Clinical and experimental

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15+ Year Member
Feb 19, 2007
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Any other primarily-research types have clients that are seriously making them reconsider the decision to pursue a clinical degree? My second ever non-research client is a multi-morbid borderline with a phone books worth of Axis III and IV, and as valuable as I think clinical training is when entering a research career...yikes! Any suggestions on how to quell those lovely daydreams about switching to an experimental program? (Half-joking, but half serious on that one;) ).

The amount of time it takes to provide quality care for some folks is just astronomical and my respect for Linehan grows by the day. I'd never half-ass treatment, especially with someone so clearly in need of help, but I'm becoming less certain that I can deal with this sort of population on a regular basis for the next few years. The simple behavioral stuff and brief diagnostic screens I do in lab doesn't faze me in the slightest but I don't know how people deal with these populations day in and day out. I'd take a complicated dataset to muck through or a computer task to design and program any day!

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Ollie, I feel your pain but I'm just the opposite. Give me a challenging Axis II patient any day over a dataset (lol). :D Like you, I realize that being a clinical psychologist means learning to deal with the research aspects as well as the clinical component. The best advice I can give is to hang in there -- dealing with difficult patients gets easier in time, especially if you have good supervision. Once you've finished your Phd you'll be able to pick and choose how much of an emphasis you wish to place on research vs treatment.
Axis-II people are my peeps!

I enjoy "some" therapy, as well as "some" assessment and "some" research....though I can't imagine doing any on a full-time basis. I saw what some post-docs went through during my practica training, and I knew then that I'd never want to do therapy full-time. My hat is off to anyone who can do therapy full-time, particularly with substance abuse / axis-II / severe populations.

As for experimental programs....the only one that really appealed to me was pharma research (as I was looking at a Ph.D./MD combo program), though the research really came secondary to med school, and it ended up being a poor research fit.
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I'm in a balanced program and I definitely have clients from time to time who make me re-consider the clinical side of things :). Meanwhile, I'm enjoying the research (as I knew I would).

Who knows? Maybe I'll land a job as a researcher yet, though I know I won't have enough output to be competitive for most positions in academic departments.
I'm aiming to work with Axis II, so we'll see how that goes. ;)
I'm aiming to work with Axis II, so we'll see how that goes. ;)

In all seriousness, I think the key to being able to handle challenging patients, especially those with personality disorders, is good supervision. The thing about these folks is that they can really make you doubt yourself because they tend to elicit major countertransference. In talking to my colleagues, this happens regardless of one's theoretical orientation. It's the nature of the beast. Having a good supervisor to lean on and help you deal with your own feelings is just very important -- at least it has been for me.

Just my 2 cents. I'm sure there are plenty of others on here who may have views on this.
psychmama....I couldn't agree more!

Thankfully most of my supervisors had solid experience handling Axis-II Dxs, so I could feel more confident that my work was the right approach. At times it really was a grind because they'd want more time, exceptions, favors, etc. The best decision I ever made was to not make exceptions. Time was time, rules were rules, and when in doubt fall back on integrity and needing to hold myself accountable to my supervisor.

I prefer a more dynamic approach to people with a borderline dx, so that was a bit of a challenge....though I found a bit of a middle ground once I established some basic DBT concepts and overlaid that with a more dynamically focused process. My favorites are still people with a narcassist dx, but they can wear you out just as much. I don't think I'll ever have more than 1 at a time if I can help it.
I think what I'm going to do is ask to pull in a co-therapist on this one. Its atypical for our clinic (I swear we're the only ones in the country who don't have vertical team model - everyplace else I know of does).

That's not going to look good for me. This is almost certainly the aforementioned countertransference speaking, but I truly feel like this client needs someone more experienced. I don't feel that way about my other cases, and I have never once felt in over my head with anyone else I see. I just don't feel like a first year therapist is best for someone with this level of pathology. Its unproductive for both of us, and I'm basically just providing supportive therapy, and trying to put out one fire after another. That's not what this person needs, and that's not even clinical psychology. My supervisor is great, but this is not at all his area either - this is one of those cases that took a pretty dramatic turn from what was initially presented.

