A Case Against Specialty In Therapy
As a therapist in Manhattan, I am often asked what I specialize in. I’ve often grappled with how to answer this question. When caught off guard, I might blurt out some uncouth version of, “um…people?”.
To be clear, this is a perfectly fair question. “People” certainly is an, ahem, broad category and it's an understandable assumption that I might have a central focus in my work. However, my reluctance to claim a speciality is not just about my desire to not limit who I work with. To take this a step further, I find the concept of speciality in mental health ripe ground for problematic treatment. This problematic is related to how we as a society relate to mental health diagnosis.
Presumably the concept of speciality for a therapist comes from an attraction to or affinity to a certain type of patient. The more we work with a patient who fits a category such as age and symptomatology, the more expertise we gain. We should all move towards what we love so if there are certain patients a therapist enjoys, I say go for it (as long as, just like everything else that comes up for a therapist, it is investigated in supervision or the therapist’s own therapy).
However, when a therapist has a “specialty”, it is typically a diagnostic one such as “Eating Disorders” or “Obsessive Compulsive Disorder”. The concept of diagnosis in itself is limiting and can shut down curiosity. Additionally, grouping people by symptom can carry less meaning than meets the eye.
The Problem with Diagnosis
In the earliest iterations of psychiatry, psychiatrists and psychotherapists used a more psychoanalytic framework to describe their patient work. For example, an analyst might describe a personality or defense structure. The field saw a need for more of a precise shorthand when describing patients and additionally wanted the utility of their work to be demonstrated by empirical studies.
The DSM I was created to meet these needs. It was framed in a psychoanalytic way and gave a lot of room to speak to a patient’s stressors that might be a factor of their symptoms.
Much to the field’s dismay, the DSM I and its second iteration, the DSM II, did not provide the clean cut evidence that had been hoped for. The psychiatry community became concerned that without quantitative studies, their work would not be seen as valid. As an attempt to prove that psychiatry was a valid field, the DSM III took less stock in external factors and focused solely on categorizing symptoms.
The Patient As The Problem?
There is a lot to say about this moment in the mental health world (and if you wanted to go down a really fun internet wormhole, I’d suggest starting here) but for our purposes I will highlight one of the main shifts. The DSM III criteria of the 1970’s, diagnoses that look very similar to the diagnoses that we use today, no longer took into account external stressors. Meaning, the central diagnostic body of work in the United States that we use today relates to symptoms as existing within the patient. It does not take into account what is happening or has happened in the patient’s life (with the exception of a few diagnoses such as Acute Stress Disorder and Post Traumatic Stress Disorder).
This is a pathologizing and limiting way to understand the human experience. I always tell my patients, people don’t feel something for no reason. That doesn’t mean, your feelings are reality. That certainly doesn’t mean, act on every feeling without impulse control. I want my patients to know that feelings deserve room and attention and are also clues that we can follow to understand what is ailing a person and why. What is happening and what has happened in a patient’s life is key to understanding how a patient experiences the world, including what is impacting them and why the patient is feeling depressed or anxious, for example.
Even with Similarities, Curiosity is Key
The concept of a therapist specializing in a particular DSM V diagnosis is working from a diagnostic schema that groups people by symptom. I can’t recall a time in my career where the root of someone’s depression, for example, has been the same as another one of my depressed patients. Maybe the thing that helps a depressed patient in the super short term is similar to other depressed patients but the more meaningful work is more individualized than that.
Just because pain expresses itself in a similar way does not mean that the root of that pain or what is needed in treatment is the same. There is a danger for a therapist to think that they know more than they do. A therapist should not think before meeting a new patient for the first time that they already know how to help them. This shuts down the open-minded curiosity that is necessary for effective treatment.
Every time I sit down with a new patient in my Manhattan office, with about 7 minutes left to the session, I ask myself, do I think I can help this person? The answer is almost always an enthusiastic yes. I do not know what that path of healing will look like yet but I believe I can discover that path with my patient as a partner. I find joy in starting therapeutic relationships anew, forgetting for a moment other patients I have known who bear similarities, in order to get to know this person with humanity and humbleness.
Finding the Gray
This is not an absolute in some ways and as I write this, I can’t help but think of patients and loved ones who have found so much solace in connections, formal (i.e. AA) and informal, with people who are diagnostically similar. Additionally, I have worked with patients who have found their diagnosis meaningful and validating of their experience. I want to allow room for all experiences including these. However, as a therapist, I advocate curiosity over speciality and diagnosis so important information is not missed and arbitrary diagnosis is not given unearned weight. I always tell people that when they are looking for a new therapist, do not limit yourself to looking for a specialist; try and find a therapist that you click with and that feels just as invested as you are in the work.
