"Therapist said I'm on the wrong meds"

[LTPpowered90]

I'm a PGY-3 new to clinic, and I've gotten desktop messages related to the thread title more than once now. In particular, I have a borderline PD patient who is already on an excessive regimen (that I mostly inherited) on 5 different medications. I thought she had developed a bit more insight into her crisis modes...and now I get a message that she had relayed to her therapist that she wasn't doing well, which of course must be the medications, and she should definitely come to the hospital for the same.

I obviously don't want to triangulate the three of us or split in front of her. I already believe her regimen is beyond excessive. Do I make a small/insignificant change? Punt back to therapy (I wish I could say, you should find a therapist doing actual therapy)? Or general advice in similar situations?

Thank you!!

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[medicool]

I am fresh out of residency and this was not an uncommon occurrence. I personally do not recommend changes unless you see a clinical basis. A lot of borderlines tend to have some amount of destabilization when providers change, so this could be her unconscious mourning of your predecessor or /and receiving sub-optimal therapy where both the patient and the therapist cant or wont see it. Look for the quality and qualifications of her therapy provider and find an alternative. Saying NO soft and firmly is a big part of PGY3 , so have fun !

 

[Liquid8]

Agree with the above in relation to a change of doctor. When I was doing similar roles it helped to discuss the change with patients, and acknowledge it as a potential source of distress. Patients are often worried that they will have to go through everything again with a new provider (potential for re-traumatisation) and that someone new is going to change or stop all their medications.

This isn't to say that if you think her regime is too excessive it can't be altered. First establish if she wants to be on more medications or not. I've found a lot of patients want to be on as few medications as possible, which can give you something to work towards. Then establish if she's actually getting any benefits from being on her current regime. If she's having side effects, then there's a reason to reduce. If there's no actual benefit to her mental state, then there is still the risk of side effects if treatment is ongoing, as well as a logical argument to change to an alternative (with reduction in existing medications coming first).

What you may find is that in the process of any reduction, things may actually improve or stabilise. If this happens during a planned washout period, there may be no need to add a replacement medication and the process can be continued with their other treatments.

 

[AcronymAllergy]

Keep in mind, the patient may also be (purposefully or not) misconstruing what the therapist said. It might've turned from, "if you believe your medications aren't working well, you might consider discussing that with your psychiatrist at your next appointment," to, "my therapist says my meds are wrong and I need to come see you now." Although I've heard enough therapists say, "oh yeah, you shouldn't be taking that" to know that it obviously happens.

Maybe discuss the situation with her and get her take on how things seem to be working? Problem-solve, review what signs she's using to determine that her medications may not be working well, etc.? I would agree that just openly contradicting (or seemingly contradicting) what the patient reports the therapist to have said may not be therapeutically effective.

 

[WisNeuro]

Keep in mind, the patient may also be (purposefully or not) misconstruing what the therapist said. It might've turned from, "if you believe your medications aren't working well, you might consider discussing that with your psychiatrist at your next appointment," to, "my therapist says my meds are wrong and I need to come see you now." Although I've heard enough therapists say, "oh yeah, you shouldn't be taking that" to know that it obviously happens.

Maybe discuss the situation with her and get her take on how things seem to be working? Problem-solve, review what signs she's using to determine that her medications may not be working well, etc.? I would agree that just openly contradicting (or seemingly contradicting) what the patient reports the therapist to have said may not be therapeutically effective.

I comment on polypharmacy all of the time. Although, as you probably also see, it's in the context of a provider wanting me to evaluate for cognitive dysfunction, but the patient is so snowed on opiates/benzos/anticholinergics, that it's impossible to tease out the etiology of the cognitive complaints with so much junk on board. Other than that, patients will ask me about Aricept commonly, so I tell them that the outcomes literature would suggest very few, if any, people benefit from the med.

But yeah, back to the OP. Particularly when it comes to individuals with Axis II stuff on board, it can be very useful to do periodic check-ins with other providers who provide a lot of care to keep everyone on the same page. I'd see about getting permission to talk with the person in the context of coordination of care. It's better than playing a game of telephone with someone prone to emotional dysregulation in the middle.

 

[thoffen]

Split treatment for patients like this should have regular communication between providers, and a clinical concern that arises about the other provider out to be communicated directly from provider to provider instead of through the patient. Really, that's best practice for anyone, but it can be impractical.

In this case, it may well be that the conversation is misconstrued when presented to you. Or disturbingly often enough it may be well accurate.

