Wednesday, January 21, 2009

Insult Me, Why Don't You?

May I suggest that part of psychotherapy is giving people feedback about themselves they may not want to hear? One of the many reasons why therapy is something different than talking with a friend, or simply 'conversation,' is that the therapist may point out to the patient certain things that in friendly conversation might seem hurtful, unkind, or downright mean. And why? Well, if you don't notice you're doing something, how can you change? Or maybe you don't want to change, but how do you come to make peace with it? Sometimes, it helps to know you're doing distasteful things. Some days I feel like I spend my days insulting people.

The thing is, people don't get offended. The don't meltdown, and there are reasons why this is. There's something about the therapeutic relationship that makes it safe to say things that aren't safe to say elsewhere. Something about the trust the patient holds makes it okay to point out their flaws. Sometimes, it takes a little bit of easing into...and sometimes it takes a little bit of building up at the same time to make it so someone is comfortable hearing something they don't necessarily want to hear. Screaming "You did WHAT?!" doesn't tend to offer room for examination. Saying, "That's interesting, you're the type of person who is usually so in tune to other people's feelings (compliment) that it's funny to hear that you were so mean to Harry (insult)." And of course, sometimes the therapist misjudges and the patient clearly feels badly and then it's time to step back-- hammering someone with something they aren't ready to hear isn't usually all that helpful.


Anonymous said...

Hmmmm. I am not certain my psychiatrist does this, though when I have recounted what he has said to me at times, to a friend of mine, she says "You'd be mad if I said that to you!". I think most of that "stuff" has been in the advice category, though. I feel I am so hard on myself that my psychiatrist props me up more than points out flaws. Sometimes he points out GOOD things bluntly. That can leave me with head cocked and a thoughtful expression, no response as I digest it. Mostly he lets me come to my own conclusions.

One time I DID feel that he insulted me (with a blunt comment which seemed unfair to me) and I felt like quitting therapy, but did not.

If you feel you are insulting people all day, how does that make YOU feel? Does that make people less depressed, more functional?

Anonymous said...

Today I felt brave enough to broach an issue that had been bothering me. From this site and podcasts I have learned about coverage. My doc took a month off for xmas.....he works hard.. no doubt...but I needed him last week and his message service gave the standard "call your family doctor, mental health team or hospital".. thanks but no thanks. I wanted my doc or his deputy.

I feel better for telling him what was bugging me.

Sorry it's a tangent. But if it's bothering you...say it. If it's delivered in a kind constructive way...I for one will not take offense... if it's advice that is for my benefit...go ahead "insult me ...gently"

Rachel Cooper said...

I'm taking a social work course in university right now and all we're learning about is the "strengths theory/perspective" - how a practitioner should empower his/her client by encouraging them to use their strengths, build on their experiences - all in very positive contexts.

Honestly, gag me with a stick - a small one. Every once in a while, we all need a good metaphorical kick in the rear end - and sometimes an insult - particularly an honest, blunt statement of fact - does the trick to wake up a person and realign their paradigm about a particular situation or experience .

Lee said...

I've met with a lot of therapists and one of the big reasons why I've left a number of them is that they were to nice. They weren't doing any of the helpful "insulting'.

DrivingMissMolly said...

As I recall, Dinah, a long time ago, you said something in a comment in response to my comment. that, "I didn't like hearing about myself," I'm not sure of the wording.

I was surprised, but not really angry. It was interesting to me.

I don't think I'm very "porous." Although I believe that I listen to my psychiatrist, I'm sure that only a little gets in. Right now I feel that he is very much a blank slate and it fills me with rage. He's so bland, boring and ineffectual. I wonder if he does this on purpose so that I project my feelings onto him or if he is just lazy.

I think I try to shrink him.

I have to protect myself because I am very, very fragile. One time we were talking in regards to my prognosis and he said if I kept more to the "reason" side than the "emotion" side there would be hope.

Later, I thought to myself that what EXACTLY the wrong thing to say to a patient with borderline personality disorder because suppressing emotion over the course of my lifetime IS the problem, not the solution. I need to learn to moderate...

Anyway, about a week before Christmas, when I was sitting in the back yard with a loaded 9mm in my lap trying to decide where on my face or head to put it, I thought of my shrink.

I knew he would be no hope. He has nothing to say. I knew he would say call 911 go to the hospital, blah, blah, blah, but...that's for legal reasons, not because he actually cares.

