Diagnoses – Therapy with Dr. Stoneface, part III

After a little break I continue my account of my therapy with Dr. Stoneface. I had described why I´ve consulted him and also the first conflicts during the probationary sessions. What I want to describe today is the diagnosis he apparently told my health insurance company, and what is wrong with it.

So. The first bills my health insurance sent to me are from two months after I started seeing Dr. Stoneface, so I guess this is when the probationary sessions were over and my health insurance had granted me I think 80 hours of transference focused psychotherapy. First a few words on how we decided to work together.

Even during the probationary sessions, first doubts had arisen. I had suppressed them, though, believing that my difficulties with him were a sign of resistance on my part. Everything I had ever read about psychotherapy seemed to confirm that. Also, I had so far never encountered a psychotherapist I had gotten along with. I had seen three mental health workers about my issues before (not counting the ones who had referred me to Dr. Stoneface and to my former therapist, as I have seen them only once for evaluation), and I had always gotten into heated arguments with them and eventually dropped out of therapy. I had heard many times this was characteristic for some mental illnesses. Also, I believed I had a lot of motives to run away because therapy would most likely be painful, a harsh blow to my exaggerated self-esteem, but I “knew” that if I ever wanted to be able to love, feel, and generally be my “true self” I had no choice. And so I decided not to “run away”.  Therefore, when Dr. Stoneface asked me if I wanted to work with him, saying no was not really an option. I trusted that if he had any doubts about being the right person to work with me, he would tell me. Blessed naivety…

I have to criticize myself to some extent, though. I don´t blame myself for having been entangled in the trap of seeing my doubts as a sign of resistance. It is a perfectly designed intellectual trap, and even people who are not clinging to loose shreds of their dissolving mind have gotten lost in it. The trap is even harder to see through when it is accepted in large parts of society, which to me it seemed to be. What I somehow blame myself for, though, is relying on a referral instead of consulting several therapists at once and trying to find the best match. I was oddly fatalistic and indifferent at the time, thinking that one therapist was as good as the other one for the dirty business that lay ahead, which was basically: breaking me. I felt unfit for making any choices for myself, and I just wanted to get the ugly stuff (therapy a.k.a. breaking me) over with and one day wake up and be a whole, healed, good person. Until then, I wanted nothing to do with myself. I was abandoning myself and made others responsible for making me sane. I felt that was fair, because I believed the process of making me sane would be a punishment more than anything else. I couldn´t want to be punished (only in a very perverted way which would have rendered the punishment ineffectual). Therefore, I needed somebody else to drag, force and batter me through this. My implicit attitude towards therapy must have been somewhere along the lines of: “I will resist all I can, but please be stronger than me!”

Good. Now that I have 600 words written on everything but my actual topic, I might finally get started. The diagnoses.

When Dr. Stoneface told me he was going to write to my health insurance company, I wanted to know what diagnoses he was going to tell them. Given that so far he hadn´t told me anything, I was quite curious. Dr. Stoneface, however, evaded the question, explaining to me that he had to tell them something in order to get them to grant those 80 therapy sessions, but that this wasn´t written in stone and that the truth was always more complicated. While this sounds incredibly reasonable at a first sight, it is actually quite an insolent excuse. First, if he just tells them “something” he is basically ripping them off. The taxpayers, mind you. So either he is a fraud, or he is bullshitting me here. Wow, very trustworthy. Second, even if the truth is always more complicated, I should have a right to know what diagnoses he ascribes to me. How am I supposed to decide what treatment I want and even if I want to work with him if I don´t know what he thinks I should be treated against? And third, if his argument for not telling me my diagnoses was really that diagnoses are simplifying a complicated truth – then he could at least have told me that complicated truth.

But he didn´t tell me the complicated truth. Even as I insisted, he only mumbled something about it being a personality thing. Yeah, I had figured out that much. Eventually, though, I dropped the issue. And the reason for this was that back then I didn´t think of all the stuff I wrote in the paragraph above. My thoughts were rather meandering around the possibility that it was maybe good for me that he refused me to tell me my diagnoses. I thought that maybe it was part of the therapeutic strategy. Maybe knowing my diagnosis would allow me to build up effective, impenetrable resistances. Maybe it would even render me incurable. At a later point in therapy I would accuse him of this, of purposefully keeping me in the dark as a therapeutic strategy. He, of course, would deny that, would deny even having a secret strategy until I doubted my own perceptions. Years later I would eventually find out I had been right.

