Setting boundaries

[psychma]

I have a young woman who I’ve worked with for a few years. I’ve always been careful about boundaries. Recently, she went through a difficult time. She is isolated from family and one day during our session she said she wished I was her sister. I was taken aback but kind of considered this transference. She began leaning a lot on me between sessions. I feel like I need to say something to reset the boundaries but am unsure of how to approach it.

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[smalltownpsych]

Gently reestablish the parameters of the relationship and discuss how your job is to help her develop ability to cope with stuff without you there. The fact that she is relying on you for emotional support is a good thing, fostering dependency is a bad thing. I might even increase sessions while she learns to not call between them. It also depends on how much of a crisis the calls are and how quickly they can be resolved and her ability to contain until she does talk to you. I tend to replace a more adaptive behavior as opposed to trying to limit an undesired behavior. In other words, don’t tell patient to stop calling, tell them we need to meet more often or you need to develop this other support plan.

 

[erg923]

I have a young woman who I’ve worked with for a few years. I’ve always been careful about boundaries. Recently, she went through a difficult time. She is isolated from family and one day during our session she said she wished I was her sister. I was taken aback but kind of considered this transference. She began leaning a lot on me between sessions. I feel like I need to say something to reset the boundaries but am unsure of how to approach it.

Grist for the therapy mill. Why is this so concerning to you? And what "boundary" did she cross, really?

You have been seeing her for.... "years?" What did you expect?

 

[psychma]

Grist for the therapy mill. Why is this so concerning to you? And what "boundary" did she cross, really?

You have been seeing her for.... "years?" What did you expect?

Don’t think she crossed a boundary. I do expect these things. Perhaps I need to look at any feelings of countertransference I may have. I’m not blaming the client. I’m wanting to handle this in a way that is most helpful.

 

[psychma]

Gently reestablish the parameters of the relationship and discuss how your job is to help her develop ability to cope with stuff without you there. The fact that she is relying on you for emotional support is a good thing, fostering dependency is a bad thing. I might even increase sessions while she learns to not call between them. It also depends on how much of a crisis the calls are and how quickly they can be resolved and her ability to contain until she does talk to you. I tend to replace a more adaptive behavior as opposed to trying to limit an undesired behavior. In other words, don’t tell patient to stop calling, tell them we need to meet more often or you need to develop this other support plan.

Thank you.

 

[erg923]

Don’t think she crossed a boundary. I do expect these things. Perhaps I need to look at any feelings of countertransference I may have. I’m not blaming the client. I’m wanting to handle this in a way that is most helpful.

I am asking what, exactly, is the objectionable issue here that prompted your post? You have seen this person for "years" as a therapist and there has recently been a "Corrective Emotional Experience." Is that not correct?

I don't know what your measurable treatment goals are for this patient? What are they?

 

[psychma]

I am asking what, exactly, is the objectionable issue here that prompted your post? You have seen this person for "years" as a therapist and there has recently been a "Corrective Emotional Experience." Is that not correct?

I don't know what your measurable treatment goals are for this patient? What are they?

I think you missed the point.

 

[erg923]

I think you missed the point.

Then help me understand.

What are your measurable treatment goals for this patient?

 

[Justanothergrad]

Then help me understand.

What are your measurable treatment goals for this patient?

This question assumes that therapy's function and purpose follow a disease model, wherein the objective is clearly identified (reduce X). This reductionism is the general foci of the MBC movement. Self-growth, etc. may well be the focus of therapy, and that doesn't make it bad/harmful/unethical even. Tons of good outcomes aren't even tied to MBC and haven't been considered (see Pim Cuijper's work). It depends how you view the role of therapy, and I'm not sure that there is a lot to suggest measurable treatment goals (despite how much I like them) are the only thing worth measuring. I dont disagree with the earlier point about grist for the mill / what was the boundary concern actually, but I have a more complicated relationship with MBC lol

 

[erg923]

This assumes that therapy's function and purpose follow a disease model, wherein the objective is clearly identified. Self-growth, etc. may well be the focus of therapy, and that doesn't make it bad/harmful/unethical even. It depends how you view the role of therapy, and I'm not sure that there is a lot to suggest measurable treatment goals (despite how much I like them) are the only thing worth measuring.

This is academic mumbo-jumbo. How is "self growth" measured?

