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Is this the patient you previously mentioned? Do you still believe they don't have a personality disorder?! Patients often misinterpret or misrepresent what has been told to them. Contact psychiatrist to coordinate care and keep an open mind about what happened. If they are good they will welcome the opportunity to talk with you and coordinate care. At the same time, it is not your role to intervene on behalf on your client or get involved in this situation.
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Sounds like this is all coming from the patient. You don't know what the psychiatrist actually said. You two should talk.
Oh goodness, you're relying on patient report still for what actually happened? Trust, but SERIOUSLY you need to be verifying! Of course you call the psychiatrist. Also, I think I gave this advice on this same patient before, but this is a person that appears to be leading to some significant and kind of complicated countertransference. I hope you're working through that somewhere. I'm not sure a patient being upset with their psychiatrist not knowing their medical history backwards and forwards would even register as a unique experience that day for me. In terms of diagnoses changing after 15 years...it does indeed unfortunately sometimes take that long for a provider to recognize or accept that the issue is a primary personality pathology....
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This is the type of complex case that is my bread and butter. Since they don’t fit into a neat diagnostic category, the diagnoses are of even less utility than they would be otherwise. Our model and way of thinking in this culture is categorical as opposed to seeing the dynamic interaction between everything. If you are going to help, you have to shift your own thinking paradigm. That is why Dr. Linehan chose dialectic as the term to describe her theory because she saw that this inability to embrace two valid but opposing truths to be a barrier to treatment. Kernberg in his Object Relations for Borderline also addresses the importance of being able to integrate and in the same text makes the point that personality development and maturation is more useful in conceptualizing than DSM categories. Clusters of symptoms are just one piece of the puzzle and the DSM is best used as a good starting point and if there is a lot of overlap which there often is then debates about which is more true is not helpful.
Short answer, I would help the patient to see the other persons perspective and how that could make some sense while validating the patients perspective and how that makes sense and then help them to integrate that and keep myself removed from the debate. This is why I think good therapy skills are important for effective psychiatry.
Short answer, I would help the patient to see the other persons perspective and how that could make some sense while validating the patients perspective and how that makes sense and then help them to integrate that and keep myself removed from the debate. This is why I think good therapy skills are important for effective psychiatry.
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What makes you think this? It seems like you're mind reading and predicting the future. As a psychiatrist, I love collaborating with therapists and getting more information in figuring out how to best take care of a patient.
You're enacting a transference reaction from the patient to her psychiatrist. Don't let that cause you to avoid reaching out to the psychiatrist.
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Actually, it’s based on negative comments I’ve read here about therapists for the most part.
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Comments from our forum isn't necessarily reflective of psychiatry as a whole, let alone this specific psychiatrist you have a question about.
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Coming back to this forum and asking different questions about your same therapy client isn't the solution. Because the root cause is a lack of adequate therapy training. Why aren't you talking to your supervisor?
Have you considered paying for your own therapy? It would be helpful to see how real therapy works, as well as explore why you react to your client and their psychiatrist in the manner you do. Otherwise, you really aren't helping your client, and perpetuating maladaptive behaviors in them at the very least.
Have you considered paying for your own therapy? It would be helpful to see how real therapy works, as well as explore why you react to your client and their psychiatrist in the manner you do. Otherwise, you really aren't helping your client, and perpetuating maladaptive behaviors in them at the very least.
Lots of assumptions there. This forum doesn’t disappoint.
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I've got one psychologist I refer to often.
Recently the referral went the other direction. Psychologist had patient down as PTSD.
I discussed with patient in consult / first appointment I disagree, don't see criteria for this diagnosis. Not to discount traumatic experiences, but not PTSD.
I reviewed with patient continue with psychologist even if we have different diagnoses which isn't as pertinent as end goal of simply functioning better. And are what we are all doing, is it helping to function better?
I call therapists back who call me.
@smalltownpsych To your point, I concur. Over the years I've labored less for hammering down a specific DSM diagnosis and put a lot more Uns. Depressive, or Uns. Anxiety, Uns. Mood, etc down. Too many overlays of symptom clusters and timeline of histories to be as precise. I'm less focused on nuances on diagnosis and more on function results for patients. I discuss these gray diagnoses and treatment approaches with patients, too.
