back to the Black Table

In the past decade, the number of people seeking psychotherapy has increased, climbing from 7.85 million in 1987 to 9.69 million in 1997, according to a national study published in the November issue of The American Journal of Psychiatry. And in the five years since 1997, those numbers have increased, according to The National Alliance for The Mentally Ill (NAMI), thanks partly to increased public acceptance aided by sympathetic portrayals in shows like The Sopranos. After Sept. 11, those seeking psychotherapy spiked dramatically.

For younger people, therapy has lost some of its stigma, perhaps because they have a greater need for help. A research report in the February issue of Professional Psychology: Research and Practice shows that college students have more complex mental problems than they did a decade ago. The study looked at more than 13,000 students over a 13-year-period and concluded that number of students with depression doubled annually. Likewise, the number of suicidal students tripled and the number of students seen after a sexual assault quadrupled.

Therapists are often imagined as these omniscient clinical magicians, dispassionate overseers of the human condition. This is of course a fallacy; they're human beings, just like their patients, with all the infallibility that comes with that.

The Black Table spoke with a licensed therapist who evaluates and does therapy with adjudicated youth in Pennsylvania and also has a private practice working with both children and adults. We found out how he views his patients, his role in their lives and why therapy might not be best for everyone.

BT: Is therapy more popular in big cities? It’s rather cliché, but it really does seem everybody in New York has been through therapy.

It's funny. Therapy seems to have a geographic appeal. While its overall popularity has increased, it seems to be more en vogue in certain places. When I lived in Los Angeles, everyone had a therapist, and if you did not have one, you were out of the loop. It was open and a rabid conversation piece. That is the impression I get of New York City, and other major U.S. cities, for that matter. It is still a major taboo in rural areas and among the African-American community, where psychological disorders are under-diagnosed, and most patients are not there voluntarily but by some sort of legal mandate.

Did you ever have a patient that you genuinely disliked?

I have some patients that have done some horrible things, but my job is not to judge them. Society has already done that. My job is to help them recognize the effects of their behaviors and change them, and to help them understand why they do what they do. If I have a personality conflict with a patient, I just refer them elsewhere.

There are two patients in my history that I have had utter contempt for. One was a 14-year old girl who had already accused four sexual partners of rape, the last of which landed her 20-year old boyfriend in jail after she told the police of their relationship and requested he be charged with statutory rape. All because she was angry that he never showed up to her house one night. I guess she was in a vindictive mood. The other was a 31-year old mother of three, suffering from borderline personality disorder, who, in a failed suicide attempt, took her three kids in her car in the garage, locked the door and attempted to kill them all by carbon monoxide poisoning.

You treat juveniles in addition to adults. Some of the kids have some extremely troubled pasts, and sometimes do some unimaginable things. What were some of the most disturbing things some of your juvenile patients have done?

The aforementioned "serial" rape accuser was tough. The sex offenders are a tough crowd, and that is generational and cyclical by nature. I had an adolescent boy who anally raped his two brothers. Numerous members of his family also molested him. I had a girl who was a self-mutilator and would carve her body up with shards of glass. I had a 12-year-old who would systematically torture animals. Those are the truly difficult cases. The drug users and "street thugs" are a dime a dozen.

Have you ever been fearful of a patient? Did you ever feel threatened?

Once. I was working with an 8-year-old boy who was a victim of abuse. His mother had smacked him in the face with a Louisville Slugger when he was being difficult about cleaning up his room. She was actively psychotic, receiving no services and not on medication.

One session, we were using dinosaurs in a play therapy activity. The patient had told his mother the week in between sessions. Upon their arrival at the next session, the mother grabbed me, pulled me aside and told me that if I had ever taught her kid anything contrary to The Bible, she would "cut my throat with a machete."

She probably would have, but I reported her and terminated the case long before she had the opportunity.

It seems that everybody is currently using or has used a therapist at some point? Is this because everybody is crazy, or because this is how our generation handles our problems?

We all have some level of neuroses, and we have all been affected by our parents or have had some traumatic incident(s) that we carry with us and are barriers in our personal relationships.
Therapy helps with this. Talking to an unbiased, nonjudgmental third party is cathartic, but I believe that in itself facilitates change. Understanding past behavioral patterns or making sense of past incidents means nothing if change does not occur in the present or the future. I subscribe to more cognitive and behavioral methods that by nature are more focused on problem solving. They’re more scientific. Unfortunately, often people use therapy to rationalize current behaviors instead of trying to change them.

Do therapists talk about their patients with one another? Like “You should’ve seen the loon I had in my office today…”

Confidentiality is pretty well respected by the therapeutic community, so rarely are names or identifying information used. However, it is common practice to discuss cases with other professionals, whether it is to vent or just to brainstorm on alternative treatment ideas. Most are compassionate in their descriptions of people and their disorders, but some patients are certifiably fucked up.

Also, some professionals see their patients as a "badge of courage," the "crazier" their patients are the more competent they appear to be. Egos get in the way, and a huge pissing contest evolves.

Did you ever second-guess how you treated a patient?

Always. While I am confident in my abilities, I am also my harshest critic. Some techniques I view as "can't miss" fail miserably with the personality type I am working with. Other times, I feel completely ineffectual, and people progress immeasurably. I am always thinking of things I could have done or said, things I should not have said, was I too passive, too pushy, etc. It used to eat me up. Lately, I have accepted therapy as a process, with its own ebb and flow, ups and downs, and good days and bad days.

You said you’ve removed yourself from treating a patient based on the negative feelings you had towards them. Has there ever been a situation where it has been reversed? For example, have you ever developed a “crush” on a patient?

Many therapists get over-involved, and I try not to. That is usually the therapist’s own issues coming to the forefront. Feelings of attraction to patients are natural; we are human, after all. The key is not letting it affect your work with them and not overstepping boundaries. You cannot help a certain chemistry or attraction you have towards someone. Helpless women can make a male therapist feel powerful, like a knight in shining armor. And some female patients will blatantly try to seduce you, but most likely that is a manifestation of their issues.

One time I was seeing a teenage boy, and his mother was a knockout. We had instant rapport, and I felt that if I had randomly met her on the street, we might have had something together. Unfortunately, she was married, and her son was my patient.