Labels

Richard 
Good day podcast fans. It's another episode of therapy natters, the podcast series where 2 psychotherapists answer your questions and have a little natter about all things therapy. I'm Richard Nicholls and with me is my co host, Fiona Biddle. Hey there, Fiona, how you doing?

Fiona 
Hi, I'm fine. Thank you sitting in the garden in the sunshine. It's lovely.

Richard 
Sweet. People complain about the English weather, because it's unpredictable. You never know what you're gonna get. And I think that's one of the reasons why I quite like it, because you don't know what you're gonna get. And because it can be foggy and miserable, one morning, and then 20 minutes later, you're walking around in the sunshine, and it's gorgeous. And it's lovely. And I've often thought that it's the, it's the contradiction of the two it's the juxtaposition of the two. That makes us appreciate stuff. I mean, I've spoke about it waffled on about it on my podcast, and I wrote it in my book, if you haven't purchased a copy of my book, listeners, feel free to have a look for me, in the book shops. And I mentioned in there about the research into the weather, that there's no correlation with good weather, and good levels of mental health, and happiness, and so on, because there's not really a strong indicator. There are lots of very miserable hot countries, warm, pleasant countries, still lots of social unrest and poverty and pain. And that has a much bigger influence than Oh, yeah, but the sun's shining.

Fiona
I completely agree. And a lot of the countries that are known for being the happiest places like Scandinavian countries, for example, they're not hot and sunny all the time. And I agree, it's a contrast. It's looking forward to spring. And then I also I don't know about you but I look forward to the cosy nights as autumn approaches, both have both have their appeal, but I wouldn't want it to be the same all the time. No, no,

Richard 
no. Variety is the spice of life as well. So we've had a load of questions. We've actually quite a few come in lately. And we've got two got two for today. And a similar sort of theme ish, right? Oh, that's not quite strictly true, is it?

Fiona  
Well, they come together on a certain couple of points. So that's why we're, we're linking them. So shall I read them? 

Richard
Go Go for it, please. 

Fiona
Okay, so the first one is from Sian in Swansea. I seem to tick every box for emotionally unstable personality disorder. But my therapist doesn't like labelling people. I totally understand where she's coming from. But it still feels really invalidating. I don't know why I feel the need for a label, but I do. Is this normal? So that's the first question and then we've got one from another anonymous person. What is the real difference between panic attacks and anxiety attacks? I was once told by a child psychologist that anxiety attacks aren't even a thing. I felt stupid after being told that anxiety attacks don't even exist. When I was attending my first psychological assessment child Centre, which I won't name because I was trying to explain what I experienced. Because I didn't directly think that I was dying at the time of this breakdown. They ruled out panic attacks. And to be honest, I was again left with no words to describe this reaction to something that powerfully triggered me. I felt frustrated because the child protection officer told me prior that what I've experienced wasn't a panic attack, but an anxiety attack. And then to have someone else say that they don't even exist was confusing. Rather than focusing on the frightening experience that I had, which to me was a breakdown in front of my family, they focused on terminology. Now, whenever I use psychological terms or diagnoses, I always feel awkward and not believed. Also, I worry that I might appear stupid to mental health professionals, if I try to describe my experiences, through labels and worry that they will think that I don't know what I'm talking about. Well, interesting.

Richard   
Yeah. It is. I think what what jumps out at me especially with the in the Anon question there is the importance of valid I don't know if it's other way around, isn't it? The same they're both looking for validation. Both of these people are saying, please understand what I'm going through. Please understand me see me sit with me get me and, and they're not being got. Or they're not being noticed that they're being understood. Sian put something into my mind when you were reading that out. And let me just go in and just have a reread of it here. I don't know why I feel the need for a label but I do is this normal? Now, to say, I tick every box or emotionally unstable personality disorder means they haven't had a diagnosis from a psychiatrist or a psychologist. It's they're doing some self diagnosing there. Because one thing, I think it's important, everybody recognises, therapists don't diagnose. As a psychotherapist, we will not diagnose anybody with a condition, because it's not for us to diagnose that takes a doctor that takes a clinical psychiatrist or a psychologist or a psychiatrist, usually, and particularly the psychiatrist, they've been to medical school, they're doctors, we might have done a heck of a lot of therapy training. But we're not psychiatrists, and we don't diagnose. And even some psychiatrists don't like those labels, either. Actually, I've met many psychiatrists at conferences and, and presentations and things and they say, we just have to because it's, it's part of the job, but I don't like it, I don't agree with it.

