Monday, April 07, 2008

Black Holes

Sometimes I do answer your questions.

A reader tells the story of a relative who had been dumped by her therapist because she had a certain personality disorder. The reader queried her own therapist about this and her therapist is said to have said:
Some (personality disordered) folks can be black sucking holes. That therapy would go on for a lifetime if her therapist let it.
Therapydoc, our reader asks, have you ever had to tell a patient, There's nothing more for me to do. If so, how did that go?

And secondly, when you have a person who is a woe is me victim, can you generally see through that? These are the people for whom trouble follows. They tend to create their own trouble, strange as that may seem. Have you run into one of those and how do you deal with that?

Hey not to tell you how to run your own blog, but that might make an interesting post

I once had a feature like this, answering reader questions, way back in the archives. Like most of my ideas, it lasted a week, for sure.

Have I ever told a patient that I've gone about as far as I can go?

In the State of Illinois, after six months of treatment, if a patient isn't getting better under a social worker's care the social worker is legally mandated to punt to another therapist. I'm not sure how the other mental health professions handle this, but social workers can't let you malinger very long.

Although six months can feel like a long time.

My style is to evaluate how therapy's going relatively often, being of the empirically-validate-your -therapy-or-you're-a-quack generation. If you have no idea what I'm talking about, don't be surprised. Therapy is usually predicated upon what the patient brings to the table, not evaluating progress. Evaluating outcomes for a treatment's intrinsic empirical value is nice in theory, but impractical.

Unless you're a behaviorist :) in which case you do it all the time.
Therapist: How many times did you shower this week?
Patient: Seven times!
Therapist: Feels great, doesn't it? (writes in notes, patient is caring for hygiene, showered 7 times. Looks a whole lot better, too).
But at the six month mark, no matter what kind of therapist you are, you're really supposed to take a good look at what's going on and decide if your patient might benefit from another doc's approach. I'll say,
We have to discuss how we're doing, seriously, in this treatment, because I'm legally mandated to make sure you see someone who will help you more than I can if I'm not doing a very good job.

Incredulity. YOU ARE????

Uh, huh.

Wow. Maybe I SHOULD see someone else!

But usually we talk about it and set a few goals and reevaluate our progress in four weeks time.

As to patients for whom worries follow, who seem to invite trouble and suffer from interminable aggravation. Am I onto them? Do I know their game?

Game? What game? This is surely justification to stay in therapy.

I tell patients who have one problem after another, As long as you need to be sick, you should probably be sick. One day you'll get sick of me, too, and sick of therapy. But if you aren't sick you can still come and see me, you know. As a matter of fact, I'm pretty sure we haven't covered 1979-1985* yet.

And those had to have been hellacious years.


*Fill in the proper years/gap.
The director of a very prestigious managed care group in Chicago now defunct) once told me, Whatever you do, make sure you keep 'em coming back. (tongue in cheek)


Anonymous said...

I suppose it really is about having the experience to judge whether the need to be sick is really a need at all. By that I mean, there's a line somewhere here, surely, that you could theoretically cross into enabling someone? I say that because I've watched my Father deteriorate across the course of 45 years of psychotherapy.

Consequently I have always supposed that part of a therapist's job, at some stage, is to say to the baby bird: "you can fly now", and give that little nudge in the right direction because folks need to learn they can go it alone.
If they need/want to fly back to nest after that, that's OK too though, right?

Radical Reminders said...

I understand having to terminate therapy for whatever reason but to say, "Some (personality disordered) folks can be black sucking holes. That therapy would go on for a lifetime if her therapist let it." That's absolutely ridiculous! Not to mention rude and damaging... i hope this person quickly realized s/he didn't want to work with a therapist that would say something like that to a patient and that s/he was better of without that particular doctor... yuck.

therapydoc said...


I always recommend, no, insist upon vacations from therapy when I'm sure a patient will benefit from them.

Sometimes it's not easy to tell when I'm joking.

Family therapists use The Paradox whenever we can. If I tell you you're sick, it's likely you'll say, Who Are You To Tell Me I'm Sick! and you'll show me you're not as sick as I say you are.

It's wonderful to see that happen, and I've seen it often.

Anonymous said...

Heh Kind of sophisticated reverse psychology. Interesting what motivates people...

Does it last?

therapydoc said...

Does it last? I'm not sure, probably not. But it's nice to see that people rise to the occasion, defend their mental health.

It's like, I can say whatever I want about my mother, but you had better NOT.

Mark said...

Interesting insight, thanks for sharing!

Anonymous said...

The "rules" must be different in Michigan for psychotherapists (non social workers) because I have seen my own therapist on and off for the last five years.

Sometimes I think I'll outlive her (I'm 40 she's about 65) and miss her therapy. Other times I wonder if I'll ever get away from needing therapy and the depression and the meds from the psychiatrist.

It's a tough road. I never thought I'd be in the situation that I'm in. And now I feel like a New Age California chick who has a therapist and a psychiatrist on staff.

But I'm not as confident as the New Age California chick in my imagination. I'm just muddling through reality and depression here in the Motor City looking for a coping mechanism that works.

therapydoc said...

Or three, right?

Scraps said...

What should a person do if s/he has a friend like that black hole? Someone whose problems seem to never get better or go away, who needs to have constant attention just to get by. Is there a way to stay in such a relationship, and how can the healthier friend keep the relationship as healthy as possible given the friend's situation? And how to avoid the pitfalls of codependency?

If you'd rather not address this in the comments or on the blog, I would be most appreciative if you could take a few minutes to email me.

therapydoc said...

What you're asking for is how to set boundaries and healthy limits on relationships, something that undoubtedly I have to address on the blog.

I'm working on it, Scraps. Remind me if it doesn't come up in the next few weeks.

Anonymous said...

Sounds like BPD to me.

(glad I'm not in Illinois)

therapydoc said...

People can be challenging.

Anonymous said...

Oh my freakin'god! If I practiced in your state I could terminate and refer at the six month mark? Wellll, that just opens all kinds of grey matter doors, doesn't it? I think I'll let this roll around a bit before offering up a solid response. Right now, I'm wondering about the effects of "abandonment" on, oh, let's say the Axis II's, speaking in generalities. Not to mention the therapist "stance", conscious or not, during the process. Interesting avenues for consideration. Fascinating. Thank you!

If you know of an interesting website I can read that offers additional insight into the clinical ramifications of this mandate (I'm thinking there are more than a few), I'd appreciate the heads up. (I'll pop back another time or you can drop 'em in my livingroom, lol.)

Great piece.

therapydoc said...

I feel the pain on the abandonment issue. mentioned it, too. Here's what I said to Jung.

I'll bookmark this because it's a great and deserves much more discussion.

I think I said it wrong on that post, and of course when words are cut and pasted, the nuance, "You don't HAVE to punt," is gone. I think I do communicate in that post that if you can justify what you're doing, if it makes sense to continue to work on goals, if objectives and goal attainment can be measured, of course you can recontract and continue to work together.

If that's not possible, then the therapist may be holding someone's hand, when what should happen is a better treatment plan, which might include doing isomething more or seeing to it that someone else does something more.

We have all kinds of rules about termination, too, and the timeliness and fashion of the termination. It's not as if abandonment isn't discussed. It's at the top of the list.

The process is not as simple as I make it out to be on that post, and I apologize for that, surely appreciate your attention.

At six months we take a hard look at what's going on. If the patient agrees that the two of us are going around in circles together and we can't stop the music, then a change is surely a good idea.

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