I want him to love me, but I hate him. I want to hurt him, not physically, of course. Now, I can't afford to see him so I am in a kind of limbo.

If I got the itch to kill myself again, I wouldn't call him. He's not warm or caring. He's cold, like my father and like my ex-husband.


PS Dinah, do you get We network? There is a show called "Hopkins" about docs and their personal lives. They actually, albeit briefly, showed a shrink who was incensed about a patient who was manic/psychotic being questioned by police about an assault. She ordered Haldol for the PT. They did not show the PT.

Anonymous said...

Ooooooooooooo so interesting and hits on so many problems I have with my shrink. The best help is when he points out something I need to change (last time, it was something like, "Wait a minute, you keep blaming other people for something that is nobody's fault." It stung, but it was right and helped me quit doing it.

But he so rarely does this. And there's the key point: if you don't do it, it's not therapy. I always feel like I'm in this amorphous void with I have ideas about what my problems are, and he has ideas about what they are, and no one ever says anything about identifying or fixing them! Argh!

And what Rach said is right too even if she doesn't like it - it's the counterpart of the criticism, the building on the good stuff. My good shrink was very tough on me over some things, but very encouraging of others.

My current shrink never does that - either the criticism or the building up, and sometimes people need it pointed out that they are fucking up (or also that they have good qualities). I think what someone said about a shrink being able to be too nice as a hindrance is very true.

Anonymous said...

As long as you aren't being judgemental when giving feedback, then I don't have a problem with it. I'm paying to receive feedback. It's helpful though if I'm given neg. feedback on how I said/did something, to at least provide a hint as to how to go about it differently next time. I detest therapists who are not active in the process, and are under the impression that simply giving me the feedback helps me change it.

shrink on the couch said...

Good advice. In some cases clearly welcome and appreciated, in others, buckle the office seat belt prep for endless defending.

Anonymous said...

So you aren't supposed to point out touchy things in friendly conversation? Hmmmm. I suppose I am just a forward and blunt sort of person.

Do you ever have patients who would rather you call a spade a spade instead of couching it in niceties?

Dr. Pink Freud said...

My experience providing therapy is that interpretations (or criticism), are likely to be rejected early on, due to the lack of a well-developed therapeutic relationship. A brilliant interpretation given too early will likely be dismissed, whereas several sessions later, the therapist would have been perceived as spot on.

Sarebear said...

I'll read the post in a bit, but given my spotty internet connection tonight, just thought I'd poke my head out of the snow and cold and say HI! I'll comment on the post itself later or tomorrow, should my connection allow, but for now, Hi. And watch out for those toolboxes.


Sarebear said...

EXCELLENT post, and point. And something that is a part of my therapy, of course, although I'm rather a skittish deer, but working on being less so is part of what I'm working on, too . . . . AND, you sounded just like my therapist, the way you phrased that example, lol . . . not that the example was me, but the way you did it, hee. Guess it works, lol.

But it also might help me deal with a SIL I have some awkward moments with, to ease into when I feel like I need to stand up for myself, like it's something far enough over the line that I'm not going to let it roll (still defining that line, but I'm a work in progress - don't wanna be a doormat, don't want to respond to every perceived slight either) this like how you said in your example, adapted to whatever situation I'm in, could surely help.

If it comes up anytime soon, I'll report back on if it helped with my, er, prickly SIL.

Oh, not report back like I'm reporting back to a therapist, to make that clear, since i've been um away from this blog as a commenter awhile, just, well, like a blog friend/commenter who's trying out an idea your post sparked, like, see. Just to make that clear (uh, yeah, I have anxiety distorders, heh, that's why I put disclaimers so much . . . . . . . .

Sarebear said...

Okay, and now I've read the comments! Sorry for the triple play, but my connection has been sooo spotty tonight (been wrestling with it lol) that I had to do this in spurts.

Therapy Patient's comment reminded me that that happens to me too. Not the 2nd paragraph, but the first.

Anonymous 1, good!! And yeah, that bugs me too. OH man my psychiatrist (who I see for meds only but it somehow stretches onnnnnn . . . . . anyway) he is SO frackin' disorganized, and phone messages, geez, OH and yesterday i had to go there cause the scrip he wrote the other week for a new med, a major med change for me, he FORGOT to sign, and it's a class TWO even, ugh, and we wait half an hour, thinking he's w/ a patient, after knocking on his door back there, . . . . . finally i come up out of the car as i had sent hubby up, me w/broken toe, and i go back and knock on door, he still puts off, and i continue w/what i'm saying, about how he forgot to sign my [medname] prescription (i said that last part louder), and then I go back to the front desk (which never has anyone at it.