I pay you. You tell me what you are doing to achieve an end result. If this is not measurable, its junk to me as a payor.

 

[Justanothergrad]

I see. How is "self growth" measured?

....

I'm assuming this is intentionally satirical?

 

[erg923]

....

I'm assuming this is intentionally satirical?

No. What are the measurable treatment goals for this patient?

 

[psychma]

No. What are the measurable treatment goals for this patient?

This patient’s treatment goals are none of your business. I carefully plan and review treatment plans and therapy tends to be short-term or shorter term. This individual’s diagnoses and treatment goals are not the question and I received an adequate answer. Thanks for playing.

 

[Justanothergrad]

No. What are the measurable treatment goals for this patient?

What if there aren't?

why would I know or why would that matter? You seem to react to duration of treatment. On a basis of what? Your reliance on MBC? By rejecting the notion of MBC and the disease model, we also can release some of the notion of a fix focus. People are far more dynamic than ebp can tap into for stuff. Sure, we can frame it as some bs cog rating scale post hoc but that isn't really a good fit to what is happening. but then again, prove any ebp is a mechanism. and none of this is relevant to the question.

 

[Indiana_Jane]

I have a young woman who I’ve worked with for a few years. I’ve always been careful about boundaries. Recently, she went through a difficult time. She is isolated from family and one day during our session she said she wished I was her sister. I was taken aback but kind of considered this transference. She began leaning a lot on me between sessions. I feel like I need to say something to reset the boundaries but am unsure of how to approach it.

Can you specify what you mean by “leaning a lot on me?” I’m guessing this means calling in between scheduled sessions but want to clarify.

Is there anything additional about this patient (that is feasible/ethical/legal to share here) that makes this feel like a serious boundary crossing? It seems like a fairly benign remark but I will admit I work with very ill patients prone to boundary violations so my threshold may be different.

 

[erg923]

What if there aren't?

why would I know or why would that matter? You seem to react to duration of treatment. On a basis of what? Your reliance on MBC? By rejecting the notion of MBC and the disease model, we also can release some of the notion of a fix focus. People are far more dynamic than ebp can tap into for stuff. Sure, we can frame it as some bs cog rating scale post hoc but that isn't really a good fit to what is happening. but then again, prove any ebp is a mechanism. and none of this is relevant to the question.

What are the treatment goals for this patients care episode?

 

[psychma]

Can you specify what you mean by “leaning a lot on me?” I’m guessing this means calling in between scheduled sessions but want to clarify.

Is there anything additional about this patient (that is feasible/ethical/legal to share here) that makes this feel like a serious boundary crossing? It seems like a fairly benign remark but I will admit I work with very ill patients prone to boundary violations so my threshold may be different.

I don’t think this was necessarily a boundary violation. I just feel the need to acknowledge her feelings and sort of redefine the boundaries. She has been contacting me more between meetings as well and also told me she wished we’d met in a different context and could be friends. She has bipolar 1 disorder and no personality pathology.

 

[psychma]

What are the treatment goals for this patients care episode

What are the treatment goals for this patients care episode?

I bet you’re fun at parties.

 

[PikminOC]

What are the treatment goals for this patients care episode?

Not sure op has to defend the treatment to you. If they have to defend it to an insurance company, that's between op and that insurance company. Not you.

 

[tr]

I have a young woman who I’ve worked with for a few years. I’ve always been careful about boundaries. Recently, she went through a difficult time. She is isolated from family and one day during our session she said she wished I was her sister. I was taken aback but kind of considered this transference. She began leaning a lot on me between sessions. I feel like I need to say something to reset the boundaries but am unsure of how to approach it.

I'd take this as a cue for Changing The Focus.
My response to this would be something like this:

"It sounds like our work together has been really important to you, and also that you are really missing the powerful supportive relationships that many people do have with their families, and that maybe you wish you had as well. I so enjoy working with you and I'm very glad that our work is helpful for you. At the same time, I think you know that I am not and can never be your relative. But I also think the feelings you are having are important to talk about. Can you say more about the thoughts and feelings that led you to make that comment just now?"