 

[AcronymAllergy]

I comment on polypharmacy all of the time. Although, as you probably also see, it's in the context of a provider wanting me to evaluate for cognitive dysfunction, but the patient is so snowed on opiates/benzos/anticholinergics, that it's impossible to tease out the etiology of the cognitive complaints with so much junk on board. Other than that, patients will ask me about Aricept commonly, so I tell them that the outcomes literature would suggest very few, if any, people benefit from the med.

But yeah, back to the OP. Particularly when it comes to individuals with Axis II stuff on board, it can be very useful to do periodic check-ins with other providers who provide a lot of care to keep everyone on the same page. I'd see about getting permission to talk with the person in the context of coordination of care. It's better than playing a game of telephone with someone prone to emotional dysregulation in the middle.

Agreed, although I would say it's one thing to tell a patient, "these medications could be contributing to your cognitive difficulties" or, "it sounds like you're not sure how effective your medications are" and suggest they consider discussing with the prescribing provider, and another to just outright tell them, "yeah, you're on the wrong meds" or, "your meds must not be working."

Also agreed RE: the above suggestions to try discussing directly with the therapist.

 

[whopper]

This is from my experience a very common thing not being addressed in texts or conventional academic training. I've seen several doctors medicate Borderline PD, and then one one med doesn't help, they add another med without taking the first one off. Within months the patient is on 3-8 meds with no real improvement other than perhaps they're zonked (which is not a real improvement but some people say "hey at least she's not pissing me off anymore").

I've said this in other threads. Polypharmacy either means the doctor is terrible or a genius. Sometimes some patients require a sophisticated medication regimen based on lots of trial and error, but from my own experience, it's usually a doctor putting a patient on a medication, it's not helping and they add another without taking the first one off.

A solution to the problem, and I don't know why I'm the only guy telling people to do this, is to have each patient keep a medication journal detailing the effects every med had on them. While doctor's notes should suffice they almost never do. Whenever I get a doctor's notes I can't read the handwriting or even if I can they're so poorly written and don't detail the effects of the meds it's like starting over again.

While therapists could be overstepping their boundaries on getting into medication management, I've seen too many good therapists in an area where their patient is not getting good psychiatric treatment and the alternative is for them to just sit there and see this go on?

 

[clausewitz2]

This is from my experience a very common thing not being addressed in texts or conventional academic training. I've seen several doctors medicate Borderline PD, and then one one med doesn't help, they add another med without taking the first one off. Within months the patient is on 3-8 meds with no real improvement other than perhaps they're zonked (which is not a real improvement but some people say "hey at least she's not pissing me off anymore").

I've said this in other threads. Polypharmacy either means the doctor is terrible or a genius. Sometimes some patients require a sophisticated medication regimen based on lots of trial and error, but from my own experience, it's usually a doctor putting a patient on a medication, it's not helping and they add another without taking the first one off.

A solution to the problem, and I don't know why I'm the only guy telling people to do this, is to have each patient keep a medication journal detailing the effects every med had on them. While doctor's notes should suffice they almost never do. Whenever I get a doctor's notes I can't read the handwriting or even if I can they're so poorly written and don't detail the effects of the meds it's like starting over again.

While therapists could be overstepping their boundaries on getting into medication management, I've seen too many good therapists in an area where their patient is not getting good psychiatric treatment and the alternative is for them to just sit there and see this go on?

Literally every text focused on specialized treatment for BPD talks about this and recommends an approach similar to the one you outline. I would recommend Gunderson's Good Psychiatric Management for Borderline Personality Disorder as the shortest and most readable of these.

 

[thoffen]

This is from my experience a very common thing not being addressed in texts or conventional academic training. I've seen several doctors medicate Borderline PD, and then one one med doesn't help, they add another med without taking the first one off. Within months the patient is on 3-8 meds with no real improvement other than perhaps they're zonked (which is not a real improvement but some people say "hey at least she's not pissing me off anymore").

I've said this in other threads. Polypharmacy either means the doctor is terrible or a genius. Sometimes some patients require a sophisticated medication regimen based on lots of trial and error, but from my own experience, it's usually a doctor putting a patient on a medication, it's not helping and they add another without taking the first one off.

A solution to the problem, and I don't know why I'm the only guy telling people to do this, is to have each patient keep a medication journal detailing the effects every med had on them. While doctor's notes should suffice they almost never do. Whenever I get a doctor's notes I can't read the handwriting or even if I can they're so poorly written and don't detail the effects of the meds it's like starting over again.

While therapists could be overstepping their boundaries on getting into medication management, I've seen too many good therapists in an area where their patient is not getting good psychiatric treatment and the alternative is for them to just sit there and see this go on?

