The Job AMA Thread! - current AMA@ChickieD through 11/16 at 11:30 PM PST



Do you have a preference for Cognitive Behavioral Therapy, Dialectical Behavior Therapy, or something else entirely? Or do you find is it ultimately patient dependent in your practice?


Just as an aside to the current conversation: you’re not alone. I had two awful experiences with different therapists then went 8 years without, before an ex pushed me into trying again. I wish I’d done that way sooner.


I have a bias against CBT. Most therapists who use “CBT” are using a manualized therapy (“one size fits all”) that focuses on behavior, which works for a particular set of symptoms, like anxiety and compulsions. Research shows that CBT has short-term (~2 years) positive effects compared to psychodynamic therapy (~7+ years). Patients report feeling like they are “failing” therapy when CBT techniques don’t work for them. I want to avoid that in my work!

DBT was developed to integrate Buddhist philosophy with psychotherapy specifically for patients with Borderline Personality Disorder. The manualized DBT approach to BPD is one of the only treatments that works for that mental illness. It’s also showing promising results with combat-related PTSD and eating disorders. It’s not appropriate for everyone and was never intended to be used broadly. People like it because it’s a system and that can be reassuring for some therapists and patients, so they want it to work for everything. It doesn’t.

I don’t use a single modality in my work. I have a broad range of theoretical knowledge from which I use a variety of techniques, but I’m pretty relational in my style. This can get a little “inside baseball,” but I tend to prefer psychoanalytic theories and techniques because they are broad and adaptable. Most currently popular modalities like Narrative Therapy, Solution Focused Therapy, CBT, or DBT are narrow collections of closely-related, similar analytic techniques that have been repackaged and rebranded. Some of that repackaging is the direct result of limiting the variables in research, some is due to vanity on the part of a therapist. It’s also easier to sell seminars and trainings if you have a manual.

I really work hard to develop treatment plans unique to each patient. I also try to meet their needs in each encounter rather than adhere to a predetermined plan. I am constantly reading and studying (in addition to required coursework) to add new tools to my tool box, but I always seem to come back to psychoanalytic perspectives.


Very illuminating - thank you for such an in-depth answer!


Thanks for your in depth answer! I had to go through an HMO last time I had a therapist, and definitely wasn’t aware that you could phone-screen them beforehand, it was just “ok, you get this guy”, done. Very good to know. And I’m actually quite curious about therapies such as vegetotherapy, so I’ll do some investigating, now that you mentioned that.

Long story short, my last therapist kept pushing and pushing for me to talk about intimate details of my sex life, even after I told him I wasn’t comfortable discussing it, and when I finally did, he laughed at me, mocked me, and kicked me out of his office. “Violating” is putting it mildly.


That is so F’ed up!


I am so sorry that you had that experience. I wish that I could say that I had never heard such a story before. :blue_heart:

If you’re curious about vegetotherapy, I’d recommend searching for “orgonomic therapy” + your location. It’s a small community of practitioners, though, so it may be tricky. My supervisor is trained in those methods and so I may also be a potential referral source. If you’re curious about somatic therapy in general, I’d also recommend sensorimotor therapy (that’s Pat Ogden’s work).


How does someone come to you? Is it a job you hang out a shingle for and wait for people to show up like a coffee shop? Assigned by a government agency? Hospital or family doctor referral? Sacrificing a goat and calling upon the gods of mental health?

Edited for “duhh, wat’s english?”


Ah, I see you have experience with Canada’s mental health care system.


There are multiple approaches to building a private practice. A significant number of therapists apply to be on insurance panels and get referrals that way. Some (depending on their credentials) get authorized to take Medicare (or the state level equivalent). Some people worked in community clinics as trainees and are then on referral lists. I don’t bill insurance and I don’t yet meet requirements for Medicare, so I rely on various directories, referral lists, and networking in order to generate new patient referrals. My best referral sources are former and current patients.

It’s rough as an out of network provider. Most people rely on their insurance to find a therapist and the people who do manage to find and choose me then have to pay me out of pocket and get reimbursed. But I don’t take on all comers. I won’t see someone without speaking to them on the phone first, so sometimes I refer people out because we are not a good fit or I know of another therapist who has expertise that I lack.


