I had an intake with a new therapist yesterday. I’ve had a lot of intakes over the years. So many. At this point I’m pretty relaxed going in to intakes, and I can autopilot explaining a lot of my issues. So I didn’t really prep a whole lot in advance, and went in without thinking overly much about what I wanted to work on (I had been referred by another therapist for some mindfulness work, but also wanted to deal with some trauma and get some support for general coping skills).
I disclosed all of my diagnoses, and when I described autism the therapist responded “That doesn’t sound much like autism to me.”
It caught me off guard. I tried to explain my symptoms, but I hadn’t thought in advance and felt tongue tied. I know my autism quite well, but somehow I couldn’t explain it in the moment when someone I was being vulnerable with suddenly questioned me and one of my core identities.
Hey therapists? If you’re going to question a patient’s diagnosis, please wait until after the first session at the very least. Build up a bit of trust. Establish a relationship. It’s so easy to put people on the defensive when you question them.
I get it. You want to find an accurate diagnosis for your patient. You want to approach their concerns with the most helpful label and lens. But boy howdy does it feel awful to walk in and be asked to defend your diagnosis. I am not a mental health practitioner who has the ability to diagnose anyone, much less myself. I can tell you how it feels for me, but it’s pretty stressful to be asked to lay out the DSM criteria and explain how I fit each of them, especially when we’re talking something as widely misdiagnosed and misunderstood as adult autism in women. It super sucks to give examples of your diagnosis and be told “no that doesn’t sound like autism to me” repeatedly. While many of us know our symptoms well, it can be hard to put them in order at a moment’s notice in a way that is easy to understand and convinces you of our diagnosis.
Of course there’s a time and a place for a therapist to push their patients to question their own identity. But that’s some pretty high level stuff and I wouldn’t want to do that with someone that I didn’t already have a solid working relationship with. If I could ask anything of my therapists it’s that they would trust me, at least a little bit, when I share my self understanding with them.
Why am I harping on about this?
The therapeutic alliance, or the feeling of solidarity between a therapist and patient is one of the highest predictors of good outcomes from therapy. Both from personal experience and from the research, I can tell you that when I trust a therapist and more importantly when I know they trust me, I am far more likely to internalize their suggestions, follow through on recommendations, and open up about challenging issues. And also from experience, one of the fastest ways for me to feel as if you don’t trust me is to invalidate my feelings and beliefs, question my statements, and put me on the defensive.
While in this case I’m specifically talking about early in the therapeutic relationship, it’s also important to remember throughout the relationship that if your client brings something new to you, don’t just dismiss it. I’ve had therapists question my asexual identity and my atheism when I brought them up, acting as if those couldn’t be the case for me. I have always walked away from those sessions feeling hurt and frustrated, and almost wishing I could quit therapy altogether. Even when you do have a solid relationship with a client, asking them to account for their basic identities is a really tricky line to walk.
Consider: Take the time to understand WHY someone identifies the way they do before responding. If you are going to question a diagnosis or identity, be specific about what seems off to you rather than just saying “it’s not that”. Work through the identity with your patient instead of dictating. Keep your first response validating, and let them share their reasoning at their own pace.
I know I’m just one person and don’t dictate the laws of good therapy, but having a validating environment is hugely important to mental health, and if a therapist’s office can’t be that I don’t know what can. So please therapists…believe your patients and validate them.