 

[psychma]

I'd take this as a cue for Changing The Focus.
My response to this would be something like this:

"It sounds like our work together has been really important to you, and also that you are really missing the powerful supportive relationships that many people do have with their families, and that maybe you wish you had as well. I so enjoy working with you and I'm very glad that our work is helpful for you. At the same time, I think you know that I am not and can never be your relative. But I also think the feelings you are having are important to talk about. Can you say more about the thoughts and feelings that led you to make that comment just now?"

That’s great.

 

[cara susanna]

It would help to know the specific behaviors the patient is doing other than the sister comment. Like, when you say leaning on you for support in between sessions, do you mean phone calls? If that were the case, I would have a conversation with the patient about why this isn't helpful for their recovery and brainstorm a plan for skills they can use or other actions they can take when they would have the urge to call you. If that doesn't work, I would set more substantial limits, including telling that patient that you won't return their call unless they explicitly say it's urgent (even then, define urgent vs. emergency).

 

[psychma]

It would help to know the specific behaviors the patient is doing other than the sister comment. Like, when you say leaning on you for support in between sessions, do you mean phone calls? If that were the case, I would have a conversation with the patient about why this isn't helpful for their recovery and brainstorm a plan for skills they can use or other actions they can take when they would have the urge to call you. If that doesn't work, I would set more substantial limits, including telling that patient that you won't return their call unless they explicitly say it's urgent (even then, define urgent vs. emergency).

Messaging with symptoms of depression for example, where they say a lot and engage casually. We have a contract where they contact with prodromal symptoms of depression/mania but this is excessive lately. I must admit I pulled back on the length of my responses which she noticed and commented on. I explained that I don’t have time for longer responses right now but that her symptoms are important to me. I asked her to contact me when symptoms are truly concerning.

 

[smalltownpsych]

Even though erg was a bit brusque or maybe even rude, it can be helpful to think about the goal of the treatment even when it is not easily measurable. It is a helpful practice for a number of reasons to explain what you are doing and why you are doing it. Helping a patient identify and address early signs of exacerbation of a chronic illness is one goal. Another is helping patient to rely on supportive relationships to ameliorate or mitigate the effects of their illness. Also, developing other support strategies or networks is a goal. I work with a number of patients with more chronic illness and my goal is always to help them continue to improve their functioning and quality of life. The trick is just to grab a few current aspects of their life that are relevant to this process. A good clinician with a little experience is typically doing this, it just takes some work to identify and articulate what that is and I do believe practice with that makes us better at helping the patient.

My first reaction when questioned by those with the insurance or corporate or agency mindset is to tell them to f’off as well, but I have spent so much time explaining what I am doing and why to real people that matter, such as the patient, their family, other colleagues, I can tell these overseers what we are doing too even though I don’t feel they deserve an explanation.

 

[BuckeyeLove]

Erg coming in hot sounding real administrationy-ish haha.

 

[summerbabe]

We have a contract where they contact with prodromal symptoms of depression/mania but this is excessive lately.

Could you amend this contract such as continuing to notice prodromal symptoms but instead of contacting you first, to intentionally engage in some adaptive coping (that has been carefully discussed and planned out) prior to calling you?

 

[psychma]

Even though erg was a bit brusque or maybe even rude, it can be helpful to think about the goal of the treatment even when it is not easily measurable. It is a helpful practice for a number of reasons to explain what you are doing and why you are doing it. Helping a patient identify and address early signs of exacerbation of a chronic illness is one goal. Another is helping patient to rely on supportive relationships to ameliorate or mitigate the effects of their illness. Also, developing other support strategies or networks is a goal. I work with a number of patients with more chronic illness and my goal is always to help them continue to improve their functioning and quality of life. The trick is just to grab a few current aspects of their life that are relevant to this process. A good clinician with a little experience is typically doing this, it just takes some work to identify and articulate what that is and I do believe practice with that makes us better at helping the patient.

My first reaction when questioned by those with the insurance or corporate or agency mindset is to tell them to f’off as well, but I have spent so much time explaining what I am doing and why to real people that matter, such as the patient, their family, other colleagues, I can tell these overseers what we are doing too even though I don’t feel they deserve an explanation.