He comes out within a minute (I had given him 2 before we left) and dang it all if he hadn't been in with a drug rep . . . . from what I could tell . . . . demeanor, dress, etc. The way they stood there and responded to what he was doing with me, just everything . . . . (I hope it was the rep for this particular med's company, HA lol).

He made us wait HALF an hour and it wasn't even a patient he was with? GEEZ.

Sorry. Rant over. I'll have a few words for him at my next appt. But it was so hard to get a psychiatrist I'm not up for another search. AND we're about to FINALLY change my antidepressant next appt, so I'm not going anywhere.

Sorry, long comment. I've learned to tell my therapist if somethings bugging me about him, altho part of that came from the book, In Session; at least, part of my courage to do so, came from that book, but my therapist is well I would have come to that anyway, book or no book. He's open to discussing anything, including the therapeutic relationship.

And there's been times that things have come up that I've felt have been blocks to the therapeutic relationships, at least when I've finally identified hey, THIS is what I think is interfering in my therapy, and it's something about when he does this, or whatever . . . . and so I bring it up.

Sometimes it's REALLY really hard, depending on what it is. Sometimes MONUMENTALLY hard, but . . . . it's been worth it.

Anyway, Guess Anony1 inspired some from me lol.

Rach, I agree. Now, my first Psychiatrist . . . . was problematic in some ways, but when we clicked, it was . . . it was well hard to describe. He was very . . . . . difficult. That's one way to put it. Blunt, is another. Thing is, I think he overused it, to the point of not listening sometimes, to the point of deciding he knew more about you before you were done talking and so tuned out .. . . reached his conclusions, as it were, I mean he WAS used to hearing lots of BS, I guess, but I'm someone who . . . . well, I've been told I've got a different . . . . perspective, way of thinking about things, from just about anyone most others have met (not that I'm saying I'm something special like that, a genius or anything, but) what I'm saying is, I think that his . . . . usual working manner would . . . . make assumptions that would often work in most situations, but . . . .I'm different in many ways . . . .and he didn't listen, quite enough.

On the other hand, I possibly didn't listen to him, enough, either, but . . . I did try, even though it was HARD. AND, like I say, there were moments of . . .well . . . even if it was some of the hardest moments, it was like a brilliant team or something, even with the bluntness, what some might call cruel, during the times we were clicking, working together . . . . . I faced up to some hard stuff about me that he'd say . . . . . I think he relied on that tactic too much though. I'm proud of what I learned from him, some of it learned by walking through the fire of DEALING with him, lol!

Some of it learned from opening up to what he had to give and teach me. But I agree, Rach. I think he might have gone a bit overboard the other way, though . . . heh. Miss him sometimes, when my current one is . . . not at his best. Can't believe I just said that. Miss the BEST of the old one, that is.

Lee, goes along w/the above agreeing w/Rach, yep!

Lily . . . . As someone who was also feeling in similar states during the holiday season, while I can't say I understand the reasons or same states of mind because we're different people, that idiot saying stick to reason instead of emotion and then there's more hope? OMGOSH! People are emotional beings!!! I haven't been diagnosed with borderline, although I do "have" borderline tendencies . . . that's the "official" word. I hate to even associate myself w/ borderline cause of stigma (have barely mentioned the word on my blog, I think, even though fighting stigma is one of my "thangs", or was . . . . been feeling purposeless . . .)

Unless you need the gun because of some personal threat to your safety or something (and don't turn that into, yeah, I need it because I need to kill myself, ha), I'd seriously recommend disposing of it in the way your community does such things, or if it's allowed to have someone trusted for you, or a legal person, a cop, lawyer, whatever, do it . . .

PLEASE don't harm yourself!!! I know I've not been around much lately but the world would be a poorer place without you. It makes me sad to picture the scene, and the all too familiar emotions that I've felt, tho I've not handled a firearm since black powder pistol shooting as a teen w/my dad a couple times in a quarry. Anyway . . . . suppressing emotions, suppressing ones' self . . . feeling like I don't get to "just be yourself", like many other people are encouraged to be, OH BOY am I familiar with THAT feeling, feeling like I have to suppress so much. Anyway. DON'T HURT YOU, K? HUGSSSSS!!!!!!

