The Worst Red Flags I’ve Seen As A Therapist

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**Alok Kanojia** (1:00)
The most selfish person you know is at therapy being told they're allowed to be selfish sometimes. Somewhere out there, the worst person you know is being fed an Instagram graphic on their algorithm telling them it's okay to put themselves first, right? So do therapists know when their patient is actually the vision, the villain? One of the most toxic people I know has been seeing the same therapist for about five years with no change in their behavior slash life, mind you. And I just have to wonder, if this therapist secretly knows that her client is actually the problem. The person I know, M, is just truly awful to everyone around her, but she's constantly raving about her therapist and how her therapist tells her that everyone else is the villain in her story, that her mom is a narcissist, her sister is a sociopath. I've never heard of a therapist casually diagnosing family members with personality disorders. Does this therapist likely know that M is actually the villain? So this is a really great question, right? So if you're a therapist, do you know when your patient could be the villain? It's kind of an interesting question, right? Like, do we know? And this is where I would say a couple of things. The first is that I think it's like super scary, but I have had so many patients who have people in their life, who are in therapy for years. And it appears that from my lens of working with my patient, that the person in their life is basically not...
That their therapist is missing this person's personality disorder. And it's shocking, I would say the most common example of this is I will be working with someone who is dating someone who has borderline personality disorder, and that person is in therapy. But the therapist seems to think that they have severe anxiety. Bipolar disorder is a very common misdiagnosis of borderline personality disorder. And so it seems like they just are working with them for years, and nothing is getting better. Now, is that actually what's going on? I don't know, right? Because the problem with that is, in my shoes, is my patient is in a relationship with someone with BPD. They have a therapist. And I'm like, oh my god, the therapist is misdiagnosing them. But maybe it's my patient, who is narcissistic or borderline or whatever, and represents this other person in a bad light. So I'm gonna go ahead and say that as a therapist, I believe that there are many therapists who misdiagnose their patients. They misdiagnose these in their patients. Now, the other scary thing is that, when I say, therapists do this, do I do this? Almost certainly, right? So there's like no reason to think that I am impervious to what my colleagues may experience as well. But what I can say is that when I work with people, I oftentimes find personality problems. Like I see a lot of narcissism, I see a lot of sociopathy, I see a lot of borderline characteristics, and there are certain signs. So like if you, I mean, this is maybe me being arrogant here, but it's not just me. I think I was taught by many therapists to detect people who are narcissistic, right? So one key thing that I've learned is that if I have a patient who is surrounded by people who are problematic, this person mistreats me, this person mistreats me, this person mistreats me, the patient is somehow responsible for that. Now, I want to be clear about this because it doesn't necessarily mean that the patient is personality disordered. Okay, this person is abusive, this person is abusive, this person is abusive. The key thing there is that it could be that my patient is narcissistic and thinks that everybody is abusive, or it could be that my patient has certain relationship patterns where they enter into relationships with people who regularly abuse them, that when someone treats them kindly, they actually freak out, they don't know what's going on, they're waiting for the other shoe to drop, and they run away from the good relationships in their life. So one of the key things that I sort of think about as a therapist is how is my patient responsible for their situation in life? Even when if it's someone who's like, let's say I have a patient who says, this person is taking advantage of me. In a weird way, I still kind of blame the patient in the sense that, okay, you are doing something that allows them to take advantage of you. So I think very heavily from a lens of what is my patient's role and responsibility in their life? And even if other people are bad to you, you may be able to do something that can change that, because ultimately, we can't control them, right? So the field that we play on is like, what the two of us can figure out, and how my patient can actually change. So that's what I kind of focus on. The interesting thing is, I do have a lot of patients that I think are, you know, have features of sociopathy, narcissism, BPD. And I see those things. I can see, and like, I'll give you guys a couple of examples of what this looks like. I keep seeing comments, Dr. K, how do I apply this to a situation in my life? That's literally why we created a coaching program. Our coaches are certified on an evidence-based curriculum designed to help you get unstuck. This involves analyzing your patterns, increasing your understanding, and working with you week to week to help you develop a plan to create lasting change. So if y'all are interested, check out the link in the description below. So number one is, if I have a patient who has a very strong external locus of control, this is a big problem. So what is external locus of control? When I have a patient who comes in who says, the things in my life happen because things outside of me control my life. So that's an external locus of control. Where is the center of control in your life? Society is this way, your boss is this way, your parents are this way, your wife is this way, your husband is this way. Where is the power in the relationship? And now sometimes that can be narcissism, but it's not always. So that's kind of what I think about. Does the patient feel empowered, or are they just a victim to everything going on around them? And then the second thing is, even if they sort of play the victim, I think this is a really important point to understand. A lot of people think that therapy is about talking about your feelings. So you come in and you talk about, oh, this person did this, and this person did this, and I feel this way, and I feel this way. And there are forms of psychotherapy that are like that. So something called supportive psychotherapy is an example of psychotherapy that's just supportive. So patient comes in every week, you just try to do your best to support them. Now, sometimes this is what people need. Like if their life is genuinely falling apart, and they have nowhere to turn to, they just need one place to go for one hour a week, or they just vent everything out, where we're not working on what's your responsibility, we're not working on what to change. They're just carrying so much weight that they need to unburden it some, they need to vent some. Then supportive psychotherapy is fine. The other thing is if you look at patients with a history of something like Down syndrome, or patients who have lower IQ, supportive psychotherapy is one of the most effective forms of psychotherapy for those people. That doesn't mean that if it's effective for you, that means you have low IQ, but there are certain populations where supportive psychotherapy is very effective. But for me, when I work with people and their emotions, the goal is to decompress the emotion so that the emotion no longer clouds your thinking. And then you should be able to see the situation, right? So, yeah, this person, you get this person a gift, and they never give you a gift, and that hurts. You feel angry, you feel frustrated, so be it, right?