You're not wrong, and yet that needs to be a provider-provider discussion.

 

[Bartelby]

1 - As others said, talking to the therapist is step number one! You don't know what (if anything) the therapist said about the medication.

2 - It seems you think the patient is on a bad medication regimen too. Don't be afraid to educate and then start taking off unnecessary medications! Sometimes being restrained in prescribing is the best service you can offer your patient.

3 - If the therapist is critical of your medication regimen, hear them out. They spend a lot of time with the patient and may introduce some useful information.

4 - If the therapist really is critical of you in front of the patient and seems to collude with avoidance / illness, try to avoid split treatment with that person in the future. That may not be an option as a resident, but keep it in mind once you become an attending. You are still fully responsible for the patient when engaged in split treatment.

 

[whopper]

Thank you for the Gunderson referral. I haven't seen a text myself so far that mentioned this phenomenon with Borderline PD. What my experience has been is Borderline PD is discussed in residency but it's not given much emphasis despite that so many people coming into the ERs and inpatient have it to a significant degree and despite that DBT is mentioned as the treatment, no one in my department where I was trained knew anything about it, so then quite inappropriately the patients were medicated in a manner defying the evidence-base. Attendings openly would dx the patient as Bipolar Disorder even full well acknowledging to others it wasn't that but wrote this into the chart and medicated the patient as if it was Bipolar Disorder.

It wasn't until my own wife, during her master's degree, started learning DBT in-depth, showed me the books on it, and taught me much about it. Where I did my forensic training, that institution was better in tune with treating Borderline.

In hindsight, and I thought this even then, how stupid and horrifying to see a doctor intentionally put a wrong diagnosis and medicate a patient based on something with no to little evidence and despite the science showing that there's treatment out there, no one in the department was trying to learn about that treatment or get someone who specialized in it into their ranks. And to see this was not just happening in one place but several places.

I completely agree with the provider-to-provider discussion. A problem, however, is that practice is visit/incentive driven. Less than half the physicians I call actually call me back. I also talk to therapists regularly and many of them tell me they did call the psychiatrist and the psychiatrist never called them back and actually refer their patients usually to me cause I do work with the therapist but I'm an exception not the norm.

Again where does this put the therapist? In a very bad position of saying it like it is or having to sit there and not say anything, or deflecting the issue while not addressing it. I can relate cause as a resident I spent years seeing attendings do something while I thought to myself "WTF?" One of the worst days I ever had as a physician was my first day at a group home where I could only see the patients once a month and everyone was on a high dosage of Lorazepam mixed with either Thorazine or Seroquel. The prior psychiatrist's goal was to zombify the patients there, not really treat them. I was able to get them off of those meds but because I could only see the patients monthly it took 6 to 9 months to make the adjustments. I still even see it now and I know all of us do. E.g. long-term high dosage Ambien prescriptions, benzo prescriptions, opioid prescriptions.

There are of course therapists that don't know what they're talking about either when it comes to meds or therapy. Now when that happens and a patient tells me the therapist told them something that I know isn't true I tell the patient and ask the patient to have their therapist directly call me or provide me with contact information so I could call them.

 

[Attending1985]

On the flip side how do You handle it when the patient is a long-term therapy and not improving? It’s touchy when the patient is attached to the therapist. How do you approach this? I recently had a patient asking for medications for worrying what other people think of her. I recommended she address this in therapy and she and her husband said despite being in biweekly therapy for the past year she’s the same or worse. I recommended seeing another therapist who I know is great and specializes in anxiety.

 

[Jules A]

While therapists could be overstepping their boundaries on getting into medication management, I've seen too many good therapists in an area where their patient is not getting good psychiatric treatment and the alternative is for them to just sit there and see this go on?

I'd question the therapists' skill and insight in this situation. I have seen this where unskilled, perhaps unmotivated, therapists stayed at a practice where the psychiatrist was known to be a terrible prescriber with poor personal boundaries eventually resulting in sanctions. The skilled therapists recognized the cluster and moved on from that clinic.

 

[WisNeuro]

On the flip side how do You handle it when the patient is a long-term therapy and not improving? It’s touchy when the patient is attached to the therapist. How do you approach this? I recently had a patient asking for medications for worrying what other people think of her. I recommended she address this in therapy and she and her husband said despite being in biweekly therapy for the past year she’s the same or worse. I recommended seeing another therapist who I know is great and specializes in anxiety.

