Second thoughts about child & adolescent...

[fiatslug]

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I just had another session with my irritable adolescent baby borderline from hell. My supervisor has insisted on continuing weekly psychotherapy with her since July, and it has been absolutely horrible: she's nearly 16 but incredibly immature for her age, average intelligence at best with no insight, totally frustrating in my attempts to engage her to talk about anything. She was initially referred for therapy because of very poorly controlled IDDM (sugars are running in the 400s, recent HgbA1C of 13.5), which felt characterologic (diagnosed at age 10). Parents are well-meaning but give in to her all the time, she does terribly in school but manages to avoid consequences (failed out of summer school--which she had to take to make up for failing her second attempt at freshman year of high school--but somehow has been socially passed into her sophomore year, which she is again failing). She has a history of burning through other therapists too. Two months ago, she stopped showing up and mom didn't return calls (I'll just admit I was thrilled). Now, a week & a half from going on maternity leave, Mom calls frantic, saying the DM clinic is saying she's going to die if she keeps going on like this, can we re-start her on Prozac (which she did somewhat better on in the past, apparently), etc. Just saw her in session for the first time in 2 months--she walked out after 15 minutes (all the while sighing, crossing her arms and saying "I didn't want to come here," "This isn't helping," etc), after which Mom came in and told me "but she likes you better than all the others!"

A very small part of this might be the maternity leave, but she's so profoundly characterologically impaired... she's just a nightmare adolescent case. What's been even more frustrating is my supervisor's persistence in pushing for psychotherapy in someone so completely uninsightful. And it just makes me wonder--do I want this? I love kids, I love working with kids, and I've only got 3 cases (the other 2 are good, although I wonder what the hell I'm really doing in play therapy). And collateral is hell!

Any thoughts? I feel so guilty passing her on to one of my colleagues... I was so hoping she'd wash out of clinic before I left!

 

[50960]

You are not her parent, and have the responsibility to get the parents on board or tell them you cannot treat her. Borderline?? maybe, adolescent...all the time. This is what you need to get good at dealing with, but do not assume total responsibility for her response. She is where she is because of many factors, and parents are a big one. You can only do good treatment if they are on board. Right now you are just another pawn for her....

 

[fiatslug]

A big part of the frustration I feel in dealing with her is actually dealing with my supervisor, whose expectations for this treatment far exceed mine. I feel like I can't "fire" my child cases, no matter how much they suck.

 

[50960]

That is too bad, and that is wrong. I would hesitate to use the term "fire", but if you are expected to treat this kid and the parents are not following everything you say as best they can, then you cannot treat this patient. Maybe someone else can, not because you don't know enough etc..., but because of transference/countertrans issues. You have to be able to maintain that control when working with kids or MANY parents will use you as another excuse why their kid is in control...

 

[raspberry swirl]

as a mere 4th year, i have nothing truly insightful to say, other than, i feel your pain ... i plan on pursuing C&A as well, but i worry about my patience level with certain teenagers. my oldest niece is 14, a freshman in high school, and although i love her more than anything, man, some days, i swear to god ... i could just scream. just about any interaction with her is just unbearable and i feel like im pulling teeth just trying to have a normal conversation- and she's my family- not a stranger in therapy!

 

[OldPsychDoc]

as a mere 4th year, i have nothing truly insightful to say, other than, i feel your pain ... i plan on pursuing C&A as well, but i worry about my patience level with certain teenagers. my oldest niece is 14, a freshman in high school, and although i love her more than anything, man, some days, i swear to god ... i could just scream. just about any interaction with her is just unbearable and i feel like im pulling teeth just trying to have a normal conversation- and she's my family- not a stranger in therapy!

TELL me about it.
My son is 14, he's totally blowing off school, he makes the whole family environment toxic, and I have to confess that I'm having homicidal ideation...

 

[Anasazi23]

I think having supervisors dump uninsightful patients on you for weekly therapy is a bane of psychiatry residency. After you graduate, you can knock her down to 2x/month or whatever you can reasonably handle.