We do have a variety of goals and resources they can turn to like DBSA meetings, working on extending their social network, early management of symptoms, etc. This has been partially formulated in conjunction with their psychiatrist who has worked together with me. One major goal is to keep them out of the hospital, so medication compliance, sleep hygiene, etc are goals. When this individual has an episode, it can damage their life and feelings of self worth. Rebuilding self-esteem is a goal. Maintaining relationships … goal. Goals are listed as actionable items in a treatment plan that is regularly reviewed. This person has made a lot of progress.

 

[R. Matey]

Even though erg was a bit brusque or maybe even rude, it can be helpful to think about the goal of the treatment even when it is not easily measurable. It is a helpful practice for a number of reasons to explain what you are doing and why you are doing it. Helping a patient identify and address early signs of exacerbation of a chronic illness is one goal. Another is helping patient to rely on supportive relationships to ameliorate or mitigate the effects of their illness. Also, developing other support strategies or networks is a goal. I work with a number of patients with more chronic illness and my goal is always to help them continue to improve their functioning and quality of life. The trick is just to grab a few current aspects of their life that are relevant to this process. A good clinician with a little experience is typically doing this, it just takes some work to identify and articulate what that is and I do believe practice with that makes us better at helping the patient.

I'm with you on this point. Reducing impairment is likely derivative of self-growth (and thus not mutually exclusive) and sometimes people need it spelled out how treatment principles apply to different areas of life. If a patient is still experiencing social and occupational impairment, they're still having problems that can be tied directly to their sx's. One case example is that I successfully implemented PE with a PTSD patient in a community setting, but their marriage was still a mess after the protocol terminated so treatment shifted to focus on building interpersonal skills. Is that self-growth or reduced social impairment? And, more importantly, does it really matter?

 

[tr]

That’s great.

Thank you, it's a CBT technique

 

[borne_before]

I wonder if you're a little freaked out because you can see yourself being like sister to this patient.. Going back to the Gloria videos:

Gloria: Yeah, and you know what else I was just thinking? I – I feel dumb saying it uh - that all of a sudden while I was talking to you I thought, "Gee, how nice I can talk to you and I want you to approve of me and I respect you, but I miss that my father couldn't talk to me like you are." (Touches her chin.) I mean, I'd like to say, "Gee, I'd like you for my father." (T: Mhm, Mhm, Mhm) I don't even know why that came to me. (Smiles)​

​

Rogers: You look to me like a pretty nice daughter. (Pause) (C: Looks down.) But you really do miss the fact that you- you couldn't be open with your own dad.​

​

Later Rogers would say: I was genuinely moved, I probably showed it, by the fact that she told me near the end of the contact that, uh, she saw me as the father she would like to have. My reply was also a thoroughly spontaneous one that she seemed to me like a pretty nice daughter. I guess I feel that we're only playing with the real world of relationships when we talk about such an experience in terms of transference and counter-transference. I feel quite deeply about that. I want to say, yes, we can put this experience into some such highly intellectualized framework, but when we do that it completely misses the point of the very immediate "I-Thou" quality of the relationship at such moments.​

​

​

Is that a sin? Maybe part of you could see yourself being a good sister to her. Anyway, maybe it's time to discuss this dependence, say something to refocus on her life: "ya know, we can't work together forever, and I am here as long as you need me, but the goal is for you to not need me." Maybe discuss the yearning for the sister relationship and behaviors she can do to create more of that support.

Just dont start meeting outside of therapy, engage in physical contact, or text the patient. Don't respond to emails or spend more than a few minutes on the phone, you've got other stuff to do, set physical and time boundaries, but up frequency if needed.

​

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[smalltownpsych]

I wonder if you're a little freaked out because you can see yourself being like sister to this patient.. Going back to the Gloria videos:

Gloria: Yeah, and you know what else I was just thinking? I – I feel dumb saying it uh - that all of a sudden while I was talking to you I thought, "Gee, how nice I can talk to you and I want you to approve of me and I respect you, but I miss that my father couldn't talk to me like you are." (Touches her chin.) I mean, I'd like to say, "Gee, I'd like you for my father." (T: Mhm, Mhm, Mhm) I don't even know why that came to me. (Smiles)​

​

Rogers: You look to me like a pretty nice daughter. (Pause) (C: Looks down.) But you really do miss the fact that you- you couldn't be open with your own dad.​