This is a huge problem, imo. I have patients come in often who have no objective cognitive deficits, but some fairly stable, with mild to moderate fluctuations over long periods, of psychiatric issues. Often they have been seeing "so and so" for several years and are VERY attached to that therapist. I don't challenge that directly, but I will counsel them on what specific therapies are indicated for their particular issues (e.g., panic control/exposure for panic attacks, prolonged exposure for PTSD, etc). This is all after I talk about how psychiatric issues impact subjective functioning in the absence of objective findings, yadda, yadda, yadda. But yeah, I think the key is that you don't directly challenge their relationship, that will get them to reject you pretty quickly, challenge the method in a gentle way, suggesting that perhaps a new therapeutic approach may offer some new tools and relief for the patient. Heck, throw in analogies if that helps.

If they have tried several antidepressants and found one that works, "Just like how some of the antidepressants you have tried did not work as well, sometimes different approaches to therapy work for some people and don't work as well for others. Some times we have to try out a different type of therapy, to get some longer-term relief." Or something like that.

 

[thoffen]

I think we're noticing a systemic problem, and thanks @whopper for sharing the therapist's side of it. Using the patient as a go-between is no excuse for bypassing an attempt at provider-provider discussion, and yet the likelihood of two willing parties existing and finding a way to make that connection is still low.

So what are we to do when it seems someone is being exposed to harm in their treatment by another party? Especially difficult when there is little certainty or that the harm isn't concretely demonstrable. And even more so in borderline dynamics as acting risks provoking abandonment crises.

 

[whopper]

On the flip side how do You handle it when the patient is a long-term therapy and not improving? It’s touchy when the patient is attached to the therapist. How do you approach this? I recently had a patient asking for medications for worrying what other people think of her. I recommended she address this in therapy and she and her husband said despite being in biweekly therapy for the past year she’s the same or worse. I recommended seeing another therapist who I know is great and specializes in anxiety.

There are bad therapists out there but I've seen even the best therapists have patients who don't like them or improve with their therapy. I've found psychotherapy to often-times be very person and situation-dependent. Some people will rightfully get all ticked off if you tell them they're being a wimp. Some people will get pissed off (which is the therapist's intent) and get ticked off and then take it, go with it, but instead of demoralizing them the anger could bolsten their resolve and then they take control of the situation that was the therapist's goal from the beginning. (And yes this is very risky cause the therapist is very possibly causing harm).
https://monstersofgeek.files.wordpress.com/2015/04/secret-wars-reed.jpg

What I tell patients is if they've seen a therapist at least 3 visits that is reasonable time for the therapist to have a diagnosis (or at least an idea of what is going on though some won't call it a diagnosis), and a plan. Also I tell patients if they've seen a therapist for about 3 months and there's no improvement they do have the right to ask what's going on and what type of results they should be seeing.

I've seen some patients stick with a therapist and get no improvement for literally years. That is way too long. Also the data on psychotherapiy shows there should usually be some type of response within several weeks, hence by 3 month rule.

 

[WisNeuro]

What I tell patients is if they've seen a therapist at least 3 visits that is reasonable time for the therapist to have a diagnosis (or at least an idea of what is going on though some won't call it a diagnosis), and a plan. Also I tell patients if they've seen a therapist for about 3 months and there's no improvement they do have the right to ask what's going on and what type of results they should be seeing.

This should definitely be something that the therapist is doing. the goals that are being worked on should be clear and generally measurable in some way, and periodic checking in on the progress should be made. Obviously some things take time, but you should still be able to identify what steps have been taken to towards the therapeutic goal, even if they are baby steps.

 

[whopper]

I also ask the patient what the therapist is doing. E.g. if a patient is in DBT I ask what stage they're in, what techniques they're using, and if the therapist hasn't done anything that's conventional then it'll be a red-flag. Doesn't mean it's bad therapy but it's worth looking into that maybe something going on is not right.

 

[sunshinefl]

(Disclaimer-Medical student potentially interested in psychiatry)

Besides maybe inpatient and prison settings where I have seen this, are there any practices (like outpatient) which include in-house therapists and psychiatrists who have a team approach with the patient?

 

[Jules A]

(Disclaimer-Medical student potentially interested in psychiatry)

Besides maybe inpatient and prison settings where I have seen this, are there any practices (like outpatient) which include in-house therapists and psychiatrists who have a team approach with the patient?

In the sense that at the OP practice where I work we rarely take medication management only patients or someone seeing an outside therapist. Virtually all my patients are seen by in-house therapists. This makes it easier for both communication and knowing the skillset of the therapist. The admin staff is also good with initial triage and usually assign new patients to a therapist who is a good fit for the presenting issues.

