Being ghosted

[anonmouse]

I am an upper-year resident, and recently I had a therapy patient ghost me. They told their medication management provider in the same clinic that they found therapy overwhelming and unhelpful, and it also seems they want to use this provider as a therapist instead. They did not even agree to reach out to let me know they were not coming back to therapy when this was encouraged. The worst part about this is I thought the therapy was going relatively well and had started to feel attached to the patient when they clearly did not feel the same way. I have discussed this with my therapy supervisor and my own personal therapist, but it still sucks and is making me question my connection with any of my patients and skill as a provider.
Is this a common experience in residency? And how do you maintain your motivation to learn and continue to improve, when there is so little gratification or evidence that you are helping?

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[littlefred]

Part of their pathology. Got to dissect the dynamics a little bit more with this one.

 

[Bartelby]

It happens to everyone from time to time! With more experience this will sting less. The best proof of your own abilities comes from helping a large number of people over time, and seeing that you really do help people get better.

Sometimes this kind of ghosting has nothing to do with you. Maybe the patient really thought they were ready for therapy, but they just weren't. Maybe they realized they don't have time in their schedule to continue. Maybe they have a help-seeking help-rejecting pattern and opted to act on their impulse rather than explore it. Who knows?

Sometimes this kind of ghosting is about you. That isn't necessarily bad. As a therapist you will develop your own style, but none of us can be the best therapist for every person and every problem. Maybe the patient finds you too blunt, maybe they think you are not blunt enough. Maybe they want you to be more directive, maybe they think you talk too much. Maybe they like that your sessions are structured and driven by measuring symptomatic outcomes, maybe they want something more unstructured and insight-focused. It's good to remind yourself that trying to be the very best fit therapist for everyone doesn't work, and that if you grow into your own style as a clinician and some patients who don't mesh with that style self-select to other providers who are a better fit that's okay!

The main time where this should give you pause is if it is a regular occurrence, or if you feel like you do not connect well with a range of patients. If it's an occasional occurrence, it's likely nothing to be too worried about.

And as for "but why ghosting?" Keep in mind that the patient has to take time off work (or other activities) and literally pay you to have an awkward conversation they probably don't want to have! Sure, it's better if they explore their reactions with you in therapy before just unilaterally terminating, but I can understand why some don't. Even just sending a message could invite engagement on a difficult topic that the patient may not want. I wouldn't take it as any kind of spiteful or devaluing act, it may very well just be avoidance.

 

[Stagg737]

So something to explore (if you haven't) is WHY you're upset about this.

Are you upset from an academic/competence standpoint because you misread the interpersonal dynamic and are questioning your judgment? If so, that's okay but it's important to remind yourself that you're a resident and this is part of learning. Sometimes lessons hurt a little and introspection and exploration of this with your therapist is a good way to grow. Give yourself some grace, this is something everyone will go through in some way.

Are you upset from a more emotional standpoint because they seemingly chose another doc over you? That's okay at this stage too, but you'll need to thicken your skin a bit and realize that while it may feel personal you shouldn't take it that way. We do need to be aware of our countertransference and keep it in check. If that's occurring here then it's another good learning opportunity.

Are you upset primarily because you were ghosted? I get that, it sucks. Maybe the patient ghosted because they're inconsiderate or just forgot. Maybe they legitimately didn't know they needed to contact you to cancel. Maybe it's part of their pathology with avoidance like others have said. When I've done ongoing therapy I make it clear from the start that we may not be a good therapeutic fit and that's okay. I try and encourage patients that if they don't feel it is beneficial or that it's a good fit that there is nothing wrong with that and I am happy to help them find another therapist if that is the case. I've had a couple patients who were terrified to tell me that because they were afraid I wouldn't see them for meds anymore and were very relieved and appreciative when I gave them praise for being forthcoming and kept seeing them for meds. That in itself can be therapeutic for some of these patients and help them build healthy confidence and assertiveness. Sometimes they'll still ghost you anyway, c'est la vie.

Regardless, you're going to encounter this many times. Remind yourself that there is only so much we can do for our patients and that there will be people who we can't help because they're not ready or don't want it.

 

[shoomer]

Part of their pathology. Got to dissect the dynamics a little bit more with this one.

Wouldn't want to assume it's always this. Even experienced therapists are not going to connect well or be helpful for all of their patients, and for a resident hitting a barrier like this is an inevitable part of the learning process.

 

[lol.psych]

Any chance they were starting to get attached, too, and it spooked 'em? (subconsciously, I mean)
If therapy was both overwhelming AND unhelpful, not sure what else to think. Like, the pt could have said it’s overwhelming and too painful to deal with, or unhelpful because they didn’t feel like you got them, but it was both!

 

[calvnandhobbs68]

Wouldn't want to assume it's always this. Even experienced therapists are not going to connect well or be helpful for all of their patients, and for a resident hitting a barrier like this is an inevitable part of the learning process.

