Therapist with scary boundaries

[Merovinge]

I work at a PHP/IOP (for adolescents) and recently took on a patient who has an outpatient therapist with truly scary boundaries. They talk daily, usually several times per day and much of this time spent talking is done in the evening to late evening hours. We have discussed this with the outpatient psychiatrist who was similarly bothered by the situation, but family feels this type of setup is ideal as the patient has not harmed themselves or attempted to end their life since this began. Our therapist has spoken to the outpatient therapist and they have made it sound like this is standard of care and typical treatment. This is not being done in a DBT framework, the therapist trained as a art therapist.

Principal question: is there any literature that exists around this type of practice? About the concerns of an over-enmeshed therapy? I can only imagine the difficulties in studying something like this, but then the family just points to the lack of literature and it "working" as proof that this should continue.

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[erg923]

They dont know if its "working." That's just a guess. Instilling this in the patient's mind (whether actually true or not) is is also likely fostering a dependence.

Do they have a treatment plan and measurable treatment goals. Is this frequency of contact needed to achieve them? I would doubt it. Who is paying for all this?

 

[randomdoc1]

There is a great illustration of a similar dynamic in this book below:
Amazon product

They talk about a therapist who was seeing a patient with borderline personality disorder, 1 weekly session become 2, then 3, then 7 days a week. Then the patient insisted the therapist give her an orgasm to prevent her from killing herself and she killed herself anyways. There's a great chapter on borderline in this book.

At the same time, if the family and patient have their mind made up, there's not much we can do. But I agree with @erg923 , this is entrenching a maladaptive dynamic unless there is some sort of specific goal to be achieved. It would be good to see what the longterm goals are, because this is not sustainable. It feels like it's "working" now, but the true test is longterm outcomes. There's many things that look like they are "working." I call them quick fixes. But they are essentially just that, nothing sustainable, the problem remains the same, if not worse. Also, this art therapist, if what I'm guessing is right, may be bringing in some of their own dysfunction and getting some sort of need met in a maladaptive way. The need to be wanted, valued, etc.

But unfortunately, if both parties have their minds made up, the most effective way to have this message delivered is let it play it's course. It reminds me of a young adult insisting to be in a dysfunctional relationship. Eventually something will break and one or both parties realize this cannot be continued. E.g. therapist moves, patient cannot and should not be able to find a provider to provide this degree of accessibility---or therapist gets burned out--- etc. etc.

 

[deleted1100659]

It seems like it will accomplish the opposite of what DBT intends, in the sense that it will create an unhealthy dependence. If someone calls their therapist everyday after hours when things get rough, I would wonder how they truly learn to utilize coping skills, since they arent being practiced. What happens if that therapist leaves the practice? Also to be blunt, I would have some serious wtf vibes, as how therapeutic can it to be call a patient every day several times a day? From the outside, it gives the appearance that the therapist is getting some kind of unhealthy gain from this. I don't think most normal people wouldnt burn out from this.

 

[hallowmann]

Virtually every time I have seen this, it has resulted in crossing ethical boundaries to the point of possible criminal charges. Not to say this is an inevitability, but this is my experience. Its not healthy for either party. Boundaries exist for a reason.

 

[erg923]

Agree with the notion of "whose needs are really being met here?"

I mean, the process literature in/of psychotherapy is there, but somewhat slim. I think the bigger questions are more face-obvious and common sensical to any trained mental health professional? Whose needs are being met with this approach, how does this foster recovery/independence and the notion of self-efficacy and internal locus of control. I mean, you have an "art therapist" doing much of what the parents need to be doing here, right?

 

[Merovinge]

Agree with the notion of "whose needs are really being met here?"

I mean, the process literature in/of psychotherapy is there, but somewhat slim. I think the bigger questions are more face-obvious and common sensical to any trained mental health professional? Whose needs are being met with this approach, how does this foster recovery/independence and the notion of self-efficacy and internal locus of control. I mean, you have an "art therapist" doing much of what the parents need to be doing here, right?

