Feb 3, 2019
28
4
Status
  1. Non-Student
Hello, I've always assumed it is normal to work with clients for therapy with med management. It fits my stereotypical image of a psychiatrist of the past and fits my idea of holistic care. I now have ~70% full private practice, about 50% of clients I meet for both meds and therapy. I pay someone who has been in private practice for years for monthly supervision. She has pointed out that in her experience, working with the same client for both meds and therapy can at times be challenging, especially with complicated cases, because it requires you to shift between the hat of the therapist and the hat of the med manager; where usually the therapist aligns and validates the client whereas the med manager is more likely to need to keep things big picture and confront the client more often.

I am considering a couple of my dual med management/therapy clients who I think would benefit from a separate therapist -- a therapist who specializes more in the issues they present with. Has anyone had a similar issue before? How did you address it? I'm finding that boundaries in private practice is an evolving learning curve for me.
 
Jun 19, 2009
210
305
Status
  1. Attending Physician
There have been a few cases where combined therapy was complicated.

1. Managing medication in severe personality disorder: During the course of a transference-focused therapy, the patient acts-out related to his/her medication (eg, takes too much, doesn't take, takes with significant illicit substance). This behavior is interpreted and the contract is re-established with the stipulation that a limit will be set with continued behavior. That limit is usually a referral to another psychopharmacologist. I found it difficult to end the whole treatment, which would be easier to do in pure therapy. This was the compromise.

2. Medication for severe mood disorder in a dynamic treatment: When I was earlier in my training, I had a patient with bipolar disorder who developed an erotic transference. I felt that the intensity of the psychoanalytic/expressive treatment was stress significant enough to be a risk for mood episode relapse. So, I referred the patient to another therapist, while transitioning to a more supportive role in my medication management.

Here are some further resources I used while training:

Amazon product
Amazon product
Another situation occurred to me.

4. Patients you don't like/those really not motivated for therapy/mild personality disorder: I've started combined therapy+rx cases with people who initially seemed interested. However, I had strong countertransference feelings. It seemed they really just wanted the meds or maybe it was my own ****. I think I just was too lazy to confront the defenses (lateness, asking me about my life, trivial themes in session, etc). In these cases, I judged the overall risk of not confronting/interpreting the behavior (ie, moving to a more supportive approach) was low risk. When the patient reduced their time and frequency with me, sometimes finding other therapists, the relationship improved. Oddly, I also found that the less I saw them, the seemingly better they sounded. Maybe it was patient-specific, but it felt like if I saw them weekly, there was always something to complain about symptomatically. Later, I became the idealized q3-month prescriber and would hear about their devalued therapist! ahhh, the split, from the good end :)
 
Last edited:
Oct 13, 2008
2,571
3,298
Status
  1. Attending Physician
There have been a few cases where combined therapy was complicated.

1. Managing medication in severe personality disorder: During the course of a transference-focused therapy, the patient acts-out related to his/her medication (eg, takes too much, doesn't take, takes with significant illicit substance). This behavior is interpreted and the contract is re-established with the stipulation that a limit will be set with continued behavior. That limit is usually a referral to another psychopharmacologist. I found it difficult to end the whole treatment, which would be easier to do in pure therapy. This was the compromise.

2. Medication for severe mood disorder in a dynamic treatment: When I was earlier in my training, I had a patient with bipolar disorder who developed an erotic transference. I felt that the intensity of the psychoanalytic/expressive treatment was stress significant enough to be a risk for mood episode relapse. So, I referred the patient to another therapist, while transitioning to a more supportive role in my medication management.

Here are some further resources I used while training:

Amazon product
Amazon product

I would like to second the utility of the first book, even though I don't work so much in a TFP framework, and the second one is now on my "buy soon" list...
 

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