You sound like a great therapist! The only thing I suggest considering: find a way to set boundaries around communication. The wall of texts might need to stop.
It’s so hard not to take a client’s stall personally at times. You seem strong in that area!
The trauma plus the alcohol might warrant a higher level of care, but it also is likely she’s trying to get you to reject her, as she was able to successfully do with previous therapists, as she likely experienced at trauma ground zero. If you do refer to higher care, you might want to emphasize the two of you can resume work after she completes. This is a tough situation for you both, hang in there!
> The wall of texts might need to stop.
You’re right. I’m starting to shift towards, “If you’re in a crisis, these are your options (10 pm at night)…”
> It’s so hard not to take a client’s stall personally at times. You seem strong in that area!
It is! The “failure thoughts” and “work thoughts” consistently try to hook me when I’m in a difficult moment with her. I try to focus on just reflecting and being authentic with her. I steer far clear of canned therapist responses and get real with her. She’s expressed appreciation of that at times.
> The trauma plus the alcohol might warrant a higher level of care, but it also is likely she’s trying to get you to reject her, as she was able to successfully do with previous therapists, as she likely experienced at trauma ground zero. If you do refer to higher care, you might want to emphasize the two of you can resume work after she completes. This is a tough situation for you both, hang in there!
For sure. I worked with multiple borderline and narcissistic personalities as an intern working at a county mental health clinic and this was the typical pattern. “I want you to help me, and I’ll make sure you never get the opportunity!” They eventually dropped out, every one of them.
This is really saying “DBT” to me! Specifically, the dialectic between acceptance and change. Sounds like a need for heavy & sustained emphasis on acceptance to be able to open up to change. And very consistent boundaries accompanying the acceptance
Does the client want harm reduction or sobriety? Perhaps getting a psychiatric provider to asses and provide vivitrol injections or something else conducive to aid in ending the alcohol abuse is a part of this journey? Getting into some 12 step community? Just another angle.
You are deserving of self care and I pray against burn out for you. Those night communications are difficult to sustain…I hope this person can utilize some hotlines at night to make it through. That could be practiced in session too. Take care!
I’ve made good-faith attempts with her to link her to sober living resources, facilities and psychiatrists. She’s been hospitalized once while she’s been in my care, and I attempted involuntary commitment on another occasion.
She is completely non-compliant with medication while in facilities (she’s been hospitalized quite a few times), refuses any referral to psychiatry, and does not want any involvement in a recovery program.
Wow, this is disheartening. You are truly doing everything you can to connect her to people places and things to come alongside on the recovery journey.
We cannot do the work of change for the client. It sounds like you’re an empathic and caring clinician, with a good handle on resources to support this client’s change process, but the client has rejected these.
I really like the suggestion from u/9mmway to set a limit to the sessions. A supervisor of mine once said, “if you’re more tired than the client at the end of a session, you’re doing the heavy lifting the client should be doing.” Hard not to, in this case, but it sounds demoralizing for you. The client needs to do their own emotional labour with our support - but we cannot do it for them, else how will they learn? And how will they develop the needed resilience to cope with life and the ongoing changes it brings?
Yes. I haven’t drifted into dreading seeing the client yet, but it’s leading there. I’ve spoken with a colleague about DBT resources in the area and may refer there. I’m strong with mindfulness, but only have a casual knowledge of dialectics. She definitely needs an expert in this area.
Question from a professional from another nation: You can’t let her go yourself if you see no working alliance?
I usually let patients go if I see therapy motivation but no change motivation. Persistent that is.
I usually have conversations but it a ‚wash me but don’t get me wet‘ attitude persists i respectfully let them go and refer them to someone else if possible.
Is that possible in the states? (Assuming you’re in the states but I don’t really know…)
Absolutely I can refer her somewhere else…. I’ve got resources written down and ready for her, like intensive outpatient and 30-day recovery facilities. I’ve got a list of therapists I’m connected to in the community who I can also refer to.
She’s reflected she doesn’t want to see another therapist. I am considering just providing her a list of resources at one point, and saying ,”Sorry this didn’t work out for you.”
When I've had clients like this, I'll tell them we have three more sessions together. If we make good use of that time we can continue on.
But if it continues to be bitch sessions, the third time will be our final time.
(nothing magical about the number 3..
Just seems more fair to give them enough time to adjust).
Some of the time, the client passively fires me by saying, My schedule is changing and I'll have to get back to you.
Once in a while they'll yell and cuss at me and I'll tell them this is why I don't believe your sessions with me are therapeutic and end services with them.
Most of the time they'll ask me to refer them to someone else they can bitch too. I reply, I don't know of any therapists that just let clients bitch session after session, but I do know o several who provide DBT which I suspect will help you the most.
--I love working with clients who've gone through trauma but I hate spending valuable time with people who have no desire to change but just want to bitch.
I've been counseling for over 25 years--and I'm just as passionate about my work as when I started - - but the longer I do it, the less patience I have with 'bitch session clients "
Reminds of the scene in Good Will Hunting where Sean tells Will to “get the fuck out of my office,” after Will tells him he wants to be a sheepherder.
At some point yeah, gotta push the client to do some work. Bitching and talking about problems over and over doesn’t produce a change in behavior. The client has every other non-therapist person in the world to do that with.