Well it's certainly meeting the parents needs of feeling like they are doing everything possible to save their child. It appears to be meeting the teenager's needs of having someone at their beck-and-call 24/7/365 to externally manage their low mood and anxiety. I presume it meets the therapist's needs to get paid and feel invaluable.

It clearly does not promote any healthy recovery, skills, independence, self-efficacy, or internal locus of control. But how does one break through a system like this where everyone involved is heavily committed to the same unhealthy setup and one of those persons is (as the mother explicitly states) "a fully licensed therapist".

 

[randomdoc1]

Well it's certainly meeting the parents needs of feeling like they are doing everything possible to save their child. It appears to be meeting the teenager's needs of having someone at their beck-and-call 24/7/365 to externally manage their low mood and anxiety. I presume it meets the therapist's needs to get paid and feel invaluable.

It clearly does not promote any healthy recovery, skills, independence, self-efficacy, or internal locus of control. But how does one break through a system like this where everyone involved is heavily committed to the same unhealthy setup and one of those persons is (as the mother explicitly states) "a fully licensed therapist".

You can't break through it. Minds are made up.

 

[Merovinge]

They dont know if its "working." That's just a guess. Instilling this in the patient's mind (whether actually true or not) is is also likely fostering a dependence.

Do they have a treatment plan and measurable treatment goals. Is this frequency of contact needed to achieve them? I would doubt it. Who is paying for all this?

The family is paying for this and has significant financial resources, I do not know the specifics on how they are paying as it does not seem appropriate to ask.

 

[singasongofjoy]

I'm not familiar with art therapists' work, but if we're talking ethics, sounds a bit out of the "scope of practice..." Are they writing progress notes after each of these chats, documenting each one according to whatever the standard is at that location? I am dying of curiosity about how they are paying for this and how it is being documented- and if the therapist has given their personal number? Is this therapist required by license to have a certain amount of supervision by another person and are they discussing such an unusual case with them because certainly seems like that's far enough out of the norm you'd expect some peer consultation at minimum or something. Hope parents can pay any eventual lawyer fees if things took that kind of turn. Wow. Nothing good will come of this. Also I wonder about psychological harm/risk etc. to the other clients in the program in some way to hear about this unusual setup / relationship. Everything about that situation is suspect. I cannot fathom their supervisor knows the true scope of their contact if it is truly that frequent.

 

[erg923]

The family is paying for this and has significant financial resources, I do not know the specifics on how they are paying as it does not seem appropriate to ask.

That was an aside. Other mentioned concerns stand and seem valid.

 

[erg923]

Well it's certainly meeting the parents needs of feeling like they are doing everything possible to save their child. It appears to be meeting the teenager's needs of having someone at their beck-and-call 24/7/365 to externally manage their low mood and anxiety. I presume it meets the therapist's needs to get paid and feel invaluable.

It clearly does not promote any healthy recovery, skills, independence, self-efficacy, or internal locus of control. But how does one break through a system like this where everyone involved is heavily committed to the same unhealthy setup and one of those persons is (as the mother explicitly states) "a fully licensed therapist".

You encourage them not to continue this specific path of care and explain why. None of the actual consequences are really on the OP here.

No one is at your "beck and call 24/7/365 to manage your emotions"...even as an adolescent. This is not (outpatient) life. If this is truly necessary for safety, then the patient needs to be at a higher level-of-care than just outpatient services. This is a skill that is taught and matured into. The parents should be PRIMARY and significantly involved in this.

 

[Merovinge]

You encourage them not to continue this specific path of care and explain why. None of the actual consequences are really on the OP here.

To which the response was show me evidence that this is not the right plan of care. Pretty hard to prove the negative here other than the thousands of studies around actually evidenced based psychotherapy practice, of which none that I am aware of mention this type of treatment.

 

[erg923]

To which the response was show me evidence that this is not the right plan of care. Pretty hard to prove the negative here other than the thousands of studies around actually evidenced based psychotherapy practice, of which none that I am aware of mention this type of treatment.