Now for the diagnoses themselves. When I had the brilliant idea of looking at my health insurance bills last fall (I kind of blame myself for not thinking about it earlier, but then again I only learned about ICD-codes in the class I took last semester), what I came up with was that Dr. Stoneface diagnosed me with dysthymia, an unspecified eating disorder (still don´t know what that was about), and an “other specific personality disorder”. This last category covers several PDs, but the only one I have ever heard of is Narcissistic Personality Disorder. Having finally some knowledge about psychiatric diagnoses, I can raise some doubts regarding the validity of the ones Dr. Stoneface ascribed to me:

1) Dysthymia.

Now, diagnostic criteria for dysthymia say it can only be diagnosed if the patient has been in a constant, slightly depressed mood for at least two years. Two years before, however, I had been in treatment for a depressive episode with suicidal ideation and self-harm (slightly depressed?), and later mixed depression and anxiety. I had suffered a severe emotional breakdown just a few months before he diagnosed me, and around the time he wrote to my health insurance company I was on the verge of another breakdown which I will detail further later in this post. Needless to say that breakdown, too, was accompanied by suicidal ideation. While I don´t generally disagree with the dysthymia diagnosis (I have always been a bit melancholic and worried), I believe I was in no shape for anyone to judge if my current difficulties were part of a depressive-neurotic character structure.  So the diagnosis seems a bit bold to me.

2) Personality Disorder, probably narcissism 

First of all, I had only just turned 18. Personality disorders are said to manifest themselves during early adulthood. Isn´t “only just 18” a bit early to diagnose one, then? He must have been pretty sure of his judgment… Even more so, of course, given that I was in a state of acute crisis when I saw him. I believe it was Dr. Psych who once said in some lecture that there is a diagnostic hierarchy: You cannot diagnose deep, permanent, underlying disorders before having dealt with the acute problems. What might look like avoidant personality disorder suddenly goes away once you´ve successfully treated the acute agoraphobia, and so on. Makes a whole lot of sense. My acute problem had clearly been named by the shrink who had referred me to Dr. Stoneface: Adjustment Disorder. Which, ironically enough, leads us directly to my complaint number 3.

3) Where is “Adjustment Disorder” in the laundry list of diagnoses Dr. Stoneface ascribed to me?  

The answer is a clear and resounding: NOWHERE.

It is not there.

When this first occurred to me, I was pretty stunned. How could it be, after all, that a diagnosis which had specifically been marked with an “S” by the doctor who had made it, “S” for “safe, sure, so-bloody-obvious”, simply disappeared from the records?

Huh. Maybe it didn´t apply anymore. Maybe it had been dealt with.

Well, if so, then this had happened without my knowledge. I had so far received no help whatsoever dealing with the break-up of my relationship. I didn´t have the impression that anything at all had happened in therapy.

Or maybe it wasn´t acute anymore? Had too much time passed since the break-up?

Well, given that my problems were still there, in that case Dr. Stoneface should have diagnosed me with a chronic version of Adjustment Disorder, if such a thing exists.

Both “arguments” are rendered invalid, anyway, though, by the fact that the break-up process was still not over by the time Dr. Stoneface made his diagnoses. After the final talk with my friend, she and I had sporadically been in touch via e-mail. And even though at first we had tried to keep it friendly and formal and far away from the painful subjects, eventually we were at it again. She wrote me about how her life was changing for the better, about how being with her new boyfriend was the happiest time of her life (seeing her dismiss our time together like this hit me to the core), and she told me that she was in this lucky position because she was a better person, a person who was willing to be hard on herself, to work on herself – willing to be a good person. She wrote me all this under the guise of trying to help me, motivate me to change, and she probably believed that herself. She also kept me up to date on how she was trying to cope with breaking up with me. About how her new boyfriend helped her cope. He was not just comforting her. He also helped her “free herself from her pathological admiration for me”. He thought that her original respect and liking for me was a form of dependence that she should get rid of. It was obvious, after all, that I was not good for her. Not good for anyone. And thus, in order to heal her, the two of them dissected my vile character, and my friend had the “courtesy” of sending me copy of that discussion.

It was after receiving that e-mail that I decided I should remove myself from the gene pool. Since I knew that I didn´t have the balls to just kill myself, I decided to further restrict my already niggardly diet until I developed fatal anorexia. (So if Dr. Stoneface diagnosed me with eating disorder, is there any, just any possibility that I told him of this plan?!)

What I am sure I told him about, though, is that e-mail. I printed it out and brought it to my next session. I was so upset I had trouble speaking. I demanded he should read that e-mail. I think my hands were actually shaking when I offered him those sheets of paper.

Dr. Stoneface´s reply: “Now what are you thinking? I´m not going to read your private correspondence!”

He said that in an irritated, indignant tone, as if I had demanded something grossly indecent. We engaged in a fruitless discussion, which basically ended by him authoritatively stating that I´d have to read the letter to him if I wanted us to discuss it.