​

Later Rogers would say: I was genuinely moved, I probably showed it, by the fact that she told me near the end of the contact that, uh, she saw me as the father she would like to have. My reply was also a thoroughly spontaneous one that she seemed to me like a pretty nice daughter. I guess I feel that we're only playing with the real world of relationships when we talk about such an experience in terms of transference and counter-transference. I feel quite deeply about that. I want to say, yes, we can put this experience into some such highly intellectualized framework, but when we do that it completely misses the point of the very immediate "I-Thou" quality of the relationship at such moments.​

​

​

Is that a sin? Maybe part of you could see yourself being a good sister to her. Anyway, maybe it's time to discuss this dependence, say something to refocus on her life: "ya know, we can't work together forever, and I am here as long as you need me, but the goal is for you to not need me." Maybe discuss the yearning for the sister relationship and behaviors she can do to create more of that support.

Just dont start meeting outside of therapy, engage in physical contact, or text the patient. Don't respond to emails or spend more than a few minutes on the phone, you've got other stuff to do, set physical and time boundaries, but up frequency if needed.

​

​

Great example. Sometimes in our training that emphasizes the importance of boundaries, which is necessary, we end up feeling uncomfortable with the feelings that can be engendered. I love transference type stuff and actually believe that the ability to express genuine feelings such as fraternal, paternal or maternal (what is the word for sisterly?) and feel safe with that is often an essential part of the healing process. Once I was talking to a very intelligent and perceptive patient about this and she said sort of tongue in cheek that I was more maternal than paternal though.

Along these lines and even more uncomfortable are the feelings that are not familial and even sexual. I had a patient tell me once about a sexual dream they had with me in it. Since this young lady was in high school I was a bit freaked out by it. It actually led to a good discussion about how feelings and thoughts about sex are normal and natural but sometimes a little embarrassing and that’s ok, healthy and normal. We laughed because the whole discussion was awkward and weird and I sounded like a typical dumb adult talking about the birds and the bees with very clinical terminology which also probably helped to appropriately diminish any feelings of sexual transference.

As therapists we are humans in relationship with other humans and helping them experience what is within the healthy range of emotional experience is part of the treatment. It is also important to help them practice that out in the real world with their relationships. If I didn’t help them bridge the experience outside of the therapy room then that becomes a problem.

 

[borne_before]

Great example. Sometimes in our training that emphasizes the importance of boundaries, which is necessary, we end up feeling uncomfortable with the feelings that can be engendered. I love transference type stuff and actually believe that the ability to express genuine feelings such as fraternal, paternal or maternal (what is the word for sisterly?) and feel safe with that is often an essential part of the healing process. Once I was talking to a very intelligent and perceptive patient about this and she said sort of tongue in cheek that I was more maternal than paternal though.

Dude, I actually deleted part of my post. But, I remember the first time I had to fire a patient because of a boundary issue. But, I remember feeling so stressed because we emphasize boundaries, but no one gives you a perfect script or road map when a patient's parent that you're doing behavioral consultation with keeps making dependent comments and keeps telling you that they're attracted to you. So stressful.

Along these lines and even more uncomfortable are the feelings that are not familial and even sexual. I had a patient tell me once about a sexual dream they had with me in it. Since this young lady was in high school I was a bit freaked out by it. It actually led to a good discussion about how feelings and thoughts about sex are normal and natural but sometimes a little embarrassing and that’s ok, healthy and normal. We laughed because the whole discussion was awkward and weird and I sounded like a typical dumb adult talking about the birds and the bees with very clinical terminology which also probably helped to appropriately diminish any feelings of sexual transference.

Going to the above: I actually sought my own therapy over this (and some other stuff). The first time that patient mentioned it to me, I was like "cool, i'm doing a good job in fostering an open environment here" and told them that I don't have the same feelings, but normalized them and what not and suggested they see someone for themselves because this might be bringing up a need.

But when it kept happening, I was like "am I sending a message here?" What's wrong with me? I also felt weirded out over having thoughts I found horrible such as "It sure would be easy to have an inappropriate relationship with you" or "I am so flattered, it feels nice to be viewed that way" even though I would never take advantage of a patient like that.

It's like that same feeling you have when you're chopping veggies and are like "i could just stab myself in the gut right now or stab my wife" or when your high up and you think "what if I jumped." The you're like WTF was that thought. What's wrong with ME for having that thought - even though you'd never do it, its still such a crazy thing.

