Through a lens clearly

I have a list of therapies that haven’t worked for me.

This is not out of spite or stubbornness.  It’s because I’m starting to see a new therapist soon, and it’s important to me that they know what I’ve already tried and have not found helpful.  I don’t want them to rehash former attempts; I want them to offer me something new.

As a result, I’ve written a lot recently about therapeutic experiences I’ve had that missed the mark.  This is not meant to discount the experience of people who find a type of therapy helpful.  My assertion is always that patients are very diverse, and therapists need to be more cognizant of those differences to ensure they aren’t following a one size fits all policy.

There is a frequent misconception that if a specific therapy is not helpful to a person, it’s a consequence of the patient not understanding, not practicing what they learned, or not trying hard enough.  In some cases one or more of these may be true.  However, it’s also true that everyone has certain methods and styles that work for them, as illustrated by the fact that some therapies for the same symptom seem to be polar opposites in approach.

One example is the advice I’ve received about coping with obsessive thoughts.  One therapist and the books he gave me advocated acknowledging the thoughts and labeling them as obsessive and unhelpful, then seeking distraction through enjoyable activities.  The next therapist felt strongly that I should not label my thoughts, but should “sit with them” and accept them, and practice mindfulness and distress tolerance.

In my case, the former style has been far and away more successful in alleviating my discomfort and increasing my functionality, even though it doesn’t always work.  (Does anything?)  So I’ve adopted it into a set of coping skills that also includes healthy habits like yoga, studying astronomy, and writing, as well as not-so-healthy ones like smoking tobacco, comfort eating, and, formerly, drinking.  However, I’ve taken some flack from certain professionals who think that I am not doing a good enough job and am simply lazy for taking a road that includes playing video games and watching nerdy TV shows I’ve seen a million times (hello, TNG!) instead of meditation.  One therapy is judged more praiseworthy than another, not because it’s working but essentially because of its cultural cachet.

This perception of people as failing by rejecting a therapy results in a certain amount of shame and reluctance to speak up.  I’ve witnessed this in rehab, where one patient was going through the one-month program for the eleventh time, and a large percentage had been there at least once before.  How is it expected that following the exact same process, with all the same information and advice, will help someone who has already “failed” ten times?  At what point should we recognize that something simply isn’t working?

Twelve-step programs are another great example.  The first question most health care workers ask when you describe yourself as an alcoholic is “do you attend Alcoholics Anonymous?”  When the answer is no, there is frowning involved.  Twelve-stepping is the only therapy many therapists seem to accept for addiction, despite its flaws.

AA touts the idea that its approach is nearly always successful, and that if it doesn’t work for someone, it’s because they are constitutionally, pathologically incapable of honesty and responsibility.  In my opinion, this is a way of saying that if a person doesn’t achieve sobriety through their method, they are a lost cause because they are simply too flawed.  There is an assumption that if you don’t do AA, you don’t really want to sober up, and won’t ever succeed.

But in reality, the program is successful in only 5 to 10% of cases, akin to the success rate of any other specific type of therapy in addiction cases.  Even assuming that half the cases in which people don’t get sober through twelve-stepping are caused by internal or external factors in the patient’s life (which I consider a fairly generous concession) upwards of 45% of cases can best be explained by the simple need to find a different therapy.

Even in cases where the widespread effectiveness of a specific therapy is scientifically demonstrated, this does not constitute a reason to insist on one therapy and dismiss others in any given patient.  Naturally, if the success rate is 90% (based on a certain definition of success and method of research) then one in ten people is still not achieving optimal results.  Isn’t that a large enough percentage that it deserves a change in attitude; an increased willingness to shift gears and listen to patients about what works for them?

My favorite therapist I’ve had, who first raised the possibility of autism with me, used to say that it’s all about through what lens you approach a problem.  Two people’s respective symptoms may receive the same diagnosis, yet stem from totally different causes and require a different lens in order to clearly understand and effectively threat them.  He suggested that my autistic tendencies are likely so deeply rooted, being, of course, not a mental illness but a neurological difference, that failure to acknowledge them– particularly in treatment of my social anxiety– had probably caused a lot of my therapy to involve barking up the wrong tree.

After spending several months addressing autism issues and going over my symptoms to see if they were in accord with the diagnosis, the sheer relief I felt was like coming up for air.  I had a lexicon, for the first time, to describe my experience of life, and validation of the fact that I felt different but that the difference might not actually be a flaw.  I think the day I was tentatively diagnosed with autism began a whole new stage of my life and certainly of my mental health.

Not every experience I’ve had with therapy– as I’ve written about before– has been so positive.  If more professionals had questioned their own assumptions, listened more carefully to me, and done more research about potential therapies, it’s possible this stage could have begun much earlier, though that’s water under the bridge now.

Mental illness and developmental differences are often very isolating and alienating.  All patients deserve the relief of knowing that the first choice isn’t always the right one, and that there is no shame in speaking up for what you need.  Therapy is about the patient, not the therapist, and their well-being comes above preconceived value judgments and generalizations.

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