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The Trouble With Specialists

3 minute read

I’m on a WhatsApp group of therapists, and, every couple of days, a message goes out that looks something like this: “Looking for a therapist who specializes in OCD, self-harm and internet addiction”, or some other combination of problems. And inevitably, a couple of therapists will say “I specialize in that.” It doesn’t seem to matter what the constellation of symptoms, there’s someone who specializes in it.

I also get occasional inquires from clients wanting to know if I specialize in eating disorders, or substance abuse, or grief, etc. etc. I admit I’ve been swept along on the specialization wave: my website proclaims that I specialize in Anxiety, Depression, Anger Management and a bunch of other things.

It’s a lie. I don’t specialize in problems. I specialize in people. Here's why that matters.

The traditional view in psychology, which is responsible for the requests for specialists, is that psychological problems are like physical problems, in that specific symptoms result from unique sources, and that those unique sources require different treatments. Thus, what makes an adolescent girl anorexic is different from what makes an adult man depressed. Furthermore, anorexia must be treated in one way, and depression in another way. Which must mean that these individuals need therapists who are specialists in those two symptoms.

It makes sense doesn't it? Unfortunately, this way of looking at psychological problems is wrong.

Here are some facts for you to consider. First, in the late 1800’s and early 1900’s, ‘hysteria’ was a common condition among women. Patients would suddenly go blind, or lose the use of a limb, or become unable to hear or speak. There was no physical cause, and eventually, full function would often be restored spontaneously. It was a big thing back then: doctors specialized in it, clinics focused on it and Freud wrote a book on it. Yet today, hysteria is virtually unknown.

Second, in Hong Kong before 1994, anorexia was very rare in the local community. What few cases there were didn’t fit the western standard — patients showed no fear of getting fat and did not have distorted body images, but rather, reported feeling too stuffed to eat. Then one day, a 14 year old girl collapsed and died of malnutrition in a Wanchai street, the papers were full of warnings about anorexia, schools were on the lookout for it, and suddenly, clinics and hospitals were flooded with dangerously thin patients who were fearful about getting fat and sure that their skeletal frames were obese.

If symptoms can appear or disappear like this, how is it possible that they come from unique sources? How is it that problems which made Hong Kong girls anorexic in 1995 didn’t exist in 1993? And whatever problems that made women hysterically blind, deaf, mute or paralyzed a hundred years ago have disappeared today?

The truth is that symptoms are simply a way of expressing psychological distress. What symptoms get “chosen” (unconsciously of course) depends partly on what is common and acceptable in the culture, and partly on what happens to give the individual short term relief from that distress. Thus, you might have two young men who find themselves feeling very anxious in social situations. One might find relief in alcohol, and develop a drinking problem. The second might control his anxiety through obsessive thoughts and behaviors and develop OCD. Their ‘choice’ of symptom is different, but their underlying source is similar. It’s unlikely, however, that either would choose hysterical blindness or anorexia, because neither are culturally accepted expressions of psychological distress in young men these days.

Taking this line of thought one step further, you might find two other young men, both of whom have OCD. However, despite having ‘chosen’ the same symptom, their root causes are totally different. In one case, extensive bullying in school caused the OCD, while the other young man developed obsessive thoughts so as to bring order to an otherwise chaotic home life.

Thus, different symptoms can have the same root cause, while similar symptoms can have different root causes. For a therapist to say “I specialize in symptom X” is like a doctor saying “I specialize in chest pain.” The root cause of chest pain can be indigestion, a pulled muscle or a heart attack. The root cause of psychological symptom ‘X’ can be anything.

Here’s one final fact: The research shows that therapists who specialize in a specific disorder have no greater success with their clients than therapists who do not specialize. So it doesn’t matter if you seek out a world famous clinic or if you just go to the therapist down the street who you like and trust — you’ve got the same chances of getting better.

The worst part about therapists ‘specializing’ in symptoms is that they can become oblivious to the individual sitting in front of them. To them, you are just another alcoholic/anorexic/self-harm/OCD/generalized anxiety, etc. case, and they follow the book on how to treat these cases. But when people are in psychological distress, what they really need is a therapist who will see them as a unique human being, not a collection of symptoms, and help them address their unique situation that is causing that distress.

Which is why I specialize in people.