So, I need to digress again, even though this entry is so long already. I know that the point of psychotherapy is that you have to talk. The basic assumption is that it is the talking that cures you. So very likely him reading the e-mail wouldn´t have much of a therapeutic effect on me. But:

1) I believe that sometimes it is more important to know what is wrong than to adhere to the rules. I could still have talked about it later, but first of all it would have been important for him to know what had upset me. Take trauma therapy, for example. The shrink who talked about that in Dr. Bla´s lecture said that in her first session she only asks her patients to give her a quick overview of the nature of their trauma, like, in one sentence. It is part of the therapeutic work to enable them to talk about it, nothing that can be demanded before treatment has even begun.

2) Even reading aloud something so humiliating might have a healing effect, granted. Such as getting the poison out of your mental system. But this can only work under certain circumstances. Like, when you know that the person who listens to this respects you, respects your shame, and most definitely is on your side. Being ashamed in front of somebody makes you very vulnerable, and I think it only has a healing effect when you feel very trusting towards that person. How do you reckon I felt about Dr. Stoneface after we had just had an argument that had ended in an ultimatum on his part? That aside, though, Dr. Stoneface didn´t even communicate to me why it was necessary for me to read it out aloud. He merely insisted that I do so if I wanted to discuss it ( thus more or less making it clear to me that it surely didn´t matter to him if we discussed it or not), leaving me with the job of figuring out why he demanded that. For all I knew, he simply thought it was indecent to read other peoples´mail, even if they asked him to; or even worse, that he thought asking him to read my mail was indecent on my part.

Now…I guess I could have made myself read it to him. I probably would have switched off my feelings (something I´m splendid at, but I had actually started therapy in order to learn to not switch off my feelings), read it to him, and then I would sat there with nothing to discuss because my mind would have been as blank as his stare, and after the session on my way home the shame would have hit me so hard I would have felt unable to ever look at myself again. And I would have blamed myself for that (and not his lack of a human reaction), because “if I had not run away from my feelings he would have been able to help me”. Yeah, right.

Thankfully, however, I did not subject myself to this exercise in humiliation. Instead, I grabbed the papers and threw them straight at him.

Dr. Stoneface, predictably, sat there like a stone. A statue, actually. “Stoical Psychotherapist in Session. A late work by Dr. Sigmund Freud.” Or in his case, Otto F. Kernberg, but I didn´t know this back then. At any rate, when he didn´t react at first I felt ridiculous, and then fear kicked in. What if something was wrong? What if I had done something horrible?

“Did I hurt you?” I asked anxiously.

I cannot translate this into English, but what happened is that when I asked him if I had hurt him, unfortunately I made a slip of the tongue and, instead of using the formal pronoun “Sie” used the informal “du”. Of course Dr. Stoneface was over this like a fucking vulture. For the rest of the session, he quizzed me about this slip of the tongue, and what it might possibly mean. The worst thing is that this type of behavior is probably not the unfortunate exception, but the rule for psychoanalysts. So, once again, I was left with dealing with my real problems on my own.

What shall I conclude? Dr. Stoneface knew of my diagnosis of Adjustment Disorder. He knew that the situation which had caused me to be given this diagnosis was far from over. Why, then, did he

1) not treat me against Adjustment Disorder?

2) feel entitled to diagnose me with grave, permanent, underlying and above all stigmatizing disorders?

3) not even mention Adjustment Disorder as a diagnosis among others in his letter to the insurance company?

What he seemingly did is that he simply replaced the acute problem, which would have forbidden him to diagnose me with anything else until he had successfully treated it, with a couple of severe diagnoses which allowed him to keep me in treatment for pretty much as long as he wanted. All I´m wondering about now is whether he was just bullshitting the insurance company or also himself.

More to follow.


2 Responses to “Diagnoses – Therapy with Dr. Stoneface, part III”

  1. vicariousrising Says:

    Stoneface sounds like a charlatan. I think your only mistake was not recognizing that your doubt about him was a warning flag. Even if resisting treatment, you should feel a level of safety and/or comfort with the therapist. If he failed to provide that atmosphere for you, then he was a bad fit. But at 18, you wouldn’t know that, especially given your history with therapists.

    It’s hard to find a decent therapist, even harder to find one that is a good working relationship with your personality or issues. I hope you don’t give up on counseling altogether because when it works, it is the difference between living and not. But definitely cut yourself loose when the person seems shifty. I don’t think you believe paranoia is one of your problems, do trust your gut about who is untrustworthy.

  2. Thank you very much for your comment.

    I´m currently not thinking of getting counseling, but I haven´t given up completely on the possibility. If I should ever choose to do so, though, I would definitely go there with a very concrete goal that allows me to measure my progress. Also, I would try something that doesn´t focus on transference.

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