how would you handle this?

[Attending1985]

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I have a therapist who works in my office that has on a few occasions told patients to ask me for a specific medication. I find this treatment inferring and I don't like therapists suggesting medications for many reasons, most importantly, that they know very little about their indications and toxicities. I always thought that therapists looked down on meds for BPD, anxiety and depression?
I didn't talk to her about it at the time as I don't have many patients who see her and I didn't want to deal with talking to her about it. In the past she has also come to me on a patient's behalf with a grievance about something I had said about encouraging the patient to work and also a patient who was upset that I told them that it was possible to recover from depression. Both times she presented it as face value and didn't seem to appreciate what this could mean for the patient.
Yesterday she came to me telling me a BPD patient I have seen a few times is upset that I don't listen to her. I'm not so arrogant as to believe that this isn't possible and that I wasn't understanding the patient. After seeing the patient she said I had rushed her through appointments. I take a full 30 minutes with the patient and know quite a bit about her life so I think this is an issue beyond feeling rushed.
My issue is that the therapist repeatedly engages in three way communication instead of encouraging the patient to speak to me directly. I know validation is important but this therapist takes it too far to the point of enforcing maladaptive behavior. This is a theme with the therapists in my department. They have the belief that "joining" with the patient is the ultimate goal with disregard for the outcome.
I am very conservative with medications and I push patients to take authority and find their own solutions which I think is somewhat threatening to this therapist. I think this is, in part, why she brings these complaints to me personally. One of my patients also relayed to me that she had disclosed to him that she has BPD.
I have to work with this person so I'm looking for input on a constructive way of addressing this with her without getting entangled in something.

 

[scentofpapaya]

How are you stuck with this therapist? Therapist suggesting you to prescribe certain medication is clearly a boundary violation. Is it that you and the therapist are both employed at a hospital setting so you are not in a position to fire her?

 

[Attending1985]

How are you stuck with this therapist? Therapist suggesting you to prescribe certain medication is clearly a boundary violation. Is it that you and the therapist are both employed at a hospital setting so you are not in a position to fire her?

Yes both employed. No position to fire her. Has worked there way longer than me.

 

[Sushirolls]

Definitely difficult situation. The range of clinical degrees for therapists, compounded by range of training quality, compounded by the folks who are accepted into the programs leads to some who lack the basic level of professionalism.

Weigh the politics of your environment. If you are a resident, discuss with your PD first. Present a plan to the PD and see if they agree it is worth pursuing. Such as a simple sit down with her to state its unprofessional to make medication recommendations and even to be disclosing one's personal conditions; and to please stop. Half the reason to consult with a PD or designated program mentor is to provide some extra CYA in case the drama blows out or proportion.

On the flip side, a medication question could have ultimately been stimulated by Uncle Bob or Auntie Priya. You will routinely find patients bringing to the treatment a different plan, and you need to be able to adapt to roll with what the patient wants or be able to defend/support your treatment recommendations. Try to view it as a test of your skills. Like when a medical student says hey, why this over this? Time to educate. Sometimes you'll discover your original way isn't as perfect as you think, and its okay to let it go. Strive to keep the patient engaged, ultimately their mind, their body, they have to want to take the pill.

 

[Attending1985]

Definitely difficult situation. The range of clinical degrees for therapists, compounded by range of training quality, compounded by the folks who are accepted into the programs leads to some who lack the basic level of professionalism.

Weigh the politics of your environment. If you are a resident, discuss with your PD first. Present a plan to the PD and see if they agree it is worth pursuing. Such as a simple sit down with her to state its unprofessional to make medication recommendations and even to be disclosing one's personal conditions; and to please stop. Half the reason to consult with a PD or designated program mentor is to provide some extra CYA in case the drama blows out or proportion.

On the flip side, a medication question could have ultimately been stimulated by Uncle Bob or Auntie Priya. You will routinely find patients bringing to the treatment a different plan, and you need to be able to adapt to roll with what the patient wants or be able to defend/support your treatment recommendations. Try to view it as a test of your skills. Like when a medical student says hey, why this over this? Time to educate. Sometimes you'll discover your original way isn't as perfect as you think, and its okay to let it go. Strive to keep the patient engaged, ultimately their mind, their body, they have to want to take the pill.

I’m an attending. Need to change my username. I totally agree that I need to be able to back up what I’m doing and that it’s also problematic to be rigid.
I can understand suggestions coming from family but a therapist is supposed to be educated on this stuff. In my case it’s generally what I’m not prescribing that causes issues. I work in a small group and the other psych is a multiple Benzo and stimulant prescriber. I think the therapists are used to a lot of coping with meds which makes their job easy.
I see a lot of chronic patients with entrenched learned helplessness and making a little headway takes a lot of work. I’m not here to dispense whatever medication is requested. When the therapist essentially backtracks any little progress it’s more than frustrating.

 

[Sushirolls]

Keep at it, its draining, the harder road to go, but society needs more like you. Don't give up, stay the course.

I suggest you sit down and educate the therapist.

My advice for all psychiatrists is to keep their finger on the pulse of a plan B. Work each job as though you have the ability and are willing to walk away. It'll help with these types of situations and your own sanity.

 

[Attending1985]

Keep at it, its draining, the harder road to go, but society needs more like you. Don't give up, stay the course.

I suggest you sit down and educate the therapist.

My advice for all psychiatrists is to keep their finger on the pulse of a plan B. Work each job as though you have the ability and are willing to walk away. It'll help with these types of situations and your own sanity.

