10 Things I Hate About... Our Profession: Ethics and Ethos in the Therapy Room

Dear Mental Health Treatment Community (Therapists, Counselors, Social Workers, Psychologists, Psychiatrists, Psychiatric APRNs, etc.):

Welcome to my soapbox. Today, I wanted to take the time to explore the 10 things I hate about our profession. This is a rant about all the crap that mental health treatment providers do that just, frankly, sucks, and shouldn’t be happening, but isn’t strictly unethical, just unappealing and disheartening to hear about again and again from clients in my therapy room, and from providers themselves.

Yeah, that’s right. I’m talking to you all. Listen up, we all have some explaining to do, and if this post makes you uncomfortable, so be it. (It makes me slightly uncomfortable writing it, so I know it’s something that needs to be said.) I’m not perfect at all of these either, but I do try to recognize them (or be open to feedback from colleagues and trusted people) in my practice, so I can continuously improve. Without further ado, here are the 10 things we need to shift in our profession:

1. Return freakin’ calls and emails from potential clients. Yes, even if you’re full. Yes, even if the client isn’t a good fit for your practice. Yes, even if you’re tired and the email seemed dumb, etc. People are desperate for help, and if their first ten attempts at reaching out to someone fall flat or garner no response, they lose steam and stop trying to get help. If we, as therapists, want a healthier society, then we need to support people’s efforts to create change in their lives by reciprocating their energy when they reach out.

2.  Geez, tell clients their diagnoses, and show them their treatment plan, if they ask to see it. I’m always shocked when providers tell me that they don’t tell clients their diagnosis for fear of “it upsetting them.” Are we not in the business of helping upset people reset emotionally? Can we not handle pushback, criticism or genuine feedback from the very people who we are treating… in an area in which they are admittedly an expert—their own experiences, thoughts, body sensations, and perceptions? This is their health record, not yours, and they deserve to know what your clinical impressions of their symptoms are, and what direction their treatment is headed in.

3. Cease claiming to offer a 'safe space for individuals to delve into their emotions' on your listings and websites. It's cliché, insincere, and devalues the true essence of our work in therapy sessions. If you're not fostering a secure environment for individuals in therapy, then it's best to step away, and figure out what is not working. If you are indeed establishing an unsafe or harmful treatment setting, then it's time to exit the profession. Seriously.

4. Stop pretending therapeutic harm is rare. It's real, it happens, and clients are suffering because we, as a profession, bury our heads in the sand, and don't gatekeep effectively.

   Therapeutic harm is a significant concern that cannot be downplayed or dismissed as an uncommon issue easily resolved by authorities. It is akin to soul murder, where individuals in need of support end up being harmed by those they trust. Recognizing the prevalence and impact of therapeutic harm is crucial, as many vulnerable clients may struggle to report such incidents, particularly in systems that are not easily navigable. (I mean, have you ever met a client, outside of the helping professions, that even knew about the fact that you can look up providers by their names online in order to make a report to their licensing board? I haven't met such a client with that kind of savvy.)

   To address therapeutic harm effectively, it is essential to take the experiences of affected clients seriously, offer them support, and guide them towards appropriate resources if they choose to take action. Prioritizing belief in their narratives, validating their encounters, and ensuring access to necessary assistance are key steps in demonstrating genuine support for those impacted by therapeutic harm.

5. Identify biases and gaps in your knowledge and seek to remedy those you can (with biases, you are required to rectify this issue ethically, so get on it, as soon as you become aware of one), and refer out when you can’t fill the knowledge gap. There are tons of therapists out here, and someone out there is an expert in the thing you’re not. They will be a better fit for the client who needs that kind of help.

6. Get really good at apologizing. I apologize regularly in session. I want clients to understand that I know I’m not perfect, and witness what a genuine acknowledgement of remorse and repair looks like. This doesn’t mean I get it right every time, but I want to get it right most of the time.