As therapists we are humans in relationship with other humans and helping them experience what is within the healthy range of emotional experience is part of the treatment. It is also important to help them practice that out in the real world with their relationships. If I didn’t help them bridge the experience outside of the therapy room then that becomes a problem.

But when it kept happening, even after stating that I do not feel the same way and would never have a romantic relationship with a patient's parent, I consulted some peers, and we had some honest communication, and in the interests of helping the parent's kid (who I view as the main patient), these feelings were getting in the way of the treatment goals (e.g., improve kids behavior) and when it was brought up a third time, I decided to refer out.

 

[smalltownpsych]

Dude, I actually deleted part of my post. But, I remember the first time I had to fire a patient because of a boundary issue. But, I remember feeling so stressed because we emphasize boundaries, but no one gives you a perfect script or road map when a patient's parent that you're doing behavioral consultation with keeps making dependent comments and keeps telling you that they're attracted to you. So stressful.


Going to the above: I actually sought my own therapy over this (and some other stuff). The first time that patient mentioned it to me, I was like "cool, i'm doing a good job in fostering an open environment here" and told them that I don't have the same feelings, but normalized them and what not and suggested they see someone for themselves because this might be bringing up a need.

But when it kept happening, I was like "am I sending a message here?" What's wrong with me? I also felt weirded out over having thoughts I found horrible such as "It sure would be easy to have an inappropriate relationship with you" or "I am so flattered, it feels nice to be viewed that way" even though I would never take advantage of a patient like that.

It's like that same feeling you have when you're chopping veggies and are like "i could just stab myself in the gut right now or stab my wife" or when your high up and you think "what if I jumped." The you're like WTF was that thought. What's wrong with ME for having that thought - even though you'd never do it, its still such a crazy thing.



But when it kept happening, even after stating that I do not feel the same way and would never have a romantic relationship with a patient's parent, I consulted some peers, and we had some honest communication, and in the interests of helping the parent's kid (who I view as the main patient), these feelings were getting in the way of the treatment goals (e.g., improve kids behavior) and when it was brought up a third time, I decided to refer out.

I think it’s normal to feel flattered and even to have inappropriate thoughts or impulses. The messages we send to patients are hard to identify and quantify and are often subconscious. I asked a colleague who was very familiar with trauma and me personally about why sexual trauma patients trusted me so much and she said it was because of my boundaries. That always confused me a little but today I’m thinking that it has to do with my awareness of personal space and physical contact. Patients with sexual trauma are highly attuned, often on a subconscious level, of some of those factors and it seems that some are drawn in too close and others are trying to get as far away as possible. Working with that is part of my treatment strategy.

 

[PsyDr]

Erg coming in hot sounding real administrationy-ish haha.

His job is interesting from a conceptual level. We can define diagnostic criteria. Then apply the treatment until the criteria are no longer present. But! There is a huge range of way symptoms can be expressed, and other problems in living for which people seek treatment. That ill defined boundary is a really interesting thing.

 

[tr]

Dude, I actually deleted part of my post. But, I remember the first time I had to fire a patient because of a boundary issue. But, I remember feeling so stressed because we emphasize boundaries, but no one gives you a perfect script or road map when a patient's parent that you're doing behavioral consultation with keeps making dependent comments and keeps telling you that they're attracted to you. So stressful.

I should think it's the same road map that is used for any interaction that generates negative or conflicted feelings in the therapist:
Discuss both the behavior and the feelings explicitly with the patient (or parent in this case), using the Five Secrets of Effective Communication.
We practiced this ad nauseam while in training, role-playing a huge variety of difficult patient interactions. It's not at all intuitive but eventually it became second nature.

Going to the above: I actually sought my own therapy over this (and some other stuff). The first time that patient mentioned it to me, I was like "cool, i'm doing a good job in fostering an open environment here" and told them that I don't have the same feelings, but normalized them and what not and suggested they see someone for themselves because this might be bringing up a need.

But when it kept happening, I was like "am I sending a message here?" What's wrong with me? I also felt weirded out over having thoughts I found horrible such as "It sure would be easy to have an inappropriate relationship with you" or "I am so flattered, it feels nice to be viewed that way" even though I would never take advantage of a patient like that.