From what you have described....its over-treatment/attention (unless you have left out alot of case details?) and likely the wrong person(s) to be giving this primary attention to their child. I'm not sure what you described is even "treatment" at this point? What are the goals? Are they measurable? What empirical validated methods/modes of "treatment" are they using?

Look.....Counseling/Psychotherapy is rehabilitative and adjunctive to living your full life. It's not your life. And it is not your parents. I think this is perfectly ok to say that to them. It's just agreed upon principles of child psychopathology/child development/behaviorism at this point. You don't really have to DO any of the reading and education for them, right? Citing a specific "study" is not necessary. Why isn't there any family's therapy going on here?

Ultimately, we don't do things like this because it's infantilizing, right? Again, this patient MAY need a temporary higher level-of-care rather than some kind of long-term evening emotional babysitter. But again, I don't know alot of the specifics and background. We would need more here.

 

[singasongofjoy]

To which the response was show me evidence that this is not the right plan of care. Pretty hard to prove the negative here other than the thousands of studies around actually evidenced based psychotherapy practice, of which none that I am aware of mention this type of treatment.

what about reverse-presenting research on why boundaries and related contracts exist in DBT? Which presumably is among the best researched and supported for whatever type of mega dysregulation this person is experiencing? I wonder if there might be evidence in that- I am unfamiliar with the DBT lit but surely there is plenty related to the boundaries. Or showing a highlighted copy of some sort of applicable ethics code related to relevant red flag areas. Is this a situation where it's suspect enough to say "tried to address directly with colleague, didn't change anything, so escalating concern" to whatever relevant credentialing board for art therapists? I don't have much experience in IOP setting but it sounds concerning enough that if i knew about it I might be feeling a little CYA coming on and thus obligated to consult with someone, though not sure who the best someone would be. Maybe the legal consultation people at APA might have helpful thoughts around it.

 

[comp1]

Is the art therapist a therapist, as in licensed? MFT? Are they more a friend? Have you checked the state license board for what they actually are? They sound like a friend who may do art on the side. If they are a therapist and this is therapy (art or otherwise), has the OP talked to them? It seems like the OP is playing a game of telephone with people peripherally involved with this friend of the patient's. If the OP is genuinely concerned about this, it's worth personally investigating. If they're not, then there's nothing to be done. This is a boundary crossing, not a violation based on the OP's description. There isn't going to be much literature on this specific type of enmeshment. It's more about understanding why everyone is doing what they are doing and making sure the behavior really is meeting everyone's goals. I do have to wonder if everything is really ideal why the patient is still in a IOP.

 

[FlowRate]

I think the only step you can take that you haven't yet would be trying to talk with the outside therapist yourself. Obviously no guarantee that they actually appreciate your concern or change their behavior.

Is the art therapist a therapist, as in licensed? MFT? Are they more a friend? Have you checked the state license board for what they actually are? They sound like a friend who may do art on the side. If they are a therapist and this is therapy (art or otherwise), has the OP talked to them? It seems like the OP is playing a game of telephone with people peripherally involved with this friend of the patient's. If the OP is genuinely concerned about this, it's worth personally investigating. If they're not, then there's nothing to be done. This is a boundary crossing, not a violation based on the OP's description. There isn't going to be much literature on this specific type of enmeshment. It's more about understanding why everyone is doing what they are doing and making sure the behavior really is meeting everyone's goals. I do have to wonder if everything is really ideal why the patient is still in a IOP.

Then I saw that you were posting basically the same thing.

 

[comp1]

I think the only step you can take that you haven't yet would be trying to talk with the outside therapist yourself. Obviously no guarantee that they actually appreciate your concern or change their behavior.

Then I saw that you were posting basically the same thing.

Yep, I'm not saying we have time to do it all or even most of the time...but if something really bothers you, make the phone call yourself!

 

[clausewitz2]

I'm not saying the therapist is sleeping with the patient...but this is how you end up sleeping with a patient.

 

[Ceke2002]

Yeah this isn't so much red flags as a whole bunch of flashing red light and sirens. At the very least they appear to potentially be contravening the ethical principals of both the the American Art Therapy Credentials Board and the American Art Therapy Association.

