worst rupture yet

bltMember

I don't even know where to start with this.

OK, I have been seeing T for two years now. After around 9 months, in October two years ago, we had a conversation about my diagnosis (dx for short from here on out). She said we might want to change it from adjustment disorder to anxiety disorder, because adjustment disorder is viewed by insurance and short term. I was unhappy with this suggestion and we got into an email conversation in which I argued that I didn't have an anxiety disorder (in fact I later realized this had triggered the memory of finding out my mom had run around telling people I had an eating disorder when there was absolutely no evidence for it).

I *thought* we agreed that she would leave the dx as adjustment disorder for the time being. But the next time we discussed it, last June, I found out she'd already changed it to anxiety disorder without telling me. Furthermore, because she didn't explain it very much, I thought it was generalized anxiety disorder rather than anxiety disorder NOS (not otherwise specified). I kind of objected to this, whereupon T said some things which I at least remembered as "I am just working the system like everyone else" and "but it gets you more stuff." So I left the conversation believing that:
1. I had a dx of GAD
2. T did not think I actually had GAD
3. T merely put down this dx in order to get insurance reimbursement

I was troubled about this and talked to some people about it, as well as posting about it on another forum. The general reaction I got is "why would you care about your insurance company??" so I decided maybe this was T's issue to worry about not mine, and I was being weird about it or something. Anyway we had some long breaks that summer and I tried to terminate in August. However, early that fall, due to health issues things got really rough in my marriage and I ended up not really terminating.

Around 8 weeks ago I started T school, and I started reading and learning about ethics and diagnosis, and of course all of these issues were now back in my mind. I tried to talk about it some with T, which was OK, and I found out what my actual dx was. T apologized if she had sounded "flip" about it previously but stated she had not done anything unethical. But then in class the same night my professor gave an example of a T using diagnosis unethically which exactly described how I had understood what happened with my T. Basically she said if someone in private practice sees a client who isn't really impaired enough to warrant a diagnosis, but they do have some symptoms, a T might give them a dx anyway so that their insurance will pay, but this is unethical and considered fraud. (My textbook further said 40% of counselors have admitted to doing this at some time).

So I emailed T about this on a Friday (edit: I think it was Thursday night), hoping she would call. I said that now that I knew my real dx (anxiety disorder NOS), I didn't even really disagree with it, but that I didn't understand why her previous communication about it had been so vague and shady-sounding. She didn't email me until more than 24 hours later, in which she said that what I thought she said "didn't sound like something she would say" and that if she DID say it, it was "inappropriate and unprofessional but not shady." Suddenly I'm like, why is she invalidating me? Why is she so defensive about this? And with the discrepancy between what I understood from her earlier, and her current stance, did it mean that she was lying to me now to cover her a**? This was all very upsetting, and I left her a phone message saying so. Again, I didn't hear back for more than 24 hours, and then it was her calling me with barely any voice, saying she had laryngitis, and could we wait until Tuesday (2 days later) to schedule for me to come in and talk about this issue. I was shocked to hear how sick she was and said OK.

But she didn't call me on Tuesday until late in the evening, saying she had left her appointment book at home, asking me for times that would work for me. I was so far gone by this point that I let her call go to VM and didn't answer the message. I didn't answer her call the next morning, either. Finally after she emailed me saying I hadn't answered her calls, I left her a message saying I didn't want to come in the next day (Friday) and that I had a conflict with my next scheduled appointment, also (which was true). I didn't hear back from her and finally emailed her to say that I was furious with her, trying to explain why, saying I didn't want to cut her off cold but I didn't see viable alternatives. The next day she spent half an hour on the phone trying to persuade me to come in anyway, while I was basically busy trying to decide whether or not she had been lying through her teeth to me. She seemed confused by the mere idea that she could have fudged a dx or that she would hide this from me. Finally I decided she was too confused to be lying so I agreed to come in today (Monday).

When I got there it was freezing out and her office was locked so I had to wait in my car. When she finally got there her whole office was freezing and I spent the first 5 minutes shivering under some blankets trying to warm up. Then I tried to explain the situation to T but she kept saying stuff like "I don't understand what else you want me to do to repair this" and "I thought I already blah blah blah..." I had to explain everything to her in excruciating detail. She didn't even understand WHY or HOW someone would misdiagnose on purpose (even though it's common practice although unethical). I guess in her mind, if you're bad enough to want therapy, you qualify for at least an adjustment disorder? I asked if she was frustrated with me and she said yes, but that I was also frustrated with her. I was starving for some empathy or validation but didn't get much if any.