Fiona 
The diagnosis model often is necessary when it's leading to prescription of medication. Or in countries where medical services are paid through insurance schemes most of the time, then they need labels for the in quotes prescription of the therapy. But where that doesn't happen, most of the time, that label doesn't actually aid in the provision of the therapy, which I think is the basis of why we continue not to diagnose.

Richard 
Also, one thing to think about here for Sian is that ticking all these boxes for emotionally unstable personality disorder is going to mean that she sees abandonment and rejection in places where it doesn't exist. She sees not being validated by people everywhere she goes, possibly, whether she's been validated or not. So it could well be that this itself is one of the traits of emotionally unstable personality disorder. Maybe we should say to some of our listeners exactly what we mean by this term, emotionally unstable personality disorder, because not everybody's going to ever have heard that before.

Fiona  
I should think an awful lot of people haven't. 

Richard
They might have heard it called Borderline. 

Fiona
Yes, it's the new description for borderline personality disorder, which I always thought was just the worst label. What on earth does it mean to be a borderline something? A border between what? So it's good that it's changed.

Richard 
Yes, it is. But still to be told, okay, we're not going to call you borderline anymore. We're gonna say that your personality is emotionally unstable,

Fiona 
and that you're disordered. I agree. I mean, this is showing that we, you and I, Richard, we're not fans of labels. But I have had clients who really liked the fact that they've got something that they can hang their hat on. And this is the reason I am like this, because of whatever the label is. So I can see that it can help. But then the other side of that is, have you got that label forever? Do you want to take it off? How do you take it off? Are you stuck with it is it tattooed to your forehead? That's another reason for not being keen on them.

Richard  
And it becomes one of the in TA. There's sometimes that phrase that comes from Bern, sometimes called Wooden Leg Syndrome. What do you expect from somebody with a wooden leg? Of course, I can't do that. What do you expect from somebody with a wooden leg? And that crutch can sometimes get in the way of somebody's progress, Somebody's development. Of course, of course, of course, I've got problems with people. What do you expect from somebody with emotionally unstable personality disorder. And I think sometimes that label can create that. And that's why thinking about it, talking about it, understanding it, and having these sorts of conversations is so important. And I think that will be one of my first things to suggest to Sian, talk to your therapist about this. That's the first thing to do. If you're feeling invalidated in therapy, that needs exploring, and that's a wonderful thing to do to learn to be vulnerable with your therapist so much that you can, you could almost criticise them and be okay with it. Because a good therapist will praise you for that. I hope.

Fiona 
I guess that's all there is to speak to the therapist. Yes, absolutely. And say that you feel invalidated. And see how the therapist responds to that because I very much suspect that that's nowhere near the intention. The lack of label is intended to be helpful for the reasons that we've gone into. But there will be other ways in which your therapist will be able to validate you, Sian. Shall we have a little look at the specific labels, the other ones We've been given by anonymous, the anxiety attacks and panic attacks. Do you, in your practice differentiate between those, Richard?

Richard 
No, I don't, because they're to me, they're just words. And everything that comes up in therapy is specific to them. If a client wants to use the term, I had a panic attack. I'm not going to be I'm hopefully not going to be too pedantic to go. Let's just double check here whether this isn't exactly just an anxiety attack. And just the word attack.

Fiona 
We talked about that. Briefly, I think it was in episode two about how panic episode is a more useful phrase. Most people find it anyway, a more useful phrase. I've never differentiated between them. Similarly, it's the words that the client uses that really matter. Although there are times of course, when we might suggest a different word that might be more applicable. But I've not I've not differentiated. So when I was looking at these questions, I Googled difference between anxiety attacks and panic attacks. And there's quite a few sites that come up with the difference. But to me, there's not really a difference. It's well, anxiety is and then goes on to describe anxiety. Well, we know anxiety is something different from a panic. But they don't then really describe what an anxiety attack is. There's something about the short duration of it that has to be there. For it to be labelled an attack, surely you can't be in high high, high anxiety for hours,

Richard 
if we're going to use these terms. That has to be some time to it, some different something that defines it. But isn't it better like you're saying just to call it whatever you want?

