The somatically preoccupied, dependent, help rejecting complainer patient

[fiatslug]

Any magic pearls that have helped in dealing with this population? I'm working in a partial hospitalization setting. I've had three of these pts in the past 2 years and they are *remarkably* challenging to work with, almost permastuck. I had great luck with one in doing role-play about her fear of going back to work, and in conversations with her outside therapist, she continues to do well. The other two: idiosyncratic somatic reactions to virtually every pharmacolgic intervention, one is a fibro patient and that is a core part of her identity, the other literally found it impossible to do anything except come into treatment and say "I can't." (Actually that was a common mantra for all three).

I give them specific goals and tasks (worked great with one of the three--the other two remained stuck). At a certain point, after several weeks and no movement on their part whatsoever, we as a team tell them "we can't be working harder than you are on your recovery," and they piddle out of treatment.

This is by far my most challenging patient to deal with. I think the fact that we had such a good outcome with one who was unbelieveably stuck has made me overly optimistic that the others, too, can change. Clinical success (or not-so-successful) stories? Articles to point me to?

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[Suedehead]

Any magic pearls that have helped in dealing with this population? I'm working in a partial hospitalization setting. I've had three of these pts in the past 2 years and they are *remarkably* challenging to work with, almost permastuck. I had great luck with one in doing role-play about her fear of going back to work, and in conversations with her outside therapist, she continues to do well. The other two: idiosyncratic somatic reactions to virtually every pharmacolgic intervention, one is a fibro patient and that is a core part of her identity, the other literally found it impossible to do anything except come into treatment and say "I can't." (Actually that was a common mantra for all three).

I give them specific goals and tasks (worked great with one of the three--the other two remained stuck). At a certain point, after several weeks and no movement on their part whatsoever, we as a team tell them "we can't be working harder than you are on your recovery," and they piddle out of treatment.

This is by far my most challenging patient to deal with. I think the fact that we had such a good outcome with one who was unbelieveably stuck has made me overly optimistic that the others, too, can change. Clinical success (or not-so-successful) stories? Articles to point me to?

sheeeesh. I've got the SAME problem. looking forward to responses.

Other than doing LONG term psychodynamically oriented psychotherapy (even psychoanalysis) for some seriously and painfully slow corrective emotional personality restructuring through transferential re-parenting (and WHO has access to this? and if someone has access, what clinicians are left that do this WELL?),.....I'm stuck.

 

[psychtrainee]

Based on my limited knowledge/experience, I'd say if goal setting and purely behavioral techniques have not been successful, probably psychodynamic therapy to get at the root of the dependence and symptom preoccupation. But also "high dose" of humanistic therapy along the way, to validate the patient. Because if one can learn, truly learn, that expressing his needs, wants, and insecurities is okay, then there may be less need to rely on dysfunctional ways to communicate them. So one part is being taught that yes, you are allowed to feel this way or want that, and another is to be taught exactly how to go about getting what you need. And lastly, acceptance, that there will always be things that you won't be able to obtain to your heart's content, be it love or ironically, acceptance itself. This is where in particular, having religious orientation can be helpful. Trusting in a higher power though I think is always helpful. There is only so much you can do and if someone always feels some level of helplessness--which we all do more or less at some point--it may be best that she rely on God than desperately search and completely rely on someone to be her rock.

 

[BobA]

Do you know any reputable hypnotists? That's what they did in the old days (pre Freud!)

We have a psychiatrist who does hypnosis and it sometimes works. It demonstrates that you're caring.

Also, consider integrating some Acceptance and Commitment Therapy groups into your partial hospital program.

Sometimes depression or substance abuse brings out the worst in people so look for co-morbid depression, or co-morbid substance abuse and see if you can treat those at all. I tend to not chase symptoms with meds in these people, but sometimes it's helpful if there is a co-morbid illness.

 

[nitemagi]

Do you know any reputable hypnotists? That's what they did in the old days (pre Freud!)

Me! 😀

But seriously, look for some minimal qualifications - namely try the directory at ASCH (asch.net) to start for your local area. I'm pretty connected with that community so can recommend people in your area if I know one.