I feel like I'm passing up a great learning opportunity, but then again, getting to see how clients like this are managed before trying to do it on my own might be the better way to go.
Bringing in another therapist could really wreak havoc on the therapeutic alliance. People with BPD often split, and I can't help but wonder if a 3rd would push this to the forefront.

If you aren't able to help this person, do you think a transfer would be a better choice, as a "fresh" start may offer less issues than introducing a 3rd person into the sessions?

I'm not sure if you are using a DBT approach, but it may be helpful to look at your delivery and see if there are things you can do to help you feel more comfortable in the work. I'm not an expert in DBT, though I have found some flexibility within the framework.

Obviously your supervisor would be in a better position to address this concern, but just my 2 cents.
Bringing in another therapist could really wreak havoc on the therapeutic alliance. People with BPD often split, and I can't help but wonder if a 3rd would push this to the forefront.

For obvious reasons, I won't get into this too much, but I don't see the above as a likely problem in this particular scenario. Borderline features are certainly present to varying degrees, but this also is not a typical borderline presentation (its not a typical anything presentation!).

Believe me, I'd PREFER a transfer, but I think all parties (client, supervisor, other therapist) would be more receptive to co-therapy at this stage. I'm absolutely useless when it comes to active therapy, but I do have a great rapport with the client so I at least think a transfer would need to be gradual.

The selfish reason is that from a training standpoint, I could stand to learn a lot from continued involvement, but I'm trying not to let that cloud my judgment of what is best for the client. Obviously I will leave any decision up to the supervisor, but I think its a good idea to suggest both.

As for DBT...we're way outside manualized treatment here and the idea is to start by using DBT tools to address emotion regulation. Which sounds like a fine plan, save for the fact that I don't have the know-how to implement it. Coupled with my lack of soft skills and COMPLETE lack of control over the sessions this is not a good combo. Part of it is just therapeutic wimpiness I need to get over anyways, but I prefer graded exposure to being thrown in a snake pit;)
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If it makes you feel any better, difficult clients like the one you're treating make even experienced therapists feel incompetent.:confused: It may not be your inexperience that's the problem...then again, I understand your concerns. I'd agree with T4C about the dangers of co-therapy due to splitting. I'd say talk to your supervisor and if you must make a change, I'd either look for another supervisor with more expertise in this area or transfer the case to another therapist.

Like T4C said, this is just an opinion. Definitely talk to your supervisor about your concerns though. :luck:
If it is any consolation, I learned the most from my most difficult patients. While they required more supervision, more time, more effort, and a lot more patience....they really pushed me to understand my limits. I look back at some of my tough cases early on, and they seem much more run of the mill now. It seems like you have your hands full with this one, so maybe in a few years you'll look back and go, "Yup....still a handful!"

As for DBT implementation, the basics aren't that bad (I believe Linehan has at least one primer out there), and sometimes the structure is welcome. I've posed the approach as a "trial", and asked for feedback about the process after a couple of sessions, and typically the pt was able to at least consider the framework.

Thinking about this makes me want to jump back into individual work.....which I'll probably want to jump back out of the next week. :laugh:

Thinking about this makes me want to jump back into individual work.....which I'll probably want to jump back out of the next week. :laugh:

T4C, I always knew there was a therapist's soul behind the "business" exterior!;) Maybe in the best of all worlds you'll successfully combine clinical and consulting work, no?:)
This is somewhat tangential, but I do know someone who switched from a clinical program to an experimental program at the same university, keeping the same (very clinical) research interests (Her advisor retired shortly after she entered the program, so she obviously couldn't keep that the same). I don't know what year she was in when she made the switched, but after graduating, she now says that she's thinking that doing clinical work might not have been so bad.