Fiona  
So prolonged anxiety, would be generalised anxiety if you wanted to label it, but really, it's just being anxious. I'm anxious most of the time, that tells enough, doesn't it? I don't see the point with the DSM, the latest edition, they divide panic attacks into two types expected or unexpected. And this is something that we see sometimes with clients that they say, it just comes out of nowhere, no idea where it what's triggering it, or if anything is triggering it, it just happens. And that is definitely true. And that leads then to the fear of the fear, which is very much a part of it, again, that we discussed in that episode we did on Agoraphobia, the fear of it happening. And when you don't know when it might happen, that's going to be a greater fear. And then the expected ones are, you know that it's quite likely to happen if you go on the tube or in a supermarket or whatever. But still differentiating that between panic and anxiety. I don't really see the point.

Richard  
One thing that Anon said was, I was left with no words to describe this reaction that was something so powerful. They want, they feel that need for the words. And to describe why they were feeling the way they were feeling. To help explain it maybe

Fiona
remember that Anon was a child at this time. So he or she, I don't know, was in a situation where there were adults. And Anon was trying to explain to them what he or she was feeling and being told that they weren't describing it adequately. Which is awful isn't it.

Richard  
And again, there's that invalidation. There's that feeling that somebody can carry everywhere they go, like Sian, this feeling that nobody gets me, nobody understands me. And that can develop into a personality trait that influences the way people see the entire world and the way that they fit in with it. Sad,

Fiona  
it says, In this phrase, I worry that I might appear stupid. Well, if you're being told, you can't even describe what you're experiencing in the way that is okay to me. Well, it's no wonder he or she would feel that but that's not Anon's problem. That's the mental health professional's problem.

Richard 
All because some professional wants to match up somebody's experiences with whatever it says in the, in the DSM, the diagnostic and statistical manual of mental disorders.

Fiona   
So in the DSM, they list specific disorders that are anxiety based, but there's three of them and the first one is called anxiety disorders, but the other is all sorts of anxiety disorders as well. But the first So, anxiety disorders number one is divided into separation anxiety disorder, selective mutism, specific phobia, social phobia, panic disorder, agoraphobia, and generalised anxiety disorder. The second category is obsessive compulsive disorders, which is divided into obsessive compulsive disorder, Body Dysmorphic Disorder, hoarding disorder, trichotillomania, and excoriation disorder. Let's go through let's read them all out. And then we'll have a look at each one. And number three is trauma and stress or related disorders. Which is divided into reactive attachment disorder, disinhibited social engagement disorder, PTSD, acute stress disorder, and adjustment disorder. So rather than jump straight to your first one that you asked what it was, let's have a look at them, shall we? So separation anxiety disorder, that's usually about children who don't want to be separated from their parents. It can be the other way around. Parents can feel separation anxiety when their children start school, for example, selective mutism. Have you ever had that one? With a client?

Richard  
Not with a client? No. Or have I? I don't know. 20 years doing this? I'm not sure. I don't think I have. I don't think I have.

Fiona 
I have just once. But for those who don't know, it's usually a child who, in quotes chooses times when they speak and times when they don't. So they might speak at home and not at school might be the other way around. Or they might speak to certain people and not other people. I use the word chooses very lightly, because it's not conscious. I'm not going to do this or I am going to do that. Specific phobia. Well, I think most people know what that is, you know, you're afraid of dogs, or you're afraid of needles or whatever that might be social phobia.

Richard
Many layers to social phobia. 

Fiona
Yeah. It's usually, I'd usually call it social anxiety rather than social phobia. Anyway, because

Richard 
Well it depends. It depends on the effect that it has. I've always thought that for something to be classed. Again, it's labels again, isn't it? A phobia means it's causing a problem even when the stimulus isn't there. It's keeping you in the house, the social phobia is keeping you in the house and you feel anxious with the potential that there could be an interaction with somebody. Whereas social anxiety you're probably fine when you're on your own, it's when you go out that the problem occurs. So I guess, labels can be useful.

Fiona 
Yeah, that one really gives you information as to what you need to find out from the client, doesn't it? That differentiation. 