Otherwise I'd recommend basic approaches
1. Meet the patient where they are
2. Use pacing and leading
3. Identify and reduce/remove secondary gain
4. The basics of don't work harder than your patient/make them meet you halfway
5. Consider actively frustrating them (see works by Fritz Perls) to get them to mobilize their own resources to complete their problems
6. Offer resources
7. Recognize limitations at a point and check yourself.

 

[fiatslug]

Nitemagi--where did you get hypnosis training?

BobA--I'd love to get some ACT training, for myself and our program. I almost went to a training a couple of weeks ago in Berkeley but couldn't get the time/conference covered by work so quickly. We're CBT based. It's tough because we've got 2-4, sometimes up to 6 weeks to work with people...

 

[nitemagi]

Nitemagi--where did you get hypnosis training?

I did a lay (non-professional) 200-hour training in college, then was mentored and supervised during residency by a psychiatrist that studied with Spiegel, Bandler and Grinder, and Erickson, and after residency I've taken ASCH trainings.

 

[splik]

Nitemagi--where did you get hypnosis training?

If you are interested in learning hypnosis I would highly recommend going to this International Society of Hypnosis Congress this year in October - it will be in Bremen, Germany. I hope someone will pay for you to go and hopefully enjoy some of Europe too! Most of the leading and most experienced people using hypnosis will be there from all over the world and they are an interesting bunch! I went to one previously and learned a great deal. I also did a lay hypnosis course and then the ASCH equivalent one in my own country and later taught on that course. I think it is a very useful tool and would like to see a basic competency in hypnosis become part of psychiatry residency training but that is unlikely to happen. Many of the tools used in hypnosis such as imagery, metaphors, stories, relaxation and there is some similarities with mindfulness of of course.

I note you are in the Pacific Northwest - if you happen to be near Seattle, UW does training in hypnosis for their FM residents - it may be weekends/evenings I'm not sure but might be worth looking into?

 

[nitemagi]

In the US, look into ASCH and SCEH.

 

[whopper]

they piddle out of treatment

Some of these patients might not really want to get better and are doing IOP simply to go through the motions. Others may have strong Axis II or IV issues that honestly might not get better with IOP treatment.

I got a case of someone with dependent PD. He gets better in the hospital, but right after we discharge him he stops his meds and gets worse, and ends up coming back in days.. He is in his fourth hospitalization since January and each time he's in the hospital he's here for weeks. He does want to get better but he also has dependent PD, and his wife used to fulfill that role and they had a codependent though unhealthy relationship in this regard. His depression has now gotten to the point where she can't handle it, (in large part because now they're housing their alcoholic son) and he's upset with her for not fulfilling her end of this relationship where he was treated like a child and enjoyed it.

To break his repeat hospitalzations, IMHO, I have to get this guy to get out of his dependent PD that he's had for decades. How the heck I can do this on an acute unit, where I cannot spend unlimited time with him, I do not know. He's also not receptive to psychotherapy and I have no illusions that I would be able to significantly improve his dependent PD within a few days to weeks even if I had hours a day to spend just on him.

My plan is to send him to long-term hospitalization and given that he's been suicidal and threatening to his wife (IMHO anger out of her not babying him) within days of being discharged-repeatedly, he meets the criteria for such, and I do believe he'll repeat the pattern if discharged. When he gets there, call up the clinical administration, tell them what's going on with that guy, and hopefully as a result of this he'll get assigned a psychotherapist who can spend hours a day with him there.

 

[DebDynamite]

This is a good thread because we have all been there with patients on this spectrum. I happily consider myself a "third wave behavior therapist" and repeatedly turn to ACT or MBSR techniques. I did NOT learn these therapies in my training. I have been pursuing them on my own for decades now. That said, I do not know of ANY psych training programs that actually certify in ACT at this time ( NV perhaps). As far as MBSR and other mindfulness practices, there are a few programs that have centers that study their effects. The commonly held theory behind successful delivery of those techniques is that the "teacher" must first become a practitioner. Thus leaving the average resident first learning how to practice prior to teaching. There are some programs that are starting to incorporate that into their training.