Finally I rather weakly said "I'm sorry I'm so hard to understand." She responded by saying if I'm not understood, maybe it's because I'm not communicating much. This, while true, was not relevant to the current situation as I'd been doing everything I could to explain to her. Plus I felt like she was arguing with my and hadn't heard any of the feeling in what I said. Finally I told her she wasn't hearing the feelings and actually said something like "would it kill you to just make an empathic reflection?" She started listening a little better after that, but pretty soon it was already 15 minutes over the hour. I knew she didn't have any other clients today so I said I'd like to finish what we were talking about but didn't know it was an option. She said we could continue but insurance wouldn't pay for the extra time so she would have to bill me for it. At that point I felt trapped as I was already over, about to get billed for the first time ever, and in no shape to leave. Plus under the circumstances it just felt cold. Like, maybe we wouldn't have gone over if you had just listened to me instead of arguing! Maybe I wouldn't be here in the first place if you had been more careful about how you talked about my dx! So I started sobbing hysterically and didn't really manage to leave until like 1:45 after my appointment time. While I was sitting there bawling, T asked if she could come sit next to me and I said no. I eventually pulled it together, we talked some more. I mentioned I was sensitive to the issue of whether she would lie to me since my dad who I was close to cheated on my mom with someone he was in a professional relationship with (hence it was unethical for that reason also) and then lied about it, and my mom exploited this fact for the entire time I was growing up to sow even more mistrust in me about him. But my mom wouldn't let me talk about this to almost anyone because she was afraid that he would lose his job because of it.

Anyway, what the hell T with the lack of empathy??? I was afraid my own T was lying to me to save her a** from getting reported, is that so hard to understand why it would be upsetting? Now I have all kinds of midterms to write and I feel so tired. All I really wanted to do today was collapse in T's arms and cry and instead I got unempathic, frustrated-with-me, why-would-you-think-that-about-me T and had to endlessly explain and argue for myself and it sucked

Sorry I wrote so much, just needed to tell the story and hopefully get some empathy finally...

3/3/141:11 PM

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exploringMember

Oh, BLT. It does sound to me like she is trying to cover her a**. If you had painted this picture so clearly for her and it was a work situation, even going so far as to express an understanding about why this would be particularly hard for you (the eating disorder allegation, your dad), she, I believe, would not have hesitated to take in your viewpoint and offer validation and empathy. Instead, it looks like she smelled danger and dodged...and then told you she was going to bill YOU for her maneauvering (no idea how to actually spell that.)Wow.

Just. Wow.

And midterms on top of that.

It sounds to me like she had an unprofessional moment with the whole "milking the system to get you stuff" thing. She is probably worried about how this could affect her. That makes it harder to empathize with others--but, regardless, that is still her job. If your doctor has diabetes he or she should not let blood sugar issues interfere with your care.

How could she have handled this in a way that would have helped? Would it be possible for you to tell her, "Look, I need an acknowledgment from you that my dx was not handled as professionally as it should have been. I can understand that, but I don't understand why you've reacted the way you have since then. Also, I need you to look at why this is triggering me with me." Or--something?

For me, thinking about telling my T something is a lot easier than doing it. Last session, though, I brought up an issue that has been on my mind for, literally, years. My T handled it with grace and humility, and told me that, had the same situation happened today, she would likely have handled it differently. I don't always get what I want or need from her, but she does try. It sounds like your T, for the most part, tries?

Anyway, I'm really sorry the session sucked. Therapy is hard enough when it goes well! I hope you are able to get past this with her, it sounds like she has mostly been a beneficial part of your life.

3/3/141:51 PM

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lucyMember

(((BLT)))
Your session sounds like it was extremely difficult and you did not receive what you needed at all.
I understand your reaction to the whole dx issue. I'd most certainly be upset about it as well. Fraud is a biggie - and it can't feel good to believe your T is engaging in this.
Plus, I kinds feel that if I'm going to be labeled can't it at least be an accurate dx?

It just doesn't feel good though.

And it certainly hurts to be invalidated. You did deserve an empathetic, caring response. I'm sorry you didn't get that when you really needed it. I understand how this situation feels like a re-enactment of old stuff.

I really hope you are able to have her work this through with you.

Good luck on your midterms.

3/3/142:53 PM

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redtomatoMember

Hi BLT -

You sound very upset about this and it seems like thinking about all of this is consuming a lot of your energy.

I'm trying to sort out what you've written and this is what I think I understand. (You can let me know if I'm off base.)