7. Assess for neurodivergence prior to slapping a big label like Bipolar Disorder or Borderline Personality Disorder on there. This doesn’t mean you need to operate outside your scope, so put down your damn pitchforks, psychologists. Nobody out here is suggesting that I, an LCSW, should be doing a ton of testing that I’m not trained in. What I am saying is this: Be curious about the possibility of neurodivergence first as an explanation (either full or partial) for the symptoms a client is experiencing. "As per the survey taken by the National Depressive and Manic-Depressive Association (DMDA), 69 percent of patients with bipolar disorder are misdiagnosed initially and more than one-third remained misdiagnosed for 10 years or more (1). Similarly, a survey done in Europe on 1000 people with bipolar disorder found a mean time of 5.7 years from the initial misdiagnosis to the correct diagnosis (2,) while another study reported that on average patients remain misdiagnosed for 7.5 years.(3) And quit assuming because a client annoys you that they have a personality disorder. Your annoyance probably has more to do with counter-transference, your nervous system dysregulation, and your own lack of differentiation of self, than your client's personality. Plus, when we think about ourselves in the room first (a.k.a., figuring out what is being stirred in us), we become better clinicians, who are better able to regulate our clients and teach them new ways of getting their needs met. It's strengths-based to 'check yourself before you wreck yourself' (clinically).

8. Adopt the golden rule when working with other providers. Think to yourself, "Is this the way I want to be treated by another professional in my field?" It is okay to disagree with other providers. It's okay to see a case differently. It is even okay to correct another provider's behavior, if you believe it to be unethical. Here's the key though: you can speak to that person privately first. Get clarification. Make sure you have a clear understanding of the situation prior to judgement. After all, isn't that what you'd want in return, if your places were reversed?

9. Get consultation when you really need it. And pay for it. Your colleagues’ time and expertise isn’t free. Sure, if you’re at lunch with someone and want to explore a simple clinical question with your friend, that’s fine. I don't mind when my friends or office mates wanna bat around ideas. However, if you want clinical consultation on a complicated case, lots of information about business or marketing techniques, or you're asking about a treatment modality that is specialized, like EMDR, Brainspotting, IFS, etc., pay an expert. Get some expert clinical consultation that is good, and good consultation usually isn’t free.

10. This one is specific to people in middle management, upper management and the C-suites at agencies, group practices and non-profits. If you haven’t seen a client in 5+ years, haven’t attended a therapy specific training in the last three years, and/or receive six-figure bonuses while your clinicians on the ground have to receive food stamps to make ends meet, then you don’t get to play dumb when your burnout rates are high, when clinicians are leaving in droves, or act like you would know exactly what to do clinically in a difficult, multi-layered case. When young clinicians come to me asking if what their COO or upper manager is asking for is ethical, and it's not, I am appalled. And guess what? Those COOs and managers get to do what they want. They've earned their stripes and they don't get replaced at agencies. They, like fat on a soup, rise to the top of the boiling pot. Don’t assume years in the field equals clinical expertise or knowledge on how to build a thriving, supportive agency environment.

There it is, folks! The spicy list of the 10 things I hate about our profession. Again, I want to reiterate, I've done many of these things before in my own practice. I've made mistakes, but as the great Maya Angelou said, "Do the best you can until you know better. Then when you know better, do better." Here’s the thing: we have to be able to have these types of conversations in order to move forward collectively towards a future where mental health treatment is accessible, safe, effective and collaborative. And this future is possible. If we all pitch in.

What do you think? Did I miss anything on this list? Are any of the points particularly powerful or thought-provoking for you? Let me know in the comments below!

Take exquisite care of yourselves,

Megan

Citations

1. Lish JD, Dime-Meenan S, Whybrow PC, et al. The National Depressive and Manic-Depressive Association (DMDA) survey of bipolar members. J Affect Disord. 1994;31:281–94.

2. Morselli PL, Elgie R. GAMIAN Europe. GAMIANEurope/ BEAM survey I—global analysis of a patient questionnaire circulated to 3450 members of 12 European advocacy groups operating in the field of mood disorders. Bipolar Disord. 2003;5:265–78.

3. Ghaemi SN, Sachs GS, Chiou AM, et al. Is bipolar disorder still underdiagnosed? Are antidepressants overutilized? J Affect Disord. 1999;52:135–44

Put Your Visor Up: Changing Automatic Negative Thoughts

Hi friends!