 

[erg923]

I'm not saying the therapist is sleeping with the patient...but this is how you end up sleeping with a patient.

 

[Ceke2002]

Our therapist has spoken to the outpatient therapist and they have made it sound like this is standard of care and typical treatment

Yeah, nah. Have a quick read through these documents and see if you agree that this therapist is practicing within typical standard of care/treatment for an Art Therapist. You could always make a call to the Art Therapy Credentials Board about your concerns as well, preferably prefer the patient ends up getting damaged by egregious levels of boundary violations.

https://www.atcb.org/wp-content/uploads/2020/07/ATCB-Code-of-Ethics-Conduct-DisciplinaryProcedures.pdf

https://arttherapy.org/wp-content/uploads/2017/06/Ethical-Principles-for-Art-Therapists.pdf

 

[Stagg737]

I'm not saying the therapist is sleeping with the patient...but this is how you end up sleeping with a patient.

This was one of my first thoughts. What are the sex/gender/sexual orientations of the patient and therapist? Seems like a perfect set up for a new, terrible reality tv show...

 

[smalltownpsych]

If you knew of a psychologist who was good with adolescents with budding borderline tendencies, maybe you could convince the parents to add them into the mix so they could build a relationship with kid and be there to help when the crash happens. I have been in that role myself a few times and it has worked out well for the patient. One way of opening this up is through referral for more diagnostic clarity and testing to rule out any potential cognitive issues that could play a role. I always think a little psych testing is useful in getting a clearer clinical picture. Also, it makes sense that the family system is idealizing the art therapist and directly challenging that will likely increase resistance so roll with the resistance. Judo therapy.

 

[Mad Jack]

Comes across as feeding that addictive tendency borderline patients have toward positive relationships. Always being there doesn't let them become comfortable with those moments of separation where they have to cope with their own insecurities and fears with regard to relationships and their own identity. Like any addiction, they'll require more and more of that attention because the moments don't do as much as they used to until they either no longer get the same sense of security and pleasant feedback from their interactions or the therapist can no longer offer any more time. Bad boundaries don't help patients, and they serve as a serious barrier to developing coping skills and a healthy sense of what interpersonal relationships should entail.

 

[smalltownpsych]

Comes across as feeding that addictive tendency borderline patients have toward positive relationships. Always being there doesn't let them become comfortable with those moments of separation where they have to cope with their own insecurities and fears with regard to relationships and their own identity. Like any addiction, they'll require more and more of that attention because the moments don't do as much as they used to until they either no longer get the same sense of security and pleasant feedback from their interactions or the therapist can no longer offer any more time. Bad boundaries don't help patients, and they serve as a serious barrier to developing coping skills and a healthy sense of what interpersonal relationships should entail.

Exactly. Definite trap of most clinicians dealing with bordeline personality. Eventually you will disappoint, invalidate, and abandon the patient and if you haven’t treated them then the spilt off rage will be coming right at you. Kernberg said to interpret the hostility. I find that if I give voice to the negatives early while we have a positive transference then the patient can begin to integrate the split off objects. One of the main things missing from DBT is what the therapy is all about from a relational stance and I think Kernberg does a good job filling out that part.

 

[Candidate2017]

Principal question: is there any literature that exists around this type of practice? About the concerns of an over-enmeshed therapy? I can only imagine the difficulties in studying something like this, but then the family just points to the lack of literature and it "working" as proof that this should continue.

Literature or science rarely convinces any patient/family to let go of anything maladaptive to which they cling for comfort.

Obviously, you've no doubt elucidated their inner rationale, educated on risks, and motivated them to change. There's not much else you can do. And if you did have the magical power to immediately change people's actions, you should be paid a lot of money to cure obesity, substance use etc.

What we do have are long term relationships (assuming the patient/family keeps coming back to see you). Long term patients do hear us and do eventually modify their behaviors over time. After all, assuming it's not for controlled substances, they keep coming back because they believe us. Rather than continued overt confrontation, I do find that it helps to develop subtle verbal or physical tics to express disapproval, such as when they talk about numerous calls from the "therapist" being helpful.