1. You don't trust the dx that T is using in your record and with insurance.

2. Further, you believe that your symptoms aren't serious enough to warrant a diagnosis.

3. And as a result, you believe your therapist is acting unethically and committing fraud.

4. You and T are in a terrible tangle in this discussion which is triggering trust issues.

It might help you to try to sort out what part of this is most important to you to resolve.

if 1 - Pull out the DSM and ask your T to show you the criteria for your diagnosis and how you fit into it.

if 2 & 3 - You have control over this. You don't have to wait for T to act "ethically" if you truly believe she is committing fraud. Simply ask her to refrain from submitting to insurance and pay her in cash. (She may be willing to accept your copay amount plus the amount she was paid by insurance rather than her full rate.)

However, if this strikes you as too much of a financial burden and you really would prefer your insurance to pay, even though it means having a dx that isn't precisely correct, you can just go along with it. Drop it as an issue and move on to other things.

I suspect that as someone in T school who is doing the book learning part of the work, you are thoughtfully considering ethics. It's a huge and extremely important topic. Despite what the books say, you will need to decide what you think is ethical. It's likely that how you think about it will change as you grow, and it's also possible that you will find there are grey areas that need consideration in context.

The thing about making diagnoses is that it is more of an art than a science. Granted, if you want to be extremely black and white, you can go through the list and make a clear cut yes or no about each symptom. Since 1952 the DSM has been revised 7 times, most recently last year. Professionals get together and talk about how mental health should be evaluated. There is often a lot of disagreement. Things change. An extreme example of this is when "homosexuality" was declassified as a mental illness according to the DSM. So, one day an individual is pathological and the next day is normal. This is an example of how much grey there can be in making a diagnosis.

When a professional makes a dx, most will consider your symptoms and their opinion of the best treatment for you. Many insurance companies have gone to evidence based treatment plans and gauge your insurance benefit on this "empirical research." But not everybody fits the precise profile and will be cured in 8-12 sessions because that's what the research shows that the average person with xyz problem needs to "get better." Insurance companies very often want the clinician to use cognitive behavior therapy because it is considered a short term treatment. That puts clients who need more intensive and often longer-term psychotherapy in a tough spot. It sounds like that's the treatment, based on your work together, that T thinks you need.

It also sounds like you and T have been butting heads about this for so long that T is feeling extremely defensive and you are feeling extremely invalidated. I think that is often a characteristic of long-term "battles" and can be very polarizing.

That said, I am guessing that the real work needs to be done on #4. Trust. This issue of insurance and diagnosis has triggered some deep concerns that are manifesting in a horrible rupture. You are taking blame ("I'm sorry I'm so hard to understand.") where there really isn't any to be had. Perhaps this is a reenactment of other significant relationships in your life. What would happen if you completely removed the whole issue of diagnosis and insurance and talked strictly about your feelings? Don't feel heard. Afraid you're not communicating well enough. Think you're being lied to. Feeling trapped. ("All I really wanted to do today was collapse in T's arms and cry") I think this is where the true healing of the rupture will come.

I know I've written a lot here and I truly hope I haven't stepped on your toes or your feelings. That's not my intent at all. I know ruptures feel like the floor is gone from under and one can get very frantic when that is the case.

My final thought is that having this conversation over email probably isn't a good thing. Even though T allows it and engages in it. Even if you find you are able to express yourself better. Too much gets muddied when we aren't face to face. If you need to use your writing to communicate, take it to session. I don't suggest this lightly because I am someone who wants to use email. I would email T all the time if I did't put some restraint on myself. Email is good for some things. But the really important stuff - like a rupture - needs to be done face-to-face.

I hope for peace and resolution for you and T.
-RT

Red Tomato
Morning Peeps

Promise me you'll always remember: You're braver than you believe, and stronger than you seem, and smarter than you think.
- A.A. Milne, Winnie-the-Pooh

3/3/143:21 PM

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ericaMember

I think what RT wrote was very wise. Making diagnoses is more like art than science. I agree with that. Many clinicians don't even really believe in the usefulness of dx. Some use NOS almost exclusively because it makes it less specific. But regardless, I think diagnoses are very much dynamic and not stagnant entities. It's a tricky process.

But, having said that, I am very sorry you've had a painful rupture with your T. It sounds like she did not understand your needs and was not very attuned. Like RT said, I would focus on that. I think once you get through that and are maybe in a better place, you can open the discussion about your dx again. I would think it may be better to repair the rupture (get some compassion, empathy, etc) first before you tackle the dx conversation, if you want to bring it up again.