I hope you are doing well. I have been remiss in not doing consistent blogging. While I wish I could promise you consistency, that probably isn't the case with me. My creativity is truly limited to when I get an idea for a post that just won't go away.

What are Automatic Negative Thoughts?

Have you ever felt like your vision or perception of events was obscured? What typically creates this sensation for you? For me, I often find that I struggle with negative thinking patterns (sometimes called Automatic Negative Thoughts or ANTs, for short). Take a gander at this article by Harvard University that explains ANTs in greater detail.

Negative thoughts can make a normally clear issue suddenly opaque and difficult to navigate. Whenever you find yourself in a new situation, such as a first date or a job interview, you may think, "This is not going to turn out well. I can already tell based on how nervous I feel." Subsequently, one of two scenarios unfolds: either the situation goes poorly, validating your initial pessimistic belief, or it goes smoothly, which you dismiss as a rare occurrence rather than the likely outcome in similar situations.

I compare Automatic Negative Thoughts to looking at the world through a windshield covered partially by a sun visor flipped down. Have you ever peered through a windshield and forgot you had left the visor down? This alters your perspective, obstructs your view, and can be difficult to immediately detect since it doesn't completely block the entire view. Automatic Negative Thoughts operate in a comparable manner: they distort your viewpoint, hinder a clear understanding of the current situation, and may not be readily apparent to you. During a recent road trip with my spouse, he repeatedly pointed out the sky, prompting me to squint and attempt to peer around the sun visor I had flipped down earlier, rather than flipping it up.. When I realized what was happening, I laughed, shoved that visor out of the way, and snapped two pictures to showcase the significant difference.

Sun visor view of the road ahead

Clear view of road through windshield

Here's what it looked like once I lifted my visor!

Shifting your Negative Thoughts

I am asking you the following question: How is my thinking obscuring or altering my perspective or view of the situation? Is there any alternate view or a way to see things differently? Can I find a way to 'flip up my visor' so I can see clearly?

Once you master the skill of noticing when your visor is down (a.k.a. negative thoughts have entered the chat), you can work on ways to question yourself and shift your visor out of the way. This doesn't mean you move to the positive, opposite statement from the negative, limiting belief you currently are holding dear. Shifts like that are often why people struggle with changing their thinking. They're trying too hard, and the alternative belief doesn't ring true to them or prepare them for the possibility of failure or difficulty.

So, your brain isn't really concerned with making you happy. It's focused on keeping you alive. This can lead to some pretty pessimistic thoughts, however. Basically, your brain is wired to recall risky situations from the past and use that info to help you stay safe in the future. When people try to change their thinking to "something more positive," your brain automatically moves away from that shift, because it won't serve the ultimate goal of 'keep you alive!'

Reflecting on the earlier example discussed in this post regarding preparing for a first date, we can examine the common errors people make when attempting cognitive restructuring or altering their mindset. Many individuals tend to begin by stating a positive opposing belief, such as declaring, "This date will be amazing. We'll probably end up getting married!" Consequently, they may come to realize that their 'positive conviction' lacks impact and appears to ignore their own feelings of anxiety or nervousness before a potentially anxiety-inducing situation. This self-dismissal is comparable to self-gaslighting. To enhance your mindset or 'shift your perspective,' consider transitioning from the assertion, "This won't go well. I'm extremely nervous." to a more balanced affirmation like "I do feel nervous, and I believe I can deal with this sensation, regardless of how this date unfolds."

Here's a formula to help you find a more neutral, helpful statement:

Acceptance (of your feelings/fears) + Confidence (in your ability to cope) - Any Predictions about the Future = Healthier, More Flexible Thought Patterns

The challenge this week is to work on just noticing when your perspective is shielded or changed by the visor (or negative thoughts) in your way. Give yourself permission to ask yourself if you need to flip up the visor or identify a more neutral thought. Ask yourself questions about the view or situation to facilitate your thinking towards more flexibility. A flexible brain can keep us safe and (moderately) happy!

Take exquisite care of yourself,

Megan

'It Ends with Us:' A Movie Review

Hi friends! I hope you are all doing well. Remember when I did the blog posts where a therapist ruins your favorite movies... Well, I'm baccccccckkkkkk!