It's a two way street. Just as we value our MSE, patients really, really read a lot into our reactions.

 

[birchswing]

I had wondered about this when seeing a lot of the new online/app therapy services that give you unlimited messaging.

Maybe the art therapist is imitating online life?

 

[futureapppsy2]

Comes across as feeding that addictive tendency borderline patients have toward positive relationships. Always being there doesn't let them become comfortable with those moments of separation where they have to cope with their own insecurities and fears with regard to relationships and their own identity. Like any addiction, they'll require more and more of that attention because the moments don't do as much as they used to until they either no longer get the same sense of security and pleasant feedback from their interactions or the therapist can no longer offer any more time. Bad boundaries don't help patients, and they serve as a serious barrier to developing coping skills and a healthy sense of what interpersonal relationships should entail.

Where did the OP say that the patient has BPD or BPD tendencies? Seriously asking, because I didn't see it. Honestly, I think a lot of sick patients (medical as well as psychiatric) can develop loose/poor boundaries with providers, especially if the providers encourage it, because, well, it's scary and stressful and there's a lot of positive reinforcement of that behavior via the relief of reassurance (think the new parent who calls the pediatrician for everything, for example). Add in the fact that the patient is a teenager and... yeah. It's not exactly diagnostic of BPD, in and of itself, IMO.

 

[Mad Jack]

Where did the OP say that the patient has BPD or BPD tendencies? Seriously asking, because I didn't see it. Honestly, I think a lot of sick patients (medical as well as psychiatric) can develop loose/poor boundaries with providers, especially if the providers encourage it, because, well, it's scary and stressful and there's a lot of positive reinforcement of that behavior via the relief of reassurance (think the new parent who calls the pediatrician for everything, for example). Add in the fact that the patient is a teenager and... yeah. It's not exactly diagnostic of BPD, in and of itself, IMO.

I think that I was reading the post two posts down and forgot that the OP's patient didn't have the diagnosis. I was a couple days into a fresh case of COVID when I wrote that and my brain was basically soup. It's very clear OP's patient could have any number of diagnoses and personality issues going on, but there's a reason I've been out of work all week and it's because my brain isn't working the best

 

[futureapppsy2]

I think that I was reading the post two posts down and forgot that the OP's patient didn't have the diagnosis. I was a couple days into a fresh case of COVID when I wrote that and my brain was basically soup. It's very clear OP's patient could have any number of diagnoses and personality issues going on, but there's a reason I've been out of work all week and it's because my brain isn't working the best

Feel better soon!

 

[Merovinge]

Where did the OP say that the patient has BPD or BPD tendencies? Seriously asking, because I didn't see it. Honestly, I think a lot of sick patients (medical as well as psychiatric) can develop loose/poor boundaries with providers, especially if the providers encourage it, because, well, it's scary and stressful and there's a lot of positive reinforcement of that behavior via the relief of reassurance (think the new parent who calls the pediatrician for everything, for example). Add in the fact that the patient is a teenager and... yeah. It's not exactly diagnostic of BPD, in and of itself, IMO.

You're correct that this patient does not have BPD, they do have fleeting periods of maladaptive demanding behaviors that are a more mild form of the modeling they witness from their parent. SI was part of a major depressive episode and has not returned since hospitalization (which is now >1 month out).

 

[smalltownpsych]

You're correct that this patient does not have BPD, they do have fleeting periods of maladaptive demanding behaviors that are a more mild form of the modeling they witness from their parent. SI was part of a major depressive episode and has not returned since hospitalization (which is now >1 month out).

The less disturbed the personality, the less risky the poor therapy boundaries. That being said, I have been getting more and more referrals where the kid and family liked the therapist but nothing changed. It is easy to connect to a kid if you don’t challenge them and/or align and support their pathology. I am thinking that this “art therapist” is doing just that. One key question to ask is what difficult thing does this kid need to do that they don’t have to do now becuase of this therapist? Also, look for key markers of improvement, academics, peer relationships, engagement in productive activities. Then again this therapist might be helping just because the kid isn’t spending those hours on social media rotting their brain and is interacting with an adult in a healthy way. The last being said because you don’t want to just lock into that if its not typical, then it’s not beneficial.