Now, when therapists just tell patients, I think you have ADHD and should "get tested" talk with your psychiatrist. Or I think you have Bipolar and talk with your psychiatrist... Or MSW tells patient I diagnosed with Borderline "I don't think you have BPD and I won't do DBT with you" these things are worthy of negative comments.
As a whole, a professional psychologist or masters level therapist who knows their job [doesn't make med recs], does their job [doesn't make med recs or attempt to change Psychiatrist Diagnoses], and reaches out [picks up the phone] on case complexity, or even clarification of why diagnoses are there, is awesome.
A therapist calls me up and like "yo, Sushi, patient says you are working with Uns. Dep. I'm seeing things that are concerning for Bipolar II. What you think?" Huh, not yet. Think you can send me your notes ongoing for symptoms that might reflect this diagnosis? I'll keep an eye on it, too and even review for symptoms further. I'll also talk with patient see if they any close family/romantic/friends who might able to provide collateral, too. I appreciate this input.
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Sorry, I have to call you out. You keep posting about a female, middle-aged client with bipolar, OCD and PTSD who stops her meds due to weight gain and is mad at her psychiatrist. So, you have more than one client with this exact same presentation?
And, if a "therapist" keeps asking questions that are very basic, then there is the presumption of incompetence.
I have put a call in to her psychiatrist. I should have done it sooner. My questions are not about therapy but how to interface with psychiatrists who are a difficult bunch sometimes. I collaborate with a psychologist who suggested letting the psychiatrist contact me. I disagree with her. I feel the need to collaborate with this individual.
At best a stereotype, but likely not even that, you may have had bad experiences but those aren't generalizable.
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Agree with Sushi, how you're perceived by peers (including psychiatrists) is going to be heavily about how you interact with them. I've had patients describe counselors who I believe to be objectively good therapists from seeing them work in person as awful and describe legitimately terrible therapists as great. I've talked to therapists who I think probably have mediocre psychotherapy skills who I would have no problems referring patients to because the counselors can interact appropriately and work well with others to move the patient forward in their care. There's plenty of crappy therapists out there, just like there's plenty of crappy psychiatrists and crappy insert-any-profession-here that are working. Don't generalize and/or internalize statements made here, it's just a forum, not a place to measure skills or aptitude.
To your OP, if you're not thinking there's significant dysfunction of certain personality traits here, I'd recommend reassessing. Everything you've described screams personality trait dysfunction. My guess is that a lot of what the patient is telling you about the interactions with the psychiatrist are not accurate. Is this the psychiatrist who told the patient that they (the psychiatrist) "tested positive for histrionic personality disorder"? Because that statement by itself if inaccurate (you don't "test positive" for a personality disorder) and sounds like something a patient who doesn't understand what they were told would say. For most patients, they may report this with some confusion or mention it but not really understand the context or intricacies. Patients with significant dysfunctional personality traits (often 'Cluster B' traits) will twist those words for some form of manipulation. It sounds like there's a lot of triangulation occurring here with the patient trying to manipulate for some kind of gain, it's your job to figure out if that's going on and if so what the gain is and how to address it.
That all being said, you should definitely reach out to the psychiatrist for clarification (as it seems you have). I'd let them know that the patient has been reporting some things which seem confusing and contradictory to what your understanding of their diagnosis and treatment is, and you'd like some clarification so you can determine how to best move forward in therapy. While it can be annoying sometimes (that's my countertransference speaking), I absolutely appreciate when a therapist reaches out to me with concerns like that because sometimes it also helps me immensely and changes my treatment plan as well.
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Yes, of course
If true: This seems quite appropriate to me. Seeing someone for a long time....progress is limited or other barriers....maybe additional previously unknown information is revealed??? First thing you need to do is start questioning the formulation of the patient. I don't really understand what the problem is here? Patients who are chronically psychiatrically involved and possibly personality disordered get "mad" at people. It happens. It's part of the pathology.