We all have these cases...residency is only 4 years...
🙂

 

[OldPsychDoc]

I think having supervisors dump uninsightful patients on you for weekly therapy is a bane of psychiatry residency. After you graduate, you can knock her down to 2x/month or whatever you can reasonably handle.

We all have these cases...residency is only 4 years...
🙂

This is fine if it gets you through the day during residency, but it's not a helpful perspective for your career. Once you start practicing, you won't be rotating off to some new experience and leaving your difficult patients for someone else. Sometimes you might get lucky and they move to a different county or something, or change insurance networks--but basically, (as with my adolescent above) you need to plan for these patients being yours FOR LIFE.

 

[Anasazi23]

True, I hear what you're saying.

The post just struck a cord with me since I have one therapy patient who...let's just say, isn't the sharpest knife in the drawer. In truth, her IQ is likely around 80-85, and her emotional reserve and psychological mindedness is close to zero - she is more concrete than the 3rd Ave. sidewalk. I was assigned to her for weekly psychodynamic psychotherapy. While this is possible, it is extremely difficult.

I've had to resort to basic supportive psychotherapy with her, since it's the only thing she responds to. Yet, they still want me to see her q week, since that's a 'long-term psychotherapy patient'. Oh well...

If I insisted, I could get her pared down...but I pick my battles.
🙂

 

[50960]

Sazi, why do you have to do psychodynamic tx on a borderline IQ patient? Doesn't sound like a good match. When I have seen pts like this I focus on behavioral interventions mixed with a bit of supportive tx. The Bx stuff is concrete enough they can follow it.

 

[MBK2003]

A big part of the frustration I feel in dealing with her is actually dealing with my supervisor, whose expectations for this treatment far exceed mine. I feel like I can't "fire" my child cases, no matter how much they suck.

In my experience this came from supervisors who did exclusively psychodynamic play therapy with the full-fee children of well-heeled parents.

In my current work I am seeing a lot of behavior modification work with children and families, and seeing that it can work much more quickly than play therapy - much to the teacher's delight, but it requires buy in from the parents. Adolescents are tough, but you need to modify your expectations of their tolerance, 25 to 30 minute is usually sufficient time alone, don't expect them to be able to go 45 minutes. If I was treating this patient in your shoes (heading into maternity leave), I'd consider behavioral modification and a DBT approach, but none of that (or meds) would be started until after maternity leave. If the family wants prozac, they can take her to a full-fee child psychiatrist to eval and start meds if indicated, or they can request transfer to a non-gravid resident in the clinic. Keep in mind that you do want to help this patient and with the appropriate approach may have very good success, but that you can't be a miracle worker in the 2 weeks prior to leave, and that this child's behavior has been going on for YEARS, and won't be fixed in 2-3 months.

Trust me, in child psych there are a lot of train wrecks (as there are in community psychiatry as well), but we can help if we develop realistic expectations for ourselves and the child. I had a totally inappropriate child therapy case last year (1 - yes - my child experience 1 case) who I was supposed to do psychodynamic play therapy with. It was completely useless, but I did make significant improvements in the child's life by getting her psychological testing to demonstrate her significant verbal LD, advocating with the school system to get non-stigmatizing remediation services, and then going back when they were not being implemented by the school, and then doing a lot of family work around her learning disability and the impact it had on how her parents perceived her level of effort and her actual level of effort. Her mood had significantly improved by the end of the school year, but I think therapy played NO PART, in fact she said, "I'm glad you helped my mom see that I am really trying to understand my homework." I actually found it to be a great experience in working with kids, families, and the systems they work in, but not a great experience in dynamic play therapy.

MBK2003

 

[50960]

Great response MBK!!

 

[OldPsychDoc]

In my experience this came from supervisors who did exclusively psychodynamic play therapy with the full-fee children of well-heeled parents.