 

[SeniorWrangler]

In my experience working with adolescents, a lot of these intractable problems are related to family issues, and you have very limited control over what the parents do or don’t do. If you as doctor say X and the art therapist says Y and they like Y better, then they’ll follow the art therapist’s lead. Eventually they’ll find, say, a naturopath, who says Z and then both the doc and the therapist will be devalued.

 

[randomdoc1]

In my experience working with adolescents, a lot of these intractable problems are related to family issues, and you have very limited control over what the parents do or don’t do. If you as doctor say X and the art therapist says Y and they like Y better, then they’ll follow the art therapist’s lead. Eventually they’ll find, say, a naturopath, who says Z and then both the doc and the therapist will be devalued.

After limited if any benefit with the naturopath, they consult mayo clinic and a few dozen others. Maybe get some TMS, ketamine treatments. And sometimes they come knocking back on your door saying, "well, none of that was helpful so here we are since last we were here, that's when we saw the most progress." lololol But yes, I've had that happen in a handful of cases.

 

[pisekar]

I work at a PHP/IOP (for adolescents) and recently took on a patient who has an outpatient therapist with truly scary boundaries. They talk daily, usually several times per day and much of this time spent talking is done in the evening to late evening hours. We have discussed this with the outpatient psychiatrist who was similarly bothered by the situation, but family feels this type of setup is ideal as the patient has not harmed themselves or attempted to end their life since this began. Our therapist has spoken to the outpatient therapist and they have made it sound like this is standard of care and typical treatment. This is not being done in a DBT framework, the therapist trained as a art therapist.

Principal question: is there any literature that exists around this type of practice? About the concerns of an over-enmeshed therapy? I can only imagine the difficulties in studying something like this, but then the family just points to the lack of literature and it "working" as proof that this should continue.

some people do that, they charge for phone calls

 

[wolfvgang22]

After limited if any benefit with the naturopath, they consult mayo clinic and a few dozen others. Maybe get some TMS, ketamine treatments. And sometimes they come knocking back on your door saying, "well, none of that was helpful so here we are since last we were here, that's when we saw the most progress." lololol But yes, I've had that happen in a handful of cases.

This happens every week in my clinic.

 

[Merovinge]

Update for those interested (based on a meeting with family, therapist and our treatment team):
Decided on nightly phone calls where useful while on IP unit
Started as being a "last resort" after exhausting coping skills but transitioned to a daily "routine" at pt's preference
Plan is to let patient decide when she wants to reduce the frequency of their interaction
Last night they picked out dresses together (online shopping) to wear when patient starts next school year
Therapist very aware this is "not normal" relationship with the patient and the she "loves her and is so proud of her growth"
Mother was "1000%" in agreement with this being very helpful and the best thing for her daughter
Therapist had tears starting to form while discussing patient improvement

I made the call to just let it lay, the enmeshment is too far gone for me to interject at this point.

 

[smalltownpsych]

Update for those interested (based on a meeting with family, therapist and our treatment team):
Decided on nightly phone calls where useful while on IP unit
Started as being a "last resort" after exhausting coping skills but transitioned to a daily "routine" at pt's preference
Plan is to let patient decide when she wants to reduce the frequency of their interaction
Last night they picked out dresses together (online shopping) to wear when patient starts next school year
Therapist very aware this is "not normal" relationship with the patient and the she "loves her and is so proud of her growth"
Mother was "1000%" in agreement with this being very helpful and the best thing for her daughter
Therapist had tears starting to form while discussing patient improvement

I made the call to just let it lay, the enmeshment is too far gone for me to interject at this point.

I have mentors that work with some of my patients and will have them in supportive roles like this "therapist". One of my clients calls them paid friends. Truth is the patient needs paid friend because the interpersonal patterns are so maladaptive, no healthy person would be friends with them. That being said, I am also working hard to shift those patterns in actual therapy and I think it is best to have clearer roles on these things. DBT has structure for skills coaches in this role as well.