It's like that same feeling you have when you're chopping veggies and are like "i could just stab myself in the gut right now or stab my wife" or when your high up and you think "what if I jumped." The you're like WTF was that thought. What's wrong with ME for having that thought - even though you'd never do it, its still such a crazy thing.

But when it kept happening, even after stating that I do not feel the same way and would never have a romantic relationship with a patient's parent, I consulted some peers, and we had some honest communication, and in the interests of helping the parent's kid (who I view as the main patient), these feelings were getting in the way of the treatment goals (e.g., improve kids behavior) and when it was brought up a third time, I decided to refer out.

I think it comes with the territory of practicing psychotherapy that you are going to become the object of some really strong transference reactions. It's pretty much unavoidable. I think transference reactions can easily turn sexual if the ages and genders of the patient and therapist are approximately in the right conformations, but nonsexual transference reactions are also often incredibly strong.

We all need to know how to discuss transference effectively with patients. Usually such discussions end up being powerful turning points in the therapy, and catalysts for positive change.

In the case where it's the parent and not the patient, I think transfer of care makes sense since you aren't trying to achieve a therapeutic breakthrough with the parent, just trying to provide good care for the kid. But it's still much easier if you approach the situation using the same type of communication tools that you would use in therapy.

 

[erg923]

This question assumes that therapy's function and purpose follow a disease model, wherein the objective is clearly identified (reduce X). This reductionism is the general foci of the MBC movement. Self-growth, etc. may well be the focus of therapy, and that doesn't make it bad/harmful/unethical even. Tons of good outcomes aren't even tied to MBC and haven't been considered (see Pim Cuijper's work). It depends how you view the role of therapy, and I'm not sure that there is a lot to suggest measurable treatment goals (despite how much I like them) are the only thing worth measuring. I dont disagree with the earlier point about grist for the mill / what was the boundary concern actually, but I have a more complicated relationship with MBC lol

Son, if someone else is paying that tab, you bet your ass there is someone measuring the ROI.

You have, have, have, to show it. You can't just cite studies that say yea, maybe, depends. You have to show it.

 

[borne_before]

I should think it's the same road map that is used for any interaction that generates negative or conflicted feelings in the therapist:
Discuss both the behavior and the feelings explicitly with the patient (or parent in this case), using the Five Secrets of Effective Communication.
We practiced this ad nauseam while in training, role-playing a huge variety of difficult patient interactions. It's not at all intuitive but eventually it became second nature.



I think it comes with the territory of practicing psychotherapy that you are going to become the object of some really strong transference reactions. It's pretty much unavoidable. I think transference reactions can easily turn sexual if the ages and genders of the patient and therapist are approximately in the right conformations, but nonsexual transference reactions are also often incredibly strong.

We all need to know how to discuss transference effectively with patients. Usually such discussions end up being powerful turning points in the therapy, and catalysts for positive change.

In the case where it's the parent and not the patient, I think transfer of care makes sense since you aren't trying to achieve a therapeutic breakthrough with the parent, just trying to provide good care for the kid. But it's still much easier if you approach the situation using the same type of communication tools that you would use in therapy.

The reason I didn't is that I am not an adult psychologist, and it was really just parent management training.

 

[Justanothergrad]

Son, if someone else is paying that tab, you bet your ass there is someone measuring the ROI.

You have, have, have, to show it. You can't just cite studies that say yea, maybe, depends. You have to show it.

there are zero studies proving a mechanism of effect or cause of psychotherapy, nor a consensus on what psychotherapy is functionally as a outcome. This model can be true, but isn't always and the disease model of symptom reduction hasn't moved the treatment outcome needle in terms of causality, prediction of outcome success, or average effect size. So, No, I don't think there is a need to produce only one side of data to simplify the actual discussion of what therapy is. We can agree third party payers like this approach, but that has zero relevance to OPs question. But the rest, no. And the data doesnt tell that either. You want to argume about MBC? sure. but this isn't it. Tldr, this point isn't relevant to the thread, nor is your prior question.