"When all you have is a hammer..."🙄

It was completely useless, but I did make significant improvements in the child's life by getting her psychological testing to demonstrate her significant verbal LD, advocating with the school system to get non-stigmatizing remediation services, and then going back when they were not being implemented by the school, and then doing a lot of family work around her learning disability and the impact it had on how her parents perceived her level of effort and her actual level of effort. Her mood had significantly improved by the end of the school year, but I think therapy played NO PART, in fact she said, "I'm glad you helped my mom see that I am really trying to understand my homework."
MBK2003

Way to advocate for your patient, MBK!

 

[medstudent99]

I just had another session with my irritable adolescent baby borderline from hell. My supervisor has insisted on continuing weekly psychotherapy with her since July, and it has been absolutely horrible: she's nearly 16 but incredibly immature for her age, average intelligence at best with no insight, totally frustrating in my attempts to engage her to talk about anything. She was initially referred for therapy because of very poorly controlled IDDM (sugars are running in the 400s, recent HgbA1C of 13.5), which felt characterologic (diagnosed at age 10). Parents are well-meaning but give in to her all the time, she does terribly in school but manages to avoid consequences (failed out of summer school--which she had to take to make up for failing her second attempt at freshman year of high school--but somehow has been socially passed into her sophomore year, which she is again failing). She has a history of burning through other therapists too. Two months ago, she stopped showing up and mom didn't return calls (I'll just admit I was thrilled). Now, a week & a half from going on maternity leave, Mom calls frantic, saying the DM clinic is saying she's going to die if she keeps going on like this, can we re-start her on Prozac (which she did somewhat better on in the past, apparently), etc. Just saw her in session for the first time in 2 months--she walked out after 15 minutes (all the while sighing, crossing her arms and saying "I didn't want to come here," "This isn't helping," etc), after which Mom came in and told me "but she likes you better than all the others!"

A very small part of this might be the maternity leave, but she's so profoundly characterologically impaired... she's just a nightmare adolescent case. What's been even more frustrating is my supervisor's persistence in pushing for psychotherapy in someone so completely uninsightful. And it just makes me wonder--do I want this? I love kids, I love working with kids, and I've only got 3 cases (the other 2 are good, although I wonder what the hell I'm really doing in play therapy). And collateral is hell!

Any thoughts? I feel so guilty passing her on to one of my colleagues... I was so hoping she'd wash out of clinic before I left!

that diabetes sounds horrible! poor girl. i would focus on her medical issues first.

 

[OldPsychDoc]

that diabetes sounds horrible! poor girl. i would focus on her medical issues first.

That's the kicker with this kind of patient--their compliance is awful because of their adolescent oppositionality run amok and enmeshed in all kids of dynamics with their disease. They HATE being diabetic. They HATE their parents. They HATE doctors. They start using meth, maybe heroin (Hell, they've got a reason to have a never ending supply of needles...), they go out and make babies... Just TRY to "focus on medical issues first". It ain't going to happen!

 

[jay dub]

A big part of the frustration I feel in dealing with her is actually dealing with my supervisor, whose expectations for this treatment far exceed mine. I feel like I can't "fire" my child cases, no matter how much they suck.

Have you talked about THIS aspect with your supervisor and told you supervisor how frustrated you are with her/him? I wonder if there's possibly some parallel process going on here? Not that talking about parallel process will make things any less frustrating, but from a learning perspective it might be interesting... You are both "being made" to do things and work with people you don't want to work with...

In the end, though, I wish you GOOD LUCK! 😳

 

[i61164]

This is a really interesting discussion. Do you guys find that adolescent psych is like dealing with your own kids when the are misbehaving/being difficult. Because if that's the case, it's no wonder there is a shortage of people going into this field.

My daughter has a way of pushing my buttons to the point where I act in a way that makes me feel ashamed. You couldn't pay me enough to fight that battle every day at work.

 

[maranatha]

At an interview a resident told me that almost 60% of applicants claim to have an interest in child psych before starting. However, the interest in child drops dramatically once they start training....I wonder how true this is.