Richard
Also what the homework would be.

Fiona
Yeah. Panic disorder. Which is Panic attacks are a sign of panic disorder. Surprisingly, enough. Agoraphobia, which is what we talked about in episode two, I think it was and generalised anxiety disorder, which is the tendency to be anxious most of the time in an awful lot of situations. So generalised.

Richard  
Yes, there was a, I'm not sure if it's still going on. But I've certainly heard, there's been a lot of generalised anxiety disorder uptake in the US after the DSM five came out. And it was, like you were saying earlier on, if somebody needs a label in order for the insurance company to pay, if the therapist doesn't know what box to tick, they tend to tick generalised and I'll just put GAD, the insurance company will pay then. And suddenly, there's this huge spike in the statistics of generalised anxiety disorder. All because the insurance companies needed a label, otherwise they weren't going to pay out for somebody's treatment. We don't get that problem over here.

Fiona 
It is easily measured with the GAD seven, which is used as a measure a lot of the time, even in the UK. If you go to your GP with anxiety or depression, they're likely to throw the GAD seven and PHQ nine at you. Which is I would say it's quite useful as a tool to see where you are and to see progress.

Richard
Yeah, to see what's happening six months later, when you go look I am improving this therapy is doing me well. Or I'm doing well 

Fiona
Or not. And then you can see actually look at your scores. You are doing better. So then in number two, the first of the OCDs is OCD. Which is a bit strange. So obsessive compulsive disorder. I think perhaps we need to do an episode on that sometime. Specifically, that would be that would be fun. Body Dysmorphic Disorder, which is a where you don't see your body accurately. So it could be as simple as thinking that you're fatter than you are or thinking that you're thinner than you are. Or it could be specific parts of your body that you see differently. Hoarding disorder. there're TV shows about that about people who hoard. Trichotillomania is pulling out your hair. Maybe from your head, but I eyebrows, eyelashes, lashes, and can be any body hair. And then excoriation disorder. You didn't know that one. Right? Not heard something called that before? Skin picking.

Richard  20:45  
Oh, that's what it's called. I just call it skin picking, obviously. But of course, there's a posh name for it.

Fiona 
Of course there is I'm shocked. You didn't know. I didn't, I had to look it up. I didn't know either. I also looked up how to pronounce it. Because I wasn't sure. So I'll be honest, I'll be honest. But yeah, I mean, that is something that's not common for us to get. But it's not that unusual to have skin picking clients. And you can see that it's a sort of obsessive compulsive process.

Richard 
I was gonna say all of these seem to overlap a little bit. Or you can have multiple ones, you get given a label that says here is your personality problem. Here's your, here's your label here's your disorder. But actually, with a lot of stuff, you can have many of these things,

Fiona  
or not, or bits of them, or sometimes or occasionally, and they don't necessarily have to be all that terrible. So you know, somebody who's hoarding to the extent that their house is dangerous to enter, that's one thing. But somebody who's, you know, keeps everything that they ever did in the loft. And you know, it's a bit cluttered. Is it necessarily, there's, again, TV programmes, talk about decluttering. And make it sound like it's the worst thing in the world to have clutter in your house? Well, doesn't have to be a problem does it? Unless it is

Richard 
nothing's a problem unless it causes problems.

Fiona  
And then the third one, so trauma and stress or related disorders, reactive attachment disorder.

Richard  22:22  
That sounds more appropriate a term than emotionally unstable personality disorder, are they related

Fiona 
emotionally unstable personality disorder is not listed in these anxiety based conditions. So I would, I would say that most people who have had a diagnosis of EUPD will have attachment issues, does that mean that they're reactive? I'm not really quite sure. But again, it's the words, does it really matter? It's what the what the person thinks, are you reacting to something? Then disinhibited social engagement disorder. I have to admit, again, I had not ever heard of that one. Put together like that. Have you?

Richard 
Not as a term like that no.