 

[smalltownpsych]

there are zero studies proving a mechanism of effect or cause of psychotherapy, nor a consensus on what psychotherapy is functionally as a outcome. This model can be true, but isn't always and the disease model of symptom reduction hasn't moved the treatment outcome needle in terms of causality, prediction of outcome success, or average effect size. So, No, I don't think there is a need to produce only one side of data to simplify the actual discussion of what therapy is. We can agree third party payers like this approach, but that has zero relevance to OPs question. But the rest, no. And the data doesnt tell that either. You want to argume about MBC? sure. but this isn't it. Tldr, this point isn't relevant to the thread, nor is your prior question.

Very irrelevant.
Psychologist: I wonder how best to respond to parent of my patient coming on to me?
Administrator: Do you have the treatment goals documented for the insurance reimbursement?
Psychologist: Huh?

 

[borne_before]

Very irrelevant.
Psychologist: I wonder how best to respond to parent of my patient coming on to me?
Administrator: Do you have the treatment goals documented for the insurance reimbursement?
Psychologist: Huh?

My adiminstration would do something like this:
Psychologist: I wonder how best to respond to parent of my patient coming on to me?
Administrator: Can we bill for that?
Psychologist: Huh?

 

[tr]

My adiminstration would do something like this:
Psychologist: I wonder how best to respond to parent of my patient coming on to me?
Administrator: Can we bill for that?
Psychologist: Huh?

Entertainingly, you can bill for it. 90785

Understanding the Interactive Complexity CPT Code 90785

Communication is key in therapy, but sometimes you may struggle connecting with a client. Thankfully, there's a code for that. Learn more about the interactive complexity code, 90785.

blog.therapynotes.com

 

[WisNeuro]

Entertainingly, you can bill for it. 90785

Understanding the Interactive Complexity CPT Code 90785

Communication is key in therapy, but sometimes you may struggle connecting with a client. Thankfully, there's a code for that. Learn more about the interactive complexity code, 90785.

blog.therapynotes.com

All for a whopping $16-17.

 

[R. Matey]

All for a whopping $16-17.

Hey now, that's a full tank of gas in 2005.

 

[WisNeuro]

Hey now, that's a full tank of gas in 2005.

With my old Civic at the time, probably.

 

[R. Matey]

With my old Civic at the time, probably.

'87 Toyota Corolla , so basically the same. This is enough for a full tank plus a snack.

 

[Justanothergrad]

Very irrelevant.
Psychologist: I wonder how best to respond to parent of my patient coming on to me?
Administrator: Do you have the treatment goals documented for the insurance reimbursement?
Psychologist: Huh?

you make it sound like the request was polite. also. I didn't ever say "huh". I understand the issue quite well

also, you forgot the MBC issue which is where that stemmed from. billing is a fine question. that isn't what op asked. it may be relevant, but isn't necessarily. remember, this stemmed from an issue extended treatment.

 

[psychma]

Thank you to those that helped. I had a conversation with her about it and it went very well. I learned a lot about her family dynamics and support and feel good about how I handled it. I feel the outcome was good for the client as well in that I appreciated how our work together has impacted her and clarifying my role along with finding areas particularly with her sister that she needs to work on that are painful to her. I appreciate those that helped. It was important to me to handle this well. Also details were changed in this story for obvious reasons.

 

[smalltownpsych]

you make it sound like the request was polite. also. I didn't ever say "huh". I understand the issue quite well

also, you forgot the MBC issue which is where that stemmed from. billing is a fine question. that isn't what op asked. it may be relevant, but isn't necessarily. remember, this stemmed from an issue extended treatment.

Ummm, I was agreeing with you and poking fun at administrators and erg. The “huh”was my response to an unbelievably irrelevant question. I also have no idea what MBC is so maybe that’s why there is a misunderstanding.

 

[R. Matey]

Ummm, I was agreeing with you and poking fun at administrators and erg. The “huh”was my response to an unbelievably irrelevant question. I also have no idea what MBC is so maybe that’s why there is a misunderstanding.

MBC = Measurement Based Care.

 

[smalltownpsych]

MBC = Measurement Based Care.

No wonder I didn’t know what it meant. Not something I’m a fan of. Also, it still has no relationship to a patient’s mom hitting on you. Maybe we should derive a scale for that so we could assess that for the bean counters. First session she scored x on the rating scale but after I told her that I didn’t date parents of patients it went down to about half that and when I told her that I would sue her for sexual harassment if she didn’t stop touching my shoulder as I held the door open at end of sessions, it went down even further. Sounds like a successful treatment.