Independent practice for LPAs?

[nitemagi]

So, I used the case of a BPD patient, who 9 times out of 10 is in your office because they are unintentionally wreaking havoc on everything around them. In those cases, my approach to building alliance is wildly different than say, a person with PTSD. I have one guy right now who has been in therapy for the better part of the last 10-15 years of his life with various providers and is still a mess. My strong belief is that he is still in therapy because no therapist has kicked his ass yet. If given an inch, he takes not a yard, but a mile. I squeezed him in for a full session when he came 30-40 minutes late, he then came late the next 3 sessions with a different tale of woe as to what went wrong in his schedule. I stayed on the phone with him for his first crisis call for 10-15 minutes, and he started trying to get his therapy over the phone. The treatment goals now are establishing boundaries, teaching him to assert control over his own life, and teaching effective communication. He comes 40 minutes late for a 60 minute session, he gets 20. All phone calls are limited to 3 minutes and then I have a patient/meeting to get to. Sessions are now not driven by his crisis of the week. Quite frankly, I am humming show tunes in my head when he launches into stories about what the new chick has done and how women can’t be trusted and blah, blah, blah. Once he has gotten enough out of his system, we redirect back to his response to the problem—never losing the fact that he can have some control over the chaos. Now we are engaging in therapy.

I am not an advocate for being mean and cold. My point is that there are times where taking the empathetic listener approach is simply not going to do much for therapy.

I heard stories about a prior resident that would start doing snow angels on the floor when his BPD patients would launch into their crisis of the moment. He'd then say "I'll stop when you stop."

Not an approach I'd advocate for most.

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[O Gurl]

I heard stories about a prior resident that would start doing snow angels on the floor when his BPD patients would launch into their crisis of the moment. He'd then say "I'll stop when you stop."

Not an approach I'd advocate for most.

Love it.

 

[DrGero]

Yes. Reading that comment on its own would make anyone cringe. Much like walking through the door in the middle of a conversation and simply hearing: “I could have strangled him.” That is the beauty of a context.

I was responding to the idea that

My general stance toward therapy is that my job is to help the person produce the changes in their life and functioning that he/she wants to make. I never want to find myself in a situation where a patient is coming back primarily because I am nice and I listen to them (read: billing for friendship). If that is the critical issue for them (lack of a support system) then my job is to help them address the interpersonal problems that are preventing them from having close relationships—not to substitute for them.

So, I used the case of a BPD patient, who 9 times out of 10 is in your office because they are unintentionally wreaking havoc on everything around them. In those cases, my approach to building alliance is wildly different than say, a person with PTSD. I have one guy right now who has been in therapy for the better part of the last 10-15 years of his life with various providers and is still a mess. My strong belief is that he is still in therapy because no therapist has kicked his ass yet. If given an inch, he takes not a yard, but a mile. I squeezed him in for a full session when he came 30-40 minutes late, he then came late the next 3 sessions with a different tale of woe as to what went wrong in his schedule. I stayed on the phone with him for his first crisis call for 10-15 minutes, and he started trying to get his therapy over the phone. The treatment goals now are establishing boundaries, teaching him to assert control over his own life, and teaching effective communication. He comes 40 minutes late for a 60 minute session, he gets 20. All phone calls are limited to 3 minutes and then I have a patient/meeting to get to. Sessions are now not driven by his crisis of the week. Quite frankly, I am humming show tunes in my head when he launches into stories about what the new chick has done and how women can’t be trusted and blah, blah, blah. Once he has gotten enough out of his system, we redirect back to his response to the problem—never losing the fact that he can have some control over the chaos. Now we are engaging in therapy.

I am not an advocate for being mean and cold. My point is that there are times where taking the empathetic listener approach is simply not going to do much for therapy.

You look like the therapist I might send all my BPD patients to. I much better function in a nondirective, empathetic mode, while I'm fully aware there are therapists out there who function much better in a directive, confrontative, problem-focused mode. I don't think that makes either therapist better or worse, just better or worse with particular patients - I think the key is knowing when to treat, consult, or refer. I can't help all patients, but perhaps I can find someone who can help you.

 

[O Gurl]

You look like the therapist I might send all my BPD patients to. I much better function in a nondirective, empathetic mode, while I'm fully aware there are therapists out there who function much better in a directive, confrontative, problem-focused mode. I don't think that makes either therapist better or worse, just better or worse with particular patients - I think the key is knowing when to treat, consult, or refer. I can't help all patients, but perhaps I can find someone who can help you.

I agree wholeheartedly. Part of our job is knowing our limitations and comfort levels with different approaches. That said, if I ever started receiving a bunch of BPD referrals from a colleague, I would hunt them down like a rabid animal and have their hide.

 

[erg923]

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