“Pathology” means a lot of things, it doesn’t mean they have a personality disorder or even referring negatively about the patient. Pathology can mean this person seems pretty avoidant in situations that are uncomfortable or possibly even what they perceive as slightly confrontational. Straight up ghosting I agree is almost always somewhat pathological rather than just letting the therapist know you don’t want to continue therapy anymore for now.

I also agree not everyone is a good fit for anyone else but both of these things can be true. OP may not have been a good fit and the patient may not have responded in a healthy way. Which is probably why they were referred to therapy in the first place.

OP like everyone says you’ll see a decent amount of this. What they did with going to their regular psychiatry appointments too and wanting this to be the only little bit of therapy they do isn’t too unusual either, I get this all the time. Idk if you guys have a more psychodynamic/analytic bent in your therapy clinic possibly (a lot of psychiatry residencies do) but many patients would also prefer something more CBT or any other cognitive/behavioral therapy or more directive therapy based. So they end up liking when I’m doing this during our appts more but then complain that their prior therapists would just “sit around and let me talk”. So I may not even be you sometimes you have to adjust the approach (which may or may not be possible in a resident clinic).

 

[smalltownpsych]

It is good to think about some of the reasons for this and why it may have occurred and especially explore your reaction to it, but don’t overthink it. There are just too many variables and whether or not i am the right fit for a patient or can help them or their motivation continues to be unpredictable no matter how experienced we become. What is funny is how I am so much more aware compared to the novice therapists yet am still often completely clueless. One of my best clinical supervisors always emphasized that the most important skill is the ability to tolerate the distress of not knowing.
I am just glad that you are learning these skills and asking these questions. Mental health practitioners that don’t have some expertise and knowledge and understanding of how to think from a psychotherapy mindset are just not helpful and even potentially harmful to our patients. It’s not just unique to our field, I spent years working in sales while I was going to school and the same applies. Like Al Pacino said in Glengarry/Glenross, “if you don’t know the con, don’t open your friggen mouth”. 😊

 

[splik]

It is natural to take it personal when this happens, especially if they are expressing a preference for someone else. Here are somethings to remember:
1. We are not going to be a great fit for everyone. if they find someone else to be a better fit that is great for them and you can be happy for them.
2. It's not about you. Especially with ghosting it can feel very unnerving because there's no closure or opportunity to understand what happened. Ideally you would be able to understand what happened but it often does not work out that way.
3. This is a great thing to focus in on supervision. Your supervisor will know if you are doing something that led the pt to flee or whether this was going to happen anyway. It still stings, but these things hurt more as a trainee because it feels more of an attack on your competence.
4. Resident clinic patients are usually much more disturbed than patients in the real world. Who do you think comes to see a resident? As a result you are more likely to have patients drop out of treatment.
5. With therapy, what we are offering to some extent is ourselves. Thus it feels so much more personal when this happens.
6. Not everyone is in a place where they are ready for therapy. It sounds like this patient was overwhelmed by the experience. I'm guessing the experience of seeing the other resident for med-management was more self-contained, more structured, and with less deep exploration which may have been more tolerable.

Recently I have had some patients drop out or "ghost" me. They were drug seeking patients who PDMP revealed were able to get their candies elsewhere. While I wish those patients would have been more amenable to get off those drugs, I am very fortunate they quietly dropped off rather than blow up in my face, make frivolous board complaints, or dispute charges etc. As horrible as ghosting can be it's much more preferable to violent confrontation.

 

[SeniorWrangler]

You could always call them up and ask, too. A friendly call is appreciated by most patients unless you left on bad terms and will do more to tell you what happened than 100 posts. You might make it clear that you're not trying to get them back, just interested in hearing their side. That happens very rarely in medicine!

 

[anonmouse]

Thank you for the responses. I did reach out to the patient after they no-showed at the last minute a few weeks in a row and they told me they were going back to their old therapist and there was nothing I could have done differently. This turned out to be a lie (they are just quitting therapy altogether).

 

[splik]

This sounds like a patient with an avoidant coping style. Avoidant patients often flee therapy. They are more likely to ghost you or make excuses because they hate confrontation. As an inexperienced therapist, you wouldn't have picked up on how they really felt about therapy because they likely hid that from you and told you what you wanted to hear. They don't want to offend or be rejected or abandoned. Often these patients numb themselves from their emotions and can often look like they are functioning quite well. They are likely to resent and feel uncomfortable with anyone who tries to make them feel anything which of course you will be asking them to do in the course of therapy. Now that you've had this experience, you will be more attuned and be able to recognize when a patient is going into detached protector mode (which is what we call it in schema therapy). This often is often the case for patients with certain personality disorders (it is the default mode for BPD patients and inexperienced therapists may mistake lack of dysregulation for the patient doing well when actually they are used well honed avoidant defenses which will interfere with their ability to benefit from therapy if not addressed).

You might find it of interest to read Trauma and The Avoidant Client by Robert Muller

 

[PsyDr]

if you watch a room full of pre-verbal toddlers, you’ll notice that they tend to have an preference for a specific other. It’s not based upon verbal behavior. As we get older, this behavior becomes obscured by things like appearance, interests, verbal behaviors, gestures, dress, culture, etc. But, there is always a component that is not quite articulated.