What are you wanting to ultimately happen here?
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Sure, if you'd like to clarify this whole situation with the psychiatrist (which seems like I good idea) you should probably reach out to them. The whole story seems bizzare (and not true....) that some psychiatrist would tell a patient that he/she "did not know if she had any of the diagnoses he had given her previously. The reason he gave my client was lack of collateral reports from family and other providers including me". You're taking a lot of stuff the patient says at face value here.
Your psychologist collaborator idea is terrible if you're the one wanting to get more info. Don't mean this to seem stand-offish but the reality is that most psychiatrists have hundreds of patients on their caseload and most therapists have caseloads in the mid double digits. If most of us even spent 5-10 minutes once a year trying to contact half our patients therapists it'd be like 20+ hours of uncompensated work a year.
The fact that you're already calling this person a "difficult" psych attending when you've yet to actually talk to them about this whole situation is somewhat telling as well.
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On the flip side, there are many reasons you'll hear us talk about therapists negatively. Some things NOT to do to avoid being viewed this way:
1. Don't demand to talk to us about why we refuse to prescribe a stimulant to a 40 yo patient with new on-set ADHD symptoms that you've been seeing for 3 months.
1b. Don't demand to talk to us about why your patient NEEDS their benzos because their anxiety is so crippling without them and they just can't survive without them.
1c. Don't call us prior to an initial eval to tell us what med the patient needs to be started on before we even see them.
1d. Don't call us to tell us we are terrible doctors because our diagnosis is clearly wrong and proceed to tell us what meds the patient should be on.
2. Don't repeatedly call us every time our chronically suicidal patients have a brief thought of "maybe I should just kill myself" despite no other worsening of symptoms.
3. Don't expect us to be available for a full hour long conversation about formulation and plans for a patient with mild to moderate dysfunction when we just changed meds earlier that week.
4. Don't contact us just to unload your own countertransference or talk about your personal problems/interactions with the patient when we've never interacted before.
I'm sure there's other things to avoid, but these are things I have either experienced myself or have seen directly happen to colleagues which will fast track a therapist onto our s*** list. In contrast, if there is a legitimate concern about a patient's treatment plan(med side effects you notice, abuse or non-compliance, etc), questions that you have, or conflicting info that you need clarified then reaching out is completely appropriate and I'd personally appreciate it even if I can't get back to them.
Well, that was fast. I heard from him while eating lunch. I introduced myself and expressed a desire to collaborate on the patient’s care. He noticed my accent and stated “you’re not from here.” I told him where I was from and he asked me where I went to school. When he found out I have a masters he stated that he preferred his patients see PhD psychologists. I told him I understood he wanted the best possible care for his patients and asked if I could still be helpful while acknowledging there are concerns about the patient’s diagnoses. He didn’t say anything so I just kept going … told him I couldn’t speak to the bipolar as I have not witness hypomania or mania, that the patient has intrusive thoughts and compulsions, and that I don’t believe she has PTSD although she has a trauma history. He was quiet again and then told me the patient displayed some dramatic behavior this year and he began to revisit her diagnoses from the past wondering if it was dramatic behavior. He confirmed that he is doubting especially in the face of no phone calls from family or other professionals. I asked how I could be the most helpful. He suggested we touch base in 3 months or sooner if anything happens. I did tell him the patient had tearfully confessed to two episodes of dramatic behavior but that I had not experienced any dramatics.
All in all, I’m glad I called. He was a little unfriendly at first but by the end of the call he was nice. I think it went well. It was premature of me to call him difficult.
All in all, I’m glad I called. He was a little unfriendly at first but by the end of the call he was nice. I think it went well. It was premature of me to call him difficult.
Agreed. I should not have called him difficult. I’m finding the situation difficult and that’s my problem.
I can’t imagine anyone doing those things.
I think I wanted reassurance that this was an okay reason for me to reach out to the psychiatrist. I did reach out and got more information.
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Reaching out for coordination of care is always fine. I just wouldn't always expect it to lead to agreement about certain things... even diagnosis.