My sad alter ego: My therapist sometimes goes awhile without doing it - sometimes I think it's because I'm really in a fragile state, and he recognizes it; other times I think it's because there's so many types of things we're talking about and doing, it can probably be hard to get to every kind of technique or whatever that a therapist applies in therapy . . . . . hrm, sounds like I'm apologizing for him or making excuses, that's funny. Wonder what that means. Lol.

Anony2, good point as well. Sometimes part of my prob w/ shrink number one.

phd in yogurtry - w/shrink #1, that seatbelt sadly become more and more as things went on . . . the last appointment was, well I was hoping for some of the old spark, the old brilliance of his, but. . . . I hadta put the seatbelt on, he wasn't listening to me. It was too bad, too . . .

catherine - some people are more able to take it up front like that than others, sooner than others . . . . I'm not one of those, lol!! You sound neat, though.

Dr. Pink Freud - Timing is essential I'd agree. I'd say that the first 6 months or more of my therapeutic relationship w/my psychologist were quite a bit of therapeutic relationship building - I don't trust easy . . . I'd never been in therapy before either.

Hope I don't come off as some arrogant, OH I gotta comment on everybody, I just wanted to, after so long . . .

AND LILY don't DON'T HURT YOURSELF heck email me and i'll give you my phone number. You can call me!!! my email I THINK is on my blog if it isn't i'll go put it there right now . . . . in my profile . . .

Long comment, hope y'all think it's good I'm back . . . dangit, there i go again, worrying what people thing . . . .woops.

Fat Doctor said...

I think this is why i shy away from therapy. I'm just too fragile for honest feedback. Deep down, I know all of my shortcomings, but I've suppressed them for a reason.

Rach said...

Hey Dinah,

As usual, a lot of good points raised - I carried this over to my own blog... Thanks!

Rach said...


My issue with the strengths perspective is that it's very critical of the biomedical model and psychoanalytic models (and any other counselling model that has an iota of paternalism involved). I do believe that I've been quite empowered by the mental health professionals that I've worked with, despite (or inspite of?) the fact that they still work within the confines of DSM-IV(R) diagnostic criteria - which the strengths perspective is also critical of.

The one thing I've learned from this sophomore Social Work course is... wait for it, wait for it....
I'm not cut out to be a social worker.

Anonymous said...

Fat Doctor:
My perspective is that therapy is more about guided introspection than being insulted. A fragile person still will do well in therapy with the right psychiatrist. When a psychiatrist makes a comment that is correct and true and reflects the way both the patient and the doctor see the patient, it just does not come across as an insult.

The most valuable thing my psychiatrist does is ask me questions. Some of the questions are ones he already knows the answer to (I think), but I don't. For example, the other day he said "You see? You CAN tell the difference when you are in an abusive situation versus a non-abusive situation, so why do you keep seeking out abusive situations?" I am guessing that he knows. I still don't know. I don't consider a comment like that insulting because I already know I end up in abusive situations.

My psychiatrist must use at least some of the "strengths" perspective because he doesn't give diagnoses to patients. He thinks that there's a continuum and that it can be counterproductive to pigeonhole clients into categories which do not take variation and nuance into account.

Anonymous said...

Rach - I also am very critical of those models, so I guess that's why it works for me.

Anonymous said...

I wish people could accept it from their friends, if it was said with love and sincerity. The best friendships I have are where it's okay to do that. Therapy definitely has a role, but truth and caring and the ability to say your piece from either direction shouldn't be restricted to that particular setting.

Anonymous said...

This is exactly why I hate psychology. The therapist is always making insensitive and insulting comments and I have a self-esteem problem so all they do is make my self-esteem problem much worse. I have tried and tried and tried and tried to explain this to pscychologists but they don't have the ability or insight that their method DOESN'T WORK to stop themselves. I MUCH PREFER STRENGTHS BASED PSCYCHOLOGY.

Dr. Pink Freud said...

I'm a clinical psychologist and strongly believe strengths must be identified and harnessed for successful treatment. Unfortunately, it has often been the case that people drop out of therapy when it's not perceived as working, rather than asking for a referral. When I meet with a patient for the first time, I use the analogy of a buying a car as a guide to finding a therapist. You don't necessarily buy the first car you drive. If your therapist isn't working out after an adequate trial number of sessions, ask for three referrals.