Psychotherapy has a component of that. Some people will like you, some won’t. One of the fascinating aspects of this work, is discovering who does well with you. It might not be people similar to you.

 

[smalltownpsych]

if you watch a room full of pre-verbal toddlers, you’ll notice that they tend to have an preference for a specific other. It’s not based upon verbal behavior. As we get older, this behavior becomes obscured by things like appearance, interests, verbal behaviors, gestures, dress, culture, etc. But, there is always a component that is not quite articulated.

Psychotherapy has a component of that. Some people will like you, some won’t. One of the fascinating aspects of this work, is discovering who does well with you. It might not be people similar to you.

It also doesn’t even align with who I like to work with or think I work well with. It is very unpredictable; however, as we improve our skills and improve our techniques we can get better at widening our reach and connecting with more, but it is always going to be much less than 100%.

 

[FlowRate]

As maybe an interesting perspective, I have a handful of patients who develop an idealizing transference toward me (their primarily meds guy, although I do try to do some light therapeutic work when it's appropriate) as the "perfect" therapist they can never have (no ability to do traditional therapy visits in this role.) And it seems to generally relate to an underlying discontent with everything they do have. Also, FWIW, these are some of the patients I would least want to actually take on as a therapy patient since they can be so draining even just in med visits.

 

[anonmouse]

if you watch a room full of pre-verbal toddlers, you’ll notice that they tend to have an preference for a specific other. It’s not based upon verbal behavior. As we get older, this behavior becomes obscured by things like appearance, interests, verbal behaviors, gestures, dress, culture, etc. But, there is always a component that is not quite articulated.

Psychotherapy has a component of that. Some people will like you, some won’t. One of the fascinating aspects of this work, is discovering who does well with you. It might not be people similar to you.

THIS I think is so true and also why this experience was so painful for me. I have a long history of being the one who's rejected/left out (by parents, peers, teachers, coworkers...) despite being a pretty agreeable person (who am I kidding...huge people pleaser). There's never been a tangible reason as to why (despite lots of therapy). Who knows, maybe there is some underyling ASD but it's a little late for that now as I've invested a lot of time and money into a career where being able to connect with others is pretty important.

And yes, I do have a group of patients who seem to really like me, but coincidentally they are all single, heterosexual, middle-aged men. Something tells me they will not be as big of fans of mine in ten years.

 

[Candidate2017]

Don't you know in psychiatry poker, a fistful of pillz trumps therapy skillz? Best to learn this residency before NPs eat your lunch.

Why does your residency split treatment within the same clinic? While split treatment increases efficiency (i.e., insurance pay), it does nothing for your learning.

As a professional, why do you feel attached to this particular patient? Or any patient?

Why do patients owe you an explanation as to why they're not returning? They make an appointment, get into a small room with you, you service them for 30-60 minutes, they pay and leave. Rinse and repeat, all day long.

If I were your clinic supervisor, I would load up your schedule with therapy as a form of exposure. As well as making you too tired to project upon patients.

 

[Candidate2017]

And yes, I do have a group of patients who seem to really like me, but coincidentally they are all single, heterosexual, middle-aged men. Something tells me they will not be as big of fans of mine in ten years.

Derm, plastics, nice wardrobe, nutrition, exercise, and controlled subs keeps them coming back.

 

[SeniorWrangler]

I recommend not giving a lot of thought to this, just like those feedback surveys you’ll get if you work for a hospital saying that only 93.5% of patients think you really care, when your peers average 93.6%. There’s no award in psychiatry for Dr. Congeniality.

 

[smalltownpsych]

THIS I think is so true and also why this experience was so painful for me. I have a long history of being the one who's rejected/left out (by parents, peers, teachers, coworkers...) despite being a pretty agreeable person (who am I kidding...huge people pleaser). There's never been a tangible reason as to why (despite lots of therapy). Who knows, maybe there is some underyling ASD but it's a little late for that now as I've invested a lot of time and money into a career where being able to connect with others is pretty important.

And yes, I do have a group of patients who seem to really like me, but coincidentally they are all single, heterosexual, middle-aged men. Something tells me they will not be as big of fans of mine in ten years.

I have a current supervisee who sounds a little similar and questions herself constantly. I would rather have someone who is not naturally charismatic and is often underappreciated to train any day of the week. It also doesn’t sound too far from myself. We connect to patients in a completely different way than any other social situation and when you begin to develop some of the techniques and ways of thinking and are able to understand and facilitate your own social/emotional growth, then that is what makes for the best clinicians. I’m taking it for granted that knowledge is not an obstacle for you so acquire as much as you can and then dive in. Completely agree with @Candidate2017 on that as well as pillz over skillz. lol

One more thought, most of our patients are not good socially either so they desperately need to connect and tend to connect easier with people that are not super social. Watch out for the addicts though because they can be an exception to that and tend to use their social and emotional abilities to attack anyone weaker in that arena to deflect from their own insecurities.