Fiona 
I've had clients who've come along who've struggled to behave appropriately in social situations, but then that tends to be there, to use a TA term again, going into child mode at times when they'd be much better off being an adult. So thinking I'm going for a job interview, but it's really important that I am myself, because I don't want to be fake. And I want them to want me as me. And so going, this is actually a picture that's just kind of come into my mind. If somebody specifically did this very long time ago, they weren't recognised themselves. You'll go to Job Interview wearing scruffy trainers, shorts and a bandana, because that's the real me. That's not probably going to help you get a job in most contexts. So that might be if that was, but that's not really that's not a disorder that's just working something out. PTSD or Post Traumatic Stress Disorder. We've touched on that a little bit before and again, we'll probably do a full one of these on that. Acute stress disorder, which I guess is sort of the opposite of generalised anxiety disorder, isn't it really, something very specific and now, or recurring but acute as opposed to chronic And adjustment disorder, a fear of change.

Richard  
All of these terms. They do dehumanise a little and I understand why people can get frustrated by it and feel ignored by some of these terms are A lot of these things, including personality disorders, don't, don't take into account the problems that somebody's situation is in somebody's poverty, for example, to give somebody who's struggling, and at the minute things are things are pretty tough, you know, energy prices are going up, food prices are going up. wages aren't, you know, things are pretty tricky. And for somebody to go, Oh, your anxiety is because of this disorder that you have. Well, no, it's not. It's because I'm struggling to feed my children. That's the problem. No, no, no, you have a personality disorder. That's what the problem is. You have an acute stress disorder, that's what the problem is no, though I'm living in sexism, racism, and homophobia or something That might be the problem.

Fiona 
Similarly, with depression, and I know, we're not talking about that. But for the sort of standard thing of go to your GP and get prescribed antidepressants. Are not then dealing with the cause of the Depression. And if you let's say you had a major bereavement, for example, then there's the psychological ways to, to move through that. But it's a process that you don't want to block. So likewise, it's it's not, it's not standalone.

Richard 
And if somebody has been traumatised by their caregivers growing up, and and it's given them this label then, in the future, of a personality disorder. That label isn't necessarily going to solve anything. But it can help people understand why they do what they do, run the way that they run away from relationships or feel the the intense frustrations or anger that can come from the slightest rejection. Understanding these terms can be helpful for people it really can. So I get why these terms need to exist. But as Sian was saying, her therapist doesn't like those labels. So in which case, something more about the fact that Sian may have traumas and that is the problem. You don't have a personality disorder, Sian, the therapist might be saying, You've been traumatised by caregivers in the past, you've been abandoned. You've been rejected, you've been neglected. That's, that's what's that's the problem. It's not that you have a personality disorder. So I get it, I totally get it. It makes a lot of sense.

Fiona    
And to be frank, I suspect that the therapist hasn't explained quite adequately, why he or she is saying they don't like labelling people. Because if it's just, oh, I don't like labelling people and carry on, then that's that's a problem. But to explain the fact that well, first off, we're not allowed to. That helps. But then going into the reasons for and against that that would be that would be of benefit. So it does come down to the fact that there are pros and cons of labelling. Significant pros and significant cons. And each person is going to be different in what they want.

Richard   
Yeah. And it's something that we all need to know about if we're going to be therapists. Or gonna go into therapy. This is something we all need to we all need to consider. Really, really do. Well, Fiona, it's been a it's been a it's been a minefield today.

Fiona  
It has it's complicated isn't it? It's a very complicated issue. Simple. It seems so simple. Labels, helpful or unhelpful? Oh, it's a minefield, as you say,

Richard  
there could be an entire podcast series all about it, I'm sure. So I guess we better leave it here for now, because time is ticking on. Listeners. If you have any questions you'd like to fire away at us, the link to our website is in the show notes. Have a look. And you'll be able to submit as a question. And whether you want your name on there or not. You can call yourself what you like. You can use a false name, you can just call yourself Anonymous as have had quite a few people already in this series so far, you can do whatever you like. But do fire off some questions. We'd love to hear from you, including people that have already had their question answered in case you've got anything you want to follow up on that. That's absolutely fine. Absolutely fine. Oh, if you really like us, feel free to leave us a positive review in the in the Apple podcasts app if that's the one you're using. Because although you can rate on Spotify. I don't think you can actually leave a review yet. They don't allow you to do that. But you can rate you can click five star. So if you really think this is a five star show, give us five stars. That'd be super duper. Right. Any closing statements Fiona before we disappear today?

Fiona  
I don't think I do. But I look forward to the next one.

Richard 
See you folks. Bye.