Thanks for the support. I need it. I will plan a strategy to discuss this with her. Need to find a group of like minded practitioners.

 

[Mindfulpsych22]

It is very frustrating when other providers interfere in this manner. I’ve found that sometimes asking the other provider questions that are gently highlighting the descrepency between their behavior and the patients treatment goals can be helpful. A few I’ve used I think his situation before:

“I’m guessing that because a lack of assertiveness is something strongly related to maintenance of anxiety/depression/bpd, you are trying to help patient X with this. It’s sounds like you are doing a great job reinforcing when she/he is assertive with you, how can we work together on helping get her /him take the the next step and be assertive with me?”

“I’m noticing that patient X seems to have a hard time talking to me directly about grievances or questions they have about my approach. What do you think is getting in the way of them approaching me directly? How can we help them work on some strategies to come to me directly?”
From there you could appear to “brainstorm” ideas and then suggest that the therapist coach the patient to speak up. When the therapist inevitably slips and engages in three way communication again, direct back to this idea “thanks for giving me the heads up! what is the plan for helping the patient communicate that to me directly? Or “I’m assuming that you will be helping the patient express that to me directly, when should I plan for that conversation?” I’m always surprised what I can get away with by communicating in a way that treats something as a suggestion is going to be the plan. If you get objections (the patient “can’t because of X, Y, Z) I’d express your concern about how that will serve them in the long run and how they will ever learn to if they can’t collaborate on this with a therapist they have such a strong alliance with 🙂😉

I’d handle the med suggestions the same way you would if he patient was getting suggestions from any other source.

 

[Attending1985]

It is very frustrating when other providers interfere in this manner. I’ve found that sometimes asking the other provider questions that are gently highlighting the descrepency between their behavior and the patients treatment goals can be helpful. A few I’ve used I think his situation before:

“I’m guessing that because a lack of assertiveness is something strongly related to maintenance of anxiety/depression/bpd, you are trying to help patient X with this. It’s sounds like you are doing a great job reinforcing when she/he is assertive with you, how can we work together on helping get her /him take the the next step and be assertive with me?”

“I’m noticing that patient X seems to have a hard time talking to me directly about grievances or questions they have about my approach. What do you think is getting in the way of them approaching me directly? How can we help them work on some strategies to come to me directly?”
From there you could appear to “brainstorm” ideas and then suggest that the therapist coach the patient to speak up. When the therapist inevitably slips and engages in three way communication again, direct back to this idea “thanks for giving me the heads up! what is the plan for helping the patient communicate that to me directly? Or “I’m assuming that you will be helping the patient express that to me directly, when should I plan for that conversation?” I’m always surprised what I can get away with by communicating in a way that treats something as a suggestion is going to be the plan. If you get objections (the patient “can’t because of X, Y, Z) I’d express your concern about how that will serve them in the long run and how they will ever learn to if they can’t collaborate on this with a therapist they have such a strong alliance with 🙂😉

I’d handle the med suggestions the same way you would if he patient was getting suggestions from any other source.

Very helpful. Thanks!

 

[Jules A]

Unfortunately this isn't uncommon. I prefer to set boundaries or it will continue to happen. It seems the degree of enmeshment is inverse to the skill of the therapist regardless of how long they have been at it. Perhaps an email like "Jane clearly values your relationship and while I'm certain she misunderstood that you were suggesting she trial a specific medication would you share the concerns she has verbalized to you so she and I can discuss the most appropriate medication options". I also applaud you for providing what you know is appropriate care as opposed to just writing whatever benzo or stimulant the patients and their therapists believe will solve all their issues.

 

[Trismegistus4]

I've encountered similar issues. I hate to malign any skilled and competent master's-level therapists who may be reading, but in residency I had only encountered doctoral-level therapists and had never encountered this phenomenon of a therapist just being a "cheerleader" for a patient. It first manifested to me with the ADHD-seekers. I had hoped that collateral info from a therapist would help buttress my case that the person in question does not in fact have ADHD, but then I began encountering cases in which I've received phone calls or letters from therapists saying they really think the person has ADHD and needs to be medicated.

 

[Attending1985]

Unfortunately this isn't uncommon. I prefer to set boundaries or it will continue to happen. It seems the degree of enmeshment is inverse to the skill of the therapist regardless of how long they have been at it. Perhaps an email like "Jane clearly values your relationship and while I'm certain she misunderstood that you were suggesting she trial a specific medication would you share the concerns she has verbalized to you so she and I can discuss the most appropriate medication options". I also applaud you for providing what you know is appropriate care as opposed to just writing whatever benzo or stimulant the patients and their therapists believe will solve all their issues.

i will definitely use this approach. Thanks for taking the time

 

[Attending1985]

I've encountered similar issues. I hate to malign any skilled and competent master's-level therapists who may be reading, but in residency I had only encountered doctoral-level therapists and had never encountered this phenomenon of a therapist just being a "cheerleader" for a patient. It first manifested to me with the ADHD-seekers. I had hoped that collateral info from a therapist would help buttress my case that the person in question does not in fact have ADHD, but then I began encountering cases in which I've received phone calls or letters from therapists saying they really think the person has ADHD and needs to be medicated.

This is a masters level therapist and I share your sentiment regarding that

 

[erg923]

While you should always be polite and courteous, and work together for the betterment/treatment of your patient, I don’t think you owe the therapist any kind of explanation regarding your choice of medications. If she asks then, you can explain your reasoning. There is reason to go on the offensive or defensive here.