And I'm here to discuss the good, bad and the ugly related to the newest blockbuster, 'It Ends with Us,' the film adaptation of the novel by Colleen Hoover. First off, can we leave space to acknowledge all of the drama between Blake Lively and Justin Baldoni? WHOA.

Okay, but you wanted to hear my thoughts on the movie. A few caveats: the book and the movie are about intimate partner violence, so if you go into the film thinking it's going to be a lighthearted comedy or romance, you will be sorely disappointed. There are a few scenes that I think could be very triggering to women, and so I am putting that information in this post. If you don't want any spoilers, now is the time to stop reading.

• The Good:

  • The film showcases how persistent and charming an abusive partner can be for many months, until they get their partner 'locked down' in some way (in a relationship, living together, marriage, expecting a child together, etc.) before showing their true colors.

  • The violence starts out as 'accidents,' a common technique used by abusive partners in order to make survivors question reality and their sanity. It's like gaslighting but on overload.

  • Generational patterns of abuse are shown, which is often missing from film or creative depictions of trauma.

  • When Lily asked her mother why she didn't leave her father, her mother states, "It would've been harder to leave... and I loved him." This illustrates the complexity of emotions survivors feel when considering the prospect of leaving. If you're interested in more commentary as to why people stay in these relationships, please have a listen to the podcast "Why She Stayed," hosted by Grace Stuart, who is a survivor and domestic violence advocate. I think she eloquently approaches this subject matter in her podcast and in her Instagram Account @gracestuart26 as well.

• The Bad:

  • While I'm grateful that the level of violence shown onscreen wasn't the same level of violence written in the novel, I will say that the power/control dynamics were not displayed well, or at all. Perpetrators of abuse don't start the cycle of abuse by hitting you accidentally. They start it by tearing you down verbally, isolating you from trusted family or friends, lying to you/manipulating you, and then treating you with kindness or acting as if it's 'all good' the next day. I won't say this is how all relationships with IPV or DV present, but the majority are not like the movie.

  • If the story were more accurate, Ryle (the abusive partner) would have come in, swept Lily off her feet (which he did) and then slowly disintegrated her relationships, made her question her self-worth, and then perhaps even discouraged her from owning a business. A perpetrator's goal is high levels of power and control within the relationship. A woman owning her own business and thus having a means of power (and access to escape) would be a threat to the abuser. Abusers eliminate all threats to their power and control systemically and slowly.

  • When Lily tells Ryle she wants a divorce, she tells him while holding their child with no witnesses present. None. And yes, I know it's more dramatic this way, but is completely unsafe. If you are leaving an abusive relationship, do not tell them in person alone. Ever. Create an escape plan, leave and don't tell them where you are. Serve them with papers and never, ever be alone with them again.

  • When Lily leaves, we only see Ryle call once and text a few times. in reality, this would have been the moment that the stalking would have began, if not before.

  • Lily's best friend, who is Ryle's sister, tells her to leave him, and they remain friends. While I loved the girl power moment, in most instances, family members of perpetrators tend to side with the abuser. Think of how our society acts when we find out a man has been accused of multiple years of sexual misconduct or abuse. I can hear the chorus of "He's such a good guy. I just can't believe it." The good guy image is a facade and families and friends believe it because they haven't lived close enough to see the person underneath the mask.

• The Ugly:

  • The violence scenes are intense, particularly one scene where Ryle attempts to sexually assault Lily. The depiction is intense and scary, and had me wanting to crawl out of my seat. Beware if you have a trauma history, this may be too much for you at this point in your recovery.

  • There was also no trigger warning or information provided at the beginning or end of the film directing people to the National Domestic Violence Hotline or the YWCA. I'm going to link those here.

In short, the movie 'It Ends with Us' does some things well, and some things poorly. A film with this subject matter has a certain responsibility to portray things accurately or at the very least, provide connection to resources. This film did neither. If you want to go see it, go with my blessing, but go in with your eyes open. May we all have the courage to support our friends, our sisters, our mothers, our aunts, when they try to leave and say, "It ends with me." And if you're in need of help ending the cycle yourself, find a good therapist who has knowledge of power and control dynamics and can support you during the abuse cycle, and in subsequent recovery.

Take exquisite care of yourself,