You should be providing evidence based best practice care/therapy for the patient. But, if your formulation and subsequent treatment plan is significantly different from their 15 year-long attending psychiatrist, that is a problem, obviously. What are the measurable treatment plan goals? Does this recent issue with the psychiatrist disturb/impede them? If so, why? What is that about? Acting out? Sabotage? Splitting?
When was the last time this patient had a truly thorough psychiatric diagnostic evaluation with fresh treatment recs? 15 years in treatment for disorders that are typically highly treatable into remission (especially OCD)??? I don't know. A fresh set of eyes might do some good here, no?
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You had a conversation with the "difficult" psychiatrist who turned out to be not so mean, and he confirmed diagnoses aren't always set in stone, and you felt better. The end. I'm glad you felt better, but that's not the point of patient care or the psychiatrist's job. Objectively, your phone call achieved nothing useful in terms of clinical patient care. So, a waste of time. This is part of why psychiatrists dislike being called by "therapists".
Again, you really need to get better training and your own therapy because everything you've said here points to you not being qualified. You need to get competent rather than waste everyone's time at best, or harming the patient at worse.
Maybe listen to your psychologist supervisor. It's ironic a supervisee who doesn't listen to their supervisor believes that psychiatrists are difficult and need to be managed.
Again, you really need to get better training and your own therapy because everything you've said here points to you not being qualified. You need to get competent rather than waste everyone's time at best, or harming the patient at worse.
Maybe listen to your psychologist supervisor. It's ironic a supervisee who doesn't listen to their supervisor believes that psychiatrists are difficult and need to be managed.
I am using ERP/CBT. Ultimately, the goal is for her to resist engaging in compulsions and be okay with uncertainty. Ideally, through our work using exposure ladders she is learning how to do some of these on her own. She appears to be. The client has been taking anafranil all this time but has refused therapy until recently.
I think you’ve misunderstood and you’re reaching. I have provided him with the clients notes which gives him more information. He gave me more information on the reason for the diagnostic uncertainty which gives me some things to watch out for. He seemed appreciative and asked me to contact him again. I don’t think he would have done that if I wasted his time. Why was I relieved? I personally feel socially anxious in these situations and feel nervous. I was relieved it went well. That wasn’t his job and even if it hadn’t gone well I would have been fine.
I never said he was mean. I meant that this was a difficult situation with a psychiatrist not that the psychiatrist was difficult.
Calm down.
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If all this doesn't affect your treatment plan, then you should not really concern yourself with her psychiatrists statements unless you think he/she is undermining the treatment/treatment plan...or is actually correct. Leave it alone.
You are a masters level therapist, so I assume you ultimately have a Ph.D. or M.D. director above you? As you should. I would talk to them about this case. SDN is not the best place for robust case formulation and discussions.
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Some fresh eyes on the case is probably best advice here.
I will definitely talk to someone else. I need a fresh perspective. I didn’t mention it, but the way she tells it they have had a casual relationship. I don’t know if it’s just wishful thinking on her part but she has reported them having rather casual talks about their kids and spouses. This has made her feel the relationship has been more important than it is. We have had to focus on the fact they don’t have a relationship (platonic) and that what matters is her medical care. I feel annoyed by providers who don’t have good boundaries. Some of the things she says he has said have given me pause. I think I started feeling upset for her (transference) and this is good for me to explore. At the end of the day, I’m not in the room with them and really don’t know who said what.
I’m sorry but casual chit chat with a long term patient is highly unlikely to be an indication of inappropriate boundaries. You have been told multiple times to seek supervision. It should be beyond clear at this point that your own thoughts and feelings about this case are where the problem lies. This is therapy 101 stuff.
No. I’m not talking about casual chit chat. What I’ve heard is not appropriate. It goes beyond casual chit chat. No need to weigh my every word on a scale. It’s a message forum and you don’t know me.
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I think this is presumptuous on the psychiatrist's part. I know many masters level therapists who are excellent, including my own analyst. I think you did an excellent job navigating that initial behavior from the psychiatrist that could have riled you up. This patient's care is better because of your actions including posting on this forum for reassurance, despite the personal and professional attacks.