I don’t think this is a “duhh” question at all! I could go on and on because I honestly think most people limit their searches for therapists to what their insurance covers. With good reason! Therapy can be expensive!

But insurance is where a bottle neck occurs because most insurance panels limit the number of practitioners on their panel and also make assumptions about therapist case loads, while most therapists are on more than one panel. A therapist could be on three insurance panels and be a Medicare provider - which is great because that means that more people have access to that therapist, right? Hold on! Most therapists have between 20 and 34 client-facing hours (not including paperwork). Most insurance panels assume that each impaneled therapist can take on 30+ patients. I think you can probably see where this is going… A therapist can have small case loads from multiple insurers that add up to a full case load but each insurer shows that therapist as available to take on new patients. The panel is not at capacity even if each individual therapist on the panel is. So, patients get stuck running around trying to find “available” therapists covered by their insurance.

Sorry! Got a bit ranty… :face_with_hand_over_mouth:


How do things go with people who were reluctant to go to therapy but got pressured into it or decided to give it a try even though they don’t want to?

Any success stories you can share?


Heh. Sorry. The “duhh” was me writing like I was drunk. I’ll go edit it again. :slight_smile:


Therapy doesn’t really go the greatest without some motivation in the patient. Without getting specific, sometimes a couple will come in where one of them doesn’t want therapy or they think that seeking couples therapy is a sign that the relationship is doomed. Sometimes that therapy is abbreviated. But I don’t view relationship counseling as having the singular goal of “saving” relationships. I view it as a process of studying the dynamics of the relationship and determining goals based on those dynamics. I don’t think that there is one kind of “good” relationship, so my patients usually stick around until they figure out what they want their relationship to be like, at a minimum.

The only exception, both in couples and in individuals, is when there is narcissistic personality disorder present. People with that disorder do not typically seek therapy, but are forced into it by a partner or family member. It doesn’t usually work out because they view everything as everyone else’s problem - because they are fucking great! It’s a bummer because they are often deeply angry and unhappy but cannot tolerate those feelings.

Teens and kids often get put in therapy as the “identified patient” in a family system, which is ineffective because a) the family dynamics are the real problem, b) the child is unable to make big changes due to lack of power, c) parents aren’t willing to spend the time or make the changes to help the child or the family, they just want a fix. I’ve had some success in giving these kids hope for their adulthood, but as soon as I suggest family treatment, they get pulled. It’s a bummer, but it would be unethical for me to not make that recommendation.

I’ve seen progress with reluctant patients, but it’s slow. It takes a long time to build trust and encourage their efforts and commitment. Sometimes that’s the therapy - just getting someone to a place where they can trust me enough to be vulnerable. Sometimes that’s really all they wanted, to be able to soften and be authentic with another human being. Those people usually leave therapy when we get into deeper issues, but come back later when they feel “stuck.” They become savvy therapy consumers!

Does that answer your questions? I hope so!


Absolutely! Thank you for the detailed response. Those are some things that I would not have thought of.


Is there a way to stop the board software from nagging you about replying too many times to someone since, y’know, it’s an AMA?

And while you’re at it powers that be, could you get it to stop saying your topic is the same as another one seemingly based solely on the fact that they are both in English? The board is a bit of a moron.


I wish someone had taught that to the therapist I saw (briefly). Face to face in charged, emotional situations, I often don’t talk as much as when some of those elements are removed, but when I wasn’t opening up right away (and providing answers before questions were even asked) I was told I was wasting her time and my money by being there. I never went back. And it’s left me forever wary of such things.


Maybe the board is bored. Especially since you are ignoring it. :grin:


Do you find that when people find out you’re a psychotherapist, they’re more guarded in social situations, because they think you’re analyzing them?


This answer is probably going to sound kind of sad - but I don’t socialize very much. I’m introverted and I don’t have very much free time since I started this career path, so I haven’t met many new people who aren’t also therapists. Of non-therapists that I’ve met (and the sample size is small), the reaction to finding out what I do has been more curiosity than standoffishness. I also don’t analyze people outside of therapy. There are usually too many other things going on for me to be able to focus attention on the way that even makes any kind of analysis possible.