3/3/143:49 PM

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armoredheartMember

(((BLT)))

I really feel for you

Some of my biggest triggers are feeling invalidated, wondering if I can trust, receiving no empathy when I need it most. It sounds to me like you explained everything pretty thoroughly to T, and there was some real lack of understanding on her end. I remember with ex-T, one of the worst feelings I had was when I brought to his attention something and his response was "Did I say that? That doesn't sound like me." When it was recorded!!! Just hearing an "I'm sorry for that" would have gone miles further.

I am really impressed with your assertiveness in explaining how you felt to her, and I feel badly for you that it was such a frustrating session. That feeling of just not being heard is the worst

I agree that it sounds like maybe the deeper level areas of trust and attunement validation may need to be repaired before coming back around to this specific discussion. I hope you can get some peace of mind enough to face midterms and there will be a healing repair with T soon

3/3/146:08 PM

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catalystMember

It's infuriating, and I've been there a lot, to try to explain something you're upset about and T is being… dense. I've been in situations too where my T/s have told me that they are frustrated with me, I appreciate the honesty but it also scares me and even if I'm still arguing I sort of flip in to please-reassure-me feelings and by that time all is so confusing and I can't make sense, and they make no sense and it's like they can't even intentionally be that hard headed. I've had a lot of arguments too about dx, or stuff I thought was just plain unethical or obnoxious.

I get it… what I read you describe I could picture myself there.

I often wondered why I even paid for sessions I spent arguing or with my T upset with me… So I understand what you're saying about that, too.

I'm sorry you didn't get more empathetic understanding - in those times they seem so bloody clueless. It's hard needing/wanting their comfort from misattunements… but not being able to attune. I had that happen with T2 about a year ago while we went through an epic rupture. When I'd feel myself getting pissed off or when I was trying to explain something and she appeared almost intentionally stupid I'd just ask for a hug. That way I can at least connect heart-to-heart. Somatically, it helped to process that way.

Anyway, I have no advice, but I do have a lot of empathy and understanding. I hope you get to see each other soon and can patch it up.

3/3/146:35 PM

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bltMember

Thank you everyone for the replies. I'm not going to reply at length yet because I'm trying to forget about this for now and get through my midterms.

3/4/145:43 PM

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catalystMember

Good luck on the midterms, BLT!!

3/4/147:21 PM

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bltMember

I want to thank everyone who responded here now. ((Exploring)) ((lucy)) ((RT)) ((erica)) ((AH)) ((catalyst))

After two weeks of no contact, I finally called T on Monday and she called me back. She sounded much more like herself and did say on the phone "yes I messed up" so that helped. I agreed to come in on Tuesday. It was a pretty good session and we talked about the diagnosis issue a lot, in terms of what symptoms she saw in me and what differentiates different diagnoses, etc. What I gathered from the conversation is that she really doesn't view this kind of thing in the cut-and-dry, bullet points way that would probably make me feel more comfortable. I think she assumes if people come in to therapy, they need help, and if they have insurance she will try to figure out what kind of diagnosis will work for them. I feel like this practice is ethically debatable, (in terms of trying too hard to find a diagnosis for someone who might not strictly be "ill") and yet it seemed to be very clearly motivated by her trying to get help for people who need it, rather than deception or personal gain (her fee for private clients is almost twice what she gets from my insurance.) In any case, T was listening to me much better and that helped a lot.

I do think there are two issues going on right now that are making things challenging. The first is that my life is going more smoothly now, so it's not as blatantly obvious to everyone why I need to be in therapy. The second is that I'm very much engrossed in school, in which I'm in a program that emphasizes short term counseling over long term therapy. So I feel weird and kind of secretive about the fact that I've been in therapy 2.5 years already and I don't feel done, as well as about the nature of the relationship between myself and T. It's just...deeper, I guess? I know a lot of the students in my program aren't interested in doing depth therapy and that the program is tilted in the other direction, and I just have to tolerate being outside of the normal if longer term therapy is where I want to go once I have my license. It's a little hard.

The feeling I have had the last couple of days is that I know in my heart I'm not really done the work I am doing with T. However, it's harder for me to justify to myself needing to work with her, because the things I'm working on are less obvious. It's less of "I need to figure out how to stop the SI and freaking out over marital issues and figure out where I'm going with my life" and more of "I want to heal the subtle disconnection that often makes me feel like life is pointless" and "I want to stop feeling like hiding under a rock and be able to live up to more of my potential." And it's also just "my relationship with T is really meaningful and growth-producing for me, and I want to continue with that." So, hard for me to see why an insurance company should pay for those things. On the other hand, I suck at self-diagnosis and probably shouldn't try to keep going there. So...I don't know.

3/20/149:04 AM

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