 

[clausewitz2]

(Disclaimer-Medical student potentially interested in psychiatry)

Besides maybe inpatient and prison settings where I have seen this, are there any practices (like outpatient) which include in-house therapists and psychiatrists who have a team approach with the patient?

An assertive community treatment team for SMI actually requires this approach to really qualify for the name, although quality of collaboration can vary.

 

[smalltownpsych]

This should definitely be something that the therapist is doing. the goals that are being worked on should be clear and generally measurable in some way, and periodic checking in on the progress should be made. Obviously some things take time, but you should still be able to identify what steps have been taken to towards the therapeutic goal, even if they are baby steps.

I encourage patients to ask questions of therapist just as I tell them to ask questions of their psychiatrist. Part of my focus of treatment is helping patients with these types of interpersonal skills. We get to practice this in session as they learn to ask questions of me. The one caveat to all of this as mentioned before is to be wary of the splitting dynamic that can occur and not just with axis II patients , we can all suffer from a self-serving bias where we see our successes and others failures. I counter that by never criticizing another provider of care. It is sort of a subset of not criticizing anyone who isn't in the room. Some of my best supervisors explained the traps of that early on in my training.

 

[whopper]

, are there any practices (like outpatient) which include in-house therapists and psychiatrists who have a team approach with the patient?

Intensive outpatient, ACT (also called PACT) teams but that was mentioned above, group homes, nursing homes. Rehab/Addiction centers.

 

[Attending1985]

My pet peeve is when therapists start engaging in triangular communication. “Patient said x,y or z about medications so I told them I’d talk to you.” We should be encouraging patient to communicate this themselves.

 

[Nasrudin]

This is a huge problem, imo. I have patients come in often who have no objective cognitive deficits, but some fairly stable, with mild to moderate fluctuations over long periods, of psychiatric issues. Often they have been seeing "so and so" for several years and are VERY attached to that therapist. I don't challenge that directly, but I will counsel them on what specific therapies are indicated for their particular issues (e.g., panic control/exposure for panic attacks, prolonged exposure for PTSD, etc). This is all after I talk about how psychiatric issues impact subjective functioning in the absence of objective findings, yadda, yadda, yadda. But yeah, I think the key is that you don't directly challenge their relationship, that will get them to reject you pretty quickly, challenge the method in a gentle way, suggesting that perhaps a new therapeutic approach may offer some new tools and relief for the patient. Heck, throw in analogies if that helps.

If they have tried several antidepressants and found one that works, "Just like how some of the antidepressants you have tried did not work as well, sometimes different approaches to therapy work for some people and don't work as well for others. Some times we have to try out a different type of therapy, to get some longer-term relief." Or something like that.

This is an interesting discussion. Regarding the above, and setting goals in therapy. I think this could be mapping onto the individual's own lack of native goals and aims. Well positioned, the therapeutic goals are aligned to repair and strengthen and reshape harmoniously the patient's own goals. Such that, while I grant you, certain modalities lend themselves better to certain psychological problems, you cannot sculpt dry sand. The patient has to have goals and then understand how their therapy and that relationship is helping them get better at pursuing them.

Such that, as the people were talking above your comment, it wasn't clear to which was the problem. No therapeutic goals. Or no personal goals for them to work from.

 

[cara susanna]

(Disclaimer-Medical student potentially interested in psychiatry)

Besides maybe inpatient and prison settings where I have seen this, are there any practices (like outpatient) which include in-house therapists and psychiatrists who have a team approach with the patient?

The VA has this, from my experience. We work pretty collaboratively with psychiatrists.

 

[smalltownpsych]

My pet peeve is when therapists start engaging in triangular communication. “Patient said x,y or z about medications so I told them I’d talk to you.” We should be encouraging patient to communicate this themselves.

I almost never want to be a go-between for any communications with patients and anyone else unless they are a pre-adolescent or intellectually disabled. At most I will meet with the patient and psychiatrist and have done that a few times in an inpatient setting where it was possible. The two times I remember doing that were pretty fun.

In one of the conjoint sessions, the patient had googled a bunch of research on medications and printed it out and was in furious debate with the psychiatrist about it all. Psychiatrist held his own and broke out some of his own references as they went back and forth. Communication went well and it reminded me a bit of a productive couples session.

In the other session, the psychiatrist was having difficulty with empathic listening to the point where the unstable patient threatened to choke him and I had to talk her down a bit before she went across the table at him. Reminded me more of my typical unproductive couples sessions.