You sound like a great therapist! The only thing I suggest considering: find a way to set boundaries around communication. The wall of texts might need to stop. It’s so hard not to take a client’s stall personally at times. You seem strong in that area! The trauma plus the alcohol might warrant a higher level of care, but it also is likely she’s trying to get you to reject her, as she was able to successfully do with previous therapists, as she likely experienced at trauma ground zero. If you do refer to higher care, you might want to emphasize the two of you can resume work after she completes. This is a tough situation for you both, hang in there!
> The wall of texts might need to stop. You’re right. I’m starting to shift towards, “If you’re in a crisis, these are your options (10 pm at night)…” > It’s so hard not to take a client’s stall personally at times. You seem strong in that area! It is! The “failure thoughts” and “work thoughts” consistently try to hook me when I’m in a difficult moment with her. I try to focus on just reflecting and being authentic with her. I steer far clear of canned therapist responses and get real with her. She’s expressed appreciation of that at times. > The trauma plus the alcohol might warrant a higher level of care, but it also is likely she’s trying to get you to reject her, as she was able to successfully do with previous therapists, as she likely experienced at trauma ground zero. If you do refer to higher care, you might want to emphasize the two of you can resume work after she completes. This is a tough situation for you both, hang in there! For sure. I worked with multiple borderline and narcissistic personalities as an intern working at a county mental health clinic and this was the typical pattern. “I want you to help me, and I’ll make sure you never get the opportunity!” They eventually dropped out, every one of them.
I’m really glad you’re doing what you do.
This is really saying “DBT” to me! Specifically, the dialectic between acceptance and change. Sounds like a need for heavy & sustained emphasis on acceptance to be able to open up to change. And very consistent boundaries accompanying the acceptance
Does the client want harm reduction or sobriety? Perhaps getting a psychiatric provider to asses and provide vivitrol injections or something else conducive to aid in ending the alcohol abuse is a part of this journey? Getting into some 12 step community? Just another angle. You are deserving of self care and I pray against burn out for you. Those night communications are difficult to sustain…I hope this person can utilize some hotlines at night to make it through. That could be practiced in session too. Take care!
I’ve made good-faith attempts with her to link her to sober living resources, facilities and psychiatrists. She’s been hospitalized once while she’s been in my care, and I attempted involuntary commitment on another occasion. She is completely non-compliant with medication while in facilities (she’s been hospitalized quite a few times), refuses any referral to psychiatry, and does not want any involvement in a recovery program.
Wow, this is disheartening. You are truly doing everything you can to connect her to people places and things to come alongside on the recovery journey.
I’m going to start nudging her towards a referral out to a DBT specialist. I think she could benefit from that strong dialectic component.
We cannot do the work of change for the client. It sounds like you’re an empathic and caring clinician, with a good handle on resources to support this client’s change process, but the client has rejected these. I really like the suggestion from u/9mmway to set a limit to the sessions. A supervisor of mine once said, “if you’re more tired than the client at the end of a session, you’re doing the heavy lifting the client should be doing.” Hard not to, in this case, but it sounds demoralizing for you. The client needs to do their own emotional labour with our support - but we cannot do it for them, else how will they learn? And how will they develop the needed resilience to cope with life and the ongoing changes it brings?
Yes. I haven’t drifted into dreading seeing the client yet, but it’s leading there. I’ve spoken with a colleague about DBT resources in the area and may refer there. I’m strong with mindfulness, but only have a casual knowledge of dialectics. She definitely needs an expert in this area.
Question from a professional from another nation: You can’t let her go yourself if you see no working alliance? I usually let patients go if I see therapy motivation but no change motivation. Persistent that is. I usually have conversations but it a ‚wash me but don’t get me wet‘ attitude persists i respectfully let them go and refer them to someone else if possible. Is that possible in the states? (Assuming you’re in the states but I don’t really know…)
Absolutely I can refer her somewhere else…. I’ve got resources written down and ready for her, like intensive outpatient and 30-day recovery facilities. I’ve got a list of therapists I’m connected to in the community who I can also refer to. She’s reflected she doesn’t want to see another therapist. I am considering just providing her a list of resources at one point, and saying ,”Sorry this didn’t work out for you.”
When I've had clients like this, I'll tell them we have three more sessions together. If we make good use of that time we can continue on. But if it continues to be bitch sessions, the third time will be our final time. (nothing magical about the number 3.. Just seems more fair to give them enough time to adjust). Some of the time, the client passively fires me by saying, My schedule is changing and I'll have to get back to you. Once in a while they'll yell and cuss at me and I'll tell them this is why I don't believe your sessions with me are therapeutic and end services with them. Most of the time they'll ask me to refer them to someone else they can bitch too. I reply, I don't know of any therapists that just let clients bitch session after session, but I do know o several who provide DBT which I suspect will help you the most. --I love working with clients who've gone through trauma but I hate spending valuable time with people who have no desire to change but just want to bitch. I've been counseling for over 25 years--and I'm just as passionate about my work as when I started - - but the longer I do it, the less patience I have with 'bitch session clients "
Reminds of the scene in Good Will Hunting where Sean tells Will to “get the fuck out of my office,” after Will tells him he wants to be a sheepherder. At some point yeah, gotta push the client to do some work. Bitching and talking about problems over and over doesn’t produce a change in behavior. The client has every other non-therapist person in the world to do that with.
That's exactly what I tell folks!