that I keep forgetting things; but then I realized, why get mad, in a few minutes I’ll forget what I was mad about.”

Rose

My mother-in-law, Rose, became ill with dementia and spent the last months of her life in a nursing home close to where we live. She and I sat in a small dining room during a visit one day a few years ago. A nurse’s aide across the room spoke irritably to a female resident in a wheelchair.

Rose watched, and when the aide left the room, she shook her head and said, “I hate it when they talk that way. She spoke to her like she was a has-been. She’s not a has-been, she’s a have-been.”

“That’s such a wise and beautiful thing to say, Rose,” I remarked.

Ronald

Around that time, I had long been working as an employed psychotherapist in nursing homes, and I was then seeing Ronald for psychotherapy in a different nursing home from where Rose resided. Ronald had been a scientist working at a prominent institute in California, and he drove a red convertible sports car — but sometimes too fast, and he sustained a brain injury in a collision.

What remaining family he had was in the Boston area, and so he found himself at a nursing home outside of Boston. Ronald was depressed and angry. He mostly stayed in his room, reading and listening to classical music. He would make derogatory comments about the other residents and the staff.

I told Ronald the story of the wise comment by my mother-in-law, and I challenged him to conduct a scientific experiment over the coming week: to go about the unit and research who the other residents have been in their lives.

The next week as I walked onto the unit, Ronald approached me holding a small notepad. Referring to notes he’d written, and pointing to different residents, he excitedly recounted things he had learned about them.   

***
 

Conducting psychotherapy with brain-injured clients has typically involved some modifications to my typical approach. It has been important for me to remain alert to the psychological consequences of organic brain dysfunction. My approach with these particular clients has been more educational and directive as opposed to my typical non-directive one; teaching about the effects of the injury and providing behavioral guidance and specific suggestions for social functioning. The information I provide in treatment is more concrete, and offered in smaller bits, with frequent repetitions to aid retention and recall.

I have found it to be enormously gratifying to work with these clients and encourage my colleagues to welcome rather than avoid these opportunities. It allowed me the chance to work with clinicians who taught me to appreciate the psychiatric effects of medical conditions. The work also allowed me opportunities to make a positive difference in the lives of persons who had been severely injured, and in the lives of some family members who had been devastated by the injury to their loved one.