I have not had the opportunity yet to work long-term with patients who are more dependent- avoidant than borderline with these techniques however. Here is a good link to brief "homework" assignments that help the patient help themselves (if they will do the daily work) over time:

http://marc.ucla.edu/body.cfm?id=22

(http://marc.ucla.edu )

I tell my patients to put their phones in "airplane mode" while using them so as to avoid interruptions, or to turn off their phone if they are streaming via their computers.

Please update us if you come across anything else that is helpful. I have more counter transference towards this population than any other; all help is appreciated!

 

[kugel]

If I got to run things (and the more I talk the less likely that becomes),
we would get a plan together with the outpatient clinic.
Something like:
"You can visit the clinic 5 days per week in the following way: You can meet with a peer support specialist 2 days per week, depression group 1 day per week, relationship group 1 day per week, and therapist 1 day per week. In addition, your outpatient psychiatrist will see you once every 2 weeks for a while, tapering down to 1/month. In addition, we want you to begin the Peer Support Specialist training. We also want you to begin volunteering at least 4 hours per week at some local organization (library, food bank, animal shelter, VA hospital, etc.) Now, if you do at least 75% of these things, then every week we will provide transportation for you to get to the clinic every day, AND we will give you 4 bus passes per week to assist in getting to the volunteer job and getting to/from the grocery. And we need you to sign these Consents to Release Information to all the other area psych hospitals explaining our treatment program and requesting transfer back here if you arrive at their hospital.
But you need to understand something: You will Not be admitted to inpatient psychiatry in the next 90 days. Even if you harm yourself, you may be held in the psych ER for up to 24 hours, but you will then be discharged. This is because we strongly believe that readmission to the inpt unit is not helping you - and in fact that it is Harming you by causing you to become more dependent on the hospital."

An alternative to no admission is the planned, frequent, short admission.
"We will admit you every Friday evening through Sunday afternoon (though this may entail waiting in the Psych ER some of that time) for 3 weeks, then every other week for 6 weeks, then every month for 3 months. However, if you end up admitted to the psych ER any other times, you will lose some of the outpatient services for 7 days. You will only have access to "check in" with the triage worker for ~ 15 min/day at the outpt clinic that week. All other non-medication services at the clinic will be suspended for 7 days. And no bus passes."

 

[fiatslug]

If I got to run things (and the more I talk the less likely that becomes),
we would get a plan together with the outpatient clinic.
Something like:
"You can visit the clinic 5 days per week in the following way: You can meet with a peer support specialist 2 days per week, depression group 1 day per week, relationship group 1 day per week, and therapist 1 day per week. In addition, your outpatient psychiatrist will see you once every 2 weeks for a while, tapering down to 1/month. In addition, we want you to begin the Peer Support Specialist training. We also want you to begin volunteering at least 4 hours per week at some local organization (library, food bank, animal shelter, VA hospital, etc.) Now, if you do at least 75% of these things, then every week we will provide transportation for you to get to the clinic every day, AND we will give you 4 bus passes per week to assist in getting to the volunteer job and getting to/from the grocery. And we need you to sign these Consents to Release Information to all the other area psych hospitals explaining our treatment program and requesting transfer back here if you arrive at their hospital.
But you need to understand something: You will Not be admitted to inpatient psychiatry in the next 90 days. Even if you harm yourself, you may be held in the psych ER for up to 24 hours, but you will then be discharged. This is because we strongly believe that readmission to the inpt unit is not helping you - and in fact that it is Harming you by causing you to become more dependent on the hospital."

An alternative to no admission is the planned, frequent, short admission.
"We will admit you every Friday evening through Sunday afternoon (though this may entail waiting in the Psych ER some of that time) for 3 weeks, then every other week for 6 weeks, then every month for 3 months. However, if you end up admitted to the psych ER any other times, you will lose some of the outpatient services for 7 days. You will only have access to "check in" with the triage worker for ~ 15 min/day at the outpt clinic that week. All other non-medication services at the clinic will be suspended for 7 days. And no bus passes."

Kugel--I think this would be an awesome intervention for huge numbers of our patients.

Deb--I really want to get formal MBSR & ACT therapy training.

Appreciate the insights & camaraderie on dealing with this challenging population!