 

[clausewitz2]

I have mentors that work with some of my patients and will have them in supportive roles like this "therapist". One of my clients calls them paid friends. Truth is the patient needs paid friend because the interpersonal patterns are so maladaptive, no healthy person would be friends with them. That being said, I am also working hard to shift those patterns in actual therapy and I think it is best to have clearer roles on these things. DBT has structure for skills coaches in this role as well.

Gen-you-wine interaction the other day:

Patient: "My therapist basically fired me because I never really did anything he suggested and always had a reason why it was impossible. Actually that's usually what I do in therapy. I show up and I rant for an hour and get stuff off my chest. I really look forward to sessions but nothing ever really changes. I do get an audience though which I like. Haha, it's almost like I'm paying for a friend!"

Me: "....yeah, basically. Were you confused about that?"

 

[smalltownpsych]

Gen-you-wine interaction the other day:

Patient: "My therapist basically fired me because I never really did anything he suggested and always had a reason why it was impossible. Actually that's usually what I do in therapy. I show up and I rant for an hour and get stuff off my chest. I really look forward to sessions but nothing ever really changes. I do get an audience thought which I like. Haha, it's almost like I'm paying for a friend!"

Me: "....yeah, basically. Were you confused about that?"

Yup. That's my patient. Fortunately, they are recognizing that no one really likes them and they do want friends and although they didn't like me pointing out that people probably don't like them for the same reasons that I don't, they have begun developing some insight and starting to change those patterns. I refuse to allow a patient to enact unhealthy interpersonal patterns and one of those is telling patients what to do outside of sessions. Others are dumping crap on people, complaining about things, trying to elicit sympathy, venting. Why would anyone want to listen to that and how is it productive? If they do have someone that is a willing victim to that, then why did they come to see me?

 

[randomdoc1]

Update for those interested (based on a meeting with family, therapist and our treatment team):
Decided on nightly phone calls where useful while on IP unit
Started as being a "last resort" after exhausting coping skills but transitioned to a daily "routine" at pt's preference
Plan is to let patient decide when she wants to reduce the frequency of their interaction
Last night they picked out dresses together (online shopping) to wear when patient starts next school year
Therapist very aware this is "not normal" relationship with the patient and the she "loves her and is so proud of her growth"
Mother was "1000%" in agreement with this being very helpful and the best thing for her daughter
Therapist had tears starting to form while discussing patient improvement

I made the call to just let it lay, the enmeshment is too far gone for me to interject at this point.

Well now we have to keep updated on the further sequence of events and when the juicy bits come it. It's become too exciting.

 

[Celexa]

Update for those interested (based on a meeting with family, therapist and our treatment team):
Decided on nightly phone calls where useful while on IP unit
Started as being a "last resort" after exhausting coping skills but transitioned to a daily "routine" at pt's preference
Plan is to let patient decide when she wants to reduce the frequency of their interaction
Last night they picked out dresses together (online shopping) to wear when patient starts next school year
Therapist very aware this is "not normal" relationship with the patient and the she "loves her and is so proud of her growth"
Mother was "1000%" in agreement with this being very helpful and the best thing for her daughter
Therapist had tears starting to form while discussing patient improvement

I made the call to just let it lay, the enmeshment is too far gone for me to interject at this point.

So it's 'the most helpful thing', but the patient needed to be admitted. Mhmmmmmm.

Agree with the person above who said it's an addictive pattern. Which is not exclusive of it being rooted in the need for a friend (sadly, probably on both ends of the relationship). Same line of BS as with all the 'medical' marijuana users who swear it's helping their anxiety while being completely functionally impaired by said anxiety and getting worse. Insight: poor

Also agree you're not gonna be able to much about that nonsense from your position.

Would bet money that IF the patient does get better and decide to reduce contact (big if, but definitely not impossible esp for a teen), the therapist may end up being the one who is hospitalized....